Recommendation A00-20

Reassessment of the Responses to Aviation Safety Recommendation A00-20

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Deficiencies in In-Flight Firefighting Standards

Background

On 02 September 1998, Swissair Flight 111, a McDonnell Douglas MD-11 aircraft, departed John F. Kennedy Airport in New York, New York, en route to Geneva, Switzerland. Approximately one hour after take-off, the crew diverted the flight to Halifax, Nova Scotia, because of smoke in the cockpit. While the aircraft was manoeuvring in preparation for landing in Halifax, it struck the water near Peggy's Cove, Nova Scotia, fatally injuring all 229 occupants on board. The investigation revealed that the flight crew had lost control of the aircraft as a result of a fire in the aircraft's ceiling area, forward and aft of the cockpit bulkhead.

On 04 December 2000, the Board released interim safety recommendations as part of its investigation (A98H0003) into this occurrence.

Board Recommendation A00-20 (04 December 2000)

The Board believes that the lack of comprehensive in-flight firefighting procedures, and coordinated aircraft crew training to use those procedures, constitutes a safety deficiency. Therefore, the Board recommended that:

Appropriate regulatory authorities review current in-flight firefighting standards including procedures, training, equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire.
A00-20

Responses to A00-20 (Transport Canada - 06 March 2001 and Federal Aviation Administration - 18 January 2001)

On 19 December 2000, Transport Canada (TC) sent a letter to the United States Federal Aviation Administration (FAA) and the European Joint Aviation Authorities (JAA). The letter supported the intent of the recommendations, acknowledged that none of the issues can be addressed in isolation, and invited the major civil aviation regulatory authorities to harmonize a strategy for their resolution.

In this letter, TC also proposed to hold a meeting in March 2001 to discuss the recommendations, to identify existing initiatives and groups that may already address some aspects covered by the recommendations, and to establish a team to develop an appropriate action strategy. The FAA responded positively on 19 January 2001 and a positive response is anticipated from the JAA.

TC will keep the TSB apprised of the outcome of the meeting and of its progress towards achieving the goals of these recommendations.

The FAA responded that it has added TSB's recommendations to the FAA's Safety Recommendation Program to ensure that they are assigned to the appropriate program offices for evaluation and action as necessary. The FAA also indicates that it has agreed to meet with TC over this matter and that the Office of Aircraft Certification, specifically the Manager of the Transport Airplane Directorate, has been assigned to lead the FAA team in this regard.

Board Assessment of the Response to A00-20 (19 March 2001)

It is apparent that both TC and the FAA agree with the thrust of the deficiencies and are committed, at least in the short term, to examine these issues and map out a course of action. Collectively, these responses are adequate and constitute a logical "first step." Until such time as the details of the proposed action plan are known, it will remain unclear the extent to which the identified deficiencies will be reduced or eliminated. Although the declared initiatives will not yield any immediate substantive change, the planned action, when fully implemented, will substantially reduce or eliminate the safety deficiency.

Therefore, the responses are considered to be Satisfactory Intent.

Next TSB action

TSB staff will closely monitor the progress of the TC/FAA deliberations to determine if their action plan addresses the identified deficiencies.

Response to A00-20 (14 December 2005)

In its update of active recommendations dated 14 December 2005, TC indicated that it has reviewed this issue and has determined that the Flight Attendant Training Standard (TP 12296) addresses the training issues as identified in the Swissair Flight 111 investigation report.

Board Reassessment of the Response to A00-20 (12 July 2006)

As of 14 December 2005, TC indicated that it has reviewed this issue and determined that the Flight Attendant Training Standard (TP 12296) addresses the training issues as identified in Recommendation A00-20. However, TC's activity update only addresses the training standard for flight attendants. It does not address the training standard for flight crew, the adequacy of existing firefighting equipment or the accessibility to spaces such as attic areas. The actions taken have not substantially reduced or eliminated the safety deficiency.

Therefore, the assessment is now Satisfactory-in-Part.

Next TSB action

TSB staff will liaise with TC to determine its activity with respect to residual risk related to the deficiency described in Recommendation A00-20.

Response to A00-20 (07 February 2007)

In addition to Flight Attendant Training Standard (TP 12296), TC's response received 07 February 2007 indicates that it is cooperating with the FAA, UK CAA and other regulatory authorities in the International Aircraft Systems Fire Protection Working Group to address deficiencies identified in Recommendation A00-20. Currently, the working group is examining the use of handheld fire fighting equipment in hidden areas as well as infra-red detection devices for use by aircrew. Additionally, the working group is developing a video to complement the FAA's Advisory Circular 120-80 In-Flight Fires which discusses the dangers of in-flight fires, with particular emphasis on hidden fires that may not be visible or easily accessed by the crew.

Board Reassessment of the Response to A00-20 (24 July 2007)

TC's activity update indicates that its action plan is indeed multi-faceted. In cooperation with other regulatory authorities it continues to identify efficiencies to improve the current in-flight firefighting standards. These initiatives, along with other complementary activities such as TC's Policy Letter 153: Practical Training - Emergency Procedure Training for Pilots, if fully implemented, will reduce the deficiency identified in Recommendation A00-20.

Therefore, the assessment is Satisfactory Intent.

Next TSB action

TSB staff will liaise with TC to determine its activity with respect to residual risk related to the deficiency described in Recommendation A00-20.

Response to A00-20 (06 March 2008)

As in its response to TSB, dated 14 December 2005, TC states that the Flight Attendant Training Standard (TP12296) addresses the training issues as identified in the Swiss Air Investigation Report for SR 111 and suggests that the recommendation be closed.

Board Reassessment of the Response to A00-20 (13 August 2008)

In its various responses, TC has declared that the training issues raised in Recommendation A00-20 are addressed by its Flight Attendant Training Standard (TP 12296) and Policy Letter 153: Practical Training - Emergency Procedure Training for Pilots. Likewise, equipment deficiencies identified in Recommendation A00-20 are being dealt with under the auspices of the International Aircraft Systems Fire Protection Working Group. These initiatives, along with other complementary activities such as TC's Policy Letter 153: Practical Training - Emergency Procedure Training for Pilots, if fully implemented, will reduce the deficiency identified in Recommendation A00-20.

Therefore, the assessment is Satisfactory Intent.

Next TSB action

TSB Air Branch staff will monitor TC's activity with respect to the risks associated with Recommendation A00-20.

FAA Response to A00-20 (06 January 2010)

In January 2010 the FAA provided an update with respect to its activity related to TSB Recommendation A00-20. The FAA states that it has published Advisory Circular (AC) 120-80, entitled In-flight Fires in January 2004 and subsequently released a complementary FAA training video entitled Fighting In-Flight Fires on 01 November 2007. The video is designed to assist in the training of airline cabin flight attendants to successfully fight and extinguish a hidden in-flight fire. It incorporates significant findings from FAA fire safety research and development. There is no information in the response that would indicate that the FAA is planning any additional initiatives related to Recommendation A00-20.

Board Reassessment of the Response to A00-20 (28 July 2010)

The Board appreciates the FAA's update. TSB was previously aware of Advisory Circular 120-80 but not that the FAA had produced and distributed a complementary video. These initiatives, while recognizing that more should be done to assist in dealing with in-flight fires, are advisory in nature and are not designed to work as a system. However, there is nothing in the response to suggest that the FAA has conducted a review of current in-flight firefighting standards to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire.

The safety analyses which led to the issuance of Recommendation A00-20 identified a deficiency in existing in-flight firefighting elements in that there is no regulatory requirement that they be designed and implemented to complement each other. While improvements have been made to individual in-flight firefighting elements, e.g. material flammability standards, there is no indication that the elements have been reviewed to ensure that they are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire.

To date, neither the FAA nor the IASFPWG, to which TC in its 06 March 2008 response relinquished leadership on this issue, has indicated any additional initiatives related to Recommendation A00-20. Hence, the lack of a systemic approach to deal with in-flight firefighting remains. Consequently, the Board believes that various initiatives will reduce, but not substantially reduce or eliminate the deficiency identified in Recommendation A00-20.

Therefore, the assessment remains as Satisfactory in Part.

Next TSB action

The residual risk is substantial but any further action would be the responsibility of the IASFPWG to mitigate the residual risk associated with Recommendation A00-20.