What happened
On 27 October 2019, an El Al Israel Airlines Boeing 737-900ER, registration 4X-EHE, was preparing for departure from Paris-Charles de Gaulle to Tel-Aviv. Following pushback from gate A38, the aircraft was positioned on taxiway P1 with engines running when an "AFT CARGO FIRE" warning activated in the cockpit.
The flight crew immediately initiated emergency procedures, deploying fire extinguishers and notifying air traffic controllers of the emergency. While the crew requested a cabin check for smoke or flames, the purser reported no visible signs of fire in the passenger cabin. Aircraft Rescue and Fire Fighting (ARFF) services arrived shortly after to inspect the exterior with thermal cameras, finding no visible flames or smoke.
Due to the ongoing fire warning, the captain ordered the disembarkation of all 163 passengers and 5 cabin crew. During the evacuation, the crew reported the smell of smoke in the cabin. Upon inspection of the aft hold, investigators found light smoke and identified a heavily damaged electric wheelchair. The device exhibited heat marks and a strong burning odor, originating from a short circuit in its electrical system that affected its removable lithium battery.
The investigation
The BEA investigation focused on the handling of mobility aids and the sequence of battery removal. While the airline's subcontractor, Alysia, recorded the presence of a battery during check-in, the investigation found that the battery had not been removed by the passenger as required by safety regulations.
Investigators examined the interactions between the passenger, the airline's ground handling agents, and airport assistance personnel. It was noted that a language barrier existed, as the passenger's proficiency in French was limited. Furthermore, the investigation looked into the security screening process, which was designed to detect explosives rather than identify the presence of lithium batteries in mobility aids.
Findings
- A short circuit in the electric wheelchair's electrical system triggered the incipient combustion.
- The passenger failed to remove the lithium battery from the wheelchair before boarding, likely due to a misunderstanding of instructions provided by ground staff.
- Ground handling procedures lacked continuous tracking of the battery's location from check-in to loading.
- The loading supervisor did not verify that the battery had been removed, assuming it was stored in a red canvas pouch attached to the chair.
- Security inspections at the time were focused on explosive detection and were not intended to identify battery placement.
Safety action
Following the incident, the handling agent, Alysia, implemented a new tracking sheet system. This document is physically attached to wheelchairs to provide a continuous record of the battery type and specific transport instructions (whether the battery must be carried in the cabin or can be placed in the hold) throughout the handling process.