Probe finds serious deficiencies in post-evacuation transportation - passengers should follow evacuation orders and leave carry-ons behind

Published 28.11.2018

Safety Investigation Authority, Finland (SIAF) has completed an investigation into the evacuation of an airliner at Turku airport, Finland, on December 3, 2017. Finnair’s scheduled service departed from Helsinki, Finland, to Gothenburg, Sweden, but diverted to Turku after smoke appeared in the cabin of the Embraer 190 operated by Nordic Regional Airlines. The captain elected to evacuate the 100 passengers and four crew members after landing. The smoke was caused by the failure of the air cycle machine in one of the aircraft's two air conditioning packs. The occurrence did not result in injuries.

A possible or confirmed fire is an extremely serious and dangerous situation on board an airplane. The probe revealed deficiencies in several areas, including the post-evacuation transportation of large numbers of passengers

SIAF issues four safety recommendations to enhance aviation safety - The authority points out that improvements in passenger transportation arrangements cannot be neglected by hiding behind red tape

Turku airport emergency plan had not taken into account the need to ensure the availability of vehicles for the transportation of large numbers of people, and the same applies to most of Finavia’s airports and aerodromes. Pursuant to the national Rescue Act, city buses were requisitioned to move passengers from the movement area to a warm evacuation facility, even though this had not been agreed on with the bus operator.

The transportation of large numbers of people from the movement area to a warm and safe location in the event of an accident or incident must be carefully planned and rehearsed; this shall be done proactively, not in an unexpected contingency. Sufficient resources shall also be allocated for the purpose.

The investigation team looked at transportation arrangements at 21 airports. The results and the alleged reasons for the existing situation left much to be desired. 15 airports had no own buses nor had they preplanned vehicle use with operators in view of various contingencies. SIAF’s Executive Director Veli-Pekka Nurmi points out that only four airports had their own buses while two airports had in place some other arrangement for obtaining suitable passenger-carrying vehicles.

SIAF therefore recommends that the Finnish Transport Safety Agency ensures, without undue delay, that airport operators include in their emergency plans contingency procedures for post-evacuation transportation of passengers within the aerodrome. Expeditious movement of passengers away from an accident site is essential and requires careful planning and rehearsing.

Nurmi explains that some operators gave justification for the poor state of the current arrangements claiming that transportation is not required by the European Union or governed by regulations. He emphasizes that the operators’ explanations and the reasoning behind them are simply inadequate, and safety can and shall be bettered without resorting to directives or regulations. Nurmi concludes that transportation arrangements based solely on the capabilities of local rescue departments and adherence to the provisions of the Rescue Act are insufficient.

SIAF also recommends that the United States Federal Aviation Administration (FAA) issues an airworthiness directive requiring a modification to be incorporated in the bag of protective breathing equipment used in the occurrence airplane to facilitate its opening. A cabin crew member was unable to open the bag — manufactured by B/E Aerospace — because a 25 kp force would have been needed for the task. Similar difficulties have also been noted during other emergencies. The tear open bag does not always open correctly, but the problem can be alleviated by modifying the opening mechanism. Difficulties in opening may jeopardize a crew member's life and health and slow down evacuation.

In addition, SIAF recommends that the Ministry of Interior cooperates with the Ministry of Social Affairs and Health, Air Navigation Services Finland and the Emergency Rescue Center Agency to align their procedures for aircraft accidents and full emergency situations. In conjunction with this, a need to amend the procedures related to the contents of alert calls, response arrangements and inter-organization communications in particular should be addressed. Differences between air traffic control’s (ATC) alerting instructions and emergency response center (ERC) procedures result in misinterpretations and therefore affect cooperation between rescue authorities and operators.

SIAF also points out that passengers will have to follow evacuation orders and leave carry-on baggage behind. Groping for carry-ons in an emergency shows blatant disregard for others and may cause deaths or injuries

Investigator in charge Ismo Aaltonen states that SIAF's safety recommendations are for the benefit of all airliner passengers and the entire aviation industry and should be taken seriously. Even though the occurrence under investigation did not lead to major damage, continuous improvement will be needed since it is always better to be safe than sorry. SIAF appeals to all passengers to follow the crew's orders and instructions in the event of an evacuation.

Investigator in charge Ismo Aaltonen explains that evacuation situations are not a place for negotiations; instead, all persons involved should function in an effective and controlled manner and leave carry-ons behind.

Crew members usually know the ropes. An evacuation is invariably a serious situation and groping for carry-ons or not heeding the crew’s orders may in the worst case lead to additional deaths and injuries. The investigation once again showed that some passengers start gathering their carry-ons after an evacuation order, Aaltonen concludes, and adds that this behavior has also been observed during several occurrences abroad.

Finally, SIAF recommends that Air Navigation Services Finland amends ATC’s alerting instructions to clearly indicate that an emergency communicated on the radio or by setting the emergency code on the transponder are given an identical classification. In this occurrence, the crew declared emergency on the radio; the event was therefore classified as a full emergency, and the ERC therefore initiated limited response.

Safety Investigation Report

More information: Veli-Pekka Nurmi, Executive Director, tel. +358 295 150701.