Safety Recommendation A-00-082

The Safety Board notes that Notice 8400.56 also directs POIs to review their operators' training programs to determine whether operators have included evacuation procedures that call for, at a minimum, evacuation through all available floor level exits that are not blocked by a hazard. The notice directs POIs, within 90 days, to document in PTRS any deficiencies found related to evacuation procedures calling for the use of all available floor level exits. The FAA informed the Safety Board that PTRS showed that approximately 420 airlines had been checked, and that all of the airlines checked either were already in compliance with the notice, or had made appropriate changes.

With the issuance of Notice 8400.56, the FAA has met the intent of Safety Recommendation A-00-82, which is classified "Closed--Acceptable Action."

Ms. Leach faxed to me a copy of FAA Notice 8400.56, "Passenger Evacuation Checklist Procedures," dated November 18, 2003. The action section of this Notice is shown below.

4. ACTION.

A. POIs shall provide the information in this notice to their respective operators by providing a copy of this notice to the program manager (part 91, subpart K), the director of safety (part 121), or the director of operations (part 135), or by referring them to the Web site indicated in paragraph 2.

B. Operators should review the abnormal and emergency checklists contained in company flight operations and safety manuals for procedures that would direct flightcrews to initiate, or consider, an emergency evacuation in all emergencies that could reasonably require an aircraft evacuation (e.g., cabin fire or engine fire).

C. POIs should review their operator's training program to determine if the operator has included evacuation procedures that call for, at minimum, evacuation through all available floor level exits that are not blocked by a hazard.

SWAT Meeting: The FAA said that current regulations already require evacuation through all available floor level exits. During the evacuation study, the Safety Board saw a significant number of evacuations that did not use all available exits, but the Board found these evacuations did not comply with any written procedures. The number and similarity of these partial evacuations lead the Board to believe that this was a developed and established procedure, even if not in the airline’s procedures. If this procedure exists, even if undocumented, the Board believes it should be documented, reviewed, and approved.

Safety Board staff indicated that if the FAA has performed the review recommended, they send a letter indicating that they performed the review and the results found. The FAA indicated their concern with taking away the pilot’s discretion to operate the aircraft in the safest manner possible, including evacuation when needed. The Safety Board agrees with the FAA’s concern. Results The FAA will send the Safety Board a letter indicating what type of a review was performed, and the results that were found. When the Safety Board receives this letter, this recommendation will be classified "Closed-Acceptable Action."

The Safety Board is concerned that the FAA does not understand the intent of this recommendation. In its recommendation letter, the Board indicated that only 4 of the 46 evacuations in the evacuation study were conducted using every exit available. Overall, of the evacuations examined in the study, 67 of the 125 floor-level exits were used. The Board was able to identify why 34 floor-level exits were not opened; for the remaining 24 floor-level exits, however, the Board could not determine why they were not used. The Board does not dispute the authority of the captain to limit the exits used during an evacuation based on potential threats to evacuating passengers.

However, the evacuation study found several incidents where the flight crew thought the situation was dangerous enough to order an evacuation, but not dangerous enough to use all floor level exits not blocked by a hazard. Flight crews are not trained and do not have procedures regarding when to order an evacuation that limits usage of exits not blocked by a hazard. If an evacuation is ordered, it should be conducted in accordance with that air carrier's FAA-reviewed and -approved procedures and training. The Safety Board's evacuation study found this was not the case and that limiting exit use during evacuations was not in accordance with air carrier's existing evacuation procedures.

An appropriate response to this recommendation might include a review of existin procedures and the development of new procedures for flight crews on when it may be appropriate to limit the usage of exits not blocked by a hazard during an evacuation. The Board asks the FAA to reconsider its position on this recommendation. Pending the FAA's taking the recommended action, Safety Recommendation A-00-82 is classified "Open--Unacceptable Response."

Letter Mail Controlled 11/14/2000 4:39:44 PM MC# 2001688 The FAA does not agree with the Board that flight attendants are not trained or were not likely to have received any guidance on evacuating an airplane using limited exits. Air carrier training programs require that all flight attendants be trained to evacuate passengers through all available floor level exits that are not blocked by a hazard. In addition, all crewmembers are trained to take directions from the pilot-in-command, especially during an emergency situation. Crewmembers are also trained, in the absence of those directions, to initiate their own actions.

If there are specific exits that the captain determines would have a positive effect on the safety of the passengers and crew, the crewmembers are trained to adhere to the captain's direction until the situation dictates that, for safety reasons, another course of action is more appropriate. As evidenced by the evacuations investigated by the Board, the captain's authority to make informed decisions regarding appropriate exits to be used does enhance the success of an evacuation.

In one case (Case No. 43), the comprehensive planning that took place for the landing and evacuation included specific direction by the captain to use overwing exits only, and is highlighted in the Board's study as a successful evacuation. The FAA will continue to ensure that flight attendants are trained to use all available floor level exits unless they blocked by a hazard. The FAA will also continue to support the captain's authority to use his/her discrection to determine if there are specific exits that should be used to ensure the safety of the passengers and crew. I consider the FAA's action to be completed on this safety recommendation.