An ATSB investigation report has found that while an emergency
passenger evacuation at Hobart was conducted rapidly and in a
pro-active manner in the interests of passenger safety, there were
problems with communication involving the pilots, ground crew, and
cabin crew that created potential risk and has led to improved
safety action for the future.
The Australian Transport Safety Bureau's final report into the
Boeing 717 evacuation on 17 May 2005 found that a right engine
starter had failed during the engine start due to loss of
lubricating oil because a seal retaining ring was incorrectly
installed. This resulted in smoke and sparks issuing from the right
aircraft engine. The smoke and sparks were reported to the captain
as a fire by the aircraft dispatcher, and the captain ordered an
emergency evacuation.
The 3 floor-level aircraft doors were opened by the flight
attendants but when the right front door was opened, the escape
slide fell to the ground uninflated. The investigation found that
the escape slide may not have been properly armed after the doors
were closed and that this was not noticed when visually
cross-checked. (The passenger operated over-wing exits were not
used as there were no passengers sitting in these rows.)
All 26 passengers successfully exited the aircraft in less than
64 seconds, but 11 reported sustaining minor injuries.
The emergency evacuation was ordered before the relevant
checklist had been completed. This resulted in a lack of emergency
lighting in the rear emergency area and delay in the extension of
wing flaps that would have been necessary had the over-wing exits
been used.
As a result of this incident, the operator has undertaken
several safety actions to enhance passenger safety. These include:
improved aircraft maintenance procedures relating to markings on
door slide brackets; defined phraseology to be used in emergency
communications between aircraft dispatchers and pilots; door
closure procedures for engine starts; improved policy on cockpit
discussion restrictions after door closure; and improved cabin crew
procedures and training.