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.
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.
Turbulence Injury - Cabin Crew
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 25 July 2021, a Boeing 737-800 which had previously been manoeuvring visually around storm cells over the Alps during the initial descent into Nice turned back on track believing the avoidance action was complete but was then unable to avoid penetrating a further cell during which severe turbulence caused a serious injury to one of the cabin crew and a lesser injury to another. Multiple aircraft in the area had been simultaneously requesting track deviations at the time with ATC displays not showing weather returns. In the absence of plans to introduce this, a corresponding safety recommendation was made.
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 13 September 2017, the airspeed of a Boeing 737-800 unexpectedly increased during an intentionally high speed descent and the Captain’s overspeed prevention response, which followed his taking over control without following the applicable procedure, was inappropriate and led directly to cabin crew injuries, one of which was serious. The Investigation found that the speed increase had been the result of a sudden decrease in tailwind component associated with windshear and noted that despite moderate clear air turbulence being forecast for the area, this had not resulted in the seat belt signs being on or any consequent cabin crew briefing.
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 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 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.
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.
On 27 August 2018, an Airbus A320 level at FL 300 encountered unanticipated turbulence which caused one of the cabin crew to fall and sustain what was belatedly diagnosed as spinal fracture. The Investigation found that the aircraft had flown through the decaying wake vortex from an almost opposite direction Boeing 747-400F at FL310 which had been observed to cross what was subsequently found to be 13.8 nm ahead of the A320 prior to the latter crossing its track 1 minute 40 seconds later that coincided with a very brief period in which vertical acceleration varied between +0.19g and +1.39g.
On 24 June 2018, a Boeing 777-300 was briefly subjected to unexpected and severe Clear Air Turbulence (CAT) whilst level at FL300 which resulted in a serious injury to one of the cabin crew as they cleared up after in-flight service. The Investigation concluded that the turbulence had occurred because of the proximity of the aircraft to a strong jet stream and that the forecast available at pre-flight briefing had underestimated the strength of the associated vertical wind shear.
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.
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.
On 7 January 2017, the crew of a Bombardier Challenger en route at FL340 over international waters between India and the Arabian Peninsula temporarily lost control of their aircraft approximately one minute after an Airbus A380 had passed 1,000 feet above them tracking in the opposite direction. The Investigation is ongoing but has noted that both aircraft were in compliance with their air traffic clearances, that a major height loss occurred during loss of control with some occupants sustaining serious injuries and that after successfully diverting, the structure of the aircraft was found to have been damaged beyond economic repair.
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.
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.
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.
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.
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.
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 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 3 December 1990 a Douglas DC9-10 flight crew taxiing for departure at Detroit in thick fog got lost and ended up stopped to one side of an active runway where, shortly after reporting their position, their aircraft was hit by a departing Boeing 727-200 and destroyed by the impact and subsequent fire. The Investigation concluded that the DC9 crew had failed to communicate positional uncertainty quickly enough but that their difficulties had been compounded by deficiencies in both the standard of air traffic service and airport surface markings, signage and lighting undetected by safety regulator oversight.
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.
An announcement by the Captain of a fully-boarded Boeing 757-200 about to depart which was intended to initiate a Precautionary Rapid Disembarkation due to smoke from a hydraulic leak was confusing and a partial emergency evacuation followed. The Investigation found that Cabin Crew only knew of this via the announcement and noted subsequent replacement of the applicable procedures by an improved version, although this was still considered to lack resilience in one respect. The event was considered to have illustrated the importance of having cabin crew close to doors when passengers are on board aircraft on the ground.
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.
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 1 August 2008, an en-route Embraer 195 despatched with one air conditioning pack inoperative lost all air conditioning and pressurisation when the other pack’s Air Cycle Machine (ACM) failed, releasing smoke and fumes into the aircraft. A MAYDAY diversion was made to the Isle of Man without further event. The Investigation found that the ACM failed due to rotor seizure caused by turbine blade root fatigue, the same failure which had led the other air conditioning system to fail failure four days earlier. It was understood that a modified ACM turbine housing was being developed to address the problem.
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 28 November 2004, a KLM B737-400 departed laterally from the runway on landing at Barcelona due to the effects on the nosewheel steering of a bird strike which had occured as the aircraft took off from Amsterdam.
Pax oxygen mask drop
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.
On 5 March 2018, the crew of an Airbus A320 in descent towards Karachi observed a slow but continuous drop in cabin pressure which eventually triggered an excessive cabin altitude warning which led them to don oxygen masks, commence an emergency descent and declare a PAN to ATC until the situation had been normalised. The Investigation found that the cause was the processing of internally corrupted data in the active cabin pressure controller which had used a landing field elevation of over 10,000 feet. It noted that Airbus is developing a modified controller that will prevent erroneous data calculations occurring.
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.
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.
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.
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.
On 14 August 2005, a Boeing 737-300 was released to service with the cabin pressurisation set to manual. This abnormal setting was not detected by the flight crew involved during standard checks. They took no corrective action after take-off when a cabin high altitude warning occurred. The crew lost consciousness as the aircraft climbed on autopilot and after eventual fuel exhaustion, the aircraft departed controlled flight and impacted terrain. The Investigation found that inadequate crew performance had occurred within a context of systemic organisational safety deficiencies at the Operator compounded by inadequate regulatory oversight.
On 17 November 2007 a Boeing 737-700 made an emergency descent after the air conditioning and pressurisation system failed in the climb out of Coolangatta at FL318 due to loss of all bleed air. A diversion to Brisbane followed. The Investigation found that the first bleed supply had failed at low speed on take off but that continued take off had been continued contrary to SOP. It was also found that the actions taken by the crew in response to the fault after completing the take off had also been also contrary to those prescribed.
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.
On 24 June 1982, a Boeing 747-200 had just passed Jakarta at FL370 in night VMC when it unknowingly entered an ash cloud from a recently begun new eruption of nearby Mount Galunggung which the crew were unaware of. All engines failed in quick succession and a MAYDAY was declared. Involuntary descent began and a provisional diversion back to Jakarta, which would necessitate successful engine restarts to clear mountainous terrain en-route was commenced. Once clear of cloud with three successful engines restarts and level at FL120, the diversion plan was confirmed and completed with a visual approach from the overhead.
On 7 September 2008 a South African Airways Airbus A319 en route from Cape Town to Johannesburg at FL370 received an ECAM warning of the failure of the No 1 engine bleed system. The crew then closed the No. 1 engine bleed with the applicable press button on the overhead panel. The cabin altitude started to increase dramatically and the cockpit crew advised ATC of the pressurisation problem and requested an emergency descent to a lower level. During the emergency descent to 11000 ft amsl, the cabin altitude warning sounded at 33000ft and the flight crew activated the cabin oxygen masks. The APU was started and pressurisation was re-established at 15000ft amsl. The crew completed the flight to the planned destination without any further event. The crew and passengers sustained no injuries and no damage was caused to the aircraft.
On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.
Unauthorised PED use
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.
Cabin air contamination
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 6 March 2018, smoke was detected coming from flight deck and passenger cabin air conditioning vents of an en-route Bombardier DHC8-400. A MAYDAY was declared to ATC but the prescribed response effectively cleared the smoke and no emergency evacuation on landing was deemed necessary. The Investigation found that the smoke was caused by oil leaking into the air conditioning system due to a failed right hand engine seal. The operator subsequently began to implement a recommended engine modification and adopt a system provided by the engine manufacturer to proactively detect such oil leaks before air conditioning systems are contaminated.
On 28 February 2019, an Embraer E195 abandoned takeoff from Exeter when fight deck fumes/smoke accompanied thrust applied against the brakes. When informed of similar conditions in the cabin, the Captain ordered an emergency evacuation. Some passengers using the overwing exits re-entered the cabin after becoming confused as to how to leave the wing. The Investigation attributed the fumes to an incorrectly-performed engine compressor wash arising in a context of poorly-managed maintenance and concluded that guidance on overwing exit use had been inadequate and that the 1.8 metre certification height limit for exits without evacuation slides should be reduced.
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.
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.
On 28 July 2018, a right engine compressor stall on an ATR72-500 bound for Port Vila followed by smoke in the passenger cabin led to a MAYDAY declaration and shutdown of the malfunctioning engine. The subsequent single engine landing at destination ended in a veer-off and collision with two unoccupied parked aircraft. The Investigation noted the disorganised manner in which abnormal/emergency and normal checklists had been actioned and found that the Before Landing Checklist had not been run which resulted in the rudder limiter being left in high speed mode making single engine directional control on the ground effectively impossible.
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 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 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the aircraft returned with both pilots making precautionary use of their oxygen masks. The Investigation found that routine engine pressure washes carried out prior to departure have been incorrectly performed and a contaminant was introduced into the bleed air supply to the air conditioning system as a result. The context for the error was found to be the absence of any engine wash procedure training for the Operator's engineers.
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.
On 9 June 2014, a 'burning odour' of undetermined origin became evident in the rear galley of an Airbus A330 as soon as the aircraft powered up for take off. Initially, it was dismissed as not uncommon and likely to soon dissipate, but it continued and affected cabin crew were unable to continue their normal duties and received oxygen to assist recovery. En route diversion was considered but flight completion chosen. It was found that the rear pressure bulkhead insulation had not been correctly refitted following maintenance and had collapsed into and came into contact with APU bleed air duct.
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.
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.
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
Hand held extinguisher used
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.
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.
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.
Evacuation on Cabin Crew initiative
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.
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 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 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 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 15 December 2015, a Boeing 737-300 crew inadvertently taxied their aircraft off the side of the taxiway into a ditch whilst en route to the gate after landing at Nashville in normal night visibility. Substantial damage was caused to the aircraft after collapse of the nose landing gear and some passengers sustained minor injuries during a subsequent cabin crew-initiated evacuation. The Investigation found that taxiing had continued when it became difficult to see the taxiway ahead in the presence of apron lighting glare after all centreline and edge lighting in that area had been inadvertently switched off by ATC.
On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.
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.
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.
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.
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.
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.
Flight Crew Evacuation Command
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.
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.
On 25 March 2008, an Air Atlanta Icelandic Boeing 747-300 was decelerating after landing at Dhaka when a fuel leak in the vicinity of the No 3 engine led to a fire which could not be extinguished. An emergency evacuation was accomplished with only a few minor injuries. The cause of the fuel leak was traced to mis-assembly of a fuel feed line coupling during a C Check some six months previously. The failure to follow clear AMM instructions for this task in two specific respects was of concern to the Investigating Agency.
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.
On 3 December 1990 a Douglas DC9-10 flight crew taxiing for departure at Detroit in thick fog got lost and ended up stopped to one side of an active runway where, shortly after reporting their position, their aircraft was hit by a departing Boeing 727-200 and destroyed by the impact and subsequent fire. The Investigation concluded that the DC9 crew had failed to communicate positional uncertainty quickly enough but that their difficulties had been compounded by deficiencies in both the standard of air traffic service and airport surface markings, signage and lighting undetected by safety regulator oversight.
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.
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.
On 9 September 2007 the crew of an SAS Bombardier DHC8-400 approaching Aalborg were unable to lock the right MLG down and prepared accordingly. During the subsequent landing, the unlocked gear leg collapsed and the right engine propeller blades struck the runway. Two detached completely and penetrated the passenger cabin injuring one passenger. The Investigation found that the gear malfunction had been caused by severe corrosion of a critical connection and noted that no scheduled maintenance task included appropriate inspection. A Safety Recommendation to the EASA to review the design, certification and maintenance of the assembly involved 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 1 August 2008, an en-route Embraer 195 despatched with one air conditioning pack inoperative lost all air conditioning and pressurisation when the other pack’s Air Cycle Machine (ACM) failed, releasing smoke and fumes into the aircraft. A MAYDAY diversion was made to the Isle of Man without further event. The Investigation found that the ACM failed due to rotor seizure caused by turbine blade root fatigue, the same failure which had led the other air conditioning system to fail failure four days earlier. It was understood that a modified ACM turbine housing was being developed to address the problem.
Cabin Crew Incapacitation
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.
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.
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.
On 25 July 2008, a Boeing 747 suffered a rapid depressurisation of the cabin following the sudden failure of an oxygen cylinder, which had ruptured the aircraft's pressure hull. The incident occurred 475 km north-west of Manila, Philippines.
Cabin Crew Medical Fitness
Passenger Illness
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.
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.
Cabin/Flight deck comms difficulty
Pax Turbulence Injury - Seat Belt Signs on
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.
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.
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.
Pax Turbulence Injury - Seat Belt Signs off
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.
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.
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.
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.
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