ASN Wikibase Occurrence # 183961
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Date: | Tuesday 15 December 2015 |
Time: | 19:45 LT |
Type: | Avro RJ85 |
Owner/operator: | CityJet |
Registration: | EI-RJT |
MSN: | E2366 |
Fatalities: | Fatalities: 0 / Occupants: 56 |
Aircraft damage: | Minor |
Category: | Serious incident |
Location: | Amsterdam-Schiphol International Airport (AMS/EHAM) -
Netherlands
|
Phase: | Pushback / towing |
Nature: | Passenger - Scheduled |
Departure airport: | Amsterdam-Schiphol International Airport (AMS/EHAM) |
Destination airport: | London City Airport (LCY/EGLC) |
Investigating agency: | Dutch Safety Board |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:CityJet flight WX198 to London City Airport was pushed back from gate D24 at Amsterdam-Schiphol Airport around 19:00 hours local time. Two of the four engines were started during push back. The crew set the parking brake and began starting the remaining two engines. Meanwhile the tug was disconnected.
The flight crew and tug driver then noticed that the aircraft began moving forward. The crew tried to use the brakes but the aircraft continued forward until it hit the tug.
The fuselage was damaged and the flight was consequently cancelled.
The aircraft was back in service on Decemer 29.
During pushback the aircraft’s brake pressure suddenly dropped, leading to a forward movement. Actions by the flight crew and the tug driver were unsuccessful in preventing a collision between the aircraft and its tug.
This serious incident was partially caused by hydraulic pressure decay from a fault in one or both parking brake motorised valves, and subsequent depletion of the brake accumulator below its design pressure.
The following contributing factors were identified:
- The initially applied (parking) brake pressure was inadequate. Additional technical or operational abnormalities must have been present to explain this, but were not identified by the investigation.
- The manufacturer’s prescribed procedures allowed the incident to occur by permitting the parking brake to be set with all three yellow hydraulic pumps disabled.
- The operator’s prescribed procedures allowed the incident to occur by permitting the parking brake to be set with all three yellow hydraulic pumps disabled and by forbidding use of the AC pump while using a towbarless tug.
- When the brake pressure dropped, the aircraft started rolling forward along the pushback line. The local wind conditions, the slope of the taxiway, and thrust from four engines running idle contributed in overcoming what brake force may have remained.
The risk of a loss of control due to brake pressure loss is largely limited to the start-up phase, where the parking brake may be used with all three yellow hydraulic pumps switched off and the accumulator as sole source of hydraulic pressure.
Accident investigation:
|
| |
Investigating agency: | Dutch Safety Board |
Report number: | |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
http://onderzoeksraad.nl/uploads/phase-docs/1163/562af2f8d2f0ovv-kwartaalrapportage-luchtvaart-kw-iv-2015.pdf Revision history:
Date/time | Contributor | Updates |
27-Jan-2016 12:38 |
harro |
Added |
31-Jan-2019 20:45 |
harro |
Updated [Time, Narrative, Accident report, ] |
14-Jun-2022 03:06 |
Ron Averes |
Updated [Location] |
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