BA Cityflyer E190 at Chambery on Jan 21st 2012, crew forgot to shut down engines

Last Update: October 22, 2013 / 17:46:47 GMT/Zulu time

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Incident Facts

Date of incident
Jan 21, 2012

Classification
Report

Flight number
CJ-8741

Destination
Chambery, France

Aircraft Registration
G-LCYJ

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

A BA Cityflyer Embraer ERJ-190, registration G-LCYJ performing flight CJ-8741/BA-8741 from London City,EN (UK) to Chambery (France) with 53 passengers and 4 crew, was on final approach to Chambery's runway 18 when the aircraft encountered windshear causing the aircraft to overspeed the set flaps. The crew reduced the flaps and went around, positioned for another approach and landed safely. While taxiing in the crew discussed the necessary actions as result of overspeeding flaps like informing maintenance, log entries and talk to operations. The aircraft arrived at the gate, the crew still discussing the consequences of the overspeed as well as fuel requirements for the return flight. The anti-collision lights are being turned off but the engines were not shut down.

Seeing that the anti-collision lights had been turned off, the ramp manager activates ground staff to chock the main gear, the agent providing chocks to the left main gear passes along the fuselage, applies the chocks to the gear then passes behind the engine to the wing tip to put a position marker there but was violently blown away by the engine exhaust and received minor injuries.

When the crew opened the aircraft doors a warning signal alerted the crew to the fact that the engines were still running, the engines were only now shut down.

The French BEA released their final report in French concluding the probable cause of the accident (ICAO: incident) was:

the improper procedure used by many ground handling organisations which suggested that the extinction of the anti-collision lights ensured the engines were stopped. This has generated an invalid assessment of the situation and led to the untimely arrival of the ground staff aft of the engine, that was still running.

The inadequate implementation of the procedure to shut the engines down by the crew by turning the anti-collision lights off before the engines were shut down contributed to the occurrence.

It is possible that the overspeed event on final approach disrupted the attention of the crew during execution of the engine shut down procedure.

The BEA reported that the ground handling company changed the procedures as result of the occurrence effective by Dec 15th 2012, the ramp manager now needs to first establish contact with the flight crew via headphones to verify the engines have been shut down, only then the manager will permit ground staff to enter danger zones by signalling thumbs up.
Incident Facts

Date of incident
Jan 21, 2012

Classification
Report

Flight number
CJ-8741

Destination
Chambery, France

Aircraft Registration
G-LCYJ

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

This article is published under license from Avherald.com. © of text by Avherald.com.
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