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|
Attributes | |
ACN | 227455 |
Time | |
Date | 199211 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ord |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : eghi |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 188 flight time total : 4098 flight time type : 1348 |
ASRS Report | 227455 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 19998 flight time type : 7500 |
ASRS Report | 227697 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence other other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While waiting for external power to be hooked up to the aircraft, the engine providing ships power was shutdown. As the flight engineer I informed the captain that we lost power and I was starting the APU. As the APU was coming on line I made a PA that everything was fine and the APU was being started. People in the right side may notice a flash of exhaust fire. This is normal. Unfortunately between starting the APU, checking some switches and making the PA (approximately 20-25 seconds) all 4 overwing exits were removed and the passengers started to evacuate/evacuation the aircraft. Our first indication of any problem was the lead flight attendant yelling for everyone not to panic and maintenance people coming up the stairs asking what the trouble was. (Approximately 40-50 people were already out of the aircraft within 30 seconds) once the power was restored to the aircraft everyone calmed down quickly. I think the problem causing the incident can be attributed to 1) poor judgement to shut down the engine without being cleared, 2) poor judgement and panic on the part of a few passengers sitting near the right wing, 3) the torchy effect of the APU looks worse at night from a dark aircraft. To correct this problem a PA should be made once everyone has boarded explaining about the APU exhaust over the right wing and anytime the APU is started normally a briefing card may be made for those seats on the right wing. I feel a failure of the captain to communicate his intentions led to the engine being shut down prior to ground per being hooked up. I think the crew responded quickly and professionally to the passengers. The passenger near the right wing may have added to the situation. Her hysterical panic effected everyone's sound judgement leading many people to actually go out on a wing they thought was on fire. Overall I think this incident will continue to happen in our industry until changes are made in the PA procedure or the exhaust position is changed. The next 2 days the same situation occurred 3 times on 4 legs. It is common (poor airport ground power and frequency control). Those times a brief to the passengers preceded the start of the APU. Supplemental information from acn 227697. Some passenger panicked seeing APU torch. Yelled fire and passengers evacuate/evacuationed through overwing exits with no authority. Flight crew unaware until situation was over. Ground crew perform excellent back up.
Original NASA ASRS Text
Title: ACR HAS PWR LOSS ON GND. START OF APU CAUSES PAX PANIC AND EVAC.
Narrative: WHILE WAITING FOR EXTERNAL PWR TO BE HOOKED UP TO THE ACFT, THE ENG PROVIDING SHIPS PWR WAS SHUTDOWN. AS THE FE I INFORMED THE CAPT THAT WE LOST PWR AND I WAS STARTING THE APU. AS THE APU WAS COMING ON LINE I MADE A PA THAT EVERYTHING WAS FINE AND THE APU WAS BEING STARTED. PEOPLE IN THE R SIDE MAY NOTICE A FLASH OF EXHAUST FIRE. THIS IS NORMAL. UNFORTUNATELY BTWN STARTING THE APU, CHKING SOME SWITCHES AND MAKING THE PA (APPROX 20-25 SECONDS) ALL 4 OVERWING EXITS WERE REMOVED AND THE PAXS STARTED TO EVAC THE ACFT. OUR FIRST INDICATION OF ANY PROBLEM WAS THE LEAD FLT ATTENDANT YELLING FOR EVERYONE NOT TO PANIC AND MAINT PEOPLE COMING UP THE STAIRS ASKING WHAT THE TROUBLE WAS. (APPROX 40-50 PEOPLE WERE ALREADY OUT OF THE ACFT WITHIN 30 SECONDS) ONCE THE PWR WAS RESTORED TO THE ACFT EVERYONE CALMED DOWN QUICKLY. I THINK THE PROBLEM CAUSING THE INCIDENT CAN BE ATTRIBUTED TO 1) POOR JUDGEMENT TO SHUT DOWN THE ENG WITHOUT BEING CLRED, 2) POOR JUDGEMENT AND PANIC ON THE PART OF A FEW PAXS SITTING NEAR THE R WING, 3) THE TORCHY EFFECT OF THE APU LOOKS WORSE AT NIGHT FROM A DARK ACFT. TO CORRECT THIS PROBLEM A PA SHOULD BE MADE ONCE EVERYONE HAS BOARDED EXPLAINING ABOUT THE APU EXHAUST OVER THE R WING AND ANYTIME THE APU IS STARTED NORMALLY A BRIEFING CARD MAY BE MADE FOR THOSE SEATS ON THE R WING. I FEEL A FAILURE OF THE CAPT TO COMMUNICATE HIS INTENTIONS LED TO THE ENG BEING SHUT DOWN PRIOR TO GND PER BEING HOOKED UP. I THINK THE CREW RESPONDED QUICKLY AND PROFESSIONALLY TO THE PAXS. THE PAX NEAR THE R WING MAY HAVE ADDED TO THE SITUATION. HER HYSTERICAL PANIC EFFECTED EVERYONE'S SOUND JUDGEMENT LEADING MANY PEOPLE TO ACTUALLY GO OUT ON A WING THEY THOUGHT WAS ON FIRE. OVERALL I THINK THIS INCIDENT WILL CONTINUE TO HAPPEN IN OUR INDUSTRY UNTIL CHANGES ARE MADE IN THE PA PROC OR THE EXHAUST POS IS CHANGED. THE NEXT 2 DAYS THE SAME SITUATION OCCURRED 3 TIMES ON 4 LEGS. IT IS COMMON (POOR ARPT GND PWR AND FREQ CTL). THOSE TIMES A BRIEF TO THE PAXS PRECEDED THE START OF THE APU. SUPPLEMENTAL INFO FROM ACN 227697. SOME PAX PANICKED SEEING APU TORCH. YELLED FIRE AND PAXS EVACED THROUGH OVERWING EXITS WITH NO AUTHORITY. FLC UNAWARE UNTIL SITUATION WAS OVER. GND CREW PERFORM EXCELLENT BACK UP.
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.