MAY 24, 2002 - 14:30 EDT

TSB: Investigation Update Into the Fire on Board Air Canada Flight 116 Boeing 767-300, 13 May 2002 - TSB Investigation # A02O0123

TORONTO, ONTARIO--On 13 May 2002, Air Canada flight 116, a Boeing 767-300 with 8 crew members and 177 passengers on board, was arriving at Toronto Lester B. Pearson International Airport (LBPIA) on a flight from Vancouver, B.C. At about 1737 EDT on final approach approximately 10 miles from the airport, the flight crew received an aft cargo bay fire warning. The flight crew followed checklist procedures, activated the cargo bay fire extinguishers and declared an emergency.

The fire indication went out some 20 to 30 seconds after activation of the fire extinguishers, but a slight smell of smoke was noticed by the cabin crew and flight crew. Flight 116 landed and stopped on the runway to allow airport firefighters to inspect the aircraft for fire. Firefighters, using infrared sensing
equipment, did not detect any sign of fire.

The flight crew taxied the aircraft to the terminal but stopped approximately 40 feet back from the gate to allow firefighters to open the aft cargo compartment for a detailed inspection. When the cargo door was opened, a significant amount of smoke was observed. Firefighters entered the cargo compartment and confirmed that the fire had been extinguished. During this time the flight crew had prepared the aircraft for emergency evacuation should that be deemed necessary. However, the situation was secured and passengers were deplaned using normal portable stairs.

The aircraft was taken to a hangar for further inspection and company maintenance personnel discovered substantial soot and fire damage on the floor of the cargo bay. The Transportation Safety Board of Canada (TSB) was notified and investigators from the Ontario regional office were deployed on the morning of May 14 to investigate.

Investigation Progress to Date

TSB investigators discovered that an intense but relatively small fire had occurred, causing significant structural damage in the floor area of the aft cargo compartment. The damage included burned insulation blanket material and two areas where holes had burned through an aluminium structural web resulting in significant heat distortion of the floor beam. There was no reported damage to any of the cargo and only minor smoke damage to two cargo containers. Before it was extinguished, the fire had progressed approximately 18 inches up the right side wall of the aircraft, outside the aft cargo compartment. The cargo bay fire-extinguishing system, a Halon-based system, effectively suppressed the fire before it could spread further.

The fire appears to have been a direct result of an electrical failure of a heater tape used to prevent water lines from freezing. The electrical failure of the heater tape ignited the covering of the insulation blankets installed below the open cargo floor and some debris found in the area. During the inspection of this and other aircraft, additional examples of overheated and burned heater tapes were discovered. None of these additional failed heater tapes resulted in an aircraft fire, although burned insulation wrap was discovered.

The TSB contacted Boeing, the US National Transportation Safety Board (NTSB), the US Federal Aviation Administration (FAA) and Transport Canada to advise them of the occurrence and invite them to participate in the investigation. Boeing deployed a technical specialist to assist in the investigation. The FAA and Transport Canada also attended the on-scene investigation in order to gain first-hand knowledge of the nature and severity of the fire.

/T/

The following matters of potential significance have been identified and are being addressed in the investigation:

* failure mechanisms and consequences of ribbon heater tape failure
* maintainability of ribbon heater tapes
* flammability of insulation blanket materials and debris in cargo bays
* effect of age, condition and contamination on the flammability of insulation blankets
* potential for fires in inaccessible areas of an aircraft where there is a lack of fire-fighting capability

/T/

Action

Air Canada has taken immediate steps to inspect aircraft and deactivate affected systems and the TSB continues to investigate. A thorough analysis of the events, materials and affected systems will be conducted in order to make findings as to causes and contributing factors. During the course of the investigation the TSB will monitor closely action taken by Air Canada, Boeing, the FAA and Transport Canada. The TSB will be continually assessing the need for further safety action. Should further safety action be deemed necessary, the TSB will communicate this need to the appropriate people and/or organizations for their prompt action, and this information will be made public.

On completion of the work of its investigators, the Board will produce its draft report which will be sent on a confidential basis to designated reviewers who, in the opinion of the Board, have a direct interest in the findings.

Typically included as designated reviewers are the operator, the regulator, the manufacturers and others who can contribute materially to the accuracy of the report or whose activities or products are discussed in the report. Those designated reviewers may use the confidential draft report only to take remedial measures or for the preparation of representations to the Board concerning the report. After the accuracy of the Board's information has been verified and the Board has considered any representations on the draft report, the final report will be made public.

The final report will include an evaluation of any safety action that has already been taken to mitigate risks identified in the investigation. It will also address any safety deficiencies that continue to be of concern to the Board, and whatever recommendations the Board may consider necessary to increase safety for the travelling public. It is not the function of the Board to assign fault or determine civil or criminal liability.

NOTE: This update is based on information assembled by the investigation staff and will be amended as other facts are gathered. The investigation is not complete and one should not attempt to infer findings as to the causes and contributing factors of this accident on the basis of this update.

-30-

FOR FURTHER INFORMATION PLEASE CONTACT:
Mike Stacey
Manager - Regional Operations (Air), Ontario
(905) 771-7676
or
Jim Harris
Public Affairs Advisor
(819) 994-8053

TSB: Investigation Update Into the Fire on Board Air Canada Flight 116 Boeing 767-300, 13 May 2002

Christopher thanks for posting that. Thank goodness a tragedy was averted. Again I think of what the TSB said about having flammable material on a plane. Without it this kind of incident simply couldn't happen.

Barbara

TRANSPORTATION SAFETY BOARD OF CANADA AVIATION SAFETY RECOMMENDATIONS

DATE ISSUED: 14 November 2002

SUBJECT: Water Line Ribbon Heater Fires and Contaminated Thermal Acoustic Insulation Blankets

Background

On 13 May 2002, Air Canada Flight 116, a Boeing 767-300, registration C-GHML, with eight crew members and 177 passengers on board, was arriving at Toronto Lester B. Pearson International Airport on a flight from Vancouver, British Columbia. At about 1732 EDT, while on final approach, the flight crew received an aft cargo bay fire warning. The flight crew followed checklist procedures, activated the cargo bay fire extinguishers and declared an emergency. Although the fire indication went out approximately 50 seconds after activation of the fire extinguishers, a slight smell of smoke continued to be noticed by the cabin crew and flight crew. Flight 116 landed and stopped on the runway to allow a preliminary examination of the aircraft by airport firefighters. Firefighters, using infrared sensing equipment, did not detect any sign of heat from the fire. The aircraft was taxied to the terminal, but stopped approximately 40 feet back from the gate to allow firefighters to open the aft cargo compartment for a detailed inspection. When the cargo door was opened, a significant amount of smoke was observed. Firefighters entered the cargo compartment and confirmed that the fire had been extinguished. The emergency situation was secured and passengers were deplaned using portable stairs. A Transportation Safety Board of Canada (TSB) investigation (A02O0123) is ongoing.

To date, the investigation has determined that an Electrofilm � brand heater ribbon, used to prevent the potable water drain/supply line from freezing, failed and exhibited signs of overheating and arcing in the vicinity of station 1395. The heater ribbon, which was spiral wrapped around the water line, burned through both the protective tape used to hold the heater ribbon in place and the Rubatex � foam thermal insulation material wrapped on top of the protective tape, igniting the non-metalized Polyethylene Teraphthalate (PET)-covering (Mylar�)of the thermal acoustic insulation blanket mounted on the vertical web of the floor beam. The fire then spread to the PET insulation blanket covering on the bottom of the pressurized hull and ignited debris in the non-fully enclosed floor area of the aft cargo compartment. The fire became self-propagating, burning its way forward, inboard and outboard, spreading approximately 46 centimetres (18 inches) up the right side wall of the aircraft before it was extinguished by halon from the fire extinguishing system. Heat from the fire was intense enough to burn holes through the aluminum web of a floor beam and significantly distort the top cap (chord) of the beam structure.

Full text of letter at:
TSB Aviation Safety Recommendations A-02-04, A-02-05

These are strong words from the TSB regarding mylar insulation:

The wide spread existence of contaminated thermal acoustic insulation materials and debris on transport category aircraft exposes the travelling public to the risk of a self propagating fire. Recent actions taken to reduce these risks are not comprehensive and do not adequately address risk in the long term. Consequently, there remains inadequate defences against contaminated insulation materials and debris propagating a fire, therefore the Board recommends that:

The Department of Transport take action to reduce the short term risk and eliminate the long term risk, of contaminated insulation materials and debris propagating fires, and coordinate and encourage a similar response from other appropriate regulatory authorities.
A02-05

Thanks for the update Chris!

Safety board warns of airplane fire risk
Last Updated Thu, 14 Nov 2002 23:22:01
OTTAWA - The organization responsible for air safety in Canada says there's a risk of fire in about 250 commercial airplanes now in use.

The Transportation Safety Board released two recommendations Tuesday from an investigation that's still underway.

The board is looking into a fire in the cargo hold of Air Canada Flight 116.

The fire started as the Boeing 767, en route from Vancouver, was on its final approach to Toronto.

Electrical fault

The fire was put out without incident, but investigators found that the intense heat had burned through a supporting strut.

Investigators say an electrical fault in a heater ribbon used to prevent water lines from freezing was the likely cause of the fire.

Debris and liquids collected on the floor of the cargo hold made it worse.

While aircraft maker Boeing and Air Canada have made some changes to prevent fires, the chair of the Transportation Safety Board says it's not enough.

Camille Theriault.

"The board believes that the recent actions taken to reduce the risks do not adequately address the problem in the long term," says Camille Theriault.

He's calling for changes to the installation of heater ribbons. He also wants airlines to ensure that debris and flammable liquids don't build up in the cargo area.

The TSB says the issues it has identified could affect about 250 aircraft in Canada.

It has sent its recommendations to the Ministry of Transport and to the Federal Aviation Administration in the U.S.

Transport Minister David Collenette issued a news release saying proposed regulations announced last month will help increase fire safety aboard aircraft.

Ottawa has 90 days to issue a formal reply to the TSB report.

Written by CBC News Online staff

http://www.cbc.ca/stories/2002/11/14/planefire021114

quote:

---

Originally posted by BF:
[qb]Transport Minister David Collenette issued a news release saying proposed regulations announced last month will help increase fire safety aboard aircraft.[/qb]

---

Here are links to the proposed regulatory changes the Minister referred to:

These proposed Regulations to Amend the Canadian Aviation Regulations (Part VII - Commercial Air Services) will introduce three new regulatory requirements into the Canadian Aviation Regulations (CARs): CAR 705.81 (Cargo and Baggage Compartment Fire Protection), CAR 705.82 (Compliance Plan) and CAR 705.83 (Quarterly Information Report). Also introduced will be a new Commercial Air Services Standard 725.81 (Cargo and Baggage Compartment Fire Protection) which describes how air operators will comply with proposed CAR 705.81. The proposed regulatory requirements incorporate new fire protection requirements for Class D cargo and baggage compartments, an upgrade of cargo and baggage compartment liners for Class C and Class D cargo and baggage compartments, and a requirement for affected air operators to submit compliance plans and quarterly information reports on their implementation progress to Transport Canada.

Canadian air operators operating aeroplanes under CAR 705 (Airline Operations) will be subjected to these proposed requirements. The aeroplanes affected will be transport category aeroplanes with an initial type certificate issued after January 1, 1958.

Canada Gazette Part 1 - Regulations Amending the Canadian Aviation Regulations (PART VII)

Canada Gazette Part 1 - Regulatory Impact Analysis Statement

Thanks Chris, it's good to see this issue addressed and taken seriously.

Fire risk still exists -- safety board

Date: 04/19/2003

VANCOUVER -- Only half-measures have been taken to prevent recurrence of a potentially disastrous fire a year ago aboard an Air Canada passenger jet carrying 185 passengers and crew between Vancouver and Toronto, the federal Transportation Safety Board warns.

Safety deficiencies identified by the board during an ongoing investigation into Flight 116 last May 13 have not been fully rectified by government and aviation authorities, raising fears a similar fire could occur on other aircraft, with tragic results.

The fire broke out in the aft cargo bay shortly before the Air Canada Boeing 767-300 was about to land at 5:30 p.m. at Toronto's Lester B. Pearson International Airport. The on-board fire extinguisher system put out the fire, and the plane landed safely and without injuries.

Safety board investigator Don Enns told CanWest News Service that the Flight 116 case would be getting more attention had the plane crashed.

"There's a lot of truth to that," he said in an interview from his Toronto office. "It's a serious situation, but it didn't result in any injury. Therefore, it takes more work to keep it on the front of everyone's radar screen."

The fire began after heater ribbon, wrapped around the potable water supply line to prevent freezing, burned through layers of protective tape and foam thermal insulation.

The fire then spread to a thermal insulation blanket covering the bottom of the pressurized hull and ignited debris in the floor area.

"Safety deficiencies identified by the board during an ongoing investigation into Flight 116 last May 13 have not been fully rectified by government and aviation authorities, raising fears a similar fire could occur on other aircraft, with tragic results."

CD, I'm glad to see that the TSB is staying on top of this serious issue but can't say I'm all that surprised that they haven't gotten the FAA to respond to their recommendations. The FAA is known to take a reactive stance- in other words they wait until tragedies happen and even then they drag their feet on making necessary changes. They've give airlines far too much time to replace mylar blankets and my understanding is that even at that they don't even check to make sure that the changes have been made. It's particularly disturbing when you have a loved one that is now a statistic of their failure to act and do the right thing. Thanks for the interesting post.

Barbara