Sent: Tuesday, August 28, 2001 12:59 PMSubject: Material being released at TSB News Conference 10:30 EDT 28 August 2001
Sent: Tuesday, August 28, 2001 11:03 AM
Subject: TSB RECOMMENDATIONS
DATE ISSUED: 28 August 2001
The Honourable David Michael Collenette,
Ms. Carol Carmody
Jean Overney, Chief Inspector
SUBJECT: Material Flammability Standards
The Circumstances of the Swissair Flight 111 Accident
On 02 September 1998, Swissair Flight 111 (SR 111), a McDonnell Douglas MD-11 aircraft, was travelling from New York to Geneva with 215 passengers and 14 crew on board. Approximately 53 minutes after take-off, as the aircraft was cruising at flight level 330, the crew noticed an unusual smell in the cockpit. Within about three and a half minutes, the flight crew noted some smoke in the cockpit and declared the international urgency signal "Pan Pan" to Moncton Air Traffic Services. SR 111 was cleared to the Halifax airport from a position 57 nautical miles to the southwest. While the flight crew was manoeuvring the aircraft in preparation for the landing in Halifax, they were unaware that there was a fire spreading above the ceiling in the front area of the aircraft. About 11 minutes after the initial assessment by the crew that some visible smoke was present, the situation in the cockpit began to deteriorate rapidly. The autopilot disconnected and the aircraft's flight data recorder began to record a rapid succession of anomalies that reflected failures related to various aircraft systems. The flight crew declared an "emergency", and indicated a need to land immediately. Within about a minute thereafter, or about 12 minutes after the initial assessment of the existence of some visible smoke in the cockpit, radio communications and secondary radar contact with SR 111 was lost while the aircraft was in level flight at about 10 000 feet above sea level. About six minutes later, the aircraft crashed into the ocean near Peggy's Cove, Nova Scotia, Canada, fatally injuring all 229 occupants.
Since the aircraft crashed into water, all fire damage occurred in flight. The ongoing investigation (A98H0003) has identified substantial fire damage above the drop-down ceiling in the forward section of the aircraft extending about 1.5 metres forward and 5 metres aft of the cockpit wall. Although the origin of the fire has not been determined, the investigation has revealed several safety deficiencies with respect to standards for material flammability. The elimination of these deficiencies would reduce the probability of loss of life resulting from in-flight fires.
In August of 1999 the Transportation Safety Board of Canada (TSB) issued two aviation safety recommendations.(1) These recommendations addressed safety deficiencies associated with the propensity of thermal acoustic insulation blankets covered with metallized polyethylene terephthalate (MPET) to propagate fire.(2) The recommendations focussed on the test criteria stipulated in the United States Federal Aviation Regulations (FARs) for the certification of such materials. Subsequently, the United States Federal Aviation Administration (FAA) issued airworthiness directives(3) mandating the removal of MPET-covered blankets from aircraft registered in the United States. Additionally, the FAA proposed regulatory changes that would require more rigorous testing of all thermal acoustic insulation materials.(4)
Despite these initiatives, the TSB is concerned that there remain safety deficiencies in the material flammability standards, and that these pose an unacceptable risk to the flying public. First, in a series of aviation safety recommendations issued in December 2000 and entitled In-Flight Firefighting, the Board stated that material flammability standards for aeronautical products are an integral component of any in-flight firefighting "system". The Board is concerned that the flammability standards for certain materials used in the pressurized portion of an aircraft are inadequate.(5) Second, despite many initiatives to mitigate electrical wire discrepancies (including action taken subsequent to the issuance of TSB Aviation Safety Advisory 980031-1, 22 December 1998), the Board believes that the certification test criteria for aircraft wires do not adequately address the potential for wire failures to ignite or propagate fires. Third, indications that the failure of certain aircraft systems, such as crew oxygen, could exacerbate a fire in progress suggest that current requirements for conducting system safety failure analysis may be inadequate.
In summary, the Board's aviation safety recommendations address these safety deficiencies:
Material Flammability Standards
The investigation has assessed the flammability characteristics of the materials present in areas of the SR 111 aircraft damaged by fire, and the regulations and guidelines that apply to the certification of those materials. The most significant material flammability deficiency discovered has been the inappropriate flammability characteristics of the MPET-covered thermal acoustic insulation blankets. Other certified materials, discussed in Appendix A, also exhibit undesirable fire-propagation characteristics. The analysis of how these materials__either alone or in concert__may have contributed to the initiation and progress of the SR 111 fire is complex, and is ongoing. However, the flammability characteristics of the materials involved, and the speed with which the fire damage occurred, raise questions about the existing standard of flammability required for materials used in the fabrication of aeronautical products.
For the most part, civil aviation authorities (CAAs) maintain their own material flammability standards, and there are slight regulatory variations among national CAA jurisdictions. However, the standards are based on, or similar to, those described in the FARs, and this discussion will be confined to the material flammability standards specified by the FARs. These regulatory standards are the minimum required for certification of aircraft. Although not required by regulations, manufacturers routinely impose supplemental testing on materials used in their products.
In general, each aircraft material must be tested to demonstrate its tendencies both to ignite and to propagate flame. The FAA has developed a series of tests which, in principle, are designed to represent the fire environment to which a given material may be exposed.(6) The FAA expectation is that one or more fire tests must be conducted on each material as a prerequisite to certification.(7) The number and severity of flammability tests required for a particular material largely depend on three criteria: the intended location of the material within the aircraft, the type, and the quantity. For example, materials used in one location, such as in partitions in occupied cabin interiors, may be subjected to more rigorous testing than materials used in other locations, such as some unoccupied spaces. Also, parts constructed of a particular type of material, such as elastomeric materials, may be subjected to less stringent tests, regardless of their intended location. Finally, the more of a particular material installed in an aircraft (either in greater quantities or in larger components), the more stringent the testing required for the material's certification.
Related Research and Development
Regulations are based upon ongoing efforts in research and development (R&D), which seek to continually improve fire safety in aviation. This R&D is primarily based on three factors: analysis of accidents and incidents, emerging technology, and new aircraft designs.(8) Although these efforts are international in scope, historically, the FAA has functioned as the lead agency as a direct consequence of its mandate.(9) Material flammability standards form an integral part of this R&D effort.
Current regulations are the result of efforts made over many years to utilize finite R&D resources to maximize safety improvements. In 1975-76 the FAA commissioned a study to determine the feasibility of, and the tradeoffs between, two basic approaches to providing fire safety improvements to the modern, wide-bodied transport fuselage.(10) Two approaches were investigated as part of that study:
The study concluded that there were merits and limitations in each approach, and that an approach combining a fire management system with selective material improvements may offer the most potential for providing timely fire protection in all cases.(11)
Ultimately, the thrust of R&D did not fully pursue this combined approach, and only limited follow-up research was conducted into the concept of developing an on-board fire management system.(12) It was reasoned that in-flight fires are rare, and typically originate in hidden and inaccessible areas; therefore, a limited use of the fire management concept would suffice. The best protection against in-flight fires, it was concluded, would be achieved through the targeted use of materials that have high fire-containment and ignition-resistance properties. It was concluded that such materials, combined with the selective use of early and reliable detection and efficient suppression techniques, would provide the required level of protection. R&D related to in-flight fires has led to increased fire protection in areas such as cargo compartments and lavatories.
While certain initiatives were taken to address the threat from in-flight fires, such as those mentioned above, the FAA's main R&D focus in the 1980s was towards increasing survivability in a post-crash fire environment. This R&D effort was, and continues to be, based on a post-crash scenario involving an intact fuselage adjacent to a fire that is sustained by uncontained aviation fuel. Full-scale burn tests using this scenario concluded that a post-crash fire within the aircraft would be sustained primarily by burning cabin interior materials. This FAA research also concluded that incapacitation of any potential survivors was primarily dependant upon toxic gases generated by a phenomenon known as "flashover".(13) At flashover, conditions rapidly deteriorate to a level at which survival is unlikely.(14) The inference__not universally accepted__is that the threat to occupants from combustion smoke and toxic/irritant gases, before flashover occurs, does not warrant the introduction of material toxicity standards. As a consequence, subsequent R&D has concentrated on developing improved flammability standards for cabin interiors, to delay the onset of flashover and thereby increase survivability. These efforts have resulted in major improvements to flammability standards for selected cabin materials, such as seat cushion fire-blocking layers and panels that release low levels of heat and/or smoke.
Consequence of Current Regulations Concerning Flammability Standards
Based on the above, under current FAA regulations, the most stringent material flammability standards are reserved for large surface panels (such as sidewalls, ceilings, stowage bins and partitions) in the occupied areas of the aircraft. Flammability standards for materials used in the remainder of the aircraft interior are less stringent.
The FARs specify the level of fire protection required, based primarily on the location of a material within an aircraft. For most of the materials used outside the occupied areas of the cabin, the performance criteria are defined by the "horizontal Bunsen burner test" for miscellaneous materials, as specified in Appendix F to FAR Part 25 Part I.(15) Unlike other fire-testing methods, which measure flame time and burn length to establish a material's capacity to self-extinguish, the horizontal burn test only measures a material's rate of burn. For material that is subjected solely to the horizontal burn test, its only known flammability characteristic is whether it will burn at or below a pre-determined rate.(16) If such materials are not required to be self-extinguishing, they must be flammable(17)and capable of sustaining or propagating fire. Furthermore, as the highest flammability standards are reserved for large surface panels in occupied areas of the cabin, it is likely that the most flammable materials will be in remote, hidden, and inaccessible areas of an aircraft. Yet these are the areas where a variety of electrical ignition sources may initiate an in-flight fire, and where there are the fewest defences in terms of detection and suppression.
Summary of Current FAR Requirements
The current FAR requirements, as described above, result in the following material flammability hierarchy:
Therefore, many aircraft materials currently in use are either flammable, or will burn within established performance criteria.
Additional Fire-Related Testing
Only a limited number of materials, most of which are used in the passenger cabin, are certified using additional tests for smoke generation and heat release. Yet some in-flight fires have shown that smoke will migrate to the occupied areas of the aircraft and can impede the crew's ability to effectively deal with the associated emergency (see examples in Appendix B). Furthermore, within present regulations, no material is required to pass a certification fire test that measures toxicity. Beyond meeting a standard of flame time and burn length, there is no regulatory requirement to determine additional flammability characteristics for many materials used in aircraft.
Information on how materials not tested for flammability characteristics, such as heat release, smoke generation and toxicity, may contribute to the severity of an in-flight fire is contained in Appendix C. However, as these flammability characteristics are by-products of the combustion process, the Board believes that the most effective means to mitigate these additional threats is to eliminate the use of all materials that sustain or propagate fire.
Existing material flammability standards allow the use of flammable materials as well as materials that propagate flame within predetermined limits. In addition to the associated fire risk, the majority of these materials pose additional hazards, as there is no regulation requiring that other flammability characteristics__such as heat release, smoke generation and toxicity__be measured. Currently, the most stringent fire tests are reserved for materials located in accessible cabin areas. As a consequence, some of the most flammable materials within the pressurized portions of an aircraft are located in hidden, remote or inaccessible areas. These areas pose a high risk of being involved in potentially uncontrollable in-flight fires.
The Board believes that the use of a material__regardless of its location, type, or quantity__that sustains or propagates fire when subjected to realistic ignition scenarios,(18) constitutes an unacceptable risk, and that, as a minimum, material used in the manufacture of any aeronautical product should not propagate or sustain a fire in any realistic operating environment. Therefore, the Board recommends that:
For the pressurized portion of an aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire.
Material Flammability Test Requirements for Aircraft Wiring
Large modern aircraft may contain more than 250 kilometres of wire of various sizes and insulating materials. Some digital flight control systems rely totally on wire interconnections, rather than the cables and pulleys used in earlier designs. The quantity and importance of electrical wire in aircraft is increasing.
During a detailed examination of the SR 111 wreckage, 20 electrical copper wires were found that displayed melted copper caused by an arcing event.(19) The significance of the arcs, in terms of whether or not they initiated the SR 111 fire, is under review; the possibility has not been ruled out. A review of data produced by the FAA, the Airline Pilots Association and Boeing shows that electrical systems have been a factor in approximately 50% of all aircraft occurrences involving smoke or fire, and that wiring has been implicated in about 10% of those occurrences. Significant examples of such occurrences can be found in Appendix D.
Unlike most materials used in the construction of aeronautical products, which are passive until involved in a fire, the failure of aircraft wiring has the capacity to play an active role in fire initiation. The failure of insulation material on a powered wire may create a high temperature arcing event and thereby ignite adjacent materials. However, despite the potential for wire to initiate a fire, the only material flammability test mandated for the certification of aircraft wire, including its associated insulation material, is the "60º Bunsen burner test."(20) This test method is designed to measure the burn length and extinguishing time of a given wire's insulation material. In effect, the sole material flammability performance criterion mandated for aircraft wire insulation material is the determination of how a single unpowered wire will behave when involved in a fire in progress. This is essentially the same basic flammability characteristic that is known about most passive materials used in the pressurized portion of the aircraft.
Typically, an aircraft wire that initiates an arcing event has sustained some preliminary damage. Damage such as cracks, cuts, stretching, contamination, and chafing can result in a breakdown of the insulation material, thereby exposing the conductor. While such damage is considered serious and would demand a repair, in many cases it can go undetected. An exposed conductor can exist indefinitely with little or no adverse effect on aircraft performance. It is only when the exposed conductor is "shorted" that an arcing event occurs.
Notwithstanding the special attention that is paid to the design, installation, and maintenance of aircraft wiring systems, wiring irregularities can develop in any aircraft. On 22 December 1998 the TSB issued Aviation Safety Advisory 980031-1, which detailed various MD-11 wiring anomalies discovered during many aircraft inspections. These anomalies included the following: chafed, cracked, broken, or cut electrical and bonding wires; inconsistencies in the routing of wires and wire bundles; loose terminal connections; excessively small wire bend radii; and unsealed electrical wire conduits. Subsequently, the FAA issued many wire-related airworthiness directives (for various aircraft, including the MD-11) as part of its MD-11 Wiring Corrective Action Plan.
Additionally, the FAA commissioned a Transport Aircraft Intrusive Inspection Project as part of its Aging Transport Systems Rulemaking Advisory Committee. This project inspected six recently retired transport category aircraft from a variety of manufacturers and operators. The study discovered wires degraded through poor repairs or splices, heat-damaged or burnt wire, vibration damage or chafing, cracked insulation, arcing, and insulation delamination.(21) The report concludes that there are risks associated with uncorrected degenerative conditions, and recommends options for prevention or mitigation of such failures. While increasing the frequency and quality of maintenance inspections is a viable option, since most of the wiring system is bundled and located in hidden or inaccessible areas, it is difficult to monitor the health of an aircraft's wiring system during scheduled maintenance with existing equipment and procedures. Therefore, it is realistic to expect that until wire maintenance inspection equipment and methods are perfected, wire failures that could result in fire ignition will continue to occur.
The electrical protection of an aircraft's wiring system is provided by a variety of circuit protective devices. The most common of these are circuit breakers, which are designed to protect the electrical distribution system__the wires__from an electrical overload. However, circuit breakers have design limitations. An overload caused by a wire failure may not lead the circuit breaker to de-energize the circuit; this may create high heat and a potential ignition. While ongoing R&D seeks to improve circuit protection devices, at this time there are portions of aircraft wiring systems that may not be protected against all electrical overload conditions.
Irrespective of efforts to design, install and maintain an aircraft's wiring system to a high standard, deficiencies with wires will likely persist and present the potential for wire failures. While all wires will arc under certain circumstances, the dynamics of how a particular wire fails during an arcing event is highly dependant on the composition of the wire insulation.(22) Understanding the dynamics of how a wire will fail under realistic conditions would be valuable, given the known consequences of the failure of an energized wire. While the FAA endorses several failure tests (for example, the dry arc tracking test procedure), it does not require any failure tests as a basis for wire certification.
The Board believes that, given the incidence of aircraft wire failures and their role as potential ignition sources, the absence of a certification requirement that measures a wire's failure characteristics, and that specifies performance standards under realistic operating conditions, constitutes a risk. Therefore, the Board recommends that:
A certification test regime be mandated that evaluates aircraft electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition.
System Evaluation: Fire Hardening Considerations
Various materials, including endcaps from both the oxygen and air conditioning systems used in the MD-11, have exhibited less-than-ideal fire propagation characteristics as described in Appendix A. The premature failure of either the aluminium endcap used in the crew oxygen system, or the elastomeric endcaps used on ducts within the air conditioning system, would likely have exacerbated the in-flight fire on board SR 111. Under current regulations, a material's intended location and application must be identified in order to define which fire tests are required for that material's certification. If a material is to be used in a designated fire zone (e.g., the engine compartment) it must be hardened to withstand the more rigorous conditions associated with that environment and so delay a failure that might contribute to a fire in progress.(23) In most other areas of the aircraft, there is no requirement to determine if a material's failure would exacerbate a fire in progress. Yet the selection of inappropriate materials may lead to premature breaches of certain systems__such as oxygen, hydraulic, wiring, and air environmental__which could exacerbate an in-flight fire.
It is an established aviation industry practice to consider the consequences of a system's failure during the certification process. FAR 25.1309 requires that a system safety analysis be conducted as part of a system's certification process. The purpose of such an analysis is to confirm that the system has been designed and installed using a fail-safe methodology.(24) This approach ensures that equipment failures will not have any adverse effect on an aircraft's safe flight and landing. Typically, this analysis does not include an assessment of the consequences of the system's failure as a result of fire. For example, the certification of oxygen systems whose design includes materials with dissimilar properties, without consideration for how this arrangement would affect the integrity of the system when it is exposed to a fire, may allow a latent failure to persist. Similarly, where an air conditioning duct system is made of dissimilar materials (such as aluminium ducts with elastomeric endcaps), an in-flight fire may cause an elastomeric endcap to fail before the aluminium portion of the same duct system. This failure of the endcap material would introduce forced air into a fire in progress and would have the potential to aggravate the fire. Assessing the impact of a system's failure when exposed to fire, and designing aircraft systems to delay failures that could seriously aggravate an in-flight fire, would provide an additional defence in limiting the size and progress of in-flight fires.
The Board believes that a fire-induced material failure in some aircraft systems has the potential to augment the combustion process and exacerbate the consequences of an in-flight fire. Therefore, the Board recommends that:
As a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures.
As the investigation proceeds, should the Board identify additional safety deficiencies in need of urgent attention, it will make further aviation safety recommendations.
Flammability testing done as part of the A98H0003 investigation has revealed that some certified materials used in the MD-11 exhibit less-than-ideal fire propagation characteristics:
Synopses of aircraft fires in which cockpit visibility was a factor:
Heat release is a measure of the amount of heat emitted by a burning material. How quickly a fire reaches flashover depends on the rate of heat release of the combustibles involved. Certain materials used in the occupied areas of the cabin must demonstrate that they will not exceed a specified maximum heat release rate and maximum total heat release. The purpose of this requirement is to delay the onset of flashover during a post-crash fire, as there is a direct correlation between a material's heat release and its contribution to the onset of flashover. In contrast, much of the flammable material that is likely to be involved in an in-flight fire is located in remote areas, such as "attic" spaces. Airflow considerations aside, compartments within aircraft can promote the accumulation of hot gases and combustion by-products, thereby creating conditions conducive to flashover.
Under existing regulations, materials other than selected cabin materials are not required to pass any heat-release test. The inference is that delaying flashover in the event of a fire in these unoccupied locations is not viewed by regulatory authorities as a safety improvement requiring additional regulation. Requiring all materials to meet a heat-release standard would provide an increased resistance to flashover and benefits comparable to those currently applicable to selected cabin materials. The Board has concerns about the lack of broader standards to limit the amount of heat that would potentially be released by burning materials within aircraft; it believes that the associated risks could be mitigated by eliminating the use of materials that sustain or propagate fire.
Material smoke-generation requirements are designed to measure the amount of smoke emitted by burning materials. The primary objective in limiting smoke generation is to maintain visibility for egress during a post-crash fire. Therefore, smoke tests are typically only required for selected materials used in occupied areas of the cabin. There is no smoke test requirement for the majority of materials in the rest of the aircraft. In-flight fires, examples of which are contained in Appendix B, indicate that smoke will migrate to the occupied areas of the aircraft and can impede the crew's ability to effectively deal with such an emergency. The effect, on the passengers, from prolonged exposure to smoke generated during an otherwise survivable in-flight fire event is largely unknown. As there are presently no provisions designed to isolate passengers from such smoke, reduced visibility during ensuing ground evacuations can be anticipated. Establishing a certification standard limiting smoke generation for all aircraft materials would increase visibility and survivability.
The Board has concerns about the lack of standards regarding smoke generation associated with burning aircraft materials; it believes that the smoke-related risks could be mitigated through the elimination of materials that sustain or propagate fire.
Materials designated for use in aircraft are not required, by regulation, to meet any toxicity standards, although manufacturers can impose toxicity criteria of their own. Regulatory requirements and strategies have focussed on improving the chances of passenger survival in the event of a post-crash fire. This is accomplished by mandating that selected cabin materials meet heat-release standards that delay the onset of flashover. This approach reflects the belief that a material's toxic effects will not be a factor until after flashover. As the flashover phenomenon is generally considered a non-survivable event, the argument is made that there is limited benefit in establishing a toxicity standard for burning materials. The physiological effects of inhaling the toxic by-products likely to be present in a post-crash fire prior to flashover, on a passenger's ability to evacuate the aircraft, are considered minimal. However, passenger evacuation is not an option in an in-flight fire. While the flight crew may be able to take limited measures to evacuate some smoke from the cabin, aircraft occupants must cope with the potentially debilitating effects of toxic and irritant gases emitted by burning aircraft materials.
As discussed in the TSB's aviation safety recommendations A00-16 to A00-20, a crew has only a limited ability to effectively assess and suppress such hidden, inaccessible fires. Therefore, in its incipient stages, the most likely in-flight fire scenario would involve an uncontrolled fire comprising known flammable materials. As there are no mandated toxicity criteria for materials used within aircraft, some of these materials are likely toxic when burned. Such toxic by-products would be spread by the air circulation within the pressurized hull and could eventually impair crew and passengers. While it can be argued that the crew are equipped with breathing apparatus that allows them to continue to function, passengers have no such equipment. The passenger oxygen delivery system is designed to be used in a depressurization event and will not protect the user against smoke or airborne toxins. In fact, the MD-11 Aircraft Operations Manual warns that passenger oxygen masks must not be released below 14 000 feet when smoke or an abnormal heat source is present, as the oxygen may increase the possibility or severity of a cabin fire.(25)
Some in-flight fires have been resolved with minimal on-board firefighting coupled with immediate action to land the aircraft (with flight crew smoke masks donned). However, immediate access to an emergency airport may not always be an option, such as during a transoceanic flight. In such cases, passengers could suffer from prolonged exposure to combustion by-products with an unknown effect on their ability to survive. The Board has concerns about the lack of standards to limit the amount of toxic emissions that would potentially be released by burning materials within an aircraft. It believes that the associated risks could be mitigated by eliminating the use of materials that sustain or propagate fire.
Synopses of several occurrences in which aircraft wiring was a factor:
1. A99-07 and A99-08 dated 11 August 1999
2. Polyethylene terephthalate film is often referred to as Mylar, a registered trademark of E.I. du Pont de Nemours and Company. Other manufacturers have metallized the film for use as a thermal acoustic insulation blanket cover material, which is known as metallized polyethylene terephthalate.
3. FAA dockets 99-NM-161-AD and 99-NM-162-AD
4. Notice of Proposed Rulemaking Docket No. FAA-2000-7909
5. For the purposes of this discussion, the pressurized portion of the aircraft, or pressure vessel, includes cockpit, cabin, avionic compartments, cargo compartments, and the various accessory spaces between the passenger compartment and the pressure hull.
6. Aircraft Materials Fire Test Handbook, DOT/FAA/AR-00/12, April 2000
7.The FAA's Airworthiness Standards contain performance requirements for the certification of aircraft. For Transport Category Aircraft, FAR Part 25 applies. Because the review of aircraft components for compliance to the FAR flammability requirements is only done in conjunction with the certification of an entire aircraft, the regulator uses these standards to approve the whole aircraft together with its integrated component parts as opposed to approving the individual aircraft parts in isolation.
8.Constantine P. Sarkos, "Future Trends in Aircraft Fire Safety Research and Development," presentation at the International Aircraft Fire Cabin Safety Conference, Atlantic City, N.J., 16-20 November 1998.
9. The FAA is mandated to conduct fundamental research related to aircraft fire safety in accordance with the Aviation Safety Research Act of 1988.
10. Feasibility and Tradeoffs of a Transport Fuselage Fire Management System, Report No. FAA-RD-76-54, June 1976.
11. An integrated fire management system is one that incorporates fire detection, monitoring, and suppression throughout the aircraft.
12. Aircraft Command in Emergency Situations (ACES) Phase 1: Concept Development, DOT/FAA/CT-90/21, April 1991.
13. Constantine P. Sarkos, "An Overview of Twenty Years of R&D to Improve Aircraft Fire Safety," Fire Protection Engineering, Number 5, Winter 2000.
14. For the purposes of this document, flashover is defined as a sudden and rapid spread of fire within an enclosure.
15. The horizontal Bunsen burner test is one in which a horizontally mounted specimen is exposed to a Bunsen burner flame for 15 seconds. The average burn rate is recorded.
16. Depending on the material's application, the performance criteria as described in the horizontal Bunsen burner test require the rate to be at a maximum of either 2.5 or 4.0 inches/minute.
17. For the purpose of this discussion, a flammable material is defined as one that is susceptible to combustion to the point of sustaining or propagating a flame.
18. The use of a realistic ignition scenario requires an assessment of the possible ignition sources, including a fire in progress and other factors that could affect the fire environment to which the material may be subjected.
19. The melting point of copper is 1083ºC.
20. FAR 25.869 requires that a single unpowered wire be mounted at 60º to a flame for a specified time in accordance with Appendix F of Part 25.
21. Transport Aircraft Intrusive Inspection Project Final Report prepared by the Intrusive Inspection Working Group, 29 December 2000.
22. Patricia L. Cahill and James H. Dailey, Aircraft Electrical Wet-Wire Arc Tracking, FAA Final Report, DOT/FAA/CT-88/4, 1988.
23. For the purposes of this discussion, hardening means taking due consideration, during the design stage, to accommodate unfavourable environmental conditions, such as heat.
24. The use of a fail-safe methodology for system evaluation ensures that the system is designed so that it is capable of compensating automatically and safely for a failure.
25. MD-11 Aircraft Operations Manual, Emergency Equipment: Oxygen, 5.0 Limitations effective 07 February 1991
|Tuesday August 28, 10:52 am Eastern
Press ReleaseSOURCE: Transportation Safety Board of Canada
TSB: Aviation Safety Recommendations: Material Flammability Standards, Investigation Into the Swissair Flight 111 Accident Occurrence Number A98h0003
OTTAWA--(BUSINESS WIRE)--Aug. 28, 2001--The Transportation Safety Board of Canada (TSB) today released three aviation safety recommendations dealing with aircraft material flammability standards.
The recommendations are the result of the continuing investigation into the crash of Swissair Flight 111 (SR 111) on 02 September 1998.
To date, the SR 111 investigation has found extensive fire damage in an area above the ceiling in the front section of the aircraft, extending about 1.5 metres forward and 5 metres aft of the cockpit wall. Although the origin of the fire has not been determined, the investigation has revealed several safety deficiencies with respect to standards for material flammability. The elimination of these deficiencies would reduce the probability of loss of life resulting from in-flight fires.
Since December 1998 the Board has released a series of safety advisories and recommendations to address a number of concerns ranging from aircraft design, certification and equipment, to crew training and procedures.
Today, the TSB is issuing three recommendations intended to address deficiencies in regulatory requirements and industry standards and practices which compromise safety. These relate to the flammability standards for materials used in the construction of aircraft, the testing procedures for aircraft electrical wires and the potential for certain aircraft systems to exacerbate a fire in progress.
``Our purpose in issuing these recommendations now is to enhance the safety of the travelling public as quickly as possible, as we have done on previous occasions during this lengthy investigation,'' said Benoit Bouchard, Chairman of the TSB.
``We want everyone to know about potential safety deficiencies as soon as we learn about them, so that public safety is not compromised while we continue our work to evaluate what happened to Swissair Flight 111.''
The first recommendation calls for improved flammability standards for materials used in the pressurized portion of an aircraft, which would prevent the use of materials that could sustain or propagate a fire. Current flammability standards allow some materials to be approved, even if they are flammable. This could pose a particularly high risk if the flammable material is concealed behind a wall or in some similarly inaccessible space.
The second recommendation relates to testing procedures currently required for the certification of electrical wires used in aircraft. The investigation assessed these procedures as inadequate because they do not require tests that measure a wire's failure characteristics. As such, wires that meet existing standards could have failure characteristics that could increase the risk of ignition. The TSB therefore recommended a more stringent certification test regime for electrical wires, including the evaluation of their failure characteristics under realistic operating conditions.
The third recommendation aims to reduce the potential for aircraft systems and sub-systems, such as the air conditioning duct system or the emergency oxygen supply lines, to worsen a fire in progress. The TSB recommended that these systems be evaluated to ensure that they are designed to minimize the risk that they will fail.
The Board believes that the three recommendations issued today describe initiatives that can be taken to reduce identified safety risks. As the investigation into SR 111 proceeds, the Board may make further recommendations, as warranted.
The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
This communique and the complete Aviation Safety Recommendations package are available on the TSB Internet site at: http://www.tsb.gc.ca
Backgrounder: TSB Aviation Safety Recommendations on Material Flammability Standards
Over the course of the Swissair Flight 111 (SR 111) investigation, the Transportation Safety Board of Canada (TSB) has looked beyond the specific circumstances of this particular accident to examine the full range of related factors that could compromise aviation safety.
On several previous occasions the TSB has issued safety advisories and recommendations focussing on specific safety deficiencies products, procedures or practices that are, or have the potential to be, detrimental to flight safety.
The Board is issuing another series of safety recommendations, this time pertaining to aviation industry standards for the flammability of aircraft materials. While the Board acknowledges that there has been some progress in the development of materials for use in cabin areas, several other serious safety deficiencies have been identified.
The TSB has, therefore, issued three safety recommendations to prompt
appropriate corrective action by the aviation industry and regulatory
Recommendation A01-02 Material Flammability Standards
Existing standards allow the use of flammable materials in the manufacture of certain aeronautical products. Because the most stringent fire tests today are reserved for seat cushions, cabin wall panels and other materials located in cabin areas, some of the most flammable materials in the pressurized portion of an aircraft tend to be located in hidden, remote or inaccessible areas. In these areas they have the potential to contribute to an uncontrollable in-flight fire.
Apart from sustaining or propagating fires, many flammable materials pose additional hazards, including heat release, smoke generation and the emission of toxins. For most materials, there are currently no regulatory restrictions regarding permissible levels of these combustion by-products. The most effective means to mitigate these additional threats is to prevent the use of any material that sustains or propagates fire.
The TSB believes that no material, regardless of its location, type or quantity, should be allowed in the manufacture of an aircraft if it can sustain or propagate a fire in progress. Therefore, the Board recommends that:
For the pressurized portion of an aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire. (A01-02)
Recommendation A01-03 Material Flammability Test Requirements for Aircraft Wiring
With some modern digital flight control systems relying totally on wire interconnections, the importance of electrical wires in aircraft is increasing. Indeed, large jets today may contain more than 250 kilometres of wire.
The insulating material on wires can become cracked, stretched, cut or chafed during normal aircraft operations. This exposes the metal conductor, which can short-circuit and produce an electrical arc. An arc, in turn, can produce high temperatures that can ignite a fire.
The failure of electrical wires can have disastrous consequences. A review of data shows that electrical systems have been a factor in about half of aircraft occurrences that involved smoke or fire, and that wiring has been implicated in about 10% of those occurrences. In the case of SR 111, 20 pieces of wire recovered from the wreckage showed signs of an electrical arcing event. No conclusions have yet been drawn regarding their role in the catastrophic fire.
Despite the potential hazards, failure tests for wires are not required by regulation. Under current certification standards, the only flammability performance criterion required to be measured for wire insulation material is the behaviour of a single un-powered wire when it is exposed to a flame.
Given the large quantity of wire in aircraft, its potential to fail, and its capacity to ignite fires, the Board is concerned by the absence of meaningful performance standards. Therefore, the TSB recommends that:
A certification test regime be mandated that evaluates aircraft electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition. (A01-03)
Recommendation A01-04 System Evaluation: Fire Hardening Considerations
Modern aircraft contain numerous systems that serve various functions, such as air conditioning, oxygen supply, hydraulic and electrical power. Under existing certification standards, these systems must be designed and installed according to a ``fail-safe'' methodology. This means that, should a system fail, there are built-in mechanisms to ensure the aircraft can continue to be operated safely. Typically, however, the tests used to certify such systems do not assess the consequences of that system's failure as a result of an in-flight fire.
Aircraft systems contain a variety of dissimilar materials, some of which will fail before others when exposed to fire. The resulting partial failure of some systems may aggravate a fire in progress. To address this concern, the Board believes that aircraft systems should be assessed for fire resistance. Consequently, the Board recommends that:
As a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures. (A01-04)
Transportation Safety Board of Canada Jim Harris, 819/994-8053 or 613/292-3765 (cell) or Transportation Safety Board of Canada Julie Hebert, 819/953-7812 or 613/292-4146 (cell)
|Subject: CP Regarding Recommendations August
Swissair investigators want airplane materials
to be less flammable OTTAWA (CP) -- Investigators into the
1998 Swissair crash released three new safety recommendations Tuesday
aimed at reducing the spread of onboard fires in aircraft.
-- Cockpit wiring on all MD-11s should be inspected.
-- Flight recorders should have independent power sources and the capacity to record up to two hours rather than 30 minutes.
-- Use of metallized Mylar blanket insulation, found to be flammable, should be reduced or eliminated.
-- The airline industry should fully review fire-fighting capabilities and improve fire suppression and detection equipment on aircraft.
The painstaking Swissair investigation has cost more than $50 million and lifted more than two million pieces of the wreckage from the ocean floor off Peggy's Cove, N.S. It is not expected to wrap up before next year.
Pilots aboard the plane reported smoke in the cockpit about 53 minutes after leaving New York en route to Geneva. The plane's electrical systems began failing about 15 minutes later and the jet plunged into the Atlantic Ocean six minutes after that.
Canada's safety board is an independent agency that reports to Parliament. Its job is to promote safety in marine, pipeline, rail, and air travel by investigating accidents to assess causes and contributing factors.
It makes recommendations geared to fix or reduce such problems and makes its findings public.
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