SMS Violation...
A Major Safety Lapse
Delta Flight: HNL to ATL
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The Crew:
The Delta captain was actually a first officer who was not senior enough to be a captain in real life, but he was allowed to fly as captain on this flight because was an Aircrew Pilot Designee (APD) in the simulator. One of the other two first officers was also an APD, who has since retired and is now back working as simulator instructor/Check Airman for Delta Professional Services (DPS).
The captain (alias first officer playing captain) was in the bunk at the time. The airplane was approximately over Salt Lake City when the laptop ignited. A lithium battery meltdown, not unlike United's on February 2023. The difference is that United turned around as they should, to ensure safety. Delta continued and kept this hidden from the public.
A flight attendant noticed smoke and a glow coming from an overhead bin on the right side of the aircraft above (approximately) rows 2-4. This quick-thinking flight attendant did not open the bin. Instead, she shot halon into the bin from the openings around the door/bin and extinguished the fire.
The captain returned from the bunk and retrieved the newly (less than a month) installed containment bag from the cabin. Unfortunately, he could not find the gloves. The gloves were stowed in the flight deck. The other first officers opened the flightdeck door and threw the gloves out the door.
Water was added to the containment bag and the captain placed the laptop into the bag and it was filled all the way to the top with water and then sealed. He noticed, and later commented, that the gloves were not insulated and the burning computer was quite hot. A flight attendant was assigned to watch the bag and to report anything that might indicate that the laptop had ignited again.
The captain and the rest of the crew decided that they should continue to Atlanta instead of diverting. The laptop was turned over to the NTSB, of which was returned to the owner a few days later and, to the best of my knowledge.There Was No Investigation.
Under SMS, airlines are federally required to assess and mitigate risk. The problems with this situation were many because the company did not follow it's SMS, but instead hid the situation. Incidents happen. The goal is that we can learn from events and mitigate the risk. But if we hide events, nothing changes.
- The flight attendant was brilliant for not opening that bin, of which could have been catastrophic had she done so. This should have been a learning point and added to training for all flight attendants, not kept silent. I don't think many would have had that kind of insight, especially when fatigued.
- The gloves were not heat resistant, and this should have been improved for the next fire.
- The company should change locations to centrally locate the gloves in the cabin by the containment bag. To this day, I believe they are still in the flight deck away from the containment bag.
- This crew continued on to destination without the legally required number of fire extinguishers, because they had used them on the fire. What if they were needed later?
Why didn't anyone report this?
Fear of retaliation!
During this time, Delta senior management was already discussing their strategy to submit me to a psychiatric evaluation because I had requested a meeting to bring safety concerns forward. Of course employes would fear retaliation if they spoke of this event. In response to this, and many more incidents, we need to eliminate fear and encourage everyone who sees something to say something, as required by law. SMS demands a reporting culture free of retaliation.
Your Safety Depends Upon it!
Enjoy the journey
XO Karlene
JFC! I'll never get on another DELTA aircraft as long as I live. I'd expect this out of some low hour regional pilot, or some low buck carriers, but this is how a MAJOR handles a Lithium Ion Battery incident? Lithium Ion batteries are the most dangerous item on any aircraft and could easily bring a plane down.
ReplyDeleteYes they could. And I was so impressed with that FA knowing not to open the bin. How many passengers or other flight attendants not have made the same decision. The reason we report these things is to learn from them. When they are hidden... nobody learns or improves. Yes... the gloves are still in the flight deck not by the containment bag. Now... if that frightens you... did you read this?
Deletehttps://karlenepetitt.blogspot.com/2023/02/airlines-hidden-secrets.html
I don't really understand what's going on with politicians class --be them inside government or inside governing bodies of companies-- as it should have happen in Boeing, Delta directing and management layers shall be completely replaced by competent and honest pros.
ReplyDeleteWhat are they waiting for, a 'Boeing Style' couple occurrences and no way to deflect blame and responsibilities?
At least, in Boeing's case there were no precedents to refer. But in the Delta situation the actual Direction and Managament layers shall completely be replaced for their lack of sense and competence. Or are they going to send a shrink to declare me a psico?
Sorry 'Señora' Karlene, for this extreme tirade, I just wanted to contrast the extreme irresponsibility and lack of awareness of the Directors and Managers in Delta, and the real possibility of them taking down that company. As already it almost happened in Boeing. Although that does not include the complimentary hundreds of lives.
No worries on the tirade. I wish the entire world would go on one for this type of behavior. Maybe something would change. Thanks for your comment!
DeleteWhen did this occur? The bin shown says ‘Reserved for First Class’ which would not naturally occur on an HNL-ATL flight given only wide bodies can fly this route and would be equipped with DeltaOne
ReplyDeleteThis occurred in 2016. I was sent the photo at the time. A dispatcher on duty was very disturbed the flight was continuing. He leaked it out to a few. Nobody at Delta could say anything, or they would be terminated for social media violation. I had this in my email with the photo. But sadly, even today... those gloves have not been insulated, and they are still in the flight deck, not co-located with the bag. To my knowledge, no flight attendant training has occurred advising the FA's to not open the bins prior to inputting extinguishing agent. The fact that it happened is not bad. The fact they continued without fire bottles... yeah, problematic. By sharing this story with everyone, the next time it happened the pilots might consider the extinguishing agent issue. This is how we learn. From incidents. Simply hiding these events is a violation of SMS, and yes... Delta had an FAA approved SMS at the time. There are so many more events similar to this that were in my report, but instead of addressing the issues they tried to kill the messenger. Also a violation of SMS. But... now that I am retired, I will continue sharing these stories, until the culture changes. That might not happen until they remove Bastian from the CEO and find another Chairman of the Board. Maybe John Nance, Captain Sullenberger, Dr. Tony Kern... a voice of safety and reason on any airline board is a great balance between safety and profit.
DeleteThanks for your comment.