Air transportation safety investigation report A98H0003
Supporting technical information (STI)
Swissair MD-11 flight crew training
MD-11 aircraft training
The Swissair standard pilot training for the MD-11 was a six-week course conducted in Swiss German. The course was adopted from the McDonnell Douglas FAA-approved course.
The first week of the MD-11 training consisted of computer-based training and fixed-based simulator training with a technical instructor. Classroom time was scheduled with captains and first officers together for a question-and-answer session with the instructors.
The computer and simulator work continued in the second week. To ensure consistent instruction, only three instructors provided this training. During this week, pilots were instructed on the use of the MD-11 flight guidance system and on the need to operate as a crew. Students were expected to study flight procedures in order to be prepared for the simulator session when the instructor demonstrated normal operations. The philosophy used was to train the crew to a very high level of skill in normal procedures. Crews well-schooled and knowledgeable in normal procedures would be better prepared to handle the higher workload associated with abnormal procedures. Crews were also trained in procedures for abnormal situations, such as smoke of unknown origin in the cockpit.
Aircraft performance training was also scheduled during the second week.
Computer and simulator training continued in the third week, and the students practised door operations on a mock-up aircraft and hands-on training with fire extinguishers.
Ten full flight simulator sessions were provided in weeks four through six. Simulator sessions 1 to 7 were conducted by a simulator flight instructor. Simulator sessions 8, 9, and 10, which were the qualification sessions for pilots, were conducted by a flight instructor. Each session was approximately 3 hours, 30 minutes.
The syllabus for simulator sessions 8 and 9 was line-oriented flight training. The session 9 scenario involved departing from Hong Kong with a smoke of unknown origin emergency on take-off. The crew implemented the associated checklist and used the SMOKE ELEC/AIR selector; the syllabus is written so that the smoke clears at the 3/1 position. The session also included a cargo fire that necessitates an emergency descent and then landing, and an evacuation of the aircraft with an uncontrolled cargo fire. Session 10 is a standard line flight from Zurich to Geneva. The session deals with high-altitude training, with a focus on engine, fuel, and one-engine fire with fuel dumping.
None of the Swissair training scenarios included flight on the stand-by instruments only, nor is such training normally provided to crew of other airlines.
Emergency procedures training
Flight crew members receive the following yearly training on the emergency and safety equipment:
- Actual donning of the life jackets;
- Actual donning of the protective breathing equipment;
- Actual handling of fire extinguishers;
- Instruction on the location and use of all emergency and safety equipment.
Flight crew members receive the following training every three years on the emergency and safety equipment:
- Actual operation of all types of exits;
- Demonstration of the aircraft evacuation slides;
- Actual firefighting using equipment representative of that carried in the aircraft on an actual or simulated fire except that, with Halon extinguishers, an alternative method acceptable to the FOCA may be used;
- The effects of smoke in an enclosed area, and actual use of all relevant equipment in a simulated smoke-filled environment;
- Security procedures.
Although aircraft crew were trained to fight in-flight fires, there were no requirements that cabin and flight crew train together, or that they be trained to follow an integrated firefighting plan and checklist procedure. At the time of the occurrence, neither flight crew nor cabin crew were trained to fight in-flight fires in the cockpit, nor was such training provided in other airlines.
Swissair cabin crew training
During initial training, cabin crew received approximately 46 hours of emergency procedures training. Training methodologies included classroom training, computer-based training, and mock-ups and hands-on activities. Annual recurrent training included approximately eight hours of emergency procedures training.
Emergency procedures training did not include "rapid clean-up" drills in the event of a "prepared emergency." Generally speaking, Canadian and American air carriers do not include "rapid clean-up" drills in their emergency procedures training. As at Swissair, this topic is covered during classroom training.
Fire/Smoke emergency procedures
Initial, non-aircraft-specific fire/smoke training for cabin crew included
- the responsibilities of cabin crew to deal promptly with emergencies involving fire and smoke, including the importance of identifying the actual source of the fire;
- the importance of informing the flight crew immediately, as well as the specific actions necessary for coordination and assistance when fire or smoke is discovered;
- the necessity for frequent checking of potential fire risk areas, including toilets, and the associated smoke detectors;
- classification of fires, and the appropriate use of extinguishing agents and procedures for particular fire situations, the techniques of application of extinguishing agents, the consequences of misapplication, and use in confined spaces; and
- the general procedures of ground-based emergency services at aerodromes.
During initial aircraft-specific fire/smoke training, and during conversion training, each cabin crew member was given realistic and practical training in the use of all firefighting equipment, including protective clothing representative of that carried in the aircraft. The training required that each cabin crew member extinguish a fire characteristic of an aircraft interior fire and that each cabin crew member don and use protective breathing equipment in an enclosed, simulated smoke-filled environment.
During recurrent training, each cabin crew member received instruction in the location and handling of emergency equipment, including firefighting equipment and the donning of protective breathing equipment. Every third year, recurrent training included live firefighting as described in the previous paragraph.
Fire/smoke emergency procedures training received by cabin crew was restricted to a cabin environment. Mock-ups and drills simulated fire/smoke in the overhead bins, waste baskets, passenger seats, lavatories, and galleys. There were no mock-ups or drills simulating fire/smoke in cabin ceilings, attic spaces, other hidden areas, cockpit, or E&E bays. Flight crew trained together with cabin crew during fire/smoke drills.
Fire/smoke training for cabin crew did not address situations involving fire/smoke in the cockpit. Emergency procedures training personnel reported that, in the opinion of the operator, the fire/smoke training provided to cabin crew adequately prepared them to perform fire/smoke emergency duties in the cockpit.
As at Swissair, fire/smoke emergency procedures training for Canadian and American cabin crews does not include drills set in the cockpit.
Air traffic controller training
Basic emergency response training
Air traffic controllers must pass a Radiotelephone Operator's Restricted Certificate examination prior to being granted a licence. The Study Guide for the Radiotelephone Operator's Restricted Certificate (Aeronautical) (RIC-21) contains information on the meaning and use of distress and urgency communications.
Basic ATC training provided in the Nav Canada Training Institute provided information, in separate lesson plans, on the responsibilities of controllers in dealing with aircraft accidents, emergencies in general, other specific emergencies, and fuel dumps and emergency descents. In their emergency training, controllers are expected to use their best judgement in handling situations not specifically covered, because it is impossible to detail procedures for all emergency situations. Information provided reminds controllers that "when an emergency occurs, time is of the essence, so all questions must be clear and concise. In order to respond effectively, the controller must rely on the information that the pilot provides." The Canadian Aeronautical Information Publication, Part 6, "Rules of the Air and Air Traffic Services," provides the following information:
6.3.1 Declaration of Emergency
Whenever pilots are faced with an emergency situation, ATC expects the pilot to take whatever action is considered necessary. ATC will assist pilots in any way possible whenever an emergency is declared. Pilots are requested to advise ATC, as soon as it is practicable, of any deviations from IFR altitudes or route necessitated by an emergency situation in order that every effort can be made to minimize confliction with other aircraft.
Information in ATC MANOPS, and the basic training lesson plans used by the Nav Canada Training Institute, emphasized the separation requirements and administrative responsibilities of controllers. There was little or no coverage of pilot actions or of aircraft flight characteristics in the event of various contingencies. The enabling objectives for the Fuel Dump and Emergency Descent Lesson Plan were as follows:
- List information to be obtained from the aircraft.
- State the option to request a different track.
- State the procedures that the pilot should be encouraged to follow.
- State the minimum altitude and restriction.
- State the separation required from the fuel dumping area.
- State the procedures for "Fuel dumping warnings and completion messages."
- Describe emergency situations that can cause a risk of collision.
- State the procedures to be followed to have aircraft operate on either side of track.
The lesson plan also described the responsibility of the controller:
This fuel dumping constitutes an emergency situation and the pilot has the ultimate responsibility for the safety of the aircraft. Our job is to offer assistance and obtain information about the operation that could affect other traffic.
Continuation emergency response training
Nav Canada conducts annual refresher training for controllers on relevant topics. The Nav Canada Technical Training Division provided regional ATC schools with the 1998 master training plans. Two lesson plans covered emergency-response topics: the appropriate response to various pilot-initiated communications regarding hijacking, and the proper safety alert phraseology for altitude and traffic alert in accordance with ATC MANOPS.
Prior to the SR 111 occurrence there was no detailed training—either basic or continuation—covering the flight and operating requirements of modern aircraft during abnormal or emergency situations or the indications that controllers might expect to receive from such aircraft. Nav Canada distributed to regional training authorities, as part of its National ATC Refresher Training package for the 1999/2000 and 2000/2001 training years, one-day human factors training modules on communications and teamwork. Controllers received an additional day of training on emergency preparedness and response. For area and terminal controllers this training constituted a half day of classroom and a half day of simulation.
Pilots from Canada's major airlines agreed to speak to refresher groups on the subject of aircraft emergencies, what activities are occurring in the cockpit, and how ATC can best assist the crew.