Safety Study - Emergency Evacuation of Commercial Airplanes

NTSB Number: SS-00-01
NTIS Number: PB2000-917002
Adopted June 27, 2000
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Executive Summary

Since its inception, the National Transportation Safety Board has been concerned about the evacuation of commercial airplanes in the event of an emergency. Several accidents investigated by the Safety Board in the last decade that involved emergency evacuations prompted the Safety Board to conduct a study on the evacuation of commercial airplanes.

Past research and studies on airplane evacuations have provided insight into specific factors, such as crewmember training and passenger behavior, that affect the outcome of evacuations; however, these studies had several limitations. First, in many of these studies, researchers did not examine successful evacuations; therefore, they were not always able to discuss what equipment and procedures worked well during evacuations. Second, only evacuations following serious accidents were examined and not evacuations arising from incidents. As a result, little is known about incident-related evacuations, which can provide insight into how successful evacuations can be performed and which can also identify safety deficiencies before serious accidents occur. Third, each study was a retrospective analysis of accident evacuations. This approach limited the researchers to information collected during the original investigation rather than collecting consistent information on a set of evacuations. Fourth, previous research on evacuations has not examined some of the most basic questions about how often commercial airplanes are evacuated, how many people are injured during evacuations, and how these injuries occur.

The Safety Board's study described in this report is the first prospective study of emergency evacuations of commercial airplanes. For the study, the Safety Board investigated 46 evacuations that occurred between September 1997 and June 1999 that involved 2,651 passengers. Eighteen different aircraft types were represented in this study. Based on information collected from the passengers, the flight attendants, the flight crews, the air carriers, and the aircraft rescue and firefighting units (ARFF), the Safety Board examined the following safety issues in the study:

  • certification issues related to airplane evacuation,
  • the effectiveness of evacuation equipment,
  • the adequacy of air carrier and ARFF guidance and procedures related to evacuations, and
  • communication issues related to evacuations.

As a result of this study, the Safety Board issued 20 safety recommendations and reiterated 3 safety recommendations to the Federal Aviation Administration.

Recommendations

As a result of this safety study, the National Transportation Safety Board made the following safety recommendations to the Federal Aviation Administration:

Require all newly certificated commercial airplanes to meet the evacuation demonstration requirements prescribed in Title 14 Code of Federal Regulations Part 25, regardless of the number of passenger seats on the airplane. (A-00-72)

Require all commercial operators to meet the partial evacuation demonstration requirements prescribed in Title 14 Code of Federal Regulations Part 121, regardless of the number of passenger seats on the airplane. (A-00-73)

Conduct additional research that examines the effects of different exit row widths, including 13 inches and 20 inches, on exit hatch removal and egress at Type III exits. The research should use an experimental design that reliably reflects actual evacuations through Type III exits on commercial airplanes. (A-00-74)

Issue, within 2 years, a final rule on exit row width at Type III exits based on the research described in Safety Recommendation A-00-74. (A-00-75)

Require Type III overwing exits on newly manufactured aircraft to be easy and intuitive to open and have automatic hatch stowage out of the egress path. (A-00-76)

Require air carriers to provide all passengers seated in exit rows in which a qualified crewmember is not seated a preflight personal briefing on what to do in the event the exit may be needed. (A-00-77)

Require the aft flight attendants on Fokker 28 and Fokker 100 airplanes to be seated adjacent to the overwing exits, their assigned primary exits. (A-00-78)

Review the 6-foot height requirement for exit assist means to determine if 6 feet continues to be the appropriate height below which an assist means is not needed. The review should include, at a minimum, an examination of injuries sustained during evacuations. (A-00-79)

Require flight operations manuals and safety manuals to include on abnormal and emergency procedures checklists a checklist item that directs flight crews to initiate or consider emergency evacuation in all emergencies that could reasonably require an airplane evacuation (for example, cabin fire or engine fire). (A-00-80)

Review air carriers' procedures to ensure that for those situations in which crews anticipate an eventual evacuation, adequate guidance is given both to pilots and flight attendants on providing passengers with precautionary safety briefings. (A-00-81)

Review air carrier training programs to ensure that evacuation procedures call, at a minimum, for evacuation through all available floor level exits that are not blocked by a hazard. (A-00-82)

Review air carrier procedures and training programs to ensure that the commands used for slide evacuations are consistent with the commands used for slide evacuations during certification. (A-00-83)

Establish a task force to address the issue of providing periodic hands-on familiarization training, or the equivalent, for aircraft rescue and firefighting personnel at all Title 14 Code of Federal Regulations Part 139 certified airports on each airplane type that serves the airport on a scheduled basis. (A-00-84)

Require air carriers to conduct periodic joint evacuation exercises involving flight crews and flight attendants. (A-00-85)

Conduct research and explore creative and effective methods that use stateof-the-art technology to convey safety information to passengers. The presented information should include a demonstration of all emergency evacuation procedures, such as how to open the emergency exits and exit the aircraft, including how to use the slides. (A-00-86)

Require minimum comprehension testing for safety briefing cards. (A-00-87)

Develop advisory material to address ways to minimize the problems associated with carry-on luggage during evacuations. (A-00-88)

Require air carriers that operate Boeing 727s to include in the auxiliary power unit (APU) procedures instructions that when passengers are on board, the flight crew will make a public address announcement about APU starts immediately prior to starting the APU. (A-00-89)

Require all newly manufactured transport-category airplanes operating under Title 14 Code of Federal Regulations Part 121 to be equipped with independently powered evacuation alarm systems operable from each crewmember station, and establish procedures and provide training to flight crews and flight attendants regarding the use of such systems. (A-00-90)

Document the extent of false indications for cargo smoke detectors on all airplanes and improve the reliability of the detectors. (A-00-91)

Also as a result of this safety study, the National Transportation Safety Board reiterated the following safety recommendations to the Federal Aviation Administration:

For a 12-month period, require that all operators of transport-category aircraft demonstrate the on-airplane operation of all emergency evacuation systems (including door opening assist mechanisms and slide or slide/raft deployment) on 10 percent of each type of airplane (minimum of one airplane per type) in their fleets. These demonstrations should be conducted on an airplane in a controlled environment so that the entire evacuation system can be properly evaluated by qualified personnel. The results of the demonstrations (including an explanation of the reasons for any failures) should be documented for each component of the system and should be reported to the FAA. (A-99-100)

Revise the requirements for evacuation system operational demonstrations and maintenance procedures in air carrier maintenance programs to improve the reliability of evacuation systems on the basis of an analysis of the demonstrations recommended in A-99-100. Participants in the analysis should include representatives from aircraft and slide manufacturers, airplane operators, and crewmember and maintenance associations. (A-99-101)

Modify the service difficulty reporting system so that it contains more complete and accurate information about component failures; for example, (a) revise the various Service Difficulty Report (SDR) forms and database to include cycles and times since last inspection for failed components; (b) relate to the operators who submit SDRs the need for complete and accurate information when they report component failures; and (c) remind Federal Aviation Administration inspectors assigned to Part 121 and Part 135 operators of their need to review the component failure reports for accuracy and completeness. (A-97-125)