Subject:      The Virgin Bus

(a post-sr111 Lesson Learnt)

Standard checklist practice requires pilots to read to each other procedures used every day and recite from memory those needed every five years.

Date:            Sat, 26 Dec 1998 20:50:02 +0800
From:         IASA Safety <safety@iasa-intl.com>
To:            Patrick Price <PAPCECST@aol.com>, JOHNDKING King jking1@mediaone.net,
                Artder van Wald avandwal@compuserve.com,
               "Babin, Jacques" <Jacques.Babin@bst-tsb.x400.gc.ca>
CC: Bob Rowland <rwroland@aol.com>, Chris & Gayle Kingswood <c.kingswood@virgin.net>,
David Evans <devans@phillips.com>, Edward Block <EdwBlock@aol.com>,
"naefw@dial.eunet.ch" <naefw@dial.eunet.ch>,
Omega Systems Group Vernon Grose <omega@omegainc.com>,
"PEddyXX@aol.com" <PEddyXX@aol.com>, "swissair_crm@e-mail.com" <swissair_crm@e-mail.com>,
Ross Coulthart <RCOULTHART@ninenet.com.au>

From: http://www.hfxnews.southam.ca/Crash/swissair202.html        of  Tues 22 Dec 98

It says (in part):

"Investigators probing the crash of Swissair Flight 111 have discovered signs of a fire in the ceiling of the plane between the forward passenger doors, the same area airlines flying similar planes have been warned to check."
"While the doors themselves showed no signs of heat damage, the ceiling between the doors does."

"It originates and stems from a centre line but it also progresses outwards from the centre line above the left and right
doors," Gerden said.

Ninety seconds before the plane's flight-data and cockpit -voice recorders stopped working, six minutes before impact,
they recorded failures in about 40 of the plane's 250 systems.

"That would have affected the displays the pilots had," Gerden said.

Commentary:

It's a little hard yet to say whether the "failures" were as a result of the checklist

or the  progressive disabling of systems by the elec initiated fire. It however reinforces

my belief that the ongoing, discretionary, time-consuming, trouble-shooting smoke

checklist MUST be discarded and manufacturers must incorporate a  "fall-back"

electrics selection that will inert the majority of the normal electrics and revert to a

"virgin" bus that has on it, very simply, the "get-you-home" items.


     At least in this way:


a.  everyone lives


b.  expensive time-consuming rescue efforts, salvage and subsequent
     crash investigations are avoided.


c.  The problem is immediately apparent and thereby fixable (if they
     wish they can power the normal electrics up again on the ground
     and just see where the inflight fire would have gone). Other
     similar jets won't then be operating for many months (years?)
     whilst the deadly glitch is uncovered (with all the abiding concerns
     of a fearful public and crews). DFDR/CVR data will still be
     available for trouble-shooting. The uncertainty of a PROBABLE
     CAUSE finding will be avoided.


d.  Fewer people would be afraid of flying if it was known
     that fire-in-the-air was now less of a wild card (despite
     being by far the worst aerial prospect short of total
     structural failure).


e.  You could perhaps then conscionably afford to live with Kapton, its
     variants and even the metalized mylar sound blankets (until the aircraft
     go out of service).

f.   Insurance underwriters and actuaries would be happier because the risks would
     diminish. Airline and manufacturer's accountants would be able to
     justify premium reductions.


g.  There'd be fewer diversions at the least hint of a "dark brown
     smell"        that is to say that:


h.  Airline crews would have more confidence about this dire emergency
     that is of greater risk to them because it affects every day of their
     working lives.


i.   Particular aircraft (and therefore airlines) won't get a bad name
     because of accidents (and the inevitable other disclosures of a probing
     investigation).


j.   Airlines that comply are seen by passengers as being very
     responsible and safety conscious.


k.  Expensive court cases that enrich lawyers, stoke premiums
     and provoke primal fears (fire and flying) would be minimized.


l.   Manufacturers that offered such an option (or retro-fit kit) would
     have a distinct commercial advantage because of their public image (at
     an insignificant cost in terms of weight, complexity, maintainability
     and justifiability).


m. Presently mooted Kapton wiring health monitoring systems may prove
     unnecessary.


n. Geriatric jets may thereby be given a new lease of life (at least
    from the wiring integrity point of view)


o. Fuel dumping may not then always prove urgently necessary
    and this can be important when enroute alternate weather
    is lousy (i.e. when holding off or pressing on to a distant
    div or destination may be required or prudent).


p.   Once the normal electrics go OFF, experience has been that any elec
      fire will fizzle out (or be easily doused). crews are then in a better
      position to communicate and back each other up (i.e. smoke masks can
      come off, intercom's not necessary, peripheral vision is restored).
      Fire-extinguishers are far more effective on a fire that is minus the
      stoking electrics. But whenever the fire is worsening the pilots are
      restricted in their movement - both by their oxygen umbilicals and a
      checklist that bans them from leaving their seats. Who fights the fire
      with the handheld then?


BUT ABOVE ALL BECAUSE


q. Crews would have a definitive operational directive rather than
    agonizing about diverting rapidly, ditching, rushing to land overweight
    in a crippled configuration, proceeding with or "holding" the existing
    trouble-shooting smoke checklists (whilst perilously waiting to see if
    things are going to get worse/improve/stay the same).


r.  The likelihood of a mid-oceanic sr111 type emergency
    carrying out an intentional (perhaps unnecessary) ditching
    with great loss of life would be much reduced. The
    ditchability of large underwing turbofans?-------They’re
    not a survivable ditching proposition -so it’s another
    strong case for adopting the Virgin Bus as a
    preferred alternative to allowing catastrophic fires
    to develop.


s. Passengers are less likely to panic if, when all their lights go
    out, they realize that the crews are erring on the side of caution and
    not toying with their lives via an Emperor Nero like fiddle with busses,
    avionics, circuit-breakers, smoke/elec/air switches, hand-held fire
    extinguishers, EVAS vision maintenance devices, below floor E/E bay
    visitations, consultations on Company freqs, wading through manuals and
    schematics etc etc. In the post sr111 climate just think for a moment
    about the possibility (and certainly the effect) of a panic-stricken
    (inebriated or not?) pax invading the cockpit -or for that matter,
    general panic.


t. Passengers are also going to be reassured that their pilots
   aren't going to be knocked out by ingestion of toxic gases
   that sneak up on them whilst they're busy trouble-shooting.
   Beyond theories on hardware causes, it goes without saying
   that the toxicological results of the flight-crew post-mortems
   may confirm the human vulnerability factor. Superimposed upon
   the hardware deficiencies, the susceptibility of crews to
   succumbing to the very toxic gases in electrical smoke might
   indicate that incident survivability is much lower than previously thought.


u. Crew uncertainty can be avoided by airlines mandating this basic
    survival configuration for whenever the smoke detectors go off (for
    cause) or a pilot or F/A reports a smoke/smell or fire whose source
    cannot be immediately determined and quelled. In this way professional
    crews no longer have the option of an adventurous (but foolhardy)
    trouble-shooting checklisting exercise - and they need not fear ridicule nor
    criticism for doing the right thing as per their Standard Operating
    Procedure. Simulator drills are likely to be more definitive than very
    airy-fairy and open-endedly inconclusive (as they are at present).


v. The very nature of electrical emergencies (as manifested by smoke
    in the cockpit or cabin) is that it can be a bottomless pit of
    possibilities - none of which are likely to have been envisaged by the
    designers (as evidenced by the MD11 smoke/elec switch design and
    function). Batteries are vulnerable to being flattened by a progressive
    electrical wiring malfunction such as a massive short. The ability
    to continue IMC operation for even a short period may be compromised.
   


w. Reliance upon automated systems (such as in the MD11) to detect,
     trouble-shoot and rectify electrical problems is akin to putting your
     faith in a fire engine that is itself on fire. Once electrical system
     integrity is compromised the whole system must be suspect.

     The latest info I have is that the investigators
     are thoroughly confused by the revelations of the
     DFDR and its timelines. They have decided that a
     lot of the data on the DFDR has been corrupted by
     the electrical malfunction (i.e. a lot of the events
     on the DFDR didn't really happen). That is one of
     the really devilish things about electrical malfunctions
     - they throw everything into a spiked anomalous
     frenzy and such devices as the DFDR begin to tell lies.

     Electric jets are just not able to operate with a "total electrics" so any problems
     must be nipped in the bud, once they're evident, via a reversion to a
     previously dormant "virgin bus" -or a repeat of sr111's outcome must
     always be a possibility.


x. Families of victims would be less frustrated by the apparently
    avoidable consequences of the present state of affairs.(because there'd
    be fewer victims and more evidence that all concerned had addressed the
    problem of fire-in-the-air and had genuinely done all that's humanly
    possible -rather than pay lip-service to a real problem that's
    unfortunately not yet statistically significant enough to warrant the
    expenditure).


y. Two man crews can cope much better if the situation doesn't
   develop. That is because, if it does, one of the likely results is
   incapacitation of at least one (or perhaps both) pilot(s). It's always
   possible too, let us not forget, that a cockpit fire can cripple the
   pilots' oxy systems (hoses, regulators or bottles). The next most likely
   happenstance is a loss-of-control caused by pilots trying to fly partial
   panel off of poorly positioned (and widely separated) standby analogue
   instruments whilst semi-asphyxiated, distracted, suffering direct (and
   peripheral) vision smoke impairment compounded by unfamiliar cockpit
   emergency flood lighting.

      If you cannot follow the logic, write me and I'll try to resolve your
      doubts. The philosophy is just as applicable to the military. Another
      subject worth thinking about is the next generation of DFDR/CVR. My
      suggestion is that they should be capable of uploading via a dedicated
      Inmarsat transponder channel and that this should happen automatically
      any time an airliner crew squawks the distress, comms loss or hijacked
      code. There is already discussion of FMS/engine/systems data being
      regularly routed this way for ops management purposes.


         Can you think of any other benefits of a "Virgin Bus"? If so, let me
         know. There's still a letter of the alphabet left.

  The virgin bus concept is discussed in:

   responses.html  

  and

   barndoor2.html

   quitsmokin.html

   basics.html
  
(also relevant)

   tofaahf.html
  
(ditto)

   seatbacks.html
  
(ditto)

   boeinglinepilot.html
  
(ditto)

   captw5.html
  
(ditto)

   pprune.html
  
(ditto)

   switcher.html
  
(ditto)

                                              
  
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