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Accident
Last updated: 12 December 2017
Status:Schlussbericht
Datum:Montag 13 Mai 2002
Zeit:17:37 EDT
Flugzeugtyp:Silhouette image of generic B763 model; specific model in this crash may look slightly different
Boeing 767-3Y0ER
Fluggesellschaft:Air Canada
Kennzeichen: C-GHML
Werknummer: 24948/380
Baujahr: 1991-07-02 (10 years 11 months)
Betriebsstunden:46830
Triebwerk: 2 Pratt & Whitney PW4060
Besatzung:Todesopfer: 0 / Insassen: 8
Fluggäste:Todesopfer: 0 / Insassen: 177
Gesamt:Todesopfer: 0 / Insassen: 185
Sachschaden: schwer beschädigt
Konsequenzen: Repaired
Unfallort:Toronto-Pearson International Airport, ON (YYZ) (   Kanada)
Flugphase: Annäherung (APR)
Betriebsart:Inländischer planmäßiger Passagierflug
Flug von:Vancouver International Airport, BC (YVR/CYVR), Kanada
Flug nach:Toronto-Pearson International Airport, ON (YYZ/CYYZ), Kanada
Flugnummer: 116
Unfallbericht:
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. 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. 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.

Probable Cause:

FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS: "1. The B110 heater ribbon attached to the water supply line failed at the site of a recent water line repair, which allowed the elements of the heater ribbon to electrically arc, providing a source of ignition to surrounding materials; 2. The polyethylene terephthalate (PET) covering material of the thermal acoustic insulation was contaminated. The contaminated material provided an ignitable source of fuel for a self-sustaining fire; 3. The open cargo floor provided a trap that collected contaminants and debris in the bilge area of the cargo compartment; the debris and contaminants were an ignitable source of fuel to sustain a fire; 4. Circuit protection devices are designed to protect aircraft wiring and not aircraft components. The lack of circuit protection of the heater ribbon system permitted the heater ribbon failure to result in an arcing event."

Accident investigation:
cover
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 2 years and 4 months
Accident number: TSB Report A02O0123
Download report: Final report

Informationsquelle:
» TSB


Sicherheitsempfehlungen
During the inspection of this and other aircraft, additional examples of overheated and burned heater tapes were discovered. Affected systems were deactivated.
On June 7, 2002 the FAA issued Airworthiness Directive AD 2002-11-11 applicable to certain Boeing Model 767-200, -300, and -300F series airplanes. This action requires an inspection of visually accessible areas for indications of overheating of the heater tape attached to the potable water fill and drain lines in the forward and aft cargo compartments, exposed foam insulation or missing or damaged protective tape around the potable water fill and drain lines, and debris or contaminants on or near the potable water fill and drain lines. It also requires corrective action, as necessary. This action is necessary to prevent overheating of the heater tape on potable water fill and drain lines, which may ignite accumulated debris or contaminants on or near the potable water fill and drain lines, resulting in a fire in the airplane. This action is intended to address the identified unsafe condition.

TSB issued 2 Safety Recommendations

Show all AD's and Safety Recommendations

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Vancouver International Airport, BC to Toronto-Pearson International Airport, ON as the crow flies is 3321 km (2076 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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