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Final Report Concerning EgyptAir Boeing 777-200 aircraft cockpit fire AT Cairo Airport On 29th July 2011 Registration SU-GBP Flight No MS 667 Cairo/ Jeddah Issued by Aircraft Accident Investigation Central Directorate Egyptian Ministry of Civil Aviation Cairo September, 2012 1 Foreword In accordance with Annex 13 to the Convention on International Civil Aviation and with European Regulation n°996/2010, the investigation has not been not conducted so as to apportion blame, nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents. Consequently, the use of this report for any purpose other than for the prevention of future accidents could lead to erroneous interpretations. 2 Table of Contents FOREWORD TABLE OF CONTENTS GLOSSARY SYNOPSIS INFORMATION ABOUT THE INVESTIGATION PROCEDURE 1 - FACTUAL INFORMATION 1.1 History of Flight 1.2 Injuries to persons 1.3 Damage to aircraft A. Examination of the aircraft. B. Accident aircraft photos. 1.4 Other Damages 1.5 Personnel Information 1.5.1 Captain A. Captain information. B. Captain statement. 1.5.2 F/O A. F/O information. B. F/O statement. 1.6 Aircraft Information 1.6.1 Aircraft General Information. 1.6.2 Important Extracts from B777 Flight Crew Operations Manual D632W001-EGP (FCOM). 1.7 Meteorological Information 1.8 Aids to Navigation 1.9 Communication 1.10 Aerodrome Information 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder CVR. 3 1.11.2 Flight Data Recorder FDR. 1.11.3 QAR (Quick Access Recorder). 1.11.4 Time correlation between CVR audio and the Cairo Airport Authority surveillance video tape for the accident. 1.12 Site and Wreckage Information 1.13 Medical and Pathological Information 1.14 Fire 1.15 Survival Aspects 1.16 Tests and Research A. Tests and researches carried out locally in Cairo. I. Examination, Analysis of burnt parts samples (collected from the cockpit) done by Central Metallurgical Research and Development Institute (CMRDI). i. XRD samples analysis results. ii. Examination of Stainless Steel Supply Tube. iii. Examination of Anti Kink Spring Supply Hoses Floor to Tee F/O Oxygen (Stainless Steel Spring). iv. Examination of other 777 Aircraft in EgyptAir Fleet II. Examination and Analysis of the “Extinguishing Foam Agent” used by Cairo Airport Authority, done by CMRDI and Ministry of Trade & Industry, Chemistry Administration. i - Results obtained from CMRDI examination, analysis ii- Results obtained from the Ministry of Trade & Industry , Chemistry examination and analysis III. Examination of Oxygen cylinder for purity, done by the Egyptian Air Force, Aviation Engineering Department, Gas Plant No. 1. IV. CVR and FDR readout. V. CVR/ video tape correlation. VI. QAR readouts. B. Tests and researches carried out by Boeing Company (USA). C. Boeing Actions 1.17 Information on Organisations and Management 4 1.18 Additional Information A. Investigation Progress Statement. B. Boeing Service Bulletin 777-33-0042. C. Boeing Service Bulletin 777-35A0027. EXHIBITS - Exhibit #1 photos for the accident aircraft - Exhibit #2 Captain Statements - Exhibit #3 F/O Statements. - Exhibit #4 QAR information - Exhibit #5 Analysis report on Residual of Ground Fire of Boeing 777, received from CMRDI, dated 13/08/2011 - Exhibit #6 Examination of Stainless Steel Supply Tube and Kink Spring - Exhibit #7 Extinguishing Foam Agent examination done by Ministry of Trade & Industry, Chemistry Administration - Exhibit #8 Examination of Oxygen cylinders for purity, done by the Egyptian Air Force 5 Glossary A/C Aircraft ATC Air Traffic Control APU Auxiliary Power Unit Capt Captain CMRDI Central Metallurgical Research and Development Institute CSN Cycles since New ECAA Egyptian Civil Aviation Authority EgyptAir M & E EgyptAir Maintenance and Engineering F/O First Officer FAA Federal Aviation Administration MCA Ministry of Civil Aviation (MCA- AAI) Ministry of Civil Aviation, Aircrafts Accidents Investigation NTSB National Transport Safety Board O2 Oxygen TSN Time since New UTC Universal Time Coordinate - 6 Synopsis Date of accident: 29th July 2011. Time of accident: 07 h 11 min UTC. Site of accident: Gate F7, Terminal 3, Cairo International Airport, Egypt. Flight Number: 667, regularly scheduled international passenger flight, Cairo/ Jeddah Aircraft type, registration: Boeing 777-200 registered SU- GBP. Operator: EgyptAir. Persons onboard: Cockpit Crew 2, Cabin Crew 8, Passengers 307 FDR information: SN 2057, P.N 980-4700-003, manufactured by AlliedSignal CVR information: SN 3667, P.N 980-6022-001, manufactured by Honeywell 7 INFORMATION ABOUT THE INVESTIGATION PROCEDURE • Just after the accidents, the aircraft was examined by specialized team including Egyptian (MCA- AAI)1, ECAA, EgyptAir M & E2, United States, the country of the aircraft manufacturer (Boeing representatives as technical advisors to the US accredited representative NTSB). Boeing representatives attended and represented NTSB, FAA and Boeing The status of the aircraft damage was recorded. Several photos were taken to thoroughly show the aircraft damage. (Refer to exhibit #1) • Official meetings were held at the (MCA-AAI) with the event flight cockpit crew (Captain and F/O). Cockpit crew responded to all investigation team inquiries. (Refer to exhibit #2 Captain Statement and exhibit #3 F/O Statement). • Aircraft FDR and CVR were removed from the aircraft for the readout analysis. They were received at the “AAI (FDR and CVR center) on 29th July 2011. (Same day of the accident). At the time of the accident, only the APU was running, the engines were not started yet; consequently the FDR did not include any information about the accident. CVR recording showed some information within the time of the accident. • Information on the QAR was read by EgyptAir M & E. It included mainly information about the APU. (Refer to exhibit #4) • Several meeting and telephone conferences were held at (MCA- AAI) and EgyptAir M & E, between Egyptian representatives (MCA-AAI, ECAA, and EgyptAir), USA representatives (NTSB, FAA) and Boeing. Meetings and conferences were held to discuss and study the factual information and the possible scenarios for the accident, and to perform necessary short terms and long term actions to maintain highest degree of safety. • A video tape was extracted from surveillance tapes developed by Cairo Airport Authority. This is a standard procedure used by Cairo Airport Authority. This video tape was received by (MCA- AAI) to support the investigation. • Time correlation between the events included in the video tape and the CVR was made by (MCA- AAI). • Samples from the burnt parts in the cockpit were collected and sent by the (MCA- AAI) to a 1 Ministry of Civil Aviation, Aircrafts Accidents Investigation 2 EgyptAir Maintenance and Engineering 8 specialized institute (CMRDI) for examination and analysis. The samples included the following: - Sample No.1: Yellow Powder (Flight Deck R.H.S.) - Sample No.2: Blue Powder (Flight Deck R.H.S.) - Sample No.3: Charred Material and Powder (R.H.S.) - Sample No.4: Bright Blue Material (Flight Deck R.H.S. AFT of Main hole Adjacent to Wiring - Sample No.5: Anti Kink Spring Supply Hoses Floor to Tee F/O O2 (Stainless steel Spring) (Refer to exhibit #5 and exhibit #6) • Examination and Analysis of the “Extinguishing Foam Agent” used by Cairo Airport Authority, was made by Ministry of Trade & Industry, Chemistry Administration, upon the request of (MCA- AAI). (Refer to exhibit #5 and exhibit #7) • Oxygen cylinder purity test was made by the Egyptian Air Force, Aviation Engineering Department, Gas Plant No 1, upon the request of (MCA- AAI). (Refer to exhibit #8) • The Boeing Company has conducted an extensive test program to determine if the oxygen system hoses were electrically conductive, and if they could have ignited if an electrical fault was present that involved these components. • The Boeing Company, in coordination with the AAI, ECAA, and NTSB, FAA, developed mitigation strategies designed to eliminate this potential source of fire in the cockpit. 9 1 - FACTUAL INFORMATION 1.1 History of Flight • On July 29, 2011, the said Boeing 777-200, Egyptian registration SU-GBP, operated by EgyptAir, arrived from Madina, Saudi Arabia (Flight No 678) and stopped at Gate F7, terminal 3, Cairo international airport almost at 0500 UTC time. • Necessary maintenance actions (After Landing Check ALC, Transit Check) have been performed by EgyptAir engineers and technicians, to prepare the aircraft for the following scheduled flight (Cairo/ Jeddah, scheduled at 0730 UTC, same day 29 July 2011, flight number 667). • The cockpit crew (Captain and F/O) for the event flight (Cairo/ Jeddah), started the cockpit preparation including checking the cockpit crew oxygen system as per normal procedures. The F/O reported that the oxygen pressure was within normal range (730 psi). • At almost 0711 UTC, and while waiting for the last passengers to board the aircraft, the F/O officer reported that a pop, hissing sound originating from the right side of his seat was heard, associated with fire and smoke coming from the right side console area below F/O window #3 (right hand lower portion of the cockpit area) [The aircraft was still preparing for departure at Gate F7, Terminal 3 at Cairo Airport at the time the crew detected the fire]. • The Captain requested the F/O to leave the cockpit immediately and notify for cockpit fire. The captain used the cockpit fire extinguisher bottle located behind his seat in attempt to fight and extinguish the fire. The attempt was unsuccessful, the fire continued in the cockpit. • The F/O left the cockpit, he asked the cabin crew to deplane all the passengers and crew from the aircraft, based on captain’s order. He moved to the stairs and then underneath the aircraft in attempt to find anyone with a radio unit but he could not. He returned to the service road in front of the aircraft and stopped one car and asked the person in the car to notify the fire department that the aircraft is burning on the stand F7 using his radio unit.
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