Air Canada 797 Accident Term Paper

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¶ … Air Canada 797 Accident

The June 2, 1983 accident of the Air Canada Flight 797, in which 23 passengers died as a result of fire soon after the plane made an emergency landing at the Cincinnati airport, is considered to be one of the most significant disasters in aviation history as it led to important changes in fire safety design and procedures for passenger aircrafts. This paper gives an overview of what happened that led up to the emergency landing and the survival factors as well as the NTSB recommendations that came out.

Events Leading to the Emergency Landing

Air Canada Flight 797, a McDonnell Douglas DC-9-32 aircraft, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. The flight left Dallas at 1625 central daylight time with 5 crew members and 41 passengers on board.

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First Signs of Trouble: The flight proceeded normally on course and without a significant incident until 1851 eastern daylight time when three circuit breakers associated with the aircraft's aft lavatory, located in the cockpit, tripped in rapid succession. At the time the aircraft was flying at its assigned flight level of 33,000 ft above mean sea level and had entered the Indianapolis airspace. The captain attempted to reset the circuit breakers but they did not hold. Assuming that the flush motor in the lavatory had seized, the captain took no further immediate action. At 1859, he made another attempt to reset the breakers with similar results. At about the same time (1900 hrs) a passenger seated in the last row reported a strange odor to a flight attendant who, on checking, discovered that light gray smoke had filled the aft lavatory. She reported the matter to the flight attendant in-charge who asked her to inform the captain and himself proceeded to spray the inside of the lavatory with a CO2 fire extinguisher. ("Aircraft Accident Report" 1983, p. 1-2)

Term Paper on Air Canada 797 Accident Assignment

The captain was informed of the fire by the flight attendant at 1902:40 who ordered the first officer to inspect the lavatory. The first officer could not get to the lavatory as the smoke had become too thick by then and, returning to the cabin, he informed the captain of the situation and advised, "we'd better go down." (Ibid, p. 3) Seconds later, and before the captain had responded to the advice, the flight attendant in charge came to the cockpit and told the captain that the passengers had been moved forward and the smoke seemed to be easing up. The captain asked the first officer to check the situation again. Finding the lavatory door hot to the touch, the first officer did not open it and instructing the cabin crew to keep it closed, returned to the cockpit. As he took his seat, he informed the captain at 1907:11, "I don't like what's happening, I think we better go down, okay?" (Ibid., p.4)

The Descent: At 1908, Flight 797 conveyed the "Mayday" distress signal to Indianapolis Center controller and informed them about the fire and the immediate need to land. At that moment the flight was 25 nautical miles from Cincinnati and, hence, it was decided to land the plane at the Greater Cincinnati Airport; the flight was cleared to make an emergency landing at the Airport at 1909:09. The tower's local controller alerted the airport fire station, and crash-fire-rescue (CFR) vehicles were dispatched and positioned for an emergency landing (Ibid.).

At 1910:25, Flight 797 contacted the Cincinnati approach controller, declared an emergency, and said that it was descending. The approach controller acknowledged and told the flight to plan for an instrument landing system (ILS) approach to runway 36. The inoperative transponder in the aircraft (due to non-availability of a.C. power) had made it difficult for the approach controller to locate Flight 797 on the radar and by the time it was positively identified, the controller realized that the flight was not adequately positioned for landing at runway 36. He, therefore, redirected the aircraft to use runway 27L for landing. The fire department was, accordingly, requested to relocate its rescue vehicles along runway 27L. (Ibid. pp. 5-6)

Inside the Airplane during Descent: As the airplane descended, the smoke rapidly spread along the passenger cabin and entered the cockpit. The captain wore smoke goggles and his oxygen regulator during the descent and had no difficulty in breathing but he did experience difficulty in seeing the instruments due to the smoke-filled cockpit. During the descent, Flight 797 encountered clouds from FL 250 to about 3000 feet and the captain descended to 2000 feet to obtain VFR conditions. However, the weather conditions and the smoke in the cockpit did not hamper the descent or landing significantly. (Ibid. p. 7)

During the initial stages of the descent, the cabin crew moved the passengers forward of row 13; briefed them on the emergency evacuation procedures, designated able-bodied male passengers to open the over-wing exits after the plane had stopped and passed out wet napkins for protection against the smoke.

After the initial level off at 3,000 feet, the captain ordered the first officer to depressurize the airplane in preparation for landing. The first officer complied; he also turned the air conditioning and pressurization packs off since he thought the packs were feeding the fire. He also opened his sliding window in an effort to clear the smoke from the cockpit, but closed it almost immediately because of the high noise level.

The Landing: At 1917:24, the runway 27 L's approach lights had been turned to full intensity. At 1917:35, Flight 797 reported the airport in sight and the approach controller cleared it to land. At 1918:48, the controller told the flight that it was 3 nautical miles from the airport and asked the tower local controller if she had the airplane in sight; the local controller said that she did. As the captain landed the plane, he made a maximum effort stop using extended spoilers and full brakes. Because of the loss of the left and right a.C. buses, the antiskid system was inoperative and the four main wheel tires blew out. The airplane was stopped just short of the intersection of taxiway J. The time of the landing was 1920:09 (Ibid., p.8).

The Fire: As soon as the plane had landed and after the captain completed the emergency engine shutdown checklist, both he and the first officer attempted to go back into the cabin and assist in the passenger evacuation, but could not do so due to the severe intensity of the smoke and heat. Thereafter, they exited the airplane through their respective cockpit sliding windows.

At the same time, as soon as the airplane stopped, the flight attendants and the passengers opened the left and right forward cabin doors; the left forward overwing exit, and the right forward and aft over-viewing exits. Slides at the left and right forward cabin doors were deployed and inflated. The 3 cabin attendants and 18 passengers used these 5 exits to evacuate the airplane. About 60 to 90 seconds after the exits were opened and moments after the 18 passengers and 5 crewmembers left the airplane, a flash fire engulfed the cabin interior and it burst into flames. Twenty-three passengers perished in the fire. The fuselage and passenger cabin were gutted before airport fire personnel could extinguish the fire (Ibid., p. 8)

Probable Cause of Accident: After an official enquiry of the accident by the National Transportation Safety Board it was determined that the probable causes of the accident were:

fire of undetermined origin,

An underestimate of fire severity, and misleading fire progress information provided to the captain

Contributory Factor: The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent was considered to be a contributory factor to the severity of the accident.

Survivability Factors:

The investigation concluded that the accident was survivable. The following survivability factors were identified:

The first noticeable abnormality during the flight occurred at 1851:14 when the flush motor's three circuit breakers tripped. The captain tried to reset them but they did not hold. As per his testimony he had assumed that the flush motor may have over-heated; he, therefore, proceeded with the flight normally and tried to reset the breakers again at 1859:58. (Ibid. p. 59) Over 11 minutes elapsed after the first breaker trip before the flight attendant informed the flight-crew about the fire. Hence, if the Captain had sent someone to check the flush motor in the lavatory after the first tripping, the fire could have been discovered earlier.

Initial actions taken by the cabin crew when the smoke was discovered were inadequate to assess the origin and scope of the fire. The flight attendant in charge did not use an axe to remove the panels behind which the smoke was emerging. Since the location and severity of the fire had not been determined the captain was provided… [END OF PREVIEW] . . . READ MORE

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