Responses to Original Swissair Accident Article
Don Ames Responded
There have been 3 major accidents in recent years which have been at least partially attributable to high tech systems and a lack of basic manual back up capabilities.( South America-757, Florida-DC-9 and Canada-MD-11) It appears that the aviation industry has come to rely too much on digital electronic instrument and flight control systems; and with insufficient thought given to how to quickly evacuate smoke from modern pressurized aircraft with a MANUAL system (whilst remaining pressurized).
We need to be sure all aircraft, and especially airliners, have a capability to:
1. Manually operate pressurization and outflow valves to quickly evacuate smoke that is in the cockpit and/or cabin
2. Be flown on instruments and communicate and navigate on battery powered emergency equipment
3. Be flown with all other electrical power disconnected
Additionally, aircrews need to be proficient in operating the aircraft on their back-up systems.
Attention given to these areas should save a lot of lives.
Comment (by IASA Safety)
3. What we should see as a result of the Swissair accident may well be somewhat cathartic for the industry, but it will be necessary as a result of Valujet 592, TWA800, sr111, Silkair (and all the non-notorious others) superimposed upon the outcome of whatever is to be the next latest tragic accident. Whether we will see it in the report is the question. But because Swissair has such abiding respect within the industry and the Swiss have always been prime instigators of ab initio technology I think you can expect to see the first developments from that neck of the woods. To paraphrase Neville Shute: "There is no byway in that highway called the sky."
hylander Responded (to the original article)
A very good article with many good suggestions for
future design progress. I hope the authorities read this.
R. Jollis Responded (to the original article)
John Sampson's article, "Swissair Flight 111, The
Accident that redefined CRM" is right on!
As long as the FAA and it's constituency, the airline
and aircraft industries, continue to measure safety in
terms of financial Return On Investment, we can expect to see more air
disasters like sr111 and TWA800. Better CRM
procedures and training can only marginally improve
our chances of survival. For a brutally straight
forward insider's look, read former US DOT
inspector general, Mary Schiavo's book, "Flying Blind,
Manage Your Outcomes
Comment (by JRS): Im not a visionary but when it comes to applying my imagination to what happened in the Swissair accident I have no trouble conjuring up two entirely separate theories:- of what did transpire - and what might have been (in different circumstances). In the first instance I see the innocent low-key beginning of the happenstance, the advice to ATC and cabin crew, the follow-up R/T, the descent checklist and then its rapid escalation through donning of masks and goggles and serious checklisting. Then come the profoundly disturbing staccato images an atmosphere of great urgency (anxiety, concern but no fear), awareness of the deteriorating environment and restricted peripheral vision, unexpected autopilot disconnect, frustration about having to wait until over-water before commencing the dump, denser smoke, upgrading the emergency, deploying the ADG, fuel starvation flame-out of number two tail engine with many resulting warnings and cautions, sudden cockpit darkness, CRT's blank out, floodlight reflections, misting goggles, instrument power failures and an alarming realization that your partial panel attitude-flying instrument scan and control inputs are very haphazard -even chaotic, eyes streaming with tears, the annoying ceaseless audio of uncancelled system alerts and warblers, intercom and R/T mistakes and confusion, ATC distractions, EICAS announcements, unanswered cabin staff queries, a pervasive and growing feeling of consummate helplessness, breathing and vision difficulties; a Flight Attendant invades the cockpit, evidently distraught - then disappears, total uncertainty as to where the checklist is at. Then, as a vaguely discerned finale ..... seeing the collapse of the other pilot with no-one to help, a feeling of immense solitude, the agony of hot molten plastic dripping from above, difficulty in concentrating, total loss of attitude and altitude awareness and eventually, on the threshold of unconsciousness, the sensation and increased noise levels as the aircraft is accelerating under g and entering its terminal unusual attitude - but peaceably, a final ethereal dissociation from recovery (as a task) because of the mental detachment that stems from the asphyxiating ingestion of toxic smoke. A last poignantly dutiful but pointless pull on the control column as the MD11 tightens into its final graveyard spiral into the waters off the cove. Declaration of a final Mayday and any thought of external succour is totally irrelevant to such a scenario. No apologies for graphic depictions, youve got to see the word-picture distinctions Ill now try to make.
In my second apparition I see a three man crew undergoing the same initial conspiracy of circumstance. In this scene the smoke detector alerts them and the captain declares: "activate the smoke checklist". After the (memory recall items), immediate action preliminaries of full-face masks, ATC and cabin staff alerting, the next step is dependent upon captains discretion. However, as with the Swissair instance, visible confirmatory smoke and fumes are evident and this is where the outcomes based approach makes the difference: the Captain orders "select the Flight Essential Bus, you have control". "Deploy the EVAS" (i.e. the inflated plastic aid to instrument vision). They feel a thump as the ADG slips down and locks into place in the slipstream and a charging light illuminates on the CIWS. The first officer is now responsible for ATC comms and flying the aircraft nothing else, so he begins a gradual descent as per his edicts to ATC. Hes declared a Pan, hes squawking emergency and he automatically has priority, so ATC must divert other traffic and clear levels below him. Its called "take control of your destiny", its not an apologetic approach. It's no longer the polite "request" - it's "require". The aircraft is now on its "virgin" bus, previously isolated from the normal electrical system and presumably having 100% integrity because of that. The captain and the flight engineer commence the challenge/reply portion of the checklist actions. It is evident that despite his killing the normal electrics, the smoke build-up is continuing, that there is a self-sustaining conflagration behind one of the overhead panels. He orders: "Call Mayday, Hold 230 knots, commence fuel dumping to 50 kilo and Inert the flight deck". The FE pulls a lanyard on the bulkhead-mounted nitrogen canister and grabs the foam extinguisher from its bracket. The FE, in anticipation, has already (per the checklist) shut off both EDCs so that there is no inflow to the cockpit but he doesnt open the outflow valve so there is only a gradual depressurization. The flight deck door is already closed so, for their purposes, the cockpit is hermetically sealed and the flame-retardant nitrogen-rich atmosphere dampens the fire. In the absence of oxygen, and with no stoking electrics, no materials fire can take hold. The FE then sprays the adhesively congealing and sealing foam spray onto the overhead panel and the smoke emanations cease. It is now up to the captain. After a pause, he considers the danger is past and orders: "Depressurize and vent smoke, continue with the smoke elimination checklist". Flight is continued, masks off, to their divert field in their significantly reduced (but not crippled) configuration. They have no weather radar, airframe or engine anti-ice but at the lower altitudes theyre not likely to need it. Flight instruments, hydraulics, avionics and comms are sufficient for recovery. There is no point in further tempting fate and trouble-shooting as the Nitrogen and foam operation was a one-shot affair. A two-man band working fate or a three-man consortium with a game-plan? Given the alarming scope and urgency of the task, vive le difference.
It is possible with todays technology to change the outcome of the in-fuselage fire-in-the-air challenge. To date its been a mish-mash apathetic and disorganized approach to resolving an unidentified issue. Im advocating both a CRM and multi-disciplinary, technical, take-charge/outcomes-based methodology. I readily concede that there are more forms of inflight fire than one confined to the cockpit or electrically initiated. However, if the cargo despatchers and security are doing their jobs we are probably talking about the worst case scenario here. Cabin fires outside the cockpit ( or wing events for that matter) make it more important that there is a third man with the technical know-how to go aft, look into it and keep the captain properly informed.
However theres a lot of inertia out there. Many CEOs just have their fingers crossed that the Swissair report will be couched in terms that enables it to be dismissed (like Valujet, TWA800,Silkair, ...) as just another "one off".... but casualty figures will probably mount as jets get older and electrics continue to be the silent servant but also tragically, sometimes, the swift unseen suffocating savage.
If you feel that there is something missing from this argument (or have something to add) please feel free to comment.
Gordon Donaldson Responded (to the original article)
This is an outstanding article. The author's
experience and passion for the subject come through
in his writing. He brings up a very important
question: Have we gone too far in assuming we can
replace a third aircrew member with electronics?
Peter P. Goldstern Responded:
Very thought provoking. Using the FE position as a pilot
training function sounds sensible but the chances are
that the unions would find a reason to object. There is
however the option of letting the customer decide.
Advertise your flights as 2 or 3 crew flights and set the
fares accordingly. If the customer would rather fly for
less with more risk, the decision is his?
Peter P. Goldstern
Original Landings.com responses