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B744, vicinity Dubai UAE, 2010

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Summary
On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.
Event Details
When September 2010
Actual or Potential
Event Type
Fire Smoke and Fumes, Ground Operations, Loss of Control
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 747-400 (international, winglets)
Operator UPS Airlines
Domicile United States
Type of Flight Public Transport (Cargo)
Origin Dubai International Airport
Intended Destination Cologne/Bonn Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Cruise
ENR
Location - Airport
Airport vicinity Dubai International Airport
General
Tag(s) Inadequate Aircraft Operator Procedures,
Air Turnback,
Copilot less than 500 hours on Type
FIRE
Tag(s) Post Crash Fire,
Dangerous Goods,
Fire-Cargo origin
HF
Tag(s) Flight Crew Incapacitation,
Plan Continuation Bias,
Ineffective Monitoring - SIC as PF
GND
Tag(s) Dangerous Goods
LOC
Tag(s) Significant Systems or Systems Control Failure,
Degraded flight instrument display,
Crew Incapacitation"Crew Incapacitation" is not in the list (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, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
Flight Control Error"Flight Control Error" is not in the list (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, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
Collision Damage
EPR
Tag(s) MAYDAY declaration
CS
Tag(s) Cabin air contamination
AW
System(s) Fire Protection
Safety Net Mitigations
TAWS Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Fatalities Most or all occupants (2)
Causal Factor Group(s)
Group(s) Aircraft Operation,
Aircraft Technical
Safety Recommendation(s)
Group(s) Aircraft Airworthiness
Investigation Type
Type Independent

Description

On 3 September 2010, the crew of a Boeing 747-400F (N571UP) being operated by UPS on a scheduled cargo flight from Hong Kong via Dubai to Cologne as UPS6 declared a MAYDAY due to a main deck cargo fire whilst about to reach their cleared level of FL320 22 minutes after take off from Dubai. An emergency descent and return to Dubai was initiated in night Visual Meteorological Conditions (VMC) but rapid smoke build up in the flight deck made it impossible to see enough to change radio frequencies and communications were continued using relay aircraft. An attempt to land back at Dubai was unsuccessful and during an attempt to reposition, the aircraft impacted terrain out of control. The aircraft was destroyed and neither pilot, the only occupants, survived.

The following diagram shows the sequence of events from the first signs of fire: + The only occupants of the aircraft were the operating crew. The 48 year-old Captain had been with UPS for 15 years and had 11,200 total flying hours including 4053 hours on the accident aircraft type over the previous 5 years. Command time on type was 1218 hours. The 38 year-old First Officer been with UPS for 4 years and had 5549 flying hours of which just 77 were on the accident aircraft type.

sequence of events
diagram showing the sequence of events on UPS 006. The diagram is not to scale.

Investigation

An Investigation was carried out by the Air Accident Investigation Sector of the UAE GCAA. The FDR and 2 hour CVR were recovered from the accident site and their data were successfully downloaded.

The only occupants of the aircraft were the operating crew. The 48 year-old Captain had been with UPS for 15 years and had 11,200 total flying hours including 4053 hours on the accident aircraft type over the previous 5 years. Command time on type was 1218 hours. The 38 year-old First Officer been with UPS for 4 years and had 5549 flying hours of which just 77 were on the accident aircraft type.

It was established that the flight, with the First Officer as PF, had been uneventful until a 'Fire Main Deck' Warning was annunciated 22 minutes after take off as the aircraft was reaching its cleared level, FL320 and shortly after crossing into the Bahrain FIR and transferring to Bahrain ACC. Three seconds later, the Captain announced that he would take over as PF and followed up by stating that they were going to return (to Dubai). He then advised ATC of the fire indication and that they needed to land as soon as possible. Doha, at 100nm and 10'o'clock relative, was offered but the Captain replied that he wished to return to Dubai and then declared an emergency.

As part of the QRH response procedure, the 'Main Deck Cargo Fire Arm' switch was depressed, which shut down air conditioning packs 2 and 3 whilst pack 1 continued to supply preconditioned air to the upper deck. The effect of this, in the absence of any active fire suppression in Class E main deck cargo compartments, is to establish a pressure differential between the upper deck and the rest of the aircraft thus preventing smoke or fumes entering that part of the aircraft. Both pilots donned their oxygen masks but had initial interphone communication difficulty that was subsequently resolved. The aircraft was put into a right turn and a descent to FL280 was begun. Then, shortly after the crew rest area smoke detector had activated and less than 3 minutes after the fire warning, the Captain suddenly requested and was immediately approved for an immediate descent to 10,000 feet. The AP was then disengaged but the Captain had difficulty controlling the aircraft manually, specifically in pitch and re-engaged the AP which restored control. It was found that the only remaining air conditioning pack was no longer functioning and smoke began to enter the flight deck. The Captain called for the smoke shutter to be opened because of the smoke ingress and the crew succeeded in setting for an ILS approach to runway 12L at Dubai as the increasing smoke appeared to have rapidly made it impossible to see the instruments.

Seven minutes after the fire warning with the cabin altitude at around 21000 feet, the Captain remarked on the high temperature in the flight deck and then almost immediately, his oxygen supply suddenly failed. The First Officer took over as PF again as the Captain left his seat in order to locate an alternative Oxygen supply. The CVR did not record any "further interaction from the Captain or enquiry by the First Officer as to the location of the Captain or the ability of the Captain to respond". Pathological information subsequently established that the Captain had "lost consciousness due to toxic poisoning".

The First Officer advised that he was unable to see enough in the smoke to be able to change the COM 1 radio frequency to Dubai and shortly afterwards communications continued using relay by other aircraft. For a short period approximately 20 minutes after the fire warning, the First Officer made MAYDAY calls on 121.5 on COM2 but no two way contact was established and Dubai ACC calls to the aircraft in 121.5 did not appear to be heard either.

By now it was quite dark. The aircraft reached an intercept heading for the Dubai ILS but at 350 KCAS and 9000 feet altitude was too high and Dubai was over flown north of the runway after the First Officer had replied "negative" when asked if an orbit to reposition on final was possible. The flight was offered runway 30 at Sharjah, which with the aircraft approaching at 4000 feet was 10 nm away to the north east and would require a left turn. The radar heading given - 095º - was acknowledged but instead the aircraft turned right - subsequently this was found to have been because a heading of 195º had been set. Soon afterwards (see the diagram below) the AP was disconnected and as the descent continued, FDR data subsequently showed that pitch control had been lost "due to the de-synchronisation of the control column inputs and the elevators". An uncontrolled descent into terrain followed and, after 59 seconds of EGPWS 'PULL UP' Warnings, impact had occurred 9nm south west of Dubai Airport just under 30 minutes from the time of the fire warning.

B744 Dubai 2010 accident crash final stretch detailed track
The track flown (yellow) relative to the Dubai 12L ILS and the Sharjah 31 Localiser (Reproduced from the Official Report)

The aircraft was completely destroyed by the ground impact and a fire with some infrastructure damage but no ground casualties. It was found that the fire prior to impact - the origin of which was traced to undeclared Class 9 Dangerous Goods which had been loaded in Hong Kong - had "resulted in the exposure of primary structural elements, components and assemblies to significant heat damage" and exposed the flight deck area to "continuous smoke and toxic fume penetration". It was concluded that the fire had “severely damaged significant systems leading to failures in aircraft controllability and crew survivability systems, failures which interfered with the normal flight management, directly with the aircraft controls and with the crew supplementary oxygen system supply". It was noted too that the fire had already caused "severe damage to flight control systems" less than three minutes after the fire warning.

The Investigation found that "at some point along the flight route, a failure event occurred that provided an ignition source to nearby flammable materials leading to an in-flight fire" with this fire then spreading and increasing in intensity rapidly. The consequences of the fire were damage to numerous critical systems which created an unsafe condition and led directly to the loss of the aircraft. A series of Primary Factors were identified including the following:

  • The condition that resulted in the ignition source
  • The flammable materials that were available to be ignited, sustain, and propagate the fire
  • The location of the fire
  • The single point of failure that compromised the critical systems
  • The subsequent fire-induced material failures that exacerbated the fire-in-progress
  • The lack of detection equipment to enable the crew to accurately assess the source and significance of the initial smoke
  • The lack of appropriate in-flight fire fighting measures required to deal successfully with the smoke and fire
  • The decision making in the first stage of the accident event sequence
  • The emergency procedures available to the crew
  • Alternative vision systems – suitable use of and safety enhancements

The Investigation examined the potential effect on the outcome of the decision to return to Dubai rather than divert to Doha, which had increased the required track miles from about 100 nm (estimated at about 20 minutes to a landing) to 180 nm and led to the complication of relay communications for the single remaining pilot. However, it was considered that the likely outcome of a diversion to Doha was "inconclusive".

The Causes of the accident were formally documented as follows:

  1. A large fire developed in palletised 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.
  2. 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.
  3. 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.
  4. 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.
  5. The progressive failure of the cargo compartment liner increased the area available for the smoke and fire penetration into the fuselage crown area.
  6. 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.
  7. 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.
  8. 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.

A total of 13 Contributing Factors were identified as follows:

  1. There is no regulatory FAA requirement in class E cargo compartments for active fire suppression.
  2. 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.
  3. 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.
  4. 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.
  5. FAA and EASA regulatory requirements do not recognise the current total fire risk associated with pallets, pallet covers and containers as demonstrated by the NTSB/FAA testing.
  6. 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.
  7. 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.
  8. The course to return to Dubai required a series of complex radio communication relays due to the inability of the Pilot Flying to view and tune the radio transceivers.
  9. 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.
  10. 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.
  11. Task saturation due to smoke and multiple systems failures prevented effective use of the checklist by the crew.
  12. 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.
  13. The Pilot Flying had not selected transponder code 7700, the emergency code, when radio communication with the destination aerodrome was not established.

36 Safety Recommendations were made by the AAIS upon the conclusion of the Investigation as follows:

  • that the FAA, in co-operation or in coordination with EASA, should review the single, universal, CFR14 fire protection certification standard that covers all transport category aircraft as a single design category and develop a dedicated protection certification standard for the cargo compartments of aircraft designed or modified as dedicated freighter or freighter/passenger combi aircraft to include the mandatory installation of fire suppression systems of cargo aircraft with Class E cargo compartments. (SR 25/2013)
  • that the FAA and EASA should provide operators of cargo aircraft of a maximum certificated take-off mass in excess of 45,500 kg with the option to modify existing Class E cargo compartments, through a process of FAA or EASA recommended modifications, to control a class E cargo fire without requiring a crewmember to enter the compartment through the use of an active fire suppression system. (SR 26/2013)
  • that the FAA in co-operation or in coordination with EASA should mandate the requirement for cargo aircraft certified under FAA 14CFR or the equivalent EASA certification requirements to have a method of detecting the early development of fire through the detection of thermal radiation, originating within class E cargo compartments, through the installation of Multi-Source Sensors (MSS) which utilise a process of thermal/heat detection in conjunction with smoke/fumes sampling. (SR 27/2013)
  • that the FAA in co-operation or in coordination with EASA should review the certification requirement for crew alerting to provide a visual means of indicating the specific location of a fire to the crew. (SR 28/2013)
  • that the GCAA should recommend to the US Department of Transportation Pipeline and Hazardous Materials Safety Administration (PHMSA) standardisation of their battery packaging regulations so that they are in harmony with the ICAO Technical Instructions (TI). The requirement is the complete harmonization of the U.S. Hazardous Materials Regulations with the ICAO TI’s for the Safe Transport of Dangerous Good by Air regarding lithium batteries. This includes incorporation of quality management provisions provided in (the DG TIs) Part 2; 9.3.1 e. (SR 29/2013)
  • that the FAA in co-operation or in coordination with EASA should develop standards for containers with suppression systems, superior heat and fire resistance and resiliency to withstand a suppression-caused pressure pulse and still contain a suppression agent in accordance with NTSB recommendations contained in NTSB A-12-68, A-12-69 and A-12-70. (SR 30/2013)
  • that the FAA, in co-operation or in coordination with EASA, should implement certification rule changes to require containers or Unit Load Devices (ULDs) which meet the standards in Recommendation [SR 30/13], develop a design standard that enables the container or ULD to be capable of internally containing or suppressing a fire agent in accordance with NTSB safety recommendations contained in NTSB A-12-68, A-12-69 and A-12-70. (SR 31/2013)
  • that the FAA should develop an Advisory Circular which addressed the use of fire containment covers for cargo stored on pallets that could be used to cover palletized cargo or cargo containers. (SR 32/2013)
  • that the FAA, in co-operation or in coordination with EASA, should introduce a requirement for mandatory full-face oxygen. (SR 33/2013)
  • that the FAA, in co-operation or in coordination with EASA, should recommend the adoption of a rotary single piece selector for oxygen quick donning anti-smoke oxygen masks. (SR 34/2013)
  • that the FAA, in co-operation or in coordination with EASA, should require the use of Evidence Based Training Programs (EBTP) in line with the requirement of ICAO Document 9995 - Manual of Evidence Based Training. In particular, require operators to implement the development of evidence based simulator training using objective FOQA accident and serious incident data of smoke filled cockpit environments for crew emergency training. (SR 35/2013)
  • that the FAA, in co-operation or in coordination with EASA, should mandate the implementation of vision assurance devices or technology for improved pilot visibility during continuous smoke, fire, fumes in the cockpit emergencies. This could include off the shelf devices or developing mask mounted thermal imaging cameras with the capability to see through smoke/fumes with sufficient clarity to view the primary cockpit instrumentation. (SR 36/2013)
  • that the FAA, in co-operation or in coordination with EASA, should develop or redesign all transport aircraft checklists pertaining to Smoke Fire Fumes events to be consistent with the Integrated, Non-alerted Smoke Fire Fumes Checklist template presented in the Royal Aeronautical Society’s specialist document Smoke, Fire and Fumes in Transport Aircraft: Past History, Current Risk and Recommended Mitigations, second edition 2013, prepared by the Flight Operations Group of the Royal Aeronautical Society. (SR 37/2013)
  • that the FAA, in co-operation or in coordination with EASA, should review the capability of Portable Electronic Device (PED) Electronic Flight Bags (EFB) which are used for non-alerted smoke fire fumes events to be viewed in smoke filled cockpits. (SR 38/2013)
  • that the FAA, in co-operation or in coordination with EASA, should provide cargo crews with a revised Fire Main Deck non-normal checklist guidance for when and how to transition from the current 22-25,000 feet fire suppression altitude to the landing phase where descending early may contribute atmospheric oxygen to a latent fire during descent. This procedure should provide a method to verify or otherwise assess the condition of the fire and to evaluate the risk to the aircraft if a descent is initiated so as not to jeopardise the safety of the crew by following the checklist instruction as directed. (SR 39/2013)
  • that the FAA, in co-operation or in coordination with EASA, should mandate a certification requirement for continuous smoke testing for flight deck smoke evaluation tests where the smoke is required to be continuously generated throughout the test for cockpit smoke clearance and develop a mitigation procedure through regulation on how to effectively manage continuous smoke in the cockpit. (SR 40/2013)
  • that the FAA, in co-operation or in coordination with EASA and Boeing, should evaluate the Boeing 747 Freighter/Combi/BCF modified aircraft for single points of failure where the critical systems protection of the aircraft is dependent on a single safety gate which is the cargo compartment liner at or contiguous with fire zone three: this is the area under the control cable truss assembly, the ECS ducting and the supplementary oxygen system supply line from the forward lower deck cargo hold to the crew oxygen storage boxes. If a deficiency in the current level of critical systems protection is determined, provide regulatory oversight to mitigate the risk of control and systems damage that can result from large cargo fires. (SR 41/2013)
  • that the FAA, in co-operation or in coordination with EASA, should review the certification and design of Boeing 747 Freighter/Combi/BCF aircraft distribution of oxygen from the supplementary oxygen bottles to the flight deck oxygen masks primarily provided through corrosion resistant steel (CRES) 21-6-9 tubes. In particular, to review the critical systems protection requirements for the area connecting the CRES supply line, via a PVC hose and connector, to the oxygen mask stowage box (MXP147-3) and provide regulatory oversight to mitigate the risk of control and systems damage that can result from large, catastrophic cargo fires. (SR 42/2013)
  • that the FAA, in co-operation or in coordination with EASA, should charter an Advisory and Rulemaking Committee (ARAC) to review the adequacy of current issue papers on the protection of critical systems from cargo fires and develop regulations and associated guidance material (e.g. Advisory Circulars) to codify the existing and proposed requirements. (SR 43/2013)
  • that the FAA, in co-operation or in coordination with EASA, should require operators to implement smoke, fire, fumes training in a dedicated smoke simulator/full immersion training device allowing crews to experience actual levels of continuous smoke in a synthetic training device or other equivalent ground-based training device as an integral process in crew emergency recurrent training. (SR 44/2013)
  • that the FAA, in co-operation or in coordination with EASA, should implement specific Standard Operating Procedures for scenario based multi-crew pilot incapacitation where one or more crew members are incapacitated resulting in a single pilot crew environment. (SR 45/2013)
  • that the FAA, in co-operation or in coordination with EASA, should implement a specific recommendation that failures of aircraft systems (such as the air conditioning packs) necessary for the continued safe flight and landing during an aircraft cargo fire event be considered in the aircraft level safety analysis and during the development of cargo fire emergency procedures. This should consider failures of dependant systems and the continued cascading failure of systems which are factors in large cargo fires. (SR 46/2013)
  • that the FAA and the EASA regulatory certification standards should consider the development of a quantitative framework for assessing the degradation of cargo compartment liner polymer matrix or the current industry standard panel material properties and the resulting degradation in the structural integrity of these structures when subjected to extreme heat, vibration and/or thermo-mechanical energy. (SR 47/2013)
  • that the FAA, in co-operation or in coordination with EASA, should develop a test method to determine flame penetration resistance of cargo compartment liners to extreme heat at the current certification requirement temperature combined with additional input loads such as vibration, multi-axial loading, intermittent pressure pulses, thermo-mechanical loadings based on differential materials coefficients, acoustic vibration and ballistic damage. (SR 48/2013)
  • that the FAA, in co-operation or in coordination with EASA and Boeing, should evaluate the Boeing 747 Freighter/Combi aircraft Class E cargo compartment for a structural-acoustic coupling phenomena in the aircraft fuselage.
Structural-acoustic coupling phenomenon in an aircraft fuselage is a known characteristic. In large Class E cargo compartments, the structural and acoustic modes can be derived for vibration analysis. Structural and acoustic analysis could determine possible occurrences of vibration in the fuselage structure during predetermined phases of flight where the vibro-acoustic signatures can be used to determine the principle sources and transmitting paths of the vibration.
Further investigation can be performed by the manufacturers of large cargo aircraft and/or the operators of these aircraft to investigate the vibration and acoustic signatures of the cargo areas for harmonic acoustic vibration resulting from the combination of engine and fuselage vibration.
Currently there is no data for the class E cargo compartments of the B744F, If such data was available through a process of acoustic mapping for structural-acoustic coupling, this data could be used to expand the UN Manual of Tests and Criteria Para. 38.3.4.3 Test T.3: Vibration test and verification data.
This could (be obtained) through a process of acoustic mapping (of) the cargo compartment interior and measuring the vibro-acoustic interior vibration and (the) vibration and resonance of the airframe structure. (Refer to GCAA SR 57/2013) (SR 49/2013)
  • that the NTSB, FAA and/or EASA fire test divisions should perform a test on lithium batteries to determine the ignition properties for lithium type batteries when subjected to external sources of mechanical energy, including acoustic energy in flight range modes, acoustic harmonic modes and a separate test to determine the susceptibility of lithium batteries to vibration from a mechanical source.
The purpose of this testing is to determine the safe limits for the air carriage of lithium type batteries in dynamic aeroelastic, vibrating structures where the battery electrolyte, composed of an organic solvent (and dissolved lithium salt), could become unstable when exposed to these forms of mechanical energy. (SR 50/2013)
  • that ICAO should review the hazardous materials classification for Class 9 materials packaging where the reconsideration of lithium batteries and other energy storage devices that are currently classified as a Class 9 hazardous material be subjected to a higher level of hazardous material classification as at present time, it is not clear that the current Class 9 hazard communication or quantity limits adequately reflect the inherent risks to aviation safety. (SR 51/2013)
  • that ICAO should develop a SARP for package level protection of batteries being shipped to include protection from thermal degradation and damage to individual cells or cell combinations in thermal runaway, and to retard the propagation of lithium battery initiated fires to other packages in the same cargo stowage location as well as to increase the amount of time it would require for the contents of the package containing lithium batteries to provide an additional source of fuel for on-board fires initiated by other sources. (SR 52/2013)
  • that ICAO should establish a task force or working group of manufacturers, operators, and regulators to develop a concept and safety case for audible emergency checklists for non-normal emergency situations and provide a feasibility working paper for industry consideration. (SR 53/2013)
  • that ICAO should establish a task force or working group of manufacturers, operators, and regulators to develop a concept and safety case for alternative vision assistance systems for the smoke, fire and fumes events in non-normal emergency situations and provide a feasibility working paper for industry consideration on the implementation requirements and required standards. (SR 54/2013)
  • that the ICAO Flight Recorder Panel should expedite the ICAO SARP on Airborne Image Recording Systems (AIRS) amendment to Annex 13 to progress this matter because of the potential benefit to air accident investigation. (SR 55/2013)
  • that the ICAO Safety Information Protection Task Force should expedite the ICAO SARP’s required for video data protection. (SR 56/2013)
  • that the ICAO Dangerous Goods Panel should amend the ICAO Technical Instructions regarding the safe carriage of lithium batteries. Specifically, it is requested that a dedicated task force within the DG panel, including the representation of qualified stakeholders, to study the safe carriage of lithium batteries and other potentially hazardous cargo and develop recommendations to the UN Manual of Tests and Criteria, The Manual of Tests and Criteria Revision 5, Lithium Metal and Lithium Ion Batteries, 38.3.4.3, Test T3-Vibration.
Structural-acoustic coupling phenomenon in an aircraft fuselage is a known characteristic. In large Class E cargo compartments, the structural and acoustic modes can be derived for vibration analysis. Structural and acoustic analysis can determine possible occurrences of vibration in the fuselage structure during predetermined phases of flight where the vibro-acoustic signatures can be used to determine the principle sources and transmitting paths of the vibration.
Given the active failure modes of lithium batteries, the battery risk factors concerning possible susceptibility to various extraneous forms of mechanical energy, for example vibration, possibly in a harmonic form, could be an initiating action risk.
The ICAO Dangerous Goods Panel is requested to evaluate data relative to the UN Manual of Tests and Criteria, Lithium Metal and Lithium Ion Batteries, 38.3.4.3, Test T3-Vibration and advise the UNECE Committee of Experts/Working Party on the Transport of Dangerous Goods if additional criteria should be adopted for the carriage lithium metal and lithium ion batteries by air transport. (Refer to GCAA SR 49/2013) (SR 57/2013)
  • that the GCAA should produce an In-Flight Emergency Response Manual (IFERM) for the use of ATCO and all ANS providers. The General Civil Aviation Authority (GCAA) should issue a manual providing formal guidance for ATCO’s to enhance responses to in flight emergencies. The manual should support CAR Part VIII, subparts 4 (ATS) and 8 (SAR). (SR 58/2013)
  • that the GCAA should require all ATC units be equipped with a dedicated transceiver which can be directly tuned to all frequencies in the aviation band(s) for use in emergency situations. (SR 59/2013)
  • that the GCAA should assist and/or support the provision of mutual radar data sharing between the Bahrain and UAE Flight Information Regions. (SR 60/2013)

The National Transportation Safety Board (USA) (NTSB) assisted with the Investigation in various ways and in the light of its early findings and those from the 2011 Asiana 747 Freighter fire, the Board commissioned a Fire Safety Study to examine the characteristics of lithium ion battery fires. The resulting NTSB Materials Laboratory Study Report 12-019 completed on 21 March 2012 was used in support of the issue, on 28 November 2012, of three NTSB Safety Recommendations to the FAA on the subject of the fire hazard in cargo aircraft on the following subjects:

  • Early detection of fires originating within cargo containers and pallets (A-12-68)
  • Flammability requirements for cargo container construction materials (A12-69)
  • Active fire suppression systems in all aircraft cargo compartments or containers, or both, such that fires are not allowed to develop (A-12-70)

The Final Report of the Investigation was published in 24 July 2013.

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