|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Controlling Facilities||tower : cgi.tower|
|Operator||common carrier : air carrier|
|Make Model Name||MD-80 Super 80|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : taxi|
ground : pushback
ground : parked
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||aircraft equipment problem : critical|
cabin event : galley fire
other anomaly other
|Independent Detector||other other : person 3|
Flight Crew Human Performance
Cabin Crew Human Performance
Chart Or Publication
|Publication||Flt Ops Manual|
Flight attendant loaded food plates and bags of bread into oven with no oven insert installed. During taxi out bags with rolls of bread caught on fire. After the fact, we learned that these ovens require the inserts because these inserts act as a barrier between the food and oven heating elements. No one involved knew this was a safety hazard prior to the fire. We were very lucky this happened near the ramp area. 5 mins after takeoff, this would have been a very different kind of problem. I have very serious recommendations which need to be implemented immediately. Bulletin to cabin attendant or bulletin to flight crew to every MD80 flight plan notifying captain of hazards of not having oven insert. Flight attendant's need training to not use these ovens without inserts. They should notify captain of any missing inserts. Maintenance should consider MEL for ovens without inserts so that they are never used. Caterers need to know that inserts are required equipment. Why were the inserts ever removed at all. Many layers of problems to this incident. Air carrier X was very lucky this time. We departed with a known insert missing from an oven, and had not a single clue that what we were doing had any safety implications at all. Callback conversation with reporter revealed the following information: the reporter stated when the flight attendant reported the oven fire she was instructed to close the oven door. The reporter said the aircraft was parked just off the gate after pushback and was quickly taxied back on to the gate. The reporter stated the fire was extinguished and it was discovered the oven insert was missing. It appears that some of the MD80's recently acquired by this air carrier require an insert in their ovens, while other fleet MD80's require none. The reporter stated the flight crew and the cabin attendant crew were unaware of these two oven configurations. The reporter said the carrier took immediate action and began training of cabin attendants, ground caterers and maintenance on oven configurations. The reporter stated the flight crews have the type of oven now listed on the flight plan and the cabin attendant crew must be briefed on the ovens actually on the airplane.
Original NASA ASRS Text
Title: AN MD80 WAS DISPATCHED WITHOUT AN OVEN INSERT. FA LOADED BAGS OF BREAD INTO OVEN. IMMEDIATELY AFTER PUSHBACK AN OVEN FIRE WAS RPTED.
Narrative: FA LOADED FOOD PLATES AND BAGS OF BREAD INTO OVEN WITH NO OVEN INSERT INSTALLED. DURING TAXI OUT BAGS WITH ROLLS OF BREAD CAUGHT ON FIRE. AFTER THE FACT, WE LEARNED THAT THESE OVENS REQUIRE THE INSERTS BECAUSE THESE INSERTS ACT AS A BARRIER BTWN THE FOOD AND OVEN HEATING ELEMENTS. NO ONE INVOLVED KNEW THIS WAS A SAFETY HAZARD PRIOR TO THE FIRE. WE WERE VERY LUCKY THIS HAPPENED NEAR THE RAMP AREA. 5 MINS AFTER TKOF, THIS WOULD HAVE BEEN A VERY DIFFERENT KIND OF PROBLEM. I HAVE VERY SERIOUS RECOMMENDATIONS WHICH NEED TO BE IMPLEMENTED IMMEDIATELY. BULLETIN TO CAB OR BULLETIN TO FLC TO EVERY MD80 FLT PLAN NOTIFYING CAPT OF HAZARDS OF NOT HAVING OVEN INSERT. FA'S NEED TRAINING TO NOT USE THESE OVENS WITHOUT INSERTS. THEY SHOULD NOTIFY CAPT OF ANY MISSING INSERTS. MAINT SHOULD CONSIDER MEL FOR OVENS WITHOUT INSERTS SO THAT THEY ARE NEVER USED. CATERERS NEED TO KNOW THAT INSERTS ARE REQUIRED EQUIP. WHY WERE THE INSERTS EVER REMOVED AT ALL. MANY LAYERS OF PROBS TO THIS INCIDENT. ACR X WAS VERY LUCKY THIS TIME. WE DEPARTED WITH A KNOWN INSERT MISSING FROM AN OVEN, AND HAD NOT A SINGLE CLUE THAT WHAT WE WERE DOING HAD ANY SAFETY IMPLICATIONS AT ALL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED WHEN THE FA RPTED THE OVEN FIRE SHE WAS INSTRUCTED TO CLOSE THE OVEN DOOR. THE RPTR SAID THE ACFT WAS PARKED JUST OFF THE GATE AFTER PUSHBACK AND WAS QUICKLY TAXIED BACK ON TO THE GATE. THE RPTR STATED THE FIRE WAS EXTINGUISHED AND IT WAS DISCOVERED THE OVEN INSERT WAS MISSING. IT APPEARS THAT SOME OF THE MD80'S RECENTLY ACQUIRED BY THIS AIR CARRIER REQUIRE AN INSERT IN THEIR OVENS, WHILE OTHER FLEET MD80'S REQUIRE NONE. THE RPTR STATED THE FLT CREW AND THE CAB CREW WERE UNAWARE OF THESE TWO OVEN CONFIGURATIONS. THE RPTR SAID THE CARRIER TOOK IMMEDIATE ACTION AND BEGAN TRAINING OF CABIN ATTENDANTS, GND CATERERS AND MAINT ON OVEN CONFIGURATIONS. THE RPTR STATED THE FLT CREWS HAVE THE TYPE OF OVEN NOW LISTED ON THE FLT PLAN AND THE CAB CREW MUST BE BRIEFED ON THE OVENS ACTUALLY ON THE AIRPLANE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.