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Accident and Serious Incident Reports: CS

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Category: Cabin Safety Cabin Safety
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Definition

Reports relating to accidents and incidents that include aspects of Cabin Safety.

Disruptive Pax

  • AT43, Jersey Channel Islands, 2012 (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.)
  • B744, Phoenix USA, 2009 (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

  • A388, en-route, southeast of Mumbai India, 2014 (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.)
  • B773, en-route, near Kurihara Japan, 2018 (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.)
  • A320, en-route, east of Miyazaki Japan, 2018 (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.)
  • B733, en-route, Santa Barbara CA USA, 1999 (On 2 September 1999, a United Airlines Boeing Boeing 737-300 in the cruise at FL240, experienced severe turbulence due to an encounter with the wake vortex from a preceding MD11 on a similar track which had climbed through the level of the B737 with minimum lateral separation, 1.5 minutes earlier.)
  • CL60 / A388, en-route, Arabian Sea, 2017 (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.)

Cabin Stowage - Pax Items

  • B734, vicinity East Midlands UK, 1989 (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.)
  • B741, en-route, Pacific Ocean, 1997 (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

  • DC93, en-route, Cincinnati OH USA, 1983 (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

  • B732, Manchester UK, 1985 (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.)
  • MD11, en-route, Atlantic Ocean near Halifax Canada, 1998 (On 2 September 1998, an MD-11 aircraft belonging to Swissair, crashed into the sea off Nova Scotia following an in-flight electrical fire.)
  • L101, vicinity Riyadh Saudi Arabia, 1980 (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.)

Evacuation slides deployed

  • B744, Phoenix USA, 2009 (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.)
  • DC91 / B722, Detroit MI USA, 1990 (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.)
  • A310, Irkutsk Russia, 2006 (On 8 July 2006, S7 Airlines A310 overran the runway on landing at Irkutsk at high speed and was destroyed after the Captain mismanaged the thrust levers whilst attempting to apply reverse only on one engine because the flight was being conducted with one reverser inoperative. The Investigation noted that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the MEL but also that the previous two flights had been carried out with a deactivated right engine thrust reverser.)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • B752, London Gatwick, 2013 (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.)

Pax oxygen mask drop

  • A388, en-route, northern Afghanistan, 2014 (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.)
  • B735, en-route, SE of Kushimoto Wakayama Japan, 2006 (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.)
  • B734, en-route, east northeast of Tanegashima Japan, 2015 (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.)
  • B733, en-route, northwest of Athens Greece, 2005 (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.)
  • B789, en-route, eastern Belgium, 2017 (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.)

Unauthorised PED use

IFE fire

Cabin air contamination

  • A320, vicinity Dublin Ireland, 2015 (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.)
  • B744, Phoenix USA, 2009 (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.)
  • DC93, en-route, Cincinnati OH USA, 1983 (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.)
  • MD11, en-route, Atlantic Ocean near Halifax Canada, 1998 (On 2 September 1998, an MD-11 aircraft belonging to Swissair, crashed into the sea off Nova Scotia following an in-flight electrical fire.)
  • A333, London Heathrow UK, 2016 (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.)

Malicious interference

Hand held extinguisher used

  • B738, en-route, Colorado Springs CO USA, 2006 (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.)
  • B744, Phoenix USA, 2009 (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.)
  • DC93, en-route, Cincinnati OH USA, 1983 (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.)
  • A320, vicinity New York JFK NY USA, 2007 (On 10 February 2007, smoke was observed coming from an overhead locker on an Airbus A320 which had just departed from New York JFK. It was successfully dealt by cabin crew fire extinguisher use whilst an emergency was declared and a precautionary air turn back made with the aircraft back on the ground six minutes later. The subsequent investigation attributed the fire to a short circuit of unexplained origin in one of a number of spare lithium batteries contained in a passenger's camera case, some packaged an some loose which had led to three of then sustaining fire damage.)

Evacuation on Cabin Crew initiative

  • B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • DH8D, Aalborg Denmark, 2007 (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.)
  • AT43, Jersey Channel Islands, 2012 (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.)
  • A320, Halifax NS Canada, 2015 (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.)
  • A320, London Stansted UK, 2019 (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”.)

Flight Crew Evacuation Command

  • DC91 / B722, Detroit MI USA, 1990 (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.)
  • A320, Bilbao Spain, 2001 (On 7th February 2001, an Iberia A320 was about to make a night touch down at Bilbao in light winds when it experienced unexpected windshear. The attempt to counter the effect of this by initiation of a go around failed because the automatic activation of AOA protection in accordance with design criteria which opposed the crew pitch input. The aircraft then hit the runway so hard that a go around was no longer possible. Severe airframe structural damage and evacuation injuries to some of the occupants followed. A mandatory modification to the software involved was subsequently introduced.)
  • A332, en-route, North Atlantic Ocean, 2001 (On 24 August 2001, an Air Transat Airbus A330-200 eastbound across the North Atlantic at night experienced a double-engine flameout after which Lajes on Terceira Island in the Azores was identified as the best diversion and a successful glide approach and landing there was subsequently achieved. The Investigation found that the flameouts had been the result of fuel exhaustion after a fuel leak from the right engine caused by a pre flight maintenance error. Fuel exhaustion was found to have occurred because the flight crew did not perform the QRH procedure applicable to an in-flight fuel leak.)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • B744, Phoenix USA, 2009 (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.)

Cabin Crew Incapacitation

  • A332, Dubai UAE, 2014 (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.)
  • B733, en-route, north of Yuma AZ USA, 2011 (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.)
  • DH8D, Yangon Myanmar, 2019 (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.)
  • B738, en-route, west of Canberra Australia, 2017 (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.)
  • B744, en-route, South China Sea, 2008 (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

  • B738, en-route, Colorado Springs CO USA, 2006 (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

  • DH8C, Toronto Canada, 2019 (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.)
  • DH8D, Yangon Myanmar, 2019 (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.)
  • A320, en-route, east of Cork Ireland, 2017 (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.)
  • B738 / B738, Toronto Canada, 2018 (On 5 January 2018, an out of service Boeing 737-800 was pushed back at night into collision with an in-service Boeing 737-800 waiting on the taxiway for a marshaller to arrive and direct it onto the adjacent terminal gate. The first aircraft’s tail collided with the second aircraft’s right wing and a fire started. The evacuation of the second aircraft was delayed by non-availability of cabin emergency lighting. The Investigation attributed the collision to failure of the apron controller and pushback crew to follow documented procedures or take reasonable care to ensure that it was safe to begin the pushback.)
  • B738, Georgetown Guyana, 2011 (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.)

Cabin/Flight deck comms difficulty

  • B763, Chicago O'Hare IL USA, 2016 (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.)
  • A333, London Heathrow UK, 2016 (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.)

Pax Turbulence Injury - Seat Belt Signs on

  • B773, en-route, east northeast of Anchorage AK USA, 2015 (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.)
  • B788, vicinity Amritsar India, 2018 (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.)
  • B738, en-route, west of Bar Montenegro, 2019 (On 13 February 2019, a Boeing 737-800 en-route over the southern Adriatic Sea unexpectedly encountered severe clear air turbulence and two unsecured cabin crew and some unsecured passengers were thrown against the cabin structure and sustained minor injuries. The Investigation found that the Captain had conducted the crew pre-flight briefing prior to issue of the significant weather chart applicable to their flight by which time severe turbulence due to mountain waves at right angles to an established jetstream not shown on the earlier chart used for the briefing was expected at a particular point on their route.)

Pax Turbulence Injury - Seat Belt Signs off

  • A332, en-route, near Bangka Island Indonesia, 2016 (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.)
  • A346, en-route, northern Turkey, 2019 (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.)
  • A332, en-route, mid Atlantic, 2013 (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.)