FIRE ANNEX SUMMARY.

A Catalog Of 80 Actual Fire Incident Reports From 6/2/1983 to 1/9/2018.

56 (70 %) were where acoustic/thermal insulation became part of the “fuel-load”

Summaries Only; taken from a catalog by this author which includes detailed reports and source URLs reports from the NTSB, NTSB Counterpart Agencies, FAA Incident, Service Difficulty Reports, or Media Reports.

A Brief Background.

In-flight fire begun by electrical malfunctions, and fed by the very aircraft materials certified by the FAA, have been known since, at least, 1991. Flammability standards are determined by the manufactures and then adopted by the FAA. For certain wire insulations, and for two of the most common fuselage acoustic insulations (metalized Mylar and Mylar), these standards and test conditions had proved to be inadequate. One of the earlier industry documents to this was this was seen in the FAA’s February 1991 Technical Center paper entitled, “Development and Growth of Inaccessible Aircraft Fires under Inflight Airflow Conditions (DOT/FAA/CT -91/2). Conclusions included that “although uncontaminated insulation blankets did not readily support combustion, contaminated insulation blankets were found to support combustion (consistent with service experience …).”

Boeing issued a ‘flammability warning’ in a Service Letter on August 6, 2004 and referenced an ‘original letter dated March 23, 1998. Similarly, Douglas issued a warning as a “All Operator Letter” dated August 9, 1996 and cited “recent MD-80, and MD-11 ground fires”, that had occurred.

The “fuel load” were the two materials surrounding most aircraft fuselages for sound and temperature indeed would burn, and especially so when covered by the typical contaminates like dust, debris, or corrosion preventative materials found in regular service. A NTSB Safety Recommendation Letter (A-12-068-070) defines the “fire load” as “the amount of combustible material that can be involved in a fire”.

As the FAA said in AD-2008-23-09, 2008, that is: “We have determined that each material is susceptible to ignition and propagation from a small ignition source and thus presents an unsafe condition”, (Ref Pg. 3-4, “Questioning the Safety Risk of AN-26”).

Due to incomplete records, this is not a complete list but, instead serves as a starting point for future development. Records from 1983 to January 2018 were reviewed from the NTSB, AAIB (Danish & UK), French BEA, FAA Service Difficulty Reports (SDR) databases, and a few media reports of accidents and incidents of fire. A further focus was placed on where the insulation materials themselves became the fuel to propagate the fire.

ANALYSIS;

56 (70 %) were Insulation - Fed Fires. These are highlighted here with an asterisk prefix.

42 (53%) were not found in the NTSB Accident/Incident database; (A/I) Reports. (As with the long-known problems of under reporting (approx 50 %) in the mandatory FAA Service Difficulty Reports, trend analysis and thusly, identification of systemic problems are lost). In-flight fires are reportable under NTSB’s Rule 830.5 (part 4).

8 Incidents sourced From NTSB Safety Recommendation Letters, - but there were no NTSB (Accident/Incident) Reports (see 12/8/05, 11/15/04, 7/6/04, 1/3/00., 3/29/99, 10/16/93, 3/17/91, and 7/11/73.) These gaps in data may be explained in NTSB Safety Report SR-02-02 (Sept 11, 2002) that says this data contains only “some non-accident events (i.e. aviation incidents)”.

3 more common scenarios of ignition seen in this catalog, as follows;

WIRES SHORTING/ARCING/ Circuit-breaker trip failures. 9 Incidents.

7/29/11. Egypt Air 777. (0xygen Flex-hose electrical short). 6/28/08. ABX 767. (0xygen Flex-hose electrical short/ mis-wiring clamping to adjacent oxygen lines). 2/23/08. EVA Airways 747-400. 7/30/03. Foreign 737-300. 11/1/99. No carrier name given 737-500. 11/28/98. Qantas 747. 9/27/98, Foreign 747. 9/2/98. Swissair MD-11. 11/24/93. SAS MD-87

MOLTEN METAL (SPATTER). 8 Incidents.

3/18/10. BEA Report on Thai Airways International Boeing 747-4D7, external power connections. 4/8/10. BEA Report on Cathay Pacific Boeing 747-400, external power connections. 2/26/07. United 777. 11/15/04. British Airways 777. 7/6/04. United 777. 3/28/04. Continental 757. 7/30/03. Foreign 737-300. 1/18/90. MD-80.

HEATING TAPES/RIBBONS. 5 Incidents.

5/13/02. Air Canada 767. B110 heater ribbon, made by Electrofilm, aft water supply/drain line. 7/17/01. Air Canada 747. Heater Sleeve fire caused by shorted lead at waste tank dump valve. 9/17/99. Delta MD-88. Electrofilm alternate static port heater Fire Damage to Blankets near static port heater. 8/8/00. AirTran DC-9-32. Static Port Heater ignited Blankets. 1/3/00. Delta MD-88. Electrofilm static port heater, thermal damaged only.. A fleet review found additional heat damage around other static port heaters. NTSB documents showed ValuJet 592 had a “molten metal” here, as well.

10 REPORTS ARE SHOWN HERE ARE IN GREATER DETAIL. Detailed reports with clear insights as to the role of flammable acoustic insulation propagated fires are difficult to find. 10 are offered here at, (2/23/08, 11/15/04, 5/13/02, 1/28/02, 8/8/00, 1/3/00, 9/17/99, 9/2/98 , March 1998, and 11/24/93.

A CATALOG OF 80 INCIDENTS, - SUMMARIES ONLY. A Full Text Version Is Available.

1/9/18. Aeroflot 737-800. Sparks and Smoke in cabin ceiling. Source, Media, Avherald. “An Aeroflot Boeing 737-800, registration VQ-BWA performing flight SU-1415 (dep Jan 8th) from Ekaterinburg to Moscow Sheremetyevo (Russia) with 149 people on board, was descending towards Moscow when sparks and smoke were observed from the cabin ceiling near the cockpit door. Cabin crew discharged fire extinguishers which stopped the sparks and smoke. The aircraft continued for a safe landing on Sheremetyevo's runway 24R. Moscow's Transport Prosecution Office reported there was sparking and smoke pollution from the video surveillance equipment due to a wiring/insulation fault. Rosaviatsia reported smoke was detected coming from the cabin ceiling in the cabin just at the cockpit door. Cabin crew discharged a fire extinguisher. After some time the sparks and smoke re-occurred, another fire extinguisher was discharged which stopped the sparks and smoke. The aircraft continued to Sheremetyevo Airport and was removed from service. The occurrence aircraft is still on the ground in Moscow about 18 hours after landing. Source Link > Avherald Link > http://www.avherald.com/h?article=4b36c104Â -------------------------------------

* 6/16/15. SCAT Airlines 737. Fire. Substantial Damage. Cause; Oxygen cylinder. No NTSB report. Source; Media Report. Scat B733 at Aktau on Jun 16th 2015, aircraft burned at gate By Simon Hradecky. -------------------------

* 7/12/13. Ethiopian Airlines 787-8. Fire in upper portion of rear fuselage. Cause; Electrical, ELT transmitter. NTSB report DCA13RA127, but few details. Source; AAIB Bulletin Special S5/2013. AAIB Link > http://www.aaib.gov.uk/cms_resources.cfm?file=/S5-2013%20ET-AOP.pdf ----------------------------

* 10/14/12. Corendon Airlines 737-800. Substantial Fire damage to cockpit. Evac. No further info. No Cause. NTSB report DCA13RA001. Earlier NTSB report removed. New one has far less data. Source; Aviation Safety Network article; “Airplane fate: Written off (damaged beyond repair).” Also a NTSB Meeting and Power Point Presentation Titled; “Using small aircraft investigative methods on transport category aircraft investigations”; slide # 40. NTSB Link > http://www.icao.int/NACC/Documents/Meetings/2015/ACCINV/D1-P9.pdf ------------------------------

* 8/15/11. A-330-222. Carrier name De-Identified. Fire in Door. No Cause. No NTSB report. Source; German BFU (German Federal Bureau of Aircraft Accident Investigation Report BFU 5x007-11. ----------------------------

* 7/29/11. Egypt Air 777. Fire in cockpit. 1 foot fuselage hole. Hull written off. No Mention of Blanket type. Cause; 02 hose spring, electrical short. A NTSB report # DCA11WA090, no detail information. Source; Egyptian Central Directorate for Aircraft Accidents Investigation Report on Flight No. 667, Cario/Jeddah, issued Sept 12, 2012. Also see ABX at 6/28/08. Possible cause for MH 370. ------------------------------

* 7/28/11. Asiana Airlines 747F. In-Flight Fire, crash into the Sea. No Cause. NTSB report # DCA11RA087, no detail information. Source; AAIB Aircraft Accident Investigation Interim Report # ARAIB/AAR1105. ------------------------------

4/2/11. MESA Airlines CL6002B19. Fire in engine generator cables. Cause; Wire shorted. SDR filed. NTSB report # DCA11FA072 said, “burning smell during final approach….. Post landing inspection found substantial damage to the right pylon in the aft equipment bay area directly above the auxiliary power unit exhaust duct. SDR # CA110404005. ---------------------------

12/16/10. Bombardier CRJ - CL6002B19. Cockpit Wires, glowing - sparking. Cause; circuit breaker wires. No NTSB report. Source; SDR # and Link > A6WA201040962 said, “While getting de-iced, pilots heard strange sound in cockpit, got up from seat, saw wires from CB panel 2 glowing and sparking.” -------------------------------

* 11/6/10. ‘Dreamliner’ - Boeing’s new 787 in certification trials. No SDR Filed. No NTSB report. Source; Boeing Media Article said, “Badly charred fuselage insulation blanket”, rear Electrical Equipment Bay. Cause; electrical arcing/molten debris. -------------------------

* 6/16/10. Delta 767. Flame behind sidewall panel. Cause Unknown. SDR filed. NTSB report # ENG10IA038, said, “a cockpit fire during preflight preparations.” --------------------------

5/16/10. United 757. Fire in cockpit. Cause; Loose windshield connections. *35 OTHER EVENTS. NTSB Report # ENG10IA029, - no detail information. NTSB Safety Letter A-07-50 mentions five previous 757 windshield events and makes no mention of insulation blankets or other fuel sources. Boeing informed the Safety Board that, from the period of January 2001 through May 2010, they had received a total of *35 reported smoke/flame events associated with the screw and

lug type power terminal connections on the Boeing 747, 757, 767, and 777 No. 1 windshields.” SDR # & Link > UALA2010051701662 said, “the crew reported a small fire in the cockpit, which was contained”. ----------------------------

* 4/8/10. Cathay 747, Reg # B-HOV > *“Burnt” Blankets in avionics compartment. Type not given. Cause; Electrical short circuit. NTSB report # DCA10WA049, no detail information. NTSB DOES NOT MENTION BURNT BLANKETS. Source; BEA. (Bureau d'Enquetes et d'Analyses) Report on B-HOV , said, the *”insulation blankets were burnt in the area surrounding the electrical connectors….. led to a deformation of the aircraft fuselage structure…. following the two serious incidents that occurred to HS-TGL (on 3/18/10) and B-HOV (here), Boeing quickly issued a second MOM (No1-1564169238) that informed operators of the new cases that had led to the fire in the *insulation blankets …. Since 2001, Boeing knew of EIGHT other similar cases on the Boeing 747-400 for which the types of GPU (Ground Power Units) used are not given:” (Ed. Note; None of the above “8 cases” are at the NTSB Accident/Incident database. (searched by dates). -----------------------------------

* 3/18/10. Thai 747, Reg # HS-TGL. * Burnt Blankets in avionics compartment. Type not given. Cause; Electrical short circuit. NTSB report DCA10WA041,- no detail information. NTSB DOES NOT MENTION BURNT BLANKETS. Source; BEA (Bureau d'Enquetes et d'Analyses) Report on HS-TGL. , said, *”insulation blankets were burnt in the area surrounding the electrical connectors.” -------------------------

1/18/10. Alaska Air 737. Fire in ceiling. Cause; Chafing wire. SDR filed. No NTSB report. Source; FAA Media Report, 9/9/2011. “US aviation regulators proposed a USD$590,000 fine against Alaska Airlines for improper maintenance that led to a small fire aboard a Boeing 737. SDR # and Link > ASAA1047267. ----------------------------

* 3/1/09. Comair CRJ. CL600. Fire through Fuselage (oxygen pipe involvement). Cause; Electrical System Fire. No NTSB report. SDR # and Link > CA090312013 which said, “cockpit area began to fill with heavy black smoke…. area continued to burn, resulting in an oval shaped 18 inch hole that had burned through the upper cockpit canopy area….”. -------------------------

* 2/28/09. Atlantic SE Airlines Bombardier CRJ - 200. Hole in Fuselage. Ignition of blankets and a flexible oxygen line. NTSB report # DCA09FA033. No mention of blanket Type. Cause; Electrical. (Ed. Note; No mention of blanket type. Also see NTSB Urgent Safety Recommendation A06-29 through -35. SDR # & Link > ASOA200900352 -----------------------------

* 6/28/08. ABX 767 Freighter. Fire Damage. Hull Loss (destroyed). Cause: Oxygen Hose Spring, electrical short circuit. NTSB report # DCA08MA076. Also see NTSB Accident Summary Report # NTSB/AAR-09/04. (Ed. Note; No mention of acoustical insulation blankets in either of these NTSB reports). See 10/14/89 for similar NTSB oxygen findings. ADs were issued in 2010 for 737s, 747s, 757s, 777s (2012). Also see 7/29/11, - Egypt Air 777. (Ed Note; “It is important to note that Boeing had received previous reports of electrical energy causing leaks in oxygen hoses. Specifically,… a 737 operator and from a 757 operator” (in August 1997). -------------------------------

* 2/23/08. EVA Airways 747-400. *Burned” Blankets. Mylar (PET), or AN-26. Cause; cable arcing. No NTSB report. SDR filed. Sources; Chinese) Aviation Safety Council Final Report, 2/25/2011, and the FAA Tech Center Report DOT/FAA/AR-TN09/43, which said, “An investigation of the incident revealed *burned thermal acoustic insulation blankets. All in-service blankets and film samples passed the required 12-second vertical Bunsen burner test for flame resistance. The contaminated blankets did not pass the voluntary guideline for flame spread. ---------------------------

* 8/20/07. American 767. Cargo compartment, *Charred Insulation. No Blanket Type Given. Cause; Wiring. No SDR filed. NTSB report # DEN07WA143, no detail information. Source; BFU (German Authorities) BFU Report EX009-0/07, said, "ruptured" wires adjacent to a wire clamp in the airplane's aft cargo compartment. The sheathing around the wire

bundles, the adjacent cargo compartment bulkhead walls and compartment insulated padding were *charred and partially consumed. --------------------------

8/20/07. China Airlines 737. *(Wing Slat) track can fuel leak. *Fire Progressed to The Fuselage. NTSB report # DCA07RA061, said, “Preliminary reports indicate that the fire originated from one of the engines and *then progressed to the fuselage. (underlining added). No Cause. No Further Information. ARIAC Report # AA2009-7, said, “a puncture in the (slat) track can” -- resulting in a fuel leak and fire. ----------------------------

2/28/07. No Carrier name. CRJ - CL6002B19. Fire thru Bulkhead. Cause; Wires shorted. No NTSB report. SDR # and Link > CA070321005 – said, “Bulkhead burn through approx 1 inch by .5 inch . (2) feeder -wires burned insulation.” -------------------------

* 2/26/07. United 777. “Blankets “Ignited, Beneath Floor Panel. Damage to Structure, E&E bay. Blanket type – PET/ Mylar/AN-26. Cause; Severe Relay Arcing. *11 IN- SERVICE REPORTS”. SDR filed but understated problem. NTSB report # ENG07RA014, no detail information. Source; AAIB Report # 2/2009 - said, “The insulation blankets ignited and a fire spread underneath a floor panel to the opposite electrical panel (P205), causing heat and fire damage to structure, cooling ducts and wiring. SDR # & Link, 2007UALA00578 - “Smoke coming from fwd outflow valve after engine start. SDR UNDERSTATED PROBLEM – said smoke only, with no mention of the actual fire seen in the AAIB report. From the AAIB report # S2/2007, (regarding) Boeing 777-222, Reg. N786UA said, “THE MANUFACTURER HAS INVESTIGATED *11 IN-SERVICE REPORTS of similar power panel events on B 777 aircraft, and has published details of preventative action that operators may take.” (Ed. Notes; CAPs ADDED). (Ed. Notes from AD 2008-23-09 - “To Remove PET (AN-26) (Mylar) by Dec 2016”- but 777s are exempted. -------------------------------

9/22/06. Delta 777. Cockpit Smoke, Fire. Electrical arcing, window. No cause. SDR filed on the 21st. . *35 OTHER EVENTS. Also a FAA Acc/Incident report# 20060922021089I , and a NTSB report # DCA06WA075, but no detail information. A NTSB Safety Letter A-07-50 mentions five previous 757 windshield events; Cause - cross threading of terminal connections. Letter makes no mention of insulation blankets or other fuel sources. Additional Information; The Safety Board has investigated several similar smoke/fire events at the windshield heat terminal connection since 2004 and is aware of many more events. In June 2010, Boeing informed the Safety Board that, from the period of January 2001 through May 2010, they had received a total of *35 reported smoke/flame events associated with the screw and lug type power terminal connections on the Boeing 747, 757, 767, and 777 # 1 windshields.” (Ed, Notes; Also see 5/16/10.) -----------------------------------

12/14/05, Atlantic SE Airlines. CRJ -200. Avionics Compartment Fire. Cause; Relay. SDR filed. No NTSB report. *7 OTHER FIRES. NTSB Safety Recommendation Letter A-06-29 through 35, said, “Similar to the December 8 (2005) event, post incident inspection of the airplane found that the captain’s oxygen supply line was blackened. These incidents represent two of the *seven fires that have occurred involving the Ultem 2200 surface of the 1K4XD contactors in CRJ-200 airplanes; *six of the seven fires occurred in the last 6 months. The fires resulted in destruction of the contactor and, in most cases, a significant fire in the avionics compartment. Although these fires have not resulted in loss of life to date, the potential exists for an uncontained fire to compromise the oxygen line, which could develop into an even more critical situation.” (Ed Note: Also see 12/28/09 and 12/8/05.) SDR # and link > ASOA051088. ---------------------------------

12/14/05. No carrier name. CRJ - CL600. Contactor burned, Avionic Bay. No Cause. No NTSB report. SDR # and link > CA051222001, said, “During an inspection of the avionics bay the contactors on the left side of the avionics bay were damaged beyond recognition and there was heavy smoke and some heat damage Cause; Contactor

burned, Avionic Bay.” (Ed. Note; same incident date seen in NTSB’s Safety Letter - but not the same carrier or SDR #.) ---------------------------------

12/8/05. Atlantic SE Airlines. CRJ - 200. Avionics Compartment Fire.. Cause; Electrical Contactor. *7 OTHER FIRES. No SDR. No NTSB report. NTSB Safety Recommendation Letter A-06-29 through 35, said, “Similar to the December 8 (2005) event, post incident inspection of the airplane found that the captain’s oxygen supply line was blackened. These incidents represent two of the *seven fires that have occurred involving the Ultem 2200 surface of the 1K4XD contactors in CRJ-200 airplanes; *six of the *seven fires occurred in the last 6 months. The fires resulted in destruction of the contactor and, in most cases, a significant fire in the avionics compartment. Although these fires have not resulted in loss of life to date, the potential exists for an uncontained fire to compromise the oxygen line, which could develop into an even more critical situation. Further, four of the fires have resulted in at least temporary loss of all EFIS information, preventing the pilots from using their primary flight instruments and increasing their workload during an emergency situation.” (Ed. Notes; Also see 12/28/09 and 12/14/05.) -------------------------

* 11/15/04. British Airways 777. Fire in E & E Bay. Cause; arcing at external power terminals. No NTSB report NTSB Safety Recommendation Letter A-07-113-116, said, “…. investigation revealed that the fire resulted from a combination of electrical arcing at the lower terminal studs at the primary power receptacle and misting hydraulic fluid from a ruptured nose landing gear line….. the molten copper plasma is free to spatter into the airplane’s electrical/electronic center compartment, introducing the potential for damage to critical aircraft components located in this compartment, such as hydraulic lines, or electrical wiring. Alternatively, molten spatter could result in ignition of nearby materials such as dust, lint or insulation materials. TWO OTHER SIMILAR EVENTS - Both events occurred while connecting ground power to the airplane. During the first reported event, which occurred on July 19, 2003, arcing was observed coming from the power receptacle. The second reported event occurred on July 6, 2004. The Safety Board notes that the design of the receptacles on the Boeing 777 is not substantially different from the receptacles used on other transport-category airplanes.” (Ed. Notes; see NTSB reports of two other such 747 incidents at 3/18/10 and 4/8/10.) (Ed. Notes; Two additional SDR incidents; SDR # DL777030671 on 7/19/03; Delta 777. “After hooking up external power, noticed arcing coming from receptacle. Disconnected cord from A/C. Receptacle had burned.” No Cause. SDR # 2004UALA00644 on 7/6/04. And United 777, Reg # 218UA. “Ext pwr cable terminals shorted between phases A & B, located on internal side of power receptacle. Cause; power unit malfunctioned.” (Ed. Note; Neither of the SDRs made mention of any burnt insulation blankets. Also a AP news article Link > http://www.iasa.com.au/folders/Safety_Issues/Aircraft_Wire/fireaboard.html --------------------------------

* 7/6/04. United 777. “Thermal Damage” - Blankets in E&E bay. Type not given. No Cause. SDR filed. No NTSB report. A NTSB Safety Recommendation Letter A-07-113-116, (ref page 2), said, - “The second reported event occurred on July 6, 2004.” SDR # and Link > 2004UALA00644. ------------------------------

3/28/04. Continental 757. Heat damage, to structure in E & E bay. Blanket Type not given. Cause; wire chaffing. SDR filed. No NTSB report. SDR # and Link > CALA0400292 said, “Heat damage to the structure is being evaluated. An FCD will be issued to inspect the rest of the fleet.” -------------------------------

* 7/30/03. Foreign 737-300. “Burned” blankets and Kapton wiring. Blanket type not given. No Cause. No NTSB report. Source; AAIB Bulletin # 6/2004.. Reg # G-LTGI said, “During pre-flight a short duration flash fire occurred below cockpit floor. Arc-tracking of galley feeder wiring. Heat cameras indicated a 800 C degree heat source near forward electronics bay. Evidence of water on wires, *aircraft insulation burned. It is probable that the arcing between the galley feeder cables eventually started a process of arc tracking of the *polyimide insulated wires, which would have continued until the circuit breakers tripped and started again when the electrical power was reapplied. The majority of the wiring bundles from this area were insulated with polyimide.” (Ed Note; Kapton). -------------------------

* 3/6/03. German Cargo Operator. 747, (Carrier name was de-identified). Fire damage, Scorched Insulation, HOLE IN STRUCTURE. No NTSB report. Source; BFU (German) Report # 6X001-03 said, “…. The whole area of the oxygen bottles up to the main cargo deck showed partially scorched insulation. Further removal work showed an about 5 cm x 10 cm big hole in the aluminum structure of the dado vent box at station (STA)780 close to the main cargo deck caused by fire. In this area about one square metre of insulation was scorched. ” ------------------------------

* 8/10/02. Foreign 747. “Burnt Blankets In Cargo Bay”. Fuselage Affected. Cause; wiring harness burned. SDR filed. No NTSB report. Source; Australian Report # 200203671 said, …..”An inspection of the forward cargo bay found signs of heat damage to a section of the sidewall lining adjacent to the main deck galley chiller boost fan….. the fuselage insulation blanket between body stations BS880 and BS900 was found burnt…..fuselage skin, stringers and frame structure also showing signs of being heat affected. SDR # and Link > AUS20020887, said, “Chiller boost fan wiring loom burned. Cargo bay insulation blankets also burned.” ----------------------

7/2/02. American 767. Hazy Smoke (Electrical) In Cabin. No Cause. SDR filed. NTSB report # NYC02WA135 said, …. “crew and passengers noticed a strong electrical odor. There was also hazy smoke in the cabin near the over wing emergency exits. The investigation is under the jurisdiction of the government of Paraguay.” SDR filed on the 21st. SDR # and Link > AALA22020982. “07/01/2002 said, …. “Enroute, experienced strong electrical smell with haze in cabin, cockpit and at overwing emergency exit. Emergency declared …. unable to duplicate problem.” -----------------------------

* 5/14/02. American 757. “*Burned” Insulation. Fuselage. Blanket type not given. No cause. SDR filed. No NTSB report. SDR # and Link > AALA20020648 said, …. “Insulations shows evidence of being *burned at 860 stringer 29R and at 880 stringer 29R. ----------------------------

* 5/13/02. Air Canada 767. “*Fire, Consumed” Blankets in aft cargo bay. PET (Mylar). Cause; Electrical. No NTSB report. Source; TSB Report # A02O0123. The following morning, the Transportation Safety Board of Canada (TSB) was notified of the occurrence. A preliminary examination showed that the B110 heater ribbon, made by Electrofilm Manufacturing Co., on the aft water supply/drain line had failed and ignited the fire. The standard Boeing 767 incorporates 26 heater ribbons. Between June 1985 and June 2002, operators of Boeing aircraft made a total of 67 REPORTS to Boeing of heater ribbon failures where thermal degradation was evident.” (Ed Note; Caps added). “1.5.6. Thermal acoustic Insulation. One material that is widely used in the aviation industry, and was used in the occurrence aircraft, is polyethylene terephthalate (PET). PET material is commonly known as Mylar. This material could be either metallized or non-metallized, and was approved for use based on the applicable FAA certification tests in place at the time of certification.” “1.8. Fire: .The fire burned miscellaneous debris and partially consumed the insulation blankets on the forward and aft face of the FS 1395 floor beam and the insulation blanket lining the bottom of the pressurized hull. As well, the fire damaged the underside of the floor board between RBL 22 and RBL 44. It breached the cargo compartment liner at RBL 44 and progressed behind the right sloping sidewall to RBL 50. The undersides of the two baggage containers loaded directly above the fire were scorched and blackened with soot, but showed no signs of damage….. Externally, the fuselage paint directly below the fire location was blistered.” SDR # and Link > CA020528010 05/13/2002. …. Aft cargo fuselage frame sta 1395, RBL 0 to 36 found badly warped and heat damaged also lower side of cargo floor panel at same location found scorched.” (Special Ed. Note; The Electrofilm Heater Ribbon is of the same manufacturer in the NTSB’s earlier review of two other fires of metalized Mylar fires next to alternate static port heaters; Delta September 17, 1999, MD-88, N947DL and Delta MD-88, Jan 3, 2000. Ref Safety letter Link > http://www.ntsb.gov/recs/letters/2001/a01_03_05.pdf OR http://www.ntsb.gov/doclib/recletters/2001/a01_03_05.pdf Also ref to AD 2007-17-19 to inspect static port heaters. Model MD-90-30s; The NTSB was concerned AD compliance that, - “5 years is too long”. Also See other Electrofilm heater fires at 9/17/99, Delta Airlines, and at 5/13/02. There are 29 Heater Ribbons/blanket Smoke/Fire Incidents from 6/14/2014 to 1996. The NTSB lists only two. There are 8 ADs from

1975 to 2007. 3 were for Electrofilm (earliest was AD 75-04-10) - Ref King Survey “History Heater Blanket/Tape Fires.”) --------------------------

* 1/28/02. Lan Chile 767. Blanket Fire Forward Cargo . Blanket Type not given. Cause; Electrical. NTSB report # DCA98RA085, no information, NTSB defers to the TSB. Source; Canadian Transportation Safety Board (TSB). Aviation Safety Recommendations issued: 14 November 2002 to: M.P. Minister of Transport and Ms. Marion Blakey Administrator, FAA said, “Subject: Water Line Ribbon Heater Fires and Contaminated Thermal Acoustic Insulation Blankets. Fire was fueled by contaminated insulation blankets. Reference to Canadian TSB Final Report # A98H0003 issued Mar 27, 2003 said, “Analysis -the most likely ignition source was an electrical arcing event involving breached wire insulation that ignited nearby MPET-covered insulation material.” - ref. page 233. “Conclusions - Aircraft certification standards for material flammability were inadequate in that they allowed the use of materials that could be ignited and sustain or propagate fire. The cover material was most likely the first material to ignite, and constituted the largest portion of the combustible materials that contributed to the propagation and the intensity of the fire. The type of circuit breakers used in the aircraft were similar to those in general aircraft use, and were not capable of protecting against all types of wire arcing events.”- ref page 253. TSB issued additional interim recommendations “detailing concerns over flammability standards for certain materials, testing, and certification of aircraft wiring, and requirements when conducting system safety analyses: (1) flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire. (A01-02) (2) A certification test regime be mandated that evaluates aircraft electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition. (A01-03). (3) As a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including subsystems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures. (A01-04). (Ed Notes; In a review of site review for all NTSB Safety Recommendation Letters on 9/20/11 incorporating the (key) word “acoustic” produced eight Letters, - but No NTSB Letters had to do with Mylar acoustic insulations. ------------------------

* 7/17/01. Air Canada 747. *Fuselage Blankets, “Burn damage.” Blanket type not given. Cause; Heater sleeve. No NTSB report. SDR # and Link > CA010905008 said, “Fire track was followed from source fwd through lightning hole of adjacent structure, & upward along frame to stringer 3 feet from aft dump valve location. Insulation blankets remvd & replcd due to *burn damage of outer layer. Boeing field rep informed. Air Canada engineering to investigate & liaise with Boeing customer reps for solution & further insp reqmts. Fleet campaign to inspect affected area is under consideration.” -------------------------

* 6/30/01. Foreign 747. “Set fire to *blanket in APU bay”. Blanket Type not given. Cause; wiring. No NTSB report. SDR # and Link > AUS20010676 said, ….. a flash fire occurred which set fire to the *thermal blanket located under the APU battery tray and also caused flash burns to maintenance personnel….. ---------------------------

* 11/29/00. AirTran DC-9-32. *Burned Blankets in fuselage. *Metalized Mylar. Electrical short. SDR Under-Reported. NTSB report # DCA01MA005. (Ed. Notes; report makes no mention to the “fire load” (a NTSB term) -of the material providing fuel for the fire, and to fire progression.) Also a NTSB Safety Recommendation Letter A-02-13 to 14 - to require all DC-9 operators to visually inspect the electrical connectors at fuselage station 237 for evidence of lavatory rinse fluid contamination and for the presence of a drip shield above the disconnect panel in accordance with Boeing Alert Service Bulletin DC9-24A190….. (Ed. Note; Unlike a American MD-82 fire this same day (see ‘11/29/00’ below), there was no NTSB information about ‘burned blanket’s’, (heat discoloration of the fuselage. However, *Burned Blankets , Metalized Mylar Blanket Fire was identified in the FAA’s presentation on Jan 23-24, 2002, ASTRAC Meeting, titled, “Concerns With Fire Safety In Hidden Inaccessible Areas” by Gus Sarkos, Manager Flight Safety Section, FAA Wm. J. Hughes Tech Center, reference page 16 of 33.) SDR # & Link > AT0000482 made NO MENTION of fire or fire damage). Also see AirTran at 8/8/00 and at 11/29/00. ------------------------------------

* 11/29/00. American MD-82. “Coating...burned away ...Blankets in sidewalls”. Metalized Mylar (MPET). No cause. NO SDR filed. NTSB report # IAD011A017. (Ed. Note; Also a FAA Accident/Incident Report # 20001129038279I. Also referenced in FAA’s ASTRAC Meeting, Jan 23-24, 2002. Also see AirTran at 8/8/00 and at 11/29/00.) -----------------------------

* 10/8/00. Northwest 757. “Fire damage to Blankets” near fan. Type not given. No cause. No NTSB report. SDR # and Link > 0003785520. ----------------------------

10/1/00. Continental MD-80. Cockpit fire behind jumpseat. Cause; Electrical - chaffing. SDR filed. FAA Accid/Incid report filed. NTSB report # ATL01IA001 said, “During cruise flight, at flight level 310, an MD-80, operated by Continental Airlines experienced an electrical fire. An emergency was declared and the flight was diverted into Birmingham, Alabama, and landed without further incident. The examination of the airplane disclosed a 2 by 1 1/2 inch fire-damaged hole in the left jump seat wall. The National Transportation Safety Board determines the probable cause(s) of this incident as follows: •the failure of maintenance personnel to follow fleet campaign directive on how to install a certificate holder.” FAA Accid/Incid report # 20001001031279I said, “experienced an electrical fire during cruise flight… the cockpit filled with smoke…. sparks emitting from the jump seat area. The jump seat rider reported that he heard an explosion and leaned forward to avoid heat. SDR # CALA0001469, said, “found 15 wires damaged.” (Ed. Note; SDR made no mention of actual fire. FAA Incident Report; “Kapton arcing burns a fist sized hole in the cockpit. Cockpit filled with smoke. Emergency landing.”) (Ed Note; FAA Accident Rpt Link > http://www.faa.gov/avr/aai/D_1002_N.TXT. CAN NO LONGER BE FOUND. Checked 10/18/10.) ----------------------

* 8/8/00. AirTran DC-9-32. Flight 913. *Static Port Heater Ignited Blankets. Cause; Wire Arcing. Aircraft destroyed. SDR filed - But Under-Reported. The NTSB report # DCA00MA079 said, “Flight returned to Greensboro with very dense smoke in the cockpit….. Extensive wire damage in electrical panel behind captain’s seat and blistering of the aircraft skin. Aircraft substantially damaged. A phase-to-phase arc in the left heat exchanger cooling fan relay, which ignited the surrounding wire insulation and other combustible materials within the electrical power center panel. Contributing to the left heat exchanger fan relay malfunction was the unauthorized repair that was not to the manufacturer's standards and the circuit breakers' failure to recognize an arc-fault. CONTRARY TO THIS RELAY BEING THE SOURCE OF THE FIRE – A NTSB SAFETY RECOMMENDATION LETTER SAID THAT THE STATIC PORT HEATER WAS THE SOURCE OF THE FIRE . The NTSB Safety Letter Recommendation Letter # A-01-83 through –87, (ref page 2), said, “that the source of the smoke in the cabin was a smoldering insulation blanket in the cargo compartment adjacent to a static port heater. Electrical arcing from the heater ignited the blanket, and the smoldering became a self-sustaining fire that grew in size. Footnote 3 > As a result of this incident, (Delta MD-88, fire near static port heaters on 9/17/99), the Safety Board issued to the FAA three recommendations (A-01-003, A-01-004, and A-01-005) regarding the inspection and design of static port heaters and the possible replacement of existing insulation blankets with an alternate that would be less likely to propagate a fire.” (Ed Note; *Metalized Mylar identified from FAA presentation Jan 23-24, 2002 ASTRAC Meeting, “Concerns With Fire Safety In Hidden Inaccessible Areas” by Gus Sarkos, Manager Flight Safety Section, FAA Wm. J. Hughes Tech Center, reference page 16 of 33. Neither of the two NTSB documents identified the type of flammable blanket involved. Also see ASTRAC Link > http://www.caasd.org/atsrac/meeting_minutes/2002/2002_01_Fire-Safety-in-Hidden-Inaccessible-Areas.pdf) SDR # & Link > AT0000374 Problem Description; Found smoke in cockpit. Aircraft out of service, further evaluation and trouble-shooting required.” (Ed. Note; SDR Made No Mention of actual fire and fire damage). The required follow up report was no filed ----------------------

* 7/1/00. Delta 767. Fire Damage to Wires and Fuselage Skin, E&E Bay. Blanket Types not given. No cause. SDR filed. No NTSB report. SDR # & Link > DL76S001247 07/01/2000. Reg # 116DL. 767332 said, “Fire damage in the E&E feeder cables behind the P37 panel, shorted. Wire bundle W298 shorted at station 317 damaging stringer 317 and scorched

fuselage skin. Used dry chemical agent to extinguish fire. Event occurred at approximately 2350/01. - during MTC - repaired all discrepant items.” -------------------------

* 4/9/00. Foreign 767. *Burnt Blanket, and wiring below cargo floor. Types not given. No cause. No NTSB report. SDR # and Link > AU000233 . 04/09/2000. Submitter Type; FOREIGN PART 129. When Discovered; INSP/MAINT (IN). How; Visual. B767238. “(AUS) “cargo hold floor wiring and *insulation blanket burnt.” ------------------------

1/3/00. Delta MD-88. Smoke in the cabin. Thermal damage to static port heater. Blanket type; MPET. No SDR filed. No NTSB report. Source; NTSB Safety Recommendation Letter # A-01-83 through –87, said, “Post incident inspection revealed evidence of arcing and thermal damage emanating from the right primary static port heater. Because the metalized Mylar-covered insulation blankets near the static port heater had been removed, the thermal damage was contained to the heater itself. Delta Air Lines concluded that the incident was likely caused by the heater element wires arcing near the thermostat case.

On the basis of the Covington, Kentucky, and Columbia, South Carolina, static port heater malfunctions and the Delta Air Lines inspection results, the Safety Board is concerned that the potential exists for additional fires caused by static port heaters on MD-80, MD-90, and DC-9 SERIES AIRPLANES to occur. (Ed. Note; CAPS ADDED). Therefore, the Safety Board believes that the Federal Aviation Administration (FAA) should issue an airworthiness directive (AD) requiring operators of MD-80, MD-90, and DC-9 series airplanes to inspect the primary and alternate static port heaters on these airplanes for evidence of electrical arcing or thermal damage and, if such damage is found, replace the heaters. The Safety Board also believes that the FAA should initiate a design review of the primary and alternate static port heaters on MD-80, MD-90, and DC-9 series airplanes and, if feasible, require design changes to reduce the potential for arcing. The FAA has already recognized that metalized Mylar coverings on insulation blankets will propagate fire and has published AD 2000-11-01, effective June 30, 2000, which requires that such blankets be replaced throughout DC-9-80 (MD-80) and MD-90 series airplanes and MD-88 airplanes with an approved substitute. However, the AD specifies a 5-year compliance time. Given the fire hazard posed by metalized Mylar-covered insulation blankets and the history of arcing/sparks from static port heaters, the Safety Board is concerned that the 5-year compliance period is too long for this particular installation.” (Ed. Notes: Same Type Incident and actual Delta fire on 9/17/99. See below. Same Electrofilm manufacturer and at other Electrofilm heater fires at 5/13/02, Air Canada 767. These two NTSB Safety Letter actions joined 2 TSB safety recommendations, 8 ADs, and over 24 SDR reports of heater tape/ribbon burns, or fires. See King survey “History Heater Blanket/Tape Fires”. 4 relevant ADs # on heater blankets; - 2000-11-01, 2001-10-10, 2001-10-11, and 2004-15-13. Searched by AD number.) SAME SCENARIO POSSIBLE FOR THE LOSS OF VALUJET 592 ! ---------------------------------

11/11/99. Alaska 737. Electrical smell, Kapton Wires Arcing, Fire Damaged. No Cause. NTSB and SDR reports. NTSB report # SEA00IA019 , Reg N772AS said, “Technicians isolated an electrical short to the forward cargo compartment. When they touched the panel around station 410, they saw some sparks…. FAA and NTSB investigators documented the damaged wiring bundles at station 420 above the forward cargo compartment ceiling on the right side of the airplane, and had them sectioned for further inspection and testing….. A total of 113 conductors were reported to have been subjected to the electrical arcing event…. The arcing burned several wire strands in two …..A small area of the edge of the insulation appeared to have been cut prior to the occurrence of the electrical arcing. SDR # and Link > ASAA9940162 “Failure of wire insulation. Wire chafing.” ---------------------------

11/1/99. Carrier name not given, 737-500. *Wiring fire, E&E bay. No Cause. *Wire Types. ETFE and Kapton No NTSB report. Source; U.K. (MOR) Mandatory Occurrence Reporting report # 199907499. Reference to page 35 of AAIB Aircraft Accident Report 5/2000. “Significant Electrical Arcing Events”. “burnt wiring loom in E&E bay, signs of arcing, large section completely charred.” ------------------------------

* 9/17/99. Delta MD-88. Burned Blankets at static port heater. *5 BY 5 FOOT AREA. Cause, static port heater. Metalized Mylar (MPET). Cause; deteriorated wires. NTSB report # NYC99IA231, said, “A *5-foot by 5-foot area of insulation, which consisted of fiberglass, covered on both sides with a metallized mylar, was burned. Deteriorated wire insulation and shorting at a short radius bend to the electrical wiring in the right side alternate static port heater, which resulted in electrical arcing and a fire sustained by overlaying thermal acoustic insulation”. Also a NTSB Safety Recommendation Letter A-01-03-05, which said, “The FAA has recognized that metalized Mylar coverings on insulation blankets will propagate fire and has published AD 2000-11-01, effective June 30, 2000, which requires that such blankets be replaced throughout DC-9-80 (MD-80) and MD-90 series airplanes and MD-88 airplanes with an approved substitute.” However, the AD specifies a 5-year compliance time. “Given the fire hazard posed by metalized Mylar-covered insulation blankets and the history of arcing/sparks from static port heaters, the Safety Board is concerned that the 5-year compliance period is too long for this particular installation. Concurrent with its inspections of the static port heaters in its MD-88 and MD-90 fleet, Delta Air lines removed the metalized Mylar-covered insulation blankets from around all of these heaters and stated that it plans to install metalized Tedlar-covered insulation blankets in those areas in the future. Further, after its examination of the damaged heaters, Delta Air Lines' Engineering Department recommended that all static port heaters in its MD-88 and MD-90 fleet be replaced and that the part be life limited to 6 years. On January 3, 2000, after the inspections and removal of the metalized Mylar-covered insulation blankets, another heater malfunction occurred, which caused smoke in the cabin of Delta Air Lines flight 1518, an MD-88, after takeoff from Columbia, South Carolina…. Post incident inspection revealed evidence of arcing and thermal damage emanating from the right primary static port heater. Because the metalized Mylar-covered insulation blankets near the static port heater had been removed, the thermal damage was contained to the heater itself. Delta Air Lines concluded that the incident was likely caused by the heater element wires arcing near the thermostat case”. (Ed Note; See 1/3/00 Delta above, same Electrofilm heater but with no blanket fire, same Electrofilm manufacturer and another Electrofilm heater fire at 5/13/02, Air Canada 767. Same Electrofilm manufacturer seen in AD ----- L-1011 fire in 1975. Also Referenced in ASTRAC 2002, Jan 23-24, Meeting. SDR # and Link > DLM88992089 “insulation fire”. ----------------------

* 4/14/99. United 767. Galley Chiller Duct Fire. Cause: Heater tape. No NTSB report. SDR # and Link > 99UAL900211 said, “ *Heater tape B109 failed causing insulation on forward galley chiller duct to ignite. 767 engineering issued callout to inspect 767 aircraft with this heater tape configuration for evidence of chafing and/or heat discoloration and to correct discrepancies. The insulation material on the chiller duct is being evaluated by 767 engineering to determine if it should be a more fire resistant material, or be wrapped with a fire resistant tape….” -----------------------------

* 3/29/99. World Airways MD-11. *Burned Blankets In Fuselage. Type -Mylar (MPET). Cause; wire chaffing. No NTSB report. Source; NTSB Safety Recommendation Letter A-99-104-106, on page 2, said, “World Airways MD-11. Registration N274WA. The safety Board’s investigation revealed that the insulation blankets between fuselage stations 1661 and 1681 were *burned” (Mylar covered blankets). ------------------------

12/22/98. Delta L-1011. Wiring Fire Below Lav. No Type. Cause; short/arcing, lav water on wire bundle. No NTSB report. SDR # & Link > DLL19982601, Reg #766DA, said, “At pushback, the battery condition light came on and the flight attendants reported flames at the base board behind 2l lav. Pax, F/A, and second officer confirmed flames and an extinguisher was discharged. Aircraft was evacuated per the check list. Found wire bundle below lav burnt. Signs of blue water station bundle. Suspect insulation break down due to blue water. No chafing noted. Cause; wire failed, lavatory.” (Ed. Note; same type incident at 3/17/91). -----------------------------

* 11/28/98. Qantas 747. “Film Consumed in the Fire”, E & E bay. Type - “polyester”. Cause; wire arcing. A NTSB report, no detail information. Source; AAIB Bulletin No: 6/99. “EW/C98/11/7 said, “Boeing 747-400 returned to London Heathrow. Small fire in the E&E bay, station 540. It was evident that a localized fire had occurred between the outer film of

the blanket and the fuselage structure. This had been associated with several damaged 24 gauge wires within a small electrical harness connected to the exhaust valve, and the outer film of the thermal insulation blanket had been consumed in the fire. The fire had affected an area of approximately 18 inches x 6 inches. BMS 8-142 type 11, class 2, for the insulation blanket bag.” NTSB report, DCA99WA014 said, “Qantas Airline Boeing 747-400 experienced an inflight fire in the E & E bay. The incident is being investigated by the British AAIB and the Australian BASI.” Ed. Note; No more information. Last chk’d 1/06/16. -------------------------

* 11/11/98. Delta MD-11. *“Ignite The Adjacent Blankets”, cargo area. Type -Mylar. Cause; power drive/control wire arcing. NTSB report # ATL99IA015. .Registration 811DE said, “While parked at the gate a fire erupted in the forward cargo compartment.” (Ref to para 10) - “The examination of the CCU revealed that the wiring damage created an excessive electrical current that vaporized several electrical pins inside the CCU. Failure of the pins allowed hot gases to escape the back cover of the CCU and *IGNITE THE ADJACENT MYLAR INSULATION BLANKET”. (Ed note, Also in NTSB Safety Recommendation Letter A-99-104-106.) --------------------------

* 9/27/98. Foreign 747. “Setting FireToThe *Blanket Insulation”. Type not given. Cause; power drive/control wire arcing. No NTSB report. Source; AAIB Bulletin No: 7/99 Ref: EW/C98/9/3. “Power Drive Unit (PDU) wire shorted against the structure *SETTING FIRE TO THE *BLANKET INSULATION.” -----------------------

* 9/2/98. Swissair MD-11. *Blankets combustible, propagated fire”. Metalized Mylar ( MPET). Cause; wire arcing. Total loss. NTSB report #DCA98RA085, no detail information, defers to the TSB. TSB Report # A98H0003, August 11, 1999: TSB Interim Recommendations. TSB issues two ASRs dealing with “the risks associated with flammability of metallized polyethylene terephthalate (MPET)-covered insulation blankets and test criteria that certified this material for use”. TSB notes that "it is likely that MPET cover material was a significant source of the combustible materials that propagated the fire" on SR 111, and believes "that the operation of aircraft outfitted with thermal acoustical insulation blankets incorporating MPET cover material constitutes an unnecessary risk." TSB asks regulatory authorities “to confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of MPET-covered insulation blankets in aircraft” (A99-07). TSB notes that thermal acoustical insulation materials on aircraft “must be judged against more rigorous flammability test criteria than prevailing U.S. Federal Aviation Administration standards, and asks regulatory authorities to validate all thermal acoustical insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than current standards and that are representative of actual in-service system performance”. (A99-08). Recall that the Canadian Transportation Safety Board could not establish a definitive connection between the blanket fires and the oxygen delivery pipelines running to the cockpit, but did comment that the use of aluminum piping (with its low melting point ) was “dangerous” in comparison with the use of stainless steel oxygen lines. A general comment could be that the destruction caused by oxygen-augmentation is always impossible to establish in the aftermath of any intense fire. And of course when it has compromised flight crew oxygen at high altitude, the outcome is almost predetermined.. --------------------------------

* March 1998. 747-200. “Fire” In a Cargo Compartment Of A “747-200 Freighter.” Cause; Ribbon Heater Fire. Insulation blanket fire. Source; Transportation Safety Board of Canada (TSB) aviation safety recommendations. date issued: 14 November 2002. “Forwarded To: The Honourable David Michael Collenette, P.C., M.P. Minister of Transport and Ms. Marion Blakey Administrator, Federal Aviation Administration. SUBJECT: Water Line Ribbon Heater Fires and Contaminated Thermal Acoustic Insulation Blankets. Boeing issued service letters for all its aircraft models (Multi-Model Service-Related Problem 25-0103). An investigation by Boeing revealed that the presence of corrosion inhibiting compounds may have contributed to the fire, and could have been the reason the fire was not self-extinguishing. The investigation also looked at the accumulation of dust, lint, and other debris such as drilling swarf on insulation blankets in the outboard sections of the passenger/cargo compartment, and concluded that it was conceivable that a large buildup of contaminants on these blankets could ignite as a result of a high temperature source. The service letter informed operators that applicable Boeing manuals would be revised to address the effects of corrosion-inhibiting compound and other materials

on the flammability of aircraft insulation blankets.” ----------------------------------

* 1/9/98. United 767. Wiring Fire in E & E bay. (Electrical and Electronics). Blanket Type MPVF. Cause, arcing. Wire insulation ETFE and Kapton wiring insulation. *9 OTHER INCIDENTS. SDR filed. A NTSB report DCA98RA016, but no mention of fire damage. said “minor damage”, and said, - The (UK) AAIB investigators found about 10 circuit breakers open in the cockpit, and also found a roughly 7-in.-long section in a bundle of more than 100 wires that was severely burned and melted. Ref page 26; 1.14 – Fire, “Apart from the burnt wiring and associated effects on the chiller unit and some insulating material in the E&E bay, there was no other fire damage.”* References to other “significant electrical arcing/fire events”….. UK Mandatory Occurrence Reporting (MOR) events; # 199907499 a 737-500 on 11/1/99 (no cause) and # 20004125 a 737 on ‘May 2000’ cause-metal shavings. Conclusion/Findings (ref page 56, #12; in-part “arc induced copper spatter could rapidly spread overheating/fire affects to adjacent areas including thermal acoustic blankets”. (Ed. Notes; ETFE is ethylene tetrafleuroethylene, ref page 23. Blanket Type; Ref page 36). “The insulation material affected by hot metal spatter on United N653UA was thought to be metalized PVF”. Also a reference to FAA Tech Center report DOT/FAA/AR-97/58; “The report questioned the validity of the current ‘vertical’ flammability tests”. SDR # & Link > 98UAL900008 wire bundle fire – no cause.

-------------------------------------

2/20/97. Northwest DC-9-15. Fire damage to wires. Not enough information. No SDR Filed. Cause; Cross-tie relay arcing. *21 failures. A NTSB Safety Recommendation Letter A-98-111, and Accident/Incident (A/I) Report said, “Aircraft experienced an in-flight electrical fire, which filled the cockpit with smoke and fumes from the left main equipment rack with charred and soot-covered wire bundles. A review of FAA service difficulty report (SDR) data for the period between January 1, 1974, and June 1, 1998, for Westinghouse relay P/Ns 914F567-3 and 914F567-4, indicated *21 reported failures. Based on the NWA incident and the continued reports of AC power relay failures, the Safety Board is concerned about the ongoing potential for an electrical fire in the DC-9 series aircraft…. ------------------------

MISC NOTES

8/9/96. All Douglas Models. Douglas AOL Letter to discontinue use of metalized Mylar (MPET). All Operator Letter (AOL) dated Aug 9, 1996 for all DC-8, 9, C-9, MD-80, 90, DC-10 and MD-11 operators. Reason; “ As a result of recent MD-80 and MD-11 ground fire incident involving insulation blankets covered with metalized Mylar material, Douglas has examined its methods for flammability testing of insulation blankets. We have concluded that an expanded set of test conditions, which includes additional ignition conditions beyond those previously required, better determines blanket flammability characteristics. All insulation blanket materials delivered on Douglas manufactured aircraft have met the applicable requirements for FAA certification. Douglas recommends that operators discontinue use of the reference (D) metalized Mylar blanket covering material and referenced (E) tapes. Douglas also recommends that Douglas expanded test criteria, which is published in the enclosed referenced (C) DMS 2446 be applied when operators are replacing blankets in aircraft in-service.” “Douglas has made the FAA and industry aware of our conclusions relative to flammability testing and is participating in a FAA/Industry Flammability Working Group that is addressing testing methods and the flammability of materials such as those used for insulation blankets.” Source; Danish AAIB Report > # 2/96. Appendix 1, MD-87, Scandinavian Airlines 11/24/1993. Reg # SE-DIB. Also at TSB; “1.14.12.2 Past Known Occurrences”. Link > http://www.tsb.gc.ca/eng/rapports-reports/aviation/1998/a98h0003/01report/01factual/rep1_14_12.asp --------------------------

MISC NOTES

May 1996. The Aircraft Airworthiness Center of the Civil Aviation Administration of China (CAAC) advises the Federal Aviation Administration (FAA) via letter of a 1995 fire on a Chinese registered MD-11, in which the metalized Mylar

thermal/acoustic insulation blanketing burned. The CAAC report cited the "potential danger" posed by the blanket material. Link > http://www.iasa.com.au/folders/Safety_Issues/Insulation_Blankets/767tapefire.html

AND

October 1996. MD-11s. Douglas Service Bulletin MD-11-25-200 to remove all MPET insulation materials. TSB Report, Reference to Interim Air Safety Recommendations: Thermal Acoustical Insulation Materials. Date issued: 11 August 1999. Sent to Jane Garvey, Administrator Federal Aviation Administration. SUBJECT: Thermal Acoustical Insulation Materials. “October of that year McDonnell Douglas had issued a Service Bulletin (MD-11-25-200) that encouraged MD-11 operators to replace insulation blankets covered with metallized PET material with blankets covered with metallized PVF material. The Service Bulletin also stated that the non-metallized PET cover material that had been used in production aircraft since September 1996 was discontinued, as it did not consistently pass a particular McDonnell Douglas flammability test. That Bulletin also stated that McDonnell Douglas was now using metallized PVF in new production aircraft. Similar Service Bulletins, regarding the use of metallized PET cover material, were issued to DC-8, DC-9, DC-10, MD-80, and MD-90 operators. TSB Link > http://www.tsb.gc.ca/eng/rapports-reports/aviation/1998/a98h0003/02sti/20safety/safetyaction.asp#thermalacousticalinsulationblanket -----------------------

* 5/11/96. ValuJet DC-9-32. Fire Damage. Fatal. INFO ONLY. NOT TALLIED. NTSB Cause; oxygen canisters. NTSB Aircraft Accident report # NTSB/AAR-97/06 (August 19, 1997) “Conclusions/Findings; # 6; The activation of one or more chemical oxygen generators in the forward cargo compartment of the airplane initiated the fire on ValuJet flight 592. One or more of the oxygen generators likely were actuated at some point after the loading process began, but possibly as late as during the airplane’s takeoff roll, # 21; Because of the rapid propagation of the oxygen-fed fire and the resulting damage to the airplane’s control cables and structure, # 27 Although the installation of safety caps would not likely have prevented the oxygen generators from being transported on board flight 592, it is very likely that had safety caps been installed, the generators would not have activated and the accident would not have occurred. – ref, pages 133 to 135. “Probable cause; …… resulted from a fire in the airplane’s class D cargo compartment that was initiated by actuation of one or more oxygen generators being carried as cargo.”- ref page 137. NTSB Rpt - Link > http://www.ntsb.gov/publictn/1997/AAR9706.pdf ------------------------

* 3/8/96. Continental DC-9-82. “Scorched” Insulation . Type not given. Cause; wire splice failed. No NTSB report. SDR # and Link > CAL960291 said, “Smoke while at the gate, smoke from overhead near entry. Found burned wiring, scorched insulation. Scorched and torn insulation (approx 1 foot in area) over STA 218 overhead panel replaced and area cleaned. Cause; failed (wiring) splice.” ------------------------

* 1/22/96. British Airways 747, Reg # G-BNLA. “Scorched” Blankets in sidewall. Type not given. Cause; wire bundle arcing. No NTSB report. Source; AAIB # 3/96, Ref : EW/C96/1/4. British Airways 747, Reg # G-BNLA. “ Insulation blanket scorched and blackened near seat 37K.” ------------------------------

* 11/26/95. Alitalia MD-82. Fire spread to Blankets in ceiling. Type not given. (MPET from ‘Table -Sept 2000’). Cause; lights. No NTSB report. Source; FAA Tech Center Report DOT/FAA/AR-97/58. Sept 1997 by Pat Cahill. Example 5 said, “Prior to take off, fire in the cabin from light ballast spread quickly through ceiling panels, wire-harnesses, insulation blankets. Tech Report Link > http://www.tc.faa.gov/its/worldpac/techrpt/ar97-58.pdf Also FAA Study DOT/FFF/AR-02/50; (same as CAA Paper 2002/01), “A Benefit Analysis for Enhanced Protection form Fires in Hidden Areas on Transport Aircraft”. Appendix 1, pg 15, said “insulation blankets partially burned” and insulation coverings burned roughly 5 by 1.5 meters (16 foot by 5 foot). Link > http://publicapps.caa.co.uk/docs/33/CAPAP200201.PDF -------------------------------

* 11/13/95. Yunnan 737. Ignited Blanket film under flooring. Type not given. (MPVF from TSB Report Swissair 111). Cause; Hot metal chips. No NTSB report. Source; FAA Tech Center Report DOT/FAA/AR-97/58. Sept 1997 by Pat Cahill. Example 4 said: “When the nut bolt was removed by an air drill, hot metal chips spewed forth and ignited the insulation blanket film under the floor. Flames propagated on the blanket covering an area of 18 by 40 inches”. * CAAC 5/24/96 letter to FAA Tech Report Link > http://www.tc.faa.gov/its/worldpac/techrpt/ar97-58.pdf Ed Note; Tech report references a Civil Aviation Administration of China (CAAC) letter dated 5/25/1996 to the FAA. ------------------------

* 9/6/95. China MD-11. “Extensive flame propagation’ Blankets in E&E bay. Type not given. (MPET from ‘Table -Sept 2000’). Cause, wire arcing. No NTSB report.. Source; FAA Tech Center Report DOT/FAA/AR-97/58. Sept 1997 by Pat Cahill. Example 3 said: “Aircraft was about to start the engines for departure from Capital Airport in China when the flight crew noticed a significant amount of smoke emanating from the E/E bay. Further inspection revealed that areas of the E/E bay were on fire. Investigators found that molten metal from arcing wires had fallen on the fuselage skin insulation blankets under the E/E bay. There was extensive flame propagation from the insulation blankets up into the E/E bay with widespread damage.” Tech Report Link > http://www.tc.faa.gov/its/worldpac/techrpt/ar97-58.pdf Ed Note; Tech report references a Civil Aviation Administration of China (CAAC) letter dated 5/25/1996 to the FAA. ----------------------------

* 6/8/95. ValuJet DC-9-32. Cabin gutted by fire. No mention of blankets. Cause; Engine explosion. NTSB Accident Report # NTSB/AAR-96/03 said, “Ref, 1.3 Damage to Aircraft. The fuselage was destroyed by fire, which gutted the interior, burned through the roof of the forward cabin area of the airplane, and consumed most of the cabin overhead. ….. The top of the cabin, above the cabin windows, was consumed by fire from the 2nd window rearward to about the 15th window. There was severe interior fire damage to the entire passenger cabin, with sooting and blackening of the interior of the cockpit. The seat fabric, carpet, and cabin interior material were nearly consumed by the fire.” -------------------------

* 10/10/94. ‘Beijing’ 737. Blankets on fire in E&E bay. Type not given. (* MPVF from TSB report; Swissair 111). Cause; Wire short. No NTSB report Source; FAA Tech Center Report DOT/FAA/AR-97/58. Sept 1997 by Pat Cahill.. Example 2 said: “After landing, the ground crew detected a burning smell. Upon opening the Electronics and Engineering (E/E) bay they found that the insulation blanket under rack 2 was on fire. Upon investigation, it was determined that improper installation of a wire bundle clamp made contact with the associated wires and caused a short circuit. The intense heat from the arcing and sparks ignited the insulation blanket. ------------------------

* 11/24/93. SAS MD-87. * “Fierce FIRE”. Blankets fuel sources over PSUs. * 2 INCIDENTS. (MPET from Danish AAIB Report # 2/96 ). Cause; Kapton wire arcing. No NTSB report. Source; FAA Tech Report DOT/FAA/AR-97/58. Sept 1997 by Pat Cahill. Example 1. “MD-87 (McDonnell Douglas) experienced a fire aboard the aircraft while taxiing towards its assigned gate at Copenhagen Airport, Denmark (EKCH). Smoke started to emerge behind and above the service units installed in the aft right-hand side of the cabin. After the aircraft parked and all passengers and crew had disembarked, the smoke intensified drastically…. *A fierce fire then erupted and spread very quickly. Investigators determined that the thermal acoustical insulation blankets acted as fuel sources which helped to spread the fire.” SAME INCIDENT seen in the Danish AAIB Report # 2/96 which after FAA Tech Center tests in 1994 EXONERATED the role of oxygen generators in the propagation of fires and included a Douglas Letter to all operators warning of the FLAMMABILITY OF DOUGLAS ACOUSTIC INSULATIONS USED IN ALL DOUGLAS AIRCRAFT. *THE SECOND INCIDENT; Two years earlier - another MD-87. Earlier Service Bulletin (Alert) # A24-123, March 19, 1991 said, “Reroute Aft Cabin Ceiling Wire Assembly. DC-9-87 (MD-87). Reason: One operator reported one instance of an electrical fire above the aft main cabin ceiling panels…. ----------------------

* 9/4/93. Dominicana 727. Fire in ceiling, A/C destroyed. No Blanket Type. No cause. No NTSB report. Source; CAA PAPER 2002/01. “A Benefit Analysis for Enhanced Protection from Fires in Hidden Areas on Transport Aircraft”. (FAA Reference DOT/FAA/AR-02/50.) said: “Approximately 15 minutes into a 30 minute flight from San Juan to Santo Domingo …. She checked the lavatory and noticed smoke inside. The airplane landed at Santo …. as the cabin began to fill with smoke….. The mechanic opened the ventral stairs and saw fire that he judged to be too big to attempt to fight with a hand held extinguisher. The airplane was destroyed by fire. The fire was determined to have originated in the area of the aft lavatory but a cause was never found”. (ref. Appendix 1, page 5L. FAA Link > http://www.fire.tc.faa.gov/pdf/capap200201.pdf ----------------------------

* 10/16/93. Swissair MD-81. Fire damage, in overhead area. Cause; Electrical Switch. No NTSB report NTSB Safety Recommendation Letter A-94-133, said , - “On Oct. 16, 1993 heavy smoke came out of the overhead of a Swissair MD-81 with substantial damage and overheated electrical components. The NTSB recommendation was to limit the emergency power switch to 10,000 cycles. (A-94-136). AD-95-11-12 affecting DC-9 series MD-80 and 88s required the repetitive replacement of the switch every 3 years. The source of the overheating was laid to the switch (in A-94-136).” ------------------------------

* 3/17/91. Delta L-1011. Fire below floor, burnt blankets, type not given. Kapton wiring insulation. No cause. No NTSB report. NTSB Safety Recommendation Letter A-91-70 through A-91-72, said, “While enroute, “it experienced a fire below the aft cabin floor and in the cabin ….a flight attendant noticed flames rising from the base of the left cabin sidewall to the height of the seatback tray…The ignition source has not been determined. A bundle of 15 electrical wires, which was present in the fire area, provided electrical power for the cargo compartment lights and potable water pressurization systems. Some of the wires in this bundle exhibited evidence of arcing, and the insulation was extensively damaged. The wires in this bundle are insulated with Kapton (aromatic polyimide). ARC TRACKING OF THIS INSULATION IS A WELL-KNOWN PHENOMENON THAT CAN RESULT IN SHORT CIRCUITING AND IGNITION, ALTHOUGH IT HAS NOT BEEN DETERMINED THAT THERE WAS AN INSULATION BREAKDOWN IN THIS INCIDENT (EMPHASIS ADDED). The Safety Board is also concerned about the degree to which dust, lint and other debris has been allowed to accumulate on the aircraft wiring. Flammability tests on items taken from the aircraft, such as insulation blankets and air diffusers, showed that they were resistant to ignition.” (Ed. Note; same type incident at 12/22/98). Also seen in TRANSPORTATION SAFETY BOARD OF CANADA AVIATION SAFETY RECOMMENDATIONS. DATE ISSUED: 14 November 2002. “Forwarded to: The Honourable David Michael Collenette, P.C., M.P. Minister of Transport and Ms. Marion Blakey Administrator, Federal Aviation Administration. SUBJECT: Water Line Ribbon Heater Fires and Contaminated Thermal Acoustic Insulation Blankets.” Link > http://www.iasa.com.au/folders/Safety_Issues/Aircraft_Wire/AirCanada767AC116/AirCanada767AC116-0.html -------------------------

1991. MD-87 CEILING FIRE. Sourced from Douglas Alert Service Bulletin # A24-123, March 19, 1991. “Reroute Aft Cabin Ceiling Wire Assembly. DC-9-87 (MD-87). Reason: One operator reported one instance of an electrical fire above the aft main cabin ceiling panels….cause wire bundle chaffing and arcing against retention clip. Recommended within 120 days”. ED. NOTES Two years later - 11/24/93. SAS MD-87. Blankets were the fuel sources over PSUs, (MPET from that AAIB report) Cause; Kapton wire arcing. Service Bulletin; # 24-151, September 29, 1994. “Inspect/Revise Aft Coatroom Wiring Installation. DC-9-87 (MD-87). Reason: One operator reported one instance of chafed wires starting an electrical fire (behind the aft right coat room) that resulted in severe airframe damage. Recommended within 12 months”. See 11/24/93 above). -------------------------------

1/18/90. Carrier? MD-80. Smoke in cockpit and a Fire. Cause; Electrical Connection. No NTSB report. Source; AAIB report 5/2000 at page 34, - ‘other incident’s. (Same AAIB report here at 1/9/98, United 767). (Buffalo to Cleveland). “cause: loose connection at generator terminal strip. The second source of smoke came from a fire started by molten metal that had sprayed an area forward and below the terminal strip”. ------------------------

* 10/14/89. Delta 727. Fire Damage. Flames from floor vent. No blanket type given. No cause. NTSB report # DCA90MA002 said, “The crew heard a muffled explosion & saw flames coming from the vent near seat 3-D while acft was parked at gate. Location of fire prevented crew from returning to cockpit to notify CFR & illuminate emerg floor lighting. Passengers & crew evacuated acft. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: a fire which started in the passenger oxygen system for undetermined reasons. Contributing to the accident was the failure of Delta Airlines to recognize, attend to and correct repeated leaks in the oxygen system. -------------------------

* 4/17/88. Continental 737. Fire Damage in ceiling. No Blanket type given. Cause; light shorting. NTSB report # ATL88IAI47 said, - “While on final approach, smoke and flames developed in cabin above overhead luggage bins over seats 16A, B & C. Acft was within 2 miles of rwy. Crew declared emergency, landed, turned off rwy expeditiously, stopped on rwy 18, & evacuated. Smoke poured from the opened cabin doors. Examination of the acft revealed that a ceiling fluorescent light fixture shorted internally resulting in the fire. An AD was issued which required the installation of a fuse assembly in the input wire to the ballast. The National Transportation Safety Board determines the probable cause(s) of this incident as follows: light(s)..shorted, acft/equip, inadequate design.. light(s)..arcing.” ED NOTES, Also a FAA Study). -------------------------------

* 10/18/85. Royal Jordanian L-1011. Fire below cargo floor. Hole thru pressure bulkhead. * No Blanket type given. Cause; electrical arc. No NTSB report. Source; NTSB Safety Recommendation Letter A-85-91-92. An in-flight fire aboard a Royal Jordanian L-1011 on Oct. 18, 1985. Preliminary examination of the airplane has revealed that the fire originated in the left aft under-floor area of the fuselage aft of the G-3 cargo compartment and forward of the rear pressure bulkhead. . Severe fire damage is evident in the area forward of the rear pressure bulkhead and aft of compartment C-3. A hole about 8 inches in diameter was burned through the pressure bulkhead, the A and B hydraulic systems were depleted, electrical wires and cables were damaged, and the captain's stabilizer control linkage was burned through. About 3 feet of the bleed air duct was missing in the area immediately forward of the rear pressure bulkhead. “To the fire's subsequent propagation being due to other fuel sources was described in a letter to the FAA dated October 25, 1985”. The preliminary evidence suggests strongly that an electrical arc occurred, which burned a hole in the duct, and that the high pressure bleed air provided the oxygen to propagate a titanium fire. *Other materials in the area may have contributed to the fire fuel sources to propagate the fire and to cause the extensive damage”.) Ed Note; No mention of acoustic insulation burned, aircraft burnt out). ----------------------------

MISC NOTES.

2/23/75. AD 75-04-10. Issued February 19, 1975. LOCKHEED L-1011s. To prevent heater blanket overheat conditions and possible fires caused by a malfunctioning cargo sump drain heater by Electrofilm electric heaters. Compliance required within 10 calendar days. Electrofilm P/N 111202-101 (LAC Control No. 672726- 101), accomplish (a) or (b): (a) Disconnect the C-1, C-2, and C-3 cargo compartment drain heaters per Lockheed Alert Service Bulletin 093-30-A032, dated January 23, 1975, or later FAA-approved revisions, or; (b) Equivalent deactivation modifications approved by the Chief, Aircraft Engineering Division, FAA Western Region. Link > http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/983FB6ED8151381F862569750048ABB5?OpenDocument&Highlight=electrofilm --------------------------

* 7/11/73. Varig 707. Fire in Lav. 124 deaths. Blanket type - *Mylar. No cause. No NTSB report. NTSB Safety Recommendation Letter A-83-70 through -81. Ref page 2 , 3rd paragraph. Said, “The Safety Board participated in the investigation of the Varig Airlines, Boeing 707 accident near Paris, France, on July 11, 1973, in which 124 persons died after a fire erupted in the rear lavatory. In summary, the Safety Board believes that the potentially catastrophic consequences of airplane lavatory or other cabin fires, as illustrated by the tragic Air Canada accident, make it imperative that the FAA address the cabin fire safety issues in a coherent program which will result in expedited positive actions. (ED NOTE; No mention of acoustic insulation burned). *

Mylar from Safety Letter A-99-104-106. Link >http://www.ntsb.gov/safety/safety-recs/recletters/A99_104_106.pdf ---------------------

* 6/2/83. Air Canada DC-9-32. * Blankets Burnt. Fire in rear cabin. 23 deaths. No Blanket type given. No cause. A NTSB report and a NTSB Safety Recommendation Letter A-83-70 through -81 which said, “On the June 2, 1983 an accident involving an Air Canada DC-9, Flight 797 occurred with 23 fatalities. “ … testimony disclosed that the smoke was coming from the wall liner and the vanity next to the airplane's rear bulkhead.” Fire began in the airplane's left rear lavatory, but the source of ignition has not yet been identified. .The NTSB recommends an evaluation of the electrical circuit protection after components or a Lav pump overheated and resulted in an in-flight fire. The FAA ruled out the pump motor and inadequate circuit protection as the fire source, but did issue AD 85-07-10 to reroute wires on ship fuselage numbers 855 (and prior) due to potential chafing of both the forward and aft Lavatory pump wiring. “The Halon-type extinguisher in the Air Canada airplane's waste receptacle discharged, however, the source of the fire was external to the receptacle and the discharge agent was not effective in extinguishing the fire. (note 1, page 4). In summary, the Safety Board believes that the potentially catastrophic consequences of airplane lavatory or other cabin fires, as illustrated by the tragic Air Canada accident, make it imperative that the FAA address the cabin fire safety issues in a coherent program which will result in expedited positive actions. (Ed Note: No mention of acoustic insulation burned). Letter Link > http://www.ntsb.gov/safety/safety-recs/recletters/A83_70_81.pdf The Safety Board's full report on this investigation is provided as Aviation Accident Report number AAR-86/02. (Link > http://www.airdisaster.com/reports/ntsb/AAR86-02.pdf ) which said, “At about 1903 EDT, while enroute at Fl 330, the cabin crew discovered a fire in the aft lavatory….. after contacting ATC & declaring an emergency, the flt crew made an emergency descent & ATC vectored the acft to the greater Cincinnati Intl Arpt…. As the aircrew stopped the plane, fire dept personnel moved into place & began firefighting operations….. as the plane stopped, the occupants began evacuating the acft. About 60 to 90 sec after the exits were opened, a flash fire enveloped the interior of the acft. 23 passengers were unable to exit the acft & died in the fire. An investigation revealed that 3 flush motor circuit breakers had popped about 11 min before smoke was detected. The captain misconstrued reports that the fire was abating when he received conflicting fire progress reports. Subsequently, he landed at the Cincinnati Intl Arpt rather than at Louisville which would have allowed him to land 3 to 5 min sooner. Wet towels & breathing thru clothing aided survival. Fire source unknown”. ED. NOTE; *Blankets Burnt. Although this NTSB Accident/Incident report did not indicate that blankets were burnt, the pictures and narrative descriptions of another FAA report did Ref. “Occurrence 7”, CAA PAPER 2002/01. A Benefit Analysis for Enhanced Protection from Fires in Hidden Areas on Transport Aircraft. FAA Reference DOT/FAA/AR-02/50 which said – “Fire had burnt through the top of the fuselage, “under floor scorched insulation” ref pa 25. Link > http://www.fire.tc.faa.gov/pdf/capap200201.pdf Same images are seen in the NTSB’s Aviation Accident Report AAR-86/02 (see above). ---------------------------------

ANOTHER AIRBUS FIRE INCIDENT on 12/8/17. Aircraft destroyed.  Added to the catalog.

12/8/17.   Qatar Airways Airbus A321 (A7-AIB) Catches Fire In Doha During WiFi Installation.

by John Ollila - Dec 10, 2017

“On Friday December 8, 2017 a Qatar Airways Airbus A321, caught fire while WiFi equipment was being installed into the aircraft.   The fire burnt through the fuselage roof as you can see from the photos that were taken on the spot. I would assume that the airline needs to write off this airframe due to excessive damage. Conclusion

This is a quite expensive mistake but luckily there were no fatalities and firefighters at the Hamad International Airport were able to put out the fire fast.

The incident won’t affect Qatar’s schedule as they have plenty of slack at the moment due to the blockage by the gulf neighbors.

Qatar Airways converted previous Airbus order to 50 Airbus A321neo one during French prime minister’s visit to the country on Thursday. Plenty of new Airbus planes coming in.

See Picture of extensive upper fuselage burn-through. (it’s typical of oxygen line compromise holings).

https://loyaltylobby.com/2017/12/10/qatar-airways-airbus-a321-catches-fire-in-doha-during-wifi-installation/

Also see Link > http://www.aviation24.be/airlines/qatar-airways/a-fire-in-the-cabin-of-a-qatar-airways-a321-completely-destroys-aircraft/

http://avherald.com/h?article=4987fb09

MS804 crash“…a number of ACARS messages indicating cockpit window temperature sensors faults and optical smoke detector activations were received between 00:26Z and 00:29Z, the crew did not respond to a hand-off from Greek to Egypt ATC,…”“….The members of the Technical Investigation Committee returned to Cairo with the boards to continue work and reading the contents of the recorders as well as analyzing them at the laboratories of the Ministry of Civil Aviation of Egypt. After the FDR data were uploaded and examined by the experts; the results indicated that the flight data had been recorded since the departure of the plane from Charles de Gaulle Airport until it stopped at 37000 thousand feet where the accident occurred. The recorded data of the recorder matched the Aircraft Communications Addressing and Reporting System (ACARS) messages which indicated smoke in the lavatory and smoke from the avionics compartment. When the CVR data was unloaded, conversation at the cabin prior to the accident it was heard, which mentioned the word fire.00:26Z 3044 ANTI ICE R WINDOW00:26Z 561200 R SLIDING WINDOW SENSOR00:26Z 2600 SMOKE LAVATORY SMOKE00:27Z 2600 AVIONICS SMOKE00:28Z 561100 R FIXED WINDOW SENSOR00:29Z 2200 AUTO FLT FCU 2 FAULT00:29Z 2700 F/CTL SEC 3 FAULTno further ACARS messages were received.

I think that its published findings thus far are quite supportive of my oxygen fire hypothesis (i.e. not unalike to what likely happened to MH370, only difference being that they (MS804) weren’t holed at height and the fire was likely at the oxygen bottles in the avionics compartment below, where most contingent damage to the very vulnerable Airbus flight control system was highly likely – unlike the sudden quenching of any flight-deck fire at cruise height when the MH370 fuselage was holed by an immediately adjacent point-source oxygen-fed fire). B777-200 flight control system, even while not being autopiloted, is nowhere near as vulnerable. It is “electronically self-repairing as well as self-correcting aerodynamically”.

So what can a pilot team do when their cockpit is full of smoke and they’ve lost their flight control system and oxygen supply? Probably do exactly what was recorded….. i.e. a L.O.C. (Loss of Control).

A320 Avionics bottles are located nowhere near the sides of the fuselage and that’s likely why there would have been no instant depressurization on MS804, just a smoke build-up that caused the pilots to actually depressurize and force open the sliding side windows.BEA found no traces of explosives on the pieces of recovered wreckage. No noise of any explosions on the CVR.

Subject: SU-GCC / Data firewalls to public disclosure

A number of such incidents such as this were discarded from my 'Catalog' because the reports lacked enough data describing an actual fire (i.e. burned, burnt, even 'thermal damage').  The most clarity of what was actually allowing a fire to grow came not from the NTSB, but rather their counterpart agencies in the AAIB, Canada, Egypt, France and the Chinese.   Additional such detail was gathered from NTSB Safety Recommendation Letters - but not seen in the Accident/Incident database.   That extremely hard to find Boeing Service Letter calling out the same warnings of insulation fires seen in that Douglas All Operator Alert 4 years earlier was an attachment to a Chinese report.   The Douglas AOL warning was a attachment to a Danish report.

I recall the FBI citing explosive evidence on TWA 800, - but then it was said the adhesives used in the seat construction was the likely source.

In the US the industry has many tools to obscure serious systemic fleet grounding issues.  For over 30 years the SDR reporting system under reporting runs at about 30 to 70 % depending on the carrier.  When the FAA enforcement data was up for a limited time, no enforcement actions regarding this were given. 

The NTSB Accident/Incident data captured only about 10 % of some 30 reports where the MPET and PET acoustic insulation was identified directly as propagating a fire ( fires are required reporting under NTSB's Rule 830.5).   The NTSB freely admits that this database is "selected" data.

The FAA's Incident database reflects less than 20 % of the same data in the NTSB's database.

MISC NOTES

10/97. All MD-11s. Douglas Service Bulletin (MD-11-25-2000) to replace metalized Mylar (MPET) with MPVF. Canadian TSB issues aviation safety recommendations for thermal acoustical insulation materials and flammability test criteria. By 1997 metallized PVF was being used in production aircraft. By October of that year McDonnell Douglas had issued a Service Bulletin (MD-11-25-2000) that encouraged MD-11 operators to replace insulation blankets covered with metallized PET material with blankets covered with metallized PVF material. The Service Bulletin also stated that the non-metallized PET cover material that had been used in production aircraft since September 1996 was discontinued, as it did not consistently pass a particular McDonnell Douglas flammability test. That Bulletin also stated that McDonnell Douglas was

now using metallized PVF in new production aircraft. Similar Service Bulletins, regarding the use of metallized PET cover material, were issued to DC-8, DC-9, DC-10, MD-80, and MD-90 operators.

MISC NOTES. 1991. FAA’s February 1991 Technical Center paper titled, “Development and Growth of Inaccessible Aircraft Fires Under Inflight Airflow Conditions (DOT/FAA/CT -91/2). Conclusions included that “although uncontaminated insulation blankets did not readily support combustion, contaminated insulation blankets were found to support combustion (consistent with service experience.” Link > http://www.dtic.mil/dtic/tr/fulltext/u2/a236031.pdf

See SAVED (for the solution to “smoke in the cockpit/cannot see”)

See this link below for past (and future) such fire events:

https://aviation-safety.net/database/events/event.php?code=FI

Also see: (reference MH370 mystery): http://tinyurl.com/or9bzf2 (and its internal links) END

10/25/16.   The Eighth Triennial International Fire & Cabin Safety Conference. 

Research                                                       

Link > https://www.fire.tc.faa.gov/2016Conference/conference.asp  

Excerpt presentations. See Link for full presentations.

INTERLABORATORY STUDY OF RADIANT PANEL TESTING FOR MEASURING FLAMMABILITY OF THERMAL ACOUSTIC INSULATION MATERIALS. Steve Rehn. The repeatability of thermal/acoustic insulation material tests in the Radiant Panel test has recently been brought into question since a new handbook is being written. A dimensional survey of each lab’s test apparatus and a round-robin material study have been completed. The results showed that test results across each lab were not as repeatable as needed. The dimensional survey showed what the biggest differences were in each lab’s test apparatus, so now further studies are being conducted to determine which of these factors has the biggest effect on calibration and material test results.

CHALLENGES AND UNEXPECTED BENEFITS OF DEVELOPING AN ACOUSTIC BARRIER FILM Greg Simon, Aero Technologies LLC, a 3M Company.   Like so many components of aircraft, acoustic barriers are an engineering challenge of balancing many competing desirable or undesirable traits. These limp mass barriers play an important role in the noise control system for aircraft, especially for business jets whose owners and operators demand premium sound quality in the cabin. The acoustic system and each of its components must not only function to reduce the transmitted noise into the cabin, but must also meet the strict fire safety standards of this industry. For decades, it has been possible to achieve these goals in the limp mass barrier component by a purposeful combination of PVC resins, phthalate plasticizers and other fire retardant additives. However, these raw materials are becoming increasingly scrutinized as potential hazards to both humans and the environment, some classes of which have recently been placed on the REACH watch list as substances of very high concern (SVHC). This paper presents a new class of barrier films that meet these prescriptive fire standards without the use of these undesirable raw materials.

RESEARCH INTO SMOKE, FIRE, OR FUMES OCCURRENCES ON TRANSPORT AIRPLANES.   Ray Cherry RGW Cherry & Associates.   This study has been carried out at the request of the Federal Aviation Administration (FAA) and the United Kingdom Civil Aviation Authority (UK CAA) under the provisions of a UK CAA contract. The broad objectives of the study are to collect and analyze data relating to in-service occurrences involving Fire, Smoke or Fumes on US registered aircraft. This involved the compilation of data into a bespoke Fire, Smoke or Fumes Occurrence (FSF) Database compiled in Microsoft Excel. The analysis compares genuine and false occurrences by source of fire, smoke, fumes or odors and consequences (Diversions, Overweight Landings, etc.). The data has also been analyzed to derive any likely trends in rates of occurrence. These objectives have now been achieved for data collected over the period 2002 to 2011 and are addressed in this report. A further objective of the study is to analyze the data to determine the monetary impact of the occurrences and any trends in these impacts. This will be addressed in subsequent phases of this study and this report amended to reflect the results.

------------------

10/26/16. THE EIGHTH TRIENNIAL INTERNATIONAL FIRE & CABIN SAFETY RESEARCH CONFERENCE.   Link > https://www.fire.tc.faa.gov/2016Conference/files/Materials_IV_Regulatory/DavisARACMaterials/DavisARACMaterialsAbs.pdf

Excerpts only. See link for full texts.

ARAC MATERIALS FLAMMABILITY WORKING GROUP CONTINUATION OF TASK (We're Getting the Band Back Together!!)   Jim Davis, Accufleet.  

“The Aviation Rulemaking Advisory Committee (A R A C) was formed in 1991 to inform, assist and advise the FAA in support of the rulemaking process. The committee is made up of representatives from the many stakeholders in aviation. It is an extremely successful public/private collaboration for improving aviation safety and regulatory effectiveness. The FAA has sole responsibility to task the committee with work to be done.

The FAA proposed the original task in August, 2010: to form the Materials Flammability Working Group (MFWG). The group was to review a proposed new approach for revision of flammability regulations and make recommendations.

The purpose of the new approach was to move from the current reactive set of regulations, to a proactive safety framework. The FAA proposal was to completely rewrite and update the existing flammability regulations based upon realistic threats that could occur in-flight or in a post-crash environment.  

The working group combined more than 20 members drawn from regulatory authorities, airframe manufacturers, equipment manufacturers, and operators world-wide.   Our report on the proposed revision was issued in 2012.

Critical to the success of new regulations are positive effects on costs and benefits. In January, 2015, the FAA requested that the Working Group reconstitute to provide additional cost and benefit information. Our report was issued in January of 2016. We will present an overview of our report, notes on the ARAC Working Group process, and some personal (NOT official) thoughts on what comes next”.

REFINEMENT OF THE NEXGEN BURNER USED FOR TESTING THE BURNTHROUGH RESISTANCE OF THERMAL ACOUSTIC INSULATION.   Robert Ochs, PhD – FAA Fire Safety Branch

“Abstract: The FAA Next Generation (NexGen) Fire Test Burner was originally developed to replace the Park DPL-3400 burner originally prescribed for the insulation burnthrough requirement described in FAR 25.856b. Since then, there have been significant modifications to the burner, as it has also been adapted to fire testing of seat cushions, cargo liner materials, and magnesium alloy seat structures. Those modifications include the replacement of the original stator and turbulator with new, CAD-designed and CNC-machined version of the stator and turbulator, with the removal of the igniters from the burner tube and utilizing a modified burner cone with an integrated flame ignition mechanism. The two pass-fail criteria, burnthrough time and heat flux, were evaluated with standard materials to determine the influence of the new burner components and configuration compared with the original NexGen burner configured as described in AC25.856b.”  

Misc Notes.

Ref pgs 14 and 15 from the Royal Aeronautical Report (Flight Operations Group of the Royal Aeronautical Society, SMOKE, FIRE AND FUMES IN TRANSPORT AIRCRAFT PAST HISTORY, CURRENT RISKS AND RECOMMENDED MITIGATIONS, Part 1: Reference Third Edition 2014.

5.3.   Insulation.   A developing fire needs a source of fuel for combustion. Insulation blankets, which are often located in inaccessible areas, can provide that source. The FAA has given specifications regarding the flammability of insulation blankets for initial certification of aircraft (FAA, 2005). However, as the aeroplane ages, flammable contaminants such as lubricants, corrosion inhibitors, hydraulic fluid, drilling swarf and dust can coat the insulation blankets. As shown in NTSB investigations (Keegan, 2001) and FAA tests, (Blake, 1991) these contaminated blankets can burn and provide the fuel necessary for a fire to become self-sustaining and propagate along existing ambient airflow paths.

In September 2005, the flammability requirements of thermal acoustic blankets were upgraded (FAA, 2005). This upgrade was the result of major work done by the FAA Technical Center in flammability

testing and material flammability resistance.

In some electrical fires, the panel material or wiring insulation can provide the fuel for combustion (Keegan, 2001). The requirements for the flammability of wiring insulation material are specified in 14 CFR § 25.869 and AC 25.869-2A (FAA, 2008). These requirements have been improved over the years, but there are some aeroplane fires, such as on AirTran Flight 913, which involved wiring that met the standards of the initial type certificate issuance date but did not meet the current standard.

Due to the breakdown of wiring insulation and installations over time, continued improvement and increasingly stringent regulations are necessary. The FAA found that:

“Current wire specifications do not include qualification requirements for various wire characteristics that would better define wire performance in a multi-stressor aircraft environment. Wire specifications should be revised to incorporate resistance to cut-through, abrasion, hydrolysis, and longer term heat aging, as applicable.” (FAA, 2008)

In some fires the surrounding material and location combine to create a serious hazard. AirTran Flight 913 experienced an electrical fire in the electrical power centre located just forward of the flight attendant jump-seat and directly behind the captain. The flight attendants did not attempt to find the source of the smoke nor did they attempt to discharge a fire extinguisher. The source of the smoke was uncertain and the flight attendants had not been trained to remove interior panels when searching for smoke sources.

The location of the electrical fault [and the lack of proper training] prevented fire-fighting from occurring. The fuel for the fire was wiring insulation as well as the panel material. The NTSB determined the probable cause as:

“A phase-to-phase arc in the left heat exchanger cooling fan relay, which ignited the surrounding wire insulation and other combustible materials within the electrical power center panel…” (2000).

Link > https://www.skybrary.aero/bookshelf/books/2330.pdf

---------------------------

12/22/14.   FAA Advisory Circular; Subject: In-Flight Fires. Date: 12/22/14.   Initiated by: AFS-200. AC No: 120-80A.

Excerpts. See Link for full text.

“1. PURPOSE. This advisory circular (AC) updates information regarding the hazards and risks of in-flight fires on transport category aircraft. The information includes recommended crewmember procedures and training for combating in-flight fires. The National Transportation Safety Board (NTSB) issued Safety Recommendations A-11-87 through A-11-91 during the investigation of United Parcel Service (UPS) flight 6 accident on September 3, 2010 in the United Arab Emirates. The flightcrew encountered a “Fire Main Deck” master warning about 22 minutes into the flight; they

declared an emergency and initiated a return to Dubai International Airport (DXB). The aircraft crashed inside an Emirate army post 9 miles from DXB, and both flightcrew members were fatally injured. NTSB findings revealed safety issues related to the training and use of oxygen mask; communicating with oxygen masks donned; and oxygen mask stowage and the smoke, fire, or fumes checklists. This revision to AC 120-80 is in response to NTSB recommendations A-11-88 through A-11-90.”

Ref to page 8.  “SUBTLE CAUSES OF IN-FLIGHT FIRES. a. Wiring Failures. A majority of hidden in-flight fires are the result of electrical arcs along wire bundles. In most cases, the electrical arc acts as the initiating event, igniting other surrounding materials. The surface of insulation materials is often a conveyer of these initiating events, as contamination from spillage, accumulated dirt/dust, lubrication or corrosion inhibitors on these surfaces can promote flame-spread (uncontaminated insulation materials are generally very fire-resistant). In other instances, the resetting of a tripped circuit breaker can overheat wiring, ultimately leading to failure and arcing, causing the same chain of events”.

Link > https://www.skybrary.aero/bookshelf/books/17.pdf

Replacing EVAS? (the “External Vision Assurance System)

FedEx will use smart glasses to help pilots land in emergencies

SAVED lets crews see what's outside when smoke fills the cockpit.

Jon Fingas, @jonfingas 04.12.18 in Wearables 2 Comments 1601 Shares https://www.engadget.com/2018/04/12/fedex-using-smart-glasses-in-aircraft

Osterhout Design Group

Smoke is understandably a serious danger for aircraft, and not just in life-threatening situations -- the FAA notes that there's typically one smoke-related landing per day. But how does the pilot land with a smoke-filled cockpit where they might not even see the instrument cluster, let alone the outside world? FedEx and the Osterhout Design Group have an idea. They're showing off SAVED (Smoke Assured Vision Enhanced Display -- yes, it's a forced acronym), a hybrid smart glasses and oxygen mask system that provides data from the aircraft's HUD and external cameras to help with emergency landings. Pilots won't have to fly blind or risk passing out, just to avoid a disaster.

The system is small, light and easy to install, Osterhout claims, and it's easy to see as much from a quick glance. Smart glasses are usually bulky by themselves, but they're relatively compact inside an oxygen mask.

Not surprisingly, FedEx is the first customer. It's using SAVED for both training and real-world flights. There's no mention of other customers just yet. However, it's easy to see other couriers and airlines adopting wearable tech like this in the future when it could save lives and, in the best cases, avoid crash landings. But will the FAA and/or Europe’s EASA mandate the equipment?

john.king19@comcast.net