Compendium of Complacency

Page numbers are those in the TSB’s SR 111 report

What was not being done or required before the accident:

• There was no regulatory requirement to install smoke barriers in passenger aircraft, or for such a barrier to meet a fire rating or fire blocking standard (p. 13).
• The MD-11 was not certified to conduct back-course approaches using the flight management system, FMS (p. 30).
• The flight data recorder (FDR) did not record individual air duct or zone temperatures, cabin smoke, lavatory smoke, parameters related to the in-flight entertainment system, or any system cues displayed on the system display control panel, or SDCP (p. 31 & 73).
• The cockpit voice recorder (CVR) had a 30-min. capacity. It met regulatory requirements based on 1960s technology (p. 75).
• Both recorders (FDR/CVR) were powered by the same source (p. 74).
• There was no provision for a self-contained, independent electrical power supply for standby communication and navigation, nor was this required by regulation (p. 31).
• In 1975, the FAA issued a notice of proposed rulemaking (NPRM) stating that for wire, the … requirement for smoke emission would be a value of 15 (maximum) within 20 minutes of the start of the test. Although expected to be adopted, the NPRM was terminated without affecting the existing rules (p. 41).
• The crew oxygen masks have a 6-ft. attachment line. Therefore, with the mask on, the first officer would not be able to reach any of the emergency equipment (p. 60).
• Prior to this occurrence, (air traffic) controllers did not receive basic or continuation training on aircraft in abnormal or emergency situations (p. 70).
• Quick access recorders (QARs), which capture far more information than FDRs, are not required by regulation. It is technically feasible to capture QAR information within the FDR crash protected environment (p. 76).
• The SR 111 cockpit was not equipped with an image recording device, nor was one required by regulation. New technology provides economical single-camera systems that can capture a 360� panoramic view of the cockpit (p. 76).
• The underwater locator beacon (ULB) attachments were damaged to the extent that they nearly became detached from the FDR and CVR. There is no requirement that the recorders be tested and certified with the ULBs attached (p. 78).
• Materials used in occupied areas had to be self extinguishing. No testing was required for toxicity. Less stringent flammability standards were applied to those materials used within the pressure vessel but outside the occupied areas. No requirement existed for these materials to be self-extinguishing. Therefore, many materials were certified even though they were flammable (p. 107).
• Testing during the investigation demonstrated that the flight crew oxygen system could fail in a high heat environment and accelerate a fire. Regulatory authorities have not explained how this oxygen system, using dissimilar metals (steel, aluminum) met the “fire protection and prevention” certification requirement. The same holds true for other materials that failed and exacerbated the SR 111 fire, such as the silicon elastomeric end caps on the air conditioning ducts (p. 293).
• Two blanket materials in the accident aircraft are widely used in the aviation industry, metalized polyethylene terephthalate (MPET) and metalized polyvinyl fluoride (MPVF). Both were approved based on FAA certification tests at the time. Between November 1993 and March 1999, seven known occurrences took place in which MPET and MPVF-covered insulation blankets had been ignited and propagated flame (p. 139).
• Under regulations in place at the time the MD-11 was certified, no requirement existed to determine whether a failure of any material would exacerbate a fire in progress. A premature breach of a certain system, such as oxygen, hydraulic and conditioned air, could exacerbate an in-flight fire (p. 144).
• Typically, the (FAA-required) systems safety analysis does not include an assessment of the system’s failure as a result of a fire in progress (p. 145).
• Training for use of the Smoke/Fumes of Unknown Origin Checklist was conducted in the simulator. To save simulator time, the simulated smoke was terminated when the pilots selected the first position on the selector. As was the industry norm, there was no simulator training for an ongoing fire (p. 161). Simulator training tended to reinforce a positive outcome to smoke- related events (p. 215).
• No specific training was provided for locating and suppressing fires in the cockpit or avionics compartment (p. 162).
• No specific training was provided on flying the aircraft using only standby instruments (p. 162).
• There was no specific training on the location of potential flammable material in the aircraft, especially in hidden areas (p. 162).
• There was no specific training regarding firefighting in the [cockpit] attic area [nor] specific training to the cabin crew about fighting a fire in the cockpit. Government regulations did not require it (p. 163).
• Regarding wire separation and routing, the regulation requires that a potential threat be minimized; it does not require that a potential threat be eliminated. The term “minimized” is not defined (p. 167).
• The adverse consequences of a circuit breaker (CB) reset may not be well understood. On Aug. 21, 2000, the FAA issued a bulletin on resetting circuit breakers in an attempt to standardize practices. This bulletin was only applicable to air carriers in scheduled operation with aircraft of 10 or more passenger seats or a payload of more than 7,500 lbs., and this bulletin’s expiration date was Oct. 31, 2001 (p. 170).
• There are no regulatory restrictions on the use of CBs as switches. As certified and installed, the original IFEN system did not incorporate an ON/OFF master switch (p. 171). (ASW note: the CB was used for this purpose.)

The paucity of progress since the accident:

• Europe’s Joint Aviation Authorities (JAA) require 2-hour CVR for all aircraft certified after April 1, 1998. The United States and Canada still only require a 30-min. CVR (p. 209).
• The FAA has yet to act on the recommendation for two combined FDR/CVR units with an independent back up power supply. Canada’s implementation timetable is linked to the FAA schedule (p. 265).
• Boom microphones [as opposed to cockpit area microphones] improve the clarity of the CVR information. Currently, there is no regulatory requirement for the use of boom microphones in all phases of flight (p. 210).
• There is no regulatory requirement that modern FDRs record QAR data (p. 210).
• Although it is technically feasible to do so, regulations do not require the recording of cockpit images (p. 210).
• Existing regulations do not require that underwater locator beacon attachments meet the same level of crash protection as other data recorder components (p. 210).
• No regulatory requirement exists for transport category aircraft to allow for a checklist procedure that de-powers all but essential electrical equipment for the purpose of eliminating a potential ignition source (p. 216).
• No regulatory requirement exists governing the length of time to complete checklists for odor/smoke events. The MD-11 checklist can take 30 minutes or more (p. 216-217).
• The proposed arc fault circuit breaker (AFCB) technology will improve arc detection, but the performance criteria do not limit the arc energy to a level below the ignition level of flammable materials. Such testing criteria have been established for residential AFCBs, but the draft requirements for aircraft AFCBs do not include such criteria (p. 224).
• Six power feed cables were routed together near the overhead switch panel in the accident aircraft. The regulations are such that minimum separation is needed only when a wire bundle contains essential system wires and heavy current-carrying cables (p. 225).
• The FAA still does not require more than the 60� flame test to certify wiring. A wire systems harmonization working group has been tasked to revise performance standards and tests (p. 281, 282).
• Controllers in Canada now receive refresher training on in-flight smoke and fire emergencies (p. 283).
• There is no indication that regulatory authorities will mandate the wholesale removal from existing aircraft of other flammable acoustic insulation materials that fail the radiant panel test. Therefore, known flammable materials will exist for decades in thousands of aircraft worldwide (p. 284).
• The board has yet to see significant industry-wide improvements … and is concerned that regulatory authorities and the aviation industry have not moved decisively to ensure that aircraft crews have adequate means to mitigate the risks posed by in-flight fire, by way of a comprehensive firefighting plan that includes procedures, equipment and training (p. 292).