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Safety Recommendation Details

Safety Recommendation A-14-128
Details
Synopsis: On January 7, 2013, about 1021 eastern standard time, smoke was discovered by cleaning personnel in the aft cabin of a Japan Airlines (JAL) Boeing 787-8, JA829J, which was parked at a gate at General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts. About the same time, a maintenance manager in the cockpit observed that the auxiliary power unit (APU) had automatically shut down. Shortly afterward, a mechanic opened the aft electronic equipment bay and found heavy smoke coming from the lid of the APU battery case and a fire with two distinct flames at the electrical connector on the front of the case. None of the 183 passengers and 11 crewmembers were aboard the airplane at the time, and none of the maintenance or cleaning personnel aboard the airplane was injured. Aircraft rescue and firefighting personnel responded, and one firefighter received minor injuries. The airplane had arrived from Narita International Airport, Narita, Japan, as a regularly scheduled passenger flight operated as JAL flight 008 and conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 129.
Recommendation: TO THE BOEING COMPANY: Develop or revise processes to establish more effective oversight of your suppliers (including subtier suppliers) to ensure that the product being manufactured adheres to established industry standards.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Boston, MA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA13IA037
Accident Reports: ​Auxiliary Power Unit Battery Fire Japan Airlines Boeing 787-8, JA829J
Report #: AIR-14-01
Accident Date: 1/7/2013
Issue Date: 12/1/2014
Date Closed: 3/1/2016
Addressee(s) and Addressee Status: Boeing Company (Closed - Acceptable Action)
Keyword(s): Hazmat,

Safety Recommendation History
From: NTSB
To: Boeing Company
Date: 3/1/2016
Response: From your March 31, 2015, letter, we learned that you are using a new tool called Joint Team Assessments (JTA) to focus oversight not only on direct suppliers, but also on their subtier suppliers. In our previous letter to you, we asked that you describe how the JTAs will ensure that such subtier suppliers are aware of, and in compliance with, all of your specifications. We were pleased to learn that Boeing supplier contracts require compliance with all its specifications and requirements by subtier suppliers, and require that all subtier contracts specify the same. We note that a JTA consists of representatives from Boeing and the prime supplier, who together visit the subtier supplier to verify this compliance and to assess the quality system of the subtier supplier. These procedures satisfy Safety Recommendation A-14-128, which is classified CLOSED—ACCEPTABLE ACTION.

From: Boeing Company
To: NTSB
Date: 1/4/2016
Response: -From Hillary Barr, Director, Product Safety, Chief Engineer, Air Safety Investigation: The Boeing supplier contract contains language which requires flow down of Boeing specifications and requirements if/when sub-tier suppliers will be utilized. This requirement to include flow down of Boeing specifications and requirements is also required to be included in sub-tier contracts. A Joint Team Assessment (JTA) consists of both a Boeing Supplier Quality (SQ) representative, assigned to a given (prime) supplier, as well as a quality representative from the prime supplier. Though Boeing has right-of-entry access to sub-tiers through our contract language, Boeing prefers to visit the sub-tier supplier with the prime supplier in order to reinforce the responsibility of the prime supplier to oversee its suppliers. Critical sub-tier suppliers are visited by the prime supplier and Boeing to perform a joint assessment of the quality system at that sub-tier supplier. Sub-tiers are selected for JTA’s based on factors such as volume of work, complexity of work, programs supported and quality history. One of the first priorities at the start of an assessment is that the Boeing SQ representative/s verify that a contractual relationship is in place between the prime and sub-tier supplier that includes proper flow down of Boeing contract specifications and quality requirements by the prime supplier to its sub-tier suppliers. Considering the contractual requirements that Boeing has with our prime suppliers, the Joint Team Assessments and the First Article Inspections, Boeing is confident in the quality of components provided to us by our suppliers. Repeating your reference c) question to A-14-129: Please provide more information about how the gated process does this (how assumptions made in safety assessments are identified and validated). Boeing response: Within the development process, Boeing Commercial Airplanes uses a series of gated reviews to help ensure that the requirements are identified and validated, verification is planned and performed, and safety analyses are performed and reviewed. Throughout the process, assumptions are challenged at gated reviews by a cross-section of design experts to evaluate and confirm that designs are meeting expectations. In addition, technology readiness processes implemented in the development of new technologies are intended to test and evaluate the technology’s feasibility prior to program commitment. The Boeing standard gated processes for development help evaluate and confirm that designs are program-ready and vetted by knowledgeable experts who challenge the development plan, processes, and design at hierarchical levels of integration throughout the development lifecycle of the product. These processes continue to evolve and improve, as our products do, in our efforts to provide ever safer and more reliable products. Please feel free to contact us if you have any questions.

From: NTSB
To: Boeing Company
Date: 6/16/2015
Response: We note that you have increased the focus and doubled the number of Quality Assessments conducted at your suppliers and that you are using a new tool called Joint Team Assessments to focus oversight not only on direct suppliers, but also on their subtier suppliers. Ensuring compliance of subtier suppliers is an important element of this recommendation. In our investigation of the January 7, 2013 incident at Boston’s Logan Airport, we found that the design of the rivets in the cell headers did not comply with Boeing’s specification for the battery, nor with other, similar industry standards, such as those of Underwriters Laboratories or the National Electrical Code. The design and manufacture of the subassembly of the cell headers was performed by a fourth-level subtier supplier. Boeing contracted with Thales, who contracted with GS Yuasa, who purchased the subassembly from a supplier. We ask that you describe how the Joint Team Assessments will ensure that such subtier suppliers are aware of, and in compliance with, all of your specifications. We further note that you are working to expand and strengthen industry standards addressing manuacturing quality issues, and that you intend to require your suppliers to meet these standards. Pending our receipt of a satisfactory answer regarding how the Joint Team Assessments will be able to ensure that all subtier suppliers, even those who may be far removed from Boeing, comply with your specifications; completion of the revisions to the industry standards; and the inclusion of the revised industry standards in Boeing contractual documents, Safety Recommendation A-14-128 is classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: Boeing Company
Date: 4/30/2015
Response: This safety recommendation is briefly mentioned in the following Federal Register comment. The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed special conditions titled “Special Conditions: Honda Aircraft Company, Model HA-420 HondaJet, Lithium-Ion Batteries,” which was published in 80 Federal Register 19889 on April 14, 2015.

From: Boeing Company
To: NTSB
Date: 3/31/2015
Response: -From Paul R. Richter, Chief Engineer, Product Safety: In response to safety recommendation A-14-128, Boeing has increased the focus and doubled the number of Quality Assessments conducted at our suppliers to ensure they have acceptable processes, procedures, systems and staffing to conduct oversight of sub-tier suppliers. In addition, Boeing is utilizing a new tool called Joint Team Assessments to focus our oversight not only on direct suppliers, but to partner with them to assess conformance and compliance of their sub-tier suppliers. Boeing is working within the aerospace industry to expand and strengthen industry standards on quality that Boeing then flows down as requirements to our suppliers. These industry standards include the following: Delegation of Inspection Authority (AS9105) – The delegation of inspection authority to suppliers is a well-established process – but needs to have tight controls to be effective. This standard was first flowed as a requirement in 2014. It is in the process of re-release and the improved replacement, AS9117, Delegated Product Release Verification, will be flowed down in 2015. Operator Self-Verification (ARP9162) – The inspection of operations by the manufacturing operator can be a best practice – but it too requires careful oversight by the Quality function. This standard is being revised to AS9162 and will be released as a requirement in 2015. Foreign Object Debris (FOD) Prevention (AS9146) – Boeing is leading the industry team to develop and deploy a FOD prevention document that can be contractually flowed to our enterprise supplier base. The scope of the document defines supplier requirements for FOD prevention necessary to reduce the risk of FOD within Boeing products. This document captures the best practices of the industry and will be flowed as a contractual requirement in 2015. As a result of the NTSB investigation work, Boeing (through Thales) has instituted an active FOD / contamination monitoring and control plan, above and beyond the original manufacturing plan at GS Yuasa. Boeing and Thales are actively involved in conducting regular, on-going factory audits and on-floor inspections of GS Yuasa electrode and cell manufacturing areas. In response to safety recommendation A-14-129, Boeing continually reviews and updates processes and procedures for our designs and any new technologies that are incorporated into our airplane platforms. Boeing also continually evaluates industry standards for evaluating and testing new technologies. These standards were followed during the initial battery development related to methods to test cell failures. Since the initial development of the 787 battery, Boeing has implemented a new procedure for evaluating new technologies. This procedure applies a gated process for evaluating new technology maturity and production readiness. Part of the technology evaluation process includes safety assessments of any new technology being considered for production. Though Boeing, Thales, and the industry have now elevated the understanding of the importance of testing battery cells while they were electrically connected, Boeing’s overall safety assessments and requirements for the airplane were met. The 787 includes multiple layers of protections at the component, system, and airplane level to mitigate the effects of a battery failure. In particular, the battery system was designed so that if a battery failed and initiated venting of a cell, that failure would not result in a hazard to the airplane or its occupants. The January 2013 ANA in-flight battery failure demonstrated the efficacy of these original protections—the smoke from the failure was vented overboard, the airplane structure sustained no damage, the airplane landed safely. After the Japan Airlines 787 battery event, and based on information developed in part during that investigation, a comprehensive set of battery enhancements were put in place. These enhancements are described in Boeing’s submission to the NTSB. As a result of these enhancements and the initiatives outlined in this letter, the 787 is an even safer and more reliable airplane than it was at the time of original certification.

From: Boeing Company
To: NTSB
Date: 2/24/2015
Response: -From Paul R. Richter, Chief Engineer, Product Safety, Commercial Airplanes, Boeing Company: We are continuing to evaluate these recommendations and expect to have a response for you by March 31.