Pilots didn't know about evacuation
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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?
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?
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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.
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.
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without going into the propriety or if it was a breach of SOP, if the action taken was, as stated in the first post:
I wonder why has the discussion not veered towards suspicion of aerotoxic syndrome? 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?
[rest snipped] ...detecting "a pungent burning smell" througout the cabin, cabin crew instigated an evacuation without pilot permission or knowledge.
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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.
both flight deck crew are always in possession of far more information, and see a far bigger picture, than the CCMs.
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.
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@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.
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.
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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.
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.
Great thread hitting a lot of sensitive buttons 
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.
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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.
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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.
David1300 sounds like a non-professional CRM instructor, gone awry.
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I would ask once again, just what do you know about professional airline pilots and their duties and responsibilities?
However, he probably knows a lot about posters who do not read his posts properly.
Controversial, moi?
I did not say that Manchester had anything to do with CC decisions.
So, would you prefer it if she had waited until the situation was catastrophic before she did anything about it?
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Short memories indeed
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.
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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!
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!
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.
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.
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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.
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.
Last edited by Piltdown Man; 17th Feb 2011 at 20:15.
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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.
In this case, communication was possible and not very well attempted.
Controversial, moi?
Don't wait until the situation becomes catastrophic or make a decision, bearing in mind she was unable to effectively communicate with the FD.
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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 -
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..
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.
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..
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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.
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.
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.
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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......"
There is only one statement by David 1300 which I question: to quote, "Large Airline Captains are smarter than brain surgeons......"