Ryanair B738 near Seville on Nov 8th 2013, white smoke on board
Last Update: March 14, 2016 / 14:47:12 GMT/Zulu time
Incident Facts
Date of incident
Nov 8, 2013
Classification
Incident
Airline
Ryanair
Flight number
FR-2355
Departure
Tangier, Morocco
Destination
Dusseldorf Niederrhein, Germany
Aircraft Registration
EI-DPF
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Maintenance determined an air conditioning fault causing a pipe to blow dust and/or debris into the cabin.
The airline reported a passenger reported fumes in the cabin, the crew alerted the fire services in Seville, who were on standby for the arrival of the aircraft, that landed normally. The passengers were taken to a replacement aircraft which continued towards Dusseldorf's Niederrhein (Weeze) Airport. Engineers inspected the aircraft and found a fault in the air conditioning system, the relevant safety agencies in Spain and Ireland have been advised.
A number of Spanish media reported a cabin fire and smoke in the cabin, the aircraft diverted to Seville, vacated the runway and taxied to the terminal, others reported the crew reported smoke in the cabin.
On Nov 14th 2013 Spain's CIAIAC reported that cabin crew reported dense white smoke with no odour while climbing through 8000 feet out of Tangier. The flight crew stopped the climb and diverted to Seville, the aircraft vacated the runway and stopped on the taxiways, doors were opened and passengers disembarked normally. An investigation has been opened.
On Jan 12th 2015 Spain's CIAIAC reported in an interim statement, that the examination of the aircraft revealed three air conditioning ducts in the area where the smoke originated out of position. The investigation focusses on why the ducts were in that condition and on analyzing the crew's handling of the emergency. The draft reported is being written.
A replacement Boeing 737-800 registration EI-DYI departed Seville about 4.5 hours after landing of EI-DPF and reached Cologne/Bonn at about 03:45L about 4 hours behind scheduled landing at Weeze Airport.
On Mar 14th 2016 Spain's CIAIAC released their final report concluding the probable cause of the incident was:
The probable cause of the incident with aircraft EI-DPF was the bad condition of the fire-retardant adhesive tape used to attach three sidewall riser ducts to the overhead distribution duct. Because the adhesive on the tape was weak, the joints came loose and the air that was exiting at that point probably stirred up the dust that had accumulated above the overhead panels, producing what the cabin crew identified as a thick, white, odorless and cold smoke.
The CIAIAC reported that the first officer (28, CPL, 1,919 hours total, 1,133 hours on type) was pilot flying, the captain (31, ATPL, 5,000 hours total, 4,400 hours on type) was pilot monitoring. The departure was uneventful until climbing through about 8500 feet when the purser made an emergency call to the cockpit (3 chimes). The captain instructed the first officer to also monitor the radio and picked up the interphone, the flight attendant told about smoke around the emergency exits in the cabin, something he had never seen before, the captain asked a few questions. 44 seconds after the begin of the interphone call the captain instructed the first officer to instantly begin a diversion to Seville and declare Mayday due to smoke in the cabin. The first officer declared Mayday and advised ATC they would divert to Seville stopping the climb at FL110. In the meantime the captain continued communication with the purser. After finishing the communication with the purser more than one minute after the call began the captain resumed communication with ATC, reconfirmed the Mayday and diversion to Seville.
The CIAIAC annotated that the crew did not refer to the smoke checklists but instantly concentrated on the diversion to Seville. The crew entered the new destination into the flight management system and received a warning they were too high for the approach. During the descent towards Seville the captain contacted the purser to query about the status in the cabin, the purser reported that the situation was improving, they had checked whether the smoke came from the lights with no change, the smoke could be originating from the air conditioning but they weren't sure, the smoke had dissipated but not disappeared. The captain advised they'd land in 12 minutes, shut down the left engine and the purser should then open the left forward door for the fire fighters being able to enter the aircraft.
While intercepting the ILS to Seville the captain made an announcement to passengers about the emergency and instructed the passengers to remain seated after the aircraft would come to a stop.
The aircraft touched down safely on Seville's runway 27 and vacated the runway via taxiway E3 coming to a stop just after crossing the hold short line. The left hand engine was shut down and emergency services entered the cabin through the forward left door. Fire fighters found no trace of fire, heat or smoke.
The captain decided to have the passengers disembark onto the taxiway, two busses took the passengers to the terminal. The aircraft subsequently was towed to the apron with fire fighters remaining on board.
In the meantime Seville Approach had been informed that the emergency aircraft had vacated the runway. Seville Approach therefore vectored the next arrival onto final approach and cleared the aircraft for an ILS approach, when Tower complained to Approach that the emergency was still on going and the airport was not operational requesting the aircraft on approach to be called off the approach. Approach cancelled the approach clearance and sent the aircraft on approach into a holding pattern. Subsequent research by Seville Approach to determine who had declared the airport operational revealed that the information the emergency aircraft had vacated the runway was erroneously interpreted as the airport was operational again. The airport resumed normal operation only about one hour after the emergency landing.
In a post flight interview the captain stated they did not work the smoke checklist because they did not want to delay the landing, they knew the checklist and knew one of the points was to not delay the landing. They had not received any abnormal indication on any of their displays.
The purser's testimony was summarized by the CIAIAC as follows:
After takeoff there was a call from a passenger. Since they were not yet authorized to get up, they were unable to attend to the call. About one and a half minutes later, the seatbelt sign was turned off and they were able to get up. As the purser he started giving the safety message to the passengers via the intercom when FA-2, who was standing at row 12, activated the call bell three times.
He went to the area of the call, where FA-2 and FA-3 were already standing, and immediately saw the smoke. They saw that the smoke was issuing from the overhead compartment, near the lights. The smoke was white, odorless and they could feel no heat. With this information, he proceeded to the rear of the aircraft to call the pilots.
He made the emergency call to the cockpit using code 222 and reported what was happening, relaying all the information they had up to that point.
About a minute later he received the NITS briefing from the captain, who told him of their intention to land in Seville. He passed the information to the rest of the cabin crew and they synchronized their watches. They prepared the cabin for landing and took their seats. The passengers were still seated, meaning the cabin was prepared very quickly. The smoke dissipated gradually but it did not disappear completely until they landed.
After landing two firefighters went onboard and informed them there was no danger.
Maintenance personnel examining the Rynair aircraft removed the overhead bins above seat rows 12-13 and found three flexible hoses had come loose from their overhead distribution duct joints. There was no evidence of fire, heat or smoke. The examination further revealed:
- There were two different types of adhesive tape (one was yellowish and the other white).
- The plastic tie strap could not be seen in the hoses in good condition, but it was evident below the adhesive tape.
- The marks left below the tie straps indicated that they had been installed directly on the hoses, and not on the tape, as specified in the Maintenance Manual. This installation, with the the strap directly on the hoses, is the same as current production configuration.
The CIAIAC annotated that the occurrence had experienced a landing at +2.26G 13 days prior to the occurrence. A hard landing inspection had been conducted following that event.
The CIAIAC analysed: "The smoke appeared in the passenger cabin due to a problem with the cabin’s air distribution system. Three flex hoses from the sidewall riser ducts had detached from the overhead distribution duct. The ducts are attached by placing one inside the other and securing them together using fire retardant adhesive tape and a plastic tie strap. The tape was no longer adhering the ducts together due to a problem with the adhesive, and the hoses had come loose due to the air blowing through the hoses and to vibrations during the flight. As a result, the air leaking through this loose joint must have caused the dust that had built up on top of the ceiling panels to blow out into the cabin. This, along with possible condensation of the air upon leaving the hose, must have caused what the crew identified as a white smoke. The location of the loose hoses above row 12 matched the area where the smoke was reported during the incident. Since the source of the smoke was an air leak in the distribution system, there was no associated warning or caution in the cockpit and the pilots were unaware of the problem. The smoke did not have associated with it the odor typical of smoke from a fire (such as an electrical fire). The fact that the smoke was white, and not black, also indicated that it was not from a fire. It was also not associated with a high temperature of any component in the passenger cabin. In other words, the characteristics of the smoke correlated to its origin: a leak in the air distribution system. The smoke dissipated during the flight, probably due to the decreasing amount of dust, but it did not disappear until the engines were stopped. This makes sense since when the engines were stopped, the air conditioning packs also stopped, meaning there was no more air pressure in the ducts. This is why by the time the firefighters entered the cabin, there was no smoke."
With respect to cabin crew actions the CIAIAC analysed: "The response by the cabin crew to these calls was delayed by a minute and a half, as per their statements, until the seat belt sign was turned off. Except for one flight attendant who was verbally notified of the presence of smoke, the rest of the cabin crew was unaware of the situation and had not received any alert calls from the cockpit. They thus attributed the calls to mistakes by the passengers who had intended to turn on the reading lights instead, and they waited until they were able to get up. In this incident, the smoke that appeared in the cabin did not pose any risk to the safety of the aircraft, but the presence of smoke is one of the more serious in-flight situations, requiring immediate attention and overriding the seat belt sign. The delay in responding to the calls, however, is not considered excessive, and once the seat belt sign was turned off the cabin crew responded immediately. The assignment of tasks to deal with the emergency was fast and proper, and every crew member, as they arrived at the scene, carried out the tasks defined in the procedure."
The CIAIAC anaysed with respect to the flight crew actions that the actions were quick and correct. Although the crew did not consider to work the smoke checklist, many of the items would not have been applicable to the event, there was no effect on the outcome of the event. The CIAIAC wrote: "The priority of the flight crew during the emergency was to land in Seville. All of the actions taken in the 20 min 51 sec between the emergency and the landing were focused on preparing the approach, configuring the aircraft and ensuring that the rest of the flight was carried out in a stable and controlled manner. They did not want to have to do a go-around. The constant questions to Seville regarding the runway in use, the weather at their destination and descent instructions showed the crew’s desire to plan ahead and not be caught off guard."
The CIAIAC analysed with respect to ATC: "The constant questions from the crew to ATC (runway in use, weather at Seville, descent instructions and vectors) showed an attitude by ATC that was not proactive or did not anticipate the needs of the crew, probably so as not to bother or interrupt the crew during the emergency. The result was that it was the captain who had to constantly request flight information."
With respect to the airport operations the CIAIAC analysed: "While the situation with the aircraft in distress was handled properly, the determination of the airport’s operability level following the emergency was not. Communications between the duty manager, CECOA, Seville TWR and Seville APP were not coordinated when it came to determining the airport’s operability. The duty manager unilaterally determined that the airport was fully operational without consulting with the Seville TWR and without informing it of his decision, one that was based on the fact that the aircraft was on the taxiway and clear of the runway."
One safety recommendation to Ryanair and one safety recommendation to Seville Airport were issued as result of the investigation.
Aircraft Registration Data
Incident Facts
Date of incident
Nov 8, 2013
Classification
Incident
Airline
Ryanair
Flight number
FR-2355
Departure
Tangier, Morocco
Destination
Dusseldorf Niederrhein, Germany
Aircraft Registration
EI-DPF
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Related articles
Fleet type match
Ryanair B738 at Brussels on Feb 24th 2024, nose wheel fractured on landing
A Ryanair Boeing 737-800, registration EI-DYC performing flight FR-9719 from Rome Ciampino (Italy) to Brussels Charleroi (Belgium), landed on…
Fleet type match
Ryanair B738 and Delta A333 at Barcelona on Jul 2nd 2022, A333 on departure overflew B738
A Ryanair Boeing 737-800, registration EI-DYO performing flight FR-9366 from Barcelona,SP (Spain) to Bologna (Italy) with 166 passengers and 6 crew,…
Fleet type match
Ryanair B38M near Faro on Dec 12th 2023, engine problem
A Ryanair Boeing 737-8 MAX, registration EI-HGR performing flight FR-1249 from Manchester,EN (UK) to Tenerife South,CI (Spain) with 164 people on…
Fleet type match
Ryanair B38M near Krakow on Nov 26th 2023, pilot incapacitated
A Ryanair Boeing 737-8 MAX, registration EI-IHW performing flight FR-3472 from London Luton,EN (UK) to Rzeszow (Poland), was enroute at FL370 about…
Fleet type match
Ryanair B738 at Pescara on Nov 25th 2023, lightning strike
A Ryanair Boeing 737-800, registration EI-EKG performing flight FR-5471 from Bucharest (Romania) to Pescara (Italy), was on approach to Pescara when…
Newest articles
Fleet type match
Bonza B38M at Sunshine Coast on Apr 23rd 2024, fumes in cockpit
A Bonza Airline Boeing 737-8 MAX, registration VH-UJK performing flight AB-570 from Avalon,VI to Sunshine Coast,QL (Australia), was on approach to…
Link SF34 at Sydney on Oct 24th 2022, too low of final ILS approach
A Link Airways Saab 340B on behalf of Virgin Australia, registration VH-VEQ performing flight VA-669 from Canberra,AC to Sydney,NS (Australia), was…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways