DOCSLIB.ORG

Final Report

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Final Report 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.
Load more

Recommended publications
  • Appendix of Selected Air Navigation Service Providers
    Appendix of Selected Air Navigation Service Providers This appendix contains information a focus of this study is the critical role on the primary air navigation service that scheduled airlines will play in the providers (ANSPs) for the 60 countries definition, financing, and success of air selected by Air Traffic Infrastructure traffic infrastructure programs, the chart Global Markets 2012, presenting infor- presents scheduled airline origination mation tied to improvement, support, and destination (O&D) traffic within the operation, and financing of communica- ANSP’s territory for those years. This tions, navigation and surveillance (CNS) (O&D) traffic generally has the greatest services, and air traffic management interaction with air navigation services (ATM) capabilities through 2021. and the greatest demand for the infra- structure supporting those services. Each ANSP summary identifies the nation (or state, in the parlance of the International Civil Aviation Organiza- NEXA Assessment tion) served by the ANSP, the govern- Each assessment begins with NEXA’s ment agency to which it reports (where rationale for the ANSP’s inclusion in this appropriate) and the name of the ANSP study; it is paired with a chart depicting (preceded in some cases by the name six fundamentals underlying that ratio- of the agency in which it resides). Each nale. The six are: ownership and control, includes a map of the airspace served the source of revenue, the transparency by the ANSP, along with its neighboring of its business practices, the current flight information regions, and a chart state of its infrastructure, the rating of air traffic for 2006 and 2011. Since of its (or its “owner’s”) credit risk, and the projected annual air traffic growth (for the region in which the ANSP op- erates combined, where available, with forecasts for its host country).
    [Show full text]
  • WASHINGTON AVIATION SUMMARY March 2011 EDITION
    WASHINGTON AVIATION SUMMARY March 2011 EDITION CONTENTS I. REGULATORY NEWS................................................................................................ 1 II. AIRPORTS.................................................................................................................. 5 III. SECURITY AND DATA PRIVACY ……………………… ……………………….……...7 IV. E-COMMERCE AND TECHNOLOGY......................................................................... 9 V. ENERGY AND ENVIRONMENT............................................................................... 10 VI. U.S. CONGRESS...................................................................................................... 12 VII. BILATERAL AND STATE DEPARTMENT NEWS .................................................... 14 VIII. EUROPE/AFRICA..................................................................................................... 15 IX. ASIA/PACIFIC/MIDDLE EAST .................................................................................17 X. AMERICAS ............................................................................................................... 19 For further information, including documents referenced, contact: Joanne W. Young Kirstein & Young PLLC 1750 K Street NW Suite 200 Washington, D.C. 20006 Telephone: (202) 331-3348 Fax: (202) 331-3933 Email: [email protected] http://www.yklaw.com The Kirstein & Young law firm specializes in representing U.S. and foreign airlines, airports, leasing companies, financial institutions and aviation-related
    [Show full text]
  • THE IMPLEMENTATION of the YAMOUSSOUKRO DECISION By
    THE IMPLEMENTATION OF THE YAMOUSSOUKRO DECISION By Charles E. Schlumberger Institute of Air and Space Law, Faculty of Law, McGill University, Montreal. February 2009 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Doctor of Civil Law (DCL) © Charles E. Schlumberger, 2009 THE IMPLEMENTATION OF THE YAMOUSSOUKRO DECISION TABLE OF CONTENTS ACKNOWLEDGMENTS.............................................................................................................. v ABSTRACT ................................................................................................................................. viii RÉSUMÉ........................................................................................................................................ ix INTRODUCTION.......................................................................................................................... 1 CHAPTER 1 HISTORICAL BACKGROUND OF THE YAMOUSSOUKRO DECISION................................................................................................................................... 7 1.1 Early development of air services in Africa ....................................................................... 8 1.2 Post World War II era...................................................................................................... 13 CHAPTER 2 MAJOR ELEMENTS AND OBJECTIVES OF THE YAMOUSSOUKRO DECISION............................................................................................. 20 2.1
    [Show full text]
  • MID 8-History of the Meeting
    MIDANPIRG/8- REPORT INTERNATIONAL CIVIL AVIATION ORGANIZATION REPORT OF THE EIGHTH MEETING OF THE MIDDLE EAST AIR NAVIGATION PLANNING AND IMPLEMENTATION REGIONAL GROUP MIDANPIRG/8 (Cairo, 7-11 September 2003) The views expressed in this Report should be taken as those of the Regional Planning and Implementation Group and not of the Organization. This Report will, however, be submitted to the ICAO Council and any formal action taken will be published in due course as a Supplement to the Report Approved by the Meeting and published by authority of the Secretary General The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of ICAO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontier or boundaries. TABLE OF CONTENTS Page PART I - HISTORY OF THE MEETING 1. Place and Duration ................................................................................................ 1 2. Opening ................................................................................................................ 1 3. Attendance............................................................................................................ 1 4. Officers and Secretariat .......................................................................................... 1 5. Language .............................................................................................................. 2 6. Agenda
    [Show full text]
  • Boeing 777 - Wikipedia 3/30/20, 1146 AM
    Boeing 777 - Wikipedia 3/30/20, 1146 AM Boeing 777 The Boeing 777 is a wide-body airliner developed and manufactured by Boeing Commercial Airplanes, commonly referred to as the Triple Seven.[5][6] The 777 was designed to bridge the gap between Boeing's 767 and Boeing 777 747, and to replace older DC-10s or L-1011s. Developed in consultation with eight major airlines, with a first meeting in January 1990, the program was launched on October 14, 1990 with a first order from United Airlines. The prototype was rolled out on April 9, 1994, and first flew on June 12, 1994. The 777 first entered commercial service with United Airlines on June 7, 1995. Longer range variants were launched on February 29, 2000 and were first delivered on April 29, 2004. It is the largest twinjet and has a typical 3-class capacity of 301 to 368 passengers, with a range of 5,240 to 8,555 nautical miles (9,704 to 15,844 km). It is recognizable for its large-diameter turbofan engines, six wheels on each main landing gear, fully circular fuselage cross-section,[7] and a blade-shaped tail cone.[8] It has fly-by-wire controls, a first for Boeing. It competed initially with the out-of-production Airbus A340 and McDonnell Douglas MD-11, with the Airbus A330-300 and the newer Airbus A350 XWB. The 777 is a low-wing twinjet; the original -200 is The original 777 with a maximum takeoff weight (MTOW) of 545,000–660,000 lb (247–299 t) was produced in the shortest variant.
    [Show full text]
  • Annual Report 2009 COMMISSION EUROPEAN Annual Report 2009 Report Annual Market Transport Air European the of Analyses Annual
    Annual Report 2009 Annual analyses of the European air transport market Annual Report 2009 EUROPEAN COMMISSION Air Transport and Airport Research Annual analyses of the European air transport market Annual Report 2009 German Aerospace Center Deutsches Zentrum German Aerospace für Luft- und Raumfahrt e.V. Center in the Helmholtz-Association Institute of Air Transport and Airport Research February 2011 Linder Hoehe 51147 Cologne Germany Head: Prof. Dr. Johannes Reichmuth Authors: Erik Grunewald, Amir Ayazkhani, Dr. Peter Berster, Gregor Bischoff, Prof. Dr. Hansjochen Ehmer, Dr. Marc Gelhausen, Wolfgang Grimme, Michael Hepting, Hermann Keimel, Rainer Kiehne, Alexandra Leipold, Dr. Sven Maertens, Melanie Murphy, Dr. Peter Meincke, Dr. Janina Scheelhaase web: http://www.dlr.de/fw Final Report 2011-02-15 Release: 1.8 Page 1 Annual analyses of the European air transport market Annual Report 2009 Document Control Information Responsible project manager: DG MOVE Project task: Annual analyses of the European air transport market 2009 EC contract number: TREN/05/MD/S07.74176 Release: 1.8 Save date: 2011-02-15 Total pages: 203 Change Log Release Date Changed Pages or Chapters Comments 0.1 2010-01-21 0.2 2010-04-15 0.21 2010-04-23 1st Draft Report 2009 0.3 2010-07-26 Final Draft Report 2009 0.31 2010-09-02 0.32 2010-09-08 0.33 2010-09-20 corrections after review 0.34 2010-10-21 Final Report 2009 - Draft 1.0 2010-10-28 final language check Final Report 2009 1.1 2010-10-29 internal 1.2 2010-12-10 internal 1.3 2010-12-13 internal 1.4 2010-12-20 Final Report 2009 1.5 2011-01-21 1, 2 Final Report 2009 1.6 2011-01-27 1 Final Report 2009 1.7 2011-01-28 Summary detail Final Report 2009 1.8 2011-02-15 Disclaimer Final Report 2009 Disclaimer and copyright: This report has been carried out for the Directorate-General for Mobility and Transport in the European Commission and expresses the opinion of the organisation undertaking the contract TREN/05/MD/S07.74176.
    [Show full text]