Edit Accident: B772, Denver CO USA, 2001 (GND FIRE HF)

Accident Form

When:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Event Type:	AGC AI AW BS CFIT CS FIRE GND HF LB LOC LOS RE RI WAKE WX
Day/Night:	None Not Recorded Day Night
Flight Conditions:	None Not Recorded VMC IMC On Ground - Low Visibility On Ground - Normal Visibility
One sentence description:	On 5 September 2001, a British Airways Boeing 777-236 on the ground at Denver USA, was substantially damaged, and a refuelling operative killed, when a fire broke out following the failure of a refuelling coupling under pressure because of improper attachment.
Validation Code:

Add Aircraft Involved

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Add Location en-route

Origin: Destination:

Add Location Airport

Airport: In Vicinity of airport:

Airport: In Vicinity of airport:

Add Location

Coordinates: Location: ICAO Region: AFIAPACCARSAMEURMIDNAMNAT ICAO Territory: AGANAYBGBIBKCCTDADBDFDGDIDNDRDTDXEBEDEEEFEGEHEIEKELENEPESEVEYFAFBFCFDFEFGFHFIFJFKFLFMFNFOFPFQFSFTFVFWFXFYFZGAGBGCGEGFGGGLGMGOGQGSGUGVHAHBHCHDHEHFHHHKHLHRHSHTHUKLALBLCLDLELFLGLHLILJLKLLLMLOLPLQLRLSLTLULWLXLYLZMBMDMGMHMKMMMNMPMRMSMTMUMWMYMZNCNFNGNINLNSNTNVNWNZOAOBOEOIOJOKOLOMOOOPOROSOTOYPAPGPHPJPKPLPMPOPPPTPWRCRJRKRORPSASBSCSESFSGSKSLSMSOSPSUSVSYTATBTDTFTGTITJTKTLTNTQTRTTTUTVTXUAUBUDUEUGUHUIUKULUMUNURUSUTUUUWVAVBVCVDVEVGVHVIVLVMVNVOVQVRVTVVVYWAWBWIWMWPWRWSYYPZZKZM

Add General Tags

Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures

Add AGC Tags

Tags: Call Sign Confusion Loss of Comms Incorrect Readback missed Phraseology Language Clarity Low Fuel Status CPDLC Flight Crew Oxygen Mask Use Take off without clearance Landing without clearance Military Formation Clearance Military/Civil Coordination Provision of Aircraft Performance Data ATC Clearance Cancelled

Add AI Tags

Tags: CA Incursion DA Incursion PA Incursion TSA Incursion GPS VFR Navigation ATC Complicit Aircraft not in contact with Airspace ATC

Add BS Tags

Tags: Large Birds Flocking Birds Significant Airframe Damage Flight Crew Injury Engine damage Coastal Location Migration Engine Ingestion Prior verbal warning

Add CFIT Tags

Tags: Into water Into terrain Into obstruction No Visual Reference Lateral Navigation Error Vertical navigation error Pressure altimeter setting error VFR flight plan IFR flight plan

Add FIRE Tags

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Add HF Tags

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Add GND Tags

Tags: Taxiway collision On gate collision Aircraft / Aircraft conflict Aircraft / Person conflict Aircraft / Vehicle conflict Aircraft / Object or Structure conflict ATC clearance error Ground de/anti icing Jet Blast / Prop wash Surface Friction Towed aircraft involved Aircraft Push Back Incorrect Parking Position Airbridge Positioning Both objects moving Wingtip clearance Centreline obscured Accepted ATC clearance not followed Surface Lighting control Hold Loading Passenger Loading Cargo Loading Fuel Loading Dangerous Goods Engine Ground Running Engine Powered Systems Test No Flight Crew on Board

Tags: Taxiway collision On gate collision Aircraft / Aircraft conflict Aircraft / Person conflict Aircraft / Vehicle conflict Aircraft / Object or Structure conflict ATC clearance error Ground de/anti icing Jet Blast / Prop wash Surface Friction Towed aircraft involved Aircraft Push Back Incorrect Parking Position Airbridge Positioning Both objects moving Wingtip clearance Centreline obscured Accepted ATC clearance not followed Surface Lighting control Hold Loading Passenger Loading Cargo Loading Fuel Loading Dangerous Goods Engine Ground Running Engine Powered Systems Test No Flight Crew on Board

Add LB Tags

Tags: Accepted ATC Clearance not followed SID bust Clearance readback error undetected TCAS RA response Manual flight Pressure altimeter setting error

Add LOC Tags

Tags: Airframe Structural Failure Significant Systems or Systems Control Failure Degraded flight instrument display Uncommanded AP disconnect AP Status Awareness Non-normal FBW flight control status Loss of Engine Power Crew Incapacitation Flight Management Error Flight Control Error Environmental Factors Bird or Animal Strike Aircraft Loading Malicious Interference Temporary Control Loss Extreme Bank Extreme Pitch Last Minute Collision Avoidance Hard landing Take off Trim Setting Incorrect Thrust Computed Unintended transitory terrain contact Collision Damage Incorrect Aircraft Configuration Aerodynamic Stall

Add LOS Tags

Tags: TCAS RA Mis Flown Accepted ATC Clearance not followed See and Avoid Ineffective Required Separation not maintained Released to Own Separation Level Bust Lateral Navigation Error ATC Error Near Miss Lateral Offset in use Mid-Air Collision Uncommanded AP disconnect Military Aircraft involved Apparent de-selection of transponder Transponder non selection

Add RI Tags

Tags: ATC error Accepted ATC Clearance not followed Incursion pre Take off Incursion after Landing Runway Crossing Intersecting Runways Intersecting extended centrelines Towed aircraft involved Near Miss Ground Collision Phraseology Intentional Premature Rotation Vehicle Incursion

Add RE Tags

Tags: Overrun on Take Off Overrun on Landing Directional Control Undershoot on Landing Wrong Runway Excessive Airspeed RTO decision after V1 High Speed RTO (V above 80 but not above V1) Unable to rotate at VR Frozen Deposits Collision Avoidance Action Parallel Approach Operations Excess Water Depth Late Touchdown Significant Tailwind Component Significant Crosswind Component Thrust Reversers not fitted Landing Performance Assessment Off side of Runway Misalignment on runway Taxiway Take Off/Landing Runway Length Temporarily Reduced Intentional Premature Rotation Incorrect Aircraft Configuration Reduced Thrust Take Off

Add WAKE Tags

Tags: ICAO Standard Wake Separation prevailed ICAO Standard Wake Separation not met Accepted ATC clearance not followed Own separation In trail event Cross track event Pilot over compensation Intersection take off Intersecting extended centrelines Intersecting runways

Add WX Tags

Tags: In Flight Airframe Icing In Flight Icing - Piston Engine In Flight Icing - Turbine Engine CAT encounter En route In-cloud air turbulence Hail damage Volcanic Ash Effects Sand/Dust limited IFV Fog In Cloud on Visual Clearance Precipitation-limited IFV Strong Surface Winds Mountain Waves Lightning Damage Low Level Windshear

Add EPR Tags

Tags: Emergency Descent Emergency Evacuation Airport Emergency Medical Response MAYDAY declaration PAN declaration “Emergency” declaration Slide Malfunction RFFS Procedures Evacuation difficulties in Water Delay in Declaration of Emergency

Add CS Tags

Tags: Disruptive Pax Turbulence Injury - Cabin Crew Turbulence Injury - Pax with Seat Belts on Turbulence Injury - Pax with Seat Belts off Cabin Stowage - Pax Items Toilet compartment fire Cabin furnishings fire Evacuation slides deployed Pax oxygen mask drop Unauthorised PED use IFE fire Flight deck comms difficulty Cabin air contamination Malicious interference Hand held extinguisher used Evacuation on Cabin Crew initiative Flight Crew Evacuation Command Cabin Crew Incapacitation Cabin Crew Medical Fitness Passenger Illness Faulty or misused PED

Add AW Tags

System(s): Airframe Air Conditioning and Pressurisation Autoflight Communications Electrical Power Equipment / Furnishings Fire Protection Flight Controls Fuel Hydraulic Power Ice and Rain Protection Indicating / Recording Systems Landing Gear Landing Lights Navigation Oxygen Airborne Auxiliary Power (APU) Propellers Rotors Engine - General Engine Fuel and Control Bleed Air Other Emergency Evacuation Contributor(s): Maintenance Error (valid guidance available) Maintenance Error (invalid guidance available) Inadequate Maintenance Schedule Inadequate Maintenance Inspection Inadequate QRH Drills OEM Design fault Damage Tolerance Contributing ADD Component Fault in service Component Fault after installation Pilot verbal-only defect communication Corrosion/Disbonding/Fatigue Cross Connection Engine Compressor Washing

Add Safety Net Mitigation

Malfunction of Relevant Safety Net: None Yes No GPWS: None Effective Partially effective Available but ineffective TAWS: None Effective Partially effective Available but ineffective TAWS with RAAS: None Effective Partially effective Available but ineffective TCAS: None Effective Partially effective Available but ineffective STCA: None Effective Partially effective Available but ineffective MSAW: None Effective Partially effective Available but ineffective APM: None Effective Partially effective Available but ineffective APW: None Effective Partially effective Available but ineffective Mode 'S' EHS: None Effective Partially effective Available but ineffective Wind Shear Escape Guidance: None Effective Partially effective Available but ineffective Stall Protection: None Effective Partially effective Available but ineffective A-SMGCS: None Effective Partially effective Available but ineffective EMAS: None Effective Partially effective Available but ineffective TOCWS: None Effective Partially effective Available but ineffective

Add Causal Factor Group(s)

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Add Safety Recommendations

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Accident Report text:

==Description== On 5 September 2001, a British Airways [[B772|Boeing 777-236]] on the ground at Denver, Colorado, was substantially damaged, and a refuelling operative killed, when a fire broke out following the failure of a refuelling coupling under pressure because of improper attachment. ==Synopsis== This is Summary and Probable Cause of the accident published by the National Transportation Safety Board (NTSB) (USA) '''''“During refuelling, with the airplane parked at the gate to unload passengers, a pressurized refuelling hose broke loose from the airplane and a fire erupted. The hose which broke loose was the inboard of two hoses which had been attached by the refueller to the left wing refuelling panel. Examination of the hose revealed that it came loose due to the fracture of the three refuelling adapter ring locking lugs on the airplane's inboard left wing refuelling port. Metallurgical examination of the inboard (fractured) adapter and the outboard adapter indicated that although the inboard adapter had a different microstructure and probably a different heat treatment history from the outboard adapter, they both met the applicable requirements for ultimate tensile strength and chemistry. Additionally, the metallurgical examination found the locking lug fractures to be the result of a one-time ductile overstress with no indications of pre-existing cracking, corrosion, or defects that would have degraded the load-carrying capacity of the adapter. Therefore, the failure of the adapter was the result of an overload applied at the time of the separation. The investigation revealed that the refueller had improperly positioned the hydrant truck in relation to the airplane's left wing refuelling panel prior to commencing refuelling operations. Because of this positioning, the lift platform's left railing obstructed the normal nozzle attachment procedure to the airplane's inboard manifold adapter. Subsequently, while attaching the nozzle, the refueller improperly routed the hose over the top of the front railing, around the left forward corner support of the railing structure, and aft to the airplane's inboard manifold adapter ring. The investigation also revealed evidence consistent with the refueler lowering the lift platform, for personal comfort during the long refueling, and the refueling hose then catching on the platform's left front railing and bumper. Vertical pull tests indicated that the three nozzle attachment lugs were capable of supporting a load in excess of 10,000 pounds if the load was applied along the nozzle centerline. However, the weight bearing capability of the lugs dropped off as the load was applied at increasing angles off the centerline. At an angle of 30 degrees off centerline, the lugs failed below 1,000 pounds of load. The refueler's improper routing of the fuel hose would have placed an off-axis load of approximately 52 degrees. The angular force applied to the manifold adapter ring was amplified when the refuelling hose was pressurized. The combination of the two forces resulted in the adapter ring's failure. Pressurized fuel discharged forming a fuel mist cloud that subsequently ignited. The resulting fire resulted in fatal injuries to the refueller. The airplane's lower leading edge panels, the refuelling control panel, and the outboard portions of the left engine fan cowl and thrust reverser were thermally damaged. The hydrant truck was destroyed in the fire. Since the accident, two companies have introduced modifications to help position hydrant dispenser trucks during single person operations, and industry groups are examining the need for changes to existing industry standards and practices of aircraft fuelling.''' '''The National Transportation Safety Board determines the probable cause(s) of this accident as follows:''' '''the overstress fracture of the airplane's refuelling adapter ring that resulted from the abnormal angular force applied to it. The applied angular force occurred due to the ground refueller inadequately positioning the hydrant fuel truck (in relation to the airplane), and his inattentiveness while lowering the refuelling lift platform, thus permitting the refuelling hose to become snagged and pulled at an angle. The fracture of the adapter ring during the refuelling led to the ignition of the pressurized (mist producing) spilled fuel and subsequent fire. "''' ==Related Articles== *[[Ground Operations]] *[[Fire]] *[[Refuelling & Defuelling Risks]] ==Further Reading== *For further information, see the [http://www.skybrary.aero/bookshelf/books/1058.pdf NTSB Report (DEN01FA157)].

Summary:

This is a minor edit Watch this page

Cancel