KLM B772 over Mediterranean on Feb 9th 2023, cabin problems - electrical fire in oven
Last Update: June 10, 2024 / 13:28:02 GMT/Zulu time
Incident Facts
Date of incident
Feb 9, 2023
Classification
Incident
Airline
KLM
Flight number
KL-591
Departure
Amsterdam, Netherlands
Destination
Johannesburg, South Africa
Aircraft Registration
PH-BQO
Aircraft Type
Boeing 777-200
ICAO Type Designator
B772
The Dutch Onderzoeksraad (DSB) reported they have dispatched investigators to Schiphol Airport for investigation concerning an aircraft that returned to Schiphol with "cabin problems".
A passenger reported there was a strange smell, fellow passengers were standing, sobbing, shaking, terrified. An electrical fire in an oven in the aft galley had started, toxic gasses came from the aft of the cabin. The passengers in the aft cabin were moved to the middle of the cabin while flight attendants in protective masks rushed with fire extinguishers to put the fire out. The toxic smell continued until they disembarked the aircraft. After landing passengers were attended to by medical staff, but they all were doing okay. The passenger stated cabin crew needs trauma counselling. A replacement aircraft is going to take them to Johannesburg.
On Jun 1st 2023 the Dutch Onderzoeksraad (DSB) reported an aft galley oven overheated prompting the return to Amsterdam. The occurrence was rated a serious incident and is being investigated by the DSB.
In January 2024 the DSB added, that six halon fire bottles were used by cabin crew. Subsequently 3 cabin crew and 12 passengers suffered breathing difficulties. The investigation is ongoing.
ON Jun 10th 2024 the DSB released their final report concluding the probable causes of the serious incident were:
Cause of the smoke originating from the oven
The use of a meal tray carrier with a mostly closed backside extended the heating time of the oven significantly and it disturbed the airflow in it. The result was a raised temperature behind the oven. This influenced the control circuitry in such a way that the heating elements were inadvertently commanded on. It caused the temperature behind the oven to increase even further, keeping the power control board in a faulty condition. At this point, the 3-phase safety device was already damaged and inoperable and could not turn off electrical power to the oven. The temperature inside the oven also continued to rise to such a degree that it experienced an overheat condition and smoke was coming from the oven into the galley.
The removal of electrical power to the oven, as dictated by the Oven smoke/fire procedure, did not happen during the entire oven overheat event as the galley area main power was not switched off. Also, at no point was the correct position of the galley area main power button verified by checking the powering of other galley electrical equipment. The circuit breaker of the oven was not pulled by the cabin crew nor were they directed to do so by the Oven smoke/fire procedure.
The flight crew did not switch off the utility bus as directed by the Smoke, Fire or Fumes checklist as they considered it as unnecessary. The reason for this was that they were convinced that the power to the aft galley was already removed by means of switching off the galley area main power switch. As a result, electrical power to the failed oven remained connected even after the flight and cabin crew assessed the oven overheat event as stopped.
As a result of the failure of the heating elements, the temperatures behind the oven dropped significantly so that the power control board functioned correctly again and transmitted the commanded ‘off’ signal by the oven control module to the heating elements. The oven overheat event thus stopped. The oven overheat event did not cause damage to the direct surrounding area of the oven. All heat damage remained limited to the inside of the oven.
The operator indicated that at the time of the occurrence, Service Information Letter H0212-25-0164 had not been incorporated in maintenance procedures. This service information letter gives additional instructions for the checking of the 3-phase safety device and the replacement of it every five years and is incorporated in the Component Maintenance Manual.
Service Bulletin 2000-25-0001, which recommends the incorporation of an improved power module, motor, fan and heating elements among other upgrades, had also not been incorporated by the operator. The incorporation of this service bulletin has been proven to prevent a potential failure of the oven control module and temperature probe from controlling the temperature in the oven. The implementation of this service bulletin was deemed unsuitable by the operator due to certification requirements of the modification and limitations on the use of the oven.
Operator’s firefighting procedures and firefighting efforts by the flight and cabin crew
No flames were observed inside the oven, but the orange glow in the back of the oven together with the amount of smoke caused by the overheat event led the crew to believe that a fire must have been present. In the eyes of the crew, the use of Halon fire extinguishers was therefore warranted. The application of Halon into the oven did not provide any cooling capability but increased the amount of emitted smoke coming from the oven. The Halon gas was exposed to temperatures well above its decomposition temperature and became toxic. The use of Halon fire extinguisher agent was therefore inappropriate during the oven overheat event.
The training of the cabin crew stressed the importance of not manipulating and not resetting tripped circuit breakers. This led to the general impression by the cabin crew that pulling of a circuit breaker was also not allowed even in the presence of fire or smoke emitting from electrical equipment. Only after consultation with the flight crew, the pulling of a circuit breaker was allowed.
During the investigation, the airline was already alerted by the Dutch Safety Board on the importance of pulling a circuit breaker in case of an electrical fire/smoke event to ensure that the oven in question is no longer powered. Also, the importance of keeping the oven door shut during an overheat event was pointed out by the Dutch Safety Board during the investigation, as the oven is designed to confine high temperatures to the inside of the oven.
Aircraft Registration Data
Incident Facts
Date of incident
Feb 9, 2023
Classification
Incident
Airline
KLM
Flight number
KL-591
Departure
Amsterdam, Netherlands
Destination
Johannesburg, South Africa
Aircraft Registration
PH-BQO
Aircraft Type
Boeing 777-200
ICAO Type Designator
B772
This article is published under license from Avherald.com. © of text by Avherald.com.
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