Narrative:Caribbean Airlines Flight 527, a Boeing 737-800 aircraft (9Y-SXM), departed from New York-JFK Airport, NY, USA on a scheduled flight to Georgetown-Cheddi Jagan International Airport, Guyana.
The aircraft landed on runway 06 at 11:33 hrs and was cleared by ATC to taxi via taxiways Charlie and Alpha to the International Apron. The First Officers read back was correct. However, one minute and 30 seconds later, as the aircraft was taxiing on Charlie, the Captain asked the First Officer "Where we goin? Bravo?", to which the First Officer responded affirmatively.
The aircraft then turned right onto taxiway Bravo, then turned left on to the apron and taxied behind a Fly Jamaica Boeing 767 (N767WA) parked in Parking Position 3. There was a wing walker on the ramp ahead, at the tail end of Parking Position 1 near to taxiway Alpha. Another wing walker was standing by the tail of the B767 in Parking Position 3, and a marshaller was at the head of Parking Position 2.
At 11:36, as the B737 taxied behind the B767, the right winglet of the B737, hit the trailing edge of the B767s right elevator, cut off the tail cone and sliced through the left elevator. The B737 then came to a halt and the captain shut down the engines.
Probable Cause:
Findings: Causal.
1. The NTHS ramp personnel were not aware of the Airside Directive forbidding the taxiing of large aircraft behind parked B767s on the International Apron.
2. The CAL flight crew was not aware of the Airside Directive forbidding the taxiing of large aircraft behind parked B767s on the International Apron.
3. The Airside Directive forbidding the taxiing of large aircraft behind parked B767s on the International Apron was inadequately distributed.
4. After preparation of its AIRSIDE DIRECTIVE, the CJIA did not follow through with its responsibility to ensure that relevant information was transmitted to the GCAA and Jeppesen for inclusion in the AIP and the Jeppesen Charts respectively.
5. The Jeppesen and AIP airport charts for CJIA did not forbid the taxiing of large aircraft behind parked B767s on the International Apron.
6. The B737 First Officer erred when he misdirected the Captain to turn on taxiway Bravo, rather than taxiway Alpha.
7. Wing walker C intentionally moved the safety cone placed to mark the position of the B767s tail.
8. Wing walker C did not adequately monitor the track of the B737s right winglet to ensure clearance from the B767s tail.
9. Wing walker B did not adequately monitor the track of the B737s right winglet to ensure clearance from the B767s tail.
10. Wing walker B attempted to marshal the B737 aircraft off to the left of the yellow taxi line to avoid the B737s right winglet hitting the tail of the B767.
11. Wing walker B did not give a "Stop" signal to the B737 in time.
12. Wing walker C did not give a "Stop" signal to the B737 in time.
13. The right hand Number 3 Windshield Panel of the B737 was not heated, and was obscured by moisture, preventing the First Officer from adequately monitoring the clearance of the right winglet from the tail of the B767.
14. The right winglet of the B737 struck the elevators and tail cone of the B767.
15. Wing walker C had not been adequately trained.
16. The practical marshaller training by NTHS was not approved or monitored by CAL, CJIA or GCAA.
17. Wing walkers/marshallers on the CJIA ramp were following an unapproved procedure of directing aircraft off the yellow line to avoid other aircraft.
18. CAL and CJIA management were not aware of this unapproved procedure.
19. NTHS was aware of, and condoned, this unapproved procedure.
20. B737 pilots were routinely taxiing off the yellow line.
21. No hazard reports regarding this unapproved procedure were made to NTHS, CJIA or GCAA.
22. The dimensions of the layout of the CJIA International Apron did not meet the ICAO Recommended Standards for the aircraft it handled.
23. The SMSs of CJIA and CAL were inadequate.
24. NTHS had an SMS program, but it was not approved, nor was it required to be approved.
25. NTHS was not certified, approved or monitored by any other organization or authority, nor was this required.
26. Neither GCAA nor CJIA provided oversight of CJIA ramp operations.
27. The GCAA approved the Aerodrome Manual which was deficient. This was especially so in the SMS
28. GCAA inspection of records, during aerodrome inspections, was deficient as there was no demand for presentation of agreements/records between the CJIA and its clients operating at the airport.
29. GCAA did not adequately assess the inherently unsafe situation existing in the dimension and layout of the international apron.
Accident investigation:
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Investigating agency: | GAAIU  |
Status: | Investigation completed |
Duration: | 2 years and 6 months | Accident number: | GAAIU 3/1/12 | Download report: | Final report
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Classification:
Ground collision
Damaged on the ground
Follow-up / safety actions
GAAIU issued 16 Safety Recommendations
Issued: -- | To: | 9Y-SXM(1) |
CJIA Airside Directives should be transmitted to all stakeholders at CJIA, in a timely manner, and there should be records of their delivery and receipt. |
Issued: -- | To: | 9Y-SXM(10) |
There should be valid written agreements between CJIA and air operators and handling companies. |
Issued: -- | To: | 9Y-SXM(11) |
New Timehri Handling Services should be certified and monitored by the GCAA. |
Issued: -- | To: | 9Y-SXM(12) |
Unofficial procedures at CJIA should be immediately halted. |
Issued: -- | To: | 9Y-SXM(13) |
Boeing 737-800 series aircraft Number 3 Windshield Panels should be heated. |
Issued: -- | To: | 9Y-SXM(14) |
The SMS of CJIA should be upgraded to a fully functioning level. |
Issued: -- | To: | 9Y-SXM(15) |
All stakeholders, including ANS and GCAA, should be included in the CJIA Safety Committee. |
Issued: -- | To: | 9Y-SXM(16) |
The GCAA should give guidance and insist that the dimensions and layout of the international apron, comply with the required standards; or request from CJIA proof that the safety standard would be maintained by alternative safety measures. |
Issued: -- | To: | 9Y-SXM(2) |
The term large aircraft in the CJIA Directives should be defined by aircraft category, gross weight or dimensions. |
Issued: -- | To: | 9Y-SXM(3) |
Apron Procedures should include the Airside Directives, and be published in the Taxi and Parking Restrictions in the Guyana AIP and the Jeppesen Charts for CJIA. |
Issued: -- | To: | 9Y-SXM(4) |
The ADO should be provided with information regarding the size of the incoming aircraft. |
Issued: -- | To: | 9Y-SXM(5) |
The ADOs office should be equipped with a whiteboard showing the parking positions on the International Apron. |
Issued: -- | To: | 9Y-SXM(6) |
The ADO should be aware of the Taxi and Parking Restrictions published in the Guyana AIP and the Jeppesen charts. |
Issued: -- | To: | 9Y-SXM(7) |
The ADO should inform ATC of the parking position allocation of incoming aircraft. |
Issued: -- | To: | 9Y-SXM(8) |
Taxi and Parking Restrictions should be reconsidered to avoid potential conflict of aircraft. |
Issued: -- | To: | 9Y-SXM(9) |
In accordance with ICAO Doc 9137 AN/898 Part 8, Airport Operational Services, First Edition 1983, Paragraph 2.2.3.1, the CJIA Airport Operations Section should be responsible for the day-to-day control and organization of the safe and expeditious movement of aircraft around the airport and to and from the aircraft stands. |
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Photos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from New York-John F. Kennedy International Airport, NY to Georgetown-Cheddi Jagan International Airport as the crow flies is 4070 km (2544 miles).
Accident location: Exact; deduced from official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.