Aviation Accident Summaries

Aviation Accident Summary ERA15IA198

Orlando, FL, USA

Aircraft #1

N610RL

DASSAULT-BREGUET MYSTERE FALCON 900

Analysis

During the airplane’s descent to its destination airport, the cabin attendant noticed a “weird smell” in the galley area; she checked the appliances but could find nothing wrong with them. She then turned around and opened the area in the galley where they kept the crystal glasses and noticed a “glow behind it,” which was an electrical fire. The pilot extinguished the fire using two halon fire extinguishers, and the airplane incurred minor damage. Examination of the area behind the crystal storage area revealed sooting, a burnt wiring bundle containing the 28-volt direct current wiring and ground wires for the cabin lighting, and a tripped circuit breaker for the cabin lighting. Two of the insulation bags in the area of the burnt wiring bundle had been fire damaged, and the wires had been routed over the insulation bags instead of directly next to the airplane's structure. The wires were also in contact with or near a soft oxygen line, which had been completely burned through. Examination of the oxygen line revealed no evidence of copper on the exposed coil; thus, the wiring had chafed against itself and not against the soft oxygen line. During the 26 years between the completion of the airplane and the incident, numerous modifications to the lighting, interior, and galley had been made by several maintenance, repair, and overhaul organizations, which required rerouting and re-securing wiring, as well as removal and replacement of interior panels, partitions, and cabinetry near the fire. The oxygen line and wiring in the area of the fire damage had been changed from the originally specified configuration; it did not conform to the manufacturer's cabin oxygen system drawing or the manufacturer's installation standard. Further, a clamp on the oxygen line near the fire damaged area appeared to be the wrong part number clamp. A spacer and a support in this area were missing, which would have been used to achieve and maintain separation between the oxygen line and wiring. Postincident examinations of exemplar airplanes revealed that on three of the seven airplanes, the layout of the oxygen line and electrical wiring was in compliance with manufacturer installation standards. However, on the other four airplanes, incorrect routing, spacing, or support was found, which likely occurred during maintenance.

Factual Information

HISTORY OF FLIGHTOn April 16, 2015, about 1910 eastern daylight time, a Dassault-Breguet, Mystere Falcon 900B, N610RL, owned and operated by RLB Holdings Transportation LLC., received minor damage from an inflight electrical fire. The airplane had departed Westchester County Airport (HPN), White Plains, New York about 1715, destined for the Orlando International Airport (MCO), Orlando, Florida. The pilot, copilot, cabin attendant, and 12 passengers were not injured. The corporate flight was being operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. According to the cabin attendant, she noticed "a weird smell" in the galley area and started checking the appliances. She could find nothing wrong with them and asked the pilots if they had any idea where the smell was coming from. She turned around and opened the area in the galley that they kept the glasses (crystal) in and noticed "a glow behind it." The pilot then came back to assist her. He grabbed a fire extinguisher, discharged it completely, and then asked her for another one. She handed him the second one and he was able to put out the fire. The pilot then told her to watch the area. According to the pilot, they noticed the strange odor when they were on the Standard Terminal Arrival Route (STAR) for MCO descending through 20,000 feet above mean sea level. They checked that all the ovens, microwaves, and warmers were in the "off" position. All were found to be "off", but the smell continued and then smoke appeared. The crew declared an emergency and asked for priority to the nearest airport. The pilot then "gave the flight controls" to the copilot who took over flying and the radio duties (the autopilot was on and engaged). The copilot then turned off the power to the cabin and to the galley. The pilot then used a fire extinguisher to extinguish fire. The fire was suppressed by getting behind the crystal storage and spraying the area with a Halon portable fire bottle. The crew decided to continue to Orlando as it had large runways with excellent fire and rescue capabilities. The landing was normal. The crew evacuated the passengers and fire personnel double checked the airplane for any signs of continued fire or hot spots. None were found. According to the copilot, they noticed a smell at first and then smoke from somewhere in the airplane when they were on the STAR for MCO at approximately 1910. They determined that it was coming from the galley area, declared an emergency, and asked for vectors to the nearest airport. After the sight of smoke, and the cabin attendant assuring that everything was powered off, the pilot "gave the controls" to him. The pilot then went back into the cabin to assist the flight attendant by spraying the galley area with a halon fire extinguisher. No more smoking was observed so they decided to continue to MCO for an "abnormal approach and landing" with priority from air traffic control. After landing they could see signs of burnt wiring behind the galley. PERSONNEL INFORMATIONPilot According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with a rating for airplane multi-engine land and airplane single-engine land. Commercial privileges for airplane single-engine sea, rotorcraft-helicopter, and instrument helicopter. He also held a flight instructor certificate with ratings for airplane single and multi-engine, rotorcraft-helicopter, and instrument airplane and helicopter, as well as type ratings for the BAE-125, BE-400, CE-750, DA-50, G-1159, IA-JET, LR-JET, and MU-300. His most recent FAA first-class medical certificate was issued on November 18, 2014. He reported that he had accrued 6,200 total hours of flight experience, 500 of which was in the incident airplane make and model. Copilot According to FAA and pilot records, the copilot held an airline transport pilot certificate with ratings for airplane single-engine land, and airplane multi-engine land. Commercial privileges for airplane single-engine sea. He also held a flight instructor certificate with ratings for airplane single engine, and instrument airplane, as well as type ratings for the BE-300, and DA-50. His most recent FAA first-class medical certificate was issued on September 9, 2014. He reported that he had accrued 5,200 total hours of flight experience, 180 of which was in the incident airplane make and model. Cabin Attendant At the time of the accident, the cabin attendant had been serving as a crew member on the Falcon 900 for 3 years. Her most recent recurrent training had occurred in the Fall of 2014, at Flight Safety International's Teterboro Learning Center where she had attended the Corporate Cabin Attendant and General Emergency Training Course for corporate and general aviation aircraft. The course met the minimum recommendations for International Civil Aviation Organization (ICAO) and International Standard for Business Aircraft Operations (IS-BAO) certification, as well as many of the regulatory requirements for 14 CFR Part 135.331. AIRCRAFT INFORMATIONThe incident airplane was a long-range, swept wing, executive jet of conventional metal construction designed to accommodate up to 19 passengers. It was equipped with retractable landing gear and was powered by three Garrett TFE 731-5BR-1C geared turbofan engines, each producing 4,750 pounds of takeoff thrust. The fuselage consisted of the nose cone, the cockpit, the passenger cabin, the rear lavatory, the baggage compartment, the rear compartment, the auxiliary power unit and the No. 2 engine compartment (with its thrust reverser). The cockpit, passenger cabin, and baggage compartment were pressurized. The baggage compartment was accessible in flight. According to FAA and maintenance records, the airplane was manufactured in 1988 in Merignac, France by Dassault Aviation SA. It was then ferried in "green" condition to Dassault Falcon Jet's Little Rock, Arkansas completion center where the passenger oxygen system was installed under an FAA supplemental type certificate (STC) and Dassault Falcon Jet routing instructions. Additional avionics, and the interior was also installed, and the exterior was painted. It was completed in 1989. The airplane's most recent continuous airworthiness inspection was completed on April 13, 2015. At the time of the incident; the airplane had accrued approximately 9,949 total hours of operation. During the 26 intervening years between the completion of the airplane at Dassault Falcon Jet's completion center and the incident, multiple C Checks (which are performed every 3,750 flight cycles or 72 months) had occurred, which required portions of the airplane's interior to be removed. During this same time period, numerous modifications had been made to the airplane by several maintenance, repair, and overhaul (MRO) organizations including multiple lighting, interior, and galley modifications, which required rerouting and re-securing of wiring, as well as removal and replacement of interior panels, partitions, and cabinetry, in the vicinity of the area of the fire. METEOROLOGICAL INFORMATIONThe recorded weather at MCO, at 1853, included: wind 040°at 11 knots, 7 miles visibility, scattered clouds at 6,000 feet, broken clouds at 8,000 feet, temperature 23° C, dew point 22° C, and an altimeter setting of 30.08 inches of mercury. AIRPORT INFORMATIONThe incident airplane was a long-range, swept wing, executive jet of conventional metal construction designed to accommodate up to 19 passengers. It was equipped with retractable landing gear and was powered by three Garrett TFE 731-5BR-1C geared turbofan engines, each producing 4,750 pounds of takeoff thrust. The fuselage consisted of the nose cone, the cockpit, the passenger cabin, the rear lavatory, the baggage compartment, the rear compartment, the auxiliary power unit and the No. 2 engine compartment (with its thrust reverser). The cockpit, passenger cabin, and baggage compartment were pressurized. The baggage compartment was accessible in flight. According to FAA and maintenance records, the airplane was manufactured in 1988 in Merignac, France by Dassault Aviation SA. It was then ferried in "green" condition to Dassault Falcon Jet's Little Rock, Arkansas completion center where the passenger oxygen system was installed under an FAA supplemental type certificate (STC) and Dassault Falcon Jet routing instructions. Additional avionics, and the interior was also installed, and the exterior was painted. It was completed in 1989. The airplane's most recent continuous airworthiness inspection was completed on April 13, 2015. At the time of the incident; the airplane had accrued approximately 9,949 total hours of operation. During the 26 intervening years between the completion of the airplane at Dassault Falcon Jet's completion center and the incident, multiple C Checks (which are performed every 3,750 flight cycles or 72 months) had occurred, which required portions of the airplane's interior to be removed. During this same time period, numerous modifications had been made to the airplane by several maintenance, repair, and overhaul (MRO) organizations including multiple lighting, interior, and galley modifications, which required rerouting and re-securing of wiring, as well as removal and replacement of interior panels, partitions, and cabinetry, in the vicinity of the area of the fire. WRECKAGE AND IMPACT INFORMATIONExamination of the area behind the crystal storage area of the galley by maintenance personnel from J & M Aircraft Services and Duncan Aviation, revealed the presence of sooting, and the remains of a burnt wiring bundle behind the plenum ducting. Further examination by Duncan Aviation personnel revealed that the plenum ducting had no edge protection strip (caterpillar strip) or anti-chafe material installed on the sharp edge of the plenum ducting, the burnt wiring bundle contained the 28-volt direct current wiring and ground wires for the EMTEQ LED cabin headliner and downwash lighting, and that the associated circuit breaker in the cockpit (28VDC Bus A1 "FWD Cabin Ceiling A"), had been tripped. They also observed that two of the insulation bags had been fire damaged, the wires had been routed over them instead of directly next to the airplane's structure, and that they had been in contact with, or in close proximity to, a soft oxygen line which had been completely burned through. ADDITIONAL INFORMATIONIn order to improve safety, the participants in the investigation took the follow actions: Duncan Aviation: - On April 21, 2015, Duncan Aviation filed a Service Difficulty Report (SDR) with the FAA to disseminate and alert the aviation community of the event. - On January 19, 2016, Duncan Aviation published Service Alert 2015.12.1, titled: Inflight Fire, advising inspectors at all of their facilities to inspect for chaffing/pinching of wire, and degradation of existing wire. To inspect for proper clearance between wire routing and all aircraft articles, and that Varglass sleeve, spiral wrap, caterpillar strip, etc., could provide additional protection to wire insulation. Additionally, to use relevant devices (mirror, endoscope, etc.) to inspect inaccessible areas. Dassault Aviation: - On April 22, 2015 Dassault Aviation published a TOME III Event Report, to analyze the technical events that had occurred that could affect the safety of the airplane, and disseminated the information to the European Aviation Safety Agency (EASA), Direction générale de l'aviation Civile (DGAC), Organisme pour la Sécurité de l'Aviation Civile (OSAC), Bureau d'Enquetes et d'Analyse pour la Sécurité de l'Aviation Civile (BEA), and the Federal Aviation Administration (FAA). - On November 25, 2015, Dassault Falcon Customer Service Published Falcon Service News Flash FSN-211-R00-A, titled: Inflight Electrical Fire. This was an immediate-action publication which notified operators and Dassault authorized service centers that urgent action was required, and described the event, with recommendations and electrical standard practices, along with links to the relevant procedures in the maintenance documentation. INJURIES TO PERSONSNarrative injuries to persons place holder DAMAGE TO AIRCRAFTNarrative damage to aircraft place holder OTHER DAMAGENarrative other damage place holder COMMUNICATIONSNarrative communications place holder FLIGHT RECORDERSNarrative flight recorders place holder MEDICAL AND PATHOLOGICAL INFORMATIONNarrative medical and pathological information place holder FIRENarrative fire place holder SURVIVAL ASPECTSNarrative survival aspects place holder TESTS AND RESEARCHOxygen System Examination of the oxygen system revealed that the burned soft oxygen line was part of the supply system for passenger and third crew member (cabin attendant) masks. The oxygen system used gaseous oxygen stored in a high-pressure cylinder to provide passengers and crew members with low pressure oxygen when necessary. There were three separate systems: - The crew distribution system which included two plug-in connectors for pilot and copilot masks. - The supply system for passenger and third crew member masks. - The first aid system which included two plug-in connectors in the passenger cabin. All three systems were supplied by a high-pressure oxygen cylinder which was located under the left side of the airplane's floor, aft of the passenger door. The passenger oxygen system included: - An oxygen controller. - A passenger distribution system which provided oxygen to the passenger masks, to the first aid, and third crew member (cabin attendant) mask. The oxygen controller operated in two modes and its indicators and controls were located on its front panel. It was installed on the copilot console and would ensure automatic or manual activation of the passenger oxygen system and shutting-off of the passenger oxygen system. The controller was supplied under a pressure of 70 pounds per square inch (psi). At low altitudes it would deliver oxygen under 19 psi, and at high altitudes under 70 psi. The boundary altitude between the two modes was 18,000 feet. The front panel included a four-position rotary type selector, a test socket, a pneumatic indicator, and a high-pressure gauge. The four-positions of the selector corresponded to the following functions: - "NORMAL": The normal inflight position. Automatic oxygen flow was available in case of depressurization (mask boxes would open, and oxygen masks would be supplied with oxygen during the remainder of the flight). - "FIRST AID": Oxygen flow would be available for the first aid masks. Automatic function was retained. And it could also be used to supply passenger masks under 19 psi after the "OVERRIDE" position had been used. - "OVERRIDE": In the event of automatic system malfunction, this position would ensure mask box opening and high-pressure oxygen supply to the passenger masks. - "CLOSED": The passenger system supply was shut off, and the oxygen cylinder would supply only the crew system. Mask boxes were provided above each passenger seat, in the lavatory, and above the cabin attendant jump seat. Each box was equipped with a dual pressure-operated latch, and internal door which would maintain the mask in the stowed position, and a cover held by a magnet. The masks were connected to the boxes by a cord ended by a pin which would actuate a small valve incorporated in the latch. Rated operating pressure of the latch was between 29 and 58 psi and if the latch failed to operate automatically, the passenger masks could be released by pulling open the cover of the box. In automatic operation, when oxygen pressure on the latch built up to 70 psi, the latch piston would push the box cover open and release the internal door. An elastic strap in the bottom of the box would push the mask out of the box and cause it to fall and hang in view of the passenger at the end of its cord. Pulling on the mask would then cause the valve to open and oxygen to flow. The mask would be held over the face by an elastic strap passed behind the head. In case of an automatic system failure, or to deploy the masks manually, the oxygen controller

Probable Cause and Findings

Unknown maintenance personnel’s inadequate securing of a wiring bundle during a maintenance, repair, or modification event, which led to chafing of the wiring bundle, an electrical short and arcing, and a subsequent in-flight fire.

 

Source: NTSB Aviation Accident Database

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