What happened
On April 14, 2001, a Boeing 737-400, registration PP-NAC, was operating flight 9422 from São Paulo to Recife, with scheduled stops in Rio de Janeiro and Salvador. During the descent into Salvador, a flight attendant reported a strong smell of burning in the forward galley area. The crew performed checks on the electrical panels and systems, but found no anomalies. They implemented smoke removal procedures by turning off the galley power and increasing air conditioning flow.
The aircraft landed at Salvador Airport at 12:42 PM. After the engines were shut down and the cargo holds were opened, ground personnel discovered fire and smoke in the rear cargo compartment. An evacuation was ordered, and airport fire services were deployed to extinguish the flames. While the aircraft sustained severe damage to the internal structure of the rear cargo hold, there were no injuries among the 89 passengers or 8 crew members.
The investigation
CENIPA's investigation focused on the origin of the fire and the operational response. Investigators examined items recovered from the cargo hold, including two bags, but found no evidence that the contents were explosives or the direct cause of the fire. The investigation noted that the aircraft lacked a fire detection and extinguishing system in the cargo compartments, as it had been authorized for operation before new regulations requiring such equipment were implemented.
Furthermore, the investigation found that the passenger tickets provided by the operator did not include instructions regarding the prohibition of dangerous goods. It was also noted that the airports in São Paulo and Rio de and Janeiro lacked X-ray equipment to screen checked baggage, meaning the contents of the luggage were not verified prior to loading.
Findings
- Design deficiency: The aircraft was not equipped with a fire detection or suppression system in the cargo compartments, which prevented the crew from identifying the emergency during flight.
- Infrastructural deficiency: The lack of X-ray screening at departure airports allowed potentially combustible materials to be loaded into the cargo hold.
- Deficient judgment: The crew failed to declare an emergency or request landing priority despite the smell of burning, and they taxied the aircraft to a passenger boarding bridge rather than stopping immediately for evacuation.
- Deficient supervision: The airline failed to provide adequate warnings or instructions to passengers regarding the transport of dangerous goods.