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Attributes | |
ACN | 748009 |
Time | |
Date | 200707 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ord.airport |
State Reference | IL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 748009 |
Person 2 | |
Affiliation | other |
Function | other personnel other |
Events | |
Anomaly | cabin event other non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : ecam other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Supplementary | |
Problem Areas | Company Cabin Crew Human Performance |
Primary Problem | Cabin Crew Human Performance |
Narrative:
This paragraph summarizes the information that was gathered during the post slide deployment conversations with the parties involved. Even though the initial focus centers on the failure of the 'B' flight attendant to arm the doors at the proper time; I believe the predep commands/procedures need to be reviewed. The 'boarding is complete; secure cabin for departure' command is misleading and opens the crew up to misinterp. When the word 'secure' is used; I can see where it could be easily substituted for 'armed;' especially when being pressed for time. This is exactly what happened to our 'B' flight attendant. She heard the word 'secure' and improperly applied the procedures associated with 'arm doors and xchk; stand by for all' call. Flight was scheduled to depart at XB10. The inbound flight arrived at XA45. Boarding for flight began at XB05. Fueling and utility services (trash removal) were behind as well. Midway through the boarding process; I was informed by the 'a' flight attendant that the 2 large trash bins in the aft galley had not been dumped. A call was made to operations requesting that utility return to complete the task. As the boarding process was in its final stage; fueling and aft galley trash removal had not been completed. The 'a' flight attendant had conferred with the 'B' flight attendant and it was decided that enough room was available in the forward galley bins for trash stowage so as to not incur a further delay. As the agent verified that all passenger were on board; the 'a' flight attendant made the announcement 'boarding is complete; secure cabin for departure.' she then asked me if it was 'ok to close?' I said 'no' as we had not completed fueling and had not received a fuel slip. We still had 1000 pounds of fuel to xfer. This information was derived while monitoring the fuel page on the lower ECAM. Around this time; utility showed up at the 1L door in order to complete the removal of the aft galley trash. The 'a' flight attendant commented that since we were waiting for the fuel slip; we may as well let utility finish their job. I concurred and after reviewing where we were in the fueling process; selected the door page on the lower ECAM in order to review the arming status. At this point; I noticed that both the 2R and 2L doors were armed even though they should not have been. I then called for the 'a' flight attendant in order to have her instruct the 'B' flight attendant to disarm the aft doors. As the 'a' flight attendant arrived at the cockpit door and while we were discussing the aft slides being improperly armed; we observed the amber 2L door open indicator illuminate on the lower ECAM door page along with the white 'armed' indicator beside it. This was my first indication of slide deployment even though we heard no associated sound. This concludes the facts as I know them. Apparently; utility personnel opened the 2L door in order to discard the 2 large trash bags. The 2 aft doors had been armed prematurely not utilizing published procedures and the 2L door had been opened without verifying that it was not armed. When the command 'boarding is complete; secure cabin for departure' is given; it appears that the main task involved is the closing of the cabin overhead bins. A command such as 'boarding is complete; close overhead bins' would satisfy existing procedures and would eliminate any vague interpretation prevalent in the current 'secure' command. Unfortunately; without any amendments to the current procedures; I can predict with relative certainty that this incident will again be duplicated. I am not familiar with the training given to station personnel concerning the opening of aircraft doors. This information needs to be obtained through the appropriate channels. Additionally; both the 'B' and 'C' flight attendants; who recently attended recurrent ground school; said they had never heard of the 'boarding is complete; secure cabin for departure' command.
Original NASA ASRS Text
Title: A320 CAPTAIN REPORTS INADVERTENT SLIDE DEPLOYMENT BY UTILITY CREW REMOVING TRASH FROM THE AFT GALLEY.
Narrative: THIS PARAGRAPH SUMMARIZES THE INFO THAT WAS GATHERED DURING THE POST SLIDE DEPLOYMENT CONVERSATIONS WITH THE PARTIES INVOLVED. EVEN THOUGH THE INITIAL FOCUS CENTERS ON THE FAILURE OF THE 'B' FLT ATTENDANT TO ARM THE DOORS AT THE PROPER TIME; I BELIEVE THE PREDEP COMMANDS/PROCS NEED TO BE REVIEWED. THE 'BOARDING IS COMPLETE; SECURE CABIN FOR DEP' COMMAND IS MISLEADING AND OPENS THE CREW UP TO MISINTERP. WHEN THE WORD 'SECURE' IS USED; I CAN SEE WHERE IT COULD BE EASILY SUBSTITUTED FOR 'ARMED;' ESPECIALLY WHEN BEING PRESSED FOR TIME. THIS IS EXACTLY WHAT HAPPENED TO OUR 'B' FLT ATTENDANT. SHE HEARD THE WORD 'SECURE' AND IMPROPERLY APPLIED THE PROCS ASSOCIATED WITH 'ARM DOORS AND XCHK; STAND BY FOR ALL' CALL. FLT WAS SCHEDULED TO DEPART AT XB10. THE INBOUND FLT ARRIVED AT XA45. BOARDING FOR FLT BEGAN AT XB05. FUELING AND UTILITY SVCS (TRASH REMOVAL) WERE BEHIND AS WELL. MIDWAY THROUGH THE BOARDING PROCESS; I WAS INFORMED BY THE 'A' FLT ATTENDANT THAT THE 2 LARGE TRASH BINS IN THE AFT GALLEY HAD NOT BEEN DUMPED. A CALL WAS MADE TO OPS REQUESTING THAT UTILITY RETURN TO COMPLETE THE TASK. AS THE BOARDING PROCESS WAS IN ITS FINAL STAGE; FUELING AND AFT GALLEY TRASH REMOVAL HAD NOT BEEN COMPLETED. THE 'A' FLT ATTENDANT HAD CONFERRED WITH THE 'B' FLT ATTENDANT AND IT WAS DECIDED THAT ENOUGH ROOM WAS AVAILABLE IN THE FORWARD GALLEY BINS FOR TRASH STOWAGE SO AS TO NOT INCUR A FURTHER DELAY. AS THE AGENT VERIFIED THAT ALL PAX WERE ON BOARD; THE 'A' FLT ATTENDANT MADE THE ANNOUNCEMENT 'BOARDING IS COMPLETE; SECURE CABIN FOR DEP.' SHE THEN ASKED ME IF IT WAS 'OK TO CLOSE?' I SAID 'NO' AS WE HAD NOT COMPLETED FUELING AND HAD NOT RECEIVED A FUEL SLIP. WE STILL HAD 1000 LBS OF FUEL TO XFER. THIS INFO WAS DERIVED WHILE MONITORING THE FUEL PAGE ON THE LOWER ECAM. AROUND THIS TIME; UTILITY SHOWED UP AT THE 1L DOOR IN ORDER TO COMPLETE THE REMOVAL OF THE AFT GALLEY TRASH. THE 'A' FLT ATTENDANT COMMENTED THAT SINCE WE WERE WAITING FOR THE FUEL SLIP; WE MAY AS WELL LET UTILITY FINISH THEIR JOB. I CONCURRED AND AFTER REVIEWING WHERE WE WERE IN THE FUELING PROCESS; SELECTED THE DOOR PAGE ON THE LOWER ECAM IN ORDER TO REVIEW THE ARMING STATUS. AT THIS POINT; I NOTICED THAT BOTH THE 2R AND 2L DOORS WERE ARMED EVEN THOUGH THEY SHOULD NOT HAVE BEEN. I THEN CALLED FOR THE 'A' FLT ATTENDANT IN ORDER TO HAVE HER INSTRUCT THE 'B' FLT ATTENDANT TO DISARM THE AFT DOORS. AS THE 'A' FLT ATTENDANT ARRIVED AT THE COCKPIT DOOR AND WHILE WE WERE DISCUSSING THE AFT SLIDES BEING IMPROPERLY ARMED; WE OBSERVED THE AMBER 2L DOOR OPEN INDICATOR ILLUMINATE ON THE LOWER ECAM DOOR PAGE ALONG WITH THE WHITE 'ARMED' INDICATOR BESIDE IT. THIS WAS MY FIRST INDICATION OF SLIDE DEPLOYMENT EVEN THOUGH WE HEARD NO ASSOCIATED SOUND. THIS CONCLUDES THE FACTS AS I KNOW THEM. APPARENTLY; UTILITY PERSONNEL OPENED THE 2L DOOR IN ORDER TO DISCARD THE 2 LARGE TRASH BAGS. THE 2 AFT DOORS HAD BEEN ARMED PREMATURELY NOT UTILIZING PUBLISHED PROCS AND THE 2L DOOR HAD BEEN OPENED WITHOUT VERIFYING THAT IT WAS NOT ARMED. WHEN THE COMMAND 'BOARDING IS COMPLETE; SECURE CABIN FOR DEP' IS GIVEN; IT APPEARS THAT THE MAIN TASK INVOLVED IS THE CLOSING OF THE CABIN OVERHEAD BINS. A COMMAND SUCH AS 'BOARDING IS COMPLETE; CLOSE OVERHEAD BINS' WOULD SATISFY EXISTING PROCS AND WOULD ELIMINATE ANY VAGUE INTERP PREVALENT IN THE CURRENT 'SECURE' COMMAND. UNFORTUNATELY; WITHOUT ANY AMENDMENTS TO THE CURRENT PROCS; I CAN PREDICT WITH RELATIVE CERTAINTY THAT THIS INCIDENT WILL AGAIN BE DUPLICATED. I AM NOT FAMILIAR WITH THE TRAINING GIVEN TO STATION PERSONNEL CONCERNING THE OPENING OF ACFT DOORS. THIS INFO NEEDS TO BE OBTAINED THROUGH THE APPROPRIATE CHANNELS. ADDITIONALLY; BOTH THE 'B' AND 'C' FLT ATTENDANTS; WHO RECENTLY ATTENDED RECURRENT GND SCHOOL; SAID THEY HAD NEVER HEARD OF THE 'BOARDING IS COMPLETE; SECURE CABIN FOR DEP' COMMAND.
Data retrieved from NASA's ASRS site as of January 2009 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.