DC-10 In-flight Fire – Newburgh, New York – September 5, 1996
• The FE skipped two steps on the second checklist he completed:
CABIN/CARGO SMOKE LIGHT ILLUMINATED
• CA requested a descent and diversion 3 ½ minutes after the
warning light illuminated
DC-10 In-flight Fire – Newburgh, New York – September 5, 1996
• The crew did not complete the Evacuation Checklist
• Upon landing, the aircraft was still partially pressurized and the
crew’s evacuation of the aircraft was impeded and delayed
• The emergency descent checklist was not called for or completed
DC-10 In-flight Fire – Newburgh, New York – September 5, 1996
• The CA was very busy:
− Monitoring the spread of the fire
− Communicating with ATC
− Trying to coordinate their diversion and emergency descent
− Monitoring the flying pilot (FO)
− Concerned with testing the fire detection system
− Interactions with the FE
The CA showed signs of being overloaded:
− Emergency descent was delayed
− Never called for any checklists to be completed
− Did not adequately monitor the FE’s completion of checklists
− Mistakenly transmitted his remarks to the crew over the ATC
frequency
DC-10 In-flight Fire – Newburgh, New York – September 5, 1996
• The FE was very busy:
− Selecting and completing emergency checklists and procedures
− Trying to determine data and Vref speeds needed for landing
− Completing normal approach and landing checklists
− Monitoring the progress of the fire
− Working with the CA to test the fire detection system
The FE showed signs of being overloaded:
− Missed items on checklists
− Five times over the span of almost six minutes, he asked for
the 3-letter identifier of the airport they were diverting to
− Did not adequately monitor the status of the aircraft
pressurization
The…events took place over a time span of less than 4
minutes during a critical phase of flight…the events
occurred simultaneously with radio transmissions,
configuration changes, airspeed changes and constantly
changing altitude…
What we learned from this event is that running the
emergency checklists may not be a classical situation
where one has plenty of time for analysis and application
of curative measures.
ASRS Report – Accession Number 437830
During approach…the gear failed to come
down…after notifying the tower we had a ‘Gear
Indication Problem’…
The QRH procedure…requires cycling the gear
handle…after 4 or 5 attempts the landing gear came
down…
ASRS Report – Accession Number 426768
We were told to execute a left 360 degree turn. We
questioned this with the controller, but he said it was
necessary for separation. We reluctantly complied since
we did not have a need to land immediately. I felt that
this was not acceptable, as we were an emergency.
ASRS Report – Accession Number 433902
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Broad, Over-arching Issues
15 Different Categories of Issues:
Selected Emergency Equipment and Evacuation Issues
Issues Related to the Aircraft
Issues Related to Training
Issues Related to Humans
Issues Related to Checklists and Procedures
Critical Aircraft
Systems
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Automation
Issues
Issues Related to the Aircraft
Systems within flight protection envelopes, automated systems, etc.
Warnings, warning systems, and “warning overload”
What kinds of automation should be used and under what circumstances
and when should automation not be used?
Issues in reverting to manual flying, degradation in hand flying skills, etc.
MD-81 Dual Engine Failure – Gottrora, Sweden – December 27, 1991
• Despite the aircraft breaking into 3 pieces on landing, all 129 on
board survived
• Grey smoke filled the cockpit and the crew attempted an emergency
landing using only back-up instruments as the EFIS screens were blank
• 77 seconds into the flight both engines lost power
• The left engine surged 39 seconds later
• 25 seconds after departing Stockholm the right engine surged
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