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B773, Mauritius, 2018

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Summary
On 16 September 2018, a Boeing 777-300 was beginning its takeoff from Mauritius when an inadvertently unsecured cabin service cart left its stowage in the forward galley area and travelled at increasing speed towards the rear of the cabin injuring several passengers before it stopped after meeting an empty seat towards the rear of the cabin. The Investigation noted that cabin crew late awareness of an abnormal aircraft configuration and its consequences had led to them generally prioritising service delivery over safety procedures prior to takeoff with this then leading to an overlooked safety task not being detected.
Event Details
When September 2018
Actual or Potential
Event Type
Human Factors
Day/Night Day
Flight Conditions
Flight Details
Aircraft BOEING 777-300
Operator Air France
Domicile France
Type of Flight Public Transport (Passenger)
Origin Mauritius/Sir Seewoosagur Ramgoolam
Intended Destination Paris/Charles de Gaulle Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Take Off
TOF
Location - Airport
Airport Mauritius/Sir Seewoosagur Ramgoolam
HF
Tag(s) Procedural non compliance
Outcome
Damage or injury Yes
Injuries Few occupants
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 16 September 2018, a Boeing 777-300 (F-GSQL) being operated by Air France on a scheduled international passenger flight from Mauritius to Paris CDG as AF463 was beginning its takeoff when an unsecured cabin service cart left its forward galley stowage and travelled almost the full length of the cabin before being stopped by impact with an unoccupied passenger seat. Eight passengers were injured, one seriously. Once airborne, an assessment of the seriously injured passenger was made and it was decided that their condition was such that the flight continuing to Paris as planned would be the best option.

Investigation

An Investigation was carried out by the French Civil Aviation Accident Investigation Agency, the BEA, based mainly on crew and passenger statements which included that of the a doctor who had been on board and had assessed and assisted the seriously injured passenger.

What Happened

For operational reasons, the aircraft used to operate the accident flight was not the one initially scheduled. This change, although not involving the substitution of a different aircraft type, did involve the aircraft having a differently configured cabin which, when the cabin crew were only notified late of the details of the new cabin configuration, put them under workload pressure prior to and during passenger boarding.

As the aircraft began its takeoff, a fully loaded cabin service cart containing retail sales items located at the front galley (position 1 in the illustration below) and weighing around 80 kg came out of its stowage because the retaining latches had not been set. (NB: No mention was made in the Official Report of the foot-applied brake which these industry standard carts also have.) The cart then began to roll down the right-hand cabin aisle at an increasing speed before being stopped by impact with a fortunately empty seat in the row adjacent to the door 4R (position 3). The cart injured eight passengers whilst in transit, one of whom sitting in row 25 (position 2), had been leaning into the aisle and when hit by the cart had sustained a serious facial injury. The Chief Purser, who was stationed at Door 2L subsequently stated that he had “heard a loud noise and thought he saw an in-flight retail trolley go by” but as the takeoff was in progress he was unable to move or use the interphone. Soon after the aircraft became airborne, the cabin crew at door 4R notified him that an in-flight retail cart “had arrived in his zone” and having realised that the injuries included one which was serious, the Chief Purser then notified the flight crew and appealed over the PA for any doctors to make themselves known.

A doctor responded to the appeal and attended the seriously injured passenger who had been leaning into the aisle as the cart came past and had sustained a serious facial injury. The doctor was admitted to the flight deck and held a teleconference call with a paramedic on the ground on the basis of which it was decided that the passenger’s condition did not require the aircraft to divert and that she would be regularly monitored during the flight by the doctor and a member of cabin crew and handed over to medical specialists immediately on arrival in Paris.

The cabin as configured with the track of the cabin service cart shown (position 2 is the seat occupied by the seriously injured passenger). [Reproduced from the Official Report]

It was noted that the aircraft operator has an Operations Control Centre (OCC) to provide tactical oversight of its operations including, as in this case, determining and then supporting any unplanned but necessary aircraft substitutions such as the one *necessary for this flight. The physical configuration of aircraft within an aircraft type is liable to differ and this information was contained in the ‘configuration catalogue’ which when necessary an OCC controller checks and then communicates to those who need to know. The OCC controller overseeing this change was found to have misread the catalogue and communicated the wrong configuration, which included 42 more business class seats than were actually available and commensurately less economy and premium economy seats.

The correct configuration for the allocated aircraft would normally be provided to all operating crew on their tablets but this facility did not extend to these changes and so they only found out what they were after the Chief Purser discovered a paper copy of this information on the aircraft after the cabin crew had boarded the aircraft. This information was relevant to the pre-flight catering onload and to passenger seat allocation and service. During his subsequent on-aircraft briefing, the Chief Purser reminded his team that the passengers may well not be as relaxed as usual because of a boarding delay due to a late catering upload and the non routine stowage it had required. He subsequently stated that time pressure had dictated that the catering stowage had been “done in a disorganised manner” with the cabin crew assisting with loading which was “not standard practice”. The Chief Purser also decided that as no aircraft loading plan was available, the mandatory check that the seals on loaded cabin service carts were intact would be deferred until after takeoff instead of being done before departure as it would normally be so as not to further delay boarding. It was noted that this check could only be done by removing each cart from its stowage and then returning and re-securing it.

The member of cabin crew who overlooked the securing of the cart in its stowage subsequently stated that passenger boarding had commenced before the crew had been able to complete stowage of all the cabin service carts in their correct locations. Having been assigned to look after business class passengers, she had eventually become “overwhelmed” by the unusually high pre-takeoff cabin service workload caused by more than four times the number of business class passengers, the majority of whom had been upgraded from economy since the flight had been sold for an aircraft configured with 422 economy class seats whereas the substitute aircraft had only 206 of these.

A total of six Contributory Factors to the accident were identified by the Investigation as follows:

  • The failure of the Operations Control Centre (OCC) to communicate the correct aircraft configuration during the aircraft substitution process, possibly related to the use of a non-automated tool to select the configuration.
  • The incorrect aircraft configuration provided by the OCC controller led to a large number of passengers not accustomed to the services provided in business class being upgraded to that class and to the incorrect loading of the on-board cabin service carts by the caterers which increased cabin crew pre departure workload.
  • The fact that the cabin crew receipt of the usual flight preparation documentation was delayed because these documents were not available on their tablets led the crew to adapt quickly to an unexpected situation without evaluating whether it would be advisable to postpone some elements of passenger service.
  • The focus of the cabin crew on passenger services to the detriment of certain safety actions, due in particular to their desire to re-arrange the loading of cabin service carts to limit the impact for passengers during the flight and to provide the correct passenger service to a higher than usual number of passenger requests because business class was full.
  • The unusually high workload before and during boarding of the particular member of cabin crew who was responsible for securing the cabin service cart that was not properly stowed.
  • The failure of the cabin crew team to follow standard reporting procedures, which did not allow for a final check of the inadequately secured galley cart before take-off.

Safety Action taken by Air France as a result of the event whilst the Investigation was in progress was noted to have included but not been limited to the following:

  • The introduction of a crosscheck on cabin configuration by the operations controller and the cabin crew manager.
  • The automation of the aircraft configuration management system.
  • Documentation relating to all possible aircraft configurations is now available to cabin crew on their tablets.

The Final Report was published in English translation on 19 June 2020 following the initial and definitive publication in French on 29 May 2020. No Safety Recommendations were made.

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