lørdag 8. august 2020

Dårlig kommunikasjon i denne saken - Gatwick - Curt Lewis


Report: Airbus A320 contained engine failure and unnecessary emergency evacuation at Gatwick Airport


Date:
Friday 1 March 2019
Time:
20:20
Type:

Airbus A320-214
Operator:
LaudaMotion
Registration:
OE-LOA
C/n / msn:
3147
First flight:
2007-05-09 (11 years 10 months)
Engines:
2 CFMI CFM56-5B4/P
Crew:
Fatalities: 0 / Occupants: 7
Passengers:
Fatalities: 0 / Occupants: 169
Total:
Fatalities: 0 / Occupants: 176
Aircraft damage:
Substantial
Aircraft fate:
Repaired
Location:
London-Stansted Airport (STN) (   United Kingdom)
Phase:
Takeoff (TOF)
Nature:
International Scheduled Passenger
Departure airport:
London-Stansted Airport (STN/EGSS), United Kingdom
Destination airport:
Wien-Schwechat International Airport (VIE/LOWW), Austria
Flightnumber:
OE327
Narrative:
LaudaMotion flight 327, an Airbus A320, was a scheduled flight from London Stansted Airport, U.K. to Vienna International Airport, Austria. The captain was the PF for the sector and it was a line training sector for the co-pilot. There were five flight attendants (FAs), including an additional crew member.
The aircraft pushed back and taxied out to runway 22 without event. ATC clearance was then given for the aircraft to line up and take off from runway 22. At the time it was dark outside, and the weather was clear with the wind from 160° at 5 kt. In the cabin, the lights had been dimmed for takeoff, as is normal practice.
Having lined up on the runway, the captain set the throttles to full power/toga and commenced the takeoff roll. About one second after the co-pilot said "thrust set", at a groundspeed of 31 kt, a loud bang was heard and the aircraft immediately drifted towards the left of the runway. The captain said "stop stop stop" and rejected the takeoff.
The aircraft came to a stop between the centreline and the left side of the runway. The captain then set the parking brake, selected the public address system (PA) button and announced "attention crew: on station" twice. The co-pilot then informed ATC that they were stopping on the runway and then completed the actions for 'ENG 1 FAIL' and 'ENG 1 REVERSER UNLOCKED' electronic centralised aircraft monitor (ECAM) messages; there were no fire indications. The left engine was shutdown at 20:06:23 hrs.
After the ECAM messages had been actioned the captain contacted the RFFS, who were quickly on the scene, to confirm that there were no signs of fire visible from the outside. As a result, it was decided to vacate the runway using the thrust from the right engine and he asked ATC for clearance to do so.
At 20:07:21 hrs, just as the captain was about to make a PA to instruct the FA to return to normal operations, he noticed an amber 'DOOR L [LEFT] FWD [FORWARD] CABIN' caution message illuminated on the ECAM. At first, he thought it was a fault but then saw the evacuation slide deployed at Door L1 out the left cockpit window and passengers moving across the front of the aircraft. The captain then had a conversation with the Senior Flight Attendant (SFA), over the interphone, during which the captain asked why the evacuation had been initiated. She replied that she believed he had ordered one, which he denied. After this conversation, the APU was started and the right engine, which was still operating while the evacuation was underway, was selected off at 20:09:38 hrs.
During the evacuation, the escape slide at door 3R (aft right-hand side) initially inflated and floated in the air because the engine was still running. This exit was then blocked. The slide at door 3L inflated correctly. Several passengers brought hand baggage with them, but it was removed from them and placed by door 3R. A similar situation with baggage occurred at doors 1L and 1R.
Probable Cause:

AAIB Conclusions:
The left engine experienced a contained engine failure. All the damage found in the engine was consistent with the release of one or more high-pressure compressor stage 1 blades as a result of high-cycle fatigue arising from aerodynamic excitation of the blades. A single inlet guide vane lever arm, which had been improperly assembled in the connecting link on the inlet guide vane actuation ring, was identified as the source of the stimulus that resulted in the blade release.
As a result of the engine failure and subsequent rejected takeoff, the Senior Flight Attendant commanded an emergency evacuation that was not necessary in the circumstances. This was probably the result of a combination of factors that heightened her emotional response to the event and affected her decision making. The factors included inexperience as a flight attendant, weaknesses in her training and communication difficulties during the event.
As a result of the flight crew not being consulted before the evacuation was commenced, the right engine remained running for the first few minutes of the evacuation. This led to an increased risk of serious injury to those passengers that evacuated on the right side of the aircraft. Indeed, several passengers sustained minor injuries having been blown over by the exhaust.
During the evacuation several passengers hindered the evacuation by taking their cabin baggage with them. While some were removed by the flight attendants at the supervised exits, this was not possible at the overwing exits. Two Safety Recommendations are made regarding passengers evacuating with carry-on baggage.
Accident investigation:
Investigating agency: 
AAIB 
Status:
Investigation completed
Duration: 
1 year and 5 months
Accident number:
AAIB-25599
Download report:

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