Transportation Safety Board releases report on airplane fire that injured seven at Montreal-Trudeau airport

The Transportation Safety Board of Canada released Tuesday its report of an investigation of involving a fire involving an airplane that had landed and stopped at its gate in Montreal, which resulted in an evacuation of the cabin and sent five passengers to the hospital.

TSB noted in its report that the evacuation was “hampered” by passengers trying to take their carry-on luggage with them and that some ground service employees had not received practical training specific to the models of fire extinguishers found on the apron, though they received theoretical training on generic fire extinguishers.

“The investigation found that a connector in the fuel system on the belt loader disconnected while the engine was running,” TSB stated in a release, of the incident Nov. 4, 2013 involving a Royal Air Maroc plane that had arrived at Montreal-Pierre Elliott Trudeau International Airport (formerly known as Dorval) from Casablanca.

“Consequently, fuel sprayed onto the hot surface of the exhaust and caused a fire.”

TSB investigates marine, pipeline, railway and aviation incidents and does not determine civil or criminal liability.

Its investigation into the November, 2013 fire also found that some service providers – including the company operating the belt loader – “had not yet been integrated” into the airport’s safety management system. As a result, those service providers “were not monitored” by the quality assurance program of Aéroports de Montréal, which operates Montreal-Trudeau airport.

The belt loader was manufactured by TUG Technologies Corp. and operated by Servisair Inc., a ground services supplier – whose services include baggage handling – contracted by Royal Air Maroc.

The Boeing 767, which was carrying 243 passengers and eight crew members, had stopped at a gate at about 4:45 pm. The engines were shut down and passengers were starting to leave the airplane when a fire broke out “under a belt loader that an employee on the ground was positioning under the left aft cargo door,” TSB stated in its investigation report.

“The smell of the smoke from the fire penetrated the cabin, prompting the captain to order the evacuation of the aircraft. Some passengers evacuated the aircraft through the boarding bridge while others used the evacuation slides.”

The airport firefighters soon arrived.

“It is estimated that 100 to 150 people evacuated through the evacuation slides and found themselves wandering on the apron in search of help,” TSB said. “Ground crew and airport security staff led them inside the terminal where airport and airline personnel took over. Of the seven passengers who suffered minor injuries or were overcome by smoke, five were transported to hospital by ambulance.

TSB noted that all of Servisair’s belt loaders in Canada have since had their fuel systems inspected.

“During a meeting with other service providers using the same type of equipment, the company shared its observations concerning the risks associated with the vulnerability of the fuel system on equipment with this engine model,” TSB noted. “The company installed an emergency switch on all belt loaders that did not already have one. The maintenance program checklist for this belt loader model was modified to include a specific inspection for the filter regulator and its associated lines, connectors and fixing rings.”

TSB also found that the fire extinguisher mounted on the belt loader was not used.

“Because this extinguisher was quite close to the flames, the ground crew opted to use the larger-capacity and more easily accessible wheeled fire extinguishers,” TSB stated. “However, although the first wheeled extinguisher operated as intended, it did not extinguish the fire. As for the second wheeled fire extinguisher, the airport firefighters found that it initially failed to work because there was a kink in its hose. However, it was not possible to determine whether this extinguisher could have put out the fire before the firefighters arrived.”

TSB added that TUG Technologies provided an inspection bulletin to customers, “identifying the preventive maintenance instructions to check the fuel lines and their fittings.” TUG also now “provides stock belt loaders with an emergency stop button positioned at each location where there are operator controls (along with the ignition switch).”

TSB noted that Servisair employees “assigned to the baggage room who did not work on the apron received limited training when recruited that was specific to their tasks, while employees who worked on the apron normally received one week of theoretical in-class training followed by practical training on the apron.”

But theoretical training “on the use of generic fire extinguishers did not include instruction on the extinguisher models found on the apron,” TSB added. “As for practical training, it did not include instruction on how to use fire extinguishers nor what to do in emergency situations when passengers are evacuated onto the apron. Two employees from another major airline who were providing turn-around maintenance on the occurrence flight took part in the response. The investigation revealed that their employer had provided them adequate training on the handling of ramp fire extinguishers and basic response in emergency situations.”

TSB also noted that passengers started to panic when smoke entered the cabin.

“Passengers began pushing and shoving, causing some passengers to fall down in the aisle,” TSB stated. “The cabin crew tried to help them while having to deal with panicking passengers trying to step over the fallen passengers.”

Some passengers then opened the doors behind the wings, “triggering the automatic deployment of the evacuation slides, which are always armed on these doors. Seeing these newly created exits, several passengers chose to evacuate by sliding down the evacuation slides to the apron.”

TSB added: “Some passengers tried to take their carry-on luggage with them, hampering the evacuation.”