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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

  • A333, en-route, Kota Kinabalu Malaysia, 2009 (On 22 June 2009, an Airbus A330-300 being operated by Qantas on a scheduled passenger flight from Hong Kong to Perth encountered an area of severe convective turbulence in night IMC in the cruise at FL380 and 10 of the 209 occupants sustained minor injuries and the aircraft suffered minor internal damage. The injuries were confined to passengers and crew who were not seated at the time of the incident. After consultations with ground medical experts, the aircraft commander determined that the best course of action was to complete the flight as planned, and this was uneventful.)
  • 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.)
  • B772, en-route, Northern Kanto Japan, 2014 (On 16 December 2014, a US-operated Boeing 777-200 encountered a significant period of severe clear air turbulence (CAT) which was unexpected by the flight crew when travelling eastbound over northern Japan at night between FL 270 and FL290. The decision to turn back to Tokyo to allow the nine seriously injured passengers and crew to be treated was made 90 minutes later. The Investigation concluded that the CAT encountered had been correctly forecasted but the Operator's dispatcher-based system for ensuring crew weather awareness was flawed in respect of international operations out of 'non hub' airports.)
  • 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.)
  • AT76, en route, west-southwest of Sydney Australia, 2014 (On 20 February 2014, the mishandling of an ATR 72-600 during descent to Sydney involving opposite control inputs caused an elevator disconnect and a serious cabin crew injury. After recovery of control, the flight was without further event. Post flight inspection did not discover serious structural damage caused to the aircraft and it remained in service for a further five days. The complex Investigation took over five years and examined both the seriously flawed flight crew performance and the serious continued airworthiness failures. Despite extensive safety action in the meantime, the concluding report still made five type airworthiness-related safety recommendations.)

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.)
  • 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.)
  • 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.)

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.)
  • 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.)
  • 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.)
  • A319, London Heathrow UK, 2013 (On 24 May 2013 the fan cowl doors on both engines of an Airbus A319 detached as it took off from London Heathrow. Their un-latched status after a routine maintenance input had gone undetected. Extensive structural and system damage resulted and a fire which could not be extinguished until the aircraft was back on the ground began in one engine. Many previously-recorded cases of fan cowl door loss were noted but none involving such significant collateral damage. Safety Recommendations were made on aircraft type certification in general, A320-family aircraft modification, maintenance fatigue risk management and aircrew procedures and training.)

Pax oxygen mask drop

  • 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.)
  • 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.)
  • B789, en-route, eastern Belgium, 2017 (On 29 April 2017, a Boeing 787-9 which had just reached cruise altitude after despatch with only one main ECS available began to lose cabin pressure. A precautionary descent and PAN was upgraded to a rapid descent and MAYDAY as cabin altitude rose above 10,000 feet. The Investigation found that aircraft release to service had not been preceded by a thorough enough validation of the likely reliability of the remaining ECS system. The inaudibility of the automated announcement accompanying the cabin oxygen mask drop and ongoing issues with the quality of CVR readout from 787 crash-protected recorders was also highlighted.)
  • B735, en-route, SE of Kushimoto Wakayama Japan, 2006 (On 5 July 2006, during daytime, a Boeing 737-500, operated by Air Nippon Co., Ltd. took off from Fukuoka Airport as All Nippon Airways scheduled flight 2142. At about 08:10, while flying at 37,000 ft approximately 60 nm southeast of Kushimoto VORTAC, a cabin depressurization warning was displayed and the oxygen masks in the cabin were automatically deployed. The aircraft made an emergency descent and, at 09:09, landed on Chubu International Airport.)

Unauthorised PED use

IFE fire

Cabin air contamination

  • B738, Glasgow UK, 2012 (On 19 October 2012, a Jet2-operated Boeing 737-800 departing Glasgow made a high speed rejected take off when a strange smell became apparent in the flight deck and the senior cabin crew reported what appeared to be smoke in the cabin. The subsequent emergency evacuation resulted in one serious passenger injury. The Investigation was unable to conclusively identify a cause of the smoke and the also- detected burning smells but excess moisture in the air conditioning system was considered likely to have been a factor and the Operator subsequently made changes to its maintenance procedures.)
  • 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.)
  • 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.)
  • B763, Montreal Quebec Canada, 2013 (On 4 November 2013, smoke began to appear in the passenger cabin of a Boeing 767 which had just begun disembarking its 243 passengers via an airbridge after arriving at Montreal. The source was found to be a belt loader in position at the rear of the aircraft which had caught fire. Emergency evacuation using the airbridge only was ordered by the aircraft commander but cabin conditions led to other exits being used too. The fire was caused by a fuel leak and absence of an emergency stop button had prevented it being extinguished until the airport fire service arrived.)

Malicious interference

Hand held extinguisher used

  • 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.)
  • 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.)
  • 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

  • A320, London Stansted UK, 2019 (On 1 March 2019, an Airbus A320 left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.)
  • 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.)
  • DC3, vicinity Yellowknife Canada, 2013 (On 19 August 2013, a fire occurred in the right engine of a Douglas DC3-C on take off from Yellowknife. After engine shutdown, a right hand circuit was made in an attempt to land back on another runway but trees were struck and the aircraft crash-landed south of it. Emergency evacuation was successful. The Investigation found that a pre-existing cylinder fatigue crack had caused the engine failure/fire and that the propeller feathering pump had malfunctioned. It was found that an overweight take off had occurred and that various unsafe practices had persisted despite the regulatory approval of the Operator's SMS.)
  • 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.)
  • DH8D, Saarbrucken Germany, 2015 (On 30 September 2015, the First Officer on an in-service airline-operated Bombardier DHC-8 400 selected the gear up without warning as the Captain was in the process of rotating the aircraft for take-off. The aircraft settled back on the runway wheels up and eventually stopped near the end of the 1,990 metre-long runway having sustained severe damage. The Investigation noted that a factor contributing to the First Officer's unintended action may have been her "reduced concentration level" but also highlighted the fact that the landing gear control design logic allowed retraction with the nose landing gear airborne.)

Flight Crew Evacuation Command

  • B772, London Heathrow UK, 2008 (On 17 January 2008, a British Airways Boeing 777‑200ER crash-landed 330 metres short of the intended landing runway, 27L, at London Heathrow after a loss of engine thrust on short final. This un-commanded reduction of thrust was found to have been the result of ice causing a restriction in the fuel feed system. Prompt crew response minimized the extent of the inevitable undershoot so that it occurred within the airport perimeter.)
  • 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.)
  • B738, Glasgow UK, 2012 (On 19 October 2012, a Jet2-operated Boeing 737-800 departing Glasgow made a high speed rejected take off when a strange smell became apparent in the flight deck and the senior cabin crew reported what appeared to be smoke in the cabin. The subsequent emergency evacuation resulted in one serious passenger injury. The Investigation was unable to conclusively identify a cause of the smoke and the also- detected burning smells but excess moisture in the air conditioning system was considered likely to have been a factor and the Operator subsequently made changes to its maintenance procedures.)
  • 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.)
  • D328, Mannheim Germany, 2008 (On 19 March 2008, a Cirrus AL Dornier 328 overran runway 27 at Mannheim after a late touchdown, change of controlling pilot in the flare and continued failure to control the aircraft so as to safely complete a landing. The Investigation attributed the late touchdown and subsequent overrun to an initial failure to reject the landing when the TDZ was overflown and the subsequent failure to control the engines properly. The extent of damage to the aircraft was attributed to the inadequate RESA and extensive contextual safety deficiencies were identified in respect of both the aircraft and airport operators.)

Cabin Crew Incapacitation

  • 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.)
  • 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.)
  • B712 / CRJ7, vicinity Strasbourg France, 2019 (On 12 April 2019, a Boeing 717-200 commenced a go around at Strasbourg because the runway ahead was occupied by a departing Bombardier CRJ700 which subsequently, despite co-ordinated TCAS RAs, then came to within 50 feet vertically when only 740 metres apart laterally as the CRJ, whose crew did not see the 717, passed right to left in front of it. The Investigation attributed the conflict primarily to a series of flawed judgements by the TWR controller involved whilst also noting one absent and one inappropriate ATC procedure which respectively may have provided a context for the resultant risk.)
  • A332, Dubai UAE, 2014 (On 23 October 2014 an Airbus A330-200 made a sharp brake application to avoid overrunning the turn onto the parking gate at Dubai after flight. A cabin crew member who had left their seat prior to the call from the flight deck to prepare doors, fell and sustained serious neck and back injuries. The investigation found that the sudden braking had led to the fall but concluded that the risk had arisen because required cabin crew procedures had not been followed.)

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.)
  • 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.)
  • 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, 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.)
  • 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.)

Cabin/Flight deck comms difficulty

  • 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.)
  • 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.)

Pax Turbulence Injury - Seat Belt Signs on

  • 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.)
  • 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.)
  • 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.)

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 2020, 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.)
  • B788, en-route, Chengde China, 2019 (On 15 August 2019, a Boeing 787 descending towards destination Beijing received ATC approval for convective weather avoidance but this was then modified with both a new track requirement and a request to descend which diminished its effectiveness. A very brief encounter with violent turbulence followed but as the seat belt signs had not been proactively switched on, the cabin was not secured and two passengers sustained serious injuries and two cabin crew sustained minor injuries. The Investigation noted that weather deviation requests could usefully be accompanied by an indication of how long they were required for.)
  • 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.)
  • 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.)