Air transportation safety recommendation A95-06

Reassessment of the response to Aviation Safety Recommendation A95-06

Pre-landing briefings

Background

In February 1995, the Transportation Safety Board of Canada (TSB) made six aviation safety recommendations in its Safety Study of Evacuations of Large Passenger-Carrying Aircraft. This study examined the Canadian experience with the evacuation of passengers from large aircraft and identified safety deficiencies associated with communications during evacuations, exit operation, passenger preparedness for evacuations, and the presence of fire, smoke, and toxic fumes.

The safety study analyzed the results of investigations into 21 occurrences between 1978 and 1991. These occurrences involved 2444 persons and resulted in 91 fatalities and 78 serious injuries, of which 36 fatalities and 8 serious injuries occurred during the evacuation process.

The Board concluded its Safety Study and released the Safety Study of Evacuations of Large Passenger-Carrying Aircraft SA 9501 on 22 February 1995.

Board Recommendation A95-06 (February 1995)

Passengers' lack of preparedness to act appropriately during an evacuation was evident in several occurrences. There were two occurrences in which passengers might not have perceived the danger they were in and therefore reacted in an inappropriate manner.

Currently, Canadian air carriers routinely make pre-landing announcements requesting that passengers return to their seats, fasten seat-belts, place seatbacks and table trays in the upright and locked position, and stow carry-on-baggage in preparation for landing.

In April 1994, a proposed amendment to ANO Series VII, Nos. 2, 3 & 6, regarding bilingual safety briefings was published in the Canada Gazette. The proposed amendment stated that “An air carrier shall ensure that all passengers on board an aeroplane are provided with a standard safety briefing, ... prior to each landing.” The proposed standard safety briefing required prior to each landing would have included the basic pre-landing announcement currently made by Canadian air carriers with one addition: “on flights of two hours duration or more, the location of emergency exits and exit location signs” was to be included. Passengers would not, however, be advised to review the safety features card.

The Board has since been advised that Transport Canada has abandoned its original proposal and will now require pre-landing briefings only on flights in excess of four hours.

Over the years, various organizations and cabin safety specialists have advocated pre-landing safety briefings as an effective means of enhancing passenger preparedness and, ultimately, passenger performance during an evacuation. There is a general consensus that passengers should be reminded to relocate their primary and alternative exits, review the safety card, and, when appropriate, be advised of an overwater approach.

While the Board agrees with Transport Canada's recent initiative to require a standard safety briefing prior to landing on certain flights, there is concern that safety information found only on the safety features card, such as exit operation, recommended brace positions, floor proximity emergency path lighting, use of the escape slides, and life jacket location and donning instructions, will not be reinforced prior to landing.

Since most emergency evacuations are unplanned and occur during the landing phase, the Board recommends that:

Transport Canada's response to Recommendation A95-06 (May 1995)

Transport Canada agrees with the concept of providing passengers with safety information that would assist them in the event of an emergency requiring an evacuation. In fact, Canada will be a world leader in requiring the safety briefing prior to landing to include the location of emergency exits on flights of four hours duration or more.

The issue of prior to landing briefings has been thoroughly reviewed and was discussed extensively during the Canadian Aviation Regulation Advisory Council (CARAC) process. During this review it was felt that some safety information needed to be reinforced on long flights, however there was insufficient data to support a requirement to provide passengers with information relative to an unplanned emergency evacuation prior to every landing.

Board assessment of the response to Recommendation A95-06 (June 1995)

In light of Transport Canada (TC)'s response “... there was insufficient data to support a requirement to provide passengers with information relative to an unplanned emergency evacuation prior to every landing...”, it appears that they may have misunderstood the intent of Recommendation A95-06.

The Board was not recommending that a pre-landing safety briefing be required prior to every landing. Rather, the Board was recommending that air carriers be encouraged to include “sufficient detail” in the routine pre-landing briefing so as to prepare passengers for an unplanned emergency evacuation. “Sufficient detail” is left to the discretion of the carriers and could range from a simple reminder to review the safety features card on short flights to a complete safety demonstration on long flights.

Following a discussion with TC personnel to clarify this point, staff were advised that when guidance material for the proposed CARs is developed, air carriers could be encouraged to include “sufficient detail” in their pre-landing briefing.

Based on TC's initiative to move towards safety briefings on flights of more than four hours, and on the follow-up staff discussion, the response to Recommendation A95-06 is assessed as Satisfactory Intent.

Board reassessment of the response to Recommendation A95-06 (November 1996)

After clarification, air carriers will be encouraged to use “sufficient detail” in safety briefings and TC has moved towards safety briefings on flights of more than 4 hours. Canadian Aviation Regulations (CARs) 705.43 and 725.43 (1) (e) apply. On flights of four hours or more the location of emergency exits must be included.

The Board concludes that there is insufficient detail in safety briefings prior to landing.

Therefore, the response to Recommendation A95-06 is assessed as Satisfactory in Part.

Board reassessment of the response to Recommendation A95-06 (November 1997)

Reference CARs 705.43 and 725.43 (1) (e) - flights of four hours or more the location of emergency exits must be included.

There is no reference to the safety features card, which includes exit operation, brace positions, emergency lighting, slides, etc.

Therefore, the response to Recommendation A95-06 is assessed as Satisfactory in Part.

Board reassessment of the response to Recommendation A95-06 (April 1999)

There has been no change since the 1997 reassessment.

Therefore, the assessment of Recommendation A95-06 remains Satisfactory in Part.

Board reassessment of the response to Recommendation A95-06 (February 2004)

As indicated in the 1999 reassessment, CARs 725.43 addresses the original safety deficiency for the most part, however, some aspects of the deficiency, i.e. adequacy of briefing content, has not been actioned.

Therefore, the assessment of Recommendation A95-06 remains Satisfactory in Part.

As such, “Further Action is Unwarranted” with respect to Recommendation A95-06 and the status is changed to Inactive.

Board review of Recommendation A95-06 deficiency file status (April 2014)

The Board requested that Recommendation A95-06 be reviewed to determine if the deficiency file status was appropriate. After an initial evaluation, it was determined that the safety deficiency addressed by Recommendations A95-06 needed to be reassessed.

A request for further information was sent to Transport Canada and a reassessment will be conducted upon receipt of Transport Canada's response.

Therefore, the assessment remains Satisfactory in Part.

Consequently, the status of Recommendation A95-06 is changed to Active.

Transport Canada's response to Recommendation A95-06 (July 2015)

Transport Canada Civil Aviation (TCCA) agrees with the spirit of the recommendation.

As previously noted, the issue of pre-landing safety briefings was thoroughly reviewed and discussed extensively during the Canadian Aviation Regulation Advisory Council (CARAC) process.

Subparagraph 725.43(1) (d) (iii) requires that, prior to landing on flights scheduled for four hours or more, passengers be advised of the location of emergency exits.

Although no additional regulatory changes regarding the content of the pre-landing briefing have been made, air operators have received a reminder of their responsibilities regarding passenger safety briefings, along with a recommendation that passenger safety briefings include clear direction to leave all carry-on baggage behind during an evacuation. This guidance is available in Advisory Circular 700-012 – Passenger Safety Briefings.

Transport Canada will continue to monitor, and suggests closing this item.

Board reassessment of the response to Recommendation A95-06 (March 2016)

Transport Canada has taken the following actions to address this recommendation: the requirement to provide passengers with a safety briefing on flights in excess of four hours, which includes the location of emergency exits, was included in section 725.43 of the Commercial Air Service Standards. As well, an Advisory Circular was published, which encourages air operators to include information in their pre-landing briefing, reminding passengers to leave their personal belongings behind in the case of an evacuation.

These actions will substantially reduce the safety deficiency identified in Recommendation A95-06, and therefore, the Board re-assesses TC's response to the recommendation as being Fully Satisfactory.

Next TSB action

This deficiency file is Closed.