Inadvertent Slide Deployments Update

Inadvertent Slide Deployments Update Kai 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

IATA COSC Cabin 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 CC 1 SCC CC 2 Unruly passenger 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 Safety Inadvertent slide deployment events Anabel Brough Cabin Safety Manager

SPI/SPT event trends

Employees involved in events

Events categorised by fleet

Cabin crew communications

Questions?

WATCHDOG Prevention of Inadvertent Slide Deployment Source: local591.com Kai Bredemeier Cabin & Cargo Architect for Cabin Safety Systems IATA Cabin Operations Safety Conference 16 18 May 2017, Doha

17 WATCHDOG - IATA Cabin Operations Safety Conference 2017, Doha Source: IATA, TFC Käufer, Brainsumers.com

100% PLUG & PLAY SOLUTION SOLUTION FOR ALL AIRCRAFT IN LINE WITH CREW OPS INTUITIVE CONCEPT EFFECTIVE 18 WATCHDOG - IATA Cabin Operations Safety Conference 2017, Doha

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Procedure design for prevention of inadvertent slide deployments Dr Steve Jarvis Jarvis Bagshaw Ltd, UK steve@jarvisbagshaw.com Designer of easyjet s door procedures Novice in all things cabin safety

ISD process example (easyjet) 2013 Procedures uniquely designed for easyjet but parts may be transferable with CAUTION (to some operators) 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) Techniques have influenced many operators since 2013

Fatigue? Pressure? Distraction? Non-adherence to SOPs? Human Factors of ISDs Nice Story (academia and crew) 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?

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