Subject: Swissair Flt 111 emergency procedures

To IASA et AL,

John,

I have absorbed your wise words, but you did not relieve me by - may I say it in this way - justifying the flight crew's actions. I have asked AVIATOR and got their reply just a minute ago (you will find it at the bottom).

1. We can agree that the CAUSE is not related to the flight crew's actions.

2. We can agree on (emergency) checklists that are not appropriate (be it in a 'Kaptonized’ a/c or not) and that need to be redressed.

3. We can agree that resetting tripped circuit-breakers may work out as being a bomb igniter.

4. We can agree that SR111 was VERY close to Halifax airport under extremely stressed conditions.

5. We can agree that SR111 was above MLW.

6. We can agree that SR111 should have started dumping fuel at an earlier stage, and not just waiting for HFX radar.

But:

7. If the flight crew had to deal with the smoke/fire (and foremost the cause of it), they also had to deal with taking the right decision(s) at the right moment. We know from the ATC transcript that they had 10 minutes of CONTROLLED flight in front of them (I add: this does not necessarily mean that these 10 minutes would cover the appropriate technical environment for a successful landing at HFX). How can you be so sure that they took the right decision(s)? The flying characteristics of the MD-11 allow 7,000 fpm descent rate, 6,000 fpm a no-brainer. The books tell. The emergency checklist tells the crew on the chapter fire/smoke to land as soon as possible.

Sampson comments below in two shades of blue: (I love a challenge and you guys are too easy – come on!)

What I’m commenting upon I’ve either coloured dark red (or very red) or refers to your prose that’s immediately prior to my blue remarks. Please note that the first thing that they teach you in staff college is that a good argument is an unemotional, factual and dissective one.

Re Red text above: Not quite true. From the DFDR and the CVR, they went to the air conditioning smoke checklist first (Swissair standard procedure). They first paged through the aircon schematics on their synoptics screen (historical fact from DFDR). The aircon checklist (I have a copy) is a 22 item list that asks four times, after AirCon config changes, "Has the Smoke Decreased?". You can imagine that that is a time-consuming process (pausing to assess/awaiting the cabin attendant’s input). I would question the Swissair priorities because aircon bleed-air sourced oil-contaminated smoke or mist is just not going to kill you. The smoke/fumes of unknown origin checklist should obviously be first cab off the rank. The Smoke Elec/Air rotary doesn’t get touched until the next checklist in the specified order (i.e. it says as last item of aircon checklist: "Now refer to Emerg Procedure-Smoke & Fumes of Unknown Origin") I’ll reproduce that (in full) so that you can see just how time-consuming that second checklist is (and if you think that this is a prelude to me trying to justify the life-saving immediacy of my "VIRGIN BUS", you are correct)

MD11 Smoke/Fumes of Unknown Origin (verbatim)
CABIN Bus P/B	OFF
PAUSE long enough for cabin crew to evaluate whether it appears smoke or fumes have started to decrease.
Smoke/Fumes decrease?	Yes? Continue with cabin bus inop
No?	Cabin bus P/B ON
Smoke/Elec/Air Selector	PUSH & Rotate
Rotate Smk/elec/air sel clockwise pausing at each position long enough to evaluate whether smk/fumes decrease	When a decrease is noted, leave the selector in that position for the rest of the flight. Continue with that generator, channel and aircon system inop and observe associated consequences.
Note:	-When rotating Smk/Elec/Air Selector autothrottle will disengage and be unusable. The autopilot may disengage but then you can use the other autopilot. -Nuisance stick shaker may occur. [stick-shaker CB’s on overhead panel at E1(capt) E31 (F/O)] -following essential systems are inoperative or OFF in accordance with Smk/Elec/Air selector positions
Smoke Selector posn 3/1 OFF	Only captain’s VHF 1 and interphone available DU 4, 6, 8, MCDU2, FMS2, IRS 2 (after 15 mins) Radar2, all NavAIDS Bleed Air 1, Pack 1, ECON system, Wing Anti-ice, F/O pitot heat Auto SLAT extension Landing Gear aural warning Auto-brakes FOR APPROACH: set flap limit selector to OVRD 1 Go-around mode is not available
Smoke Selector posn 2/3 OFF	Bleed air 3, Pack 3, Wing anti-ice Aux pitot heat Fuel dump low-level (i.e. you can dump beyond amount set limit) Horizontal stabilizer trim switches on control column Engine 2 reverser
Smoke Selector posn 1/2 OFF	Only VHF2 and 3 available (i.e. they will need to keep switching freqs) DU 1, 2, 3 and MCDU1, FMS 1 IRS1 and AUX IRS after 15 mins (autopilot no longer available) Radar 1 and all NavAIDS Bleed air 2, Pack 2, Wing and Tail anti-ice Captain’s pitot heat GPWS, GPWS below G/Slope lights Auto ground spoilers Engine reversers 1 & 3 FOR APPROACH: set flap limit selector to OVRD 2 On Captain’s SISP push Flt Dir P/B to OFF Go around mode is not available
If smoke & Fumes are not eliminated, land at nearest available airport.
END	If successful, Smoke & Fumes removal checklist comes next (14 items) & that includes descent to 12,000ft (terrain permitting) and a note that soot deposits may contaminate CRT’s (i.e. displays) and cockpit windows.

You cannot criticise the SR111 crew for carrying out their airline’s SOP (standard Operating Procedure). I think the ordering is completely wrong (aircon first is lethal – but that is what they did actually do). You will note that, if they got as far as the third (1/2 off) selection, they must remember to set their allocated comms freq on VHF 2 or 3 (and ALSO switch their TX selection to that set or they will be incommunicado with the ground). You’ll also see that it is possible to dump too much fuel (with 2/3 OFF) and that the option of `landing at nearest available’ is the very last item. Obviously this style of checklist should not be acceptable in the 21^st century. It has killed enough people already. By comparison the Virgin Bus solution allows everyone to live and the origins of the smoke to be easily trouble-shot on the ground later (but it probably needs a more acceptable name). Please accept the 15 mins timings above with a grain of salt. If there’s a massive short and the relevant CB’s have not popped (or the BATT CB’s have) the 15 mins of BATT power comes down to zero rapidly. I also see that there is no mention of "DEPLOY the ADG (air driven generator)" in any of the three checklists. Hmmmm?? Maybe it’s automatic. Or of donning masks (or PAN, Mayday). I suppose these are just "givens" (aka basic airmanship).

8. Why then not taking the shortest course down to earth?

It’s not SOP to descend until the last item (or once into the Smoke Removal Checklist)

9. OLeary is an MD-11 1st FO. He could read in here, but has he ever experienced 7,000 fpm?

He is ex-military so he would have hacked >40,000fpm (idle + Speedbrake) standard max rate descent in the T2 Buckeye as a naval cadet. The readiness to do so is not the question / the need to do so, at the time (in the then prevailing circumstance) is the question.

10. Is it not so that smoke in the cockpit should be a happenstance with emergency ranking? With a captain aboard who is an MD-11

prime instructor himself?

Ah, but there’s smell and then there’s smoke and cooking odours (maybe even cigar smoke if pax can smoke in the Swissair cabins). It doesn’t necessarily all happen at once. It can be an insidious developing process.

11. Is it necessary to 'learn' in a FSIM about smoke (difficult to imitate), under the circumstance that smoke is always a hazard? Because

'something is burning'?

Just about all meaningful "abnormal" circumstances are nowadays reproducible in the simulator. However considerable effort is required (repetitive, then multiple, smoke grenades) for a realistic scenario. Most smoke grenades are a little toxic and it’s also not good for the sim electronics. So admittedly most smoky SimEXes are unrealistic and taper off into a premature discussion. That may need looking into.

12. Is it of real importance that cabin crew and passengers could be alarmed because of immediate descent and inherent depressurization anomalies? The only thing that counts in my opinion is SURVIVAL. These poor souls will have had their portion of panic aboard anyway, and with devastating outcome.

This is still hindsight. In many (if not most) instances smelt smoke turns out to be imagination or something relatively innocuous). It is quite possible to be premature, and to be fairly later accused of crying wolf. Your solution doesn’t work in the middle of the POND, unless you also want to dump and commit to a premature/lethal ditching – but the Virgin Bus selection will work anywhere (particularly if it’s mandatory once smoke is confirmed). Post SR111, pax panic may well become a much more significant factor (than it has to date). Some hectic manoeuvre may win you some really aggravated cockpit visitors.

13. Is it not so that crews might feel uncomfortable to make the choice for immediate descent without verifying where the smoke is coming from (check-listing), because of apparent 'punishment' by their management (if a coffee maker was just on fire... or something like it).

Precisely, that’s where the Virgin Bus comes in. Once you’re convinced you’ve got a genuine problem you select the Virgin Bus (by SOP) and get that lethal power off the shaky wire - and you’re then looking good. After you confirm that you’ve thereby squelched the fire you can proceed with the Aircon checklist/smoke removal or order up a cold salad and a weak Scotch. No one can criticise you for success ( because you will be using the new millenium’s approved, standard, Y2K certified, procedure for confirmed smoke).

14. Why was it not a serious consideration to get down immediately from FL300? No one should feel comfortable at this altitude with smoke circling around. Circling around? They put on their masks!

See the first two checklists (it’s not called for). Masks are not called for by checklists either. I guess it’s left as an instinctive thing / an airmanship recall item. I note that pursuant to the HMAS Westralia engine room fire (that killed four sailors) the RAN is now banning Naval beards. It seems that smoke-mask sealing was a factor. This also needs consideration for airline flight crews.

15. Looking at the kinetic energy, dragging, etc.: a lower altitude is always better in these circumstances. The chances that one finds the cause of the smoke is relatively minimal, emergency checking et al.

A full-blown max-rate descent was only appropriate if the skipper had decided that they were in a survival situation and needed the immediate straight-in approach (obviously the situation had not yet got anywhere near that stage). Once he’d turned away from Halifax it was not then a big deal. They continued a reasonably high rate descent while they continued trouble-shooting and the last (mode Charlie) transponder reported altitude was 9700 ft. That equated to the height where they said their last R/T words and all electrical hell THEN broke loose. One could argue that a guaranteed way of provoking loss of control is to expect two-man crews to do too much at once. A three-man crew’s capacity is quite another matter however.

16. Emergency descents have been done before, and successfully.

Of course (when appropriate) but always remain in themselves a dicy deal with smoke masks ON and a cockpit filling with smoke at night (with no outside lights on the ground). It’s very easy to fly into the water at night (particularly if the other pilot’s just disabled the GPWS as part of the trouble-shooting).

17. Let's be clear on the subject of NO SELF-DENIAL. The FAA is under fire because of their bloody self-denial.

The FAA is more properly described as "a bunch of minimalists". They actually deny themselves nothing (including the power of life and death). In the big picture SR111 is nothing more than an actuarial blip that helps confirm or deny a trend.....

This is no path to go for flight crews. They MUST have a clear vision of their responsibilities in emergency situations. It can't be that they can't spell 'Kapton', it can't be that they panic because of hectic audio alarms, it can't be that they don't want to stress the airframe, 'because the situation could improve'. I'm sure that airframes have been greatly stressed since September 2.

And successfully... No casualties...

I would agree that Swissair crews had probably never heard of Kapton before 3 Sep 98 and Zimmerman/Loew never did. You cannot expect crews to act beyond their experience, knowledge or training. The checklists as they stand are abysmally optimistic and lethally time-consuming. In a Kaptonized era that is quite unwarranted, in fact 180 degrees out. What you can do is stick your tongue firmly in your cheek and ask whether the pundits who see CRM (Cockpit Resource Management) as a catch-all/cure-all are really genuine. So many academics and organisations are making big brass out of CRM nowadays that it’s in genuine danger of becoming the replacement Degree for underwater basket-weaving. If you look at a CRM syllabus it’s so esoteric that you wonder if it’s aviation they’re talking about. (see: http://www.caar.db.erau.edu/crm or download the 7mb guide at: http://www.caar.db.erau.edu/crm/resources/misc/raesperf/perfstan.htm ). You’ll be amazed how academics can complicate something so intrinsically simple – moral: keep the academics out of the equation or the concept of CRM will soon equate to Quantum Theory. Simply stated, Crew Training needs to be about coordination, cooperation and "take-charge" attitudes. Or as F/O Oleary put it: "aviate, navigate and communicate" in that order. Your point about hectic audio alarms and warblers is quite a good one though. They are best cancelled quickly because they can distract, disconcert and provoke.

It is far from my intention to nail the crew post-mortem. That’s not the message I’m getting here. My only intention is that we should make clear that we have a) A PROBLEM (smoke/fire/malfunction) and b) that flight-crews are / need to be trained to deal with THAT PROBLEM, eventually by taking THE CORRECT DECISION, whatever this decision may be under THE circumstances. Flight-crews are better paid than plumbers and they are responsible for all the souls aboard. These souls depend ALSO (not only) on THEIR decision-making. If there is something rotten in Denmark (wiring, etc.) we also need to look at the Danish inhabitants. They also play their part, even if they are not the CAUSE of the trouble.

Yes I agree, this is a multi-faceted problem and many of the culprits are going to ground or throwing up smoke-screens. And that is also why I put my web-site up and am tub-thumping and lobbying so that this tragic accident need not be repeated. I can discern, in recent FAA actions and pronouncements, that they are beginning to appreciate that many regulators’ heads will roll if there is allowed to be a carbon copy of SR111. But our puny actions are like a tick screwing an elephant –the pachyderm doesn’t feel much at the time but the progeny could turn out to be quite horrific. They could turn out to be a whole herd of "told you so’s" burrowing into the FAA’s elephantine sinecures.

Yes, John, I agree: it is always the same... hindsight in the cosy arm chair. But that does not make the issue less valuable. Passengers feel secure for no sense reasons, but their faith in their crew is not the least one on their list. It is not a mere matter of CABLES, but also of PEOPLE... in the cockpit... and BEHIND the cockpit door.

I think Swissair has learnt a very valuable (but expensive) lesson but let’s face it. In the big scheme of things 229 dead souls is not a record-breaker. It’s really up to the regulators to take on board these lessons learnt and dynamically go for a fix. I consider that in the face of so much Kapton (decades of it yet to go) the only realistic solution is the Virgin Bus (hate that name but it’s unfortunately apt). There is however one thing that you can realistically count on. As with TWA800, Valujet 592 and Silkair (amongst others) nothing will occur very fast. When it does it will be a compromise and there will be no mention of Kapton as the actual culprit, faulty check-listing, missing Flt Eng’s nor dopey simulator drills. The STC for the IFE will get a mention in some minor admin capacity and crews will be exhorted to land ASAP when they smell smoke. EVAS will be rejected for the same old reason – cost of training flight-crews (but it could be done in the sim). Passenger insecurity is an ephemeral thing. Like lambs to the slaughter they will innocently assume that whatever needed to be done was done – they don’t know what you and I know. The litigants will argue endlessly about fault and responsibility and negligence, but at the end of the day what goes on behind closed court-room doors won’t be relevant to aviation in the next millenium. The underwriter’s actuaries will rule off their ledgers, tot up the cost and divide by the next statistically assured accident - then adjust their premiums.

We have no CVR, DFDR to know/understand what has been going on in that cockpit during the first 10 minutes after pan-pan-pan. What we have is the ATC transcript and TSB's announcement 'that the flight crew responded calmly and professionally'. Well, maybe too calmly... I figured out that their descent rate was so 'regular' that I couldn't believe it. I think because of their priority to dump fuel. Dumping fuel takes a lot of time. Too long for the fire on hand. This cannot be an eye-opener???!!!!

Dumping fuel is the logical thing to do if you’re going to land a partially disabled bird on an unfamiliar runway (no thrust reversers/no antiskid/slats out/short of cockpit lighting/no landing lights/no ILS?). It would rapidly slip down the list of "things to do today" if the situation suddenly turned to worms. Let’s not forget that they had a minor problem and were sanely doing the correct SOP thing when it became a bigger problem (and they duly upgraded it to a full emergency/land immediately). Shortly thereafter it got bigger than both of them. We could surmise about what might have been possible if an engineer had been there to do his part but that would be just surmise and speculation. However I can tell you that, with my old F.E.’s, I could simply have said: "See to that will you ENG" and I would have had full confidence that he would have done what needed to be done –including ripping away cabin lining to expose the facts, pulling CB’s and attacking the flames with a hand-held – whilst keeping me informed and making sage recommendations). That’s real CRM.

So, on my part, NO accusations, but MANY questions. Post-mortem or not: 227 souls NOT on the stick ALSO lost their lives. What was

THEIR yardstick? Pray!!!

Regards

Art der van Wald

Here follows the response from AVIATOR:

Art, you're not going to believe this but I just let my feelings shoot out. I just made a post at Yahoo telling it like I saw it. Im sure my friend Stuart Allsop will be mighty mad. Art, that crew stumbled and bumbled its way through that incident that only by the grace of god did they even make 10.000ft. That aircraft like you said could easily show 6000fpm. In fact, at Stuart's web site it clearly shows their rate starting out at 4000fpm and shallowing all the way down. He never even held 4000fpm for more than a few minutes. As far as declaring an emergency, damn, any smoke to me is a damn emergency. You wouldnt believe how fast I’d be getting light and getting down. Like I told Stuart but he refuses to believe me, forget the damn book. Forget what the numbers say I can do. Im going to squeeze every ounce of performance out of that airframe. When these aircraft are designed and tested, they are designed to withstand dozens of times the force of book listed loads. The wing on the 777 can withstand 120 times design load. I just dont believe he couldnt have done better than he did.

I don’t disagree – but you’ve got to have justification for precipitate non-SOP action. A professional just cannot go off aerobatically half-cocked at the first sign of a puzzling malfunction. (and I don’t believe 120 times design load by the way – that’s an over-the-top exaggeration –and irrelevant). Let’s take a few lessons from Ed Block about sanguinary, pertinent and immutable fact. Rossco Coulthart told me after his Stateside media foray that he was most impressed with Block because he talked in irrefutable facts. If I was a KLM honcho, that Ader, is what I’d be interested in –wholly and solely. You’re wasting your time if you appeal to anything but commonsense and come armed with other than facts and informed (but acknowledged) speculation. And that must be based on a firm foundation of developed argument.

It was almost as if they were afraid to stress the airframe at all. I understand they were heavy but they should have been lightening that load from the second they saw visible smoke.

I agree that holding the fuel dump until overwater was not a brilliant move. I’m not sure exactly when in the time-line they actually saw (and not just smelt) smoke.

Forget pan pan, Art, if I may be blunt, pan pan doesn't mean a shit. Its like asking for priority. It has no value other than to alert a controller that you have an uncertain non life threatening situation.

See: responses.html

under "Manage Your Outcomes"

Hell, smoke? visible smoke? That E word is going to fly out of my mouth. Smoke is not an uncertain situation, it's a potential disaster. It signifies an uncertain situation. A situation which is not endangering the aircraft and it provides radio silence by other aircraft. I have read reports where they smelled smoke not 5 mins after departing JFK. I want to know why he didn't remain in the area to dump and get back into JFK if that report is true. ??

Haven’t heard that one at all

Anyway, I'm going to go enjoy your email and answer you as soon as possible.

Kevin

For my INFO could I have the URL’s of "Stuart’s web-site" and the particular YAHOO Board (mentioned above). Or is it the families’ board?

Hope all the above is helpful. After all it was addressed to me and I never feel afraid to stick my neck out. Feel free to lop it off - but proceed with caution. FACTS almost rhymes with AXE.

IASA