Crash: Asiana B744 near Jeju on Jul 28th 2011, fire in cargo hold

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Crash: Asiana B744 near Jeju on Jul 28th 2011, fire in cargo hold

By Simon Hradecky, created Thursday, Jul 28th 2011 05:33Z, last updated Wednesday, Sep 19th 2012 17:44Z

An Asiana Cargo Boeing 747-400, registration HL7604 performing flight OZ-991 from Seoul (South Korea) to Shanghai (China) with 2 crew, was enroute near Jeju Island (about 250nm south of Seoul) when the crew reported the cargo in the hold had caught fire and they needed to divert to Jeju Airport, then the aircraft disappeared from radar. Parts of a wing and other debris were located 130km/70nm west of Jeju. Both crew were killed. Their bodies were recovered from the sea floor 104km west of Jeju Island on Oct 30th 2011.

South Korea's Transport ministry reported, the Boeing 747-400 freighter was carrying 58 tons of cargo including 0.4 tons of hazardeous materials like Lithium batteries, paint, amino acid solution and synthetic resin. The crew had reported the cargo on fire with Shanghai Center and was diverting to Jeju Airport when it crashed about 70nm west of the Island at 04:12L (19:12Z Jul 27th), 67 minutes after it had taken off Seoul.

South Korea's Coast Guard reported both crew members were killed.

The flightplan identified Boeing 747-400 registration HL7604.

Asiana reported that radar contact with HL7604, manufactured Feb 2006, was lost at 04:11L when the aircraft was at 7600 feet MSL, the crew had reported control problems. The captain (52) had 14,123 hours flying experience, the first officer (44) had 5,211 hours flying experience. All cargo, 90% of which was standard cargo and IT products, the remainder comprised liquids (e.g., paint, resin solution, ...), was in compliance with IATA regulations.

A listener on frequency of Shanghai's Air Traffic Control Center reported, that the Asiana had just checked in with Shanghai when the crew reported they had a fire in the cargo hold, Shanghai's Pudong Airport was too far away, their only possible point of diversion was Jeju. The crew's distress was clearly audible and increasing during the transmissions.

A Shanghai Center Air Traffic Controller reported that the first indication of problems was the aircraft's transponder transmitting the emergency code just prior to the crew reporting on frequency near SADLI waypoint (N31.833 E124.998). The crew reported they had a cargo fire and requested to return to Seoul. The aircraft was handed off to the next sector while it was descending, the controller however watched the aircraft on his radar screen until it descended through 2400 feet and disappeared from the screen.

The NTSB reported on Aug 2nd the aircraft HL7604 crashed into the sea about 70 miles west of Jeju Island after the flight crew "reportedly declared an emergency due to a cargo fire and attempted to divert to Jeju International Airport." The NTSB assigned an accredited representative as state of manufacture and participates in the investigation led by South Korea's ARAIB.

Jeju's Maritime Police reported the wreckage and the bodies of the two pilots were discovered on the sea floor 104km west of Jeju Island on Sunday noon (Oct 30th) by a private salvage team hired by Asiana. The bodies were subsequently recovered from part of the fuselage which is believed to be the cockpit.

Debris floating off Jeju Island (Photo: AP):

Map (Graphics: AVH/Google Earth):

By Simon Hradecky, created Monday, Aug 3rd 2015 17:31Z, last updated Monday, Aug 3rd 2015 17:31Z

South Korea's ARAIB have released their final report in Korean concluding the probable cause of the crash was:

Physical evidence does not permit to identify the exact cause of why the fire broke out. The fire started near the palettes ML and PR, quickly grew and could not be suppressed with part of the agent being released into the exhaust air.

Contributing factors were:

- the combination of class 3 flammable emulsions (paint) in palette ML as well as flammable and corrosive liquids and class 9 lithium-ion batteries in palette PR.
- the aircraft was not equipped with class E cargo bay with pro-active fire suppression systems making it difficult to suppress a large fire.

The ARAIB reported ACARS message have been received indicating the activation of cautions, warnings and alerts for (in sequence of occurrence over a period of 7 minutes):

EQUIPMENT SMOKE
EQUIP COOLING
CGO DET 11 MN DK
CGO DET 6, 10 MN DK
CGO DET 7, 16, 5, 4, 3, 8 MN DK
PACK 2, 3
SATCOM SYSTEM
A/P SINGLE SYS
YAW DAMPER LWR
STAB TRIM, STAB TRIM 2
AUTOPILOT DISC
DET APU FIRE
FMC LEFT
DOOR ENTRY L5
FLIGHT RCDR SYS
AUTOTHROT DISC
ELEVATOR FEEL
BTL LOW CARGO
CGO DET AFT 4
BAT DISCH APU
SUPRNMRY OXY ON
APU
ELT ON
YAW DAMPER UPR
RUD RATIO DUAL
FLAPS CONTROL

Palettes ML (top) and PR (bottom) before loading and distribution of goods on cargo deck, brown marks indicates hazardeous goods (Photo: ARAIB):

Palettes ML (top) and PR (bottom) before loading and distribution of goods on cargo deck, brown marks indicates hazardeous goods (Photo: ARAIB)

The actual flight trajectory (Graphics: ARAIB):

Key Events and location (Graphics: ARAIB):

Main Cargo Deck air flow and suppression agent distribution (Graphics: ARAIB):

Example of a main cargo video surveillance to monitor for smoke (Photo: ARAIB):

The inside of the main cargo door showing fire damage (Photo: ARAIB):

By Simon Hradecky, created Wednesday, Sep 19th 2012 17:43Z, last updated Wednesday, Sep 19th 2012 17:43Z

South Korea's ARAIB have released their preliminary report stating the first officer declared emergency about 50 minutes after takeoff from Seoul and 3 minutes after reporting on Shanghai frequency reporting a fire and requested to descend to 10,000 feet, 40 seconds later the first officer requested to divert to Jeju and reported they had an aft cargo fire. Subsequent communication between Incheon (Seoul) Radar and OZ-991 was done with the help of Korean Air flight KE-886, who relayed communication between radar and OZ-991. 12 minutes after declaring emergency the captain of OZ-991 reported they had lost rudder control, a minute later the captain stated they needed to open the hatch. 15 minutes after declaring emergency OZ-991 reported all flight controls were not working, the first officer added they had severe vibrations on the aircraft and needed to attempt an emergency ditching. 21 minutes after declaring emergency the first officer stated altitude control was not possible due to severe vibrations, "going to dtich ... ah" - and communication was lost.

One minute prior to the emergency call the crew had received a message "CARGO FIRE MAIN DECK ZONE-11 LOOP-A FAIL", just prior to the emergency call the message "CARGO FIRE MAIN DECK ZONE-6 AND 10 LOOP-A FAIL" arrived followed by "CARGO FIRE MAIN DECK ZONE-3, 4, 5, 7, 8, AND 16 LOOP-A FAIL", "CARGO FIRE EXTINGUISHING ARMED 'NO ACTION REQUIRED'", "YDM-LWR FAIL (Yaw Damper Lower)", "APU FIRE LOOP-A & -B", "DOOR L5 SWITCH FAIL" , "FLIGHT RECORDER FAIL", "FMC-L FAIL (NO BUS OUTPUT)", "CARGO BOTTLE A LOW PRESSURE & CARGO BOTTLE B LOW
PRESSURE", "CARGO AFT-4 LOOP-A FAIL" within 4 minutes.

ACARS messages transmitted 6-7 minutes after the first "CARGO FIRE MAIN DECK ZONE-11 LOOP-A FAIL" message indicated: "EMERGENCY LOCATOR TRANSMITTER ON", "DC CURRENT SENSOR-6 FAIL (BCU-2)", "APU DUCT FAIL", "FLAP LEVER RVDT FAIL (FCU'S), "UPPER YAW DAMPER ACTUATOR LVDT FAIL (YDM-UPR)".

First debris was found floating at position N33.2522 E125.0186 about 2 hours after communication with the aircraft was lost.

The captain (52, ATPL, 14,123 hours total, 6,896 hours on type) was assisted by a first officer (44, ATPL, 5,211 hours total, 492 on type). The aircraft had accumulated 28,752 flight hours in 4,799 flight cycles. The aircraft had undergone all necessary maintenance, the aircraft logs showed 208 logged faults in the 6 months prior to the crash, all of which were corrected properly and none relevant to the situation on board prior to the crash.

According to all ACARS messages received the aircraft had passed position N31.533 E124.588 at about the time of the first fire indication.

Examination of aircraft debris recovered from the sea floor revealed discolorisation and soot, evidence of thermal damage and fire, on the outside and inside of door L5, further components between FS1740 and FS2360 also showed evidence of thermal damage, a recovered skin panel from FS2180 to FS2360 revealed evidence the fire had burned through the skin panel. Cargo items had melted.

The autopsy of both flight crew revealed no evidence that any of them had consumed medications, toxic agents or alcohol. Both died as result of multiple rib fractures and rupture of multiple organs including heart and lungs as result of impact forces.

The investigation so far determined that cargo stored on the aircraft between FS1700 and the aft bulkhead had caught fire. There was no evidence of fire/thermal damage aft of the pressure bulkhead, sections forward of FS1700 showed damage by sooting.

The aircraft had been carrying 39,331 kg of cargo, 18,934 kg of which were loaded at Incheon Airport. A total of 2,092 kg was declared as dangerous goods, loaded near the left cargo door on the main deck. These goods consisted of flammable liquids, corrosive liquids and lithium-ion batteries, the shipment consisting of 198 cells rated at 25Ah at 3.65V. All dangerous cargo had been placed onto 2 palletes and had been loaded without problems, no observation of damage or leakages. The goods had been previously stored according to regulations. The captain had supervised the transport from the warehouse and loading of the two palettes onto position ML and PR on the aircraft.

Palette MR was recovered from the sea floor, films contained in the palette showed burns and blackened traces. recovered containers 43L and 44L from the lower deck showed no signs of fire or soot.

The Rails holding cargo pallets and recovered from the sea floor showed:
Bottom floor: no traces of fire or soot
SL: traces of soot and melting
SR: traces of soot and light melting, severe corrosion
PR: traces of soot and blue dye splatters, cargo net with burnt traces
ML: traces of burning and soot
LR: no traces of fire

The cargo pallet positions (Graphics: ARAIB):

The cargo pallet positions (Graphics: ARAIB)

One package containing 12 Lithium-Ion battery cells (Photo: ARAIB):

A burnt through skin panel (Photo: ARAIB):

Cargo door L5 (Photo: ARAIB):

Reader Comments:

@ jan
By leeveraction on Saturday, Sep 26th 2015 18:16Z

It will take another couple of further crashes before the operator/owners realize that this is necessary. I see a future where hazmat items are kept in a jettisonable container either internal or external to the A/C. If internal, this does mean redesigning the pressure vessel part of the cargo A/C and thus, substantial money and paperwork. The cheaper option is to vastly upgrade the internal fire suppression systems to deal with Class D fires.

I realize this is a late comment, however...
By Daniel H on Monday, Sep 14th 2015 23:30Z

...the final report states "flammable and corrosive liquids AND class 9 lithium-ion batteries in palette PR."

To me, that's like saying "Let's place these fireworks next to these cans of gasoline. And let's place these oxygen generators in between them. That way, if there is a fire, we won't have a small, localized situation, but instead we'll have a massive, out-of-control conflagration in just a few minutes."

It says the captain supervised the transport and loading of the hazardous goods. I doubt very much he was aware that "flammable and corrosive liquids" were being loaded right next to "class 9 lithium-ion batteries."

Crazy. Absolutely 100% crazy.

@Jan
By (anonymous) on Wednesday, Aug 5th 2015 15:05Z

This is not a bad idea actually. And perhaps some drag chute can be added to the pallets so that they cause less damage if coming down on land. Probably the engineering though wouldn't be straightforward for designing a door through which jettison could occur without causing rapid depressurisation. But there must be a way to do it. Could the depressurisation even help extinguish some flames?

Throw the cargo overboard
By Hud on Wednesday, Aug 5th 2015 10:41Z

@Jan good idea and it can be done.
B744 can transport an engine under the wing called Fifth Pod.
Maybe it can accommodate special designed jettison able cargo hold with GPS locator.

With a simple idea to put surveillance cameras being opposed by stubborn commenters here how can you come up with this brilliant idea?

Keep thinking out of the box Jan!

Throw the cargo overboard
By Jan on Wednesday, Aug 5th 2015 08:19Z

It should be possible to design a cargo hold in such a way that cargo can be jettisoned in an emergency. Why dump just fuel if you can dump cargo too? Just think of the tales people could tell - "I can't believe they dumped my baggage in the sea just because the hydraulics failed." It would add some weight and expense, but may pay off in saving lives and expensive aircraft.

By willy on Tuesday, Aug 4th 2015 23:15Z

Why is the word COMPARE over every Snap these days?

@Simon (old comment)
By John on Tuesday, Aug 4th 2015 14:38Z

The comment is quite old, but I have to laugh at the idea that if you ban Li-ion batteries then "that's the end of business travel". Really? What are the business travellers going to do then? Go by ship? Maybe taxi across continents? Economics of course has to be factored in but if it's the only factor the consequences are not good at all. And even if you remove the horrible element of people dying because of this, I can't see how aircraft going down due to Li-ion is good from an economic perspective either. Jeesh.

@By a Gent
By Phil Squares on Tuesday, Aug 4th 2015 12:42Z

You are a little confused on what ACARS and EICAS is. The crew does not see the malfunction list on the ACARS. The message is sent automatically and in most cases, the malfunction is of a very minor nature.

What the crew sees is on the EICAS (engine indicating and crew alerting system). There are Warnings (RED), Cautions (YELLOW) and advisories (WHITE). Those are what the crew sees and should react to.

By (anonymous) on Tuesday, Aug 4th 2015 09:52Z

How many jets have been taken out now due to fire from lithium-ion ??

ACARS Overload?
By A Gent on Tuesday, Aug 4th 2015 09:00Z

No matter the nature of the principal issue, ow on earth can one, two-person crew manage 26 ACARS malfunction alerts, probably displaying as fast as the system could report them? EFB or not, they still have to look them up and choose to take action or defer. One trying to fly an increasingly crippled bird the the other, we hope, trying to work through endless alerts. Perhaps something was lost in the translation... They had no chance and RIP.

Lithium cells
By Sky driver on Tuesday, Aug 4th 2015 06:41Z

Keep in mind what can lead to a first cell overheating and exploding, that will lead to adjacent cell overheating and a chain reaction: either an external overheating, like a local fire, an over voltage from the electrical plug for a connected device and last but not least the cell being bumped or smashed.
Cells on a pallet can easily be bumped/partially smashed when being loaded, with damage not visually obvious if not reported by loading operator.
Then overheating of the first cell will take its time to erupt...

Cockpit...air
By Ray Dahl on Monday, Aug 3rd 2015 23:36Z

The -400 has an overhead venturi-like opening in the cockpit that sucks the smoke out. Also, the emergency exit on top of the fuselage can be opened if de-pressurized. I have no idea how effective they would be under the circumstances.

By Miles on Monday, Aug 3rd 2015 20:06Z

The sad thing about these events is the same: nothing will be done until a passenger plane goes down. Typical aviation rule of thumb for any issue, be it basic fire suppression (Valujet 592), cockpit security (9/11 attacks), and now drones (coming soon to an airliner near you).

By Aaron on Monday, Oct 22nd 2012 17:33Z

I like where your head is at and it would work in a 777, 767, 757, A300, A330, MD-11 and DC-10 freighter aircraft, but the problem with the 747 is the cockpit windows don't open.

Batteries and others
By Sasha on Saturday, Sep 29th 2012 07:58Z

1. cockpit windows can be opened in any plane at any altitude to clear smoke. O2 prob you have only above 13500 ft ( most small planes have no pressurized cabin and still climb this high )
2.in case of fire: go to nearest runway asap, go down to min.safe altitude to speed up ditching if required
3.ban impossible. means all passengers need to leave home not only laptops but cellphones, cameras etc.

means it can also happen to you at home, in a bus, in a hotel, everywhere. As they burn with 6000c temperature, there is no safe containment.

Safer Cargo Holds.
By bob on Wednesday, Sep 26th 2012 00:56Z

They need to come out with better cargo containers that can contain such fires.

Also, they need video cameras in the cargo hold so the pilot can see first hand the situation and make decisions.

I think waiting for the flame to hit the sensor and then the alarm sounds is too late. They need better technology, because it's not like they are going to stop shipping these risky battery types on aircraft anytime soon.

I feed bad for the crew, what a horrible ordeal they experienced.

FAA film on extinguishing li-ion battery fires in cabin
By WalterWest on Saturday, Sep 22nd 2012 18:21Z

The fire hazard of a product is the sort of thing best determined under controlled circumstances in a lab, not by dissecting a downed aircraft.

Here is the FAA film on the subject of extinguishing lithium ion batteries in devices in the cabin.

Perhaps individual cells in individual devices, in other words smallish hazards not immediately adjacent to other smallish hazards, are okay in aircraft cabins. I'd like to think airlines can handle that.

In the case of the laptop in use, it is overheating in the computer parts or a defect in the battery starting the fire.

But imagine a pallet with 12 boxes of 12 sets those Li-ion batteries down in your cargo hold. They aren't in a device that can overheat, but they could have manufacturing defects in their cases rupture at low pressure, causing them to over-heat. Or they could be heated up by a small otherwise controllable fire near by.

airline communication
By ryuzaki1012 on Thursday, Sep 20th 2012 23:23Z

do airlines in emergency usually try to contact another aircraft of the same airline or does it usually just not matter or does it depend on the type of emergency. here i see that the asiana aircraft talked between a korean airlines flight.

If by Truck or Ship?
By DR on Thursday, Sep 20th 2012 18:09Z

Do these batteries catch fire while being transported by Truck or by Ship?

Is this just an Aircraft problem?

LiPo hazard
By John on Thursday, Sep 20th 2012 14:28Z

Reading through all of this I get the creeps thinking a box of those batteries 'prepared' by wrong minded people could be a risk of it's own. Could be as effective (devastating) as a bomb or gun! Proper packaging should be the key. The burden of safety should rest by the manufacturers. Let them make, buy or invent a container that contains a fire within. Should make the batteries more expensive but the skies safer.

@ X
By Freddy Freakoutski on Thursday, Sep 20th 2012 09:11Z

They were below 10k feet when they opened the hatch so there were no altitude problems such as hypoxia, i assume they opened it to clear the smoke from the cockpit and they had thier O2 masks on.

the hatch opens inwards so there is no possibility of it hitting the rudder.

By X on Thursday, Sep 20th 2012 07:15Z

They opened cockpit hatch during flight? Did it hit and damage rudder?? How is it possible to open hatch in-flight....????

Lithium out of control
By Dave on Thursday, Sep 20th 2012 06:55Z

There are just too many incidents involving lithium batteries in the preceding years, where large quantities of lithium batteries are transported they should be transported by sea in a position on deck that when and if fire breaks out it can be dumped or dealt with. There is no time or method at present to deal with fire on board an aircraft for this nature of cargo.
I was ramp supervisor of GHC handling this aircraft on prior routing FRA-INC and see in my everyday workload the amounts of Lithium being transported both in pax and cargo aircraft. It is disturbing to know that an aircraft which one handled 24 hours prior was lost with all hands in these circumstances.

Re: TangoSierra
By Simon on Thursday, Sep 20th 2012 06:30Z

"No commercial arguments, please"

LOL. What kind of baloney is that? You take economics out of aviation and guess how many flights are left? It's quite simple, actually. You ban Li-ion batteries from aircraft, that's the end of business travel. With airlines already going bankrupt left and right, you can easily imagine what that means. The entire industry would be done for.

Don't jump to conclusions. Wait for the investigation report. Then think.

Anonymous is absolutely right about proving negative statements. You cannot prove Li-ion batteries are 100% safe. Nothing is. The fact of that matter is that millions of Li-ion batteries travel safely on aircraft every day. If it can be proven that there is a safety issue (big if, considering the prior sentence), adequate measures will have to be developed and implemented. But outright banning such a common item will never happen unless we're willing to end commercial aviation.

Until it's not really clear and proven that lithium batteries did NOT cause these fatal accidents, why not simply ban th
By (anonymous) on Wednesday, Nov 2nd 2011 16:16Z

@TangoSierra

It doesn't work this way. It is not logically possible to prove negative statements, only positive statements are provable, hence the opposite of what you suggested is true - no one will ban batteries until it's proven with a high degree of certainty that they cause the crash.

The same principle applies here as in the general case of the presumption of innocence, where the burden of proof is on the prosecution.

Lithium Batteries
By TangoSierra on Wednesday, Nov 2nd 2011 02:46Z

There were several crashes now involving lithium batteries.

IATA is publishing its DGR bible every single year with big fanfare.

Until it's not really clear and proven that lithium batteries did NOT cause these fatal accidents, why not simply ban them for transportation on aircraft?

No commercial arguments, please, against this proposed ban! We are talking about human lives, about people who perished. And every single life lost is one too much!

mike
By (anonymous) on Tuesday, Nov 1st 2011 08:11Z

I'm not an aviator but I have a simple question - is there any reason why the flight crew of cargo only aircraft should not be provided with escape systems - ejection seats?

Suicide
By viscount on Monday, Oct 31st 2011 21:27Z

@MartinM
"I don't think an aviator would do to a fellow colleague,".

It wouldn't be the first time a Capt., committed suicide and murder. Consider Egypt Air of Nantuket, Japan DC-8 into Tokyo bay to name just a few.
Sad.

@Florian - suicide ??
By MartinM on Monday, Oct 31st 2011 19:10Z

ummmm... suicide by the Capt.? that seems something a big company or insurance would say in order for not paying or to avoid investigations going on if something really bad needs to be buried.

Anyway, if the Capt. did that, makes him not only a suicider but a murderer, wich I don't think an aviator would do to a fellow colleague, even in dispair seems highly unlikely.

An over all things, you really think that a Capt. would be soooo terribly stupid to do a life insurance and just wait a couple of weeks to do a crazy thing like this? ummm...

Re: Batteries?
By Florian on Monday, Oct 31st 2011 18:22Z

Please hold on with your battery comments, there's wild speculation that the captain had taken out multiple life insurances the weeks before the crash. If that's true, then it's probably a suicide of the captain, dragging a F/O and plane along with him....

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