Accident and Serious Incident Reports: GND
Accident and Serious Incident Reports: GND
Definition
Reports relating to accidents associated with Ground Operations.
The accident reports are grouped together below in subcategories.
Dangerous Goods
On 27 October 2019, an under-floor hold fire warning was annunciated in the flight deck of a Boeing 737-900 which had been pushed back at Paris CDG and was about to begin taxiing. Since there were no signs of fire in the passenger cabin or during an emergency services external inspection, a non-emergency disembarkation of all occupants was made. The hold concerned was then opened and fire damage sourced to the overheated lithium battery in a passenger wheelchair was discovered. The Investigation identified a number of weaknesses in both the applicable loading procedures and compliance with the ones in place.
On 28 July 2011, 50 minutes after take off from Incheon, the crew of an Asiana Boeing 747-400F declared an emergency advising a main deck fire and an intention to divert to Jeju. The effects of the rapidly escalating fire eventually made it impossible to retain control and the aircraft crashed into the sea. The Investigation concluded that the origin of the fire was two adjacent pallets towards the rear of the main deck which contained Dangerous Goods shipments including Lithium ion batteries and flammable substances and that the aircraft had broken apart in mid-air following the loss of control.
On 30 March 2017, a significant amount of fuel was found to be escaping from a Boeing 747-8F as soon as it arrived on stand after landing at Prestwick and the fire service attended to contain the spill and manage the associated risk of fire and explosion. The Investigation found that the fuel had come from a Bell 412 helicopter that was part of the main deck cargo and that this had been certified as drained of fuel when it was not. The shipper s procedures, in particular in respect of their agents in the matter, were found to be deficient.
On 7 October 2013 a fire was discovered in the rear hold of an Airbus A330 shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.
On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.
De-Icing/Anti-Icing of Aircraft on the Ground
Failure to de/anti ice when facilities available
- CL60, Birmingham UK, 2002 (On 4 January 2002, the crew of US-operated Bombardier Challenger lost control of their aircraft shortly after taking off from Birmingham and after one wing touched the ground, it rolled inverted, crashed and caught fire within the airport perimeter and all five occupants died. The Investigation found that the cause of the accident was failure to remove frost from the wings which reduced the wing stall angle of attack below that at which the stall protection system was effective. It was considered that the combined effects of non-prescription drug, jet lag and fatigue may have impaired crew performance)
- AT72, vicinity Manchester UK, 2016 (On 4 March 2015, the flight crew of an ATR72 decided to depart from Manchester without prior ground de/anti icing treatment judging it unnecessary despite the presence of frozen deposits on the airframe and from rotation onwards found that manual forward control column input beyond trim capability was necessary to maintain controlled flight. The aircraft was subsequently diverted. The Investigation found that the problem had been attributable to ice contamination on the upper surface of the horizontal tailplane. It was considered that the awareness of both pilots of the risk of airframe icing had been inadequate)
- C208, Helsinki Finland, 2005 (On 31 January 2005, the pilot of a Cessna 208 which had just taken off from Helsinki lost control of their aircraft as the flaps were retracted and the aircraft stalled, rolled to the right and crashed within the airport perimeter. The Investigation found that the take off had been made without prior airframe de/anti icing and that accumulated ice and snow on the upper wing surfaces had led to airflow separation and the stall, a condition which the pilot had failed to recognise or respond appropriately to for undetermined reasons)
- CL60, Montrose USA, 2004 (On 28 November 2004, the crew of a Bombardier Challenger 601 lost control of their aircraft soon after getting airborne from Montrose and it crashed and caught fire killing three occupants and seriously injuring the other three. The Investigation found that the loss of control had been the result of a stall caused by frozen deposits on the upper wing surfaces after the crew had failed to ensure that the wings were clean or utilise the available ground de/anti ice service. It was concluded that the pilots' lack of experience of winter weather operations had contributed to their actions/inactions)
- AT72, vicinity Tyumen Russian Federation, 2012 (On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up)
- JS41, en-route, North West of Aberdeen UK, 2008 (On 9 April 2008, a BAe Jetstream 41 departed Aberdeen in snow and freezing conditions after the Captain had elected not to have the airframe de/anti iced having noted had noted the delay this would incur. During the climb in IMC, pitch control became problematic and an emergency was declared. Full control was subsequently regained in warmer air. The Investigation concluded that it was highly likely that prior to take off, slush and/or ice had been present on the horizontal tail surfaces and that, as the aircraft entered colder air at altitude, this contamination had restricted the mechanical pitch control)
Ground de/anti icing not available
- PRM1, vicinity Annemasse France, 2013 (On 4 March 2013, a Beechcraft Premier 1A stalled and crashed soon after take off from Annemasse. The Investigation concluded that the loss of control was attributable to taking off with frozen deposits on the wings which the professional pilot flying the privately-operated aircraft had either not been aware of or had considered insignificant. It was found that the aircraft had been parked outside overnight and that overnight conditions, particularly the presence of a substantial quantity of cold-soaked fuel, had been conducive to the formation of frost and that no airframe de/anti icing facilities had been available at Annemasse)
- C208, vicinity Pelee Island Canada, 2004 (On 17 January, 2004 a Cessna 208 Caravan operated by Georgian Express, took off from Pellee Island, Ontario, Canada, at a weight significantly greater than maximum permitted and with ice visible on the airframe. Shortly after take off, the pilot lost control of the aircraft and it crashed into a frozen lake)
Inadequate de/anti icing
- MD81, vicinity Stockholm Arlanda Sweden, 1991 (On 27 December 1991, an MD-81 took off after airframe ground de/anti icing treatment but soon afterwards both engines began surging and both then failed. A successful crash landing was achieved after the aircraft emerged from cloud approximately 900 feet above terrain and only eight of the 129 occupants were seriously injured. The Investigation found that undetected clear ice on the upper wing surfaces had been ingested into both engines and caused damage which initiated the surging. Without training in the identification and elimination of engine surging, the pilots had not taken corrective action and so both engines had failed)
Control hazards resulting from ground de/anti ice procedures
- ATP, Helsinki Finland, 2010 (On 11 January 2010, a British Aerospace ATP crew attempting to take off from Helsinki after a two-step airframe de/anti icing treatment (Type 2 and Type 4 fluids) were unable to rotate and the take off was successfully rejected from above V1. The Investigation found that thickened de/anti ice fluid residues had frozen in the gap between the leading edge of the elevator and the horizontal stabiliser and that there had been many other similarly-caused occurrences to aircraft without powered flying controls. There was concern that use of such thickened de/anti ice fluids was not directly covered by safety regulation)
- B463, en-route, South of Frankfurt Germany, 2005 (On 12 March 2005, the crew of a BAe 146-300 climbing out of Frankfurt lost elevator control authority and an un-commanded descent at up to 4500 fpm in a nose high pitch attitude occurred before descent was arrested and control regained. After landing using elevator trim to control pitch, significant amounts of de/anti-icing fluid residues were found frozen in the elevator/stabilizer and aileron/rudder gaps. The Investigation confirmed that an accumulation of hygroscopic polymer residues from successive applications of thickened de/anti ice fluid had expanded by re-hydration and then expanded further by freezing thus obstructing the flight controls)
- D328, Isle of Man, 2005 (On 28 November 2005, a Dornier 328 being operated by EuroManx on a scheduled passenger service departing from Isle of Man for an unspecified destination was unable to rotate at the speed calculated as applicable and the take off was successfully rejected. The Investigation found that the crew were unaware of the AFM 'Normal Procedures' requirement to use take off speeds after application of thickened de ice fluids which are typically around 20 knots higher than normal speeds)
- DH8A, Ottawa Canada, 2003 (On 04 November 2003, the crew of a de Havilland DHC-8-100 which had been de/anti iced detected a pitch control restriction as rotation was attempted during take off from Ottawa and successfully rejected the take off from above V1. The Investigation concluded that the restriction was likely to have been the result of a remnant of clear ice migrating into the gap between one of the elevators and its shroud when the elevator was moved trailing edge up during control checks and observed that detection of such clear ice remnants on a critical surface wet with de-icing fluid was difficult)
Unintended side effects due inadequate/incorrect ground de/anti icing procedures/techniques
- A320, en-route, Kalmar County Sweden, 2009 (On 2 March 2009, communication difficulties and inadequate operator procedures led to an Airbus A320-200 being de-iced inappropriately prior to departure from Vasteras and fumes entered the air conditioning system via the APU. Although steps were then taken before departure in an attempt to clear the contamination, it returned once airborne. The flight crew decided to don their oxygen masks and complete the flight to Poznan. Similar fumes in the passenger cabin led to only temporary effects which were alleviated by the use of therapeutic oxygen. The Investigation concluded that no health risks arose from exposure to the fumes involved)
Aircraft Push Back
On 28 March 2018, a Boeing 767-300 and a Boeing 737-700 were being simultaneously pushed back in darkness from adjacent parking positions as cleared when their respective tailplanes collided causing substantial damage. The comprehensive Investigation found that the 737 clearance conflicted with both a previously-issued clearance to the 767 aircraft and with the actual location of the 737. It also found that the controller’s error had been compounded by the wing walkers tasked with external monitoring of both pushbacks being in the drivers’ cabs because it was raining and a context of systemic ramp operations inadequacy was identified as contributory.
On 13 February 2019, a Boeing 787 departing Amsterdam was given a non-standard long pushback by ATC in order to facilitate the use of its stand by an incoming flight and when a Boeing 747 was subsequently given a normal pushback by a single tug driver working alone who was unaware of the abnormal position of the 787 and could not see it before or during his pushback, a collision followed. The Investigation concluded that the relevant airport safety management systems were systemically deficient and noted that this had only been partially rectified in the three years since the accident.
On 16 June 2021, a Boeing 737-400 was taxiing for departure at night after push back from stand when the ground crew who completed the push back arrived back at their base in the tug and realised that the tow bar they had used was not attached to it. The aircraft was prevented from taking off and it was then found that it had taxied over the unseen towbar and sustained damage to both nose gear tyres such that replacement was necessary. The Investigation concluded neither ground crew had checked that the area immediately ahead of the aircraft was clear.
On 23 March 2019, the crew of a fully-loaded Airbus A320 about to depart Bristol detected an abnormal noise from the nose landing gear as a towbarless tug was being attached. Inspection found that the aircraft nose gear had been impact-damaged rendering the aircraft no longer airworthy and the passengers were disembarked. The Investigation noted that tug driver training had been in progress and that the tug had not been correctly aligned with the nose wheels, possibly due to a momentary lapse in concentration causing the tug being aligned with the nose leg rather than the nose wheels.
On 30 March 2017, a Boeing 787 taxiing for departure at night at Singapore was involved in a minor collision with a stationary Airbus A380 which had just been pushed back from its gate and was also due to depart. The Investigation found that the conflict occurred because of poor GND controlling by a supervised trainee and had occurred because the 787 crew had exercised insufficient prudence when faced with a potential conflict with the A380. Safety Recommendations made were predominantly related to ATC procedures where it was considered that there was room for improvement in risk management.
Jet Blast/Prop Wash
On 4 September 2022, a Boeing 777F restarting its taxi out at Frankfurt after being obliged to stop part way round a turn to await a further clearance when changing from Apron Control to Tower used asymmetric thrust to break away when so cleared. This resulted in sufficient jet efflux to cause a number of unsecured freight containers to move and led to a minor injury to a ramp worker who fell trying to avoid being hit by one. Both the aircraft operator and the airport operator decided to strengthen their published thrust use procedures when taxiing on the Apron.
Significant damage was caused to the tailplane and elevator of a Boeing 737-400 after the pavement beneath them broke up when take off thrust was applied for a standing start from the full length of the runway at Aberdeen. Although in this case neither outcome applied, the Investigation noted that control difficulties consequent upon such damage could lead to an overrun following a high speed rejected takeoff or to compromised flight path control airborne. Safety Recommendations on appropriate regulatory guidance for marking and construction of blast pads and on aircraft performance, rolling take offs and lead-on line marking were made.
Taxiway Collision
On 28 March 2018, a Boeing 767-300 and a Boeing 737-700 were being simultaneously pushed back in darkness from adjacent parking positions as cleared when their respective tailplanes collided causing substantial damage. The comprehensive Investigation found that the 737 clearance conflicted with both a previously-issued clearance to the 767 aircraft and with the actual location of the 737. It also found that the controller’s error had been compounded by the wing walkers tasked with external monitoring of both pushbacks being in the drivers’ cabs because it was raining and a context of systemic ramp operations inadequacy was identified as contributory.
On 13 February 2019, a Boeing 787 departing Amsterdam was given a non-standard long pushback by ATC in order to facilitate the use of its stand by an incoming flight and when a Boeing 747 was subsequently given a normal pushback by a single tug driver working alone who was unaware of the abnormal position of the 787 and could not see it before or during his pushback, a collision followed. The Investigation concluded that the relevant airport safety management systems were systemically deficient and noted that this had only been partially rectified in the three years since the accident.
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 13 April 2012 a Boeing 737-800 being taxied off its parking stand for a night departure by the aircraft commander failed to follow the clearly and correctly marked taxi centrelines on the well-lit apron and instead took a short cut towards the taxiway centreline which resulted in the left winglet striking the left horizontal stabiliser and elevator of another Ryanair aircraft correctly parked on the adjacent stand causing damage which rendered both aircraft unfit for flight. The pilot involved was familiar with the airport and had gained almost all his flying experience on the accident aircraft type.
On 14 April 2011, a Ryanair Boeing 737-800 failed to leave sufficient clearance when taxiing behind a stationary Boeing 767-300 at Barcelona and the 737 wingtip was in collision with the horizontal stabiliser of the 767, damaging both. The 767 crew were completely unaware of any impact but the 737 crew realised the close proximity but dismissed a cabin crew report that a passenger had observed a collision. Both aircraft completed their intended flights without incident after which the damage was discovered, that to the 767 requiring that the aircraft be repaired before further flight.
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For all accident reports held on SKYbrary, see the Accidents and Incidents.
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