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Accident: ABX Air
Cargo B762 at San Francisco on Jun 28th 2008, on fire while
parked, no arson
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By Simon Hradecky, created
Tuesday, Jun 30th 2009 18:25Z, last updated Wednesday,
Jul 1st 2009 06:47Z
The NTSB reported
in a press release, that the cause of the fire was a
short circuit to the supplemental oxygen system, that
reached the oxygen hose. The design of the hose included
an internal spring, which could be heated by the
inadvertent application of electrical current, causing
the plastic hose to ignite. The coil acted as ignition
source, the hose material acted as fuel and the oxygen
promoted the fire.
Boeing had already identified the safety issues
involving conductive hoses and had issued a service
bulletin advising operators to replace conductive with
non-conductive hoses. The FAA approved the bulletin,
but did not
issue an airworthiness directive.
The NTSB found that in other ABX
Boeing 767 aircraft insufficient separation existed
between wiring and oxygen system tubing, too.
The NTSB issued a safety recommendation to require
operators to replace electrically conductive with
electrically non-conductive oxygen hoses.
During the investigation the NTSB found, that the
reading lights located in the passenger service units
could become a potential source of ignition to nearby
combustible materials. The NTSB therefore recommended,
that all reading lights are to be mounted with rubber
boots or other means to provide a greater level of
electrical protection.
The final report is to be expected in a couple of weeks.
http://www.avherald.com/h?article=408ec81b/0005&opt=0
and
http://www.aircraftmechanic.org/showthread.php?1742-B-767-fire
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a.
Executive Summary: at
http://tinyurl.com/gqpnwcn
b.
“MH370 (Not really a Mystery)” at
http://tinyurl.com/or9bzf2
By Simon Hradecky, created Tuesday,
Feb 23rd 2010 21:13Z, last updated Tuesday, Feb 23rd 2010 21:17Z
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Stainless Steel Coil Spring Within
Flexible Oxygen Hose
(Photo: NTSB) |
The NTSB have released their
final report concluding:
The National Transportation Safety Board
determines that the probable cause of this
accident was the design of the supplemental
oxygen system hoses and the lack of positive
separation between electrical wiring and
electrically conductive oxygen system
components. The lack of positive separation
allowed a short circuit to breach a combustible
oxygen hose, release oxygen, and initiate a fire
in the supernumerary compartment that rapidly
spread to other areas. Contributing to this
accident was the Federal Aviation
Administration’s failure to require the
installation of nonconductive oxygen hoses after
the safety issue concerning conductive hoses was
initially identified by Boeing.
Following findings were listed by the NTSB:
1. The pop and hissing sounds heard by the
flight crew immediately before the fire was
discovered were consistent with the ignition of
an oxygen hose by an internal rather than
external heat source.
2. The design of the oxygen hose assembly
allowed the internal spring to become a source
of ignition when it was electrically energized,
the polyvinyl chloride hose material to act as a
fuel, and the oxygen within the hose to promote
burning.
3. The fire aboard the ABX Air airplane most
likely began when a combustible and electrically
conductive oxygen hose in the supernumerary
compartment became energized by a short circuit,
which caused the hose to ignite and burn
through, and the release of oxygen from the hose
caused adjacent materials to ignite and burn at
an accelerated rate.
4. Although no evidence was found to indicate
that previous oxygen system leaks contributed
directly to the fire in the supernumerary
compartment, oxygen leaks are a safety hazard
because of their potential to facilitate a fire.
5. Aircraft rescue and firefighting personnel
extinguished the fire in a timely manner.
6. The skin-penetrating nozzle was an effective
tool in extinguishing the fire, especially
because the forward doors were rendered
inoperable by the fire and could not be used to
gain access to the fire.
7. The type of training that the driver of
Rescue 49 received on the operation of the
high-reach extendable turret with
skin-penetrating nozzle was not sufficient to
allow him to successfully insert extinguishing
agent into the cockpit on his initial attempts.
8. Aircraft rescue and firefighting personnel
who are not sufficiently trained on the
high-reach extendable turret with
skin-penetrating nozzle may not be able to use
the device effectively when fighting aircraft
fires.
9. Combustible oxygen hoses with an electrically
nonconductive design would prevent the internal
coil spring from becoming electrically
energized, mitigating the possibility that the
hoses would melt and ignite.
10. It is likely that the modifier of the
accident airplane would have recognized the use
of a part that was potentially combustible
before releasing the airplane to the operator if
the Federal Aviation Administration had issued
an appliance airworthiness directive that cited
the part manufacturer as well as the airplane
model.
11. Protecting oxygen system tubing from
inadvertent short circuits is important because
of the proximity between the tubing and
electrical wiring in a compressed area as well
as the potential severity of a fire involving
oxygen.
12. An effective method of electrically
grounding the supplemental oxygen system to the
airframe would help ensure that oxygen system
components are protected from short circuits.
13. Because aging polyvinyl chloride flexible
hoses are more likely than newer hoses to be
cracked or otherwise degraded, aging hoses are
more likely to leak oxygen, which, along with an
ignition source, could result in a fire.
14. Passenger service unit reading lights with
exposed electrical contacts have the potential
to move to positions that create inadvertent
short circuits and produce sparks near
combustible materials.
15. Installing smoke detectors in supernumerary
compartments would help flight crews identify
the existence of a fire in an accessible,
possibly unoccupied space and initiate
suppression of the fire before it could
propagate and become uncontrollable.
16. The number of reported discrepancies
regarding the accident airplane’s oxygen system
was excessive and indicative of a chronic
problem with the system, yet ABX Air’s
continuing analysis and surveillance program did
not include adequate actions for resolving the
discrepancies and preventing additional oxygen
leaks from occurring.
The crew was preparing for departure, all
freight had been loaded, the doors were already
closed, when the crew performed their oxygen
check, which completed normally. About 6 minutes
later the first officer went to the
supernumerary compartment, located right behind
the cockpit, to turn off the lights. At that
time he did not notice anything abnormal.
One minute later, when the crew was running the
engine start checklist, they heard a loud pop
followed by a hissing sound followed by the
first officer noticing a big fire in the back.
Subsequently the lavatory smoke detector
activated and a fire bell sounded. The crew
called ATC informing of a cargo fire, ground
control confirmed to "roll the trucks", then the
crew executed the fire and evacuation checklist.
They could not exit through the L1 or R1 doors
due to the location and intensity of the fire,
so that both pilots evacuated through their
cockpit windows. The first officer used his
escape rope to climb down, then instructed
ground personnel to move the stairs under the
captain's window, so that the captain climbed
down those stairs.
Due to the extensive damage ABX Air confirmed
the airplane to be a hull loss.
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Oxygen System Components in Supernumerary Compartment
(Photo: NTSB):

Proximity of Electrical Wiring to Oxygen System Tubing
(Photo: NTSB):

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By Simon Hradecky, created Tuesday,
Jul 22nd 2008 22:36Z, last updated Wednesday, Jul 1st 2009
06:42Z
"Maintenance in work" says a sign attached to the wall,
that once separated the cockpit from the cabin, as the
airplane was being prepared to be towed away from the
stand, where it had caught fire. Heat and smoke caused
severe damage not only to the fuselage, but also in the
cockpit.
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| Smoke
and heat damage in the cockpit,
photo: Vlasta Sajfr |
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Location of fire, photo:
Vlasta Sajfr |
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By Simon Hradecky, created Thursday,
Jul 3rd 2008 20:17Z, last updated Wednesday, Jul 1st 2009 06:42Z

The National Transportation Safety Board reported today
that ABX Air had received a threat against an
unspecified aircraft within a week prior to the
accident.
The fire started immediately behind the cockpit outside
the cargo hold.
Cockpit Voice Recorder and Flight Data Recorder have
already been sent to Washington for analysis. Both
pilots have been interviewed yesterday.
The NTSB is expected to conclude its on-scene
investigations by July 6th.

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By Simon Hradecky, created Sunday,
Jun 29th 2008 07:01Z, last updated Wednesday, Jul 1st 2009
06:41Z
An
ABX Air Boeing 767-200, registration N799AX
preparing to perform freight flight GB1611 from
San Francisco, CA to Wilmington, OH (KILN)(USA),
was parked at the ramp, plot 11, with engines
shut down to be loaded and fueled, when fire
broke out immediately behind the cockpit. The
two pilots were on board, one received minor
injuries and was brought to hospital. The Air
Mail facilities (including DHL and USPS) with
more than 100 workers have been evacuated as
well.
Fire brigades reportedly had to cut a hole in
the cockpit area to gain access. The fire was
quickly contained.
The airport reported that the airplane will be "unuseable
for a while".
Track of last GB1611 (June 21st):
http://flightaware.com/live/flight/ABX1611/history/20080622/0517Z/KSFO/KILN
More pictures are available at:
Jack Hannen's KSFO Gallery (http://www.pbase.com/ksfo/burned_dhl_767_sfo)
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