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Crash: UPS B744 at Dubai on Sep 3rd 2010, cargo fire
| By Simon Hradecky, created Monday, Apr 4th 2011 08:06Z, last updated Monday, Apr 4th 2011 08:36Z The General Civil Aviation Authority (GCAA) of the United Arab Emirates have released a preliminary report reporting, that the first officer (ATPL, 6130 hours total, 78 on type) was pilot flying, the captain (ATPL, 11410 hours total, 367 hours on type) was pilot monitoring. The airplane departed Dubai with some defects that were deferred according to minimum equipment list requirements and did not contribute to the crash.
The airplane carried no declared shipments of hazardeous cargo. The package details for the cargo on board however identified many shipments as lithium batteries or electronic devices containing or packed with lithium batteries. These shipments were distributed throughout the cargo decks and not concentrated in a specific area. At least 3 shipments contained lithium ion batteries specified as hazard class 9 and should have been identified on the cargo manifest. The other cargo mainly consisted of clothes, shoes, books, toys, lighting, transformers, solenoids, USB drives, circuitry, etc.
The airplane departed Dubai's runway 30R. During climb out the crew received a PACK 1 (left hand air conditioning system) fault while climbing through 13,000 feet, that could be reset by the captain. The airplane continued to climb to its assigned cruise level 320. Near the top of climb an alert consistent with the fire alert bell could be heard on the cockpit voice recorder, the captain assumed role as pilot flying and the first officer as pilot monitoring working the relevant checklists. The captain radioed Bahrain that they had a fire indication for the main deck and needed to land as soon as possible. Bahrain ATC offered Doha as their closest airport in a distance of 100nm, distance to Dubai was 148nm. The captain decided - and was cleared - to return to Dubai and declared emergency.
2 minutes after the first fire bell the autopilot disconnected followed by a second fire alert 3 minutes after the first alert. At that time the crew donned their oxygen masks and smoke goggles, PACK 1 shut down (but no discussion of that PACK 1 shut down was recorded by the cockpit voice recorder). The oxygen masks hindered their Intercom communication however, which interfered with their cockpit resource management (the aircraft was not equipped with "hot mikes", a switch had to be moved on the audio control panel or the microphone button on the yoke be depressed to talk).
After having been cleared to FL270 the crew requested an immediate descent to 10,000 feet and following clearance performed a rapid descent to 10,000 feet. Bahrain ATC advised that they were now tracking directly towards Dubai and cleared the flight to land on Dubai's runway 12L at the crew's discretion.
The crew worked the fire main deck checklist, in that process PACK 2 and PACK 3 were manually selected OFF (that checklist was changed by Boeing in December 2010 now requiring either PACK 1 or PACK 3 continue to run to prevent excessive smoke accumulation in the cockpit), the aircraft began to depressurize.
The captain commented that he had limited pitch control in manual flying mode and asked the first officer to determine the cause of the pitch anomaly. Data off the flight data recorder (FDR) showed the elevators did not deflect to the range required by the control inputs.
5 minutes after the first alert the autopilot was re-engaged and the descent stabilized. At that time the captain told the first officer to pull the smoke evacuation handle, which was not part of the checklist. The captain advised ATC that the cockpit was full of smoke and commented to the first officer about the inability to see the instruments. Subsequently he asked the first officer to input DXB (Dubai) into the flight management system which the first officer acknowledged. The first officer commented about the increasing temperature on the flight deck.
The ILS frequency for Dubai's runway 12L was selected (although it did not become clear whether Dubai had been programmed into the FMS).
The GCAA annotated: "Based on the information available to date, it is likely that less than 5 minutes after the fire indication on the main deck, smoke had entered the flight deck and intermittently degraded the visibility to the extent that the flight instruments could not effectively be monitored by the crew."
7 minutes after the first alert the cabin altitude was at 20,000 feet and the captain declared lack of oxygen. The captain handed control to the first officer and left his seat to fetch some portable oxygen. Subsequent recordings of the cockpit voice recorder did not indicate any further interaction from the captain until impact.
8 minutes after the first alert Bahrain instructed the aircraft to change to Dubai's frequency. At approximately the same time the first officer transmitted "mayday, mayday, mayday can you hear me?". He explained that due to smoke view of cockpit instruments, radio panels and flight management system had been compromised, a frequency change was impossible. He decided to stay on Bahrain's frequency for the remainder of the flight, aircraft in the area began to relay between N571UP and Bahrain ATC.
10 minutes after the first alert the first officer radioed that he was "looking for some oxygen". United Arab Emirates ATC transmitted on the guard frequency but did not receive an acknowledgement from the first officer (although he later transmitted on the guard frequency). The airplane levelled at 10,000 feet about 84nm west of Dubai.
14 minutes after the first alert the first officer requested immediate radar vectors to the nearest airport again mentioning difficulty to see the instruments.
21 minutes after the first alert, about 26nm west of Dubai, the aircraft descended to 9000 feet followed by a further gradual descent towards runway 12L, the speed was 340 knots.
26 minutes after the first alert, 10nm west of Dubai, relay aircraft advised N571UP was too high and too fast and recommended to do a 360 (full circle), the first officer replied "Negative" however. At this time the gear lever was selected down, the CVR recorded the sounds of the gear lever movement, however the first officer commented the gear was not functioning. The speed brakes lever was moved towards extend, at the same time the CVR recorded sounds consistent with a flaps handle movement.
The aircraft overflew Dubai Airport's northern boundary at a heading of 117 degrees and a speed of 340 knots at 4500 feet descending. After overflying the airport the aircraft was cleared directly to Sharjah Airport some 10nm to the left of the aircraft position. The first officer requested and received vectors to Sharjah's runway 30, a heading of 095 to position towards final approach to Sharjah. The first officer selected 195 into the master control panel, the airplane began to turn right, the autopilot disconnected and the airplane entered a descending right turn with the speed reducing to 240 knots until impact. Several aural ground proximity warnings sounded including sink rate, too low terrain and bank angle warnings.
29 minutes after the first alert radar contact was lost and the aircraft impacted a perimeter road of a military installation, the right wing impacted several buildings, the engines separated, the fuselage went through a number of service sheds. The aircraft left ground tracks of 620 meters length at a heading of 243 degrees, the fuselage, wings and engines were spread over an area of 300 meters. A post accident fire damaged the majority of the wreckage.
The GCAA determined based on data available that the fire began in the forward cargo main deck compartment.
The investigation is continuing.
Several safety recommendations have already been issued as result of the ongoing investigation, all related to the transport of Lithium batteries. The FAA had already issued a safety alert for operators (SAFO), see: News: The risks of lithium batteries in aircraft cargo.
Location where the fire started (Graphics: GCAA):
Crash site overview (Photo: GCAA):
Map of crash site (Graphics: GCAA):
Flight trajectory Dubai area (Graphics: GCAA):
Flight trajectory complete (Graphics: GCAA):
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By Simon Hradecky, created Wednesday, Jul 24th 2013 18:28Z, last updated Wednesday, Jul 24th 2013 18:28ZThe United Arab Emirates' GCAA have released their final report concluding the probable causes of the crash were:
- A large fire developed in palletized cargo on the main deck at or near pallet positions 4 or 5, in Fire Zone 3, consisting of consignments of mixed cargo including a significant number of lithium type batteries and other combustible materials. The fire escalated rapidly into a catastrophic uncontained fire.
- The large, uncontained cargo fire, that originated in the main cargo deck caused the cargo compartment liners to fail under combined thermal and mechanical loads.
- Heat from the fire resulted in the system/component failure or malfunction of the truss assemblies and control cables, directly affecting the control cable tension and elevator function required for the safe operation of the aircraft when in manual control.
- The uncontained cargo fire directly affected the independent critical systems necessary for crew survivability. Heat from the fire exposed the supplementary oxygen system to extreme thermal loading, sufficient to generate a failure. This resulted in the oxygen supply disruption leading to the abrupt failure of the Captain’s oxygen supply and the incapacitation of the captain.
- The progressive failure of the cargo compartment liner increased the area available for the smoke and fire penetration into the fuselage crown area.
- The rate and volume of the continuous toxic smoke, contiguous with the cockpit and supernumerary habitable area, resulted in inadequate visibility in the cockpit, obscuring the view of the primary flight displays, audio control panels and the view outside the cockpit which prevented all normal cockpit functioning.
- The shutdown of PACK 1 for unknown reasons resulted in loss of conditioned airflow to the upper deck causing the Electronic Equipment Cooling [EEC] system to reconfigure to “closed loop mode”. The absence of a positive pressure differential contributed to the hazardous quantities of smoke and fumes entering the cockpit and upper deck, simultaneously obscuring the crew’s view and creating a toxic environment.
- The fire detection methodology of detecting smoke sampling as an indicator of a fire is inadequate as pallet smoke masking can delay the time it takes for a smoke detection system to detect a fire originating within a cargo container or a pallet with a rain cover.
Contributing Factors
- There is no regulatory FAA requirement in class E cargo compartments for active fire suppression.
- Freighter main deck class E fire suppression procedures which relay on venting airflow and depressurisation as the primary means of controlling a fire are not effective for large Class E cargo fires involving dangerous goods capable of Class D metal fire combustion.
- No risk assessment had been made for the failure of the cargo compartment liner based on the evolution of cargo logistics and associated cargo content fire threats, cargo hazards and bulk carriage of dangerous goods.
- The regulation standards for passive fire suppression do not adequately address the combined total thermal energy released by current cargo in a large cargo fire and the effect this has on the protection of critical systems.
- FAA and EASA regulatory requirements do not recognize the current total fire risk associated with pallets, pallet covers and containers as demonstrated by the NTSB/FAA testing.
- Class 9 Hazmat packing regulations do not address the total or potential fire risk that can result from lithium battery heat release during thermal runaway. Although non-bulk specification packaging is designed to contain leaks and protect the package from failure, the packaging for Class 9 does not function to contain thermal release.
- The growth rate of container and pallet fires after they become detectable by the aircraft’s smoke detection system can be extremely fast, precluding any mitigating action and resulting in an overwhelming total energy release and peak energy release rate for a standard fire load that cannot be contained.
- The course to return to Dubai required a series of complex radio communication relays due to the Pilot Flying’s inability to view and tune the radio transceivers.
- The relay communication between the Pilot Flying, relay aircraft and the various ATC stations resulted in communication confusion, incomplete and delayed communications, which contributed to the escalated workload and task saturation for the Pilot Flying.
- The Fire Main Deck non-normal checklist in the QRH was not fully completed by the crew or adhered to regarding the fire suppression flight level or land at nearest airport instruction.
- Task saturation due to smoke and multiple systems failures prevented effective use of the checklist by the crew.
- Communications between the ATCO units involved multiple stages of information exchange by landline and the destination aerodrome was not fully aware of the specific nature of the emergency, the difficulty that the Pilot Flying was experiencing or the assistance required.
- The Pilot Flying had not selected transponder code 7700, the emergency code, when radio communication with the destination aerodrome was not established.
The GCAA reported that the crashes of the UPS Boeing 747-400 at Dubai and the Asiana Boeing 747-400 near Jeju, see Crash: Asiana B744 near Jeju on Jul 28th 2011, fire in cargo hold, show significant similiarities despite different locations of the origins of fires.
The GCAA further stated: "Based on the NTSB cargo pallet and container fire testing, approximately within ten minutes a large catastrophic fire can occur which cannot be contained."
The GCAA analysed with respect to the circumstances leading to the captain leaving his seat and become incapacitated: "The incapacitation of the Captain early in the event sequence was a significant factor in the investigation. Based on the elevated temperature testing results and incidental CVR comments, it is now understood why the oxygen flow stopped after the PVC hose connector had failed, the direct effect of this failure on the crew survivability and subsequent events in the accident timeline. At 15:19:15, the Captain says ‘it’s getting hot in here’, at 15:19:56 there is the first indication that the Captains oxygen supply was compromised. The Captain’s incapacitation was possibly preventable as there was additional supplemental oxygen available in the aft of the cockpit area and in the supernumerary area. The Captain requested oxygen from the F.O. several times over approximately one minute. The First Officer due to possible task saturation was either not aware of the location of the supplementary oxygen bottles or able to assist the Captain. It is not known if the Captain located either of the oxygen bottles although they were within 2 meters of the Captains position."
The GCAA analysed that the fire, according to studies and experiments conducted by the NTSB, broke out about 10-15 minutes prior to the smoke detector alert.
The GCAA analysed with respect to time of fire detection to loss of contact: "A study conducted by the Transportation Safety Board of Canada, in which 15 in-flight fires between 1967 and 1998 were investigated, revealed that the average elapsed time between the discovery of an in-flight fire and the aircraft ditched, conducted a forced landing, or crashed ranged between 5 and 35 minutes, average landing of the aircraft is 17 minutes. Two other B747 Freighter accidents caused by main deck cargo fires have similar time of detection to time of loss of the aircraft time frames, South African Airways Flight 295 was 19 minutes before loss of contact and Asiana Airlines Flight 991 was eight minutes. Both aircraft had cargo that ignited in the aft of the main deck cargo compartment. The accident aircraft in this case, was 28 minutes from the time of detection until loss of control in flight. The cargo that ignited was in the forward section of the main deck cargo compartment. The average time is seventeen minutes. This should be factored into the fire checklist that an immediate landing should be announced, planned, organised and executed without delay. These findings indicate that crews may have a limited time to complete various checklist actions before an emergency landing needs to be completed and the checklist guidance to initiate such a diversion should be provided and should appear early in a checklist sequence."
The GCAA analysed in this view with respect to checklists and diversion guidance: "Currently SFF checklist methodology concerns whether or not crews should be given guidance to divert and where in the checklist this guidance should appear. In many current non alerted SFF checklists, guidance to complete a diversion and/or emergency landing is given as one of the last steps, if it is given at all, and the guidance to complete such a diversion is only pertinent if efforts to extinguish the SFF were unsuccessful. In the absence of active fire suppression the philosophy implicit in this design is that continued flight to a planned destination is acceptable if in-flight smoke or fire is extinguished. If crews follow these types of checklists exactly as written, a diversion is initiated only after the completion of steps related to other actions, such as crew protection (i.e., donning of oxygen masks and goggles), establishing communication, source identification and troubleshooting, source isolation and firefighting, and smoke removal, and then only if the SFF is continuing."
With respect to smoke entering the cockpit and the failure of PACK 1 the GCAA analysed: "The flight crew was able to restore Pack 1 operation at climb 12,200 ft (UTC 15:00:03) by accomplishing a reset per the PACK 1,2,3 non-normal procedure. All three packs were on at the time of the FIRE MAIN DECK indication (UTC 15:13:46). Pack 2 and Pack 3 were then shutoff. This is the expected result of the crew performing the FIRE MAIN DECK non-normal procedure. Pack 1 was the only remaining source of flight deck ventilation per system design. However, FDR indicates that Pack 1 stopped operating at UTC 15:15:21. The shutdown of Pack 1 resulted in loss of all ventilation to the flight deck, which compromised flight deck smoke control. Furthermore, with no packs operating, the Forward Equipment Cooling System automatically reconfigured into the “closed loop” mode, which changed the cooling air to the flight deck instruments from pack air (outside “fresh” air) to recirculated air via the equipment cooling fan. Consequently, any smoke that would have migrated to the E/E Bay would have been drawn into the Forward Equipment Cooling System and supplied to the flight deck instruments."
In addition the GCAA released following 95 findings:
3.1 FINDINGS
Findings The findings are statements of all significant conditions, events or circumstances in the accident sequence. The findings are significant steps in the accident sequence, but they are not always causal or indicate deficiencies.
1. The crew of the inbound sector from Hong Kong reported a PACK 1 failure. This failure could not be replicated on the ground in Dubai by the ground engineer.
2. The Boeing 747-400 fleet was experiencing a lower than predicted MTBF of the turbine bypass valve [TBV], which is a component of the AC PACKs.
3. A consignment of mixed cargo including a significant number of batteries, including lithium types, was loaded on the inbound flight from Hong Kong onto the pallets located at MD positions 4, 5, and 6, amongst other positions. This cargo was not unloaded in Dubai.
4. At least three shipments including lithium type batteries should have been classified and fully regulated as Class 9 materials per ICAO Technical Instructions, and thus should have appeared on the cargo manifest. These shipments were located in the cargo at MD positions 4 and 5.
5. Shippers of some of the lithium battery cargo loaded in Hong Kong did not properly declare these shipments and did not provide Test Reports in compliance with the UN Recommendations on the Transport of Dangerous Goods Manual of Tests and Criteria, Section 38.3, to verify that such these battery designs were in conformance with UN Modal Regulations.
6. The aircraft was airworthy when dispatched for the flight, with MEL items logged. These MEL items are not contributory to the accident.
7. The mass and the Center of Gravity [CG] of the aircraft was within operational limits.
8. The crew was licensed appropriately and no fatigue issues had been identified.
9. The Captains blood sample was positive for ethyl alcohol with a concentration of (11 mg/dl).
10. Currently a universal fire protection certification standard covers all transport category aircraft.
11. FAA Advisory Circular 25-9A Smoke Detection, Penetration, And Evacuation Tests And Related Flight Manual Emergency Procedures does not require the consideration of continuous smoke generation for cockpit smoke evacuation, the FAA recommends that the airframe design address this situation but it is not mandatory.
12. The crew were heard to confirm the oxygen mask settings during preflight, however sound spectrum analysis indicated that for unknown reasons, the First Officer’s mask was set to Normal instead of 100%, which likely allowed ambient air contaminated with smoke to enter his mask.
13. The take-off at 14:50 UTC and initial climb were uneventful.
14. At 14:58 UTC, Pack 1 went off line and was reset 2 minutes later by the PM.
15. The crew acknowledged Bahrain radar and crossed into the Bahrain FIR at 15:11 UTC.
16. At some point prior to the fire warning, contents of a cargo pallet, which included lithium batteries, auto-ignited, causing a large and sustained cargo fire which was not detected by the smoke detectors when in the early stages of Pyrolysis.
17. Pallets with rain covers can contain smoke until a large fire has developed.
18. Two minutes after passing into the Bahrain FIR, Twenty one minutes after take-off there is a fire alert at 15:12 indicating a, FIRE MAIN DK FWD.
19. The Captain assumes control as Pilot Flying, the F.O begins the FIRE MAIN DK FWD non-normal checklist.
20. The Capt advises the F.O they are to return to DXB before alerting Bahrain Area East Control [BAE-C] of the fire onboard, declaring an emergency and requesting to land as soon as possible.
21. BAE-C advised the crew that Doha airport was 100 nm to the left. The turn back to DXB totaled 185 nm track distance. The likely outcome of a hypothetical diversion is inconclusive.
22. At the time the Captain decided to turn back, the crew was not yet aware of the full extent of the fire and its effects.
23. By the time that the smoke in the cockpit and fire damaged controls became apparent, diverting to Doha was no longer a feasible option.
24. The course to DXB resulted in the airplane flying out of direct radio communication with ATC, requiring a complex relay of communication and increased task saturation for the F.O.
25. In addition to the energy release from Lithium batteries resulting in combustion, there is an associated mechanical energy release. This mechanical energy release is capable of compromising the integrity of packaging and creating incendiary projectiles.
26. The control of the aircraft when in manual control was compromised due to the thermal damage to the control cable assemblies. The first indication of the deteriorated synchronization problems between the control column movement and elevator position appear when the Captain disconnects the autopilot.
27. The time interval between fire detection and the onset of aircraft system failures was two minutes and thirty seconds at the point of detection. In all probability the fire had damaged the control cables prior to autopilot disconnection.
28. The aircraft begins to turn on to a heading for DXB and descends. As it was dusk, the aircraft is now descending to the east and back into an easterly time zone where there is limited available ambient solar light.
29. The cargo compartment liner failed as a fire and smoke barrier under combined thermal and mechanical loads.
30. Consequently, the damaged cargo compartment liner exposed the area above the cargo bay in fire zone 3 to sustained thermal loading either breaching the cargo compartment liner or causing the aluminium structure retaining the liner to collapse, exposing the area above and adjacent to the breach to continuous thermal loading.
31. Consequently, the damaged cargo compartment liner exposed the supernumerary and cockpit area to sustained and persistent smoke and toxic fumes.
32. Based on the NTSB pallet and container testing results, it is now known that the growth rate of container fires after they become detectable by the aircraft’s smoke detection system can be extremely fast, precluding any mitigating action and resulting in an overwhelming fire that cannot be contained.
33. The high thermal loading damaged or destroyed the supporting trusses for the control cables directly affecting the control cable tension. The control column effectiveness was significantly reduced, subsequently the movement of the elevators, speed brake, rudders, brakes and landing gear control had been compromised.
34. The high thermal loading caused damage to the ECS ducting,
35. The ACARS/AHM data indicates a series of sensor failures and fire wire loops tripping to active in the area of the fire, the fault timing and the fire warning are corollary.
36. The crew donned their oxygen masks, and experienced difficulty hearing each other.
37. The oxygen masks had a required setting of100% and in emergency for smoke in the cockpit.
38. The oxygen selector position cannot be viewed when the mask is on. The technique used to determine the selector position when the mask was on was not an operator technique or reinforced through training scenarios and non-cognitive muscle memory techniques.
39. The mask settings remain unchanged for the duration of the flight.
40. The main deck fire suppression system was activated and the cabin depressurized.
41. Lithium-metal cell thermal stability and reactions that occur within a cell with elevated temperatures, up to the point of thermal runaway are not oxygen dependent. Electrolyte or vent gas combustion properties and the fire hazards associated with thermal runaway reactions do not respond to the FL250 assumed hazard mitigation methodology.
42. The Class E cargo compartment fire suppression strategy of preventing venting airflow in to cargo compartment, depressurization and maintaining 25,000ft cabin altitude may not be effective for Class D metal fires.
43. For unknown reasons Pack 1 went off and was not mentioned by the crew. The cockpit smoke prevention methodology when the fire suppression is active is to have pack one on low flow pressurizing the cockpit area to a higher than ambient pressure, preventing smoke ingress.
44. It is unknown in this instance that if Pack one had been active this method would have worked as described based on the volume and flow of the smoke The Capt requests a descent to 10,000ft
45. The QRH Fire Main Deck checklist does not address the key factor of descend or divert decision making. The checklist fire suppression methodology advises the crew to remain at 25,000 cabin pressure altitude to suppress a fire or land at nearest suitable airport. It does not provide guidance for when or how to transition to landing or the fact that descending early might provide more atmospheric oxygen to the fire. There is no intermediate step to verify or otherwise assess the condition of the fire and to evaluate the risk to the aircraft if a decent is initiated.
46. The Class E certification standards for fire suppression does not require active fire suppression.
47. Within three minutes of the fire alarm, smoke enters the cockpit area. This smoke in the cockpit, from a continuous source near and contiguous with the cockpit area, entered with sufficient volume and density to totally obscure the pilot’s view of the instruments, control panels and alert indicating systems for the duration of the flight.
48. Once the liner had been breached, the openings in the liner would progressively expand, allowing an increase in the volume of dense noxious smoke, fire and combustion by-products to escape the cargo compartment.
49. The cargo compartment liner structure certification does not include extreme heat and other input loads such as vibration, multi-axial loading, intermittent pressure pulses, thermo mechanical loadings based on differential materials coefficients, acoustic and ballistic damage testing.
50. The crew made several comments concerning their inability to see anything in the cockpit. The crew in the smoke environment had reduced visibility and could not view the primary instruments such as the MFD, PFD, Nav Displays or the EICAS messages.
51. The Captain selected the Autopilot on and leveled out following the pitch control problems. The aircraft remained in a stable steady state when controlled via the AP. There was no communication between the Captain and the F.O. that the controllability problem was resolved using the AP.
52. Effective elevator and rudder control was only available with the autopilots. The aircraft was controllable with the AP as the servos are electrically controlled and hydraulically actuated, which for pitch control is in the tail section aft of the rear pressure bulkhead, and the fire had not compromised the electrical cabling to the actuators.
53. The PF was not fully aware of the extent of the control limitations, could not see the EICAS messages and was not aware of all of the systems failures.
54. The Captain called for the smoke evacuation handle to be pulled as the smoke accumulated in the cockpit. The smoke evacuation handle when pulled opens a port in the cockpit roof, which if the smoke is sustained and continuous, will draw smoke through the cockpit as the pressure is reduced by the open port venturi effect compounding the problem. The smoke evacuation handle remained open for the remainder of the flight.
55. There are several instances of checklist interruption at critical times at the beginning of the emergency. The speed and quick succession of the cascading failures task saturated the crew. The smoke in the cockpit, combined with the communications problems further compounded the difficult CRM environment. With the incapacitation of the captain, the situation in the cockpit became extremely difficult to manage.
56. One factor when dealing with the QRH and running checklists is that the B747 does not have a hot microphone function. This caused increasing difficulty managing cascading failures and high workload.
57. The crew was unable to complete the Fire Main Deck checklist. The aircraft was not leveled off at 25,000 ft. Directly descending to the 10,000 ft may have exacerbated fire and smoke problem due to the extra available oxygen.
58. The Captain instructed the F.O. to input DXB RWY12L into the FMC. This action was completed with difficulty due to the smoke. There was no verbal confirmation of the task completion, however, the the aircraft receivers detected the DXB Runway 12L glide slope beam when approaching Dubai.
59. Captain made a comment mentioning the high cockpit temperature, almost immediately the Captains oxygen supply abruptly stopped without warning, this occurred seven minutes six seconds after the first Main Deck Fire Warning.
60. The Captain’s inability to get oxygen through his mask was possibly the result of the oxygen hose failure near the connector. The high thermal loading was conducted through the supplementary oxygen stainless steel supply lines heating the supplementary oxygen directly affecting the flexible hose connector causing the oxygen supply line to fail.
61. Systems analysis indicates that the oxygen supply is pressure fed, therefore venting oxygen could be released by a failed oxygen hose which could then discharge until the oxygen line fails or the oxygen supply is depleted.
62. The Captain requests oxygen from the F.O. several times over approximately one minute. The First Officer due to possible task saturation was not able to assist the Captain.
63. The oxygen requirement of the Captain became critical, the Captain removes the oxygen mask and separate smoke goggles and leaves the seat to look for the supplementary oxygen. The Captain did not return. The Captain was in distress locating the supplementary oxygen bottle and could not locate it before being overcome by the fumes.
64. The Captain was incapacitated for the remainder of the flight. A post-mortem examination of the Captain indicates that the cause of death was due to carbon monoxide inhalation.
65. A full face emergency oxygen supply is available in the cockpit. Oronasal masks are available in the lavatory, jump seat area and crew bunk area.
66. Due to the Captain’s incapacitation the F.O became P.F. for the remainder of the flight, operating in a single pilot environment. Exposure to this type of environment in a controlled training environment could have been advantageous to the remaining crew member.
67. The FO had breathing difficulties as the aircraft descended as the normal mode function of the mask supplies oxygen at a ratio to atmospheric, ambient air. The amount of oxygen supplied was proportional to the cabin altitude.
68. The cockpit environment remained full of smoke in the cockpit, from a continuous source near and contiguous with the cockpit area for the duration of the flight.
69. As the flight returned towards DXB, the crew were out of VHF range with BAE-C and should have changed VHF frequencies to the UAE FIR frequency 132.15 for the Emirates Area Control Center [EACC]. Due to the smoke in the cockpit the PF could not view the audio control panels to change the frequency selection for the duration of the flight.
70. The flight remained on the Bahrain frequency 132.12 MHz on the left hand VHF ACP for the duration of the flight. To solve the direct line of communication problem, BAE-C requested traffic in the vicinity to relay communication between crew and BAE-C.
71. The PF made a blind Mayday call on 121.5 MHz at 15:21 UTC.
72. The PF had to relay all VHF communication through other aircraft. The radio communication relay between the PF, the relay aircraft and the ANS stations resulted in confusion communicating the nature and intent of the PF’s request for information with the required level of urgency.
73. The PF requested from the relay aircraft immediate vectors to the nearest airport, radar guidance, speed, height and other positional or spatial information on numerous occasions to gauge the aircraft’s position relative to the aerodrome and the ground due to the persistent and continuous smoke in the cockpit.
74. The relay aircraft did not fully comprehend or communicate to the BAE-C controller the specific nature of the emergency and assistance required, particularly towards the end of the event sequence.
75. There was a multi-stage process to complete a standard request for information between the accident flight and the destination aerodrome via the relay aircraft and the ATCU.
76. The flight crew did not or could not enter the transponder emergency code 7700, however all ATCUs were aware that the airplane was in an emergency status.
77. DXB controllers were aware that the flight was in an emergency status, however were not aware of the specific nature of the emergency or assistance required, due to the complex nature of the relayed communications.
78. There was no radar data sharing from the UAE to Bahrain ATC facilities. Bahrain had a direct feed that goes to the UAE but there was no reciprocal arrangement. This lack of data resulted in the BAE-C ATCO not having radar access the SSR track of the accident flight.
79. The ATC facilities are not equipped with tunable transceivers.
80. The accident aircraft transmitted on the Guard frequency 121.5 Mhz. The transmissions were not heard by the EACC or DXB ATC planners due to the volume of the 121.5 Mhz frequency being in a low volume condition.
81. The PF did not respond to any of the calls from the ACC or the relay aircraft on 121.5 MHz, which were audible on the CVR, after the Mayday transmission.
82. During the periods when direct radio communications between the pilot flying and the controllers was established, there was no negative effect. Therefore it is likely that if direct 121.5 contact had been established the communications task could have been simplified.
83. The relay aircraft hand off between successive aircraft caused increasing levels of frustration and confusion to the PF.
84. All Dubai aerodrome approach aids and lighting facilities were operating normally at the time of the accident.
85. There is no requirement for full immersion smoke, fire, fumes cockpit training for flight crews.
86. The PF selected the landing gear handle down. The landing gear did not extend, likely due to loss of cable tension.
87. The flaps extended to 20°. This limited the auto throttle power demand based on the max flap extension placard speed at 20° Flaps.
88. The PF was in radio contact with a relay aircraft, who advised the PF through BAE-C that Sharjah airport was available, and a left hand turn onto a heading of 095° was required.
89. The PF made an input of 195° into the MCP for an undetermined reason when 095° was provided. The aircraft overbanked to the right, generating a series of audible alerts. It is probable that the PF, in the absence of peripheral visual clues, likely became spatially disorientated by this abrupt maneuver.
90. The aircraft acquired 195°, the AP was selected off. The throttle was retarded and the aircraft began a rapid descent.
91. The PF was unaware of the large urban area directly in the airplane’s path. The aircraft began a descent without a defined landing area ahead.
92. Spatial disorientation, vestibular/somatogyral illusion due to unreliable or unavailable instruments or external visual references are a possibility. The PF was unaware of the aircraft location spatially. The PF may have been attempting an off airfield landing, evidenced by numerous control column inputs.
93. The control column inputs to the elevators had a limited effect on the descent profile. The pilot made a series of rapid column inputs, in response to GPWS warnings concerning the sink rate and terrain. The inputs resulted in pitch oscillations where the elevator response decreased rapidly at the end of the flight
94. The available manual control of pitch attitude was minimal, the control column was fully aft when the data ends, there was insufficient trailing edge up [nose up] elevator to arrest the nose down pitch. Control of the aircraft was lost in flight followed by an uncontrolled descent into terrain.
95. The aircraft was not equipped with an alternative viewing system to allow the pilot(s) to view the instruments and panels in the smoke filled environment.
Fire damaged and ruptured Lithium batteries recovered from the wreckage (Photo: GCAA):
Original with opened electronics (Photo: GCAA):
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By Simon Hradecky, created Friday, Sep 3rd 2010 16:56Z, last updated Monday, Apr 4th 2011 08:36Z | | Smoke rising from crash scene |
A UPS Boeing 747-400 freighter, registration N571UP performing flight 5X-6 from Dubai (United Arab Emirates) to Cologne (Germany) with 2 crew, was returning to Dubai after declaring emergency, when the airplane crashed onto a free space west of Dubai Silicon Oasis and Al-Ain Highway (E66) about half way between Emirates Road (E311) and Outer Bypass Road (E611) at 19:42L (15:42Z). Both crew perished in the crash.
UPS confirmed their Boeing 747-400 performing flight 5X-6 from Dubai to Cologne with 2 crew crashed on takeoff. In an update of Sep 4th UPS confirmed both crew member perished. In another update on Sep 5th UPS said, the captain (48) joined UPS in 1995, the first officer (38) in 2006, both pilots were based in Anchorage,AK (USA). The airframe N571UP was only three years old and had accumulated 9977 hours in 1764 takeoffs and landings.
An airport official said, the crew reported technical problems while on approach to Dubai.
An United Arab Emirates official said, the crew reported fire on board while on approach to Dubai. The airplane, that had taken off at 18:40L (14:40Z) was being vectored towards a military compound.
United Arab Emirates General Aviation Civil Authority said, that the crew had reported smoke and fire in the cockpit and was returning to Dubai International Airport. The airplane failed to land however and disappeared from radar screens shortly thereafter. The bodies of both pilots have been recovered.
On Sep 5th the United Arab Emirates (UAE) General Civil Aviation Authority (GCAA) released a brief preliminary report stating, that the airplane had departed Dubai International Airport at 18:53L (14:53Z). UAE ATC Center received information from Bahrain Center at 19:15L (15:15Z), that the airplane was returning to Dubai with smoke in the cockpit unable to maintain altitude. UAE ATC issued a clearance when the airplane was about 40km (21.6nm) from touchdown, the airplane however was too high (8500 feet at 24km/13nm from touchdown). The airplane passed very high overhead the airfield and entered a right hand turn, the crew was advised all runways were available for landing. The airplane tracked southwest when it rapidly lost altitude, radar contact was lost at 15:42Z, the airplane crashed into an unpopulated area between Emirates Road and Al Ain Highway. The cockpit voice recorder was recovered 6 hours after impact, the flight data recorder is still being searched for. The NTSB team is expected to arrive at the crash site today (Sep 5th), too. On Sep 7th the flight data recorder was recovered and was found in reasonable condition.
The NTSB reported on Sep 4th, that UPS Flight 6, a Boeing 747-400 freighter registration N571UP, crashed while attempting to land at Dubai International Airport, from where the airplane had departed about 45 minutes earlier. The crew had declared an emergency and requested an immediate return to Dubai. The two crew were fatally injured, the NTSB does not know whether there have been fatalities on the ground. The NTSB have assigned an Accredited Representative as state of operator, state of aircraft design and manufacture and state of engine design and manufacture. The investigation is led by the United Arab Emirates Civil Aviation Authority.
Residents of Dubai Silicon Oasis said, the airplane crashed right in front of their apartment blocks moving in an westsouthwesterly direction. After verifying the wreckage location in daylight the following day (Sep 4th) a resident put the wreckage position at N25.098 E55.360. From point of first impact the airplane slid about 400 meters.
Aviation sources in Dubai report, that the crew declared emergency reporting a fire in the cockpit shortly after takeoff and attempted to return to the airport's runway 30L dumping fuel. The airplane was seen flying very low at a shallow descent until impact, where the airplane erupted in a large fire ball. Several buildings, apparently all of them under construction, have been set on fire by the crash.
Pilots on frequency of Bahrain Center reported, that the airplane had been enroute overhead the Arabian Gulf about 120nm westnorthwest of Dubai when the crew performed an emergency descent and reported a fire in the cockpit. Later they reported they were unable to read their instruments and were unable to change frequency asking for frequent updates on their altitude and speed from ATC. They were vectored for a straight in approach to Dubai's runway 12L. Being too high and too fast for landing they were offered to divert to Sharjah or join a right hand downwind for another visual approach to runway 12L. The airplane impacted ground about 20 minutes after declaring emergency.
The UAE GCAA reported on Sep 23rd that the data were completely and successfully downloaded from the flight data and cockpit voice recorders and analysis is making progress. The investigation is focussing on "understanding the issues involved around the cargo carried and the associated risks." The airplane had just reached the top of climb at 19:12L (15:12Z) when the crew received a main deck fire warning. The crew executed the according checklists and requested the nearest airport from Bahrain ATC. They were offered Doha but decided to return to Dubai. Over time a number of additional fire warnings arrived from the main and lower cargo deck. There is evidence that during the descent the crew had difficulty to see their primary flight instruments due to thick smoke. There is also evidence that there was difficulty in the communication. The aircraft subsequently overflew Dubai's runway at 4000 feet and entered a right hand turn. About 5 minutes later air traffic control alerted emergency services that there had been an accident at the Nad Al Sheba area.
The FAA reported in their Safety Alert for Operators (SAFO) 10017, that the airplane's cargo contained a large quantity of lithium batteries. While the investigation is still underway and the cause of the crash has not been determined, the FAA believes it is prudent to inform operators of this fact as well as remind operators of the characteristics of thermal runaways of lithium batteries. The FAA states further, that the fire suppression agent Halon 1301 found in class C cargo compartments is ineffective controlling lithium metal cell fires. For an earlier SAFO including a video see: How to fight fires caused by Lithium batteries in portable electronic devices
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Boeing stated in a message to all Boeing 747-400 freighter operators released on Oct 13th, that they plan to modify the fire indication checklists following discovery on the flight data recorders of this crash, that none of the air conditioning systems was working following the fire indication. Boeing plans to add text indicating that after two of the three air conditioning systems are shut down per system design following a fire indication, either air conditioning system 1 or 3 must continue to work in order to prevent excessive smoke accumulation on the flight deck. This modification is planned to be released with the November flight crew operating manual bulletins, further modifications of the manuals are under consideration.
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Metars:
OMDB 031700Z 22004KT 8000 NSC 35/29 Q1000 NOSIG
OMDB 031600Z 24004KT 8000 NSC 36/27 Q1000 NOSIG
OMDB 031500Z 32006KT 290V030 8000 NSC 35/28 Q0999 NOSIG
OMDB 031400Z 30010KT 8080 NSC 36/26 Q0999 NOSIG
OMDB 031300Z 31011KT 290V350 8000 NSC 37/27 Q0999 NOSIG
OMDB 031200Z 30012KT 8000 NSC 37/27 Q1000 NOSIG
Aerial view of crash site (Photo: flaphandlemover):
Crash site in daylight (Photo: APA/EPA/Ali Haider):
Overview of crash site (Photo: AP/Kamran Jebreili):
Detail Map, final position identified by aerial view (Graphics: AVH/Google Earth):
Map including nearby Airbase (Graphics: AVH/Google Earth):
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