DCA06MA022

NTSB accident investigation · Douglas DC-8 · Philadelphia, PA · February 8, 2006

Accident · Minor injuriesClass 1 · MajorFinal report
Date
February 7, 2006, 23:59 local (Feb 8, 2006, 04:59 UTC)
Place
Philadelphia, PA
Injuries
3 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N748UPDouglas DC-8
Weather
Visual (VMC) · Night
Status
Completed · report January 31, 2008
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20060207001809A
Case key
63204

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

an in-flight cargo fire that initiated from an unknown source, which was most likely located within cargo container 12, 13, or 14. Contributing to the loss of the aircraft were the inadequate certification test requirements for smoke and fire detection systems and the lack of an on-board fire suppression system.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireDescent
Cargo/baggage - fireCause
Fire extinguisher,cargo - lack ofFactor
Fire warning system,cargo - inadequate
Smoke detector(s) - inadequate
Acft/equip,inadequate standard/requirementFactor
Inadequate certification/approvalFactor

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/2007/AAR0707.pdf. The Aircraft Accident Report number is NTSB/AAR-07/07.

On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport, Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/2007/AAR0707.pdf. The Aircraft Accident Report number is NTSB/AAR-07/07.

On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident.

The accident occurred on the second day of a 5-day, 8-leg trip sequence for the flight crew. The airplane pushed back from the gate at Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, and departed for PHL about 2241. The first officer was the flying pilot, and the captain performed the duties of the pilot monitoring.

The accident flight crew reported that the flight was uneventful until just after beginning the descent to PHL. At 2334:39, while the airplane was descending through flight level 310 about 50 nautical miles southwest of Washington, D.C., the cockpit voice recorder (CVR) recorded the first officer asking the captain and the flight engineer if they detected an odor that smelled "like wood burning." The flight engineer replied that he had "smelled it for a couple of seconds." About 1 minute later, the first officer stated, "[it's] pretty strong now." Subsequently, the CVR recorded a sound similar to the cockpit door or seat operating and the flight engineer stating, "[it's] more in the back." About 3 1/2 minutes later, the first officer again stated that the odor smelled like wood, and the flight engineer agreed that the odor did smell like wood burning and stated that it did not smell electrical in nature.

During postaccident interviews, the captain stated that he considered diverting to another airport soon after the odor was first detected but that he chose to continue to PHL because there was no evidence of a problem, such as the illumination of the cargo smoke warning lights. The first officer stated that the odor did not appear to be a threat because the flight engineer did not see any visible smoke; therefore, the first officer did not believe that there was any need to divert. Further, the accident flight crew stated that unusual odors could be common from nonthreatening factors (such as flying over forest fires or unusual cargo).

Over the next 4 minutes, the captain and flight engineer tried to identify the source of the odor by conducting several emergency checklist steps, including increasing the bleed air flow and checking the bleed air switches. As the airplane was descending through about 18,000 feet and was about 65 miles from PHL, the CVR recorded the flight engineer stating that he set the air conditioning packs to maximum flow and turned off the recirculation fan. Shortly thereafter, the flight engineer and captain conducted the Approach checklist.

At 2344:59, the first officer contacted the PHL Terminal Radar Approach Control, and the approach controller instructed the flight to descend to 6,000 feet. The CVR then recorded the captain asking, "can you still smell it in the back there?" The flight engineer replied, "yeah . . . smells like it was more to the back there." The first officer then asked, "smells like cardboard burning doesn't it? you didn't see smoke though something like that?" The flight engineer again went back to check the main cargo compartment with his flashlight, and he stated that the odor was "definitely stronger in the back" but that there was no smoke or haze. Over the next 10 minutes, the captain and flight engineer continued to troubleshoot the problem.

At 2354:42, as the airplane was descending through about 3,600 feet, the flight engineer stated, "we got cargo smoke." The captain replied, "let's do that checklist if you got time." The first officer then stated that he would be turning toward the airport. At 2355:01, the PHL approach controller cleared the visual approach to runway 27R and then instructed the flight crew to contact the air traffic control tower (ATCT). Ten seconds later, the captain made initial contact with the ATCT local controller, who cleared the flight to land on runway 27R. After acknowledging the clearance, the captain reported that the cargo smoke indicator had illuminated and requested that emergency response equipment meet them upon landing. The local controller immediately activated the crash phone and advised approach control of the emergency.

At 2355:57, the flight engineer stated, "[it's] showing that we have a lower aft cargo fire section C." Subsequently, the captain told the first officer and flight engineer to don their oxygen masks if they had not done so already. The captain then asked the flight engineer to accomplish the Lower and/or Main Cargo Compartment Smoke or Fire checklist by himself, and the flight engineer proceeded to execute the checklist.

According to air traffic control transcripts, the Philadelphia approach controller asked the PHL ATCT local controller whether the flight was going to land on the left side, referring to runway 27L, which is the runway at PHL designated for use in emergency situations. At 2356:12, the local controller cleared the flight to land on runway 27L, and the captain acknowledged the landing clearance but not the change in landing runway.

The flight engineer continued the Lower and/or Main Cargo Compartment Smoke or Fire checklist items. When he reached the step to close the cargo air shutoff valve, he stated that he had to "go in the back and do that." During postaccident interviews, the flight engineer stated that, when he opened the door of the access panel to the cargo air shutoff valve, black smoke billowed out of the access panel.

At 2357:47, the first officer called for the Landing checklist. About 21 seconds later, the ATCT local controller stated, "just confirmed you are lined up for the left side it appears that you are lined up for the right." The first officer replied, "I thought we were cleared for the right . . . are we cleared to land on the right?" At 2358:16, the local controller replied, "you are cleared to land on the right we will just tell fire." The airplane landed on runway 27R about 2359.

Immediately after touchdown, the flight engineer reported smoke in the cockpit. After the airplane came to a stop, the first officer called for an emergency evacuation, and the captain and first officer conducted the Emergency Evacuation checklist. All of the flight crewmembers successfully evacuated the airplane using the emergency slide located at the left forward door.

Aircraft

Registration
N748UP
Reported as
Douglas DC-8
Category
Airplane
Serial number
45948
Airframe hours
67,676
Engine
CFM International CFM56-2C1, 22,000 hp, turbo fan
Damage
Destroyed
Fire
Both
Flight
Part 121
Operator
United Parcel Service Co
Registered owner
United Parcel Service Co
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · February 1, 2006 · 2 hours before
Departed
ATL · Atlanta, GA
Destination
PHL · Philadelphia, PA
Airport
PHL · Philadelphia Intl

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Co-pilot
Age
40
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Multi-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
January 1, 2006
Seat
Right
Flight hours
7,500 total · 5 in the last 90 days · 5 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
300° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
34 °F, dew point 18 °F
Altimeter
30.04 inHg
Observed at
kphl

Docket · 168

The files NTSB released with the investigation on July 12, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 194 MB in all.

Order of Hearing: Exhibit 1AItem 1 · .PDF · 140 KBDesignation of Parties To The Hearing: Exhibit 1BItem 2 · .PDF · 29 KBNotice of Hearing: Exhibit 1CItem 3 · .PDF · 27 KBDesignation of Hearing Officer: Exhibit 1DItem 4 · .PDF · 38 KBDesignation of Chairman of Board of Inquiry: Exhibit 1EItem 5 · .PDF · 180 KBOperations 2 - Factual Report of Group ChairmanItem 6 · .PDF · 201 KBOperations 2 - Attachment 1 - Interview SummariesItem 7 · .PDF · 89 KBOperations 2 - Attachment 2 - Flight PapersItem 8 · .PDF · 695 KBOperations 2 - Attachment 3 - Aircraft Operating Manual ExcerptsItem 9 · .PDF · 2.3 MBOperations 2 - Attachment 4 - Quick Reference Handbook ExcerptsItem 10 · .PDF · 480 KBOperations 2 - Attachment 5 - Flight Operations Manual ExcerptsItem 11 · .PDF · 503 KBOperations 2 - Attachment 6 - BulletinsItem 12 · .PDF · 247 KBOperations 2 - Attachment 7 - DC-8 Aircraft Systems Manual ExcerptsItem 13 · .PDF · 1.2 MBOperations 2 - Addendum 1Item 14 · .PDF · 584 KBOperations 2 - Addendum 2Item 15 · .PDF · 615 KBATC 3 - FAA Accident PackageItem 16 · .PDF · 5.0 MBSystems 9 - Factual Report of Group ChairmanItem 17 · .PDF · 1 photo · 649 KBSystems 9 - Factual Report Addendum 1Item 18 · .PDF · 181 KBFlight Data Recorder 10 - Specialist's Factual ReportItem 19 · .PDF · 137 KBFlight Data Recorder 10 - Attachment 1: Tabular FDR DataItem 20 · .CSV · 629 KBMaintenance Records 11 - Attachment 2 - Airplane and Engine InformationItem 21 · .PDF · 40 KBMaintenance Records 11 - Attachment 4 - Airplane Technical LogItem 22 · .PDF · 320 KBMaintenance Records 11 - Cargo Loading Information and InterviewsItem 23 · .PDF · 31 KBMaintenance Records 11 - Attachment 3 - UPS DC-8 Minimum Equipment ListItem 24 · .PDF · 37 KBMaintenance Records 11 - Factual Report of Group ChairmanItem 25 · .PDF · 41 KBMaintenance Records 11 - Attachment 1 - Operator CertificatesItem 26 · .PDF · 65 KBMaintenance Records 11 - Attachment 5 - Weight and BalanceItem 27 · .PDF · 284 KBMaintenance Records 11 - Attachment 6 - Ceiling Light DeferralItem 28 · .PDF · 708 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 29 · .PDF · 181 KBLou Lombardi interview summaryItem 30 · .PDF · 10 KBExhibit 16A - Factual Report of Survival Factors/Airports and Emergency Response Group ChairmanItem 31 · .PDF · 169 KBAirports/ARFF 16 - Attachment 1 - Interior Arrangements for UPS DC-8 Cargo AirplaneItem 32 · .PDF · 84 KBAirports/ARFF 16 - Attachment 2 - UPS Service Engineering Order Number DC8-5210-3206-BItem 33 · .PDF · 1.6 MBAirports/ARFF 16 - Attachment 3 - UPS DC-8 External Access Door DiagramItem 34 · .PDF · 128 KBAirports/ARFF 16 - Attachment 4 - UPS DC-8 Emergency Equipment Location and Forward Area Installation DiagramsItem 35 · .PDF · 199 KBAirports/ARFF 16 - Attachment 5 - UPS Boeing DC-8 Escape Tapes: Maintenance PracticesItem 36 · .PDF · 97 KBAirports/ARFF 16 - Attachment 6 - PHL Airport DiagramItem 37 · .PDF · 163 KBAirports/ARFF 16 - Attachment 7 - PHL Airport Self-Inspection for February 07, 2006Item 38 · .PDF · 510 KBAirports/ARFF 16 - Attachment 8 - PHL Operation Section: Shift Highlights for February 07, 2006Item 39 · .PDF · 135 KBAirports/ARFF 16 - Attachment 9 - PHL Field Condition Report for February 08, 2006Item 40 · .PDF · 215 KBAirports/ARFF 16 - Attachment 10 - NOTAMsItem 41 · .PDF · 87 KBAirports/ARFF 16 - Attachment 11 - PHL Triennial Drill InformationItem 42 · .PDF · 623 KBExhibit 16E - Airports/ARFF 16 - Attachment 12 - PHL Fire Communication Center Dispatch LogItem 43 · .PDF · 550 KBAirports/ARFF 16 - Attachment 13 - Standby Positions for ARFF at PHLItem 44 · .PDF · 226 KBAirports/ARFF 16 - Attachment 14 - ARFF Incident ReportItem 45 · .PDF · 423 KBAirports/ARFF 16 - Attachment 15 - PHL ARFF Equipment ListItem 46 · .PDF · 131 KBAirports/ARFF 16 - Attachment 16 - PHL ARFF Training RecordsItem 47 · .PDF · 5.0 MBExhibit 16B - PowerPoint Presentation by Captain Gary Loesch of PHL ARFFItem 48 · PPT · 31.4 MBExhibit 16C - Airports/ARFF 16 - Attachment 17 - Written Statements from UPS & Off-Airport Fire Dept.Item 49 · .PDF · 707 KBExhibit 16D - Advisory Circular 150\5210-17, “Programs for Training of Aircraft Rescue and Firefighting Personnel,” Dated March 9, 1994Item 50 · .PDF · 1.3 MBExhibit 16F-14 CFR Part 139.1 ApplicabilityItem 51 · .PDF · 75 KBHazardous Materials 17 - Group Chairman's Factual ReportItem 52 · .PDF · 107 KBHazardous Materials 17 - Attachment 1: Contents of Packages Contained in ULD Numbers 12 & 13Item 53 · .PDF · 48 KBHazardous Materials 17 - Attachment 2: Items Sent Back to NTSB HeadquartersItem 54 · .PDF · 16 KBHazardous Materials 17 - Attachment 3: UPS Hazardous Materials Forms (Shipping Papers)Item 55 · .PDF · 979 KBHazardous Materials 17 - Attachment 4: MSDS (Abaco Inc.): n-Amyl Methyl KetoneItem 56 · .PDF · 51 KBHazardous Materials 17 - Attachment 5: MSDS (Rema Tip Top): 74A & 74B Vulcanizing CompoundItem 57 · .PDF · 106 KBHazardous Materials 17 - Attachment 6: MSDS (CSB Battery of America Corp.): Lead Acid BatteryItem 58 · .PDF · 61 KBHazardous Materials 17 - Attachment 7: MSDS (Zurn Industries): Neo-Seal Gasket CementItem 59 · .PDF · 58 KBHazardous Materials 17 - Attachment 8: MSDS (Bernz-O-matic): ButaneItem 60 · .PDF · 605 KB
All 168 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N748UP · 1

Matched to the same aircraft by N-number and date.