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Aircraft Accident Report ARAIB/AAR1105 Aircraft Accident Report Crash Into The Sea After An In-Flight Fire Asiana Airlines Boeing 747-400F, HL7604 International Waters 130 km West Of Jeju Int'l Airport 28 July 2011 24 July 2015 Aircraft and Railway Accident Investigation Board This aircraft accident report has been prepared in accordance with the Article 25 of the Aviation and Railway Accident Investigation Act of the Republic of Korea. According to the provisions of the Article 30 of the Aviation and Railway Accident Investigation Act, it is stipulated; The accident investigation shall be conducted separately from any judicial, administrative disposition or administrative lawsuit proceedings associated with civil or criminal liability. And in the Annex 13 to the Convention on International Civil Aviation, Paragraphs 3.1 and 5.4.1, it is stipulated as follows: The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of the activity to apportion blame or liability. Any investigation conducted in accordance with the provision of this Annex shall be separate from any judicial or administrative proceedings to apportion blame or liability. Thus, this investigation report shall not be used for any other purpose than to improve aviation safety. In case of divergent interpretation of this report between the Korean and English languages, the Korean text shall prevail. Aircraft Accident Report Aviation and Railway Accident Investigation Board. Crash Into The Sea After An In-Flight Fire, Asiana Airlines, Boeing 747-400F, HL7604, International Waters 130 km West Of Jeju International Airport, 28 July 2011. Aircraft Accident Report ARAIB/AAR-1105. Sejong Special Self-governing City, Republic of Korea. The Aviation and Railway Accident Investigation Board (ARAIB), Republic of Korea, is a government organization established for independent investigation of aviation and railway accident, and the ARAIB conducts accident investigation in accordance with the provisions of the Aviation and Railway Accident Investigation Act of the Republic of Korea and Annex 13 to the Convention on International Civil Aviation. The objective of the investigation by the ARAIB is not to apportion blame or liability but to prevent accidents and incidents. The main office is located in Sejong Special Self-governing City. Address: #94, Dasom 2-ro, Sejong Special Self-governing City, 339-012 Tel.: (82)-44-201-5447 Fax: (82)-44-201-5698 e-mail: [email protected] URL: http://www.araib.go.kr Contents Figures ··························································································································· ⅵ Tables ····························································································································· ⅸ Abbreviations ················································································································· ⅹ Crash Into The Sea After An In-Flight Fire ····························································· 1 Synopsis ··························································································································· 1 1. Factual Information ··································································································· 3 1.1 History of Flight ····································································································· 3 1.2 Injuries to Persons ································································································ 12 1.3 Damage to Aircraft ······························································································· 12 1.4 Other Damage ········································································································ 12 1.5 Personnel Information ··························································································· 12 1.5.1 The Captain ········································································································· 12 1.5.2 The First Officer ································································································ 14 1.6 Aircraft Information ······························································································ 15 1.6.1 Aircraft History ··································································································· 15 1.6.2 Scheduled Maintenance and Fault History ······················································ 16 1.6.3 Aircraft System ··································································································· 18 1.6.3.1 Air Conditioning and Pressurization System ················································ 18 1.6.3.2 Fire Warning and Detection System ····························································· 21 1.6.4 Weight and Balance ··························································································· 23 1.6.5 ACARS ················································································································ 24 1.6.5.1 General ACARS Information ········································································· 24 1.6.5.2 ACARS Messages ··························································································· 26 1.7 Meteorological Information ··················································································· 29 1.7.1 Precipitation and Temperature of Incheon Airport ········································· 29 1.7.2 Area Weather Condition ···················································································· 29 1.7.3 Weather Conditions of Departure and En-route Alternate Airports ············· 31 1.8 Aids to Navigation ································································································ 31 1.9 Communications ····································································································· 32 - i - 1.9.1 Voice Communications Between the Aircraft and ATCs ······························ 32 1.9.2 Direct Line Communications Between ATCs ················································· 32 1.9.3 Air Traffic Control Communications Facilities ··············································· 33 1.10 Aerodrome Information ······················································································· 34 1.11 Flight Recorders ·································································································· 34 1.11.1 Flight Data Recorder ······················································································· 35 1.11.2 Cockpit Voice Recorder ·················································································· 35 1.11.3 Underwater Locator Beacon ············································································ 35 1.11.4 Search Operations for Flight Recorders ························································ 36 1.12 Wreckage and Impact Information ···································································· 36 1.12.1 Accident Site ····································································································· 37 1.12.2 Wreckage Recovery ·························································································· 38 1.12.3 Wreckage Examination ····················································································· 40 1.13 Medical and Pathological Information ······························································ 55 1.14 Fire ························································································································ 55 1.14.1 Fire Damage of the Airframe ········································································· 56 1.14.1.1 Wreckage Between FS1700 and APB ························································ 56 1.14.1.2 Wreckage Forward of FS1700 and Aft of APB ······································ 57 1.14.1.3 Small Miscellaneous Portions of Wreckage ··············································· 59 1.14.1.4 Cargo Control Panels ···················································································· 59 1.14.1.5 Riser Ducts ···································································································· 59 1.14.1.6 Forward Main Cargo Deck Ceiling Panels ················································ 60 1.14.1.7 Upper Deck Interior Panel ··········································································· 60 1.14.2 Cargo Fire ········································································································· 61 1.14.3 Thermal Damage Map of the Entire Fuselage ············································· 63 1.15 Survival Aspects ·································································································· 66 1.15.1 Search and Rescue ··························································································· 66 1.15.2 ELT ···················································································································· 68 1.16 Tests and Research ····························································································· 68 1.16.1 Wreckage Reconstruction ················································································· 69 1.16.2 Chemical Properties Test and Analysis of On-board Dangerous Goods ··· 71 1.16.3 Simulation of Cargo Loading and Transport Condition Testing ················ 72
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