Issue Number 236
February 1999
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

"Where There's Smoke..." with a  Bottle Refracting Light a Burning a HoleA special report issued by the Flight Safety Foundation in 1994 noted that "aircraft fires are rare, but their prospect is terrifying." When such events do occur, crew and passengers often have only moments to escape toxic fumes and acrid smoke. (FSF Cabin Crew Safety, Vol. 28, No. 6 and Vol. 29, No. 1).

Some of the more common causes of inflight smoke and fumes reported to ASRS are hydraulic fluid leaks in air conditioning packs, and electrical shorts in cockpit instrumentation. But several ASRS reports describe highly unusual incidents involving inflight smoke and suspected fire. We begin with a First Officer whose thirst had nearly unquenchable consequences.

Other pilots may wish to follow our reporter's lead and consider adopting personal procedures to prevent such "pants on fire" experiences.

Flames in the Louvers

The Captain of a twin turboprop Beech 99 reports that he and his co-pilot followed emergency procedures to the letter when flames were spotted in the engine louvers during a cargo flight:

Return to LandThe pilot of a twin-engine General Aviation aircraft was on an IFR flight plan in instrument conditions when smoke filled the cockpit. Quick thinking and good resource utilization saved the day:

As a result of this incident, the reporter has adopted a procedure -- keeping close at hand the approach plates for the departure airport -- that is standard for many commercial operations, and recommended for any pilot flying in actual instrument conditions.

Preparation for Medical EmergenciesA Captain reports to ASRS that he has adopted a new type of personal checklist following an inflight medical emergency:

If the crew had filled out the aircraft logbook with a notation regarding the emergency items, the Emergency Medical Kit and portable oxygen bottles might have been replenished at the diversion location before the flight continued. This reporter's company and others might also consider implementing a procedure for company dispatchers to follow when an aircraft diverts for a medical emergency. In the meantime, the reporter's idea of a diversion checklist is a good one.

"A Case or Cursed Cuisine" with a Guy Turning Green In Front of a Plate of FoodA First Officer's experience with inflight illness underscores the wisdom of policies in place at many airlines that prohibit flight crews from eating the same meals during a flight or on layovers.

We hope that all flight crews will take our reporter's warning to heart, along with the additional thought that special precautions against food poisoning need to be taken by those flying overwater routes. Ill crew members cannot easily be replaced once an aircraft is mid-Pacific or mid-Atlantic.

Going for the Green

An air carrier Captain prefaces his report of a runway incursion by noting, "Follow the Yellow Brick Road -- or in this case, the inlaid green taxi centerline lights -- and you may not get to the Emerald City, or to the correct runway either."

The reporter fell into two traps -- assuming that his aircraft was intended to follow the green taxi centerline lights, and that they would lead him to the desired runway. In this instance, one or both of these assumptions turned out to be incorrect. The First Officer's concern about the taxi route should have been a heads-up to the crew to contact Ground Control for clarification.

ASRS Recently Issued Alerts On...
FK-10 stabilizer trim failure attributed to tail icing
Cessna 210 engine seizure attributed to a broken crankshaft
L-1011 system failure warnings caused by cockpit electrical fire
B-727 jammed aileron due to autopilot aileron servo malfunction
Autoflight disconnects attributed to a passenger's hearing aid
December 1998 Report Intake
 Air Carrier/Air Taxi Pilots 1,895
 General Aviation Pilots 604
 Controllers 75
 Cabin/Mechanics/Military/Other 165
 TOTAL 2,739