Air France B773 at Paris on Jul 28th 2013, evacuation while boarding due to fumes

Last Update: July 8, 2015 / 13:36:58 GMT/Zulu time

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Incident Facts

Date of incident
Jul 28, 2013

Classification
Accident

Airline
Air France

Flight number
AF-116

Departure
Paris Charles de Gaulle, France

Destination
Shanghai, China

Aircraft Registration
F-GSQA

Aircraft Type
Boeing 777-300

ICAO Type Designator
B773

An Air France Boeing 777-300, registration F-GSQA performing flight AF-116 from Paris Charles de Gaulle (France) to Shanghai (China) with 315 people on board, was boarding at the gate when the crew noticed a strong burning odour on board and saw smoke in the cabin. The captain ordered the evacuation of the aircraft, the first officer declared Mayday and requested emergency vehicles. The overwing exits were opened for the evacuation, a number of passengers evacuated that way. One passenger received a serious injury during the evacuation and was taken to a hospital.

France's BEA reported in their weekly bulletin released Aug 8th that the crew noticed a strong burning odour on board and noticed visible smoke in the cabin, the captain ordered the evacuation which in part was performed through the overwing exits. One passenger evacuating that route received an elbow fracture.

On Jul 8th 2015 the BEA released their final report (in English!) concluding the probable causes of the accident were:

Smoke in the cabin and in the cockpit was generated by pyrolysis of oil at the level of the APU in the ventilation system. The presence of oil was due to a leak in a seal caused by failure of an APU ball race.

The flight crew decided to disembark the passengers quickly. The cabin crew positioned at doors 3 did not understand the Captain’s intentions and decided to carry out an emergency evacuation by opening the emergency exits. During this evacuation one passenger was seriously injured.

The imprecise language used by the Captain contributed to the misinterpretation of the order given.

The absence of a dedicated procedure for quick deplaning contributed to the Captain’s imprecise language and to erroneous interpretation by the cabin crew at door 3.

The BEA reported the flight crew consisted of the captain ( 20,732 hours total, 3,415 hours on type), a first officer ( 10,792 hours total, 4,773 hours on type) and a second first officer (6,008 hours total, 3,374 hours on type). The crew was carrying out their departure briefing and pre-flight checklist in the cockpit, when the flight crew noticed a burning smell in the cockpit. The captain and the second first officer left the cockpit to investigate the source of the smell, 25 seconds later the flight attendants at door 3 phoned the cockpit (first officer receiving the call) reporting a smell of sulphur need doors 5, passengers were worried. The captain in the meantime reached door 2, noticed the smell and saw a slight pall of smoke in the cabin, the captain instructed the galley ovens to be checked.

The first officer remaining in the cockpit in the meantime received a smoke indication for the upper forward crew rest area, cabin crew also received this indication on their control panels.

The captain instructed cabin crew in the forward area of the aircraft to don fire protection equipment, protective breathing equipment and fire extinguisher, and investigate the forward crew rest area.

The flight attendant at door 3 again called the cockpit informing of a lot of smoke in the cabin, the first officer confirmed smoke was now also entering the cockpit.

The captain returned to the cockpit, the first officer advised about the "SMOKE REST UPPER DOOR 1" indication and the first officer had turned off both air conditioning systems due to the presence of smoke in the cockpit. The captain therefore decided to evacuate the aircraft and instructed via the PA system: "Cabin Crew to your stations". The first officer radioed ATC, declared Mayday and requested immediate assistance by fire crews.

Cabin crew, noticing the increasing panic amongst asked passengers via PA to remain seated. Cabin crew at doors 3 and 4 armed the evacuation slides at their doors and started to brief passengers at the emergency exits about their role in the evacuation.

The Ramp Manager contacted the flight deck reporting that there was smoke coming from the APU. The crew shut the APU down in response.

45 seconds after his "to your stations" call the captain instructed via PA: "Cabin crew this is the cockpit, evacuate the passengers via the doors, only via the doors."

A cloud of thick smoke was forming at the cabin ceiling moving from the aft of the aircraft towards the front, passengers moved towards doors 3D and 3G, flight attendants at doors 5 took out their breathing protection equipment, flash lights and megaphones, the two first officers opened the cockpit windows to ventilate the cockpit, the smoke began to dissipate in the cockpit.

While the captain developed the feeling that the evacuation was proceeding normally, the situation in the cabin developed differently.

The BEA wrote:

The flight attendants at doors 4G/4D initially planned to evacuate passengers through these doors, then finally decided to direct them to the front of the aeroplane.

The flight attendants at doors 3G/3D opened the doors, taking into account the following:

- the expressions used by the Captain (which they heard distinctly) could have led them to think an evacuation through this door was authorised;
- visual contact with the flight attendants located at doors 2 and 4 was made impossible by the open overhead lockers, the passengers standing in the aisle and the partitions between classes;
- the panicking passengers demanded very loudly that the doors be opened;
-ˆˆ they had no precise information about the causes of the phenomena experienced in the cabin;ˆˆ
- their current experience seemed to them to be of a critical nature.

The flight attendant who was checking the forward crew rest quarters came out while the evacuation was underway. He helped to expedite the evacuation. He did not find any signs of a fire, only the presence of thick smoke.

The reserve co-pilot saw the deployment of the door 3 slides. The Captain then moved towards the rear of the cabin, and noticed that the doors were open and went through each of these doors to ask the passengers who were still on the wings to return inside the cabin.

The passengers evacuated by the slides were assisted by ground personnel and taken to the terminal. One of the passengers fractured his elbow during the evacuation.

The chief flight attendant checked the cabin and confirmed to the flight crew that the evacuation was over.

Seeing no more smoke on board the aircraft, the flight crew and the chief flight attendant held a debriefing in the cockpit on how the evacuation had taken place.

A post occurrence examination of the APU found that the ball race at the air compressor of the ventilation system was damaged which led to deterioration of modules around the compressor and ultimatey damaging a carbon seal of the bearing resulting in oil lubricating the bearing passed into the compressor. The BEA wrote: "The cause of the deterioration of the ball race could not be determined. It had been replaced by Honeywell during the last APU overhaul in 2009."

The BEA analysed:

The oil used for APU lubrication (Mobil Jet Oil II) is the same as that used for the engines. This oil contains high pressure anti-wear additives. When they reach a high temperature (pyrolysis), these lubricants can release volatile organic substances that are potentially dangerous, like the TriCresyl-Phosphates (TCP) which are neuro-toxic. It was not possible to determine if such substances were released during the event.

No blood tests were performed after this event. Examination of the breathing equipment did not make it possible to determine if the people on board had been exposed to TCP.

There is a type of oil supplied by the NYCO company, certified for APU, that does not release TCP. However the operator had decided not to use this oil, to ensure that it was not erroneously put into the engines, for which it is not certified.

The BEA highlighted lessons learned as result of the occurrence:

Crisis Situation Management

The flight crew detected the presence of a suspicious smell. The Captain immediately decided to leave the cockpit with the reserve co-pilot to determine the origin of this smell. The absence of the Captain from the cockpit had the following consequences:

- he did not perceive the situation experienced by the flight attendant at door 3;
- the co-pilot took the initiative of shutting down the air conditioning units without consulting the Captain.

The Captain therefore did not have all of the information when he returned to the cockpit. However he immediately planned to carry out an emergency evacuation, and then after receiving the information of the presence of smoke at the APU level, he asked for the aeroplane to be evacuated by the passenger air bridges. The cockpit may be considered the command post. As this event illustrates, it appears useful that the Captain remains in the cockpit. In this way he may rely on the procedures available, especially those for ‘‘smoke, fire or fumes’’ and on his crew to inform him of the situation in the cabin.

If this event had occurred during flight, the crew would probably not have left the cockpit. It would seem opportune to reflect on the difference in crew behaviour when in flight and on the ground.

Nevertheless this single event does not make it possible to reach a conclusion on the strategy to adopt in all the emergency situations which may arise on the ground and in flight.

Evacuation

The airline operations manual does not provide for evacuation of the aeroplane by the boarding doors. The terms used by the Captain when he planned the evacuation were: ‘‘this is the cockpit, cabin crew to your stations’’ . These words are those associated with the emergency evacuation procedure and result in preparing the cabin crew for this possibility. The Captain indicated 45 seconds later ‘‘Cabin crew this is the cockpit, evacuate the passengers, evacuate the passengers through the doors, only through the doors’’. These words do not make it possible to understand unambiguously that the Captain is requesting evacuation through the boarding doors.

Door 3 cabin crew were in a considerably stressful context. They perceived the situation as being critical and, being in doubt about the order given, they decided to proceed with evacuation with the slides.

The Captain did not have a procedure associated with the strategy he wished to implement: rapid disembarkation at the ramp. He therefore used language which was not fully suited to the situation. In the absence of procedure, the cabin crew were in doubt about the order given and also therefore about the terms of it performance. Some airlines have thus defined a procedure for this sort of situation.

Smoke Toxicity

The airline had decided to use an oil for which pyrolysis may generate toxic gases. This choice had been made on the basis of technical considerations and human factors relating to the activity of mechanics. The airline had not assessed the possible consequences in the event of the oil overheating by the APU for the aeroplane occupants. It may be helpful to consider these aspects in the framework of a safety study.

Wearing Protection

The crew was exposed to smoke that may have been toxic. The majority of the crew members did not wear the protection they had available. When in doubt, the crew members must wear suitable protection to ensure their duty of safety.
Incident Facts

Date of incident
Jul 28, 2013

Classification
Accident

Airline
Air France

Flight number
AF-116

Departure
Paris Charles de Gaulle, France

Destination
Shanghai, China

Aircraft Registration
F-GSQA

Aircraft Type
Boeing 777-300

ICAO Type Designator
B773

This article is published under license from Avherald.com. © of text by Avherald.com.
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