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Accident and Serious Incident Reports: CS

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Category: Cabin Safety Cabin Safety
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Definition

Reports relating to accidents and incidents that include aspects of Cabin Safety.

Disruptive Pax

  • B744, Phoenix USA, 2009 (On 10 January 2009, a Boeing 747-400 being operated by British Airways on a scheduled passenger flight from Phoenix USA to London had been pushed back from the gate in normal daylight visibility and the engines start was continuing when fumes and smoke were observed in the cabin and flight deck. The aircraft commander decided to return to the stand but there was some delay while the tug was reconnected and the movement accomplished. The intensity of the fumes increased and as the aircraft came to a halt on the stand an emergency evacuation was ordered.)
  • AT43, Jersey Channel Islands, 2012 (On 16 July 2012, the left main landing gear of a Blue Islands ATR 42-300 collapsed during landing at Jersey. The aircraft stopped quickly on the runway as the left wing and propeller made ground contact. Although the crew saw no imminent danger once the aircraft had stopped, the passengers thought otherwise and perceived the need for an emergency evacuation which the sole cabin crew facilitated. The Investigation found that the fatigue failure of a side brace had initiated the gear collapse and that the origin of this was a casting discontinuity in a billet of aluminium produced to specification.)

Turbulence Injury - Cabin Crew

  • B738, en-route, west of Bar Montenegro, 2019 (On 13 February 2019, a Boeing 737-800 en-route over the southern Adriatic Sea unexpectedly encountered severe clear air turbulence and two unsecured cabin crew and some unsecured passengers were thrown against the cabin structure and sustained minor injuries. The Investigation found that the Captain had conducted the crew pre-flight briefing prior to issue of the significant weather chart applicable to their flight by which time severe turbulence due to mountain waves at right angles to an established jetstream not shown on the earlier chart used for the briefing was expected at a particular point on their route.)
  • A332, en-route, mid Atlantic, 2013 (On 2 September 2013, an Airbus A330-200 crossing the ITCZ at FL400 at night encountered sudden severe turbulence unanticipated by the crew resulting in serious injuries to a few cabin crew / passengers and minor injuries to twelve others. An en route diversion to Fortaleza was made. The Investigation found that the origin of the turbulence was severe convective weather and failure to detect it in an area where it had been forecasted indicated that it was probably associated with sub-optimal use of the on-board weather radar with the severity of the encounter possibly aggravated by inappropriate contrary control inputs.)
  • B741, en-route, Pacific Ocean, 1997 (On 28th December 1997, a Boeing 747-100 being operated by United Airlines, which had departed from Tokyo for Hawaii, encountered severe turbulence thought to have been associated with a Jet Stream over the Pacific Ocean.)
  • A388, en-route, southeast of Mumbai India, 2014 (On 18 October 2014, an Airbus A380 descending at night over north east India unexpectedly encountered what was subsequently concluded as likely to have been Clear Air Turbulence after diverting around convective weather. Although seat belt signs were already on, a flight deck instruction to cabin crew to be seated because of the onset of intermittent light to moderate turbulence was completed only seconds before the sudden occurrence of a short period of severe turbulence. Two unrestrained passengers and two of the cabin crew sustained serious injuries. There were other minor injuries and also some cabin trim impact damage.)
  • B738, en-route, east southeast of Adelaide Australia, 2017 (On 13 September 2017, the airspeed of a Boeing 737-800 unexpectedly increased during an intentionally high speed descent and the Captain’s overspeed prevention response, which followed his taking over control without following the applicable procedure, was inappropriate and led directly to cabin crew injuries, one of which was serious. The Investigation found that the speed increase had been the result of a sudden decrease in tailwind component associated with windshear and noted that despite moderate clear air turbulence being forecast for the area, this had not resulted in the seat belt signs being on or any consequent cabin crew briefing.)

Cabin Stowage - Pax Items

  • B734, vicinity East Midlands UK, 1989 (On 8 January 1989, the crew of a British Midland Boeing 737-400 lost control of their aircraft due to lack of engine thrust shortly before reaching a planned en route diversion being made after an engine malfunction and it was destroyed by terrain impact with fatal or serious injuries sustained by almost all the occupants. The crew response to the malfunction had been followed by their shutdown of the serviceable rather the malfunctioning engine. The Investigation concluded that the accident was entirely the consequence of inappropriate crew response to a non-critical loss of powerplant airworthiness.)
  • B741, en-route, Pacific Ocean, 1997 (On 28th December 1997, a Boeing 747-100 being operated by United Airlines, which had departed from Tokyo for Hawaii, encountered severe turbulence thought to have been associated with a Jet Stream over the Pacific Ocean.)

Toilet compartment fire

  • DC93, en-route, Cincinnati OH USA, 1983 (On 2 June 1983, a DC9 aircraft operated by Air Canada was destroyed following an in-flight fire which began in one of the aircraft’s toilets. 23 passengers died in the accident.)

Cabin furnishings fire

  • L101, vicinity Riyadh Saudi Arabia, 1980 (On 19 August 1980, a Lockheed L1011 operated by Saudi Arabian Airlines took off from Riyadh, Saudi Arabia - seven minutes later an aural warning indicated a smoke in the aft cargo compartment. Despite the successful landing all 301 persons on board perished due toxic fumes inhalation and uncontrolled fire.)
  • B732, Manchester UK, 1985 (On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.)
  • MD11, en-route, Atlantic Ocean near Halifax Canada, 1998 (On 2 September 1998, an MD-11 aircraft belonging to Swissair, crashed into the sea off Nova Scotia following an in-flight electrical fire.)

Evacuation slides deployed

  • MD83, Ypsilanti MI USA, 2017 (On 8 March 2017, a Boeing MD83 departing Ypsilanti could not be rotated and the takeoff had to be rejected from above V1. The high speed overrun which followed substantially damaged the aircraft but evacuation was successful. The Investigation found that the right elevator had been locked in a trailing-edge-down position as a result of damage caused to the aircraft by high winds whilst it was parked unoccupied for two days prior to the takeoff. It was noted that on an aircraft with control tab initiated elevator movement, this condition was undetectable during prevailing pre flight system inspection or checks.)
  • B738 / AT46, Jakarta Halim Indonesia, 2016 (On 4 April 2016, a Boeing 737-800 crew taking off in normal night visibility from Jakarta Halim were unable to avoid an ATR 42-600 under tow which had entered their runway after ambiguity in its clearance. Both aircraft sustained substantial damage and caught fire but all those involved escaped uninjured. The Investigation concluded that contributory to the accident had been failure to use a single runway occupancy frequency, towing of a poorly lit aircraft, the potential effect on pilot detection of an obstruction of embedded approach lighting ahead of the displaced landing threshold and issues affecting controller traffic monitoring effectiveness.)
  • B752, en-route, North Sea, 2006 (On 22 October 2006 a blue haze was observed in the passenger cabin of a Boeing 757-200, operated by Thomsonfly, shortly after reaching cruise altitude on a scheduled passenger flight from Newcastle to Larnaca. A precautionary diversion was made to London Stansted, where an emergency evacuation was carried out successfully.)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • A343, Toronto Canada, 2005 (On 2 August 2005, an Air France Airbus A340 attempted a daylight landing at destination on a rain-soaked runway during an active thunderstorm and overran for 300 metres ending up in a ravine from where, despite its destruction by fire, all occupants escaped. The Investigation recommendations focussed mainly on crew decision making in adverse weather conditions and issues related to the consequences of such an overrun on survivability.)

Pax oxygen mask drop

  • B744, en-route, South China Sea, 2008 (On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.)
  • A320, Hiroshima Japan, 2015 (On 14 April 2015, a night RNAV(GNSS) approach to Hiroshima by an Airbus A320 was continued below minima without the prescribed visual reference and subsequently touched down 325 metres before the runway after failing to transition to a go around initiated from a very low height. The aircraft hit a permitted ground installation, then slid onto the runway before veering off it and stopping. The aircraft sustained extensive damage and an emergency evacuation followed with 28 of the 81 occupants sustaining minor injuries. The Investigation noted the unchallenged gross violation of minima by the Captain.)
  • B733, en-route, north of Yuma AZ USA, 2011 (On 1 April 2011, a Southwest Boeing 737-300 climbing through FL340 experienced a sudden loss of pressurisation as a section of fuselage crown skin ruptured. A successful emergency descent was made with a diversion to Yuma, where the aircraft landed half an hour later. Investigation found that the cause of the failure was an undetected manufacturing fault in the 15 year-old aircraft. One member of the cabin crew and an off duty staff member who tried to assist him became temporarily unconscious after disregarding training predicated on the time of useful consciousness after sudden depressurisation.)
  • A388, en-route, northern Afghanistan, 2014 (On 5 January 2014, an Airbus A380-800 en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door skin which was initiated due to a design issue with door Cover Plates, which had not been detected when the Cover Plate was replaced with an improved one eighteen months earlier. Safety Issues related to cabin crew use of emergency oxygen and diversions to aerodromes with a fire category less than that normally required were also identified.)
  • B734, en-route, east northeast of Tanegashima Japan, 2015 (On 30 June 2015, both bleed air supplies on a Boeing 737-400 at FL370 failed in quick succession resulting in the loss of all pressurisation and, after making an emergency descent to 10,000 feet QNH, the flight was continued to the planned destination, Kansai. The Investigation found that both systems failed due to malfunctioning pre-cooler control valves and that these malfunctions were due to a previously identified risk of premature deterioration in service which had been addressed by an optional but “recommended” Service Bulletin which had not been taken up by the operator of the aircraft involved.)

Unauthorised PED use

IFE fire

Cabin air contamination

  • A333, London Heathrow UK, 2016 (On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded Airbus A330-300 prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions. The Investigation found that the smoke had been caused when an APU seal failed and hot oil entered the bleed air supply and pyrolysed. Safety Recommendations in respect of both crew communication and procedures and APU auto-shutdown were made.)
  • B752, en-route, North Sea, 2006 (On 22 October 2006 a blue haze was observed in the passenger cabin of a Boeing 757-200, operated by Thomsonfly, shortly after reaching cruise altitude on a scheduled passenger flight from Newcastle to Larnaca. A precautionary diversion was made to London Stansted, where an emergency evacuation was carried out successfully.)
  • B734, vicinity East Midlands UK, 1989 (On 8 January 1989, the crew of a British Midland Boeing 737-400 lost control of their aircraft due to lack of engine thrust shortly before reaching a planned en route diversion being made after an engine malfunction and it was destroyed by terrain impact with fatal or serious injuries sustained by almost all the occupants. The crew response to the malfunction had been followed by their shutdown of the serviceable rather the malfunctioning engine. The Investigation concluded that the accident was entirely the consequence of inappropriate crew response to a non-critical loss of powerplant airworthiness.)
  • L101, vicinity Riyadh Saudi Arabia, 1980 (On 19 August 1980, a Lockheed L1011 operated by Saudi Arabian Airlines took off from Riyadh, Saudi Arabia - seven minutes later an aural warning indicated a smoke in the aft cargo compartment. Despite the successful landing all 301 persons on board perished due toxic fumes inhalation and uncontrolled fire.)
  • AT75, Port Vila Vanuatu, 2018 (On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the ‘Before Landing’ Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.)

Malicious interference

Hand held extinguisher used

  • B744, Phoenix USA, 2009 (On 10 January 2009, a Boeing 747-400 being operated by British Airways on a scheduled passenger flight from Phoenix USA to London had been pushed back from the gate in normal daylight visibility and the engines start was continuing when fumes and smoke were observed in the cabin and flight deck. The aircraft commander decided to return to the stand but there was some delay while the tug was reconnected and the movement accomplished. The intensity of the fumes increased and as the aircraft came to a halt on the stand an emergency evacuation was ordered.)
  • B738, en-route, Colorado Springs CO USA, 2006 (B738 diversion into KCOS following in-flight fire. The fire started after a passenger's air purifier device caught fire whilst in use during the flight. The user received minor burns and the aircraft cabin sustained minor damage.)
  • DC93, en-route, Cincinnati OH USA, 1983 (On 2 June 1983, a DC9 aircraft operated by Air Canada was destroyed following an in-flight fire which began in one of the aircraft’s toilets. 23 passengers died in the accident.)
  • A320, vicinity New York JFK NY USA, 2007 (On 10 February 2007, smoke was observed coming from an overhead locker on an Airbus A320 which had just departed from New York JFK. It was successfully dealt by cabin crew fire extinguisher use whilst an emergency was declared and a precautionary air turn back made with the aircraft back on the ground six minutes later. The subsequent investigation attributed the fire to a short circuit of unexplained origin in one of a number of spare lithium batteries contained in a passenger's camera case, some packaged an some loose which had led to three of then sustaining fire damage.)

Evacuation on Cabin Crew initiative

  • DH8D, Edmonton AB Canada, 2014 (On 6 November 2014 a DHC8-400 sustained a burst right main gear tyre during take-off, probably after running over a hard object at high speed and diverted to Edmonton. Shortly after touching down at Edmonton with 'three greens' indicated, the right main gear leg collapsed causing wing and propeller damage and minor injuries to three occupants due to the later. The Investigation concluded that after a high rotational imbalance had been created by the tyre failure, gear collapse on touchdown had been initiated by a rotational speed of the failed tyre/wheel which was similar to one of the natural frequencies of the assembly.)
  • A319, Helsinki Finland, 2018 (On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an Airbus A319 taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.)
  • SB20, Werneuchen Germany, 2002 (On 10 July 2002, a Saab 2000 being operated by Swiss Air Lines on a scheduled public transport service from Basel to Hamburg encountered extensive thunderstorms affecting both the intended destination and the standard alternates and due to a shortage of fuel completed the flight with a landing in day VMC at an unmanned general aviation airstrip where the aircraft collided with an unseen obstruction. After the aircraft came to a stop with the landing gear torn off, the two cabin crew conducted the passenger evacuation on their own initiative. There was no fire and only one of the 20 occupants was injured. The aircraft was declared a hull loss due to the damage sustained relative to the location.)
  • B772, San Francisco CA USA, 2013 (On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.)
  • MA60, Kupang Indonesia, 2013 (On 10 June 2013, a Merpati Nusantara Xian MA60 flown by a First Officer undergoing supervised line training made an unstable visual approach at destination which culminated in a sudden further increase in the rate of descent. The aircraft initially touched down on the runway with a vertical acceleration of 6g and then, after a bounce of -3g, stopped in 200 metres. The impact resulted in the wing box separating from the fuselage. The Investigation found that the Power Levers had been unintentionally moved into the ground range shortly before touchdown without either pilot being aware.)

Flight Crew Evacuation Command

  • DC10, Newburgh NY USA, 1996 (On 5 September 1996, a DC10 operated by Fedex, was destroyed by fire shortly after landing at Newburgh, USA, following a fire in the cargo compartment.)
  • B744, Phoenix USA, 2009 (On 10 January 2009, a Boeing 747-400 being operated by British Airways on a scheduled passenger flight from Phoenix USA to London had been pushed back from the gate in normal daylight visibility and the engines start was continuing when fumes and smoke were observed in the cabin and flight deck. The aircraft commander decided to return to the stand but there was some delay while the tug was reconnected and the movement accomplished. The intensity of the fumes increased and as the aircraft came to a halt on the stand an emergency evacuation was ordered.)
  • B732, Manchester UK, 1985 (On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • B738, Naha Japan, 2007 (On 20 August 2007, as a Boeing 737-800 being operated by China Airlines on a scheduled passenger flight arrived on the designated nose-in parking stand at destination Naha, Japan in daylight and normal visibility, fuel began to leak from the right wing near to the engine pod and ignited. An evacuation was quickly initiated and all 165 occupants including 8 crew members were able to leave the aircraft before it was engulfed by the fire, which spread rapidly and led to the destruction of the aircraft and major damage to the apron surface. As the stand was not adjacent to the terminal and not served by an air bridge, there was no damage to structures. All occupants had left the aircraft before the Airport RFFS arrived at the scene.)

Cabin Crew Incapacitation

  • B744, en-route, South China Sea, 2008 (On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.)
  • B733, en-route, north of Yuma AZ USA, 2011 (On 1 April 2011, a Southwest Boeing 737-300 climbing through FL340 experienced a sudden loss of pressurisation as a section of fuselage crown skin ruptured. A successful emergency descent was made with a diversion to Yuma, where the aircraft landed half an hour later. Investigation found that the cause of the failure was an undetected manufacturing fault in the 15 year-old aircraft. One member of the cabin crew and an off duty staff member who tried to assist him became temporarily unconscious after disregarding training predicated on the time of useful consciousness after sudden depressurisation.)
  • A319, en-route, east of Dublin Ireland, 2008 (On 27 May 2008 an Airbus A319-100 being operated by Germanwings on a scheduled passenger flight from Dublin to Cologne was 30nm east of Dublin and passing FL100 in the climb in unrecorded daylight flight conditions when the Purser advised the flight crew by intercom that “something was wrong”, that almost all the passengers had fallen asleep, and that at least one of the cabin crew seated nearby was “unresponsive”. Following a review of this information and a check of the ECAM pressurisation page which showed no warnings or failures, a decision was taken to don oxygen masks and the aircraft returned uneventfully to Dublin without any further adverse effects on the 125 occupants. A MAYDAY was declared during the diversion.)
  • DH8D, Yangon Myanmar, 2019 (On 8 May 2019, a Bombardier DHC8-400 making its second approach to Yangon during a thunderstorm touched down over halfway along the runway after an unstabilised approach but then briefly became airborne again before descending very rapidly and sustaining extreme structural damage on impact before sliding off the end of the runway. The Investigation found that prior to the final rapid descent and impact, the Captain had placed the power levers into the beta range, an explicitly prohibited action unless an aircraft is on the ground. No cause for the accident other than the actions of the crew was identified.)
  • B738, en-route, west of Canberra Australia, 2017 (On 13 March 2017, the crew of a Boeing 737-800 responded to an increase in indicated airspeed towards Vmo after changing the FMS mode during a high speed descent in a way that more abruptly disconnected the autopilot than they were anticipating which resulted in significant injuries to two of the cabin crew. The Investigation found that the operator’s customary crew response to an overspeed risk at the airline concerned was undocumented in either airline or aircraft manufacturer procedures and had not been considered when an autopilot modification had been designed and implemented.)

Cabin Crew Medical Fitness

Passenger Illness

Faulty or misused PED

  • B738, en-route, Colorado Springs CO USA, 2006 (B738 diversion into KCOS following in-flight fire. The fire started after a passenger's air purifier device caught fire whilst in use during the flight. The user received minor burns and the aircraft cabin sustained minor damage.)

Evacuation on Pax Initiative

  • DH8C, Toronto Canada, 2019 (On 10 May 2019, a Bombardier DHC8-300 taxiing in at Toronto at night was hit by a fuel tanker travelling at “approximately 25 mph” which failed to give way where a designated roadway crossed a taxiway causing direct crew and indirect passenger injuries and substantial damage. The Investigation attributed the collision to the vehicle driver’s limited field of vision in the direction of the aircraft coming and lack of action to compensate for this, noting the need for more effective driver vigilance with respect to aircraft right of way rules when crossing taxiways. The aircraft was declared beyond economic repair.)
  • B738 / B738, Toronto Canada, 2018 (On 5 January 2018, an out of service Boeing 737-800 was pushed back at night into collision with an in-service Boeing 737-800 waiting on the taxiway for a marshaller to arrive and direct it onto the adjacent terminal gate. The first aircraft’s tail collided with the second aircraft’s right wing and a fire started. The evacuation of the second aircraft was delayed by non-availability of cabin emergency lighting. The Investigation attributed the collision to failure of the apron controller and pushback crew to follow documented procedures or take reasonable care to ensure that it was safe to begin the pushback.)
  • A320, en-route, east of Cork Ireland, 2017 (On 2 November 2017, the flight crew of an Airbus A320 climbing out of Cork detected a “strong and persistent” burning smell and after declaring a MAYDAY returned to Cork where confusing instructions from the crew resulted in a combination of the intended precautionary rapid disembarkation and an emergency evacuation using escape slides. The Investigation highlighted the necessity of clear and unambiguous communications with passengers which distinguish these two options and in particular noted the limitations in currently mandated pre flight briefings for passengers seated at over wing emergency exits.)
  • B738, Georgetown Guyana, 2011 (On 30 July 2011, a Boeing 737-800 overran the wet landing runway at Georgetown after a night non-precision approach, exited the airport perimeter and descended down an earth embankment. There were no fatalities but the aircraft sustained substantial damage and was subsequently declared a hull loss. The Investigation attributed the overrun to a touchdown almost two thirds of the way down the runway and failure to utilise the aircraft’s full deceleration capability. Loss of situational awareness and indecision as to the advisability of a go-around after a late touchdown became inevitable was also cited as contributory to the outcome.)
  • DH8D, Yangon Myanmar, 2019 (On 8 May 2019, a Bombardier DHC8-400 making its second approach to Yangon during a thunderstorm touched down over halfway along the runway after an unstabilised approach but then briefly became airborne again before descending very rapidly and sustaining extreme structural damage on impact before sliding off the end of the runway. The Investigation found that prior to the final rapid descent and impact, the Captain had placed the power levers into the beta range, an explicitly prohibited action unless an aircraft is on the ground. No cause for the accident other than the actions of the crew was identified.)

Cabin/Flight deck comms difficulty

  • A333, London Heathrow UK, 2016 (On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded Airbus A330-300 prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions. The Investigation found that the smoke had been caused when an APU seal failed and hot oil entered the bleed air supply and pyrolysed. Safety Recommendations in respect of both crew communication and procedures and APU auto-shutdown were made.)
  • B763, Chicago O'Hare IL USA, 2016 (On 28 October 2016, an American Airlines Boeing 767-300 made a high speed rejected takeoff after an uncontained right engine failure. A successful emergency evacuation of the 170 occupants was completed as a major fuel-fed fire destroyed the failed engine and substantially damaged the aircraft structure. The failure was attributed to an undetected sub-surface manufacturing defect which was considered to have escaped detection because of systemically inadequate materials inspection requirements rather than any failure to apply existing practices. Safety issues in relation to an evacuation initiated by cabin crew following a rejected takeoff and fire were also examined.)

Pax Turbulence Injury - Seat Belt Signs on

  • A388, en-route, Bay of Bengal India, 2019 (On 10 July 2019 an Airbus A380 in the cruise at night at FL 400 encountered unexpectedly severe turbulence approximately 13 hours into the 17 hour flight and 27 occupants were injured as a result, one seriously. The detailed Investigation concluded that the turbulence had occurred in clear air in the vicinity of a significant area of convective turbulence and a jet stream. A series of findings were related to both better detection of turbulence risks and ways to minimise injuries if unexpectedly encountered with particular reference to the aircraft type and operator but with wider relevance.)
  • B788, vicinity Amritsar India, 2018 (On 19 April 2018, a Boeing 787-8 suddenly encountered a short period of severe turbulence as it climbed from FL160 towards clearance limit FL 190 during a weather avoidance manoeuvre which had taken it close to the Amritsar overhead and resulted in a level bust of 600 feet, passenger injuries and minor damage to cabin fittings. The Investigation found that the flight had departed during a period of adverse convective weather after the crew had failed to download a pre flight met briefing or obtain and review available weather updates.)
  • B738, en-route, west of Bar Montenegro, 2019 (On 13 February 2019, a Boeing 737-800 en-route over the southern Adriatic Sea unexpectedly encountered severe clear air turbulence and two unsecured cabin crew and some unsecured passengers were thrown against the cabin structure and sustained minor injuries. The Investigation found that the Captain had conducted the crew pre-flight briefing prior to issue of the significant weather chart applicable to their flight by which time severe turbulence due to mountain waves at right angles to an established jetstream not shown on the earlier chart used for the briefing was expected at a particular point on their route.)
  • B773, en-route, east northeast of Anchorage AK USA, 2015 (On 30 December 2015, a Boeing 777-300 making an eastbound Pacific crossing en-route to Toronto encountered forecast moderate to severe clear air turbulence associated with a jet stream over mountainous terrain. Some passengers remained unsecured and were injured, one seriously and the flight diverted to Calgary. The Investigation found that crew action had mitigated the injury risk but that more could have been achieved. It was also found that the pilots had not been in possession of all relevant information and that failure of part of the air conditioning system during the turbulence was due to an improperly installed clamp.)

Pax Turbulence Injury - Seat Belt Signs off

  • A346, en-route, northern Turkey, 2019 (On 21 August 2019, an Airbus A340-600 encountered sudden-onset moderate to severe clear air turbulence whilst in the cruise at FL 360 over northern Turkey which resulted in a serious passenger injury. The Investigation found that the flight was above and in the vicinity of convective clouds exhibiting considerable vertical development but noted that neither the en-route forecast nor current alerting had given any indication that significant turbulence was likely to be encountered. It was noted the operator’s flight crew had not been permitted to upload weather data in flight but since this event, that restriction had been removed.)
  • A388, en-route, Wyoming USA, 2020 (On 2 February, an Airbus A380 in the cruise at night at FL 330 encountered unforecast clear air turbulence with the seatbelt signs off and one unsecured passenger in a standard toilet compartment sustained a serious injury as a result. The Investigation noted that relevant airline policies and crew training had been in place but also observed a marked difference in the availability of handholds in toilet compartments provided for passengers with disabilities or other special needs and those in all other such compartments and made a corresponding safety recommendation to standardise and placard handhold provision in all toilet compartments.)
  • A332, en-route, mid Atlantic, 2013 (On 2 September 2013, an Airbus A330-200 crossing the ITCZ at FL400 at night encountered sudden severe turbulence unanticipated by the crew resulting in serious injuries to a few cabin crew / passengers and minor injuries to twelve others. An en route diversion to Fortaleza was made. The Investigation found that the origin of the turbulence was severe convective weather and failure to detect it in an area where it had been forecasted indicated that it was probably associated with sub-optimal use of the on-board weather radar with the severity of the encounter possibly aggravated by inappropriate contrary control inputs.)
  • A332, en-route, near Bangka Island Indonesia, 2016 (On 4 May 2016, an Airbus A330-200 in the cruise in day VMC at FL390 in the vicinity of a highly active thunderstorm cell described by the crew afterwards as ‘cumulus cloud’ encountered a brief episode of severe clear air turbulence which injured 24 passengers and crew, seven of them seriously as well as causing some damage to cabin fittings and equipment. The Investigation was unable to determine how close to the cloud the aircraft had been but noted the absence of proactive risk management and that most of the injured occupants had not been secured in their seats.)