Accident and Serious Incident Reports: CS
Accident and Serious Incident Reports: CS
Definition
Reports relating to accidents and incidents that include aspects of Cabin Safety.
Fire
Toilet compartment fire
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
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.
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.
On 2 September 1998, an MD-11 aircraft belonging to Swissair, crashed into the sea off Nova Scotia following an in-flight electrical fire.
IFE fire
On 2 September 1998, an MD-11 aircraft belonging to Swissair, crashed into the sea off Nova Scotia following an in-flight electrical fire.
Faulty or misused PED
On 1 October 2020, a Boeing 787-9 was approaching the top of descent when the cabin crew discovered a mobile phone crushed in a flat bed seat which had just been changed to the seated position for landing. A fire which had started was extinguished and the Captain declared a ‘PAN’ to ensure the fire service attended the arrival. The Investigation noted that there are currently no seat design requirements to prevent electronic devices from becoming trapped in seats and that it is proving challenging to find a workable solution. A Safety Recommendation to improve seat design regulations was made.
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.
Hand held extinguisher used
On 8 November 2022, a De Havilland Canada DHC8-200 experienced radio altimeter failure during descent into Sydney. The crew were unaware this would prevent use of reverse pitch after touchdown and the consequences for brake use and temperature on the long taxi in. The brakes slowly became less effective, then failed and caught fire as the aircraft reached its gate. A successful emergency evacuation followed, and the airport fire service extinguished the brake fires. It was concluded that the aircraft operator had provided insufficient guidance on both radio altimeter failure and the reversion of both engines to manual control.
On 9 February 2023, a Boeing 777-200ER was en route near Marseille when the cabin crew observed smoke coming from a rear galley oven, which was spreading into the rear passenger cabin. After an initial use of multiple Halon fire extinguishers, the smoke ceased after about 20 minutes, but the fumes remained. Although this meant no ongoing emergency existed, some cabin crew and passengers experienced breathing difficulties and it was decided to return to Amsterdam. The cabin crew response to the situation was subsequently assessed as contrary to applicable procedures and relevant cabin crew training seemingly inadequate.
On 1 October 2020, a Boeing 787-9 was approaching the top of descent when the cabin crew discovered a mobile phone crushed in a flat bed seat which had just been changed to the seated position for landing. A fire which had started was extinguished and the Captain declared a ‘PAN’ to ensure the fire service attended the arrival. The Investigation noted that there are currently no seat design requirements to prevent electronic devices from becoming trapped in seats and that it is proving challenging to find a workable solution. A Safety Recommendation to improve seat design regulations was made.
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.
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
Flight Crew Evacuation Command
On 2 January 2024, an Airbus A350-900 collided with a Bombardier DHC8-300 almost immediately after the A350 made a night touchdown in good visibility at Tokyo Haneda. The DHC8 had entered the runway for departure without clearance. Both aircraft caught fire. The DHC8 was destroyed and five of the six occupants died. The A350 then veered off the runway and stopped. All 379 occupants evacuated the A350 prior to its complete destruction by fire. A tower visual-only runway incursion warning was unnoticed for over a minute, and stop bar lighting was out of service for upgrading.
On 15 December 2019, an Airbus A330-200 turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
On 5 August 2019, an Airbus A321 crew declared a MAYDAY immediately after clearing the landing runway at Valencia when a hold smoke warning was annunciated. An emergency evacuation was completed without injuries. This warning followed “white smoke” from the air conditioning system entering both the passenger cabin and flight deck in the four minutes before landing which had prompted the pilots to don oxygen masks. The Investigation found the white smoke was the direct consequence of an oil leak from the right engine as a result of the misalignment and breakage of a bearing and its associated hydraulic seal.
On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.
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.
Evacuation on Cabin Crew initiative
On 12 May 2022, an Airbus A319 about to become airborne at Chongqing veered off the side of the runway at high speed following an inadvertent and unintended rudder input by the non-flying pilot when distracted by unexpected movement of a loose object. Continuation over rough ground across an open ditch resulted in detachment of both engines and both main landing gear assemblies and a resulting fire, which impeded the emergency evacuation. The severe fire and impact damage to the aircraft rendered it a hull loss but the evacuation was completed with only a few minor injuries.
On 2 February 2013, an ATR 72-500 bounced repeatedly when making a night landing at Rome Fiumicino which, in the presence of dual control inputs causing a pitch disconnect, resulted in complete detachment of the landing gear and a veer off before stopping. The accident was attributed to uncharacteristic mishandling by the type experienced Captain in the presence of ineffective crew resource management because of an extremely steep authority gradient resulting from a very significant difference in flight time on the aircraft type (9607 hours / 14 hours). The Investigation attributed an unacceptable delay in the rescue services’ response to managerial incompetence.
On 5 August 2019, a Cessa 560XLS touched down in runway undershot at Aarhus whilst making a night ILS approach there and damage sustained when it collided with parts of the ILS LOC antenna caused a fuel leak which after injury-free evacuation of the occupants then ignited destroying most of the aircraft. The Investigation attributed the accident to the Captain’s decision to intentionally fly below the ILS glideslope in order to touch down at the threshold and to the disabling of the EGWPS alerting function in the presence of a steep authority gradient, procedural non-compliance and poor CRM.
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”.
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.
Evacuation on Pax Initiative
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.
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.
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.
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.
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.
Evacuation slides deployed
On 15 December 2019, an Airbus A330-200 turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
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.
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.
On 3 December 2017, an Embraer E190 en-route at FL310 was already turning back to Helsinki because of a burning smell in the flight deck when smoke in the cabin was followed by smoke in the flight deck. A MAYDAY was declared to ATC reporting “fire on board” and their suggested diversion to Turku was accepted. The situation initially improved but worsened after landing prompting a precautionary emergency evacuation. The Investigation subsequently attributed the smoke to a malfunctioning air cycle machine. Issues with inaccessible cabin crew smoke hoods and with the conduct and aftermath of the evacuation were also identified.
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.
Cabin/Flight deck comms difficulty
On 2 January 2024, an Airbus A350-900 collided with a Bombardier DHC8-300 almost immediately after the A350 made a night touchdown in good visibility at Tokyo Haneda. The DHC8 had entered the runway for departure without clearance. Both aircraft caught fire. The DHC8 was destroyed and five of the six occupants died. The A350 then veered off the runway and stopped. All 379 occupants evacuated the A350 prior to its complete destruction by fire. A tower visual-only runway incursion warning was unnoticed for over a minute, and stop bar lighting was out of service for upgrading.
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.
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.
Medical
Cabin Crew Incapacitation
On 17 November 2021, after a Boeing 737-800 commenced initial descent into Patna from FL350, a cautionary alert indicating automatic pressurisation system failure was annunciated. When the initial actions of the prescribed non-normal procedure did not resolve the problem, the system outflow valve was fully opened, and a rapid depressurisation followed. After this incorrect action, the relevant crew emergency procedures were then not properly followed. It was further concluded that the captain had temporarily lost consciousness after a delay in donning his oxygen mask. The context for the mismanaged response was identified as outflow valve in-service failure.
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.
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.
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.
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
none on SKYbrary
Passenger Illness
none on SKYbrary
Turbulence Injuries
Turbulence Injury - Cabin Crew
On 18 December 2022, an Airbus A330-200 in cruise at FL400 in visual meteorological conditions (VMC) was flown through the isolated top of a building convective cloud after its vertical development rate was underestimated. A short but severe turbulence upset and brief loss of control resulted. A few minutes earlier air traffic control (ATC) had advised that “moderate to extreme precipitation and turbulence could be expected for the next 40 miles." Cabin service was in progress, and the turbulence resulted in 24 unsecured cabin crew and passengers being injured, four seriously. Some cabin trim detached and some equipment was damaged.
On 28 May 2021, a Boeing 767-300 climbing over central South Korea with extensive cloud, including embedded cumulonimbus, and near an active transverse jetstream axis below the intended cruise altitude encountered severe turbulence as it re-entered clouds on a resumed climb. A serious injury occurred to one of the cabin crew. She was unable to return to her crew seat and secure herself because of the flight crew’s short notice that turbulence risk would increase from moderate to severe. Opportunities for further improvement in both aircrew turbulence risk prevention procedures and pilots’ turbulence risk response training were identified.
On 25 February 2015, a Boeing 737-800 encountered severe clear air turbulence as it crossed the Pyrenees northbound at FL 380. Two of the four cabin crew sustained serious injuries and it was decided to divert to Bordeaux where the flight arrived 35 minutes later. The turbulence and its consequences were attributed to the flight’s lateral and vertical closeness to a correctly forecast opposite-direction jet stream core and specifically to allowing cabin service to commence despite being near the boundary associated with severe turbulence following a negative ATC response when asked whether other flights had reported severe turbulence.
On 5 December 2021, an Airbus A359-900 crew encountered a very brief episode of unexpected clear air turbulence associated with visible signs of convective weather in the vicinity. Not having had prior warning, the senior cabin crew member fell and was seriously injured. The investigation concluded that the risk of turbulence prevailing for the location and season as the end of daylight approached was greater than perceived by the pilots, despite their familiarity with the local area and its weather. The investigation further concluded that releasing the cabin crew from their previously secured positions had been inappropriate.
On 31 July 2021, a Boeing 737-800 descending through an area of convective activity which was subject to a current SIGMET encountered some anticipated moderate turbulence whilst visually deviating around storm cells without reducing speed. When it appeared possible that the maximum speed may be exceeded because of turbulence, the autopilot was disconnected and a severe pitch up and then down immediately followed resulting in serious injuries to two of the four cabin crew and a passenger. This disconnection was contrary to the aircraft operator’s procedures and to the explicit training received by the pilot involved who was in command.
Pax Turbulence Injury - Seat Belt Signs on
On 7 January 2023, a fully secured passenger on a Boeing 737-800 close to a convective cloud it was about to enter was forced against a seat arm rest during a momentary encounter with strong turbulence. Although feeling pain, the passenger did not consider it significant. But when the pain continued, they sought a medical assessment, which found two broken lower ribs and attributed this injury to a change in lateral acceleration due to translational movement and yawing of the aircraft.
On 31 July 2021, a Boeing 737-800 descending through an area of convective activity which was subject to a current SIGMET encountered some anticipated moderate turbulence whilst visually deviating around storm cells without reducing speed. When it appeared possible that the maximum speed may be exceeded because of turbulence, the autopilot was disconnected and a severe pitch up and then down immediately followed resulting in serious injuries to two of the four cabin crew and a passenger. This disconnection was contrary to the aircraft operator’s procedures and to the explicit training received by the pilot involved who was in command.
On 17 January 2021, a Boeing 777-300 which had just begun descent into Beirut encountered unexpected moderate to severe clear air turbulence which resulted in one major and several minor injuries to unsecured occupants including cabin crew. The Investigation found that the flight crew had acted in accordance with all applicable procedures on the basis of information available to them but noted that the operator’s flight watch system had failed to generate and communicate a message about a relevant SIGMET until after the severe turbulence episode due to a data processing issue not identified as representing an operational safety risk.
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.
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.
Pax Turbulence Injury - Seat Belt Signs off
On 18 December 2022, an Airbus A330-200 in cruise at FL400 in visual meteorological conditions (VMC) was flown through the isolated top of a building convective cloud after its vertical development rate was underestimated. A short but severe turbulence upset and brief loss of control resulted. A few minutes earlier air traffic control (ATC) had advised that “moderate to extreme precipitation and turbulence could be expected for the next 40 miles." Cabin service was in progress, and the turbulence resulted in 24 unsecured cabin crew and passengers being injured, four seriously. Some cabin trim detached and some equipment was damaged.
On 16 January 2022, an Airbus A320 in cruise unexpectedly and very briefly encountered light clear air turbulence. Despite being secured in a seat, one passenger sustained a serious injury not assessed as such by the passenger or the cabin crew at the time, but which subsequently resulted in hospitalisation with a broken rib. The minor turbulence encountered had included a lateral movement which caused firm impact with the seat armrest. The operators’ response included amending the safety briefing and related procedures and introducing a new video on turbulence awareness to be shown immediately after the briefing.
On 16 January 2020 an Airbus A380 in the cruise at FL 400 in an area of correctly forecast convective turbulence encountered severe turbulence not anticipated by the crew who had not put on the seatbelt signs or alerted the cabin crew in time for the cabin to be secured. An unsecured passenger was seriously injured and several other passengers and an unsecured member of cabin crew were lifted off their feet but managed to avoid injury. The Investigation concluded that the flight crew had not made full use of the capabilities of the available on board weather radar equipment.
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.
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.
Cabin Stowage - Pax Items
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.
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.
Disruptive Pax
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.
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.
Malicious interference
On 19 May 2016, fire broke out on board an Airbus A320 en route to Cairo at night. The fire spread rapidly from the forward area of the aircraft and rapidly intensified. Loss of control due to conditions on the flight deck resulted in descent and sea impact with all 66 occupants killed. Work for the Investigation (reproduced in the final report) which identified a leak from the flight crew emergency oxygen system as the fire source was eventually discounted. It was concluded that the origin was activation of explosive materials in the forward galley just behind the flight deck.
On 2 February 2016, an Airbus A321 Boeing 757-200F in the climb after departing from Mogadishu had just passed FL100 when an explosion occurred inside the passenger cabin. This led to significant structural damage to a small area of the fuselage, which caused cabin depressurisation, the ejection of one passenger, and led to three others being seriously injured. The damaged aircraft was recovered to Mogadishu without any further consequences, and the explosion was found to have been intentionally caused by the ejected male passenger. A series of Safety Recommendations were issued, aimed at improving security screening of passengers boarding flights from Mogadishu.
Cabin air contamination
On 2 January 2024, an Airbus A350-900 collided with a Bombardier DHC8-300 almost immediately after the A350 made a night touchdown in good visibility at Tokyo Haneda. The DHC8 had entered the runway for departure without clearance. Both aircraft caught fire. The DHC8 was destroyed and five of the six occupants died. The A350 then veered off the runway and stopped. All 379 occupants evacuated the A350 prior to its complete destruction by fire. A tower visual-only runway incursion warning was unnoticed for over a minute, and stop bar lighting was out of service for upgrading.
On 9 February 2023, a Boeing 777-200ER was en route near Marseille when the cabin crew observed smoke coming from a rear galley oven, which was spreading into the rear passenger cabin. After an initial use of multiple Halon fire extinguishers, the smoke ceased after about 20 minutes, but the fumes remained. Although this meant no ongoing emergency existed, some cabin crew and passengers experienced breathing difficulties and it was decided to return to Amsterdam. The cabin crew response to the situation was subsequently assessed as contrary to applicable procedures and relevant cabin crew training seemingly inadequate.
On 6 June 2023, a Boeing 717-200 was on base leg about 10 nm from Hobart, Australia, when chlorine fumes became evident on the flight deck. As the aircraft became fully established on final approach, the captain recognised signs of cognitive impairment and handed control to the initially unaffected first officer. Just before touchdown, the first officer was similarly affected but was able to safely complete the landing and taxi in. The same aircraft had experienced a similar event two days earlier with no fault found. The Investigation determined that the operator’s procedures for responding to crew incapacitation in flight had been inadequate.
On 15 December 2019, an Airbus A330-200 turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
On 5 August 2019, an Airbus A321 crew declared a MAYDAY immediately after clearing the landing runway at Valencia when a hold smoke warning was annunciated. An emergency evacuation was completed without injuries. This warning followed “white smoke” from the air conditioning system entering both the passenger cabin and flight deck in the four minutes before landing which had prompted the pilots to don oxygen masks. The Investigation found the white smoke was the direct consequence of an oil leak from the right engine as a result of the misalignment and breakage of a bearing and its associated hydraulic seal.
Pax oxygen mask drop
On 8 February 2022, a Boeing 767-300ER inbound to Madrid at FL340 experienced a failure of automatic pressurisation control, followed almost three hours later by a failure of manual control and rapidly rising cabin altitude. An emergency was declared and descent made to FL120 where manual control was regained. The flight was completed without recurrence. The failure cause was found to have been water leaking from a tube with a broken clamp which, when it froze, had blocked the air conditioning outflow valve doors. Elements of the system design, scheduled maintenance requirements, and fault detection were identified as contributing factors.
On 5 January 2024, a Boeing 737-9 which had just departed Portland was climbing through 14,800 feet when there was a loud bang followed by a rapid decompression. The cause - the loss of a fuselage plug fitted at an unused door location - was immediately obvious. An emergency was declared and a landing back at Portland was made after a total of twenty minutes airborne. The Investigation is continuing but has found that the fuselage plug involved was installed without being properly secured and noted that the aircraft had only recently been delivered new to the operator.
On 17 November 2021, after a Boeing 737-800 commenced initial descent into Patna from FL350, a cautionary alert indicating automatic pressurisation system failure was annunciated. When the initial actions of the prescribed non-normal procedure did not resolve the problem, the system outflow valve was fully opened, and a rapid depressurisation followed. After this incorrect action, the relevant crew emergency procedures were then not properly followed. It was further concluded that the captain had temporarily lost consciousness after a delay in donning his oxygen mask. The context for the mismanaged response was identified as outflow valve in-service failure.
On 18 March 2020, a Fokker 100 en-route to Port Moresby experienced a failure of the cabin pressurisation and air conditioning system due to a complete failure of the bleed air system. An emergency descent and a PAN were declared and a diversion to Madang completed. The Investigation noted unscheduled work on the bleed air system had occurred prior to the departure of the flight and that long running problems with this system had not been satisfactorily resolved until after the investigated occurrence when four malfunctioning components had finally been systematically identified and replaced.
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.
Unauthorised PED use
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