The Cockpit and the Cabin: 2019 Incident at Stansted
We talk a lot about Cockpit Resource Management and the importance of the captain and the first officer acting as a team. A related issue which has had a lot less focus is the importance of communication between the cockpit and the cabin.
On the first of March 2019, an Airbus A320-214 registration OE-LOA suffered an engine failure before take off at London Stansted. There were seven crew on board and 169 passengers. The incident resulted in two passengers needing hospital treatment and ten passengers with minor injuries which were treated on the scene. The full details of the incident are covered in AAIB Bulletin 9/2020. For this post, I am focusing on human factors.
The Airbus A320 was departing London Stansted for a scheduled flight to Vienna. The flight crew lined up on the runway and the commander, who was Pilot Flying, applied full power for the take-off roll. The first officer called out “THRUST SET” but then, while travelling at a groundspeed of 31 knots, there was a loud bang and the aircraft veered left. The commander called “STOP STOP STOP” and rejected the take-off, coming to a halt between the centre-line and the left side of the runway.
The captain set the parking brake and used the public address system to alert the cabin crew by announcing “ATTENTION CREW: ON STATION” twice.
The first officer alerted ATC to the fact that they were stopped on the runway and completed the actions for ENG 1 FAIL and ENG 1 REVERSER UNLOCKED messages on the electronic centralised aircraft monitor. There was no indication of fire. The commander shut down the left engine and contacted the Rescue and Fire Fighting Services, asking them to confirm that there were no signs of fire visible from the outside.
The Rescue and Fire Fighting Service arrived quickly and reported that there was no sign of fire. The flight crew agreed that they would vacate the runway using the thrust from the right engine and contacted ATC for clearance to do so.
So far, this is all standard procedure, except that in the cabin, things were not going as expected.
There were five cabin crew on board that day. Soon after the take-off roll, they heard a loud noise and felt the aircraft drift to the left before coming to a stop.
Four of the cabin crew heard the captain call ATTENTION CREW: ON STATION. This command is meant to alert the cabin crew that there is an emergency on ground. Upon hearing this announcement, the cabin crew are to move to their doors and remaining on high alert, waiting for additional commands from the cockpit.
The Senior Cabin Crew Member, who was at the front of the cabin, heard the loud bang and felt the aircraft veer to the left but did not hear the captain’s announcement.
The second cabin crew member, referred to in the report as FA2, stood and looked out of the left forward cabin door window.
At the rear of the aircraft, FA3 heard the bang and saw red and yellow lights through the passenger windows. FA4, stationed at the left-side rear exit, was the most experienced of the cabin crew. She reassured him and the fifth crew member, both newly qualified, and advised them to stay calm and wait for instructions from the flight crew. FA3 and FA4 stood at their assigned exits.
The fifth cabin crew member was on a familiarisation flight having completed training and was not assigned an operational role. As there didn’t seem to be any danger or immediate urgency, the additional cabin crew member did not take any action but waited for further instructions from the flight deck.
There are three interphones in the cabin which the cabin crew use for communication: one at the front and two at the rear of the aircraft. One of these is attached to the rear aisle swivel seat which folds into the wall; when opened and locked in position, it provides a forward-facing seat for a cabin crew member. When FA3 stood up, he lifted the release latch for the seat, which allows the seat to automatically fold back into the stowed position. However, as the seat folded, the interphone handset fell out of its cradle and the cable became trapped in the folded seat.
This happened a lot with these phones, apparently, although no cabin crew member had ever reported it. The FA3 remained standing, looking out the right-side door to see what was happening.
The Senior Cabin Crew Member at the front of the cabin was not sure what was going on but she stood up when she saw the other cabin crew standing at their exits. She said later that she felt shocked and overwhelmed and that all of the passengers were looking at her.
She picked up the interphone to check with FA3 at the rear of the aircraft that everything was OK. However, FA3 hadn’t placed the interphone back on the cradle and the cable was still trapped, which muted the sound of the chime.
The Senior Cabin Crew Member tried again to contact FA3, explaining afterwards that she was trying to work out whether an evacuation was necessary. As FA3 was not responding, she switched to the public address system, saying “Can you hear me?”
This got FA3’s attention. The Senior Cabin Crew Member attempted to communicate with him via hand signals but the cabin lights were not on and she couldn’t see well enough to understand the signals he was making. She could not see that the interphone was trapped.
FA3 finally freed the interphone so that he could speak to her. He said later that after the captain’s announcement, a few seconds felt like minutes, because none of them knew what was happening.
The Senior Cabin Crew Member said that both of the cabin crew at the rear of the aircraft looked scared and shocked. She understood FA3 to say that he had seen flames and sparks from the engine.
That’s the information she was looking for and she announced “EVACUATE, EVACUATE, EVACUATE” over the interphone. FA3 didn’t understand why she would be commanding an evacuation over the interphone. He told her she should announce it over the PA system, which she then did.
Normally, an emergency evacuation is initiated by the captain, using the public address system. However, if there is no evacuation command from the cockpit and there is no doubt that an evacuation is necessary, a cabin crew member can initiate an evacuation. The situations under which a cabin crew member can carry out an evacuation are specifically listed:
- Immediate danger (fire, smoke, explosion, water, etc)
- Cockpit crew is incapacitated (injured, not on board)
- Communications down due to heavy damage to aircraft
After the event, the Senior Cabin Crew Member confirmed that she knew the guidance but also that she wasn’t thinking about it at that moment. She didn’t think to contact the flight crew. She said that she didn’t have much contact with the pilots and only a limited understanding of their responsibilities in an emergency. “For me,” she said, “it was the door closed, I have nothing to do with them.”
One minute and twenty seconds had elapsed between the “ATTENTION CREW: ON STATION” command by the captain and the “EVACUATE” command by the Senior Cabin Crew Member.
Meanwhile, FA3 never saw any signs of fire and says he never told her that there were flames and sparks outside. But FA4, who was across from him at the left-side rear exit, said that she also thought she heard him saying that he’d seen fire outside. She then heard him tell the Senior Cabin Crew Member to repeat the evacuation command “out loud”. She tried to contact the Senior Cabin Crew Member via the other interphone but got no response. She then heard the Senior Cabin Crew Member repeat the “EVACUATE” command over the public address system. She hesitated for a moment but when she saw that FA3 was already opening his door, she opened her door in order to evacuation the passengers.
The passengers reported later that the cabin crew seemed to be having problems communicating, shouting in English and German and using hand gestures before using the public address system to speak between the front and back of the cabin. Four of the passengers said that they never heard or did not understand the command to evacuate.
When FA3 opened his assigned exit, the right hand door at the rear of the aircraft, the inflated escape slide was floating almost horizontally instead of resting on the ground. He had no idea why the escape slide hadn’t extended correctly, however it was clearly unsafe, so he blocked the exit. Both cabin crew members called out evacuation commands to the passengers and helped them disembark through the left-side door. They took hand luggage away from the passengers attempting to carry it off the plane, piling the luggage by the right-side door.
The aisles became blocked as people attempted to take their baggage from under their seats and from the overhead bins. Other passengers shouted at them to leave their luggage behind. Passengers exiting from the overwing exits, which were not manned by cabin crew, were seen on CCTV leaving the aircraft with their baggage. One passenger estimated that about half of the passengers took their hand baggage with them.
At the front of the cabin, both exits quickly became blocked as the cabin crew attempted to take the hand luggage away from the passengers. The passengers leaving via the slide at the front right-side of the aircraft were subjected to jet exhaust from the right engine, which was causing “wind speeds” of 65 mph and greater. Some passengers were blown over several times and others had their belongings blown away.
Once the passengers had all been evacuated, the cabin crew checked the cabin. FA3 asked the additional crew member to disembark and help him assist the passengers on the ground, planning to follow her down.
Back in the cockpit, the flight crew had informed ATC of their intention to vacate the runway using the thrust from the right engine. Just as the captain was about to make an announcement for all cabin crew to return to normal operations, he saw a caution message on the ECAM (Electronic Centralized Aircraft Monitor): DOOR L FWD CABIN was lit up in yellow. He initially assumed that the notification was a fault with the left forward cabin door sensors. Looking out the left window, he saw the evacuation slide had been deployed out of that door and worse, a passenger was crossing in front of the aircraft.
He called the Senior Cabin Crew Member and, according to the report, he “asked her why the evacuation had been initiated” … although I’m pretty sure that is not quite the phrasing he used! The cabin crew member replied that she believed he’d ordered an evacuation.
After making it clear that he had not, in fact, ordered an evacuation, he realised that there were passengers on the right side of the aircraft, near the running engine. He started the APU (Auxiliary Power Unit) and shut down the right engine. Three minutes had passed since the shutdown of the left engine.
Once it became clear that there was no reason to evacuate, FA3 disembarked to find the additional crew member who he had sent down to help the passengers.
I can’t help but imagine the conversation in the cockpit. One the aircraft was safely shut-down, the first officer went into the cabin to find out what had happened.
The cabin was empty except for three cabin crew. Piles of abandoned baggage were piled by the exits. The first officer asked the missing cabin crew members to return to the aircraft. There really wasn’t much else that anyone could do.
If you are wondering about the "incident" at #Stansted: a plane was stopped just before getting on the runway because of an engine failure.
Everyone is ok, we are on a bus waiting to get back to the Terminal. pic.twitter.com/7f1IvCi8dG
— Chiara Nardi (@chiara_nardi) March 1, 2019
Local ambulances quickly arrived on the scene. Two passengers were injured and were taken to hospital. Ten passengers were treated for minor injuries on the spot: cuts, grazes, bruises and sprains.
The Airbus A320 was towed off of the runway to a remote parking position. The airline organised a replacement aircraft which flew the scheduled flight to Vienna later that evening.
From the AAIB Bulletin:
Once they had noticed that an evacuation had commenced there was realistically no way that the flight crew would have been able to recover the situation. It may have been prudent to action the EMER EVAC checklist to ensure that the aircraft systems were all in as safe a state as possible for the passengers to exit the aircraft. However, given that passengers were potentially going to encroach into the right engine’s inlet suction danger area it was probably quicker to select the eng master to off. Had the commander prioritised shutting down the engine and thus had a more succinct discussion with the SFA, the right engine could have been shut down sooner.
I can’t help but think that it is asking a lot of him to have the presence of mind to cut off the “You did what???” conversation in order to shut down the remaining engine but it’s clear that those exiting from the front right engine were at real risk of being sucked into the engine.
Any of the cabin crew could have contacted the cockpit at any point but their training had not supported interactions with the flight crew. The cabin crew knew the pilots would be busy in an emergency but they did not have any understanding of what the pilots might be doing up there or how long it would take. As a result, although they only spent just over a minute waiting for an instruction, it seemed like a very long time.
The Senior Cabin Crew Member, in particular, should have contacted the flight deck as she had not heard the announcement. However, it had never occurred to her to contact the pilots. As far as she was concerned, she was on her own. She had qualified as a cabin crew member in May 2017. The six week training course was designed for 20 to 25 trainees but on her course, there were 39 trainees. The airline went bankrupt at the end of that year and she did not fly for three months.
The new operator who took over the airline was under pressure to have trained staff available for flights and in May 2018, she completed a five-day classroom-based (theoretical) SFA course and was promoted to Senior Cabin Crew Member. Between the large group in her initial training, her low amount of practical experience and the intensive theory training compacted into just five days, she was clearly lacking in the skills and judgement required of a Senior Cabin Crew Member.
All of the cabin crew had trained for evacuations following an emergency. However, every emergency that they simulated included a practice evacuation. At no point had they practised returning to normal operation — as far as the training was concerned, emergencies ended in an evacuation.
I’ve focused on the cabin crew here, however if you are interested in other issues raised by this incident, it is worth reading the conclusions of the AAIB Bulletin 9/2020. The report deals in detail with the causes of the engine failure, which I have skipped over, as well as the emergency response and problems with the interphone.
The report also spends a fair amount of time on the fact that many of the passengers collected their bags, intending to leave the aircraft with them, which slowed down the evacuation. Luggage was taken away from the passengers disembarking through the manned exits but this left the cabin crew needing to find a place to store the bags without causing an obstruction. Studies have shown that this compulsion to take the luggage in an emergency is not overcome by briefings and instructions and, in fact in one case, even trained flight crew attempted to take their baggage with them in an evacuation. The bulletin quotes the Royal Aeronautical Society, which recommends that the overhead bins which do not contain emergency equipment be locked remotely, before making two Safety Recommendations.
Safety Recommendation 2020-018
It is recommended that the European Union Aviation Safety Agency commission research to determine how to prevent passengers from obstructing aircraft evacuations by retrieving carry-on baggage.
**Safety Recommendation 2020-019**
It is recommended that the European Union Aviation Safety Agency consider including a more realistic simulation of passenger behaviour in regard to carry-on baggage in the test criteria and procedures for the emergency demonstration in CS-25.
CS-25 is the regulation which requires that all crew and passengers can be evacuated within ninety seconds and airline operators must demonstrate that they can meet this requirement in the dark with minor obstructions. However, the simulated evacuations do not, at present, require the further complication of passengers attempting to retrieve their baggage and leave the aircraft with it.
The operator has taken several safety actions, principally based around the training of its flight attendants.
These changes include the requirement for the cabin crew to at least try to contact the flight crew before commanding an evacuation.