Inadvertent Slide Deployments Update - IATA Cabin Operations... · Inadvertent Slide Deployments Update Kai Bredemeier, ... SOLUTION FOR ALL AIRCRAFT ... Procedure design for prevention

Inadvertent Slide Deployments UpdateKai Bredemeier, Airbus Industrie

Anabel Brough, Emirates Airline

Carlos Dias, TAP Portugal

Dr. Steve Jarvis, Director Jarvis Bagshaw Ltd.

Host Ruben Inion, Austrian Airlines

Inadvertent Slide Deployments

Inadvertent Slide Deployments

IATA COSCCabin Operations Safety Conference| Doha, May 2017

Loving every moment

#IATACabinSafety

Investigation| Analysis and Follow-up

1. Factual information

2. Analysis

3. Conclusions

List the findings, causes and/or contributing factors established in the

investigation. The list of causes and/or contributing factors should include both

the immediate and the deeper systemic causes and/or contributing factors.

4. Safety recommendations

Case Study and Facts in the Cabin

History of the flight

Flight time: 30 minutes

Cabin crew: 03

Passengers: 128

Unruly passenger

SCC

CC 1

CC 2

Cabin Crew

relocated

Cabin Crew

Contributing factors

• Changing crew configuration (relocation of CC Door 1L – Door 2R)

• Unruly passenger

Contributing factors. Actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The identification of contributing factors does not imply the assignment of fault or the determination of administrative, civil or criminal liability.Source: Annex 13

Thank You!

Cabin SafetyInadvertent slide deployment events

Anabel Brough

Cabin Safety Manager

SPI/SPT event trends

Employees involved in events

Events categorised by fleet

Cabin crew communications

Questions?

Kai Bredemeier

Cabin & Cargo Architect for Cabin Safety Systems

IATA Cabin Operations Safety Conference16 – 18 May 2017, Doha

WATCHDOGPrevention of Inadvertent Slide Deployment

Source: local591.com

WATCHDOG - IATA Cabin Operations Safety Conference 2017, Doha17

Source: IATA, TFC Käufer, Brainsumers.com

WATCHDOG - IATA Cabin Operations Safety Conference 2017, Doha18

100% PLUG & PLAY SOLUTION

SOLUTION FOR ALL AIRCRAFT

IN LINE WITH CREW OPS

INTUITIVE CONCEPT

EFFECTIVE

Thank you

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Procedure design for prevention of inadvertent slide deployments

Dr Steve JarvisJarvis Bagshaw Ltd, UK

steve@jarvisbagshaw.com

Designer of easyJet’s door procedures

Novice in all things ‘cabin safety’

ISD process example (easyJet) 2013• Up to 2013, ISDs normal rate (e.g.

about 0.02 per 1000. Good rate for A320s)

• Over 1,100 departures per day

Since 2013 implementation…

• 1 Cabin Crew ISD in last 4 years

• Cabin Crew still open doors from inside (A320)

Procedures uniquelydesigned for easyJet but parts may be transferable with CAUTION (to some operators)

Techniques have influenced many operators since 2013

Human Factors of ISDs• Fatigue?• Pressure?• Distraction?• Non-adherence to SOPs?

• Obvious solution appears to be reduce the above• BUT… are the categorized causes…

– A. correctly attributed?– B. Really a reflection of base-rates?– C. Relevant?

Nice Story (academia and crew)

Design Process• Two ingredients to EVERY ISD:1. Action: lift door handle. 2. Condition: door armed

RISK• Inadvertent Consequences

i.e. more ISDs

Use of:• Cognitive interviewing• Observations• Ergonomic assessments• Analysis of all critical

error paths• Integrated solution to

resolve all paths together

Thanks for Listening

Dr Steve Jarvis

Jarvis Bagshaw Ltd, UK

steve@jarvisbagshaw.com

Inadvertent Slide Deployments UpdateKai Bredemeier, Airbus Industrie

Anabel Brough, Emirates Airline

Carlos Dias, TAP Portugal

Dr. Steve Jarvis, Director Jarvis Bagshaw Ltd.

Host Ruben Inion, Austrian Airlines