Ryanair B738 near Fuerteventura on Feb 10th 2018, passenger injured by stopped descent
Last Update: December 12, 2018 / 15:51:50 GMT/Zulu time
Spain's CIAIAC reported the occurrence was rated an accident, an investigation has been opened.
On Dec 12th 2018 the CIAIAC released their final report concluding the probable causes of the accident were:
The investigation has determined that the accident probably occurred when the crew executed a sudden manual maneuver to maintain the specified flight level.
A contributing factor was the decision to disengage the autopilot to carry out the maneuver manually, which contributed to the abrupt nature of the maneuver.
The CIAIAC summarized the sequence of events:
On Saturday, 10 February 2018, a Boeing 737-8AS aircraft operated by Ryanair was en route at FL370 in Canaries airspace, when the crew requested to descend to FL130, which they were cleared to do by air traffic control.
According to the radar data, at 16:38:04, as the aircraft was descending from FL370, it was instructed by the control service to stop the descent at FL360 due to a potential conflict with another aircraft.
Seconds later, at 16:38:07, according to flight recorder data, the aircraft’s pilot selected the ALT HOLD mode on the mode control panel (MCP) in order to maintain the altitude. At that time the aircraft was passing through FL364 at a high rate of descent.
One second later, as the aircraft was crossing through FL363, the pilot decided to disengage the autopilot. The pilot, as per his statement, thought they had gone past their cleared flight level of FL360 and seeing that the recovery maneuver was taking too long, he decided to manually return to the flight level instructed by air traffic control.
While executing this manual maneuver, one passenger fell, causing significant injuries to one leg. It was not possible to determine when exactly during the maneuver the passenger was injured, and therefore what the vertical acceleration was at the time. However, the data recorded in the flight recorder showed large swings in the position of the control column, which resulted in large increases in the pitch angle and in large vertical acceleration peaks. The maximum vertical acceleration value reached was 1.69 g.
The aircraft was not damaged.
The CIAIAC stated based on the FDR the minimum FL reached was FL357 before the aircraft climbed back to FL360. The crew had selected ALT HOLD at FL363 after receiving the stop descent instruction at FL364, noticed that the aircraft was very slow to level off while descending through FL360, at which point the crew disconnected the autopilot and manually levelled off. A passenger who was standing in front of the aft lavatory waiting to use the bathroom and who held his child in his arms fell and was injured, the child also fell and hit his head. A doctor on board evaluated the injured passenger and determined a leg could be fractured.
The CIAIAC summarized the flight attendants' statements:
The seatbelt sign was not lit, though they expected the flight crew to turn it on in the next few minutes to begin the procedure to secure the cabin for landing.
They did agree in stating that the injured passenger had a child (approximately 5 years old) in his arms and that he was exiting the right-hand lavatory.
The crew felt a series of violent shakes, which they initially identified as turbulence. In all their experience as flight attendants, they had never experienced such a sudden movement in an aircraft.
These sudden movements caused all four flight attendants to fall to the floor. The injured passenger turned his body to the left to try to shield the child, which forced his legs into an unnatural position. He broke his ankle when he fell due to the jolts. The child hit the back of his head, which caused some bruising. No one else was injured.
After the event, the injured passengers cried out in pain. Their relatives were also upset and raised their voices at the flight attendants, complaining about what had happened.
Flight attendant number 2 played the role of intermediary with the flight crew, informing them of the event using the company’s standard PAA format (problem/actions taken/additional information).
They asked the flight crew to request medical assistance upon landing.
When they reached the parking stand, there was no medical assistance ready to treat them. The ramp agent was unaware of the need for medical assistance and called the airport nurse, who reported to the aircraft five minutes later. Upon arriving she was informed of the situation and she called an ambulance, since one was not available at the Fuerteventura Airport. The telephone operator instructed the nurse not to move the patient until the ambulance arrived, which happened one hour and ten minutes after the notification was made.
The CIAIAC analysed the medical response:
According to the communications transcript, at 16:47:25 the crew informed the approach controller that there was an injured passenger on board who may have a broken leg, and requested medical assistance upon reaching the Fuerteventura Airport.
After this, at 16:48:55, the approach controller informed the tower controller at the Fuerteventura Airport that the aircraft operated by Ryanair had requested an ambulance.
At 16:50, the tower controller at the Fuerteventura Airport contacted the airport’s CEOPS to coordinate the medical response, as noted in the airport’s operations log. This log states that: “TWR informs that RYR8421 requests nurse due to pax with broken leg on board”. It further showed an estimated landing time of 17:25 for the aircraft. Thus, the entry in the airport’s operations log does not agree with what the crew requested. The crew requested medical assistance, not a nurse.
According to the “Guidelines for requesting emergency medical assistance at the airport”, laid down by the Fuerteventura Airport operator, after receiving this request for medical assistance, the CEOPS should have immediately notified the first aid service, which is run by nurses and who are tasked with evaluating if it is necessary to call the 112 emergency services number. Investigators were unable to determine when the first aid service was first informed of this medical emergency and if it ruled out the need to request an ambulance to treat the injured passenger.
The nurse who was on duty at the airport when the aircraft landed reported to the scene quickly to evaluate the condition of the injured passenger. After this initial assessment, she called for an emergency ambulance, which was delayed in arriving because it was on call at a location far away from the airport. There are several ambulances on the island of Fuerteventura, but only one emergency ambulance. According to the airport’s operations log, the incident was resolved at 18:24, after waiting 43 minutes for the ambulance.
Aircraft Registration Data
This article is published under license from Avherald.com. © of text by Avherald.com.
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