Air Canada Flight 797

"Flight 797" redirects here. For the 1987 aviation incident involving the airline Varig, see Varig Flight 797.

Air Canada Flight 797

File:Aircanada797burning.PNG C-FTLU after the flashover following its emergency landing.
Accident
Date	(1983-06-02)June 2, 1983
Summary	In-flight fire
Site	Cincinnati-Northern Kentucky International Airport, Boone County, Kentucky, United States
Aircraft type	McDonnell Douglas DC-9-32
Operator	Air Canada
Registration	C-FTLU
Flight origin	Dallas/Fort Worth Int'l Airport
Stopover	Toronto International Airport
Destination	Montreal-Dorval International Airport
Passengers	41
Crew	5
Fatalities	23
Injuries	16
Survivors	23

Air Canada Flight 797 was a scheduled trans-border flight that flew on a Dallas/Fort Worth-Toronto-Montreal route. On (1983-06-02)June 2, 1983, the aircraft developed an in-flight fire behind the washroom that spread between the outer skin and the inner decor panels, filling the plane with toxic smoke. The spreading fire also burned through crucial electrical cables that knocked out most of the instrumentation in the cockpit, forcing the plane to divert to an alternate landing field. Ninety seconds after the plane landed and the doors were opened, the heat of the fire and fresh oxygen from the open exit doors created flashover conditions, and the plane's interior quickly became completely engulfed in flames, killing 23 passengers who were yet to evacuate the aircraft.

As a result of this accident, many regulations were implemented around the world to make airplanes safer, including the installation of smoke detectors, emergency lighting leading to exit doors and increased fire fighting training and equipment for crew members.

Details

At 16:20 CDT (21:20 UTC) on (1983-06-02)June 2, 1983, the Air Canada aircraft registered C-FTLU took off from Dallas-Fort Worth International Airport; it was to make a stop at Toronto International Airport (now Toronto Pearson International Airport) in Mississauga, Ontario, ultimately bound for Dorval Airport (now Montréal-Pierre Elliott Trudeau International Airport) in Dorval, Quebec.

Donald Cameron was the captain and Claude Ouimet served as first officer. While flying over Louisville, Kentucky, an in-flight fire began in or around the rear lavatory of the McDonnell Douglas DC-9-32. The pilots heard a popping sound around 18:51, during dinner service, and discovered that the lavatory's circuit breakers had tripped. It was not uncommon, however, for an airplane's lavatory circuits to pop occasionally, a problem often preceded by the common aftermath of passengers completing their in-flight meals, so Cameron waited around eight minutes to give the tripped circuits time to cool down before attempting to reactivate them at 18:59.

A strong, noxious odor coming from the rear of the plane was first reported to the cabin crew around 19:00. Flight attendant Judi Davidson traced the odor to the lavatory. She attempted to look into the lavatory but was forced back by a thick grey smoke rapidly filling the small room; she then ordered the third ranking crew member to find Sergio Benetti, the chief cabin crew officer, and ask him to investigate. As Benetti sprayed the interior of the affected lavatory with a CO₂ extinguisher, Davidson reported the fire to the captain while flight attendant Laura Kayama began urging the passengers on the sparsely populated flight to come away from the front and rear of the plane and sit closer together in a compact group around the over-wing exits. At no time did any of the cabin crew mention to either Cameron or Ouimet that they had not yet seen flames, and the one person who had managed to get a good look at the scene—Benetti—had not reported seeing anything resembling the traditional causes of airline fires in pre-smoking-ban days: Flames from a trash bin fire or the paper towel dispenser, both of which were commonly set ablaze by passengers who would smoke in the lavatories on long flights. However, around 19:04, Benetti reported that he thought the fire was probably out because of how much he had doused the lavatory and that "it's gonna be easing up soon". This came less than a minute after Ouimet had attempted to investigate the fire but had been driven back by the thick smoke, causing him to strongly recommend landing the plane.

Just three minutes later, however, at 19:07, passengers began smelling smoke in the cabin again, and just two minutes after that—19:09—the "Master Breaker" alarm went off in the cockpit, and electrical systems throughout the plane began to fail, including power for the elevator trim system. This made controlling the plane's descent extremely difficult and required a great amount of physical exertion from the pilot and first officer. In addition, the PA system failed, leaving the flight attendants unable to communicate efficiently with the passengers; nevertheless, attendants were able to instruct passengers sitting in the exit rows on how to open the doors, a practice that was not standard on commercial airline flights at the time.

At 19:20, Cameron and Ouimet made an extremely difficult emergency landing at the Greater Cincinnati Airport, located in Boone County, Kentucky across the Ohio River from Cincinnati, Ohio. During the evacuation, the overwing aircraft doors were opened, causing an influx of air that fueled the fire. Ouimet escaped through the co-pilot's emergency window shortly after the plane landed, but Cameron, who had expended a great deal of physical energy while trying to keep the plane under control, was unable to move due to exhaustion. Firefighters doused Cameron in firefighting foam through Ouimet's window, shocking him back to consciousness; Cameron was then able to open the pilot's emergency escape window and drop to the ground, where he was dragged to safety by Ouimet. Cameron was the last person to make it out of the plane alive. Less than 90 seconds after touchdown, the interior of the plane flashed over and ignited, killing 23 of the 41 passengers. The passengers trapped inside the plane died from smoke inhalation and burns from the flash fire. Dianne Fadley, a survivor, stated in an interview for an episode of the Canadian TV series Mayday about the incident entitled "Fire Flight" that "it was almost like anybody who got out had nothing wrong"; of the eighteen surviving passengers, three received serious injuries, thirteen received minor injuries, and two were uninjured, while none of the five crew members sustained any injuries. "You made it and you were completely fine," Fadley concluded, "or you didn't make it."

Twenty-one Canadians and two Americans died. Many of the bodies were burned beyond recognition. Almost all of the victims were in the forward half of the aircraft between the wings and the cockpit. Some bodies were in the aisles, and some bodies were still in the seats. Two victims were in the back of the aircraft, even though the passengers were moved forward after the fire had been detected; the disoriented passengers moved beyond the overwing exits and succumbed. The blood samples from the bodies revealed high levels of cyanide, fluoride, and carbon monoxide, chemicals produced by the burning plane.

NTSB investigation

Though the fuselage was nearly destroyed by the intensity of the fire, the cockpit voice recorder (CVR) and flight data recorder (FDR) for flight 797 were still in good condition and produced vital useful data for the subsequent National Transportation Safety Board (NTSB) investigation. On the CVR, NTSB investigators heard eight sounds of electrical arcing—likely inaudible to the crew—beginning at 18:48 CDT. Three minutes later, at 18:51, the popping sounds that Cameron and Ouimet would later identify as the left toilet circuit breaker tripping are audible on the CVR; Cameron attempts to reset the circuits twice over the next 60 seconds, but the CVR records the breakers immediately popping again after each reset attempt. Cameron would attempt once more to reset the breakers at 18:59, but the CVR records arcing sounds followed by the popping sound of the breakers continuing to trip again after each reset over the next 60 seconds. At 19:02, the CVR records Flight Attendant Judi Davidson entering the cockpit to deliver the first report of a possible fire in the lavatory. Though a number of wires in the lavatory section were later found with insulation stripped away, NTSB investigators were unable to determine whether this insulation damage was the cause of the fire or was caused by the fire.

This particular DC-9 had experienced a number of problems over the months leading up to the incident; 76 maintenance reports had been filed in the plane's logs in the previous year, and the CVR records Cameron telling Ouimet to "put [the tripping breakers] in the book there" when the breakers fail to respond to the first reset attempt at 18:52. Nearly four years earlier, on September 17, 1979, the plane, then serving as Air Canada Flight 680 (Boston, Massachusetts to Yarmouth, Nova Scotia), had suffered an explosive decompression in the rear bulkhead that required rebuilding the tail section and replacing or splicing most of the wiring and hydraulic lines in the back of the plane; Cameron noted in an interview for the "Fire Flight" episode of Mayday that the Air Canada maintenance crew "did a heck of a job getting everything put back together" after the decompression incident. Investigators were unable to find signs of arcing in any of the wire splices from the repairs done four years earlier, though much of the wiring in the rear of the plane was severely damaged or destroyed by the fire itself.

Despite finding neither the specific wires that caused the short circuit (the usual cause of arcing sounds and the likely cause of the breaker trips) nor the origin point of the fire that later consumed the plane, investigators determined that a short circuit likely sparked and ignited surrounding materials (such as insulation blankets) that sustained and propagated a fire that burned behind the wall of the lavatory, with the plane's outer skin serving as a conduit for smoke to seep in through the seams in the interior panels and collect near the apex of the cabin.

Notable passengers

• Stan Rogers was a Canadian folk singer, known for songs like "Northwest Passage", "The Mary Ellen Carter", "Song of the Candle", and "Barrett's Privateers". He was going home on Flight 797 after attending the Kerrville Folk Festival in Texas. He died in the fire at the age of 33.
• Also on board was George Curtis Mathes Jr., founder of the electronics company that bears his name. He died in the fire.

A diagram of Air Canada Flight 797 from the NTSB; the diagram indicates locations of surviving passengers, deceased passengers, and flight attendants

Aftermath

As of 2010, this 1983 accident is Air Canada's most recent fatal accident.

Although it is customary for airlines to retire a flight number after a major incident, as of 2010 Air Canada still uses Flight 797 on its Montréal-Los Angeles route, flown using an Airbus A319.

Safety recommendations

As a result of this accident and other incidents of in-flight fires on passenger aircraft, the NTSB issued several recommendations to the Federal Aviation Administration (FAA), including:

• Safety Recommendation A-83-70, which asked the FAA to expedite actions to require smoke detectors in lavatories;
• Safety Recommendation A-83-71, which asked the FAA to require the installation of automatic fire extinguishers adjacent to and in lavatory waste receptacles;
• Strong recommendation that all U.S.-based air carriers review their fire training and evaluation procedures; procedures were to be shortened and focused on taking "aggressive actions" to determine the source and severity of suspected cabin fires while finding the shortest and safest possible emergency descents, including landing or ditching;
• Strong suggestion that passenger instruction in how to open emergency exits become standard practice within the airline industry.
• Strong recommendation for expedited FAA rule changes mandating that all U.S.-based air carriers install (or improve existing) in-cabin fire safety enhancements, including (but not limited to):
  • Fire-blocking seat materials to limit both the spread of fire and the generation of toxic chemicals through ignition;
  • Emergency track lighting at or near the floor, strong enough to cut through heavy fuel fire smoke;
  • Raised markings on overhead bins indicating the location of exit rows to aid passengers in locating these rows in case of passenger visual impairment (either pre-existing or caused by emergency conditions);
  • Hand-held fire extinguishers using advanced technology extinguishing agents such as Halon.

Criticism and controversy

Newspapers and other media criticized the actions taken by the crew and said that the pilots took too long to initiate an emergency descent; the initial NTSB report was especially critical of Cameron for not asking about the exact nature of the fire and not immediately initiating emergency descent when the fire was first reported. Cameron admitted in a press conference following the issuance of the NTSB report that he assumed the problem was a bin fire, a common cause of lavatory fires when smoking was still allowed on flights.

Pilots and airline personnel throughout the industry petitioned the NTSB to revise its report. First Officer Claude Ouimet sent the NTSB a detailed defense of the crew's actions, including the decision to land in Cincinnati instead of Standiford Field Airport in Louisville, Kentucky, the airport closest to where the crew first notified Air Traffic Control in Indianapolis, Indiana that they needed to make an emergency landing. Ouimet stated that Louisville was too close to be able to descend from cruising altitude to an emergency landing safely, and even landing in Cincinnati was a questionable proposition given Cameron's difficulties in controlling the plane. After reviewing Ouimet's missive and re-evaluating the available data, the NTSB issued a revised version of the report which included Ouimet's explanation of the landing decision, though the report was still critical of Cameron's decision not to inquire about the fire itself. In an interview for the "Fire Flight" episode of Mayday, Cameron said of his actions that day, "All I know was that I did the best I could."

The crew of Flight 797 later received a number of citations from Canadian aviation organizations for their heroic actions in getting the plane down safely.

C-FTLU and N994Z

After this incident, Air Canada sold another of their DC-9 aircraft (tail number N994Z) to Ozark Air Lines. On December 20, 1983, that aircraft, operating as Ozark Air Lines Flight 650, hit a snow plow in Sioux Falls, killing the snow plow operator and separating the right wing from the aircraft. A wing from C-FTLU was used to replace the one separated on N994Z after the incident. The aircraft was later sold to Republic Airlines, and acquired by Northwest Airlines after Republic merged with Northwest. As of 2010, N994Z is assigned to Delta Air Lines, which now owns Northwest Airlines.

Dramatization

The episode "Fire Flight" of Mayday (known as "Fiery Landing" of Air Emergency in the USA, Air Crash Investigation in the UK and Australia) portrays the disaster.

See also

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• British Airtours Flight 28M
• China Airlines Flight 120
• Swissair 111

External links

• A photo of the burning airliner at Airliners.net
• NTSB full accident report
• NTSB brief DCA83AA028
• 39.0489°N 84.6678°W / 39.0489; -84.6678