IceTrojan

I'm having a #faceplam moment here, and I'm trying not to feel bad about it because it involved the two students who died:
Given the numerous FT observations of passenger behavior on the China-based airlines (as well as my own observations), I'm saddened that I'm not surprised that they weren't wearing their seatbelts.

This report would qualify as a dark comedy.

The Executive Summary definitely is "interesting"

Let's hope.

IceTrojan

Ok, now I'm sucked in and reading the main text. A few highlights:

"When the cabin manager came to the cockpit and asked if they should initiate an evacuation, the PM (pilot monitoring, or trainer) said “standby.”
-- This could have been a MUCH worse horror story.

"He (an FA sitting at Door 2L, designated L2A) saw fire and smoke outside the door 2R window and determined that they needed to evacuate. Before he could get back to his exit, he heard the cabin manager making her announcement for passengers to remain seated (per PM's instruction). He told flight attendant L2B to go to door 1L and stop her from making the announcement while simultaneously commanding the evacuation to begin in both Korean and English. He did not hear a command from a flight crewmember to evacuate; he initiated the evacuation entirely on his own."
--- This guy deserves a medal!

"Flight attendant L3 reported losing consciousness for a few seconds after impact. When she regained consciousness, she was still restrained in her jumpseat but recognized they were in a “very bad situation.” She was confused because she heard the cabin manager make an announcement. She tried to use the interphone to independently command an evacuation but reported it did not work. She released her seatbelt and tried to open her door, but it would not open. She recognized flight attendant L2A’s voice when he commanded an evacuation and shortly thereafter saw light coming from across the airplane at door 3R. Passenger 30K (who reported that he opened door 3R) was there directing passengers out the door."
[...]
"L3 noticed that several passengers were not evacuating. She commanded them to evacuate but realized that some passengers were trapped. She went to the back of the airplane and tried to help extricate them until firefighters arrived, but she was forced to evacuate because of the smoke and difficulty breathing."
--- More kudos to L3 and 30K!

"According to the cabin manager, she retrieved a knife from the galley between the doors 2R and 2L, and the observer (relief FO) punctured the slide/raft with it (to free a pinned FA). She then retrieved a fire extinguisher, and the observer attempted to extinguish an interior fire."
--- Definitely a cabin crew I would totally fly with. And good on the FO for helping.

"At 1149:41, video footage showed an individual walking across the runway from the debris field toward the airplane. Although the individual’s path was partially hidden on the video by the smoke plume, the individual appeared to be walking from the general vicinity of where the R4 jumpseat was found. When the individual neared the edge of the runway in the vicinity of a runway distance-remaining marker behind the airplane, passengers ran to and began assisting
the person."
--- Holy smokes...

"Rescue 10’s in-vehicle video footage showed passenger 41E lying in a right lateral recumbent (fetal) position and covered by a layer of foam as Rescue 10 approached. Rescue 10 rolled over passenger 41E at 1150:46 ... The fire attack supervisor directed the driver of Rescue 37 to dispense agent into door 2L, and she complied but ran out of water and departed the area by making a sweeping right turn in front of the left wing. During this turn, Rescue 37 rolled over passenger 41E at 1201:11."
--- Sounds like a hectic and chaotic scene with foam everywhere. But run over twice? Poor 41E.

Upon arrival, an SFFD city assistant division chief assumed incident command. He assigned an SFFD city battalion chief as the fire attack supervisor ... Neither the SFFD city assistant division chief who served as incident commander nor the SFFD city battalion chief who served as fire attack supervisor had any previous experience working at an airport ... (footnote) The fire attack supervisor stated that he was a commercial pilot with about 3,500 hours of flight time, the majority of which was in helicopters.
--- More bravado? I'm a big honcho from the city, I must be the best at everything!

He (the fire attack supe) advised them (other firefighters) that he had been notified that everyone had already evacuated and not to proceed with a search saying, “anybody’s in there right now is dead.” The rescue squad persisted and the fire attack supervisoreventually relented, stating “okay. Don’t go too deep.”
--- I'm pulling these excerpts and pasting in real-time, and this is kind of infuriating. Who IS this dipwad???

About 1215, the fire attack supervisor was notified that four “cabin crew” were missing. He then instructed a rescue squad to place a ladder at the cockpit window and “try and break the window open.” When the rescue squad stated they preferred to use the open door 1L, he replied that the fire was “right there” and that they would have to deal with a secure cockpit door.
--- Anger is filling me... I really should stop reading and go to bed...

IceTrojan

"One of the reported problems was the inability for responding mutual aid units from the City of San Francisco to speak directly with units from the airport. According to the assistant deputy chief in charge of the SFFD-AB, the communication frequencies used at the airport were different than those used at the city, and the procedure was for the arriving SFFD city vehicles to switch to a designated frequency for the airport."
[...]
"An SFPD lieutenant reported that SFPD officers stationed at the airport could not speak directly to firefighters via radio."

--- I thought this was one of the lessons learned from 9/11, when the NYPD, PANY/NJ, and FDNY couldn't radio each other.

"The firefighter who initially directed Rescue 10 around the body (of 41E) stated in his interview that he noticed a young female on the ground in the fetal position. She looked to be dead “by appearance,” but he did not check her vital signs. While he was moving his driver into position, he saw a lieutenant and told her about the body. She replied, “yes, yes, okay, okay. We’ve gotta get a line inside.” In her interview, the lieutenant stated that she saw the body and “immediately categorized it as a casualty.”
--- I hope this lieutenant doesn't sleep well at night. Just sloppy.

"...Budgeted for the purchase of two dedicated SFFD-AB mass casualty unit vehicles, each holding 250 backboards, one to be purchased in 2014/15 and one in 2015/16"
--- Because 2 29-year-old buses with mechanical problems, and one not starting, aren't a good idea?

"Purchase of a 767-200 aircraft to be used for emergency training"
--- For those following AA 762 retirements, this should perk your ears.
"Of the four responders who saw passenger 41E before she was struck by any ARFF vehicles, two had the necessary medical training and were in a position to triage her ... Although at least two firefighters had both the time and opportunity for triage to be performed on passenger 41E to verify their visual assessment of her condition, they did not do so."
--- Ugh.

Overall, the report is pretty damning of the OZ's training, the qualifications of the flight crew, and the Busch-league antics of SFFD on-scene leadership.

makfan

I have read almost all the report. Later on, the report casts doubt as to whether passenger 41E would have survived even had she not been run over. It doesn't mitigate the chaos, though.

As I read the report, some things really angered me, and yet some things really amazed me.

Read the report on the injuries, survivability and evacuation. I find it almost remarkable that there was only one fatality that was not preventable. (One person in the back is believed to have been struck in the head by the L4 door when it detached from the plane.) 99% of the people survived, and 98% of the passengers SELF-EVACUATED, despite only having 3 working exit doors and several severely injured crew members. Nobody was paralyzed. The uninjured cabin crew did an outstanding job in the emergency.

What happened in terms of the delayed evacuation is not all that surprising. The flight deck crew had no idea how bad it was, and naturally chose to follow their evacuation checklist. (The checklist includes things like turning off the engines so people don't get sucked in trying to evacuate). Ordering an evacuation is one of the few times where the cabin crew can override the captain's explicit instructions, and the flight attendant who was most aware of the seriousness of the situation appropriately did just that.