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-   -   UPS 747 Dubai Final Report (https://www.pprune.org/rumours-news/519857-ups-747-dubai-final-report.html)

DozyWannabe 1st Aug 2013 19:51


Originally Posted by last747fe (Post 7968785)
I was overseas when this accident Happened and for many months was devastated thinking had I been there as a PFE It might of had a different outcome. After reading this excellent prepared report, I now see that for sure there would have been 3 dead crew members.

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

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

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

Sqwak7700 1st Aug 2013 20:39


Not the appropriate forum but do you want to substantiate the above claim?
Yeah, gladly. Name one measure the FAA has put in place to mitigate fatigue? You do know that fatigue shows up in almost all accident reports as being a factor. Has been this way for a long time. Was part of the Colgan/continental Q400 and I'm sure it will be part of the Asiana report as well.

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

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

egravitics 3rd Aug 2013 05:53

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

The FAA has 135 fire/smoke incidents with batteries classed as the cause, on or in the vicinity of aircraft between March 1991 through July 2013 (report).

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

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

Mr Angry from Purley 4th Aug 2013 15:19


Yeah, gladly. Name one measure the FAA has put in place to mitigate fatigue? You do know that fatigue shows up in almost all accident reports as being a factor. Has been this way for a long time. Was part of the Colgan/continental Q400 and I'm sure it will be part of the Asiana report as well.
Colgan - was that the FAA rules or commuting / sleeping habits of crewmembers?. Will the FAA have the balls to look at commuting?
Asiana - sleepiness maybe, jury is out on fatigue though.

BOAC 4th Aug 2013 15:29


jury is out on fatigue though
- I would be very surprised if it was even a factor in this accident.

ZFT 4th Aug 2013 17:20

Givemewings


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


Unfortunately neither EASA nor FAA regulations mandate them.

barit1 4th Aug 2013 20:12

This may be too outlandish a concept for a profit-minded freight carrier, but nothing ventured, nothing gained:

The F-111 had an escape module that might look attractive to a 74F crew. The whole cockpit flies up and away from the unrecoverable aircraft.

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

flyboyike 5th Aug 2013 01:50

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

StormyKnight 5th Aug 2013 05:11

Even a parachute & a escape shoot may be enough like the one added to the 727 desert test crash aircraft.

JammedStab 5th Aug 2013 05:24


Originally Posted by Mr Angry from Purley (Post 7976198)
Colgan - was that the FAA rules or commuting / sleeping habits of crewmembers?. Will the FAA have the balls to look at commuting?

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

mutt 5th Aug 2013 06:07


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

JammedStab 5th Aug 2013 09:19


Originally Posted by Sqwak7700 (Post 7972099)
You do know that fatigue shows up in almost all accident reports as being a factor. Has been this way for a long time. Was part of the Colgan/continental Q400 and I'm sure it will be part of the Asiana report as well.

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

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

Capn Bloggs 5th Aug 2013 12:12


What is there to look at in commuting. Thousands do it every day.
Like she did? You should be thrown in jail for being irresponsible. :ouch:

JammedStab 5th Aug 2013 12:38


Originally Posted by Capn Bloggs (Post 7977402)
Like she did? You should be thrown in jail for being irresponsible. :ouch:

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

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

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

Capn Bloggs 5th Aug 2013 13:36

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

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

birdstrike 5th Aug 2013 15:27

I think there is a bit of hypocrisy going on here.

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

but

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

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

flyboyike 5th Aug 2013 17:37


Originally Posted by JammedStab
While I am all for better rules to lessen fatigue, I have a great deal of difficulty believing that the Colgan accident had much to do with fatigue...

That's funny, I have no such difficulties.

tdracer 8th Aug 2013 20:59


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

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

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

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

givemewings 8th Aug 2013 23:46

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

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

tdracer 9th Aug 2013 04:42


Stormy, it's been awhile since I watched that doco on the desert crash test, but I don't think they added anything to that 727- those stairs were standard fit on that model... they just modified it to allow deployment in flight (or was it removed altogether- need to watch again)
The aft stairs on the 727 were never intended to be operable 'in-flight', but pre-D.B. Cooper there was nothing to prevent their deployment in-flight (I recall the DC-9 having a similar setup). After the D.B. Cooper hijacking, a fix was implemented to prevent in-flight deployment. It was super simple - basically a spring loaded weather-vane that would rotate with free-stream airflow and block the door from opening (again, memory says a similar fix was implemented on the DC-9). Naturally this became known as the "D.B. Cooper fix" :).

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

stilton 9th Aug 2013 05:23

Actually the stairs were completely removed.

peakcrew 9th Aug 2013 20:18

This is a fascinating thread. I am very impressed by the standard of the report, and how little the thread has deviated.

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

So, what am I missing?

sludge 9th Aug 2013 20:41

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

Pinkman 9th Aug 2013 20:49

747 Cargo Space Isolation
 

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

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

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

peakcrew 9th Aug 2013 21:37

Thanks, Pinkman. I'll have a look at that. Sorry to hear about your friend - it can't be easy for you or him to be reading this now.

Pope Mobile 9th Aug 2013 23:11

Sludge,
I wondered about that too. Was that from breathing in the fumes in the cockpit?

Astrosfan 9th Aug 2013 23:38


The Captains blood sample was positive for ethylalcohol with a concentration of (11 mg/dl). ????
From p. 96 of the report:

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

BuzzBox 10th Aug 2013 00:42


...their report states that the ethanol reported in these cases are from post-mortem ethanol formation and not from the ingestion of ethanol.
Further to that:


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

Many species of bacteria, yeast and fungi produce ethanol and other volatile organic compounds as a byproduct of their metabolism. Candida albicans has been identified as the microbe most often responsible for postmortem production of ethanol in humans. This species of yeast is commonly found in humans in vivo. However, microbes not normally found in vivo, such as the Mucor species of mold, are commonly found in decaying organic matter and soil; they may be introduced from the environment if the circumstances surrounding death are violent, as is often seen in aviation accidents. After death, endogenous and/or exogenous microbes begin rapidly consuming glucose and other nutrients present in the body and produce ethanol and/or other organic volatiles as metabolic byproducts. Under optimal conditions, substantial concentrations of ethanol may be formed within hours of death.
Source: http://www.faa.gov/data_research/res...media/0404.pdf

tdracer 10th Aug 2013 00:54


I noted one posting that raised my eyebrows - that freighters don't have cabin doors to separate them from the hold. I had never considered this before, and wonder what the reason (or at least the justification) is. To me, the default would seem to be to keep the crew isolated from the cargo unless there is a particular reason for them to go back.
Perhaps because that post is wrong. I can't speak for all Freighters out there, but EVERY Boeing produced freighter has a fire resistant door between the flight deck and the cargo compartment (freighter conversions are STC - so they may be different).

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

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

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

Etud_lAvia 10th Aug 2013 01:34

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

sludge 10th Aug 2013 12:04

Thanks for the explanation for the ethyl alchohol, really glad to hear that.

peakcrew 10th Aug 2013 14:43

Thanks, tdracer and Etud_lAvia: there seems to be a difference of opinion here :)

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

JammedStab 10th Jul 2015 23:51

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

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

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

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

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

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

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

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

CCA 11th Jul 2015 03:39


make things barely visible again.
I'm afraid not, the smoke will now be in the bottle as well!

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

Huck 11th Jul 2015 05:25

It's surprising how the press hasn't discussed this accident while covering the increasing shift of air freight into the bellies of passenger airplanes.

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

Boeing Cargo Planes Lose to Boeing Passenger Planes - Businessweek

SAMPUBLIUS 11th Jul 2015 05:32

RE ESCAPE MODULES
 
'

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

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


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

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

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

JammedStab 11th Jul 2015 07:26


Originally Posted by CCA (Post 9042176)
I'm afraid not, the smoke will now be in the bottle as well!

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

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

framer 11th Jul 2015 07:41

Most of the reputable Airlines banned Lithium Ion Batteries in April this year unless they are held within the device that they operate.sounds like the Industry is slowly waking up.

Yaw String 11th Jul 2015 09:34

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

neilki 11th Jul 2015 23:32

fatigue?
 

Originally Posted by Mr Angry from Purley (Post 7976198)
Colgan - was that the FAA rules or commuting / sleeping habits of crewmembers?. Will the FAA have the balls to look at commuting?
Asiana - sleepiness maybe, jury is out on fatigue though.

Er. the FAA has done nothing? 14 CFR Part 117 seems to be something. Perhaps not well read in Purley, but had a decent impact in FAA land.


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