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An ATSB investigation report has found that while an emergency passenger evacuation at Hobart was conducted rapidly and in a pro-active manner in the interests of passenger safety, there were problems with communication involving the pilots, ground crew, and cabin crew that created potential risk and has led to improved safety action for the future.

The Australian Transport Safety Bureau's final report into the Boeing 717 evacuation on 17 May 2005 found that a right engine starter had failed during the engine start due to loss of lubricating oil because a seal retaining ring was incorrectly installed. This resulted in smoke and sparks issuing from the right aircraft engine. The smoke and sparks were reported to the captain as a fire by the aircraft dispatcher, and the captain ordered an emergency evacuation.

The 3 floor-level aircraft doors were opened by the flight attendants but when the right front door was opened, the escape slide fell to the ground uninflated. The investigation found that the escape slide may not have been properly armed after the doors were closed and that this was not noticed when visually cross-checked. (The passenger operated over-wing exits were not used as there were no passengers sitting in these rows.)

All 26 passengers successfully exited the aircraft in less than 64 seconds, but 11 reported sustaining minor injuries.

The emergency evacuation was ordered before the relevant checklist had been completed. This resulted in a lack of emergency lighting in the rear emergency area and delay in the extension of wing flaps that would have been necessary had the over-wing exits been used.

As a result of this incident, the operator has undertaken several safety actions to enhance passenger safety. These include: improved aircraft maintenance procedures relating to markings on door slide brackets; defined phraseology to be used in emergency communications between aircraft dispatchers and pilots; door closure procedures for engine starts; improved policy on cockpit discussion restrictions after door closure; and improved cabin crew procedures and training.

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Last update 01 April 2011