A333, Manila Philippines, 2013
From SKYbrary Wiki
Revision as of 19:18, 11 December 2016 by Timo.Kouwenhoven
|On 7 October 2013 a fire was discovered in the rear hold of an Airbus A330 shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.|
|Actual or Potential
|Fire Smoke and Fumes, Ground Operations, Human Factors|
|Flight Conditions||Not Recorded|
|Type of Flight||Public Transport (Passenger)|
|Origin||Singapore Changi Airport|
|Intended Destination||Manila/Ninoy Aquino International Airport|
|Take off Commenced||Yes|
|Location - Airport|
|Airport||Manila/Ninoy Aquino International Airport|
|Tag(s)||Inadequate Airport Procedures|
|Tag(s)||Procedural non compliance|
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 7 October 2013, an Airbus A330-300 (RP-C3336) being operated by Philippine Airlines which had recently arrived at Manila after a passenger flight from Singapore as PR 512 was on the parking stand at night when an ECAM Warning of aft cargo smoke was annunciated. The warning was subsequently confirmed by the crew to be the result of a fire in the aft hold. The RFFS attended and the fire was extinguished. The aft hold was found to have sustained substantial damage as a result of the fire.
An Investigation was carried out by the Philippines Aircraft Accident Investigation and Inquiry Board (AAIIB), which was not notified by the aircraft operator of the event until the following morning.
It was noted that the previous flight had been normal and had not encountered significant turbulence. It was established that when the ramp service agent who was intending to open the rear hold door approached it, there were no unusual indications but "from his position on the Lower Deck Loader there was smell of burnt plastic/rubber" and "when he opened the (rear hold) door there was thick smoke and hot air pushing out". The agent immediately moved the Loader away from the door but did not return to close the door for a reported 15 minutes, after which he "then informed the Ramp Supervisor" who called the Airport Fire Service.
During this time, after passenger disembarkation but with all the crew members still on board, an ECAM Warning of "Aft Cargo Smoke" was annunciated in the flight deck. At about the same time, "the rear cabin crew heard crackling sounds and later noticed smoke coming from the rear of the cabin". One of them "rushed to the cockpit and personally relayed to the (aircraft commander that there was) smoke in the rear cabin". In response, both pilots went into the passenger cabin and having "verified (that there was) smoke in the rear cabin, the commander returned to the flight deck" "and discharged the Fire Extinguishing Bottles for the aft cargo compartment". He then left the flight deck, but on subsequently remembering that with the battery already off, the fire bottles would not have discharged, he returned, put the battery on and repeated the firing of the fire extinguishing bottles. The crew left the aircraft but it is unclear whether the commander himself apprised the situation externally before leaving the parking stand. It is stated that when he left the parking stand "the cause and source of the smoke was undetermined".
Meanwhile, five firemen had quickly responded to the Ramp Supervisor's call but arrived "without (a) fire truck and (had) used two [...] 10 lbs standby ramp fire extinguishers (after) the three 150 lbs (available) standby fire extinguishers failed to function". Approximately eight minutes after the five firemen had arrived the scene, a single fire truck arrived and positioned to the rear of the aircraft on the right. Eventually, the efforts of "ground personnel and the responding fire fighting entities" resulted in the suppression of the smoke and fire.
The six ULDs in the rear hold were unloaded and four of them were found to have been "affected by the fire" with the hold itself having sustained "substantial damage by fire".
The Investigation found that the fire had been the result of mixing of the spilled contents of "individual small containers of dangerous substances containing potassium permanganate and glycerine" which had been in the checked bags of some passengers who were Kayak athletes and which had been loaded into one or more of the ULDs then placed in the rear hold at Singapore.
It was concluded that the small quantities of dangerous goods involved "were not adequately covered by manual/psychological and technology inspection/monitoring" prior to departure from Singapore. The consequences of this and the possible inappropriate securing of the items involved was considered to have created "the probability of inadvertent mixing while in flight".
It was also noted that:
- Once aware of the problem, the aircraft commander had failed to promptly carry out the applicable crew procedures which included discharging the hold fire extinguishers and calling directly for support from the airport RFFS.
- Passengers are not adequately informed about what dangerous goods are permitted and the requirements for the packing of those which are.
- Airport personnel need effective training and equipment in order to be able to properly inspect to confirm that only permitted and correctly packed dangerous goods are transported by air.
The Probable Cause of the Accident was determined as "The (unintended) mixing of (the) dangerous substances glycerine and potassium permanganate (which) initiated (an) incipient fire in aft cargo compartment".
Two Contributory Factors were also identified:
- (The) inadequate system (for) identifying (items) of passengers’ checked-in baggage that contain Dangerous Goods.
- (The failure of the aircraft commander to ensure) the timely implementation of the procedures for (an) Aft Cargo Compartment Smoke Warning.
One Underlying Factor was also identified:
- Inadequate passenger information and airport security procedures (in respect of) the identification and control of the updated list of dangerous goods and its safe handling.
Four Safety Recommendations were issued as follows:
- that the CAA Philippines (CAAP) Security and Intelligence Service (CSIS) shall coordinate with (its) counterpart International Civil Aviation Organisation (ICAO) security organisation on the security aspects of the forensic related findings of this incident for widest dissemination to ICAO Member States’ airport security organizations.
- that the CAA Philippines (CAAP) Security and Intelligence Service (CSIS) shall coordinate with OTS, DOTC, National Aviation Security stakeholders and security staff of Air Operators and Service Providers, on the security findings of this report for urgent implementation on cargoes and passenger baggage inspections in all airports in the country.
- that the CAA Philippines (CAAP) Flight Standards Inspectorate Service (FSIS) shall ensure that simulator training of airline pilots (includes the) scenario (of) fire (in) any (part) of the aircraft at any (point in) the flight including at (the) parking bay (and) standard procedures to be implemented by the aircrew and that (the applicable) syllabus is updated (to include) such (a) training event.
- that the CAAP Aerodrome and Air Navigation Service (ANSOO) shall ensure that all chartered airports in (the) country especially Manila are advised to review the readiness status of (their) fire fighting equipment and manpower on alert (and) ensure that all Airports under CAAP supervision are periodically inspected and tested on (their) capability readiness.
A Summary of the Final Report of the Investigation on which this summary is based was made available in April 2016.