Table of Contents
For several decades now, there have several occurrences of uncontrolled in-flight fires leading to fatal deaths. Transportation of lithium batteries has been cited as the main cause of in-flight fires. Data from the Federal Aviation Administration Office of Security and Hazardous Materials indicates that 132 cases are involved smoke, extreme heat, fires or explosions caused by batteries or battery-powered devices (Webster, 2004, 18). With the various risks posed by lithium batteries, various stakeholders in the aircraft industry have stipulated new safety regulation aimed at controlling the shipment of these batteries. IATA and PHMSA require that all shippers must adhere to the set rules. Lithium ion and lithium batteries shipped without equipment are not allowed on passenger aircraft. The pilots, the cabin crew and aircraft manufacturers are apprehensive that existing standards are not strong enough to contain Lithium (Boeing, 2000). This report aims to addresses the flight accidents or incidences contributed to by human factors, evaluation of the human factors and errors leading to accidents using the SHEL model and other analytical tools, identify and analyses key areas of policy change that may be applied by air flight stakeholders and recommends policy change to all concerned parties.
Accidents/Incidents resulting from lithium batteries
On August 2004, in MePhis Tennessee, a fire destroyed some freight that included lithium-ion batteries estimated as $20,000. The cargo contained in a unit load device (ULD) belonging to the Federal Express Corporation (FedEx Express) hub. The ULD had been put on a loading equipment and was halfway onto an aeroplane headed for Charles de Gaulle Airport when workers doing the loading smelled smoke (Royal Aeronautical Society, 2013). Upon returning the smoking ULD to the loading machine and lowering it on the ground, when it was opened by the Memphis fire department, a fire spread inside destroying the ULD and the aeroplane Boeing MD-11 that was operated by FedEx Express.
On 3 September 2010, a Boeing 747-400 F left Dubai, UAE for Cologne Germany operating as UPS Flight 006. 22 minutes after departure at an altitude of 32,000ft, a fire warning bell was activated, and the crew were warned a main deck cargo fire. On turning back towards Dubai, which was less than 150 nautical miles, the plane was depressurized at 10,000ft due to a fault in pack 1 and an automatic feature in packs 2 and 3. Five minutes later, after the fire bell rang, the pilots reported that the deck was full of smoke leading to degradation in flight visibility and the flight crew found it difficult to operate and monitor the flight instruments (Boeing, 2000). The captain delegated the first officer to fly the plane as he retrieved portable oxygen aft of the flight deck. The captain however never returned and the First officer advised air traffic of increasing smoke in the flight deck and of his inability to set radio frequencies. On trying to slow the aeroplane to land, the landing gear failed to extend. The areophane overflew Dubai, entered a descending right turn and impacted the desert nine nautical miles south of Dubai.
Investigations indicate that due to the location of the initial fire and the contents of the shipping containers near that place, lithium batteries were considered as the possible cause of the fire. On July 2011, Boeing 747-400F operating as Asiana Flight 991 left Incheon, South Korea for Shanghai China. Fifty minutes later, the First Officer reported a cargo fire and requested for emergency descent and diverted to Jeju. The crew reported Rudder control problems and the plane dived into the sea. Evidence of soot on several pieces of the wreckage, the outflow valves and the smoke evacuation shutter showed a serious in-flight fire (Royal Aeronautical Society, 2013). The soot could be associated with the cargo in the aft portion of the aeroplane. Just like in the UPS Flight 0006, there were lithium batteries in the cargo of Asiana 991.
Other incidents include the destruction of freight on two cargo pallets at the Northwest Airlines Cargo facility at Los Angeles International airport of April 28, 1999. The pallets had been offloaded a passenger flight from Osaka, Japan. On September 26, 1996, wires that were connected to eight lithium batteries were short and burned a hole in their package in Airborne Express sorting Area in Wilmington, Ohio. In 2002, a fireboard box started smoking while inside a FedEx Express ULD in Indianapolis, Indian. The contents of the box were lithium batteries that had short-circuited, damaging the interior box and a fire flared up.
SHEL Model Analysis
SHEL is an abbreviation for Software, Hardware, Environment, and Liveware. Liveware represents the human element of the system. In these accidents, the crew and other staff work together through communication with each other. The team can communicate with those in the control room through machines and can get orders on where to land. The Pilot and the First Officer work together, but there is a breakdown when the pilot fails to return due to smoke. The flight crew did not have oxygen masks and visual aids that would help them prepare and land the aeroplane expeditiously within a short time frame while minimising the possibility of igniting an in-flight fire (Kraus and Watson, 41). The flight deck of Boeing 747 needed to have air pressure to resist smoke ingress from the rear of the aircraft. The air conditioning system was compromised, and therefore, it did not provide the required pressure on the flight deck. This is a clear show of teamwork. The first officer tries to engage the landing gear in enabling them land safely, but it fails since the aircraft is burning. Cabin and the flight crew should be trained on circuit breakers to understand the location of circuit breakers. Therefore, he has no control of the aeroplane anymore. Further, the environment of operation is not conducive since the cabin is filled with smoke. The pilot cannot thus access the aircraft control buttons and hence cannot be able to communicate with others (Kraus and Watson, 2001, 17).
Additionally, the PEAR model developed by Dr Michael Maddox has been used in the aviation maintenance environment (Kraus and Watson, 2001, 18). PEAR stands people, environment, actions and resources. Though the crew have received the requisite training, the accidents happen due to the failure of communication which is occasioned by the destruction of the aircraft control gadgets and reduced visibility due to smoke. To salvage the situation, the pilots try to change their landing points and engage the right gears only to realise the gears have failed. They cut off the resources by smoke which hinders their access to the control and monitoring gadgets due to lack of visibility caused by the smoke (Hawkins, 1987). The stakeholders engage in investigations to establish the cause of the fire, and most of their results point to lithium batteries.
Key areas of policy change
The stakeholders should also be concerned about the changes taking place in the regulatory framework of the shipping policies. There have been increased abuse of the strict ICAO dangerous goods regulations that apply to the production, testing, marking, packaging and transporting of lithium batteries. The abuse of these laws by battery manufacturers and shippers have threatened the safety of passengers. On the ban of lithium batteries, there is a need to improve safety and ensure strict enforcement of the set regulations through imposing of fines and criminal penalties (The Guardian, 2016). Recently, PBRA advocated for new regulations that eliminated the need for regulatory approvals and the establishment of new law requirements under the UN model regulations consistent with the industry practices. In 2013, the International Civil Aviation Organization (ICAO) gave new provisions relating to the shipment of lithium batteries by air. However, the provisions need more improvement since they lack a requirement to store batteries in a compartment equipped with adequate fire suppression, lack of standards for cargo compartment suppression that address lithium battery fires and lack of quantity limits for a compartment or aircraft (Bachtel, 1998).
The stakeholders should also look into the changes in packaging, marking and labelling. The new requirements in the UPS battery shipping policy require that all standalone shipments of lithium batteries should be transported according to regulation under section 1A or section 1B of ICAO/IATA packaging instructions 965 and 968. On April 2016 the ICAO enacted a ban on carrying standalone lithium ion batteries (UN3480) as cargo on passage aircraft. To ship lithium batteries through the air, all packages should have labels and marks. Section 1A require that all Class 9Hazard Class label and a Cargo Aircraft Only label while Section 1B indicates that all shipment requires all Class 9 Hazard label, a CAO label and a lithium battery handling/mark label (IATA, 2014).
To avoid future risks caused by a shipment of lithium batteries, there is a greater need to ban lithium batteries on the flight. Lithium batteries are a source of most fires on aircraft. Most of the lithium batteries are shipped in passenger aircraft rather than in dedicated cargo planes. These pose a greater threat to the passengers and the aircraft (IATA, 2014). Lithium batteries ignite themselves and burn with a heat of about 600C. They also produce fumes that upon build up the lead to explosions causing damage to on-board suppression systems. I recommend that a ban on lithium batteries should, therefore, incorporate all lithium batteries including those in personal gadgets of individuals on-board the aircraft. Further, IATA, ICOA and other stakeholders should ensure that the lithium batteries are packaged, labelled and marked clearly to avoid future problems. I also recommend that lithium batteries should be securely cushioned to prevent shifting during transportation or loosening of terminal caps. The batteries should be enclosed in an inner packaging made of non-conducive materials (UPS, 2016, 2).
Lithium batteries pose a great danger to aircraft and therefore, should the regulations and policies governing its transportation by air need to amended and changed to ensure the safety of passengers. All stakeholders should be involved in the policy changes to ensure success.
- Bachtel, B. (1998). Foreign Object Debris and Damage Prevention. Aero Magazine. Available at http://www.boeing.com/commercial/aeromagazine/aero_01/textonly/s01txt.html. Accessed on 22 November 2016
- Boeing. (2000). In-flight Smoke. Retrieved from Boeing.com: Available at http://www.boeing.com/commercial/aeromagazine/aero 14/inflight story.html.
- Hawkins, F.H. (1987). Human Factors in Flight, Aldershot, Gower: Technical Press Ltd.
- IATA (2014). Carriage of Lithium Batteries. Available at https://www.iata.org/policy/Documents/lithium-batteries-position-paper.pdf. Accessed on 21 November 2016.
- Kraus, D.C. and Watson J. (2001). Guidelines for the Prevention and Elimination of Foreign Object Damage/Debris (FOD) in the Aviation Maintenance Environment through Improved Human Performance.
- Royal Aeronautical Society. (2013). Smoke, Fire and Fumes in Transport Aircraft. History, current risk and recommended mitigations available at https://flightsafety.org/files/RAESSFF.pdf. Accessed on 22 November 2016.
- The Guardian. (2016). UN Panel Backs banning Lithium-ion Battery Shipments on Passenger Planes. Available at https://www.theguardian.com/world/2016/jan/28/un-panel-backs-banning-lithium-ion-battery-shipments-on-passenger-planes. Accessed on 23 November 2016.
- UPS. (2016). International lithium battery regulations. Available at: https://www.ups.com/media/news/en/ca/intl_lithium_battery_regulations.pdf. Accessed on 22 November 2016.
- Webster, H., (2004).Flammability Assessment of Bulk-Packed, Nonrechargeable Lithium Primary Batteries in Transport Category Aircraft” Office of Aviation Research, Washington, DC, p. 18.