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APPENDIX 3 Do You Smell Smoke? Issues in the Design and Content of Checklists for Smoke, Fire and Fumes Barbara K. Burian, PhD SJSU at NASA Ames Research Center Barbara Burian directed the Emergency and Abnormal Situations (EAS) Study in the Human-Systems Integration Division (formerly the Human Factors Research and Technology Division) at NASA Ames Research Center. She is a Senior Research Associate with the San Jose State University and her work on EAS was funded by NASA’s Aviation Safety and Security Program. Abstract An in-flight smoke or fire event is an emergency unlike almost any other. The early cues for conditions such as air conditioning smoke or an electrical fire are often ambiguous and elusive. Crews may have very little time to determine if there really is smoke, fire, or fumes and if so, to locate the source and extinguish it. The checklists crews use for these conditions must help them respond quickly and effectively and must guide their decisions. This paper discusses three sets of issues in the design and content of checklists for in-flight smoke, fire, and fumes events. Introduction When a smoke, fire, or fumes (SFF) event occurs in-flight, time is the most precious resource crews have. Yet, at least some of this resource must be invested to determine if suspicious cues do in fact indicate smoke or fire, as cues are often ambiguous, especially for air conditioning, electrical and other non-alerted sources (i.e., SFF for which there are no aircraft detection systems). Also, false alarms occur frequently enough (e.g., Blake, 2000) to make crews want to have a definitive picture of their situation before committing to a diversion and emergency landing. When smoke or fire does occur, a cascading loss of systems is likely if it spreads, and the crews’ ability to respond effectively may become impaired (e.g., National Transportation Safety Board (NTSB), 1974; Transportation Safety Board (TSB) of Canada, 2003). Thus, rapid isolation and elimination of the ignition source are necessary to prevent the condition from escalating. However, timely decisions to divert and complete an emergency landing are also essential if the ignition source cannot be identified or if efforts to extinguish a fire are unsuccessful. The stress and workload of responding to these events is exceptionally high and unlike many other types of emergency or abnormal situations, the flight and cabin crews absolutely must communicate and co-ordinate their assessment and response. However, even the most rigorous joint training cannot realistically present crews with the full extent of the demands they will face when dealing with smoke, fire, and fumes in flight. Checklists are indispensable tools to guide crews’ decision-making and response when faced with multiple tasks during these high stress events. Checklist designers must carefully consider all essential tasks crews must perform and prioritise when those tasks are to be accomplished, given the wide range of potential SFF events: those that are easily identified, isolated and extinguished as well as those whose sources are unknown, hidden, and cannot be put out. Further, designers must determine the best way to help crews access the correct checklist quickly, especially when the crews may not be able to tell what kind of SFF they are dealing with. Designers must make sure that no bottlenecks exist within the checklists, especially given the time-criticality of many of these events, and must design the checklist to facilitate the high degree of communication and coordination that is needed between flight and cabin crews. Clearly, a wide variety of difficult issues face designers of checklists for in-flight SFF. Part of what makes responding to some of these issues so difficult is that they involve tradeoffs that require making choices that may conflict with each other. For example, toxic fumes and smoke can quickly enter a cockpit during a SFF event. Therefore, oxygen masks and goggles should be donned by a flight crew at the first sign of SFF; a delay in donning them may result in the crew realising they are needed when it is too late and the crew’s ability to function effectively has already become impaired (NTSB, 1998). On the other hand, oxygen masks can make communication difficult and goggles can restrict one’s vision; should donning such protective gear be required if the SFF event is unlikely to cause the flight crew difficulty (e.g., a burnt muffin in the back galley)? How does one write a checklist so that crews will be adequately protected when they need to be, but also not be unduly restrained when such equipment is unnecessary? This paper will examine SFF checklist design and content issues related to three areas: 1) accessing the correct checklist; 2) guidance to divert, descend, and complete an emergency landing; and 3) source identification, isolation, and elimination. The ways that these issues have been addressed in many current SFF checklists will be compared to newer approaches taken in an air carrier checklist and in a new SFF checklist template, proposed by an aviation industry ‘steering committee’ (Flight Safety Foundation, 2005) 1. Design tradeoffs that exist between some of the issues will also be addressed. The issues will be considered only as they relate to checklists for nonalerted, rather than alerted, SFF events. As stated earlier, non-alerted SFF are those for which no sensors, detectors, or alarms exist, other than the humans onboard the aircraft. They commonly include such events as air conditioning smoke or fumes; electrical smoke, fire, or fumes; galley fires; cabin fires; fluorescent light ballast smoke or fire; and fires of ‘an unknown origin’. Accessing the Correct Checklist Currently, when crews wish to complete a checklist for a SFF situation, they typically access a checklist that has been developed for a specific type of smoke, fire, or fumes, (e.g., Air Conditioning Smoke). Thus, crews are presented with a list of several different SFF checklists and they must first determine what type of SFF they have in order to select the proper checklist from the list. However, some cues for non-alerted events are often quite ambiguous and making a distinction between air conditioning, electrical, materials, fluorescent light ballast, dangerous goods (i.e., hazardous materials), or some other type of SFF can be quite difficult. Precious time is wasted if a crew completes a checklist for the wrong type of SFF. In response to these issues, a few air carriers (e.g., United Airlines) have independently developed a single integrated checklist to be used for multiple types of non-alerted SFF events. With such an integrated checklist, the time crews would initially spend trying to figure out which checklist to complete is actually spent by completing actions that have applicability for all types of non-alerted events. Similarly, the template developed by the steering committee, and proposed for industry-wide use, is for an integrated non-alerted SFF checklist. As can be seen in the template, which is included in this Appendix, the first 11 steps/Sections are to be accomplished irrespective of the specific type of SFF faced. Actions that are pertinent to specific types of SFF are grouped according to SFF type and appear in Sections 12, 13, and 14. Even though the template guides development of a single checklist to be used for multiple types of SFF events, crews may still be required to access more than one checklist during their response to such events. For example, the template calls for crews to refer to a separate Smoke Removal Checklist when necessary. (A template for the separate smoke removal checklist was not developed by the steering committee; manufacturers and/or air carriers are expected to FEBRUARY 2007 23
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