NTSB · Safety Recommendation
Safety Recommendation A-91-071
Recommendation
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: NOTIFY PRINCIPAL MAINTENANCE INSPECTORS AND OPERATORS OF TRANSPORT CATEGORY AIRCRAFT OF THE FIRE HAZARD POSED BY ACCUMULATIONS OF LINT AND OTHER DEBRIS ON WIRE BUNDLES.
Safety Issue and Context
ON MARCH 17, 1991, AT 1618 ATLANTIC STANDARD TIME, DELTA AIR LINES FLIGHT 15, LOCKHEED L-1011-385-3, N753DA, WAS EN ROUTE FROM FRANKFURT, GERMANY TO ATLANTA, GEORGIA AT FLIGHT LEVEL (FL) 330 WHEN IT EXPERIENCED A FIRE BELOW THE AFT CABIN FLOOR AND IN THE CABIN. THE FLIGHT WAS CONDUCTED UNDER THE OPERATING RULES OF PART 121 OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) AND CARRIED 218 PASSENGERS, 10 FLIGHT ATTENDANTS, 2 PILOTS, AND 1 FLIGHT ENGINEER.
FLIGHT 15 HAD EN ROUTE FOR ABOUT 7.5 HOURS, WHEN ABOUT 180 MILES EAST OF GOOSE, BAY, LABRADOR, CANADA, A FLIGHT ATTENDANT NOTICED FLAMES RISING FROM THE BASE OF THE LEFT CABIN SIDEWALL PANEL TO THE HEIGHT OF THE SEATBACK TRAY AT THE NEXT TO LAST ROW PASSENGER SEATS (SEAT 41A). THE FLIGHT ATTENDANT PROMPTLY DISCHARGED A HALON FIRE EXTINGUSIHER INTO AN OPENING IN THE BASE OF THE SIDEWALL FROM WHICH THE FLAMES APPEARED TO ORIGINATE. THE FIRE WAS EXTINGUISHED AND A PRECAUTIONARY LANDING WAS MADE AT GOOSE BAY.
Response History
October 20, 1992 · NTSB Correspondence · FAA
THE BOARD NOTES THAT THE FAA AGREES WITH THIS RECOMMENDATION & ON 12/9/91, ISSUED HANDBOOK BULLETIN 91-15, ORIGIN & PROPAGATION OF INACCESSIBLE AIRCRAFT FIRE UNDER IN-FLIGHT AIRFLOW CONDITIONS. THIS BULLETIN PROVIDES INFORMATION ON THE POTENTIAL SAFETY HAZARD (APPLICABLE TO ALL TRANSPORT CATEGORY AIRCRAFT) FROM THE ACCUMULATION OF LINT & OTHER DEBRIS ON WIRE BUNDLES. ALSO, THIS BULLETIN HAS BEEN COORDINATED WITH THE AIRCRAFT CERTIFICATION SERVICE & WILL BE DISTRIBUTED TO ALL CERTIFICATION OFFICES FOR THEIR INFORMATION & COORDINATION WITH MANUFACTURERS FOR INCLUSION IN FUTURE DESIGN CONSIDERATIONS.
BASED ON THIS INFORMATION, RECOMMENDATION A-91-71 IS CLASSIFIED AS "CLOSED--ACCEPTABLE ACTION."
August 13, 1992 · Recipient Response · FAA
THE FAA AGREES WITH THIS SAFETY RECOMMENDATION. ON DECEMBER 9, 1991, THE FAA ISSUED HANDBOOK BULLETIN 91-15, ORIGIN AND PROPAGATION OF INACESSIBLE AIRCRAFT FIRE UNDER IN-FLIGHT AIRFLOW CONDITIONS. THIS BULLETIN PROVIDES INFORMATION ON THE POTENTIAL SAFETY HAZARD APPLICABLE TO ALL TRANSPORT CATEGORY AIRCRAFT FROM THE ACCUMULATION OF LINT AND OTHER DEBRIS ON WIRE BUNDLES. THIS BULLETIN REQUESTS THAT PRINCIPAL MAINTENANCE INSPECTORS OF TRANSPORT CATEGORY AIRCRAFT OPERATORS ENSURE THAT PROGRAMS ARE IN PLACE TO ADDRESS THE INSPECTION OF AIRCRAFT WIRING AND THE REMOVAL OF CONTAMINANTS, ESPECIALLY IN INACCESSIBLE AREAS.
THIS BULLETIN HAS BEEN COORDINATED WITH THE AIRCRAFT CERTIFICATION SERVICE AND WILL BE DISTRIBUTED TO ALL CERTIFICATION OFFICES FOR THEIR INFORMATION AND COORDINATION WITH MANUFACTURERS FOR INCLUSION IN FUTURE DESIGN CONSIDERATIONS.
April 29, 1992 · NTSB Correspondence · FAA
In Safety Recommendation A-91-71 we proposed that the FAA notify principal maintenance inspectors and operators of transport category aircraft of the fire hazard posed by accumulations of lint and other debris on wire bundles. Safety Recommendation A-91-72 proposed that the FAA require that transport category aircraft manufacturers and airlines amend maintenance mauals as necessary to ensure thorough inspection and cleaning of areas where lint and other debris may accumulate and pose a potential fire hazard. We note that the FAA has drafted an airworthiness inspector's handbook bulletin entitled "Origin and Propagation of Inaccessible
Aircraft Fire Under Inflight Airflow Conditions." Pending the issuance of the bulletin and further evaluation, Safety Recommendations A-91-71 and -72 are classified as "Open--Acceptable Response."
October 30, 1991 · Recipient Response · FAA
THE FAA HAS DRAFTED AN AIRWORTHINESS INSPECTOR'S HANDBOOK BULLETIN ENTITLED ORIGIN AND PROPAGATION OF INACCESSIBLE AIRCRAFT FIRE UNDER INFLIGHT AIRFLOW CONDITIONS. THIS BULLETIN PROVIDES INFORMATION ON THE POTENTIAL SAFETY HAZARD APPLICABLE TO ALL TRANSPORT CATEGORY AIRCRAFT FROM THE ACCUMULATION OF LINT AND OTHER DEBRIS ON WIRE BUNDLES. THIS BULLETIN REQUESTS THAT PRINCIPAL MAINTENANCE INSPECTORS DISSEMINATE THIS INFORMATION TO ALL OPERATORS OF TRANSPORT CATEGORY AIRCRAFT.
THE BULLETIN ALSO REQUESTS THAT PRINCIPAL MAINTENANCE INSPECTORS REVIEW THEIR OPERATORS' MAINTENANCE PROGRAMS TO ENSURE THAT THEY INCLUDE INSPECTION OF AIRCRAFT WIRING AND REMOVAL OF CONTAMINANTS, ESPECIALLY IN ACCESSIBLE AREAS.