What happened
On January 21, 2012, a Fokker F28MK0100, registration PR-OAF, operated by Avianca - Oceanair Linhas Aéreas, was climbing through flight level 200 after departing from Brasília International Airport (SBBR). During the climb, the crew observed fire and thick smoke emanating from the right-hand side of the windshield heating system.
In response to the emergency, the captain disengaged the autopilot and initiated an emergency descent. The crew donned oxygen masks and smoke goggles while declaring an emergency with Air Traffic Control. The copilot utilized a fire extinguisher to apply chemical powder to the flames, successfully extinguishing the fire by the time the aircraft descended to flight level 100. The aircraft returned to Brasília and performed a safe emergency landing on runway 29R. There were no injuries among the 5 crewmembers or 91 passengers, though the aircraft sustained minor damage to the right windshield and heating system.
The investigation
CENIPA's investigation focused on the origin of the fire and the crew's management of the emergency. Technical analysis of the aircraft's components, specifically the windshield (PN D20543-406) and the transformer (PN AE5751MK1), revealed that the transformer terminals for the right-hand windshield heating system had been incorrectly installed.
The investigation also examined cockpit management and communication. It was noted that the crew taxied with the flight deck windows open, which may have delayed their perception of the initial electrical issue. Furthermore, the investigation found that the crew's coordination was hindered by the use of oxygen masks, and there were lapses in following standard operating procedures (SOPs), including the failure to perform certain checklists and the lack of timely communication with the cabin crew. The purser was unable to establish contact with the flight deck for four minutes following the start of the emergency.
Findings
- Inadequate installation of the transformer terminals in the right-hand windshield heating system caused a short circuit, which was the direct source of the fire and smoke.
- The crew's perception of the developing problem may have been delayed due to the non-observance of sterile cockpit procedures and taxiing with open windows.
- The captain experienced high workload due to manual flight, managing the emergency, and communicating with ATC.
- Coordination between the flight deck and cabin crew was compromised during the initial stages of the emergency.