Human Performance Factors For Elementary Work and Servicing
Case Study #4: In-Flight Fire, Landing Gear Well
Transportation Safety Board Report Number A98Q0087
Mirabel/Montreal International Airport, Quebec
18 June 1998
The aircraft, a Fairchild-Swearingen Metro II (SA226-TC), from Dorval / Montréal International Airport, Quebec, around 0701 eastern daylight time bound for Peterborough Airport, Ontario. On board were nine passengers and two pilots. About 12 minutes after take-off, at an altitude of 12 500 feet above sea level (asl), the crew advised air traffic control (ATC) that they had a hydraulic problem and requested clearance to return to Dorval. ATC granted this request. Around 0719, at 8600 feet asl, the crew advised ATC that the left engine had been shut down because it was on fire. Around 0720, the crew decided to proceed to Mirabel / Montréal International Airport, Quebec. At 0723, the crew advised ATC that the engine fire was out. On final for Runway 24, the crew advised ATC that the left engine was again on fire. The landing gear was extended on short final, and when the aircraft was over the runway, the left wing broke upwards. The fuselage pivoted more than 90° to the left around the longitudinal axis of the aircraft and struck the ground. All 11 occupants were fatally injured.
Other Factual Information
During the ground acceleration phase, the aircraft was pulling to the left of the runway centreline, and the right rudder was required to maintain take-off alignment. Two minutes later, the aircraft was cleared to climb to 16 000 feet above sea level.
At 0713, the crew advised the controller of a decrease in hydraulic pressure and requested to return to the departure airport. The controller immediately gave clearance for a 180° turn and descent to 8000 feet asl. During this time, the crew indicated that, for the moment, there was no on-board emergency. The aircraft initiated its turn 70 seconds after receiving clearance.
At 0713:36, something was wrong with the controls. Shortly afterward came the first perceived indication that engine trouble was developing, and the left wing overheat light illuminated about 40 seconds later. Within 30 seconds, without any apparent checklist activity, the light went out.
At 0718:12, the left engine appeared to be on fire, and it was shut down. Less than one minute later, the captain took the controls. The flight controls were not responding normally: abnormal right aileron pressure was required to keep the aircraft on heading.
At 0719:19, the crew advised air traffic control (ATC) that the left engine was shut down, and, in response to a second suggestion from ATC, the crew agreed to proceed to Mirabel instead of Dorval. Less than a minute and a half later, the crew informed ATC that flames were coming out of the "engine nozzle". Preparations were made for an emergency landing, and the emergency procedure for manually extending the landing gear was reviewed. At 0723:10, the crew informed ATC that the left engine was no longer on fire, but three and a half minutes later, they advised ATC that the fire had started again. During this time, the aircraft was getting harder to control in roll, and the aileron trim was set at the maximum. Around 0727, when the aircraft was on short final for Runway 24L, the landing gear lever was selected, but only two gear down indicator lights came on. Near the runway threshold, the left wing failed upwards. The aircraft then rotated more than 90º to the left around its longitudinal axis and crashed, inverted, on the runway. The aircraft immediately caught fire, slid 2500 feet, and came to rest on the left side the runway. When the aircraft crashed, firefighters were near the runway threshold and responded promptly. The fire was quickly brought under control, but all occupants were fatally injured.
Aircraft Hydraulic System
The aircraft hydraulic system--which does not include the brake system--supplies pressure to operate the flaps and the landing gear in normal operation and to lower the landing gear in an emergency. The approved hydraulic fluid for the aircraft hydraulic system is MIL-H-83282. The approved fluid for the landing gear struts (shock-absorbing systems) is MIL-H-5606.
At 0712, there were indications of a main hydraulic system failure. The L HYD PRESS and R HYD PRESS lights came on, and the hydraulic pressure was decreasing. It was decided to turn back to Dorval and, when required, use the prescribed manual procedure to lower the landing gear. During the turn to Dorval, the flight controls did not feel normal, the IGNITION MODE - AUTO FUNCTION light for the left engine illuminated, and there was a left-wing overheat indication.
Hydraulic Fluid Analyses
The hydraulic fluids collected from the aircraft were analyzed. Samples of hydraulic fluid were also taken from other aircraft in the company fleet, a hydraulic generator cart, and other aircraft not owned by this carrier. The analyses were done by the Department of National Defence Quality Engineering Test Establishment in Ottawa, Ontario. The results of the chemical analyses were as follows:
- The MIL-H-83282 brake fluid from the aircraft contained 34% MIL-H-5606.
- The MIL-H-83282 hydraulic fluid from the aircraft contained 14% MILH-5606.
- The MIL-H-5606 fluid from the left landing gear strut of the aircraft contained 5% MIL-H-83282.
- The MIL-H-5606 fluid from the nose gear strut of the aircraft contained 14% MIL-H-83282.
- The wheeled hydraulic generator contained MIL-H-83282 hydraulic fluid with 17% MIL-H-5606. This unit is used to replenish fluids in the aircraft.
- On another aircraft operated by the air carrier, the brakes contained 29% MIL-H-5606, and the aircraft hydraulic system contained 18% MIL-H-5606.
- An aircraft operated by another air carrier contained MIL-H-83282 fluid with 13% MIL-H-5606.
In general, the mixed hydraulic fluids had the qualities of MIL-H-83282 fluid: smell, look, feel, viscosity, etc. However, the MIL-H-5606 contamination in a hydraulic system containing MIL-H-83282 fluid lowers the flashpoint of the fluid.
Wing Overheat Indication
The crew noted a hydraulic failure indication, control problems, and problems with the left engine, and the wing overheat light came on continuously, all within two minutes. Within 30 seconds of the overheat light illuminating, the light went out without any apparent checklist activity. There is no indication that the wing overheat checklist was initiated: both bleed air switches were found in the ON position, and the landing gear was not lowered until the aircraft was on final approach.
The investigation determined that overheating of the left landing gear brakes during taxi and take-off caused a fire in the nacelle after gear retraction. The fire spread within the wing structure, leading to wing failure on final approach to land.
Causes and Contributing Factors
It was found that:
- The crew did not realize that the pull to the left and the extended take-off run were due to the left brakes' dragging, which led to overheating of the brake components.
- Dragging of the left brakes was most probably caused by an unidentified pressure locking factor upstream of the brakes on take-off. The dragging caused overheating and leakage, probably at one of the piston seals that retain the brake hydraulic fluid.
- When hydraulic fluid leaked onto the hot brake components, the fluid caught fire and initiated an intense fire in the left nacelle, leading to failure of the main hydraulic system.
- When the L WING OVHT light went out, the overheating problem appeared corrected; however, the fire continued to burn.
- The crew never realized that all of the problems were associated with a fire in the wheel well, and they did not realize how serious the situation was.
- The left wing was weakened by the wing/engine fire and failed, rendering the aircraft uncontrollable.
Findings as to Risk
- Numerous previous instances of brake overheating or fire on SA226 and SA227 aircraft had the potential for equally tragic consequences. Not all crews flying this type of aircraft are aware of its history of numerous brake overheating or fire problems.
- The aircraft flight manual and the emergency procedures checklist provide no information on the possibility of brake overheating, precautions to prevent brake overheating, the symptoms that could indicate brake problems, or actions to take if overheated brakes are suspected.
- More stringent fire-blocking requirements would have retarded combustion of the seats, reducing the fire risk to the aircraft occupants.
- A mixture of the two types of hydraulic fluid lowered the temperature at which the fluid would ignite, that is, below the flashpoint of pure MIL-H-83282 fluid.
- The aircraft maintenance manual indicated that the two hydraulic fluids were compatible but did not mention that mixing them would reduce the fire resistance of the fluid.
- The master cylinders were not all of the same part number, resulting in complex linkage and master cylinder adjustments, complicated overall brake system functioning, and difficult troubleshooting of the braking system. However, there was no indication that this circumstance caused residual brake pressure.
- The latest recommended master cylinders are required to be used only with specific brake assembly part numbers, thereby simplifying adjustments, functioning, and troubleshooting.
- Although the emergency checklist for overheating in the wing required extending the landing gear, the crew did not do this because the wing overheat light went out before the crew initiated the checklist.
- The effect of the fire in the wheel well made it difficult to move the ailerons, but the exact cause of the difficulty was not determined.
Mixing of Hydraulic Fluids
Analysis of fluid from the accident aircraft's main and brake hydraulic systems revealed a mixture of MIL-H-83282 and MIL-H-5606 hydraulic fluids. These hydraulic fluids are nearly identical in colour and consistency. The mixture had a flashpoint of approximately 114ºC (239ºF).
The SA226 and SA227 specification originally called for MIL-H-5606, with a minimum flashpoint of 82ºC, to be used in the aircraft's main and brake hydraulic systems. However, after two Swearingen SA226-TC Metroliner II cockpit fire accidents in which the MIL-H-5606 hydraulic fluid was involved, the FAA issued Airworthiness Directive (AD) 83-19-02, applicable to certain Swearingen SA226 airplanes, including the Mirabel accident airplane. The AD required that operators drain and purge the main hydraulic and brake system reservoirs, refill them with MIL-H-83282 hydraulic fluid with a minimum flashpoint of 205ºC, and change the placards on both reservoirs to specify the MIL-H-83282 fluid. The accident aircraft was placarded in accordance with AD 83-19-02.
Current maintenance instructions state that MIL-H-83282 is to be used in the main and brake hydraulic systems of the aircraft. However, there is no reference to indicate that MIL-H-83282 is used because of the higher temperature at which its vapours will ignite or that a mixture of MIL-H-83282 and MIL-H-5606 can have a significantly lower flashpoint than the 205ºC flashpoint for pure MIL-H-83282. Given that MIL-H-5606 was the original specified fluid for SA226 and SA227 aircraft, that MIL-H-5606 and MIL-H-83282 are similar in appearance and most properties, and that there are no cautions about the consequences of using a mixture of the two fluids, the Board believes that MIL-H-5606 is being mistakenly used by some air operators and aircraft maintenance engineers as an alternative hydraulic fluid in systems requiring MIL-H-83282. Therefore, in view of the increased risk of fire occurring on Fairchild/Swearingen SA226 and SA227 aircraft resulting from the incorrect use of MIL-H-5606 hydraulic fluid, the Board recommended that:
Transport Canada, as a matter of urgency, notify all Canadian operators of Fairchild/Swearingen SA226 and SA227 aircraft of the importance of, and requirement for, using only MIL-H-83282 hydraulic fluid in the main and brake hydraulic systems of these aircraft; and Transport Canada, in consultation with the Federal Aviation Administration and the aircraft manufacturer, review the adequacy of existing aircraft standards, procedures, manuals and maintenance practices for the Fairchild/Swearingen SA226 and SA227 aircraft with an aim to ensuring that only MIL-H-83282 hydraulic fluid is used in the main and brake hydraulic systems of these aircraft.
This report concludes the Transportation Safety Board's investigation into this occurrence. Consequently, the Board authorized release of this report on 02 April 2002
Contributing Human Factors
The main factors contributing to this occurrence were as follows:
- Lack of Awareness: The flight crew were unaware of the possible cause of the extended take-off, or that all the subsequent problems were associated with a fire in the wheel well. They did not realize how serious their situation was.
- Lack of Resources: The aircraft flight manual and the emergency procedures checklist provide no information on the possibility of brake overheating, the symptoms that could indicate brake problems, or actions to take if overheated brakes are suspected. Also, the aircraft maintenance manual indicated that the two hydraulic fluids were compatible, but did not indicate that mixing them would reduce the fire resistance of the fluid.
- Lack of Knowledge: Not all crews flying this type of aircraft are aware of it's history of numerous brake overheating or fire problems.