Pilots didn't know about evacuation
It seems true that...
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.
The debate centres around the SCCM initiating an evacuation in the circumstances that were present at the time
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.
'smoke filled cabin'
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.
Join Date: Nov 1999
Posts: 2,312
Likes: 0
Received 0 Likes
on
0 Posts
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?
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.
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.
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.
Join Date: Mar 2000
Location: Arizona USA
Posts: 8,571
Likes: 0
Received 0 Likes
on
0 Posts
She planned to speed up a slow disembarkation into a rapid disembarkation of the passengers but the words came out wrong.
That is precisely the reason the SCCM should be replaced...and shown the door.
Join Date: Mar 2007
Location: Sunny Sussex
Posts: 154
Likes: 0
Received 0 Likes
on
0 Posts
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?
ps, a question to Mr Arizona; When did you last operate with cabin crew?
Join Date: Jul 2006
Location: USA
Posts: 451
Likes: 0
Received 0 Likes
on
0 Posts
Once again....
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.
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.
Join Date: Oct 2006
Location: Europe
Posts: 251
Likes: 0
Received 0 Likes
on
0 Posts
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 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.
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.
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).
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).
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.
Join Date: Jan 2008
Location: Australia
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
@Juud - agree with BOAC - great summary.
As a regular passenger (disdainfully referred to as SLF by some
), I sometimes wonder who made decisions in the seconds leading up to this event:
YouTube - China Airline flight 120 fire accident at Naha Airport
and the flight crew in 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.
As a regular passenger (disdainfully referred to as SLF by some
), I sometimes wonder who made decisions in the seconds leading up to this event:YouTube - China Airline flight 120 fire accident at Naha Airport
and the flight crew in 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.
Per Ardua ad Astraeus
Join Date: Mar 2000
Location: UK
Posts: 18,579
Likes: 0
Received 0 Likes
on
0 Posts
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!
Still interested in what the SCCM was actually intending!
Controversial, moi?
Personally, I prefer the mistake the SCCM made in this instance to the one made at Manchester.
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.
Last edited by M.Mouse; 16th Feb 2011 at 15:13.
Join Date: Jan 2006
Location: up north
Posts: 310
Likes: 0
Received 0 Likes
on
0 Posts
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.
Join Date: Jan 2008
Location: Australia
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
@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
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
Join Date: Mar 2000
Location: Arizona USA
Posts: 8,571
Likes: 0
Received 0 Likes
on
0 Posts
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.
) are at all relevant to the present discussion.
Join Date: Jan 2008
Location: Australia
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
@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) are at all relevant to the present discussion.
what 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.
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
) are at all relevant to the present discussion.what 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.
PPRuNe supporter
Join Date: Dec 2003
Location: Planet Earth
Posts: 1,677
Likes: 0
Received 0 Likes
on
0 Posts
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.
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.
Controversial, moi?
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?.
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.
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
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.
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.