Thursday, January 11, 2007

AAIB: Cabin crew caused incident on turboprop

by B. N. Sullivan

A report from the UK's Air Accidents Investigation Branch (AAIB) on its investigation of a 2005 incident on an Emerald Airways flight says that the action of the cabin crew nearly caused the aircraft to crash. The incident, during which the aircraft's center of gravity was dangerously altered, happened aboard a British Aerospace ATP turboprop aircraft, and caused minor injuries to thirty-three passengers and four crew members.

According to a news article about the AAIB report, published on the Airport Business website, here is what happened:
The drama on board the Emerald Airways flight began soon after it took off from the Isle of Man's Ronaldsway airport on the evening of May 23, 2005, en route to Liverpool.

A broken seal caused a fine mist of hydraulic fluid, which staff confused for smoke, to fill the front of the 64-seat plane.

The investigation said cabin crew failed to follow standard emergency procedures and rushed the 33 passengers, many struggling to breathe, towards the rear of the plane.

This caused the aircraft to dip dangerously to the rear as the centre of gravity shifted backwards under the weight of people moving to the back.

...

Air accident investigators said the cabin crew, who declared an emergency, did not establish whether the hydraulic system problem and the onset of "smoke" were related.

They also did not follow the prescribed actions with regard to smoke on board, did not inform the flight crew they had moved the passengers to the back, and prior to landing back at Ronaldsway airport were not aware the nose wheel steering system was inoperative.
An emergency was declared to ATC and the aircraft returned to Ronaldsway where it managed to make a safe landing.

As a result of this incident, the AAIB made the following safety recommendation to the British Civil Air Authority (CAA):
Safety Recommendation 2006-069

It is recommended that the Civil Aviation Authority advises all operators of Commercial Air Transport aircraft in the UK register of the need to ensure that the training of cabin crew members includes an awareness that handling problems may result from the movement of the aircraft's CG position, should a significant redistribution of passengers be required in flight. This awareness training should include the necessity to both inform and seek the approval of the flight crew prior to such a redistribution taking place and should be reflected in the appropriate Cabin Crew Safety Manuals.
In May of 2006, the CAA suspended Emerald Air's operator certificate, although it's not clear if this incident had anything to do with the suspension. The airline has ceased operation.

Here's the link to the AAIB Air Accident Report for this incident: Aircraft Accident Report No 1/2007 (4-page 'PDF' file)