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A332, Dubai UAE, 2014
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Revision as of 22:51, 6 December 2018 by Integrator3
|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.|
|Actual or Potential
|Flight Conditions||Not Recorded|
|Domicile||United Arab Emirates|
|Type of Flight||Public Transport (Passenger)|
|Origin||Ahmedabad International Airport|
|Intended Destination||Dubai International Airport|
|Take off Commenced||Yes|
|Location - Airport|
|Airport||Dubai International Airport|
|Tag(s)||Copilot less than 500 hours on Type|
|Tag(s)||Procedural non compliance|
|Tag(s)||Cabin Crew Incapacitation|
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 23 October 2014, an Airbus A330-200 (A6-EKR) being operated by Emirates Airline on a scheduled passenger flight from Ahmedabad to Dubai as EK539 braked sharply as it was about to turn onto the allocated parking gate and a member of the Cabin Crew who was standing in the forward galley area fell and sustained serious injuries. After receiving first aid, the cabin crew member was admitted to a hospital for treatment.
An investigation was carried out by the UAE GCAA Accident Investigation Sector. Information on the taxi in was recovered from the aircraft QAR.
The 46 year-old Captain had 5540 hours total flying experience including 2776 hours on type and had been acting as PF for the arrival at Dubai. The 33 year-old First Officer had 1372 total flying hours, all but 2.5 hours of which were on type.
It was established that after vacating the runway, the aircraft routed as shown in the diagram below using both engines until it was about to make the final right turn onto the assigned parking gate. The No.2 engine was then shut down in accordance with Standard Operating Procedures (SOPs) and taxiing using the No. 1 engine. It was found that once the aircraft was on taxiway K, one of the 12 cabin crew had left her designated crew seat adjacent to the R4 door at the rear of the aircraft and walked forwards towards the L2 door position where she was to perform her nominated duty as the L2 door checker. However, in order to first retrieve her uniform hat from stowage at the very front of the aircraft, she had walked past the L2 door towards the front of the aircraft. By the time she reached this area, the aircraft was on taxiway Z and about to turn right onto the assigned parking gate. With the MLG already abeam the gate centreline, “the Captain applied firm braking in order not to overshoot the final turn” causing a sharp reduction in forward speed.
The cabin crew member involved subsequently stated that although she had reached the stowage location at the time of the brake application, she was unsure whether she had been standing still or still walking. She did conclude since she had not yet retrieved her hat and had nothing to hold on to, when the brakes were applied she had not opened the cupboard. At that point, she “lost her balance and was thrown towards the forward section of the aircraft into the business class galley, making contact with the galley worktop surface before falling onto the floor, sustaining serious injuries to her neck and back”. It was estimated that she had walked almost 40 metres between leaving her crew seat and falling - and that she had done so in medium heeled shoes rather than low heeled cabin shoes.
The Investigation examined the applicable Operations Manual content in respect of “Cabin Crew Safety-related Duties after Landing” and found that the Landing Checklist included the following:
- Remain seated until the seat belt sign is switched off unless it is necessary to perform a safety related duty.
- After the final turn on to the parking stand, the flight deck crew will announce “Cabin Crew, prepare all doors and cross check.”
The fact that the Cabin Crew procedures at the time of the event allocated some door duties to cabin crew with allocated crew seats not near those doors was considered. It was noted that most of the distance walked by the injured cabin crew had been necessary to reach her allocated door duty position rather than to retrieve her hat. It was further noted that changing position prior to the flight crew announcement to prepare doors for arrival was “an established cabin crew action which was not in accordance with the Operator’s SOPs or cabin manuals” when necessary to reach a door “prior to passengers leaving their seats and blocking the aisle, preventing access to the door”. It was considered that “had the (cabin crew involved) not left her seat (during taxi in) it is likely that she would not have been able to assume her safety function at the L2 door”.
It was noted that “although the Investigation could not determine whether (the) style of shoe (worn had) affected the crewmember's balance when the aircraft brakes were applied firmly”, the accepted practice of shoe changing for in flight cabin service had not been risk assessed and there were no “mitigating advisory actions” in respect to cabin crew walking through the aircraft cabin during taxi whilst wearing high heeled/medium heeled shoes.
It was also found that an amended procedure in relation to door checking which “eliminated the risk of walking long distances in the cabin while the aircraft is moving” was due to be implemented on 1 November 2014 and had already been published prior to the investigated event (on 16 October 2014).
Using QAR data, a detailed analysis of the approach to the final turn was made. It was calculated that the maximum applied brake pressure had been reached 5 seconds before the right turn had commenced and that the effect of this brake application had been “a deceleration from 14 knots to 4 knots within 4 seconds” and occurred concurrently with the No 2 engine shutdown. It was found that the FCOM included the remark that "during engine shutdown, a slight jerk forward may occur if the flight crew apply the brakes during aircraft movement”. It was also noted that although the time after initiating the shutdown “was sufficient to complete the engine shutdown procedure […] the transition from completing the (shutdown) checklist and commencing to turn the aircraft turn was short and this required the Captain to apply firm braking to make the final turn”. It was concluded that “the flight crew’s situational awareness of the (right turn into the gate) may have been compromised by the time constraint imposed by the short taxi distance, the speed of the aircraft and carrying out the engine shutdown procedure”. However, it was considered that “although, the application of the braking caused the SCCM to lose her balance and fall”, it amounted to “a contributing factor and not the direct cause of this event” given that “the Accident most likely would not have happened had (she) stayed seated until the aircraft completed the final turned onto the parking bay”.
The formal statement of Cause of the accident was that “the cabin crew member left her jump seat before the final turn onto the parking stand and before the Flight Crew announced: “Cabin Crew, Prepare all doors and cross check””.
A Contributing Factor was determined to have been “the sudden firm braking action which caused the cabin crew member to lose her balance and fall”.
Three Safety Recommendations were made as a result of the Investigation as follows:
- that Emirates Airline should assess the risk to female cabin crewmembers of wearing high/medium heeled shoes during the critical phases of the flight (taxi, take-off, climb, descent and landing). [SR19/2016]
- that Emirates Airline should, to eliminate the risk of cabin crewmembers walking long distances during taxi, give consideration to monitoring the revised door checker SOP that was published on the 16 October 2014 for consistent application. [SR20/2016]
- that Emirates Airline should consider monitoring the existing procedure of cabin crew leaving their jump seats to disarm their door before the final turn and upon the flight crew PA for consistent application. [SR21/2016]
The Final Report of the Investigation was issued on 3 March 2016.