After passengers used the emergency slides to escape a smoke-filled cabin while carrying their hand bags, and ATSB investigation criticized Qantas’ safety video.
It was implemented in response to a safety event in 2019 in which a “haze” developed inside the cabin when an A330 returned to Sydney due to a hydraulic leak.
The investigation also claimed that the flight crew was not informed of a “unusual scent” that the cabin staff had noticed upon arrival.
As a result, Qantas changed its safety video and said it now offers additional training for pilots and cabin personnel on how to handle such circumstances.
“The ATSB found limitations and inconsistencies in how Qantas’s safety video and briefing card described emergency slide use and what to do with cabin baggage in an emergency,” said ATSB chief commissioner Angus Mitchell.
“For example, the pre-flight video showed a passenger sitting down and placing their bag next to them, just prior to sliding.
“The management of passengers in an emergency situation is the last line of defense to avoid injuries and fatalities, so it is important passengers are well informed through the provision of sufficient and accurate communication about what they may be required to do.”
According to the ATSB, a hydraulic leak forced the Perth-bound Airbus A330-200 carrying 2 flight crew, 8 cabin crew, and 222 passengers to return to Sydney on the morning of December 15, 2019.
A haze started to gather in the cabin and flight deck as the plane was being towed back to the terminal, and both passengers and crew started to feel sick, including having their eyes and throat irritation.
The captain ordered the evacuation after informing the first officer and the cabin service manager that it was necessary.
During the evacuation, 129 of the passengers departed using aerobridges, while the remaining 93 used one of the three deployed escape slides.
“A number of passengers used the escape slides in a manner that increased the risk of injury, and unfortunately six passengers were injured,” said Mitchell.
While other passengers suffered only minor wounds like knee sprains, friction burns, and elbow cuts and abrasions, one passenger who utilized an escape slide had significant wounds including tendon ruptures in both knees.
In addition, at least 40 passengers were seen leaving via aerobridges with carry-on luggage on CCTV and another video; some of these passengers returned their bags after the evacuation command, which probably prolonged the evacuation procedure.
“Some passengers also brought cabin baggage to the top of the emergency slides, and while some complied with cabin crew and left them behind, others were shown on CCTV with their luggage in hand, after using a slide,” Mr. Mitchell continued
“Passengers should always leave their belongings behind during an evacuation.”
The ATSB discovered that basic directives like “leave everything behind” and “jump and slide” were not among the principal instructions used by the Qantas cabin crew to guide passengers in an evacuation.
Since the event, Qantas has changed the video that it uses for its passenger safety briefings and is working to add the phrase “leave everything behind” to its standard evacuation instructions.
The timing of the evacuation, when the aircraft landed at the terminal and the cabin crew had disarmed the doors, created a significant problem, according to the ATSB. The investigation revealed that two members of the cabin crew did not rearm their doors before opening them during the evacuation.
“Crew members must remain prepared to react to an emergency at any time until everyone has disembarked the aircraft,” Mitchell said.
After that, Qantas instituted routine training that mandates cabin staff members to physically perform the evacuation protocols at a terminal.
A rudder servo-hydraulic pipe ruptured while the aircraft was in flight, causing a hydraulic breakdown that caused it to return to Sydney.
The flight crew began the aircraft’s auxiliary power unit (APU) after landing and turning on the APU to bleed air to preserve electricity and air conditioning in the cabin while waiting for engineers and a tow.
The APU air intake then consumed the leaking hydraulic fluid, which was then atomized and disseminated throughout the cabin and flight deck via the air conditioning system as the aircraft was being towed back to the terminal.
Before and after the aircraft was hauled back to the terminal, some members of the cabin crew noticed strange odors, although they at the time did not alert the flight crew.
As part of the smoke and fumes protocol, the ATSB may have instructed the flight crew to switch off the APU bleed air.
“Communication between the cabin crew and flight crew is essential in abnormal situations, and it is important for information to be relayed as soon as it becomes available,” Mitchell said.
The ATSB study also stated that Qantas lacked a “rapid disembarkation” process, which would have allowed for a quicker deplaning than typical at a slower, more regulated pace than an emergency evacuation.
“Accidents around the world continue to show there is a significant risk of injury to passengers when escape slides are used,” Mitchell said.
“This risk is acceptable in a life-threatening situation where the alternative may be catastrophic, but in cases such as a fumes event — particularly if the aerobridge is already attached — a rapid disembarkation procedure may be preferable.”
In May 2022, Qantas said that it was reviewing its present non-routine debarkation process and seeking to include a pertinent procedural framework.
“In this case, given the information available and the physical symptoms being experienced by crew and passengers, the captain’s decision to evacuate was a sound one,” Mitchell concluded.
In a statement, Qantas said, “The captain made the right decision to evacuate the aircraft and our crew worked hard to get passengers off the aircraft as quickly and as safely as possible. We know this would have been a very unsettling experience for our customers, and we thank them for responding when they were asked to evacuate.
“Since this incident occurred back in 2019, we have provided additional training for pilots and cabin crew in responding to situations like this.
“While we already reminded customers to leave cabin baggage behind in cabin crew safety briefings and on safety cards, we also updated our safety video in February 2020 which reinforced this point.
“This incident is an important reminder for all air travelers to make sure they’re watching safety videos and demonstrations and reading the safety cards, even if they fly with us regularly.
“Evacuations are extremely rare, but it’s important customers know what to do if they are instructed to evacuate the aircraft.”