Cockpit blind spots hampered crew response to burning jet at O’Hare
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Your minivan might have a rear camera, but many commercial airplanes do not — leaving potential cockpit blind spots for pilots who cannot see their planes’ own wings and engines, whether on the ground or in the air.
That lack of visibility appeared to make the evacuation of an American Airlines jetliner more perilous at O’Hare Airport a year ago after an engine exploded and caught fire as the plane thundered down a runway, readying to lift off for Miami, according to records from federal investigators still probing the incident. Flight attendants also had problems communicating with the cockpit crew as chaos reigned in the cabin, and the evacuation process was hampered by another engine that remained running as passengers slid to safety, those records show.
After hearing a “ka-boom” and feeling the aircraft pull as it accelerated to roughly 150 mph, the pilot quickly aborted the takeoff, sending the Boeing 767-300 screeching to a halt with 3,775 feet of pavement left on the 13,000-foot strip.
The pilot was hailed for his quick thinking, which may have saved the lives of the 161 passengers and nine crew members, for if Flight 383 made it aloft, it might not have made it back down safely.
But the records from the National Transportation Safety Board – the federal agency probing the near-catastrophe – prompt a number of questions about what happened next and why, as the airplane rolled to a stop.
The pilot and co-pilot apparently did not initially realize the right engine had blown, or the extent of what would become a roaring fire along that wing, the records show.
As they sat in the cockpit going over a required “checklist,” flames licked at the side of the fuselage, with smoke pouring in and passengers in full panic trying to get off, fearing an explosion or incineration.
Flight attendants tried to call into the cockpit for direction, but either couldn’t figure out the right phone code or couldn’t reach the pilot or the co-pilot once they dialed – apparently because the “chime” of their call was obscured by a “fire bell.”
With passengers demanding to get off the plane, the flight attendants began opening doors and deploying inflatable chutes used to slide to the ground, though one was deployed near the right engine that was burning, so people were sent to other exits.
Evacuations near the left engine were problematic because it was still running – with such dangerous force that one passenger was blown over after coming down a chute, records show.
While the pilot and the co-pilot, also known as the first officer, heard “commotion” in the cabin, they apparently didn’t realize a full evacuation had been completed until they eventually emerged from the cockpit, records indicate. They were greeted by a harried flight attendant who told them everyone was safely off and now they all had to get out.
The smoke was so thick the pilot was unable to see into the first-class section of the cabin. He was the last one down the chute.
When the pilot was interviewed by the NTSB days after the Oct. 28, 2016, incident, he was asked if there “was anything he could recall that may need to be improved,” records show.
He said “he learned from videos of the evacuation that the left engine was still running when the flight attendants popped the slides. Had he had the situation awareness when he heard the commotion, he would have shut down the left engine sooner.”
The pilot was asked whether a camera “showing the exterior of the airplane would have helped them with their situational awareness of what was occurring outside, he stated that it would have.”
The pilot relayed that “from the cockpit they could not see their wings or the engines. Had they been able to assess the situation it may have changed their decision, especially if they would have known how large the fire was.”
Flight attendants up front also apparently couldn’t see the engines from their vantage point, which was problematic because they opened a door on the right side only to realize the “the fire was right there.”
Flight attendants then “blocked the exit and redirected the passengers,” records show.
The camera reference in the NTSB documents could signal the agency is thinking about crafting an industry-wide safety recommendation on the use of such video, experts said, though NTSB spokesman Peter Knudson said it’s too early to know for sure.
The agency still hasn’t determined a cause of the fire. Knudson said that could come early next year, with the investigation now “in the final stages.”
A number of newer, larger commercial planes have “external” cameras – including some Airbus models – with images accessible on cockpit monitors to help primarily with taxiing.
American Airlines has 20 Boeing 777-300s that have cameras which make “wings and engines . . . viewable from the cockpit,” said airline spokeswoman Leslie Scott. “That is standard from Boeing,” the Chicago-based manufacturer, “for that particular aircraft.”
Scott said via email that the carrier won’t comment on any possible expansion of cameras “due to the fact that the NTSB hasn’t issued their findings/recommendations yet and this topic may be germane to that.”
Veteran pilot and aviation consultant John Cox described aircraft cameras as “helpful particularly in maneuvering” on airfields, where massive jets need to move into gates and through other tight spots.
Brian Hennessy, also a commercial pilot and consultant, said it’s unclear how often video feeds would be used if their availability was expanded but, generally speaking, the more information for pilots, the better. “The key is it has to be usable and accessible, at the right time,” he said.
In 2012, the NTSB recommended the Federal Aviation Administration — the federal agency that regulates airlines, airports and airspace — require “the installation of an anti-collision aid, such as a camera system,” on certain planes “to provide a cockpit indication that will help pilots determine wingtip clearance and path during taxi.”
The NTSB wrote at the time it had “investigated 12 accidents since 1993 that occurred during taxi when a large airplane’s wingtip collided with another airplane or object on the taxiway.”
The FAA rejected the recommendation, saying, “From a safety risk management perspective, the limited safety benefit of a taxi anti-collision system, such as wingtip cameras, does not justify the cost burden of an FAA mandate for their installation on the transport airplane fleet.”
It’s unclear whether any FAA mandates will emerge from the Flight 383 case.
NTSB investigators found a turbine disk in the right engine fractured, leading to an “uncontained engine failure” and “a pool fire under the right wing.”
One or more of the disk fractures “exhibited features consistent with fatigue cracking,” according to the NTSB. That can occur when there’s a “microscopic impurity” in the materials, and heat and other stress can exploit such cracks over time, experts said.
GE Aviation, which made the engine, has issued a “service bulletin” advising anyone still using this type of engine built between 1984 and 2000 to have it inspected, said company spokesman Rick Kennedy, adding there are likely fewer than 1,000 such engines still in use. “We have received no notifications from anybody” of the same flaws, Kennedy said.
However, attorney Floyd Wisner, whose west suburban law firm represents 48 passengers on the flight that day, said there have been problems involving “similar engines or the same engines with perhaps a different disk.”
Wisner said he’s aware of 60 or so passengers overall who sued GE, Boeing and American – or intend to. Two dozen of his clients already settled their claims or are close to doing so through a mediation process.
The city of Chicago, which owns O’Hare, hasn’t been sued, but the incident is likely to cost the Emanuel administration more than $800,000 for, among other things, airfield repairs, and overtime for emergency responders, an official said.
At least 20 passengers were hurt, one seriously.
Some of them were injured coming down the chute, with one passenger telling investigators “no one was there to assist” and “he tumbled off the slide,” only to stand up and get “blown over by the thrust coming out of the back of the engine,” records show.
Flight attendants had complaints about passengers, too, relaying stories of at least two refusing to leave their bags, even as a flight attendant tried to tug one away, records show.
One flight attendant suggested to the NTSB a potential solution was to issue “fines” for “passengers who take luggage” against commands.
Scott said the American crew worked heroically to get everyone safely from the flight, and the employees were recognized by the company earlier this year.
Other areas of apparent interest to the NTSB as the probe winds down: How pilots and flight attendants are trained to deal with such emergencies. Records show they’re not trained together, and smoke isn’t used during simulated events.