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SR 111 Investigation Report

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1.18.1  Swissair Training Flight Crew Flight Attendant Training Human Factors Training

Back to the top  Flight Crew  Aircraft Training (STI1-101)

Swissair pilots who transition to the MD-11 from other company aircraft were required to complete Swissair's standard six-week training course. The Swissair syllabus was adopted from the McDonnell Douglas, FAA-approved course. On these courses, captains and first officers were trained together, and there was a focus on the need to operate together as a crew.

As well as being trained to follow specific checklist procedures appropriate to the type of emergency, Swissair flight crews were trained to react to an emergency situation according to the following philosophy: Power, Performance, Analysis, Action. This sequence was designed to ensure the aircraft is configured appropriately, the situation is properly assessed from all perspectives, proper priorities are established, and appropriate outside resources are used as necessary.  Smoke/Fumes/Fire Training

During the Swissair standard six-week pilot training course for transitioning to the MD-11, procedures for smoke/fumes/fire were covered in classroom discussions and in simulator training. Pilots were instructed to don their full-face oxygen masks at the first sign of smoke because of the danger of inhaling toxic fumes. Donning the oxygen masks was considered a memory item; therefore, it was not included as an item in the written checklist. The decision about whether to commence an emergency descent was considered a flight crew judgment call based on their perception of the threat. Initiating an emergency descent was also considered a memory item and was not included in the written checklist.

The flight crews were taught to evaluate any emergency situation before starting a checklist. For smoke/fumes events, flight crews were taught that unless they were certain that the source of smoke/fumes was the air conditioning system, they were to use the Smoke/Fumes of Unknown Origin checklist (see Appendix C – Swissair Smoke/Fumes of Unknown Origin Checklist). If flight crews were certain that the source of smoke/fumes was the air conditioning system, they could use the Air Conditioning Smoke checklist (see Appendix B – Swissair Air Conditioning Smoke Checklist).

A decision about whether to initiate a diversion for a precautionary or emergency landing was to be based on best judgment, with consideration given to the nature of the perceived threat. The company General/Basics Flight Crew Manual stated the following:

If a flight cannot be made to the regular destination, a diversion must be made to the most suitable alternate aerodrome providing the best available operational and passenger handling service.

To best meet this stipulation, the first choice would be an airport with a Swissair or contracted handling agent, such as Boston. Halifax was also a suitable, approved en route airport for the diversion of Swissair MD-11s.

The General/Basics manual also stipulated the various conditions that would require the flight crew to land at the nearest emergency aerodrome. These conditions included the following fire- or smoke-related scenarios:

  • Any fire on board an aeroplane, including engine fire, if firefighting is not possible or ineffective; or
  • Persistent smoke of unknown origin.

The General/Basics manual defined an emergency aerodrome in the following way:

Emergency aerodrome in this context means an aerodrome where a safe landing for the respective type of aeroplane in the configuration can be made, disregarding repair facilities, or passenger handling, etc.

At Swissair, and throughout the aviation industry, it was generally accepted that human sensory perception can be used to help differentiate between air conditioning and electrical smoke/fumes. For example, smoke/fumes from an electrical event would be expected to be acrid, and cause irritation to the eyes and respiratory tract. This information might be supplemented by looking for other potential clues about the source of the smoke, such as the colour, intensity, and the location from which the smoke/fumes are emanating, and any associated aircraft system anomalies.

The human sense of smell is the most rudimentary and least understood of all the human senses, and the experience of various smells is a subjective phenomenon. Although the threshold concentrations required to detect many substances through smell are low,[87] humans are generally not good at identifying the specific source of a smell.[88] Although ability to identify odours has been shown to be augmented by other characteristics of the source of the odour (e.g., irritation, acridity, pungence),[89] this is unlikely to assist a crew in distinguishing between different types of smoke that are quite similar in this regard. In addition, an individual's ability to discriminate between odours has been shown to be affected by attentiveness, temporary medical states such as congestion, and temporary physical states such as hunger.[90] The odour and smoke that appeared in the SR 111 cockpit consisted of the by-products of combustion, but the limited cues available were perceived by the pilots as pointing to an air conditioning source.

Training for the use of the Smoke/Fumes of Unknown Origin Checklist was conducted in the simulator. During MD-11 transition training, all three positions of the SMOKE ELEC/AIR selector are exercised. Flight crews were required to examine which aircraft systems were and were not available at each selector position. Flight crews were instructed that it takes about five minutes to exchange 100 per cent of the air in the aircraft. This was intended to provide guidance regarding how long it might take to assess whether the selection of a particular position was leading to the dissipation of the smoke/fumes. The information about the air exchange time was not written in any manuals or checklists, including those supplied by the manufacturer.

One simulator training session involved a scenario in which a "smoke of unknown origin" emergency occurred on take-off. The flight crew was expected to follow the Smoke/Fumes of Unknown Origin Checklist and to use the SMOKE ELEC/AIR selector. To save simulator time, the simulated smoke was terminated when the pilots selected the first position of the selector. As was the industry norm, there was no simulator training for an ongoing fire. Therefore, the pilots were not exposed to the combination of fire-related effects, such as a deteriorating cockpit environment with decreased instrumentation. The same simulator session also included an uncontrolled cargo fire scenario. The flight crews were expected to complete an emergency descent, followed by a landing and evacuation.

No specific training was provided for locating and suppressing fires in the cockpit or avionics compartment. Such training was not required by regulations, nor was it common industry practice to provide it.

No specific training was provided on flying the aircraft using only the standby instruments; there is also no regulatory requirement for such training. Several operators of transport category aircraft were canvassed to determine whether they provided this training to their pilots; none did.

Consistent with industry norms, there was no specific training on the location of potential flammable material in the aircraft, specifically in the hidden areas. The absence of such training reflected the lack of knowledge within the industry about the presence of materials used in the construction of the aircraft that, although certified for use, could be ignited and propagate flame.  Back-Course Approaches

Although the FMS database in the MD-11 does not store approach guidance information for back-course approaches, this would not have precluded the SR 111 pilots from conducting a back-course instrument approach using autopilot tracking methods, or conducting an NDB approach to Runway 06 for which data is stored in the MD-11 FMS database.

Because Swissair crews flew scheduled flights into airports equipped with back-course approaches, procedures existed, and flight crews were trained, for conducting non-FMS back-course approaches. Swissair MD-11 flight crews are trained, as part of their simulator training program, to conduct back-course approaches into Dorval Airport in Montréal, Quebec. The first officer had received this training within the previous six months; the captain, being a qualified simulator instructor, was also familiar with back-course approaches.

To conduct any approach, the pilots would want to know detailed approach procedure information, which is normally obtained from a hard-copy approach chart. Alternatively, if the situation warranted, sufficient partial information could also be obtained by asking the ATS controller for specific information. When flying a back-course approach in the MD-11, the autopilot can be used to fly the approach in the track mode; however, the pilots use track mode and heading mode constantly in training and in line operations. Therefore, flying a back-course approach would require more flight crew input and constitute a higher crew workload than is involved in conducting FMS-directed instrument approaches for which information is provided in the MD-11 FMC database. Some MD-11 operators have decided not to establish procedures for back-course approaches.  Fuel Dumping

One simulator training session included an engine fire scenario that involved fuel dumping. As is normal industry practice, Swissair instructs its pilots that fuel dumping can be handled in two ways depending on the urgency: if the aircraft is in an emergency situation, fuel dumping can be initiated immediately and continued until shortly before landing; or if the situation and time permits, the aircraft can be flown to a designated fuel dumping area.

Back to the top  Flight Attendant Training (STI1-102)

All of the flight attendants on board SR 111 were trained in accordance with the approved Swissair training requirements that were based on, and in accordance with, the JAR OPS. This training included initial and recurrent training on firefighting. The syllabus for the training included the importance of identifying the source of a fire, location and handling of firefighting equipment, communicating with the cockpit, firefighting responsibilities, and proper techniques for firefighting including use of fire extinguishers.

There was no specific training regarding firefighting in the attic area, nor was there any training specific to accessing other areas within the pressurized portions of the aircraft that are not readily accessible. There was also no specific training provided to the cabin crew about fighting a fire in the cockpit. This was consistent with government regulations and industry standards.

Back to the top  Human Factors Training

Swissair provided human factors training, commonly referred to as cockpit (or crew) resource management (CRM), to flight crew and cabin crew. The training for the flight crew consisted of a biennial, two-day course. The cabin crew received a two-day course as part of the initial cabin crew training program; then during the yearly cabin crew recurrent training, one and a half hours were reserved for CRM. Prior to 1997, this course was taught separately to flight crews and cabin crews. In 1997, Swissair began including the M/C in the flight crew training for one of the days. Course topics include the following:

  • Communication;
  • Conflict resolution; and
  • Behaviour in emergencies.

In addition to the formal human factors training flight crews receive, Swissair employs a staff psychologist who is available for both flight and cabin crew to deal with personal matters or for any additional human factors information.

[87]    Guydon, A. C. (1987). Human Physiology and Mechanisms of Disease, 4th Ed. Philadelphia: Saunders and Co.

[88]    Desor, J. A. and Beauchamp, G. K. (1974). The Human Capacity to Transmit Olfactor Information. "Perception and Psychophysics," 16, 551–556. In: Kalat, J. W. (1992). Biological Psychology, 4th Ed. Belmont, California: Wadsworth.

[89]    Pansky, B., Allen, D. J. and Budd, C. G. (1988). Review of Neuroscience, 2nd Ed. New York: Macmillan.

[90]    Ibid.

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Updated: 2003-03-27

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