LAX01IA066

NTSB incident investigation · Lockheed L-1011-385-1 · Honolulu, HI · December 30, 2000

Incident · No injuriesIncident investigationFinal report
Date
December 29, 2000, 21:15 local (Dec 30, 2000, 07:15 UTC)
Place
Honolulu, HI
Injuries
300 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N735DLockheed L-1011-385-1
Weather
Instrument (IMC) · Night/dark
Status
Completed · report November 25, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20001229031759I
Case key
50852

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

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Probable cause

the electrical wire arcing and burning as result of insulation degradation, which more than likely resulted from improper clamping.

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.

In flight encounter with weatherCruise - normal
Weather condition - precipitation static conditionsFactor
Airframe/component/system failure/malfunctionCruise - normal
Maintenance,installation - improperUnknownCause
Miscellaneous,bolt/nut/fastener/clamp/spring - improperCause
Electrical system,electric wiring - arcingCause
Electrical system,electric wiring - burnedCause

Analysis

The air transport aircraft was cruising 2 hours after departure at 32,000 feet in clouds when it experienced an electrical discharge near the co-pilot's over window panel. Just prior to the discharge event, the flight crew observed a phenomenon known as St. Elmo's Fire, during which time loud popping noises were heard in the radios. After the discharge, sparks, smoke, and a strong acrid smell of electrical burning were noted from near the co-pilot's over window panel. The smoke and fume checklist was performed, halon was applied on two separate occasions, and the relative circuit breakers and electrical switches were opened. The flight landed uneventfully 45 minutes later. Post incident examination of the affected wires revealed that electrical arcing and shorting had occurred between the airplane structure, a clamp, and a 30-wire bundle. The affected wire bundle passed behind the flight engineer's station and overhead to the heated windshields. The wire bundle and its clamps were examined and it was noted that the wires were insulated with aromatic polyimide, which is susceptible to arc tracking and insulation flashover. Though the insulation did not display complete insulation breaches, it was noted that the arcing event initiated near a clamp, which was destroyed by the event. The clamp aft of the burned area was of normal size, while the clamp forward of the destroyed one was too small. It is plausible the insulation was either chafed or crimped by the damaged clamp, allowing the arcing event to take place. In turn, the arc tracking and insulation flashover then consumed the surrounding wires.

Factual narrative

History of flight

On December 29, 2000, about 2115 Hawaiian standard time, a Lockheed L-1011-385-1 transport category airplane, N735D, operated by Delta Airlines as flight 219, experienced an electrical fire forward of the flight engineer's station while en route from San Francisco, California, to Honolulu, Hawaii. The flight was about 2 hours out of Honolulu when the event took place, and continued for an uneventful landing, arriving at the gate at 2330. There were no injuries to the airline transport rated captain, commercial rated first officer, airline transport rated flight engineer, 10 flight attendants, or the 287 passengers. The regularly scheduled domestic flight was operating under 14 CFR Part 121, and an instrument flight plan had been filed. The flight originated from San Francisco at 1910 Pacific standard time.

According to the flight crew, the airplane was in cruise flight at 32,000 feet mean sea level (msl) in clouds at the time of the incident. The captain reported the flight was encountering light and moderate turbulence in clouds. The flight was also experiencing a phenomenon called Saint Elmo's fire. The phenomenon is a discharge of static electricity often seen on airplanes flying through or near stormy weather. Static electricity from clouds collects on the airplane structure and discharges from sharp points in the form of visible light. This activity lasted for about 3 minutes, during which time loud popping noises were heard in the radios.

Subsequently, a loud electrical discharge occurred above the co-pilot's side window. Sparks, smoke, and a strong acrid smell of electrical burning accompanied the discharge from the panel. Oxygen masks and smoke goggles were donned and the smoke and fume checklist was performed. The smoke slowly dissipated.

After about 5 minutes the acrid smell increased and a glow was observed behind the same panel. Halon was discharged under the panel. All windshield heat switches were turned off and circuit breakers were opened and again the smoke dissipated.

After about 15 minutes the smell of burning increased and a glow was observed under the panel. Panel screws were removed for better access and view. Halon was again applied and additional bottles of halon were brought forward by a flight attendant as a precaution. The flight crew declared an emergency to air traffic control (ATC), and as a result ATC cleared the flight direct to Honolulu. The last 45 minutes of flight were conducted with no fire or smoke.

Wreckage and impact information

Post incident examination of the cockpit's burned area revealed electrical arcing had occurred between the airplane structure, an Adel clamp, and a 30-wire bundle. Twenty of the 30 wires were observed burned. The burned wire bundle passed behind the flight engineer's station and overhead to the heated windshields.

Static dischargers, which are used to dissipate static electricity into the atmosphere, were examined after the incident and were found intact.

Tests and research

The wire bundle and three clamps were removed and sent to the Safety Board's Materials Laboratory for examination, along with photographs of the wires taken before their removal. The wire bundle contained a burned area that nearly separated it into two segments (one segment being shorter than the other). The wire bundle consisted of four wires of 10-gage diameter, four wires of 16-gage diameter, and eight twisted pairs with red and blue markings. Heat-stamped numbers were found on most 10- and 16-gage wires, but the twisted wires had no numbers or marking sleeves.

Examination of the photographs depicted the shorter end of the burned bundle had been installed forward or furthest from the flight engineer station, and a "shadowed" area of the bundle was hanging beneath a molten clamp. The shadowed area was an area of less blackened material approximately equal in width as a sample clamp. The photographs revealed the burned portion of the wire bundle was aft of the molten clamp, toward the flight engineer station. Up to 4.2 inches of wires in the bundle were missing from aft of the molten clamped area.

Numerous wires were melted and resolidified. Some wires had been fused into solid copper for up to 0.6 inches in length, while others displayed resolidified beads of molten wire metal at their burned tips.

The wires appeared to contain silver to gray colored plating on copper cores with an aromatic poyimide-type of insulation (such as MIL-W-81381, or also known as Kapton). This was similar to the wire type Lockheed used as original equipment hook-up wire in L-1011 airplanes. The insulation style was tape wrapped with a yellowish-golden topcoat. A green vendor number found on many wires was 59 92507.

Microscopic examination (variable, at approximately 10-20 power) of undamaged wires revealed a general condition of wire that was smooth. The insulation reflected light evenly without a dry look. No microscopic radial cracks were found in the insulation. Impressed and deformed areas were found along the lengths of some individual wires.

As a test of insulation flexibility, the intact end of one undamaged 16-gage wire (wire number 3041 119 AN 2 16) was wrapped tightly around a 1-inch diameter form three times. Microscopic examination revealed no splits in the insulation. Wrapping a 10-gage wire around the same 1-inch form revealed two small breaches in the topcoat. The first was along the spiral feature of the insulation construction. The second was at the intersection of a heat-stamped character and another spiral. Neither breach appeared visually to extend to the conductor, and no further testing was done to establish the electrical integrity of the sample.

The three clamps submitted were "P" shaped clams with rubber padding seated in the inside circumference. A normal clamp of this type is made of a metal band that has a straight side, which extends from a bolt-hole, then gradually loops around into a "U" shaped cup, which holds the wires. The clamp band then bends 90 degrees at the other end, which contains another bolt-hole. This allows the mating of the bolt-holes on each end of the clamp. The clamp is then lined (insulated) with a rubber piece, which rests on the inside of the metal band. The rubber insulator has a flat end and a wedged end near the mating ends of the clamp.

The three clamps were examined, and it was noted that one of the clamps was separated into two segments and the other two clamps were intact. The separated clamp was missing nearly half of the circumference that had been padded with rubber. The remaining padded portion on the damaged clamp contained the end of the pad without the wedge. The damaged clamp was compared to the other two, and it was noted that the clamp's normally straight side was bent 90 degrees, which with the two bolt-holes mated would have created a tennis racquet shape. The section of the damaged clamp, which usually contains the part number, was destroyed.

The two intact clamps were marked with different part numbers; one being LS9345-8, and the other LS9345-7. Review of the photographs revealed the -8 clamp was located aft of the damaged clamp and the -7 clamp was positioned forward of the damage clamp. The -8 clamp was larger in diameter, but the overall shape was distorted, so that when the clamp was closed, it resembled the shape of a tennis racquet, rather than a "P." The wire bundle was placed into the -8 clamp and the fit was snug, but the wires could be moved longitudinally. The bolt could be inserted through the bolt-holes of the -8 clamp. The wire bundle was then placed into the -7 clamp and the fit was tight, but the bundle could be installed and the bolt could be inserted. When the wire bundle was in the smaller -7 clamp, smaller wires tended to get between the wedge of the rubber pad and the ends of the metal clamp band.

Aircraft

Registration
N735D
Reported as
Lockheed L-1011-385-1 (L-1011)
Category
Airplane
Serial number
193C-1226
Airframe hours
58,217.8
Engine
Rolls-Royce RB211-22B, 43,600 lbs thrust, turbo jet
Damage
Minor damage
Fire
In-Flight
Flight
Part 121
Registered owner
Delta Airlines Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 3, 2000
Departed
SAN · San Fransisco, CA
Destination
HNL · Honolulu, HI
Flight plan
IFR

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 17, 2000
Seat
Left
Flight hours
19,000 total · 3,202 in this make and model · 189 in the last 90 days · 10 in the last 24 hours
Role
Co-pilot
Age
46
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
8,200 total · 6,871 in this make and model · 165 in the last 90 days · 10 in the last 30 days
Role
Flight engineer
Injuries
None
Certificate
Flight engineer

Weather

Conditions
Instrument (IMC) · Night/dark

FAA reports on this event · 1

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