A flight attendant can become, with little or no prior notice, the first responder at an accident scene. “That requires him or her not only to know what to do when notified of an impending emergency, but also when to take action without being notified,” said Gary Morphew, senior advisor and instructor at (L/D)max Aviation Safety Group. As the keynote speaker at the International Cabin Safety Conference, held in Amsterdam in October, he outlined safety issues concerning cabin crewmembers, many of which were discussed by other speakers.1
“Flight attendants are trained for emergency evacuations, and all the evidence shows they do their job well in such difficult conditions,” Morphew said. “But it’s important that they be encouraged to talk about their experiences afterward. Management often isn’t very encouraging about this, but should be.
“When the evacuation works well, everyone wants to know. And when things don’t go as well, everyone wants to learn from the cabin crewmembers’ experience.”
Morphew outlined what he sees as today’s most important challenges in cabin safety. Besides sharing of cabin crewmembers’ narratives of emergency events, he listed training for runway overruns, survivability investigations, mitigating turbulence injuries and fatigue management.
“Runway overruns are one of the more common accident types, and result in more fatalities and injuries than the more dramatic and better publicized runway incursions,” Morphew said. “The flight crews are well trained in dealing with these events. But once the flight attendants are strapped in their seats for takeoff or landing, they don’t actually have to do anything except be alert. I’m sure they try to be, but takeoffs and landings are such a routine experience for them that it would be surprising if the attention didn’t wander sometimes.”
More research into survivability factors in accidents is needed, he continued.
“Any cabin injuries should be thoroughly investigated, not just recorded and tallied,” he said. “We might be surprised at what we learn about factors involved. And cabin configurations have many variables. Operators can revise them fairly quickly. Business class equipment is constantly being upgraded to lure these all-important customers. The seats and amenities are designed for comfort, but has anyone thought about their safety implications in an accident?
“At the other end of the economic scale — and the other end of the plane, the back end — you have another consideration if seat spacing has been reduced. Think of 29-in [74-cm] seat pitch. Yes, civil aviation authorities conduct evacuation demonstrations with different seating configurations, but even the most ‘realistic’ evacuation test cannot match the conditions in an actual emergency — if only for psychological reasons. A participant always knows in the back of his or her mind, the worst that can happen in a simulated evacuation might be a sprained ankle.”
Although he believes any cabin safety–related event should be thoroughly investigated, Morphew acknowledged that commercial motivations play a role: “They want to get that aircraft back into service as soon as possible.”
Turbulence is the most common source of flight attendant injuries, he said, adding, “Better procedures to reduce the threat have evolved. Still, we need to make further progress. When any flight attendant becomes incapacitated, it isn’t just a problem for the individual. It means that flight attendant may no longer be an effective first responder in a survivable accident.”
Probably every airline flight attendant in the world has experienced fatigue on the job. “Fortunately, today fatigue risk management systems [FRMS] are taken seriously by regulators and operators,” he said. “Technology is lending a hand, too. Jeppesen Systems offers the CrewAlert iPhone application for fatigue data collection.
“Moreover, the Jeppesen Crew Fatigue Assessment Service (CFAS), which is Web-based, makes it practical to perform a systemwide assessment of planned and actual crew pairing or rostering, using the Boeing Alertness Model to measure fatigue. You can efficiently survey a route, a fleet or your entire operation — and it’s now available to all airlines, large or small. It integrates into an SMS [safety management system] or FRMS.
“The chances are, CFAS will be widely used for flight crews. For cabin crews? We’ll see.”
- The proceedings of the conference have been published by its sponsor, (L/D)max Aviation Safety Group. Phone +1 805.285.3629; in the United States and Canada, toll-free, 877.455.3629.
Learning From a Cabin Pressure Loss
ASW: What action did you and WestJet take immediately following the incident?
KH: The crew was immediately pulled from duty and contacted by our leadership team to ensure their well-being. They were then deadheaded home and had a safety debriefing with our Inflight Safety team the following day.
ASW: Who was included in the safety review team (SRT) that you convened?
KH: An SRT is composed of a lead investigator; leaders responsible for corrective action plans [CAP]; required stakeholders, as identified by the lead investigator and/or the leader responsible for CAP; and a Safety Services representative.
ASW: What did they find specifically relating to the cabin crewmembers and cabin procedures?
KH: The cause of the depressurization was not attributed to the cabin crew. However, the execution of their decompression procedures allowed us to identify opportunities for improvement with our current procedures. Specifically, we identified the operation and differences of the fixed oxygen masks located in the galley compared to those located in the cabin; the effects that chemical oxygen generators have on the cabin environment (heat, smell and smoke); the stowage of fixed oxygen masks for landing after deployment, specifically the masks in the galley that hang over the aircraft doors; and procedural differences between a rapid decompression and a gradual loss of cabin pressure.
ASW: How were these findings communicated to WestJet management?
KH: Inflight Management is a member of the SRT and was responsible for developing corrective actions for these findings.
ASW: What corrective actions were taken?
KH: Changes were made to our training programs — initial and recurrent — and to our flight attendant manual to address the four findings just mentioned. We also sent out safety communications to all our flight attendants to make them aware of the incident.
Cabin Crew Checklists: A Safety Innovation?
ASW: We have heard that the practice of medicine has incorporated some SOPs from aviation. What have “they” learned from “us”?
Jeffrey Hendren: Pilots researching human factors, as well as external experts — in some cases consulting with medicine and social psychology — helped drive the momentum of what we have learned in aviation about human factors and the importance of breaking barriers. Through incidents such as the Kegworth disaster involving British Midlands Flight BD 92 in England in 1989,1 we have learned about tangible (e.g., flight deck door) and intangible (e.g., cabin crew hierarchy) factors that create fatal communication barriers.
It’s natural that medicine would relate what we have learned about these barriers to the hospital operating room. Doctors are the “pilots,” and nurses and other medical professionals are analogous to the flight attendants; we face the same type of barriers and stereotypes. In many surgical suites, we are starting to see a “preflight” operating team briefing between the surgeons, anesthetists, nurses and assistants; much like our safety demonstrations, the patient is also included in the briefing.
What medicine has really started to embrace is the checklist. There are simply too many steps, too many things to remember, so the checklist helps to ensure the medical professionals have reviewed each of their responsibilities and contributions to the team, assessed hazards for both the patient and the professional (e.g., needle sticks), have reinforced the protection of the sterile zone around the surgical patient, and have a protocol for adverse events. Hospitals using checklists have measured reductions in rates of post-surgical infection, medication error and patient mortality.
ASW: Can aviation, particularly in cabin safety, learn from medical practices?
JH: That is the really exciting part for us in the cabin safety world. Medicine is generating fresh ideas with compelling evidence-based research. The way that some hospitals have adopted checklists is unusual. You might think that the surgeon would be the one conducting the checklist, but what they have found in some cases is that it can be more effective if the circulating nurse runs the checklist. We can take our CRM [crew resource management] skills to the next level by challenging the hierarchy in the cabin in a similar way. Instead of the captain always running the preflight briefing, we can increase engagement and demonstrate how communication is everyone’s responsibility by rotating the source of the briefing.
ASW: Your presentation concerned checklists for cabin crewmembers. Why are they needed? Are all cabin crewmember actions currently memory items only?
JH: I can’t speak for all airlines, but my research has revealed the majority of airlines provide very little in the way of checklists for cabin crew. You will almost always find an emergency landing checklist in the flight attendant manual. You may find a preflight equipment inspection checklist, but the vast majority are not mandatory, and often leave a lot of room for interpretation.
When we look at pilot duties, they have almost no memory action items. All duties, including those that one might consider normal or routine, are backed up with a checklist. So why not extend the same strategies to other in-flight operations that include multiple steps and many individuals contributing to the team? Flight attendants are just as fallible as any other human being, and air operators and the regulators should consider that when developing standard operating procedures and the inclusion of checklists into normal, abnormal and emergency situations. Take something like arming doors; though uncommon, there are incidents of blown slides [ASW, 7/07, p. 22]. Could a checklist help prevent or reduce the occurrence?
ASW: You conducted a survey of flight attendants at Canadian North about their views on including more checklist items. What did you find out?
JH: We were not shocked to discover that 80 percent of flight attendants polled do not use the optional preflight equipment checklist. We were impressed to see that 85 percent of flight attendants polled would view positively a mandatory formal checklist system. We learned that 92 percent of respondents believe a checklist will help to trap errors. When it comes to communication, 85 percent of respondents feel that they would be far more comfortable raising a concern or challenging a fellow crewmember when an error is made if they had a checklist to back it up.
ASW: What is the next step?
JH: We will test several checklists. This phase will use sample checklists of various designs and content to determine what works best for flight attendants. There are always two pilots, but in the cabin, we can have anywhere from one to five flight attendants, and that creates a challenge on how the checklist can be completed. There is also a concern about becoming too dependent on checklists, so we still need to encourage the out-of-box thinking adaptable to different situations in the cabin.
After proving the checklists’ design and usage, we will have to decide which procedures require a checklist, and how to capture that in our manuals and training programs. Checklist discipline is something that plays a large role in pilot training, and currently there is no direction from the regulator on checklist discipline for flight attendants.
ASW: How do you expect the industry and regulators to react to the idea?
JH: Implementing a checklist program is far less costly than other innovations that are currently being discussed. Ultimately, the safety culture of the operator will determine whether the crewmembers buy in or not. At Canadian North, we have a strong safety culture, and our flight attendants are engaged and passionate about what they do.
It is not on regulators’ radar at the moment. Transport Canada is currently occupied with the implantation of SMS [safety management systems]. But cabin checklists are very much in line with the spirit of an SMS. We need to ensure that any initiatives include performance metrics that will help back up our hypotheses and prove our outcomes.
- The accident occurred on final approach to East Midlands Airport, Kegworth, Leicestershire, England. The aircraft struck the embankment of the M1 motorway short of the airport, with 39 passengers killed immediately and eight more later dying from their injuries. The U.K. Air Accidents Investigation Branch accident report said that the cause was “the incorrect response of the flight crew” to a fan blade fracture of the no. 1 engine, mistakenly throttling back the no. 2 engine.The report said, “Although the cabin crew immediately became aware of heavy vibration at the onset of the emergency, and three aft cabin crew saw flames emanating from the no. 1 engine, this information was not communicated to the pilots.”
The Cabin Scene in an Emergency Landing
- “There was no time for the flight crew to brief the cabin crew or issue a ‘brace, brace’ command;
- “The cabin crew initiated the evacuation;
- “The captain initially gave the instruction to ‘evacuate’ over the VHF [very high frequency] radio, but ATC [air traffic control] informed him of this, [and] he then repeated it over the cabin PA [public address] system;
- “Some passengers attempted to retrieve personal items during the evacuation;
- “The evacuation alarm was perceived by the cabin crew as sounding ‘faint’ in the cabin;
- “The evacuation alarm was later found to operate OK, except at [door 1 left], which was silenced due to a stuck reset switch; [and,]
- “Nine of the 32 premium economy video monitors detached from the seat backs during the impact.”