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the engine was still on fire, and upon landing the flightcrew
discharged the fire bottles. An emergency evacuation was performed
and the fire was extinguished with the assistance of airport fire
department personnel. Twenty-eight passengers received minor
injuries during the evacuation.
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A. National Transportation Safety Board Findings.
(1) Fire Warning and Flightcrew Actions. The investigation
revealed that the flightcrew immediately retarded the No. 1 engine
throttle after receiving the fire warning. According to the
flight data recorder (FDR), the fire warning ceased after
88 seconds. The flightcrew subsequently selected the No. 1 engine
fuel lever to “OFF” and discontinued the engine fire procedures
without discharging the fire extinguishing bottles. Although the
flightcrew followed its company's A300 Operating Manual Procedures
(which were based on Airbus Flight Crew Operating Manual (FCOM)
procedures), the investigation revealed inadequacies in the
A300-600's in-flight engine fire procedures.
(2) Fire Loop System Design Anomaly. The NTSB investigation
found that the engine fire detection system in the A300-600
consists of two identical but independent heat-sensitive fire
loops and a fire detection control unit (FDC). Normal operation
of the fire loops is with both systems ON, and when both loops are
selected ON, each loop must provide either an overheat or fault
signal to the FDC unit to trigger the fire warnings. If only one
of the loops senses an overheat, a loop fault is generated.
Additionally, if a loop failure occurs when a fire warning is
active, the fire warning will cease, and a loop fault signal will
be indicated. Should this occur, the faulty loop must be manually
selected OFF to reacquire the fire warning. The NTSB is concerned
that flightcrews of the A300-600 and A310 airplanes may be misled
to believe that a fire has been extinguished when a fire warning
is replaced by a loop fault.
(3) Cause of Engine Fire. Examination of the engine revealed
that all of the accessory gearbox (AGB) adapter attachment bolt
inserts had backed out. This allowed the fuel lines (cross-over
tubes) to unseat from the adapter, thus permitting pressurized
fuel to spray onto the hot engine parts and ignite. The adapter
had been reworked in accordance with an August 25, 1994, GE
Service Bulletin (SB) specifying new adapter inserts that were
supposed to permit a higher bolt torque to eliminate fuel leaks
from the adapter cross-over tube interface. The new AGB adapter
inserts were found to be inadequate.
B. NTSB Safety Recommendations. Based on its investigation of
the incident, the NTSB made three safety recommendations. The
NTSB safety recommendation addressed in this bulletin is listed in
subparagraph (1) below, while the safety recommendations in
subparagraphs (2) and (3) are provided as information to the
reader.
(1) NTSB safety recommendation A-99-33 recommends that the
Federal Aviation Administration (FAA) issue a flight standards
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information bulletin (FSIB) requiring principal operations
inspectors (POI’s) to emphasize:
(a) the importance of flightcrews deactivating the
faulted fire detection loop if an engine or auxiliary power unit
(APU) fire warning changes to a loop fault; and
(b) the proper method for identifying a failed fire
detection loop (applicable to all Airbus A300-600 and A310
airplanes that have not been modified in accordance with the
appropriate Airbus Service Bulletin to automatically arm the
remaining fire detection loop).
(2) NTSB safety recommendation A-99-32 recommends that the
FAA "issue an airworthiness directive to require that all
operators of airbus A300-600 and A310 airplanes modify engine and
auxiliary power unit (APU) fire detection systems to automatically
arm the remaining loop for fire detection in the event of a single
loop fault in the engines or APU."
(3) NTSB safety recommendation A-99-34 recommends that the
FAA "require that Airbus include supplementary information to the
in-flight engine fire procedure specified in the A300-600 and A310
Flight Crew Operating Manuals that indicates an appropriate amount
of time flight crews should wait after the throttle is retarded to
idle before the fuel lever is selected OFF and that all operators
of A300-600 and A310 airplanes adopt the new Airbus in-flight
engine fire procedure."
3. DISCUSSION.
A. Engine Idler Adapter Insert Redesign. Measures have been
taken to correct the design deficiencies of the GE engine AGB
idler adapter inserts that caused the engine fire. The FAA issued
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