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National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National...

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National Transportation Safety Board Carol Carmody Chairman Carol Carmody Chairman Speaking at the Aging Aircraft Conference September 12, 2001
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Page 1: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Carol CarmodyChairman

Carol CarmodyChairman

Speaking at the

Aging Aircraft ConferenceSeptember 12, 2001

Page 2: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

FAA PassengerGrowth ForecastFAA PassengerGrowth Forecast

1 Billion

664.5Million 2001 2011

Pass

enge

rs

Page 3: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

FAA FleetGrowth Forecast

FAA FleetGrowth Forecast

2001 2011

U.S

. Jet

Tra

nspo

rts

7,500

5000

Page 4: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Fleet Average Age ForecastFleet Average Age Forecast

20.0

18.0

15.8 1998 2008

Ave

rage

Age

Page 5: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Aloha Flight 243 (1988)Aloha Flight 243 (1988)

Page 6: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Narita 747 Engine SeparationNarita 747 Engine Separation

Page 7: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Wire failures in 1970sled to Navy findings

Wire failures in 1970sled to Navy findings

Wire insulation cracked in Navy F-4 Phantoms, such as this.

Page 8: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Finding #24 from TWA 800 ReportFinding #24 from TWA 800 Report

Until recently, insufficient attention has beenpaid to the condition of aircraft electricalwiring, resulting in potential safety hazards.

Page 9: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Air Canada DC-9, CVG, June 2, 1983

Electrical Events Preceding TWA 800Resulted in Numerous Safety

Recommendations

Electrical Events Preceding TWA 800Resulted in Numerous Safety

Recommendations

Page 10: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

L-1011 In-flight Fire,March 17, 1991, Near Goose Bay, Canada

FIRELOCATION

Page 11: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Although the Board continued to recommendthat the FAA call for better care of electrical

systems, the fleet did not change:

1991 Debris found in L-1011

1998 Debris found in surveyed 747

Page 12: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Fluid Testing of Wires DuringTWA800 Investigation

Fluid Testing of Wires DuringTWA800 Investigation

Arcing event photographed during short circuit created by fluid drip on wires.

Page 13: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Identify and Protect Critical CircuitsIdentify and Protect Critical CircuitsFirst, identify/triage what is critical:

Passenger Entertainment?Potential fire hazards or problems leading to falsecockpit indications?Wires leading into fuel tanks, fire systems, or foremergency oxygen?

Then identify how to protect the criticalcircuits.

Page 14: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Electrical fires continuewhile fleet changes waitElectrical fires continuewhile fleet changes wait

Nov 2000, turn-back at ATL. Lav fluid in wirebundle led to fire that burned through skin.

Page 15: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

B-767 Wire Fire, LHR, Jan 9, 1998

Example of direct & secondary damage, due toinadequate clearance between bundles

Example of direct & secondary damage, due toinadequate clearance between bundles

REMOTE SECONDARY DAMAGE TO THRUST

REVERSER INDICATIONCIRCUIT CARD

Page 16: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

FAA Developing Automated ServiceDifficulty Reporting (SDR) System

FAA Developing Automated ServiceDifficulty Reporting (SDR) System

Will facilitate trend analysis & prevention.

Scheduled Implementation:3rd Q 2003

Page 17: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Investigation into TWA 800 led to findingaging problems in systems.

Page 18: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Wire bundle separation for FQISWire bundle separation for FQIS

Page 19: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Non-standard wire repairs

Insulation cracks

Conductive residues

Drill shavings

Com pression dam age to

Residue visible on surface - highconcentrations of silver, copper,and sulfur

Photos from TWA800 wreckagePhotos from TWA800 wreckageTeflon Wrap

Fiberglass LacingBraid

Page 20: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Photos of Transport Airplane WiringPhotos of Transport Airplane Wiring

Degraded racewayclamps & chafes

Contaminants

Cracks

Page 21: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

FAA Aging Systems PlanFAA Aging Systems Plan

• Establish oversight within FAA• Review fleet & fix• Enhance maintenance• Add to aging research• Improve Reporting• Evaluate additional maintenance needs• Improve wire instructions

Page 22: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Boeing (5 seats)Airbus (4 seats)Airborne ExpressAir CanadaAirTran AirwaysBombardier

FAA & JAA (2 seats)

ATSRAC Group Membership Example(Example: Standard Wire Practice Manual Revision Group)

British AirwaysCessnaDassaultDelta AirlinesNBAASR TechnicsUnited Airlines

Page 23: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Safety Recommendation A-00-108(Initial Text)

Safety Recommendation A-00-108(Initial Text)

Regardless of the scope of theATSRAC’s eventual recommendations,address all of the issues identified in theAging Transport Non-Structural SystemsPlan.

Page 24: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Thai International Airways TG114Thai International Airways TG114

Initial explosion and fire in Boeing 737 on March 3, 2001.

Page 25: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

SwissAir 111 MD-11 ReconstructionSwissAir 111 MD-11 ReconstructionInterior, as viewed forward to the cockpit door.

Accident of Sept 2, 1998, at Peggy’s Cove, Nova Scotia.Airplane built in 1991.

Page 26: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

NTSB, USAF, and FAA Lab WorkFound Problems in Aged Wiring

NTSB, USAF, and FAA Lab WorkFound Problems in Aged WiringExamples: Hardened and split insulation Work-hardened conductors (fatigued) in

crimps Average distance between breached wires measurable in hundreds of feet.

Page 27: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Wire Performance RequirementsWire Performance RequirementsFAA EAPAS calls for R&D to: Investigate and develop performancerequirements, test criteria and procedures foraircraft wire. Estimated completion in 3rd Q 2002 To result in report for inclusion in TSOor FAR Part 25.

Page 28: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

8+ Years Between Accident and FAAPlanned Implementation (no slippage)

8+ Years Between Accident and FAAPlanned Implementation (no slippage)

Initial TWA800 Rescue & Recovery by New York City and Suffolk County Police

Page 29: National Transportation Safety Board Carol Carmody · 2002. 2. 7. · 3rd Q 2003. National Transportation Safety Board Investigation into TWA 800 led to finding aging problems in

National Transportation Safety Board

Carol CarmodyChairman

Carol CarmodyChairman

Speaking at the

Aging Aircraft ConferenceSeptember 12, 2001


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