Preliminary Report of Boeing 747-400F Fatal Accident, Dubai -3Sep10
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This link (posted earlier by Mark in CA) works for me http://www.gcaa.gov.ae/en/ePublicati...7%20DXB%20.pdf, at least as posted http://goo.gl/t1g9g
I hope I never get to experience something like this in the remainder of my flying career. I can’t imagine what those two pilots went through in the remaining minutes of their flight... RIP.
A fire onboard an aircraft has to be the most terrifying thing a pilot as to deal with, with perhaps the exception of a hijacking. This reminds me of the Swissair flight that crashed off the East coast of Canada. It's a reminder that no matter what, a fire onboard an aircraft as to be dealt with in a speedy matter and landing the aircraft the upmost priority even if not the best suitable airport for commercial reasons. Perhaps even the emergency check list should be put aside if time is at a premium and all efforts put into getting the aircraft on the ground ASAP.
Notables from the initial report...
"The inbound crew entered a logbook item for a PACK 1 fault which was reset on the inbound sector HKG-DXB."
"The take off and climb out from DXB was uneventful with the exception of a PACK 1 fault which was reset by the PNF at 14:55 UTC at 13,000 ft enroute to the BALUS waypoint."
"Based on the DFDR data, at 15:15 UTC, PACK 1 shut down, with no corresponding discussion recorded on the CVR."
Could a possible problem with PACK 1 have been a contributing factor here?
Oxygen to the mask of both pilots (or lack of) seems to be a major contributing factor in this crash...
"At approximately 15:19 UTC, during the emergency descent, at approximately 20,000 ft cabin altitude, the CAPT, as PF, declared a lack of oxygen supply.
Following a brief exchange between the CAPT and F/O regarding the need for oxygen, the CAPT transferred control of the aircraft to the F/O as PF. Portable oxygen is located on the flight deck and in the supernumerary area, aft of the flight crew’s positions when seated.
At this point the recorded CVR is consistent with the CAPT leaving his seat, after which there is no further CVR information that indicates any further interaction from the CAPT for the remainder of the flight."
This is not good, the PF (F/O) is now looking for some oxygen...
"At 15:22 UTC, the F/O informed the relay aircraft that he was ‘looking for some oxygen’."
Low time crew on aircraft type?
CAPTAIN
FLT CREW LICENSE FAA AIRLINE TRANSPORT PILOT –AIRPLANE MULTIENGINE LAND
TOTAL TIME (TT)
11,410 hours
TIME LAST 6 MONTHS 209 hours
B747-4F (TT)
367 hours
CO-PILOT/FIRST OFFICER FAA AIRLINE TRANSPORT PILOT -
FLT CREW LICENSE AIRPLANE MULTIENGINE LAND
TOTAL TIME 6,130 hours
TIME LAST 6 MONTHS 130 hours
B747-4F (TT) 78 hours
With 367 hours total on type the captain was still relatively new to this aircraft. The F/O on the other hand was inexperienced on type with only 78 hours total. Given the gravity of the situation that day with what seems to be some sort of compounded multiple failures of the aircraft’s systems (PACK 1 shutting down, lack of oxygen, flight control problems…) could their low time on type have played a role in the crash?
So in the end what have we learned from this initial report?
That there was a fire in the main cargo deck, the crew did their best in getting the aircraft out of FL320 down to 10,000 feet but that on the way down the captain may have been lost due to lack of oxygen, leaving possibly the aircraft in the hands of a very low time pilot on type continuing by himself to try to save the aircraft under very extreme conditions with a fire burning, smoke in the cockpit, problems communicating and perhaps even lack of oxygen to his mask. The aircraft approached DBX on a flight profile that suggests things were getting out of control (too high and too fast). The gears were lowered at above their operational speed and reported not to be functioning, the spoilers were then extended and so were the flaps (perhaps above their operational speed too). The aircraft overflew/overshot the airport at 4500 feet at 340 kts. The PF was advised of an alternate airport at 095 degrees from their position and 10 NM.
Shortly after acknowledging this information either both pilots or as this scenario in this initial report leads us to believe, the only pilot left flying the aircraft must have succumbed to the lack of oxygen or the fire itself as the aircraft’s A/P disconnected, it entered a descending RH turn from 4000 feet while the speed bled back to 240 kts until impact.
There are too many questions left to be answered before some sort of judgement can be truly accessed in this tragedy. Hopefully some good will come out of it.
However IMHO something immediate should be done about those lithium batteries. They should not be charged before transport especially if they are to be air freighted.
A fire onboard an aircraft has to be the most terrifying thing a pilot as to deal with, with perhaps the exception of a hijacking. This reminds me of the Swissair flight that crashed off the East coast of Canada. It's a reminder that no matter what, a fire onboard an aircraft as to be dealt with in a speedy matter and landing the aircraft the upmost priority even if not the best suitable airport for commercial reasons. Perhaps even the emergency check list should be put aside if time is at a premium and all efforts put into getting the aircraft on the ground ASAP.
Notables from the initial report...
"The inbound crew entered a logbook item for a PACK 1 fault which was reset on the inbound sector HKG-DXB."
"The take off and climb out from DXB was uneventful with the exception of a PACK 1 fault which was reset by the PNF at 14:55 UTC at 13,000 ft enroute to the BALUS waypoint."
"Based on the DFDR data, at 15:15 UTC, PACK 1 shut down, with no corresponding discussion recorded on the CVR."
Could a possible problem with PACK 1 have been a contributing factor here?
Oxygen to the mask of both pilots (or lack of) seems to be a major contributing factor in this crash...
"At approximately 15:19 UTC, during the emergency descent, at approximately 20,000 ft cabin altitude, the CAPT, as PF, declared a lack of oxygen supply.
Following a brief exchange between the CAPT and F/O regarding the need for oxygen, the CAPT transferred control of the aircraft to the F/O as PF. Portable oxygen is located on the flight deck and in the supernumerary area, aft of the flight crew’s positions when seated.
At this point the recorded CVR is consistent with the CAPT leaving his seat, after which there is no further CVR information that indicates any further interaction from the CAPT for the remainder of the flight."
This is not good, the PF (F/O) is now looking for some oxygen...
"At 15:22 UTC, the F/O informed the relay aircraft that he was ‘looking for some oxygen’."
Low time crew on aircraft type?
CAPTAIN
FLT CREW LICENSE FAA AIRLINE TRANSPORT PILOT –AIRPLANE MULTIENGINE LAND
TOTAL TIME (TT)
11,410 hours
TIME LAST 6 MONTHS 209 hours
B747-4F (TT)
367 hours
CO-PILOT/FIRST OFFICER FAA AIRLINE TRANSPORT PILOT -
FLT CREW LICENSE AIRPLANE MULTIENGINE LAND
TOTAL TIME 6,130 hours
TIME LAST 6 MONTHS 130 hours
B747-4F (TT) 78 hours
With 367 hours total on type the captain was still relatively new to this aircraft. The F/O on the other hand was inexperienced on type with only 78 hours total. Given the gravity of the situation that day with what seems to be some sort of compounded multiple failures of the aircraft’s systems (PACK 1 shutting down, lack of oxygen, flight control problems…) could their low time on type have played a role in the crash?
So in the end what have we learned from this initial report?
That there was a fire in the main cargo deck, the crew did their best in getting the aircraft out of FL320 down to 10,000 feet but that on the way down the captain may have been lost due to lack of oxygen, leaving possibly the aircraft in the hands of a very low time pilot on type continuing by himself to try to save the aircraft under very extreme conditions with a fire burning, smoke in the cockpit, problems communicating and perhaps even lack of oxygen to his mask. The aircraft approached DBX on a flight profile that suggests things were getting out of control (too high and too fast). The gears were lowered at above their operational speed and reported not to be functioning, the spoilers were then extended and so were the flaps (perhaps above their operational speed too). The aircraft overflew/overshot the airport at 4500 feet at 340 kts. The PF was advised of an alternate airport at 095 degrees from their position and 10 NM.
Shortly after acknowledging this information either both pilots or as this scenario in this initial report leads us to believe, the only pilot left flying the aircraft must have succumbed to the lack of oxygen or the fire itself as the aircraft’s A/P disconnected, it entered a descending RH turn from 4000 feet while the speed bled back to 240 kts until impact.
There are too many questions left to be answered before some sort of judgement can be truly accessed in this tragedy. Hopefully some good will come out of it.
However IMHO something immediate should be done about those lithium batteries. They should not be charged before transport especially if they are to be air freighted.
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Fire --> eventual Loss of Control
Nice summary.
Several parallels with:
Several parallels with:
Clipper 160 / 3Nov73 Cargo B707-320, N458PA departed JFK with 15360 pounds of 12 different hazardous materials and other cargo (payload = 52912 lb), bound for Scotland and Frankfort. \\ Crew were offered no notification of Hazmat aboard.
That cargo-B707 crew overflew usable airfields in an attempt to return to BOS; smoke in cockpit; then eventually LoC near airport:P.C. = smoke in cockpit, continuously generated, smoke led to emergency situation and loss of control during final approach, when crew (in un-coordinated action) de-activated the Yaw Damper, with incompatible configuration of Extended Flight Spoilers and Extended Flaps. AAR included reports of witness-pilots' observation of accident aircraft in unusual attitude. [ICAO "AAD"; and Air Line Pilot May90, CV Glines' Hazmat article. AW 102:47+ Mr10 '75, 51+ Mr 24 '75, 57-9 Mr 31 '75.]]
As a lowly CFI, I wonder why the crew elected to go to DXB (150nm away) instead of DOH (100nm away)? Do you more experienced folks have any idea why they would have gone to a more distant airport? Had you been in their shoes, what factors would you consider before selecting an airport in this situation?
regards
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See posts#12 and #14: I think trying to locate plates etc for a new airfield, with a major problem on board and PROBABLY still having all the stuff for departure point 'out' makes a bit of sense? I'm not sure they would have made Doha anyway.
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Could a possible problem with PACK 1 have been a contributing factor here?
What is not clear is that will pack 2 or 3 supply the positive pressure to the cockpit if Pack 1 is inop.
Oxygen to the mask of both pilots (or lack of) seems to be a major contributing factor in this crash...
This is not good, the PF (F/O) is now looking for some oxygen
It is beyond belief how the chain of events/holes in the cheese lined up. Every safety feature seems to have failed.
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I just can't help thinking...
"What would have been different about the outcome of this tragic accident if it had been a Classic B747 freighter?"
I ask as a long-time flyer of 747 Classic freighters, much of it HKG-DXB-MAN, and return.
In my mind, I find myself applying the same string of events to a flight I might have been on board, and trying to see how the outcome may have been different.
"What would have been different about the outcome of this tragic accident if it had been a Classic B747 freighter?"
I ask as a long-time flyer of 747 Classic freighters, much of it HKG-DXB-MAN, and return.
In my mind, I find myself applying the same string of events to a flight I might have been on board, and trying to see how the outcome may have been different.
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Yep the classic would have been a different story F/E could have sorted out the pack issue and the classic freighters should have the cockpit vent to allow ram air into the cockpit giving a positive pressure preventing the smoke entry. Plus a third man could have also helped with getting an oxy bottle.
The -8F is fitted with a cockpit vent switch might be a nice mod to fit to the 744F/BCFs!
The -8F is fitted with a cockpit vent switch might be a nice mod to fit to the 744F/BCFs!
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Also... If they had followed the checklist and stayed at FL250 for a while there would not have been enough oxygen to sustain combustion and the fire would have gone out?
Am I correct in thinking that?
Am I correct in thinking that?
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BOAC
"...I think trying to locate plates etc for a new airfield, with a major problem on board..."
The SR111 accident should have taught every one by now to get down and to land at the closest airport/pavement with uncontrollable smoke in the cabin. With max auto brakes [3000psi] the B74 can easily be stopped on any 5000' pavement, including a highway if necessary. To be sure, the prehistoric training "mind set" of having to land at a "suitable airport" needs to change.
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combustion: NOT directly related to Partial Pressure
A QUESTION posed, a few slots earlier:
"... at FL250 ... there would not have been enough oxygen to sustain combustion ..."
This mis-perception, and the idea of "turning OFF the Packs to suffocate any fire", have been recurring pilot-assertions. An erroneous assertion.
Combustion could be slowed by decreasing the CONCENTRATION of oxygen: eg, for inerting an empty tank (or dry-bay) one could decrease the O2-concentration from 20% to 10% (using increased concentration of N2).
Lesson from various inflight fires teach us:
-- Hot-SMOKE accumulated in the fuselage-crown [stacking downward toward the cabin floor] will become the most flammable substance onboard. SMOKE BURNS!!!
-- Generally, for smoke removal, our normal Outflow Valve should be up HIGH, not beneath the cabin floor [or instead design-in a smoke-chute with the intake in the ceiling-crown area].
"... at FL250 ... there would not have been enough oxygen to sustain combustion ..."
This mis-perception, and the idea of "turning OFF the Packs to suffocate any fire", have been recurring pilot-assertions. An erroneous assertion.
Combustion could be slowed by decreasing the CONCENTRATION of oxygen: eg, for inerting an empty tank (or dry-bay) one could decrease the O2-concentration from 20% to 10% (using increased concentration of N2).
Lesson from various inflight fires teach us:
-- Hot-SMOKE accumulated in the fuselage-crown [stacking downward toward the cabin floor] will become the most flammable substance onboard. SMOKE BURNS!!!
-- Generally, for smoke removal, our normal Outflow Valve should be up HIGH, not beneath the cabin floor [or instead design-in a smoke-chute with the intake in the ceiling-crown area].
Last edited by IGh; 5th Apr 2011 at 14:24.
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Also... If they had followed the checklist and stayed at FL250 for a while there would not have been enough oxygen to sustain combustion and the fire would have gone out?
However that would not be an option if they did not have oxygen to the masks.
Last edited by 742; 5th Apr 2011 at 16:33. Reason: wording
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I would like to see proper mask and communications system installed. I have first hand experience with the crappy set-up in the 744, and it truly is inadequate.
Every time I put the mask on in the sim we end up with the same communications problems - loud breathing and venting noise picked up by the mask microphone and amplified over the cockpit speaker making conversation between the crew extremely hard.
Then you also end up with a fogging goggle which you have to lift off your face to clear (yeah, I know, use the venting button but it doesn't work in the sim, which has the same masks as the aircraft) Granted, the sim uses compressed air with moisture, and the aircraft uses oxygen that is very dry, so maybe it would not be a problem in the aircraft.
I think the short term solution would be to install a cockpit smoke door that isolates the flight deck. I've also wondered if the smoke barrier door was properly closed. I always make a point of checking this door to make sure it is properly closed. Ground staff are always very lax about making sure the door is properly closed. They often place it in the jamb but fail to use pressure to actually hear it click. This then results in the door flying open during rotation.
I really do feel for these guys, the speed at which it all turned ugly is quite alarming. While I contend that Doha was the nearest, when looking at your ND and comparing those two blue circles, the difference between 100 and 148 is not much, especially when you can barely look at your instruments.
Everyone can make the decision sitting on their couch in a comfortable room, but these guys made this decision while their eyes were burning from smoke, they had problems breathing, and they were loosing sight of instruments and controls that were at arms reach. Not to mention starting to loose control effectiveness.
I really can't fault them for choosing Dubai. If they ended high with 150 miles to run to an airport they knew, then they would have probably ended up higher into Doha and had to circle as well.
Every time I put the mask on in the sim we end up with the same communications problems - loud breathing and venting noise picked up by the mask microphone and amplified over the cockpit speaker making conversation between the crew extremely hard.
Then you also end up with a fogging goggle which you have to lift off your face to clear (yeah, I know, use the venting button but it doesn't work in the sim, which has the same masks as the aircraft) Granted, the sim uses compressed air with moisture, and the aircraft uses oxygen that is very dry, so maybe it would not be a problem in the aircraft.
I think the short term solution would be to install a cockpit smoke door that isolates the flight deck. I've also wondered if the smoke barrier door was properly closed. I always make a point of checking this door to make sure it is properly closed. Ground staff are always very lax about making sure the door is properly closed. They often place it in the jamb but fail to use pressure to actually hear it click. This then results in the door flying open during rotation.
I really do feel for these guys, the speed at which it all turned ugly is quite alarming. While I contend that Doha was the nearest, when looking at your ND and comparing those two blue circles, the difference between 100 and 148 is not much, especially when you can barely look at your instruments.
Everyone can make the decision sitting on their couch in a comfortable room, but these guys made this decision while their eyes were burning from smoke, they had problems breathing, and they were loosing sight of instruments and controls that were at arms reach. Not to mention starting to loose control effectiveness.
I really can't fault them for choosing Dubai. If they ended high with 150 miles to run to an airport they knew, then they would have probably ended up higher into Doha and had to circle as well.
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Glueball - like Sqwak, and unlike you, I was not wishing to imply any criticism of the crew's decision in my post, but like Sqwak to show (from my smoke-free couch) what the thinking may have been.
Sqwak7700 wrote...
"I really can't fault them for choosing Dubai. If they ended high with 150 miles to run to an airport they knew, then they would have probably ended up higher into Doha and had to circle as well".
You are correct that second guessing the crew is easy when sitting at home behind a computer.
Without second guessing the crew about the airport choice or other decisions they took, what strikes me from the initial report, aside from the fire itself was the apparent problems the crew had with their O2 system and that there is a very strong possibility that the captain never made it back to his position behind the controls leaving the aircraft and its problems to be handled and dealt with by a very low time F/O on type.
If this is the case then it is no wonder that things went from very bad to worse awfully fast. Trying to navigate, communicate, fight a fire, a possible flight control problem and lack of O2 probably in the end, overwhelmed the F/O as they would have most other pilots trying to fly and land a crippled 747 bearing in mind he was effectively in a “single pilot operation”.
"I really can't fault them for choosing Dubai. If they ended high with 150 miles to run to an airport they knew, then they would have probably ended up higher into Doha and had to circle as well".
You are correct that second guessing the crew is easy when sitting at home behind a computer.
Without second guessing the crew about the airport choice or other decisions they took, what strikes me from the initial report, aside from the fire itself was the apparent problems the crew had with their O2 system and that there is a very strong possibility that the captain never made it back to his position behind the controls leaving the aircraft and its problems to be handled and dealt with by a very low time F/O on type.
If this is the case then it is no wonder that things went from very bad to worse awfully fast. Trying to navigate, communicate, fight a fire, a possible flight control problem and lack of O2 probably in the end, overwhelmed the F/O as they would have most other pilots trying to fly and land a crippled 747 bearing in mind he was effectively in a “single pilot operation”.
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If this is the case then it is no wonder that things went from very bad to worse awfully fast. Trying to navigate, communicate, fight a fire, a possible flight control problem and lack of O2 probably in the end, overwhelmed the F/O as they would have most other pilots trying to fly and land a crippled 747 bearing in mind he was effectively in a “single pilot operation”.
I think the environment was so harsh that it made even simple tasks like switching frequencies impossible. That is very worrying. When you take this into account, then you realize he could not see the FMC, could not see the MCP, and certainly could not look out the window. Bearing that in mind, he did an incredible job of getting so close to almost landing on the first attempt.
The possibility of the O2 failing is quite disturbing as well. The crew bottles are all located in the right side, I believe in front of the forward lower lobe cargo door. They are not in the main deck, but the oxygen lines certainly run by the side-walls to get up to the flight deck.
From an engineering perspective, I guess it is good to have them down low and all in the same place. But everything in aviation has backups, should they all be grouped together? Maybe a little redundancy is in order with separate systems for CA and FO.