The ATSB collects and analyses data from accidents and incidents involving aircrew, ground personnel and passenger safety. In this issue of the ATSB Supplement, a selection of Australian cabin safety occurrence briefs are summarised and one from the Transportation Safety Board of Canada.
Photographs of the burnt out Saudi Arabian Airlines Lockheed Tristar at Riyadh on 19 August 1980 following an emergency landing. All 287 passengers and 14 crew on board died from smoke inhalation from a fire in the aft cargo hold which started shortly after takeoff. Despite the successful landing the crew were unable to open the doors. Emergency services took 20 minutes to open one door. A serious breakdown of crew coordination was cited as one of the significant factors in the disaster.
This report from the Transportation Safety Board of Canada (A99AO046) highlights the need for continued care and vigilance in the use of ground-handling equipment to ensure safe movement to and from aircraft for passengers, aircrew and ground personnel.
In March 1999 a five year-old child was injured during disembarkation from a B767 at a Canadian airport. The aircraft was parked on the open ramp away from an aerobridge.
After the first 10 passengers had left the aircraft a flight attendant exited the aircraft carrying an infant in a car seat. When the flight attendant stepped on to the passenger stand he noticed it was descending slowly away from the aircraft. As he turned to tell the in-charge flight attendant, the infants five year-old brother, who was following with his mother, stepped out of the aircraft and fell between it and the stairs to the apron below. The child suffered a broken arm and lacerations to the head in the fall and was taken to hospital for treatment and observation.
The locking mechanism used to hold the upper stairs in position is a fairly simple mechanical device. The pawl that prevents the stairs from descending is held in place against the dog rail by a spring and released by energising a solenoid. In this occurrence the pawl had only partially engaged the dog rail and after several passengers had travelled over the stairs had slipped off. This allowed the upper stairs to descend away from the aircraft. According to the report it was unclear whether this was due to a weakness in the spring, a mechanical resistance in the mechanism or a combination of both. In any case proper functioning of the locking mechanism was impeded.
The locking mechanism was not functioning properly and as a consequence disengaged and allowed the upper stairs to descend away from the aircraft. There was no policy in place requiring the passenger stand operator to do a close visual inspection of the locking mechanism to ensure full engagement.
Passenger stand operators reported that they would take only a cursory look at the locking mechanism when leaving the vehicle. Any visual inspection would have been impeded because the pawl, the dog rail, and the background were all painted the same dark green colour and on this particular vehicle a support brace impeded the operators view. Operators of the passenger stand reported that they had not received formal training on the operation of the equipment.
Other contributing factors to the occurrence were the failure to follow the maintenance schedule and the absence of a requirement to visually inspect the locking mechanism of the passenger stand before use.
Safety action taken:
Since the occurrence the company has completed a comprehensive inspection of all company passenger stands. All pawl mechanisms were painted in contrasting colours to facilitate determination of the pawl position and support braces were relocated to prevent the impediment of the operators view of the pawl. All airstairs units were put on a weekly follow-up routine to ensure all checks are completed on time.
The company, the TSB and the Canadian regulator Transport Canada, have disseminated details of the occurrence to local and international air transport operators regulators and industry associations to alert other operators using similar equipment of the potential for injury and the steps that may be taken to avoid similar occurrences.
Occ No. 200100741, 22 February 2001
At top of descent to Los Angeles the cabin crew of a Boeing 747 aircraft reported smoke and fumes emanating from the cabin ceiling located in the vicinity of the rear right side (R5) emergency exit door. Smouldering paper tissues were found in an overhead light fitting. Cabin crew removed the tissues and discharged a fire extinguisher onto the light fitting, tissues and surrounding area. The cabin crew remained in the vicinity and monitored the area until passengers disembarked at Los Angeles.
The company reported that the light fitting is a night light and is always on. The light has a blue plastic cover that should always be in place and which was not fitted on this occasion.
The investigation was unable to determine why or who placed the tissues in the light fitting.
The company issued an Important Information bulletin to flight attendants advising that any visible cabin light fitting must have a protective grill or glass covering the bulb.
Occ no. 200104168, 21 August 2001
During the cruise the passenger seated in 56C was warned several times for lighting cigarettes. Most cigarettes were extinguished and confiscated by the crew but one was dropped and ignited a blanket. The cabin crew members were quick to extinguish the smouldering blanket. The passenger was off-loaded in Bangkok.
Occ No. 200104464, 5 Sept 2001
During a flight between Melbourne and Sydney a smouldering fire was detected and extinguished in the waste bin of the aft toilet of the aircraft. A particular passenger was strongly suspected of smoking in the toilets during flight and the pilot in command requested that security staff meet the aircraft upon arrival in Sydney. The aircraft landed without further incident.
Occ No. 200103578, 10 July 2001
The aircraft was on climb passing FL200 when a passenger sustained a head injury from a bottle of liquor that was accidentally dropped from an overhead locker by another passenger who was removing a piece of luggage. The injury was treated immediately by the cabin crew to stop the blood flow. A paramedical team met the aircraft on arrival at Rome.
Occ No. 200103478, 15 July 2001
During disembarkation a passenger was struck on the head by a metal scooter that fell from on overhead storage bin. The passenger received a bleeding cut to the head, was given first aid and attended by the Rescue Fire Fighting Service. The passenger was later transported to a local medical centre for treatment.
Occ No. 200100393, 24 Jan 2001
During the cruise cabin crew were required to abruptly cease cabin service when the flight crew turned on the fasten seat belt sign due to severe turbulence associated with thunderstorm activity. They were not able to secure the cabin prior to landing and as a result the aircraft landed with the cabin insecure. The pilot in command reported later that he did not consider it safe to turn the sign off during the descent.
Occ No. 200103943, 8 August 2001
During the cruise a passenger seated in 20C was struck on the head by a plastic bottle full of water, which had been stored in the overhead locker by a cabin crew member. The passenger later collapsed, became ill and required medical attention. An ambulance was organised to meet the aircraft on arrival at Darwin.
Occ No. 199902180, 24 April 1999
The aircraft was cleared for takeoff when the flight attendant advised the pilot that a cat had escaped from a cage in the cargo hold and was loose in the cabin. The flight attendant locked the cat in the toilet while the pilot returned the aircraft to the ramp. The cat was removed through the toilet door without further incident.
Occ No. 200102090, 3 May 2001
During the cruise the crew noticed smoke in a rear toilet. The cabin crew found a smouldering tissue box that appeared to have been used to extinguish a cigarette and then water used to extinguish the potential fire. At the time the no smoking sign was extinguished.
|Type:||Educational Fact Sheet|
|Publication date:||12 October 2000|