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| Date: | Thursday 9 February 2023 |
| Time: | c. 11:15 UTC |
| Type: |  Boeing 777-206ER |
| Owner/operator: | KLM |
| Registration: | PH-BQO |
| MSN: | 35295/609 |
| Year of manufacture: | 2007 |
| Fatalities: | Fatalities: 0 / Occupants: 304 |
| Other fatalities: | 0 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | south of Marseille -
 France
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Amsterdam-Schiphol International Airport (AMS/EHAM) |
| Johannesburg-O.R. Tambo International Airport (JNB/FAOR) | |
| Investigating agency: | Dutch Safety Board |
| Confidence Rating: |  Accident investigation report completed and information captured |
KLM flight KL591, a Boeing 777-206ER, experienced smoke in the cabin, originating from an oven in the aft galley. Six halon fire bottles were used by cabin crew.
Three cabin crew members and twelve passengers indicated breathing difficulties.
At the time of the incident the flight was en route at FL330 south of Marseille, France. The flight crew elected to turn back to Amsterdam-Schiphol International Airport (AMS).
Cause of the smoke originating from the oven
The use of a meal tray carrier with a mostly closed backside extended the heating time of the oven significantly and it disturbed the airflow in it. The result was a raised temperature behind the oven. This influenced the control circuitry in such a way that the heating elements were inadvertently commanded on. It caused the temperature behind the oven to increase even further, keeping the power control board in a faulty condition.
At this point, the 3-phase safety device was already damaged and inoperable and could not turn off electrical power to the oven. The temperature inside the oven also continued to rise to such a degree that it experienced an overheat condition and smoke was coming from the oven into the galley.
The removal of electrical power to the oven, as dictated by the Oven smoke/fire procedure, did not happen during the entire oven overheat event as the galley area main power was not switched off. Also, at no point was the correct position of the galley area main power button verified by checking the powering of other galley electrical equipment. The circuit breaker of the oven was not pulled by the cabin crew nor were they directed to do so by the Oven smoke/fire procedure.
The flight crew did not switch off the utility bus as directed by the Smoke, Fire or Fumes checklist as they considered it as unnecessary. The reason for this was that they were convinced that the power to the aft galley was already removed by means of switching off the galley area main power switch. As a result, electrical power to the failed oven
remained connected even after the flight and cabin crew assessed the oven overheat event as stopped.
As a result of the failure of the heating elements, the temperatures behind the oven dropped significantly so that the power control board functioned correctly again and transmitted the commanded ‘off’ signal by the oven control module to the heating elements. The oven overheat event thus stopped. The oven overheat event did not cause damage to the direct surrounding area of the oven. All heat damage remained limited to the inside of the oven.
The operator indicated that at the time of the occurrence, Service Information Letter H0212-25-0164 had not been incorporated in maintenance procedures. This service information letter gives additional instructions for the checking of the 3-phase safety device and the replacement of it every five years and is incorporated in the Component Maintenance Manual.
Service Bulletin 2000-25-0001, which recommends the incorporation of an improved power module, motor, fan and heating elements among other upgrades, had also not been incorporated by the operator. The incorporation of this service bulletin has been proven to prevent a potential failure of the oven control module and temperature probe from controlling the temperature in the oven. The implementation of this service bulletin was deemed unsuitable by the operator due to certification requirements of the modification and limitations on the use of the oven.
Accident investigation:
 |
|
Sources:
https://nos.nl/artikel/2463128-klm-toestel-keert-na-brand-aan-boord-veilig-terug-naar-schiphol
https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-boeing-777-registered-ph-bqo-operated-by-klm-on-09-02-2023-en-route/
https://www.flightradar24.com/data/aircraft/ph-bqo#2f225a46
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 26-Jan-2024 12:29 | harro | Updated [Other fatalities, Source, Narrative] |
| 10-Jun-2024 09:41 | ASN | Updated [Total occupants, Location, Narrative, Accident report] |
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