In-Flight Fires Wreak Havoc With Systems Reliability

Air Safety Week, Sept 22, 2003

Issues:

* Recall the military aphorism to train like you fight and fight like you've trained.

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

'No company procedure'

Case: A310 cargo flight with a malfunctioning transformer rectifier on #2 engine producing smoke.

Details: "I was the captain. Departed Memphis. Climbing through 13,000 feet, we heard a 'pop' and the FO's instrument panel went blank for about 2-3 seconds, then returned to normal. The R-hand ECAM indicated a DC electrical advisory. The transformer rectifier #2 indicated 30 volts and 0 amps. There is no company procedure for this situation. Approximately 5 seconds later, we smelled burning electrical fumes. Went on oxygen, declared an emergency for return to Memphis. The 250-knot speed limitation was surpassed due to the emergency.

"[After landing] company flight safety personnel interrupted us as we were attempting to complete our duties while completing the maintenance logbook. We were given a new flight release and told that the airplane next door would be ready soon.

"Overall recommendations: 1) crew be permitted to finish their duties and get appropriate medical attention as required ... 2) the airplane was equipped with the old style oxygen masks and goggles. The mask covers the entire nose and my glasses do not fit correctly, making it difficult to see. I had my arms and hands at all angles trying to focus on the little print on the approach charts. I strongly recommend that all aircraft be outfitted with the full-face oxygen masks ASAP.

"Call back conversation: The PIC [pilot in command] further stated that the position of the smoke masks hampered their attempt to don it. The A300 masks are located by the pilot's knee but the A310's masks are on the side behind the pilot, making it difficult to obtain. The transformer rectifier had 'fried itself' after a maintenance review. The maintenance person said that 'there was nothing you could do' in these cases and that is why there is not a checklist procedure outlining steps for a problematic transformer rectifier. Reference may be made to this anomaly within the miscellaneous section of 'cautions' in the flight handbook. The person interrupting maintenance debrief and [interrupting] the PIC was a new safety person that was on his first assignment and was acting in an over-eager way. At last contact, the PIC was told [by the company] 'they are working on the problem of mask design."

Issues:

* The absence of a specific company procedure may be typical of cascading electrical failure scenarios.

* Momentary or permanent loss of instruments also can attend a cascading electrical failure.

* Crew was hampered visually by ill-fitting smoke goggles.

* Note inexperienced ground personnel, a trend that may continue as cashstrapped airlines opt for greater use of contract ground crews. Aircrews in an emergency cannot assume that ground personnel are experienced.

'Misled by smoke'

Case: Canadair regional jet crew reported dense cabin smoke just after takeoff.