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Inadvertent Slide Deployment Prevention
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Carlos Dias Safety Officer Cabin
TAP Portugal
Martin Ruedisueli Manager Flight Safety Cabin Swiss International Air Lines
Cabin Operations Safety Conference May 2014
Inadvertent Slide Deployment Prevention
Cabin Operations Safety Conference May 2014 Madrid, Spain
Carlos Dias Cabin Safety Officer
Martin Ruedisueli Manager Flight Safety Cabin
Cabin Operations Safety Conference May 2014
Contents
• Objective • The Safety study • General overview of the Industry
– STEADES: Safety Trend Evaluation Analysis & Data Exchange System – GADM: Global Aviation Data Management
• Group benchmark – ISD rate – Door Operation (Inside\outside\approaching gate) – Number of sectors flown (departures) – Fleet size – Probable cause for the ISD occurrence (investigation)
• Analysis – Contributing Factors – Professional groups involved
• Conclusion
Cabin Operations Safety Conference May 2014
Objective
Inadvertent Slide Deployment incidents review for the last 10 years. Raise the awareness of the industry about the potential risk of ISD (injuries, costs). Broaden your view regarding the promotion of ISD prevention campaign and mitigation actions by using new innovative methods.
Cabin Operations Safety Conference May 2014
Safety study according to ICAO Doc. 9859 (3rd edition)
Safety studies are analyses used to gain an understanding of broad safety issues or those of a global nature. For example, the airline industry may produce safety recommendations and implement measures to reduce accidents and incidents during the approach and landing phases. Individual service providers may find that these global recommendations improve safety performance in the context of their aviation activities.
Cabin Operations Safety Conference May 2014
General Data overview of the Industry 2009 - 2013
Reports of inadvertent slide deployments were received at a relatively consistent rate with no observable increasing or decreasing trend of reports per 1000 flights.
This chart presents the rate of inadvertent slide deployment reports and overall STEADES reports per 1000 flights per quarter between 2009 and 2013.
STEADES
Cabin Operations Safety Conference May 2014
Preventive measures
Cabin Operations Safety Conference May 2014
Contributing Factors
SOP Non-Compliance Fleet Management Inadequate SOPs Lack of Training Ad hoc situations Multi-tasking and workload Miscommunication or lack of Time pressure Distraction Fatigue Door design
Flight Crew Cabin Crew Maintenance Service providers
• Catering • Cleaning
Professional Group
Cabin Operations Safety Conference May 2014
Benchmark among IATA COSTF MEMBERS
Cabin Operations Safety Conference May 2014
Benchmark (professional group involved)
2013 16 Airlines Total Departures: 2,36 Millions
Cabin Operations Safety Conference May 2014
Benchmark (Contributing factors)
Cabin Operations Safety Conference May 2014
Operational Environment OUTSIDE
FROM OUTSIDE
Terminal Building
FROM INSIDE
APP GATE
Cabin Operations Safety Conference May 2014
Benchmark (Average ISD occurrences 2013)
OPE
RATO
RS
Open from | Disarming at Professional group: Cabin Crew
ISD’s per 1000 Sectors
Cabin Operations Safety Conference May 2014
Known Operacional Environment OUTSIDE
North Terminal Building
@APP GATE
APP GATE None
FROM OUTSIDE | GATE Distractions
FROM INSIDE | GATE SOP Non compliance Insufficient communication Irregular operations Operational environment Distractions Automatic reactions Time pressure
Above ↗ Operators average (0,008/1000 departures) Below
APP GATE None
FROM OUTSIDE | GATE SOP Non compliance Distractions Insufficient Training
FROM INSIDE | GATE SOP Non compliance
Identifying contributing Factors | average
Cabin Operations Safety Conference May 2014
Inside versus Outside…
ISD’s per 1000 Sectors (Takeoff\Landing)
Cabin Operations Safety Conference May 2014
In Conclusion
• Door opening – Inside: 69% – Outside: 31%
• Sequence on: Door disarm opening from inside has a higher probability of ISD occurrence
• Contributing factors found on this study – SOP Non compliance – Distractions
• Maintenance and Catering found involved in the activity regarding ISD occurrences
Cabin Operations Safety Conference May 2014
Proactive approach
• SOP non compliance can be related with several factors e.g. cultural issues – Develop policies in order to promote that SOPs are
conceived to avoid honest errors – Promote safety culture
• FDA (Flight data analysis) can contribute to identify inadvertent door operation
• Data analysis will improve accordingly as taxonomy is standardized
• Definition of an Inadvertent slide deployment
Cabin Operations Safety Conference May 2014
Inadvertent Slide Deployment Prevention
Martin Ruedisueli Manager Flight Safety Cabin
Carlos Dias Safety Officer Cabin
Turbulence Management
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Johnny Chin Assistant Manager Flight Safety
Singapore Airlines
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Turbulence An Unpleasant But Familiar Experience
Safety, Security and Environment (SSE)
IATA Cabin Operations Safety Seminar Madrid, Spain 21st of May, 2014
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Severe Turbulence Cases
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Flight Details #1
Date: October 2011
Sector: Shanghai (PVG) to Singapore (SIN)
Flight Time: 5hrs 40mins
Aircraft Type: B777-300
Pax Load: 3P 22J 159Y (incl. 3 infants)
Crew: 3 Pilots / 15 Cabin Crew (incl. 1 SNY)
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ICAO Definition
Accident. An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which: a) a person is fatally or seriously injured as a result of
– being in the aircraft, or – direct contact with any part of the aircraft, including parts
which have become detached from the aircraft, or – direct exposure to jet blast, – except when the injuries are from natural causes, self
inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew
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ICAO Definition
Serious injury. An injury which is sustained by a person in an accident and which: a) requires hospitalization for more than 48 hours,
commencing within seven days from the date the injury was received; or
b) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); or
c) involves lacerations which cause severe hemorrhage. nerve, muscle or tendon damage; or
d) involves injury to any internal organ; or e) involves second or third degree burns, or any burns
affecting more than 5 per cent of the body surface; or f) involves verified exposure to infectious substances
or injurious radiation.
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Flight Path
FL350
HKG FL310
PEK FL360
Vertical Gmax: 1.74g
Vertical Gmin: -0.36g
ALT gain/loss: 100ft Source: DFDR
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Pax Seating Plan
No. of Casualties: 16 Pax / 5 Cabin Crew
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Arrival in Singapore
IFS made cabin PA for pax who required medical attention to remain onboard (no immediate medical evacuation required)
16 pax and 05 cabin crew sought medical assistance – 14 adults and 02 infants (pax) – All were sent to the airport transit clinic
06 were referred to hospital for treatment – 01 was hospitalized and the rest was discharged
All 05 cabin crew only sought medical treatment the next day
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Findings
The flight flew through the outer edge of a weather build up.
Flight Crew could have employed a more active weather scanning technique (esp. in tilt management.)
Communications between “Flight Crew & Cabin Crew” and between “Cabin Crew and Cabin Crew” were not optimal – Failure of Cabin Crew to inform Flight Crew of
seriousness of event in the cabin
– Failure of Cabin Crew to inform IFS when Flight Crew contacted the cabin
– Failure of Flight Crew to correctly assess the situation
After Landing Activities – Documentation (CCVR), failure to advise CMD that it was a
draft and that her final report would be more comprehensive.
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Flight Details #2
Date: May 2013
Sector: Singapore (SIN) to Riyadh (RUH)
Flight Time: 9hrs 05mins
Aircraft Type: A330-300
Pax Load: 258
Crew: 4 Pilots / 10 Cabin Crew
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SIN - RUH
No. of casualties: 01 Pax / 03 Cabin Crew
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Flight Details #3
Date: May 2013
Sector: Singapore (SIN) to London (LHR)
Flight Time: 14hrs 05mins
Aircraft Type: A380-800
Pax Load: 328
Crew: 3 Pilots / 23 Cabin Crew
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SIN - LHR
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SIN- LHR
No. of casualties: 11 Pax / Nil Cabin Crew
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SIN- LHR The Clean-Up
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SIN- LHR After the Clean-Up
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SIN – LHR Arrival in LHR
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Follow Up Actions
1. Training in the effective use of the weather radar on all fleets – Weather radar system and usage for both RDR4000/4B weather radars.
2. Operating procedures with regards to weather avoidance – Include weather avoidance and techniques as part of the briefing by
instructors for the RT sessions – A generic PowerPoint presentation on weather avoidance and turbulence
management for all fleet.
3. Turbulence Management Working Group to review the turbulence management, with an added focus on post occurrence handling of such event. – Cabin crew should actively patrol the cabin to look out for pax with injuries
after a severe turbulence, coupled with a post turbulence announcement. – The post event communication between cabin and cockpit crew needs to be
improved.
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Turbulence Management - Moving Forward
Flight Ops will issue circulars at the start of each turbulence season for technical crew awareness.
Flight Ops Notice (FON) will be issued every month from June-November on the status of crew and pax injury to maintain awareness.
Cabin Crew will issue circulars and briefing sheet periodically to enhance crew awareness.
Implementation of PIREPs
SEP Documentation – Inflight Management of Significant Incident
Review of activation of Fasten Seatbelt Signs at a higher altitude during aircraft descend. - KIV
Software based logic to inform aircraft of turbulence on their planned flight path through aircraft to aircraft (via a ground station) communications. – KIV
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Unruly Passenger – Consequences of an improper
assessment by Cabin Crew
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Philippe Bricaud Head of Standards and Cabin Crew Training
Air France
Interactive Panel Discussion on Unruly Passenger Prevention and Management
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Moderator: ;
Tim Colehan,Assistant Director External Affairs, IATA
Panel Members: Auguste Hocking, Legal Analyst, IATA
Brian Kinane, Air Crew Security Training Manager, Emirates
Lorena Guardia, Cabin Crew Safety Analyst, LAN Group Airlines
Captain Christian Thein, Flight Operations Security Representative, Luxair
To represent, lead and serve the airline industry
Panel on Unruly Passenger Prevention and Management IATA Cabin Operations Safety Conference 22 May, 2014
Panelists Auguste Hocking, Legal Counsel, IATA
Brian Kinane, Training Manager - Security, Emirates
Captain Christian Thein, Flight Operations Security Representative, Luxair
Lorena Guardia, Cabin Crew Safety, LAN Airlines
IATA Cabin Operations Safety Conference 22 May, 2014
Moderator: Tim Colehan, Assistant Director External Affairs, IATA
Unruly Behaviour Brian Kinane
Training Manager - Security
©2013 Emirates. All Rights Reserved.
Restraints
0.00000%
0.00005%
0.00010%
0.00015%
0.00020%
0.00025%
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Restraints as % of passengers carried
2014 - %
2013 - %
2012 - %
2011 - %
2010 - %
Alcohol
• Sociable • Relaxed • Comfortable • Happy
Continue RSA
Monitor
• Shows reduced inhibitions • Has impaired judgment • Talks / laughs louder than
normal • Seems overly friendly • Argues or baits • Uses foul language more
frequently • Increases alcohol
consumption • Is careless with personal
belongings
4Ds Communicate Monitor
• Moves in slow motion • Responds slowly to questions • Appears glassy-eyed • Loses train of thought • Makes irrational statements • Spills drinks • Walks awkwardly • Stumbles or falls down • Is unable to sit up straight
Deny Communicate Offload
BEHAVIOURS / SIGNS ACTIONS / OPTIONS
TRAFFIC LIGHT GUIDE
Note: some signs & symptoms associated with intoxication may actually be related to a medical condition
Thank you
©2013 Emirates. All Rights Reserved.
Luxair Luxembourg Airlines S.A. Unruly Passengers Policy IATA Cabin Operations Safety Conference 22/05/14 Presented by Capt. Christian Thein
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Luxair Upax background
• Doubling of unruly passenger events 2010-2013
• Different events on business and leisure flights
• Empower staff to stop the problem at the gate
• Behavioural change within the European society:
‘I want what I want and when I want it!’
• Solid legal framework in Luxembourg and Europe
• Single CCM operation on Embraer 145
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Updated Upax policy since 2013
• Zero tolerance / denied boarding
• Guidance for all 4 ICAO Upax levels
• Pre-flight observation of passengers
• Emphasis on conflict resolution and de-escalation
• Passenger Warning Cards and restraint kits
• Prosecution/blacklisting of offenders and legal support to staff
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Upax training
• Combined training for cockpit and cabin crew:
• Communication
• Captain’s authority and support
• Safety concerns (single cabin crew)
• CCM customer care training
• Hands-on CCM training on restraint techniques
• Effective Passenger Warning Card distribution
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Challenges
• Free alcohol service
• Standardizing of staff response
• Single CCM operation:
• Passenger involvement
• Safety risk
• Blacklisting of passengers
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Thank you for your attention
UNRULY PASSENGERS Presented By Lorena Guardia Cabin Safety
May 2014
U n ru ly Pa ssen gers 2 0 1 3
197 reports registred 234,000 total legs
27309
Total
197
Others
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Physical Agression
Alcohol Smoking
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Instructions Insults
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Actual scenario • Different regulations • Different criteria
U n ru ly Pa ssen gers 2 0 1 3
Future Challenge • Establish only one unruly policy • Enforced training for cabin crew and pilots
U n ru ly Pa ssen gers 2 0 1 3
Panelists Auguste Hocking, Legal Counsel, IATA
Brian Kinane, Training Manager - Security, Emirates
Captain Christian Thein, Flight Operations Security Representative, Luxair
Lorena Guardia, Cabin Crew Safety, LAN Airlines
IATA Cabin Operations Safety Conference 22 May, 2014
Moderator: Tim Colehan, Assistant Director External Affairs, IATA
Resources For information on the Tokyo
Convention and Montreal Protocol www.iata.org/policy
Download Guidance on Unruly Passenger Prevention & Management: www.iata.org/whatwedo/safety/Pages/cabin-safety.aspx
IATA Cabin Operations Safety Conference 22 May, 2014
Refreshment Break
Top Cabin Safety Issues of Concern and Regional Initiatives
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Moderator: Gennaro “Rino” Anastasio, Cabin Safety Officer, Alitalia
Panel Members: Steven Bereznak, Chair Cabin Operations Committee, Airlines for America (A4A)
Darryl Heck, Chair Cabin Safety Subcommittee, National Airlines Counsil of Canada (NACC)
Anna V. Serdyuk, Senior Cabin Crew Instructor, Aeroflot, representing FATA
Top Cabin Safety Issues of Concern and Regional Initiatives
Panel Members Steven Bereznak (American Airlines), Chair Cabin Operations
Committee, Airlines for America (A4A) Darryl Heck (WestJet), Chair Cabin Safety Subcommittee, National
Airlines Council of Canada (NACC) Anna V. Serdyuk (Aeroflot) representing Federal Air Transport Agency
(FATA) CSWG, Russia Moderator: Gennaro “Rino” Anastasio (Alitalia), Vice-Chair Cabin Management
Group (CMG), Association of European Airlines (AEA)
Top Cabin Safety Issues of Concern and Regional Initiatives
NACC
A4A
FATA
APCSWG AEA
IATA Cabin Operations Safety Conference Steven Bereznak Manager Cabin Safety/ASAP
May 2014
Presentation Overview
About American Airlines
About Airlines for America
Top Cabin Safety Issues
American Airlines Group is the holding company for American Airlines and US Airways. American operates an average of nearly 6,700 flights per day to 340
destinations in 57 countries
Hubs in Charlotte, Chicago, Dallas/Fort Worth, Los Angeles, Miami, New York, Philadelphia, Phoenix and Washington, D.C.
American is a founding member of the oneworld® alliance, whose members and members-elect serve 981 destinations with 14,244 daily flights to 151 countries.
Combined fleet size – 1,000 aircraft
A319 B737 E190 A320 B757 MD-80 A321 B767 A330 B777
Employees 120,000 Flight Attendants 24,000 Pilots 13,000
Cabin Operations Committee Airline Members Alaska Airlines American Airlines Delta Air Lines Hawaiian Airlines JetBlue Airways Southwest Airlines United Continental US Airways
Cabin Operations Committee Mission/Charter The mission of the Cabin Operations Committee is to develop,
promote, implement and enhance comprehensive passenger and cabin initiatives and training programs that assure safe, efficient cabin operations. Its vision is an accident-free, cost-effective cabin environment for passengers and employees.
Cabin Safety
Risk of slide deployment
Turbulence injury
Portable electronic devices in the cabin
Distraction
Threat of procedural drift
Date
IATA Cabin Safety Conference
Darryl Heck, May 21, 2014
About NACC
About WestJet
Top Threats to Cabin Safety in Canada
Regional Initiatives
PRESENTATION OUTLINE
Trade association, representing Canada’s four largest passenger airlines, founded in 2008 by Air Canada, Air Transat, Jazz Aviation LP and WestJet to promote safe, sustainable and competitive air travel.
Working with governments, regulators and partners on:
Cost competiveness - Lower infrastructure costs and taxes
Safety and Security - Effective and efficient systems
Environmental responsibility – Better environmental performance
ABOUT NACC
Founded in 1996 with three aircraft serving 5 cities in Western Canada
Today, almost ten thousand employees with 120 aircraft serving 90 domestic and international destinations
Awarded third in Canada’s top 100 employers by Aon Hewitt
Independently recognized as Canada’s most admired corporate culture
Recognized by J.D. Power as Customer Service Champion
About WestJet
Top Cabin Safety Threats - Direct
Undisclosed and unknown dangerous goods in the cabin
Portable electronic devices proliferation and expanded use
Unruly passengers
Medical incidents
Flight attendant fatigue
Complacency
The challenge of fast-paced change
Slow adoption and lack of understanding of risk based, quality focused, safety management systems
Lack of harmonization and inconsistencies between regulatory jurisdictions
Top Cabin Safety Threats - Indirect
Benchmarking with other airlines
Sharing data and best practices
Partnering with regulatory authority (Transport Canada) to improve:
Consistent application of regulations
Innovation in processes to improve safety effectiveness and efficiency
SMS effectiveness
The culture of generative safety
Regional Initiatives
Thank you
Darryl Heck, Cabin Safety Sub-committee
IATA Сabin Operations Safety Conference
FATA Сabin Safety Work Group
What is AEROFLOT?
National Carrier and the largest airline in Russia, founded on March 17, 1923 – one of Russia’s most recognized brands
Carried 20.9 million PAX in 2013, together with the airlines of Aeroflot group - 31.4 million PAX
Fleet – 154 aircraft - is among Europe’s most modern, youngest and fast growing
Joined IATA in 1989, a full member of SKY TEAM – since 2006
Excellent safety record, the first Russian Carrier to be included in IATA’s Operational Safety Audit (IOSA) Registry
Who is Anna Serdyuk?
1980 – joined Aeroflot Cabin Crew team
1990 – acquired experience as instructor in LH, BA, Airbus and Boeing Training Centers
1999 – transferred to Aeroflot Training Department
2006 – Cabin Crew Training Manager
2012 – senior Cabin Crew Instructor in Aeroflot Service on Board Department
What is FATA Work Group?
Federal Air Transport Agency (FATA) is an executive body in the sphere of Air Transport in the structure of the Ministry of Transport of the Russian Federation. FATA Cabin Safety Work Group was organized in 2009 by a chief state Expert and Inspector Sergey Slepukhin. Today - its Leader is a chief state Expert and Inspector – Vladimir Bolotov About 30 members constantly work in the Group. They are the representatives of the leading airlines and training centers, most qualified and experienced CC managers, instructors and inspectors.
The main task of the FATA Cabin Safety Working Group is to improve Cabin Operations Safety in all Russian Airlines. It coordinates efforts in introducing the international safety standards and promotes the best and most effective practice of different airlines. The work is organized through monthly meetings and annual conferences.
What was done?
Guidelines for CC Training Line Checklist Guidelines for CC Department Structure and Organization Medical On Board Provision, First Aid on Board What is to be done? Cabin Attendant Operations Manual Cabin Crew certification: - Qualification requirements - Knowledge check organization - Questionnaire for Cabin Crew
Polling Question
Do you follow Standard Safety Rules on board an aircraft (such as NO SMOKING/ NO alcohol consumption/ PEDs OFF/ FASTEN SEATBELTS/baggage stowage)?
A/ yes, always B/ only when told by Cabin Crew C/ these silly rules are not for me
SAFETY THREATS
Unruly passengers
Commercial pressure on CC priority of comfort and service
Security threats
THANK YOU!
AEA CMG Gennaro Anastasio
Alitalia
Cabin Management Group (CMG)
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AEA - brings together 30 major airlines, and has
been the trusted voice of the European airline industry for over 50 years
CMG has currently 15 active airline members Annual meetings & active LinkedIn discussion forum
Current Safety & Security Concerns
New PED rules Turbulence Smoke and fumes Lithium battery fire Unruly passengers Crew member fatigue
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Polling Question
What are your top safety issues? 1. SOP Non-Compliance 2. Unruly Passenger 3. Lithium Battery/Fire and Smoke 4. All of Above 5. Other
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Thank you
Lunch Break
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