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F111UPS767
24th Jul 2013, 12:46
http://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/40/2010-2010%20-%20Final%20Report%20-%20Boeing%20747-44AF%20-%20N571UP%20-%20Report%2013%202010.pdf

Sober Lark
24th Jul 2013, 13:50
Other than the safety recommendations the section I find most engaging is 2.4.1 on page 161.

F111UPS767
24th Jul 2013, 14:07
The findings are statements of all significant conditions, events or circumstances in the accident sequence. The findings are significant steps in the accident sequence, but they are not always causal or indicate deficiencies.

1. The crew of the inbound sector from Hong Kong reporteda PACK 1 failure. This failure could not be replicated on the ground in Dubaiby the ground engineer.

2. The Boeing 747-400 fleet was experiencing a lower thanpredicted MTBF of the turbine bypass valve [TBV], which is a component of theAC PACKs.

3. A consignment of mixed cargo including a significantnumber of batteries, including lithium types, was loaded on the inbound flightfrom Hong Kong onto the pallets located at MD positions 4, 5, and 6, amongstother positions. This cargo was not unloaded in Dubai.

4. At least three shipments including lithium typebatteries should have been classified and fully regulated as Class 9 materials per ICAO TechnicalInstructions, and thus should have appeared on the cargo manifest. Theseshipments were located in the cargo at MD positions 4 and 5.

5. Shippers of some of the lithium battery cargo loadedin Hong Kong did not properly declare these shipments and did not provide TestReports in compliance with the UN Recommendations on the Transport of DangerousGoods Manual of Tests and Criteria, Section 38.3, to verify that such these batterydesigns were in conformance with UN Modal Regulations.

6. The aircraft was airworthy when dispatched for theflight, with MEL items logged. These MEL items are not contributory to theaccident.

7. The mass and the Center of Gravity [CG] of theaircraft were within operational limits.

8. The crew was licensed appropriately and no fatigueissues had been identified.

9. The Captains blood sample was positive for ethylalcohol with a concentration of (11 mg/dl).

10. Currently a universal fire protection certification standardcovers all transport category aircraft.

11. FAA Advisory Circular 25-9A Smoke Detection,Penetration, And Evacuation Tests And Related Flight Manual EmergencyProcedures does not require the consideration of continuous smoke generation forcockpit smoke evacuation, the FAA recommends that the airframe design addressthis situation but it is not mandatory.

12. The crew were heard to confirm the oxygen masksettings during preflight, however sound spectrum analysis indicated that for unknown reasons, theFirst Officer’s mask was set to Normal instead of 100%, which likely allowedambient air contaminated with smoke to enter his mask.

13. The take-off at 14:50 UTC and initial climb wereuneventful.

14. At 14:58 UTC, Pack 1 went off line and was reset 2minutes later by the PM.

15. The crew acknowledged Bahrain radar and crossed intothe Bahrain FIR at 15:11 UTC.

16. At some point prior to the fire warning, contents ofa cargo pallet, which included lithium batteries, auto-ignited, causing a largeand sustained cargo fire which was not detected by the smoke detectors when inthe early stages of Pyrolysis.

17. Pallets with rain covers can contain smoke until alarge fire has developed.

18. Two minutes after passing into the Bahrain FIR,Twenty one minutes after take-off there is a fire alert at 15:12 indicating a,FIRE MAIN DK FWD.

19. The Captain assumes control as Pilot Flying, the F.Obegins the FIRE MAIN DK FWD non-normal checklist.

20. The Capt advises the F.O they are to return to DXBbefore alerting Bahrain Area East Control [BAE-C] of the fire onboard,declaring an emergency and requesting to land as soon as possible.

21. BAE-C advised the crew that Doha airport was 100 nmto the left. The turn back to DXB totaled 185 nm track distance. The likelyoutcome of a hypothetical diversion is inconclusive.

22. At the time the Captain decided to turn back, thecrew was not yet aware of the full extent of the fire and its effects.

23. By the time that the smoke in the cockpit and firedamaged controls became apparent, diverting to Doha was no longer a feasibleoption.

24. The course to DXB resulted in the airplane flying outof direct radio communication with ATC, requiring a complex relay ofcommunication and increased task saturation for the F.O.

25. In addition to the energy release from Lithiumbatteries resulting in combustion, there is an associated mechanical energy release. This mechanicalenergy release is capable of compromising the integrity of packaging andcreating incendiary projectiles.

26. The control of the aircraft when in manual controlwas compromised due to the thermal damage to the control cable assemblies. Thefirst indication of the deteriorated synchronization problems between the controlcolumn movement and elevator position appear when the Captain disconnects theautopilot.

27. The time interval between fire detection and theonset of aircraft system failures was two minutes and thirty seconds at thepoint of detection. In all probability the fire had damaged the control cablesprior to autopilot disconnection.

28. The aircraft begins to turn on to a heading for DXBand descends. As it was dusk, the aircraft is now descending to the east andback into an easterly time zone where there is limited available ambient solarlight.

29. The cargo compartment liner failed as a fire andsmoke barrier under combined thermal and mechanical loads.

30. Consequently, the damaged cargo compartment linerexposed the area above the cargo bay in fire zone 3 to sustained thermalloading either breaching the cargo compartment liner or causing the aluminiumstructure retaining the liner to collapse, exposing the area above and adjacentto the breach to continuous thermal loading.

31. Consequently, the damaged cargo compartment linerexposed the supernumerary and cockpit area to sustained and persistent smokeand toxic fumes.

32. Based on the NTSB pallet and container testingresults, it is now known that the growth rate of container fires after theybecome detectable by the aircraft’s smoke detection system can be extremely fast, precluding any mitigating action andresulting in an overwhelming fire that cannot be contained.

33. The high thermal loading damaged or destroyed thesupporting trusses for the control cables directly affecting the control cabletension. The control column effectiveness was significantly reduced,subsequently the movement of the elevators, speed brake, rudders, brakes andlanding gear control had been compromised.

34. The high thermal loading caused damage to the ECSducting,

35. The ACARS/AHM data indicates a series of sensorfailures and fire wire loops tripping to active in the area of the fire, thefault timing and the fire warning are corollary.

36. The crew donned their oxygen masks, and experienceddifficulty hearing each other.

37. The oxygen masks had a required setting of100% and inemergency for smoke in the cockpit.

38. The oxygen selector position cannot be viewed whenthe mask is on. The technique used to determine the selector position when the mask was on wasnot an operator technique or reinforced through training scenarios and non-cognitivemuscle memory techniques.

39. The mask settings remain unchanged for the durationof the flight.

40. The main deck fire suppression system was activatedand the cabin depressurized.

41. Lithium-metal cell thermal stability and reactionsthat occur within a cell with elevated temperatures, up to the point of thermal runaway are notoxygen dependent. Electrolyte or vent gas combustion properties and the firehazards associated with thermal runaway reactions do not respond to the FL250assumed hazard mitigation methodology.

42. The Class E cargo compartment fire suppressionstrategy of preventing venting airflow in to cargo compartment,depressurization and maintaining 25,000ft cabin altitude may not be effectivefor Class D metal fires.

43. For unknown reasons Pack 1 went off and was notmentioned by the crew. The cockpit smoke prevention methodology when the firesuppression is active is to have pack one on low flow pressurizing the cockpitarea to a higher than ambient pressure, preventing smoke ingress.

44. It is unknown in this instance that if Pack one hadbeen active this method would have worked as described based on the volume andflow of the smoke The Capt requests a descent to 10,000ft

45. The QRH Fire Main Deck checklist does not address thekey factor of descend or divert decision making. The checklist fire suppressionmethodology advises the crew to remain at 25,000 cabin pressure altitude tosuppress a fire or land at nearest suitable airport. It does not provideguidance for when or how to transition to landing or the fact that descendingearly might provide more atmospheric oxygen to the fire. There is nointermediate step to verify or otherwise assess the condition of the fire andto evaluate the risk to the aircraft if a decent is initiated.

46. The Class E certification standards for firesuppression does not require active fire suppression.

47. Within three minutes of the fire alarm, smoke entersthe cockpit area. This smoke in the cockpit, from a continuous source near andcontiguous with the cockpit area, entered with sufficient volume and density tototally obscure the pilot’s view of the instruments, control panels and alert indicatingsystems for the duration of the flight.

48. Once the liner had been breached, the openings in theliner would progressively expand, allowing an increase in the volume of densenoxious smoke, fire and combustion by-products to escape the cargo compartment.

49. The cargo compartment liner structure certificationdoes not include extreme heat and other input loads such as vibration,multi-axial loading, intermittent pressure pulses, thermo mechanical loadingsbased on differential materials coefficients, acoustic and ballistic damagetesting.

50. The crew made several comments concerning theirinability to see anything in the cockpit. The crew in the smoke environment hadreduced visibility and could not view the primary instruments such as the MFD,PFD, Nav Displays or the EICAS messages.

51. The Captain selected the Autopilot on and leveled outfollowing the pitch control problems. The aircraft remained in a stable steadystate when controlled via the AP. There was no communication between theCaptain and the F.O. that the controllability problem was resolved using theAP.

52. Effective elevator and rudder control was onlyavailable with the autopilots. The aircraft was controllable with the AP as theservos are electrically controlled and hydraulically actuated, which for pitchcontrol is in the tail section aft of the rear pressure bulkhead, and the firehad not compromised the electrical cabling to the actuators.

53. The PF was not fully aware of the extent of thecontrol limitations, could not see the EICAS messages and was not aware of all of the systemsfailures.

54. The Captain called for the smoke evacuation handle tobe pulled as the smoke accumulated in the cockpit. The smoke evacuation handlewhen pulled opens a port in the cockpit roof, which if the smoke is sustainedand continuous, will draw smoke through the cockpit as the pressure is reduced bythe open port venturi effect compounding the problem. The smoke evacuation handleremained open for the remainder of the flight.

55. There are several instances of checklist interruptionat critical times at the beginning of the emergency. The speed and quick succession of thecascading failures task saturated the crew. The smoke in the cockpit, combinedwith the communications problems further compounded the difficult CRMenvironment. With the incapacitation of the captain, the situation in thecockpit became extremely difficult to manage.

56. One factor when dealing with the QRH and runningchecklists is that the B747 does not have a hot microphone function. Thiscaused increasing difficulty managing cascading failures and high workload.

57. The crew was unable to complete the Fire Main Deckchecklist. The aircraft was not leveled off at 25,000 ft. Directly descendingto the 10,000 ft may have exacerbated fire and smoke problem due to the extraavailable oxygen.

58. The Captain instructed the F.O. to input DXB RWY12Linto the FMC. This action was completed with difficulty due to the smoke. Therewas no verbal confirmation of the task completion, however, the aircraftreceivers detected the DXB Runway 12L glide slope beam when approaching Dubai.

59. Captain made a comment mentioning the high cockpittemperature, almost immediately the Captains oxygen supply abruptly stoppedwithout warning, this occurred seven minutes six seconds after the first MainDeck Fire Warning.

60. The Captain’s inability to get oxygen through hismask was possibly the result of the oxygen hose failure near the connector. Thehigh thermal loading was conducted through the supplementary oxygen stainlesssteel supply lines heating the supplementary oxygen directly affecting theflexible hose connector causing the oxygen supply line to fail.

61. Systems analysis indicates that the oxygen supply ispressure fed, therefore venting oxygen could be released by a failed oxygenhose which could then discharge until the oxygen line fails or the oxygensupply is depleted.

62. The Captain requests oxygen from the F.O. severaltimes over approximately one minute. The First Officer due to possible tasksaturation was not able to assist the Captain.

63. The oxygen requirement of the Captain becamecritical, the Captain removes the oxygen mask and separate smoke goggles andleaves the seat to look for the supplementary oxygen. The Captain did notreturn. The Captain was in distress locating the supplementary oxygen bottleand could not locate it before being overcome by the fumes.

64. The Captain was incapacitated for the remainder ofthe flight. A post-mortem examination of the Captain indicates that the causeof death was due to carbon monoxide inhalation.

65. A full face emergency oxygen supply is available inthe cockpit. Oronasal masks are available in the lavatory, jump seat area andcrew bunk area.

66. Due to the Captain’s incapacitation the F.O becameP.F. for the remainder of the flight, operating in a single pilot environment.Exposure to this type of environment in a controlled training environment couldhave been advantageous to the remaining crew member.

67. The FO had breathing difficulties as the aircraftdescended as the normal mode function of the mask supplies oxygen at a ratio toatmospheric, ambient air. The amount of oxygen supplied was proportional to thecabin altitude.

68. The cockpit environment remained full of smoke in thecockpit, from a continuous source near and contiguous with the cockpit area forthe duration of the flight.

69. As the flight returned towards DXB, the crew were outof VHF range with BAE-C and should have changed VHF frequencies to the UAE FIRfrequency 132.15 for the Emirates Area Control Center [EACC]. Due to the smokein the cockpit the PF could not view the audio control panels to change thefrequency selection for the duration of the flight.

70. The flight remained on the Bahrain frequency 132.12MHz on the left hand VHF ACP for the duration of the flight. To solve the direct line ofcommunication problem, BAE-C requested traffic in the vicinity to relaycommunication between crew and BAE-C.

71. The PF made a blind Mayday call on 121.5 MHz at 15:21UTC.

72. The PF had to relay all VHF communication throughother aircraft. The radio communication relay between the PF, the relayaircraft and the ANS stations resulted in confusion communicating the natureand intent of the PF’s request for information with the required level ofurgency.

73. The PF requested from the relay aircraft immediatevectors to the nearest airport, radar guidance, speed, height and otherpositional or spatial information on numerous occasions to gauge the aircraft’sposition relative to the aerodrome and the ground due to the persistent andcontinuous smoke in the cockpit.

74. The relay aircraft did not fully comprehend orcommunicate to the BAE-C controller the specific nature of the emergency andassistance required, particularly towards the end of the event sequence.

75. There was a multi-stage process to complete astandard request for information between the accident flight and thedestination aerodrome via the relay aircraft and the ATCU.

76. The flight crew did not or could not enter thetransponder emergency code 7700, however all ATCUs were aware that the airplanewas in an emergency status.

77. DXB controllers were aware that the flight was in anemergency status, however were not aware of the specific nature of theemergency or assistance required, due to the complex nature of the relayedcommunications.

78. There was no radar data sharing from the UAE toBahrain ATC facilities. Bahrain had a direct feed that goes to the UAE butthere was no reciprocal arrangement. This lack of data resulted in the BAE-CATCO not having radar access the SSR track of the accident flight.

79. The ATC facilities are not equipped with tunabletransceivers.

80. The accident aircraft transmitted on the Guardfrequency 121.5 Mhz. The transmissions were not heard by the EACC or DXB ATCplanners due to the volume of the 121.5 Mhz frequency being in a low volumecondition.

81. The PF did not respond to any of the calls from theACC or the relay aircraft on 121.5 MHz, which were audible on the CVR, afterthe Mayday transmission.

82. During the periods when direct radio communicationsbetween the pilot flying and the controllers was established, there was nonegative effect. Therefore it is likely that if direct 121.5 contact had beenestablished the communications task could have been simplified.

83. The relay aircraft hand off between successiveaircraft caused increasing levels of frustration and confusion to the PF.

84. All Dubai aerodrome approach aids and lightingfacilities were operating normally at the time of the accident.

85. There is no requirement for full immersion smoke,fire, and fumes cockpit training for flight crews.

86. The PF selected the landing gear handle down. Thelanding gear did not extend, likely due to loss of cable tension.

87. The flaps extended to 20°. This limited the autothrottle power demand based on the max flap extension placard speed at 20°Flaps.

88. The PF was in radio contact with a relay aircraft,who advised the PF through BAE-C that Sharjah airport was available, and a lefthand turn onto a heading of 095° was required.

89. The PF made an input of 195° into the MCP for anundetermined reason when 095° was provided. The aircraft overbanked to theright, generating a series of audible alerts. It is probable that the PF, inthe absence of peripheral visual clues, likely became spatially disorientatedby this abrupt maneuver.

90. The aircraft acquired 195°, the AP was selected off.The throttle was retarded and the aircraft began a rapid descent.

91. The PF was unaware of the large urban area directlyin the airplane’s path. The aircraft began a descent without a defined landingarea ahead.

92. Spatial disorientation, vestibular/somatogyralillusion due to unreliable or unavailable instruments or external visualreferences are a possibility. The PF was unaware of the aircraft locationspatially. The PF may have been attempting an off airfield landing, evidencedby numerous control column inputs.

93. The control column inputs to the elevators had alimited effect on the descent profile. The pilot made a series of rapid columninputs, in response to GPWS warnings concerning the sink rate and terrain. Theinputs resulted in pitch oscillations where the elevator response decreasedrapidly at the end of the flight

94. The available manual control of pitch attitude was minimal,the control column was fully aft when the data ends, there was insufficienttrailing edge up [nose up] elevator to arrest the nose down pitch. Control ofthe aircraft was lost in flight followed by an uncontrolled descent intoterrain.

95. The aircraft was not equipped with an alternativeviewing system to allow the pilot(s) to view the instruments and panels in thesmoke filled environment.

LiveryMan
24th Jul 2013, 14:11
Crikey, look at the tar/smoke trail behind the smoke shutter. No wonder these poor folks succumbed to the fire/smoke.

F111UPS767
24th Jul 2013, 14:11
Causes are actions, omissions, events, conditions, or acombination thereof, which led to this accident.

3.2.1 A large fire developed in palletized cargo on themain deck at or near pallet positions 4 or 5, in Fire Zone 3, consisting ofconsignments of mixed cargo including a significant number of lithium typebatteries and other combustible materials. The fire escalated rapidly into acatastrophic uncontained fire.

3.2.2 The large, uncontained cargo fire that originatedin the main cargo deck caused the cargo compartment liners to fail under combined thermal and mechanicalloads.

3.2.3 Heat from the fire resulted in the system/componentfailure or malfunction of the truss assemblies and control cables, directly affecting thecontrol cable tension and elevator function required for the safe operation of the aircraft when inmanual control.

3.2.4 The uncontained cargo fire directly affected theindependent critical systems necessary for crew survivability. Heat from thefire exposed the supplementary oxygen system to extreme thermal loading,sufficient to generate a failure. This resulted in the oxygen supply disruptionleading to the abrupt failure of the Captain’s oxygen supply and theincapacitation of the captain.

3.2.5 The progressive failure of the cargo compartmentliner increased the area available for the smoke and fire penetration into thefuselage crown area.

3.2.6 The rate and volume of the continuous toxic smoke,contiguous with the cockpit and supernumerary habitable area, resulted in inadequatevisibility in the cockpit, obscuring the view of the primary flight displays, audio control panelsand the view outside the cockpit which prevented all normal cockpit functioning.

3.2.7 The shutdown of PACK 1 for unknown reasons resultedin loss of conditioned airflow to the upper deck causing the ElectronicEquipment Cooling [EEC] system to reconfigure to “closed loop mode”. The absence of a positive pressuredifferential contributed to the hazardous quantities of smoke and fumes entering the cockpit andupper deck, simultaneously obscuring the crew’s view and creating a toxic environment.

3.2.8 The fire detection methodology of detecting smokesampling as an indicator of a fire is inadequate as pallet smoke masking can delay the time ittakes for a smoke detection system to detect a fire originating within a cargo container or apallet with a rain cover.


3.3 CONTRIBUTING FACTORS

Contributing factors. Actions, omissions, events,conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced theprobability of the accident or incident occurring, or mitigated the severity ofthe consequences of the accident or incident.

The identification of contributing factors does not implythe assignment of fault or the determination of administrative, civil or criminalliability.

3.3.1 There is no regulatory FAA requirement in class Ecargo compartments for active fire suppression.

3.3.2 Freighter main deck class E fire suppressionprocedures which relay on venting airflow and depressurisation as the primary means of controlling afire are not effective for large Class E cargo fires involving dangerous goodscapable of Class D metal fire combustion.

3.3.3 No risk assessment had been made for the failure ofthe cargo compartment liner based on the evolution of cargo logistics andassociated cargo content fire threats, cargo hazards and bulk carriage ofdangerous goods.

3.3.4 The regulation standards for passive firesuppression do not adequately address the combined total thermal energyreleased by current cargo in a large cargo fire and the effect this has on theprotection of critical systems.

3.3.5 FAA and EASA regulatory requirements do notrecognize the current total fire risk associated with pallets, pallet coversand containers as demonstrated by the NTSB/FAA testing.

3.3.6 Class 9 Hazmat packing regulations do not addressthe total or potential fire risk that can result from lithium battery heatrelease during thermal runaway. Although non-bulk specification packaging isdesigned to contain leaks and protect the package from failure, the packagingfor Class 9 does not function to contain thermal release.

3.3.7 The growth rate of container and pallet fires afterthey become detectable by the aircraft’s smoke detection system can beextremely fast, precluding any mitigating action and resulting in anoverwhelming total energy release and peak energy release rate for a standardfire load that cannot be contained.

3.3.8 The course to return to Dubai required a series ofcomplex radio communication relays due to the Pilot Flying’s inability to viewand tune the radio transceivers.

3.3.9 The relay communication between the Pilot Flying,relay aircraft and the various ATC stations resulted in communicationconfusion, incomplete and delayed communications, which contributed to the escalated workload and task saturationfor the Pilot Flying.

3.3.10 The Fire Main Deck non-normal checklist in the QRHwas not fully completed by the crew or adhered to regarding the firesuppression flight level or land at nearest airport instruction.

3.3.11 Task saturation due to smoke and multiple systemsfailures prevented effective use of the checklist by the crew.

3.3.12 Communications between the ATCO units involvedmultiple stages of information exchange by landline and the destinationaerodrome was not fully aware of the specific nature of the emergency, thedifficulty that the Pilot Flying was experiencing or the assistance required.

3.3.13 The Pilot Flying had not selected transponder code7700, the emergency code, when radio communication with the destinationaerodrome was not established.

3.3.14 Task saturation due to smoke and multiple systemsfailures prevented effective use of the checklist by the crew

3.3.15 The incapacitation of the Captain early in theevent sequence, resulted in a single pilot scenario. The numerous cascadingfailures and smoke in the cockpit resulted in task saturation and an extremeworkload for the remaining pilot.

3.3.16 The crew was not equipped with an alternativevision system or method for managing a smoke filled cockpit that would allowthe crew to view the primary instruments.

F111UPS767
24th Jul 2013, 14:18
4. SAFETY RECOMMENDATIONS

Advisory Note: Inthe Section 2, Analysis, reference is made to the FAA CFR14 regulations, so,for those Safety Recommendations addressed both to FAA and EASA, they arewritten as follows: “FAA in co-operation (or in coordination) with EASA to”. Inthis case FAA will act as the focal point and as the responsible authority forreplying to the Safety Recommendations, which will be coordinated with EASA.

4.1 SR 25/2013: The FAA in co-operation or incoordination with EASA to review the single, universal, CFR14 fire protectioncertification standard that covers all transport category aircraft as a singledesign category and develop a dedicated protection certification standard forthe cargo compartments of aircraft designed or modified as dedicated freighteror freighter/passenger combi aircraft to include the mandatory installation offire suppression systems of cargo aircraft with Class E cargo compartments.

4.2 SR 26/2013: The FAA and EASA are requested to provideoperators of cargo aircraft of a maximum certificated take-off mass in excessof 45,500 kg with the option to modify existing Class E cargo compartments,through a process of FAA or EASA recommended modifications, to control a classE cargo fire without requiring a crewmember to enter the compartment throughthe use of an active fire suppression system.

4.3 SR 27/2013: The FAA in co-operation or incoordination with EASA to mandate the requirement for cargo aircraft certifiedunder FAA 14CFR or the equivalent EASA certification requirements to have amethod of detecting the early development of fire through the detection ofthermal radiation, originating within class E cargo compartments, through theinstallation of Multi-Source Sensors [MSS] which utilise a process ofthermal/heat detection in conjunction with smoke/fumes sampling.

4.4 SR 28/2013: The FAA in co-operation or incoordination with EASA to review the certification requirement for crewalerting to provide a visual means of indicating the specific location of afire to the crew.

4.5 SR 29/2013: GCAA recommends that PHMSA standardisethe battery packaging regulation to be in harmony with the ICAO TechnicalInstructions [TI]. The requirement is the complete harmonization of the U.S.HMR with the ICAO TI’s for the Safe Transport of Dangerous Good by Airregarding lithium batteries. This includes incorporation of quality managementprovisions provided in Part 2; 9.3.1 e.

4.6 SR 30/2013: The FAA in co-operation or incoordination with EASA to develop standards for containers with suppressionsystems, superior heat and fire resistance and resiliency to withstand asuppression-caused pressure pulse and still contain a suppression agent inaccordance with NTSB recommendations contained in NTSB A-12-68,69,7098. 98 NTSBA-12-68,69,70 Develop fire detection system performance requirements for theearly detection of fires originating within cargo containers and pallets and,once developed, implement the new requirements. (A-12-68) Develop firedetection system performance requirements for the early detection of firesoriginating within cargo containers and pallets and, once developed, implementthe new requirements. (A-12-69) Develop fire detection system performancerequirements for the early detection of fires originating within cargocontainers and pallets and, once developed, implement the newrequirements. (A-12-70)

4.7 SR 31/2013: The FAA in co-operation or incoordination with EASA to implement certification rule changes to requirecontainers or Unit Load Devices (ULDs) which meet the standards inrecommendation 4.6, develop a design standard that enables the container or ULDto be capable of internally containing or suppressing a fire agent inaccordance with NTSB recommendations contained in NTSB A-12-68,69,70.

4.8 SR 32/2013: The FAA to develop an Advisory Circular[AC] addressing the use of fire containment covers for cargo stored on palletsthat could be used to cover palletized cargo or cargo containers.

4.9 SR 33/2013: The FAA in co-operation or incoordination with EASA to provide a requirement for mandatory full-face oxygen.

4.10 SR 34/2013: The FAA in co-operation or incoordination with EASA to recommend the adoption of a rotary single pieceselector for oxygen quick donning anti-smoke oxygen masks.

4.11 SR 35/2013: The FAA in co-operation or incoordination with EASA to require the use of Evidence Based Training Programs[EBTP] in line with the requirement of ICAO Document 9995 - Manual of EvidenceBased Training. In particular, require operators to implement the developmentof evidence based simulator training using objective FOQA accident and seriousincident data of smoke filled cockpit environments for crew emergency training.

4.12 SR 36/2013: The FAA in co-operation or incoordination with EASA to mandate the implementation of vision assurancedevices or technology for improved pilot visibility during continuous smoke,fire, fumes in the cockpit emergencies. This could include off the shelf devicesor developing mask mounted thermal imaging cameras with the capability to seethrough smoke/fumes with sufficient clarity to view the primary cockpitinstrumentation.

4.13 SR 37/2013: The FAA in co-operation or incoordination with EASA to develop or redesign all transport aircraft checklistspertaining to Smoke Fire Fumes events to be consistent with the Integrated,Non-alerted Smoke Fire Fumes Checklist template presented in the RoyalAeronautical Society’s specialist document Smoke, Fire and Fumes in TransportAircraft: Past History, Current Risk and Recommended Mitigations, secondedition 2013, prepared by the Flight Operations Group of the Royal AeronauticalSociety.

4.14 SR 38/2013: The FAA in co-operation or incoordination with EASA to review the capability of Portable Electronic Device(PED) Electronic Flight Bags (EFB) which are used for non-alerted smoke firefumes events to be viewed in smoke filled cockpits.

4.15 SR 39/2013: The FAA in co-operation or incoordination with EASA to provide cargo crews with a revised Fire Main Decknon-normal checklist guidance for when and how to transition from the current22-25,000 feet fire suppression altitude to the landing phase where descendingearly may contribute atmospheric oxygen to a latent fire during descent. Thisprocedure should provide a method to verify or otherwise assess the conditionof the fire and to evaluate the risk to the aircraft if a descent is initiatedso as not to jeopardise the safety of the crew by following the checklistinstruction as directed.

4.16 SR 40/2013: The FAA in co-operation or incoordination with EASA to mandate a certification requirement for continuoussmoke testing for flight deck smoke evaluation tests where the smoke isrequired to be continuously generated throughout the test for cockpit smokeclearance and develop a mitigation procedure through regulation on how toeffectively manage continuous smoke in the cockpit.

4.17 SR 41/2013: The FAA in co-operation or incoordination with EASA and Boeing to evaluate the Boeing 747Freighter/Combi/BCF modified aircraft for single points of failure where thecritical systems protection of the aircraft is dependent on a single safetygate which is the cargo compartment liner at or contiguous with fire zone three:this is the area under the control cable truss assembly, the ECS ducting andthe supplementary oxygen system supply line from the forward lower deck cargohold to the crew oxygen storage boxes. If a deficiency in the current level ofcritical systems protection is determined, provide regulatory oversight tomitigate the risk of control and systems damage that can result from largecargo fires.

4.18 SR 42/2013: The FAA in co-operation or incoordination with EASA to review the certification and design of Boeing 747Freighter/Combi/BCF aircraft distribution of oxygen from the supplementaryoxygen bottles to the flight deck oxygen masks primarily provided throughcorrosion resistant steel (CRES) 21-6-9 tubes. In particular, to review thecritical systems protection requirements for the area connecting the CRESsupply line, via a PVC hose and connector, to the oxygen mask stowage box[MXP147-3] and provide regulatory oversight to mitigate the risk of control andsystems damage that can result from large, catastrophic cargo fires.

4.19 SR 43/2013: The FAA in co-operation or incoordination with EASA are requested to charter an Advisory and RulemakingCommittee (ARAC) to review the adequacy of current issue papers on theprotection of critical systems from cargo fires and develop regulations andassociated guidance material (e.g. Advisory Circulars) to codify the existingand proposed requirements.

4.20 SR 44/2013: The FAA in co-operation or incoordination with EASA to require operators to implement smoke, fire, fumestraining in a dedicated smoke simulator/full immersion training device allowingcrews to experience actual levels of continuous smoke in a synthetic trainingdevice or other equivalent ground-based training device as an integral processin crew emergency recurrent training.

4.21 SR 45/2013: The FAA in co-operation or incoordination with EASA to implement specific Standard Operating Procedures[SOP] for scenario based multi-crew pilot incapacitation where one or more crewmembers are incapacitated resulting in a single pilot crew environment.

4.22 SR 46/2013: The FAA in co-operation or incoordination with EASA to implement a specific recommendation that failures ofaircraft systems (such as the air conditioning packs) necessary for the continuedsafe flight and landing during an aircraft cargo fire event be considered inthe aircraft level safety analysis and during the development of cargo fireemergency procedures. This should consider failures of dependent systems andthe continued cascading failure of systems which are factors in large cargofires.

4.23 SR 47/2013: FAA and EASA regulatory certificationstandards to consider the development of a quantitative framework for assessingthe degradation of cargo compartment liner polymer matrix or the currentindustry standard panel material properties and the resulting degradation inthe structural integrity of these structures when subjected to extreme heat,vibration and/or thermo-mechanical energy.

4.24 SR 48/2013: The FAA in co-operation or incoordination with EASA to develop a test method to determine flame penetrationresistance of cargo compartment liners to extreme heat at the currentcertification requirement temperature combined with additional input loads suchas vibration, multi-axial loading, intermittent pressure pulses,thermo-mechanical loadings based on differential materials coefficients,acoustic vibration and ballistic damage.

4.25 SR 49/2013: The FAA in co-operation or incoordination with EASA and Boeing to evaluate the Boeing 747 Freighter/Combiaircraft Class E cargo compartment for a structural-acoustic coupling phenomenain the aircraft fuselage. Structural-acoustic coupling phenomenon in anaircraft fuselage is a known characteristic. In large Class E cargocompartments, the structural and acoustic modes can be derived for vibrationanalysis. Structural and acoustic analysis could determine possible occurrencesof vibration in the fuselage structure during predetermined phases of flightwhere the vibro-acoustic signatures can be used to determine the principlesources and transmitting paths of the vibration. Further investigation can beperformed by the manufacturers of large cargo aircraft and/or the operators ofthese aircraft to investigate the vibration and acoustic signatures of thecargo areas for harmonic acoustic vibration resulting from the combination ofengine and fuselage vibration. Currently there is no data for the class E cargocompartments of the B744F, If such data was available through a process ofacoustic mapping for structural-acoustic coupling, this data could be used toexpand the UN Manual of Tests and Criteria Para. 38.3.4.3 Test T.3: Vibrationtest and verification data. This could through a process of acoustic mappingthe cargo compartment interior and measuring the vibro-acoustic interior vibration and vibration andresonance of the airframe structure. Refer to GCAA SR 4.33

4.26 SR 50/2013: The NTSB, FAA and/or EASA fire testdivisions to perform a test on lithium batteries to determine the ignitionproperties for lithium type batteries when subjected to external sources ofmechanical energy, including acoustic energy in flight range modes, acousticharmonic modes and a separate test to determine the susceptibility of lithiumbatteries to vibration from a mechanical source. The purpose of this testing isto determine the safe limits for the air carriage of lithium type batteries indynamic aeroelastic, vibrating structures where the battery electrolytecomposed of an organic solvent [and dissolved lithium salt] could becomeunstable when exposed to these forms of mechanical energy.

4.27 SR 51/2013: ICAO to review the hazardous materialsclassification for Class 9 materials packaging where the reconsideration oflithium batteries and other energy storage devices that are currentlyclassified as a Class 9 hazardous material be subjected to a higher level ofhazardous material classification as at present time, it is not clear that thecurrent Class 9 hazard communication or quantity limits adequately reflect theinherent risks to aviation safety.

4.28 SR 52/2013: ICAO to develop a SARP for package levelprotection of batteries being shipped to include protection from thermaldegradation and damage to individual cells or cell combinations in thermalrunaway, and to retard the propagation of lithium battery initiated fires toother packages in the same cargo stowage location as well as to increase theamount of time it would require for the contents of the package containinglithium batteries to provide an additional source of fuel for on-board firesinitiated by other sources.

4.29 SR 53/2013: ICAO is requested to establish a taskforce or working group of manufacturers, operators, and regulators to develop aconcept and safety case for audible emergency checklists for non-normalemergency situations and provide a feasibility working paper for industryconsideration.

4.30 SR 54/2013: ICAO is requested to establish a taskforce or working group of manufacturers, operators, and regulators to develop aconcept and safety case for alternative vision assistance systems for thesmoke, fire and fumes events non-normal emergency situations and provide afeasibility working paper for industry consideration on the implementationrequirements and required standards.

4.31 SR 55/2013: ICAO Flight Recorder Panel to expeditethe ICAO SARP on Airborne Image Recording Systems [AIRS] amendment to Annex 13to progress of this subject due to the potential benefit to air accidentinvestigation.

4.32 SR 56/2013: ICAO Safety Information Protection TaskForce to expedite the ICAO SARP’s required for video data protection.

4.33 SR 57/2013: ICAO Dangerous Goods Panel to amend theICAO Technical Instructions regarding the safe carriage of lithium batteries.Specifically, the request is to establish a dedicated task force within the DGpanel, including the representation of qualified stakeholders, to study thesafe carriage of lithium batteries and other potentially hazardous cargo anddevelop recommendations to the UN Manual of Tests and Criteria, The Manual ofTests and Criteria Revision 5, Lithium Metal and Lithium Ion Batteries,38.3.4.3, Test T3-Vibration. Structural-acoustic coupling phenomenon in anaircraft fuselage is a known characteristic. In large Class E cargocompartments, the structural and acoustic modes can be derived for vibrationanalysis. Structural and acoustic analysis can determine possible occurrencesof vibration in the fuselage structure during predetermined phases of flightwhere the vibro-acoustic signatures can be used to determine the principlesources and transmitting paths of the vibration. Given the active failure modesof lithium batteries, the battery risk factors concerning possiblesusceptibility to various extraneous forms of mechanical energy, for examplevibration, possibly in a harmonic form, could be an initiating action risk.ICAO Dangerous Goods Panel is requested to evaluate data relative to the UNManual of Tests and Criteria, Lithium Metal and Lithium Ion Batteries,38.3.4.3, Test T3-Vibration and advise the UNECE Committee of Experts/WorkingParty on the Transport of Dangerous Goods if additional criteria should beadopted for the carriage lithium metal and lithium ion batteries by airtransport. Refer to GCAA SR 4.25

4.34 SR 58/2013: GCAA to produce an In-Flight EmergencyResponse Manual [IFERM] for the use of ATCO and all ANS providers. The GeneralCivil Aviation Authority (GCAA) to issue a manual providing formal guidance forATCO’s to enhance responses to in flight emergencies. The manual should supportCAR Part VIII, subparts 4 (ATS) and 8 (SAR).

4.35 SR 59/2013: GCAA to require all ATC units beequipped with a dedicated transceiver which can be directly tuned to allfrequencies in the aviation band(s) for use in emergency situations.

4.36 SR 60/2013: GCAA to assist and/or support theprovision for mutual radar data sharing between Bahrain and the UAE FlightInformation Regions.

VinRouge
24th Jul 2013, 20:20
The only way i could have seen any happy ending in this would have involved a ditching.

Either a third crew ember to fight the fire, or report its out of control...

Heard a good rue of thumb once, ay have read it, 5 Mins to get a serious fire under control... Failing that, a further 5 mins to get on the deck, crash-and or ditch.

JammedStab
24th Jul 2013, 20:51
With these fires, once things start going out of control, if terrain is reasonable, your best bet may be to just put it down wherever you can.

Like that Asiana 747 cargo fire, your time is limited. When you are alone, new on the machine(in this case), can't see, are breathing smoke and systems are failing, you are not going to make it to the airport.

Nearest suitable airport is an issue as well. When there are two good airports but one is almost twice as far away, why choose the one almost twice as far away, when the nearer one is almost perfectly positioned for a descent.

Easy to say from a comfortable chair but something that is a good idea to think about in advance.

Coagie
24th Jul 2013, 21:00
Frightening! These batteries were just cargo. Makes you wonder about using Lithium Ion batteries for anything other than low current applications, aboard an aircraft. They just don't seem to stack well together. Once you space them, so enough air circulates around them to cool them, any space saving advantage is gone over conventional batteries. Maybe they need to be liquid cooled, like a car engine or World War One machine gun, to be close enough together to save space. Of course, it may be better to just go to conventional batteries, but, it's my understanding, that Boeing has painted itself into a corner, on the 787, and can't go to another battery type, because of some needed characteristic of the Lithium Ion battery. Something about rate of current draw, maybe. I don't recall.

BuzzBox
24th Jul 2013, 22:44
The report certainly reinforces the need to get an aircraft on the ground ASAP in the case of a fire. The way I read it though, these guys had little chance of surviving, no matter what they did. From the time the fire was detected they only had about 3 minutes before systems began failing and the cockpit filled with smoke, to the point where they couldn't see enough to change ATC frequencies, let alone look outside. The report suggests that a ditching was unlikely to have been successful.

Very tragic.

413X3
24th Jul 2013, 23:07
They were close enough to DXB to pick up the ILS signal. Sadly if they picked the alternate which was many miles closer, they may have had a chance. Not to mention a trusty flight engineer would have helped the captain get a new oxygen mask, and been able to assist in the work load.

BuzzBox
24th Jul 2013, 23:24
For what it's worth:

Doha Diversion:

The investigation examined the possible outcome of an alternative scenario of diverting to DOH at the first indication of the fire. From the point where the diversion to Doha was advised there were 100 track miles to DOH. A performance analysis based on a 3°-4° descent angle and a descent speed of 300kts, indicate that from the notification until overhead DOH could have been achieved in approximately 17 minutes. Adding time for speed reduction and radar vectoring to the approach configuration, approximately 20 minutes would have been required.

Assuming the systems failure timeline remained linear, a similar level of controllability problems would have been apparent, including the oxygen supply problem and the elevator and speed brake problems identified earlier.
Additionally, the landing gear would not have been able to extend unless the crew used the manual gear extension procedure. How an auto landing without landing gear would have concluded is not known.79 The aircraft was within 20,000 lbs of the take-off fuel, fully loaded and in all probability would have made a wheels up landing.

A descent, based on the fire suppression methodology of venting airflow and depressurisation of the cargo hold to reduce the available oxygen, could have exacerbated the fire, accelerating the cascading failure scenarios and the cascading failures.

However, it is clear that a major difficulty faced by the crew was a consequence of the course change back to DXB. Once the smoke prevented the crew from changing radio frequencies, the communications, navigation, and surveillance difficulties increased. On a course to Doha, the flight would have been in direct contact with BAE-C, and if relays were required as the airplane descended toward the airport, direct landline communication between BAE-C and Doha Approach would have greatly simplified the radio communication. ATC radar surveillance and coordination would also have been simplified. The SSR data would have been available to the ATCO and there would have been more available ambient light due to the longitude of Doha.

Analysis of the diversion to DOH and the likely outcome is speculative as the crew incapacitation and smoke/fumes in the cockpit would have prevailed as the rate of failure on the timeline of the failures was linear regardless of the destination. In addition, the aircraft control was seriously compromised by the fire and consequential events, a factor that was not apparent to the crew as they could not view the primary instruments, or the and alert and notification display. The likely outcome of the diversion to DOH is therefore inconclusive, although the communication and task saturation issues experienced by the remaining pilot would have been negated by a DOH diversion. The communications difficulties with the relay aircraft/BAH-C/EACC/DXB chain of events was the result of the course change toward DXB.

Ditching:

The option to ditch was reviewed during the simulator sessions in Seattle. Although feasible, the inability to see the instruments, particularly the radar altitude or outside of the cockpit window was problematic. The control of the aircraft descent with the AP was another issue that was unresolved.
Attempting to ditch using the auto flight functions was possible, however the last five hundred feet managing the rate of descent, attitude, speed and gauging the sea state in all probability precluded this as an option.

This exercise was inconclusive.

jcjeant
24th Jul 2013, 23:30
Hi,

This exercise was inconclusive.
It's one thing they not simulated ... escape with parachute ....
At least if they had parachute .. they had a chance of survival ...
I don't think that on cargo flight .. parachutes for pilots will be a weight penalty

galaxy flyer
24th Jul 2013, 23:41
Jcjeant,

Without ejections seats, escape with parachutes would be extremely unlikely. The crew was incapacitated, would have to go downstairs leaving the plane on autopilot to open the door(s). Parachuting from any airliner (DB Cooper, excepted) has not been tested or certified.

GF

archae86
24th Jul 2013, 23:52
The A350 first flight trials included crew parachutes and a specially altered cargo door modified to provide an escape pathway.

This suggests that the Airbus people did not like the odds of parachute exit being successful in an unmodified aircraft even under the risk-tolerant regime of first flights.

junebug172
24th Jul 2013, 23:58
Great video regarding battery fires. FAs are taught not to dump ice on the fire as it actually acts as an insulator and makes it hotter.


Extinguishing In-Flight Laptop Computer Fires - Lithium Battery Thermal Runway - YouTube (http://youtu.be/vS6KA_Si-m8)

clayne
25th Jul 2013, 08:25
Just sad...

The Captain was 48 years old and his date of hire with the operator was July 10, 1995. He had flown for several commuter airlines, and previous to UPS was furloughed from US Airways. A search of FAA records indicated that he had no accidents, incidents, or violations in aviation and no record of any investigations pending.

The First Officer was 38 years old and was hired by the operator on June 20, 2006. He had been previously employed by Chautauqua Airlines.
A search of FAA records indicated that he had no accidents, incidents, or violations in aviation and no record of any investigations pending.

[...]

The cargo identified on scene included clothing, machined parts and subassemblies, flashlights, gun parts, costume jewellery, cases for electronic equipment, USB flash drives, un-populated circuit boards, espresso makers, automotive entertainment and navigation systems, bike frames, pellets for injection moulding, wrist watch components, rubber bracelets, cell phones, MP3 and MP4 players, mannequin heads, wigs, shoes. No items posing a flammable fuel load or capable of acting as an ignition source were visually identified except for batteries and battery containing devices.


2 pilots dead, 747 toast, all because of some ****ty consumer goods out of Hong Kong that should have been declared as hazardous. Complete waste.

How much more will it take to realize Li and Li-ion are inherently dangerous - and even more so when being pumped out of countries who could give a damn about safety or reliability.

Cyrano
25th Jul 2013, 09:11
This is a very sad read.

What astonishes me even more is the document referred to in the report, the FAA/Transport Canada cargo aircraft fire risk model (here (PDF)) (http://www.fire.tc.faa.gov/pdf/TC-13-2.pdf).

It seeks to predict statistically how many N-registered cargo aircraft will crash over the 10 years between 2012 and 2021, and how many of those crashes will be due to lithium batteries.

The report (see page 14) predicts about 6 crashes during this time (95% confidence interval is between 2 and 12 crashes). But what I find scariest is that it predicts that of an average 6 crashes, 4 would be caused by lithium batteries in cargo. :uhoh:

bigjames
25th Jul 2013, 09:18
5. Shippers of some of the lithium battery cargo loadedin Hong Kong did not properly declare these shipments and did not provide TestReports in compliance with the UN Recommendations on the Transport of DangerousGoods Manual of Tests and Criteria, Section 38.3, to verify that such these batterydesigns were in conformance with UN Modal Regulations.

is any action being taken against the shippers who did not properly declare their consignment? i should hope so!

fantom
25th Jul 2013, 10:08
I salute the authors of this fine report; it is as thorough as it could be.

clayne
25th Jul 2013, 10:33
Yes it is amazingly thorough and how it should be done. I was surprised, honestly. I do hope UPS takes action against whoever the rogue shipper was. 2 hard workers are dead and countless hours into an airframe are completely lost.

Cows getting bigger
25th Jul 2013, 11:57
Agreed, exceptional report.

Eclectic
25th Jul 2013, 12:08
Impressively thorough report.
Two good lives wasted for an insignificant consumer bauble.

Events a bit like SAA 295
Then it was 81 seconds from first alarm to CVR failure.

Desert185
25th Jul 2013, 14:31
Exceptional report.

I knew the Captain, who was a fine man, a loving husband and father and a very conscientious crewmember. I watched him progress from FE, to FO, then Captain on the Classic. We had many good flights and layovers.

Poor crew was dealt a bad hand on that flight. I can't help but think that having a Classic, three-person crew might have resulted in a more successful outcome. When things go really ugly, a good PFE/FE is a big asset.

Swissair at Halifax was a real eye-opener. I remember doing an onboard fire scenario in the simulator where it was emphasized to get the airplane on the ground (or ditch if over water) within 15-20 minutes. That's a pretty tall order in real time when there is heavy smoke, poor comm with ATC, the smoke mode fails with #1 Pack and your O2 quits. Imagine being over 30 West or someplace similar at night. I never bought into the FL250 fire fighting technique, particularly with Li batteries onboard or an O2-fed fire. Sometimes you get the bear, and sometimes the bear gets you, I guess.

I'm retired from UPS, but I understand they now have EVAS and fire resistant ULD's. Glad to hear. Any on board fire/smoke mitigation is a good thing.

Speed of Sound
25th Jul 2013, 14:38
I agree with others about the quality and detail of this report, which makes it even more astonishing that virtually nothing is said about an absence of cockpit door or a screen, other than that they are generally absent on a freighter.

I'm amazed that a report which suggests video recording of the flight deck and even a 'pre-recorded audio checklist', would not at least make a suggestion that some form of barrier be considered to prevent smoke ingress into the flight deck.

Smoke killed the Captain and smoke stopped the FO from having a fighting chance to put it down on some tarmac.

A sad, sad story and I agree with others about some legal redress from the rogue battery shippers.

givemewings
25th Jul 2013, 14:42
I only read the summary on AvHerald, but it did surprise me to read that generally, no sim training is done with pilots in a smoke-filled environment. This is a standard training item for cabin crew, why not pilots?? Or are their operators who do such training?

I too hope they go after the shippers who falsified the decs (because that's what it is). I used to ship and accept freight, one of my jobs was to inspect the parcels and some of the items that were other than described was crazy. And in most cases all because the shipper thought fees or customs charges would be less :ugh:

As for parachuting, it was successfully done on a study in the US where they crashed a 727 on autopilot- however, just like DB Cooper, they used the stairs. Doubtful it could be done normally unless modified like the A350 another poster mentioned. I recall something about Air Force One having (or previously having) this ability but not sure if I am getting confused with the escape pod/hatch which is not designed for parachute egress...

Lithium battery fires have always been covered in FA training, however since UPS some airlines have installed containment equipment onboard. I trained with this within the last 3 months and hope I never have to use the bloody thing for real!

Una Due Tfc
25th Jul 2013, 15:36
Excellent report, but will anything be done? It seems to me that there is a lack of protection for the crews flying freighters. Once no fee paying passengers die then the public and the regulators seem to quickly forget. I sincerely hope after this and the AAR 744F to see Li-ion batteries go the same way as chemical oxygen generators i.e. only by land or sea. A passenger 777 almost got brought down in China a couple of years ago by a Li battery fire in the cargo hold too.

Eclectic
25th Jul 2013, 17:42
Of the 9 747 hull losses, since the beginning of 2000, 7 were freighters.

Willit Run
25th Jul 2013, 19:16
Since the two 747 fire accidents; a lot has been learned and contemplated about. We now regularly do drills in the sim, from a regular cruising flight level, to see how well and fast we can don the masks and goggles; one person runs as much of the checklist as he can whilst the other trys his best to get the ship on a runway in good enough shape to walk away, within 12 minutes!!!
In this scenario, the plane is likely to burn up anyway, so saving ones arse is the main focus here.
The industry learned that we must keep one pack on, preferably, pack one, if thats deferred, pack three must be on; to make sure the smoke evacuation system works as designed.

The thought of ditching a 747 for a fire is something I hope no one ever has to do. It scares the beejeebies out of me just thinking about it.
Our company has installed EVAS systems as well, but we have received no training yet to use them.

I wish we could have some specially made battery ULD's that would make surviving one of these fires a little more assured.

From our HAZMAT guru, supposedly, there have been no cases of properly tested lithium ion batteries causing problems. Only non-tested batteries. (Except for maybe that 787 issue).

Luckily for us, we always have a ride-on mechanic and usualy several deadheaders who could help.

These two guys didn't have a chance. From the point of the first fire alarm to being unable to see, was like 3 minutes! Im amazed they did as well as they did. they had everything against them.

Una Due Tfc
26th Jul 2013, 00:53
The 777 incident I mentioned was caused by a baggage handler dropping a suitcase that had a laptop in it. I read the incident report while I was on freq on our briefing system so the finer details escape me but I remember the cause and the airline involved. If li-ion batteries are mishandled then they can fail very easily, and the symptoms may not be noticed for quite some time. Luckily this 777 was on climb out when the crew got a fire warning, imagine if they had been at cruising level.....

Brian Abraham
26th Jul 2013, 01:14
Those talking of parachutes, the KC-135 and E-6 (the military 707) both have blast doors to enable parachute egress, though the 135 crews have had their parachutes taken away as a cost saving measure.

A little difficult to see how a similar arrangement may be incorporated for crews on the upper deck of a 74, outside of a scramble down the stairs to access a hatch on the lower deck.

Air Force pulls parachutes from KC-135s (http://www.940wg.afrc.af.mil/news/story.asp?id=123089391)

amicus
26th Jul 2013, 01:53
I worked on this terrible crash as an expert witness for several months and I hope and pray that all this excellent report's safety recommendations are implemented without hesitation or modification, the brave crew who perished and freight pilots everywhere deserve nothing less.
Those poor souls suffered and died because of totally inadequate regulations, a very dangerous and unacceptable cargo,and overall deficiencies in both A/C design and equipment.
Let us shout and holler until these safety regulations and hazardous cargo regulations are fixed and corrected as so excellently detailed in this fine report. Let us get it done in their memory and never ever take no or delays or inaction for an answer.

Una Due Tfc
26th Jul 2013, 01:57
Well said Amicus. Laptops and Pro spec cameras should be carry on only, and pallets of Li-ion batteries should be banned from air freight period. If there is thermal runaway in a pallet of these things at altitude then the crew is :mad:

Sqwak7700
26th Jul 2013, 10:58
Experience from this accident investigation in conjunction with FAA experiments suggest passive fire suppression in large cargo compartments due to oxygen deprivation may not be effective.

Uh, any other freighter pilots that have a problem with this statement? How does the FAA retain a valid certification for freighter aircraft with Class E compartments while simultaneously acknowledging this little gem.

Why can't we have the same level of protection in the main deck as we do in the lower lobes? I know it takes more structure, but the prediction in the accident report is for 4.1 more hull losses between now and 2021. At the very least, make self-fueled hazmat a road or water transport only class.

I hope and pray that all this excellent report's safety recommendations are implemented without hesitation or modification, the brave crew who perished and freight pilots everywhere deserve nothing less.

Unfortunately, the regulatory agencies have a very bad record implementing safety recommendations from accident report. I can only speak for the US system on this, but the NTSB is regularly ignored by the FAA on these recommendations. It usually takes 3 or 4 major accidents before the FAA finally begins to implement the safety recommendations of the NTSB.

Take fatigue for example, it has been a factor in almost every accident and the FAA happily ignores any NTSB recommendations on how to mitigate it.:hmm:

last747fe
31st Jul 2013, 02:03
I was a classic engineer with Ups and flew this route many many times. I flew with this Captain when he was an FO and as a captain. Great guy. I was overseas when this accident Happened and for many months was devastated thinking had I been there as a PFE It might of had a different outcome. After reading this excellent prepared report, I now see that for sure there would have been 3 dead crew members. The rapidly damaged structure would have negated any system recovery attemps. Once the liner was breached and ducting dammaged there was no way to remove the smoke. I might have been able to have provided O2 for the Captain and provided a few more moments before the end.

Heathrow Harry
31st Jul 2013, 07:35
Slightly off topic but everyone should realise how fast a little bit of smoke can turn into a lot in less time than it takes to read this

I was once in an office when smoke started to come through the floor - just a thin stream but in 2 seconds the place was solid and we just got out and closed the door and evacuated the building

If you ever see smoke treat it as the worst emergency there is - and you might get out

Bergerie1
31st Jul 2013, 10:07
Heathrow Harry,

I couldn't agree more! And I speak from experience.

Capn Rex Havoc
1st Aug 2013, 07:49
givemewings-

The company I work for uses smoke in the simulator for the smoke/fire drills. It is extremely realistic at night, with the smoke generated so thick that it is indeed hard to see the items on the overhead panel. Guaranteed to make one sweat, and appreciate how hard these poor blokes from UPS had it.

givemewings
1st Aug 2013, 16:03
Cheers Rex. Seems there's a few, but not all, doing this. I just wondered since it's so widespread (pretty much across the board actually) with CC, why not with pilots? Perhaps now it will be...

Mr Angry from Purley
1st Aug 2013, 19:21
SQWARK 7700
Take fatigue for example, it has been a factor in almost every accident and the FAA happily ignores any NTSB recommendations on how to mitigate it.

Sqwark
Not the appropriate forum but do you want to substantiate the above claim?:\

DozyWannabe
1st Aug 2013, 19:51
I was overseas when this accident Happened and for many months was devastated thinking had I been there as a PFE It might of had a different outcome. After reading this excellent prepared report, I now see that for sure there would have been 3 dead crew members.

I'm glad that you said that, because coming from a former FE it means a lot more than it would coming from a non-flyer like myself.

Having read the report I felt much the same way - regardless of the smoke/incapacitation factor, once the flames and/or heat had begun affecting the control cables it would have been effectively "game over" within a matter of minutes. The seven-four may be a tough old bird - one of the toughest in service, but as I understand it from an outside perspective neither she nor any other airliner could withstand damage to those control junctions and stay flying.

The report is definitely a sobering read - between this accident and National 102 at Bagram we've been privy to two textbook examples of a worst-case/no-win scenario, and my heart goes out to everyone affected.

Sqwak7700
1st Aug 2013, 20:39
Not the appropriate forum but do you want to substantiate the above claim?


Yeah, gladly. Name one measure the FAA has put in place to mitigate fatigue? You do know that fatigue shows up in almost all accident reports as being a factor. Has been this way for a long time. Was part of the Colgan/continental Q400 and I'm sure it will be part of the Asiana report as well.

And the US aviation industry is still unable to implement a watered down version of the UK's AFTLS. This is long overdue, and still not implemented to this day. And on top of it, Cargo carriers are excluded. They took one of the most important parts of these regs (time behind the door) and reduced it by a few hours. No science behind that, just purely commercial. All science says you should have 8 hours of rest per night, but the FAA knows better.

If anyone needs to support their claim, then it should be the individual defending the FAA. I would REALLY love to see that turd polish. :yuk:

egravitics
3rd Aug 2013, 05:53
The final report is harrowing reading, dealing with an unstoppable, overwhelming event. However the wider question is whether the event was preventable, either by not flying that type of cargo or mandating specific packing and handling conditions to mitigate or limit the extent.

The FAA has 135 fire/smoke incidents with batteries classed as the cause, on or in the vicinity of aircraft between March 1991 through July 2013 (report (http://www.faa.gov/about/office_org/headquarters_offices/ash/ash_programs/hazmat/aircarrier_info/media/Battery_incident_chart.pdf)).

Seems fortunate that most incidents are detected on the ground before or after a flight. Not included in the FAA battery-incident report is UPS flight 1307 (7th FEB 2006) as the NTSB couldn't determine an absolute cause of the cargo bay fire. The NTSB didn't rule out lithium-ion batteries as the fire's origin (last para, page 50 (http://www.ntsb.gov/doclib/reports/2007/AAR0707.pdf)).

The cynical view is that the aviation and/or battery industries have a Ford Pinto-esque approach which is partly rooted in pragmatism and partly actuarial - that 6 incidents a year is a very small proportion of the total number of batteries flown per year and the incovenience/cost of preventing each incident, most of which are on the ground, could easily exceed the associated losses. I hope the people who might be that cynical are given the opportunity to read this final report.

Mr Angry from Purley
4th Aug 2013, 15:19
Yeah, gladly. Name one measure the FAA has put in place to mitigate fatigue? You do know that fatigue shows up in almost all accident reports as being a factor. Has been this way for a long time. Was part of the Colgan/continental Q400 and I'm sure it will be part of the Asiana report as well.


Colgan - was that the FAA rules or commuting / sleeping habits of crewmembers?. Will the FAA have the balls to look at commuting?
Asiana - sleepiness maybe, jury is out on fatigue though.

BOAC
4th Aug 2013, 15:29
jury is out on fatigue though - I would be very surprised if it was even a factor in this accident.

ZFT
4th Aug 2013, 17:20
Givemewings


All of our simulators too are equipped with smoke generation systems but many airlines don’t install them due to perceived health and safety issues.


Unfortunately neither EASA nor FAA regulations mandate them.

barit1
4th Aug 2013, 20:12
This may be too outlandish a concept for a profit-minded freight carrier, but nothing ventured, nothing gained:

The F-111 had an escape module (http://www.nationalmuseum.af.mil/factsheets/factsheet.asp?id=14319)that might look attractive to a 74F crew. The whole cockpit flies up and away from the unrecoverable aircraft.

It's really a matter of cost vs. the value of crews' lives. :ouch:

flyboyike
5th Aug 2013, 01:50
The "escape module" would be an engineering challenge as well, I would imagine. The F-111 had the advantage of being much smaller, not to mention of being a military aircraft, where sitting on explosives was not as frowned upon.

StormyKnight
5th Aug 2013, 05:11
Even a parachute & a escape shoot may be enough like the one added to the 727 desert test crash aircraft.

JammedStab
5th Aug 2013, 05:24
Colgan - was that the FAA rules or commuting / sleeping habits of crewmembers?. Will the FAA have the balls to look at commuting?


What is there to look at in commuting. Thousands do it every day.

mutt
5th Aug 2013, 06:07
And the US aviation industry is still unable to implement a watered down version of the UK's AFTLS. This is long overdue, and still not implemented to this day. FAA 117 Duty Time, will come into affect 04th Jan 2014

JammedStab
5th Aug 2013, 09:19
You do know that fatigue shows up in almost all accident reports as being a factor. Has been this way for a long time. Was part of the Colgan/continental Q400 and I'm sure it will be part of the Asiana report as well.



While I am all for better rules to lessen fatigue, I have a great deal of difficulty believing that the Colgan accident had much to do with fatigue. Yes, they got forgot to turn of whatever anti-ice switch in their aircraft and therefore got a nuisance stall warning, but that has happened to plenty of people regardless of their level of fatigue(ask an ATR pilot who flies winter ops).

To think that the ridiculous reaction of the captain to the stall warning(pulling aggressively) was something that only happened because he was tired seems way off base. This is an instinct reaction by him, why? who knows but I highly doubt that if it had been earlier in his duty day after an nice long well-rested vacation that he would have done any different. The fact that he had an extremely poor flying record seems a more likely answer. He was just a weak pilot.

Capn Bloggs
5th Aug 2013, 12:12
What is there to look at in commuting. Thousands do it every day.
Like she did? You should be thrown in jail for being irresponsible. :ouch:

JammedStab
5th Aug 2013, 12:38
Like she did? You should be thrown in jail for being irresponsible. :ouch:

I should be thrown in jail for saying that thousands commute everyday?

Whatever this FO did, I doubt it has anything to do with the captain's reaction to the stall warning.

Commuting by airline is like any other activity on time off. You can be responsible or irresponsible. I know a guy that wakes up at about 2 AM to drive more than a couple of hours for his 6 AM show for his 13 hour duty day that he bids. Should the FAA look at this as well. What about people who come back from a holiday on the other side of the world with a 12 hour time change the night before their early morning start at work. Should the FAA regulate our holidays. Maybe they should say that we need to make an effort to be well rested but can't micromanage our lives.

Capn Bloggs
5th Aug 2013, 13:36
Jammed old chap, I made my comment on jail based on what she did. Go and find that out and you'll see what I'm on about. I don't have a problem with pilots commuting a sector or two on their days off.

In my country it is a legal requirement that you be adequately rested before flight. That does not mean paxing (or driving) at all hours of the night to get to work! Why should you be allowed to pax back from a holiday and not have exactly the same time free of duty afterward before working as you would have had if that pax ride had been duty travel, considering the time zones?

birdstrike
5th Aug 2013, 15:27
I think there is a bit of hypocrisy going on here.

As pilots we are all very quick to criticise airline management / accountants, the CAA, the FAA etc for failing to take measures to enhance safety

but

when there is any call to restrict long time / distance commuting immediately pre-flight the immediate response is 'not fair, shouldn't interfere' etc.

Whilst it might be hard to PROVE that long commutes cause fatigue, it certainly cannot be argued that they in any way improve safety.

flyboyike
5th Aug 2013, 17:37
While I am all for better rules to lessen fatigue, I have a great deal of difficulty believing that the Colgan accident had much to do with fatigue...


That's funny, I have no such difficulties.

tdracer
8th Aug 2013, 20:59
Quote:
Experience from this accident investigation in conjunction with FAA experiments suggest passive fire suppression in large cargo compartments due to oxygen deprivation may not be effective.
Uh, any other freighter pilots that have a problem with this statement? How does the FAA retain a valid certification for freighter aircraft with Class E compartments while simultaneously acknowledging this little gem.

Why can't we have the same level of protection in the main deck as we do in the lower lobes? I know it takes more structure, but the prediction in the accident report is for 4.1 more hull losses between now and 2021. At the very least, make self-fueled hazmat a road or water transport only class.Unfortunately 'active' fire suppression wouldn't have much mattered - Li-Ion batteries provide their own oxidizer when they start to burn. So any conventional aircraft fire suppression would have - at best - marginally slowed the fire's progression to surrounding materials (same thing with chemical oxygen generators as was the case in the ValueJet crash in the Everglades).

The only fire suppression agent that's been demonstrated to be truely effective for aviation cargo fires is Halon - manufacture of which has been effectively banned due to environmental concerns (there has been success with a baking soda based agent in smaller areas - specifically engine fires - but not for the area of a massive cargo hold). We're basically using stockpiled and recycled Halon for new aircraft production - how long do you think that's going to last? Oh, and it would take a LOT of Halon to produce the minimum 5% concentration necessary to extinguish a conventional fire in an area the size of a 747F main deck.

The only real viable option is your last sentence - ban self oxidizing materials from air freight. It was done years ago for model rocket motors (with no reported self-ignition incidents). Yet we continue to allow a material with a known history of self ignition a free pass.

givemewings
8th Aug 2013, 23:46
Stormy, it's been awhile since I watched that doco on the desert crash test, but I don't think they added anything to that 727- those stairs were standard fit on that model... they just modified it to allow deployment in flight (or was it removed altogether- need to watch again)

As long as the consumer wants low priced batteries and the companies turn a profit, it will be difficult to change anything. I too used to be guilty of buying spare camera batteries etc online and having them sent to me... without even thinking to ask the shipper how they sent them. After working in freight, I then understood the issues and risks involved. I've even reported seller to Ebay after they repeatedly refused to ship items to me safely or notify the actual contents of parcels (even after offering to pay extra costs) The key is education, sadly like most industries the almighty dollar wins and the average Joe consumer does not care about some poor freight crew who died while bringing their cheap :mad: batteries from China....

tdracer
9th Aug 2013, 04:42
Stormy, it's been awhile since I watched that doco on the desert crash test, but I don't think they added anything to that 727- those stairs were standard fit on that model... they just modified it to allow deployment in flight (or was it removed altogether- need to watch again)


The aft stairs on the 727 were never intended to be operable 'in-flight', but pre-D.B. Cooper there was nothing to prevent their deployment in-flight (I recall the DC-9 having a similar setup). After the D.B. Cooper hijacking, a fix was implemented to prevent in-flight deployment. It was super simple - basically a spring loaded weather-vane that would rotate with free-stream airflow and block the door from opening (again, memory says a similar fix was implemented on the DC-9). Naturally this became known as the "D.B. Cooper fix" :).

I've seen the documentary on the 727 desert crash - as best as I could tell all they did was remove the 'D.B. Cooper fix' :ok:.

stilton
9th Aug 2013, 05:23
Actually the stairs were completely removed.

peakcrew
9th Aug 2013, 20:18
This is a fascinating thread. I am very impressed by the standard of the report, and how little the thread has deviated.

Whilst things like not allowing self-oxidising materials in bulk on planes makes sense, I noted one posting that raised my eyebrows - that freighters don't have cabin doors to separate them from the hold. I had never considered this before, and wonder what the reason (or at least the justification) is. To me, the default would seem to be to keep the crew isolated from the cargo unless there is a particular reason for them to go back. I'd even go so far as to say that the crew compartment should be separately pressurised.

So, what am I missing?

sludge
9th Aug 2013, 20:41
. The Captains blood sample was positive for ethylalcohol with a concentration of (11 mg/dl). ????

Pinkman
9th Aug 2013, 20:49
that freighters don't have cabin doors to separate them from the hold.

Some configurations do, or did. When the SAA 747-200 Combi Helderberg (on which a friend of mine's GF died) caught fire and ultimately came apart between Taipei and Mauritius the wreckage was recovered including the door between the pax section and the cabin. The handle had been smashed - presumably someone tried to get into the cargo section to extinguish the fire. But from the photos it wasn't a fireproof door by any means.

The report resulted in an impressive number of recommendations: I leave you to decide how many were actually implemented:

http://lessonslearned.faa.gov/SA295/SAAIB_report.pdf

peakcrew
9th Aug 2013, 21:37
Thanks, Pinkman. I'll have a look at that. Sorry to hear about your friend - it can't be easy for you or him to be reading this now.

Pope Mobile
9th Aug 2013, 23:11
Sludge,
I wondered about that too. Was that from breathing in the fumes in the cockpit?

Astrosfan
9th Aug 2013, 23:38
The Captains blood sample was positive for ethylalcohol with a concentration of (11 mg/dl). ????

From p. 96 of the report:

The [FAA Civil Aerospace Medical Institute] laboratory performed an independent analysis of the specimens sent by the FAA to the institute. The CAMI specimen analysis indicates the presence of ethanol in samples from the captain and first officer; however, their report states that the ethanol reported in these cases are from post-mortem ethanol formation and not from the ingestion of ethanol.

BuzzBox
10th Aug 2013, 00:42
...their report states that the ethanol reported in these cases are from post-mortem ethanol formation and not from the ingestion of ethanol.

Further to that:

Ethanol analysis is one of the most common tests performed on forensic specimens. The presence of ethanol in aircraft accident victims constitutes an important part of both aircraft accident investigations and litigation. Using modern analytical techniques, there is little doubt as to the quantitative amount of ethanol present in a postmortem specimen. The origin of the ethanol detected, however, is an important variable that must be considered when interpreting ethanol results in postmortem specimens.

Many species of bacteria, yeast and fungi produce ethanol and other volatile organic compounds as a byproduct of their metabolism. Candida albicans has been identified as the microbe most often responsible for postmortem production of ethanol in humans. This species of yeast is commonly found in humans in vivo. However, microbes not normally found in vivo, such as the Mucor species of mold, are commonly found in decaying organic matter and soil; they may be introduced from the environment if the circumstances surrounding death are violent, as is often seen in aviation accidents. After death, endogenous and/or exogenous microbes begin rapidly consuming glucose and other nutrients present in the body and produce ethanol and/or other organic volatiles as metabolic byproducts. Under optimal conditions, substantial concentrations of ethanol may be formed within hours of death.

Source: http://www.faa.gov/data_research/research/med_humanfacs/oamtechreports/2000s/media/0404.pdf

tdracer
10th Aug 2013, 00:54
I noted one posting that raised my eyebrows - that freighters don't have cabin doors to separate them from the hold. I had never considered this before, and wonder what the reason (or at least the justification) is. To me, the default would seem to be to keep the crew isolated from the cargo unless there is a particular reason for them to go back.


Perhaps because that post is wrong. I can't speak for all Freighters out there, but EVERY Boeing produced freighter has a fire resistant door between the flight deck and the cargo compartment (freighter conversions are STC - so they may be different).

In the case of the 747-400F, there is a door between the upper deck and the main deck (fire resistant), and another door between the flight deck and the rest of the upper deck. Per the AFM and a placard on the main deck/upper deck door, it must be closed for takeoff and landing, and in-flight except when main deck access is required (e.g. care and feeding of live cargo). The flight deck door may be left open in-flight (given there was no one else on the aircraft it wouldn't surprise me if they left it open to provide easier access to the galley and lav), but the upper deck door was almost certainly closed.

I've only skimmed the report, but it sounds like the cargo fire was almost directly under the upper deck, and it's intensity quickly compromised the smoke/fire barrier between the main deck and upper deck. The smoke problem in the flight deck was then compounded by the miss-fortune of having Pack 1 drop (for those who may not know - standard procedure on a 747F for main deck fire is to depressurize the airplane to rob the fire of oxygen, while the flight crew uses supplemental oxygen, then use Pack 1 to supply air to the upper deck to keep it at a higher pressure to prevent smoke entering).

Unless someone is proposing that the main deck be lined with several tons of steel fire barriers (and the usable payload be reduced to ping pong balls and down pillows), the only way to have prevented an event of this type is to ban significant quantities of self oxidizing cargo.

Etud_lAvia
10th Aug 2013, 01:34
I don't know the current FARs, but back in the day FAA allowed nets of a certain strength instead of a bulkhead/door behind the cockpit on freighters, the theory being that the net would provide a limited degree of protection from shifting cargo in a rapid deceleration or impact situation.

sludge
10th Aug 2013, 12:04
Thanks for the explanation for the ethyl alchohol, really glad to hear that.

peakcrew
10th Aug 2013, 14:43
Thanks, tdracer and Etud_lAvia: there seems to be a difference of opinion here :)

Since there is no effective way to protect an aircraft from a fire in self-oxidising materials, it seems to be insane to allow bulk transport by air. I'd go so far as to ban their carriage in the hold at all, even in luggage. An individual laptop (or smartphone) battery could cause enough damage to seriously compromise a flight because they have tremendous energy density.

JammedStab
10th Jul 2015, 23:51
I have finally started reading the entire report in detail. With the smoke so bad, the F/O was basically blind when it came to tuning radios and seeing the flight instruments. It appears that he could get his face close enough to the MCP to be able to see at least some of it as even near the end, he was able to arm the approach.

Unlike some planes, the 747 pilot sits quite far away from the instrument panel which is usually at arms length with a glareshield that sticks out quite far and sort of blocks you from being able to press your face against the flight instrument display. It would be near impossible to get your face close enough to the instrument displays to see anything while still seated. This explains why he kept asking for his present altitude, heading and speed. Being unable to change radios he had to stay on a different frequency from ATC and relay information.

That he was able to actually get toward and fly over the Dubai airport seem amazing for someone with less than 100 hours on type. I notice that he did fly the 757/767 so that probably help in terms of some familiarity with MCP controls and possibly radios.

Doing most stuff would have to be in the blind with possible exception of some or most MCP knob movement. These knobs are each shaped differently for speed, heading, and altitude so that they can be recognized by feel while flying. I know the feel of the heading select knob and the Altitude knob and the speed knob as they are quite different. But it would still be extremely difficult to correctly manipulate the controls properly when certain square buttons need to be pushed and displays on the MCP for selected speed, altitude and heading need to be read. I think if the MCP alone can be read in its entirety, with practice someone could work out an autoland without being able to see the flight instruments or a ditching could be attempted by descending to 200 feet over the water capturing the altitude and then configuring and descending at 100 fpm into the water. Just remember to set the local altimeter setting on both sides(once again near impossible for the left side) so maybe selecting transponder #2 might work).

As I read the report, I become convinced that if put all of a sudden in the same position without previous real thought or practice and planning, most of us likely would have crashed as well trying to do this in the blind whether ditching or trying an approach. Perhaps a good amount of experience would have made it possible but when you can't even see what you are selecting, it would be extremely time consuming to figure it all out.

As the report states, "The aircraft was not equipped with an alternative viewing system to allow the pilot(s) to view the instruments and panels in the smoke filled environment." I have actually been in the demonstration booth at an NBAA convention for the EVAS smoke vision system as seen in the link below. It really works in an environment where you cannot see a think a few inches from your face. See link below for a demo(start at 1:20) but the video only shows for a couple of seconds the actual difference this system makes.

As I was thinking about this this morning, something occurred to me as I was looking right at a potential desperate solution to be able to find something to be able to make things barely visible again.

It was my large clear plastic water bottle. Dump out the water(and depending on the bottle, you may be able to barely see what you are selecting as you need to look at various radio frequencies, a section of the PFD flight instrument display, or the radio panel. No guarantees but it is worth a try and might actually work.

CCA
11th Jul 2015, 03:39
make things barely visible again.


I'm afraid not, the smoke will now be in the bottle as well!

You will have to decide the water bottle trick prior to losing visibility or decide to carry an empty water bottle.

Huck
11th Jul 2015, 05:25
It's surprising how the press hasn't discussed this accident while covering the increasing shift of air freight into the bellies of passenger airplanes.

If this had happened in 2015, the fire could have started on an Emirates or Delta flight......

Boeing Cargo Planes Lose to Boeing Passenger Planes - Businessweek (http://www.bloomberg.com/bw/articles/2014-07-03/boeing-cargo-planes-lose-to-boeing-passenger-planes)

SAMPUBLIUS
11th Jul 2015, 05:32
'The whole cockpit flies up and away from the unrecoverable aircraft.

Yep - good theory but NOT easy to do. How many know that then B1 bomber was initially designed and flown with a crew escape module. And it was tested on a supersonic sled, air dropped, etc> I wuz working For Rockwell at the time on that program. And very much involved in the manufacturing- assembly area as part of tooling. The total complexity involved re quick auto disconnect of all controls, the deployment of multiple parachutes, the provisions for landing on hard ground or in the water- upright and being aerodynamically stable plus altitude- oxygen provisions, etc even where cost was NOT an issue cannot be simply described.

And despite best attempts and extensive quality control issues- it was a failure. One test pilot was killed during initial testing when things went barf and the parachutes did not properly deploy
https://en.wikipedia.org/wiki/Rockwell_B-1_Lancer

Rockwell's design featured a number of features common to 1960s U.S. designs. Among these was the use of a "crew capsule" that ejected as a unit during emergencies, which was introduced to improve survivability in the case of an ejection at high speed.



On 29 August 1984, B-1A (AF Ser. No. 74-0159) stalled and crashed while performing minimum control speed tests at low altitude. The crew used the escape capsule (https://en.wikipedia.org/wiki/Escape_crew_capsule) to leave the bomber, but the parachutes deployed improperly, causing the capsule to hit nose down. The impact killed the B-1's pilot, Rockwell test pilot Doug Benefield, and seriously injured two other crew members.[157] (https://en.wikipedia.org/wiki/Rockwell_B-1_Lancer#cite_note-Jenkins_p63-158)[158] (https://en.wikipedia.org/wiki/Rockwell_B-1_Lancer#cite_note-159)



I doubt any civilian large commerical aircraft could afford the cost..

JammedStab
11th Jul 2015, 07:26
I'm afraid not, the smoke will now be in the bottle as well!

You will have to decide the water bottle trick prior to losing visibility or decide to carry an empty water bottle.

Good point. So it could work depending on how you went about it. Just a desperation idea. You might be able to see the MCP or radio frequency through water in the bottle. Worth a try anyways.

framer
11th Jul 2015, 07:41
Most of the reputable Airlines banned Lithium Ion Batteries in April this year unless they are held within the device that they operate.sounds like the Industry is slowly waking up.

Yaw String
11th Jul 2015, 09:34
If anyone needs evidence of badly packaged,and consigned,non declared dangerous goods,out of Hong Kong,PM me...I had a smoking cargo of after market lithium laptop batteries,packed together,20 in a box,no correct separators,removed from my 777,before departure,2 years ago.
The said cargo,20 boxes,arrived on an Airbus,from Hong Kong,transiting on my flight, to Montivideo.....
Holly Sxxt...
Fortunately,very alert loaders noticed fine smoke as they closed the cargo doors...potentially the worst incident in my 44 years of aviation.

neilki
11th Jul 2015, 23:32
Colgan - was that the FAA rules or commuting / sleeping habits of crewmembers?. Will the FAA have the balls to look at commuting?
Asiana - sleepiness maybe, jury is out on fatigue though.
Er. the FAA has done nothing? 14 CFR Part 117 seems to be something. Perhaps not well read in Purley, but had a decent impact in FAA land.

Less Hair
12th Jul 2015, 06:09
Some FAA movie about laptop battery fires. When you see how difficult it is to just cool it down you get an idea that to deal with lithium battery cargo fires is next to impossible in flight. Just scary. How about iPads and all that EFB stuff inside the cockpit?

How about some fireproof insulated bag with a fire suppression system inside to put burning stuff in and contain the gases? (for just a single burning laptop)

https://www.youtube.com/watch?v=vS6KA_Si-m8

Earl
12th Jul 2015, 06:35
Does UPS have USA loaders and handlers there or local ones.
I worked for Midex airlines 3 years there in UAE,
A300.
We did many flights to Afghanistan same time this accident happened.
Many times we would have the cargo manifest and no Dangerous goods listed,
Then while DXB ground ones locals loaded we would see the orange stickers on the cargo.
Where is the NOTAC, was none.
Happened often.
Like we need need to overlook this issue.
I hope they look deeper into this.

Squawk7777
12th Jul 2015, 23:08
Could somebody do me or actually those two deceased UPS pilots a favor and mail this accident report to Jörg Handwerg, Captain and spokesperson for the German pilot union Vereinigung Cockpit (VC)? He was the first person I know to publicly criticize those two pilots in the German newspaper "Süddeutsche Zeitung (SZ)" for taking too long to return back to the airport. :eek::ugh::mad:

JammedStab
13th Jul 2015, 00:12
Could somebody do me or actually those two deceased UPS pilots a favor and mail this accident report to Jörg Handwerg, Captain and spokesperson for the German pilot union Vereinigung Cockpit (VC)? He was the first person I know to publicly criticize those two pilots in the German newspaper "Süddeutsche Zeitung (SZ)" for taking too long to return back to the airport.

I would say that as a general rule, it would be a better decision to go to good airport 100 miles away rather than 180 miles away.

While it may not have made a difference in this case, it may have in another situation. Perhaps if the pallet on fire had been in a different location, arriving 10 or 15 minutes earlier would have made a difference. Perhaps if Pack 1 had been working or the smoke evacuation handle in the cockpit had not been pulled or an early descent accomplished(all of which made things worse), that extra 10-15 minutes early arrival would have made a difference.

Aside from the radio communication difficulties that resulted from returning to Dubai, it is difficult to say what the difference would have been if they had arrived 15 minutes earlier into Doha.

Choosing a significantly farther very suitable airport to return to is not the best choice as a general rule in this situation even if subsequently turns out that it would not have made a difference.

JammedStab
13th Jul 2015, 01:10
I am not saying that the end result would have been different for me or that my actions would have been any different. However, with the benefit of hindsight and time to calmly think about things and what to do if this happens in the future.....

....while it happened to be batteries this time, it can be and could have been another source for the fire. The crew was not aware of the source at the time. Decisions at the time have to be based on the fact that there is smoke, not what the exact source is which doesn't really matter at that point.

We have known for a long time that fires are bad so land at the nearest suitable airport.

The checklist says to stay at FL250. I am not sure of the point of disregarding it and going to a much lower altitude so early based on the new destination distance. The report says that this may have made the fire worse. It certainly didn't make things better. I suppose one could be thinking that they want to be close to the water in case an immediate ditching is required if things get desperate all of a sudden instead of having to take 10 minutes to descend from FL 250.

I am not sure what the smoke evacuation checklist said at the time but it now says that pulling the smoke evacuation handle which opens a port in the ceiling in the cockpit. This is for when the smoke source is in the cockpit and that if the smoke or fumes source is not on the flight deck, this action may bring the smoke or fumes into the flight deck or increase the amount flowing into the flight deck which appears to be the case here.

The O2 mask on the right side was apparently not set to the 100% mode for departure according to the report. They claim that they can tell by sound analysis(if you believe that). They also seem to feel that it was never set to 100% during the emergency which seems difficult to believe but that is what the report says. If so, it shows the importance of checking that the mask is at 100% on the pre-flight. As well, the continuous flow option was never used. Unfortunately we don't get a lot of opportunity to practice selecting continuous flow in newer aircraft as the mask is stowed in that compartment instead the way it was in the old days with the mask hanging nearby. It can be very handy to practice making that selection whenever one gets the opportunity in the sim as it is done by feel only. This will ensure that no smoke is going in the mask.

The pack 1 failure had to be the worst luck in the world(as it is designed to keep smoke out of the cockpit through a higher pressure level) and happened after the fire warning sounded. Perhaps things were already bad at that point, I'm not sure. But I believe they followed the checklist to manually turn off the other packs. The checklist has subsequently been changed by Boeing.

737er
13th Jul 2015, 07:53
The pack 1 failure had to be the worst luck in the world(as it is designed to keep smoke out of the cockpit through a higher pressure level) and happened after the fire warning sounded. Perhaps things were already bad at that point, I'm not sure. But I believe they followed the checklist to manually turn off the other packs. The checklist has subsequently been changed by Boeing.



No kidding. These poor guys. Not to mention the O2 mask. They did a great job.

This was a "Fate is the Hunter" flight from hell. I hope we get something out of it. The report was well done.

400drvr
13th Jul 2015, 20:02
Does anybody really think anything will change? Sure the safety recommendations will be made bla bla bla but when push comes to shove there is to much money to be made than to worry about the safety of the crew, aircraft, and those below. And, yet you can't put extra lithium batts in your checked bag. Hell even GA Corporate A/C have the system that allows you to see the instruments in the event the cockpit is filled with smoke. I know I'm preaching to the choir but I just don't expect a thing to change. Still waiting for the Asiana final report, if it ever makes the light of day and I would bet it will be a very similar read.

It's a real joke but it will continue. Glad I will be retiring soon enough. I'm tired of playing Russian Roulette with this.

Chronus
14th Jul 2015, 20:55
The single cause of this accident was a part of the cargo it carried.
Of significance is the quote from the accident investigation report:

"The Cargo Group examined shipping invoices for the cargo on board the
aircraft, and at least three shipments of lithium batteries which should have been declared as hazardous materials were identified in the pallets at positions 4 and 5. There were no declared shipments of hazardous materials on board the accident flight. "

If they should have been declared as hazardous, then why were they not so declared.

Given the lesson in the Valuejet flight 592 this is an accident that should not have happened.

400drvr
14th Jul 2015, 22:15
Given the lesson in the Valuejet flight 592 this is an accident that should not have happened.

And sadly it was not the last. An Asiana cargo 744 went down off of Cheju Island a couple of years later. Another out of control fire that a Class E compartment was never meant for.

GBV
18th Jul 2015, 18:07
a bit off topic, but i was wondering if the South African authorities should have a look at the Herderberg crash again. It states in the final report that the fire originated in a pallet containing computers fitted with lithium batteries. They were considered not likely to cause any ignition or explosion by the time of the investigation, but how about now with further studies on lithium batteries?

flatfootsam
21st Jul 2015, 05:17
Good point. The Margo commission report of the Boeing 747Helderberg accident makes a summary case for the fire leading to an inflight break up when the report analyses the possible effect of a fire burning through the crown of the upper fuselage. Reading between the lines, Boeing where highly reticent regarding this possibility, and according to the commission, Boeing 'contested' any scenario that involved a break-up of the aircraft and thus the commission did no more than mention the two possible scenarios in the final report.

However, the Asiana B744F accident of 2011 which had a cargo of around 200kgs of Li-metal/Li-ion batteries at the rear of the upper deck does separate in flight at around FL140 following a sustained upper deck cargo fire, loss of control and a rapid descent. The fuselage separation location and the HazMat cargo location being approximate...therein lies a tale.