Emergency Landing in Killeen

2nd Quater 2009 Smoke Signals April 2009 EVASWorldwide Case Study: Boeing 777 Smoke Accident On February 26, 2007 at 1000, a contactors of the right main bus. wiring. The flight crew responded United Airlines Boeing 777-222ex- The heat generated during the to the bus failure and a burning perienced a smoke event at failure resulted in the contactor smell by shutting down the right London Heathrow Airport, UK. casings becoming compromised, engine and taxiing to a nearby The accident occurred during causing molten metal droplets stand. The Airfield Fire Service at- engine start after pushback from to fall down onto the insulation tended the aircraft when it arrived the stand. After the right gen- blankets below. The insulation on stand and entered the Main erator came online an electrical blankets ignited and a fire spread Equipment Centre where they dis- failure occurred in the right main underneath a floor panel to the covered significant smoke but no bus. The failure resulted in severe opposite electrical panel (P205), fire. The passengers were evacu- internal arcing and short cir- causing heat and fire damage ated uneventfully via steps. cuits inside the two main power to structure, cooling ducts and continued on page 2 Getting Control of LOC Front and centre on all new head- The specialised HUD symbology al attitude and recover the aircraft up displays being installed in Fe- is a product of a broader pro- back to normal parameters or dEx Express widebodies will be a gramme within FedEx starting otherwise risk a loss-of-control single number in a large font that later this year to arm pilots with (LOC) accident. appears only when a pilot needs it the knowledge, simulator skills continued on page 3 most - the g-load on the aircraft. and equipment to detect and recover large swept-wing aircraft As an aircraft upset recovery aid, from in-flight upsets - situations the G-meter’s simplicity belies the where an aircraft for whatever years of analysis, flight-testing reason is pitched, rolled or yawed and internal funding that went beyond the normal limits. Upsets into FedEx’s decision to include it. require pilots to assess the unusu- Upcoming Tradeshows April 20 - 23, 2009 Bombardier M&O Conference: Addison, Texas April 21 - 23, 2009 CASS: Orlando, Florida May 11 - 14, 2009 EBACE: Geneva, Switzerland Smoke Signals is written and produced by June 24, 2009 Allison Markey, Aviation Safety Specialist Safety Operating Systems NBAA Regional: St. Paul, MN 1 Case Study: Boeing 777 Smoke Accident cont. continued from page 1 smoke 42 seconds after the initial beneath the power panel. There The investigation identified the electrical failure event and this was extensive fire damage to the following causal factors: triggered the ‘Equipment Cooling fire-retardant insulation blankets Override’ mode. Three minutes located behind the power panel 1. An internal failure of the Right and 13 seconds after the failure and beneath the panel under the Generator Circuit Breaker or Right event the flight crew first noticed floor. Nearby components in- Bus Tie Breaker contactor on the an electrical burning smell. It was cluding a floor panel, equipment P200 power panel inside the not until 4 minutes and 30 sec- cooling system ducting, other Main Equipment Centre resulted onds after the failure event that wire bundles and some structural in severe internal arcing and the flight crew became aware of frames and stringers in the vicin- short-circuits which melted the smoke – this was when the tug ity were later determined to have contactor casings. The root cause driver advised on interphone that suffered sufficient heat damage to of contactor failure could not be there was a lot of smoke com- require replacement. determined. ing out of the vents. No smoke was seen in the flight deck until 2. The open base of the P200 pow- after the APU was shut down – 14 er panel allowed molten metal minutes after the failure event. droplets from the failed contac- The flight crew’s lack of awareness tors to drop down onto the insula- of the significant smoke in the tion blankets and ignite them. MEC may have delayed their decision to shut down and evacuate 3. The aircraft’s electrical protec- the passengers. Their focus was tion system was not designed to on the bus failure and a percep- detect and rapidly remove power tion of an overheat problem; the from a contactor suffering from possibility of a fire in the MEC severe internal arcing and short- appeared to have been dismissed. circuits. If the aircraft’s warning system Above: Fire damage to P200 power panel had provided a ‘smoke’ warning to (cover removed), showing burnt-out RGCB 4. The contactors had internal and RBTB contactors (viewed looking for- the flight crew when smoke was ward and to the right) design features that probably first detected, then the flight crew contributed to the uncontained might have expedited the shut- failures. down and evacuation. The fire and smoke in the MEC An inspection inside the MEC was caused primarily by ignition after the accident revealed ex- of the insulation blankets from tensive heat and fire damage to hot molten metal droplets falling the P200 power panel which is down from the failed contactors. located to the right of the nose Some of the floor panel burning gear wheel well (see Figure 1). and ancillary equipment burning The worst affected components would also have contributed to of the power panel were the the smoke. Right Generator Circuit Breaker Above: Burnt aircraft structure and insula- (RGCB) and Right Bus Tie Breaker tion blankets located directly below P200 The flight crew did not become (RBTB) contactors, parts of which power panel (viewed looking down and aft; aware of any smoke until some had melted and vaporised (see the floor panel has been removed) time after the insulation blan- Figure 2). There was evidence kets started to burn. The smoke that molten metal had dripped Final Report by AAIB published April detector in the MEC detected down onto the insulation blankets 16, 2009 2 Getting Control of LOC cont. continued from page 1 board that experienced an upset in the classroom and in the Flight International joined Fe- and subsequent LOC initiated by simulator using the industry-de- dEx experimental test pilot an uncommanded rudder fault. veloped recovery aid, which was Bob Moreau in a Boeing MD-11 recently updated for the second simulator on 18 December at Although the industry as a whole time to include recovering a large the company’s headquarters in came together in the aftermath of swept-wing aircraft in the high- Memphis, Tennessee, to perform Flight 427 to develop the Airplane altitude environment. unusual attitude recoveries with Upset Recovery Training Aid, a the HUD system and discuss the workbook and video explaining Unlike the training aid, which company’s unique approach to how swept-wing aircraft should assumes the aircraft is control- upset training, a curriculum that be recovered from upsets that lable through the primary flight may become a standard training cause unusual attitudes, accidents controls, FedEx is leaning toward tool for FedEx pilots later this year. continue. Several recent high- teaching its 4,700 pilots to be profile crashes (see table) that more open minded as to the FedEx is not alone in its efforts claimed all lives on board reveal cause of the upset and method as the industry as a whole is that pilots in each case did not of recovery. “We don’t assume a mobilising to reduce LOC ac- properly handle low-speed stall normal aircraft,” says Moreau. “A cidents, events the Flight Safety scenarios in the high-altitude big aircraft doesn’t get into those Foundation says are the top killers phases of flight, a finding safety situations unless something is of crews and passengers in the experts say is a symptom of amiss.” airline industry. A list of LOC ac- inadequate knowledge and train- cidents between 1998 and 2007 ing in relation to swept-wing jets compiled by Boeing reveals that despite having upset recovery there were 22 that resulted in training materials available. more than 2,051 fatalities world- wide. Air transport-certificated pilots do not have “the baseline knowl- SPECIAL HAZARD TRAINING edge that we’ve believed them to have”, says John Cox, chief execu- The US Federal Aviation Adminis- tive of Washington-based Safety tration, which had largely stayed Operating Systems and a former on the sidelines on LOC preven- airline pilot and top safety official tion despite a long-standing Na- with the Air Line Pilots Associa- Airlines are now training pilots more tional Transportation Safety Board tion. extensively on “special hazard” LOC prevention in initial and recurrent recommendation to train crews simulator training. “to respond to sudden, unusual The FAA’s new rule, expected to or unexpected aircraft upsets”, be finalised by late 2010, will give As such, the FedEx programme proposed early in January making carriers five years after that to is likely to teach pilots to adopt certain “special hazard” LOC train- implement a host of new training alternate control strategies, using ing a mandatory element of initial requirements for pilots, including secondary or tertiary flight-con- and recurrent simulator training upset-recovery scenarios in the trol methods, to regain and retain for airline pilots. simulator. control of the aircraft. FedEx’s 4,700 pilots receive five days of The NTSB issued its recommenda- PREVENTION TECHNIQUES flight training a year, composed tion in 1996 after the fatal 1994 of one day of ground school, one crash near Pittsburgh Interna- Like many airlines, FedEx in the day of computer-based training tional airport of USAir Flight 427, past has voluntarily included and three days of simulator train- a Boeing 737-300 with 132 on some LOC prevention techniques ing.

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