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Date: May 8, 2001
In reply refer to: A-01-16 through -22
Honorable Jane F. Garvey
Administrator
Federal Aviation Administration
Washington, D.C. 20591
On November 20, 2000, about 1222 eastern standard time, a flight attendant/purser was
killed during an emergency evacuation of American Airlines flight 1291, an Airbus
Industrie A300B4-605R, N14056, at Miami International Airport (MIA), Miami, Florida. The
airplane was pressurized until the flight attendant/purser opened the left front door (1L); he was
then forcibly ejected from the airplane. Visual meteorological conditions prevailed, and an
instrument flight plan was filed. The flight was operating as a 14 Code of Federal Regulations
Part 121 scheduled international passenger flight. There were 133 persons on board. During the
emergency evacuation, in addition to the 1 flight attendant/purser who was killed, 3 passengers
sustained serious injuries; 18 passengers and 1 flight service director1 sustained minor injuries; and
the 2 pilots, 6 flight attendants, 1 off-duty flight attendant, 1 flight service director, and the
remaining 100 passengers reported no injuries. The airplane sustained minor damage.
The flight departed MIA for Port Au Prince International Airport, Haiti, and had been
airborne for about 8 minutes when the flight crew encountered a problem with the automatic
pressurization system. The captain stated to National Transportation Safety Board investigators
that the automatic cabin pressurization controllers would not control cabin pressure when the
airplane was climbing through 16,000 feet and that the electronic centralized airplane monitor
1 Flight service directors are language translators who receive emergency procedures training for land and
over-water evacuations for the aircraft to which they are assigned.
2
(ECAM) display2 showed the forward outflow valve3 opened fully.4 The cabin altitude was
climbing at a rate of 2,000 feet per minute, and the cabin altitude indicator showed 7,000 feet.
The captain decided to operate the pressurization system in the manual mode (and closed the
outflow valves) and, about 11 minutes after departure, indicated to air traffic control (ATC) that
the flight would return to MIA. At that point, the pilots began performing the American Airlines
A3005 Cabin Pressurization Manual Control Checklist,6 which is contained in the American
Airlines A300 operating manual.
The captain stated to Safety Board investigators that during the return to MIA, the flight
attendant call chimes sounded erratically and the lavatory smoke detectors sounded continually.
Passengers and cabin crewmembers complained about pressure in their ears. About 3 minutes
before landing, the captain declared an emergency to ATC and requested that aircraft rescue and
firefighting (ARFF) personnel stand by for the landing. After the airplane landed at MIA, ARFF
personnel checked the exterior of the airplane and reported no signs of fire. The cockpit voice
recorder indicates that a flight attendant reported smelling smoke to the flight crew. The captain
indicated to Board investigators that he observed the illumination of a cargo loop light7 on the
cockpit overhead panel. The captain then ordered an emergency evacuation of the airplane, and
the American Airlines A300 Ground Evacuation Checklist8 was performed. The flight attendants
heard the sounding of the evacuation signaling system and attempted to open the emergency exits
to begin the emergency evacuation but were having difficulty doing so. A flight attendant
reported to the flight crew that the doors would not open. While the flight attendant/purser was
struggling to open the 1L door of the airplane, the door suddenly burst open, and he was forcibly
ejected onto the ramp and was killed. Preliminary findings from the investigation revealed that
excess air pressure inside the cabin caused the door to burst open.
Although this accident investigation is ongoing,9 the Safety Board identified several safety
issues that require the Federal Aviation Administration’s (FAA) attention.
2 The ECAM display is a cathode ray tube screen located in the cockpit. The system is automatic and displays
messages and system diagrams to pilots. It provides operational assistance for both normal and abnormal airplane
system situations.
3 The two outflow valves open and close during flight and on the ground to maintain control of cabin
pressurization.
4 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.
5 All A300 airplanes that American Airlines operates are A300-600 airplanes.
　
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