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Safety Recommendation Details

Safety Recommendation A-83-045
Details
Synopsis: A PRIMARY FACTOR IN ASSURING THE RAPID AND SAFE EVACUATION OF PASSENGERS FROM AN AIRPLANE IN AN EMERGENCY IS THE ADEQUATE TRANSFER OF PASSENGER SAFETY INFORMATION. PASSENGER BRIEFING CARDS ARE REQUIRED TO BE AVAILABLE TO PASSENGERS AND ORAL BRIEFINGS OF PASSENGERS ARE REQUIRED BEFORE ALL U.S. AIR CARRIER AND AIR TAXI FLIGHTS BY FEDERAL AVIATION REGULATIONS AND BEFORE INTERNATIONAL FLIGHTS BY INTERNATIONAL CIVIL AVIATION ORGANIZATION ANNEX 6 STANDARDS. HOWEVER, INFORMATION GATHERED IN MANY ACCIDENT INVESTIGATIONS HAS LED THE SAFETY BOARD TO CONCLUDE THAT THE PRESENT SYSTEM FOR EDUCATING PASSENGERS ABOUT AIRPLANE SAFETY FEATURES IS INADEQUATE AND HAS FAILED TO ACHIEVE ITS PURPOSE OF INCREASING SURVIVABILITY. THE MOST RECENT EXAMPLE IS THE SEPTEMBER 13, 1982, CRASH OF A SPANTEX DC-10 AT MALAGA, SPAIN.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: SPONSOR A GOVERNMENT/INDUSTRY TASK FORCE OPEN TO FOREIGN PARTICIPANTS MADE UP OF REPRESENTATIVES FROM THE AIRPLANE MANUFACTURERS, AIR CARRIER AND COMMUTER OPERATORS, RESEARCHERS, FLIGHT ATTENDANTS, AND CONSUMERS (1) TO IDENTIFY THE TYPE OF SAFETY INFORMATION THAT IS MOST USEFUL AND NEEDED BY PASSENGERS, (2) TO IDENTIFY AND DEVELOP IMPROVED INSTRUCTIONAL CONCEPTS FOR CONVEYING THE SAFETY INFORMATION, AND (3) TO RECOMMEND APPROPRIATE CHANGES TO THE OPERATING REQUIREMENTS REGARDING PASSENGER ORAL BRIEFINGS AND INFORMATION BRIEFING CARDS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: KING SALMON, AK, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA82AA015
Accident Reports: Reeve Aleutian Airways, NIHON YS-11A, N169RV
Report #: None
Accident Date: 2/16/1982
Issue Date: 7/12/1983
Date Closed: 10/2/1989
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/2/1989
Response: This safety recommendation was made originally in 1983 and reiterated in the Safety Board's 1985 Safety Study entitled "Airline Passenger Safety Education: A Review of Methods Used to Present Safety Information" (NTSB/SS-85/09). The study clearly described the need for comprehensive research to examine behavioral factors that cause passengers not to heed or not to understand safety information. After Safety Recommendation A-83-45 was issued in 1983, the FAA and the Flight Safety Foundation (FSF) jointly sponsored the International Aircraft Occupant Safety Conference and Workshop in 1984 and again in 1988. The proceedings of the 1984 conference and workshop contained the following FSF endorsement of Safety Recommendation A-83-45: "FSF agrees with the NTSB recommendation of July, 1983, to FAA with regard to efforts in passenger education. These efforts should encompass those aspects described in the Combined Analyses Section of these proceedings." Clearly, the attendees found, and the FSF agreed, that the 1984 conference and workshop was not intended as the forum, as the FAA contends, to examine passenger education called for in Safety Recommendation A-83-45. As a matter of fact, the Evacuation and Survival Workshop, which considered passenger education along with several other topics, pointed to only three topics that were deemed critical to passenger education and failed to address the need to convene a government/industry task force that was called for in Safety Recommendation A-83-45. The 1988 FSF/FAA Conference and Workshop dedicated one of its four workshops to passenger education. The FAA presented the status of several ongoing and proposed research and rulemaking projects--disappointingly, none of the projects addressed the Safety Board's concerns that prompted Safety Recommendation A-83-45. The Safety Board will review closely the yet-to-be published proceedings of the 1988 conference Data Source: NTSB Recommendations to FAA and FAA Responses and workshop for possible recommendations to the FAA to convene a government/industry task force to fully examine passenger safety education. In 1986, the FAA convened the Emergency Evacuation Task Force that examined the design, reliability, maintenance, and operation of emergency evacuation systems including exit doors, evacuation slides, and emergency lighting subsystems. One working group was tasked with examining training, the operation of emergency evacuation systems, and in particular the actions of flight attendants and the behavior of passengers during evacuations. This working group met once. The FAA chairman of the group deemed that an in-depth review of passenger issues was inappropriate for the meeting because the Safety Board was about to publish a safety study on passenger education; the chairman agreed to the Safety Board representative's suggestion to mail the study on passenger safety education to all attendees. Unfortunately, because the group did not meet again before its final report was published, the attendees did not have the opportunity to discuss and recommend any possible future efforts to better prepare passengers for emergency evacuations. The group's final report and recommendations failed to address any passenger safety education topics. Advisory Circular (AC) 121-24A entitled "Passenger Safety Information Briefing and Briefing Cards" dated May 9, 1989, that is referred to in your letter of July 3, 1989, has been reviewed and compared to comments the Safety Board provided the FAA on October 28, 1988, on the proposed revisions to AC 121-24. Unfortunately, of the 8 sections of the proposed AC that the Safety Board commented on with 12 specific topics that the AC should address, only 4 topics were included in the revised AC 121-24A. Although the FAA has maintained that the issuance of the AC fulfills the intent of Safety Recommendation A-83-45 because "The FAA has sponsored a government/industry task force..." the Safety Board, as evidenced by the two FSF/FAA Conferences and Workshops and the FAA Emergency Evacuation Task Force, remains unconvinced that these forums fulfilled the intent of this safety recommendation, and furthermore, the FAA failed to take positive action on the 1983 FSF recommendation to convene a government/industry task force. The Safety Board believes that the revised AC in itself clearly fails to represent marked improvements over the earlier AC because the revisions are not based upon a systematic analysis of the factors that affect passenger safety education. In conclusion, the Safety Board is disappointed that after 6 years the FAA has not determined those factors that affect the attentiveness of passengers to safety information and the passengers' ability to act correctly on the safety information. In view of the FAA failure to take the action called for in this safety recommendation during the 6 years it has been under consideration, the Safety Board finds it necessary to classify Safety Recommendation A-83-45 as "Closed-- Unacceptable Action."

From: FAA
To: NTSB
Date: 7/3/1989
Response: "IN MAY 1989, THE FAA ISSUED ADVISORY CIRCULAR (AC) 121-24A, "PASSENGER SAFETY INFORMATION BRIEFING AND BRIEFING CARDS." THIS AC PROVIDES INFORMATION REGARDING THE ITEMS THAT ARE REQUIRED TO BE COVERED IN ORAL PASSENGER BRIEFINGS AND ON PASSENGER BRIEFING CARDS, AND PROVIDES SPECIFIC INFORMATION ABOUT AIR CARRIER OPERATIONS CONDUCTED UNDER 14 CFR PART 121. THE AC ALSO PROVIDES SUGGESTIONS FOR MAKING THE INFORMATION INTERESTING AND MEANINGFUL... I BELIEVE THE FAA HAS MET FULLY THE INTENT OF THIS SAFETY RECOMMENDATION. THE FAA HAS SPONSORED A GOVERNMENT/INDUSTRY TASK FORCE, HAS IDENTIFIED AND DEVELOPED IMPROVED CONCEPTS FOR CONVEYING THE SAFETY INFORMATION TO PASSENGERS, AND HAS RECOMMENDED APPROPRIATE CHANGES, THROUGH THE ISSUANCE OF THE AC, TO THE OPERATING REQUIREMENTS REGARDING PASSENGER ORAL BRIEFINGS AND INFORMATION BRIEFING CARDS. I PLAN NO FURTHER ACTION...

From: NTSB
To: FAA
Date: 1/30/1989
Response: Thank you for your letter in further response to the National Transportation Safety Board's Safety Recommendation A-83-45, concerning conveyance of safety information to air carrier and commuter passengers. Members of the Safety Board staff attended the FAA/Flight Safety Foundation (FSF) Conference and Workshops on International Aircraft Occupant Safety, held from October 31 to November 3, 1988. One of the four workshops was for the topic of passenger education. This meeting of government and industry personnel is viewed as a positive step, as was the International Aircraft Safety Seminar, held December 11- 14, 1984. Whether these workshops will result in viable actions which address the concerns of the Safety Board remains to be seen. The Safety Board notes that the FAA has under development a revision to its advisory circular (AC) on passenger education. The Safety Board looks forward to reviewing this proposed revision; presumably it will incorporate the recommendations of the passenger education workshop referenced above. However, the FSF conference will only result in recommendations being made to the FAA, not in the actual change which the safety recommendation calls for. The 1984 conference and the AC have not achieved those positive results. Since this safety recommendation is now five years old, and since there has not yet been substantial change in passenger survival education, Safety Recommendation A-83-45 will remain classified as "Open-- Unacceptable Action," pending the results of the FSF conference and further action by the FAA.

From: FAA
To: NTSB
Date: 8/5/1988
Response: THE FAA IS SPONSORING THE FLIGHT SAFETY FOUNDATION (FSF) CONFERENCE AND WORKSHOPS ON INTERNATIONAL AIRCRAFT OCCUPANT SAFETY, WHICH WILL BE BEGIN ON OCTOBER 31, 1988. ONE OF THE FOUR WORKSHOPS IS SCHEDULED TO ADDRESS THE TOPIC OF PASSENGER EDUCATION. ADMINISTRATOR MCARTOR BELIEVES THAT THE INTENT OF THE SAFETY RECOMMENDATION HAS BEEN MET WITH THE SCHEDULING OF THE CONFERENCE. ADDITIONALLY, THE FAA HAS DRAFTED AN ADVISORY CIRCULAR (AC) ON PASSENGER BRIEFINGS AND INFORMATION. THIS AC WILL ADDRESS THE INCLUSION OF INFORMATION ON THE PASSENGER BRIEFINGS AND CARDS AND PROVIDE INFORMATION REGARDING TECHNIQUES AND METHODS TO MAKE THE BRIEFINGS AND CARDS MORE ATTRACTIVE AND UNDERSTANDABLE. THE FAA WILL PUBLISH THE AC IN THE FEDERAL REGISTER FOR COMMENT AND WILL PROVIDE THE BOARD WITH A COPY AS SOON AS IT IS ISSUED.

From: NTSB
To: FAA
Date: 10/25/1985
Response: From the Safety Study Airline Passenger Safety Education: A Review of Methods Used to Present Safety Information (NTSB/SS-85/09). The Board adopted this Safety Study on 10/25/1985. In view of the findings of this Special Study, the Safety Board reiterates its earlier recommendation that the FAA: A-83-45. The Federal Aviation Regulations require merely that passengers be “orally briefed” on the location of emergency exits before each flight. However, for many years airlines have directed flight attendants to physically point to each emergency exit during the pre-takeoff safety briefings. The Safety Board believes that this practice is an effective way of informing passengers where each exit is located relative to each passengers’ seat. Nevertheless, the Safety Board is disturbed that its investigators have observed that at least two U.S. airlines have discontinued this practice and instead ask that passengers refer to their safety cards for the location of the emergency exits. The Safety Board is concerned that this practice may establish an undesirable precedent that other airlines may follow. In 1972, the Safety Board issued a safety recommendation to the FAA to amend 14 CFR 121 to require that emergency exits by physically pointed out before each flight so that passengers would better know the location of exits. The FAA disagreed by stating that the regulations were adequate without the requirement to physically point to each exit; the status of this recommendation is “Closed—Unacceptable Action.” In view of the findings of this study, which show that passengers should be given clear and unambiguous instructions of the location and operation of safety equipment including the location of exits, and in view of the practice of at least two airlines to no longer require flight attendants physically point to exits, the Safety Board urges the FAA to reconsider this earlier safety recommendation: A-72-128.

From: NTSB
To: FAA
Date: 6/13/1985
Response: The members of the Safety Board staff who attended the FAA/Flight Safety Foundation (FSF) Conference and Workshop on Cabin Safety, held on December 11-14, 1984, found that relatively little attention was given to passenger education during workshop discussions and that, in general, the intent of Safety Recommendation A-83-45 that a government/industry effort to identify the needed improvements was not fulfilled. Although the Safety Board is aware that the final conference report has yet to be released, we would anticipate that it will do no more than recommend that the FAA conduct research into the entire issue of passenger information, and that it will not identify specific improvements needed. Since this is what the Board recommended in the first instance, Safety Recommendation A-83-45 will remain classified as "Open--Unacceptable Action," pending further action by the FAA to identify, evaluate and develop improved passenger education techniques.

From: FAA
To: NTSB
Date: 5/2/1985
Response: FAA LTR: WE BELIEVE THAT THE BOARD'S ASSESSMENT THAT THE PASSENGER EDUCATION TOPIC WAS INADEQUATELY COVERED AT THE WORKSHOP IS PREMATURE. THE FINAL REPORT RESULTING FROM THE CONFERENCE IS EXPECTED TO BE FINALIZED BY MID-JULY 1985 AND SHOULD PROVIDE PERTINENT INFORMATION TO AID IN THE ASSESSMENT OF THE QUESTION AS TO THE DIRECTION THE FAA SHOULD PROCEED TO RESPOND TO THE BOARD'S CONTENTION THAT THE PRESENT BRIEFING/CARD PROGRAM HAS FAILED TO ACHIEVE INCREASING SURVIVABILITY. A DECISION REGARDING WHETHER THE FAA SHOULD SPONSOR ANOTHER SEMINAR, WHICH EXPLORES SOLELY THE ISSUES OF PASSENGER EDUCATION WILL BE MADE AFTER OUR REVIEW OF THE FINAL REPORT OF THE CONFERENCE AND WORKSHOP ON CABIN SAFETY BEING PREPARED BY THE FSF.

From: NTSB
To: FAA
Date: 1/10/1985
Response: The Safety Board has been withholding comment on the FAA's letter pending review of the proceedings of the Aircraft Cabin Safety Seminar described in your letter. The Safety Board notes that the seminar, Conference and Workshop on Cabin Safety, originally proposed for mid-1984, was held December 11 to 14, 1984. Members of the Safety Board staff attended the conference and workshop and found that little attention was given to the important topic of passenger education. Only small portions of two sessions (Session V: Evacuation and Survival, and part of the Working Group, Session 3) addressed the intent of Safety Recommendation A-83-45. The Safety Board believes this is not adequate coverage for such a critical topic. Additionally, the amount of time that has been lost in developing adequate passenger education techniques greatly concerns the Safety Board. Safety Recommendation A-83- 45 has been classified as "Open--Unacceptable Action." The Safety Board urges that the FAA sponsor the government/industry task force to identify and evaluate passenger education techniques as recommended. The Safety Board continues to believe that past accidents demonstrate that current passenger education systems are not adequate and must be improved if passenger survivability is to be increased. The opportunity to discuss openly matters of aviation safety are appreciated.

From: FAA
To: NTSB
Date: 3/22/1984
Response: FAA COMMENT: THE FEDERAL AVIATION ADMINISTRATION (FAA) DOES NOT BELIEVE THAT THERE IS SUFFICIENT JUSTIFICATION THAT WOULD WARRANT OUR SPONSORSHIP OF A GOVERNMENT/INDUSTRY TASK FORCE AS RECOMMENDED BY THE BOARD, HOWEVER, THE FAA HAS UNDERTAKEN THE FOLLOWING PROGRAMS RELATED TO THE ENHANCEMENT AND TRANSFER OF CABIN SAFETY INFORMATION: (1) BY MID-1984 THE FAA PROPOSES TO SPONSOR AN AIRCRAFT CABIN SAFETY SEMINAR. THE PURPOSE OF THIS SEMINAR IS TO PROVIDE THE AVIATION COMMUNITY WITH THE LATEST KNOWLEDGE AND THINKING ABOUT CABIN OCCUPANT SAFETY WITH RESPECT TO DESIGN, PRACTICE, AND PROCEDURES. THE OBJECTIVES ARE TO CONDUCT A COMPREHENSIVE REVIEW OF ALL ASPECTS OF AIRCRAFT CABIN SAFETY WITH REGARD TO DESIGN, CREW PROCEDURES AND TRAINING, EQUIPMENT, AND PASSENGER EDUCATION THAT HAVE A BEARING ON THE IMPROVEMENT OF OCCUPANT SURVIVAL DURING EMERGENICES, BOTH IN FLIGHT AND ON THE GROUND. TENTATIVE SESSION NO. 5 OF THE SEMINAR IS DIRECTED TO PASSENGER EDUCATION, SUCH AS: A. PASSENGER BRIEFINGS: COMPARISON OF LIVE BRIEFINGS WITH TELEVISED BRIEFINGS, USE OF EMERGENCY BRIEFING CARDS, EFFECT OF VOICE QUALITY ON PASSENGER ATTENTIVENESS, DEPARTURE LOUNGE SELF-BRIEFING MATERIAL, BRIEFING MESSAGE CONTENT, ETC. B. FREQUENT TRAVELER TRAINING: DISCUSSION OF PARA- SAFETY SPECIALISTS WHO COULD ASSUME RESPONSIBILITY UNDER CABIN STAFF. (2) WE ARE UPDATING ADVISORY CIRCULAR NO. 121-24, PASSENGER SAFETY INFORMATION BRIEFING AND BRIEFING CARDS.

From: NTSB
To: FAA
Date: 12/7/1983
Response: The Safety Board agrees that properly trained flight crews and appropriately marked emergency evacuation routes and equipment are essential to assure the rapid and safe emergency evacuation of passengers. However, the critical and probably the least predictable factor in an evacuation is the passenger. The Safety Board maintains its stated position that passenger survivability must be enhanced through improved techniques in passenger safety education which will heighten the probability that the information will be recalled in an emergency. Your response to Safety Recommendation A-83-45 indicates that you believe the present regulations and guidance material are adequate to assist air carrier operators in complying with the FAA requirements. The guidance materials referred to in your letter, Advisory Circular (AC) 121-24, and Society of Automotive Engineers (SAE) Aerospace Recommended Practice (ARP) 1384 specify the content and minimum requirements for presenting passenger safety information through cards and oral briefings. Admittedly, it is difficult to define whether the content or presentation techniques employed for passenger safety information assure adequate retention. However, the Safety Board believes that the evidence is clear that current techniques do not. As indicated in the FAA sponsored study mentioned in your response, 30 percent of the persons interviewed did not even give their attention to the safety briefing. We believe that an improvement in the content or presentation format is needed to get these persons to pay attention and to further the retention of the safety information vital to survival by all passengers. The issue at the heart of the Safety Board's recommendation is not whether there is adequate guidance provided to operators to meet the current operating rules of 14 CFR 121 but whether the current requirements and guidance material result in the most appropriate and effective means of passenger education. The Safety Board believes that passenger education can and must be improved, and suggests that the best way to determine what new and improved instructional techniques and concepts are available is for the FAA to confer with those persons and researchers active in the area of passenger safety. The ineffectiveness of current techniques to convey and promote the retention of passenger safety information has been documented again in the May 5, 1983, Eastern Air Lines L-1011 near-ditching off the coast of Miami, Florida. Although 89 percent of the passengers questioned said that they were attentive to the oral briefing, numerous passengers failed to don their lifevests properly, and some inflated their vests inside the cabin. Consequently, the Safety Board requests that the FAA reconsider its response to this safety recommendation in light of the foregoing discussion. Pending your review and response, Safety Recommendation A-83-45 will be classified as "Open--Unacceptable Action."

From: FAA
To: NTSB
Date: 9/22/1983
Response: FAA LETTER: RESPONSE FROM THE FAA STATING THAT THE SUBJECT IS ADEQUATELY COVERED IN FAR SECTIONS 121.571, 121.573 AND 121.333. ALSO, AC 121-24 PROVIDES INFORMATION AND GUIDANCE FOR USE BY AIR CARRIERS IN THE PREPARATION OF PASSENGER SAFETY INFORMATION BRIEFING AND BRIEFING CARDS. VARIOUS INVESTIGATIONS AND PUBLICATIONS HAVE BEEN SPONSORED BY THE FAA, E.G., FAA REPORT NO. IRC-79-1, AN INVESTIGATION OF FACTORS AFFECTING AIRCRAFT PASSENGERS ATTENTION TO SAFETY INFORMATION PRESENTATIONS, AND SOCIETY OF AUTOMOTIVE ENGINEERS S-9 (CABIN SAFETY COMMITTEE) HAS DRAFTED AEROSPACE RECOMMENDED PRACTICE 1384.