Reassessment of the Responses to Aviation Safety Recommendation A00-16
Lack of a Systemic Approach to In-Flight Firefighting
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.
Board Recommendation A00-16 (04 December 2000)
In-flight firefighting "systems" should include all procedures and equipment necessary to prevent, detect, control, and eliminate fires in aircraft. This systems approach would include material flammability standards, accessibility, smoke/fire detection and suppression equipment, emergency procedures and training. All of these components should be examined together and the inter-relationships between individual firefighting measures should be reassessed with a view to developing improved, comprehensive firefighting measures. The Board believes that the most effective in-flight firefighting capability will exist when the various elements of the firefighting system are integrated and complementary. The Board therefore recommended that:
Appropriate regulatory authorities, in conjunction with the aviation community, review the adequacy of in-flight firefighting as a whole, to ensure that aircraft crews are provided with a system whose elements are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire.A00-16
Responses to A00-16 (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 Responses to A00-16 (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 A00-16 (14 December 2005)
In its 14 December 2005 letter to the TSB, TC indicates no change from its initial response (dated 06 March 2001) with respect to its action plan in response to the risks identified in Recommendation A00-16.
Board Reassessment of the Response to A00-16 (12 July 2006)
In TC's response of 06 March 2001, TC stated its support for Recommendation A00-16 and its intention to coordinate harmonized regulations with the FAA. Although the FAA has yet to introduce regulatory changes, in January 2004, it released Advisory Circular AC 120-80 dealing with in-flight fires. In a letter to the TSB dated 07 April 2004, TC stated that, in the light of AC 120-80, it intended to review its response to recommendations A00-16 to A00-20. The review was to determine whether the safety action taken by Canadian operators needed to be reinforced by means of safety communication, promotional activity, or by regulatory changes. In its 14 December 2005 letter to the TSB, TC indicates no change from its initial response (dated 06 March 2001) with respect to its A00-16 action plan without mention of the content of its 07 April 2004 letter.
It is the Board's understanding that TC remains committed to its 07 April 2004 response, which, if fully implemented, will reduce the safety deficiency described in Recommendation A00-16.
Therefore, the assessment remains at Satisfactory Intent.
Next TSB action
TSB staff will liaise with TC to solicit an update with respect to the activities proposed in the 07 April 2004 letter to the TSB.
Response to A00-16 (07 February 2007)
TC's response indicates that it is participating with other regulatory authorities within the International Aircraft Systems Fire Protection Working Group. The uses of handheld fire fighting equipment in hidden areas as well as infa-red detection devices are being evaluated. The working group is also producing a video to 'educate' flight/cabin crew about dealing with in-flight fires.
TC's response does not refer to its commitment made to the TSB in its 07 April 2004 letter.
Board Reassessment of the Response to A00-16 (24 July 2007)
TC's latest response highlights some actions taken in cooperation with other regulatory authorities. The 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. Hence the residual risk associated with the lack of a systemic approach to deal with in-flight firefighting will remain. Consequently, these and previously mentioned initiatives, if implemented, will reduce but not substantially reduce the risks in the deficiency identified in Recommendation A00-16.
Therefore, the assessment is assigned Satisfactory in part.
Next TSB action
TSB staff will follow-up with TC to solicit an update with respect to the activities proposed in its 07 April 2004 letter to the TSB.
Response to A00-16 (06 March 2008)
Transport Canada states that it is participating with members from the FAA, the UK Civil Aviation Authority and others in the International Aircraft Systems Fire Protection Working Group (IASFPWG) on an ongoing basis. This working group is examining the use of handheld fire fighting equipment in hidden areas as well as infra-red detection devices and in cooperation with TC and the CAA (UK), is developing a video to educate flight/cabin crew about in-flight fires, particularly "hidden" fires, and how to deal with them.
Future rule making activity will be contingent on internationally harmonized requirements.
Board Reassessment of the Response to A00-16 (13 August 2008)
The response provides no indication that the various in-flight firefighting initiatives are complementary and optimized to work as a system that would provide the maximum probability of detecting and suppressing any in-flight fire as stated in Recommendation A00-16. Hence the residual risk associated with the lack of a systemic approach to deal with in-flight firefighting will remain.
Consequently, these and previously mentioned initiatives, if implemented, will reduce but not substantially reduce the risks in the deficiency identified in Recommendation A00-16.
Therefore, the assessment remains as Satisfactory in part.
Next TSB action
TSB Air Branch staff will continue to monitor TC's activity with respect to the risks associated with Recommendation A00-16.
FAA Response to A00-16 (06 January 2010)
In January 2010 the FAA provided an update with respect to its activity related to TSB Recommendation A00-16. 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 A00-16.
Board Reassessment of the Response to A00-16 (28 July 2010)
The Board appreciates the FAA's update. TSB was previously aware of AC 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.
The safety analyses which lead to the issuance of Recommendation A00-16 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 A00-16. 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 A00-16.
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 A00-16.
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