Tag Archives: battery

Dreamliner fire: firefighter injured when battery explodes

By ThinkReliability Staff

On January 7, 20 13, smoke was discovered on a recently deplaned Boeing 787 Dreamliner. The recently released National Transportation Safety Board (NTSB) investigation found that an internal short circuit within a cell of the auxiliary power unit (APU) battery spread to adjacent cells and led to a thermal runway which released fire and smoke aboard the aircraft. A firefighter responding to the fire was injured when the battery exploded. Only 9 days later, an incident involving the main battery, which is the same model as that used for the APU, resulted in an emergency landing of another Boeing 787. As a result of these two incidents, the entire Dreamliner fleet was grounded for 3 months for the ensuing investigation and incorporation of modifications. (See our previous blog about the grounding.) Before the fleet was allowed to resume operations, certain protective modifications were required to be implemented.

The investigation determined that the internal short circuit, which provided the initial heat source for the fire within the battery cell, could not be definitively determined due to severe damage in the area, but was potentially related to defects discovered during the manufacturing process. (Defects that could result in this type of short circuit were found on similar components.) The investigation found issues within the manufacturing process and with the oversight of subcontractors by contractors, as opposed to the manufacturers themselves.

The high temperatures resulting from the battery fire allowed it to spread to adjacent cells. Localized high temperatures were found greater than allowable at times of maximum current discharge, such as the APU startup, which had recently occurred. The high temperatures were not detected by the monitoring system (the impact could have been minimized had the issue come to light sooner), because temperatures were not monitored at individual cells, but only on two cell bus bars.

The systems were not prepared to deal with a spreading fire as the design of the aircraft assumed that a short circuit internal to the cell would not propagate. The NTSB determined that the guidance provided to determine key assumptions was ineffective and that the validation of these assumptions had failed. Likely related to this assumption, the safety assessment and testing on the battery system was ineffective. The rate of occurrence of cell venting (the spreading of fire from cell to cell) was calculated by the manufacturer to be 1 in 10 million flight hours. The two occurrences that resulted in the grounding both involved cell venting and occurred while the 787 fleet had less than 52,000 flight hours.

Immediate actions that were required by the NTSB prior to a return to flight were to enclose the battery case, vent from the interior of the enclosure containing the battery to the exterior of the plane (keeping smoke out of the occupied spaces), and modify the battery to minimize the most severe effects from an internal short circuit. The NTSB also made multiple safety recommendations to the manufacturer, subcontractor and the Federal Aviation Administration (FAA).

One of these recommendations was to ensure that assumptions are validated. According to the NTSB report, “Validation of assumptions related to failure conditions that can impact safety is a critical step in the development and certification of an aircraft. The validation process must employ a level of rigor that is consistent with the potential hazard to the aircraft in case an assumption is incorrect.” This statement is true for any object that’s manufactured. Just replace the word “aircraft” with whatever is being manufactured, such as “car” or “pacemaker”. (See another disaster that resulted from not validated assumptions: the collapse of the I-35 Bridge.)

Click on “Download PDF” above to view a high level Cause Map of this issue.

The Dreamliner’s Battery Nightmare

By Kim Smiley

On January 16, 2013, the Federal Aviation Administration issued an emergency directive grounding all Boeing 787 Dreamliners operated by United States carriers during the investigation into two recent battery fires.  This emergency grounding is an unusually extreme step, especially given that the Dreamliner is a new plane with only six operated by US carriers at this time.

This issue can be analyzed by building a Cause Map, an intuitive, visual format for performing a root cause analysis.  A Cause Map is built by determining how the issue affects the goals of an organization and then asking “why” questions to find the causes that contributed to the problem.  In this example, the schedule goal is impacted because the Dreamliners have been grounded.  Why?  The Dreamliners were grounded because there is a known fire risk because there were two battery fires onboard these airplanes nine days apart.  The fact that the Dreamliner is the first major airliner to extensively use lithium-ion batteries and that fires in these batteries are particularly dangerous also contribute to the problem.   Lithium-ion batteries were used because they are lighter than other batteries and lighter planes use less fuel.  Fires in lithium-ion batteries are dangerous because they are difficult to extinguish because oxygen is released as they burn, which feeds the fire.

Several other goals are also worth considering like the customer service goal which is impacted by the negative publicity generated by this issue and the safety goal because there is a potential for injuries.   The economic impact of this issue could also be very significant since each Dreamliner costs $200 million and there are 800 planes on order in addition to about 50 that were already in service that may need to be repaired.

The battery fires are still being investigated but the cause isn’t known yet.  It may be an issue with manufacturing or the design itself.  What is known is that the Dreamliner is a brand new design that incorporates many new elements such as mostly electrical flight systems, an airframe that uses composite materials and the use of the lithium-ion batteries themselves.  The design process was also different from previous Boeing designs with much of the work outsourced to a network of global suppliers and very tight deadlines.

As more information becomes available, the Cause Map can easily be expanded to incorporate it.  To view a high level Cause Map of this issue, click on “Download PDF” above.