Recommendation R20050003

Recommendation issued to: Qantas Airways Limited

Recommendation details
Output No: R20050003
Date issued: 17 March 2005
Safety action status:

Output text

Safety Recommendation

The Australian Transport Safety Bureau recommends that Qantas Airways Ltd, review the adequacy of their procedures for the deployment of over-wing slides during known brake fire situations. This review should take into consideration the visual cues used and potential risk to passengers of evacuating within close proximity of a fire zone

Initial response
Date issued: 06 July 2005
Response from: Qantas Airways Limited
Action status: Closed - Accepted
Response text:

Operator Evacuation Policy and Procedures:

Historically the Emergency Procedures training for cabin crew has required that the door primary cabin crew (CC) is responsible for ensuring that the area adjacent to their door is safe for door opening in an evacuation. Reasons for this include:

  • The door primary CC is in the best position to assess the environment immediately adjacent their door through visual inspection.
  • Limiting available exits effects the time taken for evacuation.
  • Complexity is added to the evacuation process if doors are made unavailable by the Flight Crew during the evacuation announcement. Complexity can add to confusion and time required to execute an evacuation.
  • Qantas has a Precautionary Disembarkation procedure that caters for disembarkation in non-normal circumstances when a evacuation is not yet but maybe required. This allows certain doors to be directed for use during disembarkation in an expeditious but planned manner.

Feedback from Aircraft Manufacturer:

Boeing was contacted regarding Over-wing Slide Evacuations during Brake Fire Situations.

They replied that they were unaware of evacuation reports with associated brake fires interfering with slides or passengers disembarking from an over-wing slide.

Additionally Boeing stated that they did not have specific procedures or practices when there are underwing fires. Boeing stated that operators are best equipped to develop such procedures, due to the great variety of factors which must be considered, many of which are operator unique.

Feedback from Slideraft Manufacturer:

Goodrich was contacted regarding Over-wing Slide Evacuations during Brake Fire Situations.

They stated that for the single piece slide for the 747 Door 3, it appears that the body gear are slightly back of that door, while the wing gear may be about even with it. The slide will carry the evacuees further aft, approximately under and aft of the actual Door 4 location.

Because of the environmental factors, the Goodrich representative thought that the crewmembers should be best suited to decide about potential fire threats. The Goodrich representative argued against assigning one solution to all potential problems in regard to limiting door three slide availability. The Goodrich representative acknowledged that crewmembers at Door 3 likely won't be able to see debris on the ground where the Door 3 slide will land. However the Overwing Deployment Indicator (ODI) was designed to indicate to the crewmember that the slide had fully inflated.

National Transportation Safety Board (NTSB) Safety Study: Emergency Evacuation of Commercial Airplanes NTSB/SS-00/01:

Chapter 6 of this study contains a section titled 'Exit Selection'. This study found the 'Flight attendants are trained to assess which exits are useable, and in no study case did a flight attendant open an exit that increased the potential harm to a passenger.' The report also found that some carriers have procedures that direct flight attendants which exits to use or which exits not to use. Other carriers were found to have procedures where the Fas determine which exits to use.

Some carriers that train CCs to determine which exits to use in an evacuation have what the NTSB describe as a passenger deplaning procedure that may be used when passenger safety will not be compromised. This procedure will direct certain doors to be used during the deplaning. This is similar to the Precautionary Disembarkation procedures utilised by this operator.

The study continues, to state 'Limiting the number of exits used during an evacuation can have a dramatic effect on evacuation times.'

Panel Discussion:

The panel discussion was limited to addressing the specific ATSB recommendation pertaining to a brake fire scenario.

Discussion included the limitations associated with the field of view from the doors three (D3) primary CC position. The general consensus was that even though the D3 could not see the under wing area a significant fire would be evident by smoke and flames. Additionally the ODI was available to check proper deployment. Information from Goodrich, supported by investigation observations, indicates that the actual D3 slide evacuates passengers under doors 4, some distance from the underwing area. This area is also monitored by the Doors 4 (D4) CC when that slideraft is deployed.

Additionally, once down the slide the direction of travel directs passengers further away from the underwing/brake area.

Another consideration with limiting exit in the case of an evacuation was the possibility of increasing complexity at a very time critical period. The potential of cabin crew misinterpreting the doors to be used or not was seen as an increased risk to the effectiveness and rapidity of the evacuation. The existing Precautionary Disembarkation procedure is already established for less critical deplaning where specific doors may be selected.

The panel agreed there were potential safety gains that could be made by improvement of Emergency Procedures training to crew:

  • Emphasis to door primary CCs of the importance to continuously monitoring the integrity of their assigned slide and the safety of the area where the slide has deployed. This monitoring process should continue until the passenger evacuation is complete. This is already included in recurrent training but will be included in Cabin Crew initial modules that cover Land Emergency Theory and practical exercises.

The panel acknowledged that there has already been a significant amount of crew training pertaining the QF6 brake fire and evacuation event and it's significant factors.


The panel concluded that current generic evacuation procedures were the most effective and expeditious method to ensure a successful passenger evacuation. Improvements of crew Emergency Procedures training will enhance and reinforce these procedures.

ATSB Response Status:  Closed-Accepted

Last update 03 April 2012