PB86-9 10402‘ ~ -’ TRANSPOWTATiQN SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT AIR CANADA FLIGHT 797 MCDONNELL DOUGLAS DC-9-32, C-FTLL GREATER CINCINNATI . INTERNATIONAL AIRPORT COVINGTON, KENTUCKY JUNE 2, 1983 NTSBIAAR-86102 (SUPERSEDES - - NTSB/AAR-84/09) 5 UNITED STATES.. -u GOVERNMENT %?%$A1 TECHNICAL ,- 1 ‘NE~=~A~~~~FNo~~~~‘cE-: sPalwq10. VA. 22161 -: - _ . .: -. - TECHNICAL REPORT DOCUMENTATION PAGE 1 . Report No. 2.Government Accession No. 3.Recipient’s Catalog No. NTSB/AAR-86/02 PB86-910402 . 4 Ti t 1 e ano Subt i t lo Aircraft Accident Report-Air ’ ’ R~&‘%%&%~p 1986 * Canada Flight 797, McDonnell Douglas DC-9-32, C-FTLU, Greater Cincinnati International Airport, Covington, 6.Performing Organization Kentuckv, June 2, 1983 (SuDersedes NTSB/AAR-84/09) Code 7. Author(s) 8.Performing Organization Report No. 9. Performing Organization Name and Address 10.3v;;ik $i t No. National Transportation Safety Board 1l.Contract or Grant No. Bureau of Accident Investigation Washington, D.C. 20594 l3.Type of Report and Period Covered 12.Sponsoring Agency Name and Address Aircraft Accident Report June 2, 1983 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 14.Sponsoring Agency Code 15.Supplementary Notes 16.Abstract On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. The flight left Dallas with 5 crewmembers and 41 passengers on board. About 1903, eastern daylight time, while en route at flight level 330 (about 33,000 feet m.s.l.1, the cabin crew discovered a fire in the aft lavatory. After contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent, and ATC vectored Flight 797 to the Greater Cincinnati International Airport, Covington, Kentucky. At 1920:09, eastern daylight time, Flight 797 landed on runway 27L at the Greater Cincinnati International Airport. As the pilot stopped the airplane, the airport fire department, which had been alerted by the tower of the fire on board the incoming plane, was in place and began firefighting operations. Also, as soon as the airplane stopped, the flight attendants and passengers opened the left and right forward doors, the left forward overwing. exit, and the forward and aft right overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire enveloped the airplane interior. While 18 passengers and 3 flight attendants exited through the forward doors and slides and the three overwing exits to to NI’CR Prrrm 17C: 7 /a,.. h,f”. - . i __ . Abstract Cont’d On August 8, 1984, the National Transportation Safety Board adopted the report and probable cause of the accident. On December 20, 1984, the Air Line Pilots Association submitted a petition for reconsideration of the contributing factors statement of the probable cause that was adopted in the original report. As a result of the Air Line Pilots Association’s petition, the accident report and the probable cause have been revised. The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident. ‘_ . i-j . -- .- . CONTENTS a SYNOPSIS . , . 1 , 1. FACTUAL INFORMATION. .................. 2 1.1 History of the Flight ..................... 2 1.2 Injuries to Persons ...................... 8 1.3 Damage to Airplane ...................... 9 1.4 Other Damage ........................ 9 1.5 Personnel Infor mation ..................... 9 1.6 Airplane Information ..................... 9 1.6.1 Flight and Cabin Maintenance Logbook Writeups .... ...... 10 1.6.2 Passenger Cabin Modification. ................. 11 1.7 Meteorological Information. .................. 12 1.8 Aids to Navigation ...................... 12 1.9 Communications ....................... 12 1.10 Aerodrome Information ..................... 12 1.11 Flight Recorders ....................... 13 1.12 Wreckage and Impact Information ................ 14 1.12.1 External Fuselage ....................... 14 1.12.2 Interior Fuselage Forward of the Aft Lavatory .......... 16 1.12.3 Aft Lavatory Area ...................... 16 1.12.4 Cargo and Aft Accessory Compartments ............. 25 1.12.5 Cockpit Controls and Instruments ................ 27 1.13 Medical and Pathological Information .............. 27 1.14 Fire Response ........................ 28 1.15 Survival Aspects ....................... 30 1.16 Tests and Research ...................... 35 1.16.1 Federal Bureau of Investigation (FBI) Laboratory Tests. ...... 35 1.16.2 Electrical System Components ................. .35 1.16.3 Flush Motor and Lavatory Components. ............. 36 1.16.4 Flush Motor Seizure Test. ................... 38 1.16.5 Fire and Heat Tests ...................... 38 1.16.6 Airplane Cabin Fire Research. ................. 42 1.17 Other Information. ...................... 43 1.17.1 Air Canada Operational Procedures ............... 43 l.17.2 Useof Aft Lavatory. ....................... 46 1.17.3 Smoke Detectors ....................... 47 1.17.4 Examination of Other DC-9 Airplanes .............. 47 , 1.17.5 Air Traffic Control Procedures ................. 47 1.17.6 Air. Traffic Control Radar Data ................. 50 1.17.7 DC-g-32 Descent Performance .................. 51 2. ANALYSIS .......................... 53 2.1 General ............................ 53 2.2 Fire ............................. 53 2.3 Operational and Survival Factors ................ 59 2.4 Firefighting .......................... 68 2.5 In-flight Fire Prevention/Detection ................ 68 3. CONCLUSIONS. ....................... 69 3.1 Findings . .. ‘;............................................... 69 3.2 Probable Cause :- ...... 71 .1.. 111 4. RECOMMENDATiONS. , . 71 5. APPENDIXES ........................ 79 Appendix A-Investigation and Hearing. ............. 79 Appendix B-Personnel Information ............... 80 Appendix C-Airplane Information. ............... 82 Appendix D-Cockpit Voice Recorder Transcript ......... 83 Appendix E-14 CFR 25 Flame Resistance Criteria ........ 97 Appendix F-Air Canada DC-9 Emergency Equipment ....... 98 Appendix G--Petition for Reconsideration of Probable cause. ................ .-. .. ..-. ..... i . 99 Appendix H-NTSB Response to Petition for Reconsideration of Probable Cause ....................... 109 . -iv‘ -_ : . NATIONAL +RANSPORTATION SAFETY HOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT . a Adopted: January 31,1986 AIR CANADA FLIGHT 797 MCDONNELL DOUGLAS DC-9-32, C-FTLU n GREATER CINCINNATI INTERNATIONAL AIRPORT COVINGTON, KENTUCKY JUNE 2,1983 SYNOPSIS On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. The flight left Dallas with 5 crewmembers and 41 passengers on board. About 1903, eastern daylight time, while en route at flight level 330 (about 33,000 feet m.s.l.), the cabin crew discovered smoke in the left aft lavatory. After attempting to extinguish the hidden fire and then contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent and ATC vectored Flight . 797 to the Greater Cincinnati International Airport, Covington, Kentucky. At 1920:09, eastern daylight time, Flight 797 landed on runway 27L at the : Greater Cincinnati International Airport. As the pilot stopped the airplane, the airport fire department, which had been alerted by the tower to the fire on board the incoming ,.; plane, was -in place and began firefighting operations. Also, as soon as the airplane stopped, the flight attendants and passengers opened the left and right forward doors, the left forward overwing exit, and the right forward and aft overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire engulfed the airplane interior. While 18 ~ passengers and 3 flight attendants exited through the forward doors and slides and the three open overwing exits to evacuate the airplane, the captain and first officer exited through their respective cockpit sliding windows. However, 23 passengers were not able to get out of the plane and died in the fire. The airplane was destroyed. The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain. The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident. ” -2- 1. FACTUAL INFORMATION 1.1 History of the Flight The in-flight fire On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. At 1625 central daylight time, Flight 797 left Dallas with 5 crewmembers and 41 passengers on board and climbed to its assigned en route altitude, flight level (FL) 330 1 (approximately 33,000 feet m.s.1.). A/ According to the captain, about