risk, perception, and probability of smoke, fire and fumes
DESCRIPTION
Reducing the Risk of Smoke and Fire in Transport Airplanes: Past History, Current Risk, and Recommended Mitigations By: John M. Cox, FRAeS President Safety Operating Systems. Risk, Perception, and Probability of Smoke, Fire and Fumes. What are the odds?. Probability. - PowerPoint PPT PresentationTRANSCRIPT
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Reducing the Risk of Smoke and Reducing the Risk of Smoke and Fire in Transport Airplanes: Fire in Transport Airplanes:
Past History, Current Risk, and Past History, Current Risk, and Recommended MitigationsRecommended Mitigations
By:By:
John M. Cox, FRAeSJohn M. Cox, FRAeSPresidentPresident
Safety Operating SystemsSafety Operating Systems
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Risk, Perception, and Risk, Perception, and Probability of Smoke, Fire Probability of Smoke, Fire
and Fumesand Fumes
What are the odds?What are the odds?
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Probability Probability In-flight fire is the 4In-flight fire is the 4thth leading cause of leading cause of
fatalities in commercial jet aircraft fatalities in commercial jet aircraft accidents 1987 – 2004 (Boeing Study)accidents 1987 – 2004 (Boeing Study)• Loss of Control (LOC)Loss of Control (LOC)• Controlled Flight into Terrain (CFIT)Controlled Flight into Terrain (CFIT)• Specific Component failure (non-Specific Component failure (non-
powerplant)powerplant)
Probability is > 1 in 10,000Probability is > 1 in 10,000
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ProbabilityProbability
IATA STEADES DATAIATA STEADES DATA36 months: Jan. 2002 to Dec. 200436 months: Jan. 2002 to Dec. 2004Total Air Safety Reports (ASRs) = 2,596Total Air Safety Reports (ASRs) = 2,596
17011701 of the 2596 events were in-flight of the 2596 events were in-flight occurrences of smokeoccurrences of smoke
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WhenWhen
IATA DATA
Cruise
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WhereWhere
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ProbabilityProbability > > 10001000 in-flight smoke events occur in-flight smoke events occur
annuallyannually Resulting in >Resulting in >350350 unscheduled or unscheduled or
precautionary landingsprecautionary landings In-flight smoke rate is In-flight smoke rate is 11 in in 50005000
flightsflights In-flight smoke diversion rate is In-flight smoke diversion rate is 11 in in
15,00015,000 flights flightsIATA DataIATA Data
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TermsTerms AC 25-1309 1AAC 25-1309 1A
• Catastrophic (not all fires are, but potential)Catastrophic (not all fires are, but potential)• Extremely improbableExtremely improbable
1 x 101 x 10-9-9 or less or less
Probability of diversion due to cockpit Probability of diversion due to cockpit smoke could be a reasonably probable smoke could be a reasonably probable event and within the range of remote event and within the range of remote ((HalfpennyHalfpenny) ) 1 x 10 1 x 10 -5-5
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HistoryHistory July 1785, Jean-François July 1785, Jean-François
Pilâtre de Rozier’s Pilâtre de Rozier’s hydrogen balloon hydrogen balloon ignited and burned over ignited and burned over the English Channel. the English Channel.
Aviation’s first fatal Aviation’s first fatal accident was an in-flight accident was an in-flight firefire
Credits - 2001 National Air and Space Museum,Smithsonian Institution (SI Neg. No. A-4691)
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Propeller TransportsPropeller Transports Trans World Airlines, Trans World Airlines,
July 11, 1946, July 11, 1946, Lockheed Lockheed Constellation Constellation • Smoke overwhelmed Smoke overwhelmed
the crewthe crew Similar accidents from Similar accidents from
generator leads issue generator leads issue still occurstill occur
• Open Flight Deck Open Flight Deck Window did not allow Window did not allow landinglanding
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Propeller TransportsPropeller Transports
American Airlines, American Airlines, November 11, 1947, November 11, 1947, DC-6DC-6
• Fire from heater Fire from heater ingesting fumesingesting fumes
Fume ignition remains Fume ignition remains an issuean issue
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1973 and B707 fires1973 and B707 firesVarig Flight 860, July 11, 1973Varig Flight 860, July 11, 1973
Cabin fire with heavy smokeCabin fire with heavy smoke
Landed in a field 70 second from Paris OrlyLanded in a field 70 second from Paris Orly
Crew and Passenger experienced smoke Crew and Passenger experienced smoke inhalation inhalation
Open Flight Deck Windows did not provide Open Flight Deck Windows did not provide sufficient visibility sufficient visibility
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Varig Flight 860Varig Flight 860
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Pan Am Flight 160Pan Am Flight 160 November 3, 1973November 3, 1973 Cargo Flight - Hazardous Material Cargo Flight - Hazardous Material
FireFire Smoke overwhelmed Flight DeckSmoke overwhelmed Flight Deck
• Continuous Smoke GenerationContinuous Smoke Generation Flight Deck Window Opened - Not Flight Deck Window Opened - Not
Successful LandingSuccessful Landing
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ChangesChanges RegulationRegulation
• Smoke GogglesSmoke Goggles• Smoke Removal ProceduresSmoke Removal Procedures• Tightened Hazardous Material Tightened Hazardous Material
RequirementsRequirements• Banned Smoking in LavatoriesBanned Smoking in Lavatories• Improved Cabin AirflowsImproved Cabin Airflows• Waste Towel Receptacle Made More Fire Waste Towel Receptacle Made More Fire
ResistantResistant
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Air Canada Flight 797Air Canada Flight 797
June 2, 1983 – DC-9-30 June 2, 1983 – DC-9-30 Fire began in Aft Lavatory – Spread Fire began in Aft Lavatory – Spread
• Cause believed to be electrical near Cause believed to be electrical near flush motorflush motor
Smoke filled Cabin and Flight DeckSmoke filled Cabin and Flight Deck Flight Deck Door BrokenFlight Deck Door Broken
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Air Canada Flight 797Air Canada Flight 797 F/A and Passengers Smell SmokeF/A and Passengers Smell Smoke Pilots Hear Circuit Breaker TripPilots Hear Circuit Breaker Trip
• Reset onceReset once Smoke IncreasesSmoke Increases COCO2 2 Fire Extinguisher Discharged into Fire Extinguisher Discharged into
LavatoryLavatory• Not effectiveNot effective• Not applied directly at base of fireNot applied directly at base of fire
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Air Canada Flight 797Air Canada Flight 797 Fire and Smoke SpreadFire and Smoke Spread First Officer Went Aft to Investigate First Officer Went Aft to Investigate Flight Deck Door Left OpenFlight Deck Door Left Open First Officer Switched Off Air-First Officer Switched Off Air-
conditioning Packsconditioning Packs• Ventilation flow aft stoppedVentilation flow aft stopped
Flight Deck Windows Opened and Flight Deck Windows Opened and ClosedClosed• ReversedReversed• High Noise High Noise
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ChangesChanges Lavatory Fire DetectionLavatory Fire Detection Full Face Masks Portable Crew Full Face Masks Portable Crew
OxygenOxygen Protective Breathing EquipmentProtective Breathing Equipment Fire Blocking Seats (650,000)Fire Blocking Seats (650,000) Halon Fire Extinguisher (2 – 2.5 lb)Halon Fire Extinguisher (2 – 2.5 lb) AC 25-9AC 25-9
• Smoke TestingSmoke Testing
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Single Failure – Single Failure – Multiple ResultsMultiple Results
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Single Failure – Single Failure – Multiple ResultsMultiple Results
RAF Nimrod ExampleRAF Nimrod Example• #1 Engine DC Wire Loom Failure#1 Engine DC Wire Loom Failure• Uncommanded Opening of #4 Engine Uncommanded Opening of #4 Engine
StarterStarter• Starter Turbine Valve Over SpeedsStarter Turbine Valve Over Speeds
Air from operating engineAir from operating engine• Starter Turbine DisintegratesStarter Turbine Disintegrates• Turbine Escapes HousingTurbine Escapes Housing• Turbine Punctures Fuel TankTurbine Punctures Fuel Tank• Severe Fuel Tank FireSevere Fuel Tank Fire• Ditching in the North Sea – All SurvivedDitching in the North Sea – All Survived
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Single Failure – Single Failure – Multiple ResultsMultiple Results
Swiss Air 111Swiss Air 111• In-Flight Entertainment Systems WiringIn-Flight Entertainment Systems Wiring
Likely initial location of arcing and/or fireLikely initial location of arcing and/or fire• Spread to Nearby WiringSpread to Nearby Wiring
Multiple system failureMultiple system failure Flight instruments failedFlight instruments failed
• Unrelated Systems Affected by Initial EventUnrelated Systems Affected by Initial Event
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Location, Location, LocationLocation, Location, Location Inaccessible Areas Contain Inaccessible Areas Contain
• Wiring Wiring • Thermal Acoustic BlanketsThermal Acoustic Blankets• ContaminatesContaminates
ConductiveConductive Non-ConductiveNon-Conductive LiquidsLiquids Corrosion BlockCorrosion Block LubricantsLubricants
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Unprotected Area of AircraftUnprotected Area of Aircraft
Examples were all unprotected areasExamples were all unprotected areas• No DetectionNo Detection• No SuppressionNo Suppression
Most in-flight fires are in unprotected Most in-flight fires are in unprotected areasareas
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Unprotected Area of AircraftUnprotected Area of Aircraft
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WiringWiring
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WiringWiring
2/3 In-Flight Fires are Electrical2/3 In-Flight Fires are Electrical
2003 MITRE Report2003 MITRE Report• 81 Large Transports Inspected81 Large Transports Inspected
40 wiring anomalies PER airplane average40 wiring anomalies PER airplane average• 39 Small Transports Inspected39 Small Transports Inspected
58 wiring anomalies PER airplane average58 wiring anomalies PER airplane average
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WiringWiring FAA Report 1995 to 2002 FAA Report 1995 to 2002
• 397 Wiring Failures397 Wiring Failures 84% burned, loose, damaged, shorted, 84% burned, loose, damaged, shorted,
failed, chafed or broken wires failed, chafed or broken wires
TWA 800 NTSB ReportTWA 800 NTSB Report• Examined 25 Transport AircraftExamined 25 Transport Aircraft
24 had metal shavings in wiring bundles24 had metal shavings in wiring bundles 5 showed evidence of heat or fire damage 5 showed evidence of heat or fire damage
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WiringWiring Supplemental Type CertificateSupplemental Type Certificate
• FAA Study of 316 Circuit BreakersFAA Study of 316 Circuit Breakers Many lugs contained two different size wiresMany lugs contained two different size wires Violation of 14 CFR Part 25.1357 Violation of 14 CFR Part 25.1357
• Swiss Air 111 IFESwiss Air 111 IFE No wiring routing drawingsNo wiring routing drawings By-Passed Cabin Bus SwitchBy-Passed Cabin Bus Switch
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WiringWiring
Arc Fault Circuit Breaker
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WiringWiring
Arc Fault Circuit Breaker
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WiringWiring
Flash of unprotected circuit
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Vision AssuranceVision Assurance
Vision to Maintain Vision to Maintain ControlControl
NavigateNavigate Accomplish Accomplish
ChecklistChecklist LandLand
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Full Face MasksFull Face Masks Full Face MasksFull Face Masks
• Better protectionBetter protection• Better ability to purgeBetter ability to purge• Eliminates ability to Eliminates ability to
only use maskonly use mask FedEx 1406FedEx 1406
Sufficient Oxygen Sufficient Oxygen Supply for LandingSupply for Landing• MEL does not consider MEL does not consider
Smoke/Fire/FumesSmoke/Fire/Fumes
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Halon Fire ExtinguishersHalon Fire Extinguishers
FAA Tests FAA Tests • 2 ½ lb did not 2 ½ lb did not
extinguish fireextinguish fire
• 5 lb could have 5 lb could have extinguish fireextinguish fire
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Fire Access PortsFire Access Ports Access to Previously Inaccessible Access to Previously Inaccessible
AreasAreas• Allow extinguishant in without Allow extinguishant in without
increasing airflowincreasing airflow
Universal CompatibilityUniversal Compatibility• Flexible tubes allow high flow rate of Flexible tubes allow high flow rate of
extinguishantextinguishant
Some Areas Are Too Large for PortsSome Areas Are Too Large for Ports• Attic of wide body aircraft Attic of wide body aircraft
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Mark Location of AccessMark Location of Access
Provide Marking of Access to Provide Marking of Access to Inaccessible AreaInaccessible Area• Where is it safe to open an areaWhere is it safe to open an area• Where is will there be collateral damageWhere is will there be collateral damage
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TrainingTraining
FAA Tech Center
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TrainingTraining FAA TestsFAA Tests
• Line Flight AttendantsLine Flight Attendants With 2 ½ lb Halon – Fire was not With 2 ½ lb Halon – Fire was not
extinguishedextinguished PBE problemsPBE problems Smoke MigrationSmoke Migration
• Training was not adequate Training was not adequate
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TrainingTraining SmokeSmoke
• ToxicityToxicity Improved but still a serious considerationImproved but still a serious consideration
• LocationLocation AccessAccess
• Remove panel or “ax it”Remove panel or “ax it”• Collateral DamageCollateral Damage
• AmountAmount ContinuousContinuous
• Combustion ongoingCombustion ongoing
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TrainingTraining
Smoke BarrierSmoke Barrier• Maintain Maintain
Close the Door!Close the Door! ““Captain there is smoke in the galley”Captain there is smoke in the galley”
• CommunicationCommunication
• Protect Flight Deck from SmokeProtect Flight Deck from Smoke
• MaintenanceMaintenance Swiss Air 111 exampleSwiss Air 111 example
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TrainingTraining
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TrainingTraining Smoke Barrier ExamplesSmoke Barrier Examples
• Cubana DC-8, October 6, 1976Cubana DC-8, October 6, 1976 Explosion in cargo holdExplosion in cargo hold Smoke in cabinSmoke in cabin Flight Attendant Flight Attendant openedopened the Flight Deck the Flight Deck
DoorDoor Captain’s voice on CVR “Close the door! Captain’s voice on CVR “Close the door!
Close the door!”Close the door!” Smoke filled the Flight DeckSmoke filled the Flight Deck
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TrainingTraining
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TrainingTraining Smoke Barrier ExamplesSmoke Barrier Examples
• AirTran Flight 913 – August 8, 2000AirTran Flight 913 – August 8, 2000 Just after takeoff – Electrical FireJust after takeoff – Electrical Fire Location aft of Captain behind circuit breakers – Location aft of Captain behind circuit breakers –
Forward F/A jumpseatForward F/A jumpseat
• Smoke in Galley AreaSmoke in Galley Area F/A F/A openedopened door found pilots wearing masks and door found pilots wearing masks and
gogglesgoggles No attempt to fight fireNo attempt to fight fire
• Returned for landingReturned for landing
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TrainingTraining Use of the AxUse of the Ax
When?When?
Where?Where?
How?How?
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Ventilation and Open WindowsVentilation and Open Windows
SootSootOpenOpen
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Open WindowOpen Window 70 Seconds from Runway70 Seconds from Runway Open Window did NOT Provide Open Window did NOT Provide
Sufficient VisibilitySufficient Visibility High NoiseHigh Noise Reverse Air FlowReverse Air Flow
• Cabin Air into Flight DeckCabin Air into Flight Deck Visibility is Proportional to Increase Visibility is Proportional to Increase
Flow RateFlow Rate• Double the rate double the visibilityDouble the rate double the visibility
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ConclusionsConclusions There are going to be in-flight firesThere are going to be in-flight fires
Multiple layers of mitigation are Multiple layers of mitigation are necessarynecessary
Implementation Implementation • FAA NPRMsFAA NPRMs
Wiring & Fuel TankWiring & Fuel Tank
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ConclusionsConclusions Fire is an Fire is an
unexpected eventunexpected event
Fire is a very high Fire is a very high stress eventstress event
Fire may be from Fire may be from an unexpected an unexpected sourcesource
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Most Recent ExampleMost Recent Example
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AcknowledgementsAcknowledgements Ms. Allison MarkeyMs. Allison Markey FAA Technical CenterFAA Technical Center
• Mr. Gus Sarkos Mr. Gus Sarkos • Mr. Dave BlakeMr. Dave Blake• Mr. Rob PappasMr. Rob Pappas
Dr. Kathy AbbottDr. Kathy Abbott Mr. Tony BroderickMr. Tony Broderick Dr. Barbara BurinDr. Barbara Burin Captain Ron McDonaldCaptain Ron McDonald NTSBNTSB BEABEA ERAUERAU
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Thank You!Thank You!