Incident: Boeing 787 Lithium-Ion Battery Fire Incident Analysis

Published Date: 2013-02-07

Postmortem Analysis
Timeline 1. The software failure incident involving a fire aboard a Boeing 787 due to an internal short circuit within a lithium-ion battery occurred on January 7, as mentioned in Article 17335.
System unknown
Responsible Organization unknown
Impacted Organization 1. Boeing - The software failure incident involving a short circuit in a lithium-ion battery on a Boeing 787 led to the grounding of the entire fleet of Dreamliners worldwide [17335].
Software Causes unknown
Non-software Causes 1. Internal short circuit within a single cell inside a lithium-ion battery [17335]
Impacts unknown
Preventions 1. Implementing reinforced separators with ceramic particles in the lithium-ion batteries, similar to what was done in the Chevrolet Volt, could have potentially prevented the short circuit and subsequent thermal runaway in the Boeing 787 battery incident [17335]. 2. Conducting more rigorous and comprehensive testing, including tests that simulate extreme conditions and abuse, could have helped identify potential issues with the battery cells before they led to a failure in the aircraft [17335]. 3. Enhancing the design and certification assessment process for new technologies like the lithium-ion batteries in the Boeing 787 to ensure that assumptions made during certification align with real-world performance and potential failure scenarios [17335].
Fixes 1. Reinforcing the separator with ceramic particles in the lithium-ion battery, similar to what was done in the Chevrolet Volt battery, to mitigate the shrinking problem [Article 17335]. 2. Implementing designs that better protect the electrical bays and aircraft from potential fire damage [Article 17335].
References 1. National Transportation Safety Board (NTSB) [Article 17335] 2. Boeing [Article 17335] 3. Dr. K.M. Abraham [Article 17335] 4. Tesla Motors CEO Elon Musk [Article 17335]

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization, multiple_organization <Article 17335> provides information about a software failure incident related to the Boeing 787 Dreamliner battery problem. The incident involved a short circuit within a lithium-ion battery cell, leading to a fire on a Japan Airlines 787 in Boston. This incident was not an isolated case, as it was mentioned that there were two events in two weeks on two separate aircraft, indicating a recurrence of the issue [17335]. The article also mentions that the entire fleet of Dreamliners was grounded pending investigation by the FAA, and several airlines, including All Nippon Airways and United, continued canceling 787 flights many weeks into the future, suggesting a widespread impact on multiple organizations [17335].
Phase (Design/Operation) unknown The articles do not mention any software failure incident related to the development phases such as design or operation. Therefore, the information to answer this question is 'unknown'.
Boundary (Internal/External) within_system (a) within_system: The software failure incident related to the Boeing 787 battery problem was primarily attributed to internal factors within the system. The National Transportation Safety Board (NTSB) investigation revealed that the fire aboard a Boeing 787 was caused by an internal short circuit within a single cell inside a lithium-ion battery [Article 17335]. The NTSB found evidence that the fire started with a short circuit in cell no. 6 and propagated to the other cells, ruling out mechanical damage as a cause of the short circuit. The investigation focused on factors such as the state of charge of the battery cells, manufacturing processes, and the design of the battery [Article 17335]. (b) outside_system: There is no information in the articles suggesting that the software failure incident related to the Boeing 787 battery problem was caused by contributing factors originating from outside the system.
Nature (Human/Non-human) non-human_actions (a) The software failure incident in this case was not related to non-human actions but rather to a physical issue within the lithium-ion battery cells, specifically a short circuit in cell no. 6 that led to a fire aboard a Boeing 787 [17335]. (b) The failure was not due to human actions but rather a result of a short circuit within the lithium-ion battery cell, which was a non-human factor that caused the incident [17335].
Dimension (Hardware/Software) hardware (a) The software failure incident related to hardware: - The article discusses a software failure incident related to a Boeing 787 Dreamliner, where the National Transportation Safety Board (NTSB) identified an internal short circuit within a single cell inside a lithium-ion battery as the cause of a fire aboard the aircraft [Article 17335]. - Investigators found evidence of a short circuit in cell no. 6 of the lithium-ion battery, leading to a "thermal runaway" that propagated to other cells, ultimately causing the fire [Article 17335]. - The NTSB ruled out mechanical damage as a cause of the short circuit and focused on the internal factors within the battery cells as the origin of the failure [Article 17335]. (b) The software failure incident related to software: - The software failure incident in this case is not directly attributed to software issues but rather to a hardware-related problem within the lithium-ion battery cells of the Boeing 787 Dreamliner [Article 17335]. - The investigation primarily focused on the internal short circuit within the battery cells and did not point to any software-related contributing factors as the cause of the incident [Article 17335].
Objective (Malicious/Non-malicious) unknown The articles do not mention any software failure incident related to a malicious or non-malicious objective.
Intent (Poor/Accidental Decisions) unknown The articles do not mention any software failure incident related to poor decisions or accidental decisions.
Capability (Incompetence/Accidental) accidental (a) The articles do not mention any software failure incident related to development incompetence. (b) The software failure incident related to the Boeing 787 battery fire was not accidental but was attributed to an internal short circuit within a single cell inside a lithium-ion battery [Article 17335].
Duration temporary The software failure incident discussed in the articles is related to a temporary failure rather than a permanent one. The incident involving the lithium-ion battery on the Boeing 787 Dreamliner was a temporary failure caused by specific contributing factors, such as a short circuit within a single cell of the battery, leading to a fire. The National Transportation Safety Board (NTSB) found evidence of a short circuit in cell no. 6, which initiated a thermal runaway that propagated to other cells [Article 17335]. This incident was not a permanent failure introduced by all circumstances but rather a specific issue within the battery system.
Behaviour unknown (a) crash: The software failure incident in the article is not related to a crash of the system. The incident described pertains to a battery problem on Boeing 787 Dreamliners, specifically related to a short circuit within a lithium-ion battery cell [Article 17335]. (b) omission: The software failure incident is not attributed to the system omitting to perform its intended functions at an instance(s). The focus of the incident is on the internal short circuit within the battery cell leading to a fire, rather than the system omitting any functions [Article 17335]. (c) timing: The software failure incident is not due to the system performing its intended functions too late or too early. The issue discussed in the article is related to a specific internal short circuit within a lithium-ion battery cell, not a timing-related failure [Article 17335]. (d) value: The software failure incident is not caused by the system performing its intended functions incorrectly. The incident revolves around a short circuit within a specific cell of the lithium-ion battery, leading to a fire, rather than the system functioning incorrectly [Article 17335]. (e) byzantine: The software failure incident is not characterized by the system behaving erroneously with inconsistent responses and interactions. The incident described is focused on a specific internal short circuit within a lithium-ion battery cell on Boeing 787 Dreamliners, leading to a fire, rather than erratic or inconsistent system behavior [Article 17335]. (f) other: The software failure incident in the article does not fall under the categories of crash, omission, timing, value, or byzantine behaviors. The incident is specifically related to a short circuit within a lithium-ion battery cell on Boeing 787 Dreamliners, leading to a fire, which does not align with the other defined behaviors of software failure [Article 17335].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence delay, non-human, theoretical_consequence (a) death: The articles do not mention any deaths resulting from the software failure incident. [17335] (b) harm: The articles do not mention any physical harm to individuals resulting from the software failure incident. [17335] (c) basic: The articles do not mention any impact on people's access to food or shelter due to the software failure incident. [17335] (d) property: The software failure incident did not directly impact people's material goods, money, or data. The focus of the incident was on the internal short circuit within a lithium-ion battery on a Boeing 787. [17335] (e) delay: The incident did cause delays in the operation of the Boeing 787 Dreamliners, as the entire fleet was grounded pending investigation by the FAA. This led to the cancellation of flights by airlines such as All Nippon Airways and United. [17335] (f) non-human: The software failure incident primarily affected the lithium-ion battery system on the Boeing 787 aircraft, which led to a fire. Non-human entities, such as the battery cells and aircraft systems, were impacted. [17335] (g) no_consequence: The software failure incident had real observed consequences, such as the grounding of the entire fleet of Boeing 787 Dreamliners and the cancellation of flights by airlines. [17335] (h) theoretical_consequence: The articles discuss potential consequences of the software failure incident, such as the possibility of a short circuit within the battery cells leading to thermal runaway and fire. The NTSB is investigating various factors like the state of charge of the battery cells, manufacturing processes, and battery design to determine the root cause of the short circuit. [17335] (i) other: The articles do not mention any other specific consequences of the software failure incident beyond those discussed in the options (a) to (h). [17335]
Domain transportation The software failure incident discussed in the provided article is related to the transportation industry. The incident involved a Boeing 787 Dreamliner aircraft, where a fire was attributed to an internal short circuit within a lithium-ion battery on board the aircraft [Article 17335]. This incident led to the grounding of the entire fleet of 50 Dreamliners in service worldwide, impacting the transportation sector significantly.

Sources

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