Recommendation

Operator Evacuation Policy and Procedures:

Historically the Emergency Procedures training for cabin crew
has required that the door primary cabin crew (CC) is responsible
for ensuring that the area adjacent to their door is safe for door
opening in an evacuation. Reasons for this include:

• The door primary CC is in the best position to assess the
  environment immediately adjacent their door through visual
  inspection.
• Limiting available exits effects the time taken for
  evacuation.
• Complexity is added to the evacuation process if doors are made
  unavailable by the Flight Crew during the evacuation announcement.
  Complexity can add to confusion and time required to execute an
  evacuation.
• Qantas has a Precautionary Disembarkation procedure that caters
  for disembarkation in non-normal circumstances when a evacuation is
  not yet but maybe required. This allows certain doors to be
  directed for use during disembarkation in an expeditious but
  planned manner.

Feedback from Aircraft Manufacturer:

Boeing was contacted regarding Over-wing Slide Evacuations
during Brake Fire Situations.

They replied that they were unaware of evacuation reports with
associated brake fires interfering with slides or passengers
disembarking from an over-wing slide.

Additionally Boeing stated that they did not have specific
procedures or practices when there are underwing fires. Boeing
stated that operators are best equipped to develop such procedures,
due to the great variety of factors which must be considered, many
of which are operator unique.

Feedback from Slideraft Manufacturer:

Goodrich was contacted regarding Over-wing Slide Evacuations
during Brake Fire Situations.

They stated that for the single piece slide for the 747 Door 3,
it appears that the body gear are slightly back of that door, while
the wing gear may be about even with it. The slide will carry the
evacuees further aft, approximately under and aft of the actual
Door 4 location.

Because of the environmental factors, the Goodrich
representative thought that the crewmembers should be best suited
to decide about potential fire threats. The Goodrich representative
argued against assigning one solution to all potential problems in
regard to limiting door three slide availability. The Goodrich
representative acknowledged that crewmembers at Door 3 likely won't
be able to see debris on the ground where the Door 3 slide will
land. However the Overwing Deployment Indicator (ODI) was designed
to indicate to the crewmember that the slide had fully
inflated.

National Transportation Safety Board (NTSB) Safety
Study: Emergency Evacuation of Commercial Airplanes
NTSB/SS-00/01:

Chapter 6 of this study contains a section titled 'Exit
Selection'. This study found the 'Flight attendants are trained to
assess which exits are useable, and in no study case did a flight
attendant open an exit that increased the potential harm to a
passenger.' The report also found that some carriers have
procedures that direct flight attendants which exits to use or
which exits not to use. Other carriers were found to have
procedures where the Fas determine which exits to use.

Some carriers that train CCs to determine which exits to use in
an evacuation have what the NTSB describe as a passenger deplaning
procedure that may be used when passenger safety will not be
compromised. This procedure will direct certain doors to be used
during the deplaning. This is similar to the Precautionary
Disembarkation procedures utilised by this operator.

The study continues, to state 'Limiting the number of exits used
during an evacuation can have a dramatic effect on evacuation
times.'

Panel Discussion:

The panel discussion was limited to addressing the specific ATSB
recommendation pertaining to a brake fire scenario.

Discussion included the limitations associated with the field of
view from the doors three (D3) primary CC position. The general
consensus was that even though the D3 could not see the under wing
area a significant fire would be evident by smoke and flames.
Additionally the ODI was available to check proper deployment.
Information from Goodrich, supported by investigation observations,
indicates that the actual D3 slide evacuates passengers under doors
4, some distance from the underwing area. This area is also
monitored by the Doors 4 (D4) CC when that slideraft is
deployed.

Additionally, once down the slide the direction of travel
directs passengers further away from the underwing/brake area.

Another consideration with limiting exit in the case of an
evacuation was the possibility of increasing complexity at a very
time critical period. The potential of cabin crew misinterpreting
the doors to be used or not was seen as an increased risk to the
effectiveness and rapidity of the evacuation. The existing
Precautionary Disembarkation procedure is already established for
less critical deplaning where specific doors may be selected.

The panel agreed there were potential safety gains that could be
made by improvement of Emergency Procedures training to crew:

• Emphasis to door primary CCs of the importance to continuously
  monitoring the integrity of their assigned slide and the safety of
  the area where the slide has deployed. This monitoring process
  should continue until the passenger evacuation is complete. This is
  already included in recurrent training but will be included in
  Cabin Crew initial modules that cover Land Emergency Theory and
  practical exercises.

The panel acknowledged that there has already been a significant
amount of crew training pertaining the QF6 brake fire and
evacuation event and it's significant factors.

Conclusion:

The panel concluded that current generic evacuation procedures
were the most effective and expeditious method to ensure a
successful passenger evacuation. Improvements of crew Emergency
Procedures training will enhance and reinforce these
procedures.

ATSB Response Status:  Closed-Accepted