DCA13IA037

NTSB incident investigation · Boeing 787 · Boston, MA · January 7, 2013

Incident · No injuriesClass 1 · IncidentFinal report
Date
January 7, 2013, 10:30 local (15:30 UTC)
Place
Boston, MA
Damage
Minor damage
Phase of flight
Other
Aircraft
JA829JBoeing 787
Defining event
Other: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report August 5, 2015
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
Case key
85973

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

On this page

Probable cause

an internal short circuit within a cell of the auxiliary power unit (APU) lithium-ion battery, which led to thermal runaway that cascaded to adjacent cells, resulting in the release of smoke and fire. The incident resulted from Boeing's failure to incorporate design requirements to mitigate the most severe effects of an internal short circuit within an APU battery cell and the Federal Aviation Administration's failure to identify this design deficiency during the type design certification process.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Electrical power system: battery/chargerAircraft › Aircraft systems · FailureAll aircraft: 37 casesProbable cause
Electrical power system: battery/chargerAircraft › Aircraft systems · DesignAll aircraft: 37 casesProbable cause
Design: equipment designOrganizational issues › Development · FAA/RegulatorAll aircraft: 35 casesProbable cause
Design: equipment designOrganizational issues › Development · ManufacturerAll aircraft: 35 casesProbable cause
OversightOrganizational issues › Support/oversight/monitoring · FAA/RegulatorAll aircraft: 7 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · ManufacturerAll aircraft: 61 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/01. On January 7, 2013, about 1021 eastern standard time, smoke was discovered by cleaning personnel in the aft cabin of a Japan Airlines (JAL) Boeing 787-8, JA829J, which was parked at a gate at General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts. About the same time, a maintenance manager in the cockpit observed that the auxiliary power unit (APU) had automatically shut down. Shortly afterward, a mechanic opened the aft electronic equipment bay and found heavy smoke coming from the lid of the APU battery case and a fire with two distinct flames at the electrical connector on the front of the case. None of the 183 passengers and 11 crewmembers were aboard the airplane at the time, and none of the maintenance or cleaning personnel aboard the airplane was injured. Aircraft rescue and firefighting personnel responded, and one firefighter received minor injuries. The airplane had arrived from Narita International Airport, Narita, Japan, as a regularly scheduled passenger flight operated as JAL flight 008 and conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 129.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/01. On January 7, 2013, about 1021 eastern standard time, smoke was discovered by cleaning personnel in the aft cabin of a Japan Airlines (JAL) Boeing 787-8, JA829J, which was parked at a gate at General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts. About the same time, a maintenance manager in the cockpit observed that the auxiliary power unit (APU) had automatically shut down. Shortly afterward, a mechanic opened the aft electronic equipment bay and found heavy smoke coming from the lid of the APU battery case and a fire with two distinct flames at the electrical connector on the front of the case. None of the 183 passengers and 11 crewmembers were aboard the airplane at the time, and none of the maintenance or cleaning personnel aboard the airplane was injured. Aircraft rescue and firefighting personnel responded, and one firefighter received minor injuries. The airplane had arrived from Narita International Airport, Narita, Japan, as a regularly scheduled passenger flight operated as JAL flight 008 and conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 129.

Aircraft

Registration
JA829J
Reported as
Boeing 787
Category
Airplane
Serial number
34839
Damage
Minor damage
Fire
On-Ground
Flight
Part 129
Operator
Japan Airlines International Co Ltd
Registered owner
Japan Airlines International Co Ltd
Airworthiness certificate
Standard, Transport
Departed
Narita, OF
Destination
BOS · Boston, MA
Airport
BOS · Gen Edward Lawrence Logan Intl

Weather

Conditions
Visual (VMC) · Day

Docket · 104

The files NTSB released with the investigation on April 23, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 312 MB in all.

Order of Hearing 1AItem 1 · .PDF · 34 KBDesignation of Chairman of Board of Inquiry 1BItem 2 · .PDF · 41 KBDesignation of Hearing Officer 1CItem 3 · .PDF · 44 KBDesignation of Parties to Hearing 1DItem 4 · .PDF · 34 KBNotice of Hearing 1EItem 5 · .PDF · 38 KBInvestigative Hearing Exhibit List 1FItem 6 · .PDF · 67 KBInvestigative Hearing Witness List 1GItem 7 · .PDF · 155 KBInvestigative Hearing Witness Professional Biographies 1HItem 8 · .PDF · 300 KBMaterials 15A – Excerpts from Thales Lithium Ion Cobalt Battery with Internal Contactor Flammability AnalysisItem 9 · .PDF · 167 KBMaterials 15B – Excerpts from Thales BCU/Battery System Safety Assessment ReportItem 10 · .PDF · 201 KBMaterials 15C – Excerpts from Thales Lithium Ion Cobalt Battery with Internal Contactor Acceptance Test ProcedureItem 11 · .PDF · 221 KBMaterials 15D – Excerpts from Thales Lithium Ion Cobalt Battery with Internal Contactor-Climatic Environmental Qualification Test ReportItem 12 · .PDF · 130 KBMaterials 15E – Excerpts from Thales Li-Ion Battery System Safety AssessmentItem 13 · .PDF · 188 KBMaterials 15F – Excerpts from Thales Lithium Ion Cobalt Battery with Internal Contactor Battery Verification ReportItem 14 · .PDF · 335 KBMaterials 15G – Excerpts from Boeing Battery Specification Control DrawingItem 15 · .PDF · 504 KBMaterials 15H – Materials Laboratory Factual ReportItem 16 · .PDF · 12.8 MBMaterials 15I – Fire Investigation Factual ReportItem 17 · .PDF · 2.0 MBAirworthiness 17A – Excerpts from Boeing Battery Specification Control DrawingItem 18 · .PDF · 106 KBAirworthiness 17B – Special Conditions: Airbus Model A380-800 Airplane, Lithium Ion Battery InstallationItem 19 · .PDF · 91 KBAirworthiness 17D – Excerpts from Boeing Battery Charger Unit (BCU) Specification Control DrawingItem 20 · .PDF · 106 KBAirworthiness 17E – Example of Lithium Ion Battery Information Available on the Internet from www.batteryuniversity.com, Author: Isidor BuchmannItem 21 · .PDF · 254 KBAirworthiness 17F – Boeing Provided Presentation about Battery Smoke and Venting at Hamilton Sundstrand Airplane Power Systems Integration Facility (APSIF)Item 22 · .PDF · 63 KBAirworthiness 17G – Thermal Environment section from Thales/GS-Yuasa Interface Control DocumentItem 23 · .PDF · 89 KBAirworthiness 17H – Excerpts from Thales BCU Q2 Qualification Test Procedure, Electrical PerformanceItem 24 · .PDF · 165 KBAirworthiness 17J – Airworthiness Group Chairman Factual ReportItem 25 · .PDF · 4.8 MBSystem Safety and Certification 18A - System Safety and Certification Group Chairman Factual ReportItem 26 · .PDF · 364 KBSystem Safety and Certification 18B – Table 4-2 Boeing Electrical Power System and Window Heat Control Unit Safety AssessmentItem 27 · .PDF · 91 KBSystem Safety and Certification 18C – Table 3-1 Boeing Electrical Power System and Window Heat Control Unit Safety AssessmentItem 28 · .PDF · 160 KBSystem Safety and Certification 18D – Partial Fault Tree “Vent without Fire (With or without Smoke)” Boeing Electrical Power System and Window Heat Control Unit Safety AssessmentItem 29 · .PDF · 141 KBSystem Safety and Certification 18E – Issue Paper Boeing Model 787-8 Special Condition: Lithium-Ion Battery InstallationsItem 30 · .PDF · 389 KBSystem Safety and Certification 18F – Special Conditions: Boeing Model 787-8 Airplane; Lithium Ion Battery InstallationItem 31 · .PDF · 91 KBSystem Safety and Certification 18G – Proposed Special Conditions: Boeing Model 787-8 Airplane; Lithium Ion Battery InstallationItem 32 · .PDF · 86 KBSystem Safety and Certification 18H – FAA response, Dated March 13, 2013, to NTSB E-Mail, Dated February 12, 2013Item 33 · .PDF · 1.2 MBSystem Safety and Certification 18I – Federal Aviation Administration Battery Requirements TimelineItem 34 · .PDF · 188 KBSystem Safety and Certification 18J – FAA Memo from Manager, Transport Standards Staff, Aircraft Certification Service, Dated January 4, 2001Item 35 · .PDF · 68 KBSystem Safety and Certification 18K – Federal Aviation Administration TSO-C179, Rechargeable Lithium Cells and Lithium BatteriesItem 36 · .PDF · 132 KBInterim Report 19A - Interim Factual Report dated March 7, 2013Item 37 · .PDF · 2.7 MBVideo Compilation - Emergency Response to 787 Auxiliary Power Unit Battery FireItem 38 · .PDF · 145 KBInterim Factual Report 03-07-2013Item 39 · .PDF · 2.6 MBMaterials Laboratory Factual Report 13-013Item 40 · .PDF · 117 photos · 12.7 MBSystem Safety and Certification Group Chairman's Factual ReportItem 41 · .PDF · 305 KBAirports/ARFF 16 - Factual Report of Airport Emergency Response Group ChairmanItem 42 · .PDF · 231 KBAirports/ARFF 16 - Attachment 1: BOS Airport DiagramItem 43 · .PDF · 908 KBAirports/ARFF 16 - Attachment 2: BOS ARFF Fire Alarm LogItem 44 · .PDF · 213 KBAirports/ARFF 16 - Attachment 3: BOS ARFF Incident ReportItem 45 · .PDF · 432 KBAirports/ARFF 16 - Attachment 4: BOS ARFF InterviewsItem 46 · .PDF · 292 KBAirports/ARFF 16 - Attachment 5: BOS ARFF Response RouteItem 47 · .PDF · 421 KBAirports/ARFF 16 - Attachment 6: JAL Mechanic StatementItem 48 · .PDF · 195 KBAirports/ARFF 16 - Attachment 7: BOS ARFF Boeing 787 Familiarization Training RecordsItem 49 · .PDF · 288 KBAirports/ARFF 16 - Attachment 8: Boeing Emergency Response Diagrams for Li-ion BatteryItem 50 · .PDF · 223 KBAirworthiness Factual Report of Group ChairmanItem 51 · .PDF · 37 photos · 4.8 MBCockpit Voice Recorder 12 - Specialist Summary Report of InvestigationItem 52 · .PDF · 90 KBComputed Tomography Specialist's Factual ReportItem 53 · .PDF · 108 photos · 9.1 MBFlight Data Recorder 10 - Factual Report of Group ChairmanItem 54 · .PDF · 4.7 MBFlight Data Recorder 10 - Attachment 1: Tabular Data From Forward EAFRItem 55 · ZIP · 887 KBFlight Data Recorder 10 - Attachment 2: Tabular Data From Aft EAFRItem 56 · ZIP · 373 KBOn Scene Fire Investigation Factual Report 13-014Item 57 · .PDF · 32 photos · 1.9 MBWitness Statement - Station ManagerItem 58 · .PDF · 76 KBWitness Statement - Turn Around CoordinatorItem 59 · .PDF · 115 KBPilot StatementItem 60 · .PDF · 37 KB
All 104 files on NTSB’s docket