In-Flight Fires Wreak Havoc With Systems Reliability

Air Safety Week, Sept 22, 2003

Issue: Mask design. Is emergency equipment optimally user-friendly in a time of high workload and stress, to include pilots who wear spectacles?

Highly stressful scenario

Case: B747-200 cargo flight, smoke in the cockpit and an altitude deviation.

Details: "Shortly after descending through 10,000 feet ... the FE [flight engineer] reported smoke in the cabin. Bluish-colored smoke was indeed evident ... the FE went briefly downstairs to make certain there was not a fire in the main cargo area. When the FE returned the FO and I were already using oxygen masks. I told the approach controller ... that I wanted the emergency equipment standing by. We received some delaying vectors as we were descending to the assigned 4,000 ft. [altitude], and there was considerable amounts of conversation both on the interphone within the cockpit, as well as with ATC. Jumping from one audio source to another (interphone button on the audio selector panel, then pushing the Com #1 button for ATC) was a significant factor, due to running emergency, approach and landing checklists, as well as normal commands and responses (flap selections, landing gear, etc), we leveled off at 4,000 ft. briefly but the PF [pilot flying] was hand-flying and inadvertently descended to 3,600 feet ... during a high workload time.

"On several occasions, I communicated on the 'wrong audio button' and may have used language on one occasion that was inappropriate for standard ATC communications.

"The altitude discrepancy was quickly corrected. I believe we also missed a heading assignment sometime during this high workload time frame.

"The difficulty of communicating with oxygen masks on, using at least 2 sources of audio, while performing normal, abnormal and emergency checklists under a highly stressful scenario of smoke and possibility of fire while airborne cannot be overemphasized."

Issues:

* Familiarization and acclimation training. Perhaps crews could regularly train for the real thing by using masks when not under the stress of an actual event.

* Is emergency equipment maximally user-friendly in a time of high workload and stress?

* Altitude bust a possible byproduct of 'task fixation' in the emergency.

'I missed it!'

Case: MD-11 has smoke in cockpit.

Details: "Smoke of unknown origin while in cruise. Emergency landing in Atlanta.

"When asked by the FO what to enter on the FMS [flight management system] fuel dump page, I responded with the default of 430K pounds (no change). However, I added that this would give us 80K pounds of fuel remaining. We were both on oxygen and my [audio] pick-up was weak unless I held it close to my lips. All the FO heard was the end of my statement, so he set 48,000 pounds in the dump window. I missed it! We landed 45,000 pounds overweight, but well within runway allowable, thanks to relief pilot, who caught error.

"Lesson: answer the question and keep it simple when in this type of situation. As in a lot of scenarios such as this, communications was a key factor in the outcome. Continued practice during simulator training working various abnormal situations with the oxygen masks on would be helpful."