NTSB Says Chaotic 2016 Evacuation of Jet Put Lives at RiskBy
American Airlines 767 burst into flames after engine exploded
NTSB calls for update of 30-year-old FAA evacuation guidance
The emergency evacuation of a wide-body airliner in Chicago was anything but orderly.
As flames engulfed the right wing, passengers screamed and clambered over seats even before the American Airlines jet came to a stop on the runway after the aborted takeoff, ignoring flight attendants’ pleas to stay seated. Within seconds, people were surging onto the runway even though the engine was still blasting exhaust, sending them rolling like tumbleweeds.
“Although everyone successfully evacuated, the investigation revealed ways that the evacuation could have been improved,” U.S. National Transportation Safety Board Chairman Robert Sumwalt said Tuesday at a meeting to conclude its investigation.
The NTSB found Tuesday that the airline crew made errors that helped lead to injuries in the evacuation and called on U.S. airline regulators to improve training and guidance for such events. The safety board also praised some actions of the pilots and flight attendants, as they raced to save 161 passengers while a massive fire engulfed the right wing.
No one died in the Oct. 28, 2016, incident as Flight 383 prepared for takeoff, but the severity of the fire and the chaotic evacuation made it one of the most serious aviation incidents in recent years. It has also given the NTSB a platform to raise longstanding concerns about aircraft evacuations.
Including this case, there have been four emergency evacuations revealing similar difficulties since 2015, and the Federal Aviation Administration’s guidance on evacuations hasn’t been updated in 30 years, according to the NTSB.
“Many of the flight attendants being hired weren’t even born when this was written," Sumwalt said.
American is “proud” of the how its pilots and flight attendants responded to the emergency, the company said in a statement. “The flight attendants performed a successful evacuation of all passengers and crew, despite concerns for their own personal safety. The cabin crew’s judgment, skill, and self-discipline likely prevented significant injuries.”
The Boeing Co. 767-300 bound for Miami was accelerating for takeoff at O’Hare International Airport when its right engine exploded, spraying metal debris. After reaching 154 miles (248 kilometers) per hour, pilots hit the brakes and stopped as leaking fuel ignited and engulfed the right wing.
An imperfection in the metal used to make a spinning disk within the engine caused it to weaken and break apart, the NTSB said in documents it released earlier.
The CF6-80 engine was made by General Electric Co. in 1997. Since the accident, the company has recommended that operators perform ultrasound inspections capable of detecting cracks within the disks. Rick Kennedy, a spokesman for GE Aviation, said Tuesday that about 50 of the engines have been inspected and no issues were discovered.
While this case is the only time an engine failed in this way, it revealed safety issues, according to NTSB. The flaw in the metal would have been detected using technology capable of seeing beneath the surface of the metal, but such scans weren’t required.
U.S. aviation regulators and aircraft manufacturers have taken steps in recent decades to improve passenger safety during evacuations, such as reducing the flammability of plane interiors and making seats more impact-resistant. But the Chicago incident highlights how human behavior and the chaos of an emergency still creates risk. Crashes on or near the ground during takeoff and landing killed more people around the world than other accident causes from 2007 through 2016, according to Boeing.
The NTSB said the pilots performed admirably to stop the jet after the explosion just as it was about to lift off. But afterward, with the plane stopped on the runway and a fireball engulfing the American plane’s right wing, poor communication and panic dominated, according to the NTSB.
Flight attendants and pilots are supposed to coordinate an evacuation, but attendants reported they could not reach the cockpit. Two of them said they couldn’t operate the intercoms to phone the pilots. American had 13 different models of intercoms on its fleet and flight attendants weren’t trained on each model.
The NTSB recommended improving the training and American said in an email that it has already done so.
The captain told investigators the evacuation checklist the cabin crew was required to follow was "cumbersome" and slowed the cockpit crew’s response. NTSB also recommended adapting the checklist to speed evacuations in cases when a fire occurs on the ground.
Passengers repeatedly failed to follow crew instructions. In multiple cases, they took luggage with them, which airlines prohibit because it can slow an evacuation or block aisles. In one case, an attendant tried unsuccessfully to wrestle a large bag away from a woman after she refused to leave it, according to NTSB records. The attendant said she gave up because the dispute was slowing the evacuation.
"Let me say a word to the flying public," Sumwalt said. "Follow your crew’s instructions. Things can be replaced. People can’t."
Because at least some passengers in emergency evacuations almost always try to take their bags with them, potentially putting lives at risk, the NTSB also recommended that the FAA do more to educate people to the risks.
"What happened in this accident is not new," said Peter Wentz, an NTSB investigator who specializes in evacuations.
A 77-year-old man suffered multiple broken bones and swelling on the scalp, according to NTSB. Twenty others, including one crew member, reported more minor injuries, according to NTSB. The plane was carrying 161 passengers and nine crew members.
The fire was so hot that it burned through the fuselage and the tip of the wing slumped onto the runway.