# NTSB DCA08MA076: Boeing 767, N799AX, San Francisco, CA, June 28, 2008

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 1 · Major · Final report
- Date: June 28, 2008, 10:15 local (17:15 UTC)
- Place: San Francisco, CA
- Coordinates: 37.610763, -122.379699 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=37.6108&lon=-122.3797&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Defining event: [Standing-engine(s) start-up: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report March 28, 2010
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Parties: Boeing, FAA
- Safety recommendations: Yes
- NTSB case key (mKey): 68326
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA08MA076.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68326/pdf
- Board report AAR0904 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0904.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68326
- Page: https://openairdocs.org/ntsb/DCA08MA076

## Probable cause

The design of the supplemental oxygen system hoses and the lack of positive separation between electrical wiring and electrically conductive oxygen system components. The lack of positive separation allowed a short circuit to breach a combustible oxygen hose, release oxygen, and initiate a fire in the supernumerary compartment that rapidly spread to other areas. Contributing to this accident was the Federal Aviation Administration’s failure to require the installation of nonconductive oxygen hoses after the safety issue concerning conductive hoses was initially identified by Boeing.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Oxygen system: passenger oxygen system](https://openairdocs.org/ntsb-findings/01023520): Aircraft › Aircraft systems · Design (probable cause)
- [Selection/certification/testing: equip certification/testing](https://openairdocs.org/ntsb-findings/04012015): Organizational issues › Development · FAA/Regulator (probable cause)
- [Fire protection system: smoke, detection](https://openairdocs.org/ntsb-findings/01022611): Aircraft › Aircraft systems · Not specified
- [Policy/procedure](https://openairdocs.org/ntsb-findings/04021000): Organizational issues › Management · Operator

## Analysis

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09/04/SUM. On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport, San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121. At the time of the fire, the airplane was parked near a loading facility, all of the cargo to be transported on the flight had been loaded, and the doors had been shut.

## Factual narrative

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09/04/SUM. On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport, San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121. At the time of the fire, the airplane was parked near a loading facility, all of the cargo to be transported on the flight had been loaded, and the doors had been shut.

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Standing-engine(s) start-up: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) (defining event)
- [Standing-engine(s) start-up: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330)
- [Standing-engine(s) start-up: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150)

## Aircraft

- Registration: [N799AX](https://openairdocs.org/deregistered/N799AX-2009-10-22), registration cancelled 2009-10-22, S/N 23432, built 1987 (OpenAirDocs)
- Reported make and model: BOEING 767 (281)
- Registry model: [Boeing 767-200](https://openairdocs.org/model/boeing-767-200) (registry code 1385120) (OpenAirDocs)
- Registry engine: [GE CF6-80 series](https://openairdocs.org/engine/ge-cf6-80-series) (registry code 30025, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 23432
- Airframe hours: 47068
- Engines: general electric CF6-80A turbo jet; general electric CF6-80A turbo jet
- Damage: Destroyed
- Fire: On-Ground
- Flight: Part 121
- Operator: ABX Air, doing business as Dhl
- Registered owner: ABX Air, Inc
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, June 28, 2008
- Flight plan: Unknown
- Airport: SFO, San Francisco International

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 54; injuries: none; airline transport; airplane ratings: multi-engine land; medical: class 1, with waivers/limitations; last flight review February 18, 2008; seat: left; flight hours: 11,469 total
- Co-pilot; age 42; injuries: none; airline transport; airplane ratings: multi-engine land; medical: class 1, without waivers/limitations; last flight review April 18, 2008; seat: right; flight hours: 5,275 total

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20080628839489A](https://openairdocs.org/incident/20080628839489A), Jun 28, 2008: Boeing 767281, San Francisco, CA, Substantial damage. (-23) On June 28, 2008, at approximately 2212 PDT, an abx air flight crew of a B767-281 (N799AX) operatings as cargo flight 1611 out of San Francisco…

## Docket (41 files)

The files NTSB released with the investigation on February 25, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68326. 48.6 MB in all.

- Operations 2 - Factual Report of Group Chairman (item 1, .PDF, 754 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304789&FileExtension=.PDF&FileName=Operations%202%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Operations 2 - Attachment 1 - Interview Summaries (item 2, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302016&FileExtension=.PDF&FileName=Operations%202%20-%20Attachment%201%20-%20Interview%20Summaries-Master.PDF
- Operations 2 - Attachment 2 - Flight Papers (item 3, .PDF, 7.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302018&FileExtension=.PDF&FileName=Operations%202%20-%20Attachment%202%20-%20Flight%20Papers-Master.PDF
- Operations 2 - Attachment 3 - 767 Operating Manual Excerpt (item 4, .PDF, 9.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302020&FileExtension=.PDF&FileName=Operations%202%20-%20Attachment%203%20-%20767%20Operating%20Manual%20Excerpt-Master.PDF
- Operations 2 - Attachment 4 - Flight Operations Manual Excerpt (item 5, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302021&FileExtension=.PDF&FileName=Operations%202%20-%20Attachment%204%20-%20Flight%20Operations%20Manual%20Excerpt-Master.PDF
- Survival Factors 6 - Factual Report of Group Chairman (item 6, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304871&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Survival Factors 6 - Factual Report of Group Chairman ERATTA (item 7, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40311936&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Factual%20Report%20of%20Group%20Chairman%20ERATTA-Master.PDF
- Survival Factors 6 - Attachment 1 Door Operation (item 8, .PDF, 869 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304938&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%201%20Door%20Operation-Master.PDF
- Survival Factors 6 - Attachment 2 - SFO Accident Incident Report (item 9, .PDF, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304942&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%202%20-%20SFO%20Accident%20Incident%20Report-Master.PDF
- Survival Factors 6 - Attachment 3 - FAA Memo ABX 1611 Communication with Ground Control (item 10, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304944&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%203%20-%20FAA%20Memo%20ABX%201611%20Communication%20with%20Ground%20Control-Master.PDF
- Survival Factors 6 - Attachment 4 Airport Event Chronology (item 11, .PDF, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304947&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%204%20Airport%20Event%20Chronology-Master.PDF
- Survival Factors 6 - Attachment 5 Witness Statements (item 12, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309458&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%205%20Witness%20Statements-Redacted.PDF
- Survival Factors 6 - Attachment 6 Photographs (item 13, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304952&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%206%20Photographs-Master.PDF
- Survival Factors 6 - Attachment 7 SFO Video of Firefighting Activities (item 14, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309109&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%207%20SFO%20Video%20of%20Firefighting%20Activities-Master.PDF
- Survival Factors 6 - Addendum 1 (item 15, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315450&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%201-Master.PDF
- Airworthiness Factual Report of Group Chairman (item 16, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305397&FileExtension=.PDF&FileName=Airworthiness%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Airworthiness Group Chairman's Errata and Addendum (item 17, .PDF, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315448&FileExtension=.PDF&FileName=Airworthiness%20Group%20Chairman%27s%20Errata%20and%20Addendum-Master.PDF
- Flight Data Recorder 10 - Specialist's Factual Report (item 18, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305218&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Maintenance Records 11 - Factual Report of Group Chairman (item 19, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307404&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Maintenance Records 11 - Attachment 1 - Operating Certificate (item 20, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300720&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%201%20-%20Operating%20Certificate-Redacted.PDF
- Maintenance Records 11 - Attachment 2 - ABX Service Check (item 21, .PDF, 654 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300721&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%202%20-%20ABX%20Service%20Check-Redacted.PDF
- Maintenance Records 11 - Attachment 3 - ABX MEL Defect Log (item 22, .PDF, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306543&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%203%20-%20ABX%20MEL%20Defect%20Log-Master.PDF
- Maintenance Records 11 - Attachment 4 - ABX STC - Cargo Conversion (item 23, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306544&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%204%20-%20ABX%20STC%20-%20%20Cargo%20Conversion-Redacted.PDF
- Maintenance Records 11 - Attachment 5 - ABX AD Status Report (item 24, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306545&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%205%20-%20ABX%20AD%20Status%20Report-Master.PDF
- Maintenance Records 11 - Attachment 6 - ABX SDR and MISR Reports (item 25, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306546&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%206%20-%20ABX%20SDR%20and%20MISR%20Reports-Master.PDF
- Maintenance Records 11 - Attachment 7 - ABX Major Repairs and Alterations (item 26, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306547&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%207%20-%20ABX%20Major%20Repairs%20and%20Alterations-Master.PDF
- Maintenance Records 11 - Attachment 8 - ABX Oxygen System Maintenance Documents (item 27, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307403&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%208%20-%20ABX%20Oxygen%20System%20Maintenance%20Documents-Redacted.PDF
- Maintenance Records 11 - Attachment 9 - ABX Supernumerary Log Pages (item 28, .PDF, 580 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306549&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%209%20-%20ABX%20Supernumerary%20Log%20Pages-Redacted.PDF
- Maintenance Records 11 - Attachment 10 - ABX Weight and Balance Computer Installation (item 29, .PDF, 478 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306550&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%2010%20-%20ABX%20Weight%20and%20Balance%20Computer%20Installation-Redacted.PDF
- Maintenance Records 11 - Attachment 11 - ABX Galley Light Installation (item 30, .PDF, 946 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306551&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%2011%20-%20ABX%20Galley%20Light%20Installation-Redacted.PDF
- Maintenance Records 11 - Attachment 12 - ABX Mechanic Interviews (item 31, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306552&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%2012%20-%20ABX%20Mechanic%20Interviews-Master.PDF
- Maintenance Records 11 - Attachment 13 - ABX Corrective Actions (item 32, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306553&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Attachment%2013%20-%20ABX%20Corrective%20Actions-Master.PDF
- Maintenance Records 11 - ABX Air, Inc. FAA PMI Statement (item 33, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309729&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20ABX%20Air,%20Inc.%20FAA%20PMI%20Statement-Master.PDF
- Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 34, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306608&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Cockpit Voice Recorder 12 - Errata (item 35, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307438&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Errata-Master.PDF
- Materials Laboratory 15 - Factual Report 08-116 (item 36, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305066&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2008-116-Master.PDF
- Materials Laboratory 15 - Group Chairman Fire Factual Report (item 37, .PDF, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306946&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Group%20Chairman%20Fire%20Factual%20Report-Master.PDF
- Materials Laboratory 15 - Flexible Oxygen Line Fire Test Factual Report (item 38, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306813&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Flexible%20Oxygen%20Line%20Fire%20Test%20Factual%20Report-Master.PDF
- Computed Tomography Specialist Factual Report (item 39, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306844&FileExtension=.PDF&FileName=Computed%20Tomography%20Specialist%20Factual%20Report-Master.PDF
- Party Submission - The Boeing Company (item 40, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313400&FileExtension=.PDF&FileName=Party%20Submission%20-%20The%20Boeing%20Company-Redacted.PDF
- Maintenance Records 11 - Group Chairman's Factual Report Errata (item 41, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315527&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Group%20Chairman%27s%20Factual%20Report%20Errata-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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