13 9 AC FEEDBACK FORM. For your convenience, the AC Feedback Form is the last page of this AC. Note any deficiencies found, clarifications needed, or suggested improvements regarding the contents of this AC on the Feedback Form.
ORIGINAL SIGNED by /s/ Robert C. Carty Deputy Executive Director, Flight Standards Service
Appendix A A-1 APPENDIX A. LESSONS LEARNED THROUGH RELEVANT ACCIDENTS
AND INCIDENTS The following event summaries use information from the National Transportation Safety Board (NTSB) Aviation Accident Reports that document crewmember communication as a contributing factor in these accidents. The accident or incident is briefly summarized, the NTSB’s identified contributing factors are listed, and the FAA’s lessons learned are provided. Training programs that include scenario-based training (SBT) based from actual accidents may further the understanding and comprehension of crewmember procedures during such events. “Lessons Learned” will allow for a much broader knowledge base and responses that will result in a higher probability of an effective alignment of the flight deck or pilots’ and the cabin or flight attendant’s procedures.
EVENT — September 28, 2007:
A McDonnell Douglas DC-9-82 (MD-82) experienced an engine fire on climbout from Lambert-St. Louis International Airport.
The NTSB identified contributing factors that included crewmember communication were:
1. Two flight attendants seated in the aft cabin discussed hearing popping noises they thought could be associated with the left engine. Neither conveyed this information to the flight deck or the lead flight attendant.
2. After landing, the pilots did not seek information from the flight attendants because they believed the flight attendants would pass any significant information to them. However, long after the fuel spill, during the debriefing on the ground, a flight attendant stated she had smelled fuel earlier, but she did not pass this information to the flight deck when it happened.
LESSONS LEARNED:
To maintain readiness during unusual events that do not require an immediate evacuation, pilots and flight attendants should continually assess the situation for changes by actively exchanging information about conditions inside and outside of the airplane. For example, pilots should solicit information from available resources, including flight attendants, air traffic control (ATC), and Aircraft Rescue and Fire Fighting (ARFF) personnel. Flight attendants should determine the usability of emergency exits and provide this information to the flightcrew. Exchanging this type of information can help a crew maintain readiness to evacuate if necessary.
NOTE: The NTSB has had longstanding concerns about the need for effective communications between pilots and flight attendants. There have been numerous safety recommendations and reports on this subject.
REFERENCE(S):
NTSB Aircraft Accident Report NTSB/AAR-09-03 at https://www.ntsb.gov/investigations/accidentreports/reports/aar0903.pdf.
Appendix A A-2 EVENT — March 5, 2015:
A Boeing MD-88, on landing at LaGuardia Airport, departed the left side of the runway, made contact with the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay.
The NTSB identified contributing factors that included crewmember communication were:
1. The flight and cabin crews did not conduct a timely or an effective evacuation because of the flightcrew’s lack of assertiveness, prompt decision making, and communication, and the flight attendants’ failure to follow standard procedures once the captain commanded the evacuation.
2. The flight attendants were not adequately trained for an emergency or unusual event that involved a loss of communications after landing, and the flight attendants’ decision to leave their assigned exits unattended after the airplane came to a stop resulted in reduced readiness for an evacuation.
3. A RFF personnel may have arrived at the accident scene sooner if they had received more timely and precise information about the accident and its location.
4. Even though the initial uncertainty regarding the total number of passengers aboard the accident flight, including lap-held children, did not lead to any adverse outcomes, such uncertainty could be detrimental under other accident circumstances, especially if search and rescue efforts are needed.
NTSB RECOMMENDATIONS:
• Flight attendant training programs that include scenarios requiring crew coordination regarding active monitoring of exit availability and evacuating after a significant event that involves a loss of communications.
• Develop best practices related to evacuation communication, coordination, and decision making during emergencies.
REFERENCE(S):
NTSB Aircraft Accident Report NTSB/AAR-16/02 at https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1602.pdf.
Appendix A A-3 EVENT — July 9, 1995:
An ATR 72-212 aft passenger door separated after takeoff from O’Hare International Airport at an altitude of 600 feet. The flight attendant at the door stated she did not think of calling the flight deck when she heard the sound of the door leak before it separated, because the aircraft was under sterile flight deck conditions. When asked as to what conditions she would call the flight deck during the sterile period, she responded she would for fire or a problem passenger.
According to the No. 1 flight attendant, she did not use the interphone to contact either the No. 2 flight attendant or the flight deck crew regarding the noise from the door. When asked to describe the procedure for closing the door, the No. 1 flight attendant twice stated that you pull the door up, disconnect the pin, and pull down on the handle to lock the door. After an Association of Flight Attendants-CWA (AFA-CWA), AFL-CIO union representative reminded her that this airplane had the new modified door, she corrected herself and said you “pull the handle up” to lock the door.
Confusion over the interpretation of the sterile flight deck rule is not unusual, as our studies have shown. The study, “Cockpit/Cabin Communication: II. Shall We Tell the Pilots?” by Rebecca D. Chute and Earl L. Wiener, states:
“Flight attendants… are now expected to determine which situations are essential to the safe conduct of the flight [regarding sterile cockpit]. So consider… what we have called ‘the flight attendant’s dilemma.’ [He/]She must not only be concerned about the reception [he/]she will receive [from] the cockpit, but must also pass judgment on whether the information [he/]she considers conveying to the captain is ‘critical’... The scales appear to be tipped toward taking no action. Rather than take the chance of being wrong and thereby breaking the law, or at the least embarrassing themselves and perhaps subjecting themselves to a reprimand from the captain, they [may] likely opt not to communicate valuable, safety-related information to the pilots [due to the lack of training]. The puzzlement is that it is hard to say which choice is ‘erring on the side of caution.’ Whose caution? The flight attendant’s caution over the possibility of violation and/or reprimand, or over a possible accident or unmanageable cabin situation? The Dryden accident is a tragic reminder of opportunities lost.”
REFERENCE(S):
• “Cockpit/Cabin Communication: II. Shall We Tell the Pilots?” by Rebecca D. Chute and Earl L. Wiener from the 1996 International Journal of Aviation Psychology, Volume 6, Issue 3 at https://humanfactors.arc.nasa.gov/awards_pubs/publication_view.php?publication_id=566.
• NTSB Identification: CHI95IA215 at https://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20001207X03883&ntsbno= CHI95IA215&akey=1.
Appendix A A-4 EVENT — March 10, 1989:
A Fokker F28-1000 crashed on takeoff from Dryden Regional Airport.
During the stop in Dryden, heavy snow fell and ice accumulated on the wings. Passengers questioned the cabin crew about snow accumulations. However, these questions were not passed on to the flightcrew. The company’s procedures, at the time of the accident, discouraged communication between the flightcrew and cabin crewmembers regarding operational issues.
Relaying questions from the passenger cabin would have been considered outside the scope of cabin crew duties, and was therefore not conducted.
In a fully functional Crew Resource Management (CRM) environment, safety-related information from passengers or other crewmembers should be encouraged, as cabin crewmembers are considered to be a CRM resource, and within operational protocols (such as communicating during takeoff roll) should be expected to identify a potential safety issue to the flightcrew.
An off-duty pilot (passenger) was also concerned about the snow, but did not inform the cabin crew or flightcrew out of professional courtesy.
On the second rotation, the airplane lifted off the runway. No altitude was gained and the aircraft settled in a nose-high attitude, striking trees. The aircraft crashed, and came to rest in a wooded area and caught fire. The pilots, 1 flight attendant, and 21 passengers were killed. Forty-four passengers and one crewmember survived with injuries.
LESSONS LEARNED:
1. Flightcrew communications regarding safety issues should be open and effective.
2. Each crewmember must clearly give and receive communication in such a way that the flight safety decisions can be made appropriately.
REFERENCE(S):
• FAA Lessons Learned From Transport Airplane Accidents website at https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=31.
• FAA Accident & Incident Data web page at https://www.faa.gov/data_research/accident_incident/.
Appendix A A-5 EVENT — August 19, 1980:
A Lockheed L-1011, took off from Riyadh International Airport.
Seven minutes after takeoff, an aural warning indicated smoke in the aft cargo compartment. In response to information received from the flight attendants, the Flight Engineer (FE) went into the passenger cabin and reported there was fire and smoke in the aft area of the cabin. The captain decided to return to Riyadh.
During the return flight, the flight attendants attempted to fight the fire, which had burned through the cabin floor fire extinguishers. The aircraft landed back at Riyadh some 20 minutes later, and did not make an emergency stop, but instead taxied off the runway to a taxiway. It was several minutes after stopping before the engines were shut down. Following the landing, and prior to initiation of an evacuation, all of the occupants were incapacitated by the smoke and fire inside the airplane. An evacuation was never initiated. All 301 passengers and crew perished in the fire.
LESSONS LEARNED:
1. Having and using an emergency evacuation checklist would have enabled the crew’ s ability to properly configure the airplane and rapidly initiate an evacuation that could have saved lives.
2. The failure of the captain to prepare the cabin crew for immediate evacuation upon landing, and his failure in not making a maximum stop landing on the runway, with immediate evacuation.
3. The failure of the captain to properly utilize his flightcrew throughout the emergency.
4. The failure of headquarters management personnel to ensure that its personnel had adequate equipment and training to function as required during an emergency.
In “Communication from the Cabin Crew To the Cockpit Crew,” by the editors of Japan Air Lines’ Flight Safety Magazine state, “This incident illustrates that, just as with communication from the cockpit, information directed to the cockpit must not only be timely but must contain sufficient detail for an accurate assessment of the situation.” Refer to the Flight Safety Foundation’s January/February 1990 Cabin Crew Safety newsletter, Volume 25, Number 1, at https://flightsafety.org/ccs/ccs_jan-feb90.pdf.
The NTSB determined the most probable causes of the accident and contributors to its severity:
• A fire of undetermined origin,
• Underestimation of fire severity,
• Misleading fire progress information provided to the captain, and
• The time taken to evaluate the nature of the fire and to decide to initiate an emergency descent.
REFERENCE(S):
FAA Lessons Learned From Transport Airplane Accidents website at https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=27.
Appendix A A-6 EVENT — December 20, 1995:
A Boeing 747 veered off the left side of runway 4L during an attempted takeoff at John F. Kennedy International Airport. Of the 468 persons aboard (451 passengers, 12 cabin crewmembers, 3 flightcrew members, and 2 flight deck jump seat occupants), 24 passengers sustained minor injuries, and a flight attendant received serious injuries. The airplane sustained substantial damage. Communication was an issue in the cabin crew’s actions immediately after the airplane came to a stop.
LESSONS LEARNED:
1. While the decision not to evacuate the airplane may have been appropriate, these decisions were made without adequate knowledge of the post-accident condition of the airplane. Flight attendants had vital information they did not relay to the purser or the flightcrew. For example, flight attendants did not provide information to the flightcrew about the separation of the No. 4 engine, the severe floor disruption in the forward cabin, the smell of smoke and kerosene in the cabin, or the condition of the injured flight attendant.
2. Normally, the public address ( PA) and interphone systems provide effective means of communication among flight attendants and between the cabin and flight deck. In this accident, the purser was unaware his PA announcements were only audible in the forward cabin, and thus passengers and flight attendants in the rear of the airplane did not receive any information about the decision not to evacuate. Further, the purser and three flight attendants attempted to use the interphone system without success.
3. Flight attendants did not use megaphones as an alternative t o these communications systems.
4. The deadheading flight attendant went forward in the cabin to find out what was planned, but he did not return to the aft cabin to share the information with the other flight attendants.
5. Carriers need to have adequate procedures for flight attendant communications, including those for coordinating emergency commands to passengers, transmitting information to flightcrews and other flight attendants, and handling post-accident environments in which normal communications systems have been disrupted.
REFERENCE(S):
NTSB Aircraft Accident Report NTSB/AAR-96/04 at https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9604.pdf.
Appendix A A-7 EVENT — June 2, 1983:
A DC-9-32 cruising at 33,000 feet experienced a fire in the aft lavatory.
The cabin crew informed the captain of a fire. The captain contacted ATC and declared an emergency. The flightcrew made an emergency descent, and ATC vectored the aircraft to the Greater Cincinnati International Airport.
When the aircraft landed and stopped on the runway, the passengers began evacuating while fire department personnel began firefighting operations. About 60 to 90 seconds after the exits were opened, a flash fire enveloped the interior of the aircraft. Twenty-three of the 41 passengers were unable to exit the aircraft and died in the fire.
LESSONS LEARNED:
1. T he captain misconstrued reports the fire was abating when he received conflicting fire progress reports from the cabin crew.
2. He landed at the Greater Cincinnati International Airport rather than at Louisville International Airport, which would have allowed him to land 3 to 5 minutes sooner.
3. Wet towels and breathing through clothing aided survival.
4. A flight attendant who saw the smoke tried to find the origin of the fire while fighting it.
There was so much smoke she was not successful in locating the source. She closed the lavatory door and asked another flight attendant to notify the flight attendant in charge who then notified the flightcrew. No information was passed on to the flightcrew regarding the extent of the fire and smoke, or that the origin of the fire was unknown.
5. The captain did not question the flight attendant for this information and several critical minutes were wasted before the flightcrew put the aircraft into an emergency descent.
REFERENCE(S):
FAA Lessons Learned From Transport Airplane Accidents website at https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=26.
Appendix A A-8 EVENT — January 8, 1989:
A Boeing 737-400 left Heathrow Airport for Belfast International Airport with 8 crewmembers and 118 passengers on board. As the aircraft was climbing, the outer panel of one blade in the fan of the No. 1 (left) engine detached.
During the descent while attempting to complete checklists, the crew was interrupted numerous times by air traffic communications, and did not complete an evaluation of their situation. A proper assessment of their flight situation may have resulted in discovering the wrong engine had been shut down and possibly avoiding the accident. Thirty-nine passengers died in the accident and a further eight died later from their injuries.
LESSONS LEARNED:
1. Three cabin crewmembers had observed flames coming from the No. 1 engine, but did not communicate this information to the flightcrew. In a fully functional CRM environment, safety-related information from passengers or other crewmembers should not be discouraged.
Cabin crewmembers should be considered as a CRM resource, and within operational protocols (such as communicating during emergency situations), be expected to identify a potential safety issue to the flightcrew.
2. Adherence to rigorous flight deck discipline and operational procedures, including completion of checklists, is an essential component of effective CRM.
3. Flightcrew communications regarding airplane safety readiness should be open and effective.
Each crewmember must clearly give and receive communication in such a way that the flight safety decisions represent the best product of this open, two-way communication.
NOTE: Joint training exercises were stressed by the Civil Aviation Authority (CAA) after this flight, stating such training would provide pilots with the knowledge that cabin crew are a source of information that should be considered in emergencies. Cabin crew could be trained to communicate with the pilots in a timely way of the sights and sounds witnessed in and from the cabin.
REFERENCE(S):
• The United Kingdom Air Accidents Investigation Branch’s (AAIB) Aircraft Accident Report 4/90 at https://assets.publishing.service.gov.uk/media/5422fefeed915d13710009ed/4- 1990_G-OBME.pdf.
• FAA Lessons Learned From Transport Airplane Accidents website at https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=62.
Appendix A A-9 EVENT — October 28, 2016:
A Boeing 767-323 sustained uncontained engine failure and a subsequent fire at Chicago O’Hare International Airport.
The lack of communication resulted in the flightcrew being unaware of the developing situation in the cabin and the flight attendants initiating an evacuation with the left engine still operating.
If the left engine had been shut down earlier, the 4L slide would have been available for evacuation sooner because the slide would not have been affected by the jet blast coming from the engine.
During a post-accident interview, one flight attendant stated his opinion that it was not a priority to be on the phone if an engine fire occurred. If that were the case, the flight attendants could have activated the evacuation signaling system located on the flight attendant jump seat control panels, which would have provided an aural and a visual alert in the flight deck. If any of the flight attendants had taken that action, the flightcrew members would immediately have known that an evacuation was underway, and they could have reacted accordingly.
The flight attendants were trained to use the signaling system for an evacuation, and evacuation procedures in the flight attendant manual stated, “on aircraft such equipped, turn on signaling system,” so it is unknown why none of the flight attendants used the system to alert the flightcrew.
The captain (in a post-accident interview) stated that, if he had that awareness when he heard the commotion, he would have shut down the left engine sooner. The flight attendants had both the evacuation signaling system and the interphone system available to them to communicate with the flightcrew, but none of the flight attendants activated the signaling system, and the flight attendants who attempted communication using the interphone system were unsuccessful in reaching the flightcrew.
Flight attendant No. 3 tried to use the interphone to make an announcement in the cabin to calm the passengers but could not recall how to use the interphone.
Depending on their delivery date, Boeing 767-300-series airplanes have either a classic- or new-model interphone system. The new-model interphone, which was installed on the accident airplane, requires additional steps to operate compared with the classic-model interphone. During recurrent training, which the accident flight attendants received, the subject was presented via a web-based course and not through hands-on experience using an interphone during simulated emergencies.
At the time of the accident, the air carrier operated 13 different interphone systems across its airplane fleet, and the differences among interphone systems could affect evacuation communications during an emergency if company flight attendants were not familiar with and trained to proficiency on the various interphone system models.
REFERENCE(S):
NTSB Aircraft Accident Report NTSB/AAR-18/01 at https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1801.pdf.
Appendix A A-10 EVENT — June 26, 2016:
An Airbus A330-323 made an emergency evacuation at a parking stand after an auxiliary power unit (APU) failure filled the cabin with smoke at Heathrow Airport.
The AAIB investigation of the June 2016 incident at Heathrow Airport also demonstrated evacuation-related communication and coordination problems between flight and cabin crews.
The AAIB’s report stated that the flight attendant who initiated the evacuation did not activate the evacuation signal (similar to the event of October 28, 2016). However, another flight attendant went to the flight deck to report that an evacuation was underway, and the captain saw (from a reflection in the terminal building) that an aft emergency slide had been deployed.
The captain then made an announcement to stop the evacuation because he thought that he had isolated the source of the smoke and wanted to prevent unnecessary injuries. However, the captain did not discuss the situation in the cabin with the flight attendants before making his announcement, which indicated “a breakdown in communication and co-operation between flight crew and cabin crew members.”
The AAIB’s report also indicated that the captain’s announcement caused confusion. One of the flight attendants thought that the captain was not aware of the smoke in the cabin, so she shouted to the passengers to keep moving. Another flight attendant, who saw the captain standing in the flight deck, told the captain that the evacuation should continue because of “thick smoke” in the cabin, and the captain made a subsequent announcement indicating that the evacuation should continue via a jet bridge (which was in place before the evacuation).
The AAIB’s report concluded that “prompt and effective communication between the cabin and the flight deck might have avoided an evacuation” and that one reason for the initiation of the evacuation was that the flight attendants “did not receive specific instructions from the flight crew.”
REFERENCE(S):
AAIB Investigation to Airbus A330-323, at https://www.gov.uk/aaib-reports/aaib-investigationto-airbus-a330-323-n276ay.
Appendix A A-11 EVENT — September 8, 2015:
A Boeing 777-200 equipped with two GE90-85B engines experienced an uncontained left engine failure during the takeoff ground roll and caught fire at McCarran International Airport. The fire was extinguished by ARFF personnel. The 157 passengers and 13 crewmembers evacuated on the runway via emergency exit slides.
The NTSB Aviation Accident Final Report on British Airways Flight 2276 states, “When the relief pilot went into the cabin to assess the situation outside of the airplane, a flight attendant told him that she had been trying to call the flight crew. The CVR recorded a sound similar to an interphone call from the cabin to the flight deck, but the flight crewmembers most likely did not answer the call because they were focused on securing the left engine and deciding whether to evacuate.”
REFERENCE(S):
NTSB Identification: DCA15FA185 at https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150908X35241.
EVENT — October 29, 2015:
The following accident is still under investigation at the publication of this AC, but the NTSB has cited that communication and coordination issues between the flight and cabin crews are contributing factors in the investigation.
A Boeing 767-200ER with 101 occupants aboard was taxiing for departure at Fort Lauderdale-Hollywood International Airport when fuel began leaking from the left engine, causing a fire.
REFERENCE(S):
NTSB News Release at https://www.ntsb.gov/news/press-releases/Pages/PR_20151103.aspx.