Preliminary Report of Boeing 747-400F Fatal Accident, Dubai -3Sep10
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121.337 Protective breathing equipment.
There is still that weakness, in the wording, of FAR 121.337, "Protective breathing equipment": There is NO REQUIREMENT for any O2 supply for pilots after landing (with smoke-filled cockpit), while attempting self-extraction from a cockpit with NO pilot's Sliding Window [eg, B747].
The current cockpit "PBE" (caution mixed definitions evolved with FAR employing "PBE" in varying contexts) re' the smoke-hood next to the Extinguisher, is required only for ONE guy (during fire fighting). No rule to provide any O2 during egress, after landing.
There are Safety Rec's on this subject, not clearly focused on specific weaknesses, recurring citations since 1996 ValuJet investigation.
AAR98-03 [FedEx Sep96] Pg60, re' self-extraction after landing:
UPS 1307 / 7Feb06 DC8-71F N748UP, inflight smoke, PHL, post landing fire; from NTSB/AAR-07/07, pg 21+:
The current cockpit "PBE" (caution mixed definitions evolved with FAR employing "PBE" in varying contexts) re' the smoke-hood next to the Extinguisher, is required only for ONE guy (during fire fighting). No rule to provide any O2 during egress, after landing.
There are Safety Rec's on this subject, not clearly focused on specific weaknesses, recurring citations since 1996 ValuJet investigation.
AAR98-03 [FedEx Sep96] Pg60, re' self-extraction after landing:
… During the evacuation, the flight engineer stated that before he entered the foyer area to evacuate via the R1 door, he filled his lungs with oxygen from his oxygen mask. He did not use the PBE, which would have provided him with protection from the smoke while he attempted to open the foyer doors. In post accident interviews, he stated that he was anxious to open the exit doors quickly, and he forgot that the PBE was available. The Safety Board concludes that crew-members who do not use PBE during a smoke or fire emergency may place themselves at unnecessary risk in attempting to ... escape ... Although most carriers’ emergency evacuation checklists instruct crewmembers to don PBE when circumstances warrant, there is no reference to the PBE in the FedEx “Emergency Evacuation” checklist. Therefore, the Safety Board believes that the FAA should require FedEx to modify its evacuation checklist and training to emphasize the availability of PBE during evacuations in an environment containing smoke, fire, or toxic fumes....
[Note that for both the Saudia and the '96 FedEx exemplar, at the time of the landing, neither cockpit had yet accumulated significant smoke-density.]UPS 1307 / 7Feb06 DC8-71F N748UP, inflight smoke, PHL, post landing fire; from NTSB/AAR-07/07, pg 21+:
1.15.1 Emergency Evacuation
After the airplane landed … checklist … proceeded to evacuate … the flight engineer stated that he took a breath of oxygen from his mask before … then went to open the L1 door. … reached down and deployed the L1 door slide and evacuated … then yelled back … slide was “good.”
The first officer … leaned out his window to get fresh air but that he inhaled smoke. … transmitted to the ATCT … evacuating … the smoke was so heavy that he could not see his hand in front of him … proceeded to … L1 door slide while black smoke was rolling out of the door. … after he evacuated … he could see black smoke billowing out of the windows and the door but that there were neither flames nor heat….
After the airplane landed … checklist … proceeded to evacuate … the flight engineer stated that he took a breath of oxygen from his mask before … then went to open the L1 door. … reached down and deployed the L1 door slide and evacuated … then yelled back … slide was “good.”
The first officer … leaned out his window to get fresh air but that he inhaled smoke. … transmitted to the ATCT … evacuating … the smoke was so heavy that he could not see his hand in front of him … proceeded to … L1 door slide while black smoke was rolling out of the door. … after he evacuated … he could see black smoke billowing out of the windows and the door but that there were neither flames nor heat….
Last edited by IGh; 13th Apr 2011 at 17:46.
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NTSB report and recommendations on oxygen and comms
PPRuNe Towers: that is a sobering read. 
Training and practice with protective gear is what you fall back on when, all of a sudden, you need to use it.
NTSB recommendations will be, one hopes, acted upon with alacrity.
Training and practice with protective gear is what you fall back on when, all of a sudden, you need to use it.
NTSB recommendations will be, one hopes, acted upon with alacrity.
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It is hard to believe that the training, in the use of the emergency equipment, was so deficient.
There is limited time for training. The trainee has a limited mental space and attention span. Thus the focus of training is on tasks that happen either with regularity or predictability. Training for events which happen rarely slide.
Then there is the temptation to train towards the last accident. Pilots need more training in fire/smoke events...oh wait, they need more hand flying time, etc. It's rare for an accident report to come out these days without a recommendation that the pilot needs more training on something.
AFAIS the real take away message from this report is that when fire/smoke events happen the industry needs to do a better job of reducing task load. As one pilot said "there is just too much coming together at once." It's the same old story of complex systems interacting in complex ways.
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Thing is, what chemicals are in your brain affecting your decision making during a major fire? A few antibiotics will give me brain fog never mind lithium battery fumes... do you think of they were put back in the sim they would have made the same or different choices?
We are given minimal emergency training ( and I'm my company it's in the middle of the night for me). People can react to a real life or death situation in many ways ( military pilots have usually been there done that and know how they will be . Civilians may or may not. )
Their choices must have been the best they could with what they had which wasn't much.
We are given minimal emergency training ( and I'm my company it's in the middle of the night for me). People can react to a real life or death situation in many ways ( military pilots have usually been there done that and know how they will be . Civilians may or may not. )
Their choices must have been the best they could with what they had which wasn't much.
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Interim report released:
http://www.gcaa.gov.ae/en/ePublicati...%20Rev%201.pdf
It really should be read carefully. I know that many of us knew of the gist of what was coming after reading the NTSB report into masks and training for their use but it really doesn't make the interim report any easier to work through.
Rob
http://www.gcaa.gov.ae/en/ePublicati...%20Rev%201.pdf
It really should be read carefully. I know that many of us knew of the gist of what was coming after reading the NTSB report into masks and training for their use but it really doesn't make the interim report any easier to work through.
Rob
Sobering Read !
However, some very interesting details:
Oxygen mask of Captain reportedly set to 100%, F/O to Normal.
strangely the effect appeared to be inverse. Captain complained much earlier and more explicitely about oxygen problem than F/O who remained conscious another 21 minutes after the CPT leaving the cockpit to apparently get himself the portable oxygen.
Both did not activate emergency setting in their masks.
Fire location was worryingly close to oxygen system. (That is something to be seriously considered in future for loading flammable materials IMHO).
Flight controls were compromised almost instantly after the fire warning pointing to a rather intense fire from the beginning.
Effects did not deteriorate much after that, i.e. no slow progessive failure of controls, pointing to no significant increase of fire intensity after intial event.
Unfortunately the effects on the controls were much more severe on the F/O side (explaiined in the report by the fact that only on the CPT side there is a tension regulator in the fwd quadrant - why is there none on the F/O side?)
seems to be an unfortunate coincidence: Oxygen system more compromised on CPT side, control system more compromised on F/O side.
Very interersting is the cargo list of that flight. The amount of batteries on that flight is amazing. There seems to not have been much on that plane without batteries...
The fact that the fire appears to have started/ progresssed very quickly and intensely at the beginning points towrads a rather big load of similar and highly combustible items to have been the initial ignition source, therefore items 7, 8 and 13 would be of special interest.
Of these the LiFePo are normally not considered very susceptible to fire. They are normally considered to be among the safest of the Lithium based batteries. Which would from my POV put item 7 in the focus out of those defiend as items of special interest.
Although I'm not to sure a 4S4P pack would be sufficient to cause that much damage that quickly with the oxygen available at 32kft.
(I've seen bigger packs burn in model boats and while I wouldn't want to sit on top of that the amount of fire was merely sufficient to burn a small hole into the plastic hull but would have hardly melted any metal around it, e.g. steel control cables).
Edit: After reading the report again I saw that there appear to have been 50 of these 4s4p packs.
That would be defintiely a serious volume!
Having that in mind you can probably skip what I wrote about item 7 probably not being sufficient and not being prime suspect.
For me now it probably would be one of the prime suspects, especially since the location also seems to match to the likely area of the fire origin.
/Edit
On the other hand some high volume shipments did not make it onto the list of interest. For instance the ULD on 10L: There were reportedly 820 2s 1,9Ah LiIon cells. That would be a SERIOUS volume of combustible material. I have got no idea why it did not make it on the list. Likewise the 250 LiPo batteries also in 10L.
Therefore I'm not 100% convinced they highlighted the right items.
If I got it right the criterion to make it on the list was that something was not right with the declaration. Maybe wrong declaration was not the main culprit here?
However, some very interesting details:
Oxygen mask of Captain reportedly set to 100%, F/O to Normal.
strangely the effect appeared to be inverse. Captain complained much earlier and more explicitely about oxygen problem than F/O who remained conscious another 21 minutes after the CPT leaving the cockpit to apparently get himself the portable oxygen.
Both did not activate emergency setting in their masks.
Fire location was worryingly close to oxygen system. (That is something to be seriously considered in future for loading flammable materials IMHO).
Flight controls were compromised almost instantly after the fire warning pointing to a rather intense fire from the beginning.
Effects did not deteriorate much after that, i.e. no slow progessive failure of controls, pointing to no significant increase of fire intensity after intial event.
Unfortunately the effects on the controls were much more severe on the F/O side (explaiined in the report by the fact that only on the CPT side there is a tension regulator in the fwd quadrant - why is there none on the F/O side?)
seems to be an unfortunate coincidence: Oxygen system more compromised on CPT side, control system more compromised on F/O side.
Very interersting is the cargo list of that flight. The amount of batteries on that flight is amazing. There seems to not have been much on that plane without batteries...
The fact that the fire appears to have started/ progresssed very quickly and intensely at the beginning points towrads a rather big load of similar and highly combustible items to have been the initial ignition source, therefore items 7, 8 and 13 would be of special interest.
Of these the LiFePo are normally not considered very susceptible to fire. They are normally considered to be among the safest of the Lithium based batteries. Which would from my POV put item 7 in the focus out of those defiend as items of special interest.
Although I'm not to sure a 4S4P pack would be sufficient to cause that much damage that quickly with the oxygen available at 32kft.
(I've seen bigger packs burn in model boats and while I wouldn't want to sit on top of that the amount of fire was merely sufficient to burn a small hole into the plastic hull but would have hardly melted any metal around it, e.g. steel control cables).
Edit: After reading the report again I saw that there appear to have been 50 of these 4s4p packs.
That would be defintiely a serious volume!
Having that in mind you can probably skip what I wrote about item 7 probably not being sufficient and not being prime suspect.
For me now it probably would be one of the prime suspects, especially since the location also seems to match to the likely area of the fire origin.
/Edit
On the other hand some high volume shipments did not make it onto the list of interest. For instance the ULD on 10L: There were reportedly 820 2s 1,9Ah LiIon cells. That would be a SERIOUS volume of combustible material. I have got no idea why it did not make it on the list. Likewise the 250 LiPo batteries also in 10L.
Therefore I'm not 100% convinced they highlighted the right items.
If I got it right the criterion to make it on the list was that something was not right with the declaration. Maybe wrong declaration was not the main culprit here?
Last edited by henra; 12th Nov 2011 at 12:00. Reason: Reread report: Quantity of LiPos mistaken
