Cabin Safety - Inadvertent Slide Deployment (ISD)

The arming of aircraft doors is an important activity to facilitate the rapid deployment of emergency slides in the event of an aircraft evacuation being required. 

The need to arm and disarm doors introduces the possibility that cabin crew open the aircraft door while it is still armed, leading to an inadvertent slide deployment (ISDs). 

ISDs may injure passengers and crew on board the aircraft, in addition to those who might be in the vicinity of the aircraft door outside the aircraft using ground servicing equipment. As well as the potential harm posed to individuals, the aircraft will be grounded with cost implications to undertake restorative maintenance. 

For someone involved in an ISD, the SIRM highlighted the importance of applying just culture principles, with emphasis on providing them with reassurance, guidance and support. 

Reducing skill based errors 

The SIRM highlighted techniques that can reduce skill-based errors (slips, lapses) from happening, such as the use of Shisa Kanko when arming or disarming doors – known as “pointing and calling” or “pointing and acknowledging”. Its objective being to move from unconscious skill-based activities to a more conscious execution of the task, significantly improving accuracy in application.  

Other techniques include strategies to force a person to pause and consider the task in hand, by verbalising “stop-drop-review”. 

What is the role of training? 

Training is important to ensure crew are familiar with the door opening procedure adopted in their airlines. New cabin crew undertake intensive training where a large amount of knowledge is delivered in a short space of time. Some operators noted feedback from their trainees that with so much information being delivered it was difficult to retain everything. The opportunity to re-enforce learning on the door opening procedure is important, for example even on ‘graduation day’ there is the possibility to re-enforce learning. 

Gaging the effectiveness of training can be challenging. One approach to establish how well someone has understood a procedure is to ask a trainee if they can explain back to the instructor what’s in the procedure and how they have interpreted it. 

Updating the door opening procedure can result in safety improvement. However, the scope of updating a procedure shouldn’t be underestimated, as for large operators it may require a large retraining programme. 

Identified Hazards 

As with many errors, ISDs typically result from systemic issues, with the error being a symptom of an issue ‘upstream’ in the system. 

• Distraction – taking various forms, including a distraction from a passenger asking questions about routing through the airport or connecting to their next flight. 
• Operators with differing fleets – swapping between different aircraft manufacturers and/or models / wide body/narrow body that have different door layouts or operating procedures. 
• Experience and/or recency - the covid pandemic resulted in a significant amount of staff churn. As the industry recovered it was necessary to undertake large recruitment campaigns, leading to very high proportion of cabin crew who were new to the environment.  
• Training effectiveness – the initial cabin crew training phase can be intensive, with a large amount of information to digest in a short space of time, crew may not be fully familiar with the door opening procedure. 

Call to Action - Industry 

• Ensure just safety culture is applied throughout an investigation into a deployment event. 

• Provide peer support to crew who have been involved in an ISD 
• Consider the use of techniques such as “Stop-Drop-Review” or applying Shisa Kanko – known as “pointing and calling” or “pointing and acknowledging” to reduce skill based errors. 
• In addition to monitoring actual inadvertent slide deployment events, establish safety performance indicators utilizing near miss data (precursors), such as the number of events where doors were found still armed by crew (but without an ISD) 
• Explore with original equipment manufacturers potential modifications to aircraft if certain types show a prevalence for a higher rate of ISDs due to aircraft design. 
• Train for real world scenarios – consider for inclusion in training scenarios where cabin crew may encounter distractions such as the presence of a passenger asking questions. 

 Call to Action – IATA 

• Continue to regularly review and assess this safety issues within the Safety Issue Hub, promoting good practice and mitigations. 

 Useful Links 

• IATA Cabin Operations Safety Best Practices Guide Section 10 – Aircraft Door Safety