Laudamotion A320 at London on Mar 1st 2019, rejected takeoff after loud bang, evacuation
Last Update: August 6, 2020 / 10:40:54 GMT/Zulu time
A passenger reported there was a huge bang due to an engine (CFM56) failure, the aircraft skidded to a stop, and they evacuated via the slides.
The airline reported the crew rejected takeoff due to a problem with one of the engines.
A ground observer reported a streak of flames came out of the left hand engine followed by white sparks just when the aircraft had moved a few meters.
On Mar 4th 2019 another passenger (nickname Mike), who had already posted a comment here on Mar 2nd 2019 15:04z, followed up reporting he was able to see the left hand wing and the exhaust of the left hand engine from his seat, a bang and a brief streak of flames (estimated length of flame 2-3 meters) associated with a puff of smoke was released from the engine. The event looked like similiar to an engine failure by an A330 in Manchester filmed by Simon Lowe (see video referenced below). The aircraft came to a stop, the cabin was quiet, no sounds, no alerts, no beeps. Both engines had been shut down, the APU was running. No smoke or unusual odour occurred. No smoke or other anomaly was seen from the engine. In a distance emergency vehicles could be seen responding, a lot of flashing blue lights surfaced, the fire engines arrived and looked at what appeared to be a leak from the left hand engine. The flight attendants were communicating with each other shouting from the front of the cabin to the back of the cabin and back. One of them shouted "it doesn't work", then they began to shout "evacuate". An evacuation through all doors, including all left hand doors, was performed. The passenger annotated he didn't notice any of the flight attendants to check the left hand engine through any of the windows. After sliding down the passenger still did not see any trace of fire or smoke. The passenger summarized the event is pretty well described by the A330 video, much better than he could have put it into words.
The AAIB announced they have dispatched a go team to Stansted to investigate the occurrence.
On Mar 8th 2019 the AAIB reported the aircraft sustained substantial damage when the #1 engine failed, the takeoff was rejected at low speed followed by a "full evacuation". The highest level of injury is still unknown. The occurrence was rated an accident and is being investigated by the AAIB.
On Aug 6th 2020 the AAIB released their final report concluding the probable causes of the accident were:
The left engine experienced a contained engine failure. All the damage found in the engine was consistent with the release of one or more high-pressure compressor stage 1 blades as a result of high-cycle fatigue arising from aerodynamic excitation of the blades. A single inlet guide vane lever arm, which had been improperly assembled in the connecting link on the inlet guide vane actuation ring, was identified as the source of the stimulus that resulted in the blade release.
As a result of the engine failure and subsequent rejected takeoff, the Senior Flight Attendant commanded an emergency evacuation that was not necessary in the circumstances. This was probably the result of a combination of factors that heightened her emotional response to the event and affected her decision making. The factors included inexperience as a flight attendant, weaknesses in her training and communication difficulties during the event.
As a result of the flight crew not being consulted before the evacuation was commenced, the right engine remained running for the first few minutes of the evacuation. This led to an increased risk of serious injury to those passengers that evacuated on the right side of the aircraft. Indeed, several passengers sustained minor injuries having been blown over by the exhaust.
During the evacuation several passengers hindered the evacuation by taking their cabin baggage with them. While some were removed by the flight attendants at the supervised exits, this was not possible at the overwing exits. Two Safety Recommendations are made regarding passengers evacuating with carry-on baggage.
The AAIB analysed:
After the failure of the left engine the flight crew responded correctly by rejecting the takeoff, bringing the aircraft to a stop and announcing “attention crew: on station” to the FAs and actioning the ECAM checklist. As the engine failure was secured by the crew actioning the ECAM checklist and there were no other causes for concern, the decision to vacate the runway under the power of the right engine was appropriate.
The crew were subsequently surprised to see a cabin door open, a slide deployed and passengers walking in front of the aircraft. The commander then contacted the SFA to ask why an evacuation had been initiated. After this exchange he realised that passengers were going towards the right engine, which was still operating. Had any of them entered the right engine’s inlet suction danger area (Figure 1, Area A), it is possible that they could have been sucked into the engine. The right engine was shutdown 2 minutes after the commander noticed that Door 1L was open.
Once they had noticed that an evacuation had commenced there was realistically no way that the flight crew would have been able to recover the situation. It may have been prudent to action the EMER EVAC checklist to ensure that the aircraft systems were all in as safe a state as possible for the passengers to exit the aircraft. However, given that passengers were potentially going to encroach into the right engine’s inlet suction danger area it was probably quicker to select the eng master to off. Had the commander prioritised shutting down the engine and thus had a more succinct discussion with the SFA, the right engine could have been shut down sooner.
Flight attendant aspects
All evacuations carry risk of passenger injury so flight attendants should not command an evacuation unless there is no doubt that it is required. The operator’s Flight Safety Manual listed the circumstances when flight attendants should initiate an evacuation and none of these criteria applied. A combination of factors combined to overwhelm the SFA and cause her to command the evacuation over the PA.
At the front of the aircraft, the noise of the engine failure sounded very loud to the two FAs. The SFA was startled by the noise of the engine failure and the movement of the aircraft to the side of the runway. This appears to have caused her to narrow her attention to the aircraft sounds so that she did not hear the “attention crew: on station” command. The other FAs all heard it and were not aware that she had not.
Initially it was organised and calm in the cabin at the rear of the aircraft. The crew members there were helped by the calming influence of FA4 who was more experienced. Also FA3 and the ACM were recent recruits and may have benefitted from the recency of their training.
Communication between the SFA and FA3 was not effective in either means or content. The crew members’ and passengers’ accounts suggested that communication was attempted using a combination of the PA system, the interphone, shouting and hand gestures. A combination of English and German language was used.
The interphone at the FA3 seat was knocked off by the force of the folding seat closing. This resulted in the attention-getting chime and lights being inhibited so there was a delay between the SFA calling and establishing communication. The FAs reported that the handsets were prone to falling out of the cradle.
It was dark outside, and the cabin lights were dimmed for takeoff. The lack of light in the cabin made it difficult to see what was happening at the rear of the aircraft so communication by hand signals was not effective and the SFA could not see that the interphone was stuck.
The communication difficulty meant that the SFA could not establish whether the situation was safe at the rear of the aircraft. The SFA formed the impression that all the other flight attendants were scared. Only one minute and twenty seconds elapsed between the “attention crew: on station” command and the ‘evacuate’ command by the SFA. It would have felt like much longer to the flight attendants, especially the SFA who had heard nothing from the cockpit and felt under pressure from the passengers. Altogether this increased her anxiety and uncertainty and contributed to her commanding the evacuation.
Any FA could have contacted the cockpit during this time. The FAs who heard the “attention crew: on station” command would have been unlikely to do so because they understood the procedure to wait. The SFA had not heard this command but it did not occur to her to contact the pilots. As well as her emotional state, this may have been partly because her interactions with them were so limited under normal circumstances. The operator did not provide training for FAs and pilots designed to increase their interaction and understanding of each other’s roles. All FAs had been trained that the pilots would be busy in an emergency, but they had no understanding of the tasks the pilots were doing or how long they would take.
Not all passengers heard the evacuation command on the PA. If the evacuation signal had been used the passenger response and the overall evacuation may have been quicker.
However, this was not available to the FAs and the pilots were unlikely to operate it given they had not commanded the evacuation.
The SFA had recently been promoted after a relatively short time as an FA. During her time as FA, there was a period where she did not fly due to the operator’s bankruptcy. As a result, she did not meet the operator’s requirement for promotion in terms of duration of operational experience. Her initial training course as an FA was within a large group which may have resulted in aspects not being fully explained or understood by all that attended.
The pressure to have staff operationally available for flights after the bankruptcy and change of operator meant that the subsequent training for SFA was purely theoretical and short in comparison to the operator’s more recent practice. These factors may have meant that the SFA was not well prepared for her role in the emergency.
All FA practical training for emergencies involved a practice evacuation. None of them had practiced a return to normal operation. This may have resulted in a false expectation that all emergencies would result in an evacuation.
Overall, it seems that the SFA’s emotional response to the emergency was aggravated by her general inexperience and the communication difficulties the FAs encountered. Despite meeting regulatory requirements, there were weaknesses in her training that meant she was not well prepared for the situation. Together this resulted in an overwhelming ‘flight’ response in which she felt the need for herself and everyone else in the cabin to escape the situation as quickly as possible. She did not contact the pilots and ended up commanding an evacuation. The operator has undertaken to implement a range of improvements to FA training and to instruct FAs to attempt to establish communication with the flight deck before commanding an evacuation.
Once the evacuation was commenced it was important that it proceeded in as safe and efficient a manner as possible to minimise the risk of passenger injury. In general, the evacuation proceeded swiftly, without significant panic or delay. The event provided an opportunity to learn about factors that influence a safe and efficient evacuation.
Many passengers in this evacuation collected their bags and attempted to leave the aircraft with them. At the supervised doors, the FAs removed baggage from them. At the unsupervised overwing exits passengers with bags could exit unchallenged. Baggage brought to the exits created difficulty for the FAs who then needed to remove it and store it somewhere which could have created an obstruction. The carried baggage probably slowed the evacuation and had the potential to damage the escape slides or injure other passengers on the slides. It was not possible to determine how long the evacuation took compared to the CS-25 requirement of 90 seconds.
The safety studies by the NTSB, TSB Canada, EASA and the Royal Aeronautical Society show that carried baggage has long been an issue. Appendix 1 lists many of the evacuation events identified in these four studies and provides additional details. It shows that it is extremely common for passengers to carry off bags in evacuations, even when there is a clear and immediate threat to life from remaining on board the aircraft. One of the events shows that even trained flight crew are not immune from the compulsion to keep their possessions with them. There were several examples where witnesses reported that this passenger behaviour slowed the evacuation or that the evacuation took longer than 90 seconds.
The Royal Aeronautical Society commented that:
‘This trend appears to be increasing and can only be exacerbated by the increasing volume of cabin baggage being permitted by some operators for commercial reasons.’
The Society made a recommendation to consider physical means of preventing passengers retrieving their baggage:
‘Aviation authorities should consider the feasibility of introducing a certification requirement for a means of remotely locking, from the flight deck, overhead bins in passenger cabins that do not contain emergency equipment, for taxi, take-off and landing.’
Current mitigations for the issue include passenger briefing and printed instructions on the cabin safety card. However, the motivation for passengers to remain united with their baggage is extremely powerful and, in some cases, the danger is not immediately apparent to passengers. These factors may lead passengers to feel it is safe to pause and collect baggage and for the evacuation to proceed at a slower pace. For a high proportion of passengers, briefing and instruction by FAs does not overcome this.
The AAIB released two safety recommendations, both dealing with passenger behaviour in evacuations:
- Safety Recommendation 2020-018
It is recommended that the European Union Aviation Safety Agency commission research to determine how to prevent passengers from obstructing aircraft evacuations by retrieving carry-on baggage.
- Safety Recommendation 2020-019
It is recommended that the European Union Aviation Safety Agency consider including a more realistic simulation of passenger behaviour in regard to carry-on baggage in the test criteria and procedures for the emergency demonstration in CS-25.
This article is published under license from Avherald.com. © of text by Avherald.com.
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