On 27 October 2017, an aircraft returned to Auckland after advice from ATC that the right engine may have been affected by ingestion of FOD during engine start - a clipboard and paper left just inside the right hand engine by an employee of the airline’s ground handling contractor acting as the aircraft loading supervisor. The subsequent inspection found paper throughout the engine and minor damage to an engine fan blade and the fan case attrition liner. The Dispatcher overseeing the departure said she had seen the clipboard inside the engine but assumed it would be retrieved before departure.
An Investigation was carried out by the Australian Transport Safety Bureau (ATSB).
It was established that about 10 minutes prior to the eventual departure of the aircraft from its parking gate, the employee of the airline’s contracted ground handling provider tasked with loading the aircraft hold had put the last container onto the aircraft and was “organising his paperwork”. As it was raining, he reported having decided to put the clipboard to which the paperwork was attached in the right engine to avoid it getting wet and being blown by the wind, intending to retrieve it later. He had then gone to the flight deck, given some paperwork to the flight crew and then proceeded to prepare for the imminent pushback.
During this time, the Dispatcher reported having cleared the ground and servicing equipment from the aircraft vicinity and carried out a ‘duty of care’ walk-around during which she had noticed the clipboard in the right engine but took no action as she assumed that the loading supervisor would return for it. The subsequent engine start was normal but as the aircraft began to taxi, the loading supervisor realised his clipboard and paperwork were missing and initially thought the Dispatcher had it. When this was found not to be the case, the ground crew returned to where the aircraft had been parked and found paper debris on the ground. They then asked their “operations area” to contact the departed aircraft flight crew. Twelve minutes after the leading hand had first realised he no longer knew where his clipboard was, the aircraft took off.
Soon after this, as the aircraft was climbing through FL 150 with no abnormal engine indications, a call was received from the Auckland APP controller asking the crew to contact the Auckland GND controller direct. The Captain, who had been PF, handed control to the First Officer, made the requested call and was told that the ground crew had lost their paperwork which had been placed in the engine inlet and that paper debris had been found on the apron where the aircraft had been after starting the engines. After making a call to the Company Engineer at Auckland and being told that a piece of sheared metal had been found in the vicinity, he decided to make a precautionary return and landed back after an hour airborne. An inspection of the engine by engineers found minor damage had been caused to one engine fan blade and to the fan case attrition liner.
In respect of the loading supervisor’s action, it was noted that ground staff would normally use a metal box on the pushback tractor’s loader for sheltering such paperwork in case of adverse weather but on this occasion, the pushback tractor had not yet arrived. The loading supervisor did state that he had not felt any pressure to rush the departure and the Dispatcher stated that she had not viewed the clipboard as a foreign object as it belonged to the loading supervisor and she had assumed that he would retrieve it later, prior to engine start-up. It was noted that “there was no guidance on how paperwork was to be prepared and managed by ground crew during adverse weather conditions”.
An internal investigation by the contracted ground handler, Aerocare, found that the Jetstar Airways “Operational Manual” detailed the Dispatcher’s responsibilities when conducting the ‘duty of care’ walk-around and provided details of the actions involved. Whilst there was no explicit requirement to check the engine cowlings/intakes for foreign objects, this Manual did require that all staff operating near an aircraft due to depart must be constantly on the lookout for abnormalities and any seen must be reported to the leading hand or the Supervisor before the departure of the aircraft.
In respect of the communications with flight crew, in this case after it was realised what had probably happened, it was noted that there was no documented procedure by which the ground crew could establish communications with a flight crew in the event of any non-normal or emergency situation, either before or after the aircraft had departed. Also in respect of communications, the Captain stated that he had had to make numerous calls to various agencies in order to obtain more information about the incident which had taken up considerable time. He also stated that “poor communications” had meant that he had been unable to contact the Company Maintenance Controller to discuss the engine’s status.
Safety Action taken by Jetstar Airways as a result of the event and known to the Investigation was recorded as the issue of an updated aircraft dispatch procedure, which included:
a specific warning about not placing items in the engine cowling improved detail around checks and responsibilities a section on emergency and non-normal procedures detailed methods for re-establishing communications between ground crew and flight crew such as visually gaining the attention of the flight or contacting them via radio.
The Final Report was published on 27 February 2018. No Safety Recommendations were made.
https://skybrary.aero/index.php/A320,_Auckland_New_Zealand,_2017
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