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Incident Reports

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This category contains articles on particular Accidents and Incidents. The severity of the actual outcome is not the primary qualification for inclusion. Instead, each event has been included because the investigation findings were considered to be illustrative of safety issues which it would be especially useful to make more widely available. The information contained in each summary article on an individual accident or incident is derived from the published Official Investigation Reports. Content in this category comes from Skybrary, ICAO and wikipedia among other sources and is used with permission.

AGC = Air Ground Communications (including Call Sign Confusion), AI = Airspace Infringement, AW = Airworthiness, BS = Bird Strike, CFIT = Controlled Flight into Terrain, FIRE = Fire (includes post crash fore and non fire source fumes), GND = Ground Operations, HF = Human Factors, LB = Level Bust, LOC= Loss of Control, LOS = Loss of Separation, RE = Runway Excursion, RI = Runway Incursion, WAKE = Wake Turbulence, WX = Weather.

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.

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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.,_Auckland_New_Zealand,_2017

On 12 December 2015, a Boeing 737-800 (EI-DLR) being operated by Ryanair on a domestic passenger flight from Seville to Barcelona as FR6399 which had just begun disembarking its passengers in normal night visibility conditions via an air bridge connected to door 1L, was lifted off its nose landing gear to a height of approximately 2 metres still attached to the air bridge until the door failed and the aircraft nose gear dropped back to the apron. Two of the 76 persons on board sustained minor injuries. Damage was caused to both the aircraft 1L door and the air bridge. 

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The aircraft after lifting by the air bridge due to its contact with Door 1. [Reproduced from the Official Report]

Investigation A Serious Incident Investigation was carried out by the Spanish Commission for the Investigation of Accidents and Incidents (CIAIAC). The 30 year-old Captain was a Spanish national and had 7,400 hours total flying experience of which 6,200 hours were on type. The 24 year old First Officer was a Portuguese national and had 350 hours total flying experience of which 50 hours were on type.

It was noted that the event had occurred at gate 101 at Terminal 2, the older of the two terminals at Barcelona which is situated to the north of runway 25R. It was found that the air bridge at gate 101 had been installed in 1991 and its hydraulic system subsequently refurbished in 2001. Its screen and control panel were then renovated in 2005 and most recently, in June 2015, its translation and control system had been renovated as part of a larger programme of air bridge renovation being undertaken by a contractor to the Airport Operator AENA, the Spanish Airports and Air Navigation Authority.

It was established that after passenger disembarkation had started and over half of the 159 passengers on board on arrival had already left the aircraft, the air bridge attached to door 1L had begun to lift the front of the aircraft off the ground. An alarm sounded at the air bridge control console and when the cabin crew realised what was happening, "they stopped the disembarkation of the passengers and asked the people still on board to move towards the front of the aircraft to sit down anywhere, as the door was expected to collapse and the aircraft nose to fall". This then happened and the remaining passengers were subsequently disembarked through door 2L at the rear of the aircraft and taken to the terminal by bus. Two of the passengers reported sustaining minor injuries.

It was noted that since the elevation of the aircraft by the air bridge was gradual, and the aircraft had remained at the same height as the air bridge as this was happening, there had been no actual risk to the passengers who were disembarking when the elevation began. However, likelihood of the subsequent collapse of the aircraft door due to it carrying part of the weight of the aircraft had represented a risk to any unseated passengers which had been successfully mitigated by the prompt intervention of the cabin crew.

Functional testing of the air bridge found that it was not possible to reproduce or replicate the failure which had occurred but subsequent testing did show that the air bridge involved had a pre-existing intermittent fault in its hydraulic lifting circuit electrovalve which had randomly been blocking or freezing in an open position. Similar testing of other Terminal 2 air bridges, and in particular one which was of the exactly the same design as the one under investigation but which had not yet been renovated, found that there was a 1 second time limit on the activation of the elevation system hydraulic pressure which meant that any blockage of the controlling electrovalve would not be followed by continued uncontrolled lifting (or lowering). This finding led to the further finding that the renovation schedule had included the installation of a new control panel which included modified software for the control of air bridge elevation. This new control software was found to have increased the time limit for the activation of the elevation system hydraulic pressure from 1 second to 10 minutes but had not addressed the potential consequences of this change in the event of a malfunctioning system electrovalve. More generally, it was found that this oversight was a result of a failure to include in the renovation work programme any inspection of the condition of the control elements that were not being modified.

Given this dual origin of the malfunction, it could be deduced that the lifting of the air bridge had occurred when its self-levelling system had been activated by the slight change in aircraft height as passenger disembarkation proceeded which was detected by the "safety shoe" mounted between the L1 door and the height of the air bridge floor. The consequent input of hydraulic pressure was not then immediately stopped when the electrovalve (again) malfunctioned because of the increased time limit for availability of pressure in the circuit.

It was concluded that the specification of the programme to partially renovate the air bridges at Terminal 2 had been inadequate in that it had failed to consider the effect of the intended changes in the system on the parts of it that were not being renovated. It was noted that the renovation work was being undertaken by a Temporary Joint Venture - a "UTE" - consisting of Adelte Ports & Maritime and Luis Pares.

The Cause of the uncontrolled lifting of the air bridge was formally documented as "the combination of the failure of the electro-valve in the hydraulic elevation circuit and the modification of the interval for the activation of the pump in this circuit of the self-levelling system that had been introduced during the (partial) renovation of the air bridge a few months earlier”.

Safety Action taken by Barcelona Airport as a result of the investigated occurrence was noted to have included "making sure that all air bridge hydraulic elevation pumps have a maximum activation interval of 1 second".

Two Safety Recommendations were made as a result of the Investigation as follows:

  • that Barcelona Airport which is responsible for preventive maintenance before and after the process of renovating the air bridges should verify the good condition of the components that will remain in them after the modification process. [80/16]
  • that the Adelte-Luis Pares Joint Venture (the contractor undertaking the Terminal 2 air bridge renovation programme for Barcelona Airport) should assess all possible failure modes (which may arise in the modified air bridges as a result of the renovation work). [81/16]


The co-pilot of the Germanwings plane that crashed into the French Alps on Tuesday appeared to want to "destroy the plane", French officials have said.

There are now many serious questions raised by the French prosecutor about the safety protocols for the pilots and crew on board.


Description: This video takes a look at the benefits of angle of attack indicators, and how they provide pilots a visual reference on how close their wings are to stalling.

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