# Presentation: 024287

## Strategic Approach to Fire Safety16 November 2004

- Kendall Krieg
- Boeing Commercial Airplanes

**Notes:**
My Name is Kendall Krieg, Manager of Fire Safety at Boeing Commercial Airplanes.

Thanks for attending and participating in the presentation today. I believe you will find this information valuable in defining a new course for aviation fire safety.

Please hold questions to the end.

## U.S.A. and Canadian Operators Accident RatesHull Loss and/or Fatal accidents - Worldwide Commercial Jet Fleet - 1959 through 2003

- U.S.A. and Canadian Operators Accident RatesHull Loss and/or Fatal accidents - Worldwide Commercial Jet Fleet - 1959 through 2003

- Accident
- rate (accidents per
- million
- departures)

- 2003 STATISTICAL SUMMARY, MAY 2004

**Source: http://www.boeing.com/news/techissues/pdf/statsum.pdf**

-  Commercial jet transport has achieved significant improvements in safety in four decades, and has maintained a very low accident rate.

- 1 accident Worldwide
- (0.4 US) per Million
- departures

**Notes:**
In the ’50s, 60’s, 70’s the events were frequent. Therefore, safety action was apparent, relevant and responsive. 

Since the accident rate has been reduced so dramatically, accident data is no longer effective for strategic or prioritization direction. 

Instead, we need to shift priorities to daily events (that lead up to accidents) ... to have an effective and responsive strategic approach..

## Fire Safety Strategy Summary

- Similar to other accident causes, fire events were much more frequent in the early years of commercial jet aviation
- Many fire safety improvements have been adopted... cargo systems, seats, cabin materials, lavatories, insulation and so on
- Fire accidents have been reduced to a very low rate
- But today's fire safety strategy remains based on events from early in the history of jet transport
- _Proposed Strategic Focus_
- Focus on the _prevention_ of frequent ‘precursor’ events to enhance fire safety

**Notes:**
Fire safety has also improved significantly since the early years

The aviation industry has responded to smoke and fire related accidents with changes to enhance fire safety in cargo systems, seats, cabin materials, lavatories, insulation, and so on. Industry is now at a point where significant fire accidents have become very infrequent.

Since the accidents are at such a low rate, the data is not relevant to providing a proactive strategy.

Data from the frequent daily precursor events is a lot more effective and responsive at driving industry strategy for improving fire safety. The fire safety strategy should be built around eliminating the daily events that will reduce the overall probability of the major low frequency accidents.

Additionally, continuing to focus the fire strategy on the historic infrequent and unique events based post accident forensic objectives creates over-lapping mitigation that is counter-productive to global aviation safety.

## Timeline of Regulatory Change		- Materials Example

**1945**
**CAR 4B ****Cabin Materials**

**1988**
**CFR 25-66**
**CFR 121-198****Smoke Release**

**1986**
**CFR 25-60**
**CFR 121-202**
**Cargo Liners**** **

**1972**
**CFR 25-32****Cabin Materials**

**FIRE SAFETY REGULATION TIME LINE**

**2003**
**CFR 25-110**
**CFR 121-289**
**Insulation**

**1940**

**1967**
**CFR 25-15**
**CFR 121-30****Cabin Materials**

**1984**
**CFR 25-59**
**CFR 121-184****Seat Cushions**** **

**1986**
**CFR 25-61**
**CFR 121-189****Heat Release**

**Source: J. Peterson (Boeing) - modified**

* **Fire strategy historically based on prior events*

- 727
- Salt Lake

- L1011
- Riyadh

- MD11
- Peggy’s Cove

- 737
- Manchester

**Notes:**
This is the timeline of airplane material changes that have occurred over the last six decades.

727 – Salt Lake City, 1965
L1011 – Riyadh, 1980
737 -  Manchester, 1986
MD11 – Peggy’s Cove, 1998

Action has followed incidents.

## Frequent

- Rare

- Event
- Progress

- Increasing
- Impact

**Notes:**
This diagram represents the progression [enter], frequency [enter] and impact [enter] of fire and smoke events from bottom to top.

Any one of numerous small frequent events may progress into a significant event by progressing from an ignition source, igniting materials, propagating and then resulting in significant impact to the airplane.

## Counter Methods for Fire Events

- Ignition and Overheat Prevention

- Flammability Reduction

- Detectionand Suppression

- Procedures

- Proactive

- Reactive

-  Focus strategy on ‘proactive prevention’

**Source: K. Krieg/R. Nicholson/T. Porter  (Boeing)**

**Notes:**
Using the same diagram, [enter] these are the counter actions for the progression of fire events.

The bottom of the chart is Proactive and the top is Reactive [enter] to the fire event sequence.

[enter] Priority should be on the Proactive Prevention.

## Pressurized Compartment Industry Fire Safety Activities

- Flammability Reduction

- Detectionand Suppression

- Procedures

- Insulation Film Flammability

- Aging Wiring Research (complete)

- Reduced Flammability Hidden Materials
-  Wiring
-  Other Materials

- Smart Circuit Breaker Development

- Improved Crew Procedures

- Halon Replacement (*)
- Potty Bottles
- Hand-helds
- Cargo

- Component Overheat
- Protection (on-going)

- Accident Investigation
- Analysis,
- Recommendations
- Design Changes
- Procedure Changes
- Service Bulletins
- Airworthiness Directives
- Corrective Action

- Hidden Area Contamination and aging materials

- Detector- False Alarm
- Reduction Research

- Detection/Suppressionin Hidden Areas

- Insulation Burn-Through Resistance

- Improved Cabin Materials (low heat release)
- Consistency of test standards (Seats/OSU)

- Suppression in Cabin Area

- Brominated Fire Retardant (BFR) Reduction (*)

**Source: K. Krieg/R. Nicholson/T. Porter  (Boeing)**

- Focus, Priority, Effectiveness ... Strategy?

- Ignition and Overheat **Prevention**

- Enhanced Depowering

- (*) Note: Not safety enhancement, however common industry resources

**Notes:**
Using the same pyramid again, this is what industry is doing and/or considering [enter]

[enter] Is this Focus, Priority, Effectiveness ... a Strategy?

## Post Crash Fuel-Fed Fires

- Post Crash Fuel-Fed Fire

-  Accident **Prevention** through CAST

**Notes:**
Let’s talk about ‘Post Crash Fuel-Fed’ fires and accident prevention through CAST

Note: Europe similar approach to CAST is JSSI – Joint Safety Strategic Initiative

## Fatalities by Accident CategoryFatal Accidents - Worldwide Commercial Jet Fleet: 1994 - 2003

- Fatalities by Accident CategoryFatal Accidents - Worldwide Commercial Jet Fleet: 1994 - 2003

- 32

- 2

- 2

- 2

- 16

- 2

- 3

- 1

- 3

- 24

- 6

- 2

- 1

- 8

- Number of fatal accidents 105 total

**Note:**  Accidents involving multiple, non-onboard fatalities are included

- Accidents involving single, non-onboard fatalities are excluded
- Fatalities/accidents are placed in one category only.

- * CFIT = Controlled Flight Into Terrain
- ** RTO = Refused Takeoff

- Fatalities

- 1

- CFIT*

- In-flight
- fire

- Mid-air
- collision

- Fuel
- tank
- explosion

- Landing

- Takeoff
- configuration

- Fuel
- exhaustion

- Wind
- shear

- Runway
- incursion

- Loss of
- control in
- flight

- Unknown

- Turbulence

- RTO**

- Misc.
- fatality

- Total Fatalities = 6,795 (6,484 onboard)

- 2003 fatalities = 484 (483 onboard)

- Structure

- 103

- 2,131

- 121

- 1,701

- 420

- 339

- 231

- 225

- 85

- 192

- 121

- 37

- 29

- 12

- 3

- 2

- 1

- 258

- 502

- 2003 STATISTICAL SUMMARY, MAY 2004

- Post Crash Fuel-fed Fire(Potential)

**Notes:**
This chart represents the collection by cause of fatal accidents for the last ten years worldwide.

CFIT and ground events have been the primary causes for post crash Fuel-Fed fires.

Therefore, these root causes have the most potential impact on reducing post crash fuel-fed fire fatalities. [enter]

## In the U.S., our focus was set by theWhite House Commission on Aviation Safety

**1.1**** ****Government and industry should establish a national goal to reduce the aviation fatal accident rate by a **_**factor of five within ten years**_** and conduct safety research to support that goal**
**1.2****	****The FAA should develop **_**standards for continuous safety improvement**_**, and should **_**target its regulatory resources  based on**_** ****performance against those **_**standards**_

**Source: Safer Skies Briefing, 6/2003, K. Olsen (FAA)**

- In the U.S., our focus was set by theWhite House Commission on Aviation Safety

**Notes:**
In 1998, the FAA-led Commercial Aviation Safety Team (CAST) identified strategic items when implemented meet the 10-year goal to reduce the commercial aviation accident rate in the United States by 80 percent.

## The National Civic Aviation Review Commission (NCARC) on Aviation Safety Provided Additional Direction

**FAA and the aviation industry must develop a strategic plan to improve safety, with specific **_**priorities based on objective, quantitative analysis of safety information and data**_
**Government should expand on their programs to improve aviation safety in other parts of the world**

**Source: Safer Skies Briefing, 6/2003, K. Olsen (FAA)**

**Notes:**
Likewise, the NCARC (a.k.a. Norman Mineta report) provided additional similar direction.

(Optional) Additionally, the Federal Aviation Administration Technical Center, published a similar document "Aircraft Safety Research Plan", in November 1991 with similar conclusions. In fact, it went on to say that this level of improvement could not be obtained through accident mitigation. It could only be obtained by eliminating the accidents.

## Savings ~ $56/Flt. Cyc Or ~ $620 Million Dollars/Yr.

**Dollars/Flt. Cyc**

**Part 121 Aviation Industry Cost Due to Fatal/Hull Loss Accidents**

**100**

**80**

**60**

**40**

**20**

**0**

**Historic cost of accidents/flt. cyc**

**73 % Risk Reduction**

- Savings ~ $56/Flt. Cyc Or ~ $620 Million Dollars/Yr.

**Cost of Accident fatalities following implementation of the CAST plan @ 2007 levels**

- 2002

- 2007

- 1998

- Post Crash Fuel-fed Fire(Potential)

**Source: Safer Skies Briefing, 6/2003, K. Olsen (FAA)**

**Notes:**
As a result of efforts within the CAST plan, the root cause of the risk elements are being reduced systematically by 73 % by year 2007 in the United States.

Subsequently, there will be a substantial safety and economical benefit to industry.

## Hull Loss & Fatal Accidents  (U.S.)

**Hull Loss & Fatal Accidents  (U.S.)**

**Percentage of Total Fatality Risk Mitigated by the CAST  Plan**** **

**(2007 Implementation Values)**

** **

- Total

- LOC Flt

- CFIT

- Fire/Explosion

- Runway Collision

- LOC GND

- Midair

- Crew Inc

- Eng-UCEF

- Sys-Comp

- Turbulence

- Evac

**Percentage of Risk**

- Risk Eliminated

- Risk Remaining

- CAST 1987-2000 Fatal/Hull Loss Dataset –
- Security events excluded.

- Post Crash Fuel-fed Fire
- (Potential)

- LOC = Loss of control

**Notes:**
By reducing the risk in key areas, CAST is projecting significant reductions in the hull loss and fatal accidents in the U.S..

CFIT, Runway Collision, LOC on Ground risks are nearly eliminated within the U.S. ... as will be the post crash fires. [enter]

We now need to expand through ICAO (International Civil Aviation Organization) and other organizations worldwide. 

## In-Flight Hidden Fires

- In-flight Hidden Fires

** ****Prevention**

**Notes:**
Let’s discuss in-flight hidden fires

## In-Flight Hidden Fires

**Significant progress has been made in reducing major fire events.**
**Frequent small scale smoke and fire events continue to occur**
**Smaller events are ‘precursor’ to the very rare significant smoke/fire events**
**Industry addresses events based on single event diagnosis**
**Also, there are significant economic impact of small events due to air turn backs, diversions, and subsequent maintenance**
**A different approach based on ‘root cause’ criteria that focuses on prevention is now required to reduce risk of major fires and improves economics**
**Use the CAST ‘data driven’ process as a model for in-flight fires**
**Focus industry resources on global solutions, processes and tools to ****prevent small scale frequent fire and smoke events to reduce the risk of major events**

- In-flight Hidden Fires

**Notes:**
Major in-flight fires also occur at a very low rate.

The industry changes over the years have not significantly impacted the number of reported hidden smoke and fire events which continue to occur on commercial transport category airplanes. These occurrences can be considered precursor events to the more significant smoke/fire events and as such directly relate to the risk of smoke/fire accidents.

A data-driven diagnostic and prognostic approach focused in leading event criteria is needed. [enter]

What are the significant equipment types causing issues?
What are the changes occurring in industry that may increase or decrease the rate of in-flight fires?
What global solutions, practices and technologies would significantly reduce the events?

This type of approach will have a much bigger impact at reducing risk, the multiple small frequent hidden events and eliminating Air Turn Backs and Diversions.

## Smoke Event Sources for a RepresentativeAirplane Model – November 1992 through April 2001

**http://www.boeing.com/commercial/aeromagazine/aero_14/**

**Smoke Event Sources for a Representative****Airplane Model ****– November 1992 through April 2001**

**Environmental**
**Control System**

**Electrical Power**

**Galley**

**Wiring**

**IFE**

**No Data**

**Flight Deck Equip**

**Cargo**

**ECS**

**Inlet Air**

**Fuel/Hydraulic**

**Other**

**Maintenance**

**Lighting**

**APU**

**Window Heat/Heaters**

**Engine**

**Galley Contents**

**Smoking material**

- Electrical Source

- 64%

- Material Source

- 12%

- Air Conditioning Source

- 14%

- In-flight Hidden Fires

- Prime source of
- Small up to Significant
- Hidden In-flight Fires

**Notes:**
Boeing has investigated the root cause of smoke and fire events. The summary is included in the April 2001 Aero magazine, No. 14.

The blue (64%) portion of the pie represents the majority of the root causes of smaller events that may lead to significant in-flight fires.

## In-Flight Hidden Fire Event Sequence - Example

- In-flight Hidden Fires

**Notes:**
This diagram defines how an in-flight fire may progress from minimal to significant from left to right.

Moving to the right is the result. Move to the left depicts why the next step happened

The left side of the chart is where the industry has maximum safety leverage and economic opportunity [enter]

## Conclusions and Recommendations

**Post-Crash Fuel-Fed Fire**
-  Fire Safety Industry adopt and accept the CAST Risk Reduction plan for accident prevention.
- Worldwide implementation through ICAO and others
**In-Flight Hidden Fires**
** ****Fire Safety Industry Should Implement:**
- Improved maintenance practices and methods - ATSRAC
- Systems ‘over-current’ and ’over-heat’ protection (1)
- Non-Essential Equipment standards enhancement
- Aftermarket (STC) equipment installation standards enhancement
- Smart Circuit Breaker (arc fault/GFI) _with_ fault ID servicing tools (1)
- Contamination/Aging – Materials and Maintenance
**The UK AAIB advocates a similar approach:**
**Bulletin No: 6/2004, Dated 21 May 2004. (2)**

**(2)Source:**http://www.dft.gov.uk/stellent/groups/dft_avsafety/documents/page/dft_avsafety_029072.hcsp

- (1) Priority on non-critical systems

**Notes:**
For Post Crash Fuel-fed fires, the Fire Safety industry should:
Support the CAST approach to eliminate the risk of post-crash fuel fires. Expand worldwide through International Civil Aviation Organization (ICAO) and other organizations

For In-flight Hidden Fires:
Implement a new strategic and data driven approach targeted on improved maintenance, over-current, over-heat, ignition source reduction and contamination mitigation.
ATSRAC – Aging Transport Systems Rulemaking Advisory Committee

The June 2004 AAIB report draws a similar conclusion

Most importantly, industry RESOURCES should be re-focused in these areas with the highest priority

Boeing is focusing its fire safety strategy based on these priorities.

## Conclusions and Recommendations (cont’d)

- Recommend: Industry Strategic Steering Committee (CAST like) for all fire types:
- Industry working together to measurable common goals  (i.e. standards) to enhance safety
- Data Driven Process focused on Prevention
- Forensic:
- Identify and eliminate the historical risks
- Diagnostic
- Identify and eliminate the current risks
- Prognostic
- Forecast the future risks and design them out of the future
- Target resources and implementation process for maximum effective industry value
- Boeing supports and is ready to participate in industry team(s) based on PREVENTION.

**Notes:**
We need an industry led strategic steering team to define the opportunities and priorities for fire safety. This plan needs to be integrated with airplane level safety needs and resources (i.e. CAST resources to eliminate accidents should out-weigh post crash fire mitigation resources). 

For example, In-flight fires should focus on prevention using forensic, diagnostic and prognostic data to drive strategy [enter]

The team should always be looking ahead to understand issues that may negatively impact fire safety ... with action before incidents.

Finally, Boeing supports a fire safety strategy focused on prevention and a strategic data-based approach.

Thanks. Questions?

Examples, if needed: Space Shuttle Columbia: Foam events (diagnostic: prior to accident, forensic: post accident), IFE (prognostic for all new equipment)

## The Fourth Triennial International Aircraft Fire and Cabin Safety 

**The Fourth Triennial ****International Aircraft Fire and Cabin Safety **
**Research Conference**

**The Fourth Triennial ****International Aircraft Fire and Cabin Safety **
**Research Conference**