On 4 April 2003, an Airbus A330-200, registered VH-EBA, was being readied for departure for a flight from Sydney to Melbourne. The flight crew was provided with the load sheet based on information about the intended number of passengers and the amount of freight to be carried onboard the aircraft. The two forward left aircraft doors (DL1 and DL2) were closed in preparation for the pushback from the terminal, and the airbridges providing access to doors DL1 and DL2 were retracted clear of the aircraft. The flight crew notified the ground engineer that departure was imminent. They completed the `Before Pushback or Start' checklist, and verified that the aircraft doors were closed on the `DOOR/OXY' page on the system display of the electronic centralised aircraft monitoring (ECAM) system.
The passenger and baggage counts were lower than had been expected, and the aircraft weight and balance data differed from the load sheet that had been provided to the flight crew. The assigned load controller reconciled those differences by reassigning seating of passengers to restore the aircraft into an `in trim' configuration, and transmitted the final load sheet to the flight crew. However, although the seating reallocation had been performed in the computer system, those passengers had yet to be physically moved to their reassigned seats.
The airbridge servicing door DL2 was returned to the aircraft to allow the ground-based service agents to supervise the movement of the passengers to their reassigned seats. The cabin crew customer service manager (CSM) reopened DL2 to allow the ground-based service agents to board the aircraft without seeking permission from the pilot in command. The operator's procedures specified that: `If a door must be re-opened, the Customer Service Manager must request permission from the captain prior to re-opening a door'.
The ground engineer supervising the dispatch of the aircraft was standing at the nose of the aircraft, and did not notice that the airbridge had been returned to door DL2. The operator's procedures specified that: `If access is required to the cabin once the aircraft has been cleared to the dispatching engineer, clearance must be sought from the captain through the engineer'.
The ground engineer was not informed that the airbridge had been returned to door DL2, and clearance to open the door was not sought. When door DL2 was re-opened, the DL2 door symbol on the ECAM `DOOR/OXY' synoptic would have changed from green (closed and locked) to amber (door not locked). The amber door indication (door not locked), which was suppressed when the door was closed, would also have appeared on the ECAM `DOOR/OXY' synoptic. Those were the only visual indications available to the flight crew to indicate that door DL2 had been re-opened. No aural warning would have accompanied those changes to the ECAM `DOOR/OXY' synoptic, because the aircraft engines had not been started. The flight crew had previously verified that the aircraft doors were closed, and there was no requirement for them to conduct another check of the doors before commencement of the pushback.
The flight crew obtained clearance for pushback from air traffic control and the pushback from the terminal was commenced. As the aircraft moved rearwards, the opened door DL2 impacted the airbridge. The door and airbridge were deflected into the aircraft fuselage, causing significant damage to the fuselage skin and associated structure. Damage to the airbridge was limited to surface scraping and associated paint loss.
None of the passengers, crewmembers or ground personnel were injured.
The operator conducted an investigation into the incident, and determined that a number of individual/team actions, task/environmental conditions and organisational factors had contributed to the development of the occurrence. In addition, the operator's investigation identified a number of procedural and training deficiencies, particularly in the areas of cross-functional communication and coordination.
As a result of its investigation into this occurrence, the operator conducted a fleet-wide review of its airbridge return and aircraft door opening procedures. That review has resulted in amended procedures that ensure improved communication and coordination between departments sharing responsibility for the dispatch of company aircraft.
|Date:||04 April 2003||Investigation status:||Completed|
|Time:||0710 hours EST|
|State:||New South Wales|
|Release date:||01 March 2004|
|Report status:||Final||Occurrence category:||Incident|
|Highest injury level:||None|
|Aircraft manufacturer||Airbus Industrie|
|Type of operation||Air Transport High Capacity|
|Damage to aircraft||Minor|
|Departure point||Sydney, NSW|
|Departure time||0710 hours EST|