Communiqués

TSB #A08-2002

TSB ISSUES AIR SAFETY RECOMMENDATIONS RELATED TO
ITS INVESTIGATION OF AN IN-FLIGHT FIRE ABOARD AN
AIR CANADA 767-300 INVESTIGATION NUMBER A02O0123

Ottawa – November 14, 2002 – The Transportation Safety Board (TSB), today released two Safety Recommendations resulting from an ongoing investigation (A02O0123) into an in-flight fire that occurred on May 13, 2002, aboard an Air Canada 767-300 aircraft.

The recommendations draw attention to the fire risks associated with water line heater ribbon installation failures and with contaminated insulation materials and debris collecting in aircraft spaces. Heater ribbon failure was a contributing factor to the ignition of a fire in the cargo hold of the Air Canada aircraft. Contaminated insulation blankets and debris, collected on the floor of the cargo hold, helped to propagate the fire.

The crew received an indication of fire in the cargo hold. The crew followed emergency procedures and the fire was extinguished using the on-board fire suppression system. The aircraft landed safely and no injuries resulted from the incident.

"We don't believe in holding off our recommendations for a final report. We believe in making our recommendations public as quickly as possible so that appropriate action can be taken to deal with safety deficiencies. Our sole objective is to ensure that problems are fixed, that they are fixed quickly, and fixed for good," said Camille Thériault, Chairman of the TSB. "Should this investigation produce any other issues, be assured that we will make our findings public without delay," he added.

The TSB releases Safety Recommendations prior to the completion of an investigation when it identifies a significant safety issue. This builds on past TSB practice. Over the years, safety recommendations issued prior to the completion of investigations have led to improved transportation safety.

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or to determine civil or criminal liability.

The Safety Recommendations and photographs are available on the TSB Internet site.

Speeches

Introduction

Thank you, ladies and gentlemen, for being here today. The Transportation Safety Board of Canada values and supports concerns of Canadians for safety in the air, at sea and in the railway and pipeline systems.

Safety is a concern we all share, which is why we are releasing two recommendations today in an investigation that is still on-going. As we have done in the past, when we learn of situations that could have an impact on transportation safety, we immediately alert the industry, the regulators in Canada and elsewhere and, through you, the broader public.

We don't believe in holding off our recommendations for a final report. We believe in making our recommendations public as quickly as possible so that appropriate action can be taken to deal with safety deficiencies.

Our sole objective is to ensure that problems are fixed, that they are fixed quickly, and fixed for good.

In the next few minutes, the investigators, Mr. Peter Rowntree, the Investigator in Charge, Mr. Daniel Verreault, the Director of Air Investigations, and I will give you a brief overview of the ongoing investigation of an in-flight fire which occurred last spring – they will share what they have found to date, and what the Board is recommending.

TSB

Before I get started though, permit me to remind you that the Transportation Safety Board is an independent agency dedicated to enhancing transportation safety. Our role is to investigate accidents or incidents involving aircraft, ships, trains and pipelines.

Our mandate is to find out what happened, and why. We look for safety deficiencies, and make recommendations that those deficiencies be addressed.

Our job is not to assign fault or liability.

Overview of the occurrence

With the respect to the current investigation:

On May 13th 2002, Air Canada Flight 116 left Vancouver for Toronto. When the aircraft was approximately 10 miles from Toronto on final approach, the flight crew received an indication of fire in the cargo hold.

The flight crew followed the appropriate checklist, activated the fire extinguishing system and declared an emergency. Less than a minute later, the fire indication light went out and the aircraft landed without further incident.

Once on the ground, airport firefighters inspected the aircraft and declared it safe. When maintenance crews inspected the aircraft later that evening, they discovered that there had been a fire in the floor of the cargo compartment of the aircraft.

We were notified, our investigators were deployed to the scene and they began a comprehensive investigation into the circumstances surrounding the occurrence. A detailed report will be published when the investigation is completed.

The investigation has, so far, uncovered two areas of particular concern. Therefore, the Board is releasing these recommendations today.

The first issue involves "water-line heater ribbon installations."

The second issue that concerns us relates to how the fire progressed once it was ignited.

Following the occurrence, Air Canada, Boeing, Transport Canada, and the Federal Aviation Administration took a number of actions to address the issues raised by the investigators. In our opinion, these issues present a potential risk to the traveling public. The Board believes that the recent actions taken to reduce these risks do not adequately address the problem in the long-term.

I would now like to call on Mr. Rowntree and Mr. Verreault.

------------ Presentation by Peter Rowntree ------------

Wrap up

As you have seen, these two issues pose a serious risk. The Transportation Safety Board releases safety recommendations prior to the completion of an investigation when it identifies a significant safety issue. In this case, the widespread use of heater ribbons and the common existence of contaminated insulation blankets and debris exposes the travelling public to risk. Accordingly, we have issued two safety recommendations.

With respect to the issue of water line heater ribbons, the Transportation Safety Board recommends that:

the Department of Transport take action to reduce the short term risk, and eliminate the long term risk, of heater ribbon installation failures starting fires, and coordinate and encourage a similar response from other appropriate regulatory authorities.

With respect to the issue of contaminated thermal acoustic insulation blankets, the Transportation Safety 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.

As I stated earlier, in its ongoing investigation, the Transportation Safety Board has made these early recommendations in the interest of advancing transportation safety. We at the TSB work very hard to ensure that recommendations are issued in a timely manner to benefit transportation in Canada and around the world. Should this investigation produce any other issues, be assured that we will make our findings public without delay.

I want to thank you for your attention, and I welcome your questions.

Safety Recommendations

Report Graphics

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