1983 — June 2, Air Canada Fl. 797, in-flight hidden fire, emer. landing, Covington, KY– 23

— 23  Aircraft Crashes Record Office (Geneva, Switzerland).  Ohio, 1980-1989.

— 23  National Fire Protection Association. Key Dates in Fire History. 1996.

— 23  NTSB. Aircraft Accident Report (NTSB/AAR-86/02). Air Canada Flight 797… 1986.

 

NTSB Synopsis:

 

“On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. The flight left Dallas with 5 crewmembers and 41 passengers on board.

 

“About 1903, eastern daylight time, while en route at flight level 330 (about 33,000 feet m.s.l.), the cabin crew discovered smoke in the left aft lavatory. After attempting to extinguish the hidden fire and then contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent and ATC vectored Flight 797 to the Greater Cincinnati International Airport, Covington, Kentucky.

 

“At 1920:09, eastern daylight time, Flight 797 landed on runway 27L at the : Greater Cincinnati International Airport. As the pilot stopped the airplane, the airport fire department, which had been alerted by the tower to the fire on board the incoming plane, was in place and began firefighting operations. Also, as soon as the airplane stopped, the flight attendants and passengers opened the left and right forward doors, the left forward overwing exit, and the right forward and aft overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire engulfed the airplane interior. While 18 passengers and 3 flight attendants exited through the forward doors and slides and the three open overwing exits to evacuate the airplane, the captain and first officer exited through their respective cockpit sliding windows. However, 23 passengers were not able to get out of the plane and died in the fire. The airplane was destroyed. (NTSB 1986, 1)

 

Original Probable Cause: “The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and conflicting fire progress information provided to the captain.

 

“Contributing to the severity of the accident was the flightcrew’s delayed decision to institute an emergency descent.” (NTSB/AAR-84-09, Aug 8, 1984, p. 1.)

 

Revised Probable Cause: “The National Transportation Safety Board determines that the probable causes of the accident were a fire of undetermined origin, an underestimate of fire severity, and misleading fire progress information provided to the captain.

 

“The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent contributed to the severity of the accident.” (NTSB/AAR-86/02, Jan 31, 1986, p.1)

 

NTSB Revision: “On August 8, 1984, the National Transportation Safety Board adopted the report and probable cause of the accident. On December 20, 1984, the Air Line Pilots Association submitted a petition for reconsideration of the contributing factors statement of the probable cause that was adopted in the original report. As a result of the Air Line Pilots Association’s petition, the accident report and the probable cause have been revised. [The probable cause noted above is the revised probable cause.]

 

NTSB Conclusions:

 

“….

 

  1. The smoke in the aft lavatory was discovered by a flight attendant. The smoke was reported to the captain as a fire.

 

  1. The source of the smoke was never identified either by the flight attendants or the first officer. The captain was never told nor did he inquire as to the precise location and extent of the ‘fire,’ which had been reported to him. Thereafter, he misconstrued reports that the fire was abating and he delayed his decision to declare an emergency and descent.

 

  1. Because of the delayed decision to descent, the airplane lost the opportunity to be landed at Louisville. Had the airplane been landed at Louisville, it could have been landed 3 to 5 minutes earlier than it actually did land at Cincinnati. The delayed decision to descent and land contributed to the severity of the accident….

 

  1. The first officer turned off the air conditioning and pressurization packs in the belief that the airflow was feeding the fire. The resulting loss of circulation accelerated the accumulation of smoke, heat, and toxic gases in the cabin and likely decreased the time available for evacuation….

 

  1. When the airplane stopped, smoke had filled the cabin and visibility within the cabin was almost nonexistent 2 to 3 feet above the cabin floor.

 

  1. A flashfire occurred within the cabin within 60 to 90 seconds after the doors and overwing window exits were opened. Flames from this fire were not evident until after the survivors had left the airplane. Flames from the original fire never were evident within the airplane or to persons on the ground.

 

  1. This was a survivable accident.” (NTSB/AAR-84-09, Aug 8, 1984, pp. 70-71.)

 

“Recommendations

 

“On July 11, 1973, the Safety Board participated in the investigation of a Varig Airlines, Boeing 707 accident near Paris, France, in which 124 persons died after a fire erupted in the rear lavatory. As a result of that accident, the Safety Board, on September 5, 1973, issued the following Safety Recommendations to the Federal Aviation Administration:

 

Require a means for early detection of lavatory fires on all turbine-powered, transport-category aircraft operated under Part 121 of the Federal Aviation Regulations, such as smoke detectors or operating procedures for the frequent inspections of lavatories by cabin attendants. (Safety Recommendation A-73-67)

 

Require emergency oxygen bottles with full-face smoke masks for each cabin attendant on turbine-powered transport aircraft in order to permit the attendants to combat lavatory and cabin fires. (Safety Recommendation A-73-68)

 

Organize a government/industry task force on aircraft fire prevention to review design criteria and formulate specific modifications for improvements with respect to the fire potential of such enclosed areas as lavatories in turbine-powered aircraft operating under the provisions of Part 121 of the Federal Aviation Regulations. (Safety Recommendation A-73-70)

 

“Following the investigation of the Pan American World Airways, Inc., Boeing 707 accident that occurred on November 3, 1973, while the flightcrew was attempting to land at Boston, Massachusetts, after the detection of a fire in the cargo compartment, the Safety Board issued these additional Safety Recommendations to the FAA:

 

Provide operators of the subject aircraft with data to enable flightcrews to identify smake sources, and require operators to establish procedures in their operating manuals to control and evacuate smoke effectively during the specific flight regimes. (Safety Recommendation A-73-121 issued January 10, 1974.

 

Require that transport category airplanes certified under Part 4B of the Civil Air Regulations prior to the effective date of amendment 4B-8 comply with FAR 25.1439 of the Federal Aviation Regulations. (Safety Recommendation A-74-5, issued February 6, 1974)

 

Require that a one-time inspection be made of all smoke goggles provided for the flightcrew of all transport category airplanes to assure that these goggles conform to the provisions of Part 25.1439 of the Federal Aviation Regulations. (Safety Recommendation A-74-6, issued February 6, 1974)

 

“As a result of two other lavatory fires, one aboard a Boeing 747 airplane on July 17, 1974, and the other aboard a Boeing 727 airplane on August 9, 1974, the Safety Board recommended that the FAA:

 

Require that automatic-discharge fire extinguishers be installed in lavatory waste paper containers on all transport aircraft. (Safety Recommendation A-74-98, issued December 5, 1974)

 

“In response to Safety Recommendation A-73-67, the FAA issued an Air Carrier operations Bulletin (No. 1-76-17, ‘In Flight Lavatory Fires’) instructing Principal Operations Inspectors to encourage air carriers to prohibit smoking in the lavatories and to institute routine flight attendant inspections of lavatories before takeoff and periodically during flight. This action was followed by an Airworthiness Directive which required the installation of ‘No Smoking’ and ‘No Cigarette Disposal’ signs in the lavatories of transport category airplanes.

 

“Although these actions fell short of the Safety Board’s intention to promote the installation of smoke detectors such as those using ionization and photo-electric technology to trigger an alarm signal, the Safety Board, in May 1979, closed Safety Recommendation A-73-67 and assessed the FAA’s action as acceptable. While the Safety Board at that time was sympathetic to the industry’s position that the lack of demonstrated reliability and the potential for false alarm problems associated with such smoke detectors would degrade their effectiveness, it now is convinced that the technology exists to provide an effective and reliable early warning fire detection system in the lavatories of transport category airplanes. Further, the Safety Board notes that the FAA report ‘Feasibility and Tradeoffs of a Transport Fuselage Fire Management System,’ (FAA RD 76-54), dated June 1976) concludes that such systems are feasible with current technology….” (NTSB/AAR-84-09, Aug 8, 1984, pp. 71-72.) [Goes on to end on p. 77.]

 

Sources

 

National Fire Protection Association. Key Dates in Fire History. 1996. Accessed 2010 at:  http://www.nfpa.org/itemDetail.asp?categoryID=1352&itemID=30955&URL=Research%20&%20Reports/Fire%20statistics/Key%20dates%20in%20fire%20history&cookie%5Ftest=1

 

National Transportation Safety Board. Aircraft Accident Report. Air Canada Flight 797, McDonnell Douglas DC-9-32, D-FTLL, Greater Cincinnati International Airport, Covington, Kentucky, June 2, 1983 (NTSB/AAR-84/09). Washington, DC: NTSB, 8-8-1984. Accessed 2-22-2017 at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR84-09.pdf

 

National Transportation Safety Board. Aircraft Accident Report. Air Canada Flight 797, McDonnell Douglas DC-9-32, D-FTLL, Greater Cincinnati International Airport, Covington, Kentucky, June 2, 1983 (NTSB/AAR-86/02, supersedes NTSB/AAR-84/09). Washington, DC: NTSB, Jan 31, 1986. Accessed 2-22-2017 at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR86-02.pdf