Pilots didn't know about evacuation [Archive]

Cmon-PullUP

10th Feb 2011, 08:52

I have never worked for a company where the crew couldn't initiate evacuation, but ONLY if the situation was CLEARLY CATASTROPHIC or after a severe incident where the CC was unable to get in contact with the FD.

For anything else, it is the Captains decision, and there might very well be factors internal or external that the CC don't know about, but that would endanger evacuation (eg running engines, fire, other aircrafts ect)

But of course, we don't want to be too harsh to our crew for taking initiative :\ :{

If the Captain hadn't been informed / consulted and the situation was not clearly catastrophic, then the SCCM is to blame for all injuries. The Captain has been bypassed and had no saying, and he might have chosen a very different and better informed decision had he been consulted about the situation.

Poor decision to disregard the Captain and give a **** about CRM, when there were time to make a proper decision by the right people. The Captain might only have needed 5-10 seconds to make his mind up, and injuries might have been avoided completely.

Aldi seems like a more safe place to work for some people!!

Basil

10th Feb 2011, 08:56

Tricky one!
In my experience, CC were authorised to initiate an evacuation without a command from the captain or FO in a CATASTROPHIC situation.
In their particular circumstances, whether or not a smell of smoke/burning with no obvious evidence of fire constitutes a catastrophic situation - well??
(p.s. Crossed with CP)

Edited to say that I would not wish to discourage CC from using their initiative in a life-threatening situation.

helen-damnation

10th Feb 2011, 09:16

Each company will have their own instructions for the crew of which this is one example. It is not from the company concerned and shouldn't be used as such:

Normally, the Captain will give the command, "EVACUATE", repeated 2-3 times.
If no Flight Crew member has provided the necessary direction, the purser/CCM should attempt to contact the flight deck by interphone to obtain instructions.
An evacuation must not be initiated while the aircraft is moving. However, any Crew Member may initiate evacuation in cases of extreme/catastrophic emergency.

The obvious question here is: what do you define as extreme/catastrophic?

Quality Time

10th Feb 2011, 09:31

IMO this was not extreme/ catastrophic.

Not only that, it appears that the Flight Deck were more than aware of the situation and were busy dealing with it?

Having said that - it's very difficult to predict actions under stressful conditions. We always need some luck!

ShyTorque

10th Feb 2011, 09:43

But surely the flight deck crew should have been informed, to safeguard their safety too?

M.Mouse

10th Feb 2011, 09:57

From the AAIB report it is clear that, while CC have the authority to order an evacuation, the company policy is that they should only do so in an extreme/catastrophic situation. My airline has similar wording in the manuals.

The situation on that aircraft was clearly not extreme/catastrophic. The flight crew were concious, aware and able to communicate. The cabin crew member acted outside their remit.

In SEP refresher training it is always interesting to ask CC to describe examples of what they consider a catastrophic situation. The answers are often illuminating.

Max Angle

10th Feb 2011, 10:01

How many people would have been injured or worse had she not ordered an evacuation?None at all, they had a knackered recirc fan. The company's evacuation guidance (which is reproduced in the report) was unfortunately not followed, people got needlessly injured as a result.

The answers are often illuminating.They most certainly are.

BSD

10th Feb 2011, 10:03

Oh please no! I find myself agreeing with 411a. Except of course for his last sentence starting then again...

The reason that the flight deck should be informed/responsible for the decision to evacuate is beautifully put by McBruce. The burning smell may be the passengers going through the engines!

I have worked for one airline in which the cabin crew could make an independent decision, witout informing the flight deck to initiate an evacuation. The chance of an uncoordinated accident as a result, always frightened me.

In my present company, normally the Flight deck make the decision, the Capt. initiates it but there is provision for the cabin crew to ascertain that the flight deck are capable of making the decision; i.e haven't become incapacitated. Then they would take over. Key word there is of course normal - specious really, as normal and evacuation make for strange bedfellows, to say the least. Still not perfect perhaps but better methinks.

Interesting report though, we all live and learn and hopefully make things better as a result.

BSD.

Flying_Frisbee

10th Feb 2011, 10:04

10th Feb 2011 11:43 ShyTorque
But surely the flight deck crew should have been informed, to safeguard their safety too?

I was wondering that too. I can appreciate any crew member being able to order an evacuation, but surely everyone on board, including the flight crew, would be included?

Lord Spandex Masher

10th Feb 2011, 10:12

None at all, they had a knackered recirc fan

Did the cabin crew know that?

I'm not condoning any actions merely trying to see it from the hosties point of view.

Just because you can't see flames doesn't mean there aren't any.

HPbleed

10th Feb 2011, 10:15

If the Senior had stuck her head through the door and just said quite simply, "Captain, I'm going to start an evacuation." That would have been enough to get the Flight Decks attention. From the AAIB report she hardly tried to tell them, it sounds like she made her own decision and that was that. Told the rest of the Cabin Crew and off they went.

A quick sentence and that would have given enough time for the flight crew to say either "NO! STOP! We have it under control!" or "Ok, if you think it's that serious, take your station and we'll commence it, under my authority."

Once again, lack of communication, from both sides of the door have led to an event which COULD have led to more serious injuries. SEP refresher training for all I think.

rsuggitt

10th Feb 2011, 10:27

IMHO as humble SLF, the CC played it safe, which is the correct thing to do. I thought the whole ethos of flying was safety first, not protocol.

Talking in hindsight about any crew communication issues..... communication goes both ways... maybe the FD crew could have told the CC that the problem had been identified and was being resolved ?

Cmon-PullUP

10th Feb 2011, 10:30

Just because you can't see flames doesn't mean there aren't any.

If you can't see flames but only limited amount of smoke (hence not so dense you can't see through it), then it's hardly clearly catastrophic and there is time to think. - You don't come across as a pilot, but i can inform you that the pilots won't use half hours assessing a situation with smoke, just seconds. But thats also enough to - as in this case - establish if it is something that is under control and well known or something more serious and then take the appropiate actions.

THAT is the reason the Captain should have been informed, and passenger injuries would most likely have been non-existent.

In reality i don't think it is the CC that fails here, but the company for not training them well enough to do the job they do.

IMHO as humble SLF, the CC played it safe, which is the correct thing to do. I thought the whole ethos of flying was safety first, not protocol.

Talking in hindsight about any crew communication issues..... communication goes both ways... maybe the FD crew could have told the CC that the problem had been identified and was being resolved ?

It is not "playing it safe" when people get injured for no reason at all, and the protocol is there for exactly that reason: "Play it safe"

How could the FD communicate that the problem was under control when they were never involved in the process from the CC? we don't tell them about every little technical fault for a various of reasons, but they probably would have been told if they took the interphone and informed that "we have some smoke development in the rear", what do you want us to do? - and take it from there.

Super VC-10

10th Feb 2011, 10:33

Presumably they are expected to use their judgement in a potentially catastrophic situation. Fires can develop rapidly, such as the recent one in Russia.

Piltdown Man

10th Feb 2011, 10:43

...having received an unsatisfactory response

In whose opinion? Her's or the Captain's? It's NOT her call. The flight crew were not incapacitated and were working on the problem. Passengers were disembarking so we are not talking about a Flight 163 scenario. The doors were open, there was no smoke.

To me, it appears that even with the flight deck door open and being fully aware that the crew were working on the problem, the SCCM still decided to order an evacuation. At that point, she was then NOT part of the crew and effectively a loose cannon and certainly not working under the Captain's authority. Her actions actually undermined it. Maybe it was panic or even poor training. The AAIB report states "However, the flight crew were not incapacitated and it is evident that verbal communication with them would have been possible had the member of cabin crew persisted." No medals should be awarded for unnecessary and dangerous decisions taken in isolation. But it was the SCCM's statement after the event saying she'd do the same again that suggests she is doing the wrong job. So I'll stick with my "churlish" remarks.

And I'll pose another question to those who think the SCCM did the right thing. Would it have been acceptable for any of the other cabin crew or even a passenger to have initiated the evacuation? If not, why not? So why didn't they?

For what it is worth, recycling fans small horrible when they fail. I have had several fail in flight and the acrid, pungent, electrical burning smell takes ages to dissipate. Similar to smoke, the odour appears to get into fabric and soft furnishings and stay for ages. The smell lingers long after the source expires. Returning to this incident, I can understand the cabin crews' distress because to them it would appear that either no action has been taken or what has been done was ineffective. Unfortunately, this is one of those occasions where over-reaction has caused unnecessary injuries.

Checkboard

10th Feb 2011, 11:03

From the report: Air Accidents Investigation: Boeing 757-204, G-BYAT (http://www.aaib.gov.uk/publications/bulletins/february_2011/boeing_757_204__g_byat.cfm)

The SCCM then returned to the forward cabin and contacted all the crew using the Alert Call on the cabin interphone. They confirmed that there was a pungent burning smell throughout the cabin; there was no smoke, but the smell was strongest in the rear of the aircraft. However, the flight crew did not respond to this call.

The SCCM returned to the flight deck to update the commander, and while the flight crew acknowledged her presence, she did not convey her concerns on the need to evacuate the passengers as the flight crew were busy dealing with the incident. She considered that she needed to disembark the passengers as quickly as possible and so, as there were no steps at the rear of the aircraft, when she returned to the cabin she announced, in a calm manner, over the passenger address system: “Please evacuate the aircraft as quickly as possible. Leave all hand baggage behind.” The cabin crew at the rear doors re-armed their doors and deployed the slides. A total of 43 passengers used the slides, with four of them receiving minor injuries.(Emphasis mine.)

Not a very clear command - perhaps she intended the passengers to simply hasten disembarking via the (already open and in use) forward door and aerobridge?

scotbill

10th Feb 2011, 11:06

Always understood the authority for cabin crew to commence an evacuation on their own initiative was envisaged for a situation where urgent action was clearly necessary - e.g crash landing. This does not appear to have been the case in these circumstances.

Lord Spandex Masher

10th Feb 2011, 11:18

In whose opinion?

Her's. Obviously. Which is why she reacted as she did. She made it her call. Again, I am not condoning her actions just trying to see it from her point of view.

Unfortunately, this is one of those occasions where over-reaction has caused unnecessary injuries.

And if she had taken NO action and people had been injured or killed because the situation was worse than it appeared how would you be reacting now? She'd would still be getting a slating from you no doubt.

we are not talking about a Flight 163 scenario

I mentioned that scenario to highlight how quickly situations can get out of hand.

You don't come across as a pilot

I'm not trying to. I am trying to see this from the perspective of the cabin crew. Try it sometime and you might realise why people react the way they do.

If you can't see flames but only limited amount of smoke (hence not so dense you can't see through it), then it's hardly clearly catastrophic and there is time to think

How can you say that with any kind of certainty? How would the cabin crew know? They wouldn't.

What materials burn without smoke? Have you heard of flashover?

It's easy to sit in the comfort of your armchair with full knowledge of what has happened. But try and put yourself in that situation, honestly, and tell me how you would react.

How quickly could it have gone out of control?

Basil

10th Feb 2011, 12:22

MM,
Many years ago my *airline changed from separate FC & CC SEP training to combined exercises.
Great idea! We both discovered that we held some misconceptions of each other's thought processes and both benefited from the combo - as, of course, did flight safety.

* Can't remember if same one as yours.

skytrax

10th Feb 2011, 12:36

Its easy to speak (post) after you read the article. But if you are at the back of the plane with that strong burning smell, hving no info/PA from the FD I bet many of you would have a different opinion.

IMO CC did the right thing. They had no ideea whats going on, they played it safe. Purser tried to get more info, couldnt, so she got everyone out. Better be safe than sorry.

situation wasnt catastrophic? well, there's a fine line here. what should they hv done? wait for the flames? many of you say now that it wasnt catastrophic but you werent there at that time to make the judgment without knowing whats wrong.
same old story. we are all brave and bright in front of the computer.

763 jock

10th Feb 2011, 13:31

I had exactly the same failure on a B757 at MAN about 10 years ago. We were boarding at the time, strong electrical burning smell in the flight deck and cabin. We stopped the boarding and disembarked those already on board. No fuss, no drama. Certainly no need for slides.

Heathrow Harry

10th Feb 2011, 13:35

"If you can't see flames but only limited amount of smoke (hence not so dense you can't see through it), then it's hardly clearly catastrophic and there is time to think"

Ever been in a fire?

I was in an office (in London) once and a few whisps of smoke came through the floor - within 10 seconds the place was so full of smoke you couldn't see your hand in front of your face

if you see smoke GET THE HELL OUT OF THERE

I suspect in this case the pilots where wrapped up trying to figure out what might be wrong and just didn't pay the CC any attention when she poked her head around the door

Sure, she should have said something to get their attention but she was down back and they were up front - better to have 4 minor injuries than a blazing plane full of people

RatherBeFlying

10th Feb 2011, 14:02

The fumes from this non-catastrophic failure are like all combustion byproducts -- toxic. Keeping people in a confined space with toxic fumes is not conducive to their health. People with asthma, allergies and other respiratory pathologies are at particular risk.

Many fires do self-extinguish, but without clairvoyance there is nothing to distinguish the first waft of smoke/fumes between a small release of toxic fumes or the beginnings of a conflagration that will in the next several seconds consume the entire aircraft.

If the CC waits for visible flames or heavy smoke, lives will be lost.

Green Guard

10th Feb 2011, 14:18

I have never worked at a company that has required the cabin crew to seek my permission to evacuate

....and what would they do if your aircraft is moving along taxiway or runway ? Sometimes it can take quite looong....

that will in the next several seconds consume the entire aircraft.

If I were you I would "rather never been flyıng", nor even using a car or a bus either.

Lord Spandex Masher

10th Feb 2011, 14:22

Green Guard,

They are trained to check outside. Hopefully that's what they'll do!

con-pilot

10th Feb 2011, 14:48

On one incident there was a deadheading FA sitting by the overwing exit on a 727, an aircraft she was not familiar with.

When the FE started the APU it torched and some flames came up by the window she was sitting by.

She immediately screamed for everyone to evacuate, jumped up, ran across the aisle to the other side's overwing exit and opened it. Then as the confused and now frightened passengers started yelling and standing up, the assigned Cabin Crew managed to tackle the out of control deadheading FA and informed the Captain to stop the aircraft as passengers were trying to leave the cabin.

As it turned out there were no serious injuries as no passenger was actually able to leave the aircraft as it was taxing.

In the case that is the subject of this thread, tell the cockpit crew first, if they are not paying attention to you, whack them up the side of the head if you have to, but tell them before one starts to evacuate passengers via the slides.

M.Mouse

10th Feb 2011, 15:03

Decent airlines have SOPs. They are there for a reason and developed after much thought and debate and also are apporved by the regulatory authorities. SOPs will never be perfect but had the CC member actually adhered to her training and followed SOPs the incident would never have happened.

Her comment that she would consider doing the same again was probably bravado speaking and her trying to justify her completely and utterly incorrect actions.

Actions have consequences and if you operate outside how the aircraft operator wants its aircraft operated (SOPs) then you had better be very sure of what actions you are about to take.

BOAC

10th Feb 2011, 15:06

Not a very clear command - perhaps she intended the passengers to simply hasten disembarking via the (already open and in use) forward door and aerobridge? - like CB, I suspect the wrong form of words was used and the rear crew picked up on the 'evacuation' bit? A salutary lesson for all.

HPbleed

10th Feb 2011, 15:49

I don't think so, she says in the report she would do the same again. If passengers had evacuated and she thought she could pin the blame on someone misunderstanding something she had said, do you not think she might have done that? Rather than take the flak and say that she would do it again.

No, she initiated an evacuation and meant to do it. Loose cannonball.

As to another comment, she would have been at the front whilst pax were disembarking, so a quick shout through the door would have got the attention of the crew. The fact she acted on her own, without knowing the full facts really worries me.

There was no heat, or smoke. The only sign that I can fathom is the SMELL... yes SMELL of burning. That could be anything...oil, APU fumes, confused with Antiice fluid, air con smoke. Practically anything. If it's not immediately obvious then yes, get the pax off quickly, but no need for unnacceptable risk with slide deployment. IMO.

virginblue

10th Feb 2011, 16:05

potentially catastrophic situation

The problem with that is that you only know if a situation is "potentially catastrophic" if you wait and see how it turns out. However, if a strong odour suggests a fire somewhere, you could see it as "potentially catastrophic". It is always easy to say it was not with hindsight.

The report also suggests that the odour in the back was much stronger than in the front where the captain was.

corestore

10th Feb 2011, 16:07

I'm not an aviation professional, but I am a fireman, so I know a bit about fire. Been in quite a few too.

In the circumstances described, with the aircraft at the gate and the main door open, it seems to me that the most appropriate course of action, if the senior decided they needed to get everyone off the plane immediately, would be an emergency disembarkation via the main door. I haven't read the report yet, but I wonder why that option wasn't considered, or was rejected.

If conditions had deteriorated this could have been escalated to a full evacuation forthwith.

I'll say this much: as a firefighter, it would take a lot for me to criticise a... premature... evacuation. Yes it carries the risk of injuries, but I'd sooner have them off when it wasn't really necessary than not off soon enough; things can do downhill more rapidly than you would believe possible.

I'll leave discussion of the training, SOP, and CRM issues to the professional aviators!

bunkrest

10th Feb 2011, 18:50

I'm going to dip my toe in the water with a (former) cabin crew perspective. Don't be too harsh!

Firstly I understood and respected the chain of command. I also understood the importance of keeping the flight crew in the communication loop; that their situational awareness could only be enhanced by a clear description of whatever might be happening in the furthermost reaches of the cabin.

The training I received encouraged cabin crew to work on their own initiative when the situation demanded it. If the situation was clearly catastrophic,(and this was very well defined) then you commenced an evacuation even without the Captain's command.

However training also underscored other greyer areas. That you may be involved in what seemed like a 'contained' emergency that suddenly and without apparent warning deteriorated into something immediately life threatening. Where reaching for the interphone might mean you get to find out exactly how fire retardant your polyster mix uniform actually was. Obviously initiating an evacuation when the aircraft was moving, had the engines running or indeed had several thousand feet of cloud beneath it was best avoided. I think the best advice I was given was - if you are thinking 'should I?' then don't.

In my experience training was very concentrated on in flight emergencies and less on ground based ones. 180 passengers 25,000ft up have little option but to listen and be directed by crew. Good communication under these circumstances is relatively easy. However transfer the situation to the ground where the passengers know they are on terra firma, sense impending disaster and want a swift and immediate exit and you have a very challenging and dynamic situation in the cabin. Under these circumstances communication is far more likely to break down and hasty, incorrect decisions made by the cabin crew. I don't know what the current sep is like, I'm a couple of years out of date, but I think it's a training area that needs to be explored thoroughly.

islandhopper

10th Feb 2011, 21:07

As a Capt I've no problem with cc initiating an evacuation - just as long they realise that the bloody engines might still be running !!!!!!!

AnthonyGA

10th Feb 2011, 21:28

This is all kind of amusing. As a passenger, if the aircraft is stopped on the ground and I have any reason to suspect there may be a fire on board, I'll initiate my own evacuation. The cabin and flight crew can stay on board and argue about protocol if they want, but I'll be outside the aircraft and safe in the meantime. I don't care about regulations or legal consequences in emergencies. There's a reason why all passengers have access to instructions that explain how to open the doors.

I do know one thing: a fire can be blazing away in an aircraft even before the smell is noticed in the cabin (much less on the flight deck). And a smell can turn into a cabin filled with flame in a few seconds. So I absolutely cannot blame a FA for initiating evacuation—better safe than sorry. And if she hadn't, I would have (at least for my own evacuation, others can figure things out for themselves). Her only mistake was not making clear to the flight deck that an evacuation might be a good idea. After all, they are in danger, too, and if they discover a fire too late, they might not make it outside. Aircraft fires do not follow chain-of-command protocols.

islandhopper

10th Feb 2011, 22:01

Thats fine mate , but as I said above don't blame me if you get sucked into a running engine because YOU think its appropriate to get out......

iamorgan

10th Feb 2011, 23:35

I agree. As SLF, I think there comes a point where you have to take action. Tbh, engines clearly shut down -airbidge attached, f/d door open and slides disarmed.

Reminds me of BA PHX incident which happened because of poor communication.

Tankengine

11th Feb 2011, 01:10

"slides disarmed" unwittingly good point iamorgan,

someone doing their own evacuation may fall 40' onto concrete!:ugh:

411A

11th Feb 2011, 02:01

Loose cannonball.

Yup.
Far too many of these in the CC ranks today, in many airlines.
We have a sure cure for this in my airline...it's called termination.

indamiddle

11th Feb 2011, 02:15

many years ago on an F27 in oz, nsw. just finished shutting down l/h engine the capt called crew over interphone to " get the passengers off now" . hearing the tone in his voice the cabin crew did exactly that. they then reported to capt still on the deck "cabin evacuated". that really got his attention. what he had meant to tell the cc was a heavy storm was about to hit tha a/p and he didn't want anyone getting wet!
it's always about communication

Flying Lawyer

11th Feb 2011, 03:28

AnthonyGA"I don't care about regulations or legal consequences in emergencies."
"others can figure things out for themselves."Does it not occur to you that procedures are in place for good safety reasons?
There's a reason why all passengers have access to instructions that explain how to open the doors.
I've always assumed it is so that passengers can assist CC if required in the event of an emergency. eg If one or more CC have been incapacitated. It had never occurred to me until I read your post that some of my fellow passengers might regard it as an invitation to open a door if they consider it necessary. A troubling thought.

Fatfish

11th Feb 2011, 04:55

Ah! the pilots take too long with their evacuation checks. Lets just evacuate and feed the pax into the meat grinders hung below the wings. :ok:

skytrax

11th Feb 2011, 06:18

Once the slides are deployed they get an indication in the cockpit. I reckon they knew whats going on, only that they didn make the decision for it.
As a pilot if you see the slides are deployed what would you do? would you shut the engines and go out of the cockpit to see what the ..... is going on?

There are two different perspective here.
1.You have the cockpit, confined, no burning smell or very little, going trough checklists.
2.You also have the CC with 200 pax on board looking at them and a strong burning smell they have no ideea where is coming from. CC is thinking if its safe to stay on board or get out, they wait for some info that doesnt come.

Purser tried to get more info, couldnt, so got everyone out.
Cant blame any of the parts involved but IMO FD should have had a quicker reaction to either communicate with the CC/pax or initate the precautionary disembarkation.

763 jock

11th Feb 2011, 06:43

skytrax. You obviously have no experience on the B757. There are no indications on the FD that slides are deployed. You can't even tell if they are armed or disarmed. Please get your facts right.

Desk-pilot

11th Feb 2011, 08:08

It seems to me that with hindsight perhaps this lady might have tried the emergency call button to contact the FD before deciding to evacuate. I think it would be churlish however to criticise her with the benefit of hindsight.

I'm sure that evacuation is not something she undertook lightly but knowing how fast a fire can spread in an aircraft cabin I don't think anyone can really criticise her for being proactive in getting pax off.

Having been in one or two incidents myself (as flight-deck) I know how easy it is to find your actions questioned after the event by somebody in the calm of an air conditioned office!

DP

skytrax

11th Feb 2011, 08:10

My bad in regards to that. I have no experience on B757.
However I still belive that a quicker response from the FD would have ruled out the evacuation. IMO this incident was caused by bad CRM.

PantLoad

11th Feb 2011, 09:13

Normally, at a real airline (one that has SOPs that are taught, evaluated, and reinforced), the cabin crew does have the authority to command an evacuation. However, these instances are limited to cases that obviously require an evacuation such as: after a crash with major structural damage, (it is obvious the pilots are incapacitated and evacuation is warranted), a fire, dense smoke, or any situation that poses imminent danger and the pilots cannot be contacted. Things of this nature....

In the Bus, there is a cockpit switch that has two positions: one, where only the cockpit can trigger the evacuation alarm, the other where either the purser or the pilot(s) can trigger the alarm. My old company's SOP (from which I retired) was to position the switch to 'cockpit only'.

Never, at my old airline, have we had a problem where the cabin crew initiated an evacuation on their own without communicating first with the cockpit. But, I came from a 'legacy carrier' where our cabin crew are fairly bright....not someone who was sacked from Burger King.

However, we have had instances where passengers panicked and bailed out on their own. One time, during push back and engine start, a CFM 56 torched a bit. One idiot saw this, and before you know it, the over-wing exit was opened and people were jumping out.

As the ticket prices lower (due to the attributes of deregulation), we see more idiots traveling.

We really can't say what happened in this instance, as news reports are usually wrong. At my university, the students who were sharp typically majored in engineering, science, or math. The ones less gifted usually majored in band or journalism. So, it never surprised me that reports related to aviation are typically incorrect.

Fly safe,

PantLoad

Cmon-PullUP

11th Feb 2011, 09:13

This SCCM was according to report in physical contact with the FD but they didn't respond to her because they were busy.

Well, then surely they are working on the problem, and her job is to STAND BY and wait for further instructions, OR in the important cases make sure she get response, eg. slap a shoulder or whatever is required.

But no, she took her own actions and for doing that in those circumstances, she is in the wrong job.

Very dangerous for all pax, regardless of what all the uninformed and non-trained self-loading freight in here thinks :ugh:

Heathrow Harry

11th Feb 2011, 11:30

Presumably she got the brush off and rather than sit and wait she decided to take no risks

She'd have been crucified if the cabin had caught fire

Heathrow Harry

11th Feb 2011, 11:32

"Very dangerous for all pax, regardless of what all the uninformed and non-trained self-loading freight in here thinks :ugh:"

As I said earlier - when you see smoke don't hang around looking at manuals and checklists - get out of there if you can- it really does go to hell in a handbasket very very quickly

411A

11th Feb 2011, 11:40

But no, she took her own actions and for doing that in those circumstances, she is in the wrong job.
Yes, wrong job...at a telephone in reservations would be better.
At least that way she would be less of a danger to others.:}

Some years ago, we had a hostie start an evac because...she noticed slight tailpipe torching from number one engine during start.
She said nothing to anyone, just opened her door and started tossing pax out...both sides.
She was promptly terminated, and from her pay, the slideraft repacking cost was deducted.
This hostie was a silly fool.

AnthonyGA

11th Feb 2011, 12:13

Does it not occur to you that procedures are in place for good safety reasons?

Yes, and one of those procedures is evacuating the aircraft on your own. That's why you get the safety presentation that carefully points out all the exits, and how to open doors, and how to put on life vests, and so on. That presentation is there so that you can get out on your own if you have to. If the procedure were simply to wait for commands, the safety presentation would consist solely of a sign saying "do as the crew tells you." The crew is there as emergency safety technicians, not as police officers.

I've always assumed it is so that passengers can assist CC if required in the event of an emergency. eg If one or more CC have been incapacitated.

If the cabin crew requires assistance, it will explain what needs to be done. The instructions are for passengers who must fend for themselves if for some reason the cabin crew is unavailable.

It had never occurred to me until I read your post that some of my fellow passengers might regard it as an invitation to open a door if they consider it necessary. A troubling thought.

You're welcome to wait for instructions from the cabin crew. If the emergency isn't too life-threatening, that's probably a sound policy. But if it's a dire emergency, I'll leave on my own, and you can stay behind if you want. I'll try to watch you through the windows from my safe 100-meter observation position outside the aircraft—that way I can help the emergency services identify your charred remains.

There may be people who will exit for the wrong reasons; there are even FAs who will do this, sometimes. Real-life emergencies rarely take place as smoothly as they do in training courses or safety videos. But I know enough to recognize dire emergencies in most cases. And there's nothing more dangerous than fire aboard an aircraft, so if I think the aircraft is on fire, I'm out.

As for the cabin crew member who initiated the evacuation on her own in the case under discussion, I think it's better to be safe than sorry. Funny smell + no response from FD = possible fire danger = evacuate now. It's easy to criticize in retrospect, but she did what she thought she had to do. Expensive mistakes made in the interest of safety are preferable to loss of life. I'd rather be on her flight than be on a flight where we all die of smoke inhalation while she waits for a signed authorization form from the flight deck.

Flying-Jock

11th Feb 2011, 12:53

As with all things aviation is it not a case that lessons are learned from incidents and accidents...
At the end of the day no-one lost a life - better this way round learning a lesson and for training to be updated/changed!
I think some of the comments submitted here have been rather harsh...maybe it's a case of "you had to be there" to understand how alarming this situation was!

HPbleed

11th Feb 2011, 14:34

I'm going to reiterate something I said earlier, and made quite a point about it. This was a SMELL of burning. How many people in their own house would jump out the window at the first SMELL of burning?

If there was smoke, then yes, get everyone off, right away. But a smell? Please, seriously get a bloody grip. How many electrical items make a burning smell as they burn out? Most of them, and how many are there on an aircraft? If I had an evacuation for everytime there had been a funny smell on an aircraft I'd have lost count.

A lot of you haven't read the report and are making assumptions on the severity of the scenario. The facts for those who can't be bothered to read:

The cabin crew and senior SMELL burning.
Captain investigates, starts running cxlist to isolate the cause.
The smell in fact starts to decrease.
Cabin crew at rear believe it's getting worse, after being asked by the senior (who I'm sure more likely said - can you still smell burning? and it's getting worse yes? - See where this is going - Leading questions)
Senior is at the front, tries quickly to get Flight Decks attention and can't (instead of shouting if necessary - "I'm going to start an evacuation Captain"), so decides to action it herself.

Flash fires don't just start with a smell, if it was that hot there would be smoke, I can't recall one instance of a flash fire that started with just a smell.

Poor communication from all, and an itchy senior made this relatively common and simple problem turn into a mass of paperwork and headaches.

So, go on then, hands up who answered my first point about jumping out of their first floor window after smelling their toaster burning the bread? Chimps.

411A

11th Feb 2011, 14:47

Poor communication from all, and an itchy senior made this relatively common and simple problem turn into a mass of paperwork and headaches.

Chimps.
Sad but true, and there are far too many of them in the CC ranks, today.
It's all part of the perceived idea that all crew are somehow 'equal' and have the same knowledge.
Sorry...just ain't so.
Most CC are far down the list in the smarts department.:ugh:

rjay259

11th Feb 2011, 14:52

From what the SCCM had said at a recent Refresher course, after speaking with the the FD she asked passengers to exit the a/c via the airbridge rapidly (a rapid disembarkation).
The rear CC not being able to see to the middle of a/c due to a haze (and people standing up) decided that is was better to evacuate via slides.
The SCCM had made a decision after speaking with the L/R4 doors crew and hearing their concerns (for a rapid disembarkation that is).
They had also made a decision on what they saw.

At the end of the day its a 15 page report that doesn't go into lots of detail and leaves a large amount of uncertainty in what everybody was thinking and what everybody did.
We can all say that we would do things differently and that she should be doing something a little simpler, we were not there and sitting in our warm houses with a cup of cha next to us with no mounting pressure, should not criticise.

HPbleed

11th Feb 2011, 14:55

Sorry but that's not what it says in the report. She meant to do it, and would do it again. Another one who hasn't read it. :hmm:

But on the plus side, I agree it's all too easy to criticize from the comfort of ones own home. Maybe Seniors should sit in on our sims to see how we as pilots deal with things, in our way. Not enough is known about each others roles imo.

RatherBeFlying

11th Feb 2011, 15:01

How many people in their own house would jump out the window at the first SMELL of burning?In my house there are four exits for the three occupants -- compare that to a narrow tin tube with fifty semi-obese folks clinging to their cabin baggage between me and the nearest exit.

Of course in my house I do know what the smells are and where they come from and act accordingly.

In a commercial building when the alarm comes on and there is no communication within 15 seconds, I take the fire exit, alarmed or not.

The SLF are generally not educated in the various fumes or tailpipe fires; so prompt communication is key. If the crew fails to keep them in the loop, the proactive ones will be operating the exits.

rjay259

11th Feb 2011, 15:09

Ok Its a 15 page report that doesnt go into great detail, several pages contain pictures of worn out bearings and how a recirc fan goes together.
There are two types of evacuation at thomson, does it actually say that, No it doesnt.
Having spoken to the SCCM at a refresher course, she stated that she started a rapid disembarkation (an evacuation via the airbridge), one thing i didnt say earlier was that she also mentioned was that people were not clearing the airbridge very quickly either so caused a backlog.
The L/R4 doors crew then decided that things were getting worse so to punch out via the rear doors.

Hp I agree with you and think that the cc should come and sit in our sims, would be an invaluable learning exercise for both sides.

M.Mouse

11th Feb 2011, 15:17

Presumably she got the brush off and rather than sit and wait she decided to take no risks

She decided to act outside of her training and company procedures designed, discussed and evaluated to prevent unsafe actions. Her actions were unsafe, unnecessary. The report makes it clear they had a SMELL of burning, no more, no less.

She'd have been crucified if the cabin had caught fire

No she wouldn't. While SOPs may in certain circumstances be inappropriate, which is why flight crew are generally intelligent and clear thinkers able to recognise that case, she would not be criticised for complying with the procedures in which she had been trained. If thick smoke or fire had been visible her actions could possibly be justified, for a smell alone they cannot.

90% of this thread is quite troubling, especially contributions from those who should know better.

Bus Driver Man

11th Feb 2011, 15:55

Lord Spandex Masher,
I have never worked at a company that has required the cabin crew to seek my permission to evacuate. Nor have they been required to let us know they were going either.They are trained to check outside. Hopefully that's what they'll do!So it's perfectly possible that you are waiting at the holding point and for some reason cabin crew starts an evacuation without informing the cockpit?
Ok, no problem, AC is standing still and outside conditions are good.
Meanwhile, you get permission to line up and you start moving when the first passengers start to jump... I don't think it will be a pretty sight.

My company's policy:
Captain decides for evacuation after an inital call.
After this call, checklist for evacuation is being completed. (My main concern are the engines)
If evacuation is required, the captain will make the evacuation call. If it's not required he will cancel the initial call.

Exception:
If there was no initial call from the flightdeck e.g. after an runway excursion (which indicates pilot incapacitation), CCM are allowed to evacuate.

If for some reason CCM feels the need to evacuate, inform the cockpit. E.g. a fire which the FCM don't know about.

Offcourse, the example that IGh has given, where the captain delayed evacuation, was poor decision making from the captain.

alwayzinit

11th Feb 2011, 17:51

I concur fully with the idea of pre stating one profession prior to spouting.

Pilot 3rd generation, Capt for 25yrs.

Ok, the dumbness of some SLF never ceases to amaze me! How many stand up, start getting hand luggage form lockers well before the aircraft has actually stopped. In my experience no passenger yet has beaten the aircraft to the terminal, so stay sat down as you are told to!Jeez!

The thought that some of these so called experts, because they sit in the back alot, inititiating an evacuation, without it being clearly catastrophic, just stuns me. A bit like Stevie Wonder having ago at rally driving if you get my drift!

The addition of SCCMs, Pursers or whatever your company calls the Captains representative in the Cabin, into recurrent simulators is great. We tried it once and got a big thumbs up from those attending........however there were those who didn't turn up :ugh:

The biggest thing that got passed along was how long making an EVAC decision can take.

The time is needed to ensure that it is SAFE to evacuate. Engines shut down etc Emergency services alerted and finally the decision to get people to throw themselves down a teflon covered slide with concrete at the bottom.:ouch:

The fact that only 4 people were injured in this case was frankly a miracle.

So whoever said it, the SCCM in this case should have MADE sure she got a response from the FD crew. It simply was NOT in her perview or anybodyelse's to initiate an evacuation without the Captain's order.

IMHO the SCCM sounds like a loose cannon, should be busted back to a no2 or whatever and retrained in SEP and CRM.

But what do I know!

Lord Spandex Masher

11th Feb 2011, 18:32

Bus Driver Man,

So it's perfectly possible that you are waiting at the holding point and for some reason cabin crew starts an evacuation without informing the cockpit?
Ok, no problem, AC is standing still and outside conditions are good.
Meanwhile, you get permission to line up and you start moving when the first passengers start to jump... I don't think it will be a pretty sight.

It's possible yes. However, I do not think it is probable. Unless it is catastrophic at least one of 'em should have time to contact us.

I said earlier in the thread that I always have the PA selected on my audio panel so I can hear what is going on on the back, I would be aware if they started an evacuation without first communicating with me. Dunno what other people do, maybe it should be SOP. It should be SOP to inform the flight deck as well but it isn't!

Just to reiterate, I am not condoning the actions of the crew on the subject flight just trying to see it from a point of view other than my own.

411A

11th Feb 2011, 20:36

IMHO the SCCM sounds like a loose cannon, should be busted back to a no2 or whatever and retrained in SEP and CRM.

I would disagree...she should be terminated, forthwith.
Loose cannons are not appreciated, nor desired, in the cabin.
Full stop.

PS.
I've seen a few of these 'loose cannons' in several airlines, and they were all shown the door by the HR (and CC department), with very good reason.

Expunged, pronto.:ok:

LongTimeInCX

12th Feb 2011, 04:42

It seems most people would agree, the aspect of how severe the smell of smoke is, remains somewhat subjective.
Perhaps in this instance, erring on the side of caution was excessively cautious.
But like many things, if we weren't there, hard to give anything other than an opinion, however, having read the AAIB bulletin, where it is clear she had been IN the cockpit and knew the cockpiy crew were not incapacitated, I would just give her a nice warm cup of DCM. End of story.

On a more practical note, similar to spandexdude, I tend to have the PA selected on, albeit at a low volume, and whilst some may call me nosey, I like to know what is being said to the SLF. As most of our company PA's are doing nothing other than causing death by PA, (our company do it in a few languages), it is very easy to monitor, as the PA's one normally hears are the routine run of the mill type, and ones brain naturally filters it out or files it away as background music, as one naturally expects to hear the constant drone. I do not find it detracts from my monitoring of the radio, and I'm just an average capacity guy.
However, when you get an odd one, like "You in the red shirt, leave that door alone and sit the f@ck down", it gets noticed.

Also, one thing which I think works quite well for the pilots and the cabin crew, is our "Uh-Oh!" call, which our company introduced years ago.
When we have something occur which is clearly out of the ordinary, we all know it takes a while for certain problems to clarified, assessed, and a plan of action decided.
So, one of the calls we first make is: "Cabin Crew to Station"
They know, A) we are alive, B) All is not well, and C) That any second now, it might be HeyHo, off we go.
It's their clue to get their sh!t in one sock, stand to like a coiled spring, and be ready to go at the first word of "EVACUATE, EV......,etc".
They use the time to get into position, evaluate outside, inside, ready to report anything abnormal they see, they know they are the eyes and ears of the vast area we cant see, hear or smell, and mentally prepare themselves for popping the doors.
It is also reassuring for them, as they know that after the Uh-Oh call, there may be a while before the next call, and more often than not, it is the dulcet calming equivalent of "Cabin crew you may resume your normal duties, Ladies and Gentlemen, blah blah..."
However, in the event an evacuation is needed, they already know we are in control, and are ready to go, but only WHEN COMMANDED, at a seconds notice.

Works for us!

oldbalboy

12th Feb 2011, 10:41

I have read the numerous posts on this thread with great interest with a mixed opinion to many of the comments, most i presume have come from pilots though some a believe from other area's of the industry.

Now its all very well saying 'terminate' the scc involved but a lot more to the situation, a merger with many sop changes in last 3 years hasnt helped, and to be honest crm was not good it doeasnt help when pilots dont respond ( a lot of pilots/cabin crew still have crap crm skills & yes i am entitled to say this i have been cc for 30 years, 20 years as a safety security and crm instructor and still witness both good and bad crm when flying) and the scc should have been more 'forceful in the flight deck as this a/c was parked on stand therefore 'aviate navigate communicate' the first 2 are out of the equation! so would not have been dangerous at this point for scc to interupt pilots to make them aware, also FNC pax are generally much older many slow walkers little wonder the airbridge was getting congested slowing things down, we have a procedure for this situation its called a precautionary disembarkation and a PA for scc to make which avoids the 'E' word if you read the AAIB report her pa was very polite and started ladies & gentlemen!! not attention attention or the like!

Give the lady a break she made a mistake to quote basic crm 'to err is normal', no one is perfect although i have even recently flown with pilots who think they are, she didn't cause anyone to lose their life she was doing what she thought appropriate given the information she was recieving and from what she could see and smell in cabin, following the incident a thorough debrief was carried out and from that lessons were learned a clear notice was issued to cc to remind them of the criteria when 'they' can initiate the evacuation,and its also being covered on joint crm this winter, not so long ago we had a similar situation on an a/c in the final stages of boarding when a smell developed and then cabin rapidly filled with black smoke reducing visibility to nil and the crew used slides quite appropriatly to evacuate the pax as they wern't leaving via the airbridge quick enough, these situations can escalate in seconds and its understandable that the scc was concerned for the safety of her pax and crew.

I do believe in the UK we have a good safety culture not perfect but constantly developing and striving to be better, we learn from mistakes and to learn we need people to be open honest and accepting when incidents occur and changes need to be made, criticising and making sweeping statements about an individual doesnt help in these situations and remember when can all be armchair critics but we were not on that aircraft that evening!

max alt

12th Feb 2011, 12:01

I would suggest that this scenario is discussed at length by all airlines conducting crm refresher.I could facilitate this one for hours with a mixed group of pilots and cabin crew.I really thought that after many years of crm discussion it could not occur in a respected uk airline where the pilots were unaware of an evacuation.
I have also found it enlightening with the input from some of the posters who are clearly passengers ,that they would be prepared to act on there own judgement of a situation. This is to be applauded in a major incident yet questioned in minor incidents when pilots or cabin crew were available to give guidance.Would they go for the armed doors if the bread rolls were burnt taxing out and smelt it when the oven door was opened!/wet start/tail pipe fire and others, Who knows.
As has been said lessons will be learned and I am not a member of the blame group,however from my early days in aviation where crm did not exist to some 30 years later and countless crm courses,has its message got muddled.:uhoh:

Piltdown Man

12th Feb 2011, 13:16

Oldbalboy - Normally, I would go along with the sentiments expressed in your post. I do take your point about changes caused as a result of mergers (and the associated stress) and also about the possible lack of guidance from the flight deck. But the way I read this report is that post incident, in the cold light of day, the SCCM told the AAIB "She added that given similar circumstances, with no rear steps in place and with the very distinct smell of burning in the rear of the aircraft, she would again consider initiating an evacuation." I'm as imperfect as the the next person. I'll hold my hand up and say "I made a mistake." When something untoward (like unnecessarily injuring passengers) has happened, I'll listen, I'll try and learn, I'll change - because that is the only way we improve and make our industry a safer place. But the statement above is from a dinosaur in denial, someone who is unwilling listen or learn. This is why I disagree with you. If I've got this wrong, then I'll apologise and I'll change my new carear suggestion.

PM

AnthonyGA

12th Feb 2011, 13:16

I have also found it enlightening with the input from some of the posters who are clearly passengers ,that they would be prepared to act on there own judgement of a situation. This is to be applauded in a major incident yet questioned in minor incidents when pilots or cabin crew were available to give guidance.

In this case, the pilots had no awareness of what was happening in the cabin, and the cabin crew was unable to properly assess and act upon the situation. That's not a very reassuring situation for passengers. The guidance of the crew in this case was nearly worthless, since they either didn't know what was happening or misjudged it. This is a strong argument in support of taking the initiative if things appear to be going south.

Hopping off the airplane if danger appears to threaten will, at worst, perhaps get you a broken ankle and some legal troubles. Staying on the airplane in a potentially dangerous situation while you wait for the crew to figure things out can cost you your life. If the crew says evacuate, I evacuate. If the crew doesn't say evacuate but there's an obvious potential danger, I still evacuate.

As for evacuating my house if I smell something like burning, I don't do that automatically, since I know my house extremely well, and house fires are often obvious when they occur, so I have time and ability to assess the situation. If I smell something burning in a nightclub or store, however, I head for the exit without trying to guess whether it's a hazard or not. An aircraft is an environment with many people, few exits, and many hidden spots where fires can hide until they abruptly blaze out of control—all of which mean that I evacuate at the first sign of a potential fire. I've read the literature and seen the tests with respect to aircraft fires, and they are just too dangerous to allow anyone to take a chance.

Some safety principles transcend specific domains. Whether one be crew or not, "professional" or not, some concepts remain the same. If you smell something like burning, and you cannot get immediate assurance that it is not a fire, then you leave. It's just simple logic. This FA did not get the immediate assurance that was required for safety, so she evacuated. In retrospect it was unnecessary, but the FA didn't have the benefit of hindsight and she did the right thing. It amazes me that anyone would want to fire her for failing to obtain the permission of the Lord Captain. If there had been a fire, and had she not evacuated, she'd be drawn and quartered … if she survived.

oldbalboy

12th Feb 2011, 14:13

Piltdown man totally agree with you regarding her comments to the aaib hence the fact the company issued the notice making it very clear when they can initiate (before this the guidance was when the situation is life threatening?? one persons perception of this could be very different to anothers so the company clearly defined it with examples).

I wasnt there but my view point would have been to get the captains attention if they failed to respond i would have to act on my own initiative with what i could see hear and smell personally as nothing visible to crew in cabin ie smoke/flames or even a haze or misting i would have stuck to a rapid disembarkation using airbridge as to me that is not immediatly life threatening but be ready to upgrade to full evac if conditions deteriorated.

I was in a situation many years ago ( engineer & dispatcher shouting at me fire in avionics bay get everyone off now f/d door slammed in my face no response to alert call! did exactly that rapidly deplaned pax without handluggage up air bridge its suprising how fast they respond when all the crew are shouting at them!).

Evacuation should be last resort ie when life threatening as people can get hurt or worse using slides, one of the comments on the report was some pax suffered minor injury as the result of other pax colliding with them at bottom of slide, as i mentioned in earlier thread the pax profile on this route is mainly elderly/slow walker or infirm they cant get off the bottom and run like younger people and would have hoped once having initiated it the scc could have shouted back into f/deck we are evacuating am sure they would have responed then!

The AAIB made recommendations in their report and these have been adopted by the company and this has subsequently been passed to all crew via a safety notice very soon after the actual event and is being covered on this winters refresher course and on joint crm.

M.Mouse

12th Feb 2011, 16:26

If you smell something like burning, and you cannot get immediate assurance that it is not a fire, then you leave.

Actually it was a failed bearing, nothing was burning.

It's just simple logic.

No it is not. Re-read previous posts from people who actually know what they are talking about.

WingSlinger

12th Feb 2011, 17:02

I have never worked at a company that has required the cabin crew to seek my permission to evacuate. Nor have they been required to let us know they were going either. One shouldn't assume but one will that there is a fair chance that we would realise. Loud PA, doors opening, stamping of feet, screaming(!).

It must have been the quietest, most orderly, evacuation ever for the flight deck not to have noticed.

But wouldn't the evacuation include the flight deck crew? Shouldn't you be notified to evacuate?

SlideBustle

12th Feb 2011, 17:57

As another Cabin Crew member for a large UK airline (not the one concerned) I do think some people should really cut the SCCM some slack!

In my airline if the situation is not Catastrophic the Flight crew initate... we wait for instructions or attempt to communicate with them. However if it is Catastrophic we can initiate WITHOUT prior permission from Flight Crew... We have Evacuation Alarms on most aircraft and most doors which not all airlines have and we use them if possible/fitted to our door. Catastrophic at my airline is defined as situation that is unmanageable and poses an extreme and immediate threat to life or the pilots are likely to be incapacitated. This sounds similar to most airlines including TOM.

From reading the report I wouldn't consider the situation catastrophic, like most people on here, and if she really wanted to evacuate she should have asked the F/C first... Especially as she had already been in so had communicated beforehand. Also, as only Doors 4 was used (and 2 which was normal disembarkation) She could have popped her head in IF she was at Door 1(I presume she was) and let them know.

However, as mentioned many times before, everyones perception of ''life threatening'' and ''catastrophic'' can differ, it seems the airline has reminded all crew of the procedure and what can be classified as catastrophic. We were not onboard that aircraft, under pressure, it is easy to criticise the SCCM however she (and the rest of the crew including Flight Crew) were all under pressure. She made that decision... Probably not the best, however lessons have been learnt and she was being overcautious. Which in most cases is better than not taking things seriously which has happened before and led to loss of life.

I also think - what if the SCCM was not getting an answer from Flight Crew - I know they were investigating but what if they thought it was nothing but the crew in the cabin felt, under their experience that it was worse? Remember she did use the alert button which on the 757/767 (at my airline anyway) contacts FD and CC at the same time.. She did not get a response from Flight Crew... There may be more to the story... However either way CRM doesn't sound to be at it's best here to say the least!

I think all airlines should cover this in CRM and my airline does cover catastriophic a lot. Ironically we used to have examples however now the two examples I mentioned are the criteria. It is up to ones judgement. Of course in this incident, CRM was not at it's best but lessons can be learnt... The SCCM is not a failure, she would have been debriefed, she probably followed SOP/procedures otherwise but got carried away. Not saying it is right, but remember in CRM we learn from things...

Less of the blame, let's learn from this and improve safety that way rather than pointing a finger! She didn't cause loss of life!

oldbalboy

12th Feb 2011, 18:31

well said slide bustle

AnthonyGA

12th Feb 2011, 20:37

Actually it was a failed bearing, nothing was burning.

If you don't know what a failed bearing smells like, how do you know that nothing is burning?

411A

12th Feb 2011, 20:54

If you don't know what a failed bearing smells like, how do you know that nothing is burning?

Try common sense, AnthonyGA, rather than using what little totally inadequate 'knowledge' :rolleyes: you might possess about large airline ops.
Which, all things considered...ain't much.:ugh:

PantLoad

12th Feb 2011, 23:11

At my former company, from which I retired, we had (still have, I suppose....but, it's been several years since my departure) very detailed and explicit SOPs. Very good operation, I feel....

It's an odd thing to say, but, in a way, good SOPs take the guesswork out of flying. Less need for judgement. Less need for aviation skill. Less need for knowledge. This is not a good thinig....but, over the years of me 'constantly conforming' to 'the way they want it done', I've come to be quite comfortable with this. And, professionally, this has served me well.

In this instance (the point of this thread), SOPs would have circumvented the problem. Good, solid, well-thought-out, industry-conformaing, authority-sanctioned SOPs. Ones that work, ones that are practical, ones that make sense.

Following such SOPs are great....it's like being a little kid with a security blanket. Makes one feel warm and fuzzy. Flights, routinely, end without incident. Rain or shine, day or dark....without incident.

SOPs are a beautiful thing.....

So, did the lead flight attendant follow SOPs? Did the pilots follow SOPs? Did SOPs exist for this type of situation? Did someone, at some point in the evolution of civilization, sit down and think such a situation could manifest? Did someone or 'someones' develop an SOP for such a situation? Was the SOP well-thought-through, did it conform to industry standards, was it FAA sanctioned? (Or JAA or whatever....)

Ah, yes.....

Fly safe,

PantLoad

Bronx

12th Feb 2011, 23:16

Try common sense, AnthonyGA, rather than using what little totally inadequate 'knowledge' you might possess about large airline ops.

According to his profile AnthonyGA is a FlightSim captain.

411A

13th Feb 2011, 05:38

According to his profile AnthonyGA is a FlightSim captain.
So it seems, yet he continues to make a fool of himself with his odd statements....must be something in the local drinking water supply.:rolleyes:

TiiberiusKirk

13th Feb 2011, 08:18

Surely there must be some form of warning on the FD that a door or doors are open when the craft isn't in a parked/shut-down condition?

What about the deployment of slides, isn't that worthy of a FD alarm?

spekesoftly

13th Feb 2011, 09:22

See post #60

......... on the B757. There are no indications on the FD that slides are deployed. You can't even tell if they are armed or disarmed .........

BOAC

13th Feb 2011, 09:34

Surely there must be some form of warning on the FD that a door or doors are open when the craft isn't in a parked/shut-down condition?

a) To avoid confusion - the a/c was in a "parked/shut-down condition". Passengers were disembarking via a jetty as I recall - no engines running to eat naughty passengers. The c/crew would know this because the seat belt sign would be off. The pilots would have expected the rear doors to be opened at some point in the turn-round.

b) Yes, there are indications in the F/deck that a door/doors are open

Basil

13th Feb 2011, 10:30

It's not a great idea to post the wording of our PA alert calls on a public forum.

Mr Optimistic

13th Feb 2011, 10:48

SLF here: was the word 'emergency' used in the PA announcement ? Does an evacuation by itself mean that an emergency situation has been detected. Can CC declare an emergency ? Not impressed: if I was interviewing I would be investigating if panic was a factor in the decision making.

BOAC

13th Feb 2011, 11:57

It's not a great idea to post the wording of our PA alert calls on a public forum. - any clue as to whom that was addressed? In any case, I fancy a touch of paranoia here, since many airlines have different calls. I can see nothing to concern me.

Picking up on 'rjay' in post #71 (I have only just noticed!) From what the SCCM had said at a recent Refresher course, after speaking with the the FD she asked passengers to exit the a/c via the airbridge rapidly (a rapid disembarkation). - if this is THAT purser and THAT incident THAT is not what she reportedly said. She did NOT order a "rapid disembarkation" nor did she ask the passengers to 'exit the a/c" - she said 'EVACUATE". I quote from the report

"Please evacuate the aircraft as quickly as possible. Leave all hand baggage behind.”

One would expect then, a properly trained rear crew to react accordingly and deploy the slides (as they did). I still accord with Checkboard that it was an incorrect and unfortunate PA. I am convinced she did not intend an 'emergency evacuation' in any way.

Bus Driver Man

13th Feb 2011, 12:02

It's not a great idea to post the wording of our PA alert calls on a public forum.

Indeed. Edited my post.

blue up

13th Feb 2011, 12:22

So, night flight, on stand at Glasgow (no rear steps or GPU), smell of burning, APU switched off (dark and with PEEPLS lights on), only one door to get 233 people off. Engines off, front door open, slides disarmed, pax standing in aisle, no visual contact between rear crew and either FD or other CC, no instant access to CC checklists (dark and probably manuals stowed safely in OH lockers behind milling pax). Snap decision needed to make up a call to get pax moving to evac...well, clear the aircraft, but not by using the 'slide-blowing' standard call. Strange how you can't come up with a word like "Vacate" or "De-plane" when you are in a hurry but might grab at "Evacuate" or something similar when the heat is on.

she returned to the cabin she announced, in a calm manner, over the passenger address system: “Please evacuate the aircraft as quickly as possible. Leave all hand baggage behind.”

Reminds me of that skipper who shouted "Open the door, we've got some late passengers" which must've sounded quite like "Open doors, evacuate passengers" because the slide got blown. I'm told he got 'terminated' and has spent the rest of his life pontificating on Pprune:E

After those pax went down the slides it reads as if the AFRS instructed the CC to follow the fire crew out the front rather than going down the slides with the pax.

Does this all sound like an accurate description of the events?

Mr Optimistic

13th Feb 2011, 13:40

As a SLF I think that if I heard the word 'evacuate' then I would be anticipating a ride down the slide. Ditto 'leave all had luggage behind' in any instruction means timeliness is of the essence. But there wasn't even a need to 'hurry up' the de-planing was there ? Why was any haste deemed necessary when the FD were aware and the 'situation' (aka smell) hadn't markedly worsened ? As for evacuating the building but not telling the staff on the top floor............Apologies if I am taking some things as facts when there is uncertainty but frankly I am with the 'Aldi' camp.

Georgeablelovehowindia

13th Feb 2011, 13:42

OK, so lessons learned, or perhaps re-learned with regard to the importance of CRM, and no great harm done, eh? The passengers involved will no doubt have subsequently expressed their gratitude in letters to Thomson.

I'm being cynical, of course. In these litigious times the writs claiming for distress and injury will have been descending like snowflakes from the sky. I can only guess what the eventual settlement bill will run to, probably well into six figures. Yes, really.

It happened to my airline, in different circumstances - an inflight engine shutdown - a breakdown in CRM, and the senior cabin crew member, on her own initiative, having the passengers assume the 'brace' position for the landing. Again, no physical harm done, but the writs for distress duly came snowing in, and the eventual legal bill was a jaw-dropper.

Edited to add that I'm not saying that the financial implications of one's actions should sway anyone away from having the passengers' well-being in mind first, last, and always. It's just a sad reflection on our times.

Heliport

13th Feb 2011, 19:53

Does this all sound like an accurate description of the events?

Rather than speculate, here's the AAIB description of the events:

History of the flight
G-BYAT landed at Glasgow International Airport after an uneventful flight from Funchal, Madeira. Shortly after coming onto stand, after passenger disembarkation had commenced, via door L2, the flight crew became aware of an acrid smell that appeared to be getting stronger. The co﷓pilot left the cockpit briefly, to identify whether the smell was also present in the forward galley; it was and was increasing in intensity, but there was no visible smoke in the cabin. The co-pilot returned to the flight deck and informed the commander, who turned off the APU and the Utility busbars to isolate electrical power to the galleys, before completing the relevant elements of the Smoke Removal checklist from the Quick Reference Handbook. The fire services were then requested via the ATC ground controller. At this stage it was apparent to the flight crew that the smell was dissipating.

At the same time the senior cabin crew member (SCCM) and other cabin crew members were aware of the smell. She went into the flight deck and confirmed with the flight crew that the odour was also apparent there.

The SCCM then returned to the forward cabin and contacted all the crew using the Alert Call on the cabin interphone. They confirmed that there was a pungent burning smell throughout the cabin; there was no smoke, but the smell was strongest in the rear of the aircraft. However, the flight crew did not respond to this call.

The SCCM returned to the flight deck to update the commander, and while the flight crew acknowledged her presence, she did not convey her concerns on the need to evacuate the passengers as the flight crew were busy dealing with the incident. She considered that she needed to disembark the passengers as quickly as possible and so, as there were no steps at the rear of the aircraft, when she returned to the cabin she announced, in a calm manner, over the passenger address system: “Please evacuate the aircraft as quickly as possible. Leave all hand baggage behind.” The cabin crew at the rear doors re-armed their doors and deployed the slides. A total of 43 passengers used the slides, with four of them receiving minor injuries.

Once the cabin crew had checked the cabin was clear of passengers, they were directed off the aircraft, via the airbridge at door L2, by the AFRS who had boarded the aircraft via the airbridge wearing breathing apparatus. The passengers who had evacuated the aircraft were assisted at the foot of the slides by the AFRS and airport personnel.

After the evacuation a number of comments were made by passengers concerning an apparent lack of assistance and direction given to them outside the aircraft. The airfield operator considered this was due to some agencies not being initially informed of the incident. In addition, there were reports of passengers, coming down the slides, colliding with those in the process of leaving the bottom of the slides.
Following the event the operator’s maintenance engineers traced the problem to the right recirculation fan, which was described as “barely running and giving off the burning smell”. The unit was replaced, following which the air conditioning packs and fans were run with no further smell of burning. There was no other damage to the aircraft.
SCCM comments
Following the event, the SCCM commented that the whole incident, from the initial smell to the time of the evacuation, happened very quickly. She added that given similar circumstances, with no rear steps in place and with the very distinct smell of burning in the rear of the aircraft, she would again consider initiating an evacuation.
Operations Manual
Part B of the operator’s Operations Manual includes the following in the section on evacuation drill, dealing with the command for evacuation and leaving the aircraft:
‘ On evacuation command
● In most circumstances the evacuation command will be initiated by the Commander. This will immediately cause the cabin crew to put into action their evacuation drill. If communication is impossible with the pilots and the situation is life-threatening to passengers and crew (e.g. breaking up of the aircraft, an uncontrollable fire in the cabin or ditching), the ICM will initiate the evacuation. However circumstances may also dictate that any cabin crew member initiates the evacuation if faced with a similar situation.”
Leave aircraft
● Cabin crew should leave the aircraft once all passengers have evacuated, or if at any time the area becomes too dangerous to remain inside.
● Cabin crew to take control of groups of passengers and move them away from the aircraft upwind (using megaphones).
● Attempt to keep passengers together.’
Discussion - evacuation
In this particular case, it is clear that the member of the cabin crew who initiated the evacuation was concerned that the situation in the cabin was potentially life threatening. However, the flight crew were not incapacitated and it is evident that verbal communication with them would have been possible had the member of cabin crew persisted.
Safety actions
Following this incident, the aircraft operator issued a Cabin Crew Notice reminding cabin crew of the circumstances when an evacuation can be initiated without it being ordered by the commander, and of the cabin crews’ responsibilities for the evacuated passengers.

[Captain's flying experience: 18,000 hours of which 13,000 were on type.
SCCM's flying experience not stated.]

.

overun

14th Feb 2011, 01:09

411A, do you run IQ checks on recruitment ?

and your competitors ?

SlideBustle

14th Feb 2011, 02:35

To be honest, she didn't say she would ''do the same'' she would ''consider''... if there was a different situation it may be worse... that is what she could of meant.. although of course she could have made the statement that she would do the same in that EXACT situation - which I would hope would have been addressed.

I think, 411A you are being a bit harsh here... Hopefully this SCCM hasn't seen your comments they would probably be mortified! This SCCM did not show terrible safety standards... as stated overreacted... crew CAN initiate an evacuation if they think it is life threatening... OK in this situation it was probably a bit OTT - however the perception of life threatening varies from person to person. If she had evacuated due to a bit of steam coming from the cottage pie in the ovens then I would be thinking some retraining is needed.

It is right she should and could have spoke to the Flight Crew - CRM broke down, however this situation is nowhere near as bad as many CRM breakdowns from the Flight Crew members in many accidents who didn't take situations seriously and this caused loss of lives.

Not excusing the loss of CRM or overreaction however to insult someones intelligence when infact, they were acting in good faith - ie ensuring safety. OK there was injuries and in this case the risk of injuries WAS greater than staying onboard so probably not the best. However who knows what she thought when she was stood at Doors 1 looking aft, passengers in aisle, pilots not responding to the alert call on interphone (it mentions this in the report)

However I think this discussion is good so that we (both sides of the FD door at all airlines) can learn from these incidents improving CRM.

david1300

14th Feb 2011, 03:13

@411A: you said "Let's see, smell of 'burning' but no apparent dense smoke nor fire, said SCCM would 'do the same'."

You haven't even understood (maybe you haven't even read what was said in the report) leaving out the word CONSIDER in your caustic and slating response. Seems to me your ability to comprehend what is going on and make appropriate decisions may be just as lacking as you claim for the SCCM. And this with the benefit of the printed word in fornt of, under no pressure.

Could be that you are also, to use your word, an A$$. It would be nice if next time you read fully and COMPREHEND before shooting off at the keyboard.

fergineer

14th Feb 2011, 03:45

So 411A you dont listen to what your FE says, all your copilots are next to useless, you dont trust your cabin crew cant remember if you trust your groundcrew...... so who do you trust on your aircraft? Bet I would not last very long in your outfit and there would be fun words spoken on the flight deck that is for sure. I wonder how many crew shudder when they see your name as captain on a long trip..... Must be lonely drinking on your own on stop overs.
The SCCM made a judgement call whether it was right or wrong as she could not get a word in with the Flight Crew (you were not the captain were you) If it had turned to custard she would have been the undoubted hero of the show. As for calling her names, I really do think you should give it a rest and retire.

AnthonyGA

14th Feb 2011, 05:48

Try common sense, AnthonyGA, rather than using what little totally inadequate 'knowledge' you might possess about large airline ops.

Unless airlines are giving pilots comprehensive training in the hundreds of types of smells that one might sense aboard an aircraft and what they mean, I doubt that they are any better at recognizing an overheated bearing than I am. And historical incidents prove that pilots often don't know where a smell is coming from; and if they are prudent, they treat strange smells as potential fires or chemical contamination, as they should. If they are imprudent and dismiss unidentifiable smells as harmless, sometimes bad things happen.

Even an airplane mechanic might not recognize the smell unless he has already encountered it in the past. And pilots are as different from aircraft mechanics as I am.

It's not really a question of airline ops; it's a question of fire safety, which crosses the boundaries of all industries. Airliners are particularly vulnerable to fire, but beyond that, the general principles of fire safety still apply.

Genghis the Engineer

14th Feb 2011, 07:25

One imagines that the criticism of the SCCM would have been far greater if this had been a genuine fire, the cockpit crew HAD been incapacitated, but she'd kept on wasting time trying to talk to them rather than evacuating the cabin. I'm quite sure that she knows that also, hence her comments about considering similar actions in the future.

As an aside, in the operation I work in (big research aircraft, lots of electrical equipment on board), we've recently revised cabin drills to separate "fire and smoke" from "heat and fumes" with different sets of actions, but recognition that the second has potential to escalate to the first. Discussing this with both pilots and CCMs, this clarification of the differences - rather than leaving people to make a judgement call - has been well received.

G

411A

14th Feb 2011, 07:56

The SCCM made a judgement call ...
A very poor one, it would appear....hardly appropriate for her position.
Boot her firmly out the HR door to avoid further difficulties on her part.
I expect there are plenty of other folks in the company's employ that could do the job far better.
Bet I would not last very long in your outfit
Quite likely.;)

mary meagher

14th Feb 2011, 08:17

Having read my personal copy of the AAIB report, permit me to make some observations. I have attended a lecture at Cranfield, and visited the mockup where trials to improve evacuation proceedure take place. Volunteers were used in tests; they were too orderly unless promised a cash reward, that had the effect of producing chaos, as people climbed over seats, stepped on everyone else, and BLOCKED THE EXITS! And those slides are pretty high off the ground too, I would certainly hesitate on the brink.

I also have experienced panic as SLF. It is absolutely terrifying when the cabin fills with any kind of strange vapor, be it steam, smoke, fumes, or burnt toast.

So the most dangerous thing is panic. Studies show that regular commuters on business flights are most orderly and experienced, and so survive. But old women and children just get in the way and are trampled by ordinary blokes in a panic. Only one way out, and fumes in the cabin? Enough blokes have frankly stated on this thread that they would take personal action to get the hell out. And Cranfield studies have shown that in that case, the exits get blocked!

Most on board the USAir flight that arrived in the Hudson River were commuters. Able bodied.

In short, I fully support the action of the SCCM. Hindsight is all very well, and although perhaps she should have persisted in trying to communicate with a busy flight deck - in the event of fumes or smoke, not only is there potential for catastrophic fire, but the potential for panic as well. In which case, more than one exit, please, for my family.

captjns

14th Feb 2011, 08:36

Can't lay full blame on the SCCM. She was given a set of tools, during here training, to be used during here tenure with the company.

While the report states that only 43 used the slides... does anyone know how many passengers were actually still onboard while deplaning the aircraft?

I do have one question. If the smell was more pungent in the aft section of the aircraft, why not re-direct to a forward exit.

At the end of the day no lives were lost. Is it really worth the risk when it comes to fumes, especially of an electrical nature.

Afterall... how many remember the Air Canada DC-9? June 2nd, 1983? The one with the aft toilet flush motor? How many people died?

DCA83AA028 (http://ntsb.gov/ntsb/brief.asp?ev_id=20001214X43285&key=1)

http://ntsb.gov/ntsb/GenPDF.asp?id=DCA83AA028&rpt=fi

strikemaster82

14th Feb 2011, 09:37

I'm an airline pilot, flying since 1982.

Pilots do not want their passengers to come to any kind of harm. They recognise that if slides are used, people get hurt. This SCCM should be re-trained but by her own comments she demonstrates that she may be unsuitable for the role.

Procedures are there to be followed. In my airline the cabin crew are shown photos of aircraft situations and are asked to state if they are clearly catastrophic. As someone said, if you have time to think about it, it isn't catastrophic....

Macho passenger types who would be prepared to initiate their own evacuations at the slightest sign of trouble are a menace to themselves and those around them. Contrast this, a slight burning smell, with the tragic accident at Cork the other day, and it can be seen that in this incident, passengers were injured when they need not have been.

411A

14th Feb 2011, 09:43

Pilots do not want their passengers to come to any kind of harm. They recognise that if slides are used, people get hurt. This SCCM should be re-trained but by her own comments she demonstrates that she may be unsuitable for the role.

Procedures are there to be followed. In my airline the cabin crew are shown photos of aircraft situations and are asked to state if they are clearly catastrophic. As someone said, if you have time to think about it, it isn't catastrophic....

Macho passenger types who would be prepared to initiate their own evacuations at the slightest sign of trouble are a menace to themselves and those around them.

Well said.

Callsign Kilo

14th Feb 2011, 09:49

A very poor one, it would appear....hardly appropriate for her position.
Boot her firmly out the HR door to avoid further difficulties on her part.
I expect there are plenty of other folks in the company's employ that could do the job far better.

Poor decision or not; are we in the business of catapulting someone directly into the staff car park with their P45 in hand for every fvck up? Granted; a poorly orchestrated or indeed unneeded evacuation can claim lives unnecessarily. However equally, an airline with a reputation of kicking people into touch whenever they perform something which leads to question can instil a slight instinct of paranoia and fear among staff; as a result performance suffers. As I have read, the safety considerations made by the AAIB went along the lines of the airline in question directing reference to their SEP manual with relation to evacuation without a commanders order. Hopefully this can and will be used to enforce further training and raise levels of competency in a positive sense. Sacking someone doesn't. This incident isn't a case were complete and utter incompetence or a complete disregard to the rules lead to injury and death.

To be honest 411A, I cannot make up my mind whether I'd be happy in your airline or not. Obviously it would be fantastic to be in awe of someone, like yourself, who is incapable of making a faux pas however on the flip side I would personally be in constant fear for my job on the basis of being human. Humans sometimes make errors. It's how we deal and beforehand prevent these errors which is important.

Bally Heck

14th Feb 2011, 10:03

Heliport

14th Feb 2011, 10:16

mary meagherHaving read my personal copy of the AAIB report
Do glider pilots have special versions? :confused:
Hindsight is all very well That's an interesting contrast to your sarcastic comment on another thread about "the usual overexcited emergency vehicles in attendance" following a report that an aircraft had crashed on a road near Bicester during evening rush-hour traffic.
It turned out that the aircraft was a glider that had crashed across the road without colliding with any traffic, very narrowly missing a house, and fortunately neither the pilot nor anyone else was injured.
Hindsight all very well?

Bally HeckWhich part of getting passengers safely out of a smoke filled cabin is open to criticism?It may or may not make any difference to your view but, in the interests of accuracy:
There was no smoke.
See AAIB Report (http://www.aaib.gov.uk/cms_resources.cfm?file=/Boeing%20757-204,%20G-BYAT%2002-11.pdf)

strikemaster1982 Macho passenger types who would be prepared to initiate their own evacuations at the slightest sign of trouble are a menace to ....... those around them. I agree. :ok:

H.

rsuggitt

14th Feb 2011, 10:30

A couple of things occur to me.....

[before I mention them I should announce myself to be a 300-hour PPL and a 1000-hour SLF]

Firstly, it's clear there are mixed opinions about this SCCM. I wonder if those who are predminantly critical are FD, and those who are praising are SLF. A survey might be interesting.

Secondly, I watched a TV programme at the weekend about aircraft safely. It was said that a fite incident can go from zero to fatal in 90 seconds. Anyone disagree with that ?

Bealzebub

14th Feb 2011, 11:02

Which part of getting passengers safely out of a smoke filled cabin is open to criticism?

I don't contribute to these fora too much any more, or indeed read them (too much), for reasons apparent in this thread. But gentlemen, with the best will in the world, and no hindsight, would you rather be toast in an aircraft cabin, or on the apron in Glasgow "doon a slide"?

"The smoke filled cabin" part?

The debate centres around the SCCM initiating an evacuation in the circumstances that were present at the time. There is no mention of a smoke filled cabin, more of a pungent or acrid odour. There are established protocols that don't appear to have been fully followed here. That isn't to say that the actions taken were other than with the best intent, but that Doesn't negate the risks and damage that might have been avoided if those procedures had been complied with.

Smells of burning are of course always taken seriously, but the cause may be anything from detritus in an oven, to moisture on a light fitting, to equipment warming up after an overnight cold soak. You don't send passengers down a slide simply as a precaution.

Sometimes you get burning smells at home. You identify them and try and resolve them. I doubt you call 999 (911) and evacuate your family unless more serious evidence manifested itself. Even if that were not the case, the process wouldn't likely cause injury to them.

Fire or Smoke in the confines of an aircraft cabin is a serious matter, however that doesn't mean that each and every smell, fume or odour event is cause for injuring a proportion of your passengers by sending them down slides. If it was it would be happening many times a week!

The discovery channel is all very well, but in the real day to day world, measured and sensible judgments in accordance with established operating principles need to be, and are exercised every day.

blue up

14th Feb 2011, 11:36

It seems true that...The debate centres around the SCCM initiating an evacuation in the circumstances that were present at the time

More relevant is the fact that she didn't INTEND for it to be a case of blown slides. She planned to speed up a slow disembarkation into a rapid disembarkation of the passengers but the words came out wrong. None of the words she used are in the SOP for an emergency evac. She didn't tell anyone to pull the handle, did she? Anyone suggesting that she told the CC to blow slides is guilty of exactly what they are accusing HER of, aren't they?

Might I humbly suggest that a 5-page AAIB report is not sufficient for Pprune posters to gain a full view of the story.

11,000hrs on 757/767, 8yrs CRM instructing for a large UK airline.

Mr Optimistic

14th Feb 2011, 11:42

where was that then. Sheesh. Passenger, nasty smell of burning. Worry. Expect CC to calm my nerves, crew are aware sir, nothing to worry about. Crew were aware and there was nothing to worry about, so what then happened ? Tell people to evacuate and suddenly you are not surrounded by fellow passengers but by Other People Who Are In My Way. As for not telling the FD: were the over wing exits used, engines off. Did this type require flaps to 40 degrees to assist slide off. Lucky, but career ending in my view.

Bealzebub

14th Feb 2011, 12:01

More relevant is the fact that she didn't INTEND for it to be a case of blown slides. She planned to speed up a slow disembarkation into a rapid disembarkation of the passengers but the words came out wrong. None of the words she used are in the SOP for an emergency evac. She didn't tell anyone to pull the handle, did she? Anyone suggesting that she told the CC to blow slides is guilty of exactly what they are accusing HER of, aren't they?

Yes indeed. Hence the bit you didn't quote.

There are established protocols that don't appear to have been fully followed here. That isn't to say that the actions taken were other than with the best intent, but that Doesn't negate the risks and damage that might have been avoided if those procedures had been complied with.

I entirely agree with you that a 5 page AAIB report doesn't necessarily tell the whole story, but it is more than most of what is written here normally relies on. You will understand that the reply I gave was specific to lay observers making comments based either on television documentaries or the idea that a full evacuation is somehow merited in any similar situation.

blue up

14th Feb 2011, 13:13

Sorry if it appeared that I was having a go, Bealzebub. Should have mentioned that I agreed with your post rather than leaving it looking like a criticism of it.
I just copied one phrase from your post since it highlighted exactly with what I was trying to tie down.

Too many suggestions that someone should be sacked for something that was hinted at in a short report without going to the bother of finding out further facts.

As to the overwing exits, the -204 has slides at doors-3 that drop down onto where the baggage loaders are going to be parked. Doors-2 might also be blocked by honeywaggon or baggage loading equipment. Door-1R would most likely have the ambilift on it. So, now you have 233 pax to offload via 3 doors.

Darkness, smell of burning, somebody accidentaly saying the "E-word" and slides get blown. In CRM we call it confirmation bias. I'd rather fly with CC who had learnt from this than to see them fired and replaced, as 411 etc have suggested. We prefer to learn from mistakes in a no-jeopardy environment so that nobody feels pressured to avoid having to make a descision for fear of reprisal.

411A

14th Feb 2011, 20:22

She planned to speed up a slow disembarkation into a rapid disembarkation of the passengers but the words came out wrong.
Marks of a poorly trained, non-thinking amateur.
That is precisely the reason the SCCM should be replaced...and shown the door.

Fredairstair

14th Feb 2011, 20:45

Funnily enough, one of the differences with this airline is that we have highly experienced cabin crew that are able to exercise judgement. Personally, that makes my day out much easier and I'm very happy to work with them. I don't know if this Cabin Manager got everything right, however I would point out that the end result was fairly satisfactory.

ps, a question to Mr Arizona; When did you last operate with cabin crew?

411A

14th Feb 2011, 21:11

When did you last operate with cabin crew?
Last month...and will again, next month.
Properly trained, so that their judgement is not called into question.

dash6

14th Feb 2011, 22:42

411b All your cabin crew are perfect then. Trained them yourself,did ya?

PantLoad

15th Feb 2011, 00:31

Oh how I love these discussions!

First step: Develop proper SOPs. This is easily said, but very difficult to
accomplish. (There was a point in my career when I thought this was an
easy process, until I was tasked to develop SOPs. Then, I learned.)

And, the system of development must provide for revision, as we learn shortcomings, problems, etc. Part of this process must include a channel
for feedback from the end users. In other words, the SOPs have to work!

Second step: Proper and thorough training in these SOPs. Too many less-than-legitimate operators take this step for granted. "Here, read the
book and carry on." This doesn't work. "Spoon feeding" is the key.

Third step: In management terminology, this is the 'control' step. The
operator must monitor and evaluate the compliance process. If there is a problem, the reason 'why' must be determined. It is a very common mistake by management types to blame individuals for lack of compliance. In many cases, the problem is with the SOP, not with the individual. It takes a clever managment person to delve deeply into why the world is not turning as planned.

411A is correct, although he did not go into such detail to articulate his communique. The only caution I have is that, before we condemn an individual, we must first look at the total picture, the SOP itself, the training process, and most importantly the control process.

It's been my experience (almost 40 years) that, in most cases, the problem is with the system, not with the individual.

Show me an airline with good SOPs....ones that work, are practical, relevant, etc., and I'll show you an airline that has very few incidents/accidents. Following the three steps listed above will ensure that things like this (the topic of this thread) do not occur in line flying.

Juud

15th Feb 2011, 15:31

Discounting our resident Fountain of All Knowledge and the usual bevy of instant blame-finders, this is a very interesting thread.

In addition to the excellent summing up by PantLoad of the importance of SOPs, did CRM also play a role here? The core of the fifth phase of CRM is the principle that human error is both inevitable and a valuable source of information as well. Since error is inevitable, CRM can be seen as a set of error antidotes with three lines of defense.

The main cause of this incident appears to me to be a failure in communications between cockpit and cabin crew. This vital communication seems to have failed in two, possibly three instances.

Main comms failure:
The SCCM returned to the flight deck to update the commander, and while the flight crew acknowledged her presence, she did not convey her concerns on the need to evacuate the passengers as the flight crew were busy dealing with the incident.

When effective communication is at work, what the receiver decodes is what the sender sends. A breakdown in the communication process may occur if the intended message was not encoded or decoded properly. There may also be barriers in the transfer process including: noise, vibration, radio clutter, cultural differences, distractions, fatigue, stress and incomplete messages. Lack of common experience is a major cause of communication breakdown in a cockpit. A communicator’s words cannot communicate the desired meaning to another person unless the listener or reader has had some degree of experience with the objects or topics to which these words refer. The English language can be very confusing; due to the fact that several words in the language mean different things to different people. This is the cause of confusion between what is said being received differently from what is really meant to be interpreted by the receiver. This hurdle to the communication process can be attributed to the pairing process, and specifically the cultural differences between crewmembers. Both verbal and non-verbal communications may be interpreted differently, and this may cause problems during flight, particularly in high-workload situation.
Power Distance (PD) is the distribution of “power” among individuals and groups in a society, and how inequalities in power are dealt with in these societies. Societies with a low PD believe that, inequality should be minimized, all people should be interdependent, and hierarchy is an inequality of roles. In practical terms, PD reflects that there is an unequal power relationship in the cockpit, and a subordinate should not question the decisions or actions of their superiors. The results of a cross-cultural study conducted in 2001, showed that in cultures with a high PD safety might suffer from the fact that insubordinates may not have the ability to speak up when they should, or are unwilling to make inputs regarding leaders’ actions or decisions (Baron, 1997).

There was a clear failure of communications when she stepped into the cockpit, with the result we are now discussing.
Cockpit and cabin crew can be said to hail from different cultures. They use language differently, they deal with completely different realities & challenges in their day to day work, and have different skill sets.
How much training in cross cockpit-door communications does this operator provide for its cockpit and cabin staff? Are its pilots and CC aware of their different communication styles and have they been trained in effective two-way communications under stressful circumstance?
A proper awareness of, and respect for, the chain of command is essential for a safe operation. Too much "respect" may in this case have led to a failure of communicating forcefully with clearly busy pilots.

When she returned to the cabin she announced, in a calm manner, over the passenger address system: “Please evacuate the aircraft as quickly as possible. Leave all hand baggage behind.”
In a non-standard situation you may need to use non-standard phraseology. Is the possible need to use non-standard phraseology something that gets discussed during the training at this operator, or is there an exclusive focus on the use of standard commands?

From the report´s "... she would again consider initiating an evacuation." it seems but is not entirely clear that she intended to initiate an evacuation. If so, why did she not use the company´s standard command?

When cabin crew perceives a situation on the ground to be imminently life threatening, and they are certain the engines are not running, they are obliged to start an evacuation and to inform the pilots that they are about to do so. This SCCM and the rear door CC thought the situation was about to become life threatening, and they evacuated.

In hindsight, this situation was not life threatening, and her decision to initiate an evacuation was an error. As was the fact that she did not (attempt to?) inform the pilots of her intention.
The company is to be applauded for the way they have dealt with this SCCM, for the way they have treated this as a learning experience and for the consequent clarification of when to initiate an evacuation provided to their CC.

This SCCM did the wrong thing for the right reasons.
There but for the grace.....
The beauty of this website is the opportunity to learn from this, for both cockpit and cabin crew.

BOAC

15th Feb 2011, 16:50

A good summing up. Juud.

I cannot, however, get my head around post #71 and the AAIB report - which is the 'truth'?

david1300

16th Feb 2011, 10:11

@Juud - agree with BOAC - great summary.

As a regular passenger (disdainfully referred to as SLF by some :ok:), I sometimes wonder who made decisions in the seconds leading up to this event:
KmKd-buNMVc&feature=related
YouTube - China Airline flight 120 fire accident at Naha Airport (http://www.youtube.com/watch?v=KmKd-buNMVc&feature=related)

and the flight crew in British Airtours (http://www.pprune.org/wiki/British_Airtours) Flight 28M could have made a better decision that would have saved more lives on 22 August 1985 when a highly survivable emergency turned into a disaster.

Personally, I prefer the mistake the SCCM made in this instance to the one made at Manchester.

BOAC

16th Feb 2011, 10:17

David - it is important t put the record straight on the Manchester BA accident - the crew were following the accepted company procedure for an aborted take-off - the procedure was changed by the company following the accident.

Still interested in what the SCCM was actually intending!

M.Mouse

16th Feb 2011, 14:48

Personally, I prefer the mistake the SCCM made in this instance to the one made at Manchester.

That comment is as ignorant as it is ill-informed. There is no comparison. The cabin crew did nothing wrong in that incident. The (outside) fire overwhelmed the aircraft in seconds exacerbated by the wind.

As BOAC states abandoned take-off procedures changed to include (flight crew) taking into account the prevailing wind in similar circumstances to prevent repetition of such a disaster.

Hipennine

16th Feb 2011, 20:50

Whether the SCCM made the optimal decision in this case or not, some of the discussion and comments above have demonstrated that conceptually, although SOP's may have been developed with best available knowledge at the time, they are not necessarily optimal for certain situations (viz Manchester), and unfortunately following best knowledge SOP's can still lead to tragic outcomes. Sometimes, action outside of SOP's gives a better result. The person who elects not to follow SOP's on the day can just as easily become hero or villain.

david1300

17th Feb 2011, 01:46

@BOAC & M.Mouse - my point is that the Manchester crew, even though following 'accepted company procedures', did not make the optimal decision (therefore, made a mistake). As you stated, since then "...abandoned take-off procedures changed to include (flight crew) taking into account the prevailing wind in similar circumstances". But in this case following 'accepted company procedures' resulted in many deaths.

I question whether the Manchester crew did nothing wrong - if following 'accepted company procedures' means not evaluating all risk factors and making a decision with a bad (fatal) outcome, is that right or is it wrong?

In this case I side with the SCCM, and I still hold my view: Personally, I prefer the mistake the SCCM made in this instance to the one made at Manchester. And MM, you are welcome to your personal view that this is ignorant and ill-informed, but I suggest that is just your ignorant and ill-formed personal view.

For comparison:

SCCM mistake - not following 'accepted company procedures' in what turned out to be a non-life threatening situation - outcome: minor injuries to a few, lots of criticism, opportunity to learn and improve practices

Manchester mistake - following 'accepted company procedures', not being aware of all risk factors (possibly because of following acp's) - outcome disaster for many

411A

17th Feb 2011, 02:19

In this case I side with the SCCM, and I still hold my view: Personally, I prefer the mistake the SCCM made in this instance to the one made at Manchester. And MM, you are welcome to your personal view that this is ignorant and ill-informed, but I suggest that is just your ignorant and ill-formed personal view.

Ahhh, david1300 it would be helpful to know your personal airline flying experience...as a pilot, in order to ascertain whether your remarks (such as they are:ugh:) are at all relevant to the present discussion.:bored:

david1300

17th Feb 2011, 03:00

@411b - I have clearly stated that I am a frequent passenger - one of those irritating SLF's. But it's not just my experience in flying that's relevant.

I'm applying my knowledge, training and experience from other fields (decision making under stress, for example - were the Manchester FD crew misled by following acp's so they didn't look outside and asses the risks the acp's didn't consider - like strength and direction of the wind). Also relevant is my burning desire to stay alive.

Personally, I am with BOAC in his belief that what the SCCM said and what she intended may have been different - another of my areas of knowledge, training and experience: communication under stress, where what the person says may not be exactly what they intend to convey; and where the person hearing filters what they hear to fit their paradigm.

And 411c, it is clear from your posting history that you are disdainful of almost everyone, even those who have substantial flying experience as a pilot (your attitude is consistent - you have nothing more to learn, but plenty to teach).

This discussion is all based on an incident where a SCCM initiated an evacuation. It is an incident with more relevance to decision making, communication and chains of command, than it has to piloting skills; not that I expect you to notice this. I don't therefore see the relevance of your question: "it would be helpful to know your personal airline flying experience...as a pilot, in order to ascertain whether your remarks (such as they are:ugh:) are at all relevant to the present discussion.http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/wbored.gifwhat does airline flying experience as a pilot" I know this will come as a surprise to you, but there are people who know a lot, and they are not pilots!

The relevance of my remarks are, I suggest, greater in this case than yours - the decision making was more to do with human factors than with flying skills. The learning and future improvement will come more from better decision making and communication, than it will from being a better pilot.

Dream Land

17th Feb 2011, 04:21

David 1200,
Thank you for your opinions but the fact remains that this is a professional pilots forum, so your attempts to somehow embarrass 411A are a waste of space IMHO, whether or not you agree with him is one thing, but it is posters such as him that I look forward to when I scan through the threads, now please run along.

M.Mouse

17th Feb 2011, 08:16

my point is that the Manchester crew, even though following 'accepted company procedures', did not make the optimal decision (therefore, made a mistake). As you stated, since then "...abandoned take-off procedures changed to include (flight crew) taking into account the prevailing wind in similar circumstances". But in this case following 'accepted company procedures' resulted in many deaths.

I question whether the Manchester crew did nothing wrong - if following 'accepted company procedures' means not evaluating all risk factors and making a decision with a bad (fatal) outcome, is that right or is it wrong?.

Your premise is wrong that the flight crew (because the Manchester disaster was nothing to do with the cabin crew actions, quite the contrary if you cared to read EXACTLY what happened) could have taken any different actions which would have saved the day. Nobody had ever experienced an engine failure causing a fire which was then blown onto the fuselage with such speed and ferocity that the passenegrs and crew could never all get out alive. So how in the world could they have acted any differently?

In this case I side with the SCCM, and I still hold my view: Personally, I prefer the mistake the SCCM made in this instance to the one made at Manchester.

Those people ignorant of the operational aspect of commercial flying will never understand the evolution, importance and necessity to abide by SOPs. Many of which have been developed from accidents involving loss of life.

SCCM mistake - not following 'accepted company procedures' in what turned out to be a non-life threatening situation - outcome: minor injuries to a few, lots of criticism, opportunity to learn and improve practices

All that needed to be learned was to follow her trained, sensible and clear SOPs. i.e. only initiate an evacuation without command in a clearly catastrophic situation.

Manchester mistake - following 'accepted company procedures', not being aware of all risk factors (possibly because of following acp's) - outcome disaster for many

And absolutely no other flight crew would have done anything differently given the circumstances that prevailed that day.

I'm applying my knowledge, training and experience from other fields (decision making under stress, for example - were the Manchester FD crew misled by following acp's so they didn't look outside and asses the risks the acp's didn't consider - like strength and direction of the wind). Also relevant is my burning desire to stay alive.

Again showing your ignorance. It is impossible to see anything behind you from the flight deck of a B737. Unless of course you open the window which would not necessarily have been possible with the engines running (pressurisation issues although I cannot recall the pressurisation schedule in the circumstances they faced) nor would it have even entered most flight crew's minds.

What you and many others are advocating is akin anarchy. SOPs have been developed and refined over many years and with the benefit of experience, often tragic experience. Faced with a situation the subject SCCM faced which was clearly NOT catastrophic which part of the clear SOP did she not understand? If her move was so brilliant then I would expect the SOP to read 'Do not initiate an evacuation without command unless you think you know better than everyone else'.

From my 29 years of flying experience, observation of and conversations with many fine and efficient cabin crew I'll stick with the SOP as written than you.

Using the Manchester disaster as an analogy is a poor choice. Two cabin crew members died alongside the passengers and the other two demonstrated incredible bravery before being forced to flee for their lives. I also believe that Captain Pete Terrington has never fully got over the trauma of that day. I have yet to hear any pilot criticise any of the crew for their actions that day nor claim that they would have done anything differently.

Listen to Stewardess Joanna Caston recounting her experience that day here. (http://www.youtube.com/watch?v=iY7zD7a05wg)

mary meagher

17th Feb 2011, 08:40

Dreamland, this is of course a Professional Pilot's Forum. Whenever there is a catastrophic accident, the vultures gather in great flocks and offer comment and advice that is not always useful or appropriate.

But to restrict imput to Professional Airline Pilots only would be a shame. On this particular thread, it is good to hear from Cabin Crew, Pax, Engineers, and those who study human behavior. It is even good to hear from 411A, who is certainly provocative, qualified, and ascerbic. Pilots, locked (alas) into the flight deck tend to forget that we are all willy nilly locked into the aluminum tube behind them, with very little say as to the consequence of any professional shortcomings of the crew. Surely we have a right to contribute to this discussion?

What absolutely horrified me was the video posted by David 1300 of the engine fire of the Chinese aircraft parked at the terminal gate. At the start of the video, people are still scooting down the slides, running away, a brave and foolish person is applying a hand fire extinguisher to the blaze.
At 21 seconds from this point, the whole thing goes woof.

The whole point of the AAIB report on the deployment of slides at the gate seems to hinge on a failure of communication. The Cabin Attendants did not use correct words, possibly panicked a bit. Didn't insist on talking to the flight deck, who were busy. Her fault? What were the actual injuries incurred by those who slid?

Alt Crz Green

17th Feb 2011, 10:08

Those of us who actually fly, and indeed those who are knowledgeable with the unfortunately vast subject matter provided by the field of air accident investigation, will know some simple facts. Namely, SOPs grew out of the study of actual, real accidents and were introduced to prevent the circumstances reoccurring. Therefore, we know that follow SOPs and you have a good chance of avoiding trouble, you don't and your chances of trouble increase vastly.
I ask those on these pages who advocate selective application of SOPs, or indeed willful disregard of same, show me the reports in which an accident/incident was caused due to rigorous following of SOPs?

In this case, the SOP was very simple and clear. Leave aside the assessment of whether the situation was life-threatening or not. That's a red herring. The SOP was breached prior to that assessment, namely at the time when she disregarded this part: "If communication is impossible with the pilot." It clearly wasn't impossible. The perception (if it existed) of being ignored is not "impossible." Being impossible is when the wreckage of the cockpit lies 50m from the rest of the fuselage. Standing in the same cockpit as two live and sensate pilots doesn't constitute impossible.

Aviation is about balancing risks. To those who say that a worse outcome might have been prevented by an early evacuation, let me remind you of the point of this SOP. The risk of allowing CCMs to initiate evacuations at their whim is far greater than the risk that a captain will miss something and mistakenly prevent an evacuation. The fact remains that as long as communication is possible, and quite possibly even if it's not, both flight deck crew are always in possession of far more information, and see a far bigger picture, than the CCMs.

In my company a similar SOP arose out of CCMs initiating an evacuation from a taxiing 747. There's always a good reason for SOPs.

AvMed.IN

17th Feb 2011, 11:27

without going into the propriety or if it was a breach of SOP, if the action taken was, as stated in the first post: [rest snipped] ...detecting "a pungent burning smell" througout the cabin, cabin crew instigated an evacuation without pilot permission or knowledge.

I wonder why has the discussion not veered towards suspicion of aerotoxic syndrome (http://www.avmed.in/2011/02/aerotoxic-syndrome-a-cause-for-concern/)? This, in turn, prompts me to ask, did not the timely action by CC result in prevention of ill-effects of the cause of whatever compound was emitting the noticed pungent odour? Even if it was an incorrect action, if the motive of this act of commission was the safety of the passengers, should not the CC be commended for action taken?

Lord Spandex Masher

17th Feb 2011, 11:37

All that needed to be learned was to follow her trained, sensible and clear SOPs. i.e. only initiate an evacuation without command in a clearly catastrophic situation.

So, would you prefer it if she had waited until the situation was catastrophic before she did anything about it?

both flight deck crew are always in possession of far more information, and see a far bigger picture, than the CCMs.

Codswallop. Do you have a "strong burning smell in the rear of the cabin" warning light? How do you get that information? Would it be via communication from the cabin crew?

Does you statement negate the need for CC to communicate with the flight deck should a problem arise in the cabin because the flight deck "are always" better informed? It's ok, they already know, I'll just sit here and finish my coffee and wait for them to fix it.

david1300

17th Feb 2011, 12:07

@AltCruzGreen - just to clarify - I am NOT suggesting or recommending ignoring SOP's, but I am saying that they are constantly developing, and we should examine events and if there is an application, apply that learning to SOP's. Nor have I (or anyone else that I can see from reading and rereading this whole thread) anywhere advocated allowing CCM's to initiate evacuations at their whim - your choice of emotive language and implying what isn't written is unfortunate.

As regards this comment of yours: "The fact remains that as long as communication is possible, and quite possibly even if it's not, both flight deck crew are always in possession of far more information, and see a far bigger picture, than the CCMs." (tell this to the Kegworth families) how does this sit with M.Mouse's assertion: "It is impossible to see anything behind you from the flight deck of a B737. Unless of course you open the window which would not necessarily have been possible with the engines running (pressurisation issues although I cannot recall the pressurisation schedule in the circumstances they faced) nor would it have even entered most flight crew's minds."

One very recent example: In the recent Qantas A380 incident, after being alerted by the CC, a FD crewmember came aft to have a look at the hole/s in the wing. Clearly the CC knew more about some aspects of the physical damage than the FD crew at that point in time, so much so that the FD crew deemed it prudent to visually inspect.

Then there is a reported case of FD crew shutting down the WRONG engine (Kegworth), when even the humble SLF's looking out the window could see the left engine was the problem. If the FD had consulted the CC to ask if there is any external evidence of damage/fire/smoke they would have been alerted to their error of shutting down the good engine and 47 lives, I believe, would have been saved.

@M.Mouse - I did not say that Manchester had anything to do with CC decisions. Read my post - it clearly says FD crew. I do worry when skilled pilots who have my life in their hands are so fixated that they cannot/do not read accurately or comprehend what they have read. This is what I call the human factors - you are so keen to prove your point that you do not comprehend or maybe do not even read mine. This is an example of the task fixation that happens to people under pressure - be it pressure on you to put a SLF (me) in his place; or pressure on the subject SCCM to get people off the plane as soon as possible because there may be a developing dangerous situation that could get out of control

For the record: my point about Manchester is that it had to do with FD decisions - FD crew following their then acp (accepted company procedure, or SOP's) so that they were possibly blindsided, and did not consider some basics: they believed a tyre had burst (from memory they did not know immediately there was a fire), they braked slowly and exited the runway into the wind, allowing the fire to spread; and this is where I believe they may have been blindsided: the basics when dealing with a spreading fire: WHAT DIRECTION IS THE WIND, WHERE IS THE FIRE, PUT YOURSELF BETWEEN THE WIND AND THE FIRE SO THE WIND BLOWS THE FIRE AWAY FROM YOU. IF the CC on the day had seen the fire, IF they had alerted the FD, IF plane brought to an immediate stop, shut down engines and evacuate had occurred, many lives MAY have been saved.

BOAC

17th Feb 2011, 13:06

David I do not wish to drag out the BAT accident any more than necessary, but a couple of points:

WHAT DIRECTION IS THE WIND, WHERE IS THE FIRE, PUT YOURSELF BETWEEN THE WIND AND THE FIRE SO THE WIND BLOWS THE FIRE AWAY FROM YOU.

The accident occurred in 1985. Since then both BA and the industry in general have learnt a lot about what to do with a take-off malfunction. The SOPs (ACPs) changed as a result of the AAIB findings to line up with your points which are now 'standard'. with, I believe, all operators.

IF the CC on the day had seen the fire, IF they had alerted the FD, IF plane brought to an immediate stop, shut down engines and evacuate had occurred, many lives MAY have been saved.

Not really a good idea - c/crew are trained not to interfere with/distract flight crew during take-off and landing for good reasons, and a 'ding dong' on the call button from the crew would be ignored in an aborted take-off (I've had one during a normal take-off at 'rotate' which was a junior at the back asking if the purser was doing hot towels and getting the wrong button.....). Once the Manchester aircraft had been stopped I understand the crew were well aware of the fire. Yes, it is good (as you say, in Kegworth) to be given information, but there is, as they say, a time and a place and the abort procedures are busy enough without answering a call bell.

CISTRS

17th Feb 2011, 14:02

Great thread hitting a lot of sensitive buttons :ok:

If this is a breakdown of CRM due to the SCCM not receiving a meaningful response, who is responsible for the breakdown in communication?

I suggest that the thread should be shared with Cabin Crew forum.

___________________

Engineer, SLF, glider pilot, former gliding instructor, ppl, etc.

411A

17th Feb 2011, 16:52

I do worry when skilled pilots who have my life in their hands are so fixated that they cannot/do not read accurately or comprehend what they have read.

I would ask once again, just what do you know about professional airline pilots and their duties and responsibilities?

David1300 sounds like a non-professional CRM instructor, gone awry.:rolleyes:

BOAC

17th Feb 2011, 17:18

I would ask once again, just what do you know about professional airline pilots and their duties and responsibilities? - he has already told you:ugh:
However, he probably knows a lot about posters who do not read his posts properly.

M.Mouse

17th Feb 2011, 17:42

I did not say that Manchester had anything to do with CC decisions.

Nor did I read your post(s) as saying it did.

So, would you prefer it if she had waited until the situation was catastrophic before she did anything about it?

No, but then again I would rather she didn't make unilateral decisions outside her remit.

glad rag

17th Feb 2011, 18:01

How quickly did the recent Tupolev brew up? A rear cabin fire that spread like wildfire once doors were opened to facilitate emergency egress............................must have concentrated some minds in the industry...I would hope.

Lord Spandex Masher

17th Feb 2011, 18:11

Mickey (Or Minnie, sorry I don't know),

What would you like her to do then?

Don't wait until the situation becomes catastrophic or make a decision, bearing in mind she was unable to effectively communicate with the FD.

Give her a chance!

Mr Optimistic

17th Feb 2011, 18:40

The SCCM returned to the flight deck to update the commander, and while the flight crew acknowledged her presence, she did not convey her concerns on the need to evacuate the passengers as the flight crew were busy dealing with the incident.

After the evacuation a number of comments were made by passengers concerning an apparent lack of assistance and direction given to them outside the aircraft. The airfield operator considered this was due to some agencies not being initially informed of the incident.

In most circumstances the evacuation command will be initiated by the Commander. This will immediately cause the cabin crew to put into action their evacuation drill. If communication is impossible with the
pilots and the situation is life-threatening to passengers and crew (e.g. breaking up of the aircraft, an uncontrollable fire in the cabin or ditching), the ICM will initiate the evacuation.

Piltdown Man

17th Feb 2011, 19:15

Let me tell you a story:

Some time ago, whilst devouring an excellent breakfast our aircraft generated a “ping.” There was no caption, just a local “FAULT” warning light on the R/H Recirc. Fan. The standard deal was (and still is) fly the plane, confirm the failure, run the checklist, etc. So putting the excellent breakfast aside, this procedure was started. Just as this was happening, Cherrie our No.1 rung to give us some urgent news. “Boys, there’s a horrible smell of smoke in the back by the galley. I’ve woken up the positioning crew and together we’ve felt every panel and none of them are warm. There is no smoke but we’ve placed the extinguishers and the smoke masks in the rear of the cabin, just in case. There’s something not right. I’ve told them (the cabin crew) to check every panel again every five minutes until I’ve spoken with you. What would you like us to do next?” Given that we had a fault, the crew smelt smoke, a C/B had popped and we had a fault light I considered that the problem had been identified, power removed (as it happens, against the checklist, but that’s another story) and we should have no re-occurrence. The proof of this would be a reduction in the smell of burning. I told her what we had done and what we would do next and she continued with her bit. So together as a crew we continued. Her job was to press me for an explanation as what had happened and mine was to provide an answer and a solution. There was no non-SOP stuff, just normal common sense AND SOPs. This and no more is all that is expected.

As it happened, the bearings of the R/H Recirc. failed and as a result allowed the motor windings to heat up to such a point that they short circuited and generated a warning. The aircraft systems “failed safe“ as designed and continued to be monitored. The cabin crew’s actions were appropriate and totally SOP. And that is all that had to be done. And even though this was a few years ago, I remember it well because of Cherrie’s and her superb crew’s support. But the most important thing about Cherrie would be that post incident, she would listen to and take on board any criticism (not that there was any, only praise!). After this incident, the SCCM says she’d consider doing the same thing again. The AAIB made sure that her sentiment was included in their report. She didn’t say that she’d push for a response or more information. Short of evidence to the contrary, it’s the lack of acceptance that it may have been possible to have had a better outcome that worries me.

Alt Crz Green

17th Feb 2011, 19:34

Read my statement again. I said the pilots are in possession of more information as long as communication is possible,. So if there's a funny smell at the back of the cabin they will be in receipt of said information..
In this case, communication was possible and not very well attempted.

chris weston

17th Feb 2011, 20:00

141

Correct.
411A is always worth reading.
Whether you always agree with him is quite another matter!

M.Mouse

17th Feb 2011, 22:55

Don't wait until the situation becomes catastrophic or make a decision, bearing in mind she was unable to effectively communicate with the FD.

Learning to communicate effectively would be a good starting point.

BOAC

18th Feb 2011, 07:08

I'm hoping we can drag this thread back down from the "mine's bigger than anybody else's" level we appear to have (traditionally for PPRrune) reached thanks to the regular quarterbacks. Extremely important lessons in communication derive from this event and I would hope it is frequently replayed on those sometimes stereotyped and dull CRM refresher courses.

It is disappointing that only I, David, rjay and Juud appear to have picked up on the apparent confusion, which as David rightly says, is a major factor in communication in any situation. "Is what I am going to say what I mean to say, and will people understand what I meant to say"? The old "Send three and fourpence, I'm going to a dance" for the older amongst us.

Leaving aside the breakdown in communication, which, for whatever reason appears to be a given, and picking up Juud's paragraph - When cabin crew perceives a situation on the ground to be imminently life threatening, and they are certain the engines are not running, they are obliged to start an evacuation and to inform the pilots that they are about to do so. This SCCM and the rear door CC thought the situation was about to become life threatening, and they evacuated.This is not quite what we see. If rjay's post is genuine and not a trolling post (and I note the 'silence' since), there appears to be a difference in what the Purser claims she ordered and what the AAIB say she ordered. I suggest that until this confusion is resolved, we cannot necessarily blame the purser for the slide popping since if she ordered a 'rapid disembarkation' (a standard procedure in most airlines' c/crew drill) then the rear crew may have been at fault for deploying the slides. As I say, she and/or the flight crew may take the blame for the communication breakdown, but if the claimed statement by the purser is accurate, we would probably NOT have even heard of the event.

Lastly, my personal view is that 'SLF' are fully entitled to take an interest in this topic since some of them were sent down slides (un-necessarily?) and that also we as aircraft crew should be prepared to listen to inputs from those who while not ace 'one-man bandit' pilots may well be knowledgeable in the field of human foibles which unfortunately and unavoidably form the scenery for our profession..

Lord Spandex Masher

18th Feb 2011, 07:16

Learning to communicate effectively would be a good starting point.

That works both ways though, because it takes more than one person to communicate. Are you blaming the breakdown in communication solely on the SCCM? If not then you should be castigating the FD as much as you are the CC.

A simple "Standby" from either of the FD would have told her:

- That they were busy
- To wait

Our CC are constantly told not to interrupt us if we are busy or in the middle of a checklist.

The SCCM then returned to the forward cabin and contacted all the crew using the Alert Call on the cabin interphone. They confirmed that there was a pungent burning smell throughout the cabin; there was no smoke, but the smell was strongest in the rear of the aircraft. However, the flight crew did not respond to this call.

The SCCM returned to the flight deck to update the commander, and while the flight crew acknowledged her presence, she did not convey her concerns on the need to evacuate the passengers as the flight crew were busy dealing with the incident.

mary meagher

18th Feb 2011, 08:33

Ah yes, breakdown in communication! Applies also to communication from the instruments - eg the ASI, or the ground proximity warning.....not always taken on board by pilots when otherwise distracted.

There is only one statement by David 1300 which I question: to quote, "Large Airline Captains are smarter than brain surgeons......"

Lord Spandex Masher

18th Feb 2011, 08:50

Large Airline Captains are smarter than brain surgeons

Mary, I don't see that my weight or height has got anything to with my intelligence.

KAG

18th Feb 2011, 12:53

The cockpit crew were already aware and were investigating, still didn't decide to evacuate (otherwise the CC would have known about this decision), she came to the cockpit but didn't even try to inform she decided to evacuate (like simply saying it?). Now we will try to imagine all kind of excuses, but the CC clearly :mad: up. Looks like a stubborn and macho CC to me. Nobody died during the evacuation, so not a big deal anyway.
I remember the beginning of CRM, it was all about listening to the Cabin Crew and keep them in the loop. Nowadays CRM should be about keeping the cokpit in the loop... ;-)

411A

18th Feb 2011, 20:27

Now we will try to imagine all kind of excuses, but the CC clearly :mad: up. Looks like a stubborn and macho CC to me.
Exactly.
Some (but certainly not all) cabin crew, especially those in a senior position, truly believe they are the 'cabin captain' and do as they see fit.
Time for these few to realise that...they are subordinate to those on the flight deck, period.
IE: always has been, always will be.
Why?
Because, the company says so and the regulatory authority says so.
IF they don't like this arrangement, there is the HR door to dismissal, or resignation.
Airlines would certainly be better off without these malcontents in their employ.

RatherBeFlying

19th Feb 2011, 03:30

We are seeing a huge divergence of views between those up front and those in back.

Up front there's procedures to perform, many of which are vital, time constrained and demanding of close attention to perform properly.

In back the SLF get justifiably exercised about the presence of toxic fumes or any suspected precursors of fire. Fire safety doctrines lean heavily to getting out pronto at the least suspicion of any fire as a fire can progress from fumes to conflagration in a very few seconds. History has amply demonstrated with a number of tragedies the perils of dithering.

The CC may be completely adherent to the SOPs, but the SLF will take matters in their own hands if they come to feel that the hazard is not getting the attention they feel it deserves.

Up front there can be a lag in a critical situation in back being communicated to them. Door open annunciations may not be in the SOPs, but are an instant communication that SLF and/or CC feel the need to get out pronto.

blue up

19th Feb 2011, 07:28

Just curious, but at what point does this become a legal issue of libel? A brief 5-page AAIB report (which is in variance with the internally published report) is being used as a stick to beat someone who isn't permitted to defend themself on here.
If I were a lawyer with a bit of spare time then I'd be keen to go back over the previous pages to see if a few people on here have overstepped the mark.

Mods?

BOAC

19th Feb 2011, 07:49

which is in variance with the internally published report - that is an interesting statement in itself! Can YOU substantiate that?is being used as a stick to beat someone who isn't permitted to defend themself on here. - why do you say 'isn't permitted'? Have the Purser/flight crew (or 'friends') been banned by the mods?

Door open annunciations may not be in the SOPs, but are an instant communication that SLF and/or CC feel the need to get out pronto. - NO! Rear doors and front service doors will NORMALLY be opened on a turn-round. It would require someone with enormous skill and insight (guess who?) to work out that an evacuation was taking place when doors open on the ramp.

blue up

19th Feb 2011, 09:03

that is an interesting statement in itself! Can YOU substantiate that?

Yes. I can.

BOAC

19th Feb 2011, 09:24

So, 171 posts on this thread and there are actually two different 'factual' stories of what happened! Anyone know the truth? This is silly:ugh:

Matt101

19th Feb 2011, 10:55

Now THIS is an interesting thread and debate.

I did three years in the trenches (Cabin) before I couldn't take any more, and thus have a deep respect for the job. Tiring, stressful and overwhelming at times, but always with a smile (well I worked at BA so not always ;) ) and, whilst attending to that needy passenger in 3C who is probably on the verge of being the worst passenger in history, always trying to be aware of what else is going on with regards to the safety and well being of passengers.

I think it holds self evident that CRM, or more specifically communication, is the reason this incident occurred, both between the SCCM and Flight Crew and the SCCM and the other crew and passengers. Also it might be fair to say that the unease of the SCCM might have been something the FC should have anticipated, though that is not a given.

411A is an interesting read always but I disagree that this CCM should be hung out to dry, I think she acted incorrectly but she did so with absolutely the right thing in mind and as the victim of a break down in communication.

A retrain may indeed be important and an examination of the use of correct phraseology. If an Evacuation was not intended but rather a swift disembarkation, the correct PA should have been used, if such a PA does not exist then that is something the company should address. Though I must admit the correct PA is unlikely to be one that comes quickly to mind - that's a company issue too.

More importantly I hope that this incident brings to all crew members attentions the need to keep everyone in the loop at all times.

As for pax instigating evacuations whenever they feel uncomfortable - if that becomes an SOP my mother will not be allowed to fly again....

M.Mouse

19th Feb 2011, 10:59

The CC may be completely adherent to the SOPs, but the SLF will take matters in their own hands if they come to feel that the hazard is not getting the attention they feel it deserves.

Actually no they won't.

During internal BA SEP recurrent training I recall seeing an interview conducted with one of the CC survivors of the Manchester disaster. She said that she could see the cabin ceiling glowing red at the aft of the aircraft with smoke and fumes evident and yet the majority of the passengers in that section sat almost mesmerised until spurred into action by shouted instructions from the crew.

Juud

19th Feb 2011, 14:52

As stated by Mouse; pax too stunned to react will remain in their seats until "woken up" by CC shouting command. Accumulated data available about evacuations has led to this "accepted wisdom" in the industry.

Things appear to have changed somewhat after 9/11 though.

One case in point, there are more; pax attempting to open the rear door after landing on the Hudson, with the FA trying to keep it closed.
These pax certainly attempted to take matters in their own hands.

Airbus Girl

19th Feb 2011, 15:27

Interestingly a couple of years back we did a simulated emergency scenario in the standard winter refresher, which entailed using a full crew (cabin crew + pilots) and the cabin trainer (mock up of aircraft). It was going swimmingly, pilots were being informed of a possible situation with fumes/ smoke, and asked cabin crew to keep them informed whilst they ran their checks. Then the person running the scenario escalated the event and said there was now a bit more smoke. Instead of the cabin crew coming to tell us so we could order the evacuation, we heard the cabin crew opening doors, deploying the slides and initiating the evacuation. In "theory" we hadn't turned the engines off yet, hadn't ordered any evacuation, and hadn't even been informed by the cabin crew that they had decided to initiate an evacuation. After everyone had exited the aircraft we opened the flight deck door, calmly got off, and asked why had there been an evacuation as the minor problem had been sorted and the engines had still been running. Cue plenty of "I don't know, someone opened a door so we did too" type comments.

It certainly opened my eyes!!!!

Max Angle

19th Feb 2011, 15:36

Did the same thing about 10 years ago with our lot. Same sort of scenario run in real time. Our cabin crew started an evacuation before we had landed.

Matt101

19th Feb 2011, 15:53

One would imagine however that, had it not been a simulator, the altitude of the aircraft would have been more self evident non?

The training at BA was always quite clear - clearly catastrophic and unsurvivable(sp?). (Examples were given).

I know that was not the case here but it is part of a wider discussion to be had. I spoke to pilots when I was cabin crew and again since becoming one myself. Some find it baffling that anyone would disagree that CC should be allowed to initiate an evacuation should it be necessary, others thought it should be something only allowed if it was confirmed that the FC are incapacitated.

My answer is always quite simple, if there is fire in the cabin, or indeed lapping at my feet, I would not expect anyone to sit going through their silent drills awaiting the command. Hit the evac horn (to alert everyone) look out the window, make an assessment (engines/hazards etc.) and get out. I would expect the crew on any flight to do the same, that said, if there is time for a call then the situation is not catastrophic and the evacuation command should only come from the Flight Deck. I think someone said it earlier when they said, if you have to think about it, you probably should not.

I wonder how common it actually is anyway? Is someone more clever than I (not a difficult thing to find), aware of any stats on the subject. I know that unless I felt I was without any other option the initiation of an evacuation whilst I was crew was a very last ditch option.

Juud

19th Feb 2011, 16:14

Worrying indeed AB Girl & Max Angle.
What do you both think may be the cause of this lack of knowledge/training/SOP discipline if I may ask? And What did your companies do to address this undesirable state of things?

In our mob 1 of the annual SEP refreshers always contains 2 scenarios in the full motion cabin & (rudimentary) cockpit sim. The sim also comes with "real" smelly and viz-killing smoke, noise and outside visuals. 1 scenario always ends in an evacuation so everybody gets a chance to experience the slide again, the other may or may not.
Usually the evac signal comes from the cockpit, and we evacuate accordingly. Sometimes it doesn´t, we can´t get hold of them, evac is very clearly indicated and the CC initiates one. Sometimes the situation escalates to where we think we may need to evacuate but the pilots tell us not to so we hold off a little longer and then get told to remain seated all of us.
There are always things that could/should have gone better, and they come out in the de-briefing. Usually pointed out by the "culprits" themselves.

These exercises get done usually 3 times a day, 360 days a year.
In the about 60 I have been part of, I have never experienced any of what what the 2 of you describe. Nor have I ever heard of it happening from colleagues or trainers.

The one real evacuation we´ve had in the past 10 years went textbook. The aircraft was a write off I believe, but I know nobody got injured beyond a sprained ankle.

We were lucky with overwing pax who had actually listened carefully to the brief on how to open the hatches, we were lucky that there was no fire and we had cockpit and cabin crew cooperating in an exemplary manner. The last factor being ascribed to endless, varied scenario-training of people with a modicum of intelligence and to SOP brainwashing.

BOAC

19th Feb 2011, 16:52

rjay/blue up - any more 'pearls' for the swine? Maybe we can get this back on topic!

411A

19th Feb 2011, 17:13

What do you both think may be the cause of this lack of knowledge/training/SOP discipline if I may ask?
The primary reason is...the complete and utter nonsense drilled into the heads of CC by their CC management that....'somehow, we are all equal in the airplane, each has a say that is equal to everyone elses, and the Commander had no more authority that anyone else.'

So-called CRM run amok.:yuk:

Some airlines, however...have positively not allowed this nonsense to occur, and never will.;)

flydive1

19th Feb 2011, 17:35

After everyone had exited the aircraft we opened the flight deck door, calmly got off, and asked why had there been an evacuation as the minor problem had been sorted and the engines had still been running

All fine and probably a lot of fun teasing them, but, would you really have been so coolly strolling around if you did not know it was a simulation and the cabin was full of smoke?

BOAC

19th Feb 2011, 17:46

We need some balance here! If that cabin trainer was anything like the cabin trainer I have been in many times with BA, you would have NO way of knowing if the engines were running, you were flying or underwater! As Matt says, it is useful but NOT realistic.

I have a lot more faith in cabin crew in general than some here.

Dolley

19th Feb 2011, 18:42

I'm just so glad those loose cannons are all in the cabin and none in the flight deck :hmm:

cwatters

20th Feb 2011, 09:50

I'm not saying this was the case here but.. Isn't it known that under stressful situations people sometimes fail to convey their sense of danger to others? Wasn't that cited as contributing to Avianca Flight 52 running out of fuel..

Avianca Flight 52 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Avianca_Flight_52)

Pilots thought they had made their situation clear but they had never actually declared a fuel emergency.

Airbus Girl

20th Feb 2011, 13:58

In our situation, it was very interesting to hear the de-brief. It seemed that because the cabin crew scenarios are almost always run the same way - an escalation of events leading to an evacuation - that it had become almost second nature to them to go into evacuation mode a little too quickly. This wasn't about blame, it was pure training, and they found it very useful to reflect upon the actions and the speed at which they escalated the situation, even though in the scenario there was more than enough time to follow the correct procedure, which was to inform that flight deck. But no-one did. We had been monitoring their actions ourselves, as it was just a simulation, as we found it interesting to see their decision making process. Absolutely no gripe with the cabin crew, the problem is with the "set" way they are trained - afterwards the cabin trainer asked the crew who had made the decision to evacuate. Everyone looked at everyone else, those at the back said they'd seen those at the front opening doors, so had followed suit, and those at the front, on reflection, without the pressure of the situation, said that given the scenario again they would have checked with the flight deck, because it wasn't a life threatening situation and there was time.

It was really done as a "food for thought" exercise and to ensure people were thinking for themselves and taking a moment to consider the situation rather than rushing into procedures. Procedures that are always done the same way in the simulated exercises.

Juud

20th Feb 2011, 14:19

Thank you for that background info AB Girl. :ok:

The set -escalation of events always leading to an evacuation- way of training had engendered an "evacuation bias" in the CC.

Which caused them to evacuate prematurely rather than following SOPs and communicate with the pilots before doing so.

Interesting and entirely logical conclusion.

jetset lady

20th Feb 2011, 14:23

The primary reason is...the complete and utter nonsense drilled into the heads of CC by their CC management that....'somehow, we are all equal in the airplane, each has a say that is equal to everyone elses, and the Commander had no more authority that anyone else.'

I don't think it's as simple as that, 411A. There are undoubtedly SOME cabin crew trainers in the company that bring their own brand of bitterness and inflated sense of self importance to the classroom but there are also SOME flight crew trainers that appear to hold the belief that cabin crew should be seen and not heard. This then filters down through rank and file and from what I can tell, has done for so long, it's almost expected.

Going back to the mock up scenarios, I was involved as a "passenger" in one a couple of years ago that ended in evacuation. On the call to evacuate, the flight crew gave the call as per company SOPs, "Evacuate, Evacuate...Hazard on left!" At the initial words, "Evacuate, evacuate..." the crew were up and shouting instructions and as a result, both I and the Captain sat next to me only heard "Evacuate....Left" Even knowing the SOP's we both instinctively went to the left before correcting ourselves. On talking about it outside the mock up, the Captain agreed that passengers would probably also instinctively go to the left and that maybe it would be better for the SOP's to be amended to use only positive commands, such as "Right side only", in case part of the message was lost in the confusion. When we filed back into the mockup for the debrief, I raised this question very politely, pointing out that it was only on hearing it from the perspective of a passenger that the possible problem became apparent. I was given very short shrift by the flight crew trainer and basically told that that was the flight crew SOP and who was I to dare to question it. When I looked towards the Captain who had agreed with me, he suddenly appeared to lose the power of speech and gazed at the floor. If it had been the Captain raising the issue, would he have been dismissed quite as quickly?

Some airlines, however...have positively not allowed this nonsense to occur

Ironically, I would say that the airline involved in this incident is one of them, or at least it was when I worked there. Respect for rank and seniority was constantly drilled into us with no detriment to CRM. But it seems that that's not fashionable in these supposedly enlightened times where CRM seems to be perceived by many as "lets all get along and have a lovely time" rather than as effective communication between the cabin, the flight deck and the ground.

411A

20th Feb 2011, 18:25

But it seems that that's not fashionable in these supposedly enlightened times where CRM seems to be perceived by many as "lets all get along and have a lovely time" rather than as effective communication between the cabin, the flight deck and the ground.
Yup, the 'lets all get along' scenario will many times result in botched up actions.

Also this "Evacuate, Evacuate...Hazard on left!" is a very large trouble-prone idea.
IE: Specific doors are to be identified for evac use not just a casual reference to the left or right side of the airplane.
SQ and SV did this many years ago...and it worked perfectly, and our small airline does the same.
FD crew are told to identify the specific doors to be used and SCCM's are trained likewise, if an evac is necessary.
It is no good having pax slide down, only to be greeted by a burning or still-operating engine, close by.

Basil

20th Feb 2011, 19:20

JL,

Very good suggestion re terms used.
I'd suggest you keep pushing your point at work - but, of course, not to the detriment of your career :ok:

bubbers44

21st Feb 2011, 00:37

Our procedure was never say evacuate until you say which exits not to use. Once you say evacuate nobody listens any more.

SLFinAZ

21st Feb 2011, 01:38

I've got a simple question?

How realistic is it to expect aircraft crew (both cabin and flight deck) to determine with absolute certainty that a fire (and where there is smoke there is combustion of some type) is not potentially immediately catastrophic?

To comment "it's a knackered fan" in 20/20 hindsight is not at all relevant to making a prudent real time decision. Had this been a fire similar to the recent one on the Russian airliner how would people react to the quick decisive decision of the cabin crew saving scores of lives potentially?

However having a passenger or two run thru the blender would have been a major screw up....so who in there right mind orders an evacuation without informing the flight deck directly for both their own safety and to make sure the eggbeaters are off....

bubbers44

21st Feb 2011, 02:05

The CC always has the right to evacuate without command in a crash that is unexpected. The cockpit crew should always be in command in a landing situation on the runway.. Sometimes evacuation is not neccesary so the cockpit after landing should determine what procedure to use, not the CC.

BOAC

21st Feb 2011, 07:32

While a lot of this discussion is 'useful' it is not relevant to this topic and more suited to the 'Safety' forum. Coming back from cloud-cuckoo land, let us remind ourselves of the actual situation. Aircraft on stand, engines shut down, APU power (possibly GPU? as well?) and 230 passengers standing, retrieving overhead items and disembarking via Door 2L onto a jetway. APU then shut down, so possibly a/c semi-dark on emergency lights?

So, all this guff about passengers arriving at 'burning' or 'running' engines, or 'meat grinders' or 'still airborne and opening doors' etc etc is NOT RELEVANT TO G-BYAT. In the circumstances, apart from the risk to pax from slide use and apron hazards (while there was no actual need) there was no hazard in ordering an evacuation and those risks would equally have pertained if the evacuation had been ordered by the flight crew. If we are to discuss this sensibly we need to understand the situation in the cabin properly - and we STILL do not know 'the truth' about what the SCCM did or intended to do (or why, really), nor what actual response she was getting from the Captain other than an apparent lack of two-way communication.

I suspect there were issues on both sides of the flight deck door here. Things could obviously have been done better. Perhaps one day we will find out what really happened? In my opinion there is undoubtedly more to this than meets the eye.

So - lessons learnt? SOPs reviewed and reinforced where necessary? Recurrent training has a new topic which will certainly revitalise what can be dull hours.