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441 G St. N.W.

Washington, DC 20548

June 4, 2013

The Honorable John D. Rockefeller

Chairman

The Honorable John Thune

Ranking Member

Committee on Commerce, Science, and Transportation

United States Senate

The Honorable Bill Shuster

Chairman

The Honorable Nick J. Rahall, II

Ranking Member

Committee on Transportation and Infrastructure

United States House of Representatives

Subject: FAA Oversight of Procedures and Technologies to Prevent and Mitigate the Effects of 

Dense, Continuous Smoke in the Cockpit

The FAA Modernization and Reform Act of 20121 directed the Comptroller General of the United 

States to conduct a study on the effectiveness of the Federal Aviation Administration’s (FAA) 

oversight of the use of new technologies to prevent or mitigate the effects of dense, continuous 

smoke in the cockpit of commercial aircraft. FAA oversees these procedures and technologies 

as part of its mission to provide the safest, most efficient aerospace system. In the initial phase 

of our research, we determined that there was only one technology that was developed to 

specifically target dense, continuous smoke in the cockpit and that this type of event occurred 

so infrequently that it was not practical for us to evaluate the effectiveness of FAA’s oversight.

2

However, we were able to identify relevant procedures that are more broadly targeted—for 

instance, at smoke, fire, or fume events.3

 Consistent with the mandate, we gathered 

stakeholders’ views regarding the effectiveness of FAA’s oversight of these procedures and the 

technologies related to preventing or mitigating the effects of dense, continuous smoke in the 

cockpit.

 

1

Pub. L. No. 112-95, § 316, 126 Stat. 11, 69 (2012).

2

The National Transportation Safety Board and FAA identified no accidents or incidents, respectively, occurring from 

2002 through 2012, as involving dense, continuous smoke in the cockpit.

3

We limited our consideration of “commercial aircraft” to those airplanes flown by air carriers offering scheduled, 

commercial service and operating under 14 C.F.R. Part 121.These include operations typically involving turbojet 

airplanes or any airplane with a seating capacity of more than nine passenger seats or a maximum payload capacity 

of more than 7,500 pounds.
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After discussing this issue with your offices, we determined that the content and focus of this 

GAO study—how FAA oversees the limited number of procedures and technologies that 

prevent or mitigate the effects of dense, continuous smoke in the cockpit and stakeholders’ 

views on the effectiveness of that oversight—is fully responsive to the GAO mandate contained 

in Section 316 of the FAA Modernization and Reform Act. 

To identify how FAA oversees the use of relevant procedures and technologies, we reviewed 

FAA safety standards, guidance, and reports. To identify stakeholders’ views on the 

effectiveness of FAA’s oversight, we reviewed relevant National Transportation Safety Board 

(NTSB) recommendations and interviewed 15 stakeholders representing various sectors of the 

aviation community, including: officials from FAA and NTSB, representatives from pilots 

associations (Air Line Pilots Association and Coalition of Airline Pilots Associations), an air 

carrier trade association (Airlines for America), aircraft manufacturers (Boeing and Airbus), air 

carriers (United Parcel Service and JetBlue Airways), an aviation safety organization (Flight 

Safety Foundation), and a company that manufactures a device designed to mitigate the effects 

of dense, continuous smoke in the cockpit; and four aviation safety professionals. We selected 

these entities to represent a range of constituencies and perspectives. Safety professionals 

were identified based on conversations with other stakeholders. However, all stakeholders did 

not comment on the oversight of each identified procedure or technology. Moreover, their 

opinions are not generalizable to all aviation community stakeholders. To provide context for 

this study, we obtained the numbers of accidents and incidents from 2002 through 2012 that 

involved dense, continuous smoke in the cockpit identified by NTSB and FAA, respectively.4,5

We interviewed the agency officials who generated the requested analyses and reviewed official 

documentation that accompanied the analyses. We determined that these numbers were 

sufficiently reliable for the descriptive analyses used in this report. We conducted this 

performance audit from September 2012 through May 2013 in accordance with generally 

accepted government auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings 

and conclusions based on our audit objectives. We believe that the evidence obtained provides 

a reasonable basis for our findings and conclusions based on our audit objectives.

Generally, FAA oversees the safety of commercial aviation by setting safety standards and 

conducting a range of activities to ensure compliance with those standards. These activities 

include: certifying airplane design and production, inspecting air carriers’ and maintenance and 

repair facilities’ operations, and licensing pilots and other personnel. FAA also conducts 

investigations following accidents and incidents, or in response to an apparent or alleged 

violation, and monitors safety-related data voluntarily reported by air carriers, pilots, airplane 

and parts manufacturers, maintenance personnel, and others. With regard to dense, continuous 

smoke in the cockpit, FAA’s primary emphasis is on (1) preventing sources of ignition; 

(2) reducing the flammability of materials in the aircraft; (3) detecting and suppressing fires 

early; and (4) evacuating smoke from the cockpit.

 

4

NTSB investigates and reports on civil aviation accidents, which it defines as occurrences whereby a person suffers 

death or serious injury, or in which the aircraft receives substantial damage. FAA and NTSB also investigate aviation 

incidents, which NTSB defines as occurrences other than an accident associated with the operation of an aircraft that 

affects or could affect the safety of operations. 

5

Neither NTSB nor FAA tracks the occurrence of dense, continuous smoke, and a definitive determination could not 

be made for some events.
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In summary, FAA uses a variety of approaches, including certifying airplane design and

inspecting air carriers, to oversee procedures and technologies that prevent or mitigate the 

effects of dense, continuous smoke in the cockpit. In the course of our review, we identified five 

such procedures and technologies that FAA oversees. They are: 

• Evacuation of dense smoke from the cockpit—FAA’s certification standards for aircraft 

design include that smoke evacuation must be readily accomplished. Additionally, FAA’s 

guidelines state that airplane manufacturers may demonstrate compliance with this 

requirement by evacuating dense smoke from the cockpit within 3 minutes. The guidelines 

also recommend, but do not require, that manufacturers demonstrate the capability to 

evacuate continuously generated smoke from the cockpit. However, according to FAA, no 

manufacturer has yet chosen to demonstrate this capability.

• Protective breathing equipment for the flightcrew—FAA requires air carriers to provide

protective breathing equipment that protects the flightcrew from the effects of smoke. The 

equipment must supply breathing gas for at least 15 minutes, must allow the pilots to use 

communication equipment, and must be readily accessible by the pilot. FAA inspections of 

aircraft include checks of this equipment.

• Pilot training on emergency procedures—FAA requires air carriers’ pilot training programs to 

cover principles of emergency operations and emergency communications procedures. 

Specific to in-flight smoke and fire situations, FAA recommends that air carriers’ training 

programs ensure that flight crewmembers understand the potential effects of the airplane’s 

ventilation systems on hidden fires and that pilots practice planning for an immediate 

descent and landing at the nearest suitable airport. FAA approves air carriers’ training 

program curricula and conducts periodic inspections.

• Checklist to respond to smoke in the cockpit—FAA requires that an FAA-approved checklist 

that includes emergency procedures be provided by air carriers and used by their flight 

crewmembers. FAA conducts periodic inspections related to these requirements. In addition, 

FAA participated in an industry-led effort to develop a smoke, fire, and fumes checklist 

template and recommendations related to its use. FAA recommends, but does not require,

that an air carrier’s relevant parties (e.g., directors of safety and pilots) collaborate to 

consider applying these documents in their related checklists. 

• Emergency Vision Assurance System (EVAS)—EVAS consists of an inflatable transparent 

unit that provides the pilot with a “window” to view their instruments and out the windshield 

when there is dense, continuous smoke in the cockpit. FAA has approved the installation of 

the device for several models of commercial airplanes. FAA evaluated EVAS and concluded 

that EVAS does not provide a significant safety benefit and the potential benefits of EVAS do 

not warrant the costs that would be incurred by industry if FAA were to mandate installation 

because (1) dense, continuous smoke in the cockpit is a very rare event and (2) accidents in 

which dense, continuous smoke has occurred indicate that according to FAA, such scenarios 

“are likely to be catastrophic for reasons other than flightcrew visibility (e.g., loss of airplane 
Page 4 GAO-13-551R Smoke in the Cockpit

controllability, structural failure).” Further, dense, continuous smoke in the cockpit has only 

once been identified by NTSB as a cause of a commercial aviation accident.

6

 

For three of these procedures and technologies, the stakeholders we interviewed generally 

agreed that FAA’s oversight was effective or sufficient; for the remaining two, the stakeholders

had mixed views about the effectiveness of FAA’s oversight. The stakeholders generally agreed 

that FAA’s oversight of protective breathing equipment, pilot training, and cockpit checklists was 

effective. NTSB has made recommendations related to these procedures and technologies—for 

example, that FAA require air carriers to include, as the first step in their checklists, that flight 

crewmembers don their oxygen masks and verify that they are set to supply 100 percent oxygen 

(Recommendation A-11-91). FAA is in the process of responding to NTSB on these 

recommendations. With regard to FAA’s oversight of the evacuation of dense smoke from the 

cockpit and EVAS, stakeholders had mixed views. For instance, some stakeholders—including 

the manufacturer of EVAS—said that FAA should start requiring manufacturers to 

(1) demonstrate the capability to evacuate dense, continuous smoke from the cockpit or (2) 

install a device such as EVAS that would enable the pilot to continue to navigate the airplane 

with dense, continuous smoke in the cockpit. Other stakeholders said that FAA’s oversight 

related to smoke evacuation and EVAS was sufficient. They said that FAA should not require 

manufacturers to demonstrate the capability to evacuate dense, continuous smoke from the 

cockpit because such smoke occurs so infrequently. Stakeholders that said FAA’s oversight 

was sufficient generally agreed with its rationale for not mandating the installation of EVAS. See 

the enclosure for additional details of our findings. 

We provided DOT and NTSB with a draft of this report for their review and comment. DOT 

generally agreed with the report and NTSB provided technical comments that we incorporated 

as appropriate.

We are sending copies of this report to the appropriate congressional committees, the Secretary 

of Transportation, and the Chairman of NTSB. This report will also be available at no charge on 

the GAO website at http://www.gao.gov. Should you or your staff have questions concerning this 

report, please contact me at (202) 512-2834 or dillinghamg@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the last page of this report. 

Key contributors to this report were Heather MacLeod (Assistant Director), Melissa Bodeau, Russ 

Burnett, Leia Dickerson, David Goldstein, Bert Japikse, Josh Ormond, and Jessica Wintfeld.

Gerald L. Dillingham, Ph.D.

Director

Physical Infrastructure Issues

Enclosure

 

6

On November 3, 1973, Pan American World Airways, Inc., Clipper Flight 160, a Boeing 707-321C (N458PA) 

crashed at Logan International Airport, Boston, Massachusetts. NTSB determined that the probable cause of the 

accident was the presence of smoke, which was continuously generated and uncontrollable, in the cockpit. However, 

according to FAA, even under these conditions, the NTSB does not state that the airplane crashed because the crew 

could not see the ground or instruments. The airplane was on final approach when control problems related to loss of 

electrical power caused it to stall and impact the ground.
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Enclosure

Briefing Slides
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