# NTSB ENG09IA016: Boeing 767 432ER, N840MH, St. Johns, Canada, September 8, 2009 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: September 7, 2009, 21:00 local (Sep 8, 2009, 01:00 UTC) - Place: St. Johns, Canada - Coordinates: 47.5, -52.599998 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.5000&lon=-52.6000&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) - Highest injury: No injuries - Status: Completed, report November 13, 2014 - Report: Approved by Office Director - NTSB office: Aviation Engineering Division - NTSB case key (mKey): 74697 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ENG09IA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74697/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74697 - Page: https://openairdocs.org/ntsb/ENG09IA016 ## Probable cause Incorrect installation of a wire bundle, which contained wires for oxygen system, passenger address system and lavatory power, led to chafing of the wires on structure. The chafing eventually exposed the wire conductors and resulted in electrical arcing, malfunction of the affected systems and a sulfur odor. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Oxygen system: oxygen sys wiring](https://openairdocs.org/ntsb-findings/01023597): Aircraft › Aircraft systems · Damaged/degraded (probable cause) ## Analysis The Delta Airlines 767 was two hours enroute from John F. Kennedy International Airport (JFK) to Venice Marco Polo Airport (VCE), when the cabin lights flickered, the passenger address system was intermittent and then inop, the left side oxygen masks deployed and a sulphur smell was observed, but no smoke. The flight diverted to ATL and landed without incident. Examination of the area above the forward lavatory on the left side revealed fractured wires, sooted equipment, and chafed structure. Drawings showed the wire bundle was incorrectly routed. These findings indicated that the incorrect routing allowed the wires to chafe over time. This chafe eventually exposed the conductor(s) and either two wires or a wire to grounded structure resulted in a electrical short with arcing. A review of the wire functions within the bundle showed wires related to oxygen system, passenger address system, and lavatory power. This is consistent with the reported anomalies. ## Factual narrative On September 7, 2009 at approximately 2100 EDT a Delta Air Lines (DAL) 767, N840MH, operating as flight 186, was two hours enroute from John F. Kennedy International Airport (JFK) to Venice Marco Polo Airport (VCE), when the cabin lights flickered, the Passenger Address System was intermittent and then inop, the left side oxygen masks deployed and a sulphur smell was observed, but no smoke. The flight diverted to ATL and landed without incident. There were 206 passengers, 8 cabin crew and three flight crew and no injuries were reported. DAL maintenance crews examined the area above the forward lavatory on the left side and found a wire bundle which had numerous fractured and melted wires, with soot on the bundle and immediate area. There were also signs of chaffing on a piece of support structure near the cable routing. A review of the Boeing wire installation drawings revealed that the damaged wire bundle was routed incorrectly and not properly secured. DAL performed a fleet inspection and found one other airplane with this wire bundle incorrectly routed. It was not damaged and they corrected the installation. The investigation did not determine if the incorrect routing occurred during manufacturing, maintenance, or modifications. A review of the wires in the bundle confirmed that oxygen system, passenger address system, and lavatory power wires were included in the bundle. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) (defining event) ## Aircraft - Registration: [N840MH](https://openairdocs.org/aircraft/N840MH), registered now, S/N 29718, built 2001 (OpenAirDocs) - Reported make and model: BOEING 767 432ER (432ER) - Registry model: [Boeing 767-432ER](https://openairdocs.org/model/boeing-767-432er) (registry code 1385134) (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: 29718 - Year built: 2001 - Damage: Minor damage - Fire: In-Flight - Flight: Part 121 - Operator: Delta Air Lines Inc - Registered owner: Delta Air Lines Inc - Airworthiness certificate: Unknown - Departed: JFK, NEW YORK, NY - Destination: VCE, Venice - Flight plan: Unknown ## Weather - Conditions: Not reported ## Docket (1 files) The files NTSB released with the investigation on November 13, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74697. 1.6 MB in all. - Systems 9 - Factual Report of Group Chairman (item 1, .PDF, 3 photos, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404632&FileExtension=.PDF&FileName=Systems%209%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.