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Testimony of
Bernard Loeb, Director
Office of Aviation Safety
National Transportation Safety Board
before the
Subcommittee on Oversight, Investigations, and Emergency Management
Committee on Transportation and Infrastructure
House of Representatives
Regarding
Aging
Aircraft Wiring
September 15, 1999
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Good morning, Madame Chairwoman and members of the Committee. I am
pleased to represent the National Transportation Safety Board (NTSB)
before you today regarding aircraft electrical wiring issues.
Electrical systems are critical to the safe operation of transport
category airplanes, and wiring is used to distribute power and communication
signals throughout these systems. Many transport category airplanes
contain over 100 miles of wiring. Today, I would like to discuss the
Safety Board's efforts to address aircraft wiring issues raised in
accident and incident investigations, including the recent investigations
of TWA flight 800, and the Canadian investigation involving Swissair
flight 111.
As background, let me begin by describing how electrical wiring is
constructed, routed through airplanes, and how the malfunctions can
occur. Electrical wire consists of a conductor that is encased in
a protective layer of insulation. Wire is routed throughout an airplane
in a series of bundles with clamps and connectors. Safe routing practices
include measures to prevent wires from wear, abrasion, contamination,
and contact with other components; to gently bend and turn wires during
installation to prevent cracking of the insulation; and to physically
separate wires from systems whose signals may interfere with one another.
Guidelines for these safe wire routing practices in aircraft are described
in a series of Federal Aviation Administration (FAA) advisory circulars
and manufacturer standard practices manuals.
When the protective layer of insulation on a wire is compromised
and the conductor is exposed, the potential exists for a hazardous
electrical system malfunction caused by a short circuit or an arc.
A short circuit occurs when electricity takes an unintended path.
For example, condensation and other conductive materials that are
sometimes found on wire bundles can bridge the gap between a wire
conductor and adjacent metallic structure. When electrical current
follows the unintended path to the metallic structure, a short circuit
that could interrupt the function of an electrical system occurs.
Short circuits can transfer power to adjacent wires or draw an excessive
current from the power source, overheating wires and creating fire
hazards. Electrical arcing is a type of short circuit in which high
current crosses a gap, emitting sparks. The sparks include molten
material from the wire conductor as it is vaporized by the high energy
discharge, producing extremely localized heat. The arcing could ignite
flammable products in the area and could potentially initiate an explosion.
Obviously, safeguards must be maintained to preclude arcing, particularly
in the vicinity of flammable materials or explosive fuel-air mixtures.
Since 1983, the Safety Board has investigated 15 transport category
airplane accidents or incidents that involved electrical wiring malfunctions.
As a result of those investigations, we have issued 34 safety recommendations
regarding electrical wiring malfunctions. I would like to summarize
some of the accidents and the recommendations that resulted from them.
In May 1984, the crew of a McDonnell Douglas DC-10, operated by Northwest
Orient Airlines, observed smoke and sparks in the cockpit after takeoff
from Minneapolis, Minnesota. An emergency was declared and the airplane
returned to Minneapolis and landed safely. The Board's investigation
revealed that a wire bundle behind the instrument panel was improperly
routed and contacted a metal bracket, causing several wires to short
circuit and arc. It could not be determined if the bundle was misrouted
during manufacture or subsequent maintenance, but the Safety Board
issued an urgent recommendation for an immediate inspection of this
wiring in all DC-10s. The FAA complied and, in July 1984, issued an
airworthiness directive mandating an inspection of all DC-10s to ensure
that the wiring was not chafed and was routed properly in this area.
In May 1990, a Boeing 737 operated by Philippine Air Lines exploded
and burned on the ramp in Manila, Republic of the Philippines. Of
the 119 persons on board, 8 were fatally injured. The investigation,
conducted by the Philippine government with participation from the
Safety Board, revealed that an ignition of a fuel-air mixture in the
center fuel tank was the cause of the explosion and subsequent fire.
A portion of the wiring that led to the center fuel tank float switch
was found with the insulation compromised and the conductor exposed.
The Safety Board issued an urgent recommendation to the FAA in August
1990 requesting an immediate inspection of the float switch wiring
of all similar Boeing 737s. Unfortunately, the FAA, in May 1991, informed
the Board that it did not believe this wiring failure contributed
to the accident and did not plan to mandate an inspection. The Safety
Board classified the recommendation "Closed - Unacceptable Action."
In March 1991, a Lockheed L-1011, operated by Delta Air Lines, experienced
a fire in the passenger cabin while en route from Frankfurt, Germany,
to Atlanta, Georgia, with 231 people on board. A flight attendant
saw flames coming through the cabin floor near a row of passenger
seats and discharged a fire extinguisher. The flightcrew declared
an emergency and landed safely at Goose Bay, Canada.
The investigation, conducted by the Transportation Safety Board of
Canada (TSB) with participation from the NTSB, revealed that the fire
originated near a wire bundle routed below the cabin floor that had
been routed with an extremely tight bend, which can crack wiring insulation.
Some of the wires in this bundle showed evidence of electrical arcing.
Nearby metallic debris found in the area included nail clippers and
loose screws. Adjacent portions of the wire bundle were covered with
a blanket of flammable lint and dust more than two inches high; some
of this lint appears to have fed the fire. In August 1991, the Safety
Board recommended that the FAA require specific inspections of wire
bundles on transport category airplanes to ensure proper routing and
the removal of flammable lint and dust accumulations. In October 1991,
the FAA determined that the approved inspection criteria regarding
wire bundle installations for Boeing and McDonnell Douglas aircraft
were adequate. However, the FAA issued a handbook bulletin to principal
maintenance inspectors to review their operators maintenance programs
to ensure that they included inspection of aircraft wiring. Although
in October 1992, the Safety Board classified the recommendation as
"Closed - Acceptable Action," the results of other investigations
that will be discussed later indicate that the FAA's actions did not
effectively address the issue of removing contamination from wire
bundles.
In April 1997, a Cessna 650 Citation operated as a corporate flight,
caught fire while on approach to Buffalo, New York. While descending
through 4,000 feet, the crew smelled smoke, then lost all radio communications.
After landing, ground personnel saw flames burning through the fuselage.
The flightcrew and passenger exited safely, but the airplane was substantially
damaged. The Safety Board's investigation revealed that the fire started
when contact between electrical wiring and a hydraulic line caused
the ignition of hydraulic fluid. FAA guidelines state that under no
circumstances should electrical wiring be routed within ½ inch of
a hydraulic line, and any wiring routed within two inches of a hydraulic
line should have clamps installed to ensure positive separation. However,
design drawings for the Cessna 650 specified ½ inch of clearance and
did not require clamps to ensure separation. Following the Safety
Board's findings, the FAA issued an airworthiness directive in May
1997, to mandate the installation of clamps to ensure positive separation.
During the course of the Cessna Citation investigation, the Safety
Board learned of three Boeing 767 events in which safety hazards were
created because wiring was not routed with appropriate clearance from
adjacent components. In two of the events, flight control cables failed
when they rubbed against electrical wiring resulting in arcing, and
in the other case, a cockpit fire hazard was created when electrical
wiring arced to an oxygen line in the cockpit. Based on the Cessna
650 accident and the Boeing 767 events, in January 1998, the Safety
Board issued recommendations requesting that the FAA review the design,
manufacturing, and inspection procedures of all aircraft manufacturers
to ensure that adequate clearance, in accordance with published FAA
guidelines, is specified around all electrical wiring.
Although a March 1998 response indicated FAA agreement with the intent
of these recommendations, a June 1999 letter indicated that FAA found
that manufacturers were in compliance with the intent of the published
guidelines. This response was not consistent with the Safety Board's
findings as detailed in the recommendation letter and the recommendations
are currently in an "Open" classification.
Two recent major accidents have further focused the Safety Board's
attention on aircraft wiring - TWA flight 800 off Long Island, and
Swissair flight 111 off Nova Scotia. Let me begin with a discussion
of Swissair flight 111.
On September 2, 1998, a McDonnell Douglas MD-11, operated by Swissair
as flight 111, crashed into the Atlantic Ocean near Peggy's Cove in
Nova Scotia, Canada. All 229 people on board were killed. About one
hour after takeoff from New York, the flightcrew notified air traffic
control of smoke in the cockpit, requested to divert, and was cleared
to Halifax International Airport. About 11 minutes later, the flightcrew
detected multiple airplane electrical system malfunctions. The flightcrew
declared an emergency, but all communications between air traffic
control and the flightcrew ceased shortly thereafter. Approximately
6 minutes later, the airplane crashed.
The TSB is in charge of the accident investigation, and the NTSB
is participating in accordance with the provisions of Annex 13 to
the Convention on International Civil Aviation. Approximately 90 percent
of the airplane's wreckage has been recovered from the Atlantic Ocean.
Examination of that wreckage revealed fire- and arc-damaged wires
in the ceiling of the cockpit and forward cabin area. Investigators
found evidence of electrical arcing on several wires near the cockpit
overhead circuit breaker panel. Some of the damaged wires in the forward
cabin ceiling were associated with the in-flight entertainment system
and, as a precautionary measure, the system has been disabled in all
Swissair MD-11s and Boeing 747s, the only airplanes with that particular
entertainment system.
The investigation is still underway and the TSB has not determined
if electrical arcing was the cause of the fire. However, on January
11, 1999, in coordination with the TSB, the Safety Board issued a
recommendation to the FAA for an inspection of the wires in the vicinity
of the cockpit overhead circuit breaker panel of all MD-11 airplanes.
One month later, the FAA mandated that all operators perform such
an inspection; a fleetwide inspection of all wiring in the ceiling
of the cockpit and forward cabin was subsequently performed by all
operators. Discrepancies found were reportedly not considered significant
by the operators but included broken wire insulation, loose wires,
wires improperly contacting structure, and non-conformal or damaged
clamps, standoffs, wire ties, and terminal strip covers.
Let me now discuss some of the wiring issues raised during the TWA
flight 800 investigation. As you know, on July 17, 1996, a Boeing
747, operated by Trans World Airlines as flight 800, crashed into
the Atlantic Ocean shortly after takeoff from John F. Kennedy Airport
in New York. All 230 people on board were killed. The investigation
of this accident has been one of the most extensive investigative
efforts in the Safety Board's history. Based on an evaluation of the
recovered wreckage and a detailed study of the sequence of break-up
events, we have determined that the fuel-air vapor in the center fuel
tank ignited, causing an explosion of the tank, and initiating the
breakup of the airplane.
To date, we have not identified the ignition source that sparked
the explosion on TWA flight 800. Our search for the ignition source
includes an evaluation of the airplane's wiring. The Boeing 747 has
an electronic fuel quantity indicating system (FQIS) that measures
the amount of fuel aboard the airplane and displays that information
in the cockpit. This system includes electrical probes that are mounted
in each fuel tank. As the fuel level in a tank drops, a corresponding
change in the electrical properties of the probes is detected by the
fuel quantity indicator. There are seven such probes in the center
wing fuel tank. Wiring for the probes, which is manufactured with
Teflon insulation, is designed to carry a low voltage (maximum 26
volts) and low current electrical signal needed for each fuel tank
probe to operate.
Although not yet complete, the investigation has already uncovered
several concerns about the FQIS wiring that the Safety Board addressed
in recommendations issued to the FAA in April 1998. Investigators
learned that this wiring was routed in bundles with nearly 400 other
wires, some of which carry up to 350 volts. Because of concerns about
the potential for a wiring malfunction that would permit excessive
electrical energy to enter a fuel tank and ignite an explosive vapor,
the Safety Board recommended that the FAA require the FQIS wiring
to be separated from other wires to the maximum extent possible.
In September 1998, the FAA responded by issuing an airworthiness
directive mandating the separation and shielding of FQIS wiring in
Boeing 747s, and in February 1999, the FAA issued a similar airworthiness
directive (AD) to address Boeing 737 wiring. More recently, on August
30, 1999, the FAA issued a notice of proposed rulemaking to require
an inspection to detect certain discrepancies in the wiring of the
FQIS on DC-9 series airplanes in the area where the wiring passes
through the cargo compartment. According to the FAA, these discrepancies,
which may have been caused by maintenance or alteration practices,
can permit excessive electrical energy to enter the fuel tanks through
the FQIS wiring and result in a potential ignition source in the fuel
tanks. FAA action regarding the separation and shielding of FQIS wiring
in the DC-9 and other transport aircraft is pending.
Safety Board investigators also found that a connector on certain
tank probes was designed in a manner that allows its sharp edges to
cut through the insulation of wiring, which could create a spark gap.
As a result, the Safety Board recommended the replacement of such
connectors on fuel tank probes. The FAA responded by issuing an AD
(AD 99-08-02) to address this issue.
The Safety Board's investigation team has performed a detailed examination
of the wires, wire bundles, and electrical connectors that were recovered
from the TWA flight 800 wreckage. The team found:
- fuel tank wiring that had been repaired using string and adhesive
tape - a repair technique not permitted inside fuel tanks;
- wiring with insulation cracks that exposed the conductor;
- wire bundles contaminated with semi-conductive residues; and
- metal drill shavings along the path where FQIS wiring was routed.
In an effort to determine if these findings were unique to TWA flight
800 or if they existed on other transport aircraft, the Board examined
wiring on more than 20 other transport category airplanes. The examination
included 13 older Boeing 747s, similar to the TWA flight 800 airplane,
and Boeing 737, 757, 767, DC-9, MD-90, and A300 airplanes. The age
of the airplanes surveyed ranged from new to 27 ½ years old. The examinations
found:
- accumulations of contaminants on wiring that included lint, grease,
liquids, paper, and metallic corrosion inhibiting compounds;
- wire bundle clamps (designed with rubber lining to protect the
wiring) that cut into wiring when the rubber lining crumbled; and
- chafing and cracks in the insulation of wires, deep enough to
expose the conductor.
These findings have raised the Safety Board's concern about the safety
of electrical systems as airplanes age.
After participating with Safety Board investigators in the February
1998 examinations, and in response to recommendations from the White
House Commission on Aviation Safety and Security, in March 1998, the
FAA formed the Aging Non-Structural Systems team, which consisted
of Boeing and FAA personnel. This team evaluated the condition of
the wiring on five in-service transport category airplanes that were
undergoing maintenance.
The team's findings, published in the July 1998 "FAA Aging Transport
Non-Structural Systems Test Plan," were similar to the Safety
Board's earlier findings and included examples of deterioration of
wiring, connectors, and clamps, and contamination of wire bundles
with metal shavings, dust, and other fluids. The team concluded that
current maintenance practices do not adequately address wiring, and
outlined seven tasks that should be taken by the FAA by 2001 to address
these concerns. The tasks included: (1) establishing an oversight
committee, (2) conducting an in-depth review of the aging transport
fleet, (3) enhancing aging airplane systems maintenance, (4) adding
aging systems tasks to the aging airplane research program, (5) improving
reporting of wiring system discrepancies, (6) evaluating and addressing
fuel system wiring hazards, and (7) improving wiring installation
drawings and instructions for continuing airworthiness. Progress on
these tasks is being monitored by the FAA Aging Transport Systems
Oversight Committee.
However, the Safety Board's staff has noted in recent industry meetings
and seminars that operator personnel have questioned the merit of
performing wiring inspections, indicating that they have not detected
significant discrepancies. This is certainly at odds with the findings
from the Safety Board and FAA examinations. The Safety Board remains
concerned about these issues, and we will closely monitor the progress
of this effort.
The Safety Board is currently performing a series of wiring tests
in conjunction with the TWA flight 800 investigation. One test is
documenting the electrical short circuit and potential arcing characteristics
of a wire bundle contaminated with various fluids, including water
and lavatory waste. In another test, we have placed metal drill shavings
on wire bundles, then vibrated the bundles to learn how the shavings
cut into the insulation of the wires, and examined the power transferred
to adjacent wiring if this occurs. Reports on these tests will be
placed in the public docket this summer.
In another series of tests, the Safety Board will examine the concerns
operators have about handling or disturbing the wiring, especially
in older airplanes, during maintenance activities because of the potential
to crack the insulation. The NTSB obtained wiring samples from transport
airplanes -- both currently in-service and recently retired -- that
have been in service for over 20 years. We are subjecting these samples
to the same battery of tests that they were required to pass before
installation, including insulation resistance, thermal shock, bending,
and shrinkage. The results will help the Safety Board evaluate the
effect of aging on electrical wiring, and will provide new insight
into whether aged wiring provides an adequate level of safety compared
to new wiring. We note that the FAA Aging Transport Non-Structural
Systems team plans to conduct similar tests in the future. We will,
of course, share the results of our tests, which we expect to be completed
this summer, with the FAA, industry, and the public.
Significant attention has recently been given to a specific type
of wiring with insulation made from an engineered plastic coating,
sometimes referred to by the Dupont Corporation trade name Kapton,
and questions have been raised about the susceptibility of this wiring
to a phenomenon known as "arc tracking." Arc tracking occurs
when the insulating material chars. The charred insulation is conductive,
can sustain and propagate an arc along the length of the wire, and
may flash-over to consume adjacent wire insulation or other combustible
material. The majority of the wiring in the TWA flight 800 accident
airplane was insulated with a double-layered version of an engineered
plastic known by the Raychem trade name Poly-X. We are now performing
tests to determine if this type of wiring is also susceptible to arc
tracking. The Safety Board has not issued any recommendations regarding
wire insulation composition, but future recommendations may be developed
depending on the results of the tests we are conducting.
Finally, it should be noted that the primary device for protecting
an aircraft from the hazards of electrical malfunctions, the circuit
breaker, does not protect against arcing faults. Although circuit
breakers do protect against the electrical overheating of wires, they
do not protect against arcing faults because circuit breakers are
designed to activate based on the heat input. Arcs develop high energy,
but in a very short period of time. Safety Board staff has met with
industry representatives who are developing devices known as arc-fault
interrupters for potential use in aircraft. These devices can recognize
the rapid current and/or voltage signatures associated with arcing
faults and act to interrupt the circuit. We will continue to monitor
the development of this technology and believe this technology is
important to the protection of critical aircraft systems from the
dangers associated with electrical arcing.
Madame Chairwoman, we appreciate the opportunity to share some of
the Safety Board's experience with regard to aircraft wiring failures,
and to share our concerns about wiring maintenance, particularly as
airplanes age. The Safety Board is concerned that industry and regulatory
efforts have been relatively ineffective in preventing the types of
wiring hazards seen during the TWA flight 800 investigation. Our wire
examinations have shown us that it is virtually impossible to eliminate
all potential ignition sources, and underscores our belief that the
flammability of fuel vapors be reduced as much as possible. Our recommendations
to the FAA on this issue are still open.
Although the Board is not prepared at this time to offer additional
specific recommendations, our concerns regarding aging aircraft wiring
safety include: ensuring that low voltage fuel system wiring is separated
from high voltage wiring from other systems; ensuring that no wiring
is routed in proximity to flammable oxygen, fuel, and hydraulic lines
or critical flight control cables; and preventing the contamination
of wiring by fluids, flammable lint, metal shavings, or other debris.
That completes my statement, and I would be pleased to answer any
questions that you may have.
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