Aviation safety investigations & reports

Aircraft preparation occurrence involving BAe 146 300, VH-NJZ, Sydney Airport, NSW, on 22 January 2019

Investigation number:
AO-2019-006
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
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Alternate: [Download  DOCX: 179KB]
 

What happened

On the morning of 22 January 2019, a British Aerospace (BAe) 146-300, registered VH-NJZ, landed in Sydney, New South Wales, en route from Melbourne, Victoria, to Brisbane, Queensland on a scheduled freight operation.

Before commencing the cargo-unloading process, a tail strut was attached to the rear of the aircraft. After completion of the cargo-unloading and loading process, the aircraft was taxied for departure to Brisbane with the tail strut still attached. During the take-off roll, the tail strut detached, resulting in the runway being contaminated with foreign object debris.

The complete tail strut was recovered from the runway and the aircraft continued to Brisbane, where it landed without further incident.

What the ATSB found

The ATSB found that pre-departure checklist items, required to be performed by the captain and engineer in a challenge-and-response manner, were not completed. This negated the value of the checklist as a risk control, and resulted in a missed opportunity to detect the tail strut’s presence prior to departure.

The ATSB also found that the engineer performing the aircraft turn-around had no effective means or procedure to contact the aircraft while it was taxiing. As a result, and despite attempting various methods, the engineer was unable to alert the flight crew that the tail strut was still attached to the aircraft.

What's been done as a result

Following the occurrence, the operator disseminated Safety Alerts to relevant staff highlighting the despatch procedure, including the challenge-and-response requirement for the relevant cockpit to ground checklist.

The operator also provided appropriate control tower telephone numbers to engineering staff at all operating bases, allowing them to contact the tower immediately if required.

Finally, the operator emailed all company pilots, further highlighting the despatch procedure. This included the requirement that when the aircraft’s tail strut was not used, the local ground support equipment tail strut was to be visible to the flight crew prior to aircraft despatch.

Safety message

Checklists are an essential tool for overcoming limitations with memory, and ensuring that action items are completed in sequence and without omission. While their value may not be obvious for routinely performed tasks, the incomplete use of checklists has been cited as a factor in previous aircraft accidents.

Download final report
[Download  PDF: 131KB]
 
 
Alternate: [Download  DOCX: 179KB]
 

The occurrence

General details
Date: 22 January 2019   Investigation status: Completed  
Time: 0451 EDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Sydney Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Aircraft preparation  
Release date: 23 June 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer British Aerospace PLC  
Aircraft model BAe 146-300  
Aircraft registration VH-NJZ  
Serial number E3126  
Operator National Jet Express  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Sydney, New South Wales  
Destination Brisbane, Queensland  
Last update 23 June 2020