Transportation Safety Board of Canada / Bureau de la sécurité des transports du Canada
Menu (access key: M)
Skip first menu (access key: 1)
TSB Reports

Éviter tous les menus (touche d'accès : 2)

Curve Graphic

SR 111 Investigation Report

Heading Graphic

Horizontal Line

2.6.1  In-Flight Firefighting

The training received by the crew of SR 111 was consistent with industry norms; however, it did not prepare them to recognize or combat the in-flight fire. Pilot training focused on eliminating the threat from smoke in the aircraft, whether from an air conditioning or electrical source, by using the checklists provided. It was not anticipated within the aviation industry that aircraft crews could be confronted with a fire in the attic area of an aircraft. Neither were crews trained to appreciate how quickly in-flight fires can develop into uncontrollable situations. Instead, simulator training tended to reinforce a positive outcome to smoke-related events; typically the actions taken by the pilots during the simulator exercise would result in the smoke quickly dissipating. Procedures and pilot training were typically based on the premise that potential ignition sources can be successfully dealt with by procedures that isolate the source. There was little emphasis on the possibility that a fire may have already started by the time smoke is detected, or that once a fire has started, it may not be isolated or eliminated by existing checklist procedures.

At the time of the SR 111 occurrence, there was an expectation within the industry that crews would be able to distinguish, with a high degree of certainty, between smoke emanating from an air conditioning source and smoke being generated by an electrical malfunction. At Swissair, it was felt that once the pilots had made this distinction, and they were certain that the source was related to air conditioning, it would be appropriate to select the Air Conditioning Smoke checklist. However, it is an invalid assumption that human sensory perception is capable of consistently differentiating between smoke initiated by an electrical source, by an air conditioning source, or by the by-products of the combustion of other materials.

Swissair flight crews trained together with cabin crews and met industry standards for dealing with readily accessible fires in the passenger cabin area, such as fires in galleys or lavatories. None of the firefighting training included firefighting in the cockpit, avionics compartment, or in hidden areas behind panels or above the cockpit or cabin ceiling area. In general, pilots are not expected to leave their flying duties to engage in firefighting outside the cockpit. This expectation is consistent with industry norms, which dictate that the cabin crew fight the fire so that the pilots can continue to fly the aircraft.

The flight crews were trained to react to emergencies with a measured response, commensurate with the perceived threat. The SR 111 pilots would be expected to react to the appearance of the smoke by completing the Power, Performance, Analysis, Action functions, and by developing and executing a plan of action based on their appreciation of the situation. Although this item was discussed and pointed out in the respective simulator training sessions, no specific training or direction was provided regarding the urgency of starting a checklist and confirming by all possible means the type and seriousness of a smoke or fumes event.

Cabin crews were trained to locate and extinguish in-flight fires, but their training was limited to those areas of the aircraft that are readily accessible. This training would not prepare cabin crew members for firefighting in the attic area or other hidden areas. Further, cabin crews were not specifically trained to fight fires in the cockpit or avionics compartment area.

Previous | Next

Horizontal Line
Updated: 2003-03-27

Back to the top

Important Notices