SQ-368 (engine & wing on fire) final report out

[PAXboy]

If there was a fuel leak, it would have had to have been small. They were 2 hours out when they turned back and (it appears) fuel did not show as a problem. Whilst evaluating how much to dump, they would have checked levels closely and a leak should have shown up.

So, again, the question might be: If it's only an oil leak, should you have RFF waiting for you ... Whatever the current thinking is, it will now change, at least at SQ.

[A0283]

I thought that the 1985 Manchester 737 disaster had provided the global aerospace community with the following clear main lessons:

1. When a fire is detected (or even 'reasonably assumed'),
2. The pilots have to:
2.1 stop the plane as fast as they can, right where they are, so NO turning off the runway and certainly NO taxiing,
2.2 have to take into account the wind direction on the ground in deciding the heading at that stop !!
2.3 mayday,
3. Immediately prepare for and order the evacuation,
4. ...

Later 'airborne fire' related accidents have added:
1. Take all actions required to land at the nearest airport, even consider 'any reasonable' airport instead of back to the origin or planned alternate, even if that has less fire fighting equipment and services,
2. Go to the list above on landing,

This both for inside and outside fires.
The Saudi and cargo plane cases can be used for example to check the items above.

Based on this I just don't understand why they did not immediately evacuate. And think they were all very very very lucky.

Important question is - did they take the wind direction into account. Or was this just plain luck too. Losing just one window or a small hole in the fuselage ... Read the Manchester report for example.

[212man]

So, again, the question might be: If it's only an oil leak, should you have RFF waiting for you

They were waiting - you can see them in the video, and in the newspaper interview with the passenger she states they were.

[notapilot15]

I seriously doubt fire rescue was waiting, they would be much closer standing by.

There is one fire station to their left on Changi Road. But initial response came from terminal side using rapid taxiway in the opposite direction, making it a long drive.

Off-road or not, they were driving very slow on the pavement, as if they were positioning.

[rog747]

re fire service already waiting ----

another post here states that the AFS were already going out to another job and were immediately diverted to the landing SQ 777 which had just caught fire as it rolled out and they chased it as it as it was slowing
but note they were spraying foam on target within 1 min 07 secs of the aircraft coming to a full stop

at 1 min 14 secs a second foam appliance starts spraying
and at 2 min 45 sec a third one sprays rather much more effectively from behind the wing and at just under 3 mins the fire is still alight albeit much smaller & seemingly getting under control - however at this point everyone could have been off down the left chutes

had the AFS NOT been well on their way already to 777 as she was slowing to a stop and were another minute longer then the huge fire pooling under the aircraft in my opinion would have seen a very different outcome - pure luck the fire service was already on a shout and were half way to the runway as they were called to attend the 777

if they had had to wait for the fire crews and engines to be readied and started up and leave the fire station then the 777 would have been well on fire by the time they had got there

the SQ crew had given a negative reply on descent to ATC if they wanted the emergency services waiting for their the return to Changi

[Orange future]

Its interesting to read several posters here suggesting that remaining onboard may be a safer option during an external fire than evacuating pax into a hazardous situation. I guess it puts a lot of faith in the RFF.

The various training events/sims/crm's etc I have been involved in with several airlines over the years have only ever trained to evacuate in the event of fire.

Can someone point me in the direction of some study/document/guidance/publication that argues that it may be safer in some circumstances to remain onboard? When exactly is a fire considered under control?

I first became aware of this line of thinking when reading the report into the QF 380 incident in SIN. Apparently the skipper did no want to evac the pax because of the possibility of fire breaking out. But isnt that the exact reason you would WANT to evacuate?

[Piltdown Man]

...have only ever trained to evacuate in the event of fire.

Unfortunately, this is the case for most of us. But I believe a 'one-size-fits-all' approach to fire is not appropriate. An evacuation is one possibility, sitting tight is another. The important thing is that for the former to be a viable solution you need to have information about the location and extent of your fire and have faith in the RFF crew attending.

But isn't that the exact reason you would WANT to evacuate?

Yes and no. The basic problem is that it is very difficult for the fire crews to put out fires whilst people are evacuating an aircraft. At a CAT 10 airport foam is capable of being discharged at a rate in excess of 11,000 litres per minute. That may have to stop to prevent evacuating passengers from being injured, thus jeopardising those still on board. Fire or frying pan?

PM

[PAXboy]

The only certainty is that the Changi RFF are good.

Looking again at the China 120 at Naha, the video recording is at 4.29 before the first appliance shows up and the 738 was well alight before the recording starts. To be fair, once they are on site, they operate extremely well and contain the fire within the first two minutes.

[BugSmasher1960]

Originally Posted by Orange future

I first became aware of this line of thinking when reading the report into the QF 380 incident in SIN. Apparently the skipper did no want to evac the pax because of the possibility of fire breaking out. But isnt that the exact reason you would WANT to evacuate?

From the captain of that flight's book:

"Behind me, one of the pilots asked why we weren't doing an emergency evacuation. It was a good question. We looked at all the threats and considered all our options, and we ultimately came to a conclusion and I made the decision. My decision was simple: where are the passengers safest right now; inside or outside? Given the current situation with no fire I thought the passengers and crew were safer inside the fuselage than evacuating down the slides onto the dangerous runway.

We had wheelchair passengers and babies onboard, and I knew the elderly passengers would be injured descending the slides and some would break their legs and hips as the slid to the bottom of the steep evacuation slides. Other passengers in a panic would jump from the aircraft, down the same slides, the concertina into the injured. I figured that 5% of the passengers would have fractures escaping from the lower deck slides, 10 percent from the upper deck slides; that would equate to 30 fracture cases with our 440 passenger load. But it gets worse. The passengers who survived the slides would run the risk of slipping over on fuel or foam, or could become confused and walk in front of engine 1 that was still running and be sucked into it. Passengers who had survived to this stage might walk through jet fuel, creating a spark or taking flash photography and igniting the fuel. Even if all passengers did get off safely, then we would have the dangerous situation of all the passengers being outside and all the supervising staff being inside the aircraft. Who would be monitoring the passengers at this time? A friend of mine commanded an evacuation of his aircraft in Osaka. After the passengers cleared the slides they ran away from the aircraft and some ran on to an active runway where a Boeing 747 was making another emergency landing.

We had a discussion rather than an argument about it. Harry pointed at the last images to display: the wheels on the left body landing gear had reached 900 deg C - they were getting hotter, but there was no fire."

[HamishMcBush]

Off-road or not, they were driving very slow on the pavement, as if they were positioning.

Probably because they had been advised that the plane had already radioed in to say that emergency services were not required on landing. At that time, little did anybody know that just after touching down a fire would start. Maybe with an update that the AFS were already "in action" on the ground, the decision was made that it would be safer to keep all PAX onboard so that the fire could be tackled with maximum effect and without having to worry about stray (and possibly disoriented) people around the plane.

Full details of the whole drama are needed before we can criticise or commend those on the flight deck for not ordering an evacuation

[SloppyJoe]

You have got to be kidding right? Look at the picture taken by a passenger on the first page of this thread.

I really hope you are not in a job where making any sort of critical decision is required.

[tonytales]

Let me write as a Tech Manager who personally stopped and evacuation:
An EAL DC8-51 had a RMLG downlock failure coming into KJFK. I went out to a runway with the NY Port Authority Fire Chief and viewed a flypast with binoculars and saw the right gear swinging free. So a landing was planned. Crash trucks all lined up and I with the Fire Chief at approach end of the runway. It was then I realized, to avoid blocking the active, they were landing on a runway with a stiff crosswind that was blowing the aircraft toward the bad gear. I protested to the Chief but things were all gelled.
The aircraft went by us and we turned and followed it at full bore. A/C touched smoothly, rolled for a bit and then the RMLG walked in under the fuselage and down she went on Nbr. 3 and 4 engines still going at a fair rate of speed.
Sparks, smoke bits but the plane stayed straight and as it came to a stop Nbr 4 engine decided to catch fire. By then the PONYA fire people had caught up and the engine disappeared under a mountain of foam. I mean that literally.
I jumped out of the car and saw the chutes properly coming out on the port (windward) side and none on the fire side. However, the stiff wind blew them under the fuselage before they really inflated so essentially, there was no usable chute as they were curled under the fuselage. I happened to be Chief of my local volunteer fire department so had some understanding of when a fire is out. I looked up and saw (a DC-8 was a tall aircraft) that it was impossible to use them chutes but I could see the pax upstairs were ready to go. A Flight Attendant was in the door looking horrified. I waved my arms, screamed at them - "Stay - Stay - there is no fire". - I was at the aft slide, I ran forward and stopped the forward evacuation too, they had the same problem. Some people were on the wing and I yelled for them to stay there, no danger.
Later, the Fire Chief asked me if I had the authority to stop an evacuation. I told him I was the Senior Ground Person (a General Foreman) from Eastern Air Lines on the ground and that he would have had dead bodies or extreme trauma victims now if I hadn't stopped them.
Each situation is unique. You have to use some judgment. However if there had been an active fire (say a puncture in the wing feeding fuel) I would have grabbed the bottom of the chutes and pulled them out to the port side so they could have been used.
Staying in a plane with an exterior fire is daft unless the exterior fire surrounds the aircraft. Then you can only pray the fire service can make a path.
And I say God Bless the Fire Services.

[Stu B]

Seems a good reason for installing fin-mounted (and other) external surveillance cameras so the Captain has the best possible understanding of what is really happening outside.

[BugSmasher1960]

Originally Posted by tonytales

Staying in a plane with an exterior fire is daft unless the exterior fire surrounds the aircraft.

Perhaps.

Would it still be daft to initiate an evacuation if you had grounds to believe there was more than a slight chance of fire surrounding the slides before everyone could have been evacuated?

In the situation where the captain knew there was a fire - had every reason to conclude that it was due to leaking fuel (which spreads on ground contact) - knew that help from an extremely capable response unit was around a minute away - why is it not a logical decision to use the short-term safety of the cabin knowing that (a) rescue services are capable of delivering a mother-load of foam on the fire and (b) knowing that rescue services will prioritize the safety of the evacuees should they need to leave the safety of the cabin?

In summary:

EVACUATION:

- Known fuel leakage

- Rescue services not on scene yet

- Unknown if passengers will be engulfed in pool of burning fuel before evacuation completed

- Unknown if opening door will expose them to more danger

NON-EVACUATION

- Known that hull is sealed and can provide short-term protection

- Known that extremely capable rescue services are seconds away.

End of the day it's a judgement call. Risks either way. In the case of a cabin / cargo fire then for sure - get the heck out of there. In the case of a wing fire - not necessarily that cut and dried IMHO. If anything that Chinese example impressed me as to how well the cabin held up for quite some time; one of the big differences there being the length of time it took for rescue services to start the foam.

[YRP]

Originally Posted by notapilot15

I seriously doubt fire rescue was waiting, they would be much closer standing by.

There is one fire station to their left on Changi Road. But initial response came from terminal side using rapid taxiway in the opposite direction, making it a long drive.

Off-road or not, they were driving very slow on the pavement, as if they were positioning.

It is really hard to judge speed in a video taken from such a low angle. Something can cover a lot of distance in the towards/away from camera direction without much change in angular position.

I'll bet they was motorin' it.

[ACMS]

Stu B:--- It's been said before many times but I'll say it again.
The 777-300ER IS fitted with a ground manoeuvre camera system that allows the crew to see the inboard section of the right wing. They would have been able to see that fire ok. Unless the GMCS was inop.......

[armchairpilot94116]

Remaining on this Ci plane and waiting for the trucks to put out the fire wouldn't have worked. There is very little time to spare when on fire.


https://www.google.com/search?q=pict...H204bx0S9FM%3A


image upload no compression



Perhaps it should be standard procedure in an EMERGENCY / NON STANDARD landing to :

1. Come to complete stop on runway ASAP. No bothering exiting the active.
2. Shut all engines immediately.
3. Assess Situ, no fire, sit tight till Fire and Rescue can examine the aircraft.
4. Fire? EVAC ASAP even before Fire equipment arrive, at the first notice of fire, from Tower, Cabin Crew, Ground crew.

[CodyBlade]

I concur.
One cannot invent own SOP.

[PAX_Britannica]

Analysis of QF32 evacuation decison ?

Originally Posted by BugSmasher1960

From the captain of that flight's book:

"Behind me, one of the pilots asked why we weren't doing an emergency evacuation. It was a good question. We looked at all the threats and considered all our options, and we ultimately came to a conclusion and I made the decision. My decision was simple: where are the passengers safest right now; inside or outside? Given the current situation with no fire I thought the passengers and crew were safer inside the fuselage than evacuating down the slides onto the dangerous runway.

We had wheelchair passengers and babies onboard, and I knew the elderly passengers would be injured descending the slides and some would break their legs and hips as the slid to the bottom of the steep evacuation slides. Other passengers in a panic would jump from the aircraft, down the same slides, the concertina into the injured. I figured that 5% of the passengers would have fractures escaping from the lower deck slides, 10 percent from the upper deck slides; that would equate to 30 fracture cases with our 440 passenger load. But it gets worse. The passengers who survived the slides would run the risk of slipping over on fuel or foam, or could become confused and walk in front of engine 1 that was still running and be sucked into it. Passengers who had survived to this stage might walk through jet fuel, creating a spark or taking flash photography and igniting the fuel. Even if all passengers did get off safely, then we would have the dangerous situation of all the passengers being outside and all the supervising staff being inside the aircraft. Who would be monitoring the passengers at this time? A friend of mine commanded an evacuation of his aircraft in Osaka. After the passengers cleared the slides they ran away from the aircraft and some ran on to an active runway where a Boeing 747 was making another emergency landing.

We had a discussion rather than an argument about it. Harry pointed at the last images to display: the wheels on the left body landing gear had reached 900 deg C - they were getting hotter, but there was no fire."

Unless I missed something, the ATSB QF32 report is very thin on the subject of the evacuation decision, focussing almost entirely on the oil feed stub pipe.

All we seem to get is:

Originally Posted by Aviation Safety Investigation Report 089

The crew’s decision to perform a precautionary disembarkation via the stairs likely provided the safest option, particularly given the low immediate safety threat and the elevated risks associated with an emergency evacuation into a potentially hazardous external environment.

Is there any more detailed review out there ?

P.s. - I mean: There is more discussion in the report of what was done, but not so much evaluation of what was done.

[lurker999]

QF32 never had a fire and had an engine that couldnt be shutdown.

seems a fair enough decision not to order an evac.


this aircraft had most of one wing burning. i cant see many similarities here.