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Attributes | |
ACN | 204606 |
Time | |
Date | 199203 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 17800 flight time type : 1700 |
ASRS Report | 204606 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other other : unspecified |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
We had been taxiing for approximately 4-5 mins, when the evacuate/evacuation signal sounded. I stopped the aircraft, and within a few seconds, the flight attendant at door 1L reported that as she adjusted the red 'warning' strap, the slide deployed. I then made a PA announcement for the passenger to remain seated. The #1 engine was shut down, and we were later towed to the gate. The evacuate/evacuation signal is not 'distinctive' enough-the initial thought was that it was a lavatory smoke detector. Callback conversation with reporter revealed the following information: callback to reporter revealed that the aircraft had left the gate 3 mins prior to event. After aircraft was stopped, the flight attendant X said 'do not evacuate/evacuation' and went on to explain that she was seated by 1L and noted the red strap was twisted. She only tried to untwist it and the door and slide deployed. The company pressed charges and held a hearing. At that hearing, it was demonstrated that she could not, from her seat with her harness on, even reach the handle. A study by the air carrier maintenance and engineering departments, however, stated that this was an impossibility, to deploy the chute without turning the handle 90 degrees and exerting at least 15 pounds of pressure on the handle. Captain reporter told of 1 other instance, different aircraft, different day, that while passenger were deplaning from door 1R, the door handle popped out or up out of the locked position on door 1L without being touched. Captain then went on to state that this aircraft has another door problem, that of 1R 'gapping' or not staying seated in its locked position and actually moving up and in on takeoff. The 1 instance he quoted was when this occurred, the flight crew returned to the airport for correction of the door. He maintains that it is a function of the differential pressure, why it does this he isn't certain. The door gaps about 3 to 4 inches. Reports of this from other crews from initial report. The door that was used for passenger boarding at ord was 2L. There is a possibility of the 1L door not being checked for proper handle position. That does not explain the later incident at den or the problem with 1R gapping problems. Reporter not happy with alarm for evacuate/evacuation. Not distinctive enough. He further reported that air carrier had put out a low profile letter reference the door situation on strap operation and cautions in door handle activation. Not a bulletin and strictly low key as if it were just a human factor issue.
Original NASA ASRS Text
Title: AS FLT ATTENDANT ADJUSTS A TWISTED DOOR WARNING STRAP THE DOOR OPENS AND THE SLIDE DEPLOYS DURING TAXI.
Narrative: WE HAD BEEN TAXIING FOR APPROX 4-5 MINS, WHEN THE EVAC SIGNAL SOUNDED. I STOPPED THE ACFT, AND WITHIN A FEW SECONDS, THE FLT ATTENDANT AT DOOR 1L RPTED THAT AS SHE ADJUSTED THE RED 'WARNING' STRAP, THE SLIDE DEPLOYED. I THEN MADE A PA ANNOUNCEMENT FOR THE PAX TO REMAIN SEATED. THE #1 ENG WAS SHUT DOWN, AND WE WERE LATER TOWED TO THE GATE. THE EVAC SIGNAL IS NOT 'DISTINCTIVE' ENOUGH-THE INITIAL THOUGHT WAS THAT IT WAS A LAVATORY SMOKE DETECTOR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: CALLBACK TO RPTR REVEALED THAT THE ACFT HAD LEFT THE GATE 3 MINS PRIOR TO EVENT. AFTER ACFT WAS STOPPED, THE FLT ATTENDANT X SAID 'DO NOT EVAC' AND WENT ON TO EXPLAIN THAT SHE WAS SEATED BY 1L AND NOTED THE RED STRAP WAS TWISTED. SHE ONLY TRIED TO UNTWIST IT AND THE DOOR AND SLIDE DEPLOYED. THE COMPANY PRESSED CHARGES AND HELD A HEARING. AT THAT HEARING, IT WAS DEMONSTRATED THAT SHE COULD NOT, FROM HER SEAT WITH HER HARNESS ON, EVEN REACH THE HANDLE. A STUDY BY THE AIR CARRIER MAINT AND ENGINEERING DEPARTMENTS, HOWEVER, STATED THAT THIS WAS AN IMPOSSIBILITY, TO DEPLOY THE CHUTE WITHOUT TURNING THE HANDLE 90 DEGS AND EXERTING AT LEAST 15 POUNDS OF PRESSURE ON THE HANDLE. CAPT RPTR TOLD OF 1 OTHER INSTANCE, DIFFERENT ACFT, DIFFERENT DAY, THAT WHILE PAX WERE DEPLANING FROM DOOR 1R, THE DOOR HANDLE POPPED OUT OR UP OUT OF THE LOCKED POS ON DOOR 1L WITHOUT BEING TOUCHED. CAPT THEN WENT ON TO STATE THAT THIS ACFT HAS ANOTHER DOOR PROBLEM, THAT OF 1R 'GAPPING' OR NOT STAYING SEATED IN ITS LOCKED POS AND ACTUALLY MOVING UP AND IN ON TKOF. THE 1 INSTANCE HE QUOTED WAS WHEN THIS OCCURRED, THE FLC RETURNED TO THE ARPT FOR CORRECTION OF THE DOOR. HE MAINTAINS THAT IT IS A FUNCTION OF THE DIFFERENTIAL PRESSURE, WHY IT DOES THIS HE ISN'T CERTAIN. THE DOOR GAPS ABOUT 3 TO 4 INCHES. RPTS OF THIS FROM OTHER CREWS FROM INITIAL RPT. THE DOOR THAT WAS USED FOR PAX BOARDING AT ORD WAS 2L. THERE IS A POSSIBILITY OF THE 1L DOOR NOT BEING CHKED FOR PROPER HANDLE POS. THAT DOES NOT EXPLAIN THE LATER INCIDENT AT DEN OR THE PROBLEM WITH 1R GAPPING PROBLEMS. RPTR NOT HAPPY WITH ALARM FOR EVAC. NOT DISTINCTIVE ENOUGH. HE FURTHER RPTED THAT ACR HAD PUT OUT A LOW PROFILE LETTER REF THE DOOR SITUATION ON STRAP OP AND CAUTIONS IN DOOR HANDLE ACTIVATION. NOT A BULLETIN AND STRICTLY LOW KEY AS IF IT WERE JUST A HUMAN FACTOR ISSUE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.