Smok Aircraft

Smoke/Fire/Fumes
Industry Initiative
Barbara Holder, Ph. D. Bill McKenzie

Human Factors Specialist, Aviation Manager,
Manager, Flight
Flight Procedures
Procedures Flight
Flight Crew
Crew Operations
Operations
System Safety Boeing
Boeing Commercial
Commercial Airplanes
Airplanes
Boeing Commercial Airplanes
Captain Harold (Chip) Sieglinger Captain H.G. (Boomer) Bombardi
Chief Pilot, Flight Technical Services, Safety Representative, International Federation
Long Beach Division of Air Line Pilots'
Boeing Commercial Airplanes Associations (IFALPA)
Boeing is a trademark of Boeing Management Company.
Copyright © 2006 The Boeing Company. All rights reserved.
Overview
Smoke/Fire/Fumes industry Initiative
• Situation
• The challenge
• The process
• Results
• Next steps
Copyright © 2006 the Boeing Company McKenzie.2

The Situation

Situation
Smoke, fire, fumes events occur

daily in commercial aircraft

Situation: We Assume the Crew Can
Identify the Specific Situation...
No pilot has a certified nose
Electrical? Air
conditioning?
Captain, we
smell smoke
back here
Incoming information may be:
• Vague
• Incomplete
• Inaccurate
• Contradictory
Situation
There is a wide range of possible smoke,

fire, fumes sources and situations
“Wing fire” Everything in between “Oven smoke”

Situation
Manufacturer and
Customer checklists
vary widely in format
and content

Situation
• AC 120-80: In-Flight Fire Fighting

– Focused on cabin crew
– Driving change at carriers
– Insufficient flight crew guidance
• Air carriers are changing their checklists to:
– Meet AC 120-80 guidelines
– Improve crew performance
– Standardize across all fleets (Airbus/Boeing/...)

Situation
Interaction
• SFF outcomes result from the interaction of the situation,

checklist, flight crew characteristics
• Today there is no common approach to
managing this interaction
The Challenge

The Challenge
Provide the best possible crew

guidance for managing in-flight
smoke, fire, fumes (SFF) events

The Challenge
Provide a single integrated checklist that is:

• Usable across all non-alerted SFF events
• Usable by flight crews world-wide
• Unambiguous
• Easy to find

The Challenge
Provide a checklist with guidance that is “explicit”

• Common actions to perform regardless of source
• Crew Communication
• Timing for diversion and landing initiation
• Smoke/fumes removal
• Additional actions to do if smoke persists
• Loss in capability and operational consequences

The Challenge: Striking a Balance
Provide specific
guidance to the Every situation
flight crew is different

The Process

The Process

The Process: Initial Workshop
“Initial Workshop”
Data
28 people Each Stakeholder
Oct ‘04 Philosophy
provided
Checklist(s)
Airlines (IATA and four air carriers)

Pilots (IFALPA)
Manufactures
(Airbus, Boeing, Bombardier, Embraer)
Hosted by Bombardier in Montreal

The Process: Key Representatives
Some Key Industry Representatives for Airlines,
Pilots, and Manufacturers
• Captain H. G. (Boomer) Bombardi • Ronald Haughton

• James Burin • Barbara Holder, Ph. D.
• Mike Galusha • Captain Thomas Phillips
• Captain Jerry Gossner • Captain Klaus Walendy
• Peter Harrison • Captain Dave Young
• Captain Chip Sieglinger

The Process
The objectives of “Initial” meeting were to:

1. Review available data provided by participants
2. Develop an industry consensus on a philosophy for
flight crew response to the challenge of in-flight smoke,
fire, fumes events per the terms of reference
3. Develop a “generic” draft checklist template that
embodies the consensus philosophy

The Process: Terms of Reference
Checklist must address:

1. Source identification
2. Timing for descent and diversion initiation
3. Timing for “Smoke/fumes removal” versus
“Source identification”
4. Additional steps for cases when suitable airports are
distant and smoke persists
These four because they continue to be inconsistent

The Process
To scope our task, our focus was not about....

• Airplane design changes
• Crew training
• Ground coordination
• ATC coordination...etc.

The Process
Define a Define a Publish

Common Checklist new SFF
Philosophy Template Checklists
Establish
Establish
common
common
concept
concept
definitions
definitions

The Process: Industry Meetings
“Initial “Checklist
“Symposium”
Workshop” Meetings”
15
15 people
people
28
28 people
people
55+
55+ people
people
Airlines (IATA) Airlines (IATA)

Pilots (IFALPA) Pilots (IFALPA)
Manufactures Manufactures
(Boeing, Airbus, (Boeing, Airbus, + Regulators (FAA/JAA)
Bombardier, Embraer) Bombardier, Embraer)
+ Other agencies
(NTSB, TSB)
Oct 2004 Nov and Dec 2004 March 2005

The Results

The Results
Industry Recommendations
Concept Checklist
Philosophy Definitions Template

The Results
Standardized Procedures
• Standardized Procedures
• Common approach for manufacturers and operators
• Common pilot actions to be performed
(“non-alerted” events)
• Checklist template that addresses:
– Source identification
– Timing for diversion
– Smoke/fumes removal versus source identification
– Additional actions to identify source

The Results
Boeing Checklist Changes
A combined checklist
that addresses:
• Electrical Smoke
• Air Conditioning Smoke
• Cabin Smoke
• Fumes
• Smoke Removal is next
to Smoke/Fire/Fumes
checklist

The Results
Industry Working Together Process
1. Gathered key stakeholders with common problem

(manufactures / carriers / pilots)
2. Scoped the task to realistic goals
3. Established common underlying philosophy
and definitions
4. Coordinated with regulators and broader industry
5. Published results
– Flight Safety Foundation article
– AC120-80 (TBD)

Next Steps

Next Steps
Model Breakout Sessions
Concept Checklist
Request Feedback on Industry guidelines

Next Steps
Model Breakout Sessions
737 747 767/757 777 717 MD11
Request feedback on proposed

Smoke/Fire/Fumes checklists

Next Steps
Publish Boeing checklists in 2006 in

model block revision cycle

Funny Comments Heard at the Workshop
• I have pilots that operate in dumb mode. Maybe the

pilots at your airline are smart all the time, but mine
go into dumb mode.
• I just use a lizard eye while the copilot is trying to divert
• You can confirm the fire is out when you can put your
tongue on it
• A fire on your airplane may not be serious....but a fire
on my airplane is a serious fire
• I like to use the first officer as a canary
• There isn’t an emergency I can’t make worse

Funny Comments Heard at the Workshop
• For sure you can land an EMB 170 anywhere - unless

you are over the Amazon
• With all the IDGs out, I have more capability in this
airplane than in my 737-200 brand new
• Everybody’s confused
• In ditching training we were taught that each minute
of flying is a week of swimming
• If there is any doubt in my military mind, we’re diverting

Thank You

Attachments
• Cross Model Smoke Comparison

• Philosophy
• Definitions
• Template
• Template with Rationale

Cross-Model Smoke Source Comparison
Smoke Events 11/92 to 6/00
70% 70%
Electrical Air Conditioning Material
64%
51%
48%
45%
41%
Pressure 38%
Vessel
Smoke 31%
Sources 26%
21% 21%
16% 15% 14%

12%
7%
6%
4% 4% 4%
777 747-400 MD11/DC10 767 757 737 717/DC9

<---------- Complex Simpler ---------->
Concept Checklist

Philosophy
Smoke/Fire/Fumes Philosophy and Definitions
• This philosophy was derived by a collaborative group of

industry specialists representing aircraft manufacturers,
airlines/operators and professional pilot associations.
The philosophy was used to construct the Smoke/Fire/
Fumes Checklist Template.

Philosophy
General
• The entire crew must be part of the solution.
• For any smoke event, time is critical.
• The Smoke/Fire/Fumes Checklist Template:
– Addresses non-alerted smoke/fire/fumes events
(smoke/fire/fumes event not annunciated to the flight crew
by aircraft detection systems);
– Does not replace alerted checklists (e.g., cargo smoke)
or address multiple events;
– Includes considerations to support decisions for immediate
landing (an overweight landing, a tailwind landing, a ditching,
a forced off-airport landing, etc.); and,
– Systematically identifies and eliminates an unknown
smoke/fire/fumes source.
Philosophy
General (continued)
• Checklist authors should consider a large font for legibility of
checklist text in smoke conditions and when goggles are worn.
• At the beginning of a smoke/fire/fumes event, the crew should
consider all of the following:
– Protecting themselves (e.g., oxygen masks, smoke goggles);
– Communication (crew, air traffic control);
– Diversion; and,
– Assessing the smoke/fire/fumes situation and
available resources.

Philosophy
Initial Steps for Source Elimination
• Assume pilots may not always be able to accurately identify the
smoke source due to ambiguous cues, etc.
• Assume alerted-smoke-event checklists have been accomplished
but the smoke’s source may not have been eliminated.
• Rapid extinguishing/elimination of the source is the key to prevent
escalation of the event.
• Manufacturer’s initial steps that remove the most probable
smoke/fumes sources and reduce risk must be immediately
available to the crew. These steps should be determined by
model-specific historical data or analysis.
• Initial steps:
– Should be quick, simple and reversible;
– Will not make the situation worse or inhibit further assessment
of the situation; and,
– Do not require analysis by the crew.
Philosophy
Timing for Diversion/Landing
• Checklist authors should not design procedures that
delay diversion.
• Crews should anticipate diversion as soon as a
smoke/fire/fumes event occurs and should be reminded
in the checklist to consider a diversion.
• After the initial steps, the checklist should direct
diversion unless the smoke/fire/fumes source
is positively identified, confirmed to be extinguished
and smoke/fumes are dissipating.
• The crew should consider an immediate landing anytime
the situation cannot be controlled.

Philosophy
Smoke or Fumes Removal
• This decision must be made based upon the threat being
presented to the passengers or crew.
• Accomplish Smoke or Fumes Removal Checklist procedures
only after the fire has been extinguished or if the
smoke/fumes present the greatest threat.
• Smoke/fumes removal steps should be identified clearly as
removal steps and the checklist should be easily accessible
(e.g., modular, shaded, separate, standalone, etc.).
• The crew may need to be reminded to remove smoke/fumes.
• The crew should be directed to return to the
Smoke/Fire/Fumes Checklist after smoke/fumes removal if
the Smoke/Fire/Fumes Checklist was not completed.

Philosophy
Additional Steps for Source Elimination
• Additional steps aimed at source identification
and elimination:
– Are subsequent to the manufacturer’s initial steps
and the diversion decision;
– Are accomplished as time and conditions permit,
and should not delay landing; and,
– Are based on model-specific historical data
or analysis.
• The crew needs checklist guidance to systematically
isolate an unknown smoke/fire/fumes source.

Philosophy, Concept, Template
Concept Checklist

Concept Definitions
• Confirmed to be extinguished: The source is visually

confirmed to be extinguished. (You can “put your tongue
on it.”)
• Continued flight: Once a fire or a concentration of
smoke/fumes is detected, continuing the flight to the
planned destination is not recommended unless the
source of the smoke/fire/fumes is confirmed to be
extinguished and the smoke/fumes are dissipating.
• Diversion may be required: Establishes the mindset
that a diversion may be required.

Concept Definitions
• Land at the nearest suitable airport: Commence

diversion to the nearest suitable airport. The captain also
should evaluate the risk presented by conditions that may
affect safety of the passengers associated with the
approach, landing and post-landing.
• Landing is imminent: The airplane is close enough
to landing that the remaining time must be used to
prepare for approach and landing. Accomplishing further
smoke/fire/fumes-identification steps would delay landing.

Concept Definitions
• Land immediately: Proceed immediately to the nearest

landing site. Conditions have deteriorated and risks
associated with the approach, landing or post-landing are
exceeded by the risk of the on-board situation. “Immediate
landing” implies immediate diversion to a landing on a
runway; however, smoke/fire/fumes scenarios may be
severe enough that the captain should consider an
overweight landing, a tailwind landing, a ditching, a forced
off-airport landing, etc.
• Crew: For the purposes of this document, the term “crew”
includes all cabin crewmembers and flight crewmembers.

Philosophy, Concept, Template
Concept Checklist

Checklist Template

Checklist Template

Checklist Template With Rationale
Smoke/Fire/Fumes Checklist Template (With Rationale)
• This document describes the rationale for the proposed

in-flight Smoke/Fire/Fumes (SFF) Checklist Template
steps. The rationale includes the purpose of the step
and the reason for its sequential placement in the
checklist.

Checklist Template With Rationale (continued)
Protect the flight crew then assess the situation

1. Diversion may be required.
Rationale: This step establishes the mindset that a
diversion may be required. We use the word “may”
because the crew should not initiate a diversion before
a preliminary assessment of the immediate fire/source.
This step is placed at the beginning of the checklist
to establish immediately in the minds of the flight crew
a diversion may be required.

2. Oxygen Masks (If required) ………………………....ON, 100%

3. Smoke Goggles (If required) ………….………….................ON
Rationale: These steps protect the flight crew from smoke
inhalation and fume absorption. Oxygen masks are on at 100%
so O2 supply does not mix with smoke or fumes. Steps are early
in the checklist to ensure the cockpit crew is protected
immediately after smoke/fumes detection. Steps are separate
because they may be separate devices. The flight crew should
don oxygen masks anytime smoke/fumes are detected on the
flight deck. The trigger to don masks is the smoke not the
checklist. The steps are not recall nor are they required because
oxygen masks and smoke goggles may not be required for all
smoke events. We rely on cockpit crew judgment to decide when
to don the devices. The “if required” statement also permits
airlines to be flexible in training when to don the masks or to leave
the timing decisions to the cockpit crew’s discretion.
4. Crew and Cabin Communications ………………....Establish

Rationale: This step initiates timely coordination and
communication between the cabin and cockpit crew. The step is
placed after 2 and 3 to not delay donning of oxygen masks and
goggles if required. The communication with cabin crew is made
explicit in the step because the cabin crew is an important
resource for assisting the cockpit crew with source identification
and confirmation of elimination.
Source elimination steps
5. Manufacturer’s initial steps (1) …………..…….. Accomplish
Rationale: These steps quickly isolate probable ignition sources
based on historical fleet data or analysis. The cockpit crew is
expected to take action without delay and without assessment.
The steps are placed early in the checklist to immediately isolate
probable sources to reduce the risk of event escalation.
Smoke Removal Reminder

Anytime smoke or fumes become the greatest threat,
accomplish SMOKE OR FUMES REMOVAL checklist.
Rationale: Smoke removal should be accomplished only
when the smoke/fumes are the greatest threat or when the
source is confirmed extinguished. Smoke removal may
change the airflow and make the situation worse by fanning
an ignition source or it may mask the source. Smoke
removal steps must be clearly identified and be easy to find.
The removal steps may be left out of the checklist to keep
the checklist uncluttered and short.

6. Source is immediately obvious and can be
extinguished quickly:
If Yes …………….. Go to Step 7.
If No ……….………Go to Step 9.
Rationale: This step is an immediate assessment of the
source and situation without waiting for the effect of initial
actions. The crew must determine if the source is
extinguishable. The outcome of the assessment
is a decision to extinguish the
7. Extinguish the source.
If possible, remove power from affected equipment by
switch or circuit breaker on the flight deck or in the cabin.
Rationale: After source is identified, the crew should use
all available resources to actively extinguish the source.
This step comes after the source is identified.
8. Source is visually confirmed to be extinguished:
If Yes, Consider reversing manufacturer’s initial steps
……………Go to Step 17
If No………Go to Step 9
Rationale: The crew must confirm that the source is extinguished.
The outcome of the assessment is a decision the source is
extinguished or to continue the checklist. This step is placed early
in the checklist to prevent escalation of the event.
9. Remaining minimal essential manufacturer’s action
steps...........Accomplish
[These are steps that do not meet the “initial steps” criteria but are
probable sources] (2)
Rationale: Additional manufacturer action steps that do not meet
the “initial actions” criteria outlined in the SFF philosophy. For
example, steps that make the cabin dark or may interfere with
source identification. No further assessment should be made prior
to diversion.
10. Initiate a diversion to the nearest suitable airport while
continuing the checklist.
Rationale: The cockpit crew should not delay a diversion
if the source remains unknown or cannot be extinguished.
The step is placed here to get the airplane headed toward
a suitable airport.
Warning: If the SFF situation becomes unmanageable,
consider an immediate landing.
Rationale: The purpose of this warning is to remind
the crew an immediate landing may be required if the
situation deteriorates. The step is placed here after
the initial probable source elimination steps have been
accomplished, but before the additional source elimination
steps which may be lengthy.

Additional Source Elimination Steps
11. Landing is imminent:
If Yes …………….. Go to Step 16.
If No ……….………Go to Step 12.
Rationale: If landing is imminent, the crew should stop the
checklist and focus on landing the airplane without the added
workload and distraction of doing this checklist. This step is
placed here because all probable source isolation steps have
been accomplished.

12. XX system actions ………….. Accomplish
[Further actions to control/extinguish source.]
If dissipating ………………… Go to Step 16.
13. YY system actions ………….. Accomplish
14. ZZ system actions ………….. Accomplish
Rationale: Additional source identification and isolation guidance
may be required when the airplane is far from a suitable landing
site. These system steps are presented here to systematically
isolate an unknown source. These steps come late in the
checklist after a diversion was initiated because they may take
time. The sequence of these steps is determined by the greatest
hazard they pose to the airplane.
15. Smoke/fire/fumes continue after all system-related steps

are accomplished:
Consider Landing Immediately………Go to Step 16.
Rationale: This is the final assessment step in the
checklist. The outcome of the assessment is an
immediate landing or landing at a suitable airport
if the additional steps identified the source.

Follow-Up Actions
16. Review Operational Considerations.
Rationale: Operational considerations provide information
to support crew decision making. The cockpit crew may
need to be reminded to review considerations that may
affect continued flight operations and decisions. Operational
considerations may vary by airplane model and may be
lengthy so should be provided outside of the checklist.
17. Accomplish SMOKE OR FUMES REMOVAL checklist,
if required.
Rationale: This step reminds the cockpit crew to remove
smoke or fumes. This step is best accomplished after the
source has been isolated and extinguished.

18. Checklist complete.
Rationale: This step indicates there are no more steps in the checklist.
Operational Considerations:
These items appear after “checklist complete.” This area should be
used to list operational considerations, such as an overweight landing,
a tailwind landing, a ditching, a forced off-airport landing, etc.
Notes:
1. These aircraft-specific steps will be developed and inserted by the
aircraft manufacturer.
2. Bracketed text contains instructions/explanations for the checklist
author.
3. “XX”, “YY”, and “ZZ” are placeholders for the environmental control
system, electrical system, in-flight entertainment system and/or any
other systems identified by the aircraft manufacturer.

Smok Aircraft

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Smoke/Fire/Fumes

Barbara Holder, Ph. D. Bill McKenzie

Smoke/Fire/Fumes industry Initiative

Copyright © 2006 the Boeing Company McKenzie.2

Copyright © 2006 the Boeing Company McKenzie.3

Smoke, fire, fumes events occur

Copyright © 2006 the Boeing Company McKenzie.4

No pilot has a certified nose

There is a wide range of possible smoke,

“Wing fire” Everything in between “Oven smoke”

Copyright © 2006 the Boeing Company McKenzie.6

Copyright © 2006 the Boeing Company McKenzie.7

• AC 120-80: In-Flight Fire Fighting

Copyright © 2006 the Boeing Company McKenzie.8

• SFF outcomes result from the interaction of the situation,

Copyright © 2006 the Boeing Company McKenzie.10

Provide the best possible crew

Copyright © 2006 the Boeing Company McKenzie.11

Provide a single integrated checklist that is:

Copyright © 2006 the Boeing Company McKenzie.12

Provide a checklist with guidance that is “explicit”

Copyright © 2006 the Boeing Company McKenzie.13

Copyright © 2006 the Boeing Company McKenzie.14

Copyright © 2006 the Boeing Company McKenzie.15

Copyright © 2006 the Boeing Company McKenzie.16

Airlines (IATA and four air carriers)

Hosted by Bombardier in Montreal

Copyright © 2006 the Boeing Company McKenzie.17

• Captain H. G. (Boomer) Bombardi • Ronald Haughton

Copyright © 2006 the Boeing Company McKenzie.18

The objectives of “Initial” meeting were to:

Copyright © 2006 the Boeing Company McKenzie.19

Checklist must address:

Copyright © 2006 the Boeing Company McKenzie.20

To scope our task, our focus was not about....

Copyright © 2006 the Boeing Company McKenzie.21

Define a Define a Publish

Copyright © 2006 the Boeing Company McKenzie.22

Airlines (IATA) Airlines (IATA)

Oct 2004 Nov and Dec 2004 March 2005

Copyright © 2006 the Boeing Company McKenzie.24

Copyright © 2006 the Boeing Company McKenzie.25

Copyright © 2006 the Boeing Company McKenzie.26

Copyright © 2006 the Boeing Company McKenzie.27

1. Gathered key stakeholders with common problem

Copyright © 2006 the Boeing Company McKenzie.28

Copyright © 2006 the Boeing Company McKenzie.29

Request Feedback on Industry guidelines

Copyright © 2006 the Boeing Company McKenzie.30

737 747 767/757 777 717 MD11

Request feedback on proposed

Copyright © 2006 the Boeing Company McKenzie.31

Publish Boeing checklists in 2006 in

Copyright © 2006 the Boeing Company McKenzie.32

• I have pilots that operate in dumb mode. Maybe the

Copyright © 2006 the Boeing Company McKenzie.33

• For sure you can land an EMB 170 anywhere - unless

Copyright © 2006 the Boeing Company McKenzie.34

Copyright © 2006 the Boeing Company McKenzie.35

• Cross Model Smoke Comparison

Copyright © 2006 the Boeing Company McKenzie.36

16% 15% 14%

777 747-400 MD11/DC10 767 757 737 717/DC9