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Accident and Serious Incident Reports: GND

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Revision as of 12:56, 8 July 2018 by Integrator2 (talk | contribs) (Inadequate de/anti icing)
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Category: Ground Operations Ground Operations
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Definition

Reports relating to accidents associated with Ground Operations.

The accident reports are grouped together below in subcategories.

Dangerous Goods

  • A333, Manila Philippines, 2013 (On 7 October 2013 a fire was discovered in the rear hold of an Airbus A330 shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.)
  • B744, en-route, East China Sea, 2011 (On 28 July 2011, 50 minutes after take off from Incheon, the crew of an Asiana Boeing 747-400F declared an emergency advising a main deck fire and an intention to divert to Jeju. The effects of the rapidly escalating fire eventually made it impossible to retain control and the aircraft crashed into the sea. The Investigation concluded that the origin of the fire was two adjacent pallets towards the rear of the main deck which contained Dangerous Goods shipments including Lithium ion batteries and flammable substances and that the aircraft had broken apart in mid-air following the loss of control.)
  • B738, Dubai UAE, 2013 (On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.)
  • B744, vicinity Dubai UAE, 2010 (On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.)
  • B748, Prestwick UK, 2017 (On 30 March 2017, a significant amount of fuel was found to be escaping from a Boeing 747-8F as soon as it arrived on stand after landing at Prestwick and the fire service attended to contain the spill and manage the associated risk of fire and explosion. The Investigation found that the fuel had come from a Bell 412 helicopter that was part of the main deck cargo and that this had been certified as drained of fuel when it was not. The shipper’s procedures, in particular in respect of their agents in the matter, were found to be deficient.)
  • DC93, en-route, north west of Miami USA, 1996 (On 11 May 1996, the crew of a ValuJet DC9-30 were unable to keep control of their aircraft after fire broke out. The origin of the fire was found to have been live chemical oxygen generators loaded contrary to regulations. The Investigation concluded that, whilst the root cause was poor practices at SabreTech (the maintenance contractor which handed over oxygen generators in an unsafe condition), the context for this was oversight failure at successive levels - Valujet over SabreTech and the FAA over Valujet. Failure of the FAA to require fire suppression in Class 'D' cargo holds was also cited.)
  • B742, Halifax Canada, 2004 (On 14 October 2004, a B742 crashed on take off from Halifax International Airport, Canada, and was destroyed by impact forces and a post-crash fire. The crew had calculated incorrect V speeds and thrust setting using an EFB.)

De-Icing/Anti-Icing of Aircraft on the Ground

Failure to de/anti ice when facilities available

  • CL60, Birmingham UK, 2002 (On 4 January 2002, the crew of US-operated Bombardier Challenger lost control of their aircraft shortly after taking off from Birmingham and after one wing touched the ground, it rolled inverted, crashed and caught fire within the airport perimeter and all five occupants died. The Investigation found that the cause of the accident was failure to remove frost from the wings which reduced the wing stall angle of attack below that at which the stall protection system was effective. It was considered that the combined effects of non-prescription drug, jet lag and fatigue may have impaired crew performance)
  • AT72, vicinity Manchester UK, 2016 (On 4 March 2015, the flight crew of an ATR72 decided to depart from Manchester without prior ground de/anti icing treatment judging it unnecessary despite the presence of frozen deposits on the airframe and from rotation onwards found that manual forward control column input beyond trim capability was necessary to maintain controlled flight. The aircraft was subsequently diverted. The Investigation found that the problem had been attributable to ice contamination on the upper surface of the horizontal tailplane. It was considered that the awareness of both pilots of the risk of airframe icing had been inadequate)
  • C208, Helsinki Finland, 2005 (On 31 January 2005, the pilot of a Cessna 208 which had just taken off from Helsinki lost control of their aircraft as the flaps were retracted and the aircraft stalled, rolled to the right and crashed within the airport perimeter. The Investigation found that the take off had been made without prior airframe de/anti icing and that accumulated ice and snow on the upper wing surfaces had led to airflow separation and the stall, a condition which the pilot had failed to recognise or respond appropriately to for undetermined reasons)
  • CL60, Montrose USA, 2004 (On 28 November 2004, the crew of a Bombardier Challenger 601 lost control of their aircraft soon after getting airborne from Montrose and it crashed and caught fire killing three occupants and seriously injuring the other three. The Investigation found that the loss of control had been the result of a stall caused by frozen deposits on the upper wing surfaces after the crew had failed to ensure that the wings were clean or utilise the available ground de/anti ice service. It was concluded that the pilots' lack of experience of winter weather operations had contributed to their actions/inactions)
  • AT72, vicinity Tyumen Russian Federation, 2012 (On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up)
  • JS41, en-route, North West of Aberdeen UK, 2008 (On 9 April 2008, a BAe Jetstream 41 departed Aberdeen in snow and freezing conditions after the Captain had elected not to have the airframe de/anti iced having noted had noted the delay this would incur. During the climb in IMC, pitch control became problematic and an emergency was declared. Full control was subsequently regained in warmer air. The Investigation concluded that it was highly likely that prior to take off, slush and/or ice had been present on the horizontal tail surfaces and that, as the aircraft entered colder air at altitude, this contamination had restricted the mechanical pitch control)

Ground de/anti icing not available

  • PRM1, vicinity Annemasse France, 2013 (On 4 March 2013, a Beechcraft Premier 1A stalled and crashed soon after take off from Annemasse. The Investigation concluded that the loss of control was attributable to taking off with frozen deposits on the wings which the professional pilot flying the privately-operated aircraft had either not been aware of or had considered insignificant. It was found that the aircraft had been parked outside overnight and that overnight conditions, particularly the presence of a substantial quantity of cold-soaked fuel, had been conducive to the formation of frost and that no airframe de/anti icing facilities had been available at Annemasse)
  • C208, vicinity Pelee Island Canada, 2004 (On 17 January, 2004 a Cessna 208 Caravan operated by Georgian Express, took off from Pellee Island, Ontario, Canada, at a weight significantly greater than maximum permitted and with ice visible on the airframe. Shortly after take off, the pilot lost control of the aircraft and it crashed into a frozen lake)

Inadequate de/anti icing

  • MD81, vicinity Stockholm Arlanda Sweden, 1991 (On 27 December 1991, an MD-81 took off after airframe ground de/anti icing treatment but soon afterwards both engines began surging and both then failed. A successful crash landing was achieved after the aircraft emerged from cloud approximately 900 feet above terrain and only eight of the 129 occupants were seriously injured. The Investigation found that undetected clear ice on the upper wing surfaces had been ingested into both engines and caused damage which initiated the surging. Without training in the identification and elimination of engine surging, the pilots had not taken corrective action and so both engines had failed)

Control hazards resulting from ground de/anti ice procedures

  • ATP, Helsinki Finland, 2010 (On 11 January 2010, a British Aerospace ATP crew attempting to take off from Helsinki after a two-step airframe de/anti icing treatment (Type 2 and Type 4 fluids) were unable to rotate and the take off was successfully rejected from above V1. The Investigation found that thickened de/anti ice fluid residues had frozen in the gap between the leading edge of the elevator and the horizontal stabiliser and that there had been many other similarly-caused occurrences to aircraft without powered flying controls. There was concern that use of such thickened de/anti ice fluids was not directly covered by safety regulation)
  • B463, en-route, South of Frankfurt Germany, 2005 (On 12 March 2005, the crew of a BAe 146-300 climbing out of Frankfurt lost elevator control authority and an un-commanded descent at up to 4500 fpm in a nose high pitch attitude occurred before descent was arrested and control regained. After landing using elevator trim to control pitch, significant amounts of de/anti-icing fluid residues were found frozen in the elevator/stabilizer and aileron/rudder gaps. The Investigation confirmed that an accumulation of hygroscopic polymer residues from successive applications of thickened de/anti ice fluid had expanded by re-hydration and then expanded further by freezing thus obstructing the flight controls)
  • D328, Isle of Man, 2005 (On 28 November 2005, a Dornier 328 being operated by EuroManx on a scheduled passenger service departing from Isle of Man for an unspecified destination was unable to rotate at the speed calculated as applicable and the take off was successfully rejected. The Investigation found that the crew were unaware of the AFM 'Normal Procedures' requirement to use take off speeds after application of thickened de ice fluids which are typically around 20 knots higher than normal speeds)
  • DH8A, Ottawa Canada, 2003 (On 04 November 2003, the crew of a de Havilland DHC-8-100 which had been de/anti iced detected a pitch control restriction as rotation was attempted during take off from Ottawa and successfully rejected the take off from above V1. The Investigation concluded that the restriction was likely to have been the result of a remnant of clear ice migrating into the gap between one of the elevators and its shroud when the elevator was moved trailing edge up during control checks and observed that detection of such clear ice remnants on a critical surface wet with de-icing fluid was difficult)

Unintended side effects due inadequate/incorrect ground de/anti icing procedures/techniques

  • A320, en-route, Kalmar County Sweden, 2009 (On 2 March 2009, communication difficulties and inadequate operator procedures led to an Airbus A320-200 being de-iced inappropriately prior to departure from Vasteras and fumes entered the air conditioning system via the APU. Although steps were then taken before departure in an attempt to clear the contamination, it returned once airborne. The flight crew decided to don their oxygen masks and complete the flight to Poznan. Similar fumes in the passenger cabin led to only temporary effects which were alleviated by the use of therapeutic oxygen. The Investigation concluded that no health risks arose from exposure to the fumes involved)

Aircraft Push Back

  • B752 / CRJ7, San Francisco CA USA, 2008 (On 13 January 2008, a Boeing 757-200 and a Bombardier CL-600 received pushback clearance from two adjacent terminal gates within 41 seconds. The ground controller believed there was room for both aircraft to pushback. During the procedure both aircraft were damaged as their tails collided. The pushback procedure of the Boeing was performed without wing-walkers or tail-walkers.)
  • A332, Karachi Pakistan, 2014 (On 4 October 2014, the fracture of a hydraulic hose during an A330-200 pushback at night at Karachi was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. After some delay, during which a delay in isolating the APU air bleed exacerbated the ingress of fumes, the aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it which prevented use of the exit adjacent to it for evacuation.)
  • 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.)
  • B789 / A388, Singapore, 2017 (On 30 March 2017, a Boeing 787 taxiing for departure at night at Singapore was involved in a minor collision with a stationary Airbus A380 which had just been pushed back from its gate and was also due to depart. The Investigation found that the conflict occurred because of poor GND controlling by a supervised trainee and had occurred because the 787 crew had exercised insufficient prudence when faced with a potential conflict with the A380. Safety Recommendations made were predominantly related to ATC procedures where it was considered that there was room for improvement in risk management.)
  • ATP, Jersey Channel Islands, 1998 (On 9 May 1998, a British Regional Airlines ATP was being pushed back for departure at Jersey in daylight whilst the engines were being started when an excessive engine power setting applied by the flight crew led to the failure of the towbar connection and then to one of the aircraft's carbon fibre propellers striking the tug. A non standard emergency evacuation followed. All aircraft occupants and ground crew were uninjured.)
  • B738, London Stansted UK, 2008 (On 13 November 2008, a Boeing 737-800 with an unserviceable APU was being operated by Ryanair on a passenger flight at night was in collision with a tug after a cross-bleed engine start procedure was initiated prior to the completion of a complex aircraft pushback in rain. As the power was increased on the No 1 engine in preparation for the No 2 engine start, the resulting increase in thrust was greater than the counter-force provided by the tug and the aircraft started to move forwards. The towbar attachment failed and subsequently the aircraft’s No 1 engine impacted the side of the tug, prior to the aircraft brakes being applied.)
  • MD82 / MD11, Anchorage AK USA, 2002 (On 17 March 2002, at Ted Stevens Anchorage Airport, a McDonnell Douglas MD82 operated by Alaska Airlines, on a night pushback in snow conditions collided with an inbound taxiing McDonnell Douglas MD-11. The MD82 suffered substantial rudder damage although the impacting MD11 winglet was undamaged.)
  • B763 / A320, Delhi India, 2017 (On 8 August 2017, a Boeing 767-300 departing Delhi was pushed back into a stationary and out of service Airbus A320 on the adjacent gate rendering both aircraft unfit for flight. The Investigation found that the A320 had been instructed to park on a stand that was supposed to be blocked, a procedural requirement if the adjacent stand is to be used by a wide body aircraft and although this error had been detected by the stand allocation system, the alert was not noticed, in part due to inappropriate configuration. It was also found that the pushback was commenced without wing walkers.)
  • B742, Stockholm Arlanda Sweden, 2007 (On 25 June 2007, a Boeing 747-200F being operated by Cathay Pacific on a scheduled cargo flight from Stockholm to Dubai had completed push back for departure in normal daylight visibility and the parking brakes had been set. The tow vehicle crew had disconnected the tow bar but before they and their vehicle had cleared the vicinity of the aircraft, it began to taxi and collided with the vehicle. The flight crew were unaware of this and continued taxiing for about 150 metres until the flight engineer noticed that the indications from one if the engines were abnormal and the aircraft was taxied back to the gate. The tow vehicle crew and the dispatcher had been able to run clear and were not injured physically injured although all three were identified as suffering minor injury (shock). The aircraft was “substantially damaged” and the tow vehicle was “damaged”.)
  • CRJ7 / CRJ2, Charlotte NC USA, 2008 (On 28 June 2008, a Bombardier CRJ 700 operated by PSA Airlines, during daytime pushback collided with a stationary CRJ 200 of the same company at Douglas International Airport Charlotte, North Carolina.)
  • RJ85 / RJ1H, London City Airport, London UK, 2008 (On 21 April 2008, an Avro RJ85 aircraft was parked on Stand 10 at London City Airport, with an Avro RJ100 parked to its left, on the adjacent Stand 11. After being repositioned by a tug, the RJ85 taxied forward and to the right, its tail contacting the tail of the RJ100 and causing minor damage to the RJ100’s right elevator.)
  • B772 / A321, London Heathrow UK, 2007 (On 27 July 2007, a British Airways Boeing 777-200ER collided, during pushback, with a stationary Airbus A321-200. The A321 was awaiting activation of the electronic Stand Entry Guidance (SEG) and expecting entry to its designated gate.)

Jet Blast/Prop Wash

  • B734, Aberdeen UK, 2005 (Significant damage was caused to the tailplane and elevator of a Boeing 737-400 after the pavement beneath them broke up when take off thrust was applied for a standing start from the full length of the runway at Aberdeen. Although in this case neither outcome applied, the Investigation noted that control difficulties consequent upon such damage could lead to an overrun following a high speed rejected takeoff or to compromised flight path control airborne. Safety Recommendations on appropriate regulatory guidance for marking and construction of blast pads and on aircraft performance, rolling take offs and lead-on line marking were made.)

Taxiway Collision

  • B738/B738, Girona Spain, 2010 (On 14 January 2010, two Ryanair Boeing 737-800 aircraft were operating scheduled passenger flights from Girona to Las Palmas and Turin respectively and had taxied from adjacent gates at Girona in normal day visibility in quick succession. The Turin-bound aircraft taxied first but because it was early at the holding point for its CTOT, the other aircraft was designated first for take off and during the overtaking manoeuvre in the holding area, the wing tip of the moving Las Palmas aircraft hit the horizontal stabiliser of the Turin bound aircraft causing minor and substantial damage to the respective aircraft. None of the respective 81 and 77 occupants were injured and both aircraft taxied back to their gates.)
  • B744, Paris CDG France, 2003 (On 18 January 2003, a Boeing 747-400F being operated by Singapore Airlines Cargo on a scheduled cargo flight from Paris CDG to Dubai taxied for departure in darkness and fog with visibility less than 100 metres in places and the right wing was in collision with a stationary and unoccupied ground de/anti icing vehicle without the awareness of either the flight crew or anybody else at the time. Significant damage occurred to the de icing vehicle and the aircraft was slightly damaged. The vehicle damage was not discovered until almost two hours later and the aircraft involved was not identified until it arrived in Dubai where the damage was observed and the authorities at Paris CDG advised.)
  • E190 / Vehicle, Paris CDG France, 2014 (On 19 April 2014, an Embraer 190 collided with the tug which was attempting to begin a pull forward after departure pushback which, exceptionally for the terminal concerned, was prohibited for the gate involved. As a result, severe damage was caused to the lower fuselage. The Investigation found that the relevant instructions were properly documented but ignored when apron services requested a 'push-pull' to minimise departure delay for an adjacent aircraft. Previous similar events had occurred on the same gate and it was suspected that a lack of appreciation of the reasons why the manoeuvre used was prohibited may have been relevant.)
  • B744 / B763, Melbourne Australia, 2006 (On 2 February 2006, a Boeing 747-400 was taxiing for a departure at Melbourne Airport. At the same time, a Boeing 767-300 was stationary on taxiway Echo and waiting in line to depart from runway 16. The left wing tip of the Boeing 747 collided with the right horizontal stabiliser of the Boeing 767 as the first aircraft passed behind. Both aircraft were on scheduled passenger services from Melbourne to Sydney. No one was injured during the incident.)
  • B738 / B738, Dublin Ireland, 2014 (On 7 October 2014, a locally-based Boeing 737-800 taxiing for departure from runway 34 at Dublin as cleared in normal night visibility collided with another 737-800 stationary in a queue awaiting departure from runway 28. Whilst accepting that pilots have sole responsible for collision avoidance, the Investigation found that relevant restrictions on taxi clearances were being routinely ignored by ATC. It also noted that visual judgement of wingtip clearance beyond 10 metres was problematic and that a subsequent very similar event at Dublin involving two 737-800s of the same Operator was the subject of a separate investigation.)
  • A343, Frankfurt Germany, 2008 (On 21 August 2008, an Airbus A340-300 being operated by an undisclosed operator by a German-licensed flight crew on a scheduled passenger flight from Teheran to Frankfurt collided with a stationary bus with only the driver on board whilst approaching the allocated parking gate in normal daylight visibility. The No 4 engine impacted the bus roof as shown in the photograph below reproduced from the official report. None of the occupants of either the aircraft or the bus were injured.)
  • B772 / A321, London Heathrow UK, 2007 (On 27 July 2007, a British Airways Boeing 777-200ER collided, during pushback, with a stationary Airbus A321-200. The A321 was awaiting activation of the electronic Stand Entry Guidance (SEG) and expecting entry to its designated gate.)
  • A321, Daegu South Korea, 2006 (On 21 February 2006, an Airbus A321-200 being operated by China Eastern on a scheduled passenger flight from Daegu to Shanghai Pudong failed to follow the marked taxiway centreline when taxiing for departure in normal daylight visibility and a wing tip impacted an adjacent building causing minor damage to both building and aircraft. None of the 166 occupants were injured.)
  • MD82 / MD11, Anchorage AK USA, 2002 (On 17 March 2002, at Ted Stevens Anchorage Airport, a McDonnell Douglas MD82 operated by Alaska Airlines, on a night pushback in snow conditions collided with an inbound taxiing McDonnell Douglas MD-11. The MD82 suffered substantial rudder damage although the impacting MD11 winglet was undamaged.)
  • B744 / A321, London Heathrow UK, 2004 (On 23 March 2004, an out of service British Airways Boeing 747-400, under tow passed behind a stationary Airbus A321-200 being operated by Irish Airline Aer Lingus on a departing scheduled passenger service in good daylight visibility and the wing tip of the 747 impacted and seriously damaged the rudder of the A321. The aircraft under tow was cleared for the towing movement and the A321 was holding position in accordance with clearance. The towing team were not aware of the collision and initially, there was some doubt in the A321 flight deck about the cause of a ‘shudder’ felt when the impact occurred but the cabin crew of the A321 had felt the impact shudder and upon noticing the nose of the 747 appearing concluded that it had struck their aircraft. Then the First Officer saw the damaged wing tip of the 747 and informed ATC about the possible impact. Later another aircraft, positioned behind the A321, confirmed the rudder damage. At the time of the collision, the two aircraft involved were on different ATC frequencies.)
  • B738/A321, Prague Czech Republic, 2010 (On 18 June 2010 a Sun Express Boeing 737-800 taxiing for a full length daylight departure from runway 06 at Prague was in collision with an Airbus 321 which was waiting on a link taxiway leading to an intermediate take off position on the same runway. The aircraft sustained damage to their right winglet and left horizontal stabiliser respectively and both needed subsequent repair before being released to service.)
  • A343 / B744, London Heathrow UK, 2007 (On 15 October 2007, an Airbus 340-300 being operated on a scheduled passenger flight by Air Lanka with a heavy crew in the flight deck was taxiing towards the departure runway at London Heathrow at night in normal visibility when the right wing tip hit and sheared off the left hand winglet of a stationary British Airways Boeing 747-400 which was in a queue on an adjacent taxiway. The Airbus 340 sustained only minor damage to the right winglet and navigation light.)

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For all accident reports held on SKYbrary, see the Accidents and Incidents.