UPS 747 Dubai Final Report
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Findings
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.
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.
Last edited by F111UPS767; 24th Jul 2013 at 14:13.
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Causes and Contributing Factors
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.
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.
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Safety Recommendations
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.
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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.
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.
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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.
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.
Last edited by JammedStab; 24th Jul 2013 at 21:00.
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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.
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.
Very tragic.
Last edited by BuzzBox; 25th Jul 2013 at 00:06.
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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.
For what it's worth:
Doha Diversion:
Ditching:
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.
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.
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.
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.
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Hi,
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
This exercise was inconclusive.
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
Last edited by jcjeant; 24th Jul 2013 at 23:30.
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
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
A350 provision for parachute exit on initial test
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.
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.
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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
Extinguishing In-Flight Laptop Computer Fires - Lithium Battery Thermal Runway - YouTube
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Just sad...
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.
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.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.
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.
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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)).
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.
What astonishes me even more is the document referred to in the report, the FAA/Transport Canada cargo aircraft fire risk model (here (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.
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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!
is any action being taken against the shippers who did not properly declare their consignment? i should hope so!