Boeing 777-236, G-VIIC
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AAIB Bulletin No: 9/2004 |
Ref: EW/G2004/03/19 |
Category: 1.1 |
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INCIDENT |
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Aircraft Type and
Registration: |
Boeing
777-236, G-VIIC |
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No & Type of Engines: |
2 General Electric GE90-85B
turbofan engines |
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Year of Manufacture: |
1997 |
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Date & Time (UTC): |
28 March
2004 at 0317 hrs |
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Location: |
In the
cruise between Barbados and
London |
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Type of Flight: |
Public Transport (Passenger) |
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Persons on Board: |
Crew - 15 |
Passengers - 176 |
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Injuries: |
Crew - Nil |
Passengers - Nil |
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Nature of Damage: |
Nil |
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Commander's Licence: |
Airline Transport Pilot's
Licence |
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Commander's Age: |
53 years |
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Commander's Flying
Experience: |
13,729 hours
(of which 3,884 were on type) |
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Last 90 days - 264 hours |
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Last 28 days - 93 hours |
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Information Source: |
Aircraft Accident Report Form
submitted by the pilot |
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History of the flight
Approximately three and a half hours
into a scheduled flight from Barbados to
London, a crew member noticed an unusual
odour in the cabin.
Two minutes later
a toilet smoke warning sounded and smoke
was seen emanating from beneath the door
of toilet 'N'; located by the R4 door.
Fire fighting equipment was gathered and
the toilet door was partially opened
revealing flames and smoke. A BCF
fire extinguisher was discharged into
the toilet compartment and the door
closed. When the fire was confirmed as
extinguished, the area was investigated.
The source of the fire was found to be
in a stowage area behind the toilet
vanity mirror.
All three shelves of the stowage area
were full of items required to service
the toilet such as paper towels and
tissue boxes. In the roof of the stowage
area is a ballast assembly that was hot
to the touch. In contact with this were
some of the flammable materials
including a charred pack of paper
napkins. These were dampened with water
and all paper items removed from the
heat source.
Acting on a request from the aircraft
commander, another Boeing 777 captain,
travelling as a passenger, attempted to
trip the circuit breaker controlling the
electrical supply to the ballast
assembly. The circuit breaker, J8 on
panel P320 named 'LAV LIGHTS RIGHT', was
identified and tripped but the lighting
in toilet 'N' remained illuminated.
Tripping of the 'LAV LIGHTS LEFT'
circuit breaker was considered but
dismissed and instead, the electrical
supply to the ballast assembly itself
was removed at the unit. The
toilet was declared unserviceable for
the rest of the flight.
Further Investigation
It was noted that next to the stowage
unit, written in black felt tip pen,
were the words 'Do not over stock,
only 1 each item'. The company
subsequently found this written in all
toilets throughout their Boeing 777
fleet but they were unable to establish
the source.
It was also noted that the correct
circuit breaker to trip the power supply
to this toilet's ballast assembly was
named 'LAV LIGHTS LEFT',
even though the
toilet is situated on the right side of
the aircraft. In addition
to controlling the ballast power supply
to the right toilets, this circuit
breaker, ambiguously, also controls some
services to the left toilets.
Follow-up action
As a result of this incident the
company issued Red Notice RN03W/04 to
all Boeing 777 Cabin Crew. This notice
requires Cabin Crew, as part of their
security check, to ensure that the upper
shelf behind the mirror is not used for
storage of any flammable material.
During subsequent checks by Cabin Crew,
flammable material has been discovered
on the upper shelf and the company is
currently designing a modification to
physically prevent items from contacting
the ballast assembly. |
