Recommendation R20050004

Recommendation issued to: Civil Aviation Safety Authority

Recommendation details
Output No: R20050004
Date issued: 17 March 2005
Safety action status:

Output text

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Bureau, review the adequacy of operator 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: 18 July 2005
Response from: Civil Aviation Safety Authority
Action status: Closed - Accepted
Response text:

CASA considers that the company procedures and actions of the crew in this accident to be appropriate. It is universal practice that crew check for fire outside before deploying slides. This was not only carried out, but in the case of L3 the crewmember asked a passenger to check the lower section of the slide before the crew member initiated evacuation instructions.

Given that there was no control by crew members of passengers once evacuated, until the crew members themselves evacuated, there would in fact be nothing to prevent passengers evacuated from a forward or aft slide entering the landing gear area.

Many operators, both within Australia and internationally, provide the Pilot in Command (PIC) with two options to facilitate the rapid removal of passengers, Such options allow the PIC to consider the degree of urgency required in evacuating passengers from the aircraft, while accepting that, during an evacuation, personal injuries may occur in the rapid use of evacuation slides.

Option one, the 'Precautionary Disembarkation,' provides for a more orderly rapid evacuation of passengers in situations such as bomb threats. In these circumstances, passengers are required to be removed from the aircraft quickly although in a somewhat orderly way, to minimize risk of personal injury. The Precautionary Disembarkation also allows the PIC to nominate, if necessary, which slides/stairs/aerobridge to use, depending upon the specific situation/emergency.

The second option relates to full scale evacuations whereby all available doors/escapes slides are to be used with the only priority being passengers and crew leaving the aircraft as quickly as possible. This overriding priority has been re-enforced as a result of numerous aircraft accidents where passengers have survived the impact, only to be overcome by smoke and fumes.

Further, integral to cabin crew evacuation procedures and training, is the requirement for each crewmember to conduct an outdoor inspection of their respective exit prior to opening. This inspection will determine if there are any hazards, for example fire/excessive smoke/water or obstructions. Should such a hazard exist, the exit may remain closed and passengers will be re-directed to a useable doorlslide.

In this particular accident, assuming the cabin crew at the over-wing exit followed their procedures as required and checked outside conditions prior to opening the over-wing doors, they may well have determined that it was safe to operate these exits and evacuate passengers down the off-wing slides. Had the gear fire been more intensive and smoke and/or flames were evident, then the crew would not have opened these exits, and instead, re-directed passengers to exits clear of the wings.

The Pilot in Command, once the evacuation order is given, relies entirely on the judgment of the cabin crew at their specific doors as to the usability or otherwise of that exit.

Additionally, if the PIC has determined that an evacuation is necessary, he/she has also concluded that the time available to get all onboard off the aircraft is the overriding critical factor.

Based on the available information, it would appear that the procedures and training put in place by the operator is sufficient.

ATSB Response Status: Closed-Accepted

Last update 03 April 2012