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Air Accident Investigation Unit
Ireland
IncIdent RepoRt Boeing 737-8AS, eI-enB
Kerry Airport (eIKY), co. Kerry, Ireland 21 december 2010
Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010
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Air Accident Investigation Unit Report 2012-004
AAIU Report No: 2012-004
State File No: IRL00910128
Published: 29/02/2012 In accordance with the provisions of SI 460 of 2009, the Chief Inspector of Air Accidents, on 22 December 2010, appointed Paddy Judge as the Investigator-in-Charge to carry out a Field Investigation into this Incident and prepare a Report. The sole purpose of this Investigation is the prevention of aviation Accidents and Incidents. It is not the purpose of the Investigation to apportion blame or liability.
Aircraft Type and Registration: Boeing 737-8AS, EI-ENB
No. and Type of Engines: 2 x CFM56-7B
Aircraft Serial Number: 40289
Year of Manufacture: 2010
Date and Time (UTC): 21 December 2010 @ 09.13 hrs
Location: Kerry Airport (EIKY), Co. Kerry, Ireland
Type of Flight: Public Transport, Scheduled
Persons on Board: Crew - 7 Passengers - 170
Injuries: Crew - Nil Passengers - Nil
Nature of Damage: None
Commander’s Licence: JAA ATPL(A)1
Commander’s Details: Male, aged 47 years
Commander’s Flying Experience: 13,000 hours, of which 6,100 were
on type
Notification Source: ATC Duty Manager Shannon
Information Source: AAIU Field Investigation
AAIU Report Form submitted
by Commander
1 JointAviationAuthoritiesAirTransportPilotLicence(Aeroplane)
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SYNoPSIS
Shortlyafterlanding,smokewasobservedinboththecockpitandcabin.Theaircraftwasstopped,theengineswereshutdownandanevacuationwascarriedout.Notechnicaldefectwasfoundduringthesubsequentexamination.Itisprobablethatthesmokewascausedbytheenginesingestinggranularurea,whichhadbeenusedtode-icetherunwayduringaverycoldweatherperiod.
NoTIFICATIoN
TheAirAccidentInvestigationUnit(AAIU)wasfirstinformedoftheoccurrencebytheAirTrafficControl(ATC)StationManageratShannon.AnAAIUResponseTeamoftwoInspectorsdispatchedbyrailinmoderatesnowtoEIKYandarrivedat18.30hrs.
1 FACTUAL INFoRMATIoN
1.1 History of the Flight
TheflightdepartedfromStanstedAirport(EGSS)intheU.K.andflewdirectlytoEIKY.ThecockpitcrewconsistedofaCommander,whowasaninstructorpilot,anewlyqualifiedFirstOfficer(FO),whowasmakinghisfirstlandingwithpassengersonboardandaSafetyPilot(SP)occupyingthejumpseat.TheFOwasthePilotFlying(PF)andtheCommanderwasthePilotNon-Flying(PNF).
Theweatherconditionsweregoodfortheapproachandtherunwaysurfacewasreporteddry.Thedescent,approachandlandingwerereportednormal.Afterlandingreversethrustwasselected.AstheaircraftdeceleratedtheSPreportedsmokeontherighthandsideofthecockpit.Theaircraftwasturnedofftherunwayandbroughttoahaltonthetaxiwayadjacenttotheramp.ShortlyafterwardstheCabinServicesSupervisor(CSS)alsoreportedsmokeinthecabin.
Theengineswereshutdownandanevacuationwasimmediatelycommencedfollowingwhichthepassengerswalkedtotheairportterminalbuilding,ashortdistanceaway.
1.2 Commander
TheCommanderreportedthatafteranuneventfullandingbytheFOonRunway(RWY)26hetookcontroloftheaircraftatabout60kts,aspernormalprocedure.Atabout50ktstheSPreportedsmokeontherighthandsideofthecockpit.ThiswasfollowedbyacallfromtheCSSthattherewassmokeinthecabin.Atthetimetheaircraftwasturningofftherunwayontothetaxiway.
HereportedthatthesmokecontinuedtothickenontheflightdeckandhetoldtheFOtodonhisoxygenmaskasthesmokewasdenseontherighthandsideofthecockpit.OnhearingthecallfromthecabinheaskedtheSPtoansweritandtoopenthecockpitdoortoviewthecabin.Hestatedthathewasunabletoseethebackofthecabinclearlydueto“grey/blue slightly acrid smoke”.Basedonthisassessmenthedecidedtoimmediatelyevacuatetheaircraft,thisbeingthesafestoption.Hethenshutdowntheenginesandcarriedouttheevacuationprocedures.
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Air Accident Investigation Unit Report 2012-004
Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010
1.3 Safety Pilot (SP) TheSPstatedthatATChadreportedthattherunwaywasdryforlanding.Thelanding,whichwas
conductedwithflapsat40andauto-brakesettingat3,wassmoothandnormalreversethrustwasused.
Duringthelandingrollhesawblue/violetsmokeontherighthandsideoftheflightdeck,whichhereported.Thesmokeormistwasacridandaffectedthebackofhisthroat.
HeansweredacallfromtheCSSwhotoldhimthattherewassmokeinthecabin.Whentheaircrafthadstoppedheopenedthedoorandlookedbackdownthecabin.Hestatedthathecouldseeabouthalf-waydownthecabin.
Hemadea“PAN2”transmissiontoATCandsaidthattheFireServicesreactedverypromptlytothiscall.HestatedthattheAuxiliaryPowerUnit(APU)wasnotstartedaftershutdown.
1.4 Cabin Services Supervisor (CSS)
TheCSSreportedthatwhenheobservedvapourlikesteamalloverthecabinafterlandinghecalledthecockpit.Hesaidthatthevapourappearedverydenseintheflightdeckwhenthecockpitdoorwasopenedandthatitseemedtobegettingdenserinthecabinatthetime.
Hesaidthathehadneverseenthisamountofvapourinthecabinbeforebutthathehadheardthatanincidentofasimilarnaturehadhappenedtoacompanyaircraftsomeweekspreviously,whichhebelievedmighthavebeenduetode-icingfluid.HehadtriedtocommunicatethistotheSPwhoansweredhiscallfromthecockpit.
FollowingtheCommander’sordertoevacuate,whichwasgivenoverthepublicaddress(PA)system,heandthecrewimmediatelycommencedanevacuationusingallexits.
Hestatedthatduringtheevacuationallfourdoorslideswereusedaswellasthreeofthefourover-wingexitsandthattheevacuationwascompletedinabout30seconds.TheCSSreportedthatapassengerhadbeenunabletoopenoneover-wingexit,whichwasthereforeunused.However,itwassubsequentlyfoundtobeserviceablewhenchecked.Theover-wingexitswerenotmannedbythecabincrewbutapassengerclosetoeachhadbeenearlierbriefedonhowtoopenit.
Hereportedthatitwasverydifficulttodealwiththosepassengerswhobroughtcarry-onbaggagewiththemduringtheevacuation,eventhoughtheyhadbeentoldnottobringanything.Hesaidthatitwasnotpossibletoremovehandbaggagefromindividualsduringtheevacuationwithoutdisruptingtheevacuationflowandreducingtherateofegressofpassengers.Hestatedthatcrowdcontroloutsidetheaircraftwasdifficult,eventhoughheusedaloudhailer.
1.5 Injuries to Persons NoinjurieswerereportedtotheInvestigation.
1.6 Damage to Aircraft Theaircraftwasnotdamaged.
2 PAN: Whena“PAN-PAN”radiotransmissionisrepeatedthreetimesitindicatesthatanurgentmessageaboutthesafetyoftheaircraftisbeing
transmitted.
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1.7 Licences
TheCommander’slicencewasaJointAviationAuthorities(JAA)AirlineTransportPilotLicence(ATPL),issuedbytheCivilAviationAuthority(CAA)UK.
Hislicence,typeratingandClassOnemedicalcertificatewerevalid.Hehadatotalof13,000flyinghoursofwhich6,100hourswereontheB737-800type.
TheSPheldaJAAATPLlicence,issuedbytheIrishAviationAuthority(IAA).Hislicence,typeratingandClassOnemedicalcertificatewerevalid.Hehadatotalof2,600flyinghoursofwhich2,300hourswereontheB737-800type.
TheFOheldaJAACommercialPilotLicence(CPL),issuedbytheIAA.Hislicence,typeratingandClassOnemedicalcertificatewerevalid.Hehadatotalof322flyinghoursofwhich2.5hourswereontheB737-800type.
Thetrainingrecordforeachcabincrewmemberwasfoundtobecurrent.
1.8 Hand Baggage
AirportsecuritycamerasrecordedthatthefirstFireServiceappliancearrivedattheaircraft22secondsaftertheaircraftcametoahalt.Oneminuteandfivesecondslatertheportdoorsopened,theslidesinflatedandpassengersimmediatelybegantoleavetheaircraft.Thesecuritycameras(Photo No. 1)recordedthatasignificantnumberofthepassengerscarriedhandbaggageastheywalkedtowardstheairportterminalbuilding.
Photo No. 1: Passengers after emergency evacuation.
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Air Accident Investigation Unit Report 2012-004
Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010
TheInternationalCivilAviationOrganisation(ICAO)TrainingManual,Document7192,PartD-3containsproceduresregardingcarry-on/handbaggage.However,theNationalTransportationSafetyBoard(NTSB)oftheUnitedStates,inaSafetyStudy3of46emergencyevacuationspublishedin2000,identifiedthatnearly50percentofpassengerswhobroughtcarry-onluggageonboardattemptedtoremoveabagduringemergencyevacuations.Reportsissuedbyotherinvestigativeauthoritiesonotherevacuationshavefoundthatsomepassengershaveresistedtheremovalofcarry-onbaggagebycabincrew,therebydisruptingorderlyevacuation.
1.9 Weather
TheweatherreportforEIKYatthetimeoftheincidentwasthatthewindwascalm;thevisibilitywasinexcessof10km.Therewassomecloudat3,000ftwithatemperatureof-9ºCandadewpointof-11ºC.
ThemonthofDecember2010inIreland,duringwhichtheincidentoccurred,wasthecoldestsinceweatherrecordscommenced,consequentlythenormalsuppliesofrunwayde-icingfluidhadbeenexhausted.
TheAirportinformedtheInvestigationthatalthoughsnowhadbeenexpectedduringtheearlymorningperiodthishadnotoccurred.
1.10 Site Inspection
Theaircraftwasinspectedandnodefectortechnicalanomalywasfoundwhichcouldexplainthepresenceofsmokeduringthelandingroll.
TherunwayandtaxiwaywereinspectedbytheInvestigationthefollowingmorning.Thesehadbeensweptclearofsnow,whichhadbeenremovedtothesidesoftherunway.Thecentresectionoftherunwaywasbareandclearbutfoundtobelightlycoveredbysignificantamountsofgranularureathathadbeenspreadontherunwaybyamechanicalspreader.
1.11 Runway Anti-Icing Agents
1.11.1 General
Olderrunwayde-icing/anti-icingmethods,suchastheapplicationofureaorglycol,arenolongerusedastheyhavebeenreplacedbymoremodernmethodsthataremoreenvironmentallyfriendlyinthemain.Inaddition,chloridesalts,commonlyusedonroadsetc.,cannotbeusedwhereaircraftmoveduetotheircorrosiveeffectonaircraftstructuresandsystems.
1.11.2 Urea
Ureagranulesarecolourless,odourlessandhaveameltingpointof132.7ºC.Asampleofthegranularureausedontherunwaywasobtained,whichwasheatedusinghotair.Itinitiallymeltedtoaclearliquidthatsubsequentlyboiledwithanacridandpungentsmell(ammoniaisreleasedoncontactwiththewatervapourintheair).Agreyhuewasobservedintheairandapowderyresidueremainedaftertheliquidhadevaporated.
Whenureaisusedasananti-iceformationagent,precipitation(snoworrain)fallingontheureadissolvesit.Theresultingmixturehasalowerfreezingpoint.Thougheffectivedownto-9.5ºCitisoflimiteduseattemperaturesbelow-4ºC.
3 NTSB/SS-00/01,titledEmergency Evacuation of Commercial Airplanes
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1.12 Cockpit Voice Recorder (CVR)
TheCVRwasdownloadedandwasfoundtobeofgoodquality,butitwasdifficulttodecipherduetothesoundofbreathingsubsequenttotheFOdonninghisoxygenmask.TheCVRconfirmedtheaccuracyoftheflightandcabincrew’srecollections.However,itterminatedwhiletheengineswerespoolingdownanddidnotrecordthesubsequentevacuationorder,PAannouncementsortheconductofassociatedprocedures.
TheCVRelectricalpowersourceonthisaircraftisfromthe115VACTransferBusNo.2.ThisBusisde-energisedwhentheenginesareshutdownunlesstheAuxiliaryPowerUnit(APU)isrunningwithitsgeneratoronlineorexternalpowerhasbeenconnected;insuchcasestheCVRwillthenrunforanadditional5minutes.
IfneitherexternalnorAPUelectricalpowerisavailable,theCVRceasesrecordingwhentheelectricalpowersupplyfromtheenginesislostduringshutdown.
1.13 AAIB Safety Recommendation (SR) 2005-075
FollowinganinvestigationintoanincidentinvolvingaUnitedKingdomregisteredaircraftin2005theUKAirAccidentInvestigationBranch(AAIB)issuedSafetyRecommendationNo.2005-075,whichstated:
For newly manufactured aircraft, the Joint Airworthiness Authorities should require that the cockpit voice recorder and cockpit area microphone are provided with an independent 10 minute back-up power source, to which the cockpit voice recorder and cockpit area microphone are switched automatically, in the event that normal power is interrupted.
1.14 CVR Power Supply
TheInvestigationnotesthat,inresponsetoAAIBSR2005-075, theEuropeanAviationSafetyAuthority(EASA)currentRulemakingProgrammefor2012-2015,TaskNo.RMT.0268proposesarevisionofFDRandCVRcertificationspecifications.However,notimingorworkmethodforthisTaskisscheduledintheProgramme.
TheInvestigationnotesthattheFederalAviationAdministration(FAA)2010RuleOptionrequiresthatCVRsofnewB737aircraftmusthaveOption2371B628B41CVRPower–RIPS4,whichprovidesforanindependentpowersupplytopowertheCVRforanadditional10minutesintheeventthatnormalpowerislostorinterrupted.HoweverthisoptionisonlymandatoryforaircraftregisteredintheUnitedStates.ThereisnoequivalentrulingintheEuropeanUnion.
On31January2011theInternationalCivilAviationOrganisation(ICAO)issuedStateLettersproposingthatAnnex6Part1,(CommercialAirTransport–Aeroplanes),Section6.3.4.1,incorporatesaprovisionthatanalternateCVRpowersupplyengagesfor10minuteswhennormalpowertotheCVRislost,whetherbyenginesshutdownorbyanyotherlossofpower.Thisproposalwouldbecomemandatoryforaircraftover27,000kgsforwhichtheapplicationfortypecertificationissubmittedonorafterthe1January2018.
4 RIPS:RecorderIndependentPowerSupply
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Air Accident Investigation Unit Report 2012-004
Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010
1.15 Previous Incident
AsimilarincidenthadoccurredononeoftheOperator’sflightstoGirona(Spain)threeweekspreviously.Thepilotsubsequentlyreportedthatduringthelandingrollbluesmokeappearedintheflightdeckaccompaniedbysmokeinthecabin.A“PAN”callwasmade,butasthedistancetotheairportterminalwasshorttheaircraftwastaxiedtowardsthestand.Thesmokeclearedanddidnotreturn.
Whentheaircraftarrivedonstandtheengineswereshutdownandthepassengersdisembarkednormally.Followingthisthesubsequentengineeringinvestigationfoundnocausefortheincidentandtheaircraftwasreleasedbacktoservice.Itoperatedthereafternormallywithnofurtherreportofsmoke.
1.16 De-icing and Anti-icing
IAAguidanceonmovementareade-icing/anti-icingtoairportoperatorsisprovidedinALM002ofwhichSection7.3.12referstoICAOAirportServicesManual,Part2(Doc9137).Chapter7.1.1ofthisdocumentaddressestheissuesofsnowandiceremovalfromthemovementareaandstates:
It is impossible to decide, in advance, on the measures that should be adopted in order to improve the friction coefficient (μ value) on a movement area where ice, snow, slush, water and other contaminants result in impaired friction characteristics since, at a particular airport, the meteorological conditions can lead to a number of different situations demanding entirely different countermeasures.
Ingeneralliquidpotassiumacetate(KAc)isusedatIrishAirportsasananti-icingagent.Thiscanalsobespreadinconjunctionwithurea(hopperspreadbeforehand),inwhichcaseKAcdissolvestheureagranules.SincesuppliesofKAcwereexhaustedbythetimeoftheincidentureawasusedonitsown.
TheIAAsubsequentlyinformedtheInvestigationthatairportshaveincreasedtheirstocksofKActoensuretheywillhavesufficientstockanditisnotanticipatedthatureawillbeusedwithanyleveloffrequency.
2. ANALYSIS
2.1 General
ThetechnicalexaminationoftheaircraftbytheInvestigationfoundnofaultintheaircraftoritssystems.Theaircraftwaslaterreleasedtoserviceandthereafteroperatednormally.
AtthetimeoftheincidenttheweatherinIrelandhadbeenunseasonablycoldforthepreviousmonth.Becauseofthis,thesuppliesofrunwayde-icingfluidhadbeenexhaustedatEIKYand,ifairportoperationsweretocontinue,granularureawasoneofthefewalternativesavailable.Thiswasspreadontherunwayasananti-icingmeasureinordertoallowcontinuedsafeoperationofflightsfromtherunway.Inthiscase,althoughsomesnowhadbeenexpected,nonehadfallenandconsequentlytheureahadnotdissolvedandsignificantamountsremainedingranularformonthecentreoftherunway,whichwasbareandclearofsnow.
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Afterlanding,theenginesspooledupduetoreversethrustbeingselected,aspernormalprocedures.Itisprobablethattheureaontherunwaywastheningestedintotheenginesandrapidlyheatedtoahightemperaturebyenginecompressionbeforebeingdispensedbytheairconditioningsystemthroughouttheflightdeckandcabin.
Thiswouldhaveresultedintheacridsmokeobservedinboththecockpitandcabin.
2.2 Evacuation Order
Whensmokewasreportedinthecockpit,theaircraftwasdeceleratingandapproachingashorttaxiwaythatledtotheramp.CCTVrecordedtheaircraftcomingtoastopontherampandlaterthedoorsopeningandtheevacuationcommencing.ItisunclearatwhatpointtheorderwasmadetoevacuatetheaircraftastheCVRrecordingstoppedduringengineshutdown.
AlthoughtheSCMmentionedapreviousincidenttotheSP,whoansweredhiscall,thisinformationwasnotconveyedtotheCommander.Inanycase,asnodetailsofthecauseofthatincidentwereavailable,itisunlikelythatitwouldhavebeenafactorintheCommander’sdecisionmakinghadhebeeninformed,asitsrelevancewasunknown.
Fireinanaircraftisamostseriousoccurrenceandifsuspectedmustbeaddressedimmediately.Thefirstpriorityisthesafetyofpassengersandcrew;iftheycanbeevacuatedsafelyitiscriticalthatthisisdoneassoonaspossible.Thereforewhenfacedwithacridsmokeinboththecockpitandcabinfromanunknownsourceandpossiblyafire,theCommandercorrectlydecidedtoshuttheenginesdownandorderanevacuation.
TheInvestigationnotesthat,althoughapassengerclosetoeachover-wingexithadbeenearlierbriefedonhowtoopenit;oneover-wingexitwasnotopenedduringtheevacuation.Neverthelesstheotherthreeexitswereopenedand,astheseover-wingexitswerenotmannedbythecabincrew,theevidencefromthisandotherevacuationssupportstheimportanceofbriefingpassengersatsuch“self-helpexits”.
Historicallyureawasoncecommonlyusedasananti-icingagentonrunwaysandtaxiways.Currently,itisrarelyusedandconsequentlyitsfumesandsmellarenotrecognisedwhenflightcrewareexposedtoitsaffectsforthefirsttime.Consequently,ifitisspreadonrunwayortaxiways,pilotsshouldbeadvisedaccordinglyandaSafetyRecommendationisissuedinthisregard.
2.3 Passenger Hand Baggage
TheairportCCTVrecordedpassengersleavingtheaircraftandapproachingtheterminalbuildingwithhandbaggage.TheSCMreportedthatsomepassengershadbroughttheirhandbaggagewiththemduringtheevacuationeventhoughtheyhadbeentoldnottodosointheevacuationannouncementmadebythecabincrew.
Passengerswhotakecarry-onbaggageofftheaircraftduringanemergencyevacuationimpedetheevacuationbecauseitrestrictstheevacuationflowrate,whichiscriticalespeciallyintheeventofafireorthesuspicionofone.Furthermore,aircraftemergencyslidesarenotdesignedtoaccommodatehandbaggageandcanthereforebedamaged.Thereisalsoasignificantriskthatapassengerwithhandbaggagecanlosebalancewhiledescendingtheslideandconsequentlysufferinjuryoncontactwiththeground.Inaddition,itdelaystheevacueeclearingawayfromtheslideafterdescent.Finally,itnegatesthecertificationprocessthatgovernsaircraftdesignandsafeevacuationprocedures.
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Air Accident Investigation Unit Report 2012-004
Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010
Thereasonsgivenbypassengersfortakingoffcarry-onbaggageincludethatvaluablessuchaswallets,passportsandkeysareintheluggage.Althoughitcanbearguedthatthefourcabinstaffcouldhaveforciblytakenthecarry-onbaggagefrompassengersduringtheevacuation,thiswasonlypossibleatthepassengerdoors,wherethecabincrewwerelocated.However,previousinvestigationshaveshownthatitwouldhavereducedevacuationflowratesaspassengersresistedand,bearinginmindtheextentoftheproblemrecordedinPhoto No. 1,itwouldnothavebeenpossibletosubsequentlystoreitwithoutblockingtheoppositeemergencyexit.Therefore,itwasnotpossible.
TheInvestigationbelievesthattheonlypracticaloptionforcabincrewistorepeatedlyandvigorouslyorderpassengersnottoremovecarry-onbaggageduringtheevacuation.
TheInvestigationisoftheopinionthatthisissueappliestomostCommercialAirTransport(CAT)aeroplaneoperationsthathaveanunplannedemergencyevacuationandtheNTSBstudyin2000hasshownthatalmost50%ofpassengerswithcarry-onbaggagetakeitwiththemduringanemergencyevacuation.TheInvestigationthereforeconsidersthatthisissueshouldbeexaminedbytheinternationalcivilaviationcommunityinordertopreventlossoflifeduringafutureemergencyevacuationwherespeedofevacuationisessential.AlthoughtheICAOTrainingManual,Document7192,PartD-3indicatestrainingrequirementsregardingcarry-on/handbaggage,thisisinthecontextofgeneraloperations.TheInvestigationisoftheopinionthatguidanceregardingemergencyproceduresshouldalsobegivenandconsequentlyaSafetyRecommendationisissuedtotheInternationalCivilAviationOrganisation(ICAO)inthisregard.
2.4 Cockpit Voice Recorder (CVR) Power Supply
BecausetheCVRrecordingstoppedduringengineshutdownitwasnotpossibletoclarifywhathappenedsubsequently,astheCVRnolongerrecordedactivitiesinthecockpitduetothefailureoftheelectricalpowersupplyfromtheengines.TheInvestigationnotesthatin2010theFAAintroducedarequirementthataCVRshouldcontinuetorecordintheeventofnormalpowerfailurefornewaircraftregisteredintheUnitedStates.However,thereisnosuchrequirementforaircraftregisteredintheEuropeanUnion.
TheInvestigationnotesthat,inresponsetoaUKAirAccidentInvestigationBranch(AAIB)SRNo.2005-075regardingCVRpowersupply,ataskwasallocatedinEASA’scurrentRulemakingprogrambutnotimeconstraintorurgencyisidentifiedforthisfuturework.
ThisInvestigationbelievesthisissueshouldbeaddressedandmakesaSafetyRecommendationtoEASAaccordingly.
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3 CoNCLUSIoNS
(a) Findings
1. Duringdecelerationfollowinganormallanding,acridsmokewasobservedinthecockpitandcabin.
2. Thesourceofthesmokewasnotidentified.
3. Theaircraftwasstoppedontherampandtheengineswereshutdown.
4. Anemergencyevacuationwassuccessfullyconducted.
5. Depositsofgranularurea,whichhadbeenusedasananti-iceprecaution,werefoundontherunway.
6. Theflightcrewhadnotbeenadvisedthatureawasbeingusedasananti-icingagent.
7. TheCVRrecordingceasedwhiletheengineswereshuttingdown.
8. Passengerstookcarry-onbaggageofftheaircraftduringtheemergencyevacuation.
(b) Probable Cause
Ingestionofgranularureawhileusingreversethrust.
(c) Contributory Factor(s)
Aprolongedspellofcoldweatherresultedingranularureabeingusedtoanti-icetherunwayafternormalde-icingfluidstockshadbeenexhausted.
4. SAFETY RECoMMENDATIoNS
It is recommended that:
1. TheIrishAviationAuthorityshouldrequireairportoperatorstoadvisepilots,viaNOTAM,ATISorVHFtransmission,whenureaisbeingusedasananti-icingagentonrunwaysortaxiways.IRLD201202
2. EuropeanAviationSafetyAgency(EASA)shouldintroducearequirementthattheCVRshouldcontinuetorecordintheeventofpowerfailure. IRLD201203
3. TheInternationalCivilAviationOrganisation(ICAO)shouldexaminetheissueofpassengerstakingoffcarry-onbaggageduringanemergencyevacuationandprovideguidanceforcabincrewinsuchsituations.IRLD201204
-END-
Produced by the Air Accident Investigation Unit
AAIU Reports are available on the internet www.aaiu.ie
In accordance with Annex 13 to the International Civil Aviation Organisation Convention, Regulation (EU) No 996/2010, and Statutory Instrument No. 460 of 2009, Air Navigation (Notification
and Investigation of Accidents, Serious Incidents and Incidents) Regulation, 2009, the sole purpose of these investigations is to prevent aviation accidents and serious incidents. It is not the purpose of any such accident investigation and the associated
investigation report to apportion blame or liability.
A safety recommendation shall in no case create a presumption of blame or liability for an occurrence.
A.A.I.U., Department of Transport Tourism and Sport, 2nd Floor, Leeson Lane, Dublin 2, Ireland.Tel (24x7): +353 1 604 1293 or +353 1 241 1777 Fax: +353 1 604 1514 Email: info@aaiu.ie Web: www.aaiu.ie
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