Preliminary Report of Boeing 747-400F Fatal Accident, Dubai -3Sep10 [Archive]

aviatorhi

4th Apr 2011, 04:10

Having just departed from there, they would possibly, have nav aids set up..(possibly)..for an immediate return...(some company procedures are like this).....so having landed at DXB, perhaps several times, they would be happier to go back there than to DOH, which they might never have visited, or even heard of.

So you're suggesting that adhering to "procedures" is more important than common sense and staying alive?

To the original person asking:

We'll probably never know what went on in the decision making process to say with any great certainty how the CA arrived at the decision to go to DXB, I wasn't there and I won't comment on it, other than to say he did what he considered was best.

Personally, for anything other than a fire or structural problem I would have gone to DXB, even for an engine failure. The moment you fire and structural integrity are involved I find the nearest available airport I feel I can land the airplane on, end of story, I don't give consideration to mx facilities, ground facilities/equipment etc. etc. when I'm staring death in the face, I get my butt back on the ground and worry about that stuff later. Engine failures, systems problems etc. etc. that warrant a return I will always go to a company mx base where possible, or wherever I just came from.

What is interesting is to consider that if, they have not quite made the runway at DXB, the area that they would have landed in is highly populated, with residents and industry.
I hope that DXB APT is considering that aspect of the accident also.

I think they'd shut down 3/4 of the airports in the world after giving that "consideration".

Huck

4th Apr 2011, 04:18

Do you more experienced folks have any idea why they would have gone to a more distant airport? Had you been in their shoes, what factors would you consider before selecting an airport in this situation?

Without too much thought:

- Proximity
- Runway length
- Weather
- Firefighting capability
- Company presence
- Maintenance support

But it's pretty much drilled into you from your first day of 121 training, nearest suitable is nearest suitable. You cannot bypass the closest suitable airport without a really good reason - a safety-related reason.

But Doha was another country, they've never been there before, and their charts may not have contained Doha. So you're looking at getting vectors and all pertinent approach info on guard freq from a strange country's controllers. I can see how Dubai would be a very attractive alternative.

Mark in CA

4th Apr 2011, 05:39

http://www.gcaa.gov.ae/en/ePublicati...t%20132010.pdf
Just getting "404 Not Found" error.

This link seems to work: http://goo.gl/t1g9g

172_driver

4th Apr 2011, 07:24

Interesting read, and got me thinking about the Class E cargo compartment. Except from closing the door, what means are there to exclude smoke from the flight deck? In this particular incident it seems the smoke brought the aircraft down, made the crew unable to operate the aircraft to landing.

Class E Cargo Compartment: A Class E cargo compartment is one on airplanes used only for the carriage of cargo and in which:
i. There is a separate approved smoke or fire detector system to give warning at the pilot or flight engineer station;
ii. There are means to shut off the ventilating airflow to, or within, the compartment, and the controls for these means are accessible to the flight crew in the crew compartment;
iii. There are means to exclude hazardous quantities of smoke, flames, or noxious gases, from the flight crew compartment
iv. The required crew emergency exits are accessible under any cargo loading condition.

I am also thinking of this NPA (http://www.easa.europa.eu/ws_prod/r/doc/NPA/NPA%202008-10.pdf) concerning the safety off Class B compartments, similar to Class E doesn't require fire suppression system and too big for efficient use of hand held extinguishers.

Ashling

4th Apr 2011, 07:44

The Swissair reminded us of what our priorities need to be if we're on fire. Get on the ground without delay, you may only have a few minutes to do so. Split cockpit, one does the flying and talking to ATC, one does as much of the checks as time allows. You will have @ 15mins max possably significantly less. If you think you need to allow time to complete the checklist, company procedures etc think again.

No ejection seats in commercial aircraft.

NigelOnDraft

4th Apr 2011, 08:03

The frequent Pack 1 issue might be significant:Based on the DFDR data, at 15:15 UTC, PACK 1 shut down, with no corresponding discussion recorded on the CVR.givenNote7 : This check list was revised through a Boeing MOM in December 2010 advising operators that either air conditioning pack one or pack three must be operating to prevent excessive flight deck smoke accumulation during a main deck fire
Note8 : When the Main Deck Cargo Fire Arm switch is depressed, PACK 2 and 3 shut down while PACK 1 continues to supply conditioned air to the upper deck. This provides a positive pressure differential between the upper deck and the rest of the airplane preventing smoke or fumes entering occupied areas.
Appreciate there might not be a simple answer, but does this sort of fault:The take off and climb out from DXB was uneventful with the exception of a PACK 1 fault which was reset by the PNF at 14:55 UTC at 13,000 ft enroute to the BALUS waypoint.indicate the Pack shutting itself down? Or just a more minor fault, but it continues to operate?

In short, seems Packs 2 & 3 were manually (and automatically as per Note 8?) deselected, but it was important, for Smoke clearance, that Pack 1 operated. Given Pack 1's misbehaviour on previous leg, and on this leg prior the fire, maybe it recurred? One of those unfortunate "holes in the cheese lining up"? Maybe the "Fire Checklist" needs a line added "ensure Pack 1 or 3 operating..." to cover this unfortunate co-incidence?

Add: never flown a 744, not Boeing for some years, so thoughts appreciated from those who have. And maybe 744F specifically?

BOAC

4th Apr 2011, 08:14

Interesting - does the Dec 2010 QRH change restrict or caution against onward ops with Pack 1 u/s? Any 747 drivers to comment on the MEL for Pack1?

I cannot see anything in the pre-Dec QRH that places any distinction between PACKS 1/2/3 failure

Mariner

4th Apr 2011, 10:00

The links don't work for me. Looks like the GCAA website is u/s. Cannot imagine the whole world is trying to download the report.

Anyone with another option?

Nickdj

4th Apr 2011, 10:14

This link works for me:
http://www.easa.europa.eu/ws_prod/r/doc/NPA/NPA%202008-10.pdf

cheers

Mariner

4th Apr 2011, 10:29

I meant the link to the Preliminary Report from the UAE CAA. It's website is not reacting.

RegDep

4th Apr 2011, 10:54

This link (posted earlier by Mark in CA) works for me http://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/16/2010-GCAA%20Accident%20Preliminary%20Report%20B747%20DXB%20.pdf, at least as posted http://goo.gl/t1g9g

rondun

4th Apr 2011, 10:56

It's website is not reacting.
Works for me.
Use this link (http://www.gcaa.gov.ae/en/pages/newsdetails.aspx?NewsID=254) to get to the news page, then click the link beside "view report" to download the pdf.

Skittles

4th Apr 2011, 10:58

If it doesn't work try opening it in a different browser.

It will not open in Chrome for me, but it will in Firefox.

Jet Jockey A4

4th Apr 2011, 14:08

I hope I never get to experience something like this in the remainder of my flying career. I can’t imagine what those two pilots went through in the remaining minutes of their flight... RIP.

A fire onboard an aircraft has to be the most terrifying thing a pilot as to deal with, with perhaps the exception of a hijacking. This reminds me of the Swissair flight that crashed off the East coast of Canada. It's a reminder that no matter what, a fire onboard an aircraft as to be dealt with in a speedy matter and landing the aircraft the upmost priority even if not the best suitable airport for commercial reasons. Perhaps even the emergency check list should be put aside if time is at a premium and all efforts put into getting the aircraft on the ground ASAP.

Notables from the initial report...

"The inbound crew entered a logbook item for a PACK 1 fault which was reset on the inbound sector HKG-DXB."

"The take off and climb out from DXB was uneventful with the exception of a PACK 1 fault which was reset by the PNF at 14:55 UTC at 13,000 ft enroute to the BALUS waypoint."

"Based on the DFDR data, at 15:15 UTC, PACK 1 shut down, with no corresponding discussion recorded on the CVR."

Could a possible problem with PACK 1 have been a contributing factor here?

Oxygen to the mask of both pilots (or lack of) seems to be a major contributing factor in this crash...

"At approximately 15:19 UTC, during the emergency descent, at approximately 20,000 ft cabin altitude, the CAPT, as PF, declared a lack of oxygen supply.

Following a brief exchange between the CAPT and F/O regarding the need for oxygen, the CAPT transferred control of the aircraft to the F/O as PF. Portable oxygen is located on the flight deck and in the supernumerary area, aft of the flight crew’s positions when seated.

At this point the recorded CVR is consistent with the CAPT leaving his seat, after which there is no further CVR information that indicates any further interaction from the CAPT for the remainder of the flight."

This is not good, the PF (F/O) is now looking for some oxygen...

"At 15:22 UTC, the F/O informed the relay aircraft that he was ‘looking for some oxygen’."

Low time crew on aircraft type?

CAPTAIN
FLT CREW LICENSE FAA AIRLINE TRANSPORT PILOT –AIRPLANE MULTIENGINE LAND

TOTAL TIME (TT)
11,410 hours
TIME LAST 6 MONTHS 209 hours
B747-4F (TT)
367 hours

CO-PILOT/FIRST OFFICER FAA AIRLINE TRANSPORT PILOT -
FLT CREW LICENSE AIRPLANE MULTIENGINE LAND

TOTAL TIME 6,130 hours
TIME LAST 6 MONTHS 130 hours
B747-4F (TT) 78 hours

With 367 hours total on type the captain was still relatively new to this aircraft. The F/O on the other hand was inexperienced on type with only 78 hours total. Given the gravity of the situation that day with what seems to be some sort of compounded multiple failures of the aircraft’s systems (PACK 1 shutting down, lack of oxygen, flight control problems…) could their low time on type have played a role in the crash?

So in the end what have we learned from this initial report?

That there was a fire in the main cargo deck, the crew did their best in getting the aircraft out of FL320 down to 10,000 feet but that on the way down the captain may have been lost due to lack of oxygen, leaving possibly the aircraft in the hands of a very low time pilot on type continuing by himself to try to save the aircraft under very extreme conditions with a fire burning, smoke in the cockpit, problems communicating and perhaps even lack of oxygen to his mask. The aircraft approached DBX on a flight profile that suggests things were getting out of control (too high and too fast). The gears were lowered at above their operational speed and reported not to be functioning, the spoilers were then extended and so were the flaps (perhaps above their operational speed too). The aircraft overflew/overshot the airport at 4500 feet at 340 kts. The PF was advised of an alternate airport at 095 degrees from their position and 10 NM.

Shortly after acknowledging this information either both pilots or as this scenario in this initial report leads us to believe, the only pilot left flying the aircraft must have succumbed to the lack of oxygen or the fire itself as the aircraft’s A/P disconnected, it entered a descending RH turn from 4000 feet while the speed bled back to 240 kts until impact.

There are too many questions left to be answered before some sort of judgement can be truly accessed in this tragedy. Hopefully some good will come out of it.

However IMHO something immediate should be done about those lithium batteries. They should not be charged before transport especially if they are to be air freighted.

IGh

4th Apr 2011, 15:15

Nice summary.

Several parallels with:
Clipper 160 / 3Nov73 Cargo B707-320, N458PA departed JFK with 15360 pounds of 12 different hazardous materials and other cargo (payload = 52912 lb), bound for Scotland and Frankfort. \\ Crew were offered no notification of Hazmat aboard.

That cargo-B707 crew overflew usable airfields in an attempt to return to BOS; smoke in cockpit; then eventually LoC near airport:
P.C. = smoke in cockpit, continuously generated, smoke led to emergency situation and loss of control during final approach, when crew (in un-coordinated action) de-activated the Yaw Damper, with incompatible configuration of Extended Flight Spoilers and Extended Flaps. AAR included reports of witness-pilots' observation of accident aircraft in unusual attitude. [ICAO "AAD"; and Air Line Pilot May90, CV Glines' Hazmat article. AW 102:47+ Mr10 '75, 51+ Mr 24 '75, 57-9 Mr 31 '75.]]

GrassRootsFlying

4th Apr 2011, 16:49

As a lowly CFI, I wonder why the crew elected to go to DXB (150nm away) instead of DOH (100nm away)? Do you more experienced folks have any idea why they would have gone to a more distant airport? Had you been in their shoes, what factors would you consider before selecting an airport in this situation?

In my old company it was more a question of time rather than distance to nearest available. Don't know the answer in this case but it may have been quicker to get back to DXB as well as the other factors mentioned.
regards

BOAC

4th Apr 2011, 17:09

See posts#12 and #14: I think trying to locate plates etc for a new airfield, with a major problem on board and PROBABLY still having all the stuff for departure point 'out' makes a bit of sense? I'm not sure they would have made Doha anyway.

VFD

5th Apr 2011, 01:53

Could a possible problem with PACK 1 have been a contributing factor here?
Since Pack 1 was the source to have positive pressure in the cockpit and Pack 2 & 3 were shut down with the fire list, I would say a big YES.
What is not clear is that will pack 2 or 3 supply the positive pressure to the cockpit if Pack 1 is inop.
Oxygen to the mask of both pilots (or lack of) seems to be a major contributing factor in this crash...
The captain went looking for O2 7 minutes after fire alarm. Either the bottle was near empty, plumbing to mask was damaged from the fire, or mask malfunction.
This is not good, the PF (F/O) is now looking for some oxygen
Imagine what the F/O was thinking when the Captain never came back.

It is beyond belief how the chain of events/holes in the cheese lined up. Every safety feature seems to have failed.

EW73

5th Apr 2011, 02:31

I just can't help thinking...
"What would have been different about the outcome of this tragic accident if it had been a Classic B747 freighter?"

I ask as a long-time flyer of 747 Classic freighters, much of it HKG-DXB-MAN, and return.

In my mind, I find myself applying the same string of events to a flight I might have been on board, and trying to see how the outcome may have been different.

:confused:

SMOC

5th Apr 2011, 03:13

Yep the classic would have been a different story F/E could have sorted out the pack issue and the classic freighters should have the cockpit vent to allow ram air into the cockpit giving a positive pressure preventing the smoke entry. Plus a third man could have also helped with getting an oxy bottle.

The -8F is fitted with a cockpit vent switch might be a nice mod to fit to the 744F/BCFs!

bbrunton

5th Apr 2011, 03:52

Also... If they had followed the checklist and stayed at FL250 for a while there would not have been enough oxygen to sustain combustion and the fire would have gone out?

Am I correct in thinking that?

GlueBall

5th Apr 2011, 04:10

"...I think trying to locate plates etc for a new airfield, with a major problem on board..."

DOH is a major airport with radar environment. You certainly wouldn't need "to look" for Jepp charts in an emergency. Don't you think that the controllers would give you priority and all necessary vectors and frequencies for a straight-in approach and landing?

The SR111 accident should have taught every one by now to get down and to land at the closest airport/pavement with uncontrollable smoke in the cabin. With max auto brakes [3000psi] the B74 can easily be stopped on any 5000' pavement, including a highway if necessary. To be sure, the prehistoric training "mind set" of having to land at a "suitable airport" needs to change. :ooh:

IGh

5th Apr 2011, 14:08

A QUESTION posed, a few slots earlier:
"... at FL250 ... there would not have been enough oxygen to sustain combustion ..."

This mis-perception, and the idea of "turning OFF the Packs to suffocate any fire", have been recurring pilot-assertions. An erroneous assertion.

Combustion could be slowed by decreasing the CONCENTRATION of oxygen: eg, for inerting an empty tank (or dry-bay) one could decrease the O2-concentration from 20% to 10% (using increased concentration of N2).

Lesson from various inflight fires teach us:

-- Hot-SMOKE accumulated in the fuselage-crown [stacking downward toward the cabin floor] will become the most flammable substance onboard. SMOKE BURNS!!!

-- Generally, for smoke removal, our normal Outflow Valve should be up HIGH, not beneath the cabin floor [or instead design-in a smoke-chute with the intake in the ceiling-crown area].

742

5th Apr 2011, 14:09

Also... If they had followed the checklist and stayed at FL250 for a while there would not have been enough oxygen to sustain combustion and the fire would have gone out?

This is an important point that does not seem to be appreciated with regard to a main deck fire. Depressurize IAW the checklist, hold FL250 until near the airport and then make like a brick for the runway end.

However that would not be an option if they did not have oxygen to the masks.

Sqwak7700

5th Apr 2011, 15:45

I would like to see proper mask and communications system installed. I have first hand experience with the crappy set-up in the 744, and it truly is inadequate.

Every time I put the mask on in the sim we end up with the same communications problems - loud breathing and venting noise picked up by the mask microphone and amplified over the cockpit speaker making conversation between the crew extremely hard.

Then you also end up with a fogging goggle which you have to lift off your face to clear (yeah, I know, use the venting button but it doesn't work in the sim, which has the same masks as the aircraft) Granted, the sim uses compressed air with moisture, and the aircraft uses oxygen that is very dry, so maybe it would not be a problem in the aircraft.

I think the short term solution would be to install a cockpit smoke door that isolates the flight deck. I've also wondered if the smoke barrier door was properly closed. I always make a point of checking this door to make sure it is properly closed. Ground staff are always very lax about making sure the door is properly closed. They often place it in the jamb but fail to use pressure to actually hear it click. This then results in the door flying open during rotation.

I really do feel for these guys, the speed at which it all turned ugly is quite alarming. While I contend that Doha was the nearest, when looking at your ND and comparing those two blue circles, the difference between 100 and 148 is not much, especially when you can barely look at your instruments.

Everyone can make the decision sitting on their couch in a comfortable room, but these guys made this decision while their eyes were burning from smoke, they had problems breathing, and they were loosing sight of instruments and controls that were at arms reach. Not to mention starting to loose control effectiveness.

I really can't fault them for choosing Dubai. If they ended high with 150 miles to run to an airport they knew, then they would have probably ended up higher into Doha and had to circle as well.

BOAC

5th Apr 2011, 15:54

Glueball - like Sqwak, and unlike you, I was not wishing to imply any criticism of the crew's decision in my post, but like Sqwak to show (from my smoke-free couch) what the thinking may have been.

Jet Jockey A4

5th Apr 2011, 16:12

Sqwak7700 wrote...

"I really can't fault them for choosing Dubai. If they ended high with 150 miles to run to an airport they knew, then they would have probably ended up higher into Doha and had to circle as well".

You are correct that second guessing the crew is easy when sitting at home behind a computer.

Without second guessing the crew about the airport choice or other decisions they took, what strikes me from the initial report, aside from the fire itself was the apparent problems the crew had with their O2 system and that there is a very strong possibility that the captain never made it back to his position behind the controls leaving the aircraft and its problems to be handled and dealt with by a very low time F/O on type.

If this is the case then it is no wonder that things went from very bad to worse awfully fast. Trying to navigate, communicate, fight a fire, a possible flight control problem and lack of O2 probably in the end, overwhelmed the F/O as they would have most other pilots trying to fly and land a crippled 747 bearing in mind he was effectively in a “single pilot operation”.

Sqwak7700

5th Apr 2011, 16:28

If this is the case then it is no wonder that things went from very bad to worse awfully fast. Trying to navigate, communicate, fight a fire, a possible flight control problem and lack of O2 probably in the end, overwhelmed the F/O as they would have most other pilots trying to fly and land a crippled 747 bearing in mind he was effectively in a “single pilot operation”.

I'm not sure, we're talking about a 6000hr plus pilot here. Sure, he was very low time in type, but he probably came from another heavy at UPS. And an airplane is an airplane, you still do profile calculations the same way, and you still need to slow down for landing.

I think the environment was so harsh that it made even simple tasks like switching frequencies impossible. That is very worrying. When you take this into account, then you realize he could not see the FMC, could not see the MCP, and certainly could not look out the window. Bearing that in mind, he did an incredible job of getting so close to almost landing on the first attempt.

The possibility of the O2 failing is quite disturbing as well. The crew bottles are all located in the right side, I believe in front of the forward lower lobe cargo door. They are not in the main deck, but the oxygen lines certainly run by the side-walls to get up to the flight deck.

From an engineering perspective, I guess it is good to have them down low and all in the same place. But everything in aviation has backups, should they all be grouped together? Maybe a little redundancy is in order with separate systems for CA and FO.

Jet Jockey A4

5th Apr 2011, 16:41

Sqwak7700, I agree with you in principal and I'm not trying to knock down the F/O here but in my books he was still a low time pilot on type regardless of past experience.

I don't know about you or others but when new to a type rating it takes me more than 78 hours to get comfortable in a new aircraft.

All I'm saying is it could have played a role in this aggravated situation.

Under extreme stress like in this one sometimes "seat of the pants" flying is going to save you but most would require lots of hours on type (certainly more than 78 hours) to get the "feel" of the airplane.

ZimmerFly

5th Apr 2011, 21:17

I fear your assertions are wrong. Altitude (25,000ft. suggested by Boeing) does reduce the effects of fire. 21% Oxygen is available at all altitudes, but there just aint enough of it to sustain fire at 25,000ft. Try breathing, or getting a piston engine to work at that altitude....without supplemental oxygen or a supercharger. :8

From the FAA website: [slide #12 of the presentation]

Pressure dependence

􀁻The burning rate and flame spread decrease as pressure decreases.
􀁻The time to ignition scales inversely with pressure so as the pressure decreases the time to ignition increases.
􀁻The overall effect of reduced pressure acts to inhibit the fire.

http://www.fire.tc.faa.gov/2010Conference/files/Advanced_Material_Research_II/ZarzeckiBurningCharacteristics/ZarzeckiBurningCharacteristicsPres.pdf

arem

5th Apr 2011, 21:22

Lots of talk about DOH v's DXB, but I seem to remember we use to teach in the sim that if you ain't on the ground in 14mins with a fire on board that is not under 'control' you are dead meat!!

fireflybob

5th Apr 2011, 22:01

And then there is also the option of ditching?

742

5th Apr 2011, 22:19

And then there is also the option of ditching?

And then I think the challenge becomes defining the decision point. If you are not near an airport you should be at altitude, unpressurized, so as to starve the fire (in the case of a main deck fire). So by definition if you are low you are near an airport.

The odds of surviving an open water ditching of a 747, not to mention a 747F with a bunch of 10' pallets that may be coming forward, can not be good.

EW73

6th Apr 2011, 02:41

Actually, I thought about the ditching option too..

I see the B747 freighter setup as the best for a water landing...

All the pallets are loaded on the main deck, none are at the level of the upper deck, and in the calm waters of the gulf, I don't see sufficient risk of the load taking out the flight deck high enough to gamble that against what has ultimately occurred.

All other freighter aircraft have their freight loaded on the same deck level as the flight deck, and therefore a much higher risk to the flight crew during a ditching.

EW73 :confused:

Ex Douglas Driver

6th Apr 2011, 14:14

The latest QRH amendment for the 744 freighter has clarified the requirement for one pack to remain operating:

FIRE MAIN DECK
(4) MAIN Deck CARGO FIRE ARM switch . . . . Confirm. . . . . . ARMED
SATCOM will shut down to prevent overheating.
System shuts down two packs and respective PACK EICAS messages are shown.

(5) PACK control selectors . . . . . . . . . . One pack on, two packs OFF
! Select the pack control selectors that have the PACK messages shown.

WARNING! Either pack 1 or 3 must be operating to prevent excessive smoke accumulation on the flight deck.

IGh

6th Apr 2011, 16:20

ZimmerFly --- Thanks for that reference (??from the 2007 gathering??). Good pressure- data there, but other variables (ventilation needed to remove accumulated smoke in the ceiling-crown area) also affect choice. Also, this CARGO-ops event reminds me that the pilots have different choices (with no pax aboard) than in most historic fire mishaps [eg, cargo pilots now bring the Cabin Altitude up to 25000ft].

?? TELL ME -- does newest CARGO B747 include the designed-in Smoke-Chute to pull hot-smoke out of the Ceiling-Crown???
Or is the Outflow Valve still in the same location (beneath the main deck Cabin Floor)???

Re' the earlier lessons (biology acts on partial pressure of O2 but combustion is limited by CONCENTRATION of O2) maybe there is more to learn, and other variables acting to increase smoke concentration.

Decades ago, we faced repeated fire-mishaps, where mishap-pilots (or F/E) selected PACKs-OFF, in their mis-perception that decreased ventilation could HELP, by "suffocating the fire". But the PACKs-OFF choice then STOPPED any removal of HOT SMOKE from the ceiling-crown area:The Saudia and Air Canada cases provide lessons for pilots in the hazard created inside the cabin when smoke is allowed to accumulate: smoke is combustible, and may become the most flammable substance inside the cabin. In both cases, crews had turned OFF the Air Conditioning Packs while still in flight. Packs-OFF thus limited venting of the smoke, with their "hidden fire" threatening to ignite the accumulated smoke into a "flash fire". Pilots should be taught, just as are the firefighters, that smoke burns! That smoke should be jettisoned overboard. However, in the Air Canada case (DC-9) the loss of electrical power from normal buses had caused the pneumatic high-stage Augmentation Valve to close, thus limiting airflow during Idle-power descent (then later the F/O switched-off the Supply Switches which stopped all in-flow / out-flow). The Saudia aircraft landed with Packs Off, and furthermore had its Outflow Valve CLOSED. [Mine from decades ago.]

F111UPS767

6th Apr 2011, 18:04

Why is 25,000 feet chosen for cruise in cargo aircraft (until further descent when a landing site is available) following a cargo fire? Why not stay up higher if you are already there? Is 25,000 feet a compromise chosen for physiological problems that could occur if one stayed higher? If at a pressure altitude of 25,000 feet, and descent is made in about 4 minutes to sea level, could that present a physiological problem?

When an airfield is available for landing, how far out and in what configuration should descent be made to land and minimize time in the lower atmosphere with its higher concentration of oxygen? Figure both for an average cruise altitude (35,000 feet) and also from the cargo fire level off altitude of 25,000 feet.

Example: Based on a single 757 simulator test, descent was made from 35,000 feet /.80 Mach / 270 KIAS. Gear and SB were extended. During descent, with gear down and locked, speed was increased up to 310 KIAS. Autopilot would not hold this configuration and was disconnected. Distance to 3,000 ft was about 25 NM and time about 4.5 minutes. (Disclaimer: Not sure the numbers and memory are accurate.)

Huck

6th Apr 2011, 19:25

WARNING! Either pack 1 or 3 must be operating to prevent excessive smoke accumulation on the flight deck.

Another QRH item written in blood.....

EDLB

6th Apr 2011, 19:46

FoxHunter

6th Apr 2011, 19:58

Before you get all excited about bringing the cabin to 25000 feet.
A lithium battery fire does not need additional oxygen. There is enough chemical energy in the batteries themselves to sustain burning.

I think the idea is to delay/stop all the other contents of the cargo area from burning.

ManaAdaSystem

6th Apr 2011, 20:54

Captain, we have a cargo fire!

OK, lets do the drill and get down fast!
No, cancel that, lets stay up here and let the flames die out!

But Captain, we have batteries in the cargo!

OK, lets get down now! Quick!

But Captain, we have other cargo as well!

OK, lets stay up here and let the flames die out!

But Captain, we don't have enough crew oxygen!

OK, let stay here until it hits 500 PSI, Then lets get down quick!

To be continued by the arm chair elite.

ZimmerFly

6th Apr 2011, 21:36

As far as I know, every 747 from the first -100 to the last 744F has the same Sextant Mounting / Smoke Port in the flight deck crown. Outflow valves remain beneath the main deck floor. I have no information on the 747-8.

iskyfly

6th Apr 2011, 22:31

i could have sworn this was discussed before...

oh wait... yes, it was. http://www.pprune.org/rumours-news/426218-ups-aircraft-down-dubai.html

MountainBear

7th Apr 2011, 01:36

i could have sworn this was discussed before... oh wait... yes, it was. UPS Aircraft Down In DubaiAh yes, that's the game. Let's go back and see who was correct and how much bull**** was spread around it that thread. Interestingly, the person who was spot on only has two posts to date. Airbusdriver123 reported:

Flight from Dubai to Germany
Emergency with Barhain Control and emergency descent to 10000 ft
Fire in flight deck
unable to read instruments or changing freq with UAE control
several a/c relay transmission and radar vectors from UAE control on to Barhain freq
Last position on OMDB was 7000 ft - 6 nm final 12L. All of which is confirmed in it's major details by the preliminary report. Not surprisingly, he was immediately called a liar in that thread. You wanna come back and apologize "justforfun"?:mad:

sevenstrokeroll

7th Apr 2011, 02:11

great tragedy...and with a very modern aircraft.

its funny how we learn things in flying...tragic fires in the air...valuejet in florida, swissair near peggy's cove...and the one that had the most profound effect on me, EK Gann's fire in the C54.

In the book, "Fate is the Hunter" I'm sure many of you will remember how he threw the book away and found a hole and spiraled down to a landing. Remember?

Anyway, since that book made an impression on me and evaluating the three jet fires, I think ashling was right...get on the ground anywhere fast , even using barnstorming techniques instead of heading for an airport...unless you find yourself on top of one.

if you can, look out the window and head for what you[ve got...beggars can't be choosers.

Batteries can go on a ship...no oxygen generators, batteries, or other flamables on planes.

lambert

7th Apr 2011, 08:08

Batteries can go in a/c too - if they are packed and properly declared in accordance with the Dangerous Goods Regulations.

F111UPS767

7th Apr 2011, 12:14

Has there ever been a fire in a (cargo) aircraft when out of range of an airport when the aircraft descended to 25K and depressurized?

Jet Jockey A4

7th Apr 2011, 12:21

lambert wrote...

"Batteries can go in a/c too - if they are packed and properly declared in accordance with the Dangerous Goods Regulations".

Perhaps but I still maintain that the batteries should not be charged at all. They can be charged at final destination prior to consumer delivery.

That's the only way to insure no thermal accident causing fires.

Feathers McGraw

7th Apr 2011, 12:33

The problem with that is that Lithium batteries are shipped with partial charge because if they are left uncharged the consequent low voltage state leads to internal damage which renders them useless in service. It's the same reason that phones and other devices that use Li batteries switch off when only just below the nominal 3.6/3.7V cell voltage, if you let them drop to below 3.0V then they accumulate damage and the service life is massively reduced.

IGh

7th Apr 2011, 16:25

Re' Smoke Removal, Sextant Port, Ovhd Escape Hatch, proposed Smoke-Chute :

GCAA's Preliminary Rpt, Pg11, Note 9:
Smoke Evacuation Handle -- a handle immediately aft of the P5 overhead panel that when pulled opens a circular, manually displaced vent in the overhead fuselage section of the flight deck.

Hmmm -- so that "circular ... vent" that the report mentioned could NOT be the Overhead Escape Hatch [not circular]??? -- In old military transports, a pilot could pull such a handle to release the Overhead Escape Hatch.

IGh

7th Apr 2011, 17:40

"... evaluating ... fires ... get on the ground anywhere fast ..."

Such an EMERGENCY LANDING, off-airport, has been accomplished during inflight fires -- just not recently. Until the fires aboard the new DC-6 (4Nov47 & 11Nov47), transport aircraft had deploy-able barium nitrate Landing Flare meant as a safety feature for emergency night landing [another hazardous engineered safety feature].

Recall that the Boeing-PIC, while flying over the North Cascades, elected to attempt an emergency landing near Oso -- rather than attempt to get back to BFI:19Oct59 B707-22 / N7071 upset, wing/fuel/structure fire, of a Boeing Trainer. During crew training for Braniff pilots, while practicing dutch roll recoveries, the yaw-roll upset severed three of its engines. An ensuing wing-fire consumed wing structure, ongoing fire motivated pilots to attempt a crash landing in the North Fork of the Stillaguamish River (near Oso northeast of Seattle) at 1620 PST. Four crew-observers survived by taking ditching stations in the aft cabin (three operating crew were killed). One of those observer/survivors was a Boeing pilot (Bill Allsopp).

TWA Lockheed Constellation NC86513 Star of Lisbon / 11Jul46, near Reading, PA. Sixteen minutes after T/O (during practice engine-out ops) an F/E smelled odor of burning insulation; when he opened cockpit-bulkhead Door to cabin blast of heat and dense black smoke poured into cockpit. Smoke in cockpit inhibited pilots Nilsen and Brown from seeing panel. Cockpit crew-hatch was opened to clear air, but this only drew more smoke into cockpit. Capt-IP Brown opened right sliding window; Brown put head out window and flew aircraft to emergency landing (smoke created danger of losing control). Landed 2 miles NE of airport, skidded 1000' across hay field. Tanks ruptured, fuel fire. IP-PIC RF Brown survived (burned, amputee), five other pilots/FEs died inside the burning wreck….

NW Flt 1-11 / 14Jul60 DC-7C N292 ditched 5 miles east of Polillo Island, P.I. (Pacific), at 0430 Manila time [night]. Departed Okinawa at 1712 hrs GMT enroute Manila. … magnesium fire; descended through cloud with moderate rain (night), rain increased intensity of Magnesium fire on #2 Eng Nose Case; fire in left wing -- structural failure feared \\ ditched at 2030z, 67 nm NE of Manila (five miles from shore) sob = 7 crew and 51 pax (1 fatality, 44 injured)….

Varig 820 / 11Jul73 B707-345C PP-VJZ inflight cabin fire, crash landed short of Paris/Orly. Killed: 7 crew + 116 pax. Survivors: 10 crew + 1 pax.
From Rio de Janeiro to Paris, Cruised FL330/370/390 (10 hours). Descended toward Paris … At 1358:20 hrs pilots radioed "... problem with fire on board." Pilots requested "emergency descent". … 10 nm out, pilots reported "total fire" … Last radio transmission at 1401:10 hrs.… oxygen masks and anti-smoke goggles, but excessive black smoke obscured the pilots view of the instruments and forward vision; PIC then decided to make a forced landing; pilots opened sliding-windows to regain vision, pilot viewed forward through opened sliding-window…. aircraft trailing smoke under rear fuselage…. impacted at 1403 hrs about 5 km short of Rwy 7, in a open farm-gardening area; configuration: LG down, partial flaps….

Aeroflot / 16Oct86 Tu-134 enroute, fire in cargo bay, executed a forced landing near Skytivkar, Russia. Sob = 82, two crew killed. [Flt Int'l, 24Jan'87, pg 38.]

Aeroflot / 17Nov90 Tu-154 CCCP-85664, a Cargo Fire aboard -- forced landing near Velichovky USSR [location? per Flt Int'l]. … Enroute Basel/Switzerland to Moscow … While enroute over Czechoslovakia crew reported fire and smoke in cabin. Crew radio'd Prague Airport to prepare for their emergency landing. Shortly later aircraft lost Communications (lost electrical pwr?). Crew elected to make a forced landing, landed near Dubenec/CSSR [cited location per CW's translation]… at 1521 hrs local time. Crew of six escaped wreckage. …

Aeroflot / 13Jan95 Tu-134A, crash-landing near Sverdlovsk (now Jekanterinenburg). \\ The Russian aircraft was en-route from Tjumen (Siberia) to Ufa and Wolgograd, when crew noticed a cockpit indication of "smoke in the baggage hold"…. asked ATC for a emergency descent for landing at the nearest airport, Sverdlosk-Koltosvo. … emergency landing in a wooded area, 30 miles from the airport. Sob = 68 , fatalities = 22....

sb_sfo

8th Apr 2011, 14:44

UPS to Become First Global Carrier to Add (http://finance.yahoo.com/news/UPS-to-Become-First-Global-bw-2365992208.html?x=0&.v=2)

wozzo

8th Apr 2011, 16:24

PC World:

The House of Representatives has passed legislation that prevents the United States government from implementing more stringent rules classifying lithium batteries as a hazardous material. Does that mean the batteries are not hazardous? Not necessarily. The move is based on lobbying and financial interests, rather than environmental or safety concerns.

More: House Passes Bill Declaring Lithium Batteries Safe - PCWorld Business Center (http://www.pcworld.com/businesscenter/article/224714/house_passes_bill_declaring_lithium_batteries_safe.html)

Graybeard

8th Apr 2011, 16:58

We have the best government money can buy..

Sqwak7700

9th Apr 2011, 05:11

Pathetic. The fact that it was a cargo plane and happened in a strange land means no-one in government gives a crap. Couple this with money from lobby groups and you have another opportunity to improve safety pushed to the side.

What a collection of corrupt immoral gits we have for a government. :yuk:

Shell Management

9th Apr 2011, 13:44

The fact that the US Government has just run out of money does rather put that in perspective.:E

I did have the very debate about the laxness of the US approach last year with SNS3guppy. Sadly some people still think that the US is a world leader in aviation safety.:ugh:

BOAC

9th Apr 2011, 13:53

Sadly some people still think that the US is a world leader in aviation safety. - mostly Americans, I suspect!

Touch'n'oops

10th Apr 2011, 23:47

I'd really hate to think the position and feeling the F/O found himself in.

- New on type (Only 78 hours)

- Oxygen masks not working properly (Are 747 masks that bad or like in my sims people just don't know how adjust the settings once on?)

- Captain (Who is also low hour on type), out of seat and disappeared into the smoke.

- Cockpit visibility zero. I think the F/O didn't know how close and fast he was to DXB due to his instruments being obscured. Maybe one to remember in future, is to ask for a running commentary from radar (You don't have to listen to it.)

- Dubious Flight controls. How does the 747 A/P adjust the elevator? Is the mechanism near the control surface? Might explain why the A/P did better job at controlling the aircraft, this is assumed as A/P was left in!

I remember seeing a photo on the wall the 737 briefing room in Crane Bank (BA's SIM CENTRE) of a 737 cockpit after a smoke event. Smoke had adhered to all instruments.

This accident throws up a conflict in my mind, between floor it (Possibility of ending hot and high, as in this case) or take a little bit of extra time to get it right first time (Swiss SR111, ran out of time).

One thing this does enforce, on first confirmation of fire or smoke get going down!

Huck

11th Apr 2011, 00:05

I think that if you can't evacuate cockpit smoke, and your oxygen mask doesn't work, everything else is irrelevant.....

Dano22

11th Apr 2011, 01:36

BOAC

11th Apr 2011, 06:58

Are 747 masks that bad or like in my sims people just don't know how adjust the settings once on- have you considered that the crew oxy system could have been compromised by the fire?

Mariner

11th Apr 2011, 11:32

There are two crew oxygen bottles in the forward cargo compartment, situated in the cargo compartment sidewall just behind the forward cargo door. A pressure reducer reduces the bottles high pressure of up to 1850 psi to a medium pressure. A single medium pressure line goes forward and upward through the sidewall of the maindeck to the cockpit, where another pressure regulator is situated behind the coat rack. After the pressure is further reduced to ± 100psi, the system splits up in 4 lines to the respective crew oxygen masks.

So as it appears that the captains oxygen supply was compromised (ie. burned through) with the First Officer apparently still having oxygen, the fire must have progressed inside the cockpit area, as that is where the system splits up.

This story just goes from bad to worse...

As far as keeping smoke out of the cockpit:
From the B777 FCOM:
777F
The flight deck and supernumerary cabin receive 100% fresh conditioned air from the left pack. To prevent smoke and objectionable odors from entering the occupied compartments, the flight deck and supernumerary cabin are maintained at a slightly higher pressure than the main deck cargo and lower cargo compartments.

Unfortunately, the worlds most popular widebody freighter doesn't have it set up like that.

Jet Jockey A4

11th Apr 2011, 13:24

Mariner wrote...

"As far as keeping smoke out of the cockpit:
From the B777 FCOM:

Quote:
777F
The flight deck and supernumerary cabin receive 100% fresh conditioned air from the left pack. To prevent smoke and objectionable odors from entering the occupied compartments, the flight deck and supernumerary cabin are maintained at a slightly higher pressure than the main deck cargo and lower cargo compartments.

It's a shame the worlds most popular widebody freighter doesn't have it set up like that."

Well the 747 was originally designed and built in the 60s and the 777 in the 90s. Needless to say with 30 years difference a lot of new engineering ideas could be incorporated in the 777.

BARKINGMAD

11th Apr 2011, 17:33

A very sad event which will happen again and again IAW the "Tombstone Imperative".

I dream that one day we can pillory and maybe hang the DESIGNERS who drew up the specs for such things as O2 masks and smoke clearance procedures.

After a decade and a half wearing the light blue or "growbag" flying suits in 'Bett Windsor's Flying Club', I was horrified in my first civilian simulator smoke exercise at how awful and well-nigh impossible it was to communicate with both my colleague in the other seat and the "ATC" outside. The accoustic qualities of the "Eros" O2 mask (and others?), as described in this topic by "Sqwak7700", should have resulted in these items NEVER being certified for aviation use-what were the FAA/CAA thinking when they OK'd them?!

The early HS125 had a white "pingpong ball" handle beneath the right hand pilot's seat which was supposedly to be operated for smoke clearance. The RAF Dominie pilots who regularly froze in the -200 series of this great little craft (whilst the trainee navs cooked in the back!) discovered that they could stay warm at the front by partially opening this vent, resulting in the DV at the aircraft rear being nearly closed, but still controlling the cabin alt. The flow of warm air FORWARD to the flight deck was very pleasant, but the smoke clearance emgy checklist still commanded one to operate this lever!!!! C'mon Mr Hawker Siddley, what WERE YOU thinking of?????

Re the issue of approach plates for aircraft on fire diversions, hopefully the relevant "target" airfield ATC can provide, at short notice, the best rwy QDM, freq, safe platform alt and QNH? I don't think the MDA, marker check alt, G/A procedure and all the other gubbins littering todays plates would be high on my priorities list, maybe other contributors would like to add/subtract form these items?

After Valujet and other air disasters, why can't dangerous items like Lithium batteries in bulk be prohibited from air carriage? At least on a bulk sea carrier you can heave the lot overboard on the heads of the pirates???

Sorry, did someone shout "Economics" from the back of the room?!:ugh:

BOAC

11th Apr 2011, 17:47

Hello Barking - re 'Div' plates, if that was for my posts #30 & #40 I repeat I was merely offering a possible explanation for the decision, not criticism nor affirmation. (I still don't think they would have made Doha).

PS Good luck with your other 'quest' here. Nil carborundum.

ZimmerFly

11th Apr 2011, 18:15

I believe the air conditioning on the 744F is not as bad as you make out.

From the FCOM of a well know operator of 744F :

Cargo Fire Arm

When a Cargo Fire Arm switch is pushed, pack operation and air distribution is configured to starve the affected zone of fresh air, minimize air movement, purge smoke from the flight deck and upper deck, and increase the supply of fresh air to the flight deck.
:8

Mariner

12th Apr 2011, 01:32

I have that very same text in my FCOM's Zimmerfly. I'm certainly not saying it is bad.
However, it appears that it didn't work very well in this instance.

The idea of a kind of sealed cockpit with a bit of positive pressure appeals to me.

Jet Jockey, I did go back and change my statement from it is a shame to unfortunately. Not putting the blame on Boeing here.

Boeing sure improved on the 747 over the years, as the 74-8 has a dedicated pack for the cockpit, plus an alternate ventilation system, allowing clean outside air into the cockpit even when all packs are off. Good thing.
But no mention about a slightly higher pressure in the cockpit. Perhaps that would be difficult to achieve with all those control cables.
Unfortunately.

Mariner

12th Apr 2011, 09:39

Some 744 freigters have one PBE mounted against the rear cockpit bulkhead. Plus a portable oxygen bottle with a full-face mask (for walk-around purposes after a decompression), stored in a closet in the rear of the cockpit. Which would serve for evacuating purposes as well I guess.

Getting to, and donning them, would be another matter. You would have to take your crew oxygen mask off, as the hose would not be long enough to reach either PBE or bottle.
Not an easy task in thick smoke.

For evacuation the 744F has a crew service door on the upper deck, right behind the cockpit, with an evacuation slide. Might be easier (if that is the correct word here) than the cockpit escape hatch, and almost as close.

The 744BCF has upper deck emergency doors with slides (from it's passenger flying days) on the rear of the upper deck. In that case your best chance might be the overhead escape hatch in the cockpit, as the BCF has a rather long upper deck.

IGh

12th Apr 2011, 19:40

There is still that weakness, in the wording, of FAR 121.337, "Protective breathing equipment": There is NO REQUIREMENT for any O2 supply for pilots after landing (with smoke-filled cockpit), while attempting self-extraction from a cockpit with NO pilot's Sliding Window [eg, B747].

The current cockpit "PBE" (caution mixed definitions evolved with FAR employing "PBE" in varying contexts) re' the smoke-hood next to the Extinguisher, is required only for ONE guy (during fire fighting). No rule to provide any O2 during egress, after landing.

There are Safety Rec's on this subject, not clearly focused on specific weaknesses, recurring citations since 1996 ValuJet investigation.

AAR98-03 [FedEx Sep96] Pg60, re' self-extraction after landing:… During the evacuation, the flight engineer stated that before he entered the foyer area to evacuate via the R1 door, he filled his lungs with oxygen from his oxygen mask. He did not use the PBE, which would have provided him with protection from the smoke while he attempted to open the foyer doors. In post accident interviews, he stated that he was anxious to open the exit doors quickly, and he forgot that the PBE was available. The Safety Board concludes that crew-members who do not use PBE during a smoke or fire emergency may place themselves at unnecessary risk in attempting to ... escape ... Although most carriers’ emergency evacuation checklists instruct crewmembers to don PBE when circumstances warrant, there is no reference to the PBE in the FedEx “Emergency Evacuation” checklist. Therefore, the Safety Board believes that the FAA should require FedEx to modify its evacuation checklist and training to emphasize the availability of PBE during evacuations in an environment containing smoke, fire, or toxic fumes....
[Note that for both the Saudia and the '96 FedEx exemplar, at the time of the landing, neither cockpit had yet accumulated significant smoke-density.]

UPS 1307 / 7Feb06 DC8-71F N748UP, inflight smoke, PHL, post landing fire; from NTSB/AAR-07/07, pg 21+:
1.15.1 Emergency Evacuation
After the airplane landed … checklist … proceeded to evacuate … the flight engineer stated that he took a breath of oxygen from his mask before … then went to open the L1 door. … reached down and deployed the L1 door slide and evacuated … then yelled back … slide was “good.”

The first officer … leaned out his window to get fresh air but that he inhaled smoke. … transmitted to the ATCT … evacuating … the smoke was so heavy that he could not see his hand in front of him … proceeded to … L1 door slide while black smoke was rolling out of the door. … after he evacuated … he could see black smoke billowing out of the windows and the door but that there were neither flames nor heat….

PPRuNe Towers

21st Sep 2011, 10:05

Strongly recommend a read:

http://www.ntsb.gov/doclib/recletters/2011/A-11-087-091.pdf

Rob

Lonewolf_50

21st Sep 2011, 17:40

PPRuNe Towers: that is a sobering read. :uhoh:

Training and practice with protective gear is what you fall back on when, all of a sudden, you need to use it.

NTSB recommendations will be, one hopes, acted upon with alacrity.

Daysleeper

21st Sep 2011, 17:59

Strongly recommend a read:

Seconded.

It is hard to believe that the training, in the use of the emergency equipment, was so deficient.

MountainBear

21st Sep 2011, 19:46

It is hard to believe that the training, in the use of the emergency equipment, was so deficient. It's to be expected.

There is limited time for training. The trainee has a limited mental space and attention span. Thus the focus of training is on tasks that happen either with regularity or predictability. Training for events which happen rarely slide.

Then there is the temptation to train towards the last accident. Pilots need more training in fire/smoke events...oh wait, they need more hand flying time, etc. It's rare for an accident report to come out these days without a recommendation that the pilot needs more training on something.

AFAIS the real take away message from this report is that when fire/smoke events happen the industry needs to do a better job of reducing task load. As one pilot said "there is just too much coming together at once." It's the same old story of complex systems interacting in complex ways.

jumbobelle

22nd Sep 2011, 20:40

Thing is, what chemicals are in your brain affecting your decision making during a major fire? A few antibiotics will give me brain fog never mind lithium battery fumes... do you think of they were put back in the sim they would have made the same or different choices?
We are given minimal emergency training ( and I'm my company it's in the middle of the night for me). People can react to a real life or death situation in many ways ( military pilots have usually been there done that and know how they will be . Civilians may or may not. )
Their choices must have been the best they could with what they had which wasn't much.

PPRuNe Towers

11th Nov 2011, 20:34

Interim report released:

http://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/16/2010-Interim%20Report%20B747-400F%20-%20N571UP%20-%20Report%2013%202010%20-%20Rev%201.pdf

It really should be read carefully. I know that many of us knew of the gist of what was coming after reading the NTSB report into masks and training for their use but it really doesn't make the interim report any easier to work through.

Rob

henra

12th Nov 2011, 10:13

Sobering Read !

However, some very interesting details:
Oxygen mask of Captain reportedly set to 100%, F/O to Normal.
strangely the effect appeared to be inverse. Captain complained much earlier and more explicitely about oxygen problem than F/O who remained conscious another 21 minutes after the CPT leaving the cockpit to apparently get himself the portable oxygen.
Both did not activate emergency setting in their masks.

Fire location was worryingly close to oxygen system. (That is something to be seriously considered in future for loading flammable materials IMHO).

Flight controls were compromised almost instantly after the fire warning pointing to a rather intense fire from the beginning.
Effects did not deteriorate much after that, i.e. no slow progessive failure of controls, pointing to no significant increase of fire intensity after intial event.

Unfortunately the effects on the controls were much more severe on the F/O side (explaiined in the report by the fact that only on the CPT side there is a tension regulator in the fwd quadrant - why is there none on the F/O side?)
seems to be an unfortunate coincidence: Oxygen system more compromised on CPT side, control system more compromised on F/O side.

Very interersting is the cargo list of that flight. The amount of batteries on that flight is amazing. There seems to not have been much on that plane without batteries...

The fact that the fire appears to have started/ progresssed very quickly and intensely at the beginning points towrads a rather big load of similar and highly combustible items to have been the initial ignition source, therefore items 7, 8 and 13 would be of special interest.
Of these the LiFePo are normally not considered very susceptible to fire. They are normally considered to be among the safest of the Lithium based batteries. Which would from my POV put item 7 in the focus out of those defiend as items of special interest.
Although I'm not to sure a 4S4P pack would be sufficient to cause that much damage that quickly with the oxygen available at 32kft.
(I've seen bigger packs burn in model boats and while I wouldn't want to sit on top of that the amount of fire was merely sufficient to burn a small hole into the plastic hull but would have hardly melted any metal around it, e.g. steel control cables).

Edit: After reading the report again I saw that there appear to have been 50 of these 4s4p packs.
That would be defintiely a serious volume!
Having that in mind you can probably skip what I wrote about item 7 probably not being sufficient and not being prime suspect.
For me now it probably would be one of the prime suspects, especially since the location also seems to match to the likely area of the fire origin.
/Edit

On the other hand some high volume shipments did not make it onto the list of interest. For instance the ULD on 10L: There were reportedly 820 2s 1,9Ah LiIon cells. That would be a SERIOUS volume of combustible material. I have got no idea why it did not make it on the list. Likewise the 250 LiPo batteries also in 10L.
Therefore I'm not 100% convinced they highlighted the right items.
If I got it right the criterion to make it on the list was that something was not right with the declaration. Maybe wrong declaration was not the main culprit here?