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Airborne fires from damaged electrical wiring- Recent investigations and recommendations
Rob Carter & Anne Evans Air Accidents Investigation Branch, Farnborough, UK
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ICAO Annex 13ICAO Annex 13(Ninth edition (Ninth edition -- July 2001)July 2001)
Accidents and Serious Incidents
“ … the difference between an accident and a serious incident lies only in the result … “
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Four AAIB serious incidents Nov 2002 - July 2003
• 1) Concorde, G-BOAC, 13 June 2003• 2) Boeing 737-300, G-LGTI, 20 July 2003• 3) Boeing 737-436, G-DOCE, 30 May 2003• 4) Boeing 737-436, G-DOCH, 8 Nov 2004
• all AAIB ‘Field’ investigations
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• UK Press - The Times, London, June 2004
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Incident 1 - Concorde G-BOAC on 21 June 2003
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Area offire damage
1st StandbyFuelPumpTank 3
2nd StandbyFuelPumpTank 3
Tank 3Refuel valve
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ChafedWire
‘Spark Erosion’hole in aluminiumhoneycomb panel
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Fwd toilet service panel
Incident 2 -B737-300, G-LGTI, 30 July 2003
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Fwd toilet service panel
FWD
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Incident 3 -B737-436, G-DOCE, 30 May 2003
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• G-DOCE - 30 May 2003
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Incident 4 - B737-436, G-DOCH, 8 November 2002London Heathrow to Kiev, 68 passengers
Event started ~78 nm west of Stansted, passing FL240
Turnback to Stansted, divert to Heathrow, landed 29 minutes after event
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G-DOCH - Forward galley area
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G-DOCH 8/11/02
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Water hose, Ty-Wraps/’Zip’ straps & wiring looms
Braided water hose detail
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Circuit breakers - G-DOCH
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Airframe Parts Catalog
Galley CMM
Aircraft MM
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G-DOCH, Operational issues
Communications isolation of flight deck from cabin
Difficulty of reaching door with oxygen mask on
Commander off flight deck - no monitoring of FO
Selection of diversion - diverted traffic
Electrical locking of Phase 2 doors
‘SMOKE’ checklist design in QRH/FRCs
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• QRH checklist redesign
New Previous
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ATSRAC & EASG
• Ageing Transport Systems Rulemaking Advisory Committee
• Chartered January 1999
• Tasks 1 to 10, with Working Groups (Regulators, DoD, airframe manufacturers, airlines, trade associations … )– Sampling inspections - Fleet history– Maintenance criteria - Standard practices– Existing training programs - Systems certification– Wiring Practice manual - Enhanced training– Enhanced maintenance - Small transport aeroplanes
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Results ...
• Initial tasks completed - further tasks added
• Draft Advisory Circulars (ACs) on:-
– EZAP (Enhanced Zonal Analysis Procedure)– Visual inspections
– Protections and cautions
– Wiring practices manual
– Development of enhanced training programmes
• Recommendations to FAA and changes to industry practices
• Recommendation to FAA “ … aggressively pursue and promote arc-fault circuit breaker development.”
• Draft FAA NPRM
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Arc fault interrupters/CBs ...
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AAIB Recommendations
• Safety Recommendation 2004-18 -– “… that the FAA accelerate publication and adoption of guidance material
produced by ATSRAC …”
• Safety Recommendation 2004-19 -– “ … that the EASA expedite the transcription of the material in the FAA
Advisory Circulars …”
• Safety Recommendation 2003-108 -– “ … that the FAA expedite a requirement for the replacement of existing
type circuit breakers by arc fault circuit breakers …”
• Safety Recommendation 2003-128 -– “ … that the EASA expedite a requirement for the replacement of existing
type circuit breakers by arc fault circuit breakers …”
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• Thank you
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The Fourth Triennial The Fourth Triennial The Fourth Triennial International Aircraft Fire and Cabin Safety International Aircraft Fire and Cabin Safety International Aircraft Fire and Cabin Safety Research ConferenceResearch ConferenceResearch Conference
The Fourth Triennial The Fourth Triennial The Fourth Triennial International Aircraft Fire and Cabin Safety International Aircraft Fire and Cabin Safety International Aircraft Fire and Cabin Safety Research ConferenceResearch ConferenceResearch Conference