Session 4. Cabin Safety Aspects in Accident Investigation

Transcription

1 1 Session 4 Cabin Safety Aspects in Accident Investigation

2 Overview Information specific to cabin safety Types of occurrences / ICAO templates Preparing for the investigation Self-protection at crash site Points to remember Q&A 2

3 Information Specific to Cabin Safety General information Documentation Aircraft (cabin specific) information Human performance Additional information Interviews 3

4 Flight information General Information Date and time occurrence, flight number, a/c type, location Injuries to persons Meteorological conditions 4

5 Injuries to Persons 5

6 Documentation Gather documentation from following sources Operator State of Operator Other sources e.g. aerodrome where accident occurred 6

7 Operator Documentation Evaluate operator policies & SOPs Relevant to occurrence Actions expected of cabin crew Evaluate operator training programme Assess content Adequacy in preparing cabin crew Additional operator documents Provide insight into organisational factors Training records, log books, etc. Rostered duties (including at least 72 hours prior to accident) 7

8 State of Operator Documentation Expand beyond operator Examine role of State of Operator Review regulatory requirements and oversight docs To determine adequacy of existing regulations Effectiveness of State s oversight activities These include Approval of manuals and training content Exemptions issued Inspections conducted Any relevant findings/observations 8

9 Documentation - Other Sources Review other documents Such as aerodrome certification manual Typically includes aerodrome ERP Medical and pathological records Factual information such as cause of occupant s death 9

10 Aircraft (Cabin Specific) Info Documenting cabin of accident aircraft is key part of investigation process Further details in Session 6 10

11 Human Performance Cabin Crew Evaluate how cabin crew performed during occurrence Operational factors Organizational factors Task-related factors System/equipment factors 11

12 Operational Factors Cabin crew member s knowledge of systems/equipment Experience level & proficiency Crew compatibility Supervision/command & control relationships Operational pressure 12

13 Crew selection Organizational Factors Aircraft qualifications for single cabin crew member Training Operator procedures and processes incl. scheduling and reporting of fatigue risk 13

14 Task components Task-related Factors Number, duration, etc. Workload tempo/saturation Judgement & decision-making Situational awareness Distractions 14

15 System/Equipment Factors Design/location of equipment Lighting Inadvertent operation Confusion of controls/switches Suitability of cabin crew clothing 15

16 Human Performance Pax Evaluate how pax performed during occurrence Pax actions/responses during pre-flight activities Listening to safety briefings, reading briefing card Pax behaviour & reactions during occurrence Understanding crew instructions during emergency Difficulties experienced Assisting crew in opening exits Post-accident actions Responses to instructions from personnel such as RFF Actions taken to increase survivability 16

17 Additional Information Insight into cabin safety aspects or survival factors Gather info regarding post-accident activities Emergency response RFF SAR 17

18 Additional Information Other pertinent information Characteristics of crash site which affected survivability e.g. remote area If occurrence took place at aerodrome Additional info on aerodrome Its characteristics Any special features e.g. arresting systems 18

19 Types of Occurrences Events classified as accidents, as per ICAO s definition Evacuation Ditching or inadvertent water contact Fire, smoke, and/or fumes Turbulence Decompression Aircraft damage Fatal or serious injuries (miscellaneous) 19

20 ICAO Templates for Investigation App D - G to Chap 5 provide guidance for investigating different types of occurrences Detailed templates cover all areas General information Documentation (different sources) Aircraft cabin-specific aspects Human performance (cabin crew & pax) Additional information Interviews Explain what to gather (specific info) and why (objective) 20

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22 An accident occurs 22

23 Preliminary Information Upon receiving notification of accident, obtain as many details as possible Capture preliminary information in occurrence summary App A to Chap 5 presents sample occurrence summary 23

24 Departure Preparations Gather launch information Verify Necessary documents Clothing suitable for environment All required inoculations & vaccinations Investigation field kit Necessary funds for mission Follow quick reference checklist App D to Chap 4 - example checklist 24

25 Investigation Field Kit Kit should contain sufficient equipment to enable Examination of wreckage Plotting of impact points and wreckage patterns Parts identification Recording of observations List of items in App C to Chap 4 Specific to tasks of CI CI should pre-pack field kit & essential personal items 25

26 Gathering Documentation Operator records Training records, MEL, cabin defect log, crew reports Operator documentation OM, training programme content, aircraft specs Documentation relevant to occurrence Crew list, passenger manifest, cargo manifest Other relevant documentation State regulations and oversight records May need formal request 26

27 At the crash site 27

28 Self-protection at Crash Site Appropriate protective equipment Exposure control plan Identify hazards & manage risks Procedures for exposure incident Critical incident stress response 28

29 Means to Collect Data 29

30 Points to Remember Need to collect cabin safety info from several sources Importance of looking beyond operator Doc templates Guidance for completeness Be prepared for launch Protect yourself on site Seek assistance, if needed, after the fact 30

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