Indian incident report highlights aircraft evacuation procedures and decision making

The investigation into an evacuation of a Boeing 737-800 on a taxiway at Mumbai Airport, India revealed poor decision making and highlights the importance of aircraft evacuation procedures.

On August 27, 2010 Jet Airways Boeing 737-800 aircraft, VT-JGM, was operating flight 9W-2302 from Mumbai to Chennai. There were 139 passengers 3 flight crew members, 4 cabin crew members and 8 ACM (Additional Crew Member) cabin crew onboard.
While taxying to the runway an additional cabin crew (ACM) seated at row 35A apparently observed some fire from left engine and informed another ACM on seat 35B who also claimed to have confirmed the fire from the left engine. Immediately the ACM seated on 35B got up from his seat and went to the rear galley and informed the captain about the fire. In turn the captain asked the cabin crew in charge-CCIC (L1 Position) to confirm the fire. She also confirmed fire to the Captain. But all the indications in the cockpit were normal and there was no fire warning.

However based on the confirmation given by the CCIC he ordered for precautionary evacuation. A precautionary emergency was declared and Engines and APU were shut down. For the purpose of evacuation L2,R1 and R2 slide chutes were deployed and inflated. Also Left side aft over wing exit door and right side both over-wing exit door were opened.
During the evacuation time airport fire and rescue services were also deployed. However no foams were discharged as there was no fire/smoke. At the time of incident the taxi track was wet due drizzling of previous hours. Weather was fine. In the process of evacuation 25 passengers were injured and four of them were seriously injured with multiple fractures on the legs. There was neither smoke nor actual fire in the incident.

Investigators concluded that wrong decision of the captain to carry out evacuation for non-real emergency situation of imaginative fire from the left engine, leading to the serious injuries to passengers is the most probable cause for the incident.

Contributory factors were:

  1. Non-awareness of the effect of anti-collision light by the ACMs, cabin crew and CCIC
  2. Over reacted ACMs and absence of company policy on ACM role in the flight
  3. Failure of CCIC to play her role in evacuation
  4. Incorrect usage of non-required exit for evacuation
  5. Lack of training on over-wing exit evacuation
  6. Wrong door guarding procedure
  7. Lack of situational awareness and crew coordination of the cockpit crew.
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