TSB Sounds Alarm To
Combat Inflight Fires
FRANCES FIORINO/NEW YORK
The Transportation Safety Board of
Canada, discovering safety deficiencies in the detection and management of
inflight fires in its ongoing investigation of Swissair Flight 111, issued
a third set of recommendations related to the 1998 accident--this time
pressuring industry to swiftly improve firefighting capability.
Flight 111 was en route
from New York to Geneva on Sept. 2, 1998, when the flight crew, detecting
smoke in the cockpit, diverted the MD-11 aircraft to the Halifax, Nova
Scotia, airport. Electrical problems developed, the autopilot
disconnected, flight data (FDR) and cockpit voice recorders (CVR) ceased
functioning and voice communications were lost. Inexplicably, Flight 111
turned from the direction of Halifax and plunged into the Atlantic Ocean
near Peggy's Cove, southwest of Halifax, at 2231 local time. There were no
survivors among the 215 passengers and 14 crewmembers ( AW&ST
Nov. 23, 1998, p. 41).
full-scale reconstruction rig of the forward main deck of Swissair
Flight 111 may lead investigators to pinpoint the source and cause
of the inflight fire.
VIC GERDEN, THE LEADING Transportation Safety Board of Canada
(TSB) Swissair Flight 111 investigator, said, "We have known virtually
from the beginning that the accident . . . was somehow related to a fire
in a portion of the so-called 'attic' of the aircraft, that is, the front
section of the aircraft above the ceiling, extending about 1.5 meters
forward and 5 meters back of the cockpit bulkhead. We also know that the
fire spread along flammable material, and, because it was in an
inaccessible space, the crew would have had trouble identifying, locating
and containing the fire. We do not know yet what started the fire" (
AW&ST Dec. 7, 1998, p. 39).
In March 1999, the TSB issued four recommendations related to recording
capacity and the flight recorders' power supply. This was followed by two
recommendations in August 1999 dealing with thermal acoustical insulation
blankets and related flammability test criteria ( AW&ST Oct.
19, 1998, p. 33). Two safety advisory letters were also issued, one
pertaining to aircraft wiring and the other to overheating of cockpit map
Then Gerden last week said the board had made "a number of troubling
observations that warrant safety follow-up. These include industry-wide
shortcomings in design, equipment, crew training and awareness, and
procedures. In the case of Swissair Flight 111, these shortcomings may
have made it difficult to quickly detect and suppress this inflight fire."
He said the TSB believes that industry "has not always looked at fire
prevention, detection and suppression as being the components of an
overall firefighting 'system.' An effective firefighting system would
consider and include all aspects of firefighting, such as aircraft design,
certification of materials, accessibility to vulnerable areas of the
aircraft for firefighting purposes, effective fire detection and
suppression equipment, well-designed inflight emergency procedures and
fully trained and equipped aircraft crew."
As a result, the TSB issued the five recommendations, pointing out that
the "excellent climate of cooperation" between the TSB and the National
Transportation Safety Board, FAA, Transport Canada and Europe's Joint
Aviation Authorities would lead the world aviation community to take early
action on the issues:
- Regulatory authorities and industry should "review the adequacy of
inflight fire-fighting as a whole, to ensure that aircraft crews are
provided with a system whose elements are complementary and optimized to
provide the maximum probability of detecting and suppressing any
inflight fire." Gerden said "the TSB wants crews to be provided with a
comprehensive, integrated firefighting plan that encompasses policies,
procedures, equipment, training and other appropriate measures."
- The regulatory authorities and industry should conduct a thorough
"review of the methodology for establishing designated fire zones within
the pressurized portion of the aircraft, with a view to providing
improved detection and suppression capability." Such a review, the TSB
believes, would reveal there are indeed inaccessible aircraft areas not
considered designated fire zones where a fire could ignite and spread,
and therefore should be equipped with built-in fire
detection/suppression systems. These include electronic equipment bays
and areas behind circuit-breaker and other electronic panels. At
present, smoke/fire detection and suppression systems in transport
aircraft are required only in "designated fire zones," that is, not
readily accessible areas such as powerplants, auxiliary power units and
cargo holds that contain recognized ignition and fuel sources.
- Regulatory authorities should "take action to ensure industry
standards reflect a philosophy" that a flight crew's most appropriate
course of action is to prepare to land the aircraft expeditiously when
smoke or an odor from an unknown source is detected. (Some, but not all,
carriers have already adopted this procedure.)
- Emergency checklists for odor/smoke of unknown origin should be
redesigned so that flight crews may complete them quickly, thereby
minimizing the risk of an inflight fire being ignited or sustained.
Current checklists are lengthy and often require trouble-shooting
procedures that call for shutdown of electrical power or isolation of an
environmental system--all of which allows more time for a heat source to
ignite or feed a fire. The TSB cites the MD-11 Smoke/Fumes of Unknown
Origin Checklist as requiring up to 30 min. to complete.
- Inflight firefighting standards--including procedures, training,
design equipment--should come under industry-wide review. This would
help ensure that flight and cabin crews could respond "immediately,
effectively and in a coordinated manner" to smoke or fire conditions in
the pressurized section of an aircraft, especially in areas not readily
accessible. The TSB found there is a lack of coordinated cabin-flight
crew training and procedures to enable them to quickly locate, assess,
control and suppress an inflight fire in the fuselage.
Twenty-seven months following the crash of Flight 111, the TSB
continues its quest to discover the cause of the inflight fire on board
the MD-11. Field analysis has been completed, two million pieces of
wreckage discovered and thousands of them analyzed, reconstructed and
placed on a jig for study by investigators. The wreckage will be stored at
the Canadian Forces Base at Shearwater (near Halifax).
On Dec. 15, the TSB is to move the investigation from Shearwater to its
Ottawa facilities for the final analysis phase and eventual preparation of
the final accident report--but the board said it was impossible at this
point to even estimate when the investigation might be completed.
© December 11, 2000 The McGraw-Hill Companies
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