Checklists for Un-alerted Smoke, Fire, or Fumes - 6/14/2016

Barbara Burian

It is hard to believe that when pilots smelled something burning during flight but nothing was being alerted, they used to have to first determine or guess at the likely cause or origin - Electrical?  Air conditioning?  Galley?  Lavatory? - before determining the correct checklist to access and actions to take.  The Swissair 111 accident and others involving un-alerted smoke, fire, and fumes (SFF) brought home how impractical, inefficient, and adverse such an expectation could be.  Representatives from across the aviation industry came together about 11 years ago and developed a new approach for responding to these events - one codified in a checklist template, patterned after checklists developed at United Airlines, and published by the Flight Safety Foundation.

In this new approach, checklist actions for all (or most) un-alerted SFF events are integrated into a single checklist.  It starts with a reminder that a diversion may be necessary and then, after completing standard crew protection items (masks and goggles ON), pilots complete a set of initial actions designed to eliminate the most likely sources of SFF on that aircraft type WITHOUT analysis - no lengthy troubleshooting at this point – just turn them OFF!  The template then continues with an assessment of the situation: were the initial actions successful?  Depending upon the answer pilots are directed to do different things; if unsuccessful, they will find themselves doing a more in-depth set of actions by aircraft system/type of un-alerted SFF in sequence.  The template also includes guidance for what to do if landing is imminent, completing smoke removal checklists, and various operational considerations such as completing an overweight landing.

This checklist template is a major improvement, but to what extent is it actually being followed?  Adherence to the template guidance is voluntary.  Dr. Burian, who provided feedback on the template during its development, investigated the extent to which airlines are now following the template guidance.  She also analyzed other characteristics of the checklist, such as their lengths and font sizes used. In her analysis of the checklists in 11 Quick Reference Handbooks, she found general adoption of most template guidance; 10 provided a single checklist that integrated actions for multiple types of un-alerted SFFs and included actions to take right away to eliminate the most likely suspects of SFF without prior pilot analysis.  However, she identified some notable exceptions.  For example, none of the checklists analyzed included actions to take when landing is imminent as suggested by the template.  Furthermore, several of the checklists could be quite lengthy to complete for some types of SFF events and only three of the 11 specifically addressed SFF of an unknown origin.

Some of the results of this study were recently published in the May 2016 edition of Flight Safety Foundation’s AeroSafety World and the complete study upon which the article was based is available below.

Burian, B.K. (2016). Integrated Checklists for un-alerted smoke, fire, and fumes: Adherence to guidance from the industry. NASA Technical Memorandum (NASA TM-2016-219109) Moffett Field, CA: NASA Ames Research Center.
 

** Questions/Comments?? **

If you have any Questions or Comments regarding this Article, send us your Comments.