Pilots Claim New Checklists Could Compound Emergencies

The road to commonly accepted emergency procedures for coping with in-flight smoke and fire is paved with discord. Case in point: Delta Air Lines [DAL], which has adopted procedures propounded by aircraft manufacturer Boeing [BA]. Representatives of the pilots union believe the new checklists embody a fragmented approach that may not provide clear guidance in the face of an emergency.

Management disagrees, countering that its new procedures are based on "rigorous analysis" and "thoughtful implementation."

The dispute is playing out against a renewed call by Canadian safety officials for a unified and comprehensive strategy in the airline industry to cope with and combat in- flight fires. "We would like to see the industry adopt an integrated, comprehensive firefighting strategy for aircrews," said Wendy Tadros, member of the Transportation Safety Board (TSB) of Canada in a recent speech (see ASW, March 8). The TSB investigated the Swissair Flight 111 disaster, a crash caused by an uncontrolled in-flight fire. Its March 2003 final investigative report of that disaster maintained that "the lack of comprehensive in-flight firefighting procedures, and coordinated aircraft crew training to use such procedures, constitutes a safety deficiency."

In that report, the TSB also expressed its view of the priorities that should guide emergency drills: "Regulatory authorities [should] take action to ensure that industry standards reflect a philosophy that when odor/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously."

Boeing guidance, contained in the Quick Reference Handbook (QRH), stresses that time is of the essence and that pilots facing a smoke/fire emergency should not delay descent and landing while troubleshooting. However, members of the Air Line Pilots Association (ALPA) Air Safety Committee at Delta maintain that the specific non-normal (i.e., emergency) procedures in the Boeing QRHs (they are tailored for each aircraft type) call for identification and mitigation of the smoke/fire first. They maintain that the explicit guidance to land as soon as possible is found in the preface, yet is not reinforced in any of the non-normal procedures. The pilots believe the procedures should specify occupant protection and survivability first - which means prepare to land ASAP - followed by identification and mitigation of the smoke/fire.

"We need a single, integrated non-normal checklist (INNC) that encompasses all necessary consideration if an in-flight smoke, fume, or fire event should occur, similar to the ones in effect prior to the introduction of the Boeing QRH," wrote Capt. Bill Jones in a recent issue of the Air Safety Committee's newsletter, The Safety Mind.

In a recent interview, Jones said the carrier developed and implemented a "one stop integrated firefighting plan" 12 years ago, but that INNC concept has been foregone in favor of the Boeing QRHs. There is an ongoing effort to resolve the situation, with some recent changes made by Delta in apparent response to the pilots' concerns. "While I am pleased that Delta has made some significant modifications to the Boeing smoke/fume/fire non-normal procedures, even these modified protocols are still lacking in the integrated, comprehensive firefighting strategy called for by the TSB," Jones said. In his Safety Mind article, Jones illustrated that two schools of thought are in opposition:

"There is no industry-wide consensus or model on how to effectively construct emergency procedures that address an in-flight smoke or fire event ... Everybody does it differently, some a little and some drastically."
"Because there is no industry standard, each airline ... develops its own philosophy, procedures and method of responding to these events."
"Here at Delta ... this issue has again reappeared - like the proverbial Phoenix. The imagery of that mythical creature is tragically appropriate, with a new twist. Instead of a single, integrated procedure that was contained in the previous generation of emergency procedures, you now have a choice among three. Which one you choose ... could be critical to successfully managing a significant in-flight fire event."
"It might surprise you to know that there have been literally dozens of airborne smoke, fume and/or fire events here at Delta over the last year."
"Do you know, without reference, what the Checklist Introduction section of your QRH says regarding Non-Normal Checklist Operation when there is persistent smoke or fire?"
"Do you realize that while the checklist introduction section states that information for planning the remainder of the flight is included in the checklist, this is not the case in smoke, fume or fire events?"
"Your Air Safety Committee has several volunteers who have extensive experience and unique expertise regarding in-flight fires ... Every one of them has been asked to review the current Delta/Boeing QRH procedures and, TO A MAN, our analysis ... leads us to believe that these QRH procedures for addressing in-flight fires may not only provide inadequate assistance, but may also mislead you when faced with this critical emergency."
"To ... management's credit, they have listened to our concerns, analyzed them and drawn their own, different conclusions ... simply put, we have a professional disagreement."
Management believes it is on the right course. According to the carrier, the QRH checklists "were adopted after extensive study and review, and they are consistent with the industry standard established for Boeing aircraft."

Moreover, the Federal Aviation Administration (FAA) principal operations inspector for Delta has approved the QRH procedures, the airline said.

"We believe the QRH procedures are sound," the company asserted.

Among the Air Safety Committee's specific concerns:

The advisory "Plan to land at nearest suitable airport" is written in the passive voice and does not stress to the crew the importance of landing as soon as possible. It is a step back from Delta's pre-existing INNC.
In the SMOKE OR FUMES AIR CONDITIONING checklist in the B737 QRH, the phrase "continue flight" is used three times, which could lead the crew to continue the flight to the original destination with the directed component turned off (e.g., air conditioning pack switch turned OFF). The safety committee would prefer the word "diversion" rather than "flight" to emphasize the need to land, to maintain a sense of urgency, and to discourage continuing to destination.
Jones is hopeful these issues can be resolved. The Boeing QRH procedures, he maintained, fragment the essential guidance, and focus the pilots' minds first on isolating the source of smoke, rather than immediately orienting the crew toward occupant protection and survivability by stimulating a land ASAP mentality.

At present, he said, the lack of a standardized, integrated approach to in-flight smoke and fire is exactly contrary to the TSB's desire. "We're a tower of Babel if you look across the industry," he said. "In the present situation, the FAA can approve 10 or more checklists for the same [smoke/fire] problem for the same aircraft."

There is no effort to standardize among manufacturers, which include Airbus, Embraer [ERJ], Bombardier [BBD] and others, Jones said. This situation, he maintained, "underscores the TSB's concern" about the need for a uniform and comprehensive strategy.

"If we can get the manufacturers to adopt our philosophy of a single INNC, this battle won't have to be fought one carrier at a time," Jones said.

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The Smoke, Fire and Fumes Checklist Imbroglio

By John Sampson, ASW Contributing Editor
The Delta pilots may be looking for a common prescription for fire and smoke, but each instance will be scenario-driven and the degree of urgency (and proper emphasis) will usually be a function of ongoing developments (fire spread, smoke density and system failures).

Unfortunately within that admission lies the fundamental failing of present checklist philosophies. As typified by the Swissair Flight 111 crash, pilots don't know the scope and scale of what is really happening behind the scenes - and if they're unlucky, may never do so. Behind the cabin linings, the airflow can be spreading the fire in many different directions and the only manifestation might be cascading systems failures. Pilots are not likely to know whether the outer hull has been pierced or whether oxygen, hydraulic lines or air ducts are also in imminent peril. Declaring an emergency and routing to land ASAP at the nearest suitable airport are "givens" and hair-splitting over that primary and paramount step should not be required. The essential elements of successful resolution of a Fire of Unknown Origin start with assertive investigative action shortly followed by:

Immediate purposeful steps to stop the spread of an electrical fire (i.e. get the power off the wire). Pilots cannot wait to find the source and then electrically isolate it - which is asking for a repeat of the Swissair crash.
An active search for the source (tearing cabin and cockpit linings down as required). Flight attendants must be involved in this, and they therefore need training in assertively gaining access and tackling the site of a blaze - using screwdrivers, knives (if available) or the crash-axe with discretion and aplomb, not just squirting fire- extinguishers aimlessly into obscure spaces.
The E&E (electronics and equipment) bay and main electrical load centers should be entered to check for any smoke source - while they are still habitable (requires a flashlight, goggles, portable oxygen and a diagram that can be marked by the flight attendant dispatched below for the pilots' later edification).
If pilots are to be legally stuck in their seats on oxygen, behind locked doors, then flight attendants must be shown how to identify electrical components that may be sparking - so that pilots can trip the appropriate breakers. One cannot hope they will be trained to the level of knowledge or resourcefulness that could be expected of a flight- engineer - but without that elementary training it is really the blind (the pilots without info) leading the blind (the flight attendants who are totally out of their depth).
Hard and fast long-winded trouble-shooting checklists are what helped ensure that Swissair Flight 111 would go down.

The remark that the QRH checklists "are consistent with the industry standard established for Boeing aircraft" is a little mystifying because each aircraft type can be as unlike electrically as chalk and cheese. The MD-11 design with its very limiting Smoke/Elec/Air switch is entirely different to the B717 electrical design philosophy, for instance.

Airbus electrical design and the Boeing B777 may have some things in common as dictated by their fly-by-wire flight control systems. Some aircraft have RATs (ram air turbines) and ADGs (air driven generators) and cannot use their APUs (auxiliary power units) airborne. Others are wholly reliant upon the APU as a backup electrical and hydraulic backstop.

With respect to the need to ventilate the aircraft, particularly the enclosed flightdeck, sudden opening of a vent-hatch or sliding window in an oxygen depleted confined area could lead to a flashover (backdraft).

That "other solution" of DITCH ASAP remains one of the great unmentionables.

A Nightmare Scenario
Fire in the cargo hold

An incendiary device coupled with a strong acid to eat through the hull and defeat the suppression strategy by breaking the pressurization seal and opening the hold to external airflows.

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