Analysis of Training for Emergency Water Landings Questions Assumptions

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F L I G H T S A F E T Y F O U N D AT I O N
Vol. 33 No. 6 For Everyone Concerned with the Safety of Flight November–December 1998
CABIN CREW SAFETY
Analysis of Training for Emergency Water
Landings Questions Assumptions, Inconsistencies
Research has shown that how aircraft crewmembers
respond during emergency water landings is critical
to survival. Nevertheless, a recent study has
questioned whether crewmembers are receiving
appropriate training in view of the most common
types of water-landing accidents. Preparation and
control of passengers by aircraft crewmembers is the
single most important factor in occupant survival
during emergency water landings, the U.S. National
Transportation Safety Board (NTSB) said in 1985.1
The recent study of cabin-crewmember training for
emergency water landings,2 commissioned by the
U.S. Federal Aviation Administration (FAA), said,
“The behavior of the flight crewmembers and cabin
crewmembers in preparing for a ditching, or in the immediate
aftermath of an inadvertent water impact, can have a significant
effect on the chances for survival.”
The 1998 study compared recommendations of aircraft
manufacturers and training programs developed by U.S.
airlines. The study also compared these programs with reports
from several water-landing accidents and with debriefing notes
from a ditching-and-rescue simulation to suggest methods to
improve survivability. Written materials were provided by six
major airframe manufacturers and nine major airlines, and
interviews were conducted with training instructors
and cabin crewmembers. Seven transport-category
aircraft types were included, and flight-attendanttraining
materials for each airline included the Initial
Training Manual for Ditching/Water Survival, the
Recurrent Training Manual for Ditching/Water
Survival and the Flight Attendant In-flight Manual.
The participating organizations and the aircraft were
not identified.
“[One NTSB] recommendation for additional [flightcrewmember]
training [said,] ‘Quick-response
procedures following inadvertent water contacts [are]
needed, in addition to, or in place of, the plannedditching
training given by most carriers,’” said the study.
“Given the current scope and focus of the training programs
reviewed, this recommendation remains in need of action.
“The review of airline flight-attendant-training programs
revealed that some airlines adopt the airframe manufacturers’
suggested ditching training as their official ditching-training
curriculum. Given the limited information on ditching-related
procedures provided by the airframe manufacturers, any
ditching and water-survival training program based entirely
on that information is inadequate.”
A review of aircraft-manufacturer recommendations and airline training
programs for emergency water landings found emphasis on procedures and
equipment for ditching, although unplanned water contact near airports during
takeoff or landing — with minimal preparation time — is the most common
scenario in transport-category aircraft accidents.
FSF Editorial Staff
2 FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998
Safety researchers believe that U.S. Federal Aviation Regulations
(FARs) for transport-category aircraft primarily have treated
emergency water landing as a planned occurrence. By one
definition, researchers have considered an emergency water
landing a “ditching” if the descent rate does not exceed five feet
(1.5 meters) per second — equivalent to 300 feet (91 meters)
per minute — and vertical loads are within aircraft design
parameters.3 Ditching also has been defined as a planned
emergency event in which the flight crewmembers deliberately
land in water with the aircraft under control. Before a ditching,
cabin crewmembers presumably have some amount of time for
donning life preservers and preparing the aircraft and passengers.
Ditching generally has been contrasted by researchers with
“unplanned water contact” (sometimes called “inadvertent
water impact”) in which there is little or no time for aircraftcrewmember
preparation or passenger preparation. (Depending
on the purpose of the analysis, some researchers have adopted
more water-contact categories, such as takeoff overrun, landing
overrun, planned ditching and unplanned ditching.) Such
uncontrolled, high-energy water impacts near airports have
occurred more often than ditching during extended overwater
flights by transport-category aircraft.4
“Current water-survival-related regulations and training are
focused primarily on ditchings occurring at sea on extended
overwater flights; however, virtually all survivable
water-related accidents are inadvertent and occur near
airports,5” said the study. [Note: Numbered reference notes
within quotations in this article indicate information sources
as cited by the authors in the 1998 study for the FAA.] “Thus,
water-landing accidents are generally unplanned and, because
airline training programs rarely address issues of this nature,
flight [crewmembers] are at a disadvantage in dealing with an
inadvertent water landing.6 In fact, typical ditching procedures
may be inappropriate in such instances, as likely water-related
accident scenarios would include problems at the time of
takeoff or landing.7 … [NTSB] accident reports show that in
inadvertent, survivable water-related accidents, the aircraft is
likely to come to rest in a nose-high flotation attitude, sustain
severe damage, experience rapid flooding, and in most cases,
sink within a few minutes. … In all, the challenges to [aircraft
crewmembers] and passengers in water-related accidents are
formidable, and the preparation of [crewmembers] and
passengers for such events is crucial if they are to survive.”
From 1959 to 1979, 16 survivable air-carrier water accidents
occurred worldwide (Table 1) — approximately 10 percent of
the total survivable air-carrier accidents, said the study.8 (Water
was considered a significant factor in 11 of these accidents, and
one of these accidents was classified as a ditching in a 1996
study.)9 A 1994 report said that 33 water-impact accidents
occurred worldwide from 1982 through 1989 in the commuter
category (Table 2).10 The 1998 study said that at least 179
certificated U.S. airports are located within five miles (eight
kilometers) of a significant body of water and the number of
Table 1
Survivable Water Landings Worldwide
1959–1979
Location Aircraft Type Date
Oso, Washington, U.S. Boeing 707 Oct. 19, 1959
Boston, Massachusetts, U.S. Boeing 720 Sept. 24, 1961
Rio de Janeiro, Brazil McDonnell Douglas DC-8 Aug. 20, 1962
New York (JFK), New York, U.S. Boeing 707 April 7, 1964
Hong Kong Aérospatiale SE. 210 Caravelle June 30, 1967
Hong Kong Convair 880 Nov. 5, 1967
Los Angeles, California, U.S. McDonnell Douglas DC-8 Jan. 13, 1969
Mexico City, Mexico Boeing 727 Sept. 21, 1969
Naha, Okinawa McDonnell Douglas DC-8 July 27, 1970
St. Croix, Virgin Islands McDonnell Douglas DC-9 May 2, 1970
Miami, Florida, U.S. Lockheed L-1011 Dec. 29, 1972
Rio de Janeiro, Brazil Boeing 707 June 9, 1973
Madeira, Portugal Boeing 727 Nov. 19, 1977
Madeira, Portugal Aérospatiale SE. 210 Caravelle Dec. 18, 1977
Pensacola, Florida, U.S. Boeing 727 May 8, 1978
Palermo, Italy McDonnell Douglas DC-9 Dec. 23, 1978
Note: JFK = John F. Kennedy International Airport
Source: Richard A. Johnson, 1984, and Airclaims
FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998 3
such airports worldwide is much higher.11,12 Forty-four of the
50 busiest U.S. airports (1996 data) are located within five miles
of a significant body of water (Table 3, page 4), said the study.13
“These statistics suggest that the likelihood of [unplanned water
contact] will increase as the number of transport-category aircraft
operations increase; dramatic increases in operations are
predicted for early in the next century,14” said the study. “As a
consequence, state-of-the-art emergency equipment and
[aircraft-crewmember] training in ditching and water-survival
procedures are likely to become more important than ever before.
“Accident reports also indicate that passengers are generally
uneducated about emergency aircraft evacuation and accidentsurvival
issues … survivors reported a lack of knowledge about
obtaining and using flotation devices, were unaware that they
should leave their carry-on luggage behind, and were unaware
that the escape slide could serve as a raft. The survivors also
had little idea about what to expect during rescue or how to
use rescue equipment.
“Communication among the [aircraft crewmembers] and
passengers is especially important to managing time in
emergency situations; [unplanned water contact has] special
requirements for atypical communications. … Other factors
[that] influence survival in water-related emergencies …
include [aircraft-crewmember] leadership, passenger reactions,
aircraft damage and water conditions. … The aircraft, when
intact, should generally remain afloat in calm seas for several
minutes, usually sinking tail first. Aircraft flaps, slats, engine
pylons, probes, other parts and debris could detach [and fuel
and other aircraft fluids could leak, exposing survivors to
chemical burns and slippery surfaces that hamper rescue],
presenting hazards to survivors and [survival/rescue]
equipment. Much of the aircraft condition, as well as the ability
to deplane into the rafts, will depend on the state of the sea. In
an actual emergency situation, the hazard to passengers and
[aircraft crewmembers] will increase as time passes, and proper
[crewmember] training will allow the [crewmembers] to
function effectively and maintain control of the situation.
“Additionally, rescue operations themselves also produce
dangers, such as a raft capsizing from helicopter rotor wash
and the possibility of electrocution if passengers or [aircraft
crewmembers] grasp the steel rescue cable dangling from the
[static-electricity-charged] helicopter fuselage while … in the
water.”
The study identified deficiencies, suggested operational and
research options to address deficiencies, and recommended
changes to training programs to enhance safety in emergency
water landings.
Aircraft Manufacturers Determine
Procedures for Ditching
Aircraft manufacturers develop ditching procedures that are
the basis for airline ditching and water-survival training
programs, as required by FAR Part 25.1581. Ditching
recommendations are derived from tests and analyses of aircraft
characteristics during and after water entry, based on several
assumptions. These include a calm sea, a steady wind, minimal
aircraft velocity relative to the water, and appropriate approach
configuration, attitude, velocity and heading. Ditching analyses
include the effects of wind velocity and sea state, but flotation
analyses do not consider these variables.
“In [the flotation] analysis, flotation starts when the airplane
comes to rest,” said the study. “The initial flotation attitude
(depth and angle of the airplane in the water) is based primarily
on calculations related to the buoyancy contributions of the
wing box and fuselage. Change in airplane attitude over time,
because of inward water leakage through known sources —
[such as] vents, valves [and other openings] not closed in the
preditching procedures — is computed at multiple time
intervals until the [time that the] airplane is estimated to sink.
All of the evacuation and water-survival-related activities …
have to be achievable within this time.”
In the training materials reviewed, “preditching”
communication began with the flight crewmembers’
identification of a problem and ended when the aircraft’s
momentum finally dissipated after settling in the water. The
researchers found no suggestions from aircraft manufacturers
regarding preditching communications among aircraft
crewmembers. Nevertheless, the materials recommended a
passenger briefing with appropriate amendments to the normal
prelanding briefing. Manufacturers typically recommended
that cabin crewmembers demonstrate how to don the life vests
Table 2
Commuter Aircraft
Water-impact Accidents
1982–1989
Country Number of Accidents
United States 14
Canada 10
United Kingdom 2
Costa Rica 1
Denmark 1
Germany 1
Japan 1
New Zealand 1
Australia 1
Brazil 1
Total 33
Source: Charles C.T. Chen and Mark Muller, 1994, based on
information from the International Civil Aviation Organization
4 FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998
Table 3
Proximity to Large Bodies of Water of the 50 Busiest U.S. Airports Controlled
By the U.S. Federal Aviation Administration, 1996
Water Within Ocean, Gulf Reservoir
Rank Airport City and State 5 miles or Great Lake or Lake River
1. Chicago O’Hare International Airport, Illinois yes X
2. Dallas/Fort Worth International Airport, Texas yes X X
3. Los Angeles International Airport, California yes X
4. William B. Hartsfield Atlanta International Airport, Georgia yes X
5. Detroit Metropolitan (Wayne County) Airport, Michigan yes X
6. Miami International Airport, Florida yes X
7. Phoenix Sky Harbor International Airport, Arizona no
8. Van Nuys Airport, California yes X
9. St. Louis International Airport, Missouri yes X
10. Oakland International Airport, California yes X
11. Minneapolis-St. Paul Airport, Minnesota yes X
12. Long Beach Airport (Daugherty Field), California yes X
13. McCarran International Airport, Las Vegas, Nevada yes X
14. John Wayne Airport, Orange County, California yes X
15. Boston Gen. Edward Lawrence Logan International Airport, Massachusetts yes X
16. Charlotte/Douglas International Airport, North Carolina yes X X
17. Newark International Airport, New Jersey yes X
18. Denver International Airport, Colorado no
19. Pittsburgh International Airport, Pennsylvania yes X
20. San Francisco International Airport, California yes X
21. Philadelphia International Airport, Pennsylvania yes X
22. Cincinnati/Northern Kentucky International Airport, Kentucky yes X
23. Bush Intercontinental Airport, Houston, Texas yes X
24. Seattle-Tacoma International Airport, Washington yes X
25. Salt Lake City International Airport, Utah yes X
26. Honolulu International Airport, Hawaii yes X
27. John F. Kennedy International Airport, Jamaica, New York yes X
28. Memphis International Airport, Tennessee yes X
29. Centennial Airport, Denver, Colorado no
30. Prescott Municipal Airport, Arizona no
31. LaGuardia Airport, Flushing, New York yes X
32. Orlando International Airport, Florida yes X
33. King County International Airport/Boeing Field, Seattle, Washington yes X
34. Washington Dulles International Airport, Virginia yes X
35. Oakland County International Airport, Pontiac, Michigan yes X
36. Ronald Reagan Washington National Airport, District of Columbia yes X
37. Portland International Airport, Oregon yes X
38. Orlando Sanford Airport, Florida yes X
39. Cleveland Hopkins International Airport, Ohio yes X
40. Fort Worth Meacham Airport, Texas yes X
41. Anchorage International Airport, Alaska yes X
42. San Jose International Airport, California yes X
43. Daytona Beach International Airport, Florida yes X
44. Tampa International Airport, Florida yes X
45. Baltimore/Washington International Airport, Maryland yes X
46. San Antonio International Airport, Texas no
47. Chicago Midway Airport, Illinois yes X
48. William P. Hobby Airport, Houston, Texas yes X
49. North Las Vegas Airport, Nevada yes X
50. Phoenix/Deer Valley Airport, Arizona no
Source: U.S. Federal Aviation Administration
FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998 5
and how to use the flotation-seat cushions. The materials
recommended that, when sufficient time is available, cabin
crewmembers advise passengers to remove high-heeled shoes
and assign passengers to aid other passengers who need
assistance. The materials also said that cabin crewmembers
should assign division lines to distribute passengers evenly
among the usable exits. Unplanned water landings were not
addressed, said the study.
Aircraft manufacturers typically provided the following
immediate-action evacuation recommendations for emergency
water landings, said the study.
• “Direct passengers away from unusable exits;
• “Retrieve [emergency locator transmitters (ELTs)] from
airplane storage locations and carry [them] aboard [a]
raft;
• “Retrieve [the] survival kit;
• “Tie [the ELT] to [a] raft and deploy [the ELT], if
equipped;
• “Direct [the] first evacuees to move to center seating
areas as they enter [a] raft;
• “Keep weight distribution even [in rafts];
• “Ensure that the airplane is fully evacuated;
• “Release slide/raft from [the] airplane by releasing
the girt attachment and disconnecting or cutting [the]
mooring line;
• “Guide evacuees in the water to raft-boarding stations
and bring [them] aboard [rafts];
• “Toss [a] heavy line to any evacuees who may be
floundering in water;
• “Move rafts [away] from fuel-saturated waters, but stay
in the vicinity of the airplane until it sinks;
• “Attend to serious injuries;
• “Check [the] condition of [the] raft (repair, bail or dry
[the raft] as necessary);
• “Connect two or more rafts using [the] sea-anchor line;
[and,]
• “Deploy [the] sea anchor.”
The study said, “Care [of] the life raft is the most common
instruction. Some detail is given regarding [raft] repair, proper
inflation and keeping the raft floor dry. Some manuals also
note that the rafts are equipped with locator lights, but it is not
clarified that the lights are water-activated. Sea-anchor
deployment is referred to, but not explained. The installation
of the raft canopy is addressed, although it is noted in some
training materials that, if the raft should capsize with the canopy
deployed, the raft would be impossible to right. No advice is
offered for coping with this circumstance, and it is implied
that this occurrence would create a nonsurvivable situation. It
is suggested that the raft lifeline could be used to secure
survivors in the water until they can be assisted aboard the
raft.”
The researchers found that minimal attention was given to
water-survival issues in the training materials reviewed. The
materials said that passengers should keep their life jackets on
and stay low in the raft, that first aid should be administered,
and that reassurance concerning rescue should be given to
survivors.
The study identified the following deficiencies in the
recommendations of aircraft manufacturers regarding
emergency water landings. Nevertheless, as discussed in the
following section, some of the missing topics — such as how
to don life vests and how to distribute weight evenly in rafts
— were found in airline training materials reviewed.
• “The preditching communication guidelines give
no directions related to [aircraft-crewmember]
communication nor instructions for unplanned water
landings;
• “Basic information on evacuation is identified but not
explained. Adverse conditions such as disabled exits,
fuselage breakup, equipment malfunction, poor lighting,
evacuation of injured persons, passenger disorientation,
rising water, poor communication and environmental
stressors are not addressed. There are also no instructions
given for such activities as donning life vests or how to
distribute weight evenly in rafts;
• “No detailed information for usage of emergency
equipment is provided. … ;
• “The airframe manufacturers’ materials offer no
information on the subject of survival. … ; [and,]
• “Procedures for actual rescue, a description of rescue
devices, and important tips for rescue equipment usage
are not provided.
Examples of Airline Training
Materials Provide More Detail
In the United States, airlines must provide cabin crewmembers
FAA-approved initial training that includes safety-related
subjects and proficiency testing on various emergency skills.
6 FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998
Cabin crewmembers also are required by FAA to attend annual
recurrent training to demonstrate skills and competence in
emergency procedures, ditching and water survival, said the
study. The researchers found similar content among flightattendant-
training manuals concerning water evacuation,
including the need for careful evaluation of the emergency
situation before taking action.
“[Cabin crewmembers] are instructed to select and brief
able-bodied passengers to help retrieve stowed rafts and/or
[to] move slide/rafts, as necessary, and to lead the exit process
and take command of the rafts or slide/rafts until a
crewmember becomes available,” said the study. “The
training manuals direct that after these initial procedures are
accomplished, and at the appropriate time, the [cabin
crewmembers] would command the evacuation. They are
further directed to continue their assessment of external
conditions as the exits are activated and to redirect passengers
to another exit if the exit or its attached slide/raft becomes
unusable. Certain [cabin] crewmembers are designated to
retrieve the [ELT] from the aircraft and to carry [the ELT]
aboard the rafts. Other crewmembers … ensure that the plane
is fully evacuated. The manuals state that once the aircraft
has been fully evacuated, the [aircraft crewmembers] should
then release the rafts from the airplane and assume command
of the rafts.
“[Cabin crewmembers] are instructed to use the mooring line
to tie rafts together to prevent them from becoming separated
or lost. Directions are given in eight of the training manuals to
tie the rafts 25 feet [8 meters] apart to allow for wave action,
but one training manual recommends 15 feet [5 meters]. The
basis for this difference is unclear.”
Typical training on emergency-water-landing equipment
covered how to check and maintain proper inflation of the
buoyancy tubes of the rafts, repair raft leaks and manually
erect the raft canopy.
“There are many differences in the methods that address
individual passenger flotation,” said the study. “For example,
the procedures on flotation-seat-cushion usage vary. Some
airlines [train] the [cabin crewmembers to] advise passengers
to hold the cushions in front of their bodies, to rest their chins
on the cushions, to wrap their arms around the cushions with
their hands grasping the outside loops, and to float vertically
in the water. Others suggest that passengers lie forward on the
cushions, grasp and hold the loops beneath them, and float
horizontally.
“Flight-attendant-training programs also provide dissimilar
procedures regarding the appropriate time to inflate the life
vests. Some [train cabin crewmembers to instruct] passengers
to inflate only one chamber of a two-chamber life vest before
leaving the airplane, while others recommend inflating both
[chambers]. Similarly, some training programs [instruct cabin
crewmembers] to advise [passengers to inflate] the life vest
… by pulling the inflation-gas-cylinder rings, although a few
[training programs] advocate that life vests should be inflated
with the oral valve only.
“Divergent procedures for donning life vests are also evident;
most [cabin crewmembers] are trained to tell passengers to
tighten the life vest as [much] as possible, although one airline
[trains cabin crewmembers to] advise passengers to tighten
the life vest only until they can put a clinched fist between the
body and the vest. Another airline [trains flight] attendants
[to] instruct passengers not to tighten the vest at all. One airline,
[which] uses a life vest with a waist-and-back strap, trains
[cabin crewmembers to instruct] passengers [to] throw the life
vest behind the head, so that swimming is more easily
accomplished. No explanation for these disparate procedures
was forthcoming, leaving unclear … which, if any, of the
procedures is most effective.”
The researchers found that special needs of infants, children,
elderly passengers and handicapped passengers also received
minimal attention in the training materials reviewed.
Infant life vests and/or child life vests are not available on
all airplanes, so airlines train cabin crewmembers in a
variety of methods to secure children in adult life vests for
ditching. One method is to strap the child in an inflated
adult life vest and ask an adult to hold the child in his or
her lap. Researchers found that other airlines provide
combination child-restraint/flotation devices, but most
airlines rely on adult passengers accompanying children to
provide approved child restraints, which typically will not
float and will not accommodate a child wearing an inflated
vest, said the study.
The researchers found minimal guidelines for water survival
in the airline training-program materials reviewed, but found
more detailed information in the survival manuals packed in
survival kits aboard rafts.
“Typical duties [to be assigned by cabin crewmembers] include
signaling, being the lookout [for rescue vessels and aircraft],
collecting drinking water, rationing food and bailing water,”
said the study. “First aid specific to the aquatic environment is
not covered in the ditching and water-survival portion of most
of the training manuals, since general first aid is included in
the training syllabus … . Other significant issues not covered
in the flight-attendant training manuals include hazardous
marine life, adverse sea conditions, severe injuries, shock,
seasickness, saltwater sores, sun blindness, personal hygiene
and mental attitude. …
“None of the airlines included rescue [as a topic] in the training
manuals, nor did they report [that they incorporated] the
information anywhere else in the [standard cabin-crewmember]
training curriculum. The only instruction given on this subject
… is to wait in the raft until guidance is received from rescue
personnel.”
FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998 7
The study provided the following suggestions to improve
airline training for emergency water landings.
• “Information on preditching communication provided
in the training manuals is adequate [for] a deliberate,
controlled landing of an aircraft on water with plenty of
time to prepare. … Better crew resource management
[CRM] techniques that provide enhanced [early
communication and] coordination among the [flight
crewmembers and cabin crewmembers], especially
during the early stages of [quickly developing]
emergencies, would be helpful … ;
• “Similar communication problems exist related to
confusing emergency signals. … Since different
emergency signals are taught by the airlines, retrained
[aircraft] crewmembers [and crewmembers added by
airline mergers or other operational arrangements] may
become confused about which signal should be
recognized as indicating an emergency. This potential
dilemma could be resolved if all airlines adopted a
universal emergency signal;
• “Information concerning the evacuation phase of
water-related accidents is limited [and] … offers no
detailed guidance concerning … damage [to] the aircraft
upon water impact. The expected flotation time of specific
aircraft models is not included in the in-flight manuals,
potentially producing poor [evacuation] decisions … ;
• “Each piece of emergency equipment is defined in the
training manuals; [nevertheless], differences in the contents,
storage locations, and specific operation of emergency
equipment [may make rapid, effective action difficult for
cabin crewmembers] who are qualified on multiple aircraft
… [or impede crewmembers in moving] stowed rafts to
exits or slide/rafts from unusable exits to accessible
doorways, even with the help of able-bodied passengers;
• “It is critical that all water-related emergency equipment
[notably survival manuals] be made of waterproof
materials. … ;
• “Incorporating pictures into the training materials, or
using video presentations, would also [provide cabin
crewmembers] a better [explanation] of proper
techniques. Differences in the instructions for equipment
usage and survival-kit contents should be rectified;
• “Presently, [FAA] Advisory Circular 120–47 suggests
[italics in original] contents for survival kits, but since
there is no [FAA] technical standard order (TSO) that
specifies content, survival kits differ from airplane to
airplane;
• “The issue of managing personal flotation is [confusing].
Life vests differ in style and function not only from
airplane to airplane, but they can also vary within the
same airplane. This [means] that the vest used for the
preflight briefing is, in some cases, different from the
vests that the passengers would use;
• “Among airlines, [cabin crewmembers] offer conflicting
advice to passengers on [when and how to use] life vests.
… The ‘correct’ procedure for proper inflation of life
vests needs to be established. Instructions for managing
elderly, injured or handicapped individuals are
insufficient for a water-related emergency. The system
of assigning a buddy could be very successful in
preparing children, [handicapped passengers] or [elderly
passengers] if procedures were adopted for effectively
establishing flotation of these individuals;
• “The topic of survival is only discussed relative to the
survival kit. Although the contents of survival kits differ,
the basic information is acceptable, if expanded. Many
issues dealing with the environment, injuries and mental
attitude of victims are not discussed. For example,
passengers could be abandoning the aircraft directly into
the water instead of [into] the rafts. It is likely that jet
fuel, oil and hydraulic fluid would be contaminating the
water; these fluids can [impair] vision and hearing —
and produce nausea. [Immersion in water also presents]
a serious threat of hypothermia (Table 4, page 8) [with
survival time related to water temperature, clothing and
head covering, body type, health status, fitness and other
factors]. … ;
• “On the water, the cornerstone of survival is effective
raft management. Topics such as distributing weight in
rafts and capsizing should be expanded. … The raft
commander should instruct all passengers to wear their
life vests at all times and should designate one person to
secure himself or herself to the raft in case it capsizes.15
… It is also important to secure all of the survival
equipment in the raft to prevent loss if the raft capsizes.
In [particular], it would be beneficial for [aircraft
crewmembers] to practice righting a capsized raft during
training, especially on the open sea, if possible;
• “[Cabin crewmembers] would also have a better
understanding of basic raft-survivability [factors] if more
information on raft shapes and sizes were included in
training. For example, explanations of the bearing on
seaworthiness produced by changes in freeboard (the
distance from the surface of the water to the top of the
raft’s buoyancy tube) would better prepare
[crewmembers] to maintain raft stability and flotation,
especially with damaged rafts;
• “Essential information concerning what to expect during
the various types of rescue, and practice in the use of
rescue equipment, is omitted from training. … Rescue
procedures and the use of rescue devices should be taught
8 FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998
in the initial training class. It is important that [aircraft
crewmembers] know what to do should rotor wash from
a rescue helicopter capsize the raft and how to handle
extraction of the survivors if a rescue swimmer is not
deployed [from the helicopter]; [and,]
• “To prevent depressing the morale of survivors, [cabin
crewmembers] should … inform survivors that when a
helicopter comes to rescue them, [the aircraft] will only
accommodate a certain number of passengers, and that
remaining survivors will have to wait for [additional
flights]. [Crewmembers] should also be familiar with
the various types of rescue equipment and how to prevent
injuries while using [this equipment]. … Lack of training
and practice on rescue-related topics indicates that [cabin
crewmembers] do not have the skill or proficiency to
assist with rescue. [More comprehensive water-survival
training] materials are … readily available from civil
sources and U.S. military [services] and could be
assembled into a meaningful and relevant airline-training
program [to address deficiencies identified in this
analysis].”16
The study recommended that approved flotation-seat cushions
be installed in all passenger-carrying aircraft to provide every
passenger and [aircraft] crewmember with a means of flotation
in any emergency water landing — not only for extended
overwater flights.
The study also cited debriefing notes from a 1994 simulated
emergency water landing and examples from several accidents
as anecdotal support for the recommended improvements in
training. (See “Water-accident Experiences Support
Recommendations for Cabin-crewmember Training” on page
9.) Seven airlines, several ditching-equipment manufacturers
and 65 federal, state and local government agencies conducted
the airport-disaster exercise for the Fort Lauderdale-Hollywood
International Airport, Florida, U.S.
Table 4
Symptoms of Extended Exposure to Water at Different Temperatures
Symptom Degrees Fahrenheit Degrees Celsius Time
Loss of use of hands and forearms 38 3 15 minutes
48 9 20 minutes
70 21 3 hours
Loss of mental activity 38 3 45 minutes
48 9 1 hour
70 21 4 hours 30 minutes
Hypothermia and death 38 3 1 hour 5 minutes
48 9 1 hour 30 minutes
70 21 6 hours
Source: U.S. Federal Aviation Administration
“[In this exercise scenario, a Lockheed] L-1011 with 300
people on board [was assumed to have made an emergency
water landing in] the Intracoastal Waterway moments after
takeoff from [the airport],” said the study. “Fifty people were
[considered to be] dead and 250 ‘survivors’ were floating in
the water or clinging to aircraft wreckage, waiting to be
rescued.”
The water-emergency demonstration project generated the
following observations by participants.
• “Participants who could not hear the [cabin
crewmember’s] evacuation commands felt panic;
• “There were problems with conflicting instructions given
for the use of life vests;
• “Participants with baby carriers had numerous problems;
• “Participants who had to exit the aircraft directly into
water were frightened and unsure of what to do;
• “Participants had problems keeping the slide/rafts dry;
• “No one assumed command, which resulted in problems
with raft management;
• “No one was assigned to be the lookout;
• “The survival kit presented multiple problems (items
were very hard to open, the survival manual was not
waterproof, the sponge was small and hard to use, and
the flare was hard to light … the raft was singed while
trying to use [the flare]);
• “As participants’ hands [became] less agile from the cold,
items such as the drinking water [containers] were almost
impossible to open;
• “Seasickness created problems;
FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998 9
Water-accident Experiences Support
Recommendations for Cabin-crew Training
use of the life vests, and this became a critical problem
because 30 percent of the passengers could not swim.
One flight attendant ducked under water in an effort to
secure more life vests, and subsequently passed them
out the door to crewmembers who were assisting
passengers in the evacuation. One overwing window exit
floated inside the cabin during the evacuation,
temporarily impeding the egress of some of the
passengers; [nevertheless,] most [passengers believed
that] the initial evacuation took place very rapidly.”2
[This accident occurred on May 8, 1978 at about 2120
local time, when National Airlines Flight 193, a Boeing
727, struck Escambia Bay during a surveillance-radar
approach to Runway 25 at Pensacola (Florida, U.S.)
Regional Airport, and came to rest about three nautical
miles from the east end of Runway 25 in about 12 feet
(3.6 meters) of water. There were 52 passengers and
six crewmembers aboard the aircraft. Three passengers
were killed (drowned); two passengers and two
crewmembers received serious injuries. The aircraft was
destroyed. The weather was measured ceiling 400 feet
overcast, visibility four miles in fog and haze, and surface
wind from 190 degrees at seven knots. The NTSB said
in its final report that the probable cause of the accident
was the flight crew’s unprofessionally conducted
nonprecision instrument approach, in that the captain
and crew failed to monitor the descent rate and altitude,
and the first officer failed to provide the captain with
required altitude and approach-performance callouts.
The crew failed to check and utilize all instruments
available for altitude awareness, turned off the groundproximity
warning system, and failed to configure the
aircraft properly and in a timely manner for the approach,
said the report.]
• “Evacuation of the plane went smoothly except for two
intoxicated passengers who refused to leave the airplane
and had to be bodily removed from the cabin by the flight
crew. The [airport emergency crews and other local]
emergency crews responded immediately. When they
arrived … they saw no fire. About 80 percent of the
passengers had exited the aircraft. Rescue workers
observed a number of passengers and crewmembers
forward of the no. 1 engine, two of whom were in the
water. One of the rescuers entered the water and assisted
about 12 passengers who were in a slide/raft in the basin
at the end of the approach-lighting-system pier. Several
firefighters escorted passengers on the end of the pier
over the left wing and back onto the pier and away from
the aircraft. Firefighters also rescued another slide/raft of
passengers adrift in the basin, forward of the no. 3 engine.
All were pulled to safety and it was estimated that all
passengers were on land and safely clear of the aircraft
within five [minutes] to seven minutes.”3
The following excerpts from emergency-water-landing
descriptions were among several cited in a 1998 study for
the U.S. Federal Aviation Administration (FAA).1 The
accident-investigation narratives were considered in
developing the study’s findings on cabin-crew training:
• “The passengers were all seated with lap belts on, trays
stowed and seat backs upright as the senior flight
attendant was preparing to read the standard prelanding
announcement. There were no warnings or changes in
aircraft [attitude] or power before impact. Passengers
interviewed after the crash believed the severity of the
impact [could] be categorized as, ‘hitting very hard on
land.’ Most [passengers] reported that they were thrown
forward and/or downward. Those seated near the wing
and to the rear said that they either smelled, tasted or
were struck by jet fuel immediately after impact.
Passengers were very concerned about the possibility
of a fire, although no postcrash fire occurred. There was
a ‘gush’ of water into the airplane, and the water began
to rise very fast. Some of the injured were trapped in
their seats by the rising water.
“The passengers evacuated the cabin as the aircraft
settled tail first in the shallow water. Three overwing exits
were opened by passengers. The two forward, floor-level
doors were opened by the crew after numerous
problems. One man escaped by opening the aft-right
emergency door. The senior flight attendant tried to pull
the slide-inflation handle at the forward passenger door,
but she could not find it. She thought [that] the slide
pack may have separated from the girt bar, so she
abandoned her effort to find it. She grabbed a
megaphone and began giving orders, ‘Get your life vest
from under your seats and come forward.’ The crew
assisted passengers with the life vests, because many
were having difficulties finding and using them. The
aircraft was not equipped with (nor was it required to
carry) approved flotation-seat cushions or life rafts. Life
vests were located under the passenger seats, although
42 percent of the passengers later stated [that] they had
not seen the life-vest demonstration, and 59 percent of
the passengers admitted [that] they had not read the
briefing card [during] this trip.
“Many passengers were unaware that [life] vests were
contained in plastic bags located in fabric compartments
under their seats. Several tried to use their seat cushions
as flotation devices, but found that they came apart [in
water] and/or were not buoyant. Those [passengers] who
did secure their life vest had various problems with
the straps [and] donning the vest, and they had never
seen the light on a life vest demonstrated. The accident
investigation report [said] that 72 percent of the
passengers needed specific or direct assistance in the
1 0 FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998
[This accident occurred on Feb. 28, 1984 at about 1618
local time following an approach to Runway 4R at John
F. Kennedy International Airport (Jamaica, New York,
U.S.), when Scandinavian Airlines System Flight 901,
a McDonnell Douglas DC-10-30, touched down about
4,700 feet (1,432 meters) beyond the threshold of the
8,400-foot (2,560-meter) runway and could not be
stopped on the runway. The airplane was steered to
the right to avoid the approach-light pier at the
departure end of the runway and came to rest in
Thurston Basin, a tidal waterway located about 600
feet [183 meters] from the departure end of Runway
4R. The 163 passengers and 14 crewmembers
evacuated the aircraft safely; two flight crewmembers
and one cabin crewmember received minor injuries;
one passenger was classified as a serious injury
(hospitalized for observation because of a cardiac
condition); and eight passengers received minor
injuries. The aircraft was damaged substantially. The
weather was ceiling 200 feet overcast, visibility 3/4 mile
with light drizzle and fog, and wind from 100 degrees
at five knots. The NTSB said in its final report that the
probable cause of the accident was the flight crew’s
disregard for prescribed procedures for monitoring and
controlling airspeed during the final stages of the
approach, decision to continue the landing rather than
to execute a missed approach, and overreliance on the
autothrottle speed-control system, which had a history
of recent malfunctions.]
• “Immediately following the impact, the captain verbally
performed the passenger-evacuation checklist. The
captain, the first officer, an off-duty … captain, flight
attendants and an airport police officer (who jumped
into the water from the runway deck) assisted the
passengers in [the] evacuation. A flight attendant
deployed the evacuation slide at R-1; the R-2 slide was
disarmed before the door was opened because the flight
attendant believed that the slide would float upward and
block the exit because of the closeness of the water.
The L-2 door was opened and then closed when water
entered the cabin. Depending upon where the
passengers were seated, their evacuations were
impeded by darkness, cabin separations at seat [row] 4
and [seat row] 21, and unusable floor-level exits on the
left side.
“About 20 passengers were able to successfully
evacuate through the left-overwing exits and stand on
the wing, which was out of the water. Someone unstowed
the fabric ditching line from above a left-overwing exit
and tied [the line] to [the] wing fitting, providing these
passenger something to hold on to while awaiting
rescue. The ditching line was also unstowed from the
right overwing exit opening, but evacuees did not know
[that] it needed to be tied to the right-wing fitting. The
forward portion of the right wing was out of the water
and passengers held on to the ditching line so [that]
they could stay out of the water.
“Passengers who egressed at the two floor-level exits
entered the water and, because of the one-knot current,
some [occupants] drifted away from the airplane and
under the runway deck. Crewmembers threw flotationseat
cushions and crew life preservers, which were held
by passengers and crewmembers, some of whom could
not swim. Several [people] complained that they could
not hold on to the cushions or that the cushions did not
keep them afloat. Some clung to pilings under the deck
and floating debris. Some passengers also swallowed
fuel that was on the surface of the water. There was no
fire.
“The first rescue boat … arrived approximately 10
minutes after the accident; it was joined shortly by U.S.
Coast Guard boats, boats from other agencies, and two
[U.S.] Coast Guard helicopters. Several of the
passengers complained that waves from boats and
downwash from the rescue helicopters hampered [their]
ability to stay afloat. One passenger sustained a
fractured right ankle and a lacerated hand when a rescue
boat backed over her in the darkness. The captain and
the lead flight attendant were the last crewmembers to
leave the cabin after assisting rescue workers, who were
attempting to extricate passengers trapped in [seat] 21F
and [seat] 22A. According to U.S. Coast Guard records,
all [occupants] were removed from the aircraft within 90
minutes. …
“It should also be noted that although crewmembers
had life preservers, FAA regulations did not require life
preservers for passengers aboard this flight. Also,
because it was not required by the FAA, flight
attendants had not received hands-on ditching training
in water.”4
[This accident occurred on Sept. 20, 1989 at about 2321
local time when the flight crew of USAir Flight 5050, a
Boeing 737-400, rejected a takeoff on Runway 31 at
LaGuardia Airport (Flushing, New York, U.S.), but did
not stop the aircraft before the aircraft left the runway
and struck Bowery Bay. During the takeoff, the first officer
(pilot flying) felt the aircraft drift left, and as the takeoff
run progressed, the flight crew heard a “bang” and a
continual rumbling noise. The captain took over and
rejected the takeoff. Two passengers were killed; both
pilots and the four cabin crewmembers received minor
injuries; and 15 of 57 passengers were injured. The
aircraft was destroyed. The weather was estimated
ceiling 500 feet overcast, visibility five miles, light rain
and fog, and wind from 210 degrees at four knots. The
NTSB said in its final report that the probable cause of
the accident was the captain’s failure to exercise his
command authority in a timely manner to reject the
takeoff or to take sufficient control to continue the takeoff,
which was initiated with a mistrimmed rudder. Also
causal was the captain’s failure to detect the mistrimmed
rudder before the takeoff was attempted, said the
report.]©
FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998 11
References
1. Cosper, Donna K.; McLean, Garnet A. Analysis of
Ditching and Water Survival Training Programs of Major
Airframe Manufacturers and Airlines DOT/FAA/AM-98-/
19. A report prepared for the U.S. Federal Aviation
Administration (FAA). July 1998.
2. Cosper and McLean. Adapted from U.S. National
Transportation Safety Board (NTSB), NTSB/AAR-78/13,
NTSB Human Factors Group Chairman’s Factual
Report, National Airlines B-727, Pensacola, Florida,
U.S., May 8, 1978.
3. Cosper and McLean. Adapted from NTSB/AAR-84/15,
Scandinavian Airlines System Flight 901, McDonnell
Douglas DC-10-30 Norwegian Registry LN-RKB, John
F. Kennedy International Airport, Jamaica, New York,
U.S., February 28, 1984.
4. Cosper and McLean. Adapted from NTSB/AAR-90/03,
USAir, Inc., Boeing 737-400, LaGuardia Airport,
Flushing, New York, September 20, 1989.
• “Personal hygiene was a major issue, especially for
females;
• “Participants stated [that] they were cramped, tired and
filled with anxiety after a short time in the slide/rafts
with strangers;
• “There was no mooring line or [ELT] attached to the
raft; this caused a discussion about the storage location
of [ELTs] on various aircraft;
• “Participants did not anticipate that the [rescue]
helicopter rotor wash would be so severe;
• “Participants were unfamiliar with equipment used for
rescue;
• “Participants did not realize that they could not be picked
up from inside the raft; [and,]
• “Participants did not realize that a rescue swimmer was
not always dropped from the helicopter to aid with
rescue.”
Participating cabin crewmembers said that better training
should be developed concerning rescue procedures, rescueequipment
usage and boarding of slide/rafts in sea swells.
They said that a checklist of aquatic-rescue tasks (on
waterproof paper) and thermal blankets should be added to
survival kits. Cabin crewmembers also said that training
material should emphasize wearing life vests at all times
during rescue.
The exercise also led to suggestions for making rafts more visible
in darkness. Rescuers said that their night-vision equipment
easily detected the light from flashlights provided in survival
kits, and they said that training should require lookouts to shine
a flashlight outside the raft or slide/raft frequently to greatly
increase the visibility of survivors to rescuers.
In summary, the most recent study for FAA of cabincrewmember
training for emergency water landings yielded
recommendations consistent with several other U.S. studies
from the 1980s and 1990s. The principal finding was that
despite the rare occurrence of emergency water landings,
aircraft crewmembers should be prepared to competently direct
passengers and to employ immediately all available resources.
This competence is critical not only when there is time to
prepare for ditching, but when the emergency water landing is
unexpected, and survival depends on making every minute
count under adverse conditions.©
References
1. U.S. National Transportation Safety Board (NTSB).
Safety Study: Air Carrier Overwater Emergency
Equipment and Procedures (NTSB/SS/-85/02). 1985.
2. Cosper, Donna K.; McLean, Garnet A. Analysis of
Ditching and Water Survival Training Programs of Major
Airframe Manufacturers and Airlines DOT/FAA/AM-98-
/19. A report prepared for the U.S. Federal Aviation
Administration (FAA). July 1998.
3. U.S. National Aeronautics and Space Administration
(NASA). Structural Response of Transport Airplanes
in Crash Situations DOT/FAA/CT-83/42, November
1983. In Patel, Amit A.; Greenwood Jr., Richard P.
Transport Water Impact and Ditching Performance
DOT/FAA/AR-95/54. A report by Galaxy Scientific
Corp. for the U.S. Federal Aviation Administration.
March 1996.
4. Patel and Greenwood, 10.
5. NTSB, 1985.
6. NTSB, 1985.
7. NTSB. NTSB/AAR-78/13, Human Factors Group
Chairman’s Factual Report, National Airlines B-727,
Pensacola, Florida, May 8, 1978.
8. Johnson, R.A. Study on Transport Airplane Unplanned
Water Contact U.S. Federal Aviation Administration (FAA)
Technical Center Report DOT/FAA/TC-84/3. 1984.
9. Patel and Greenwood, 6.
1 2 FLIGHT SAFETY FOUNDATION • CABIN CREW SAFETY • NOVEMBER–DECEMBER 1998
10. Chen, C.; Muller, M. Commuter/Air Taxi Ditchings and
Water-related Impacts that Occurred from 1979 to 1989
(DOT/FAA/TC-92/4). 1994. The report focused on
aircraft that were operated in accordance with U.S.
Federal Aviation Regulations (FARs) Part 135, “Air Taxi
Operators and Commercial Operators.”
[Editorial Note: The following definitions are derived
from FARs Part 119, and FAA Aviation System Indicators:
1996 Annual Report. For data from 1996 and earlier, the
commuter air carrier category includes aircraft with a
maximum seating capacity of 30 or fewer passenger seats
and the large air carrier category refers to aircraft with a
maximum seating capacity of greater than 30 passenger
seats.
Commuter Air Carrier: An air carrier conducting
passenger-carrying operations under FARs Part 135 on
at least five round trips per week on at least one route
between two or more points according to a published
flight schedule. This category includes rotorcraft as well
as airplanes (other than turbojet-powered airplanes) with
nine or fewer passenger seats and a payload capacity of
3,400 kilograms or less.
Air Taxi — On-demand Air Charter: An air carrier
conducting nonscheduled transportation of people,
material goods or mail operating under Part 135 using
rotorcraft or using airplanes (including turbojet-powered
airplanes) with 30 or fewer passenger seats and a payload
capacity of 3,400 kilograms or less. This category also
includes scheduled passenger-carrying operations of less
than five round trips per week on at least one route
between two or more points conducted in either rotorcraft
or in airplanes (other than turbojet-powered airplanes)
with nine or fewer seats or a maximum payload capacity
of 3,400 kilograms or less. All-cargo operations
conducted with rotorcraft as well as those conducted with
airplanes having a payload capacity of 3,400 kilograms
or less are also included.]
11. U.S. Department of Transportation (DOT)/FAA.
Administrator’s Fact Book ABC-100. Washington, D.C.:
Office of Business Information and Consultation. 1996
and 1997.
12. NTSB, 1985.
13. DOT/FAA, 1997.
14. Phillips, E. “Focus on Accident Prevention Key to Future
Airline Safety.” Aviation Week & Space Technology, Aug.
29, 1994, 52-53.
15. U.S. National Aviation Schools Command. Naval
Aviation Water Survival Training Program (Initial N-1).
1991.
16. Antuñano, M.; Shaw, R.; Brown, J.; Nelson, H.; Storey,
R.Global Survival FAA-CAMI/AAM420. 1991. U.S.
Coast Guard; U.S. Department of the Navy; U.S.
Department of the Air Force. Aircraft Emergency
Procedures over Water CG-306, OPNAV-3730.4,
AFM64-61955. Washington, D.C.: U.S. Government
Printing Office. 1955.
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