Evaluation and Mitigation of Aircraft Slide Evacuation Injuries (2008)

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6Databases The databases and sources consulted in compiling the evacuation incident and accident data were the following: • The FAA’s Accident/Incident Data System (AIDS), part of the Aviation Safety Information Analysis and Sharing (ASIAS) System; • NTSB’s Aviation Accident Database & Synopses; • The CASE database produced by Airclaims; • The RGW Cherry & Associates Limited Accident Database, designed on behalf of the airworthiness authorities partic- ipating in the Cabin Safety Research Technical Group (a group formed by the aviation authorities of Canada and the United States, Europe, and Japan in the early 1990s to bring together their respective cabin safety research efforts. For additional information visit http://www.fire.tc.faa.gov/ cabin.stm); • Service Difficulty Reports (SDRs); • The Aviation Safety Reporting System (ASRS); • A direct survey of the ARFF groups of 30 major U.S. air- ports; and • A direct survey of airlines that are Air Transport Association (ATA) members. The authors of this report have also examined the potential use of SDRs and the ASRS. The very large number of SDRs means that data-mining tools may be required for searching, and this is outside the scope of this project. However, exami- nation of SDRs has allowed the authors make some qualitative assessments of the extent of information available. The ASRS is difficult to use since much of the information is de-identified and therefore cannot be correlated with identified events. Each of the databases in the list above was queried sepa- rately, using the parameters outlined in the project scope and parameters for aircraft that have inflatable slides. Those aircraft that are not large enough to have such slides are not included in this study. Challenges with the Accuracy of the Data Title 49 of the CFR (49 CFR § 830.5) requires operators to notify the NTSB of any deployment of inflatable slides. This includes inadvertent, uncommanded, and maintenance-related deployment or actual emergency deployment. According to Hynes (2000), such accidents or incidents do not always get reported to the NTSB. Based on discussions with airline safety officers conducted as part of this research, it seems that such reporting may take the form of a phone call to the NTSB, and, if the event has not resulted in damage or injuries of any kind, it may not be even logged by NTSB and would certainly not be investigated. That some forms of reporting may not be documented makes it difficult to establish a total base number of slide deployments or occurrences of emergency evacuations using slides. Even more challenging, the review of databases for this research revealed that not all incidents (as opposed to accidents) are included in FAA’s Accident/Incident Data System (AIDS). While, as expected, all accidents were noted in NTSB’s Aviation Accident Database & Synopses, a few accidents were not included in AIDS. It was expected that all incidents involving slide deployment would be recorded in NTSB’s Aviation Acci- dent Database & Synopses because of the reporting require- ment. However, perhaps due to the less formal reporting mechanism noted above, incidents that did not involve major injuries are not recorded. Surprisingly, some of these types of incidents were included in the FAA’s Accident/Incident Data System (AIDS); however, there were only a few discrepancies of this nature. Since there were discrepancies among the four databases used (FAA’s Accident/Incident Data System (AIDS), NTSB’s Aviation Accident Database & Synopses, Airclaims’ CASE, and RGW Cherry & Associates Limited Accident Database), this research was supplemented by direct contact with airlines and airport fire and rescue units. The compilation of infor- mation from all of these sources makes it reasonable to assume that nearly all cases of passenger and crew evacuations using C H A P T E R 2 Research Approach

inflatable slides for the period under study (January 1, 1996, to June 30, 2006) have been identified. In order to accurately identify cases resulting in injuries and, more importantly, to examine the injury mechanisms, addi- tional information from any record of the incident/accident or investigation was sought. In cases that were identified as accidents and involved NTSB investigation, the report and narratives—particularly those compiled by the Survivability Factors Group at NTSB—contain very useful information. Unfortunately, most narratives do not contain enough detail, particularly with regard to injury mechanisms. The most crit- ical issue is that not every accident has been investigated; therefore, it is almost impossible to obtain enough detailed information on all injury mechanisms. Surveys Three separate surveys were conducted. The first survey was designed to obtain additional details on identified incident or accident cases as well as to discover events that may not have been captured in the review for this research. The second survey was similar to the first one, but was designed to solicit information regarding the type, location, and severity of in- juries that may have been recorded by ARFF units. The third survey was developed to solicit specific information about conditions faced by first responders during aircraft emergency evacuation and to seek their recommendations. The first survey was designed in consultation with ATA’s Director of Safety (see Appendix A). The survey was distributed among the 18 member airlines of ATA. The airlines were re- quested to provide as much information as possible on the emergency evacuation events collected by the research team. The airlines were also asked to provide a list of any emergency evacuation events that had been missed by the researchers. FedEx, United, and Delta responded to the survey. FedEx provided information on the evacuation cases collected by the research team as well as a separate list of events that were missing from the collected data. The supplemental data pro- vided by FedEx are indicative of a gap in data capture owing to the circumstances previously described. Other airlines either lacked the resources to conduct a thorough review or did not retain descriptive data after complying with all reporting re- quirements and adjudicating any legal matters pertaining to incidents. Most responses simply confirmed the list of events collected by the research team and did not provide additional detailed information on injury mechanisms. A second survey was designed and sent out to the ARFF working units of about 100 airports throughout the United States (see Appendix B). The ARFF units were asked to provide detailed information on any injuries incurred during slide evacuation of commercial aircraft. Forty-one ARFF units responded to the survey; 12 of the responding ARFF units were at large airports. Finally, a third survey was also sent to the ARFF units of about 100 U.S. airports. The ARFF units were asked to list the three top issues encountered during aircraft emergency evac- uations using slides. The ARFF units were also asked to list their top three recommendations for ARFF personnel for im- proving emergency evacuation. Out of the total distributed surveys, 11 responses were received. The complete list of issues and recommendations can be viewed in Appendix C. The researchers visited Delta Airlines headquarters in Atlanta. A meeting was held with the Vice President of Safety and Security and Quality Assurance and his staff. Their facility was visited, and the research team participated in a mock slide emergency evacuation. The research team was also briefed on Delta’s cabin safety program. A list of all the emergency evacu- ation events during the period being researched was provided by Delta. There were three incidents that were not included in the NTSB and FAA accident/incident databases. Delta Air- lines has a procedure for reporting to NTSB and FAA that is similar to the reporting procedures of other airlines. As pre- viously noted, in minor incidents, the immediate reporting may take the form of a phone call to the NTSB field office. 7