What happened
Between 1978 and 1991, a series of 21 evacuations involving large, passenger-carrying aircraft occurred within Canadian airspace. These events, which included both Canadian-registered and foreign-registered planes, involved 2,305 passengers and 139 crew members. The incidents were triggered by various emergencies, most frequently fire, engine failure, and runway excursions. While some evacuations were planned, many were unplanned, occurring during takeoff, landing, or en route. The study noted that 36 fatalities and 8 serious injuries occurred specifically during the evacuation process itself, while 91 total fatalities were recorded across all studied occurrences.
The investigation
The study examined occurrence data, crew and passenger statements, and regulatory standards from Canada, the United States, and the United Kingdom. Investigators reviewed the effectiveness of emergency exits, the impact of cabin environments, and the reliability of communication systems. The scope included analyzing the physical state of the aircraft, such as the presence of debris or failed components, and evaluating passenger responses to life-threatening situations.
Findings
Fire, smoke, and toxic fumes were identified as the most significant hazards, present in 11 of the reviewed evacuations. In three of the four fatal occurrences, these elements were present. Smoke and fire often led to near-zero visibility, making it difficult for passengers to locate exits. In some cases, fire even melted aircraft windows, allowing heat and smoke to penetrate the cabin.
Several other contributing factors hindered successful egress:
- Debris and obstructions: In multiple instances, such as an evacuation in Toronto (A78H0002), debris from collapsed overhead bins, spilled galley contents, or heavy equipment blocked primary exits and aisles. In one Dryden occurrence (A89C0048), debris reached depths of 2-3 feet, immobilizing passengers.
- Equipment failure: Failed passenger seats were noted in several fatal accidents, sometimes trapping occupants. Additionally, some crew members struggled with the deployment of evacuation slides or the operation of over-wing exits.
- Communication breakdowns: In eight instances, the crew or passengers could not hear evacuation commands due to inoperable or inaudible Public Address (PA) systems.
- Passenger behavior: In 11 occurrences, inappropriate behavior was documented. This ranged from panic and aggression to "negative panic," where passengers froze. Some passengers even attempted to retrieve carry-on luggage despite instructions to leave it behind.
Safety action
Following an investigation into an occurrence in Cincinnati, a regulatory requirement for emergency floor path lighting was implemented to assist visibility during low-visibility evacuations.