Incident Overview

Date: Friday 9 January 1998
Aircraft Type: Boeing 767-322ER
Owner/operator: United Airlines
Registration Number: N653UA
Location: London-Heathrow Airport (LHR/EGLL) – ÿ United Kingdom
Phase of Flight: En route
Status: Unknown
Casualties: Fatalities: 0 / Occupants: 92
Component Affected: The wiring loom within the E&E bay.The wiring loom within the E&E bay.
Investigating Agency: AAIBAAIB
Category: Accident
During a routine flight near Paris, an ETOPS flight from Zurich to Washington DC, an aircraft experienced an unusual series of events leading to a diversion and landing at Heathrow. Initial warnings triggered circuit breaker tripping, resulting in a right thrust reversal failure and smoke generation. The commander ordered an evacuation due to the aircraft’s landing on a taxiway adjacent to the runway, with several minor injuries sustained during the evacuation. Investigation revealed a wiring loom damage caused by electrical arcing, leading to thermal damage and smoke. Prior damage to the wiring loom insulation and a replacement of the chiller unit the day before the accident further contributed to the issue. Swarf contamination within the E&E bay, coupled with incorrect chiller unit installation, exacerbated the situation, and inadequate smoke warning system detection led to the crew’s unawareness of the fire. The jammed off-wing escape slide prevented the evacuation, and worn latching on the escape slide compartment also played a role.During a routine flight near Paris, an ETOPS flight from Zurich to Washington DC, an aircraft experienced an unusual series of events leading to a diversion and landing at Heathrow. Initial warnings triggered circuit breaker tripping, resulting in a right thrust reversal failure and smoke generation. The commander ordered an evacuation due to the aircraft’s landing on a taxiway adjacent to the runway, with several minor injuries sustained during the evacuation. Investigation revealed a wiring loom damage caused by electrical arcing, leading to thermal damage and smoke. Prior damage to the wiring loom insulation and a replacement of the chiller unit the day before the accident further contributed to the issue. Swarf contamination within the E&E bay, coupled with incorrect chiller unit installation, exacerbated the situation, and inadequate smoke warning system detection led to the crew’s unawareness of the fire. The jammed off-wing escape slide prevented the evacuation, and worn latching on the escape slide compartment also played a role.

Description

Whilst in cruising flight near Paris during an ETOPS flight from Zurich to Washington, DC, abnormal warnings appeared on the flight deck instrumentation and circuit breakers began tripping. The commander, in consultation with the operator’s maintenance control centre at London-Heathrow Airport, decided to divert and land at Heathrow. The aircraft subsequently landed safely, but during the landing ground roll the right thrust reverser failed to deploy fully and smoke appeared at the forward end of the passenger cabin. As a result, the commander ordered an evacuation when the aircraft was on the taxiway, adjacent to the landing runway. During the evacuation, the right off-wing escape slide failed to deploy and several minor injuries occurred. A confusion in communication between the aircraft and various Air Traffic Control units resulted in the Heathrow Airport Tower controller being unaware that the aircraft was landing with technical problems until the evacuation was announced, whereupon the emergency services were alerted. The investigation identified the following causal factors: 1. The tripping of multiple circuit breakers had been caused by the occurrence of electrical arcing and associated thermal damage to a wiring loom adjacent to the aft/upper inboard corner of the forward galley chiller unit within the Electronic and Equipment (E&E) bay, with resultant thermal damage to an adjacent loom and smoke generation. 2. Prior damage to the wiring loom insulation adjacent the aft/upper corner of the chiller unit had occurred due to contact with such units during associated removal and installation; this chiller unit had been replaced on the day before the accident. 3. Aluminium alloy swarf was present within the E&E bay prior to the accident and had probably assisted the onset of arcing between adjacent damaged wires in the loom. 4. Incorrect installation of the chiller unit, with its heat exchanger exhaust fitted with a blanking plate, would have caused warm exhaust air to discharge from an alternative upper vent which was capable of blowing any aluminium swarf around the wiring looms. 5. The crew were unaware of the potentially serious arcing fire in the E&E bay during the flight due to failure of the bay smoke warning system to activate on the flight deck, because the density of smoke emitted by the arcing wiring in the bay was not apparently sufficient to be detected by the only smoke sensor, which was located in the card and rack cooling system exhaust duct. 6. The jamming of a severely worn latch, associated with the right off-wing slide compartment, prevented that escape slide from operating during the evacuation; such latches exhibited vibration induced wear on other aircraft.

Source of Information

https://www.gov.uk/aaib-reports/5-2000-boeing-767-322er-n653ua-9-january-1998https://www.gov.uk/aaib-reports/5-2000-boeing-767-322er-n653ua-9-january-1998

Primary Cause

Electrical arcing and thermal damage to a wiring loom adjacent to the aft/upper inboard corner of the forward galley chiller unit within the Electronic and Equipment (E&E) bay, resulting in thermal damage to an adjacent loom and smoke generation.Electrical arcing and thermal damage to a wiring loom adjacent to the aft/upper inboard corner of the forward galley chiller unit within the Electronic and Equipment (E&E) bay, resulting in thermal damage to an adjacent loom and smoke generation.

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