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ASN Wikibase Occurrence # 201109
Last updated: 28 August 2019
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Date:02-NOV-2017
Time:13:00 UTC
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-214
Owner/operator:Aer Lingus
Registration: EI-GAL
C/n / msn: 3789
Fatalities:Fatalities: 0 / Occupants: 149
Other fatalities:0
Aircraft damage: Minor
Category:Serious incident
Location:W of Cork -   Ireland
Phase: En route
Nature:International Scheduled Passenger
Departure airport:Cork Airport (ORK/EICK)
Destination airport:London-Heathrow Airport (LHR/EGLL)
Investigating agency: AAIU
Narrative:
On 2 November 2017, the Airbus A320-214 (EI-GAL) was scheduled to undertake two return flights between Cork Airport (EICK and) London Heathrow (EGLL). During the first descent of the day into EGLL, the flight crew noticed a burning smell. The commander switched off the cockpit floor heaters, suspecting that they may be the source of the fumes. The fumes appeared to dissipate and the aircraft continued to EGLL without further incident. On landing, the commander entered the occurrence into the aircraft’s Technical Logbook. In accordance with the aircraft TroubleShooting Manual (TSM), the aircraft Auxiliary Power Unit (APU) ducting, avionics bay and air conditioning were checked by maintenance personnel at EGLL, but no fault was identified. The fumes did not recur during the return flight to EICK.
At 12.34 hrs, the aircraft departed EICK for the second time that day bound for EGLL as flight EI712. On passing Flight Level (FL) 260 the Flight Crew again noticed the fumes, which this time, were strong and persistent. The Flight Crew donned oxygen masks, declared a MAYDAY and decided to return to EICK. During the diversion the Flight Crew carried out the ‘SMOKE/FUMES/AVNCS SMOKE’ checklist from the aircraft Quick Reference Handbook (QRH). This checklist involved initial troubleshooting to try to identify the source of the fumes. The Flight Crew were unable to identify the source and moved on to the second part of the checklist which requires them to put the aircraft in an emergency electrical configuration; the Flight Crew de-powered the main aircraft generators and powered the aircraft using an emergency generator known as a RAT.Whilst the aircraft was in emergency electrical configuration, it had to be flown manually, in this case by the commander, and the flight directors were not available. The fumes did not dissipate during the descent towards EICK.
In accordance with the QRH checklist, the aircraft generators were switched back on shortly before landing, restoring some of the flight instruments. It was noted by both pilots that this was not a complete restoration; the commander still had to fly the aircraft manually and flight directors were not restored. The aircraft landed safely on Runway (RWY) 35 in EICK.

On landing in EICK, the flight crew assessed the state of the aircraft, and when they were satisfied that it was safe to continue, they requested permission to taxi off the runway and onto a stand. The airport emergency services were waiting at taxiway ‘C’; when the aircraft began to taxi, they entered the runway and followed the aircraft onto the parking stand.
Once on stand, the commander set the aircraft parking brake and shut down the engines. The commander and first officer assessed the situation again and determined that the fumes were still present in the cockpit. The commander spoke briefly to both the Cabin Crew and apron staff to ensure that they were prepared for the passengers to disembark. He then made an announcement to the passengers to initiate a ‘Rapid Disembarkation’. Most of the passengers and crew exited the aircraft using the front and aft steps.
However, passengers seated in the emergency exit rows opened the overwing emergency exits and approximately 32 passengers disembarked onto the aircraft wings. Half of these passengers used the escape slides. The other half returned to the passenger cabin and exited the aircraft using the front and rear steps.

The aircraft re-entered service on November 6, 2017.

Probable Cause
1. Unintended use of the emergency overwing exits, following a return to the departure airport, due to fumes entering the cockpit.
Contributory Cause(s):
1. Rear bearing failure of the avionics bay blower fan.
2. Heightened alertness among passengers due to diversion.
3. Visual cues to passengers who saw emergency responders outside the aircraft.
4. Similarity between rapid disembarkation instruction and emergency evacuation instruction.
5. Direction to the passengers following the rapid disembarkation direction to “use the nearest available exit.”

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/serious-incident-to-the-airbus-a320-registered-ei-gal-and-operated-by-aer-lingus-on-02112017-en-ro/
https://www.independent.ie/irish-news/news/aer-lingus-flight-forced-to-make-emergency-landing-after-smoke-reported-in-cockpit-36283950.html

Accident investigation:
cover
  
Investigating agency: AAIU
Status: Investigation completed
Duration: 1 year and 6 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
09-Nov-2017 13:27 harro Added
17-Dec-2017 08:41 AF5541 Updated [Total occupants, Source]
17-Dec-2017 08:41 harro Updated [Source]
07-May-2019 19:05 harro Updated [Total occupants, Narrative, Accident report, ]
26-May-2019 10:29 harro Updated [Location]

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