C8/2008L Airliner fire at Kemi-Tornio aerodrome on 11 December, 2008

A serious incident occurred at Kemi-Tornio aerodrome on 11 December 2008 at 22:53 UTC when a Finnish Commuter Airlines passenger aircraft caught fire after landing. Accident Investigation Board Finland appointed investigation commission C8/2008L to this occurrence. Investigator Markus Bergman was named investigator-in-charge, accompanied by investigator Tapani Vänttinen as a member of the commission. Sanna Winberg, Supervisor, Safety and Cabin Service Training, was named cabin safety expert to the commission. Investigator Pekka Orava was invited as an air traffic control advisor to the commission.

After landing the auxiliary power unit (APU) start failed and simultaneously a major power failure occurred. While the passengers were still onboard the loadmaster, a member of the ground crew, detected a fire in the back of the aircraft. The aircraft’s own fire suppression system was successfully used to extinguish the fire. While the incident did not cause any injuries to persons, the aircraft suffered minor damage.

The investigation revealed shortcomings in pilot action as well as in the APU’s fire detection system and company regulations.

The incident occurred when a fire broke out in the APU while the aircraft was taxiing to stand after landing. Flames reached the APU tailpipe as well as the APU compartment. At first the pilots did not notice the fire because the aircraft’s warning system did not signal a fire alarm. The ground crew alerted the pilots of the fire. When the fire started, the passengers were still onboard and deplaned while the fire was burning. Several simultaneous faults affecting the aircraft’s operation exacerbated the severity of the incident. The pilots were occupied with the APU generator’s failure to couple, the unexpected activation of the overcurrent protection feature as well as the failed APU start, which took their attention and slowed their response to the fire. The power failure also made the cabin attendant’s work more difficult, slowing down passenger exit as normal cabin lighting was off. The air traffic control did not notice the fire, nor was it informed of the occurrence. No alert was given, nor did the emergency unit on location react to the situation during the fire.

The investigation commission issued four safety recommendations. The manufacturer of the aircraft is advised to ensure that the APU’s fire alarm system always signals a reliable warning in different kinds of fire situations. The airline is advised to ensure that the manufacturer’s AOM revisions are included in its OM-B. The airline is advised to ensure that the pilots record all appropriate information in the technical logbook with regard to faults, incidents and observations that may impact flight safety or an aircraft’s airworthiness. Finally, the airline is advised to guarantee their aircrews’ Multi-Crew Coordination competence as well as their capability to operate in accordance with the company manuals.
The draft final report was sent for comments to CAA Finland, the Center for Investigation and Prevention of Aeronautical Accidents of Brazil, the European Aviation Safety Agency as well as to the aircraft manufacturer and operator. The comments were taken into account in the final investigation report, as applicable. The aircraft manufacturer’s and operator’s comments are appended to this investigation report.

The investigation was completed on 2.2.2010.

C8/2008L Report (pdf, 0.54 Mt)