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Jet Airways 737 Engine Fire

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Old 29th Aug 2010, 07:13
  #21 (permalink)  
 
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From The Times of India, Mumbai, Aug. 29, 2010:

DGCA hauls up Jet for lapses, 10 suspended
TNN, Aug 29, 2010, 02.11am IST

MUMBAI: Two pilots and eight flight attendants of Jet Airways have been suspended by the Directorate General of Civil Aviation (DGCA) after it found ''serious procedural lapses'' during its investigation into Friday night's suspected engine fire incident. The airline's Boeing 737-800 aircraft, bound for Chennai with 131 passengers on board, was on a taxiway at the Mumbai airport when an emergency evacuation was initiated after a warning about a fire in the left engine.

Jet Airways, in its media statement, said the ''crew carried out the evacuation in accordance with standard operating procedures''. According to aviation sources, it is routine to deroster the crew involved in an incident or accident (irrespective of whether they are at fault or not). It is done to aid investigation. The DGCA, however, in a press release issued on Saturday, chose to use the word ''suspended'', instead of derostered or grounded . DGCA chief, Nasim Zaidi, was not available for comment.

''Preliminary fact-finding by the DGCA has indicated serious procedural lapses in dealing with the emergency and evacuation situation as per existing procedures laid down in aircraft rules,'' read the DGCA release. ''Hence, the pilot in command, first officer, four cabin crew members and four additional crew members have been suspended till further orders,'' the release added. The additional crew members were flight attendants flying as passengers to operate another flight.

The Jet spokesperson said the commander had ''initiated a precautionary evacuation''. ''It was carried out in the interest of safety of the passengers and crew,'' the spokesperson said.

The pilot community was divided over the action taken by the Jet commander. Though the flight attendants had confirmed that they had seen fire in the left engine, no fire alarm went off in the cockpit. Neither did the fire handles for the left engine light up. ''He erred on the side of caution. It's always better to order an evacuation than risk an explosion, what with tonnes of fuel in the wings,'' said one commander. Another felt that the commander acted in haste. ''Since the fire alarm did not go off, he should not have hurried with the evacuation. He should have waited for the airport fire brigade officials to give their opinion, and then as a precautionary measure he could have taken the aircraft to a remote bay,'' he said.

But all agreed that the most serious air safety lapse in Friday's incident occurred when the aft door on the left side of the aircraft was opened for evacuation. ''As the suspected fire was on the left engine, the emergency exits on the left hand side of the aircraft strictly should not have been opened,'' said a commander. The overwing rear exit on the left side, too, was opened, but that would have been done by passengers. ''In such situations, passengers do not pay attention to warnings,'' he added.

In Jet Airways, the pilots only give the command for evacuation; the side from which it should be initiated is decided by the flight attendants.

There was an element of surprise for passengers who used the overwing exit for evacuation. Unlike heavy aircraft like Boeing 747 and 777 or even single-aisle aircraft like Airbus 320, the overwing exits of Boeing 737s do not deploy an inflatable chute when opened. In a Boeing 737, the passengers have to slide from the leading edge of the wing to its trailing edge, then onto the flaps and fall onto the ground, which would only be a few feet below if the flaps are extended by the commander, as the norms dictate, to a convenient 40 degrees.

''We were not aware that there would be no inflatable slides at the wing exit. Passengers realised it only when they reached the exit, by which time it was not possible to turn back,'' said Srikant Barhate, a passenger onboard the Jet Mumbai-Chennai flight.
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Old 29th Aug 2010, 09:08
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TopTup you are so very true!
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Old 29th Aug 2010, 11:16
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This incident appears to confirm the wisdom of a checklist action on evacuation. 99 time out of 100 we do the evac from a screaming high-speed stop in the sim every 6 months, when, as said, the drill is to lower flaps/open DV etc etc on the slow-down.

A cunning and wise TRE will inject just this sort of scenario into a recurrent - it really is different and VERY easy to rush into an evac with flaps up or even engines running.
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Old 29th Aug 2010, 12:04
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I agree with all that.....but...

I just have never quite agreed that the 737NG EVAC Non-Normal should have been changed to a read-and-do, as a memory checklist it was more practical!

EW73
My feelings too, but it's an airline issue - when Boeing changed it to read and do, most companies followed suit. RYR have a better system of having it a memory checklist that you subsequently redo as "read and do" if circumstances permit. The only problem with that is if someone really stuffs up the sequence and orders the evac over the PA before shutting down the engines, but that's unlikely and I'm sure if it had been done in the sim, the proceedue would become purely read and do again.
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Old 29th Aug 2010, 16:10
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Because if you're going to evacuate the aeroplane, you do the evacuation checklist, which just happens to include this step:
Quote:
Engine and APU
fire switches (all) . . . . Override and pull

If an engine or APU fire warning occurs:
Illuminated fire switch . . . . . . . . . . Rotate to the stop and hold for 1 second
Well, sure; my Dash 8 evac memo says I have to pull all of the Pull Fuel Off Handles, but is it really necessary doing that with a perfectly normal engine (right engine in this case) even when a couple of steps before you cut the fuel supply via a less dramatic way?

I was thought that, while a procedure is there and it must be followed step by step, sometimes when the situation that called for the procedure was not all that urgent (as in this case) it makes one or two steps a little bit of an overreaction. So I ask again, even though it's an approved procedure, why did he do that for? Or even better, let's rephrase that: Was that really necessary?

They're not suspended because they did a terrific job anyway

"We were not aware that there would be no inflatable slides at the wing exit. Passengers realised it only when they reached the exit, by which time it was not possible to turn back,'' said Srikant Barhate, a passenger onboard the Jet Mumbai-Chennai flight.
Pay attention you moron!
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Old 29th Aug 2010, 16:21
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hi BOAC

wise TREs are an asset, lots of wisdom and experience to impart.... cunning TREs?? not welcome here old friend.
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Old 29th Aug 2010, 16:36
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Well, sure; my Dash 8 evac memo says I have to pull all of the Pull Fuel Off Handles, but is it really necessary doing that with a perfectly normal engine (right engine in this case) even when a couple of steps before you cut the fuel supply via a less dramatic way?
Is it really necessary, I don't know. People with more experience than me might be able to answer that question for you. But if the checklist says do it, and it ain't gonna kill me, then I'll do it. I think it would be a lot easier in court to explain why you did something that is on the checklist, rather than try and explain why you didn't do something that is on the checklist because you thought you knew better than the aircraft manufacturer.
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Old 30th Aug 2010, 01:22
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Is it really necessary, I don't know. People with more experience than me might be able to answer that question for you.
The very famous experience is the factor who helps you make those decisions. Those are my instructor words, by the way. His rationale seemed valid for me.

But if the checklist says do it, and it ain't gonna kill me, then I'll do it. I think it would be a lot easier in court to explain why you did something that is on the checklist, rather than try and explain why you didn't do something that is on the checklist because you thought you knew better than the aircraft manufacturer.
I just remembered that the very aircraft manual and the company SOP delegate the final authority regarding actions to take when it hits the fan to the PIC whom can decide which procedure could be more suitable for X condition not obviously stated anywhere. I'm yet to see an alleged engine fire checklist/NNC/Emergency Checklist/Memory Item that demands to conduct an evacuation. Remember the crew reportedly didn't have any fire indication whatsoever.

I like what FlyKingfisher said:

I think the crew jumped the gun on this one. If the aircraft was outbound as the TOI report states, they could have just returned to the gate instead of ordering an evac.
It would probably had been a non-event. But it looks like I'm giving more than my regular 2c...
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Old 30th Aug 2010, 07:53
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Checklists are there for a reason. They take the decision making AWAY from the pilot(s), so emotion and stress have less of an impact. Boeing instructors and designers argue over drawn out meetings as to precisely what is written when and how.

While a knowledge of the QRH is very, very useful, pilots let "expectancy" take over and assume they know the checklist and race through it. And of course, everyone knows better than the designers, the testers and manufacturers of the aeroplane!!!

The FCOM and QRH even teach you how to use the checklists!!

Memory / Recall Items are also there for a reason, ie when timely action is required. Even then, there are only 2 x instances in aviation that I can think of where there is little room for delay: engine fire and depressurisation. Even then (!!!!) methodical use of the published procedures as recall actions are to be done. The best pilots I've seen do these actions in a deliberate and methodical pace, never panicking and racing.

So, we come full circle. Do we dare question the training standards at this / these airlines? Or should we just blame the pilot doing what he thought was correct as that is all the training he ever knew or understood?

Repeating myself from previuos posts: At Air India I witnessed pilots being checked to line and passed in the sim who could not either fly straight and level with the AP and FD's off (or at times even with FD's ON!), manually fly a circuit or land with a 15 kt cross wind using raw data, and so on.... They were passed by the airline's TRE. So, as far as they were concerned they are competant pilots as the SYSTEM told them they were.
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Old 3rd Sep 2010, 14:34
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when Boeing changed it to read and do, most companies followed suit
oh dear,if people only knew the truth..Being modify when airlines have incidents/accidents and the modification is mandated..helios etc..do you think we really need a checklist entitled #Warning Horn#?Same with Boeing SOP change and the evac as well,which in my mind is definitely a MEMORY checklist.Someone screwed up a real evac though,so they changed it to a read and do..now all we need is an accident where checklist delays an evac following a catastrophic fire and theyll change it back.
Its the same principle as FO lands on wet rwy and skids off..reaction is ban all FO landings(last thing you should do of course)..same principle here..evac is obviously not suited to read and do(unless its a non-event)..with a catastrophic fire/smoke situation,I would never read and do despite what some smart alec pedant instructor says.You should know it in your sleep like the engine fire or smoke(another non-memory!!)
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Old 3rd Sep 2010, 17:10
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Look , all airlines / training establishments are forever anal about RTO with Engine Fire / Evacuation etc , and all crews should be able to deal with this in their sleep .
I am always amazed at the cock-ups when a Fire is injected at any other phase of flight , ie on the stand , during push-back , during taxi , short finals etc .
Unless a jetty is still attached to the aircraft , a Full-Blown Evacuation has to be considered immediately .
A few well chosen words from the skipper to the copilot along the lines of :-
' Prepare for evacuation ' should alert him/her to depressurise the aircraft / run the Flaps to 40 ( 737 that is ) .
I once ran a sim session that had some slack where we threw in a lot of the above scenarios along with my personal favourite , the engine failure shortly after TO/GA pressed on take-off and engines arrive at Take Off Thrust . Incredible how few crew can keep the aircraft off the grass on that one .
Point is , we gave the crew a lot to take away with them and think about . Without exception , they all thoroughly enjoyed the experience , not just a sim session where they got out and then dismissed from their minds . They were talking about it on the line too , all good for increased situational awareness.
Basically , we need to get away from boring repetitive scenarios too often . Obviously the engine fire / failure at V1 is still the flight at its most vulnerable , but it seems we are missing the boat on the more mundane periods of flight when crew are at their most laidback.
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Old 3rd Sep 2010, 17:58
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so was it an expat or not?
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Old 4th Sep 2010, 04:29
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I am guessing that the crew was Indian because with the current anti--expat sentiment if it had been an expat it would have been all over the media and news reports. Then there would be further ramblings about 5000 unemployed CPL's etc.
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Old 4th Sep 2010, 14:02
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But all agreed that the most serious air safety lapse in Friday's incident occurred when the aft door on the left side of the aircraft was opened for evacuation. ''As the suspected fire was on the left engine, the emergency exits on the left hand side of the aircraft strictly should not have been opened,'' said a commander. The overwing rear exit on the left side, too, was opened, but that would have been done by passengers. ''In such situations, passengers do not pay attention to warnings,'' he added.

In Jet Airways, the pilots only give the command for evacuation; the side from which it should be initiated is decided by the flight attendants.
I don't agree! As there wasn't any fire, then the assessment to open the left hand doors was correct. i.e. Check outside conditions .. no hazard .. open exit.
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Old 4th Sep 2010, 14:15
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starvingcfi wants to know

so was it an expat or not?
If it had been an expat in the left seat, it would have been headline news on the Times of India and IBN-CNN TV news two days before it happened.
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Old 5th Sep 2010, 16:02
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Atpl Eligibility

What Is The Eligibility Criteria For Appearing In Atpl Exams In India?can We Appear In The Exams Without Having Cpl?i Saw It In Dgca Wesite
What Is The Flying Hrs Requirement
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Old 25th Sep 2011, 18:13
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Evacuate or not?

DGCA final report is out. Avherald synopsis:
Accident: Jet Airways B738 at Mumbai on Aug 27th 2010, evacuation during taxi leads to injuries
  • Two off-duty CC deadheading call flight deck on intercom and report fire on left hand donk.
  • Tower tells flight crew no fire.
  • No abnormal indications in the cockpit.
  • Purser who happens to be married to one of the off-duty CC who reported the fire also confirms fire to flight deck
PIC criticised by DGCA for ordering evacuation. FO criticised for not suggesting to shut the engine down and return to the gate on single engine.

It turns out both deadheaders were interpreting the red glow from the anti-collision lights as the presence of fire and the purser checked from a window from which it is not possible to see the engine but as PIC with the information available at the time would you have given the order to evacuate?
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Old 25th Sep 2011, 22:13
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Ok guys, one important thing because I read a lot of BS here:

During an RTO on B737, the FO SITS ON HIS HANDS AFTER Selecting Flaps 40 (ONLY when passengers are onboard!!!) and announcing to ATC ABC123 Stopping. He/she DOES NOT start manipulating overhead switches but MONITORS THE PIC's actions and CALLS OUT any omissions .

I say again, the "Drill" is not to operate the Outfflow valve NOR is the drill to start an evacuation.

Even the "FLAPS 40" is a suggestion and not a Boeing procedure. It seriously hampers the fire departments views by the way and should only be done if evacuation is imminent. (the only reason for selecting F40) Remember that an evacuation must be a controlled event, where any omission by the crew might result in serious consequences for the passengers and CM's. DO NOT RUSH. Don't they teach that in the sim and on the line anymore?!

A company that has the FO going into the overhead while doing an RTO needs some serious bollocking
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Old 26th Sep 2011, 00:24
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Well, being India, if events happened as the report says, then what a bunch of useless cabin crew.

I find it sort of perplexing that 4 cabin crew members don't know how the anti-collision light looks like in the night. They not only made one mistake, they made two; feeding wrong information to the flight crew which subsequently provoked an evacuation and then NOT performing the evacuation correctly!
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Old 26th Sep 2011, 02:22
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PAX behaviour

Remember that an evacuation must be a controlled event


...right....

"let loose the dogs of war..."

The crew have indicated their level of knowledge already, confusing a rotating beacon reflection with an engine fire.... and the passengers have been intent on the briefing to the extent they are disturbed that the over wing slides didn't deploy... yep... "controlled event" is not going to be the adjective to be used in this event, (nor a noun...).

Avoiding confusion in evacs is hard enough on a good day, and this was not one of the better performing crowd.

Good news is probably that the pax next flight will actually listen to the briefing or even read the safety cards. Wouldn't hold my breath for that though....


The purser called the other cabin crew to evacuate through the right hand forward and rear doors, but did not instruct to open the L2 door and overwing exits. However, door L2, both left hand overwing exits as well as both doors R1 and R2 and right hand overwing exits were opened.


All injured passengers had exited the aircraft through the overwing exists on both left and right hand side.



Wow! would have been interesting with a real fire from the LH engine...
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