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
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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
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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
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Procedure design for prevention of inadvertent slide deployments
Dr Steve JarvisJarvis Bagshaw Ltd, UK
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
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