smoke/fire/fumes - · pdf filesmoke/fire/fumes event occurs and should be reminded in the...

Boeing is a trademark of Boeing Management Company.Copyright © 2006 The Boeing Company. All rights reserved.

Smoke/Fire/FumesSmoke/Fire/FumesIndustry InitiativeIndustry Initiative

Barbara Holder, Ph. D.Human Factors Specialist, Aviation System SafetyBoeing Commercial Airplanes

Barbara Holder, Ph. D.Human Factors Specialist, Aviation System SafetyBoeing Commercial Airplanes

Captain Harold (Chip) SieglingerChief Pilot, Flight Technical Services, Long Beach DivisionBoeing Commercial Airplanes

Captain Harold (Chip) SieglingerChief Pilot, Flight Technical Services, Long Beach DivisionBoeing Commercial Airplanes

Captain H.G. (Boomer) BombardiSafety Representative, International Federation of Air Line Pilots'Associations (IFALPA)

Captain H.G. (Boomer) BombardiSafety Representative, International Federation of Air Line Pilots'Associations (IFALPA)

Bill McKenzieManager, Flight Procedures Flight Crew Operations Boeing Commercial Airplanes

Bill McKenzieManager, Flight Procedures Flight Crew Operations Boeing Commercial Airplanes

McKenzie.2Copyright © 2006 the Boeing Company

Overview

Smoke/Fire/Fumes industry Initiative

• Situation

• The challenge

• The process

• Results

• Next steps

• Situation

• The challenge

• The process

• Results

• Next steps


The SituationThe Situation


Situation

Smoke, fire, fumes events occur daily in commercial aircraft

Smoke, fire, fumes events occur daily in commercial aircraft


Situation: We Assume the Crew CanIdentify the Specific Situation...

Incoming information may be:• Vague• Incomplete• Inaccurate• Contradictory

Incoming information may be:• Vague• Incomplete• Inaccurate• Contradictory

No pilot has a certified nose

Captain, we smell smoke

back here

Electrical? Air conditioning?


Situation

There is a wide range of possible smoke, fire, fumes sources and situationsThere is a wide range of possible smoke, fire, fumes sources and situations

“Oven smoke”“Oven smoke”“Wing fire”“Wing fire” Everything in betweenEverything in between


Situation

Manufacturer and Customer checklists vary widely in format and content

Manufacturer and Customer checklists vary widely in format and content


Situation

• AC 120-80: In-Flight Fire Fighting– Focused on cabin crew– Driving change at carriers– Insufficient flight crew guidance

• Air carriers are changing their checklists to:– Meet AC 120-80 guidelines– Improve crew performance– Standardize across all fleets (Airbus/Boeing/...)

• AC 120-80: In-Flight Fire Fighting– Focused on cabin crew– Driving change at carriers– Insufficient flight crew guidance

• Air carriers are changing their checklists to:– Meet AC 120-80 guidelines– Improve crew performance– Standardize across all fleets (Airbus/Boeing/...)


Situation

Interaction

• SFF outcomes result from the interaction of the situation, checklist, flight crew characteristics

• Today there is no common approach to managing this interaction

• SFF outcomes result from the interaction of the situation, checklist, flight crew characteristics

• Today there is no common approach to managing this interaction


The ChallengeThe Challenge


The Challenge

Provide the best possible crew guidance for managing in-flight smoke, fire, fumes (SFF) events

Provide the best possible crew guidance for managing in-flight smoke, fire, fumes (SFF) events


The Challenge

Provide a single integrated checklist that is:

• Usable across all non-alerted SFF events

• Usable by flight crews world-wide

• Unambiguous

• Easy to find

Provide a single integrated checklist that is:

• Usable across all non-alerted SFF events

• Usable by flight crews world-wide

• Unambiguous

• Easy to find


The Challenge

Provide a checklist with guidance that is “explicit”

• Common actions to perform regardless of source

• Crew Communication

• Timing for diversion and landing initiation

• Smoke/fumes removal

• Additional actions to do if smoke persists

• Loss in capability and operational consequences

Provide a checklist with guidance that is “explicit”

• Common actions to perform regardless of source

• Crew Communication

• Timing for diversion and landing initiation

• Smoke/fumes removal

• Additional actions to do if smoke persists

• Loss in capability and operational consequences


The Challenge: Striking a Balance

Provide specific guidance to the

flight crew

Provide specific guidance to the

flight crewEvery situation

is differentEvery situation

is different


The ProcessThe Process


The Process


The Process: Initial Workshop

“Initial Workshop”“Initial Workshop”

Airlines (IATA and four air carriers)Pilots (IFALPA)Manufactures(Airbus, Boeing, Bombardier, Embraer)

Airlines (IATA and four air carriers)Pilots (IFALPA)Manufactures(Airbus, Boeing, Bombardier, Embraer)

DataData

PhilosophyPhilosophyEach Stakeholder

provided

Each Stakeholder

provided

28 peopleOct ‘04

28 peopleOct ‘04

Checklist(s)Checklist(s)

Hosted by Bombardier in MontrealHosted by Bombardier in Montreal


The Process: Key RepresentativesSome Key Industry Representatives for Airlines, Pilots, and ManufacturersSome Key Industry Representatives for Airlines, Pilots, and Manufacturers

• Captain H. G. (Boomer) Bombardi

• James Burin

• Mike Galusha

• Captain Jerry Gossner

• Peter Harrison

• Captain H. G. (Boomer) Bombardi

• James Burin

• Mike Galusha

• Captain Jerry Gossner

• Peter Harrison

• Ronald Haughton

• Barbara Holder, Ph. D.

• Captain Thomas Phillips

• Captain Klaus Walendy

• Captain Dave Young

• Captain Chip Sieglinger

• Ronald Haughton

• Barbara Holder, Ph. D.

• Captain Thomas Phillips

• Captain Klaus Walendy

• Captain Dave Young

• Captain Chip Sieglinger


The Process

The objectives of “Initial” meeting were to:

1. Review available data provided by participants

2. Develop an industry consensus on a philosophy for flight crew response to the challenge of in-flight smoke, fire, fumes events per the terms of reference

3. Develop a “generic” draft checklist template that embodies the consensus philosophy

The objectives of “Initial” meeting were to:

1. Review available data provided by participants

2. Develop an industry consensus on a philosophy for flight crew response to the challenge of in-flight smoke, fire, fumes events per the terms of reference

3. Develop a “generic” draft checklist template that embodies the consensus philosophy


The Process: Terms of Reference

Checklist must address:

1. Source identification

2. Timing for descent and diversion initiation

3. Timing for “Smoke/fumes removal” versus“Source identification”

4. Additional steps for cases when suitable airports are distant and smoke persists

These four because they continue to be inconsistent

Checklist must address:

1. Source identification

2. Timing for descent and diversion initiation

3. Timing for “Smoke/fumes removal” versus“Source identification”

4. Additional steps for cases when suitable airports are distant and smoke persists

These four because they continue to be inconsistent


The Process

To scope our task, our focus was not about....

• Airplane design changes

• Crew training

• Ground coordination

• ATC coordination...etc.

To scope our task, our focus was not about....

• Airplane design changes

• Crew training

• Ground coordination

• ATC coordination...etc.


The Process

Establish common concept

definitions

Establish Establish common common concept concept

definitionsdefinitions

Define a Define a CommonCommon

PhilosophyPhilosophy

Define a Define a ChecklistChecklistTemplateTemplate

Publish Publish new SFF new SFF

Checklists Checklists


The Process: Industry Meetings

28 people28 people28 people

Airlines (IATA)Pilots (IFALPA)Manufactures(Boeing, Airbus, Bombardier, Embraer)


“Initial Workshop”

“Initial Workshop”

15 people15 people15 people



“ChecklistMeetings”“ChecklistMeetings”

Nov and Dec 2004Nov and Dec 2004

“Symposium”“Symposium”

Oct 2004Oct 2004

55+ people55+ people55+ people

March 2005March 2005

+ Regulators (FAA/JAA)+ Other agencies

(NTSB, TSB)

+ Regulators (FAA/JAA)+ Other agencies

(NTSB, TSB)


The ResultsThe Results


The ResultsIndustry RecommendationsIndustry Recommendations

Checklist TemplateChecklist Template

Concept DefinitionsConcept

DefinitionsPhilosophyPhilosophy


The ResultsStandardized ProceduresStandardized Procedures

• Standardized Procedures

• Common approach for manufacturers and operators

• Common pilot actions to be performed (“non-alerted” events)

• Checklist template that addresses:– Source identification– Timing for diversion– Smoke/fumes removal versus source identification– Additional actions to identify source

• Standardized Procedures

• Common approach for manufacturers and operators

• Common pilot actions to be performed (“non-alerted” events)

• Checklist template that addresses:– Source identification– Timing for diversion– Smoke/fumes removal versus source identification– Additional actions to identify source


The ResultsBoeing Checklist ChangesBoeing Checklist Changes

A combined checklist that addresses:

• Electrical Smoke

• Air Conditioning Smoke

• Cabin Smoke

• Fumes

• Smoke Removal is next to Smoke/Fire/Fumes checklist

A combined checklist that addresses:

• Electrical Smoke

• Air Conditioning Smoke

• Cabin Smoke

• Fumes

• Smoke Removal is next to Smoke/Fire/Fumes checklist


The ResultsIndustry Working Together ProcessIndustry Working Together Process

1. Gathered key stakeholders with common problem(manufactures / carriers / pilots)

2. Scoped the task to realistic goals

3. Established common underlying philosophy and definitions

4. Coordinated with regulators and broader industry

5. Published results– Flight Safety Foundation article– AC120-80 (TBD)

1. Gathered key stakeholders with common problem(manufactures / carriers / pilots)

2. Scoped the task to realistic goals

3. Established common underlying philosophy and definitions

4. Coordinated with regulators and broader industry

5. Published results– Flight Safety Foundation article– AC120-80 (TBD)


Next StepsNext Steps


Next StepsModel Breakout SessionsModel Breakout Sessions




Request Feedback on Industry guidelinesRequest Feedback on Industry guidelines


Next StepsModel Breakout SessionsModel Breakout Sessions

737737 747747 767/757767/757 777777 717717 MD11MD11

Request feedback on proposed Smoke/Fire/Fumes checklists

Request feedback on proposed Smoke/Fire/Fumes checklists


Next Steps

Publish Boeing checklists in 2006 in model block revision cycle

Publish Boeing checklists in 2006 in model block revision cycle


Funny Comments Heard at the Workshop

• I have pilots that operate in dumb mode. Maybe the pilots at your airline are smart all the time, but mine go into dumb mode.

• I just use a lizard eye while the copilot is trying to divert

• You can confirm the fire is out when you can put your tongue on it

• A fire on your airplane may not be serious....but a fire on my airplane is a serious fire

• I like to use the first officer as a canary

• There isn’t an emergency I can’t make worse

• I have pilots that operate in dumb mode. Maybe the pilots at your airline are smart all the time, but mine go into dumb mode.

• I just use a lizard eye while the copilot is trying to divert

• You can confirm the fire is out when you can put your tongue on it

• A fire on your airplane may not be serious....but a fire on my airplane is a serious fire

• I like to use the first officer as a canary

• There isn’t an emergency I can’t make worse


Funny Comments Heard at the Workshop

• For sure you can land an EMB 170 anywhere - unless you are over the Amazon

• With all the IDGs out, I have more capability in this airplane than in my 737-200 brand new

• Everybody’s confused

• In ditching training we were taught that each minute of flying is a week of swimming

• If there is any doubt in my military mind, we’re diverting

• For sure you can land an EMB 170 anywhere - unless you are over the Amazon

• With all the IDGs out, I have more capability in this airplane than in my 737-200 brand new

• Everybody’s confused

• In ditching training we were taught that each minute of flying is a week of swimming

• If there is any doubt in my military mind, we’re diverting


Thank YouThank You


Attachments

• Cross Model Smoke Comparison

• Philosophy

• Definitions

• Template

• Template with Rationale

• Cross Model Smoke Comparison

• Philosophy

• Definitions

• Template

• Template with Rationale


Cross-Model Smoke Source Comparison

70% 70%

51%

64%

38%

48%

26%

21%

7%

21%

14%

45%

31%

41%

4%

16% 15%12%

4%6%

4%

Electrical Air Conditioning Material

Smoke Events 11/92 to 6/00Smoke Events 11/92 to 6/00

Pressure Vessel Smoke Sources

Pressure Vessel Smoke Sources

777777 747-400747-400 MD11/DC10MD11/DC10 767767 757757 737737 717/DC9717/DC9

<---------- Complex Simpler ----------><---------- Complex Simpler ---------->


PhilosophySmoke/Fire/Fumes Philosophy and DefinitionsSmoke/Fire/Fumes Philosophy and Definitions

• This philosophy was derived by a collaborative group of industry specialists representing aircraft manufacturers, airlines/operators and professional pilot associations. The philosophy was used to construct the Smoke/Fire/Fumes Checklist Template.

• This philosophy was derived by a collaborative group of industry specialists representing aircraft manufacturers, airlines/operators and professional pilot associations. The philosophy was used to construct the Smoke/Fire/Fumes Checklist Template.


PhilosophyGeneralGeneral

• The entire crew must be part of the solution.

• For any smoke event, time is critical.

• The Smoke/Fire/Fumes Checklist Template:– Addresses non-alerted smoke/fire/fumes events

(smoke/fire/fumes event not annunciated to the flight crew by aircraft detection systems);

– Does not replace alerted checklists (e.g., cargo smoke) or address multiple events;

– Includes considerations to support decisions for immediate landing (an overweight landing, a tailwind landing, a ditching, a forced off-airport landing, etc.); and,

– Systematically identifies and eliminates an unknown smoke/fire/fumes source.

• The entire crew must be part of the solution.

• For any smoke event, time is critical.

• The Smoke/Fire/Fumes Checklist Template:– Addresses non-alerted smoke/fire/fumes events

(smoke/fire/fumes event not annunciated to the flight crew by aircraft detection systems);

– Does not replace alerted checklists (e.g., cargo smoke) or address multiple events;

– Includes considerations to support decisions for immediate landing (an overweight landing, a tailwind landing, a ditching, a forced off-airport landing, etc.); and,

– Systematically identifies and eliminates an unknown smoke/fire/fumes source.


PhilosophyGeneral (continued)General (continued)

• Checklist authors should consider a large font for legibility ofchecklist text in smoke conditions and when goggles are worn.

• At the beginning of a smoke/fire/fumes event, the crew should consider all of the following:– Protecting themselves (e.g., oxygen masks, smoke goggles);– Communication (crew, air traffic control);– Diversion; and,– Assessing the smoke/fire/fumes situation and

available resources.

• Checklist authors should consider a large font for legibility ofchecklist text in smoke conditions and when goggles are worn.

• At the beginning of a smoke/fire/fumes event, the crew should consider all of the following:– Protecting themselves (e.g., oxygen masks, smoke goggles);– Communication (crew, air traffic control);– Diversion; and,– Assessing the smoke/fire/fumes situation and

available resources.


PhilosophyInitial Steps for Source EliminationInitial Steps for Source Elimination

• Assume pilots may not always be able to accurately identify the smoke source due to ambiguous cues, etc.

• Assume alerted-smoke-event checklists have been accomplished but the smoke’s source may not have been eliminated.

• Rapid extinguishing/elimination of the source is the key to prevent escalation of the event.

• Manufacturer’s initial steps that remove the most probable smoke/fumes sources and reduce risk must be immediately available to the crew. These steps should be determined by model-specific historical data or analysis.

• Initial steps:– Should be quick, simple and reversible;– Will not make the situation worse or inhibit further assessment

of the situation; and,– Do not require analysis by the crew.

• Assume pilots may not always be able to accurately identify the smoke source due to ambiguous cues, etc.

• Assume alerted-smoke-event checklists have been accomplished but the smoke’s source may not have been eliminated.

• Rapid extinguishing/elimination of the source is the key to prevent escalation of the event.

• Manufacturer’s initial steps that remove the most probable smoke/fumes sources and reduce risk must be immediately available to the crew. These steps should be determined by model-specific historical data or analysis.

• Initial steps:– Should be quick, simple and reversible;– Will not make the situation worse or inhibit further assessment

of the situation; and,– Do not require analysis by the crew.


PhilosophyTiming for Diversion/LandingTiming for Diversion/Landing

• Checklist authors should not design procedures that delay diversion.

• Crews should anticipate diversion as soon as a smoke/fire/fumes event occurs and should be reminded in the checklist to consider a diversion.

• After the initial steps, the checklist should direct diversion unless the smoke/fire/fumes source is positively identified, confirmed to be extinguished and smoke/fumes are dissipating.

• The crew should consider an immediate landing anytime the situation cannot be controlled.

• Checklist authors should not design procedures that delay diversion.

• Crews should anticipate diversion as soon as a smoke/fire/fumes event occurs and should be reminded in the checklist to consider a diversion.

• After the initial steps, the checklist should direct diversion unless the smoke/fire/fumes source is positively identified, confirmed to be extinguished and smoke/fumes are dissipating.

• The crew should consider an immediate landing anytime the situation cannot be controlled.


PhilosophySmoke or Fumes RemovalSmoke or Fumes Removal

• This decision must be made based upon the threat being presented to the passengers or crew.

• Accomplish Smoke or Fumes Removal Checklist procedures only after the fire has been extinguished or if the smoke/fumes present the greatest threat.

• Smoke/fumes removal steps should be identified clearly as removal steps and the checklist should be easily accessible (e.g., modular, shaded, separate, standalone, etc.).

• The crew may need to be reminded to remove smoke/fumes.

• The crew should be directed to return to the Smoke/Fire/Fumes Checklist after smoke/fumes removal if the Smoke/Fire/Fumes Checklist was not completed.

• This decision must be made based upon the threat being presented to the passengers or crew.

• Accomplish Smoke or Fumes Removal Checklist procedures only after the fire has been extinguished or if the smoke/fumes present the greatest threat.

• Smoke/fumes removal steps should be identified clearly as removal steps and the checklist should be easily accessible (e.g., modular, shaded, separate, standalone, etc.).

• The crew may need to be reminded to remove smoke/fumes.

• The crew should be directed to return to the Smoke/Fire/Fumes Checklist after smoke/fumes removal if the Smoke/Fire/Fumes Checklist was not completed.


PhilosophyAdditional Steps for Source EliminationAdditional Steps for Source Elimination

• Additional steps aimed at source identification and elimination:– Are subsequent to the manufacturer’s initial steps

and the diversion decision;– Are accomplished as time and conditions permit,

and should not delay landing; and,– Are based on model-specific historical data

or analysis.

• The crew needs checklist guidance to systematically isolate an unknown smoke/fire/fumes source.

• Additional steps aimed at source identification and elimination:– Are subsequent to the manufacturer’s initial steps

and the diversion decision;– Are accomplished as time and conditions permit,

and should not delay landing; and,– Are based on model-specific historical data

or analysis.

• The crew needs checklist guidance to systematically isolate an unknown smoke/fire/fumes source.


Philosophy, Concept, Template





Concept Definitions

• Confirmed to be extinguished: The source is visually confirmed to be extinguished. (You can “put your tongue on it.”)

• Continued flight: Once a fire or a concentration of smoke/fumes is detected, continuing the flight to the planned destination is not recommended unless the source of the smoke/fire/fumes is confirmed to be extinguished and the smoke/fumes are dissipating.

• Diversion may be required: Establishes the mindset that a diversion may be required.

• Confirmed to be extinguished: The source is visually confirmed to be extinguished. (You can “put your tongue on it.”)

• Continued flight: Once a fire or a concentration of smoke/fumes is detected, continuing the flight to the planned destination is not recommended unless the source of the smoke/fire/fumes is confirmed to be extinguished and the smoke/fumes are dissipating.

• Diversion may be required: Establishes the mindset that a diversion may be required.


Concept Definitions

• Land at the nearest suitable airport: Commence diversion to the nearest suitable airport. The captain also should evaluate the risk presented by conditions that may affect safety of the passengers associated with the approach, landing and post-landing.

• Landing is imminent: The airplane is close enough to landing that the remaining time must be used to prepare for approach and landing. Accomplishing further smoke/fire/fumes-identification steps would delay landing.

• Land at the nearest suitable airport: Commence diversion to the nearest suitable airport. The captain also should evaluate the risk presented by conditions that may affect safety of the passengers associated with the approach, landing and post-landing.

• Landing is imminent: The airplane is close enough to landing that the remaining time must be used to prepare for approach and landing. Accomplishing further smoke/fire/fumes-identification steps would delay landing.


Concept Definitions

• Land immediately: Proceed immediately to the nearest landing site. Conditions have deteriorated and risks associated with the approach, landing or post-landing are exceeded by the risk of the on-board situation. “Immediate landing” implies immediate diversion to a landing on a runway; however, smoke/fire/fumes scenarios may be severe enough that the captain should consider an overweight landing, a tailwind landing, a ditching, a forced off-airport landing, etc.

• Crew: For the purposes of this document, the term “crew”includes all cabin crewmembers and flight crewmembers.

• Land immediately: Proceed immediately to the nearest landing site. Conditions have deteriorated and risks associated with the approach, landing or post-landing are exceeded by the risk of the on-board situation. “Immediate landing” implies immediate diversion to a landing on a runway; however, smoke/fire/fumes scenarios may be severe enough that the captain should consider an overweight landing, a tailwind landing, a ditching, a forced off-airport landing, etc.

• Crew: For the purposes of this document, the term “crew”includes all cabin crewmembers and flight crewmembers.


Philosophy, Concept, Template





Checklist Template


Checklist Template With RationaleSmoke/Fire/Fumes Checklist Template (With Rationale) Smoke/Fire/Fumes Checklist Template (With Rationale)

• This document describes the rationale for the proposed in-flight Smoke/Fire/Fumes (SFF) Checklist Template steps. The rationale includes the purpose of the step and the reason for its sequential placement in the checklist.

• This document describes the rationale for the proposed in-flight Smoke/Fire/Fumes (SFF) Checklist Template steps. The rationale includes the purpose of the step and the reason for its sequential placement in the checklist.


Checklist Template With Rationale (continued)

Protect the flight crew then assess the situation

1. Diversion may be required.

Rationale: This step establishes the mindset that a diversion may be required. We use the word “may”because the crew should not initiate a diversion before a preliminary assessment of the immediate fire/source. This step is placed at the beginning of the checklist to establish immediately in the minds of the flight crew a diversion may be required.

Protect the flight crew then assess the situation

1. Diversion may be required.

Rationale: This step establishes the mindset that a diversion may be required. We use the word “may”because the crew should not initiate a diversion before a preliminary assessment of the immediate fire/source. This step is placed at the beginning of the checklist to establish immediately in the minds of the flight crew a diversion may be required.



2. Oxygen Masks (If required) ………………………....ON, 100%

3. Smoke Goggles (If required) ………….………….................ON

Rationale: These steps protect the flight crew from smoke inhalation and fume absorption. Oxygen masks are on at 100% so O2 supply does not mix with smoke or fumes. Steps are early in the checklist to ensure the cockpit crew is protected immediately after smoke/fumes detection. Steps are separate because they may be separate devices. The flight crew should don oxygen masks anytime smoke/fumes are detected on the flight deck. The trigger to don masks is the smoke not the checklist. The steps are not recall nor are they required because oxygen masks and smoke goggles may not be required for all smoke events. We rely on cockpit crew judgment to decide when to don the devices. The “if required” statement also permits airlines to be flexible in training when to don the masks or to leave the timing decisions to the cockpit crew’s discretion.

2. Oxygen Masks (If required) ………………………....ON, 100%

3. Smoke Goggles (If required) ………….………….................ON

Rationale: These steps protect the flight crew from smoke inhalation and fume absorption. Oxygen masks are on at 100% so O2 supply does not mix with smoke or fumes. Steps are early in the checklist to ensure the cockpit crew is protected immediately after smoke/fumes detection. Steps are separate because they may be separate devices. The flight crew should don oxygen masks anytime smoke/fumes are detected on the flight deck. The trigger to don masks is the smoke not the checklist. The steps are not recall nor are they required because oxygen masks and smoke goggles may not be required for all smoke events. We rely on cockpit crew judgment to decide when to don the devices. The “if required” statement also permits airlines to be flexible in training when to don the masks or to leave the timing decisions to the cockpit crew’s discretion.



4. Crew and Cabin Communications ………………....Establish

Rationale: This step initiates timely coordination and communication between the cabin and cockpit crew. The step is placed after 2 and 3 to not delay donning of oxygen masks and goggles if required. The communication with cabin crew is made explicit in the step because the cabin crew is an important resource for assisting the cockpit crew with source identification and confirmation of elimination.

Source elimination steps

5. Manufacturer’s initial steps (1) …………..…….. Accomplish

Rationale: These steps quickly isolate probable ignition sources based on historical fleet data or analysis. The cockpit crew isexpected to take action without delay and without assessment. The steps are placed early in the checklist to immediately isolate probable sources to reduce the risk of event escalation.

4. Crew and Cabin Communications ………………....Establish

Rationale: This step initiates timely coordination and communication between the cabin and cockpit crew. The step is placed after 2 and 3 to not delay donning of oxygen masks and goggles if required. The communication with cabin crew is made explicit in the step because the cabin crew is an important resource for assisting the cockpit crew with source identification and confirmation of elimination.

Source elimination steps

5. Manufacturer’s initial steps (1) …………..…….. Accomplish

Rationale: These steps quickly isolate probable ignition sources based on historical fleet data or analysis. The cockpit crew isexpected to take action without delay and without assessment. The steps are placed early in the checklist to immediately isolate probable sources to reduce the risk of event escalation.



Smoke Removal Reminder

Anytime smoke or fumes become the greatest threat, accomplish SMOKE OR FUMES REMOVAL checklist.

Rationale: Smoke removal should be accomplished only when the smoke/fumes are the greatest threat or when the source is confirmed extinguished. Smoke removal may change the airflow and make the situation worse by fanning an ignition source or it may mask the source. Smoke removal steps must be clearly identified and be easy to find. The removal steps may be left out of the checklist to keep the checklist uncluttered and short.

Smoke Removal Reminder

Anytime smoke or fumes become the greatest threat, accomplish SMOKE OR FUMES REMOVAL checklist.

Rationale: Smoke removal should be accomplished only when the smoke/fumes are the greatest threat or when the source is confirmed extinguished. Smoke removal may change the airflow and make the situation worse by fanning an ignition source or it may mask the source. Smoke removal steps must be clearly identified and be easy to find. The removal steps may be left out of the checklist to keep the checklist uncluttered and short.



6. Source is immediately obvious and can be extinguished quickly:

If Yes …………….. Go to Step 7.If No ……….………Go to Step 9.

Rationale: This step is an immediate assessment of the source and situation without waiting for the effect of initial actions. The crew must determine if the source is extinguishable. The outcome of the assessment is a decision to extinguish the

7. Extinguish the source.If possible, remove power from affected equipment byswitch or circuit breaker on the flight deck or in the cabin.

Rationale: After source is identified, the crew should use all available resources to actively extinguish the source. This step comes after the source is identified.

6. Source is immediately obvious and can be extinguished quickly:

If Yes …………….. Go to Step 7.If No ……….………Go to Step 9.

Rationale: This step is an immediate assessment of the source and situation without waiting for the effect of initial actions. The crew must determine if the source is extinguishable. The outcome of the assessment is a decision to extinguish the

7. Extinguish the source.If possible, remove power from affected equipment byswitch or circuit breaker on the flight deck or in the cabin.

Rationale: After source is identified, the crew should use all available resources to actively extinguish the source. This step comes after the source is identified.



8. Source is visually confirmed to be extinguished:If Yes, Consider reversing manufacturer’s initial steps……………Go to Step 17If No………Go to Step 9

Rationale: The crew must confirm that the source is extinguished. The outcome of the assessment is a decision the source is extinguished or to continue the checklist. This step is placed early in the checklist to prevent escalation of the event.

9. Remaining minimal essential manufacturer’s action steps...........Accomplish[These are steps that do not meet the “initial steps” criteria but are probable sources] (2)

Rationale: Additional manufacturer action steps that do not meet the “initial actions” criteria outlined in the SFF philosophy. For example, steps that make the cabin dark or may interfere with source identification. No further assessment should be made prior to diversion.

8. Source is visually confirmed to be extinguished:If Yes, Consider reversing manufacturer’s initial steps……………Go to Step 17If No………Go to Step 9

Rationale: The crew must confirm that the source is extinguished. The outcome of the assessment is a decision the source is extinguished or to continue the checklist. This step is placed early in the checklist to prevent escalation of the event.

9. Remaining minimal essential manufacturer’s action steps...........Accomplish[These are steps that do not meet the “initial steps” criteria but are probable sources] (2)

Rationale: Additional manufacturer action steps that do not meet the “initial actions” criteria outlined in the SFF philosophy. For example, steps that make the cabin dark or may interfere with source identification. No further assessment should be made prior to diversion.



10. Initiate a diversion to the nearest suitable airport while continuing the checklist.

Rationale: The cockpit crew should not delay a diversion if the source remains unknown or cannot be extinguished. The step is placed here to get the airplane headed toward a suitable airport.

Warning: If the SFF situation becomes unmanageable, consider an immediate landing.

Rationale: The purpose of this warning is to remind the crew an immediate landing may be required if the situation deteriorates. The step is placed here after the initial probable source elimination steps have been accomplished, but before the additional source elimination steps which may be lengthy.

10. Initiate a diversion to the nearest suitable airport while continuing the checklist.

Rationale: The cockpit crew should not delay a diversion if the source remains unknown or cannot be extinguished. The step is placed here to get the airplane headed toward a suitable airport.

Warning: If the SFF situation becomes unmanageable, consider an immediate landing.

Rationale: The purpose of this warning is to remind the crew an immediate landing may be required if the situation deteriorates. The step is placed here after the initial probable source elimination steps have been accomplished, but before the additional source elimination steps which may be lengthy.


Checklist Template With Rationale (continued)Additional Source Elimination StepsAdditional Source Elimination Steps

11. Landing is imminent:If Yes …………….. Go to Step 16.If No ……….………Go to Step 12.

Rationale: If landing is imminent, the crew should stop the checklist and focus on landing the airplane without the added workload and distraction of doing this checklist. This step is placed here because all probable source isolation steps have been accomplished.

11. Landing is imminent:If Yes …………….. Go to Step 16.If No ……….………Go to Step 12.

Rationale: If landing is imminent, the crew should stop the checklist and focus on landing the airplane without the added workload and distraction of doing this checklist. This step is placed here because all probable source isolation steps have been accomplished.



12. XX system actions ………….. Accomplish[Further actions to control/extinguish source.]If dissipating ………………… Go to Step 16.

13. YY system actions ………….. Accomplish[Further actions to control/extinguish source.]If dissipating ………………… Go to Step 16.

14. ZZ system actions ………….. Accomplish[Further actions to control/extinguish source.]If dissipating ………………… Go to Step 16.

Rationale: Additional source identification and isolation guidance may be required when the airplane is far from a suitable landingsite. These system steps are presented here to systematically isolate an unknown source. These steps come late in the checklist after a diversion was initiated because they may take time. The sequence of these steps is determined by the greatest hazard they pose to the airplane.

12. XX system actions ………….. Accomplish[Further actions to control/extinguish source.]If dissipating ………………… Go to Step 16.

13. YY system actions ………….. Accomplish[Further actions to control/extinguish source.]If dissipating ………………… Go to Step 16.

14. ZZ system actions ………….. Accomplish[Further actions to control/extinguish source.]If dissipating ………………… Go to Step 16.

Rationale: Additional source identification and isolation guidance may be required when the airplane is far from a suitable landingsite. These system steps are presented here to systematically isolate an unknown source. These steps come late in the checklist after a diversion was initiated because they may take time. The sequence of these steps is determined by the greatest hazard they pose to the airplane.



15. Smoke/fire/fumes continue after all system-related steps are accomplished:

Consider Landing Immediately………Go to Step 16.

Rationale: This is the final assessment step in the checklist. The outcome of the assessment is an immediate landing or landing at a suitable airport if the additional steps identified the source.

15. Smoke/fire/fumes continue after all system-related steps are accomplished:

Consider Landing Immediately………Go to Step 16.

Rationale: This is the final assessment step in the checklist. The outcome of the assessment is an immediate landing or landing at a suitable airport if the additional steps identified the source.


Checklist Template With Rationale (continued)Follow-Up ActionsFollow-Up Actions

16. Review Operational Considerations.

Rationale: Operational considerations provide information to support crew decision making. The cockpit crew may need to be reminded to review considerations that may affect continued flight operations and decisions. Operational considerations may vary by airplane model and may be lengthy so should be provided outside of the checklist.

17. Accomplish SMOKE OR FUMES REMOVAL checklist, if required.

Rationale: This step reminds the cockpit crew to remove smoke or fumes. This step is best accomplished after the source has been isolated and extinguished.

16. Review Operational Considerations.

Rationale: Operational considerations provide information to support crew decision making. The cockpit crew may need to be reminded to review considerations that may affect continued flight operations and decisions. Operational considerations may vary by airplane model and may be lengthy so should be provided outside of the checklist.

17. Accomplish SMOKE OR FUMES REMOVAL checklist, if required.

Rationale: This step reminds the cockpit crew to remove smoke or fumes. This step is best accomplished after the source has been isolated and extinguished.



18. Checklist complete.Rationale: This step indicates there are no more steps in the checklist.

18. Checklist complete.Rationale: This step indicates there are no more steps in the checklist.

Operational Considerations:These items appear after “checklist complete.” This area should be used to list operational considerations, such as an overweight landing, a tailwind landing, a ditching, a forced off-airport landing, etc.

Notes:1.These aircraft-specific steps will be developed and inserted by the

aircraft manufacturer.

2.Bracketed text contains instructions/explanations for the checklist author.

3. “XX”, “YY”, and “ZZ” are placeholders for the environmental control system, electrical system, in-flight entertainment system and/or any other systems identified by the aircraft manufacturer.

Operational Considerations:These items appear after “checklist complete.” This area should be used to list operational considerations, such as an overweight landing, a tailwind landing, a ditching, a forced off-airport landing, etc.

Notes:1.These aircraft-specific steps will be developed and inserted by the

aircraft manufacturer.

2.Bracketed text contains instructions/explanations for the checklist author.

3. “XX”, “YY”, and “ZZ” are placeholders for the environmental control system, electrical system, in-flight entertainment system and/or any other systems identified by the aircraft manufacturer.

smoke/fire/fumes - · pdf filesmoke/fire/fumes event occurs and should be reminded in the...

Documents