National Express B463 at Sydney on Jan 22nd 2019, removal of tail stand recommended prior to departure

Last Update: June 23, 2020 / 15:12:15 GMT/Zulu time

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Incident Facts

Date of incident
Jan 22, 2019

Classification
Incident

Airline
National Jet Express

Flight number
XM-7443

Departure
Sydney, Australia

Destination
Brisbane, Australia

Aircraft Registration
VH-NJZ

Aircraft Type
BRITISH AEROSPACE BAe-146-300

ICAO Type Designator
B463

A National Jet Express British Aerospace BAe-146-300, registration VH-NJZ performing flight XM-7443 from Sydney,NS to Brisbane,QL (Australia), departed Sydney's runway 16R, however, the rear tail stand had remained attached and separated during rotation for takeoff, the tail stand came to a stop on the runway surface as foreign object debris. The aircraft climbed to FL250 enroute and landed safely on Brisbane's runway 14 about 90 minutes after departure.

Australia's Transport Safety Bureau (ATSB) reported: "At about 0455 on 22 January the aircraft took off with the rear tail stand attached. After take-off the tail stand sheared off resulting in foreign object debris on the runway." The aircraft did not sustain damage. The occurrence, described as "Aircraft preparation event", was rated an incident and is being investigated by the ATSB.

On Jun 23rd 2020 the ATSB released their final report concluding the probable causes of the incident were:

- During pre-departure checks, the full checklist between the captain and engineer was not completed. This negated the value of the checklist as a risk control and resulted in a missed opportunity to identify that the tail strut was still attached to the aircraft prior to it departing the bay.

- The engineer had no effective means or procedure to contact the flight crew while the aircraft was taxiing. As a result, the flight crew were not alerted to the error prior to take-off.

The ATSB described the sequence of events:

A licenced aircraft maintenance engineer employed by Cobham Aviation Services reported marshalling NJZ in, and the flight crew subsequently shut down the aircraft’s engines. The engineer placed chocks at the nose wheels and instructed the flight crew to release the parking brake. The engineer positioned boarding stairs at the forward left cabin door and attached a tail strut2 to the rear of the aircraft (Figure 1). The tail strut was part of the Sydney Airport ground support equipment. The engineer also had the option of using a tail strut that was carried on board the aircraft.

The engineer reported opening the aft lower cargo hold door, on the rear right side of the aircraft to retrieve the sill protectors.3 The engineer waited for the aircraft freight door to be opened remotely by the captain, installed the sill protectors, and conducted an external visual inspection of NJZ. After the inspection, the engineer engaged in a brief conversation with the flight crew, and returned to the line hut to await completion of loading by the loading team.

The captain reported completing an external visual inspection of the aircraft then returned to the cockpit to plan the next sector to Brisbane with the first officer. Upon completion of loading by the loading team, the captain positioned himself at the top of the boarding stairs and the engineer returned to the aircraft. The engineer removed the freight door sill protectors and signalled the captain to commence lowering the freight door. After the freight door was closed, the engineer visually checked that it was flush with the aircraft skin and that the locks had correctly engaged. The engineer then signalled the captain that the freight door had locked correctly. The captain replied with a thumbs-up, entered the aircraft and closed the cabin door behind him.

The engineer proceeded to the aft lower cargo hold door on the right side of the aircraft, stowed the sill protectors, closed and locked the cargo hold door. The engineer then walked back around towards the front of the aircraft and positioned the boarding stairs clear. The engineer connected a headset to the nose of the aircraft for communications with the flight crew and removed chocks from the nose landing gear wheels. The engineer then took up a position at the nose of the aircraft to commence communications with the flight crew for engine start.

The captain confirmed communications with the engineer, and the engineer responded ‘stowed and closed, you are clear all four’. The flight crew proceeded to start all four engines. After the engines were all started successfully, the engineer disconnected the headset, closed the communications panel, and proceeded into the line hut to put away the headset and torch. At 0451, NJZ taxied forward out of the bay and then toward holding point Golf for take-off on runway 16R.

At that time, a ground staff member from a different company arrived at the line hut on a tug and informed the engineer that NJZ had commenced taxiing with the tail strut still in place. Leaving the line hut, the engineer proceeded outside and saw that NJZ had commenced taxiing towards the runway. The engineer began pursuing the aircraft on foot, and attempted to attract the captain’s attention by waving his arms and shouting. The engineer, realising he wouldn’t be able to get the pilots’ attention, joined the ground staff member on the tug and proceeded after NJZ.

The engineer did not have a contact number for the Sydney Control Tower and was therefore unable to inform them of the situation quickly. Instead, he telephoned National Jet Express Maintenance Watch5 and asked them to contact the flight crew to inform them of the situation. National Jet Express Maintenance Watch relayed the message to National Jet Express Operations, 6 who in turn attempted unsuccessfully to contact both pilots by mobile phone.

The engineer, realising that he was not going to catch NJZ prior to it entering the runway, approached a nearby works safety officer. As the engineer was asking the safety officer to immediately contact the tower via radio, to prevent NJZ from taking off, the aircraft turned onto runway 16R, powered up and departed.

The captain reported that during the take-off roll, he felt his phone vibrating in his pocket but did not answer as he was concentrating on the departure.

Following the aircraft’s departure, Sydney Tower closed Taxiway Bravo and runway 16R to allow a visual inspection to take place. A Sydney Airport ground safety worker subsequently located the tail strut, took photographs, and recovered the multiple components (Figure 2). The photographs of the recovered tail strut components were sent to the engineer’s mobile phone and the engineer confirmed that the entirety of the tail strut had been recovered. The engineer relayed this information to National Jet Express Maintenance Watch, who passed it on to the captain. The captain, satisfied that the entire tail strut had departed the aircraft, continued the flight to Brisbane.

On arrival at Brisbane, air traffic control requested that NJZ land on a secondary runway in case there was any residual part of the tail strut still attached to the aircraft. The aircraft landed and stopped on the runway without incident, and the rear of the aircraft was inspected by a Brisbane Airport ground safety officer. NJZ was then permitted to taxi to its bay. Engineers subsequently inspected the rear of the aircraft and no damage was evident.

The ATSB analysed:

During pre-departure checks, the verbal exchange between the captain and engineer was not performed in accordance with the Stand-Off Bay Despatch Using Intercom challenge-and-response checklist. While that was possibly the result of it being a routinely performed task, it negated the value of the checklist as a risk control, and presented a missed opportunity to detect the tail strut prior to departure.

The engineer had no effective means or procedure to contact the aircraft while it was taxiing. Despite that, he attempted various methods to contact the flight crew but was unable to alert them to the tail strut still being attached to the aircraft prior to take-off.