NTSB/AAR-84-09 - AirDisaster.Com

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iie then proceeded "to :xaturate the washroom with CO by Spraying the PaneKng and ) the seam rrom which smoke was seeping and spraying t4: door of the trash bin. He then closer! ?he lavatory door. -3- At 1902:40, the No. 2 flight attendant reached the cockpit end told the csptain, "Excuse me, there's a fire in the washroon: in the back, they're just. . .went back XG go to pui it. out." Upon being notified cf the fire, the captain ordered the first officer to inspect the lavatory. The captain then donned his oxygen mask and selected the 1GG-perCent oxygen position on his regulator. The first officer left tine cockpit but did not take eitt'er smoke goggles or a portable oxygen bottle with him. (The airplane was not equipped with nor was it required to be equipped with self-contained breathing equipment or a full face smoke mask.) The first officer said that he could not get to the aft lavatory because tkz smoke, which had migrated over the last three to four rows of seats, was too thick. The flight attendant in charge told tbe first officer what he had seen when he opened ?he lavatory door, that he had discharged the CC extinguisher into the lavatory, end that. he had not been able to see the source of the srnzke before closing the door. He to!d the firs? office:, however, that he did not believz the fire was in the lavatory's trash container. The first officer told the flight attendant in charge that he was goirg forward to ge? smoke goggles. At 1904:0:, the first officer returned to the cockpit and told the captain thet The snloke had prevented him from entering the aft lavatory and that he thought "we'd bertei go down." He did not telj the captain that the flight attendant in charge had told him that the fire was not in the trash bin. However, at 1904:16, before the captain could resp~nd, the flight attendant in cnarge came to the cockpit and told the captain that tk passerig-rs had Seen moved fcrward and that the captain didn't "have to worry, I ;?ink its gowza :jg easing up." The firs: cfficer looked back into the cabirl. and said that i: was 1 elinost clear in the back. At 1901:23, he told the captain, "it's starting to cleai now," and thet he would go aft ag8in if thc captain wanted him to do so. According to the captain, the iirst officer's smoke goggles were srored in a bin on the right side of the cockpit and were not esiiy accessible to the firs'i officer while he was not in his sea:. Sinee tine first officer needed the goggles and since there was a hurry, the captain gave him his goggles and, 8'. i901:45, directed him to go aft. The first officer akc testified That the captain an< he "did not discus the type of iire at ell" during the tin;e he was in the cockpit before Tie went to the !tir~iory ?the second time. A? i30652: while thI2 first officer was out of the cockpit, the flight attendanz in -t!vrge tc:c' the ceptain again :hst the smoke was clearing. The captain testified that he believer: the fire was in thf lavatory trash bin and that he did not decide to descend at *-.. :I> tirne 'se.eeuse. '*I expectec: it (the fire) to be put out." in rhe meanwFs,ile? the first officer proceeded to the aft lavatory 2nd pltr on the smoke gopgies. tie tesrised thaK he h6d intended to open the door to see what the siruetic- was inside, Sat when he discovered that the lavatory door felt bot to :he touch, ;;e .&cider: mt to open it and ir,strwred the cabin crew io leave it closed. At that xime, he noticed e !!ish? attendant signaling him to burry back to the cockpit. 'The first officer :crcrsec: ?cj the cwkpi; end ggt into his seal, and a? :907:11, ne told the c~tsin, "I don': . izs:? .... .. WSPI'E hri?peni;.lg, i thilk we better go down, okay?'? The caprain tesiified that, Zr..i-. .. .. . . . . ~ ~ 6x7 :,A. !:?zi .::!!cc+ voice i!!r'iection, he knew that the first officer believed the fire L~Y_S ~ .- . .%r-:~~i .ii.. . x..i z,3~: itiz5:35, shik the officer was aft to inspect :he aft lavetol-y, the r..:.c::s:-2+ ::+..:: . . .zy;:iexed s szies of ele..i?ical malfunctions. According to :he cs*:sin, ii 3 T7hs:,:y z::,:?icz !:gh: :::xciEe:e~? ic~jcatirg that the eirpbne's left e..*. aZ d.c.
-4- electrical systems had lost power. At 1906:12, the captain called Indianapolis Center and requested the Center to standby because the flight ha3 an "electrical problem." About 30 to 45 seconds later, the Louisville high radar sector controller working Flight 797 lost the flight's radar beacon target. The controller then directed the computer to track ail primary targets. Flight 797% position was then depicted on the scope by a plus sign and associated data block. About 1307:41, after the first officer had returned to the cockpit, the master warning light illuminated and the annunciator lights indicated that the emergency 4.c. and d.c. electrical buses had lost power. The captain's and first officer's attitude directional indicators tumbled. The captain ordered the first officer to activate the emergency power switch, thereby directing battery power to the emergency ax. and d.c. buses. The attitude directional indicators' gyros began erecting, however, because of the loss of a.c. power, the stabilizer trim was inoperative and remained so during the rest of the flight. The descent At the Air Traffic Control Facilities.-At 1908:12, Flight 797 called the radar high sector controlfer at Indianapolis Center end said, "Mayday, Mayday, Mayday.'! 4i The Louisville radar high sector controller acknowledged the call, and at 1908:47, theflight told the controller that it had a fire and was going down. The controller told the flight that it was 25 nautical miles (nmi) from Cincinnati and asked "can you possibly make Cincinnati." The flight answered that it could make Cincinnati and then requested clearance; it was then clea-ed to descend to 5,000 feet. At 1909:05, Flight 79'2 reported that it was leaving FL 330. The flight then told the controller that it needed to be vectored toward Cincinnati, that it was declari,?g an emergency, and that it had changed its transponder code to 7700 -- the emergency code. However, the transponder was inoperative due to the power loss, and the emergency code was never portrayed on the Center's radarscopes. At 1909:29, the Louisville radar high sector controller directed the flight to turr, to 060° and toid it that the Greater Cincinnati Airport (Cincinnati Airport) was at "twelve o'clock at twenty miles." The controller said that it was cbvioits to hin that FIight 797 had to descenti "immediately;': therefore, he issued the clearance and stated that he was going to coordinate the descent with the other sectors at the center later. He further stated that the 060O heading was intended to place the flight on course toward Cincinnati Airport. He heard Flight 797 report leaving FL 330; however, because of the inoperative transponder, mode C altitude informetion was no longer being received and there was no indication on his radarscope that the flight was descending. At 1909:17, Indianapolis Center's Lexington low attitude D (LEX-D) controller called the approach eontroller at the Cincinnati Airport's Terminal Radar Conzrol (TRACOX) facility to alert him of an impending handoff in his southwesi sector. Six seconds leter, ?he LEY-D controller told the approach controller at Cineinanti he had a "code for you," and at 1909:25, the LEX-D controller then toid the Cincinnati approach controller that he had "en emergency for you, Air Canada seven nine seven.'? The approach controller replied, 'Zero six six two, thirty-five thousand." Zero six six two was the code assigned to Continenta: 383, a westbound iiight at FL 350. At 1909:33, the LEX-0 contro!':r answered, "Yeah, thirty-three right now, he's twenty-five southwest." The &>!roach -ontroller replied, "Radar contact, okay." tiowever, at 1909:38 when the approach eoctro&x accepted the han6off of Flight 797, he had mistaken the radar beacon 4; ~ Tie icernationai -ediotelephonie distress signal. &'hen repeated three times, it indicates imminent and grave danger and that immediate assistance is requested. -
Page 1 and 2: P
Page 3 and 4: Abstract Cont‘d The National T?a.
Page 5 and 6: 4 . 5 . RECOMMENDATIONS ...........
Page 7: 1.1 History of the Plight The in-fl
Page 11 and 12: target of Continental Flight 333 as
Page 13 and 14: At 1915:11, Flight 797 reported tha
Page 15 and 16: -9- Figure 2.--Airplane after fire
Page 17 and 18: B b -11- Between May 7, 1983, and Y
Page 19 and 20: -13- l surface, HIRL, and runway en
Page 21 and 22: -1 5- Figure 3.-Left side. of the a
Page 23 and 24: -1 T- Figure 5.-SOOt trail deposits
Page 30 and 31: -. :'ne gush fixer elow and ro the
Page 32 and 33: -26- Between FS 980 anti FS 965 the
Page 34 and 35: -28- Autopsies were performed on fi
Page 36 and 37: -30- cabin. About 2 to 3 minutes af
Page 38 and 39: -ZE-
Page 40 and 41: -34- joined by the No. 2 attendant,
Page 42 and 43: -36- 1.16.3 Flush Motor and Lavator
Page 44 and 45: !n addition, several samples of qli
Page 46 and 47: -4F- Three-?hase power was applied
Page 48 and 49: -12- The first chafe test was condu
Page 50 and 51: Individual units are protected Sy i
Page 52 and 53: -46- c "auto" position and the low
Page 54 and 55: -48- block displays the airplane's
Page 56 and 57: I -50- The approach emtroller said
Page 58 and 59:
CI D U W U wx Om NORTH RANGE IN N.M
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-51- Since the tests of tine materi
Page 62 and 63:
-56- fire damage in the area, it co
Page 64 and 65:
-53- The path of almost sll fires i
Page 66 and 67:
-60- audible to either the captain
Page 68 and 69:
-62- to 85Sume that, given the cond
Page 70 and 71:
-64- Q judge whe:her survival depen
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-66- in spite of these efforts, sev
Page 74 and 75:
-68- flight attendants to move fart
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4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 1
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Requfre tha: transport category air
Page 80 and 81:
-74- cabin emergency lights, tectii
Page 82 and 83:
-76- Issue a Maintenance Aiert Bull
Page 84 and 85:
1. investigation -79- 5. APPENDIXES
Page 86 and 87:
B Flight Attendant Benetti -81- APP
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-33- APPENDIX D 'T2,5-SCili?T DF A\
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1 r; 0 b. 3 ip 1 2 C h it r; Y b..
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0 n a - 4 0 U a rt rt *rt *- 0 d x-
Page 94 and 95:
TIME 8 SOURCe 1859:47 CAM-1 1859:5%
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8. TIME 8 SOURCE CAM- 2 CAM-2 1902:
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- I! a c. 3 - is - Q
Page 100 and 101:
INTRA-COCKPIT TIME fi SOURCE comrrr
Page 102 and 103:
APPENDIX E 14 CFR 25 FLAME RESISTAN
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NTSB/AAR-84-09 - AirDisaster.Com

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