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.
Airbridge Positioning
On 12 December 2015, whilst a Boeing 737-800 was beginning disembarkation of passengers via an air bridge which had just been attached on arrival at Barcelona, the bridge malfunctioned, raising the aircraft nose gear approximately 2 metres off the ground. The door attached to the bridge then failed and the aircraft dropped abruptly. Prompt cabin crew intervention prevented all but two minor injuries. The Investigation found that the occurrence had been made possible by the failure to recognise new functional risks created by a programme of partial renovation being carried out on the air bridges at the Terminal involved.
On 14 June 1996, a Boeing 747SP being operated by Air China on a scheduled passenger flight from Beijing to Stockholm was arriving on the designated parking gate at destination in normal daylight visibility when it collided with the airbridge. None of the 130 occupants of the aircraft suffered any injury but the aircraft was substantially damaged and the airbridge was damaged .
On 11 December 2006, a Boeing 747SP being operated by Syrian Air on a scheduled passenger flight from Damascus to Stockholm was arriving on the designated parking gate at destination in normal visibility at night when it collided with the airbridge. None of the 116 occupants of the aircraft suffered any injury but the aircraft was substantially damaged and the airbridge was damaged .
Aircraft Loading
Passenger Aircraft Hold Loading
On 30 May 2019, a DHC8-200 departing from Nuuk could not be rotated at the calculated speed even using full aft back pressure and the takeoff was rejected with the aircraft coming to a stop with 50 metres of the 950 metre long dry runway remaining. The initial Investigation focus was on a potential airworthiness cause associated with the flight control system but it was eventually found that the actual weights of both passengers and cabin baggage exceeded standard weight assumptions with the excess also resulting in the aircraft centre of gravity being outside the range certified for safe flight.
On 23 July 2015, an ATR72-600 crew suspected their aircraft was unduly tail heavy in flight. After the flight they found that all passenger baggage had been loaded in the aft hold whereas the loadsheet indicated that it was all in the forward hold. The Investigation found that the person responsible for hold loading as specified had failed do so and that this failure had not been detected by the supervising Dispatcher who had certified the loadsheet presented to the aircraft Captain. Similar loading errors, albeit all corrected prior to flight, were found by the Operator to be not uncommon.
On 26 May 2013, about 20 minutes after arrival at Singapore for a turn round expected to last about an hour and with crew members on board, a Boeing 737-900 was suddenly rotated approximately 30 degrees about its main gear by a relatively modest wind gust and damaged by consequent impacts. The Investigation concluded that the movement had been due to the failure to follow manufacturer's guidance on both adequate chocking of the aircraft wheels and the order of hold loading. It was found that the Operator had not ensured that its ground handling agent at Singapore was properly instructed.
On 30 July 1997, an Airbus A300-600 being operated by Emirates Airline was departing on a scheduled passenger flight from Paris Charles de Gaulle in daylight when, as the aircraft was accelerating at 40 kts during the take off roll, it pitched up and its tail touched the ground violently. The crew abandoned the takeoff and returned to the parking area. The tail of the aircraft was damaged due to the impact with the runway when the plane pitched up.
Passenger Loading
On 21 July 2020, a Boeing 737-800 flight crew identified significant discrepancies when comparing their Operational Flight Plan weights and passengers by category with those on the Loadsheet presented. After examining them and concluding that the differences were plausible based on past experience, the loadsheet figures were used for takeoff performance purposes with no adverse consequences detected. It was found that a system-wide IT upgrade issue had led to the generation of incorrect loadsheets and that ineffective communication and an initially ineffective response within the operator had delayed effective risk resolution although without any known flight safety-related consequences.
On 3 January 2020, an Airbus A321neo crew found that the boarded passengers were seated such that the flight could not operate within the allowable flight envelope. Necessary reseating followed with a safety report filed. An internal investigation with State Investigation Agency awareness found that a systemic company IT issue was enabling invalid outputs. When the same aircraft’s inbound flight from Bristol was checked, a similar but undetected error was found to have resulted in that flight having operated outside the allowable flight envelope. Pending a permanent fix for the computerised load control system, manual checking procedures were immediately implemented.
On 30 May 2019, a DHC8-200 departing from Nuuk could not be rotated at the calculated speed even using full aft back pressure and the takeoff was rejected with the aircraft coming to a stop with 50 metres of the 950 metre long dry runway remaining. The initial Investigation focus was on a potential airworthiness cause associated with the flight control system but it was eventually found that the actual weights of both passengers and cabin baggage exceeded standard weight assumptions with the excess also resulting in the aircraft centre of gravity being outside the range certified for safe flight.
On 13 March 2013, smoke and fumes were immediately evident when the cable of an external GPU was connected to an ERJ170 aircraft on arrival after flight with passengers still on board. A precautionary rapid disembarkation was conducted. The Investigation found that a short circuit had caused extensive heat damage to the internal part of the aircraft GPU receptacle and minor damage to the surrounding structure and that the short circuit had occurred due to metallic FOD lodged within the external connecting box of aircraft GPU receptacle.
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.
Cargo Aircraft Loading
On 1 December 2023, a Boeing 737-400 crew about to depart East Midlands on a night cargo flight set up the departure based on an incorrect loadsheet. As a result, the actual takeoff weight was 10 tonnes heavier than anticipated. Although no handling abnormality was detected, a ‘bump’ was heard during rotation and suspected to be either load shift or a tail strike. After an inspection eliminated load shift, it was decided to assume a tail strike and complete the 45-minute flight at a lower altitude. This occurred without further event and a tail strike was subsequently confirmed.
On 2 July 2021, during pre-departure loading of a Boeing 777-300 at Heathrow prior to passenger boarding with only the operating crew on board, a rear hold fire warning was annunciated and smoke and fumes subsequently entered the passenger cabin. The Investigation found that the source was a refrigerated container which had been subject to abnormal external impact prior to or during loading causing a short circuit in its battery pack. The refrigeration system involved was found by design to inhibit fire following a short circuit but it was noted that QRH response procedures did not apply to the circumstances.
On 17 December 2017, it was discovered after completion of an Airbus A330-300 passenger flight from Sydney to Bejing that freight loading had not been correctly documented on the load and trim sheet presented to and accepted by the Captain and as a result, the aircraft had exceeded its certified MTOW on departure. The Investigation found that the overload finding had not been promptly reported or its safety significance appreciated, that the error had its origin in related verbal communications during loading and noted that the aircraft operator had since made a series of improvements to its freight loading procedures.
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 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.
Fuel Loading
On 14/15 April 2022, refuelling of an Airbus A330-300 in Accra was delayed by multiple automated interruptions but resolved by changing from tanker to hydrant. Departure to Johannesburg was delayed to the following day. During the cruise at FL410, a right wing fuel pump low pressure annunciation prompted descent to FL190 to activate gravity fuel feed. An ‘ENGINE 2 STALL’ annunciation then appeared and could only be removed by manually controlling thrust at below-normal level. The fuel pump low pressure annunciation remained after landing. Initially suspected fuel contamination with water in both cases was eliminated during the investigation.
On 25 October 2021, a Boeing 737-800 had just reached its cruise altitude after takeoff from Perth, Australia, when a fuel imbalance message was displayed. Despite specified indications for a fuel leak as the cause of this message not being met, it was determined that the left engine should be shut down. A ‘PAN’ was declared and a diversion to Kalgoorlie completed. Inspection there found the fuel imbalance was within normal limits and that crew diagnosis of a fuel leak had been flawed. Non-standard closure of the crossfeed valve was suspected as the origin of the imbalance.
On 7 June 2016, a GE90-115B engined Boeing 777-300 made a high speed rejected takeoff on 3200 metre-long runway 14 at Dhaka after right engine failure was annunciated at 149KCAS - just below V1. Neither crew nor ATC requested a runway inspection and 12 further aircraft movements occurred before it was closed for inspection and recovery of 14 kg of debris. The Investigation found that engine failure had followed Super Absorbent Polymer (SAP) contamination of some of the fuel nozzle valves which caused them to malfunction leading to Low Pressure Turbine (LPT) mechanical damage. The contaminant origin was not identified.
On 9 May 2019, a Cessna 550 level at FL 350 experienced an unexplained left engine rundown to idle and the crew began descent and a diversion to Savannah. When the right engine also began to run down passing 8000 feet, an emergency was declared and the already-planned straight-in approach was successfully accomplished without any engine thrust. The ongoing Investigation has already established that the likely cause was fuel contamination resulting from the inadvertent mixing of a required fuel additive with an unapproved substance known to form deposits which impede fuel flow when they accumulate on critical fuel system components.
On 16 April 2014, a pre-flight concern about whether a Boeing 777-200ER about to depart Singapore had been overfuelled was resolved by a manual check but an en-route fuel system alert led to close monitoring of the fuel system. When a divergent discrepancy between the two independent fuel remaining sources became apparent, an uneventful precautionary air turnback was made and overfuelling subsequently confirmed. The Investigation found that a system fault had caused overfuelling and that the manual check carried out to confirm the actual fuel load had failed to detect it because it had been not been performed correctly.
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. Their respective tailplanes collided, causing substantial damage. The investigation found that the 737 clearance conflicted with both a previously issued clearance to the 767 and with the actual location of the 737. It also found that the controller’s error had been compounded because the wing walkers tasked with monitoring both pushbacks were in the drivers’ cabs because it was raining. 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.
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
Ground de/anti icing ineffective
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.
On 13 January 1982, an Air Florida Boeing 737-200 took off in daylight from runway 36 at Washington National in moderate snow but then stalled before hitting a bridge and vehicles and continuing into the river below after just one minute of flight killing most of the occupants and some people on the ground. The accident was attributed entirely to a combination of the actions and inactions of the crew in relation to the prevailing adverse weather conditions and, crucially, to the failure to select engine anti ice on which led to over reading of actual engine thrust.
On 7 November 2016, severe airframe vibrations occurred to an Avro RJ-100 which, following ground de icing, was accelerating in the climb a few minutes after departing from Gothenburg. The crew were able to stop the vibrations by reducing speed but they declared an emergency and returned to land where significant quantities of ice were found and considered to have been the cause of the vibrations. The Investigation concluded that the failure of the de icing operation in this case had multiple origins which were unlikely to be location specific and generic safety recommendations were therefore made.
On 26 December 2007, the crew of a Bombardier Challenger 604 which had received a 2-stage ground de/anti icing treatment lost roll control as the aircraft got airborne from a snow-covered runway at Almaty in freezing mist and light snow conditions and it crashed within the airport perimeter before continuing through the perimeter fence and catching fire. The Investigation concluded that the loss of control was probably caused by contamination of the wing leading edge with frozen deposits during the take off roll as a result of the crew's decision not to select wing anti-ice on contrary to applicable procedures.
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.
Ground de/anti icing not available
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.
On 13 January 2016 ice was found on the upper and lower wing surfaces of a Boeing 777-300ER about to depart in the late morning from Lisbon in CAVOK conditions and 10°C. As Lisbon had no de-ice facilities, it was towed to a location where the sun would melt the ice more quickly but during poorly-planned manoeuvring, one of the wingtips was damaged by contact with an obstruction. The Investigation attributed the ice which led to the problematic re-positioning to the operator’s policy of tankering most of the return fuel on the overnight inbound flight where it had become cold-soaked.
Failure to De/anti Ice
On 4 March 2016, the flight crew of an ATR72-500 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.
On 11 January 2017, control of a Cessna Citation 560 departing Oslo on a short positioning flight was lost control during flap retraction when a violent nose-down manoeuvre occurred. The First Officer took control when the Captain did not react and recovered with a 6 g pullout which left only 170 feet of ground clearance. A MAYDAY - subsequently cancelled when control was regained - was declared and the intended flight was then completed without further event. The Investigation concluded that tailplane stall after the aircraft was not de-iced prior to departure was the probable cause of the upset.
On 4 March 2019, a Boeing 767-300 crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.
On 13 December 2017, control of an ATR 42-300 was lost just after it became airborne at night from Fond-du-Lac and it was destroyed by the subsequent terrain impact. Ten occupants sustained serious injuries from which one later died and all others sustained minor injuries. The Investigation found that the accident was primarily attributable to pre-takeoff ice contamination of the airframe with an inappropriate pilot response then preventing an achievable recovery. It was found that significant airframe ice accretion had gone undetected during an inadequate pre-flight inspection and that there was a more widespread failure to recognise airframe icing risk.
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.
Flt Deck/Ramp crew comms
On 27 October 2017, an Airbus A320 returned to Auckland after advice from ATC that the right engine may have been affected by ingestion of FOD during engine start - a clipboard and paper left just inside the right hand engine by an employee of the airline’s ground handling contractor acting as the aircraft loading supervisor. The subsequent inspection found paper throughout the engine and minor damage to an engine fan blade and the fan case attrition liner. The Dispatcher overseeing the departure said she had seen the clipboard inside the engine but assumed it would be retrieved before departure.
Ground Collision
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. Their respective tailplanes collided, causing substantial damage. The investigation found that the 737 clearance conflicted with both a previously issued clearance to the 767 and with the actual location of the 737. It also found that the controller’s error had been compounded because the wing walkers tasked with monitoring both pushbacks were in the drivers’ cabs because it was raining. 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.
On Gate Collision
On 28 September 2022, a Boeing 777-300 taxiing for departure at London Heathrow collided with an arriving Boeing 757, which had turned onto its assigned gate prior to the stand entry guidance system being available without informing ATC. The 757 was taxiing as cleared, following the illuminated taxiway centreline lighting. The airport AIP entry stated that in the absence of stand entry guidance, aircraft must remain on the taxiway centreline. The Investigation noted that lack of stand entry guidance is a common occurrence at this airport and needs to be addressed by all those involved.
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.
On 8 August 2017, a Boeing 767-300 departing Delhi was pushed back into a stationary and out of service Airbus A320 on the adjacent gate rendering both aircraft unfit for flight. The Investigation found that the A320 had been instructed to park on a stand that was supposed to be blocked, a procedural requirement if the adjacent stand is to be used by a wide body aircraft and although this error had been detected by the stand allocation system, the alert was not noticed, in part due to inappropriate configuration. It was also found that the pushback was commenced without wing walkers.
On 19 December 2013, the left engine of a Boeing 777-200 taxiing onto its assigned parking gate after arrival at Singapore ingested an empty cargo container resulting in damage to the engine which was serious enough to require its subsequent removal and replacement. The Investigation found that the aircraft docking guidance system had been in use despite the presence of the ingested container and other obstructions within the clearly marked 'equipment restraint area' of the gate involved. The corresponding ground handling procedures were found to be deficient as were those for ensuring general ramp awareness of a 'live' gate.
On 30 September 2010, an A330-200 was about to take off from Khartoum at night in accordance with its clearance when signalling from a hand-held flashlight and a radio call from another aircraft led to this not taking place. The other (on-stand) aircraft crew had found that they had been hit by the A330 as it had taxied past en route to the runway. The Investigation found that although there was local awareness that taxiway use and the provision of surface markings at Khartoum did not ensure safe clearance between aircraft, this was not being communicated by NOTAM or ATIS.
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.
Maintenance work in progress
On 20 July 2023, a Boeing 737-800 was given a night landing clearance at Kansai with the controller unaware a runway inspection in the landing direction was in progress. When the vehicle driver heard this clearance, the driver identified the approaching aircraft position and estimated the inspection could be completed without impeding the inbound aircraft. However, on checking, the driver was instructed to exit the runway at once and did so. Minimum aircraft/vehicle separation was 3,480 metres. The immediate cause of the potential conflict was controller error when various ground movement activities were occurring towards the end of an otherwise quiet night shift.
On 30 November 2019, as an Airbus A320 was about to touch down in normal night visibility at Toyko Haneda, a runway maintenance contractor’s car began to cross the same runway without clearance, as the driver believed this was not necessary. Separation reduced to 1,417 metres shortly before the A320 began to clear the 3,000 metre runway. Planning for overnight work on the intersecting runway was found to have been inadequate and multiple related training requirements and procedures were enhanced by both the aviation regulator and the airport operator. The incursion was assessed as ICAO Category "C."
On 18 June 2021, a Boeing 787-8 being operated by British Airways was being loaded for a cargo flight at Heathrow whilst line engineering carried out checks required to permit despatch with a deferred minor defect for later rectification. The check required cycling the landing gear with locking pins inserted so that only the bay doors cycled but when this was done, the nose gear retracted and the front of aircraft dropped to the ground causing significant damage to the airframe and minor injuries to two people. The nose gear downlock pin had inadvertently been inserted into the wrong hole.
On 4 February 2018, a Bombardier CRJ900 which had just arrived at Kigali after a flight from Entebbe was found to have identical damage to all left engine fan blade trailing edges and a small bolt was subsequently found trapped in the intake acoustic lining. The Investigation concluded that the recovered bolt had probably been picked up by the outboard left main gear tyre at slow speed and then ejected into the engine as wheel speed increased during takeoff thus causing the observed damage. FOD mitigation measures at Entebbe, where a major airside construction project was in progress, were faulted.
On 20 January 2015, The APU of a Fokker 100 being routinely de-iced prior to departing Nuremburg oversped as a result of the ignition of ingested de-icing fluid in the APU. This led to its explosive uncontained failure as the result of which ejected debris entered the aft cabin and smoke occurred. No occupants were injured and all were promptly disembarked. The Investigation found that the de-icing contractor involved had not followed manufacturer-issued aircraft-specific de-icing procedures and in the continued absence of any applicable safety regulatory oversight of ground de-icing activity, corresponding Safety Recommendations were made.
No Flight Crew on Board
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.
On 26 December 2016, the wing of an Airbus A340-300 being repositioned by towing at Copenhagen as cleared hit an Avro RJ100 which had stopped short of its stand when taxiing due to the absence of the expected ground crew. The RJ100 had been there for twelve minutes at the time of the collision. The Investigation attributed the collision to differing expectations of the tug driver, the Apron controller and the RJ100 flight crew within an overall context of complacency on the part of the tug driver whilst carrying out what would have been regarded as a routine, non-stressful task.
On 29 March 2014, a Beech 1900D being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as a Boeing 737-700 was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer on control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.
Ramp crew procedures
On 27 May 2022, an Airbus A350-900 was about to push back from its gate at Brisbane to taxi for departure when a refueller nearby informed the engineer responsible for the aircraft turnround that the pitot covers were still fitted. The refueller advised their removal before pushback. This engineer was found to have certified removal of the covers in the aircraft Technical Log and removed the corresponding warning placard from the flight deck without visual or verbal confirmation that they had been removed. Multiple aspects of the handling agent’s related performance and practices were found to be deficient.
On 10 November 2022, a De Havilland Canada DHC8-200 started engines with the left engine propeller restraint strap attached. As the aircraft became airborne from Sydney, the strap was thrown free from the propeller, impacted the fuselage, and the associated securing pins penetrated the fuselage, one injuring a passenger. The aircraft returned. The investigation attributed the occurrence to the first officer not removing the strap during the walk-around inspection, the captain not noticing the strap prior to engine start, and a dispatch coordinator not noticing the strap.
On 18 July 2018, an Airbus A330-300 failed to reject its night takeoff from Brisbane despite the absence of any airspeed indication for either pilot. A PAN call was made as a climb to FL110 continued. Once there, preparations for a somewhat challenging return were made and subsequently achieved. The Investigation noted multiple missed opportunities, including non-compliance with several procedural requirements, to detect that all pitot mast covers had remained in place and was extremely concerned that the takeoff had been continued rather than rejected. Flawed aircraft operator ground handling procedures and ineffective oversight of contractors were also deemed contributory.
On 17 December 2017, it was discovered after completion of an Airbus A330-300 passenger flight from Sydney to Bejing that freight loading had not been correctly documented on the load and trim sheet presented to and accepted by the Captain and as a result, the aircraft had exceeded its certified MTOW on departure. The Investigation found that the overload finding had not been promptly reported or its safety significance appreciated, that the error had its origin in related verbal communications during loading and noted that the aircraft operator had since made a series of improvements to its freight loading procedures.
On 20 January 2015, The APU of a Fokker 100 being routinely de-iced prior to departing Nuremburg oversped as a result of the ignition of ingested de-icing fluid in the APU. This led to its explosive uncontained failure as the result of which ejected debris entered the aft cabin and smoke occurred. No occupants were injured and all were promptly disembarked. The Investigation found that the de-icing contractor involved had not followed manufacturer-issued aircraft-specific de-icing procedures and in the continued absence of any applicable safety regulatory oversight of ground de-icing activity, corresponding Safety Recommendations were made.
Towed aircraft involved
On 27 September 2017, an Airbus A320 being manoeuvred off the departure gate at Dublin by tug was being pulled forward when the tow bar shear pin broke and the tug driver lost control. The tug then collided with the right engine causing significant damage. The tug driver and assisting ground crew were not injured. The Investigation concluded that although the shear pin failure was not attributable to any particular cause, the relative severity of the outcome was probably increased by the wet surface, a forward slope on the ramp and fact that an engine start was in progress.
On 26 December 2016, the wing of an Airbus A340-300 being repositioned by towing at Copenhagen as cleared hit an Avro RJ100 which had stopped short of its stand when taxiing due to the absence of the expected ground crew. The RJ100 had been there for twelve minutes at the time of the collision. The Investigation attributed the collision to differing expectations of the tug driver, the Apron controller and the RJ100 flight crew within an overall context of complacency on the part of the tug driver whilst carrying out what would have been regarded as a routine, non-stressful task.
On 13 January 2016 ice was found on the upper and lower wing surfaces of a Boeing 777-300ER about to depart in the late morning from Lisbon in CAVOK conditions and 10°C. As Lisbon had no de-ice facilities, it was towed to a location where the sun would melt the ice more quickly but during poorly-planned manoeuvring, one of the wingtips was damaged by contact with an obstruction. The Investigation attributed the ice which led to the problematic re-positioning to the operator’s policy of tankering most of the return fuel on the overnight inbound flight where it had become cold-soaked.
On 4 June 2002, the crew of an MD82 in the cruise at FL330 with AP and A/T engaged failed to notice progressive loss of airspeed and concurrent increase in pitch attitude as both engines rolled back to thrust levels which could not sustain level flight. The aircraft stalled and a recovery was accomplished with significant altitude necessary before engine thrust was restored and a diversion made. The Investigation attributed the engine rollback to ice crystal icing obstructing the engine inlet pressure sensors following crew failure to use the engine anti-icing as prescribed. Two Safety Recommendations were made.
On 21 August 2006, a Boeing 737-500 suffered a nose landing gear collapse during towing at the Newark Liberty International Airport. A technical crew was repositioning the aircraft in visual meteorological conditions during the occurrence. No persons were injured and minor aircraft damage occurred.
Wingtip clearance
On 28 September 2022, a Boeing 777-300 taxiing for departure at London Heathrow collided with an arriving Boeing 757, which had turned onto its assigned gate prior to the stand entry guidance system being available without informing ATC. The 757 was taxiing as cleared, following the illuminated taxiway centreline lighting. The airport AIP entry stated that in the absence of stand entry guidance, aircraft must remain on the taxiway centreline. The Investigation noted that lack of stand entry guidance is a common occurrence at this airport and needs to be addressed by all those involved.
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 18 December 2018, a Boeing 787-9 was instructed to taxi to a specified remote de-icing platform for de-icing prior to takeoff from Oslo. The aircraft collided with a lighting mast on the de-icing platform causing significant damage to both aircraft and mast. The Investigation found that in the absence of any published information about restricted aircraft use of particular de-icing platforms and any markings, lights, signage or other technical barriers to indicate to the crew that they had been assigned an incorrect platform, they had visually assessed the clearance as adequate. Relevant Safety Recommendations were made.
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 20 April 2010, the left wing of an Antonov Design Bureau An124-100 which was taxiing in to park after a night landing at Zaragoza under marshalling guidance was in collision with two successive lighting towers on the apron. Both towers and the left wingtip of the aircraft were damaged. The subsequent investigation attributed the collision to allocation of an unsuitable stand and lack of appropriate guidance markings.
Wrong Surface Events
Non-active runway take off/landing
none on SKYbrary
Closed Runway take off/landing
On 28 October 2019, a Boeing 757-200 bound for Keflavik after an overnight flight was advised that a previously landed aircraft had partially overrun the end of the only available 3,054 metre-long runway, which was therefore closed. With the braking action at alternate Reykjavik unavailable, the absence of other diversion options with the fuel remaining obliged the flight to commit to landing on the closed runway, which was obstructed only at its far end. ATC required an emergency declaration and then gave a ‘land at pilot’s discretion’ clearance, and an uneventful landing followed.
Taxiway Take Off/Landing
On 6 November 2017, an Embraer E190 cleared for a normal visibility night takeoff at Nice began it on a parallel taxiway without ATC awareness until it had exceeded 80 knots when ATC noticed and a rejected takeoff was instructed and accomplished without any consequences. The Investigation found that although both pilots were familiar with Nice, their position monitoring relative to taxi clearance was inadequate and both had demonstrated a crucial lack of awareness of the colour difference between taxiway and runway lighting. Use of non-standard communications phraseology by both controllers and flight crew was also found to be contributory.
Related Articles
For all accident reports held on SKYbrary, see the Accidents and Incidents.
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