Contrasting Outcomes in Multiteam Systems – Lessons from Air Canada 797 and Air France 358 accidents


In commercial aviation, there are two teams at work during flight: cockpit crew and cabin crew. The former being led by the captain who also has the overall responsibility of the flight, with the first officer/co-pilot as a member in the cockpit. The purser leads the flight attendants in the cabin. The formal leadership roles of both crew are well defined, but come under scrutiny particularly during an emergency as was amply evident in the contrasting outcomes of flights Air Canada 797 [1] and Air France 358 [2] on 02 June 1983 and 02 August 2005, respectively.

Air Canada Flight 797 – 02 June 1983 [1]

What Happened?

It was a McDonnell Douglas DC-9-32, scheduled international passenger flight from Dallas, Texas, USA to Montreal, Quebec, Canada with en route stop at Toronto, Ontario, Canada. The flight with 5 crew, had 41 passengers on board.

At about FL330, around 2303 UTC (1903 Eastern Daylight Time), the cabin crew discovered a fire in the aft lavatory. The captain declared an emergency, and started an emergency descent to land at Greater Cincinnati International Airport, Covington, Kentucky. It landed at 2320:09 UTC (1920:09 Eastern Daylight Time) and immediately after the pilots brought the aircraft to a halt, firefighting operations began.

The flight attendants and passengers opened the left and right forward doors, the left forward over-wing exit and the forward and aft right over-wing exits. About 60 to 90 seconds after the exits were opened, a flash fire enveloped the cabin doors. During this time only 18 passengers and 3 flight attendants and besides the two pilots could exit the aircraft safely. Remaining 23 passengers, trapped inside, perished in fire.

NTSB's Air Canada Flight 797 seat Injury and Fatality Diagram

NTSB’s Air Canada Flight 797 seat Injury and Fatality Diagram

How it Happened?

The fire propagated through the amenities of the aft lavatory and had burned undetected for almost 15 minutes before the smoke was first noticed. The origin of fire could not be identified, but deliberate act or due to explosive or incendiary device was ruled out during accident investigation. The first malfunction to become evident to the cockpit crew was simultaneous tripping of three flush motor circuit breakers, about 11 minutes before the smoke was detected. However the cockpit crew did not consider this to be a serious problem.

The smoke in the aft lavatory discovered by a flight attendant was reported to the captain as a ‘fire’. The source of the smoke was not identified either by the flight attendants or the first officer. Neither the captain was told nor did he inquire about the precise location and extent of the ‘fire’ that was reported to him. Cabin crew feedback that the fire was abating misled the captain about its severity, in turn he delayed his decision to declare an emergency and to descend.

The fire consumed the lavatory walls, propagated into the ceiling, and then began to move forward. Smoke began entering the cabin, spread forward and collected along the ceiling of the cabin. The first officer turned off the air conditioning and pressurisation packs in the belief that the airflow was feeding the fire. The resulting loss of air circulation accelerated the accumulation of smoke, heat, and toxic gases in the cabin. This is likely to have reduced the time available for evacuation. By the time aircraft stopped after landing, smoke had filled the cabin reducing the visibility to just about 2 to 3 feet above the cabin floor.

A flash fire occurred within the cabin 60 to 90 seconds after the exits were opened, but the flames from this fire were not evident until after the survivors had left the plane. Flames from the original fire were not evident either within the plane or to firefighting persons on the ground

Cause of Accident – Critical Role of Multiteam System

The probable causes of the accident, determined by the National Transportation Safety Board, were fire of undetermined origin, underestimation of its severity and misleading fire progress information provided to the captain. On part of the captain, his delayed decision to descend, led to a lost opportunity to land at Louisville, which could have resulted in saving 3 to 5 minutes as compared to the final landing at Cincinnati. This delayed decision to descend and land contributed to the severity of a survivable accident.

In hindsight, what is expected in Shared Leadership

It is required that cockpit crew take immediate and aggressive action to determine the source and severity of any reported cabin fire, and to begin an emergency descent for landing or ditching if the source and severity of the fire is not positively and quickly determined or if immediate extinction is not assured. As for flight attendants, they need to recognise the urgency of informing flight crew of the location, source and severity of any fire or smoke within the cabin.


Read More

Air France Flight 358

Shared Leadership in Multiteam Systems

Bienefeld & Grote’s Study on Multiteam Systems

Lessons from the Study on Multiteam System


Acknowledgement  Image courtesy and Wikimedia Commons

1 comment

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    • Jenny Friedl on June 10, 2015 at 12:34 am
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    An explicit summary of what shared leadership in multi team systems can accomplish for both passengers and crew in difficult to evaluate or unpredictable situations. The two examples illustrated the empirical findings of Bielefeld and Grote (2014) and made the theory of MTS not only comprehensible but opened the option to apply it in other contexts than civil aviation. Thank you.

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