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Clarification of terminology (e.g., abnormal vs. emergency)
and appropriate usage
Philosophy of Response to Emergencies
Evident in Checklist Design
MD-11 In-flight Fire
Nova Scotia, Canada
September 2, 1998
If smoke/fumes are
not eliminated, land
at nearest suitable
airport
DC-9-32 In-flight Fire
Miami, Florida
May 11, 1996
Philosophy of Response to Emergencies – Checklist Design
In a study of 15 in-flight fires that occurred between
January 1967 and September 1998, the TSB of
Canada determined that the average amount of time
between the detection of an on-board fire and when
the aircraft ditched, conducted a forced landing, or
crashed was 17 minutes.
Response to Emergencies:
Job Responsibilities
Influence Perspectives and
Behavior
MD-83 Jammed Stabilizer Trim – Port Hueneme, California – Jan. 31, 2000
DISPATCH: …If uh you want to land at LA of course for
safety reasons we will do that uh wu we’ll uh tell you though
that if we land in LA uh we’ll be looking at probably an hour
to an hour and a half we have a major flow program going
right now uh that’s for ATC back in San Francisco
MD-83 Jammed Stabilizer Trim – Port Hueneme, California – Jan. 31, 2000
LA-OPS: ok also uh….just be advised uh because you’re
an international arrival we have to get landing rights. I
don’t know how long that’s gonna take me…but uh I have
to clear it all through customs first.
MD-83 Jammed Stabilizer Trim – Port Hueneme, California – Jan. 31, 2000
MX: yea did you try the suitcase handles and the pickle switches, right?
CA: yea we tried everything together, uh…we’ve run just about
everything…
MX: um yea I just wanted to know if you tried the pickles switches and
the suitcase handles to see if it was movin in with any of the uh other
switches other than the uh suitcase handles alone or nothing
CA: yea we tried just about every iteration
MX: and alternate’s inop too huh?
CA: yup, its just it appears to be jammed the uh the whole thing it
spikes out when we use the primary. We got AC load that tells me the
motor’s tryin to run but the brake won’t move it when we use the
alternate. Nothing happens
MD-83 Jammed Stabilizer Trim – Port Hueneme, California – Jan. 31, 2000
Dispatchers – Movement and scheduling of aircraft
Operations Agents – Take care of logistics related to landing
Maintenance Personnel – Fix broken airplanes
Very hard to set aside the mindset for normal mode of
operations, recognize and communicate the severity of a
situation, and to put all other considerations aside to get the
airplane safely on the ground
All were trying to do their jobs as they normally do them.
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Broad, Over-arching Issues
15 Different Categories of Issues:
Selected Emergency Equipment and Evacuation Issues
Issues Related to the Aircraft
Issues Related to Training
Issues Related to Humans
Issues Related to Checklists and Procedures
Checklist Type
and Availability
Development of
Checklists and
Procedures
Checklist
Structure and
Design
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Checklist and Procedures Issues
Development of Checklists and Procedures – When? By whom? How
certified? Are they standardized? Etc.
Checklist Structure and Design – Items, memory items, navigation,
locating correct checklist, nomenclature, format, etc.
Checklist Type and Availability – Paper, mechanical, electronic
(integrated with aircraft and in electronic flight bags), etc.
DC-9 Hard Landing – Nashville, Tennessee – January 7, 1996
• Difficulty raising gear after takeoff from Atlanta
• Ground spoilers deployed, aircraft hit the ground very hard, nose
wheel separated from the aircraft
• Later portion of the checklist directed the crew to reset the circuit
breakers which they did on final approach approximately 100 feet
(30.5 meters) above the ground
• Crew pulled the ground control relay circuit breakers, as directed by
same QRH checklist, to place systems in flight mode
• While still climbing, crew realized cabin pressurization and takeoff
warning systems were still in the ground mode
• Crew used UNABLE TO RAISE GEAR LEVER procedure in the QRH
QRH AOM
Hydraulic caution light illuminated while taxiing….I..completed
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