Prelim UPS 747 accident report (UAE)

[Kip Powick]

The UAE General Civil Aviation Authority (GCAA) published

a Preliminary Report of their investigation into the September

2010 fatal accident involving a UPS Boeing 747-400F.

A Boeing 747-44AF (SCD) cargo plane, registered N571UP, was

destroyed in an accident shortly after takeoff from Dubai Airport

(DXB), UAE. Both crew members were killed in the crash.

On September 3rd 2010, Flight UPS6 arrived from Hong Kong on a

scheduled cargo service flight into Dubai (DXB) carrying among

other items consignments of cargo that included lithium batteries.

There were no declared shipments of hazardous materials onboard

the airplane. However, at least three of the shipments contained

lithium ion battery packs that met the Class 9 hazardous material

criteria, according to the report.

The aircraft was parked at the loading position at 15:35 local

time. Several Unit Load Devices (ULD) were offloaded and new ULDs

were loaded onto the plane. The flight then took from Dubai at

18:51. The First Officer was the Pilot Flying, the Captain was the

Pilot Non Flying (PNF) for the sector to Köln/Bonn-Konrad Adenauer

Airport (CGN), Germany.

The take off and climb out from Dubai was uneventful with the

exception of a PACK 1 fault which was reset by the PNF at 18:55.

The flight transited from UAE airspace into Bahrain Airspace

where, at 19:12, the fire bell alarm sounded on the flight deck.

The airplane was approaching top of climb (FL320) at the time.

Following the fire bell annunciation, the Captain assumed control

of the aircraft as PF, and the First Officer reverted to PNF while

managing the fire warnings and cockpit checklists. The Captain

advised Bahrain Air Traffic Control (BAH-C) that there was a fire

indication on the main deck of the aircraft. The crew informed

BAH-C that they needed to land as soon as possible. BAH-C advised

the crew that Doha International Airport (DOH) was at the

aircraft’s 10 o’clock position at 100 NM DME. DOH was the nearest

airport at the time the emergency was declared, Dubai (DXB) was

approximately 148 NM DME. The Captain elected to return to DXB,

and following the request to land as soon as possible to BAH-C,

the crew declared an emergency. BAH-C acknowledged the request,

cleared the aircraft for a series of right hand heading changes

back to DXB onto a heading of 106°.

At approximately 19:14, the Auto Pilot (AP) disconnected, followed

at 19:15 by a second audible alarm similar to the fire bell. At

about this time the flight crew put on the oxygen masks and

goggles. The crew experienced difficulties communicating via the

intercom with the masks on, which interfered with the Cockpit

Resource Management (CRM).

Following the initiation of the turn back to DXB, having been

cleared to 27,000 ft, the crew requested an expedited, immediate

descent to 10,000 feet. Following ATC clearance, the flight crew

initiated a rapid descent to 10,000 ft. BAH-C advised the crew

that the aircraft was on a direct heading to DXB and cleared for

landing on DXB runway 12 left at their discretion.

The Fire Main Deck checklist was activated. According to the

system logic, the cabin began to depressurise, PACKS 2 and 3 shut

down automatically, and PACK 2 and 3 positions were then manually

selected to OFF on the overhead panel in accordance with the

checklist instructions.

At 19:15, PACK 1 shut down, with no corresponding discussion

recorded on the CVR. A short interval after the AP was disengaged,

the Captain informed the F/O that there was limited pitch control

of the aircraft in the manual flying mode, the Captain then

requested the F/O to determine the cause of the pitch control

anomaly.

During the turn back to DXB, the AP was re-engaged, and the

aircraft descent was stabilised at 19:17. The Captain told the F/O

to pull the smoke evacuation handle. This was not part of the Fire

Main Deck Non-Normal checklist.

The Captain informed BAH-C that the cockpit was ‘full of smoke’

and commented to the F/O about the inability to see the

instruments. The Captain instructed the F/O to input DXB into the

Flight Management System (FMS). The F/O acknowledged the request

and commented about the increasing flight deck temperature. It was

not clear from the CVR if the FMS was programmed for DXB, although

the DFDR indicated that the ILS/VOR frequency was changed to 110.1

MHz which was the frequency for DXB RW12L. Based on the

information available to date, it is likely that less than 5

minutes after the fire indication on the main deck, smoke had

entered the flight deck and intermittently degraded the visibility

to the extent that the flight instruments could not effectively be

monitored by the crew.

At approximately 19:19, during the emergency descent, at

approximately 20,000 ft cabin altitude, the CAPT, as PF, declared

a lack of oxygen supply. Following a brief exchange between the

Captain and F/O regarding the need for oxygen, the Captain

transferred control of the aircraft to the F/O as PF. Portable

oxygen is located on the flight deck and in the supernumerary

area, aft of the flight crew’s positions when seated. At this

point the recorded CVR is consistent with the Captain leaving his

seat, after which there is no further CVR information that

indicates any further interaction from the Captain for the

remainder of the flight.

The normal procedural requirement of transiting into the Emirates

FIR, inbound for DXB was a radio frequency change from BAH-C to

UAE-C. At 19:20, BAH-C advised the crew to contact UAE-C. At

approximately the same time, the PF transmitted ‘mayday, mayday,

mayday can you hear me?’.

The PF advised BAH-C that due to the smoke in the flight deck, the

ability to view the cockpit instruments, the Flight Management

System (FMS), Audio Control Panel (ACP) and radio frequency

selection displays had been compromised. At 19:21, the PF advised

BAH-C that they would stay on the BAH-C frequency as it was not

possible to see the radios. The PF elected to remain on the BAH-C

radio frequency for the duration of the flight. At approximately

19:22 the aircraft entered the Emirates FIR heading east, tracking

direct to the DXB RW12L intermediate approach fix. The aircraft

was now out of effective VHF radio range with BAH-C. In order for

the crew to communicate with BAH-C, Bahrain advised transiting

aircraft that they would act as a communication relay between

BAH-C and the emergency aircraft.

At 19:22, the F/O informed the relay aircraft that he was ‘looking

for some oxygen’.

Following the rapid descent to 10,000 ft the aircraft leveled off

at the assigned altitude approximately 84NM from DXB. At

approximately 19:26, the PF requested immediate vectors to the

nearest airport and advised he would need radar guidance due to

difficulty viewing the instruments.

At around 19:33, approximately 26 NM from DXB, the aircraft

descended to 9000 ft, followed by a further gradual descent as the

aircraft approached DXB, inbound for RW12L. The speed of the

aircraft was approximately 340 kts.

19:38, approximately 10NM from RW12L, BAH-C, through the relay

aircraft, advised the crew the aircraft was too high and too fast

and requested the PF to perform a 360° turn if able. The PF

responded ‘Negative’. At this time the DFDR data indicated the

gear lever was selected down, the speed brake lever moved toward

extend and at approximately the same time there was a sound

consistent with the flap handle movement; shortly afterward the PF

indicated that the landing gear was not functioning.

The aircraft over flew the DXB northern airport boundary on a

heading of 117°, the aircraft speed and altitude, was 340 kts at

an altitude of 4500 ft and descending. Following the over flight

of DXB, on passing the south eastern end of RW12L, the aircraft

was cleared direct to Sharjah Airport (SHJ) as an immediate

alternate – SHJ was to the aircraft’s left and the SHJ runway was

a parallel vector.

The relay pilot asked the PF if it was possible to perform a left

hand turn. The PF responded requesting the heading to SHJ.

The PF was advised that SHJ was at 095° from the current position

at 10 NM and that this left hand turn would position the aircraft

on final approach for SHJ (RW30). The PF acknowledged the heading

change for SHJ. The PF selected 195° degrees on the Mode Control

Panel (MCP).

The AP disconnected at 19:40, the aircraft then entered a

descending right hand turn at an altitude of 4000 ft as the speed

gradually reduced to 240 kts until the impact.

Several Ground Proximity Warning System (GPWS) caution messages

were audible on the CVR indicating: Sink Rate, Too Low Terrain and

Bank Angle warnings. Radar contact was lost at approximately

19:41. The aircraft crashed 9nm south of DXB onto a military

installation near Minhad Air Force Base.