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checklists, as occurred in this case. This investigation found that pilots may not be aware that one
of the repercussions of failing to complete the checklist is the airplane remaining pressurized upon
landing. The Board notes that regardless of a flight crew’s reasons for failing to complete the
checklist, if the pilots had known that the airplane was still pressurized, they would likely have
depressurized the airplane before permitting the door to be opened.11 Therefore, the Safety Board
believes that the FAA should require that the Airbus Industrie A300-600 operating manual clearly
state that automatic depressurization of the airplane upon landing will not occur when the
pressurization system is being operated in the manual mode. Further, the Safety Board believes
that the FAA should review all Airbus Industrie A300-600 operators’ operating manuals and
training programs and require revisions, if necessary, to ensure that they clearly indicate that
automatic depressurization of the airplane upon landing will not occur when the pressurization
system is being operated in the manual mode.
Checklists for Emergency Ground Evacuation
The Airbus Industrie A300-600 On Ground/Emergency Evacuation Checklist and the
American Airlines A300 Ground Evacuation Checklist, which are contained in the companies’
respective operating manuals, direct the flight crew to select the Ram Air switch to the
ON position during a ground evacuation. This switch allows fresh outside air to flow into the
airplane when it is airborne and depressurizes the airplane by opening both outflow valves when
the airplane is in flight or on the ground and the pressurization system is being operated in the
automatic mode. When the pressurization system is being operated in the automatic mode, the
Ram Air switch is used as a backup method of ensuring that the outflow valves are open and is
also used to open the outflow valves if the evacuation occurs less than 45 seconds after landing.
However, the Ram Air switch does not control the outflow valves if the pressurization system is
being operated in the manual mode. Therefore, when the flight crew of the accident airplane
selected the Ram Air switch to the ON position while performing the checklist for ground
evacuation,12 the outflow valves did not open and depressurize the airplane because the
pressurization system was being operated in the manual mode.
The pilots of the accident airplane stated to Safety Board investigators that they were
unaware that the Ram Air switch did not control the outflow valves when the pressurization
system was being operated in the manual mode and that this information was not included in their
ground or simulator training or documented in the operating manuals. The investigation
confirmed that the Airbus Industrie A300-600 operating manual does not state that the Ram Air
switch will not control the outflow valves if the pressurization system is being operated in the
manual mode. The investigation also confirmed that the American Airlines A300 operating
11 As indicated earlier, postaccident examination of the accident airplane by the Safety Board’s Systems Group
revealed that insulation blankets partially blocked the forward outflow valve and almost fully blocked the aft
outflow valve. Although the manual opening of the outflow valves would likely have allowed the airplane to
depressurize, the depressurization would have occurred at a rate that is substantially slower than normal because of
the partial blockage of the valves.
12 The Airbus and American Airlines checklists for emergency ground evacuation do not include information
about the operation of the pressurization system in manual mode.
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manual does not contain this information. Further, because the American Airlines training
program for the A300-600 airplane only covers the information in the American Airlines A300
operating manual, the training program also fails to address this issue.
The Safety Board is concerned that because of the lack of information in the Airbus
Industrie A300-600 operating manual and the American Airlines A300 operating manual and
training program about this issue, flight crews of A300-600 airplanes might be unaware that the
Ram Air switch will not control the outflow valves if the pressurization system is being operated
in the manual mode. The Board notes that if the pilots of the accident airplane had known that
the Ram Air switch would not control the outflow valves when the pressurization system was
being operated in the manual mode, they would likely have depressurized the airplane before
permitting the door to be opened. Therefore, the Safety Board believes that the FAA should
require that the Airbus Industrie A300-600 operating manual clearly state that the Ram Air switch
　
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