NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

SAFETY STUDY

7266

PB2000-917002

NTSB/SS-00/01

Emergency Evacuation

of Commercial Airplanes

Safety Study

Emergency Evacuation 

of Commercial Airplanes

NTSB/SS-00/01

PB2000-917002 National Transportation Safety Board

Notation 7266 490 L’Enfant Plaza, S.W.

Adopted June 27, 2000 Washington, D.C. 20594

E P L U R IB U S U N U M

N AT I O N A L T R A S PO R TA T IO N

B O A R D

SA F E T Y

N
National Transportation Safety Board. Emergency Evacuation of Commercial Airplanes. Safety

Study NTSB/SS-00/01. Washington, DC: NTSB, 2000.

Abstract: Since its inception, the National Transportation Safety Board has been concerned about the

evacuation of commercial airplanes in the event of an emergency. Several accidents investigated by the

Safety Board in the last decade that involved emergency evacuations prompted the Safety Board to

conduct a study on the evacuation of commercial airplanes. The study described in this report is the first

prospective study of emergency evacuation of commercial airplanes. For the study, the Safety Board

investigated 46 evacuations that occurred between September 1997 and June 1999 that involved 2,651

passengers. Eighteen different aircraft types were represented in the study. Based on information collected

from the passengers, the flight attendants, the flight crews, the air carriers, and the aircraft rescue and

firefighting (ARFF) units, the Safety Board examined the following safety issues in the study: (a)

certification issues related to airplane evacuation, (b) the effectiveness of evacuation equipment, (c) the

adequacy of air carrier and ARFF guidance and procedures related to evacuations, and (d) communication

issues related to evacuations. The study also compiled some general statistics on evacuations, including the

number of evacuations and the types and number of passenger injuries incurred during evacuations. As a

result of the study, the National Transportation Safety Board issued 20 safety recommendations and

reiterated 3 safety recommendations to the Federal Aviation Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation,

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical

Information Service. To purchase this publication, order report number PB2000-917002 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
iii Safety Study

Contents

Abbreviated Terms ......................................................................................................................................... v

Conversion Factors for the International System of Units (SI) .................................................................... vi

Executive Summary ............................................................................................................................ vii

Chapter 1: Introduction ..................................................................................................................... 1

Chapter 2: Background ..................................................................................................................... 5

Overview of Safety Board Activity Related to Airplane Evacuation Issues ................................................. 5

Other Studies and Research on Airplane Evacuation Issues ......................................................................... 7

Chapter 3: Study Sources and Overview of Evacuation Cases ....................................... 11

Evacuation Investigations ............................................................................................................................ 11

Selection and Notification Policy ........................................................................................................ 11

Basic Investigations ............................................................................................................................. 11

Detailed Investigations ........................................................................................................................ 12

Surveys of Evacuation Participants ............................................................................................................. 12

Flight Crews ........................................................................................................................................ 14

Flight Attendants ................................................................................................................................. 14

Aircraft Rescue and Firefighting Units ............................................................................................... 14

Passengers ........................................................................................................................................... 14

Safety Board Accident/Incident Database ................................................................................................... 15

NASA Aviation Safety Reporting System ................................................................................................... 15

Overview of Evacuation Study Cases .......................................................................................................... 15

Number of Evacuations ....................................................................................................................... 15

Evacuation Cause ................................................................................................................................ 16

Aircraft Type ....................................................................................................................................... 16

Injuries ................................................................................................................................................. 16

Locations of Evacuations .................................................................................................................... 18

Passenger Demographics ..................................................................................................................... 18

Aircraft Rescue and Firefighting Response ........................................................................................ 22

Chapter 4: FAA Requirements for Evacuation Demonstrations .................................... 23

Type Certification Requirements for Airplane Manufacturers .................................................................... 23

Operating Certificate Requirements for Air Carriers ................................................................................... 26

Safety Oversight in the Evacuation Demonstration Requirements ............................................................. 27

Chapter 5: Exits .................................................................................................................................. 31

Access to Exits ............................................................................................................................................. 32

Emergency Exit Lighting ............................................................................................................................. 37

Floor Level Exits ......................................................................................................................................... 37

Type III Overwing Exits .............................................................................................................................. 39

Exit Row Passenger Tasks ........................................................................................................................... 41

Flight Attendant Exit Assignment ............................................................................................................... 44

Evacuation Slides ......................................................................................................................................... 46

Exit Height From Ground ............................................................................................................................ 49
Contents iv Safety Study

Chapter 6: Evacuation Guidance and Procedures ............................................................... 51

Guidance to Flight Crews on When to Evacuate ......................................................................................... 51

Planned Evacuations .................................................................................................................................... 53

Exit Selection ............................................................................................................................................... 55

Slide Commands .......................................................................................................................................... 57

Airplane Familiarization for ARFF Personnel ............................................................................................. 58

Chapter 7: Communication ............................................................................................................ 59

Crew-to-Crew Communication .................................................................................................................... 59

Crew-to-Passenger Communication ............................................................................................................ 61

Preflight Safety Briefing ..................................................................................................................... 61

Safety Briefing Card ............................................................................................................................ 63

Retrieval of Carry-on Luggage ........................................................................................................... 66

Auxiliary Power Unit Torching ................................................................................................................... 68

ARFF-to-Crew Communication .................................................................................................................. 70

Communication Equipment ......................................................................................................................... 71

Airplane Cargo Smoke/Fire Indications ...................................................................................................... 74

FAA’s Service Difficulty Reporting System ................................................................................................ 75

Findings .................................................................................................................................................... 77

Recommendations ................................................................................................................................ 80

Appendixes ............................................................................................................................................. 85

A: Previous Safety Recommendations Relevant to Cabin Safety ........................................................ 85

B: Summary of the Evacuation Cases Investigated for the Study ..................................................... 109

C: Configurations of the Aircraft Types Represented in the Study ................................................... 133

D: Excerpts From the Federal Regulations Pertaining to Evacuations .............................................. 152
Contents v Safety Study

Abbreviated Terms

AASK Aircraft Accident Statistics and Knowledge database

AC advisory circular

AD airworthiness directive

ADMS accident data management system

ARFF aircraft rescue and firefighting

APU auxiliary power unit

ASRS Aviation Safety Reporting System

ATC air traffic control

ATR-42 Avions de Transport Regional ATR-42 aircraft

A300 Airbus Industrie A300 aircraft

Beech 1900 Beechcraft 1900 aircraft

CAA Civil Aviation Authority of the United Kingdom

CAMI Civil Aeromedical Institute of the FAA

CFR Code of Federal Regulations

CRJ Canadair Regional Jet aircraft

CRM crew resource management

DC-9 McDonnell Douglas DC-9 aircraft

DHC-8 de Havilland DHC “Dash” 8 aircraft

EMB-145 Embraer EMB-145 aircraft

FAA Federal Aviation Administration

F100 Fokker 100 aircraft

JAA European Joint Aviation Authorities

Jetstream 3100 British Aerospace Jetstream 3100 aircraft

JCAB Japanese Civil Aviation Bureau

MD-80 McDonnell Douglas MD-80 aircraft

NASA National Aeronautics and Space Administration

NPRM notice of proposed rulemaking

NTSB National Transportation Safety Board

PA public address

POI principal operations inspector

SDR service difficulty report

SDR system service difficulty reporting system of the FAA

SNPRM supplemental notice of proposed rulemaking

TCCA Transport Canada Civil Aviation

TSB Transportation Safety Board of Canada

737 Boeing 737
Contents vi Safety Study

Conversion Factors for the

International System of Units (SI)

To convert from into multiply by

feet (ft) meters (m) 0.3048

inches (in) centimeters (cm) 2.54

miles (U.S. statute) kilometers (km) 1.609344

pounds (lb) kilograms (kg) 0.4535924
vii Safety Study

Executive Summary

Since its inception, the National Transportation Safety Board has been concerned

about the evacuation of commercial airplanes in the event of an emergency. Several

accidents investigated by the Safety Board in the last decade that involved emergency

evacuations prompted the Safety Board to conduct a study on the evacuation of

commercial airplanes.

Past research and studies on airplane evacuations have provided insight into

specific factors, such as crewmember training and passenger behavior, that affect the

outcome of evacuations; however, these studies had several limitations. First, in many of

these studies, researchers did not examine successful evacuations; therefore, they were not

always able to discuss what equipment and procedures worked well during evacuations.

Second, only evacuations following serious accidents were examined and not evacuations

arising from incidents. As a result, little is known about incident-related evacuations,

which can provide insight into how successful evacuations can be performed and which

can also identify safety deficiencies before serious accidents occur. Third, each study was

a retrospective analysis of accident evacuations. This approach limited the researchers to

information collected during the original investigation rather than collecting consistent

information on a set of evacuations. Fourth, previous research on evacuations has not

examined some of the most basic questions about how often commercial airplanes are

evacuated, how many people are injured during evacuations, and how these injuries occur.

The Safety Board’s study described in this report is the first prospective study of

emergency evacuations of commercial airplanes. For the study, the Safety Board

investigated 46 evacuations that occurred between September 1997 and June 1999 that

involved 2,651 passengers. Eighteen different aircraft types were represented in this study.

Based on information collected from the passengers, the flight attendants, the flight crews,

the air carriers, and the aircraft rescue and firefighting units (ARFF), the Safety Board

examined the following safety issues in the study:

• certification issues related to airplane evacuation,

• the effectiveness of evacuation equipment,

• the adequacy of air carrier and ARFF guidance and procedures related to

evacuations, and

• communication issues related to evacuations.

As a result of this study, the Safety Board issued 20 safety recommendations and

reiterated 3 safety recommendations to the Federal Aviation Administration.

1 Safety Study

Chapter 1

Introduction

Since its inception, the National Transportation Safety Board has been concerned

about the evacuation of commercial airplanes in the event of an emergency. Two examples

of severe accidents investigated by the Safety Board in the last decade illustrate some of

the safety issues pertaining to emergency evacuations. These two severe accidents as well

as the occurrence of evacuations in less severe accidents prompted the Safety Board to

conduct a study on the evacuation of commercial airplanes.

On February 1, 1991, a USAir Boeing 737 (737) and a Skywest Metroliner

collided on the runway at Los Angeles International Airport.1 All passengers on the

Skywest plane died on impact. None of the passengers on the 737 died on impact, but

19 passengers died from smoke inhalation and 1 died from thermal injuries. Of the

19 smoke-inhalation fatalities, 10 died in a queue to use the right overwing exit. The

Safety Board discovered that two factors caused exit delays by several seconds:

passengers’ delay in opening the exit, and a scuffle between two passengers.

On November 19, 1996, United Express flight 5925, a Beechcraft 1900C, collided

with a King Air at the airport in Quincy, Illinois, seconds after landing.2 All 12 persons

aboard the United Express flight and the 2 pilots on the King Air died from the effects of

smoke and fumes from the postcrash fire even though they survived the impact. A pilot

employed by the airport’s fixed-base operator and a Beech 1900C-qualified United

Express pilot who had been waiting for the flight to arrive were the first persons to reach

the accident scene. They ran to the forward left side of the commuter’s fuselage where the

captain was asking them to get the door open. Both pilots attempted to open the forward

airstair door but were unsuccessful. The Safety Board determined that the instructions for

operating the door were inadequate for an emergency situation.3

 The Safety Board also

examined the airport rescue and firefighting response to the accident. The first units of the

Quincy Fire Department arrived on scene about 13 minutes after being notified of the

accident. By then, both airplanes were completely engulfed by flames. The Safety Board

1 National Transportation Safety Board, Runway Collision of USAir Flight 1493, Boeing 737 and

Skywest Flight 5569, Fairchild Metroliner, Los Angeles International Airport, Los Angeles, California,

February 1, 1991, Aircraft Accident Report NTSB/AAR-91/08 (Washington, DC: NTSB, 1991).

2 National Transportation Safety Board, Runway Collision, United Express Flight 5925 and Beechcraft

King Air A90, Quincy Municipal Airport, Quincy, Illinois, November 19, 1996, Aircraft Accident Report

NTSB/AAR-97/04 (Washington, DC: NTSB, 1997).

3 The Safety Board recommended that the Federal Aviation Administration (FAA) immediately issue a

telegraphic airworthiness directive (AD) directing all Beechcraft 1900 operators to improve the markings on

exit operations on the exterior of the airplanes. On February 4, 1997, the FAA issued AD 97-04-02 to require

installation of new exterior operating instructions, markings, and placards for the airstair door, cargo door,

and emergency exits on Beechcraft airplanes. Safety Recommendation A-97-1 was classified “Closed—

Acceptable Action” on April 25, 1997.
Chapter 1 2 Safety Study

determined that the lack of adequate aircraft rescue and firefighting services contributed to

the severity of the accident and the loss of life.

The two accidents described above highlight just a few of the safety issues related

to evacuation of commercial airplanes. In addition to accident investigations, studies

conducted by the Safety Board, the Transportation Safety Board of Canada, the Federal

Aviation Administration (FAA), and independent researchers have examined specific

factors that affect the successful evacuation of commercial airplanes.4 Although these

studies provided insight into specific factors, such as crewmember training and passenger

behavior, that affect the outcome of evacuations, they had several limitations. First, in

many of these studies, researchers did not examine successful evacuations; therefore, they

were not always able to discuss what equipment and procedures worked well during

evacuations. Second, only evacuations following accidents were examined and not

evacuations arising from incidents. As a result, little is known about incident-related

evacuations, which can provide insight into how successful evacuations can be performed

and which can also identify safety deficiencies before serious accidents occur. Third, each

study was a retrospective analysis of accident evacuations. This approach limited the

researchers to information collected during the original investigation rather than collecting

consistent information on a set of evacuations. Fourth, previous research on evacuations

has not examined some of the most basic questions about how often commercial airplanes

are evacuated, how many people are injured during evacuations, and how these injuries

occur.

The Safety Board’s study described in this report is the first prospective study of

emergency evacuations of commercial airplanes. For the study, the Safety Board

investigated 46 evacuations that occurred between September 1997 and June 1999 that

involved 2,651 passengers. Eighteen different aircraft types were represented in this study.

Based on information collected from the passengers, the flight attendants, the flight

crews,5 the air carriers, and the aircraft rescue and firefighting (ARFF) units, the Safety

Board examined the following safety issues in the study: (1) certification issues related to

airplane evacuation, (2) the effectiveness of evacuation equipment, (3) the adequacy of air

carrier and ARFF guidance and procedures related to evacuations, and (4) communication

issues related to evacuations. The study also compiled some general statistics on

evacuations, including the number of evacuations and the types and number of passenger

injuries incurred during evacuations.

Chapter 2 contains an overview of prior Safety Board activity in the area of

emergency response and evacuations, information on other accident-based evacuation

studies, and a review of laboratory research on evacuations. Chapter 3 contains a

description of the study sources used by the Safety Board as well as an overview of the

evacuation study cases. Chapter 4 discusses FAA requirements for evacuation

4 A brief overview of past research on emergency evacuation of commercial airplanes is contained in

chapter 2 of this report.

5 As used in this report and consistent with definitions in Title 14 Code of Federal Regulations (CFR)

Part 1, the term “flight crew” is used to refer to the cockpit crew; “flight attendants” refers to the cabin crew;

and “crew” and “crewmembers” are used to refer to all airplane crewmembers.
Chapter 1 3 Safety Study

demonstrations. Chapter 5 examines issues related to emergency exits. Chapter 6

discusses air carriers’ guidance and procedures related to evacuations. Chapter 7 examines

communication issues related to evacuations of commercial airplanes. The last sections of

the report contain the Safety Board’s findings and recommendations.

5 Safety Study

Chapter 2

Background

This chapter summarizes relevant accident-based and laboratory research related

to airplane evacuations, including accident studies conducted in the United States,

Canada, and the United Kingdom.

Overview of Safety Board Activity

Related to Airplane Evacuation Issues

The Safety Board routinely examines cabin safety issues during its investigations

of accidents. In addition, the Board has conducted several studies on airplane evacuation

issues.

In 1974, the Board published a special study of the safety aspects of emergency

evacuations from air carrier aircraft.6

 The study looked at 10 accidents involving

emergency evacuations. As a result of the study, the Safety Board issued several

recommendations that addressed the functionality of evacuation slides, the designation of

flight attendants for specific duties during an evacuation, and the conveyance of safety

information to passengers.7

In 1981, the Safety Board conducted a special study of cabin safety in large

transport aircraft.8

 The study focused primarily on the inadequacy of existing

crashworthiness regulations for seat and restraint systems and other cabin furnishings.

One of the conclusions reached in that study was that failed seat systems and cabin

furnishings trap occupants or become obstacles to rapid egress, thereby greatly increasing

the potential for fatalities caused by postcrash factors such as fire and smoke inhalation.

In 1985, the Safety Board released two safety studies that addressed evacuation

issues. The first study examined air carrier overwater emergency equipment and

procedures.9 The Safety Board studied 16 survivable water contact accidents that occurred

6 National Transportation Safety Board, Safety Aspects of Emergency Evacuations from Air Carrier

Aircraft, Special Study NTSB/AAS-74/03 (Washington, DC: NTSB, 1974).

7 Appendix A contains relevant National Transportation Safety Board safety recommendations issued

over the years that pertain to cabin safety and evacuation issues. The status of each recommendation is also

listed. Pertinent recommendations and the actions taken by the FAA in response to these recommendations

are discussed where appropriate in later chapters of this report.

8 National Transportation Safety Board, Cabin Safety in Large Transport Aircraft, Special Study

NTSB/AAS-81/02 (Washington, DC: NTSB, 1981).

9 National Transportation Safety Board, Air Carrier Overwater Emergency Equipment and Procedures,

Safety Study NTSB/SS-85/02 (Washington, DC: NTSB, 1985).
Chapter 2 6 Safety Study

between 1959 and 1984; most of these water accidents were inadvertent, occurred without

warning, involved substantial airplane damage, rapid flooding of the cabin, and a high

chance of injury. As a result of the study, improvements were made in life preserver

design, packaging, accessibility, and ease of donning; crew postcrash survival training;

and water rescue plans for airports near water.

Also in 1985, the Safety Board reviewed the methods used to present air carrier

passengers with safety information.10 That study represented the first systematic review of

the content and methods used to provide safety information to passengers. It considered

the merits and shortcomings of verbal briefings, demonstrations, safety cards, and

videotaped briefings. The study was based on an analysis of 21 accident investigations in

which passenger safety information briefings were a factor influencing survival. As a

result of the study and in response to Safety Board recommendations, the FAA conducted

research to determine the minimum level of acceptable comprehension of safety cards.

The Safety Board completed a special investigation report on flight attendant

training in 1992.11 That investigation found that there was a lack of guidance to FAA

inspectors regarding oversight of training, particularly flight attendant recurrent training.

Some flight attendants were not proficient in their knowledge of emergency equipment

and procedures—a situation compounded by a fact that most air carriers did not have

standard locations for emergency equipment and most carriers did not limit the number of

airplane types for which flight attendants were qualified. Another finding from the 1992

report that is particularly relevant to the current study was that many air carriers did not

perform evacuation drills during recurrent training, and they were not required to conduct

such training. As a result of that special investigation, several recommendations were

issued to the FAA that were intended to improve flight attendant training and performance

during emergency situations.

In addition to the studies summarized above, the Safety Board issued some earlier

special studies that were generally more related to occupant survival.12

10 National Transportation Safety Board, Airline Passenger Safety Education: A Review of Methods Used

to Present Safety Information, Safety Study NTSB/SS-85/04 (Washington, DC: NTSB, 1985).

11 National Transportation Safety Board, Flight Attendant Training and Performance During Emergency

Situations, Special Investigation Report NTSB/SIR-92/02 (Washington, DC: NTSB, 1992).

12 (a) National Transportation Safety Board, Passenger Survival in Turbojet Ditchings (A Critical Case

Review), Special Study NTSB/AAS-72/02 (Washington, DC: NTSB, 1972). (b) National Transportation

Safety Board, In-Flight Safety of Passengers and Flight Attendants Aboard Air Carrier Aircraft, Special

Study NTSB/AAS-73/01 (Washington, DC: NTSB, 1973). (c) National Transportation Safety Board,

Chemically Generated Supplemental Oxygen Systems in DC-10 and L-1011 Aircraft, Special Study

NTSB/AAS-76/01 (Washington, DC: NTSB, 1976).
Chapter 2 7 Safety Study

Other Studies and Research on

Airplane Evacuation Issues

In 1995, the Transportation Safety Board (TSB) of Canada issued a study of air

carrier evacuations that involved Canadian-registered airplanes or evacuations of foreignregistered airplanes that occurred in Canada.13 The TSB conducted a postaccident

examination of 21 evacuation events that had occurred between 1978 and 1991. As a

result of the study, the TSB recommended protective breathing equipment for cabin crews,

a reevaluation of escape slides, a review of the adequacy of public address systems,

implementation of joint crew training, and detailed briefings to prepare passengers for

unplanned emergencies.

The Japanese Civil Aviation Bureau (JCAB) created two task forces (one in 1993,

another in 1996) to review emergency evacuations and develop countermeasures to reduce

injury.14 The 1993 task force examined five evacuations that occurred during the early

1990s. Based on that review, the group developed a standard package of information to

improve passenger briefing systems. The JCAB requested and Japanese air carriers

instituted the recommended changes. The second task force was prompted by a serious

accident in 1996. That group recommended a systematic approach to the definition of exit

seating and the responsibilities of the cabin crew and the passengers seated in exit rows.

The group also recommended that travel group coordinators be prepared to perform

special tasks in the event of an emergency.

Two research studies funded by the FAA’s Civil Aeromedical Institute (CAMI)

used data associated with precautionary evacuations that were acquired from airport

management.15 The first study looked at egress system use; during the 1988–1996 study

period, there were 519 evacuations. The second study analyzed demographic and injury

data from 1994 through 1996 and found 193 reported injuries (including 11 broken bones)

from 109 emergency evacuations during that period.

Beginning in 1987, as a result of a 737 fire in Manchester, England, the Civil

Aviation Authority (CAA) of the United Kingdom commissioned Cranfield University to

conduct a number of experimental research studies on issues of cabin safety. In 1989, a

study of passenger behavior in airplane emergencies examined the influences of cabin

configuration on the rate at which passengers could evacuate the airplane.16 Airplane

13 Transportation Safety Board of Canada, A Safety Study of Evacuations of Large, Passenger-Carrying

Aircraft, Report SA9501 (Quebec, Ontario: TSB, 1995).

14 Hiroaki Tomita [Japanese Civil Aviation Bureau, Ministry of Transport], “For Less Injuries After

Emergency Evacuations,” Proceedings, 1998 International Aircraft Fire and Cabin Safety Research

Conference, November 16–20, 1998, Atlantic City, NJ, DOT/FAA/AR-99/68, CD-ROM (Federal Aviation

Administration, European Joint Aviation Authorities, Transport Canada Civil Aviation, Japanese Civil

Aviation Bureau, 1999).

15 Michael K. Hynes [Western Oklahoma State College], “Human Factors Research on 519 Recent U.S.

Air Carrier Passenger Evacuation Events,” Proceedings, 1998 International Aircraft Fire and Cabin Safety

Research Conference, November 16–20, 1998, Atlantic City, NJ, DOT/FAA/AR-99/68, CD-ROM (Federal

Aviation Administration, European Joint Aviation Authorities, Transport Canada Civil Aviation, Japanese

Civil Aviation Bureau, 1999).
Chapter 2 8 Safety Study

cabin configurations were evaluated under conditions in which passengers were

competing to evacuate (as would be expected in life-threatening accident situations) and

under orderly conditions (for example, during aircraft certification testing). The results

suggested that the bulkhead passageway should be wider than 30 inches and that the

distance between overwing exit row seats should have a vertical seat projection of 13 to

25 inches.17

The CAA also commissioned Cranfield University to look at the effects of

overwing exit weight and seating configuration on passengers’ ability to operate a Type III

overwing exit.18 The results of that study19 indicated that it was necessary to have a

substantial reduction (50 percent) in hatch weight in addition to an increase in the

available seat space in order to significantly reduce the time to operate the hatch. The

combined benefits of reduced hatch weight and increased seat space were found to be

more significant for females than males.

A third study conducted by Cranfield University20 looked at the influence of the

cabin crew on passenger evacuation during an emergency using both competitive and

cooperative protocols. The FAA and the CAA jointly commissioned this study. The results

showed that both the performance and number of cabin crewmembers significantly

influenced evacuation rates and passenger behavior. The finding had implications for the

selection and training of cabin crews. Additionally, evacuation times were faster from the

forward exits than from the rear of the cabin.

In addition to the Cranfield studies, other organizations, including Transport

Canada Civil Aviation (TCCA) and the Ente Nazionale Aviazione Civile, have studied

human factor aspects of emergency evacuations.21

16 H. Muir, C. Marrison, and A. Evans, Aircraft Evacuations: The Effect of Passenger Motivation and

Cabin Configuration Adjacent to the Exit, CAA Paper 89019 (London: Civil Aviation Authority, 1989).

17 Vertical seat projection is defined as the distance between two rows of seats as marked by a vertical

plumb line from the seat back of the front row and the seat cushion of the following row.

18 Emergency exit types are defined in 14 CFR 25.807. Type III exits are rectangular openings of not less

that 20 inches wide by 36 inches high with a step up from inside the airplane of not more than 20 inches and

a step down outside the plane of not more than 27 inches. Exit types are discussed later in the report.

19 P.J. Fennell and H.C. Muir, The Influence of Hatch Weight and Seating Configuration on the Operation

of a Type III Hatch, CAA Paper 93015 (London: Civil Aviation Authority, 1993).

20 H.C. Muir and A.M. Cobbett, Influences of Cabin Crew During Emergency Evacuations at Floor Level

Exits, CAA Paper 95006: Part A; FAA No. DOT/FAA/AR-95/52 (London: Civil Aviation Authority, 1996).

21 (a) H. Muir, C. Marrison, and A. Evans, Aircraft Evacuations: The Effect of Passenger Motivation and

Cabin Configuration Adjacent to the Exit, CAA Paper 89019 (London: Civil Aviation Authority, 1989). (b)

G. Sacco [Ente Nazionale Aviazione Civile] “Dimensions of Aircraft Occupants’ Motivation and

Behaviour,” Proceedings, 1998 International Aircraft Fire and Cabin Safety Research Conference,

November 16–20, 1998, Atlantic City, NJ, DOT/FAA/AR-99/68, CD-ROM (Federal Aviation

Administration, European Joint Aviation Authorities, Transport Canada Civil Aviation, Japanese Civil

Aviation Bureau, 1999). (c) Neal S. Latman [NSL Associates], “The Human Factor in Simulated Emergency

Evacuations of Aircraft Cabins: Psychological and Physical Aspects” Proceedings, 1998 International

Aircraft Fire and Cabin Safety Research Conference, November 16–20, 1998, Atlantic City, NJ,

DOT/FAA/AR-99/68, CD-ROM (Federal Aviation Administration, European Joint Aviation Authorities,

Transport Canada Civil Aviation, Japanese Civil Aviation Bureau, 1999).
Chapter 2 9 Safety Study

At a 1998 international conference on cabin safety research,22 several papers were

presented that focused on computer-based mathematical models describing aircraft

evacuations.23 Simulation models of evacuations are heavily dependent on real evacuation

data, both in terms of quantifying development parameters and in terms of verifying the

predictive accuracy of the model. For example, researchers at England’s University of

Greenwich24 undertook an extensive data extraction and application project to derive the

Aircraft Accident Statistics and Knowledge (AASK) database in order to develop

airEXODUS.25 The researchers believe that such models are useful for design and

development work, evaluation for certification, training, and for accident investigation.

22 The 1998 International Aircraft Fire and Cabin Safety Research Conference, November 16–20, 1998,

Atlantic City, NJ, DOT/FAA/AR-99/68, CD-ROM (Federal Aviation Administration, European Joint

Aviation Authorities, Transport Canada Civil Aviation, Japanese Civil Aviation Bureau, 1999).

23 (a) E.R. Galea, M. Owen, P.J. Lawrence, and L. Filippidis [University of Greenwich], “Computer

Based Simulation of Aircraft Evacuation and its Application to Aircraft Safety,” Proceedings, 1998

International Aircraft Fire and Cabin Safety Research Conference, November 16–20, 1998, Atlantic City,

NJ, DOT/FAA/AR-99/68, CD-ROM (Federal Aviation Administration, European Joint Aviation Authorities,

Transport Canada Civil Aviation, Japanese Civil Aviation Bureau, 1999). (b) Richard W. Bukowski, R.D.

Peacock, and Walter W. Jones [National Institute of Standards and Technology], “Sensitivity Examination of

the airEXODUS Aircraft Evacuation Simulation Model,” Proceedings, 1998 International Aircraft Fire and

Cabin Safety Research Conference, November 16–20, 1998, Atlantic City, NJ, DOT/FAA/AR-99/68,

CD-ROM (Federal Aviation Administration, European Joint Aviation Authorities, Transport Canada Civil

Aviation, Japanese Civil Aviation Bureau, 1999). (c) E.R. Galea and M. Owen [University of Greenwich],

“The AASK Database: A Database of Human Experience in Evacuation Derived from Air Accident

Reports,” Proceedings, 1998 International Aircraft Fire and Cabin Safety Research Conference, November

16–20, 1998, Atlantic City, NJ, DOT/FAA/AR-99/68, CD-ROM (Federal Aviation Administration,

European Joint Aviation Authorities, Transport Canada Civil Aviation, Japanese Civil Aviation Bureau,

1999).

24 E.R. Galea, M. Owen, P.J. Lawrence, and L. Filippidis [University of Greenwich], “Computer Based

Simulation of Aircraft Evacuation and its Application to Aircraft Safety,” Proceedings, 1998 International

Aircraft Fire and Cabin Safety Research Conference, November 16–20, 1998, Atlantic City, NJ,

DOT/FAA/AR-99/68, CD-ROM (Federal Aviation Administration, European Joint Aviation Authorities,

Transport Canada Civil Aviation, Japanese Civil Aviation Bureau, 1999).

25 AirEXODUS is a computer program developed at Greenwich University that simulates passengers

evacuating from an airplane.

11 Safety Study

Chapter 3

Study Sources and Overview 

of Evacuation Cases

To obtain information and data for this study, the Safety Board (1) conducted

investigations of incidents/accidents that involved evacuations between September 1997

and June 1999, (2) surveyed all groups of participants in the evacuations, (3) conducted a

review of the Board’s accident/incident database for other occurrences of evacuations, and

(4) examined incident reports made to the Aviation Safety Reporting System (ASRS) of

the National Aeronautics and Space Administration (NASA). This chapter describes these

four sources of information that were the basis for the study, and then provides an

overview of the evacuation study cases.

Evacuation Investigations

Selection and Notification Policy

Operators of civil aircraft are required to notify the nearest National Transportation

Safety Board field office following an evacuation of an airplane in which an emergency

egress system is utilized (Title 49 Code of Federal Regulations (CFR) Part

830.5(a)(7)(iv)). The Safety Board accepted cases for the study that met this reporting

criterion provided that the emergency egress system was used to remove passengers from

the airplane for their safety. This was done to exclude cases in which passengers deplaned

after an airplane became stuck after it came to a stop following landing.26

Basic Investigations

Safety Board investigators conducted two levels of investigation for the study:

basic and detailed. Basic investigations were conducted for all evacuations that occurred

in the United States that were reported to the Safety Board during the 16-month study

period. Board investigators conducted the investigations through phone calls to air carrier

and airport representatives.27 Investigators traveled to the scene of the evacuation when

the event followed an accident as defined by 49 CFR 830.2. The information collected

during the basic investigations included airplane information, the number of passengers

26 These cases were excluded because passengers were not deemed to be in imminent danger.

27 The National Transportation Safety Board routinely conducts limited investigations by telephone. For

limited investigations, Safety Board investigators will conduct a desk investigation by calling appropriate

local officials, rescue response units, FAA personnel, and other persons and organizations that may have

knowledge of the incident. From 1995 through 1999, there were 10,323 aircraft accidents investigated by the

Board, of which 8,297 were limited investigations.
Chapter 3 12 Safety Study

and crewmembers, weather, the cause of the evacuation, injury information, exits used,

slide performance,28 use of backup evacuation equipment, and any hindrances to the

evacuation process.

The Safety Board included 46 basic investigations in the study (table 3–1); 42 of

the 46 investigations were conducted sequentially from September 24, 1997, through

January 24, 1999, the planned data collection period for the study. The four additional

investigations, which were conducted after January 24, 1999, were included because they

involved evacuations of special interest for the study. Two were of accidents that involved

serious injuries during the evacuation. The third was of an evacuation that was videotaped

from start to finish. The last investigation, of an evacuation that occurred June 22, 1999,

was included in the study to support discussion on the conditions that affect a

crewmember’s decision to evacuate an airplane.

Detailed Investigations

Detailed investigations were conducted on a subset of the 46 evacuations; this

subset of evacuations involved a fire, a suspicion of fire, or slide use. The Safety Board

conducted a detailed investigation on 30 of the 46 evacuations included in this study.

Detailed investigations were limited to evacuations from airplanes operated by U.S. air

carriers; thus, the evacuation of two Canadian-operated airplanes and one Mexicanoperated airplane in which there was fire or slide use received basic rather than detailed

investigations.29

For the detailed investigations, Safety Board investigators collected the following

information from each air carrier in addition to the basic information collected: (a) the

safety briefing card(s), (b) the cabin diagram, (c) the flight crew manual pertaining to

emergency evacuations, (d) the flight crew training materials and syllabi (initial and

recurrent) pertaining to emergency evacuations, (e) the flight attendant manual pertaining

to emergency evacuations, (f) the flight attendant training materials and syllabi (initial and

recurrent) pertaining to emergency evacuations, (g) the flight crew evacuation checklists;

(h) the flight attendant evacuation checklists, (i) flight crew statements, and (j) flight

attendant statements. This information was received from all the air carriers involved in

the 30 detailed investigations.

Surveys of Evacuation Participants

Questionnaires were developed and mailed to flight crews, flight attendants, ARFF

units, and passengers who were involved in the 30 evacuations that received a detailed

28 The term “slide” as used in this report refers to both evacuation slides and sliderafts.

29 Detailed investigations were limited to U.S. carriers because in the detailed investigations, the Safety

Board requested passenger information from air carriers; the Board does not have the authority to request

such information from foreign carriers.
Chapter 3 13 Safety Study

Table 3–1. Evacuations investigated by the National Transportation Safety Board 

for its 2000 study on emergency evacuation of commercial airplanes.

Case

number

Date of 

evacuation Location Air carrier

Aircraft

type

Number of 

passengers

01 09/24/1997 Salt Lake City, Utah Frontier Airlines 737 66

02 11/04/1997 Sterling, Virginia Atlantic Coast Airlines JS3100 2

03 11/07/1997 Charlotte, North Carolina US Airways F100 99

04 12/19/1997 San Francisco, California Alaska Airlines MD-80 69

05 12/25/1997 Eugene, Oregon United Airlines 737 100

06 01/21/1998 Windsor Locks, Connecticut Continental Express ATR-42 36

07 01/22/1998 Peoria, Illinois Trans States Airlines ATR-72 10

08a 02/09/1998 Honolulu, Hawaii Hawaiian Airlines DC-9 139

09a 02/09/1998 Chicago, Illinois American Airlines 727 115

10a 02/12/1998 Arlington, Virginia Delta Air Lines MD-88 49

11 02/22/1998 Lawton–Fort Sill, Oklahoma American Eagle Saab 340 3

12 03/27/1998 Chicago, Illinois Air Canada DC-9 27

13 03/30/1998 Fort Lauderdale, Florida Royal Airlines 727 188

14 04/15/1998 Indianapolis, Indiana Chautauqua Airlines JS3100 6

15 04/18/1998 Worcester, Massachusetts United Express JS4100 29

16a 04/20/1998 Chicago, Illinois American Airlines 727 149

17 04/23/1998 Atlantic City, New Jersey US Airways Express DHC-8 19

18a 04/25/1998 Detroit, Michigan Trans World Airlines DC-9 26

19a 05/26/1998 Indianapolis, Indiana Northwest Airlines DC-9 101

20a 06/04/1998 Huntsville, Alabama Northwest Airlink Saab 340 16

21a 06/06/1998 Evansville, Indiana Trans States Airlines JS4100 20

22a 06/28/1998 Newark, New Jersey Continental Express ATR-42 45

23 07/08/1998 Rochester, New York Blue Ridge/Atlantic Coast JS4100 10

24a 07/09/1998 San Juan, Puerto Rico American Airlines A300 234

25a 07/29/1998 Newark, New Jersey Continental Airlines 737 109

26a 08/13/1998 Knoxville, Tennessee Comair CRJ 46

27a 08/27/1998 Phoenix, Arizona American Airlines MD-82 75

28a 09/10/1998 Newburg, New York Atlantic Southeast Airlines CRJ 30

29a 09/13/1998 Raleigh–Durham, 

North Carolina

US Airways Express CRJ 40

30a 10/24/1998 San Juan, Puerto Rico American Eagle ATR-42 23

31a 10/30/1998 Shreveport, Louisiana American Eagle Saab 340 27

32a 11/01/1998 Atlanta, Georgia Air Trans Airlines 737 100

33a 11/03/1998 Miami, Florida Gulfstream Beech 1900 19

34a 11/12/1998 Boston, Massachusetts Allegheny Airlines DHC-8 18

35a 12/26/1998 Dallas–Fort Worth, Texas Delta Air Lines MD-88 44

36 12/28/1998 Phoenix, Arizona United Airlines A320 145

37a 12/29/1998 White Plains, New York Business Express Saab 340 4

38 01/07/1999 San Diego, California AeroMexico MD-80 36

39a 01/08/1999 Covington, Kentucky Comair CRJ 5

40a 01/19/1999 St. Louis, Missouri Trans States Airlines ATR-72 17

41a 01/24/1999 Charlotte, North Carolina American Airlines F100 70

42a 01/24/1999 Newark, New Jersey Continental Express EMB-145 48

43a 02/17/1999 Columbus, Ohio America West A320 26

44a 05/08/1999 Jamaica, New York American Eagle Saab 340 27

45a 06/01/1999 Little Rock, Arkansas American Airlines MD-82 139

46a 06/22/1999 Scottsbluff, Nebraska United Airlines 737 63

a The Safety Board conducted a detailed investigation of the evacuation.
Chapter 3 14 Safety Study

investigation. The crewmembers and passengers were asked what suggestions they would

make to improve evacuations.

Flight Crews

Questionnaires sent to flight crews consisted of questions regarding general

information about the evacuation, communication, procedures, environment, and

equipment. Of 61 questionnaires mailed to flight crewmembers, 33 were returned to the

Safety Board. The 33 responses were from pilots who represented 20 of the 30

evacuations in the study that received detailed investigations. Fifteen of the

20 respondents were the pilots-in-command at the time of the evacuation. For all but one

of the respondents, this was their first evacuation of a commercial passenger aircraft.

Flight Attendants

Questionnaires sent to flight attendants consisted of questions regarding general

information about the evacuation, personal injuries sustained, preflight safety briefing,

communication, emergency exits, environment, passenger behavior, and training. Of 64

surveys mailed to flight attendants, 36 were returned to the Safety Board. This sample

represented 18 of the 30 evacuations that received detailed investigations. Two of the

36 respondents reported being in a prior evacuation.

Aircraft Rescue and Firefighting Units

Questionnaires sent to ARFF unit chiefs consisted of questions regarding general

information about the evacuation, communication, response, passenger behavior, and

injuries. Of 30 questionnaires mailed to ARFF unit chiefs, 20 were returned to the Board,

which represented 19 of the 30 evacuations that received detailed investigations.30

Passengers

Questionnaires sent to passengers consisted of questions regarding the preflight

safety briefing, emergency exits, carry-on baggage, evacuation slides, passenger behavior,

seat belts, communication, injury, postevacuation events, and personal information. Of

1,043 questionnaires mailed to passengers, 457 (44 percent) were returned to the Safety

Board.31 These passengers were from 18 of the 30 evacuations that received detailed

investigations.32

30 The ARFF unit at the airport in case 35 returned two questionnaires.

31 Average response rates for surveys are usually between 10 and 15 percent. Response rates over 40

percent are rare (Fred N. Kerlinger, Foundations of Behavior Research (Chicago: Holt, Rinehart, and

Winston, Inc., 1986)).

32 Passenger information was not available for nine cases. Passenger information provided by air carriers

was inadequate to determine mailing addresses in three cases.
Chapter 3 15 Safety Study

Safety Board Accident/Incident Database

For the 10-year period from January 1990 through December 1999, the Safety

Board recorded in its accident database 344 accidents involving Part 121 operations and

an additional 461 incidents. Although the database does not currently have a specific code

for evacuation events,33 these events are often reported in the brief narrative that is

included in each record. A search of the brief narratives for the past decade revealed 27

incidents and 21 accidents that included evacuation. Nine additional accidents/incidents

that include evacuations are currently under investigation. Information from evacuation

events contained in the Board’s database was used, where appropriate, to provide context

for data collected specifically for this study.

NASA Aviation Safety Reporting System

The Safety Board requested a search of the ASRS database34 for all records

pertaining to evacuations of airplanes operated by Part 121 air carriers. At the time of the

search, the database contained 66,590 full-form reports, that is, reports that contained the

reporter’s narrative. The search yielded 202 reports that reference airplane evacuations

between January 1995 and January 1999. The Safety Board reviewed these reports to

support data collected for this study.

Overview of Evacuation Study Cases

General information about the 46 evacuations is presented in this section.

Additional information will be presented in the appropriate chapters that follow. A brief

description of the circumstances surrounding each evacuation is contained in appendix B.

Number of Evacuations

There were 42 evacuations during the 16-month study period in which the Safety

Board recorded all evacuations. On average, an evacuation for the study cases occurred

every 11 days. An average of 336,328 departures occurred every 11 days in 1998 by

scheduled aircraft operating under Part 121.

33 With implementation of ADMS-2000 (accident data management system), scheduled for October 1,

2000, evacuation events will be more easily identified in the Safety Board’s accident/incident database.

34 The ASRS was established in 1975 under a Memorandum of Agreement between the Federal Aviation

Administration and the National Aeronautics and Space Administration. The ASRS collects, analyzes, and

responds to voluntarily submitted aviation safety incident reports in order to reduce the likelihood of

aviation accidents. Pilots, air traffic controllers, flight attendants, mechanics, ground personnel, and others

involved in aviation operations submit reports to the ASRS when they are involved in or observe an incident

or situation in which aviation safety was compromised.
Chapter 3 16 Safety Study

Evacuation Cause

The most frequent event leading to an evacuation was an engine fire, accounting

for 18 (39 percent) of the 46 evacuations included in the study cases; 15 involved an actual

engine fire, and 3 involved a suspected but not actual fire. Eight of the 46 evacuations

resulted from indications of fire in the cargo hold; none of these eight events, which

occurred on regional airplanes, involved the presence of an actual fire. Gear failure and

smoke in the cabin led to four evacuations each. All events causing the evacuations are

listed in table 3–2.

Aircraft Type

The evacuations investigated for this study occurred on a wide variety of aircraft.

The Boeing 737 and Saab 340 were represented the most, with five evacuations for each

type. The Canadair Regional Jet (CRJ) and McDonnell Douglas DC-9 were represented in

four evacuations each. Only one wide-bodied airplane, the Airbus Industrie A300, was

represented in the study cases. All 18 aircraft types involved in the study cases are listed in

table 3–3; a configuration of each type is presented in appendix C.

Injuries

The Safety Board obtained information on passenger injuries from two sources

during the study. First, information provided by the air carrier during the basic

investigations included injury information. Second, for the detailed investigations, the

Safety Board also obtained injury information from passenger questionnaires. In the 46

study cases, 92 percent (2,614) of the 2,846 occupants on board were uninjured, 6 percent

(170) sustained minor injuries, and 2 percent (62) sustained serious injuries (figure 3–1).

Table 3–2. Events that led to the emergency 

evacuations in the 46 study cases.

Event Number of cases

Engine fire/suspected engine fire 18a

Cargo smoke/cargo fire indication 8

Smoke in cabin 4

Gear failure 4

Smoke in cockpit 3

Overran runway 3

Bomb threat 2

Landed short of runway 1

Lavatory smoke warning 1

Baggage cart collision 1

APU torchb 1

a An engine fire was present in 15 of these cases.

b As described in Boeing’s Airliner magazine (April/June 1992), 

“The APU provides both electrical power and bleed air for the air 

conditioning system and main engine starting. A torching start may 

result from excess fuel accumulation in the APU combustor assembly 

and exhaust duct. The torching start has a characteristic ‘orange flash’.”
Chapter 3 17 Safety Study

Table 3–3. Aircraft types involved in the 46 emergency evacuations 

investigated by the National Transportation Safety Board for its 2000 

study.

Aircraft type

Seating 

capacity

Number of

evacuations

Boeing 737 108–189 5

Saab 340 20–39 5

Canadair Regional Jet 50 4

McDonnell Douglas DC-9 139 4

Avions de Transport Regional ATR-42 42–74 3

Boeing 727 70 3

British Aerospace Jetstream 4100 29 3

Airbus Industrie 320 164–179 2

Avions de Transport Regional ATR-72 64–74 2

de Havilland DHC-8 37 2

Fokker 100 107–119 2

British Aerospace Jetstream 3100 19 2

McDonnell Douglas MD-80 137–172 2

McDonnell Douglas MD-82 137–172 2

McDonnell Douglas MD-88 137–172 2

Airbus Industrie 300 220–375 1

Beechcraft 1900 19 1

Embraer EMB-145 55 1

Figure 3–1. Percent of crew and passengers who 

sustained serious or minor injuries in the 46 study 

cases.
Chapter 3 18 Safety Study

In the 46 study cases, 2,651 passengers and 195 crewmembers evacuated from

planes. There were no accident- or evacuation-related injuries in 28 of the cases (table 3–4).

Accident- or evacuation-related injuries occurred in 18 of the cases; 208 passengers and 13

crewmembers were injured, and 10 passengers and 1 crewmember were killed (table 3–5).

One of the cases (case 45, in Little Rock, Arkansas), accounted for the most injuries (65

minor, 45 serious) and all the fatalities (11). Two of the fatalities were evacuation-related:

one passenger died from smoke inhalation in the rear of the airplane; a second passenger

died 16 days after the accident as a result of thermal injuries suffered while evacuating from

an overwing exit. The type of injuries that occurred in this accident included smoke

inhalation, burns, and fractures.

In addition to the serious injuries in the Little Rock case, six serious injuries

occurred in four other cases (13, 16, 35, and 44). One passenger broke an arm jumping off

a wing, and five passengers sustained broken ankles: one jumping out of an airplane exit

that did not have a slide, one using an evacuation slide, and three sliding to the ground

from the wing flap trailing edge.

Locations of Evacuations

As mentioned previously, the Safety Board accepted evacuation cases from

throughout the United States and its territories. Every one of the evacuations in the study

occurred on airport property. Chicago O’Hare and Newark International each had three

evacuations occur on its property. Indianapolis, Charlotte, Phoenix, and San Juan had two

evacuations each (see table 3–1).

Passenger Demographics

Only 17 of the 457 passenger respondents indicated being involved in a prior

evacuation. The average age (mean and median) of passengers who responded to the

Safety Board’s questionnaire was 43 years old. Forty-five percent of these passengers

were female. The passengers averaged 5 feet 7 1/2 inches in height and weighed an

average of 165 pounds.35

Passengers reported on the injuries they sustained during their evacuations. No

attempt was made to confirm each passenger’s self-assessment. There appeared to be no

relationship between age and the injury incurred: 34 percent of the respondents older than

the median age of 43 reported injuries whereas 35 percent younger than the median

reported injuries. Reports of injuries were similar (39 percent) for passengers older than

60 years.

Despite the lack of differences with regard to injury, the older passengers (older

than 43) had different perceptions of how their physical abilities affected their evacuation.

Older passengers were more likely to disagree with statements that their physical size or

condition assisted their evacuation [χ2(4) = 12.44, p < 0.05] (figure 3–2). Further, they

35 The age of these passengers ranged from 5 to 84 years, their height ranged from 44 to 81 inches, and

their weight ranged from 45 to 285 pounds.
Chapter 3 19 Safety Study

Table 3–4. Number of occupants injured in the 46 study cases, by case.a

Case

number

Date of 

evacuation Air carrier Uninjured Minor Serious Fatal Total

01 09/24/1997 Frontier Airlines 70 1 0 0 71

02 11/04/1997 Atlantic Coast Airlines 4 0 0 0 4

03 11/07/1997 US Airways 104 0 0 0 104

04 12/19/1997 Alaska Airlines 66 8 0 0 74

05 12/25/1997 United Airlines 105 0 0 0 105

06 01/21/1998 Continental Express 38 1 0 0 39

07 01/22/1998 Trans States Airlines 14 0 0 0 14

08b 02/09/1998 Hawaiian Airlines 144 0 0 0 144

09b 02/09/1998 American Airlines 99 23 0 0 122

10b 02/12/1998 Delta Air Lines 54 0 0 0 54

11 02/22/1998 American Eagle 6 0 0 0 6

12 03/27/1998 Air Canada 32 0 0 0 32

13 03/30/1998 Royal Airlines 177 14 3 0 194

14 04/15/1998 Chautauqua Airlines 8 0 0 0 8

15 04/18/1998 United Express 32 0 0 0 32

16b 04/20/1998 American Airlines 153 2 1 0 156

17 04/23/1998 US Airways Express 22 0 0 0 22

18b 04/25/1998 Trans World Airlines 30 1 0 0 31

19b 05/26/1998 Northwest Airlines 106 0 0 0 106

20b 06/04/1998 Northwest Airlink 19 0 0 0 19

21b 06/06/1998 Trans States Airlines 22 1 0 0 23

22b 06/28/1998 Continental Express 48 1 0 0 49

23 07/08/1998 Blue Ridge/Atlantic Coast 13 0 0 0 13

24b 07/09/1998 American Airlines 224 28 0 0 252

25b 07/29/1998 Continental Airlines 93 9 0 0 102

26b 08/13/1998 Comair 48 0 0 0 48

27b 08/27/1998 American Airlines 79 0 0 0 79

28b 09/10/1998 Atlantic Southeast Airlines 33 0 0 0 33

29b 09/13/1998 US Airways Express 43 0 0 0 43

30b 10/24/1998 American Eagle 22 3 0 0 25

31b 10/30/1998 American Eagle 30 0 0 0 30

32b 11/01/1998 Air Trans Airlines 94 11 0 0 105

33b 11/03/1998 Gulfstream 21 0 0 0 21

34b 11/12/1998 Allegheny Airlines 21 0 0 0 21

35b 12/26/1998 Delta Air Lines 49 0 1 0 50

36 12/28/1998 United Airlines 145 0 0 0 145

37b 12/29/1998 Business Express 7 0 0 0 7

38 01/07/1999 AeroMexico 42 1 0 0 43

39b 01/08/1999 Comair 8 0 0 0 8

40b 01/19/1999 Trans States Airlines 18 0 0 0 18

41b 01/24/1999 American Airlines 73 1 0 0 74

42b 01/24/1999 Continental Express 51 0 0 0 51

43b 02/17/1999 America West 31 0 0 0 31

44b 05/08/1999 American Eagle 29 0 1 0 30

45b 06/01/1999 American Airlines 24 65 45 11 145

46b 06/22/1999 United Airlines 63 0 0 0 63

Total 2,614 170 51 11 2,846

a Includes accident- and evacuation-related injuries.

b The Safety Board conducted a detailed investigation of the evacuation.
Chapter 3 20 Safety Study

tended to disagree with statements that indicated their age assisted them (figure 3–3).

Overall, older passengers were no more likely to sustain an injury, but they perceived their

condition and age to hinder their evacuation.

Although age apparently had no effect on injuries, the injury rate for females was

greater than the injury rate for males. Thirty-eight percent (64) of the female respondents

reported injuries whereas 27 percent (54) of the male respondents reported injuries [χ2

(1)

= 5.80, p < 0.05]. Yet, perceptions of how physical size, condition, and age affected their

evacuation were the same for males and females.

The Safety Board surveyed passengers involved in the study evacuations on the

competitive behaviors they exhibited or observed during evacuations to gain insight on

how often passengers exhibit these behaviors. Passengers were asked to rate how much

they agreed with the statement that passengers were cooperative during the evacuation.

Seventy-five percent (331) of the passengers who responded to the statement agreed or

Table 3–5. Number of crew and passengers injured in the 

46 study cases, by severity of injuries.a

Person on board Uninjured Minor Serious Fatal Total

Crew 181 9 4 1 195

Passenger 2,433 161 47 10 2,651

Total 2,614 170 51 11 2,846

a Includes accident- and evacuation-related injuries.

Figure 3–2. Passenger agreement with the statement 

that their physical condition assisted their evacuation.
Chapter 3 21 Safety Study

strongly agreed with the statement, 13 percent (56) disagreed or strongly disagreed, and

12 percent (53) were neutral. The majority (62 percent, or 33) of the 56 passengers who

indicated uncooperative behavior were involved in three evacuations (cases 16, 24, and

32). These cases included evacuations involving an auxiliary power unit36 (APU) torching,

an engine fire, and an airplane that overran the runway and impacted a grass embankment.

Although these three cases included flames or substantial airplane damage, the severity of

an event is not necessarily indicative of uncooperative behaviors. In the most serious

accident in the study (case 45), only 6 percent of the passengers indicated disagreement

with the statement that passengers were cooperative.

The competitive behaviors passengers reported seeing included pushing, climbing

seats, and disputes among passengers. These behaviors were reported in many of the study

cases, but not all. Overall, 12.1 percent (53) of the responding passengers reported that

they climbed over seats whereas 20.4 percent (90) observed someone climbing seats.

Many (80 percent, or 42) of the passengers who indicated that they climbed over seats

were from case 45, the most serious accident in the study and which involved several

broken seats. Of all the passengers who responded to the questionnaire, 29 percent (129),

reported seeing passengers pushing; 18.7 percent (83) indicated actually being pushed,

Figure 3–3. Passenger agreement with the statements 

that their age assisted their evacuation.

36 As described in Boeing’s Airliner magazine (April/June 1992), “The APU provides both electrical

power and bleed air for the air conditioning system and main engine starting. A torching start may result

from excess fuel accumulation in the APU combustor assembly and exhaust duct. The torching start has a

characteristic ‘orange flash’.”
Chapter 3 22 Safety Study

and 5.6 percent (25) indicated pushing another passenger. Slightly more than 10 percent

(46) of the responding passengers reported seeing passengers in disputes with other

passengers.

Aircraft Rescue and Firefighting Response

Aircraft rescue and firefighting (ARFF) units responded in 42 of the 46

evacuations investigated in the study. The Safety Board examined the ARFF unit’s role in

these evacuations through questionnaires sent to the unit’s chief. In addition, the Safety

Board asked flight crews about their interaction with the ARFF unit that responded to the

evacuation.

Federal regulations determine the size of ARFF support at each certificated airport

(14 CFR 139.315). The length of aircraft serving the airport determines the ARFF Index

for an airport. For the study, questionnaires were received from eight Index E airports

(which are defined by serving airplanes at least 200 feet long), four Index D airports

(airplanes 159–200 feet), four Index C airports (airplanes 126–159 feet), and three Index

B airports (airplanes 90–126 feet).37 The Safety Board did not receive information from

any Index A airports (airplanes less than 90 feet).

In 15 of the 46 cases, the ARFF unit was notified of the event via the air traffic

control (ATC) tower crash phone. In four cases (21, 26, 33, 46), the unit received

advanced notification of the incident and emergency equipment was waiting for the

incoming airplane.38 In responding to the scene, ARFF units indicated that ATC was

effective in clearing traffic for the response and keeping traffic from the scene. The first

ARFF vehicles arrived in under 2 minutes and 10 seconds for all cases except the

McDonnell Douglas MD-82 accident in Little Rock (case 45), in which low visibility,

among other factors currently being investigated by the Safety Board, delayed arrival of

the ARFF vehicles to over 10 minutes. ARFF personnel assisted passengers in evacuating

the airplane in 14 cases by opening doors, helping passengers out of exits, helping

passengers at the bottom of evacuation slides, directing passengers away from the

airplane, and treating injured passengers and crewmembers. In cases 18, 24, and 30, the

ARFF crew extinguished the fire during the evacuation.

37 Except as provided in Part 139.319(c), Index is determined as follows: If there are five or more average

daily departures of air carrier airplanes in a single Index group serving the airport, the longest Index group

with an average of five or more daily departures is the Index required for the airport. If there are fewer than

five average daily departures in a single Index group serving the airport, the next lower Index from the

longest Index group with air carrier airplanes in it is the Index required for the airport.

38 This includes case 46, which was the only case in which off-airport ARFF units were among the first

units to assist the airplane.
23 Safety Study

Chapter 4

FAA Requirements for 

Evacuation Demonstrations

Evacuation demonstrations are FAA-required tests to evaluate the emergency

egress capabilities of airplanes. The requirement began in 1965 as a method of evaluating

air carriers’ emergency training programs. In 1967, the requirement was expanded to

include airplane manufacturers. Since then, the specific requirements have undergone

many changes (table 4–1). Currently, the FAA requires that these tests be done by

manufacturers of airplanes certified to Part 23 standards,39 and by manufacturers of

airplanes certified to Part 25 standards if the airplane contains 44 or more passenger seats.

In addition, the FAA requires air carriers operating under Part 121 to conduct a modified

evacuation demonstration on each type of airplane in their fleet that has 44 or more

passenger seats to satisfy operating certificate requirements.

Type Certification Requirements

for Airplane Manufacturers

The FAA may require airplane manufacturers to perform full-scale evacuation

demonstrations in order to acquire type certification for new airplanes, and also for

derivative models of currently certificated airplanes when the cabin configuration is

unique or when a significant number of passenger seats have been added. A full-scale

demonstration is a simulated emergency evacuation in which a full complement of

passengers deplane through half of the required emergency exits, under dark-of-night

conditions (14 CFR 25.803). A trained crew directs the evacuation, and the passengers are

required to meet certain age/gender specifications (14 CFR Part 25, Appendix J).40 In

order for manufacturers to pass the full-scale demonstrations, all passengers and crew

must evacuate the aircraft and be on the ground in 90 seconds or less.

The full-scale demonstration determines certain operating requirements that must

be met by all operators of the airplane type. For example, the number of passenger seats

on the airplane during the demonstration dictates the maximum number allowable on any

subsequent airplane of the same type. Similarly, the interior configuration cannot be

altered significantly from the one used for the demonstration. In addition, the number and

placement of flight attendants within the cabin, as well as the training program used to

train them for the demonstration, cannot be unilaterally altered by subsequent operators. If

a manufacturer or operator wants to change any of these characteristics, they must appeal

39 Part 23 contains the airworthiness standards for commuter-category airplanes.

40 Appendix D of this report contains excerpts from 14 CFR Part 25, including Appendix J of Part 25.
Chapter 4 24 Safety Study

Table 4–1. Highlights of changes made by the Federal Aviation Administration

to the requirements for evacuation demonstrations.

Source of change Effective date Description of change

Amendment 121–2a March 3, 1965 Required air carriers operating under 14 Code of Federal Regulations Part 121 to conduct full-scale evacuation demonstrations using half the required floor 

level airplane exits in 120 seconds or less. Applicable 

for initial introduction of aircraft type and model into 

service, a major change in interior configuration, or an 

increase in passenger capacity equal to or exceeding 

5 percent.

Amendment 25–15 October 24, 1967 Required Part 25 aircraft manufacturers to conduct a 

full-scale evacuation demonstration for aircraft with 

44 seats or more in 90 seconds or less. Did not 

require repeated demonstration for configuration 

changes, and allowed use of analysis in lieu of actual 

demonstration for capacity increases not exceeding 

5 percent.

Amendment 121–30 October 24, 1967 Revised Part 121 to reduce demonstration time limit 

to 90 seconds for operators.

Amendment 25–46 December 1, 1978 Revised Section 25.803 to allow use of methods other 

than an actual demonstration to show evacuation 

capability. Replaced existing Part 25 demonstration 

conditions with conditions that would satisfy requirements in both Parts 25 (airworthiness and certification) and 121 (operational). Removed the limitation 

about 5-percent capacity increases for using analysis. 

Required approval of the FAA Administrator for an 

operator to use analysis.

Amendment 121–149 December 1, 1978 Revised Part 121 to accept the results of demonstrations conducted by airplane manufacturers. Allowed 

operators to use partial evacuation demonstrations to 

satisfy training requirements.

FAA Advisory Circular 

25.803–1

November 13, 1989 Presented detailed instructions on fulfilling requirements for evacuation demonstrations and criteria for 

indicating when the demonstrations must be conducted.

Amendment 25–72 August 20, 1990 Placed the demonstration conditions from Section 

25.803(c) into Appendix J of Part 25.

ARACb

 Performance Standards Working Group 

Report, “Emergency Evacuation Requirements and 

Compliance Methods that 

would Eliminate or Minimize 

the Potential for Injury to Full 

Scale Evacuation Demonstration Participants”

1993 Background material for FAA Policy ANM 98–2.

Amendment 25–79 September 27, 1993 Revised Appendix J of Part 25 to change the 

age/gender mix, to allow ramps or stands to be used 

to help participants off wings, and to prohibit flight 

crew from taking an active role in the demonstration.

FAA Policy ANM 98–2 March 17, 1998 Emphasized the use of analysis instead of full-scale 

evacuation demonstrations for type certification of aircraft in order to decrease injuries to participants.
Chapter 4 25 Safety Study

to the FAA, and they may be required to perform another full-scale or partial evacuation

demonstration to show that the same level of safety is maintained.

In recent years, full-scale demonstrations have been criticized by airplane

manufacturers because of potential danger to the passenger participants. Although the

potential for injury is real, the only published research on injuries to participants has

indicated that most injuries incurred in the demonstrations are minor.41 The Safety Board

notes, however, that serious injuries do occur, and a serious injury was sustained during

the MD-11 evacuation certification demonstration on October 26, 1991. In correspondence

to the FAA, the Safety Board stated that full-scale demonstration provides a method to

identify strengths and weaknesses in the evacuation capabilities of an airplane before it

goes into service.42 The Safety Board further stated that as a result of past demonstrations,

inadequate evacuation slide designs have been identified and subsequently remedied, and

the number and locations of cabin crew have been altered.

In lieu of the full-scale demonstrations, the FAA sometimes allows a manufacturer

to use data from previous demonstrations or a combination of data and subsystem test

results to meet certification requirements. This analytical method uses averages of

passenger flow rates through exits, slide preparation times, and exit opening times to

calculate the number of passengers that should reasonably be expected to evacuate the

airplane within the 90-second time limit. Historically, this method to meet certification

requirements was allowed by the FAA only for passenger seating capacity increases of

5 percent or less; however, an FAA policy change in 1998 removed the 5-percent limitation.

Advisory Circular 25.803 1A August 31, 1998

(Draft)

Removed the requirement to conduct a full-scale 

demonstration when there is 5-percent or greater 

increase in passenger seats on a derivative aircraft 

model. Removed specific language that stated the 

conditions for when a full-scale demonstration should 

be conducted. Expanded the section on presentation 

of data when using analysis and testing for certification.

FAA Technical Standard 

Order C-69c, “Emergency 

Evacuation Slides, Ramps, 

Ramp/Slides, and Slide/

Ramps (new version)

August 18, 1999 Required escape slide manufacturers to conduct slide 

rate tests under conditions similar to those required 

by Part 25.803 and AC 25.803 1A. Increased minimum passenger slide rate from 60 passengers per 

minute per lane to 70.

a Amendment 121–2 is the first amendment pertinent to the 1965 regulations.

b An ARAC (Aviation Rulemaking and Advisory Committee) is a group of industry and government representatives 

convened by the FAA to facilitate the FAA’s rulemaking process. The group is charged with examining issues pertinent to a 

particular area of concern and developing recommendations for advisory material and/or revisions to current regulations.

41 Sharon A. Barthelmess, An FAA Analysis of Emergency Evacuation Demonstrations, SAE Paper

821486 (Warrendale, PA: Society of Automotive Engineers, 1982).

42 National Transportation Safety Board letter dated May 15, 1998, to the FAA Administrator regarding

FAA Policy ANM 98–2 (see table 4–1).

Table 4–1. Highlights of changes made by the Federal Aviation Administration

to the requirements for evacuation demonstrations. (Continued)

Source of change Effective date Description of change
Chapter 4 26 Safety Study

Subsystem tests are often required by the FAA when previously untested apparatus

(such as a new evacuation slide design) is added to an existing or derivative model of

airplane. The subsystem tests resemble full-scale evacuation demonstrations but are more

limited in scope. The data from subsystem tests are often used in conjunction with known

data for an evacuation analysis.

Researchers have proposed using computer programs to simulate the dynamics of

emergency evacuations as a method of satisfying evacuation demonstration requirements.43

Computer modeling attempts to integrate the complicated interactions of passengers and

their individual behaviors with the physical attributes of the airplane cabin. Sets of

algorithms are used to impose “characteristics” such as age, mobility, gender, and

personality onto the programmed “passengers,” which affect their movement within the

cabin. Included in the program are physical attributes of the cabin such as seat pitch, aisle

width, exit size and availability, smoke, fire, and other characteristics that influence the

passengers’ movements. Any or all of these variables, if data are available, can be varied by

the programmer to examine their effects on the evacuation.

The researchers who proposed using computer programs to simulate evacuations

have also suggested that using computer modeling techniques offers several advantages

over full-scale demonstrations. For instance, it is more economical, from a data gathering

standpoint, to develop a computer program that can be run many times than it is to hire

“passengers” to participate in singular evacuation demonstrations. Moreover, the modeling

program can easily be altered to examine different passenger behaviors or cabin

configurations. And, modeling eliminates any risk of personal injury to participants of

evacuation demonstrations.

Computer modeling is not recognized by the FAA as an allowable method of

demonstrating evacuation capability of airplanes. Although it is generally accepted by

industry that computer modeling will have a role in evacuation certification in the future,

more traditional methods will continue to be used until the models are validated.

Operating Certificate Requirements

for Air Carriers

Air carriers are required to obtain operating certificates from the FAA in order to

begin scheduled passenger transportation. Among the many requirements an air carrier

must fulfill in order to receive an operating certificate is evidence that its crew training

program sufficiently prepares crewmembers to evacuate passengers in an emergency.

43 E.R. Galea, M. Owen, P.J. Lawrence, and L. Filippidis [University of Greenwich], “Computer Based

Simulation of Aircraft Evacuation and its Application to Aircraft Safety,” Proceedings, 1998 International

Aircraft Fire and Cabin Safety Research Conference, November 16–20, 1998, Atlantic City, NJ,

DOT/FAA/AR-99/68, CD-ROM (Federal Aviation Administration, European Joint Aviation Authorities,

Transport Canada Civil Aviation, Japanese Civil Aviation Bureau, 1999).
Chapter 4 27 Safety Study

Since 1965, the FAA has required air carriers to demonstrate the evacuation

efficacy of their flight attendants upon initial startup of the company, or when a new type

of aircraft is introduced into service. Originally, this was accomplished through a fullscale demonstration, similar to the ones described above. In 1978, the regulations were

modified to allow partial (or mini) evacuation demonstrations to be used as evidence of

adequate crewmember training for evacuations. A partial demonstration differs from a

full-scale demonstration in that there are no passengers on board the airplane during the

demonstration, and the demonstration must be accomplished in 15 seconds or less. To

successfully accomplish a partial demonstration, trained flight attendants must, from a

start signal, get up from their seats, assess conditions, open their assigned exits if

appropriate, and inflate the evacuation slides within the allotted times. Ostensibly, the

partial demonstration provides evidence that the flight attendant training program

effectively prepares the flight attendants to respond to an emergency situation, that the

airplane configuration is functional for an evacuation, and that the equipment is reliable.

As with full-scale demonstration, specific characteristics such as the minimum number of

flight attendants and their duty stations within the cabin, the number of passenger seats,

and portions of the training program cannot be altered by the operator after the partial

demonstration has been accomplished. To alter any of these factors, the air carrier would

have to perform another demonstration.

Safety Oversight in the Evacuation 

Demonstration Requirements

Although Parts 25 and 121 outline requirements for airplane manufacturers and

operators to evaluate the evacuation capabilities of airplanes and crewmembers, these

regulations apply only to airplanes having 44 or more passenger seats. Therefore, it is

possible for a passenger to board an airplane that had no tests of the evacuation efficacy of

the airplane or its crew (table 4–2). In the study cases, 13 of the 46 airplanes (transporting

200 total passengers) were not required to undergo an evacuation demonstration.44

Similarly, an airplane that is type-certificated under Part 23 is required to perform a fullscale evacuation demonstration, but if the airplane is operated under Part 135, or under

Part 121 and has fewer than 44 passenger seats, the FAA does not require the air carrier to

perform a partial evacuation demonstration to obtain an operating certificate.

Commercial airplanes with fewer than 20 seats are not required to operate with

flight attendants on board. Therefore, the pilots have the dual role of flying the airplane

and evacuating passengers when it becomes necessary. However, there is no FAA

requirement to perform a partial evacuation demonstration on these airplanes in order to

assess the evacuation training of the pilots. The Safety Board concludes that the FAA does

not evaluate the emergency evacuation capabilities of transport-category airplanes with

fewer than 44 passenger seats or the emergency evacuation capabilities of air carriers

44 As of January 1, 1999, near the end of the planned data collection period for this study, there were 846

airplanes in operation by regional carriers in the United States that did not require evacuation certification

testing.
Chapter 4 28 Safety Study

operating commuter-category and transport-category airplanes with fewer than

44 passenger seats.

In its 1994 study on commuter airline safety,45 the Safety Board stated that the

standards for safety should be based on the characteristics of the flight operations, not the

seating capacity of the airplane, and that passengers on commuter airplanes should be

afforded the same regulatory safety protection granted to passengers flying on Part 121

airplanes. Consequently, the Safety Board recommended that the FAA

Revise the Federal Aviation Regulations such that:

• All scheduled passenger service conducted in aircraft with 20 or more passenger

seats be conducted in accordance with the provisions of 14 CFR Part 121.

(A-94-191)

• All scheduled passenger service conducted in aircraft with 10 to 19 passenger

seats be conducted in accordance with 14 CFR Part 121, or its functional

equivalent, wherever possible. (A-94-192)

The Safety Board is concerned that existing regulations which exempt certain airplanes

and operations because of passenger seating capacity is not consistent with the goal of

providing “one level of safety” for all passenger-carrying commercial airplanes.46 The

Safety Board further concludes that in the interest of one level of safety, all

passenger-carrying commercial airplanes and air carriers should be required to

Table 4–2. Overview of evacuation demonstrations required for aircraft type certification and 

air carrier operating certification.

Airplanes certified to 

the standards in—

Air carriers 

operating under—

Number of 

passenger seats 

on airplane

Full-scale 

demonstration 

required (of 

manufacturer)b

Partial 

demonstration 

required (of 

air carrier)

Part 23 (commutercategory airplanes)Part 135 Fewer than 44 Yes No

Part 23 Part 121 Fewer than 44 Yes No

Part 25 (transportcategory airplanes)Part 135 Fewer than 44 No No

Part 25 Part 121 Fewer than 44 No No

Part 25 Part 121 44 or more Yes Yes

a Details of evacuation demonstration requirements for airplane manufacturers and air carriers are contained in Title 14 

Code of Federal Regulations Parts 23, 25, 135, and 121. b In lieu of the full-scale demonstrations, the Federal Aviation Administration sometimes allows a manufacturer to 

use data from previous demonstrations or a combination of data and subsystem test results to meet certification 

requirements.

45 National Transportation Safety Board, Commuter Airline Safety, Safety Study NTSB/SS-94/02

(Washington, DC: NTSB, 1994).

46 On July 15, 1996, the Safety Board classified Safety Recommendations A-94-191 and A-94-192

“Closed—Acceptable Action” based on FAA’s commuter rule that required scheduled passenger operations

in airplanes of 10 or more passenger seats and all turbojets to be conducted according to the requirements of

14 CFR Part 121.
Chapter 4 29 Safety Study

demonstrate emergency evacuation capabilities. Therefore, the Safety Board believes that

the FAA should require all newly certificated commercial airplanes to meet the evacuation

demonstration requirements prescribed in 14 CFR Part 25, regardless of the number of

passenger seats on the airplane. Also, the FAA should require all commercial operators to

meet the partial evacuation demonstration requirements prescribed in 14 CFR Part 121,

regardless of the number of passenger seats on the airplane.

31 Safety Study

Chapter 5

Exits

Regulations for emergency exits are contained in 14 CFR 25.807. The exits range

from the largest, a “Type A” (a floor level exit door with dimensions of at least 42 inches

wide and 72 inches high), to the smallest, a “Type IV” (an overwing exit with dimensions

of at least 19 inches wide and 26 inches high). Figure 5–1 shows “Type III” exits (an exit,

typically overwing, with dimensions of at least 20 inches wide and 36 inches high). The

cases in the evacuation study included a variety of the exit types.47

Federal regulations further mandate that “the means of opening emergency exits

must be simple and obvious and may not require exceptional effort” (14 CFR 25.809(c)).

Crewmembers are required to operate each exit type on their aircraft during initial training

and every 2 years thereafter (14 CFR 121.417). Passengers will likely never have occasion

to open an airplane emergency exit prior to an actual evacuation.

Figure 5–1. Type III exits.

47 Appendix D contains excerpts from 14 CFR 25.807 and a description of all exit types.
Chapter 5 32 Safety Study

Access to Exits

Exit location, aisle width, bulkhead width, and seating density are factors in the

design of an airplane that can influence passengers’ access to exits and, consequently, the

success of an emergency evacuation. Past research has referred to these as configurational

factors.48 Factors such as aisle width or exit location are governed by Federal regulations

to ensure passenger safety. Past evacuations have prompted changes to some of these

regulations. The report of a 1985 evacuation of a 737 in Manchester, England, indicated

two configurational factors that needed to be reexamined: bulkhead passageways and seat

pitch in exit rows. Passenger reports of getting stuck at the bulkhead and exit rows led to

CAA research that found that both passageways needed widening.

In 1989, CAMI conducted evacuation trials to examine the effects of exit path

width—the distance between the forward-most point on an exit row seat and the aft-most

point on the seat directly in front of it (figure 5–2)—on the evacuation rate at Type III

overwing exits.49 Participants were required to evacuate through a Type III exit or open a

Type III exit hatch using four different seating conditions: a 6-inch unobstructed

passageway, a 10-inch unobstructed passageway, a 20-inch passageway with 5 inches of

the seat encroaching on the exit, and a central seat placement with the outboard seat

removed. The researchers reported that egress times were quicker for the seating

conditions using the 20-inch passageway and the outboard seat removed than were egress

times using the 6-inch passageway. However, the various exit widths did not affect exit

hatch removal time. As a result of these CAMI trials and the 1991 accident in Los Angeles

(described in chapter 1 of this report), the FAA issued a notice of proposed rulemaking

(NPRM) that required air carriers to increase the exit path width in exit rows from 6 inches

to 20 inches. The Safety Board commented in support of this proposed rule change in a

letter dated October 8, 1991.

Industry comments questioning the need for such a substantial change led CAMI

to conduct a study in 1992 to examine alternatives to the proposed requirement.50 In that

CAMI study, participants were required to exit through a Type III overwing exit using four

different seating conditions: a 10-inch unobstructed passageway with the seat in front of

the exit row displaced forward 15°, a 10-inch unobstructed passageway with two seats

instead of three seats, a 20-inch passageway with 5 inches of the seat encroaching on the

exit, and three 6-inch passageways leading to two exits in which the outboard seats closest

to the two exits were removed. The researchers reported that total egress time, hatch

opening time, and individual egress times were fastest for evacuations to a single exit

48 C.C. Snow, J.J. Carroll, and M.A. Allgood, Survival in Emergency Escape From Passenger Aircraft,

AM 70-16 (Washington, DC: U.S. Department of Transportation, Federal Aviation Administration, Office of

Aviation Medicine, 1970).

49 Paul G. Rasmussen and Charles B. Chittum, The Influence of Adjacent Seating Configurations on

Egress Through a Type III Emergency Exit, DOT/FAA/AM-89/14 (Washington, DC: U.S. Department of

Transportation, Federal Aviation Administration, Office of Aviation Medicine, 1989).

50 G.A. McLean, C.B. Chittum, G.E. Funkhouser, and others, Effects of Seating Configuration and

Number of Type III Exits on Emergency Aircraft Evacuation, DOT/FAA/AM-92/27 (Washington, DC: U.S.

Department of Transportation, Federal Aviation Administration, Office of Aviation Medicine, 1992).
Chapter 5 33 Safety Study

using the 20-inch passageway. However, no inferential statistics were reported to support

the claims that a 20-inch passageway provided for the best performance.

Nevertheless, based upon these studies and comments received, the FAA published

the final rule on May 4, 1992 (14 CFR 25.813, included in appendix D of this report),

which increased the exit path width to 20 inches. In response to the rule, the Air Transport

Association and several air carriers petitioned for an exemption to the rule indicating that

some distance between a 6-inch exit path and a 20-inch exit path might provide for

equivalent performance to that using a 20-inch pathway. To examine this possibility,

CAMI conducted another series of trials in 1995 to examine the effects of five exit path

widths and three seat encroachments on egress through Type III overwing exits.51 The

researchers concluded that narrow egress paths (6 and 10 inches) result in slower egress

than wider egress paths (13, 15, and 20 inches). Unlike the previous CAMI studies on exit

path width, this study did not measure exit hatch removal times for the various seating

conditions. Further, the study included a flight attendant just forward of the overwing exit,

a situation not examined in the previous studies or likely to occur in an emergency

evacuation. As a result of the flight attendant giving instructions not included in the study

protocol, several trials involving older participants were dropped; however, no mention is

made of how many trials were dropped and from which seating conditions. Finally,

participants in this experiment evacuated through the Type III exit 30 times during the

course of the experiment. This number represents a dramatic increase over previous

Figure 5–2. Type III exit row passageway width.

51 (a) G.A. McLean, M.H. George, C.B. Chittum, and G.E. Funkhouser, Effects of Seat Placement at the

Exit, Part I of Aircraft Evacuations Through Type-III Exits, DOT/FAA/AM-95/22 (Washington, DC: U.S.

Department of Transportation, Federal Aviation Administration, Office of Aviation Medicine, 1995). (b)

G.A. McLean and M.H. George, Effects of Individual Subject Differences, Part II of Aircraft Evacuations

Through Type-III Exits, DOT/FAA/AM-95/25 (Washington, DC: U.S. Department of Transportation,

Federal Aviation Administration, Office of Aviation Medicine, 1995).
Chapter 5 34 Safety Study

studies in which each participant performed in four evacuations, and it may not reflect the

performance of a novice evacuee in an actual emergency evacuation. Based upon this

research, the FAA granted air carriers an exemption to the 20-inch width requirement and

issued an NPRM on January 30, 1995, proposing an amendment to the rule that would

reduce the exit path width in exit rows to 13 inches.52

The Safety Board is concerned that the CAMI research used as a basis for the

proposed rule change contains a number of significant design flaws—such as the use of a

flight attendant at the exit and no consideration given to exit hatch removal times—that

bring into question the applicability of the research to an actual emergency evacuation

situation. Further, the Board is unaware of any other study that examines both exit hatch

removal and egress speed and compares the 20-inch exit path width with the proposed

13-inch width. The Safety Board concludes that adequate research has not been conducted

to determine the appropriate exit row width on commercial airplanes. Therefore, the

Safety Board believes that the FAA should conduct additional research that examines the

effects of different exit row widths, including 13 inches and 20 inches, on exit hatch

removal and egress at Type III exits. The research should use an experimental design that

reliably reflects actual evacuations through Type III exits on commercial airplanes. The

Safety Board also believes that the FAA should issue, within 2 years, a final rule on exit

row width at Type III exits based on the research just described.

Accident severity will also play a role in how easily passengers will be able to

reach an exit. Severe damage to the fuselage, for example, can cause interior furnishings

to be dislodged and become obstacles for passengers attempting to exit an airplane. For

the study cases, questionnaire statements from passengers and flight attendants provided

insight on how easily passengers were able to access exits and what interior furnishings

impeded their access.

In the MD-82 accident in Little Rock, Arkansas (case 45), the crash forces caused

seats to break free from their seat tracks and block aisles. In the forward portion of the

cabin, passengers had to navigate around fallen overhead bins and across a severely

deformed floor. Fortunately, the crash caused several gaps in the fuselage that passengers

were able to use for egress. As seen in figure 5–3, the crash forces split the cabin in two

separate sections divided at the wing.

In the 727 accident in Chicago (case 9), the aircraft landed short of the runway,

striking a light structure and the runway threshold. A liferaft ceiling panel door53 fell open,

blocking the main aisle to the L1 exit.54 The flight attendant assigned to the L1 exit

decided not to use the exit because the ceiling panel blocked access to the exit. Passengers

evacuated through the R1, overwing, and L2 exits (figure 5–4).

52 The Safety Board did not comment on the 1995 rulemaking.
Chapter 5 35 Safety Study

Based on the circumstances of the evacuation in this accident, the Safety Board

recommended that the FAA

Identify all airplanes operated under Title 14 Code of Federal Regulations Part

121 with liferaft ceiling stowage compartments or compartments that formerly

stored liferafts that open downward and issue an airworthiness directive to limit

the distance that those compartments can open. (A-99-10)

55

The FAA responded favorably to this recommendation by requesting that its

aircraft certification office identify airplanes affected by this recommendation and by

sending a request to the applicable manufacturers for information regarding the

installation of liferaft ceiling stowage compartments. On February 3, 2000, Safety

Recommendation A-99-10 was classified “Open—Acceptable Response.” The Safety

Board will continue to monitor the FAA’s progress on this issue.

53 The 727 is equipped with four single door liferaft ceiling stowage compartments that contain liferafts

when the airplane is being operated as an extended overwater flight. For flights that are not operated over

water, the stowage compartments are usually empty. The 4-foot by 2-foot door panels are hinged along their

aft edges and latched along their forward edges; however, the doors were not equipped with any device to

prevent them from swinging all the way down and blocking the aisle.

54 Floor level exit doors are labeled with a letter indicating which side the exit is on facing forward and a

number indicating the ordinal position the exit from fore to aft. For example, L1 indicates the exit located

most forward on the left side of the aircraft.

Figure 5–3. View of the McDonnell Douglas MD-82 accident scene that involved evacuation on 

June 1, 1999, Little Rock, Arkansas (case 45).

55 The Safety Board had issued a similar recommendation in 1990 that was applicable only to 747s. That

recommendation (A-90-59) was classified “Closed—Acceptable Action” on May 15, 1992, after the FAA

issued AD 91-22-05 applicable to 747s. Rather than issue a new recommendation applicable only to 727s,

the Safety Board decided to ask the FAA to identify all airplanes with liferaft ceiling stowage compartments.
Chapter 5 36 Safety Study

The Safety Board asked passengers and flight attendants in the 30 cases receiving

detailed investigations to indicate from a list what hindered the evacuation. The majority

of responses came from the Little Rock and Chicago cases described above; of the

46 study cases, the airplanes in those two cases experienced the most severe crash forces.

Five passengers and 1 flight attendant mentioned bulkheads, 39 passengers and 1 flight

attendant mentioned broken interiors, 16 passengers mentioned overhead bins, and

16 passengers mentioned the seatback in front of them.

In the 28 other cases for which questionnaires were distributed, one flight

attendant mentioned that her seat obstructed the evacuation, and two other flight

attendants reported galley items obstructing passenger evacuation. Eleven passengers

indicated that the seatback in front of them slowed their movement, six passengers

mentioned overhead bins, five passengers mentioned the bulkhead, and one passenger

mentioned the aisle width.

In general, passengers in the Safety Board’s study cases were able to access

airplane exits without difficulty, except for the Little Rock, Arkansas, accident that

occurred on June 1, 1999, in which interior cabin furnishings became dislodged and were

obstacles to some passengers’ access to exits.

Figure 5–4. View of a slide used in the Boeing 727 evacuation on 

February 9, 1998, Chicago, Illinois (case 9).
Chapter 5 37 Safety Study

Emergency Exit Lighting

Federal regulations require that an emergency lighting system, independent of the

main lighting system, must be installed on airplanes. The emergency lighting system must

include the following: illuminated emergency exit marking and locating signs, sources of

general cabin illumination, interior lighting in emergency exit areas, floor proximity escape

path marking, and exterior emergency lighting (14 CFR 25.812). Many of these

requirements were the result of previous Safety Board recommendations that addressed

emergency exit lights for utilization during darkness or smoke (A-72-133), improved visual

guidance to emergency exits (A-73-53), emergency lighting for passenger evacuation from

smoke-filled cabins (A-83-79), and requirements for all emergency lighting to be

illuminated during evacuations (A-90-95). All of these safety recommendations have been

classified “Closed—Acceptable Action” as a result of positive action by the FAA.

The Safety Board assessed the effectiveness of the emergency lighting systems in

the study cases by reviewing crew statements from returned questionnaires. Of the

36 flight attendants who responded, there were only two reports of failed lights, both from

flight attendants in the Little Rock accident.56 Further, 5 flight crewmembers and 10 flight

attendants reported that emergency lighting systems assisted evacuations in which

visibility was restricted. All of these crewmembers were involved in five night

evacuations. The Safety Board concludes that emergency lighting systems functioned as

intended in the 30 evacuations cases investigated in detail.

Floor Level Exits

Floor level exits were used in all 46 evacuations; 67 such exits were opened during

these evacuations. In the questionnaires, the Safety Board asked flight attendants, flight

crews, and passengers about the ease of opening floor level exit doors.

Only two flight attendants reported any difficulty with opening floor level exit

doors. These two attendants were on the MD-82 that incurred severe structural

deformation when it crashed in Little Rock (case 45). One flight attendant reported that

both of the forward floor level exit doors were inoperable because of crash forces. The

second flight attendant reported that the floor level exit door leading to the tailcone exit

could not be opened initially because of a deformation in the floor of the airplane. The

door was eventually opened through the combined efforts of the flight attendant and two

male passengers.

One flight attendant, in a postincident statement following the evacuation of a 737

in Eugene, Oregon (case 5), reported being unable to open her floor level exit door. She

56 The two flight attendants reported on questionnaires that “nothing worked basically” and both flight

attendants indicated that the escape path lighting was not adequate. However, the Safety Board received

information from firefighters and passengers that at least some lights were working. The Safety Board’s

investigation of that accident is continuing.
Chapter 5 38 Safety Study

explained how the exit door operated to a passenger, and the passenger proceeded to open

the door. A second flight attendant reported difficulty keeping a floor level exit door

latched open during the evacuation of another 737, in Salt Lake City, Utah (case 1).

None of the flight crewmembers indicated any difficulty in opening or using floor

level exit doors.

Seven passengers reported that they had difficulty attempting to open an airplane

floor level exit door during their evacuation: five were involved in the evacuation of the

MD-82 in Little Rock, Arkansas (case 45); one was involved in the evacuation of an A300

in San Juan, Puerto Rico (case 24); and the last was in the evacuation of a 727 in Chicago,

Illinois (case 16). Three Little Rock passengers attempted to open a floor level exit door

leading to the tailcone; the door exit could not be opened because of a deformation in the

floor of the airplane. The two other Little Rock passengers attempted to open inoperable

forward floor level exit doors. The 727 passenger reported opening the L2 door 10 inches

before it “jammed.” Finally, the A300 passenger attempted to open the R3 door that had

not opened as intended after a flight attendant first tried to open the door (figure 5–5).

The floor level exit door problems in the MD-82 evacuation were associated with

airplane and exit deformation that resulted from the impact sequence. The floor level exit

door problem in the A300 case was determined to be the result of the slide pack and will

be discussed in the section on evacuation slides. Finally, no determination could be made

as to why the floor level exit door on the 727 jammed. In summary, in 43 of the 46 of

evacuation cases in the Safety Board’s study, floor level exit doors were opened without

difficulty.

Figure 5–5. View of the R3 door that failed to operate as intended following the Airbus 300 

accident on July 9, 1998, in San Juan, Puerto Rico (case 24).
Chapter 5 39 Safety Study

Type III Overwing Exits

Trained crewmembers are expected to operate most of the emergency equipment

on an airplane, including most floor level exit doors. Overwing exits, on the other hand,

are expected to be and will primarily be opened by passengers. Even in airplanes where

flight attendants are assigned the responsibility for overwing exits, passengers are likely to

make the first attempt to open overwing exit hatches because the flight attendants are not

physically located near the overwing exits.

In the study cases, Type III overwing exits were used in 13 of the 46 evacuations.

In all, 36 overwing hatches were opened during these evacuations. Specific information

on overwing exit operation was collected for 6 of the 13 evacuations.57 For two of these

evacuations—the A320 in Columbus, Ohio (case 43) and the 737 in Scottsbluff, Nebraska

(case 46)—overwing exits were operated by flight attendants with no reported difficulties.

In a 727 evacuation at Chicago, Illinois (case 9), two passengers who were interviewed

indicated that they had no problems opening the overwing exit hatch. In the three other

cases, there were reported problems with opening the overwing exit hatches. In an

evacuation of a 737 in Atlanta, Georgia (case 32), one passenger reported that a woman

had been unable to open one exit hatch and eventually allowed another passenger to open

it. In an evacuation of a 727 in Chicago, Illinois (case 16), the passengers who opened the

exit hatch reported “struggling to maneuver the heavy exit” to throw the hatch out of the

airplane.58 In an MD-82 evacuation at Little Rock, Arkansas (case 45), two passengers,

ages 74 and 22, attempted to open two overwing exit hatches but were unable to do so.

One of these passengers abandoned the exit whereas the other allowed another passenger

in his row an attempt to open it. Both overwing exits were eventually opened.

A 22-year-old passenger in the Little Rock accident attempted to open a third overwing

exit by pushing the hatch out of the airplane after pulling the release handle. He stated he

put his shoulder into the hatch and pushed, even though the design of the overwing exit

was such that the hatch was to be pulled into the airplane.

In each of the 13 evacuations in which overwing emergency exits were used, all

the exits were eventually opened. However, in three of the four cases for which data were

available and a passenger opened an overwing exit hatch, the exit hatches were not always

easy for passengers to open. Passenger difficulty in opening these exits unnecessarily

caused passengers to wait to use the exits. While these delays did not appear to result

directly in any additional injuries, there exists the potential that future difficulties could

result in injuries, as occurred in the 1985 evacuation of a 737 in Manchester, England, in

which the window exit passenger attempted to open the overwing exit by pulling on the

handle of the seat adjacent to the exit. Another passenger reached over the window exit

passenger and pulled on the release handle. The exit hatch fell inward, trapping the

57 Questionnaires were mailed to passengers in a seventh case (case 27), but all of the passengers who

returned questionnaires had used slides at their exits. The remaining 6 of the 13 evacuations for which

overwing exit use was known were not included in the detailed investigations; consequently, questionnaires

were not mailed to the passengers in those cases.

58 The Type III overwing exit hatch can weigh as much as 65 pounds, have a width of 20 inches, and a

height of 36 inches.
Chapter 5 40 Safety Study

passenger next to the exit. Only with the help of another passenger was the hatch able to

be moved. The exit was reported to be opened 45 seconds after the aircraft had stopped

rolling. (The R2 exit was opened 6 seconds prior to stopping.)

Although regulations require passengers to be screened for exit row seating,59

according to information obtained from this study, the screening does not guarantee that

the passenger has read the safety briefing card or understands how to open or stow Type

III overwing exit hatches after reading the card. Many passengers, even those seated in

exit rows who are instructed that they may be called upon to help in an emergency

evacuation, admit to not reading the briefing card that might help them understand how to

operate and open overwing exits. Of the 42 passengers seated in overwing exit rows who

responded to the Safety Board’s questionnaire, 22 passengers (52 percent), representing

eight cases, indicated that they had not read the briefing card.60

As case 16 (a 727 in Chicago) illustrated, the weight of the overwing exit hatch has

also been a problem for some passengers. One air carrier acknowledges on its safety

briefing card for an airplane type with Type III overwing exits the weight and

awkwardness of this type of exit. The safety briefing card states in the introduction to the

exit row seating requirements that “emergency exits are often heavy, awkward to lift,

push, pull, and maneuver when opening. Because of this and for the safety of all

passengers, Federal law requires that we only seat qualified passengers next to exits.”

Further, it is not intuitively obvious that after pulling the latch, the hatch is to be turned

and either placed on the exit row seats or thrown out the opening. The opening and

maneuvering of this exit is also difficult to display graphically. The Safety Board

concludes that passengers continue to have problems opening overwing exits and stowing

the hatch. The manner in which the exit is opened and the hatch is stowed is not intuitively

obvious to passengers nor is it easily depicted graphically. Boeing has designed a new

overwing exit for its 737 series airplanes based on human factors principles.61 The exit is

hinged and opens outward as passengers would intuitively expect (figure 5–6). This

design also eliminates the problem of where to stow the exit hatch because it moves up

and out of the egress route. In short, the design eliminates any guesswork about how the

exit operates or what to do with the exit hatch once it is opened. The Safety Board believes

the FAA should require Type III overwing exits on newly manufactured aircraft to be easy

and intuitive to open and have automatic hatch stowage out of the egress path.

59 14 CFR 121.585 requires each certificate holder to determine the suitability of each person it permits to

occupy an exit seat.

60 Exit row passenger tasks are discussed in more detail in the next section.

61 This issue relates to Boeing’s intent to increase the passenger count on the 737-600/700/800 series

aircraft. The European Joint Aviation Authorities (JAA) determined that they would only agree to an

increased passenger count if there was a significant change to the cabin configuration. Boeing developed the

new Type III hatch in order to meet the JAA position.
Chapter 5 41 Safety Study

Exit Row Passenger Tasks

Passengers seated in an exit row may be called upon to assist in an evacuation.

Upon crew command or a personal assessment of danger, these passengers must decide if

their exit is safe to use and then open their exit hatch for use during an evacuation. These

passengers must be ready to act quickly in an emergency. However, unlike the crew, these

passengers receive no formal training on performing these tasks.

As required by the FAA, air carriers provide pictorial instructions on the safety

briefing card and adjacent to the emergency exit. In addition, Federal regulations (14 CFR

121.585(b)) provide guidelines to the air carriers as to which passengers to restrict from

exit row seating. These guidelines are reiterated on exit row briefing cards or on the

general safety cards.

Federal regulations (14 CFR 121.585(d)) also require air carriers to list the tasks

that an exit row passenger may be called upon to perform: the passenger must be able to

locate and operate the emergency exit, assess conditions outside an exit, follow

instructions of crewmembers, open and stow the exit hatch, assess the condition of and

stabilize a slide, and pass quickly through an exit. Passengers who report that they are

Figure 5–6. View of the newly designed Type III exit for the 

Boeing 737-600, -700, -800, -900.
Chapter 5 42 Safety Study

unable or unwilling to perform any of these tasks must be reseated in a nonexit row prior

to airplane movement.

The Safety Board examined passenger performance in exit rows for the six cases

for which the Board received information on the overwing exit operation. In these six

cases, 42 passengers were seated in exit rows. Responses on the questionnaires indicate

that the first task with which exit row passengers had difficulties was the decision to open

the exit. In two cases, passengers opened overwing exits that should have remained

closed. In one of those cases (case 16), an APU torched and passengers began to scream,

“Fire.” The aft flight attendant reported that she instructed passengers to remain seated,

yet passengers still opened the exit. In the other case (case 19), the flight crew ordered an

evacuation using only the forward exits; however, the exit row passengers opened the

overwing exits. In neither case had the flight crew lowered the flaps for safe egress off the

wing, and in one of these cases, a child sustained a broken arm jumping off the wing.

The second task for which problems occurred for exit row passengers was

assessing conditions outside of the exit. In one case, a passenger opened an overwing exit

and smoke began billowing into the cabin (case 45). The passenger then had to jump

through fire to get away from the airplane. Although his traveling companion was also

able to safely egress using this route, the other two passengers who used this exit received

severe burns. In a second case, one passenger stopped another passenger from opening an

overwing exit on the fire side of an airplane (case 16).

As previously discussed, one reason for these difficulties was passenger

inattention to the safety materials provided. The air carriers are required to ensure that all

passengers seated in an exit row meet the requirements contained in regulations

previously cited. Although no exit row passenger was younger than age 15, two

passengers were older than age 70, one of whom was unable to open an exit (case 45). In

addition, three passengers seated in exit rows did not speak the language in which

briefings and oral commands were given by the crew.

Some of the air carriers make a point to individually brief passengers on the exit

row tasks. In the six study cases for which the Safety Board received overwing exit

operation information, 9 of the 42 exit row passengers reported receiving such a briefing

(figure 5–7). Four of these passengers reported examining their safety card. Twenty-four

passengers reported receiving no briefing, and only two of these passengers had examined

their briefing card. The two briefed passengers who opened overwing exits reported no

difficulties. Four passengers who did not receive a briefing opened overwing exits. Two of

these passengers reported no difficulty with the exit whereas the other two reported

difficulties with their exit.
Chapter 5 43 Safety Study

The benefit of exit row passengers’ receiving oral briefings from flight attendants

is demonstrated in the runway collision in Los Angeles, California, on February 1, 1991.

The Safety Board’s report of that accident contained the following information:

Passengers seated around row 10 stated that prior to departure, the flight attendant

assigned to the R1 position interviewed a young passenger who was seated in 10D

about whether he could fulfill the duties of an able-bodied person in the event of

an emergency. The passenger advised the flight attendant that he was 17 years old.

However, to be sure the youth understood his responsibilities, the flight attendant

conducted a special oral briefing for the persons seated in and around row 10.

Passengers stated that the instructions provided by the R1 flight attendant aided in

their evacuation.

Exit procedures for emergency evacuations are critical and if not followed could

lead to tragedy. The Safety Board concludes that most passengers seated in exit rows do

not read the safety information provided to assist them in understanding the tasks they

may need to perform in the event of an emergency evacuation, and they do not receive

personal briefings from flight attendants even though personal briefings can aid

passengers in their understanding of the tasks that they may be called upon to perform.

Therefore, the Safety Board believes the FAA should require air carriers to provide all

passengers seated in exit rows in which a qualified crewmember is not seated a preflight

personal briefing on what to do in the event the exit may be needed.

Figure 5–7. Percentage of exit row passengers who indicated whether or 

not they paid attention to safety information.
Chapter 5 44 Safety Study

Flight Attendant Exit Assignment

The exit configuration of some Fokker airplanes is unique among jet airplanes in

that it does not have any exits in the rear of the airplane. On the Fokker 100 (F100), the

forward flight attendant is responsible for the L1 and R1 floor level exits, which are

adjacent to the jumpseat where the flight attendant is seated. The aft flight attendant is

responsible for opening the forward overwing exits 10 rows and 47 passengers forward of

the rear jumpseat where the flight attendant is seated (figure 5–8).62 A flight attendant

involved in the evacuation of an F100 in Charlotte, North Carolina (case 41) indicated that

passenger evacuation in this case would have been helped had there been an emergency

exit in the rear of the aircraft. The F100 on which the flight attendant was working was

equipped with floor level exits in the forward part of the cabin and four overwing exits.

The aft flight attendant’s assigned primary exit was a forward overwing exit. The two right

overwing exits were blocked by a fire on the right main gear. Passengers from the middle

and rear of the airplane were evacuating from the two left overwing exits. The passengers

at these exits operated their exits prior to the flight attendant reaching the overwing area.

Positioning a flight attendant in the rear of this airplane can limit the

crewmember’s usefulness and seems inconsistent with the requirements of 14 CFR

121.391(2)(d). According to the regulation, “during takeoff and landing, flight attendants

required by this section shall be located as near as practicable to required floor level exits

and shall be uniformly distributed throughout the airplane in order to provide the most

effective egress of passengers in the event of an emergency evacuation.” Research

conducted by CAMI shows significant differences in evacuation times based on flight

attendants’ initial position.63 Evacuations with flight attendants 24 feet aft of their primary

emergency exits proceeded significantly slower than evacuations with a flight attendant

next to the exit. Delays resulting from passenger inability to open the exit or

indecisiveness can be reduced if flight attendants are available to assist. The Safety Board

concludes that on some Fokker airplanes, the aft flight attendant is seated too far from the

overwing exits, the assigned primary exits, to provide immediate assistance to passengers

who attempt to evacuate through the exits. Therefore, the Safety Board believes that the

FAA should require the flight attendants on Fokker 28 and Fokker 100 airplanes to be

seated adjacent to the overwing exits, their assigned primary exits. In requiring the aft

flight attendants on Fokker 28 and Fokker 100 airplanes to be seated adjacent to the

overwing exits, their assigned primary exits, consideration should be given to the flight

attendants’ view of the cabin and other safety duties.

62 The configuration of the Fokker 28 is similar with respect to the aft flight attendant’s position away

from the overwing exits.

63 Mark George and Cynthia Corbett [CAMI], “Effects of Cabin Crew Location and Passenger

Motivation on Aircraft Evacuations,” Proceedings, 1998 International Aircraft Fire and Cabin Safety

Research Conference, November 16–20, 1998, Atlantic City, NJ, DOT/FAA/AR-99/68, CD-ROM (Federal

Aviation Administration, European Joint Aviation Authorities, Transport Canada Civil Aviation, Japanese

Civil Aviation Bureau, 1999).
Chapter 5 45 Safety Study

Figure 5–8. The Fokker 100 exit configuration. The aft flight attendant position 

is marked by the *

. The forward flight attendant position is marked by the X.
Chapter 5 46 Safety Study

Evacuation Slides

The FAA requirement that all exits higher than 6 feet off the ground be

accompanied by an assist means for allowing passengers to reach the ground quickly and

safely during an emergency (14 CFR 25.810) has been met through the use of selfsupporting, inflatable escape slides. The slides must be (a) automatically deployed, (b)

automatically erected in 6 seconds for all but Type C exits,64 (c) long enough for the lower

end to be self-supporting on the ground regardless of gear collapse, and (d) usable in a

25-knot wind with the assistance of only one person. Further, to ensure reliability, five

consecutive deployment and inflation tests must be conducted, one time only, without

failure for each system installation.

The Safety Board investigated 19 evacuations that involved slide use;65

7 evacuations included slides that did not operate as expected. On February 9, 1998, a

DC-9 (case 8) sustained a contained engine failure during takeoff. The tower informed the

flight crew that there was fire in the area of the airplane’s No. 2 engine. The crew stopped

on a high-speed taxiway and began to complete the engine fire and emergency evacuation

checklist.

Based on the possibility of an engine fire, the captain elected to order an

evacuation using the forward two exits (L1 and R1). The flight attendant assigned to the

R1 door opened the door; the slide deployed but did not inflate, nor did the slide inflate

after the manual inflation handle was pulled. The evacuation then proceeded out the L1

door where the airstairs had been deployed. All passengers and crewmembers used the

airstairs to leave the airplane.

An FAA cabin safety inspector examined the failed R1 slide. The specialist found

the slide not inflated, hanging outside the aircraft, and noted that the pressure gauge on the

inflation bottle read zero. After the slide was removed and attached to a fully charged

bottle, it inflated fully with no leaks.

Daily checks of the inflation bottle were required by the air carrier;66 however,

recent changes to the air carrier manuals led to confusion over who was required to

perform these checks. The carrier has subsequently adjusted the procedures in its manual

to eliminate this confusion.

The failure of the R1 slide in the above evacuation reduced to one the number of

exits originally selected by the flight crew for the 144 passengers and crew to evacuate the

airplane. This occurrence was not unique to the study. On July 9, 1998, an A300 (case 24)

experienced a fire in its No. 1 engine shortly after takeoff. The airplane returned to the

airport and an emergency evacuation was executed on the runway. The captain ordered the

evacuation on the right side of the airplane. The flight attendants were able to open and

64 The evacuation slides at Type C exits must be automatically erected in 10 seconds.

65 Flight attendants attempted to deploy 44 slides in these 19 evacuations.

66 The FAA provides guidance on checks of inflation bottles in the Air Transportation Operations

Inspection Handbook 8400.10.
Chapter 5 47 Safety Study

deploy the slides at R1, R2, and R4. However, there was a delay in deploying the R1 slide

because of a failure of the power assist in the door. Also, the R3 door partially opened

before jamming. The flight attendant tried repeatedly to open the door, but reported that he

“knew [the slide] was caught up” in the pack. Postincident testing conducted by the Safety

Board indicated that the malfunction might have been caused by a Velcro® fastener that

became hooked on a clip on the inside of the decorative cover. In addition, the slide

deployed at R4 was unusable for a period of time because winds were blowing the slide

against the airplane (figure 5–9). During this time, the 234 passengers were exiting from

only two of the eight exits on the A300.

In addition to the two evacuations described above, slides were difficult to deploy

in five other evacuations in the Safety Board’s study. On January 7, 1999, an MD-80 in

San Diego, California (case 38) was evacuated in response to a bomb threat. Three door

slides operated as designed. However, the aft tailcone slide failed to automatically inflate

after the tailcone was opened. The air carrier determined that the lanyard for inflating the

slide was not attached to the tailcone girt bar. On an F100 that was evacuated on January

24, 1999 (case 41), a flight attendant reported that the slide became temporarily jammed in

the slide pack. The attendant pulled the door closed and then shoved the door past the

“jam.” The slide eventually inflated and was used in the evacuation. The captain of an

MD-82 that was evacuated on August 27, 1998 in Phoenix, Arizona (case 27) reported

that a slide failed to inflate automatically. A flight attendant reported a similar occurrence

during the evacuation of an MD-80 on December 19, 1997 (case 4). The flight attendant

was able to manually inflate the slide. Finally, a 737 was evacuated on November 1, 1998,

Figure 5–9. View of the wind’s effect (25-knot gusts) on the evacuation slide used following the 

Airbus 300 accident on July 9, 1998, in San Juan, Puerto Rico (case 24). Passengers were able to 

use this exit after a person on the ground held the slide in place.
Chapter 5 48 Safety Study

with slides that were incorrectly placarded automatic (case 32); the slides were, in fact,

manual inflation only.

Overall, in 37 percent (7 of 19) of the evacuations with slide deployments in the

Safety Board’s study cases, there were problems with at least one slide. The Safety Board

concludes that a slide problem in 37 percent of the evacuations in which slides were

deployed is unacceptable for a safety system. Slide failure is not a new problem. In a

December 9, 1999, letter to the FAA regarding the A300 accident in San Juan (case 24 in

the Safety Board’s evacuation study), the Board discussed evacuation system failures,

including slide failures, that occurred in eight incidents prior to this study. A review of the

accident briefs in the Safety Board’s accident database yielded 37 accidents or incidents

that mentioned slide evacuations during the 1990s (January 1, 1990, to September 24,

1997) prior to the study. Of those 37 accidents/incidents, 7 (19 percent) mentioned a

failure of one or more slides.

The Safety Board has addressed the proper functioning of escape slides on several

occasions in the past. For the overall reliability of slides, the Safety Board’s 1974 special

study on emergency evacuations recommended that the FAA develop a maintenance

surveillance program to ensure greater reliability of evacuation slide systems

(A-74-106).67

Following the Safety Board’s investigation of the A300 accident in San Juan on

July 9, 1998, described earlier, the Board recommended that the FAA,

For a 12-month period, require that all operators of transport-category aircraft

demonstrate the on-airplane operation of all emergency evacuation systems

(including door opening assist mechanisms and slide or slide/raft deployment) on

10 percent of each type of airplane (minimum of one airplane per type) in their

fleets. These demonstrations should be conducted on an airplane in a controlled

environment so that the entire evacuation system can be properly evaluated by

qualified personnel. The results of the demonstrations (including an explanation

of the reasons for any failures) should be documented for each component of the

system and should be reported to the FAA. (A-99-100)

Revise the requirements for evacuation system operational demonstrations and

maintenance procedures in air carrier maintenance programs to improve the

reliability of evacuation systems on the basis of an analysis of the demonstrations

recommended in A-99-100. Participants in the analysis should include

representatives from aircraft and slide manufacturers, airplane operators, and

crewmember and maintenance associations. (A-99-101)

The FAA responded to the Safety Board’s recommendations on February 11, 2000,

stating,

67 Safety Recommendation A-74-106 was classified “Closed—Acceptable Action” on January 5, 1978,

after the FAA commenced special training for its maintenance inspectors on the maintenance, operation, and

inspection of emergency evacuation equipment.
Chapter 5 49 Safety Study

The FAA believes, in part, that some of the issues raised by the Board are

addressed in existing regulations. This is especially true of the process suggested

by Safety Recommendation A-99-100. 14 CFR 121.703(a)(17) states, in part, that

“...each certificate holder shall report the occurrence or detection of emergency

evacuation systems or components, including all exit doors, passenger emergency

evacuation lighting systems, or evacuation equipment that are found defective, or

that fail to perform the intended functions during an actual emergency or during

training, testing, maintenance, demonstrations, or inadvertent deployments.” The

FAA has reviewed the data submitted in accordance with 14 CFR 121.703 and

believes that these data can be used to begin the process of determining the actions

necessary to address the Board’s concerns for these recommendations.

A preliminary analysis of these data has identified at least six issues requiring

resolution. These issues involve evacuation system design, age-related concerns,

evacuation system certification basis, scheduled maintenance, and slide/raft

packing and installation. These issues are further divided into maintenance

manual procedures and personnel training/qualification issues. These issues will

be addressed by the FAA/industry task group.

The Safety Board has indicated in its reply to the FAA that the Board does not

believe that data submitted in accordance with 14 CFR 121.703(a)(17), which requires that

problems with evacuation systems be reported to the service difficulty reporting (SDR)

system, will be sufficiently detailed to address the issues raised in the Board’s

recommendations. Consequently, on May 11, 2000, the Safety Board classified Safety

Recommendation A-99-100 “Open—Unacceptable Response.” However, based on the

FAA’s submission to an FAA/industry task force of several issues related to slide

reliability, the Safety Board classified Safety Recommendation A-99-101 “Open—

Acceptable Response.” The Board will continue to monitor the FAA’s progress in this

area. In the meantime, the Safety Board reiterates Safety Recommendations A-99-100 and

A-99-101.

Exit Height From Ground

Although the number of serious injuries was small in the evacuations investigated

for the study, the most serious evacuation-associated injuries were the result of jumping

out of exits or off of wings, with the exception of the injuries sustained in the Little Rock

accident. Four of the six serious injuries, excluding Little Rock, were sustained by

passengers who jumped from the wings: a 10-year-old, two elderly people, and a female

of short stature weighing 200 pounds. One injury occurred when a passenger jumped from

an exit door.

The incidence of injury was likely reduced because passengers were unwilling to

jump and returned to the airplane cabin or because passengers received assistance from

ground personnel. In the 727 evacuation in Chicago following an APU torching (case 16),

passengers waited on the wings because they were afraid to jump from the wings; they

reentered the cabin to exit via the aft stairs. Passengers that used an overwing exit in a 737

evacuation in Eugene, Oregon (case 5) also reentered the cabin because they were afraid to
Chapter 5 50 Safety Study

jump from the wings. In an evacuation of a DC-9 in Indianapolis (case 19), a resourceful

ground crewmember brought a luggage cart to the wing to enable the passenger to more

easily get off the wing. In a 727 evacuation in Fort Lauderdale, Florida (case 13), a flight

crewmember who exited after all the passengers had exited noticed a dozen passengers

standing on the wing moving toward the wingtips. In this case, the crewmember ran to the

passengers and redirected them to the rear of the wing near the cabin to slide down.

As previously mentioned, current Federal regulations require an approved means

to assist passengers in descending to the ground from an exit that is higher than 6 feet from

the ground. For overwing exits, this height can be measured with the flaps in either a

takeoff or landing condition, whichever is higher. There are many airplanes whose wings

are less than 6 feet from the ground, such as the 727, 737, and CRJ. The Safety Board

questions the wisdom of this rule and believes there is a need to revisit the rationale for the

6-foot designation. An above-ground exit without a means of assistance to the ground can

alter the flow of an evacuation; some passengers in the study cases exited onto a wing and

then stayed on the wing, thus interfering with the smooth evacuation of passengers onto

and then off the wing. Passengers exiting via a door without a slide also hesitated before

jumping to the ground. Flight crewmembers in both a DC-9 evacuation in Indianapolis

(case 19) and a 737 evacuation in Eugene, Oregon (case 5) indicated in statements that

they did not want passengers to use overwing exits because of the likelihood for injury.

The Safety Board’s study cases (5, 13, 16, 19) suggest that exit assist means are needed for

some exits that are less than 6 feet from the ground. The Safety Board concludes that the

majority of serious evacuation-related injuries in the study cases, excluding the Little

Rock, Arkansas, accident of June 1, 1999, occurred at airplane door and overwing exits

without slides. Therefore, the Safety Board believes that the FAA should review the 6-foot

height requirement for exit assist means to determine if 6 feet continues to be the

appropriate height below which an assist means is not needed. The review should include,

at a minimum, an examination of injuries sustained during evacuations.
51 Safety Study

Chapter 6

Evacuation Guidance

and Procedures

Two of the 35 flight crewmembers who returned surveys indicated being in a prior

evacuation. Two of the 36 flight attendants who returned surveys reported prior

evacuation experience. In general, a crew conducting an emergency evacuation will be

doing so for their first and likely only time. The difference between a successful and an

unsuccessful evacuation can be a matter of minutes or seconds. Therefore, clear and

precise procedures must be in place and readily available to assist the crew.

Federal regulations require that each air carrier have in place approved training

programs for flight crews and flight attendants (14 CFR 121.401). The FAA principal

operations inspector (POI) assigned to an air carrier is responsible for evaluating an air

carrier’s “initial training plan and devices.” After granting initial approval, the POI

reevaluates the training program. If crewmembers are adequately trained to perform their

duties, the POI will issue a final approval of the program.

Guidance to Flight Crews 

on When to Evacuate

The decision to evacuate the aircraft will most likely be made by the flight crew or

the flight attendants. In the Safety Board’s cases, the flight crew initiated 43 of the

46 evacuations.68 The reasons for initiating these evacuations were predominately the

presence or suspected presence of fire (see chapter 3).

The Safety Board asked flight crewmembers to indicate from a list what situations

would require an emergency evacuation according to company procedures. The Safety

Board examined responses from the 14 cases in which the flight crewmember pair

(captain and first officer) returned questionnaires. Excluding the category “other,”69 only

four crew pairs indicated the same situations as requiring evacuation (table 6–1). For the

11 remaining crew pairs, the crewmember responses differed on what situations required

evacuation according to company procedures. For example, one crewmember in the 737

evacuation in Scottsbluff (case 46) indicated company procedures called for evacuation in

situations of fire in the airplane, fire outside the airplane, smoke in the airplane, and smoke

68 The flight attendants and passengers initiated the evacuation in case 29, ARFF personnel initiated the

evacuation in case 11, and passengers initiated the evacuation in case 16.

69 “Other” generally included unspecified situations that the captain or first officer judges to be a risk to

passenger safety.
Chapter 6 52 Safety Study

Table 6–1. Responses to the question “According to company policy, what constitutes a need for 

an evacuation?” for the study cases in which two flight crewmembers responded. a

Crew pair

Fire inside 

airplane

Fire outside 

airplane

Smoke inside 

airplane

Smoke outside 

airplane

Fuel 

leak Otherb

Case 10 X X X X

Case 10 X X X

Case 18 X X X X

Case 18 X

Case 19 X X X X X

Case 19 X X X X

Case 20 X X

Case 20 X X X

Case 21 X

Case 21 X X X

Case 26 X X X X X

Case 26 X X X X

Case 28 X X X X X

Case 28 X

Case 31 X X

Case 31 X

Case 33 X

Case 33 X X X

Case 34 X X X

Case 34 X

Case 35

Case 35 X

Case 37 X X X X

Case 37 X X X

Case 42 X X

Case 42 X X

Case 46 X X

Case 46 X X X X X

a The shading highlights the situations for which the crewmember responses differed on what required evacuation 

according to company procedures.

b “Other” generally included any other situation that the captain or first officer judges to be a risk to passenger safety.
Chapter 6 53 Safety Study

outside the airplane whereas the other crewmember indicated only fire in the airplane and

smoke in the airplane.

Flight crews receive some guidance from the flight operations manuals or safety

manuals. The safety manual for the A300 crew that evacuated in San Juan (case 24) lists

“initiate ground evacuation procedure (if required)” at the end of most checklists that

might lead to an evacuation. Checklist procedures that direct flight crews to initiate or

consider evacuation include emergency landing, fire (engine, APU, avionics, and cargo),

smoke (in cabin equipment, in air conditioning, and smoke removal), abnormal landing

gear, ditching, and aircraft sabotage. Similar guidance is found in the flight operations

manual for the air carrier involved in the 737 evacuation in Newark (case 25). Other air

carriers (the operator of the Avions de Transport Regional ATR-42 in case 22, and the

operator of the 737 in case 32), however, direct flight crews to initiate or consider

evacuation only for gear-up landings, ditchings, or forced landings; and while the manuals

mention procedures for clearing smoke from the cabin, there is no mention of evacuation

in these procedures.

In the Safety Board’s review of ASRS reports, there were seven reports during the

study period of evacuations that were considered but not conducted. Pilots reported

considering evacuations for opaque smoke in the cabin, tailpipe fires, engine fire

indications, cargo smoke indications, and smoke in the cockpit. Conditions or indications

that led to the evacuations in the study cases were similar to the conditions or indications

reported in the ASRS that prompted pilots to consider an evacuation but not conduct one.

Based on the ASRS reports, the flight crews’ responses to the questionnaire, and a

review of crew safety manuals, the Safety Board concludes that pilots are not receiving

consistent guidance, particularly in flight operations and safety manuals, on when to

evacuate an airplane. The Safety Board therefore believes that the FAA should require

flight operations manuals and safety manuals to include on abnormal and emergency

procedures checklists a checklist item that directs flight crews to initiate or consider

emergency evacuation in all emergencies that could reasonably require an airplane

evacuation (for example, cabin fire or engine fire).

Planned Evacuations

Each of the air carrier flight attendant manuals reviewed by the Safety Board made

a distinction between planned evacuations and unplanned evacuations. Planned

evacuations allow the crew to review procedures and to prepare passengers in flight for

the landing and an orderly evacuation. Passengers can be given brace instructions,

guidance on exit usage, and information on how and when exits should be operated.

Unplanned evacuations occur suddenly with little time to prepare. Most manuals indicate

that these unplanned evacuations occur most often after emergencies that occur during

takeoffs and landings. Further, the manuals indicate that unplanned evacuations are far

more common than planned evacuations.
Chapter 6 54 Safety Study

The majority (31) of cases in this study were reported to be unplanned

evacuations; 14 evacuations were carried out following crew planning for a possible

evacuation. The Safety Board was unable to determine the level of planning for case 17.70

The majority (24) of the unplanned evacuations were the result of an event that occurred

when the airplane was at the gate, taxiing, in the takeoff roll, or in the landing roll;

however, 7 were the result of an in-flight event.

For the planned evacuations, the amount of planning varied from case to case. At a

minimum, passengers were told they would be evacuating upon landing and to examine

their safety card. The most comprehensive planning took place for the A320 that had an

unsafe nosegear (case 43, Columbus, Ohio). The flight attendants briefed passengers on

the appropriate bracing positions and the location of exits. Passengers were reseated to be

near the overwing exits, and flight attendants were positioned next to the overwing exits to

ensure that the exits would be opened quickly. In addition, passengers were asked to

remove potentially hazardous objects prior to landing. One passenger indicated “the

amount of info and the timing of the information was outstanding—no one panicked too

much.” Another passenger indicated that the crew “deserves medals.” There were no

injuries to the 26 passengers during the evacuation.

In case 26, a CRJ that had an in-flight cargo smoke indication, passengers were

also supportive of the crew who briefed the passengers regarding the emergency prior to

landing. One passenger stated, “They kept us well informed.” Another stated, “They acted

professionally and efficiently.” A third wrote, “I appreciated how they kept us updated on

what was happening.” All passenger comments on the crew were favorable. There were

no injuries to the 46 passengers during the evacuation.

The same positive comments toward crew communication with passengers cannot

be said for the in-flight occurrences that did not include preparing passengers for possible

evacuation. In case 32, passengers were informed in-flight that a maintenance problem

had occurred and the airplane would be returning to Atlanta. The crew also informed

passengers that airport fire trucks would meet the airplane but that their presence was

normal. Passengers indicated that although the crew reassured them that there was nothing

to worry about, the crew gave no emergency landing or evacuation instructions and did

not prepare them for an emergency. Passengers in cases 21 and 24 made similar reports.

Passengers sustained minor injuries in these cases: 11 in case 32, 1 in case 21, and 28 in

case 24.

Planning for evacuations allows for more than just keeping passengers calm.

Reviewing brace positions improves the chance that passengers will be properly braced

for the emergency landing. Passengers in case 32 (a 737 with hydraulic problems) and

case 11 (a Saab 340 with unsafe gear indications) received no briefings on brace position

despite conditions on the airplane indicating a potentially dangerous landing. Planned

evacuations also allow flight attendants the time to inform passengers of what to expect,

thereby avoiding surprises that could possibly delay the evacuation. For example,

70 The Safety Board could not determine the level of planning based upon the information reported to the

investigator.
Chapter 6 55 Safety Study

passengers in case 33 (a Beech 1900) reported that they were surprised that there were no

slides at the exits. Likewise, passengers in case 24 (an A300) indicated they were

surprised to find slides instead of stairs at their exits, even though safety briefing cards

depicted slides.

Inadequate time is one reason why planned evacuations are not conducted. Many

air carriers have planned evacuation procedures that can take upwards of 30 minutes. One

carrier (case 21), however, includes in its manual two different types of planned

evacuations. One plan assumes that more than 15 minutes are available whereas the other

assumes less than 15 minutes. Another carrier (case 43) includes plans for under/over

10 minutes. However, many carriers do not specify the time to conduct a briefing in the

manual and provide little direction on how to provide a short briefing.

The Safety Board’s investigation of seven evacuations indicated that there was

adequate time for abbreviated briefings to passengers but no briefing was given. For the

three cases for which flight attendant manuals were obtained, two cases (24 and 32) had

no procedures in place for quick briefings of passengers. In case 21, where procedures

were in place, the flight crew’s failure to inform the flight attendant of the seriousness of

the event or their intent to evacuate prevented an adequate briefing. The Safety Board

concludes that passengers benefit from precautionary safety briefings just prior to

emergency occurrences. Therefore, the Safety Board believes the FAA should review air

carriers’ procedures to ensure that for those situations in which crews anticipate an

eventual evacuation, adequate guidance is given both to pilots and flight attendants on

providing passengers with precautionary safety briefings.

Exit Selection

Once a decision to evacuate is made, the crews must decide which exits to use in

evacuating the airplane. In an ideal situation, all exits would be used to get passengers off

the airplane as quickly as possible; however, this ideal is rarely achieved because exits are

blocked by hazards such as fire or smoke. Only 4 of the 46 evacuations in the study were

conducted using every exit available in the airplane cabin. Overall for evacuations in the

study, 67 of the 125 floor level exits were used, and 44 of the 121 Type III overwing exits

were used. The Safety Board was able to identify a reason for 66 exits (32 Type III,

34 floor level) not being opened; for the remaining 69 exits (45 Type III, 24 floor level),

however, the Board could not determine a reason.

Flight attendants are trained to assess which exits are usable, and in no study case

did a flight attendant open an exit that increased the potential harm to a passenger. The

flight crew for many air carriers will provide assistance to the flight attendants on exit use

based on their knowledge of the problem. The procedure for this varies among air carriers.

The air carriers involved in cases 24 and 29 instruct the flight crews to communicate

which exits not to use. The air carriers involved in cases 25 and 34 instruct the flight crews

to communicate which exits to use. Other air carriers (cases 18 and 46) indicate that flight

attendants will determine which exits to use.71
Chapter 6 56 Safety Study

A factor that influences what exits to use is perceived passenger safety during the

evacuation. The air carrier in case 21 has what is described as an expeditious deplaning

procedure in which only the airplane entry door is used with its stairs in place. Expeditious

deplaning is to be used only when there is no imminent threat to passengers. The air

carrier in case 46 has a similar procedure that calls for portable airstairs to be brought to

the airplane when passenger safety will not be compromised. Two of this air carrier’s three

evacuations involved the use of portable airstairs.

Some air carriers without specific procedures for limited evacuations will also

limit exit use for passenger safety. Three carriers (cases 10, 22, and 25) indicated in their

flight attendant manuals that certain exits are preferable (typically those lowest to the

ground) in the event of landing gear failure. Three regional carriers (cases 20, 28, and 37)

indicated in their safety manuals that floor level exits are preferable to use instead of

overwing exits.

In case 10 (an MD-88 in Arlington, Virginia), passengers exited only via the L1

slide even though other exits, including floor level exits, were available for safe use. This

air carrier has used this same method on other occasions (October 19, 1996; March 14,

2000).72 In case 19, the crew ordered the evacuation only through floor level exits to

prevent injuries associated with overwing exit use.

In the F100 evacuation following a right main gear failure in Charlotte, North

Carolina (case 3), the flight crew asked both a flight attendant and ATC if any fire was

present on or around the airplane. After receiving no report of fire, the flight crew ordered

an evacuation of the 99 passengers using only the R1 exit. After 15 passengers had

evacuated, the first officer exited the airplane using the R1 slide. Upon looking back at the

airplane, he noticed a fire around the left main gear. He shouted to the flight attendant to

evacuate using all of the right exits.

In the 737 evacuation following an engine fire in Honolulu, Hawaii (case 8), the

captain ordered an evacuation using the forward two exits indicating that he “initially did

not want to use any other exits, in the event that the wrong engine was indicated by the

tower.” As a result of a slide failure on the R1 exit, 139 passengers had to evacuate the

airplane using only one exit. The captain indicated that he “should have been informed”

when the slide failed and only one exit was then available for use.

Limiting the number of exits used during an evacuation can have a dramatic effect

on evacuation times. The Safety Board used the airEXODUS evacuation model (version 2)

to simulate an evacuation from a widebody73 aircraft with eight exits and 440 passengers

to examine the issue of limiting exit use. The number of exits used in the simulation runs

71 In the other air carrier flight crew manuals reviewed, the manuals did not discuss the issue of indicating

which exits to use during an evacuation.

72 These evacuations are described in the Safety Board’s accident/incident database.

73 A widebody aircraft model was used for the simulation runs because that aircraft type was already

available within the airEXODUS model. A smaller aircraft type was not available within the evacuation

model and would have had to be designed before using it in simulation runs.
Chapter 6 57 Safety Study

were one, two, four, or eight exits. Ten simulations were run for each exit number

condition. The mean time for the last person to exit the aircraft model was 238.4 seconds

using one exit, 188.8 seconds using two exits, 69.1 seconds using four exits, and

51.7 seconds using eight exits. Similar results would be expected with smaller aircraft,

although not as dramatic.

In none of the cases in which exit use was limited were any passengers injured

because of delays exiting the airplane. However, limiting exit use during an evacuation

raises several safety concerns. First, the procedure for when to use a limited number of

exits during an evacuation was not outlined in any air carrier procedures examined in this

study. Consequently, flight attendants were not likely trained or were not likely to have

received any guidance on evacuating an airplane using limited exits. Air carriers that have

used limited exits for evacuations have contended that this is done to minimize potential

passenger harm and panic. However, the Safety Board is unaware of any evidence or data

to suggest that fewer injuries occur or that panic is minimized when a limited number of

exits are used. The Safety Board concludes that limiting exit use during evacuations in its

study was not in accordance with the respective air carrier’s existing evacuation

procedures and that, at a minimum, all available floor level exits that are not blocked by a

hazard should be used during an evacuation. Therefore, the Safety Board believes that the

FAA should review air carrier training programs to ensure that evacuation procedures call,

at a minimum, for evacuation through all available floor level exits that are not blocked by

a hazard.

Slide Commands

Once an evacuation is underway, flight attendants are trained to begin to shout

commands to the passengers to assist in the evacuation. For an airplane equipped with

slides, these commands will include how to use the slides. For all but two air carriers

involved in the study cases, the command is “jump” or “jump and slide.” For the air

carrier in case 32, the command is “slide”; for the air carrier in case 10, the command is

“sit and slide.” In two additional cases (3 and 12), flight attendants reported using the

command “sit and slide.”

The Safety Board is not aware of any aircraft type being certificated using a “sit and

slide” procedure. The process of sitting to board the slide slows the flow at the exit location

such that certification test success would be difficult if not impossible. A procedure that

requires sitting before sliding would not allow slide manufacturers to reach the current

required slide rate of 70 people per lane per minute.74 Speed is the primary reason air

carriers command “jump and slide.” The air carrier in case 10 recognizes in its flight

attendant manual the effect of speed on evacuation and mentions a rapid slide procedure

that includes the command “jump and slide”; however, the manual does not define when to

use this more rapid slide procedure. Further, the air carrier’s passenger briefing cards

illustrate only the sit-and-slide procedure. The Safety Board understands that the purpose

74 Requirements pertaining to slide rate are contained in FAA Technical Standard Order C-69c.
Chapter 6 58 Safety Study

of the procedure is to minimize injuries, but as the data in this study indicate, very few

serious injuries occurred as a result of using the jump-and-slide procedure to board the

slides. Further, the one serious injury from a slide resulted during an evacuation using the

sit-and-slide command. Although this occurrence is more coincidence than trend, it does

demonstrate that the sit-and-slide procedure does not preclude injury. The Safety Board

concludes that evacuations involving slide use could be delayed if passengers sit at exits

before boarding a slide or if crew commands do not direct passengers how to get onto a

slide. Therefore, the Safety Board believes the FAA should review air carrier procedures

and training programs to ensure that the commands used for slide evacuations are

consistent with the commands used for slide evacuations during certification.

Airplane Familiarization

for ARFF Personnel

ARFF units expressed concern in the questionnaires that they lack the opportunity

to receive hands-on airplane familiarization and egress training. Eight ARFF units

suggested hands-on familiarization training to better prepare them to assist in airplane

evacuations. Four of these suggestions came from ARFF units at Index E airports, two

from units at Index D airports, and two from units at Index C airports. In addition to

suggesting more hands-on training, four ARFF units indicated that they had never

received familiarization training for the airplane type that was evacuated at their airport,

and an additional two units stated that they had received no training on shutting down

engines for the airplane type that was evacuated at their airport.

Through past accident investigations, the Safety Board is aware that many ARFF

personnel, especially at some of the smaller airports, are not afforded adequate

opportunity to receive hands-on familiarization training specific to the airplane types that

frequent their airports because of the lack of availability of those airplanes from air

carriers. The Safety Board also realizes that making those airplane types available to

ARFF personnel is often difficult and burdensome to air carriers at some locations.

However, the Safety Board believes that additional effort needs to be applied by the FAA

and industry to make the airplanes available for hands-on familiarization training of ARFF

personnel. The Safety Board concludes that without hands-on training specific to the

airplane types that frequent their airports, ARFF personnel may be hindered in their ability

to quickly and efficiently assist during evacuations. Therefore, the Safety Board believes

that the FAA should establish a task force to address the issue of providing periodic handson familiarization training, or the equivalent, for ARFF personnel at all 14 CFR Part 139

certified airports on each airplane type that serves the airport on a scheduled basis.
59 Safety Study

Chapter 7

Communication

Successful evacuations are dependent on good communication between all

airplane crewmembers and between the crew and the passengers.

Crew-to-Crew Communication

In case 21 (a British Aerospace Jetstream 4100), the flight crew received an

indication of a cargo fire. They declared an emergency to ATC and returned to the airport

in Evansville, Indiana. The flight crew taxied off the runway and commanded “easy victor

left.”75 The flight attendant released his seat belt and proceeded to the left exit. Upon

seeing the propeller still rotating on the left side of the airplane, the flight attendant

decided to exit through the right exit. The flight attendant was not aware of an emergency

until he heard the command for evacuation. Both flight crewmembers reported on the

questionnaire that the flight attendant had not been adequately briefed on the emergency.

In case 11, a Saab 340 evacuation in Lawton, Oklahoma, the flight crew was

diagnosing a gear extension problem and asked the assistance of the flight attendant. The

flight attendant visually inspected the gear and reported to the flight crew that the gear was

down. The flight crew indicated to the flight attendant that the gear might not have locked

and that they would be making a precautionary landing. The flight attendant was not

informed that ARFF units would be waiting for the airplane and prepared for a normal

landing. As a result, passengers also were not informed of the possible emergency

situation or that ARFF units would be waiting upon landing. At a minimum, passengers

should have been briefed on how to assume brace position. The gear collapsed on landing

and the airplane overran the runway. ARFF crews opened the overwing exit and the

passengers evacuated.

The questionnaire asked flight crews and flight attendants about the quality of

crew communication. Overall, 20 flight crewmembers indicated that their communication

was excellent with flight attendants. Eight flight crewmembers rated their communication

with the flight attendants as adequate, with some glitches. One flight crewmember rated

the communication inadequate (case 21). In four cases, the flight crews listed

communication as “other.” These included no communication (cases 16 and 45), no flight

attendant (case 33), and unable to contact aft flight attendant but indicated that the flight

attendant followed the lead of the forward flight attendants (case 18).

75 “East victor” is a code phrase for “evacuate” that allows flight attendants to get to their evacuation

positions prior to passengers. “Easy victor left” indicates to use the left exits.
Chapter 7 60 Safety Study

The flight crews in evacuations that received detailed investigations were asked on

the questionnaire what changes could be implemented to improve emergency evacuation

of passengers. One crewmember in case 21 mentioned more emphasis on crew resource

management (CRM). Four flight crewmembers (cases 19, 21, and 35) mentioned joint

training with flight attendants. In addition, two flight attendants (cases 21 and 37)

recommended joint training with the flight crew on evacuation procedures.

Twenty-three of 34 flight crewmembers indicated on the questionnaire that they

have some form of joint CRM training with flight attendants. One flight crewmember

(case 35) indicated that his joint CRM training with flight attendants was invaluable and

must continue. Included in his CRM program were simulated evacuation exercises with

flight attendants. However, only 10 of the 34 having joint CRM training with flight

attendants participated in joint evacuation exercises with flight attendants. The flight crew

in case 21 did not report joint evacuation training with flight attendants. In this case, one

flight crewmember reported that communication with flight attendants was inadequate.

The situation was similar for the flight attendants: only 3 of the 35 flight attendants who

responded to the questionnaire stated that they had participated in joint evacuation

exercises with flight crews.

The Safety Board discussed the importance of good communication between

crewmembers in its special investigation on flight attendant training76 and subsequently

issued the following recommendations to the FAA:

Amend 14 CFR Part 121.417 to require an evacuation and/or wet ditching drill

group exercise during recurrent training. Ensure that all reasonable attempts are

made to conduct joint flight crew/flight attendant drills, especially for

crewmembers operating on airplanes with two-person cockpit crews. (A-92-74)

Require that flight attendants receive crew resource management (CRM) training

that includes group exercises to improve crewmember coordination and

communication. (A-92-77)

With respect to A-92-77, the FAA responded by including flight attendants as a group that

would benefit from CRM in Advisory Circular (AC) 120-51B, which outlines CRM

training for the air carriers. The FAA further expanded CRM training for flight attendants

in AC 120-51C, which states that flight attendants should conduct CRM training with

flight crews covering shared issues such as evacuations and ditching. With respect to

A-92-74, the FAA issued Information Bulletin 95-04, “Emergency Evacuation and

Ditching Drills,” on February 14, 1995. The bulletin directed POIs to ensure that their

assigned certificate holders are aware of the performance benefits that result when flight

crews and flight attendants perform emergency evacuation and ditching drills together.

However, the FAA did not require air carriers to conduct joint exercises between flight

attendants and flight crews.77

76 National Transportation Safety Board, Flight Attendant Training and Performance During Emergency

Situations, Special Investigation Report NTSB/SIR-92/02 (Washington, DC: NTSB, 1992).

77 As a result of the FAA’s actions, the Safety Board classified A-92-74 “Closed—Unacceptable Action

on January 23, 1996, and A-92-77 “Closed—Acceptable Action” on July 15, 1996.
Chapter 7 61 Safety Study

The FAA stated in AC 120-51C that “communication and coordination problems

between cockpit crewmembers and flight attendants continue to challenge air carriers and

the FAA.” Several cases (19, 21, and 35) in the Safety Board’s study emphasize that point.

In the AC, the FAA states that it is considering several methods to improve this problem.

These methods include observation flights for flight attendants, including flight attendants

in line-oriented flight training, month-long pairings of flight crew and flight attendants,

and providing experienced flight crewmembers to teach new-hire orientation classes. The

Safety Board recognizes the benefits that each of these methods would provide. However,

the Safety Board continues to believe that joint exercises for flight crews and flight

attendants on evacuation would solve many of the CRM-related communication problems

that currently exist. Further, such training is currently being conducted and is seen as

beneficial by crewmembers that have participated in both the training and an actual

evacuation (for example, case 35). The Safety Board concludes that communication and

coordination problems continue to exist between flight crews and flight attendants during

airplane evacuations. Joint exercises for flight crews and flight attendants on evacuation

have proven effective in resolving these problems. Therefore, the Safety Board believes

that the FAA should require air carriers to conduct periodic joint evacuation exercises

involving flight crews and flight attendants.

Crew-to-Passenger Communication

As previously stated, how passengers perform during an evacuation is dependent,

in part, on how the crews prepare them for an evacuation. Two different methods of

communication are typically used by the air carriers to inform passengers what they

should do if an evacuation is conducted: the preflight verbal briefing from the crew, and a

written safety briefing card. The Safety Board examined these methods of

communication.

Preflight Safety Briefing

Federal regulations require that passengers receive a briefing prior to takeoff on

safety aspects of the upcoming flight (14 CFR 121.571). This briefing must include

information on smoking, emergency exit location, seat belts, compliance with signs, and

the location and use of flotation means. In addition, if the flight operates above 25,000 feet

mean sea level, the briefing must include information on the emergency use of oxygen.

The FAA published AC 121-24B to guide air carriers in the development of their

safety briefings. Primarily, the AC lists the material that must be covered and offers

suggestions for material that should be covered. The AC also indicates the difficulty in

motivating passengers to attend to the safety information and suggests making the briefing

as attractive and interesting as possible to increase passenger attention. Further, the AC

directs that flight attendants be animated, speak clearly and slowly, and maintain eye

contact with the passengers. Finally, the AC suggests the use of recorded videotape

because it ensures a complete briefing with good diction and allows for additional visual

information to be presented to the passengers.
Chapter 7 62 Safety Study

Thirty-five flight attendants (representing 18 cases) indicated on their

questionnaires that the preflight safety briefing on their airplane in the evacuation study

was conducted by a flight attendant. The briefing for the one wide-bodied airplane in the

study was the only reported use of a recorded video briefing. This video briefing was

conducted in Spanish and English. All 36 flight attendants who responded to the

questionnaire indicated no problems with the briefing.

The passengers’ questionnaire asked about passenger attention to the safety

briefing. Of the 377 passengers who reported whether they watched the briefing,

13 percent (50) indicated they watched none of the briefing, and 48 percent (182) reported

that they watched at least 75 percent of the briefing.

Of the 457 passengers who returned questionnaires, 54 percent (247) reported that they

had not watched the entire briefing because they had seen it before. An additional

70 passengers indicated that the briefing was common knowledge, and therefore there was

no need to watch the briefing. Table 7–1 lists all the passengers’ reasons for not watching

the entire briefing.

Passengers (141) who watched more than half of the briefing were divided evenly

on the effectiveness of the briefing: 71 who reported watching the entire briefing indicated

that the briefing was not helpful for their evacuation; the remaining 70 believed it was

helpful. The primary concern expressed by passengers was that the briefing covered

situations that did not apply to their evacuation. Passengers reported that they would have

preferred information regarding exit routes or information such as how to slide or how to

get off of wings. Those that believed the briefing was helpful believed that they were more

aware of the exit locations because of the briefing.

Table 7–1. Reasons given by passengers for not watching the 

entire preflight safety briefing.

Reason

Number of

passengers

Saw it before 247

It’s basic knowledge 70

Other 44

Reading 28

Sleeping 15

Obstructed view 10

Distracted by other person 8

Distracted by child 2

Listening to music/audio tapes 1

Too long 1
Chapter 7 63 Safety Study

The Safety Board has issued several recommendations with the intent of

improving passenger attention to preflight safety briefings. In 1974, the Safety Board

recommended that the FAA

Issue an advisory circular that would provide standardized guidance to the air

transport industry on effective methods and techniques for conveying safety

information to passengers. (A-74-113)

Eleven years later, in 1985, the Safety Board recommended that the FAA

Require that recurrent flight attendant training programs contain instructions on

the use of the public address (PA) system and techniques for maintaining effective

safety briefings and demonstrations which will improve the motivation of

passengers to pay attention to the oral briefings and to the demonstrations

(A-85-101).78

Now, 15 years later, the information obtained from the Safety Board’s current study

indicates that the problem of passenger inattention to briefings continues to exist. The

Safety Board concludes that despite efforts and various techniques over the years to

improve passenger attention to safety briefings, a large percentage of passengers continue

to ignore preflight safety briefings.

As previously mentioned, 54 percent of the responding passengers (247 of 457)

did not watch the entire briefing because they had seen it on previous flights. However,

safety information for one airplane may differ from the safety information for the next

airplane, which is why exit locations, floor path lighting, and oxygen systems are all

discussed in the oral briefing. Passengers need to be made more aware of the existence of

such differences and the need to pay attention to the safety information. With the

exception of videotaping, there has been little change over the years in how safety

information has been presented to passengers. Creative methods that use today’s state-ofthe-art technology should be explored to improve passenger attention to safety

information. Therefore, the Safety Board believes that the FAA should conduct research

and explore creative and effective methods that use state-of-the-art technology to convey

safety information to passengers. The presented information should include a

demonstration of all emergency evacuation procedures, such as how to open the

emergency exits and exit the aircraft, including how to use the slides.

Safety Briefing Card

The FAA requires that oral briefings be supplemented with printed safety briefing

cards that pertain only to that make and model of airplane and are consistent with the air

carrier’s procedures (14 CFR 121.571(b)). The safety cards must contain diagrams and

methods of operation for all emergency exits and any instructions for operating other

78 Safety Recommendation A-74-113 was classified “Closed—Acceptable Action” on September 27,

1977, based on the FAA’s issuance of AC 121-24. However, AC 121-24A, issued by the FAA on May 9,

1989, did not address the intent of Safety Recommendation A-85-101, which was consequently classified

“Closed—Unacceptable Action” on August 21, 1991.
Chapter 7 64 Safety Study

emergency equipment. Advisory Circular 121-24B provides guidelines for air carriers in

the development of their safety cards.

Passenger use of the safety cards on the airplanes in the study cases was consistent

with previous findings that passengers tend not to look at the cards.79 Of the 431

passengers who reported about reading the safety card, 68 percent (293) indicated that

they did not read the safety card. Of those, 89 percent (259) indicated that they had read

the card on previous flights. Of particular concern is that 44 percent (175) of 399

responding passengers reported that they neither examined the safety card nor listened to

the safety briefing (figure 7–1).

Of the passengers who reported reading the card, 59 percent (82) indicated that the

card was useful. The primary benefit of the card was for identifying exit location, as

reported by 77 passengers. Other benefits reported by passengers included how to use

slides, which exits had slides, and the location of emergency lights.

The Safety Board examined 22 safety briefing cards representing 25 of the 30

cases investigated in detail: 60 percent of the cards consisted of color drawings; 8 percent

were color photos; and 8 percent were black, white, and red drawings. According to AC

120-51B, the cards should be sufficiently large to compete with magazines for attention.

Twenty of the cards were as large or larger than a standard magazine.

79 National Transportation Safety Board, Airline Passenger Safety Education: A Review of Methods Used

to Present Safety Information, Safety Study NTSB/SS-85/04 (Washington, DC: NTSB, 1985).

Figure 7–1. Percentage of all passengers who indicated whether or not 

they paid attention to safety information.
Chapter 7 65 Safety Study

The Safety Board also examined the content of the safety briefing cards. All of the

cards contained information on brace positions. Thirteen of the cards included additional

brace positions, such as brace positions for children, for a parent holding an infant, and for

a pregnant passenger. Fifteen of the cards presented bracing positions for both high- and

low-density seat areas. The inclusion of bracing information is not mandatory for safety

cards.

All of the safety cards examined included instructions on operating emergency

exits. For the majority of the cards, the instructions for an exit included a clear indication

of the exit location. In cases 18 and 19 (DC-9s), exit instructions only named the exit

(“door exit”) but did not indicate its location on the airplane. The quality of the

instructions for exit operation varied widely. In cases 20, 21, and 40, the procedures

depicted to open an exit were not enhanced by enlargements or the use of color. In cases

10, 18, 19, 32, and 43, the card provided an enlarged view of the exit to clearly depict exit

operation. For overwing exits, all the safety cards depicted the procedure for stowing the

exit hatches: 10 cards indicated that the exit hatch was to be stowed inside the airplane,

and 11 cards indicated that the hatch was to be stowed outside the airplane. How to go

through an exit was also communicated in various ways: 11 cards illustrated how to move

from the wing to the ground; 1 card (in case 9) used a photo showing how to slide off the

wing; and 6 cards did not show how passengers should get off the wing. Slide use

information was likewise varied: 4 cards did not indicate either jumping or sitting before

sliding; 1 card depicted that passengers should sit and then slide; and 4 cards depicted that

passengers should jump and slide.

The Safety Board did not test passenger comprehension of the safety cards;

however, two 1997 studies found passenger comprehension of safety cards to be low. In

the first study,80 113 subjects were asked the meaning of 36 pictorials taken randomly

from 50 safety briefing cards: 12 of 36 pictures were understood by more than 67 percent

of the subjects whereas 20 of the 36 pictures were understood by less than 50 percent of

the subjects. In the second study,81 120 subjects were shown a briefing card for an MD

Super 80 and were asked the meaning of the 40 pictorials. Two-thirds (67 percent) of the

subjects understood the meaning of only half (21) of the 40 pictures.

80 J.K. Caird, B. Wheat, K.R. McIntosh, and R.E. Dewar, “The Comprehensibility of Airline Safety Card

Pictorials,” Proceedings, Human Factors and Ergonomics Society 41st Annual Meeting, September 22–26,

1997, Albuquerque, NM (Santa Monica, CA: Human Factors and Ergonomics Society, 1997) 801–805.

81 N.C. Silver and C.N. Perlotto, “Comprehension of Aviation Safety Pictograms: Gender and Prior

Safety Card Reading Influences,” Proceedings, Human Factors and Ergonomics Society 41st Annual

Meeting, September 22–26, 1997, Albuquerque, NM (Santa Monica, CA: Human Factors and Ergonomics

Society, 1997) 806–810.
Chapter 7 66 Safety Study

The Safety Board has previously recommended that the FAA

Develop tests and standards which describe the minimum level of acceptable

comprehension and performance to measure whether persons who represent

typical passengers understand the safety information presented during oral

briefings and demonstrations, on safety cards, and in videotaped briefings, and

whether these persons actually are able to perform the actions described, such as

using supplemental oxygen systems, using life preservers, and opening of exits.

(A-85-94)

The FAA responded that comprehension research had been conducted and that the results

of this research were included in AC 121-24A. The FAA further responded that safety

cards are developed by a small number of firms that conduct comprehension testing of

their material.82 The Safety Board is aware of firms that conduct comprehension testing

for safety cards; however, the Board is also aware that not all of the firms that develop

safety cards conduct comprehension testing. Further, this testing is not required by the

FAA. The Safety Board concludes that despite guidance in the form of FAA advisory

circulars, many air carrier safety briefing cards do not clearly communicate safety

information to passengers. Therefore, the Safety Board believes the FAA should require

minimum comprehension testing for safety briefing cards.

Retrieval of Carry-on Luggage

Currently, air carriers use two methods to instruct passengers not to take personal

belongings during an evacuation. The first method is the safety briefing card. All but two

of the safety briefing cards reviewed for this study indicated that carry-on luggage should

not be taken during an evacuation. The pictogram used to indicate “leave baggage” was a

suitcase in the center of a slashed circle. The second method is flight attendants’

commanding “leave everything” during the evacuation. Twenty-three of 37 flight

attendants indicated that they commanded passengers to leave everything behind. Despite

these methods, passengers often took their belongings.

Three flight attendants indicated that one way to prevent passengers from

removing carry-on baggage would be to include a statement in the preflight safety

briefing. Passengers likewise indicated the necessity of a preflight announcement

regarding carry-on baggage in emergencies. When asked how the safety briefing could be

improved, 16 passengers indicated that the preflight briefing should mention leaving

carry-on luggage behind.

Once the decision to evacuate the airplane is made, flight attendants will begin

their evacuation procedures. The speed at which passengers evacuate is highly dependent

on the actions of the flight attendants.83 Flight attendants receive both initial and recurrent

training on methods to maintain a constant flow of passengers out an emergency exit.

82 Safety Recommendation A-85-94 was classified “Closed—Acceptable Action” on February 19, 1992.

83 H.C. Muir and A.M. Cobbett, Influences of Cabin Crew During Emergency Evacuations at Floor Level

Exits, CAA Paper 95006: Part A; FAA No. DOT/FAA/AR-95/52 (London: Civil Aviation Authority, 1996).
Chapter 7 67 Safety Study

However, flight attendants reported that their attempts were often thwarted by passengers’

insistence on retrieving their carry-on luggage before evacuating.

The majority of passengers who replied to the Safety Board’s questionnaire were

carrying at least one piece of carry-on luggage. Only 25 passengers (6 percent) reported

having no bags with them in the cabin. Of the 419 passengers who reported that they

carried on bags, 208 (nearly 50 percent) reported attempting to remove a bag during their

evacuation. The primary reason that passengers stated for grabbing their bags was for

money, wallet, or credit cards (111 passengers). Other reasons included job items (65),

keys (61), and medicines (51). Most passengers exited the airplane with their bags.

Passengers exiting with carry-on baggage were the most frequently cited

obstruction to evacuation. Twenty-four of the 36 flight attendants who responded listed

carry-on baggage as an obstruction. Overall, 37 percent of the passengers indicated that

retrieving carry-on baggage slowed the evacuation; however, in five of the evacuations

(cases 9, 16, 24, 27, and 32), a majority of passengers believed that the evacuation was

slowed by carry-on baggage. Further, 70 passengers and 8 flight attendants reported

arguments between passengers and flight attendants regarding luggage.

Although not everyone attempts to retrieve and take carry-on baggage during an

evacuation, everyone in the airplane could potentially be affected by these attempts. One

passenger wrote that she convinced her grandchildren not to take their toys and coloring

books only to wait in the aisle for passengers who were retrieving luggage from overhead

bins. Another passenger without luggage reported waiting behind a passenger trying to

maneuver a garment bag through an overwing exit.

To understand what is being taught to flight attendants on the issue of carry-on

luggage during evacuations, the Safety Board reviewed flight attendant training materials

received from 15 air carriers. The materials varied from air carrier to air carrier but

included syllabi for the training, overhead projections used in training, instructor notes,

home study packets, and in one case a video used for home study. All 15 air carriers

address in training the issue of passengers’ retrieving carry-on luggage in one of two ways.

In the lessons and drills conducted by most air carriers, flight attendants are instructed to

shout the command “leave everything” to the passengers when an evacuation command is

given. Some air carriers take the extra step of explaining to the flight attendants why these

commands are important. For example, the air carrier in case 10 (an MD-88 in Arlington,

Virginia) explains on its lesson overhead projections that carry-on luggage slows the

evacuation, can damage the escape slide, and can injure other passengers at the bottom of

the slide.

The Safety Board’s review of the material received indicates that the training that

flight attendants receive with regard to passengers’ retrieving carry-on luggage does not

address what to do when passengers do not follow the command to leave everything

behind. Eight flight attendants reported arguing with passengers over the baggage. One

flight attendant (case 5), who had been taking bags from passengers, reported having to

throw bags out the exit to clear clutter at the exit. Another flight attendant (case 25)

reported throwing bags against the cockpit door. In an evacuation of a 737 in Burbank,
Chapter 7 68 Safety Study

California,84 a flight attendant threw bags in front of the unopened but usable R2 exit, thus

blocking the exit. All of the attendants were using commands such as “leave everything”

to the passengers.

The Safety Board understands the importance to passengers of having

identification, money, keys, wallets, and medicines following an emergency evacuation

given the initial uncertainty of when or if passengers will get their possessions returned if

they leave the items behind. However, passengers who attempt to take their luggage

during evacuations continue to present undue risks and delays to a successful evacuation.

By retrieving luggage during an evacuation, passengers increase the potential for serious

injuries or loss of life. The Safety Board concludes that passengers’ efforts to evacuate an

airplane with their carry-on baggage continue to pose a problem for flight attendants and

are a serious risk to a successful evacuation of an airplane. Techniques on how to handle

passengers who do not listen to flight attendants’ instructions need to be addressed.

Therefore, the Safety Board believes that the FAA should develop advisory material to

address ways to minimize the problems associated with carry-on luggage during

evacuations.

Auxiliary Power Unit Torching

On April 20, 1998, at about 8:30 p.m., a Boeing 727 (case 16) was completing its

passenger boarding at Chicago O’Hare International Airport. In preparation for the flight,

the flight crew started the airplane’s APU. Along the right side of the airplane, an orange

flame appeared that extended from the APU exhaust port forward as the APU “torched.”

The cabin lights went off just before the torching, and because the ambient light

was limited, the flame was more noticeable in the cabin. Several passengers screamed

“fire” and began to evacuate the airplane. The left overwing exit was opened and

passengers began to evacuate via the overwing and the jetway. The flight attendant in the

rear of the airplane, who reported seeing flames coming out of the right engine, attempted

to stop the evacuation, but as the rush of passengers approached her, she decided that

opening the tailcone was a more prudent action. While the flight attendant was opening

the exit, two passengers decided to open the L2 door. When the passengers finally opened

the door, they noticed the slide had failed to deploy.85 In this case, one passenger was

lowered out of the airplane by another passenger and sustained ankle injuries as a result of

being lowered out of the airplane.

Two flight attendants in the forward part of the cabin were uncertain of the reason

passengers were evacuating. One reported to the flight crew that “we have a problem,”

while the other assisted passengers out onto the jetway. A fourth flight attendant in the

middle of the airplane reported seeing flames and was thinking that it could be the APU

84 This evacuation was not one of the study cases; it occurred when analysis of study data was underway.

85 A passenger reported that the slide failed; however, the slide had not been armed.
Chapter 7 69 Safety Study

torching. However, because she was not positively certain, she went to the cockpit to

inform the captain of the engine flames.

The flight crew, when it learned of the evacuation, issued an announcement over

the public address (PA) system to remain seated. The combined efforts of the

crewmembers were able to control the passengers for an orderly exit through the tailcone

exit. Passengers on the wing then reentered the airplane and left via the aft airstairs.

However, control was not reestablished before a 10-year-old boy broke his arm jumping

off the wing of the airplane. Several other passengers also sustained injuries.

The problem of uncommanded evacuations following an APU torching in a 727 is

not new. The Safety Board’s 1974 study included a similar evacuation.86 In 1992, the

Board investigated another torching that led to an evacuation.87 As a result of that

investigation, the Safety Board recommended that the FAA

Issue an Air Carrier Operations Bulletin to require that Boeing 727 cockpit

crewmembers make a public address announcement about auxiliary power unit

(APU) starts immediately prior to starting the APU. (A-93-125)

In its October 14, 1993, letter issuing the recommendation, the Safety Board stated that

The highest percentage of unwarranted passenger-initiated evacuations have

occurred on 727 airplanes. The Safety Board believes that these frequent

occurrences are linked to the location of the 727 APU exhaust outlet, which is

clearly visible to passengers in the right overwing area.

In response to the Safety Board’s recommendation, the FAA issued Flight

Standards Information Bulletin for Air Transportation 95-04. The bulletin directed POIs to

encourage their respective certificate holders to develop procedures that include an

announcement from the flight crew before starting the APU on the 727. The bulletin also

directed POIs to review their respective certificate holders’ training program and

emergency evacuation procedures to ensure that the flight crews and flight attendants are

aware that the 727 APU starts can result in a momentary orange flash from the vicinity of

the APU exhaust near the right wing root.88

The FAA updated bulletin 95-04 with Handbook Bulletin for Air Transportation

96-03, which asked POIs to reemphasize emergency evacuation procedures on

unwarranted evacuations. In particular, crews should know the appropriate actions to take

on airplanes with APUs that have a tendency to torch. The Safety Board is concerned that

the POIs’ past efforts to encourage and to reemphasize to their certificate holders to

implement adequate procedures that would prevent unwarranted evacuations from an

86 National Transportation Safety Board, Safety Aspects of Emergency Evacuations from Air Carrier

Aircraft, Special Study NTSB/AAS-74/03 (Washington, DC: NTSB, 1974).

87 Delta Air Lines 727 APU torch in Chicago on January 17, 1992, National Transportation Safety Board

accident brief CHI93LA043 (1994).

88 Based on the FAA’s action, the Safety Board classified Safety Recommendation A-93-125 “Closed—

Acceptable Action” on July 3, 1995.
Chapter 7 70 Safety Study

APU torching have proven unsuccessful. The Board believes that these procedures should

now be required. The Safety Board concludes that unwarranted evacuations following 727

APU torching continue to exist despite past efforts by the FAA to address this issue.

Therefore, the Safety Board believes that the FAA should require air carriers that operate

727s to include in the APU procedures instructions that when passengers are on board, the

flight crew will make a PA announcement about APU starts immediately prior to starting

the APU.

ARFF-to-Crew Communication

The Safety Board asked ARFF units and flight crewmembers about the

communication between the two groups: five ARFF units and four flight crewmembers

reported the communication as exceptional, six ARFF units and four flight crewmembers

listed the communication as adequate, and three ARFF units and two flight crewmembers

listed the communication as inadequate. Responses to the questionnaire indicated that the

primary information ARFF units pass on to crews is the status of the airplane. One ARFF

unit at the evacuation of a Jetstream 4100 at Evansville, Indiana (case 21) indicated not

being able to communicate to the crew that no smoke or fire was present. Another unit at

the evacuation of an MD-88 at Dallas–Fort Worth, Texas (case 35) indicated a desire to

have known more details of the airplane problem. Both flight crewmembers for an MD-88

in Arlington, Virginia (case 10) and three flight crewmembers for a Saab 340 in

Huntsville, Alabama (case 20) indicated that they would have liked to receive information

from ARFF units on the condition of the exterior of the airplane.

The Safety Board asked the firefighters and flight crewmembers what

recommendations they would suggest to improve evacuations. Three of the ARFF units

mentioned the need for a dedicated frequency at the airport for ARFF-to-flight crew

communication. Further, five crewmembers indicated that the lack of a dedicated

frequency for communication hindered the evacuation.

The Safety Board has previously addressed the need for a dedicated frequency for

ARFF-to-crew communication. On April 28, 1997, an MD-82 sustained a left engine

turbine section failure and tailpipe fire shortly after takeoff and returned to the Tucson

International Airport at Tucson, Arizona, where the passengers and crew evacuated the

airplane. As a result of its investigation of this incident, the Safety Board issued

recommendations that asked the FAA to

Establish a designated radio frequency at all airports certified under Title 14 CFR

Part 139 that allows direct communication between airport rescue and firefighting

(ARFF) personnel and flight crewmembers in the event of an emergency and take

appropriate measures to ensure that air traffic control personnel, ARFF personnel,

and pilots are aware of its designation. (A-98-41)

Develop a universal set of hand signals for use between airport rescue and fire

fighting personnel and flight crews and flight attendants for situations in which

radio communication is lost. (A-98-42)
Chapter 7 71 Safety Study

On July 1, 1999, and in response to the recommendations, the FAA issued a revision to

AC 150-5210-7C, “Aircraft Rescue and Fire Fighting Communications.” The AC

contained recommended procedures for establishing direct flight crew/ARFF incident

commander/ATC tower communications on an aeronautical radio frequency (discrete

emergency frequency) designated by ATC from the operational frequencies assigned to

that facility. The AC also included standardized hand signals to be used for emergency

communication between ARFF personnel and airplane crews (flight crews and flight

attendants) for situations in which communication is lost.89

Five of the ARFF units that responded to the questionnaire indicated that their

airport had a dedicated frequency in place for ARFF-to-crew communication. Four of

these airports were Index E, and one was Index D. However, because many of the

responses to questionnaires from ARFF units and flight crews were obtained before AC

150-5210-7C was issued, the Safety Board is unable to evaluate the success of the

implementation of these dedicated frequencies. However, the Board has learned that

difficulties establishing the frequency with tower controllers exist at several airports.90

The Board considers these dedicated frequencies to be vital for assisting airplane crews to

conduct successful evacuations and encourages the rapid implementation of these

frequencies at all certificated airports. On May 10, 2000, the Safety Board staff requested

an update from the FAA on efforts to implement AC 150-5210-7C. The Safety Board will

continue to monitor the progress on this issue.

Communication Equipment

To assist crewmembers with communication, all passenger-carrying airplanes with

more than 19 seats are required to have a PA system (14 CFR 121.318) and an interphone

system (14 CFR 121.319). The PA system enables the airplane crews to disseminate safety

information to the passengers and to initiate evacuations. The interphone system provides

a method for the crewmembers to communicate with the cockpit or any passenger

compartment without having to leave the immediate area. In addition, each passengercarrying airplane must have a portable battery powered megaphone (14 CFR 121.309f).91

Crewmember responses to questions about use of the PA system (representing 24

of the 30 evacuations investigated in detail) indicated that the PA system was used to

initiate 18 of the 24 evacuations. In these 24 evacuations, crewmembers in 9 cases

reported using the interphone system to prepare for the evacuation. The PA system was

not functional for three evacuations. On the MD-82 that overran the runway in Little Rock

(case 45) and the 727 that landed short of the runway in Chicago (case 9), the PA systems

89 Because the revised AC met the intent of Safety Recommendations A-98-41 and A-98-42, on

December 9, 1999, and November 16, 1999, the Safety Board classified these recommendations “Closed—

Acceptable Alternate Action” and “Closed—Acceptable Action,” respectively.

90 Personal communication on May 8, 2000, with the president of the ARFF working group.

91 Not one of the flight attendants who returned a questionnaire indicated using a megaphone; therefore,

the Safety Board did not evaluate the effectiveness of megaphones for this study.
Chapter 7 72 Safety Study

were rendered inoperable by the crash forces. In both of these cases, the flight attendants

initiated the evacuation by shouting commands to evacuate. For a Saab 340 evacuation in

White Plains, New York (case 37), the crew reported that an electrical failure prevented

the use of the PA system, but the flight crew was able to shout over the engine noise to the

flight attendant to prepare for the evacuation.

In 2 of the 18 cases for which the PA system was used to initiate the evacuation,

not all flight attendants heard the PA announcement. In a DC-9 evacuation in Detroit,

Michigan (case 18), the flight attendant located at the L1 exit did not hear the PA

evacuation announcement. She had heard a flight crew conversation about an engine fire

and then saw passengers get up and begin to evacuate. In a DC-9 evacuation in

Indianapolis, Indiana (case 19), the aft flight attendant did not hear the announcement but

began evacuating upon seeing passengers in the forward section evacuating.

The interphone system failed to operate in the same three cases in which the PA

system was not functional (case 9, a 727 in Chicago; case 37, a Saab 340 in White Plains;

and case 45, an MD-82 in Little Rock). A flight attendant in the 727 crash in Chicago

reported attempting to call the cockpit but received no response. A flight attendant in a

727 evacuation following an APU torching (case 16) also reported attempting to call the

flight crew on an interphone but no one answered; however, the air carrier did not report

the interphone system as having any problems in this case.

Following the collision of an ATR-42 with a ground power unit in San Juan, Puerto

Rico (case 30), the flight attendant attempted to contact the flight crew using the

interphone 11 seconds after the collision to report a fire outside the airplane. The flight

attendant call chimes can be heard in the cockpit for 14 seconds. During this time, the

flight crew used the PA system to command passengers to remain seated. The flight

attendant decided to initiate an evacuation after failing to contact the flight crew. Eight

seconds later, the flight crew became aware of the fire outside the airplane.

The Safety Board expressed concerns about failed communication systems in its

accident report of the July 6, 1996, MD-88 uncontained engine failure in Pensacola,

Florida.92 In the accident, the flight attendant in the rear of the airplane attempted to call

the flight crew to report debris, smoke, and injuries in the back of the cabin, and to inform

them that the flight attendant was beginning an evacuation. The interphone system was not

functioning; therefore, the flight attendant began to evacuate passengers in the back of the

airplane while the flight crew, unaware of the situation in the back, instructed passengers

to remain seated.

92 National Transportation Safety Board, Uncontained Engine Failure, Delta Air Lines Flight 1288,

McDonnell Douglas MD-88, N927DA, Pensacola, Florida, July 6, 1996, Aircraft Accident Report

NTSB/AAR-98/01 (Washington, DC: NTSB, 1998).
Chapter 7 73 Safety Study

As a result of the Pensacola accident, the Safety Board recommended that the FAA

Require all newly manufactured passenger-carrying airplanes operated under 14

Code of Federal Regulations Part 121 to be equipped with independently powered

evacuation alarm systems operable from each crewmember station, and establish

procedures and provide training to flight and cabin crews regarding the use of

such systems. (A-98-22)

In a December 22, 1999, letter to the Safety Board, the FAA stated it has concluded that

sufficient rules already exist to address this safety concern. The FAA related that under the

existing rules, the crew and other passenger cabins can be notified of an impending

emergency. Also, the flight attendants can notify the flight crew utilizing the crew

interphone which has aural and visual indications in the cockpit. In addition, the FAA

related that flight attendants can notify the passenger cabin utilizing the PA system.

The FAA stated that the crew interphone and the PA systems are redundant to an

evacuation alarm, especially if used in accordance with approved training procedures. The

FAA further stated that if training procedures are not followed, neither the PA system nor

the proposed evacuation alarm would be effective. Both the PA and interphone systems

are required by 14 CFR Part 121. Finally, the FAA stated that because it believes that

existing rules sufficiently address the concern identified by this safety recommendation, it

considered its action to be completed.

As a result of the FAA’s position, the Safety Board classified Safety

Recommendation A-98-22 “Closed—Unacceptable Action” on March 23, 2000. The

Safety Board continues to investigate incidents that are hampered by inefficient methods

of communication. On March 15, 2000, a flight attendant on a 737 in Tampa, Florida,93

witnessed an engine fire and proceeded to call the cockpit via the crew interphone; she

received no answer. Thirteen persons evacuated via the R2 exit while the engines were

running. For the 737 that overran the runway in Burbank, California, on March 5, 2000

(previously mentioned), the flight crew mistakenly gave the command to remain seated to

the ATC tower instead of the cabin and never issued a command over the PA system to

evacuate. Had evacuation alarms been in place for case 16 (the APU torching in Chicago)

and the Tampa and Burbank incidents, no communication problems would likely have

occurred.

The FAA contends that evacuation alarms are redundant to current communication

systems. The Safety Board agrees that in ideal situations this may be true; however, as

situations from the study cases indicate, the ideal is often not achieved during an

evacuation. A second criticism of evacuation alarms involves a concern that flight

attendants will initiate unwarranted evacuations. In the Safety Board’s 46 study cases,

there were no unwarranted evacuations initiated by flight attendants. Further, if a flight

attendant were to initiate an unwarranted evacuation using an evacuation alarm, the flight

crew would immediately become aware of the situation and would likely be able to take

action to stop the evacuation.

93 This incident was not one of the study cases; it occurred after analysis of the study data was underway.
Chapter 7 74 Safety Study

An evacuation alarm unequivocally and immediately delivers a message

throughout the airplane that an evacuation needs to begin. The alarm operates on a system

separate from normal communications, thereby removing the possibility of selecting the

wrong channel for communicating the command. Consequently, the Safety Board

concludes that evacuations continue to occur that are hampered by inefficient

communication and that current evacuation communication would be significantly

enhanced by the installation of independently powered evacuation alarms on all newly

manufactured transport-category airplanes. The Safety Board therefore recommends that

the FAA require all newly manufactured transport-category airplanes operating under

14 CFR Part 121 to be equipped with independently powered evacuation alarm systems

operable from each crewmember station, and establish procedures and provide training to

flight crews and flight attendants regarding the use of such systems.

Airplane Cargo Smoke/Fire Indications

The May 11, 1996, crash of ValuJet Airlines flight 592 in the Everglades illustrated

the importance of rapid detection of smoke or fire in cargo bays.94 The accident resulted

from a fire in a class D cargo compartment that went undetected until electrical systems

started to be affected and smoke had penetrated the cabin. As a result of its investigation

of that accident, the Safety Board recommended that the FAA

Expedite final rulemaking to require smoke detection and fire suppression

systems for all class D cargo compartments. (A-97-56)

The FAA decided to eliminate the class D cargo compartment designation for future

airplanes and to require installation of fire or smoke detection systems on previously

certificated aircraft by 2001. As a result of this action, the Safety Board classified Safety

Recommendation A-97-56 “Closed—Acceptable Action” on August 13, 1998.

The effectiveness of a warning system is degraded when the system has a

propensity for false indications. Eight evacuations in the study cases were the result of an

indication of a cargo fire, but all were false indications. As a result of these false

indications, 205 passengers were evacuated, and 1 passenger was injured. In each of these

cases, ARFF units were unable to find any evidence of a fire in the airplane. ASRS reports

during the study period indicated an additional four evacuations for false smoke

indications. Because passengers in these four evacuations used only the main cabin door,

the evacuations were not reported to the Safety Board.95 All of these false indications

occurred in regional aircraft operations.

94 National Transportation Safety Board, In-flight Fire and Impact With Terrain, ValuJet Airlines Flight

592, DC-9-32, N904VJ, Everglades, Near Miami, Florida, May 11, 1996, Aircraft Accident Report

NTSB/AAR-97/06 (Washington, DC: NTSB, 1997).

95 Evacuations using normal egress means do not have to be reported to the National Transportation

Safety Board.
Chapter 7 75 Safety Study

The operators of the regional airplanes that had the false smoke cargo indications

in the study cases were aware of the tendency for false indications to occur on their

airplanes. The captain of the CRJ that evacuated in Knoxville, Tennessee, on August 13,

1998 (case 26) reported suspecting a false indicator but evacuated the aircraft as a

precaution. The operator of the Saab 340 that evacuated in Huntsville, Alabama, on

June 4, 1998 (case 20) had issued a notice to pilots reminding them that warm weather

often led to an increase in false cargo smoke indications. However, pilots were reminded

to treat all indications as if they were actual.

The Safety Board reviewed the FAA’s SDR system for reports of false indications

on smoke detectors. The database contained 30 reports of false cargo smoke indications

involving Saab 340s and 15 reports involving CRJs for the period from October 1998 to

November 1999.96 The actual number of events is probably much higher; only four of the

eight false indications that were documented in this study were reported to the FAA.

However, for the entire Boeing fleet of 3,259 airplanes, the SDR database reported only 16

false indications for the period from October 1998 to November 1999.

The Safety Board agrees with a policy that requires passengers to be evacuated

when an indication exists of a cargo fire. However, the Safety Board concludes that the

frequency of false indications on the two regional airplanes in the Board’s study cases—

the Saab 340 and the Canadair Regional Jet—is too high.97 Because only four of the eight

false indications in the Board’s study cases were reported to the FAA, the Safety Board is

also concerned that all false indications are not being reported in the FAA’s SDR system.

The Safety Board further concludes that there are insufficient data, however, to determine

if the frequency of false smoke indications is peculiar to the two regional airplanes in the

Safety Board’s study or if the problem is more widespread. Therefore, the Safety Board

believes that the FAA should document the extent of false indications for cargo smoke

detectors on all airplanes and improve the reliability of the detectors.

FAA’s Service Difficulty 

Reporting System

In conjunction with this study, the Safety Board examined the FAA’s SDR system

with respect to problems with evacuation systems not being reported to the SDR system,

as discussed in chapter 5, and with respect to false indications of smoke detectors not

being reported to the SDR system, as discussed in the previous section. On several

occasions in the past, the Safety Board has expressed concern with the adequacy of

96 There are 272 Saab 340s and 222 CRJs in operation in the United States.

97 The Safety Board is aware through communication with a representative of Walter Kidde, the

manufacturer of the smoke detectors on CRJs, that a newly designed smoke detector designed to reduce the

occurrence of false smoke indications will be installed on the 400 series of the CRJ. Because this aircraft has

not yet completed certification, the effectiveness of this new smoke detector design in the operating

environment has not been determined.
Chapter 7 76 Safety Study

information being reported to the SDR system. Most recently, on January 9, 1998, the

Safety Board asked the FAA to

Modify the service difficulty reporting system so that it contains more complete

and accurate information about component failures; for example, (a) revise the

various Service Difficulty Report (SDR) forms and database to include cycles and

times since last inspection for failed components; (b) relate to the operators who

submit SDRs the need for complete and accurate information when they report

component failures; and (c) remind Federal Aviation Administration inspectors

assigned to Part 121 and Part 135 operators of their need to review the component

failure reports for accuracy and completeness. (A-97-125)

On April 15, 1999, the FAA issued a supplemental notice of proposed rulemaking

(SNPRM), the objective of which, according to the FAA, is to update and improve the

reporting system to collect and disseminate clear and concise safety information to the

aviation industry. The Safety Board reviewed the SNPRM, and in a letter dated

October 26, 1999, stated that the Board believes that the SNPRM, if published as a final

rule, would significantly improve the SDR process. Pending issuance of a final rule, the

Safety Board classified Safety Recommendation A-97-125 “Open—Acceptable

Response.”

In view of the information collected in this study regarding the inadequate reporting

of evacuation system failures and false indications for cargo smoke detectors, the Safety

Board concludes that air carriers do not always make reports to the FAA’s SDR system, or

reports are inadequate, to identify the extent of component problems or failures. Therefore,

the Safety Board is reiterating Safety Recommendation A-97-125 in conjunction with this

study. In reiterating Safety Recommendation A-97-125, the Safety Board urges the FAA to

consider the inadequate reporting of evacuation system failures and false indications for

cargo smoke detectors in developing a final rule on the SDR system.
77 Safety Study

Findings

1. On average, an evacuation for the study cases occurred every 11 days. An average of

336,328 departures occurred every 11 days in 1998 by scheduled aircraft operating

under Title 14 Code of Federal Regulations Part 121.

2. In the 46 study cases, 92 percent (2,614) of the 2,846 occupants on board were

uninjured, 6 percent (170) sustained minor injuries, and 2 percent (62) sustained

serious injuries.

3. The Federal Aviation Administration does not evaluate the emergency evacuation

capabilities of transport-category airplanes with fewer than 44 passenger seats or the

emergency evacuation capabilities of air carriers operating commuter-category and

transport-category airplanes with fewer than 44 passenger seats. In the interest of

providing one level of safety, all passenger-carrying commercial airplanes and air

carriers should be required to demonstrate emergency evacuation cababilities.

4. Adequate research has not been conducted to determine the appropriate exit row

width on commercial airplanes.

5. In general, passengers in the Safety Board’s study cases were able to access airplane

exits without difficulty, except for the Little Rock, Arkansas, accident that occurred

on June 1, 1999, in which interior cabin furnishings became dislodged and were

obstacles to some passengers’ access to exits.

6. Emergency lighting systems functioned as intended in the 30 evacuation cases

investigated in detail.

7. In 43 of the 46 evacuation cases in the Safety Board’s study, floor level exit doors

were opened without difficulty.

8. Passengers continue to have problems opening overwing exits and stowing the hatch.

The manner in which the exit is opened and the hatch is stowed is not intuitively

obvious to passengers nor is it easily depicted graphically.

9. Most passengers seated in exit rows do not read the safety information provided to

assist them in understanding the tasks they may need to perform in the event of an

emergency evacuation, and they do not receive personal briefings from flight

attendants even though personal briefings can aid passengers in their understanding of

the tasks that they may be called upon to perform.

10. On some Fokker airplanes, the aft flight attendant is seated too far from the overwing

exits, the assigned primary exits, to provide immediate assistance to passengers who

attempt to evacuate through the exits.
Findings 78 Safety Study

11. Overall, in 37 percent (7 of 19) of the evacuations with slide deployments in the

Safety Board’s study cases, there were problems with at least one slide. A slide

problem in 37 percent of the evacuations in which slides were deployed is

unacceptable for a safety system.

12. The majority of serious evacuation-related injuries in the Safety Board’s study cases,

excluding the Little Rock, Arkansas, accident of June 1, 1999, occurred at airplane

door and overwing exits without slides.

13. Pilots are not receiving consistent guidance, particularly in flight operations and

safety manuals, on when to evacuate an airplane.

14. Passengers benefit from precautionary safety briefings just prior to emergency

occurrences.

15. Limiting exit use during evacuations in the Safety Board’s study was not in

accordance with the respective air carrier’s existing evacuation procedures. At a

minimum, all available floor level exits that are not blocked by a hazard should be

used during an evacuation.

16. Evacuations involving slide use could be delayed if passengers sit at exits before

boarding a slide or if crew commands do not direct passengers how to get onto a slide.

17. Without hands-on training specific to the airplane types that frequent their airports,

aircraft rescue and firefighting personnel may be hindered in their ability to quickly

and efficiently assist during evacuations.

18. Communication and coordination problems continue to exist between flight crews

and flight attendants during airplane evacuations. Joint exercises for flight crews and

flight attendants on evacuation have proven effective in resolving these problems.

19. Despite efforts and various techniques over the years to improve passenger attention

to safety briefings, a large percentage of passengers continue to ignore preflight safety

briefings. Also, despite guidance in the form of Federal Aviation Administration

advisory circulars, many air carrier safety briefing cards do not clearly communicate

safety information to passengers.

20. Passengers’ efforts to evacuate an airplane with their carry-on baggage continue to

pose a problem for flight attendants and are a serious risk to a successful evacuation

of an airplane. Techniques on how to handle passengers who do not listen to flight

attendants’ instructions need to be addressed.

21. Unwarranted evacuations following Boeing 727 auxiliary power unit (APU) torching

continue to exist despite past efforts by the Federal Aviation Administration to

address this issue.
Findings 79 Safety Study

22. Evacuations continue to occur that are hampered by inefficient communication.

Current evacuation communication would be significantly enhanced by the

installation of independently powered evacuation alarms on all newly manufactured

transport-category airplanes.

23. The frequency of false indications on the two regional airplanes in the Safety Board’s

study cases—the Saab 340 and the Canadair Regional Jet—is too high. There are

insufficient data, however, to determine if the frequency of false smoke indications is

peculiar to the two regional airplanes in the Safety Board’s study or if the problem is

more widespread.

24. Air carriers do not always make reports to the Federal Aviation Administration’s

service difficulty reporting system, or reports are inadequate, to identify the extent of

component problems or failures.
80 Safety Study

Recommendations

As a result of this safety study, the National Transportation Safety Board made the

following safety recommendations to the Federal Aviation Administration:

Require all newly certificated commercial airplanes to meet the evacuation

demonstration requirements prescribed in Title 14 Code of Federal

Regulations Part 25, regardless of the number of passenger seats on the

airplane. (A-00-72)

Require all commercial operators to meet the partial evacuation

demonstration requirements prescribed in Title 14 Code of Federal

Regulations Part 121, regardless of the number of passenger seats on the

airplane. (A-00-73)

Conduct additional research that examines the effects of different exit row

widths, including 13 inches and 20 inches, on exit hatch removal and

egress at Type III exits. The research should use an experimental design

that reliably reflects actual evacuations through Type III exits on

commercial airplanes. (A-00-74)

Issue, within 2 years, a final rule on exit row width at Type III exits based

on the research described in Safety Recommendation A-00-74. (A-00-75)

Require Type III overwing exits on newly manufactured aircraft to be easy

and intuitive to open and have automatic hatch stowage out of the egress

path. (A-00-76)

Require air carriers to provide all passengers seated in exit rows in which a

qualified crewmember is not seated a preflight personal briefing on what to

do in the event the exit may be needed. (A-00-77)

Require the aft flight attendants on Fokker 28 and Fokker 100 airplanes to

be seated adjacent to the overwing exits, their assigned primary exits.

(A-00-78)

Review the 6-foot height requirement for exit assist means to determine if

6 feet continues to be the appropriate height below which an assist means is

not needed. The review should include, at a minimum, an examination of

injuries sustained during evacuations. (A-00-79)
Recommendations 81 Safety Study

Require flight operations manuals and safety manuals to include on

abnormal and emergency procedures checklists a checklist item that directs

flight crews to initiate or consider emergency evacuation in all emergencies

that could reasonably require an airplane evacuation (for example, cabin

fire or engine fire). (A-00-80)

Review air carriers’ procedures to ensure that for those situations in which

crews anticipate an eventual evacuation, adequate guidance is given both to

pilots and flight attendants on providing passengers with precautionary

safety briefings. (A-00-81)

Review air carrier training programs to ensure that evacuation procedures

call, at a minimum, for evacuation through all available floor level exits

that are not blocked by a hazard. (A-00-82)

Review air carrier procedures and training programs to ensure that the

commands used for slide evacuations are consistent with the commands

used for slide evacuations during certification. (A-00-83)

Establish a task force to address the issue of providing periodic hands-on

familiarization training, or the equivalent, for aircraft rescue and

firefighting personnel at all Title 14 Code of Federal Regulations Part 139

certified airports on each airplane type that serves the airport on a

scheduled basis. (A-00-84)

Require air carriers to conduct periodic joint evacuation exercises

involving flight crews and flight attendants. (A-00-85)

Conduct research and explore creative and effective methods that use stateof-the-art technology to convey safety information to passengers. The

presented information should include a demonstration of all emergency

evacuation procedures, such as how to open the emergency exits and exit

the aircraft, including how to use the slides. (A-00-86)

Require minimum comprehension testing for safety briefing cards.

(A-00-87)

Develop advisory material to address ways to minimize the problems

associated with carry-on luggage during evacuations. (A-00-88)

Require air carriers that operate Boeing 727s to include in the auxiliary

power unit (APU) procedures instructions that when passengers are on

board, the flight crew will make a public address announcement about

APU starts immediately prior to starting the APU. (A-00-89)
Recommendations 82 Safety Study

Require all newly manufactured transport-category airplanes operating

under Title 14 Code of Federal Regulations Part 121 to be equipped with

independently powered evacuation alarm systems operable from each

crewmember station, and establish procedures and provide training to

flight crews and flight attendants regarding the use of such systems.

(A-00-90)

Document the extent of false indications for cargo smoke detectors on all

airplanes and improve the reliability of the detectors. (A-00-91)

Also as a result of this safety study, the National Transportation Safety Board

reiterated the following safety recommendations to the Federal Aviation Administration:

For a 12-month period, require that all operators of transport-category

aircraft demonstrate the on-airplane operation of all emergency evacuation

systems (including door opening assist mechanisms and slide or slide/raft

deployment) on 10 percent of each type of airplane (minimum of one

airplane per type) in their fleets. These demonstrations should be

conducted on an airplane in a controlled environment so that the entire

evacuation system can be properly evaluated by qualified personnel. The

results of the demonstrations (including an explanation of the reasons for

any failures) should be documented for each component of the system and

should be reported to the FAA. (A-99-100)

Revise the requirements for evacuation system operational demonstrations

and maintenance procedures in air carrier maintenance programs to

improve the reliability of evacuation systems on the basis of an analysis of

the demonstrations recommended in A-99-100. Participants in the analysis

should include representatives from aircraft and slide manufacturers,

airplane operators, and crewmember and maintenance associations.

(A-99-101)

Modify the service difficulty reporting system so that it contains more

complete and accurate information about component failures; for example,

(a) revise the various Service Difficulty Report (SDR) forms and database

to include cycles and times since last inspection for failed components; (b)

relate to the operators who submit SDRs the need for complete and

accurate information when they report component failures; and (c) remind

Federal Aviation Administration inspectors assigned to Part 121 and Part

135 operators of their need to review the component failure reports for

accuracy and completeness. (A-97-125)
Recommendations 83 Safety Study

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

James E. Hall

Chairman

John A. Hammerschmidt

Member

John J. Goglia

Member

George W. Black, Jr.

Member

Carol J. Carmody

Member

Adopted: June 27, 2000

85 Safety Study

Appendix A

Previous Safety Recommendations

Relevant to Cabin Safety

The recommendations presented in this appendix appear in sequence by safety

recommendation number. They are listed below according to the overall cabin safety

issues they address.

Crew Training: A-85-101, A-91-6, A-92-72, A-92-74, A-92-77, A-94-200, A-96-83, 

A-96-148, A-97-6.

Aircraft Equipment: A-68-31, A-72-84, A-72-133, A-72-141, A-73-42, A-73-53, 

A-74-105, A-74-106, A 74-107, A-74-108, A-74-111, A-81-21, A-81-129, A-81-130, 

A-83-79, A-88-37, A-88-107, A-90-95, A-92-78, A-96-82, A-96-84, A-96-138, A-97-1,

A-97-84, A-97-103, A-97-104, A-97-105, A-98-22, A-98-23, A-99-10, A-99-100, 

A-99-101.

Passenger Safety Briefings: A-67-16, A-70-55, A-72-128, A-74-112, A-74-113, 

A-83-45, A-85-93, A-85-94, A-85-95, A-85-96, A-85-97, A-85-98, A-85-103, A-88-128,

A-91-52, A-91-53, A-93-125, A-96-140.

Fire-blocking Materials: A-83-78, A-93-18, A-93-149, A-93-150, A-97-56.

Aircraft Rescue and Firefighting: A-83-84, A-83-87, A-84-32, A-84-34, A-84-35, 

A-91-32, A-95-77, A-97-107, A-97-108, A-98-41, A-98-42.
Appendix A 86 Safety Study

Safety Recommendation No.: A-67-16

Date Issued: April 17, 1967

Recommendation:

It is recommended that all passengers be made aware of the procedures required to

move the seats out of the way of the window exits. Further, it is recommended that

airlines utilizing movable partitions between passenger compartments assure that the

overhead signs are properly placed to depict the exact location of the window exits and

that the flight attendants be required to indicate where each emergency exit is located

during the pre-takeoff briefing.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-68-31

Date Issued: November 4, 1968

Recommendation:

(1) Air carriers be required to have the retainer bar for all door-mounted slides placed

in position for slide deployment at the floor-level emergency exits prior to the

aircraft’s departure from the ramp for flight. (2) FAA inspectors review all printed

cards used by the air carriers to supplement the oral briefing to ensure that they include

clear instructions showing the direction passengers should take upon leaving the wing

whenever over-the-wing exits are used for evacuating the aircraft. (3) All air carriers

re-emphasize, through their crew training programs, the basic philosophy of

emergency evacuation that all cabin exits that are not jumped, blocked by fire, or

otherwise rendered unusable(including ventral stairs) should be used to the extent

reasonably possible.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-70-55

Date Issued: October 29, 1970

Recommendation:

Ensure that no flight requiring the briefing of passengers regarding emergency

procedures be dispatched without an operable public address system. The system

should be functioning so that the flight deck crew can speak to the passengers and a

cabin attendant can speak to the passengers from at least one cabin station.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 87 Safety Study

Safety Recommendation No.: A-72-84

Date Issued: July 6, 1972

Recommendation:

Require self-illuminated handles for all Type I and Type A exits.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-72-128

Date Issued: August 28, 1972

Recommendation:

Revise Federal Aviation Regulation 121.571 to state that the appropriate crewmember

must physically point out the location of all emergency exits on each aircraft prior to

each takeoff. As a general rule, passengers do not listen to the oral announcements.

This was testified to during the public hearing relative to this accident. However,

passengers will tend to watch a flight attendant who physically points out the area of

exits and will retain therefore a general idea of the location of such exits particularly

those nearest to them.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-72-133

Date Issued: August 28, 1972

Recommendation:

Present provisions for emergency exit lights for utilization during darkness or smoke

conditions be evaluated. During darkness or smoke conditions, it is vitally important

to have some form of light available to direct and conduct emergency evacuations as

well as to read operating instructions. Surviving passengers indicated that the cabin

was dark, and exits were difficult to see.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-72-141

Date Issued: August 31, 1972

Recommendation:

Require all air carrier aircraft to be equipped with an audio and visual evacuation

alarm system. This system should be capable of being activated in the cockpit and at
Appendix A 88 Safety Study

each flight attendant’s station. The alarm system should be self-powered so that

interruption of the aircraft electrical systems will not interfere with use of the

evacuation alarm.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-73-42

Date Issued: June 25, 1973

Recommendation:

Amend 14 CFR 25.812 to require exit sign brightness and general illumination levels

in the passenger cabin that are consistent with those necessary to provide adequate

visibility in conditions of dense smoke.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-73-53

Date Issued: August 10, 1973

Recommendation:

Amend the existing certification and operating rules for air carrier and air taxi aircraft

to include provisions requiring tactile guidance and improved visual guidance to

emergency exits, as well as more efficient methods of indicating the location of

emergency exits in a dark or smoke environment.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-74-105

Date Issued: January 5, 1975

Recommendation:

Require that air carriers report all emergency evacuation slide deployments, failures,

and malfunctions to the FAA.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action
Appendix A 89 Safety Study

Safety Recommendation No.: A-74-106

Date Issued: January 5, 1975

Recommendation:

Develop a maintenance surveillance program to insure greater reliability of emergency

evacuation slide systems.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-74-107

Date Issued: January 5, 1975

Recommendation:

Amend 14 CFR 25.809 to require that the length of the emergency evacuation slides

be such that the angle with the ground renders the slide safe and usable after collapse

of one leg, or more, of the landing gear, and amend 14 CFR 121.310 to require that

these new slides be installed after a reasonable date.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-74-108

Date Issued: January 5, 1975

Recommendation:

Amend 14 CFR 121.310 to require, after a reasonable date, that emergency evacuation

slides on all floor-level exits be automatically inflated upon deployment.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-74-111

Date Issued: January 1, 1975

Recommendation:

Amend 14 CFR 121.318 to require after a reasonable date, that public address systems

be capable of operating on a power source independent of the main aircraft power

supply.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action
Appendix A 90 Safety Study

Safety Recommendation No.: A-74-112

Date Issued: January 5, 1975

Recommendation:

Require that air carrier passengers be alerted, during pretakeoff briefings, of the need

to familiarize themselves with the procedures involved in the operation of emergency

exits.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Alternate Action

Safety Recommendation No.: A-74-113

Date Issued: January 5, 1972

Recommendation:

Issue an advisory circular which would provide standardized guidance to the air

transport industry on effective methods and techniques for conveying safety

information to passengers.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-81-28

Date Issued: March 20, 1981

Recommendation:

Amend 14 CFR 23.783, 14 CFR 23.807(b)(3), and 14 CFR Part 91 to require external

doors and emergency exits of aircraft to be conspicuously marked on the outside with

directions for opening the door.

Recipient(s): Status:

Federal Aviation Administration Closed—Superseded

Safety Recommendation No.: A-81-129

Date Issued: September 30, 1981

Recommendation:

Require the installation of an independently powered evacuation alarm system in

passenger-carrying aircraft.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action
Appendix A 91 Safety Study

Safety Recommendation No.: A-81-130

Date Issued: September 30, 1981

Recommendation:

Promptly adopt the final rule as proposed in FAA’s Notice of Proposed Rulemaking

No. 81-1—to have the public address system on passenger-carrying aircraft capable of

operating from a power source independent of the main electrical generating system

without jeopardizing the in-flight emergency electrical power system.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-83-45

Date Issued: July 12, 1983

Recommendation:

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.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-83-78

Date Issued: October 31, 1983

Recommendation:

Expedite the rulemaking action to require at the earliest possible date that passenger

seats with fire-blocking materials be installed in transport-category airplanes.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 92 Safety Study

Safety Recommendation No.: A-83-79

Date Issued: October 31, 1983

Recommendation:

Expedite the rulemaking action to require at the earliest possible date that cabin

emergency lighting be installed for optimum effectiveness during passenger

evacuation from smoke-filled cabins.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-83-84

Date Issued: December 12, 1983

Recommendation:

Require that airport operations manuals (AOM) contain explicit instructions and

procedures for the reporting of any known change in the operating status of the airport

crash/fire/rescue (CFR) equipment to backup fire departments providing CFR services

and that all airport or airport tenant employees who may be required to operate airport

CFR equipment be knowledgeable of the instructions and procedures.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-83-87

Date Issued: December 22, 1983

Recommendation:

Issue appropriate notices and instructions to airport inspectors to encourage the

operators of Index A and B airports, as well as State airport officials, to provide handson fire fighting training to airport tenants.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 93 Safety Study

Safety Recommendation No.: A-84-32

Date Issued: April 16, 1984

Recommendation:

Revise 14 CFR 139.49(h) to require a minimum of two firefighters per vehicle and to

specifically define minimum standards for training of crash-fire-rescue personnel.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Alternate Action

Safety Recommendation No.: A-84-34

Date Issued: April 16, 1984

Recommendation:

Amend 14 CFR 139.55 to require a full-scale demonstration of certificated airport

emergency plans and procedures at least once every 2 years, and to require an annual

validation of notification arrangements and coordination agreements with participating

parties.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Alternate Action

Safety Recommendation No.: A-84-35

Date Issued: April 16, 1984

Recommendation:

Incorporate in any 14 CFR Part 139 rulemaking proposal calling for a reduction in

crash-fire-rescue capability at Index A and B airports a list of affected airports, a list of

types and schedules of air carrier aircraft serving these airports, and a description of

the effect of such a reduction on the fire fighting posture of the airports.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-85-93

Date Issued: December 17, 1985

Recommendation:

Develop test methods to improve passenger motivation to listen to safety information.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 94 Safety Study

Safety Recommendation No.: A-85-94

Date Issued: December 17, 1985

Recommendation:

Develop tests and standards which describe the minimum level of acceptable

comprehension and performance to measure whether persons who represent typical

passengers understand the safety information presented during oral briefings and

demonstrations, on safety cards, and in videotaped briefings, and whether these

persons actually are able to perform the actions described, such as using supplemental

oxygen systems, using life preservers, and opening of exits.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-85-95

Date Issued: December 17, 1985

Recommendation:

Revise, based on the results of testing of passenger comprehension of safety

information and performance of emergency procedures, the Advisory Circular entitled

“Passenger Safety Information Briefings and Briefing Cards” (AC-121-24, dated June

23, 1977, and AC-135-12, dated October 9, 1984) to include improved guidelines on

the content and presentation methods used in oral and videotaped safety briefings, and

for pictorial and printed information on safety cards.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-85-96

Date Issued: December 17, 1985

Recommendation:

Revise, based on the results of testing of passenger comprehension of safety

information and performance of emergency procedures, Air Carrier Operations

Handbooks and Bulletins and air carrier inspection training programs to include

instruction to prepare FAA inspectors to provide better guidance to airlines when

assisting them in improving the content and presentation of passenger safety

information to their passengers.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 95 Safety Study

Safety Recommendation No.: A-85-97

Date Issued: December 17, 1985

Recommendation:

Revise Advisory Circulars 121-24, dated June 23, 1977, and 135-12, dated October 9,

1984, to provide guidelines covering the following items in briefings and

demonstrations: adults donning oxygen masks before placing masks on accompanying

children; fastening an adult size life preserver or personal flotation device on a child;

and brace positions for children. As an interim measure, issue an Air Carrier

Operations Bulletin to assist FAA inspectors in providing better guidance to airlines.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-85-98

Date Issued: December 17, 1985

Recommendation:

Amend 14 CFR 121 to require pre-landing safety announcements to reinforce the pretakeoff briefings on release of seatbelts, the location of exits, the location and

operation of life preservers (in the case of overwater landings), and to urge passengers

to refer to safety cards prior to landing.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-85-101

Date Issued: December 17, 1985

Recommendation:

Require that recurrent flight attendant training programs contain instructions on the

use of the public address system and techniques for maintaining effective safety

briefings and demonstrations which will improve the motivation of passengers to pay

attention to the oral briefings and to the demonstrations.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action
Appendix A 96 Safety Study

Safety Recommendation No.: A-85-103

Date Issued: December 17, 1985

Recommendation:

Develop a program to test the feasibility, effectiveness, and passenger acceptance of

providing safety briefing information in airport terminal gate areas, and of providing

printed safety information on or inside ticket envelopes.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-88-37

Date Issued: March 15, 1998

Recommendation:

Coordinate an industry working group to develop a combined puncture/tear test that

can be used to establish new strength requirements for evacuation slide materials.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-88-107

Date Issued: September 21, 1988

Recommendation:

Revise Technical Standard Order (TSO)-C69, Emergency Evacuation Slides, Ramps,

and Slide/Raft Combinations, to require standard text for emergency handle placards,

e.g., “PULL TO INFLATE,” and to require that the text on the placard be located as

close to the appropriate manual handle as possible.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-88-128

Date Issued: October 24, 1988

Recommendation:

Instruct principal operations inspectors to determine if passenger safety cards and

flight attendant instructions to passengers for emergency evacuations are consistent

with each air carrier’s evacuation procedures.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 97 Safety Study

Safety Recommendation No.: A-90-95

Date Issued: June 25, 1990

Recommendation:

Require air carriers to implement procedures requiring that all emergency lighting be

illuminated during an evacuation.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-91-6

Date Issued: January 8, 1991

Recommendation:

Require operators of DC-9/MD-80 series airplanes to include in their flightcrew and

flight attendant training programs the Safety Board’s findings regarding the tailcone

manual release system and tailcone familiarization tours and hands-on training on the

operation of the release handle in DC-9/MD-80 airplanes using actual airplanes or

FAA-approved simulators.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-91-32

Date Issued: July 19, 1991

Recommendation:

Establish and oversee a working group, consisting of at least the Airport Operators

Council International, the American Association of Airport Executives, air carrier

associations, the Aerospace Industries Association, and the National Fire Protection

Association, to conduct an in-depth survey of 14 CFR Part 139 certificated airports to

determine the adequacy and timely dissemination of aircraft “crash crew” type

publications used by aircraft rescue and fire fighting personnel, and after reviewing the

survey information, take action as needed to improve the content of such publications

and the methods for disseminating them.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Alternate Action
Appendix A 98 Safety Study

Safety Recommendation No.: A-91-52

Date Issued: July 19, 1991

Recommendation:

Request member air carriers to depict floor proximity emergency escape path marking

systems on passenger safety briefing cards and to include descriptions of the location

and operation of the systems during flight attendant oral safety briefings.

Recipient(s): Status:

Regional Airlines Association Closed—Acceptable Action

Safety Recommendation No.: A-91-53

Date Issued: July 19, 1991

Recommendation:

Request member air carriers to depict floor proximity emergency escape path marking

systems on passenger safety briefing cards and to include descriptions of the location

and operation of the systems during flight attendant oral safety briefings.

Recipient(s): Status:

Air Transport Association Closed—Acceptable Action

Safety Recommendation No.: A-92-72

Date Issued: August 12, 1992

Recommendation:

Ensure that flight attendant training and procedures for each type of airplane include

appropriate consideration of the training and procedures used during joint Part 25 and

Part 121 certification evacuation demonstrations.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-92-74

Date Issued: August 12, 1992

Recommendation:

Amend 14 CFR Part 121.417 to require an evacuation and/or wet ditching drill group

exercise during recurrent training. Ensure that all reasonable attempts are made to
Appendix A 99 Safety Study

conduct joint flightcrew/flight attendant drills, especially for crewmembers operating

on airplanes with two-person cockpit crews.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-92-77

Date Issued: August 12, 1992

Recommendation:

Require that flight attendants receive Crew Resource Management training that

includes group exercises in order to improve crewmember coordination and

communication.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-92-78

Date Issued: August 12, 1992

Recommendation:

Amend the Federal Aviation Regulations to include ergonomic design requirements

for cabin safety equipment, including emergency exits.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-93-18

Date Issued: March 8, 1993

Recommendation:

Research the effect of aging upon the self-extinguishing ability of cabin interior

furnishings and test furnishings that were certified to 14 CFR 25.853(a)(1) to

determine if they comply with the self-extinguishing requirements. Interior

furnishings that fail to comply with 14 CFR 25.853(a)(1) should be immediately

replaced with materials that comply with 14 CFR 25.853, Appendix F.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 100 Safety Study

Safety Recommendation No.: A-93-125

Date Issued: October 14, 1993

Recommendation:

Issue an Air Carrier Operations Bulletin to require that Boeing 727 cockpit

crewmembers make a public address announcement about auxiliary power unit (APU)

starts immediately prior to starting the APU.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-93-149

Date Issued: November 10, 1993

Recommendation:

Amend 14 CFR 25.853 to include a requirement to test the fire-retardant properties of

fire blocking materials after they have been subjected to in-service wear.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-93-150

Date Issued: November 10, 1993

Recommendation:

Conduct research upon the effects of actual in-service wear on the continued

airworthiness of fire-blocking materials. Based on the findings, require periodic actual

in-service tests of fire-blocking materials to verify compliance with the requirements

of 14 CFR 25.853.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-94-200

Date Issued: November 30, 1994

Recommendation:

Revise the Federal Aviation Regulations to require all fight attendants to participate,

during recurrent training, in emergency drills that allow them the opportunity to use
Appendix A 101 Safety Study

emergency equipment and to practice procedures under simulated emergency

conditions.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-95-77

Date Issued: July 17, 1995

Recommendation:

Require that all 14 CFR 139 certificated airports identify gates that aircraft rescue and

fire fighting personnel and their equipment might need to access while responding to

emergencies, and make the necessary changes to ensure that emergency personnel and

their equipment can pass through these gates without hesitation or delay. Additionally,

the gates that are identified and the procedures required to access them should be

included in the Airport Emergency Plan.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-96-82

Date Issued: September 9, 1996

Recommendation:

Require that all transport-category aircraft manufactured before November 27, 1990,

be retrofitted with a public address system capable of operating on an independent

power source.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-96-83

Date Issued: September 9, 1996

Recommendation:

Emphasize to principal operations inspectors the importance of thoroughly reviewing

flight attendant training programs before approving them and flight attendant manuals

before accepting them.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 102 Safety Study

Safety Recommendation No.: A-96-84

Date Issued: September 9, 1996

Recommendation:

Provide guidance on how to implement the requirement that occupants who are more

than 24 months old are restrained during takeoffs, landings, and during turbulence.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-96-138

Date Issued: December 3, 1996

Recommendation:

Require all operators to inspect immediately all MD-80 and DC-9 floor level exits to

ensure that evacuation slides have been properly rigged.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-96-140

Date Issued: December 3, 1996

Recommendation:

Develop a uniform policy on shoe removal during evacuations, and require that all

operators train their flight attendants to issue commands during an emergency

evacuation consistent with that policy.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-96-148

Date Issued: December 20, 1996

Recommendation:

Amend Advisory Circular 120-51B (crew resource management training) to include

guidance regarding the communication of time management information among flight

and cabin crewmembers during an emergency.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 103 Safety Study

Safety Recommendation No.: A-97-1

Date Issued: January 3, 1997

Recommendation:

Immediately issue a telegraphic airworthiness directive directing all Beechcraft 1900

operators to (1) conspicuously identify the external air stair exit door button with

highly visible markings, (2) indicate that the button must be depressed while the

handle is rotated, and (3) include an arrow to show the direction that the handle must

be moved to open the door.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-97-6

Date Issued: February 18, 1997

Recommendation:

Require all principal operations inspectors of 14 CFR Part 121 carriers to ensure that

crew resource management programs provide pilots with training in recognizing the

need for, and practice in presenting, clear and unambiguous communications of flightrelated concerns.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-97-56

Date Issued: September 9, 1997

Recommendation:

Expedite final rulemaking to require smoke detection and fire suppression systems for

all class D cargo compartments.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action
Appendix A 104 Safety Study

Safety Recommendation No.: A-97-84

Date Issued: August 29, 1997

Recommendation:

Identify Part 139 airports that have irregular runway light spacing, evaluate the

potential hazards of such irregular spacing, and determine if standardizing runway

light spacing is warranted.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-97-95

Date Issued: August 29, 1997

Recommendation:

Require all 14 CFR Part 121 and 135 operators to review their flight attendant training

programs and emphasize the need for flight attendants to aggressively initiate their

evacuation procedures when an evacuation order has been given.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-97-103

Date Issued: September 12, 1997

Recommendation:

Evaluate the propensity of Beech 1900C door/frame system to jam when it sustains

minimal permanent door deformation and, based on the results of that evaluation,

require appropriate design changes.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-97-104

Date Issued: September 12, 1997

Recommendation:

Establish clear and specific methods for showing compliance with the freedom from

jamming certification requirements.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response
Appendix A 105 Safety Study

Safety Recommendation No.: A-97-105

Date Issued: September 12, 1997

Consider the circumstances of the November 19, 1996, Quincy, Illinois, accident when

developing methods for showing compliance with freedom from jamming

requirements, and determine whether it is feasible to require that doors be shown to be

free from jamming after an impact of similar severity.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-97-107

Date Issued: September 12, 1997

Recommendation:

Develop ways to fund airports that are served by scheduled passenger operations on

aircraft having 10 or more passenger seats, and require these airports to ensure that

aircraft rescue and fire fighting units with trained personnel are available during

commuter flight operations and are capable of timely response.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-97-108

Date Issued: September 12, 1997

Recommendation:

Add to the Safety Information Section of the FAA’s Internet Home Page a list of

airports that have scheduled air service but do not have aircraft rescue and fire fighting

capabilities.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-97-125

Date Issued: January 9, 1998

Recommendation:

Modify the service difficulty reporting system so that it contains more complete and

accurate information about component failures; for example, (a) revise the various

Service Difficulty Report (SDR) forms and database to include cycles and times since

last inspection for failed components; (b) relate to the operators who submit SDRs the

need for complete and accurate information when they report component failures; and
Appendix A 106 Safety Study

(c) remind Federal Aviation Administration inspectors assigned to Part 121 and Part

135 operators of their need to review the component failure reports for accuracy and

completeness.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-98-22

Date Issued: March 4, 1998

Recommendation:

Require that all newly manufactured passenger-carrying airplanes operated under 14

Code of Federal Regulations Part 121 be equipped with independently powered

evacuation alarm systems operable from each crewmember station, and establish

procedures and provide training to flight and cabin crews regarding the use of such

systems.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-98-23

Date Issued: March 4, 1998

Recommendation:

Require that all newly manufactured airplanes be equipped with cockpit indicators

showing open exits, including overwing exit hatches, and that these cockpit indicators

be connected to emergency power circuits.

Recipient(s): Status:

Federal Aviation Administration Closed—Unacceptable Action

Safety Recommendation No.: A-98-41

Date Issued: June 25, 1998

Recommendation:

Establish a designated radio frequency at all airports certified under Title 14 CFR Part

139 that allows direct communication between airport rescue and firefighting (ARFF)

personnel and fightcrew members in the event of an emergency and take appropriate
Appendix A 107 Safety Study

measures to ensure that air traffic control personnel, ARFF personnel, and pilots are

aware of its designation.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Alternate Action

Safety Recommendation No.: A-98-42

Date Issued: June 25, 1998

Recommendation:

Develop a universal set of hand signals for use between airport rescue and fire fighting

personnel and flight crews and flight attendants for situations in which radio

communication is lost.

Recipient(s): Status:

Federal Aviation Administration Closed—Acceptable Action

Safety Recommendation No.: A-99-10

Date Issued: February 19, 1999

Recommendation:

Identify all airplanes operated under Title 14 Code of Federal Regulations Part 121

with liferaft ceiling stowage compartments or compartments that formerly stored

liferafts that open downward and issue an airworthiness directive to limit the distance

that those compartments can open.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response

Safety Recommendation No.: A-99-100

Date Issued: December 9, 1999

Recommendation:

For a 12-month period, require that all operators of transport-category aircraft

demonstrate the on-airplane operation of all emergency evacuation systems (including

door opening assist mechanisms and slide or slide/raft deployment) on 10 percent of

each type of airplane (minimum of one airplane per type) in their fleets. These

demonstrations should be conducted on an airplane in a controlled environment so that

the entire evacuation system can be properly evaluated by qualified personnel. The

results of the demonstrations (including an explanation of the reasons for any failures)
Appendix A 108 Safety Study

should be documented for each component of the system and should be reported to the

FAA.

Recipient(s): Status:

Federal Aviation Administration Open—Unacceptable Response

Safety Recommendation No.: A-99-101

Date Issued: December 9, 1999

Recommendation:

Revise the requirements for evacuation system operational demonstrations and

maintenance procedures in air carrier maintenance programs to improve the reliability

of evacuation systems on the basis of an analysis of the demonstrations recommended

in A-99-100. Participants in the analysis should include representatives from aircraft

and slide manufacturers, airplane operators, and crewmember and maintenance

associations.

Recipient(s): Status:

Federal Aviation Administration Open—Acceptable Response
109 Safety Study

Appendix B

Summary of the Evacuation Cases

Investigated for the Study

Case No. 1

Date of Evacuation: September 24, 1997

Location: Salt Lake City, Utah

Air Carrier: Frontier Airlines

Aircraft Type: Boeing 737

Number of Passengers: 66

Description:

After takeoff from Salt Lake City, the captain advised the other crewmembers that

there was a system failure and they should “be prepared for anything.” The airplane turned

back to Salt Lake City. The flight attendants reported that the landing appeared fast and

that the airplane took a long time to slow down. After landing, the airplane took a sharp

turn to the right, began bumping, tilted right, and then stopped. When the airplane came to

a stop, the captain announced over the public address system, “Flight attendants

evacuate.” The flight attendants unbuckled their seat belts and then opened floor level exit

doors (L1, R1, R2). The escape slides immediately inflated. The flight attendants reported

that most passengers wanted to take carry-on baggage including guitars, crutches, and

cases. The flight attendants confiscated the passenger baggage. Many passengers argued

with the flight attendants and became forceful. No fire or smoke was apparent. One flight

attendant sustained a minor injury using a slide.
Appendix B 110 Safety Study

Case No. 2

Date of Evacuation: November 4, 1997

Location: Sterling, Virginia

Air Carrier: Atlantic Coast Airlines

Aircraft Type: British Aerospace Jetstream 3100

Number of Passengers: 2

Description:

After the flight crew noticed in flight a “glow” and an electrical burning smell

emanating from the communication control station panel, the captain decided to return to

Dulles International Airport. After landing, the airplane taxied off the runway, and the

passengers and crew evacuated using an airplane door. ARFF personnel found no

evidence of fire. There were no injuries reported to the Safety Board.

Case No. 3

Date of Evacuation: November 7, 1997

Location: Charlotte, North Carolina

Air Carrier: US Airways

Aircraft Type: Fokker 100

Number of Passengers: 99

Description:

The airplane landed normally, but then experienced a failure and separation of its

right main landing gear. The first officer called the tower controller to report that the

airplane had stopped on the runway and asked if there was any fire on the airplane. The

tower responded, “No.” Because of lack of fire, the captain ordered an evacuation through

the R1 exit only. A flight attendant opened the door and inflated the slide. A passenger

opened the overwing window exit at seat 12F prior to the evacuation notice but went

forward after hearing the evacuation announcement. At the exit, the flight attendant was

commanding, “Sit and slide.” After 10–15 passengers evacuated, the first officer at the

bottom of the slide noticed fire on the left main gear and ordered the right window exits to

be used also. A passenger opened the overwing window exit at seat 11F. The flight

attendants reported that many passengers attempted to take their belongings. There were

no reported injuries. The only reported equipment problem was condensation that covered

the viewer for assessing conditions outside the R1 door.
Appendix B 111 Safety Study

Case No. 4

Date of Evacuation: December 19, 1997

Location: San Francisco, California

Air Carrier: Alaska Airlines

Aircraft Type: McDonnell Douglas MD-80

Number of Passengers: 69

Description:

The airplane was taxiing to the gate when fumes and mist began to enter the cabin.

The smoke quickly filled the cabin, reducing visibility and causing respiratory distress for

passengers and the crew. The captain stopped the airplane on a taxiway and ordered an

evacuation using the public address system. All exits were opened and slides were

deployed. No problems were reported but all flight attendants commented on having to

divest passengers of carry-on baggage. The flight attendants indicated a concern that

baggage could block the path to the exit. Flight attendants also commented on how useful

their flashlights were during the evacuation. There were eight minor injuries reported to

the Safety Board.

Case No. 5

Date of Evacuation: December 25, 1997

Location: Eugene, Oregon

Air Carrier: United Airlines

Aircraft Type: Boeing 737

Number of Passengers: 100

Description:

While the airplane was standing at the gate, passengers were in the process of

deplaning when ground personnel signaled the captain that there was a fire in the No. 2

engine. The captain ordered an evacuation. The flight crew then performed the checklist

procedures. About 20 passengers exited the R2 exit via the slide. About 20 passengers

more exited via the left and right overwing exits. The slide at exit L2 had already been

disarmed, and the slide did not operate. During the evacuation, the captain noticed that the

fuel lever was in the idle position and when he retarded it to “off,” the smoke stopped

coming from the engine. The captain then stopped the evacuation. No injuries were

reported to the Safety Board.
Appendix B 112 Safety Study

Case No. 6

Date of Evacuation: January 21, 1998

Location: Windsor Locks, Connecticut

Air Carrier: Continental Express 

Aircraft Type: Avions de Transport Regional ATR-42

Number of Passengers: 36

Description:

During the landing roll, the flight crew heard a loud bang and saw an orange glow

from the right side of the airplane. After the airplane had stopped, the flight crew

attempted to extinguish the fire from the cockpit. The fire was not extinguished so the

captain ordered an evacuation of the airplane using only the left exits. The flight attendant

opened the main cabin door and the first officer opened the overwing exit. Passengers

attempted to take carry-on baggage. One minor injury was reported to the Safety Board.

Case No. 7

Date of Evacuation: January 22, 1998

Location: Peoria, Illinois

Air Carrier: Trans States Airlines

Aircraft Type: Avions de Transport Regional ATR-72

Number of Passengers: 10

Description:

While in flight, the flight crew received an indication of a fire on the right engine.

The captain used the fire bottle, but the indication stayed on. After landing, the captain

used the second fire bottle and the indication went out. The captain initiated an evacuation

on the left side of the airplane. The evacuation was conducted via the main cabin door. No

injuries were reported to the Safety Board.
Appendix B 113 Safety Study

Case No. 8

Date of Evacuation: February 9, 1998

Location: Honolulu, Hawaii

Air Carrier: Hawaiian Airlines

Aircraft Type: McDonnell Douglas DC-9

Number of Passengers: 139

Description:

During the takeoff roll, the flight crew felt and heard loud vibrations. The captain

aborted the takeoff. The tower then reported a fire on the right side, and the flight crew

ordered an evacuation using the forward exits. During the evacuation, the R1 slide did not

deploy. The investigation revealed that the inflation bottle was not charged. The airline

reported confusion over who had responsibility for performing the daily checks of the

inflation bottle. The airstairs were deployed for the L1 exit after the flight attendant heard

there was no fire. Passengers and crew deplaned without incident. No injuries were

reported to the Safety Board.

Case No. 9

Date of Evacuation: February 9, 1998

Location: Chicago, Illinois

Air Carrier: American Airlines

Aircraft Type: Boeing 727

Number of Passengers: 115

Description:

The airplane landed short of the runway threshold while attempting a landing in

fog. The captain reported issuing the “easy victor” command, but the flight attendants did

not hear this command because the public address system and radios were damaged in the

impact. A liferaft storage bin door that opened upon impact blocked the L1 exit. Further,

oxygen masks deployed, and two passengers reported seeing other passengers putting on

masks. One flight attendant reported having to rock the R2 door to get the slide out.

Another flight attendant reported a passenger helped her open the L2 exit by kicking the

door. While the passengers was evacuating, one airplane landed on the runway and

another airplane performed a “touch and go” after seeing debris on the runway. Twentythree minor injuries were reported to the Safety Board.
Appendix B 114 Safety Study

Case No. 10

Date of Evacuation: February 12, 1998

Location: Arlington, Virginia

Air Carrier: Delta Air Lines

Aircraft Type: McDonnell Douglas MD-88

Number of Passengers: 49

Description:

While taxiing, the flight crew received a report from another airplane that flames

were coming from the No. 2 engine. Thirteen passengers evacuated via the L1 slide before

the flight crew halted the evacuation. The 13 passengers were reboarded and the airplane

was towed to the gate. No injuries were reported to the Safety Board.

Case No. 11

Date of Evacuation: February 22, 1998

Location: Lawton–Fort Sill, Oklahoma

Air Carrier: American Eagle 

Aircraft Type: Saab 340

Number of Passengers: 3

Description:

In flight, the flight crew smelled an odor of electrical burning and noticed the gear

control circuit breaker had popped. The flight crew lowered the gear and received an

unsafe gear indication for the main gear. After three flybys of the tower could not

determine the status of the gear, the flight crew told the flight attendant the problem but

did not brief the passengers. ARFF units were waiting along the runway for the airplane.

Upon landing, the left main gear collapsed and the airplane left the runway. ARFF

crewmembers opened the left overwing exit and passengers evacuated. No injuries were

reported to the Safety Board.
Appendix B 115 Safety Study

Case No. 12

Date of Evacuation: March 27, 1998

Location: Chicago, Illinois

Air Carrier: Air Canada

Aircraft Type: McDonnell Douglas DC-9

Number of Passengers: 27

Description:

During taxi prior to takeoff, the flight crew smelled smoke in the cockpit and

called for the lead flight attendant to enter the cockpit to verify the smoke. Flames and

smoke were observed to be coming from the overhead console. The flight crew then

issued the evacuation command directly to the flight attendant in the cockpit. The flight

attendant called for passengers to evacuate using the forward two exits. He opened both

doors and the slides deployed. The flight attendant commanded passengers to “sit and

slide.” The flight attendant decided to evacuate forward to minimize injury from overwing

exits. No injuries were reported to the Safety Board.

Case No. 13

Date of Evacuation: March 30, 1998

Location: Ft. Lauderdale, Florida

Air Carrier: Royal Airlines

Aircraft Type: Boeing 727

Number of Passengers: 188

Description:

During the takeoff roll, the captain stated he felt a thud and observed the engine

fail and engine fire lights illuminate for the No. 2 engine. He rejected the takeoff and

brought the airplane to a stop on the runway where he ordered an evacuation. The flight

attendants were able to open all four doors, and all slides deployed normally. The

passengers opened all four overwing exits. The first officer left the airplane via the cockpit

window and noticed many passengers standing on the wing heading toward the wingtip.

The first officer then directed passengers to the back of the wing and assisted them off the

wing. There were 14 minor injuries reported, and 3 passengers sustained serious injuries

getting off the wing.
Appendix B 116 Safety Study

Case No. 14

Date of Evacuation: April 15, 1998

Location: Indianapolis, Indiana

Air Carrier: Chautauqua Airlines

Aircraft Type: British Aerospace Jetstream 3100

Number of Passengers: 6

Description:

The flight crew was advancing the propeller levers to take off when they received a

fire warning indication for the left engine. They aborted the takeoff and declared an

emergency with air traffic control (who contacted ARFF). The airplane proceeded to a

taxiway. The first officer went to the cabin and opened the right overwing exit. All

passengers and crew used this exit. No injuries were reported to the Safety Board.

Case No. 15

Date of Evacuation: April 18, 1998

Location: Worcester, Massachusetts

Air Carrier: United Express

Aircraft Type: British Aerospace Jetstream 4100

Number of Passengers: 29

Description:

After departure, the belly (POD) baggage compartment fire warning light

illuminated. The airplane returned to the airport and landed. The crew and the passengers

evacuated onto the taxiway via the entry stairs. The ARFF inspection revealed no fire. No

injuries were reported to the Safety Board.
Appendix B 117 Safety Study

Case No. 16

Date of Evacuation: April 20, 1998

Location: Chicago, Illinois

Air Carrier: American Airlines

Aircraft Type: Boeing 727

Number of Passengers: 149

Description:

While the airplane was at the gate, the auxiliary power unit (APU) torched during

start. Passengers saw the flame and proceeded to begin an uncommanded evacuation. The

left overwing exits were opened by passengers. The aft flight attendant reported

passengers moving toward the aft portion of the airplane. She tried to stop the passengers

but could not. She also reported attempting to contact the flight crew. She opened the rear

airstairs “to avoid the stampede.” The flight attendants in the front of the airplane were

unaware of why the passengers were evacuating through the jetway and told the flight

crew that a problem existed. In the rear of the airplane, two passengers opened the

unarmed L2 door and lowered a passenger out of the exit. The flight crew was able to stop

the evacuation and ordered passengers to deplane using the aft airstairs. Passengers on the

wing who were unwilling to jump to the ground reentered the cabin and deplaned via the

aft airstairs. Two minor injuries were reported, and one passenger sustained a serious

injury as a result of jumping off the wing.

Case No. 17

Date of Evacuation: April 23, 1998

Location: Atlantic City, New Jersey

Air Carrier: US Airways Express

Aircraft Type: de Havilland DHC-8 (“Dash” 8)

Number of Passengers: 19

Description:

The flight was en route when a smoke indication light illuminated for the aft

baggage compartment. The flight was diverted and landed safely. The passengers were

evacuated from the airplane via the main door. There was no evidence of smoke or fire.

No injuries were reported to the Safety Board.
Appendix B 118 Safety Study

Case No. 18

Date of Evacuation: April 25, 1998

Location: Detroit, Michigan

Air Carrier: Trans World Airlines

Aircraft Type: McDonnell Douglas DC-9

Number of Passengers: 26

Description:

The flight crew aborted takeoff after a failure of the right engine. The airplane was

stopped on the runway, and the captain ordered an evacuation through the forward exits.

The flight crew indicated that ARFF personnel were unable to indicate the extent of the

engine fire. The R1 and L1 exits were opened. Only a few passengers used the R1 exit

because the flight attendant was not directing people to it. One minor injury was reported

to the Safety Board.

Case No. 19

Date of Evacuation: May 26, 1998

Location: Indianapolis, Indiana

Air Carrier: Northwest Airlines

Aircraft Type: McDonnell Douglas DC-9

Number of Passengers: 101

Description:

The flight crew was in the process of starting the engines just after pushback when

a ground crewmember in front of the airplane called the flight crew to report a left engine

fire. A flight crewmember proceeded to use the fire bottle for the left engine, which was

not on fire. (Each crewmember had a differenent vantage of the engine.) The flight crew

commanded an evacuation using only the forward exits. Passengers in the exit row opened

their overwing exits. Both Type III exit hatches were found inside the airplane blocking

the exit rows. Ground personnel noticed passengers hesitant to leave the wing and brought

a baggage loader belt to the wings to assist passengers off the wings. Passengers insisted

on taking carry-on baggage. This created congestion in the front of the airplane so flight

attendants began tossing luggage out of the door. One captain, not on the flight, received a

minor injury while assisting at the bottom of a slide.
Appendix B 119 Safety Study

Case No. 20

Date of Evacuation: June 4, 1998

Location: Huntsville, Alabama

Air Carrier: Northwest Airlink

Airplane Type: Saab 340

Number of Passengers: 16

Description:

The baggage compartment smoke indication activated during the climb to cruise

altitude. The flight returned to the airport and landed. The airplane was stopped on the

runway, and passengers exited using the main cabin door. ARFF personnel found no

evidence of a fire. No injuries were reported to the Safety Board.

Case No. 21

Date of Evacuation: June 6, 1998

Location: Evansville, Indiana

Air Carrier: Trans States Airlines

Airplane Type: British Aerospace Jetstream 4100

Number of Passengers: 20

Description:

The airplane took off from Evansville at 9:35 a.m. The captain saw an indication of

a cargo fire and declared an emergency and returned to Evansville. The captain taxied the

airplane off the runway and commanded “easy victor left” on the taxiway. The flight

attendant determined that the forward left exit was unsafe because of a rotating propeller.

The flight attendant directed passengers out of the right rear exit. ARFF personnel found

no evidence of a fire. One passenger sustained bruised ribs jumping from the exit.
Appendix B 120 Safety Study

Case No. 22

Date of Evacuation: June 28, 1998

Location: Newark, New Jersey

Air Carrier: Continental Express

Aircraft Type: Avions de Transport Regional ATR-42

Number of Passengers: 45

Description:

The airplane taxied almost directly downwind for departure. The high ambient

temperature and a strong surface wind caused hot exhaust gases to become trapped in the

nacelle area. Eventually, this condition activated the engine fire warning system. The crew

secured both engines and ordered a precautionary passenger evacuation. The main cabin

entrance door was the only exit used during this evacuation. One minor injury was

reported to the Safety Board.

Case No. 23

Date of Evacuation: July 8, 1998

Location: Rochester, New York

Air Carrier: Blue Ridge/Atlantic Coast

Aircraft Type: British Aerospace Jetstream 4100

Number of Passengers: 10

Description:

In flight, the flight crew received an indication of a right engine fire. The flight

crew discharged the engine halon and landed the airplane. The evacuation proceeded out

the main cabin door. Thirteen passengers and crew evacuated without injury.
Appendix B 121 Safety Study

Case No. 24

Date of Evacuation: July 9, 1998

Location: San Juan, Puerto Rico

Air Carrier: American Airlines

Aircraft Type: Airbus Industrie A300

Number of Passengers: 234

Description:

Shortly after takeoff, the flight crew received an indication of a fire in the No. 1

engine. The flight crew immediately declared an emergency and returned to the departure

airport. After landing, the flight crew stopped the airplane on the runway and ordered an

evacuation using the public address system stating, “Do not use the left overwing exits.”

The power assist for doors L1 and R1 did not function. The R2 and R4 exit doors opened

as intended, but the R3 door never opened fully during the evacuation. The R4 slide was

blown by the wind, making it temporarily unavailable for passenger use. Twenty-eight

minor injuries were reported to the Safety Board.

Case No. 25

Date of Evacuation: July 29, 1998

Location: Newark, New Jersey

Air Carrier: Continental Airlines

Aircraft Type: Boeing 737

Number of Passengers: 109

Description:

While waiting for departure, the flight crew received a report from ground control

that heavy smoke had been seen coming out of the engine. The flight crew requested

ARFF support. Once on scene, ARFF personnel reported that they suspected an internal

fire. The flight crew, using the ARFF information, decided to evacuate from the right side

of the airplane. When all passengers had exited the airplane, the flight attendants

evacuated down the slides. Once on the ground, the flight attendants noticed all

passengers that evacuated to the wing were still on the wing. The flight attendants assisted

the passengers off the wings. Eleven minor injuries were reported.
Appendix B 122 Safety Study

Case No. 26

Date of Evacuation: August 13, 1998

Location: Knoxville, Tennessee

Air Carrier: Comair

Aircraft Type: Canadair Regional Jet

Number of Passengers: 46

Description:

While en route, the flight crew had a smoke cargo warning message, triple chimes,

and a smoke aural. The flight crew completed the required checklist and declared an

emergency with air traffic control. The flight attendant, briefed by the flight crew on the

problem, prepared the passengers for an emergency landing. The airplane landed and was

stopped on a high-speed taxiway at which time the captain ordered an evacuation. After

the airplane was evacuated, ARFF inspected the cargo bay. No evidence of fire was found.

No injuries were reported to the Safety Board.

Case No. 27

Date of Evacuation: August 27, 1998

Location: Phoenix, Arizona

Air Carrier: American Airlines

Aircraft Type: McDonnell Douglas MD-82

Number of Passengers: 75

Description:

ARFF advised the flight crew that fuel was coming out of the airplane’s left

engine. The flight crew ordered an evacuation and indicated that the L2 and left overwing

exits were not to be used. No injuries were reported to the Safety Board.
Appendix B 123 Safety Study

Case No. 28

Date of Evacuation: September 10, 1998

Location: Newburg, New York

Air Carrier: Atlantic Southeast Airlines

Aircraft Type: Canadair Regional Jet

Number of Passengers: 30

Description:

As the plane neared the airport, the cargo compartment fire indication light

illuminated intermittently. The flight crew discharged halon into the compartment and

continued their flight. After the airplane landed, the warning light illuminated once again

and the captain decided to evacuate the airplane on the taxiway. The L1 door was used.

There was no evidence of fire found by ARFF, and no injuries were reported to the Safety

Board.

Case No. 29

Date of Evacuation: September 13, 1998

Location: Raleigh–Durham, North Carolina

Air Carrier: US Airways Express

Aircraft Type: Canadair Regional Jet

Number of Passengers: 40

Description:

The flight crew received an in-flight indication of smoke in the cargo compartment

and declared an emergency. During the airplane’s descent, the flight attendant prepared the

passengers for an evacuation. After the airplane, and passengers exited via the forward left

exit onto the taxiway. ARFF personnel did not find any evidence of smoke or fire in the

cargo compartment. No injuries were reported to the Safety Board.
Appendix B 124 Safety Study

Case No. 30

Date of Evacuation: October 24, 1998

Location: San Juan, Puerto Rico

Air Carrier: American Eagle

Aircraft Type: Avions de Transport Regional ATR-42

Number of Passengers: 23

Description:

The airplane collided with a ground power unit after engine start, causing fuel to

leak from the No. 2 engine and ignite. After completing the checklist for engine fire on the

ground, the captain opened the left forward emergency exit. The flight attendant attempted

to contact the cockpit but received no response. On her own initiative, she opened the

main cabin door to evacuate passengers. Three passengers sustained minor injuries.

Case No. 31

Date of Evacuation: October 30, 1998

Location: Shreveport, Louisiana

Air Carrier: American Eagle

Aircraft Type: Saab 340

Number of Passengers: 27

Description:

In flight, the flight crew detected smoke in the cockpit and cabin. They declared an

emergency and landed. The flight crew stopped the airplane on a taxiway and ordered an

evacuation. The passengers exited the airplane via the left forward exit. The smoke was

from an engine malfunction. No injuries were reported to the Safety Board.
Appendix B 125 Safety Study

Case No. 32

Date of Evacuation: November 1, 1998

Location: Atlanta, Georgia

Air Carrier: Air Trans Airlines

Aircraft Type: Boeing 737

Number of Passengers: 100

Description:

In flight, the flight crew received an indication of a loss of their airplane’s “A”

hydraulic system. Upon landing, the airplane lost its “B” hydraulic system, causing the

airplane to veer off the runway and collide with an embankment. The flight crew ordered

an evacuation. One flight attendant reported difficulty opening the R1 exit because of the

incline of the airplane. Another flight attendant reported a failure of a slide to inflate

automatically. Although the placard indicated the slide was automatic, it was a manually

inflating slide. Eleven minor injuries were reported to the Safety Board.

Case No. 33

Date of Evacuation: November 3, 1998

Location: Miami, Florida

Air Carrier: Gulfstream

Aircraft Type: Beech 1900

Number of Passengers: 19

Description:

The captain reported that shortly after takeoff, while climbing through 2,800 feet,

the first officer noted smoke in the cockpit. The smoke was reported to have an acrid smell

and was light gray in color. An emergency was declared to air traffic control and both

pilots donned their oxygen masks. Oxygen was also provided to the passengers. The

captain completed the landing checklist then notified the passengers of the intent to

evacuate the airplane after landing. The airplane landed uneventfully and all passengers

were evacuated using the overwing exits. There were no reported injuries.
Appendix B 126 Safety Study

Case No. 34

Date of Evacuation: November 12, 1998

Location: Boston, Massachusetts

Air Carrier: Allegheny Airlines

Aircraft Type: de Havilland DHC-8 (“Dash” 8)

Number of Passengers: 18

Description:

While the airplane was at the gate preparing for departure, the captain noticed

smoke and sparks coming from the No. 1 engine cowling. The captain ordered an

evacuation through the right floor level exit. The flight attendant opened the exit and

placed the exit door inside the airplane to avoid hurting ramp personnel. There were no

reported injuries.

Case No. 35

Date of Evacuation: December 26, 1998

Location: Dallas–Fort Worth, Texas

Air Carrier: Delta Airlines

Aircraft Type: McDonnell Douglas MD-88

Number of Passengers: 44

Description:

The airplane was taxiing for departure when crewmembers in other airplanes

observed a fire on the No. 2 engine of the taxiing airplane. The airport tower called for

ARFF support. The captain decided to evacuate the airplane using the left (opposite fire)

side exits. The evacuation was assisted by four commuting flight attendants and two

commuting pilots. One passenger broke an ankle at the bottom of a slide.
Appendix B 127 Safety Study

Case No. 36

Date of Evacuation: December 28, 1998

Location: Phoenix, Arizona

Air Carrier: United Airlines

Aircraft Type: Airbus Industrie A320

Number of Passengers: 145

Description:

The flight crew declared an emergency en route after a suspicious package was

found. The pilot radioed for two portable stairs to be brought to the airplane to assist in

removing passengers. After the airplane landed, it was taken to a secure area where

passengers evacuated through the L1 exit down the portable stairs following a discussion

between ground personnel and flight crew. No injuries were reported to the Safety Board.

Case No. 37

Date of Evacuation: December 29, 1998

Location: White Plains, New York

Air Carrier: Business Express

Aircraft Type: Saab 340

Number of Passengers: 4

Description:

When the airplane arrived at the gate, the flight attendant observed smoke in the

vicinity of the left engine and notified the captain. The captain commanded an evacuation

on the right side. When the flight attendant opened the right door, the propellers were still

spinning. The flight crew reassessed the situation and commanded an evacuation out the

left main cabin. No injuries were reported to the Safety Board.
Appendix B 128 Safety Study

Case No. 38

Date of Evacuation: January 7, 1999

Location: San Diego, California

Air Carrier: AeroMexico

Aircraft Type: McDonnell Douglas MD-80

Number of Passengers: 36

Description:

A report of a bomb threat was transmitted to the flight crew when they were 1 hour

away from landing. The flight crew notified the flight attendants. Upon landing, the

captain ordered an evacuation. The flight attendants gave instructions to the passengers in

Spanish only. Everyone evacuated via emergency slides except the tailcone slide, which

failed to inflate. The air carrier reported that the lanyard for deploying the slide was

installed incorrectly. One minor injury was reported to the Safety Board.

Case No. 39

Date of Evacuation: January 8, 1999

Location: Covington, Kentucky

Air Carrier: Comair

Aircraft Type: Canadair Regional Jet

Number of Passengers: 5

Description:

While holding for takeoff, the captain noticed a cargo smoke warning indicator

illuminate. The captain taxied to the airport fire station 1,000 feet away. When the airplane

reached the fire station, passengers evacuated via the main cabin door. No evidence of fire

was found by ARFF personnel, and there were no injuries reported to the Safety Board.
Appendix B 129 Safety Study

Case No. 40

Date of Evacuation: January 19, 1999

Location: St. Louis, Missouri

Air Carrier: Trans States Airlines

Aircraft Type: Avions de Transport Regional ATR-72

Number of Passengers: 17

Description:

On short final approach at an altitude of less than 400 feet above ground level, the

flight crew received a fire warning for engine No. 2. The landing was continued. After

landing, the airplane was taxied clear of the runway. ARFF personnel responded; however,

the fire was reportedly extinguished prior to their arrival. Passengers evacuated through

the main cabin door. No injuries were reported to the Safety Board.

Case No. 41

Date of Evacuation: January 24, 1999

Location: Charlotte, North Carolina

Air Carrier: American Airlines

Aircraft Type: Fokker 100

Number of Passengers: 70

Description:

While taxiing, the flight crew received an indication of smoke coming from the

right main landing gear. The airplane entered a taxiway, and the flight crew ordered an

evacuation using the forward exits and the left overwing exits. The flight attendant had to

rock the L1 door to get it to open. One flight attendant incurred a sprained knee. Further, a

flight attendant reported that the window to assess conditions outside the L1 door was

covered in condensation and difficult to use. One minor injury was reported to the Safety

Board.
Appendix B 130 Safety Study

Case No. 42

Date of Evacuation: January 24, 1999

Location: Newark, New Jersey

Air Carrier: Continental Express

Aircraft Type: Embraer EMB-145

Number of Passengers: 48

Description:

After landing and during taxi to the gate, the flight crew started the auxiliary power

unit (APU). Shortly thereafter the crew received a lavatory smoke warning. The flight

crew called the flight attendant on the intercom and asked if any smoke was visible in the

lavatory or the cabin. The flight attendant reported that smoke/fire was not visible in the

lavatory or the cabin and the lavatory was not occupied. However, the flight attendant

informed the flight crew that an odor of something burning was present in the cabin. The

flight crew elected to stop the airplane and ordered an evacuation. The airplane was

inspected and there was no evidence of smoke or fire. No injuries were reported to the

Safety Board.

Case No. 43

Date of Evacuation: February 17, 1999

Location: Columbus, Ohio

Air Carrier: American West

Aircraft Type: Airbus Industrie A320

Number of Passengers: 26

Description:

Upon approach, the flight crew received indications of a gear problem. The crew

conducted a tower flyby and determined the nosegear was sideways. The flight attendants

were informed of an impending emergency landing. The flight attendants reseated the

passengers and briefed the passengers for the emergency landing. The evacuation was

carried out through the four overwing exits. There were no injuries reported to the Safety

Board.
Appendix B 131 Safety Study

Case No. 44

Date of Evacuation: May 8, 1999

Location: Jamaica, New York

Air Carrier: American Eagle

Aircraft Type: Saab 340

Number of Passengers: 27

Description:

Upon landing in rain with visibility of less than 1/4 mile, the flight crew landed the

airplane 7,000 feet down an 8,400-foot runway. The airplane proceeded off the end of the

runway and into an “engineered materials arresting system” (EMAS). The airplane sank

30 inches into the EMAS at its stopping point 214 feet across the 600-foot system. The

crew ordered an evacuation. The flight attendant decided not to lower the main cabin door

airstairs because the gear was sunken in the EMAS. One passenger broke an ankle

jumping from an exit.

Case No. 45

Date of Evacuation: June 1, 1999

Location: Little Rock, Arkansas

Air Carrier: American Airlines

Aircraft Type: McDonnell Douglas MD-82

Number of Passengers: 139

Description:

The airplane crashed after landing. Thunderstorms and heavy rain were in the area

at the time of the accident. The airplane departed the end of runway, went down an

embankment, and impacted approach-light structures. Eleven persons were killed in the

accident, and 45 sustained serious injuries. Two of the 11 fatalities involved smoke

inhalation and thermal injuries sustained during the evacuation.
Appendix B 132 Safety Study

Case No. 46

Date of Evacuation: June 22, 1999

Location: Scottsbluff, Nebraska

Air Carrier: United Airlines

Aircraft Type: Boeing 737

Number of Passengers: 63

Description:

While in flight, flight attendants observed smoke in the cabin and informed the

flight crew. The smoke was suspected to be from a light ballast. The flight crew declared

an emergency and proceeded toward an alternate airport. The flight crew had requested

that portable airstairs for getting passengers off the airplane. The airplane landed

uneventfully; however, no portable airstairs were available at the airport. Passengers left

the airplane using either a ladder from the L1 exit or stepping onto a deicing stand after

exiting onto the wing. There were no injuries reported to the Safety Board.
133 Safety Study

Appendix C

Configurations of the Aircraft Types

Represented in the Study

The diagrams in this appendix are not to scale.
Appendix C 134 Safety Study
Appendix C 135 Safety Study
Appendix C 136 Safety Study
Appendix C 137 Safety Study
Appendix C 138 Safety Study
Appendix C 139 Safety Study
Appendix C 140 Safety Study
Appendix C 141 Safety Study
Appendix C 142 Safety Study
Appendix C 143 Safety Study
Appendix C 144 Safety Study
Appendix C 145 Safety Study
Appendix C 146 Safety Study
Appendix C 147 Safety Study
Appendix C 148 Safety Study
Appendix C 149 Safety Study
Appendix C 150 Safety Study
Appendix C 151 Safety Study
152 Safety Study

Appendix D

Excerpts From the Federal Regulations

Pertaining to Evacuations
Appendix D 153 Safety Study
Appendix D 154 Safety Study
Appendix D 155 Safety Study
Appendix D 156 Safety Study
Appendix D 157 Safety Study
Appendix D 158 Safety Study