Aviation safety investigations & reports

British Aerospace Plc BAe 146-100, VH-NJR

Investigation number:
Status: Completed
Investigation completed


During taxi for takeoff, the crew of the BAe146-100 aircraft noticed a 'yellow' hydraulic system 'low quantity' warning light on the aircraft's master warning system panel.

At approximately the same time, a cabin crewmember opened the flight deck door to alert the flight crew to the presence of fumes in the cabin. Passengers and two off-duty cabin crew reported a slowly moving white haze, low on the right side of the passenger cabin, in the vicinity of row 6. The haze was acrid and transparent and caused coughing and breathing difficulties.

An off-duty cabin crewmember also went to the flight deck and told the captain that the situation in the cabin had worsened, that there was smoke on the right side of the cabin and that passengers were having difficulty breathing. Because of the urgency of the report the pilot stopped the aircraft on a taxiway and instructed the cabin crew to prepare to evacuate passengers through the left doors. After shutdown procedures were completed, he ordered the evacuation.

The two operating cabin crewmembers opened the forward and rear left doors and deployed the escape slides. The two off-duty cabin crewmembers evacuated first, one through each door, to assist passengers at the base of the slides.

A passenger reported that cabin crew who stood at the aircraft doors to control the evacuation and block access to the right doors were out of view of the cabin. Therefore, the cabin crew could not see other passengers attempt to retrieve cabin baggage; an action that clogged the aisle and slowed progress to the exits. However, cabin crewmembers reported that cabin baggage did not delay the evacuation.

A cabin crewmember at the base of a slide reported that early in the evacuation, some passengers struck others that had not yet cleared the slide. Some fell as they reached the slide base and she lifted people to avoid a bank-up and the possibility of injury. Later, the evacuation proceeded in a more orderly manner. Cabin crew reported that they did not request assistance from able-bodied passengers during the evacuation.

Medical assistance

The airport Rescue Fire Fighting Services attended shortly after the evacuation was completed. They offered medical assistance and administered oxygen to two passengers. Medical assistance was also offered to passengers and crew on arrival at the airport terminal. None of the passengers requested medical attention.

Aircraft crew actions

Company emergency procedures required flight crew to don oxygen masks at any time that smoke or fumes were detected in the cabin. The procedures also required the flight deck door to remain closed to avoid flight crew incapacitation from fumes.

Both the pilot and the cabin crewmember that opened the door to speak to the flight crew reported that they were aware of the emergency procedure requirements. However, the pilot reported that the flight crew did not don oxygen masks as there were no fumes in the area and because the urgency of the cabin crew messages conveyed the need for an immediate evacuation. The cabin crewmember reported that it was quicker to open the flight deck door and safe to do so as there were no fumes in the area.

Cabin crew who had inhaled vapours, or who had assisted passengers off the escape slide, reported that during the continued tour of duty they suffered effects that included extreme tiredness, sore muscles and minor throat and chest problems.

Hydraulic system

Two independent systems provided hydraulic power to the aircraft flight controls and landing gear. These hydraulic systems were designated 'green' (left) and 'yellow' (right).

The power generation components were housed in the hydraulic bay, situated immediately forward of the main landing gear bay, below the forward rows in the passenger cabin. A light on the flight deck instrument panel provided a low hydraulic quantity warning when the fluid level fell below the operating level.

An inspection by the operator found that a leak in a hydraulic coupling allowed fluid under pressure to escape as vapour into the hydraulic bay and enter the passenger cabin via gaps in the sidewall lining. The 'o' ring seal for the coupling was replaced and the leak stopped. After a number of subsequent flights the coupling leak re-occurred. On closer inspection it was found that the coupling had a crack along its threads. The coupling was replaced.

The company reported that a subsequent Non Destructive Test (NDT) examination of the cracked coupling revealed that the coupling had failed through the bottom of a thread due to overload, which was consistent with having been done up too tightly.

Hydraulic equipment bay sealing

The aircraft manufacturer had generated three service bulletins that either required or recommended remedial action to improve sealing between the hydraulic bay and the passenger cabin. A zonal inspection was also conducted in the area at regular intervals.

At the time of the occurrence the operator had incorporated the first two service bulletins and had scheduled, but had not commenced, the third.


As a result of the coupling leak, hydraulic vapours entered the passenger cabin, affecting passengers. Replacement of the coupling 'o' ring temporarily stopped the leak.

Following the subsequent leak an NDT report identified the overload failure of the coupling threads, which was consistent with over-tightening. This condition may have been present during the initial hydraulic leak, but was masked by the replacement of the 'o' ring seal.

Both the pilot and a cabin crewmember considered it safe to act contrary to company emergency procedures. However, these actions had the potential to result in flight crew incapacitation through exposure to fumes.

The assistance of the off duty cabin crewmembers contributed to the timely and safe evacuation. However, the use of additional able-bodied passengers to clear others from the slide may have further reduced the possibility of injury to passengers and crew.

Although crewmembers had conducted an evacuation and some had inhaled fumes, both flight and cabin crew continued the tour of duty without rest. Following abnormal events, the ability of crewmembers to carry out their safety duties for the care of passengers on subsequent flights may be adversely affected due to the effects of the event.

Significant Factors

  1. The leak in the hydraulic coupling led to the escape of hydraulic mist.
  2. Inadequate sealing of the hydraulic bay allowed the hydraulic mist to enter the passenger cabin.

Safety Action

Local Safety Action

As a result of its investigation the operator has:

  1. Carried out a fleet inspection that did not find evidence of any other coupling failures.
  2. Accelerated the scheduled program on its remaining fleet for the implementation of all the manufacturers service bulletins related to proper sealing of the hydraulic bay.
  3. Advised the ATSB that all manufacturer's advised modifications have since been incorporated on the occurrence aircraft.
  4. Recommended company procedural changes, including whenever possible using able-bodied passengers to assist at the base of slide during an evacuation and consideration of stand down of crews following an emergency.

General details
Date: 22 July 2002   Investigation status: Completed  
Time: 0935 hours EST    
Location   (show map): Brisbane, Aero.    
State: Queensland   Occurrence type: Hydraulic  
Release date: 08 May 2003   Occurrence category: Incident  
Report status: Final   Highest injury level: Minor  

Aircraft details

Aircraft details
Aircraft manufacturer British Aerospace PLC  
Aircraft model BAe 146  
Aircraft registration VH-NJR  
Serial number E 1152  
Type of operation Air Transport High Capacity  
Damage to aircraft Minor  
Departure point Brisbane, QLD  
Destination Alice Springs, NT  
Last update 13 May 2014