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American 763 takeoff incident, ORD

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American 763 takeoff incident, ORD

Old 1st Nov 2016, 04:03
  #101 (permalink)  
 
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We've had a good run of luck

Recently a number of airframes have been seriously damaged or written off by fire without losing any pax.

Going back a few decades shows a less benign record. Some of the reduced fatality count can be credited to improved design of fuel systems and structures. But some day there will be another major fuel system breach with the wind blowing the wrong way.

In that case the fatality count will be a function of delay in beginning evacuation.

I propose that RTO SOP include cabin crew at the rear stations as they are best positioned to observe the gear and wings. In case of any flames, the rear crew must have an open line to the cockpit.

Cabin crew training needs to include fire assessment and knowledge of fire propagation. They need to be able to distinguish between tire and brake fires that certification allows time for ARFF to get on the job and fuel fires that are being blown towards the the fuselage.

Report of a fuel fire should interrupt the cockpit checklists in favor of immediate shutdown for evacuation.

Admittedly fires can either die out on their own or rapidly develop into a major conflagration. We only ever know after the fact.

Elderly and fragile pax are usually the last in line for evacuation and most prone to injury going down the slides.

Once the able bodied are off, there might be time to reassess the fire danger, especially if ARFF is on the scene and getting the fire under control. But remember that most fatal fires have exacted their toll before ARFF is on the scene.
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Old 1st Nov 2016, 04:16
  #102 (permalink)  
 
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Originally Posted by RatherbyFlying
Report of a fuel fire should interrupt the cockpit checklists in favor of immediate shutdown for evacuation.
What "cockpit checklists" are you doing if not the Evacuation checklist? You've aborted (probably because of an almighty bang as the disk let go). The only thing happening then is deciding what to do. If you decide to evacuate, you must do the Evacuation checklist, you can't just "shut down and bale out". If you think your Evac checklist has too many items, then get it changed.
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Old 1st Nov 2016, 07:56
  #103 (permalink)  
 
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For those on the bus, it may be useful to have a prioritised indication (master warning for example) of door opening in the event of an RTO.

Perhaps last item in the RTO memory actions, or first line of the EVAC checklist:

"If at any time warning DOOR CABIN/EMER EXIT OPEN....... eng 1 and 2 Master off" for example.

Admittedly this could get lost in the multitude of sensory inputs and tasks but it may help avoid someone ending up in the engine.
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Old 1st Nov 2016, 11:21
  #104 (permalink)  
 
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Somewhat akin to the engine-out go-around being generally well flown, while normal configuration go-around being frequently cocked up, due to emphasis or bias in training on certain manoeuvres, I personally find there is a big gap in the training, as a crew, around evacuations, assessments of problems, and what are the immediate concerns. Generally caused by limited training resources- money, time, facilities.

In previous companies, there have been a wide variety of ways of dealing with flight deck to cabin communications in non-normal events. Added to which, a flight deck crew that has never experienced a real ground situation, or something that might develop into an evacuation, tend to be minimalist. Telling the cabin to standby being sufficient, as per company SOP.
A crew that has been in a real situation tends to gather more info, sooner.

A difference between a simple 'at stations' PA, and following on with 'report' and getting the bigger picture from each individual crew member in the immediate aftermath, via interphone?

There have been a few occasions that I can remember, where an excitable member of the cabin crew has almost created a worse situation by taking a wrong action, or the right action too early. I'd suggest that starting an evacuation prior to shutting down the engines being an example of the latter.

Are we doing it right, or have we just been lucky?
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Old 1st Nov 2016, 11:49
  #105 (permalink)  
 
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Well done to the crew, I'm sure they did a great job in the evacuation.
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Old 1st Nov 2016, 14:57
  #106 (permalink)  
 
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Not a pilot, but could someone explain why, after an RTO due to a major engine malfunction (presumably made aware to the flight crew both by cockpit indicators as well as external noise, vibration, etc.), remaining engine shutdown is not the first thing on their checklist after parking brake set? Is it because there are things like flaps down or spoiler restow that are needed to configure the plane for an evac? Or were these guys caught flatfooted by the severity of the situation and still thought there was no fire or other emergency situation?
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Old 1st Nov 2016, 16:34
  #107 (permalink)  
 
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Caught flat footed? Do you have the background and
and a grasp of the details to assign blame?
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Old 1st Nov 2016, 17:33
  #108 (permalink)  
 
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The evacuation checklist is designed to ensure the outside of the aircraft is safe for passenger egress. Clearly; shutting down the engines is a vital part of that; however -the moment the generators trip offline everything goes black. We need to ensure everything else is ready before shutting power off...
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Old 1st Nov 2016, 18:00
  #109 (permalink)  
 
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Ships with generators driven by the main engines will start the auxiliary generators when manoeuvring in confined waters. Depending solely on the main engine's generator is a big no-no and could literary leave you dead in the water.
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Old 1st Nov 2016, 21:55
  #110 (permalink)  
 
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The ability of the flight crew to rapidly assimilate exactly what's happening to their aircraft has been a factor in many incidents and accidents. Modern cockpits have many displays. Cameras are tiny and cheap nowadays. Is there a case for fitting external cameras to airliners, looking at the undercarriage, engines and perhaps control surfaces from different angles, with an ergonomic and efficient method of showing the flight crew what's happening outside? Would that be a benefit or a distraction during an emergency?
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Old 2nd Nov 2016, 00:34
  #111 (permalink)  
 
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Great idea I reckon. A camera on the vertical stab looking forward (like currently on 777/A340 family and newer), a camera on each wing sharklet/winglet looking inward at flight controls and one or two on the rear position light looking down at elevator stab. You would be able to determine things like if you had an engine fire or wing fire, condition of flight controls after malfunction or fire (calc of an abnormal Vref if flap burnt through), or which side to call exiting for an evacuation (yup the cabin crew should assess exits prior to pulling slides but it all helps). It would be an effect tool to help save lives at little cost.
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Old 2nd Nov 2016, 00:43
  #112 (permalink)  
 
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On certain types, you can stick your head out the window.
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Old 2nd Nov 2016, 02:15
  #113 (permalink)  
 
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That works on the ground and does nothing in flight.
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Old 2nd Nov 2016, 04:57
  #114 (permalink)  
 
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It MAY help after you have come to a stop in a B737 or A320 on the runway. It costs nothing and may give you vital information quickly. As for cameras, they would be ideal. The problem is the certification and cost.
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Old 2nd Nov 2016, 10:10
  #115 (permalink)  
 
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Seenitall

Be well aware that the aircraft manufacturers have paid much more than cursory attention to composing checklists. Perhaps we should trust them to have got it right?
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Old 2nd Nov 2016, 13:28
  #116 (permalink)  
 
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The problem is the certification and cost.

Is that true considering the total cost of a single a/c. If it was designed in at manufacture and amortised over a world fleet lifetime, would it be that expensive. I wonder if the same thing was said about FDR's & CVR's. There are already outside viewing cameras, so the technology is there. F1 has much expertise, although at different speed & temperature. However, it would not be a go/no-go item, probably.
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Old 2nd Nov 2016, 13:50
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I am not questioning the checklists, I am just interested is what these list give as to the order of tasks and their expected time to accomplish. What we know from the video is:
  1. Plane was billowing fire and smoke from the RHS when it stopped.
  2. The left overwing slide was blown roughly 20 seconds after the plane stopped.
  3. It was at least 40 seconds after the plane stopped that the left rear slide was blown.
  4. The LHS engine was still operating at that time with at least some significant rotational speed
Is this timeline indicative that: (a) all required checklists were performed immediately; or (b) there was some delay in executing the evac requirements.

As to the issue of not wanting to kill the engine because it supplies electrical power -- given that the plane was in take-off config, would not the APU have been operating? Please note that I am not saying that anything was done wrong. I don't know. I am just interested in understanding whether everything took place as expected in such a situation, or whether delays occurred that may indicate that there were on-board perceptions of the situation that are different from what we can see from the videos.
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Old 2nd Nov 2016, 14:00
  #118 (permalink)  
 
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What that is indicative of, Seeitall, is that the cabin crew (or a passenger) commenced the evacuation before the pilots commanded it.
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Old 2nd Nov 2016, 14:47
  #119 (permalink)  
 
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I understand that the evac may have started before the pilots commanded it. Indeed we do not yet know whether the pilots were even contemplating evacuation before it was forced from the cabin. But that is not my question. My question is only whether the 40+ second delay from stopping to engine spool down is: (a) representative of a situation on the flight deck where preparation for an evac was being performed as fast as possible given the checklists; or (b) representative of a situation that was not initially pointing to an immediate evac?

Another way to put it is as follows: what is the minimum time from a plane stopping to when an evac can begin (without running engines interfering with slides) assuming all the checklist items begun immediately and are executed without difficulty? Is this possible within 20 seconds? Or does it take 40+ seconds? If the former, it would appear that there was some delay in commencing or difficulty in performing the checklists. If the latter, then everything went as expected -- other than for the slides being deployed too soon.

Again, I don't what the correct answer is, and I certainly am unwilling to say that any mistakes are made. Because this incident is the subject of an NTSB investigation, we certainly will learn what actually occurred. But on PPRuNe, we always try to jump the gun and figure things out in advance of getting all of the facts.
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Old 2nd Nov 2016, 14:53
  #120 (permalink)  
 
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however -the moment the generators trip offline everything goes black. We need to ensure everything else is ready before shutting power off...
Standby/emergency power is still available after after gens go offline. This incident did occur in broad daylight, emergency exit lighting turns on automatically day or night.

If rear slide was deployed/being blown by #1 engine still running and passengerswere using wing slide while still running there was a clear lack of a coordinated evacuation. It should all come out in the investigation and will be interesting to read.

No intent to criticize, just adding info that may be helpful and thankful all were able to survive with only a few reported minor injuries.
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