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Why FAA approved 787 fix without 'root cause' determined for JAL, ANA events

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While a “root cause” has not been determined, NTSB has determined a cause for the JAL fire: short circuiting in a battery cell.

Why did FAA approve Boeing’s fix for the 787’s battery system before a root cause has been determined for the Jan. 7 Japan Airlines 787 fire in Boston or for the Jan. 16 All Nippon Airways 787 emergency landing at Takamatsu airport?

Back in January, when the 787 grounding had been in effect for fewer than 10 days, I wrote that “it’s now not just possible but likely the grounding will last for many weeks and perhaps even for several months or longer.” Given that the grounding imposed Jan. 16 has lasted for more than three months, I think that assessment was fairly accurate. However, I also wrote that the 787 wouldn’t be cleared to fly again until the “root cause” of the two events that led to the grounding—the lithium ion battery failures on the JAL and ANA 787s—were determined. That prediction appears to have been somewhat misguided.

Neither the US National Transportation Safety Board (NTSB) nor the Japan Transport Safety Board (JTSB) has identified a root cause in the JAL incident in Boston or the ANA incident over Japan, respectively. But while a “root cause” has not been determined, NTSB has determined a cause for the JAL fire: short circuiting occurred in cell number six of the eight-cell, 32-volt lithium ion battery used to start the aircraft’s auxiliary power unit. The short circuit led to thermal runaway—uncontrolled chemical reactions resulting from overheating—in cell number six, which “cascaded to the other cells and that resulted in the fire,” NTSB chairman Deborah Hersman has explained.

What has not been determined, of course, is the cause of the short circuiting, i.e. the root cause.

Boeing’s comprehensive fix for the battery system, developed in conjunction with lithium ion battery experts from around the world, is aimed at dealing with any contingency, including preventing a recurrence of what happened in the Boston incident. As Boeing VP and 787 chief project engineer Mike Sinnett explained on a Friday conference call with reporters, the new battery enclosure system alone “makes any kind of battery failure no longer a safety issue at all” because it would contain any fire. Boeing has also put in a number of other modifications, including measures to prevent overheating from moving uncontrollably between battery cells.

Boeing believes, and FAA has signed off on, that whatever caused the short circuiting would not be able to escalate to the fire seen in Boston Jan. 7. It is possible that the “root cause” of that event will never be fully known.

Next up for Boeing and FAA is Tuesday’s NTSB hearing on the JAL 787 fire in Boston. Sinnett will testify. He has already been rebuked by NTSB for publicly expressing conclusions about the Boston incident, and is expected to be faced with tough questions from the board about the original certification for lithium ion batteries for the 787.

There had been some thought that FAA would wait to see the results of this week’s hearing before clearing Boeing’s fix, but the agency apparently wanted to separate the hearing from its approval process for the revamped battery system. However, Japanese officials have indicated they will be watching the NTSB hearing closely. ANA and JAL operated 24 of the 50 787s that were in service when the Jan. 16 grounding was put in place (in fact, the Japanese-operated 787s were grounded hours before FAA issued its grounding order), and the Japanese government will have to give its all-clear before those planes can take to the sky again. It’s unlikely there will be friction between FAA and Japanese regulators regarding returning the 787 to service—unless there is an unexpected blockbuster in the NTSB hearing.

Discuss this Blog Entry 5

on Apr 22, 2013

But I thought that the government could solve all issues and would know if the solution was correct. Now, if and when another fire occurs, it will be Boeings issue, not the Governments. Interesting solution. Just a method for shifting the blame.

on Apr 23, 2013

Thanks, Aaron.

One does not get into the blame game. Rather than say that the "root cause search" portion of your prediction was "misguided", one could just as easily say that there was an unexpected shift from the traditional norm, and it is too soon to say if that was a wise or unwise departure into relatively unclear waters.

We read that the root cause “may never be known”. The Financial Times (FT), for example, echoes the sense of that sentence.

But the concept & attitude behind the sentence have nothing to do with the FT in the conception & / or construction of that sentence, or the idea behind it.

That is surely the same in your case.

One simply does not see the NTSB allowing that (intellectually) “unsatisfactory”, no matter how “apparently realistic” position (yet academic in nature) to become the accepted norm.

Behind the scenes, the research & search will go on!

Exactly as in the case of the fuel-flow constraint or starvation, in the case of the LHR accident, involving the B777-200ER, powered by two RR Trent 895 engines, on flight BA 038.

It is known that the RR Trent FOHE "FIX" has worked, to undo the problem born outside the engine, and “seen” in the physical fuel-flow systems, considered as part of the airframe, or as a part belonging to the passage from airframe to engine, without it being in any engine zone, in any way whatsoever.

Unless we have missed something, Boeing & RR continue the quest for the true root cause or causes, as requested by the official Enquiry and Reporting Authorities.

Here, as there, it seems that we are still very much in “wait & see mode”.

And one does not see NTSB abandoning its responsibilities and traditional efforts, even if one stands to be corrected.
.

on Apr 23, 2013

The problem we are experiencing is, in some ways, akin to wishing for the squaring of the circle.

We cannot really get our head around this ; and, in any case, our head is caught between a rock and a hard place.

We :
-- do not want "blame-game suffering” for Boeing ;
-- do want these aircraft back in the air, flying safely & soundly ;
-- see that Boeing needs a break (but, also, that that is not necessarily a prelude to sound decisions) ;

-- do want peace in our minds, in everybody's minds, but recognise that this is not easy, because we know that what we have to-day is a "super-duper containment fix", which may still be a long way off from a permanent solution, based on determination, understanding & mastery of root cause ;

-- acknowledge that the worlds of civil aviation & the air transport industry need the success of these B787 aircraft ;
-- do need to SEE & BE CONVINCED that safery is not compromised, ..... maintain trust in Boeing and the Aviation Authorities (notably, FAA & NTSB, and their clear vision;

-- do know that we are not in risk-free country.

We can all see that the monkey on each key player’s back (Boeing’s, & FAA’s, before even getting to NTSB’s) … is complicated !

Most of us are probably anything but expert on these battery issues !

on Apr 28, 2013

Many readers will not like this article, entitled , “A Back Seat for Safety at the F.A.A.”, written by JAMES E. HALL, a former Chairman of the NTSB, under the following web link, which I respectfully ask the moderators to allow (one is given to understand that there should be no copyright issue, as one is giving credit to the Author, and original publisher , but that is up to the moderators) :

http://www.nytimes.com/2013/04/26/opinion/a-back-seat-for-safety-at-the-...

Will not like the article ? Tough. It should be compulsory reading. And many observers say that those who do not like this article should both put up & shut up.
So that sets the tone ; NOT my tone ; THE tone, or an already very widely acknowledged and respected tone.

Obviously, the author thinks that the FAA did a lousy certification job, with an inadequate approach to certification, and that rhe FAA were less than diligent, indeed sloppy, in allowing things to pass, after tests which were far from tough enough.

HERE ARE JUST A FEW EXTRACTS, TO WHET THE APPETITES.

--- “If one thing is clear after this week’s National Transportation Safety Board hearings on the certification of the Boeing 787’s lithium-ion battery, it is that the Federal Aviation Administration and the industry it regulates share a cozy relationship that sometimes takes a front seat to safety. This relationship contributed to the grounding of the 787 .....and the astonishing swiftness with which the airplane was approved to return to commercial flight. “

---“ As a former chairman of the safety board, I know firsthand that effective government oversight helps prevent fatal airplane accidents. For decades, the F.A.A. has used what it calls “designated airworthiness representatives” to certify that aircraft meet government safety standards. They were experts selected and supervised by the agency, even if they worked for the manufacturer.

“But in 2005, the F.A.A. changed the process of selecting those designees, ruling that aircraft manufacturers who qualified under the new procedures could choose their own employees to certify their planes. The distinction is important, because it suggests a slide toward industry self-certification. “

COMMENT : at the time of the initial ATWOnline “Comments” format (no criticism meant ; just a time-positioning phrase), many participants made this point, even allowing for the problems of to-days “resource constraints” perceived as weighing upon the quality of the mass of certification-process work.

---- “ This laissez-faire certification system would save the aviation industry nearly $25 million between 2006 and 2015, the F.A.A. said at the time — a pittance when compared with Boeing’s $81 billion in revenue for 2012. It is no coincidence that the committee that helped develop this process was made up of industry members. Essentially, aircraft makers persuaded the F.A.A. to let them certify their own aircraft so they could save money.”

COMMENT : some of our readers, and moaners, groaners & whiners are going to have to take that on the chin. Just take it, and move on, instead of trying to justify the unjustifiable, and defend the indefensible. This is why we have said that there are big, complicated monkeys on the backs of Boeing & FAA !

---“ ....., the agency let Boeing help write the safety standards, develop the testing protocol and then perform those tests. In 2008, ..... stricter industry guidelines for these batteries were released. But the F.A.A. did not require the 787 to meet those new guidelines.”

------ “ Boeing initially estimated that there was the potential for one battery failure incident in 10 million flight hours. As it turned out, smoke and fire broke out in batteries on two separate 787’s in just the first 52,000 flight hours. Even Boeing’s chief engineer on the 787, .... acknowledged ... that one of the battery tests had been inadequate , ...not “conservative enough.”

COMMENT : draw your conclusions.

-----“ Now the 787 has been grounded for months, the F.A.A. has lost face, and Boeing has been losing $50 million a week ...... “
“... the F.A.A.’s recent decision to approve Boeing’s .... fix ...., .... seems shortsighted and represents a complete failure of government oversight. It is puzzling that the agency was so quick .... to accommodate Boeing in recertifying the safety of the airplane, without even knowing the root cause ...”

COMMENT : despite knowing how much the worlds of aviation & air transport need the B787, and no matter how much we want to see these aircraft flying safely & soundly, in normal commercial flight ops., it is a “big ask” for us, FROM THE FAA, & BOEING, that we should just look the other way, instead of intensifying the search for the “root cause”.

‘-----“Congress needs to take a closer look at the F.A.A.’s practices and procedures to make sure that safety is the top priority, and .....provide more direct government oversight as new aviation technologies are introduced.”

---“ We enjoy the safest commercial aviation system in the world. But what about tomorrow? .... this question is more important than ever. ‘’

COMMENT : Foreign counterparts are already doubting this notion of having “safest commercial aviation system in the world”.
Sadly, that is hardly surprising. That is something that the USA (the Authorities and the “people”) are going to have to take on board, avoiding all knee-jerk temptation of telling the others to go and take a walk.

on Apr 28, 2013

The article of James E. HALL is bound to be deemed controversial. It may be perceived as "disloyal" by the unseeing cheer leaders !

It will provoke reactions. That is healthy.

It is obvious that, like current NTSB Chairman HERSMAN, he feels sincerely that it is necessary to resist all sloppiness and "dumbing-down" of the rigour which has to underpin the whole body of safety considerations.

HERSMAN & HALL share the will to maintain the highest standards.

For thise of us with "outside eyes", there is a big question looming even larger, which seems to be getting through to both D. HERSMAN & J.E. HALL :
:
----" It the outside perception is that the USA are letting their standards slip, what will be the credibility, "going forward", of the FAA ?"

There are some who should reflect on this sort of question, before they start thumping the keyboard and churning out their usual knee-jerk, chauvinistic reactions.

In reality, the "outside eyes" are on USA's side !

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