1. Midway Overrun and Flight Attendant Training: Lessons Learned
Larry Parrigin
Southwest Airlines
While none of us relish the thought of our People, Customers, or aircraft being involved in an accident or incident, the opportunity exists to examine and evaluate our procedures and training under real world conditions. In this session, we’re going to look at Southwest Airlines’ accident at Midway and how it impacted procedures and training for Flight Attendants.
April 27, 2010
Southwest Airlines Inflight Training

2. Southwest Airlines Inflight Training
December 8, 2005
On December 8, 2005, Southwest Airlines flight 1248 overran the departure end of runway 31C at Chicago Midway Airport during the landing rollout. The airplane departed the end of the runway, rolled through a blast fence, a perimeter fence, and onto a roadway. The airplane came to a stop after impacting two automobiles.
April 27, 2010
Southwest Airlines Inflight Training

3. Southwest Airlines Inflight Training
Accident Summary
737-7H4, from BWI-MDW
98 passengers / 5 crewmembers
Minor injuries onboard, one ground fatality
Nosegear collapse
L1 and R2 doors used for evacuation
5-10 minutes to evacuate aircraft
The accident aircraft, a 737-7H4, was operating as flight 1248 from BWI to MDW. 98 passengers plus a crew of five (two pilots, three flight attendants) were on board. Minor injuries were reported on board the aircraft. There was one ground fatality. The nose gear collapsed, leaving the aircraft in a “tail high” attitude with the forward type 1 exits close to the ground. The L1 door escape slide and portable stairs at the R2 door were used during the evacuation. The R1 door, L2 door, and two overwing window exits were not opened. Witnesses reported the evacuation was completed five to ten minutes after the aircraft came to rest.
April 27, 2010
Southwest Airlines Inflight Training

4. Southwest Airlines Inflight Training
Emergency Procedures
Operation of megaphones
30-second review
Carry-on baggage during evacuations
In addition to the NTSB Survival Factors Group investigation, Southwest debriefed with all five crewmembers. Their observations led to several changes in emergency procedures and how we train our Flight Attendants. Procedural changes included: operation of megaphones; the “30-second review” Flight Attendants perform prior to takeoff and landing; and how to handle carry-on baggage during evacuations.
April 27, 2010
Southwest Airlines Inflight Training

5. Southwest Airlines Inflight Training
Emergency Training
Flight Attendant initiated evacuations
Aircraft power loss
Megaphones
Unusual aircraft attitudes
Assigned exit responsibilities
How we train
We also identified several areas in which our emergency procedures training could be improved. These areas included: conditions under which Flight Attendants may initiate evacuations; what to expect if the aircraft loses power, especially in regards to the flight deck door lock; more hands-on training with the megaphones; unusual aircraft attitudes as an evacuation trigger and alternate commands for dealing with steep or shallow slide angles; and remaining at your assigned exit.
We also looked at how we train our Flight Attendants, which we’ll discuss near the end of the presentation.
April 27, 2010
Southwest Airlines Inflight Training

6. Southwest Airlines Inflight Training
Megaphones
Press the button on the handle and speak normally.
Because the aircraft’s power failed, the two Flight Attendants seated on the forward jumpseat (“A” and “C” position) attempted to make announcements using one of the aircraft’s megaphones. They reported that passengers had difficulty understanding what they were saying. One of the Flight Attendants moved into the cabin, repeating the announcements every four rows because they simply could not be heard.
During the debrief, the crew said they believed the equipment to be faulty or broken, in spite of it passing the pre-flight check and being found in working order during the post-accident investigation.
The procedure for using the megaphones was “press the button on the handle and speak normally.” Flight Attendants were doing this, but the microphone was too far away from the mouth for the megaphone to pick up.
April 27, 2010
Southwest Airlines Inflight Training

7. Southwest Airlines Inflight Training
Megaphones
Press the button on the handle.
Place lips in contact with the microphone and speak.
Volume is controlled by voice intensity.
Our operating procedures were changed to reflect the manufacturer’s recommendations. Procedures now read, “Press the button on the handle. Place lips in contact with the microphone and speak. Volume is controlled by voice intensity.”
April 27, 2010
Southwest Airlines Inflight Training

8. Southwest Airlines Inflight Training
Megaphones
Use during power failures/PA inop
Importance in an evacuation
Hands-on recurring practice
In addition to updating the operating procedures, training procedures for megaphone use was improved. Additional training was added to discuss the importance of using the megaphone when the aircraft’s PA system was inoperable, due to malfunction or power failure. The megaphone was also integrated into evacuation training as an item required to be taken following an evacuation.
Additionally, our approved training materials did not specify hands-on practice with the megaphone during annual recurrent training. Following the accident, all Flight Attendants practice using the megaphone during RT.
April 27, 2010
Southwest Airlines Inflight Training

9. Southwest Airlines Inflight Training
30-Second Review
What is my brace position and the brace command?
Stay in the brace position until the aircraft comes to a complete stop and the Captain initiates an evacuation.
Operation of the assigned exit.
Exit blocked procedures
Evacuation commands.
Most carriers have a version of the “30-second review” that Flight Attendants use to focus attention during takeoff and landing. The review stated: “What is my brace position and brace command? Stay in the brace position until the aircraft comes to a complete stop and the Captain initiates an evacuation. Operation of the assigned exit. Exit blocked procedures. Evacuation commands.”
After the aircraft came to a stop, the Flight Attendants reported a 2-3 minute window where there was no communication from the flight deck. Since the power was out, the interphone system was inoperable. There was no apparent danger, so the Flight Attendants had passengers remain seated while they waited for word from the pilots to evacuate, since their procedures and review stated that the Captain would initiate the evacuation and there was no danger apparent in the cabin.
April 27, 2010
Southwest Airlines Inflight Training

10. Southwest Airlines Inflight Training
30-Second Review
Brace position and brace commands until aircraft stops.
Evacuation decision.
Assigned exit procedures.
Evacuation commands.
The 30-second review was revised to include “evacuation decision.” At this point, the Flight Attendants attempt to communicate with the Pilots and coordinate on the need for an evacuation. If they are unable to contact the flight deck, they are to assess conditions and if conditions warrant, initiate the evacuation. Language that specified the Captain as the one to initiate an evacuation was removed.
April 27, 2010
Southwest Airlines Inflight Training

11. FA Initiated Evacuations
Clarify conditions under which FAs may initiate evacuations.
Include “unusual aircraft attitudes” as an evacuation trigger.
The flight attendants on 1248 were reluctant to evacuate the aircraft. They stated that they knew the aircraft was at “nose down” attitude and they were probably no longer on the runway. However, cabin conditions were normal – no evidence of smoke or fire, and no damage to the aircraft’s interior. Evacuation training was enhanced by clarifying the conditions under which Flight Attendants may initiate evacuations. In addition to smoke, fire, visible damage, or other apparent life-threatening conditions, “unusual aircraft attitudes” was incorporated as an evacuation trigger.
April 27, 2010
Southwest Airlines Inflight Training

12. Unusual Aircraft Attitudes
A/C attitude as an evacuation trigger
Assessing slide attitude/angle
Altering evacuation commands
Training had included unusual attitudes before – in the context of exits to avoid and the difficulties in operating exits under those conditions. However, it was not mentioned in the context of indicating a serious problem with the aircraft that would necessitate an evacuation. This is an excellent example of knowledge-based training versus an integrated approach that puts the knowledge in a context that’s practical.
The L1 door was near the ground, and the inflated slide ended up resting on a landscaping berm. The slide was almost parallel to the ground, making the “cross your arms and jump” procedure impractical. Passengers jumped, then had to scoot down the slide or be pulled off by ground rescuers. Training on assessing slide angles and altering evacuation commands as conditions dictated was incorporated.
April 27, 2010
Southwest Airlines Inflight Training

13. Southwest Airlines Inflight Training
Aircraft Power Loss
Impacted systems
Communication
Flight deck door
The aircraft lost power, triggering the emergency lighting system. The PA and interphone systems were down, so the flight attendants couldn’t call the pilots. Instead, they remained seated and waited for word from the flight deck. They didn’t know that the flight deck door would automatically unlock when the aircraft’s power failed. We integrated this into CRM training. If the power’s out, open the door and communicate face-to-face.
April 27, 2010
Southwest Airlines Inflight Training

14. Southwest Airlines Inflight Training
Carryon Baggage
Flight Attendant safety
Commands
In the cabin
At the exit
As passengers evacuated, there was a question of what to do with carryon baggage as it was brought to the exit. Handling carryon baggage at that point was to shout “leave everything” as part of the evacuation commands. What to do with baggage if passenger didn’t leave it had not been addressed. Procedures were written and added to training. First, flight attendants should not endanger themselves or slow down the evacuation to fight a passenger for a carryon. Flight attendants were encouraged to alter commands to individually address passengers and direct them to leave their carryon in the seating area, clear of the aisle. If a passenger made it to the exit, they should be instructed to drop it aft of the slide, away from the evacuation path.
April 27, 2010
Southwest Airlines Inflight Training

15. Assigned Exit Responsibilities
FAs must remain at their primary exits.
Send ABAs to assess conditions if needed.
While waiting for the pilots to communicate, the “B” (aft) flight attendant and “C” (forward) flight attendant moved into the cabin to check on passengers and ask that everyone remain seated. This left three of the primary exits unattended. In the back, firefighters had positioned portable stairs at the R2 door and were attempting to open the exit. “B” made her way back and managed to disarm the door before the exit was opened.
Training was enhanced to “prioritize” flight attendant responsibilities after an accident, including exit responsibilities. The importance of attending the exits is emphasized.
April 27, 2010
Southwest Airlines Inflight Training

16. Southwest Airlines Inflight Training
Emergency Training
Integrated approach
Scenario based
Encourage “What If” thinking
The training development group also identified several “big picture” training concepts that should be included in emergency procedures training. These were: an integrated approach; scenario-based training; and encouraging Flight Attendants to ask “what if” in regards to emergency procedures.
We talked earlier about unusual aircraft attitudes; that’s one example of knowledge that was integrated into evacuation training. What we wanted to convey to the flight attendants is that procedures are related. Critical thinking is necessary for a successful outcome in emergency situations. A can lead to B, but sometimes it could lead to X, Y, or Z.
Scenarios also play an important role in training. Training was traditionally presented as, “Here are the procedures. Practice the procedures.” Not a very practical approach and not how things operate in the real world. To allow the flight attendants a chance to practice critical thinking skills, open-ended scenarios are presented in class. As the flight attendants come up with solutions, the instructor will throw another variable at them that must be solved. The scenario may start out as a “by the book” emergency: the captain has asked you to remain seated after an emergency landing. What would you do at this point? Well, now you see flames shooting up from the number two engine. What now? The point is to encourage the type of “out of the manual” thinking that is necessary to cope with ever-changing conditions.
Finally, we have brought our instructor group around to embrace the question that practically everyone hates: “What if?” Granted, some “what if” questions are outlandish, but we are encouraging our flight attendants to think. A great response to the “what if” question is the question, “What would you do?”
April 27, 2010
Southwest Airlines Inflight Training

17. Southwest Airlines Inflight Training
Questions?
Thank You
Thank you for your time and attention.
April 27, 2010
Southwest Airlines Inflight Training