Carpatair SB20 at Florence on May 28th 2012, engine fire indication

Last Update: February 4, 2014 / 18:16:06 GMT/Zulu time

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Incident Facts

Date of incident
May 28, 2012

Cause
Engine fire indication

Airline
Carpatair

Flight number
V3-444

Departure
Florence, Italy

Destination
Timisoara, Romania

Aircraft Registration
YR-SBJ

Aircraft Type
SAAB 2000

ICAO Type Designator
SB20

A Carpatair Saab 2000, registration YR-SBJ performing flight V3-444 from Florence (Italy) to Timisoara (Romania) with 45 passengers and 4 crew, was holding at the hold short line waiting for departure from runway 05 when the crew received a left hand engine's (AE2100) fire indication. The crew initiated an emergency evacuation. Four passengers received minor injuries in the evacuation and were taken to a hospital. Responding emergency services found no evidence of fire.

Passengers reported somebody was shouting there was a burning smell on board just prior to the evacuation being initiated. Several passengers fell down onto the apron and received minor injuries.

The airport was closed for about 90 minutes as a result.

Italy's ANSV reported an investigator has been dispatched on site to collect evidence.

On Apr 11th 2013 the ANSV reported in an annual review of occurrences covered by the ANSV, that from evidence available it became clear, that there had been no fire/overheat condition to the engine, however, there had been a real fire/overheat warning. Upon receiving the fire indication the crew actioned the memory items until discharge of the first fire agent, then the crew declared emergency and the captain decided to evacuate the aircraft. With no signs of visible fire from the left hand engine all emergency exits were being used including the left forward door, right hand doors and overwing exits, the evacuation was completed in 40 seconds. Responding emergency services discharged fire agent which completely removed any possibility of fire from the engine. While jumping from the aircraft, height about 1.7 meters, a number of passengers received injuries, some of them serious injuries. The aircraft does not need slides by regulations, that require slides from a height of 1.83 meters and above. The airport was closed for 82 minutes. The investigation is still ongoing in trying to determine the causes of the fire warning and the issues with the evacuation.

On Jan 28th 2014 the ANSV released their final report in Italian concluding the probable cause of the accident was:

the activation of the fire indication of the left hand engine.

Evidence rules out however that there was an engine fire. From the evidence available it was not possible to establish with certainty what caused the fire indication.

The ANSV reported in their analysis that the tower controller had the impression of white smoke coming from between the fuselage and the left hand engine. The captain visually assessed the left hand engine repeatedly, the fire indication ceased after the first fire bottle was discharged, however, the crew received a radio transmission indicating there was smoke from the engine, which prompted the commander's decision to evacuate the aircraft. The ANSV stated it was reasonable to doubt the fire had been extinguished. It was not in line with procedures however that the aircraft was evacuated through all doors rather than just the right hand doors.

The ANSV analysed that regulations do not take into account that jumping down from 1.83 meters serious injuries, like a limb fracture as seen during the evacuation, can occur. The ANSV further reasoned that in case of a crash the distance from door to floor may even be larger prompting a safety recommendation to mandate the installation of evacuation slides on the Saab 2000.