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General Aviation Safety
On 5/11/96, about 1415 eastern daylight time, a McDonnell Douglas DC-9-32 crashed into the everglades swamp shortly after takeoff from Miami International Airport, Miami Florida, the airplane, N904VJ, was operated by ValuJet Airlines, Inc., as ValuJet flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. Visual meteorological conditions existed in the Miami area at the time of the takeoff. The destination of the flight was Hartsfield International Airport, Atlanta, Georgia. Flight 592 was on an instrument flight rules flight plan.
TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the usefulness and effectiveness of the Douglas DC-9 procedures involving the partial opening of cabin doors and similar procedures adopted by some operators of other transport-category airplanes for evacuating cabin smoke or fumes and, based on that evaluation, determine whether these or other procedures should be included in all manufacturers' airplane flight manuals and air carrier operating manuals.
Original recommendation transmittal letter:
Closed - Acceptable Action
Miami, FL, United States
In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
BECAUSE THE FAA'S ACTIONS MEET THE INTENT OF A-97-63, IT IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."
Letter Mail Controlled 6/24/98 8:21:28 AM MC# 980700: The Federal Aviation Administration (FAA) completed its review of cabin smoke evacuation methods, including procedures for opening cabin doors and reconfiguration of ventilation systems. The current DC-9/MD-80 cabin smoke evacuation procedure was specifically referenced in this safety recommendation. This type of procedure could, in certain situations, remove smoke more efficiently than the existing ventilation system. All Boeing, McDonnell Douglas, and Lockheed operations manuals have procedures for evacuating cabin smoke. Most of the procedures involve reconfiguring the ventilation system rather than opening cabin doors. Although procedures that involve opening doors are available for some airplane models, many operators choose not to adopt them because they consider the procedures hazardous or impractical for their operation. The FAA believes that the inclusion of specific procedures should remain an option to the operator rather than a mandatory requirement. In evaluating whether the smoke removal procedures should be required, the FAA examined the effectiveness of the procedure against various smoke sources, including fires in accessible areas, such as the passenger cabin, and inaccessible areas, such as below the cabin, the crown, electronic equipment bays, and cargo compartments. However, regardless of which procedures operators adopt for smoke evacuation, the effectiveness of the procedures must be demonstrated, potential hazards in their use must be identified, and crewmembers must be trained to carry them out. Because cabin smoke evacuation procedures can introduce hazards, operators must have a program in place to identify which crewmember(s) will assess whether the procedures should be initiated, recognizing that the cockpit flightcrew will already be heavily tasked with diverting and landing the airplane. If a fire occurred due to a source in an accessible area, the presence of the fire would be quickly detected, and the fire could be extinguished using hand-held fire extinguishers. Although cabin smoke evacuation procedures may be desirable in this case to remove existing smoke, they probably would not be necessary to ensure the survivability of the passengers or airplane. If the fire source was in an inaccessible area, such as below the cabin, the crown, or cheek areas, smoke could conceivably enter the passenger cabin. Typically, the aircraft ventilation systems are designed to route cabin air downward, below the floor and out the aircraft. Although cabin smoke evacuation procedures could be used to evacuate this smoke, extra care would be needed to ensure that initiating the procedure will not make the situation worse. If it cannot be confirmed that the fire is extinguished, employing the procedures could possibly add oxygen to the fire or draw more smoke into the passenger area or flight deck. Although components in the electronic equipment bays may generate smoke, electronic bays are not considered fire hazards. To ensure that hazardous quantities of smoke from the electronic equipment bays do not reach occupied spaces of the airplane, the FAA requires smoke penetration resistance to be demonstrated for certification. The FAA requires cargo compartments to be designed to contain any fire that might develop and to stop hazardous quantities of smoke from cargo compartment fires from entering occupied areas of the airplane. The FAA issued its final rule to require all operators to convert Class D cargo compartments to Class C compartments, which incorporate fire detection and suppression systems. The FAA is satisfied that incorporation of the Class C features will prevent the production and migration of hazardous quantities of smoke into occupied areas of the airplane. In-flight opening of cabin doors for smoke evacuation could introduce unique hazards. Improperly disengaging the escape slide could result in an in-flight inflation. Failure to reactivate an escape slide prior to landing can result in evacuation delays. Cabin doors could be damaged if left open for landing, which would also delay evacuation. Some doors are mechanically or aerodynamically limited and cannot be opened in flight. The FAA regards the opening of doors in flight as an extreme measure to be taken only if other attempts to clear smoke fail, and the hazard due to the smoke is greater than the potential hazard of opening the door. The FAA believes that the primary effort should concentrate on fire prevention and suppression. The smoke penetration and evacuation procedures associated with the flight deck and smoke sources within the electronic bays, cargo compartments, and the flight deck undergo thorough evaluation and testing. The tests are also designed to demonstrate that smoke from these areas will not penetrate into passenger compartments to satisfy 14 CFR Parts 25.831(b) and (c), 25.855(h)(2), and 25.857(c)(3), (d)(2), and (e)(4). In 1991, Amendment 25-74 provided improved cabin fire protection for transport-category airplanes by requiring several fire protection features. This amendment added requirements for the following: lavatory smoke detector systems; automatic lavatory trash receptacle fire extinguishers; an increased number of hand-held fire extinguishers in the cabins of airplanes with passenger seating capacities greater than 200; better control on the hand-held fire extinguishing agent; and a requirement for hand-held fire extinguishers in each galley area. Amendment 25-83 provided improved flammability standards for materials used in the interiors of transport-category airplane cabins. I believe that the FAA has addressed this safety recommendation completely, and I plan no further action.
In 1975, the FAA conducted a test of this procedure in the DC-9-30 series airplane. It was determined that this procedure decreases the time it takes to evacuate smoke in the cabin than the time established through normal ventilation system procedures for this model. There are some specific concerns associated with a procedure for smoke evacuation by partial opening of cabin doors. The first is that evacuation of cabin smoke through this method by adding oxygen to the cabin introduces a potential to feed a fire. Therefore, an assessment would be necessary before mandating this procedure in other aircraft. Additionally, the procedure cannot be performed in conjunction with the cockpit smoke evacuation procedures. If it is determined that the procedure was viable for other airplanes, flight testing would have to be accomplished for each type airplane. Finally, this procedure would require an extensive revision to existing training programs for flightcrews and cabin attendants. The FAA will survey the industry to determine how many operators have a similar procedure available and to obtain information on the effectiveness of this procedure. The FAA plans to complete the survey by January 1998. I will keep the Board informed of the FAA's progress on this safety recommendation.
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