Incident: Electronics Bay Power Panel Failure on Boeing 787 Dreamliner

Published Date: 2010-11-11

Postmortem Analysis
Timeline 1. The software failure incident on the Boeing 787 Dreamliner test aircraft happened on Monday, as reported in Article 3570. 2. The incident occurred on November 8, 2010 (2010-11) based on the article's publication date of November 11, 2010 [3570].
System 1. P100 panel in the 787 Dreamliner's aft electronics bay [3570] 2. Electrical power panels in the 787 Dreamliner's control panel [4056]
Responsible Organization 1. The software failure incident on the Boeing 787 Dreamliner test aircraft was caused by the failure of the P100 panel in the electronics bay power panel, which ignited a nearby insulation blanket [3570]. 2. The delays and issues in the Dreamliner program, including the electrical fire in a control panel, were attributed to ongoing challenges with software and hardware changes, supply chain problems, assembly issues, and disruptions like the machinists strike [4056].
Impacted Organization 1. Boeing [3570, 4056] 2. Air India [4056]
Software Causes 1. The failure incident on the Boeing 787 Dreamliner test aircraft was caused by the failure of the P100 panel in the electronics bay, which ignited a nearby insulation blanket [3570]. 2. The incident led to an emergency landing and suspension of the test program, impacting the delivery schedule of the Dreamliner to customers [3570]. 3. Boeing mentioned that backup power sources were designed to automatically engage in case of a P100 panel failure to ensure the safe operation of the airplane [3570]. 4. The replacement of the failed panel and the installation of new units were part of the recovery process following the software failure incident [3570]. 5. The incident was part of a series of delays that had already affected the Dreamliner program, including issues with suppliers, assembly challenges, and previous delays due to strikes and supply shortages [4056].
Non-software Causes 1. Electrical power panel failure leading to a fire in the insulation blanket [3570] 2. Ongoing challenges with out-of-sequence production work, parts shortages, and remaining software and systems integration activities [4056] 3. Supply chain problems, slow completion of work from supplier facilities, unanticipated rework, and addition of margin into the testing schedule [4056] 4. Machinists strike causing delays in the program [4056] 5. Supply shortages due to the strike and problems with assembly [4056] 6. Need to reinforce an area within the side-of-body section of the aircraft [4056]
Impacts 1. The software failure incident involving the electrical power panel on the 787 Dreamliner test aircraft led to a fire, forcing an emergency landing in Laredo, Texas, and the immediate indefinite suspension of the test program [3570]. 2. The incident caused uncertainty regarding the viability of Boeing's plan to make the first Dreamliner deliveries to customers in the first quarter of 2011 [3570]. 3. The incident resulted in significant damage to the failed panel, leading to its replacement with a new unit [3570]. 4. The software failure incident added to the long string of delays that had already plagued the Dreamliner program, impacting the overall schedule and delivery timeline of the aircraft [4056]. 5. The delays caused by the software failure incident and other issues led to the Dreamliner being at least three years behind the original schedule promised by Boeing [4056]. 6. The software failure incident contributed to the grounding of the Dreamliner test flight program, affecting the certification process and causing further delays in the testing and delivery of the aircraft [4056].
Preventions 1. Proper testing and validation of the software and hardware components of the aircraft's electronics bay power panel before the test flight could have potentially prevented the software failure incident [3570]. 2. Implementing more robust backup power systems and redundancy mechanisms to ensure continued safe operation of the airplane in case of a failure in the primary power panel could have mitigated the impact of the software failure incident [3570]. 3. Conducting thorough inspections and maintenance checks on critical components like the P100 panel to identify and address any potential issues or faults before they lead to a software failure incident [3570]. 4. Enhancing the design and manufacturing processes to minimize the risk of software failures in critical systems, such as the electronics bay power panel, could have helped prevent the incident from occurring [3570]. 5. Improving communication and coordination between different stakeholders involved in the development and testing of the aircraft to ensure timely identification and resolution of any software-related issues that could lead to failures [4056].
Fixes 1. Implementing hardware and software changes: Boeing mentioned that they have installed an interim package of software and hardware changes on four test airplanes to resume certification flights [4056]. 2. Installing replacement electrical power panels and final software changes: Boeing plans to install and test these changes over the next several months to clear the way for function and reliability testing [4056].
References 1. Boeing statement - The articles gather information about the software failure incident from official statements released by Boeing regarding the incident [3570, 4056]. 2. Boeing spokesperson Lori Gunter - Information is sourced from statements made by Boeing spokesperson Lori Gunter regarding the incident and the subsequent actions taken by Boeing [4056].

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization (a) The software failure incident having happened again at one_organization: The software failure incident involving an electrical fire in a control panel on a Boeing 787 Dreamliner test aircraft occurred in November, leading to a halt in the test flight program [3570]. This incident was not the first setback for Boeing's Dreamliner program, as the article mentions a series of delays and challenges that have plagued the project, including issues with production, supply chain problems, and assembly difficulties [4056]. (b) The software failure incident having happened again at multiple_organization: There is no specific mention in the provided articles about similar software failure incidents occurring at other organizations or with their products and services.
Phase (Design/Operation) design (a) The software failure incident related to the design phase can be inferred from the articles. The incident on the Boeing 787 Dreamliner test aircraft was caused by a failure in the P100 panel in the electronics bay, which ignited a nearby insulation blanket [3570]. This failure was attributed to the design of the power panel and its interaction with the systems on the aircraft. The article mentions that the P100 panel receives power from the left engine and distributes it to various systems, and in the event of a failure, backup power sources are designed to engage automatically to ensure safe operation [3570]. (b) The software failure incident related to the operation phase is not explicitly mentioned in the articles provided.
Boundary (Internal/External) within_system (a) within_system: The software failure incident reported in the articles is primarily within the system. The incident involved a power panel failure in the electronics bay of a Boeing 787 Dreamliner test aircraft, which led to an electrical fire igniting a nearby insulation blanket [3570]. Boeing mentioned that the P100 panel, responsible for distributing power from the left engine to various systems, failed during the flight, causing the insulation blanket to catch fire. The backup power sources were designed to engage automatically in case of such a failure to ensure the safe operation of the airplane [3570]. (b) outside_system: There is no information in the articles to suggest that the software failure incident was caused by contributing factors originating from outside the system.
Nature (Human/Non-human) non-human_actions, human_actions (a) The software failure incident occurring due to non-human actions: - The software failure incident on the Boeing 787 Dreamliner test aircraft was caused by a power panel failure in the electronics bay, which ignited a nearby insulation blanket. This failure was a non-human action as it was due to a technical issue with the P100 panel receiving power from the left engine, leading to the fire [3570]. - The incident led to an emergency landing in Laredo, Texas, and the suspension of the test program. The backup power sources were designed to automatically engage in case of a failure to ensure the safe operation of the airplane [3570]. - The insulation blanket self-extinguished once the fault in the P100 panel cleared, indicating that the failure was due to technical issues rather than human actions [3570]. (b) The software failure incident occurring due to human actions: - The delays and setbacks in the Dreamliner program, including the software and hardware changes, replacement of electrical power panels, and final software changes, were attributed to human actions and decisions made during the development and testing phases of the aircraft [4056]. - Boeing faced challenges with out-of-sequence production work, parts shortages, software and systems integration activities, supply chain problems, and slow completion of work from suppliers, all of which were influenced by human actions and decisions within the company [4056]. - The delays in the Dreamliner program, including the machinists strike, supply shortages, assembly problems, and the need for reinforcement in certain areas of the aircraft, were all consequences of human actions and decisions that impacted the development and delivery schedule of the aircraft [4056].
Dimension (Hardware/Software) hardware, software (a) The software failure incident occurring due to hardware: - The incident reported in Article 3570 was related to a fire aboard a Boeing 787 Dreamliner test aircraft, which started when an electronics bay power panel failed, igniting a nearby insulation blanket. This failure was attributed to the P100 panel in the aft electronics bay failing during the flight, causing the insulation blanket to catch fire [3570]. (b) The software failure incident occurring due to software: - The software failure incident reported in Article 4056 was related to an on-board electrical fire in a control panel of the Dreamliner test flight program. This incident led to the halt of the test flight program and required the installation of replacement electrical power panels and final software changes over the next several months [4056].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident related to the Boeing 787 Dreamliner test aircraft was non-malicious. The incident was caused by a power panel failure in the electronics bay, which ignited a nearby insulation blanket, leading to a fire onboard the aircraft. Boeing stated that the P100 panel, which failed during the flight, caused the insulation blanket to catch fire. The incident resulted in an emergency landing and the suspension of the test program, impacting the delivery schedule of the Dreamliner [3570]. (b) The software failure incident was not malicious but rather a result of technical issues within the aircraft's systems. The failure of the power panel in the electronics bay was not intentional but rather a technical malfunction that led to the fire onboard the 787 Dreamliner test aircraft. Boeing mentioned that backup power sources were designed to automatically engage in case of such failures to ensure the safe operation of the airplane [3570].
Intent (Poor/Accidental Decisions) unknown The software failure incident related to the Boeing 787 Dreamliner test aircraft was not directly caused by poor or accidental decisions related to software. The incident was specifically attributed to a power panel failure in the electronics bay, which ignited an insulation blanket nearby, leading to a fire [3570]. The failure was described as a technical issue rather than a result of poor or accidental decisions related to software development or implementation.
Capability (Incompetence/Accidental) accidental (a) The software failure incident in the Boeing 787 Dreamliner incident was not directly attributed to development incompetence. The incident was specifically related to a power panel failure in the electronics bay, which caused an insulation blanket to catch fire [3570]. (b) The software failure incident in the Boeing 787 Dreamliner incident was accidental in nature. The fire that occurred on the test aircraft was a result of a power panel failure, which ignited a nearby insulation blanket. This incident was not intentional but rather an unintended consequence of the power panel failure [3570].
Duration temporary The software failure incident related to the Boeing 787 Dreamliner test aircraft was temporary. The incident occurred when an electronics bay power panel (P100 panel) failed during the flight, causing a nearby insulation blanket to catch fire. Backup power sources were designed to automatically engage in case of such a failure to ensure the safe operation of the airplane [3570]. Following the incident, Boeing took actions to replace the failed panel and implement software and hardware changes gradually over the next few weeks to clear the way for function and reliability testing [4056].
Behaviour other (a) crash: The incident involving the Boeing 787 Dreamliner test aircraft was not a crash but a fire incident caused by a power panel failure, leading to an emergency landing in Laredo, Texas [3570]. (b) omission: There is no specific mention of the software failure incident being related to the system omitting to perform its intended functions at an instance(s) in the articles. (c) timing: The software failure incident did not involve the system performing its intended functions too late or too early [3570, 4056]. (d) value: The software failure incident did not involve the system performing its intended functions incorrectly [3570, 4056]. (e) byzantine: The software failure incident did not involve the system behaving erroneously with inconsistent responses and interactions [3570, 4056]. (f) other: The behavior of the software failure incident was related to a power panel failure igniting a nearby insulation blanket, leading to a fire on the aircraft, which is not specifically categorized under the options provided [3570].

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) unknown (b) unknown (c) unknown (d) unknown (e) delay: The software failure incident related to the Boeing 787 Dreamliner test aircraft caused an emergency landing in Laredo, Texas, and the immediate indefinite suspension of the test program, impacting the delivery schedule to customers [3570]. (f) non-human: The software failure incident on the Boeing 787 Dreamliner test aircraft resulted in a fire starting when an electronics bay power panel failed, igniting a nearby insulation blanket. The incident did not cause injuries to people on board or on the ground, and the insulation blanket self-extinguished once the fault in the power panel cleared [3570]. (g) unknown (h) theoretical_consequence: The software failure incident on the Boeing 787 Dreamliner test aircraft led to potential consequences such as delays in the test program, uncertainty about the first Dreamliner deliveries to customers, and impacts on Boeing's stock value [3570]. (i) unknown
Domain transportation (a) The failed system was related to the aviation industry, specifically the Boeing 787 Dreamliner test aircraft [3570, 4056]. (m) The incident did not involve an industry outside of the options provided.

Sources

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