Airbus eats Paperwork

[wheels_down]

Tasty.....
A GROUND crew member forced a mid-air diversion, after leaving a clipboard in the right engine of a Jetstar A320 plane flying between Auckland and Sydney.

The worker was inspecting the aircraft when he placed a clipboard containing paperwork inside one of the engines to protect it from the rain and wind — and then forgot all about it.

The plane was scheduled to fly between Auckland, New Zealand, and Sydney on October 27 when the incident occurred. It was already in the air by the time the captain was alerted to the situation by an Auckland air traffic controller, according to an Australian Transport Safety Bureau (ATSB) report.

“While preparing the aircraft for departure the leading hand placed a clipboard in the right engine which was subsequently ingested during start-up,” the ATSB report found.

“During the (subsequent) walk-around the dispatcher noticed the clipboard in the right engine but, believing it would be retrieved prior to the aircraft departing, the dispatcher did not notify the leading hand or supervisor of the foreign object debris as per company procedures.”

The Jetstar flight. Picture: Aerocare, modified by the ATSB
The Jetstar flight. Picture: Aerocare, modified by the ATSB
The captain was notified there was a problem after debris - the remains of the clipboard - was found on the runway after the plane had taken off.

Once notified, the captain scrambled, first checking the plane’s engine instruments and finding no abnormal indications. He then pressed flight control for more information, and was informed the clipboard had been placed in the inlet and that paper debris had been found on the tarmac.

The next step was to contact the company’s engineer at the airport, to find out if is was just paperwork or a clipboard containing a metal clip, and was told that a piece of sheared metal had been found.

Uncertain what damage had been done to the engine he made the decision to return to Auckland.

The aircraft was inspected and paper was found throughout the engine.

Minor damage was found to an engine fan blade and attrition liner, a part used to dampen noise that’s located on the inside of the engine.

A forgotten clipboard in a Jetstar plane engine caused the flight drama.
A forgotten clipboard in a Jetstar plane engine caused the flight drama.
The ATSB warned of the seriousness of such a situation, staying: “The presence of foreign object debris poses a significant threat to aircraft safety. It has the potential to cause aircraft damage during critical phases of flight, costing airlines and airports millions of dollars each year.

“This incident demonstrates the effect foreign object debris has on aircraft operations and emphasises the importance of not placing objects in aircraft engines. It further highlights that all staff operating near aircraft are responsible for reporting any non-normal events they encounter.

“It should not be assumed that others will perform a task where a hazard has been identified.”

The report also detailed how the captain faced several obstacles in trying to piece together exactly what was going on.

“The captain stated that, to obtain more information about the incident, numerous calls were made to other agencies, which took considerable time. Further, due to poor communications, he was unable to contact the operator’s maintenance controller to discuss the engine’s status.”

A Jetstar spokesperson told news.com.au its safety procedures have been updated following the incident.

“A plastic clipboard was inadvertently left on the engine cowl of a Jetstar A320 aircraft by our ground handler at Auckland Airport just prior to departure,” the spokesperson said.

“While this incident didn’t impact the safe operation of the aircraft, we take it very seriously. Since this occurred we have updated our procedures which includes a specific warning about not placing items in the engine cowling and improved detail around checks and responsibilities of the aircraft dispatch process.”

[TBM-Legend]

Years ago a Pelair Westwind swallowed the TNT man's clipboard left on the wing. Bring another engine...

[framer]

I have read the ATSB report and have to say I am disappointed in the findings.
Not once does the report mention training, and the solution is to bark a bit louder at the employees , no mention of training whatsoever.
The Leading Hand placed the clipboard in the engine.....training ?
The dispatcher did a walk around and saw the clipboard but she thought it didn’t qualify as FOD as it was the aircrafts loading paperwork......training?
The problem wasn’t that the manuals had the wrong words in them, the problem is that the employees are ill equipped to hold the responsibility of their roles. That’s not their fault, they haven’t been trained properly because it costs too much.

[Rated De]

Is ground function outsourced?

The cornerstone of any Low Fare Airline...

[Octane]

A novel way of shredding documents....

[framer]

Yes it is.

[illusion]

How much training is needed to learn you don't use a jet engine intake as a desk??

Some common dog fxxk would go a long way but that's not that common any more it would seem.

[Derfred]

Is ground function outsourced?

Of course it is. But it get’s worse than that, it’s outsourced to the lowest bidder. But that doesn’t seem to concern the ATSB.

[ShyTorque]

No doubt the culprit thought he was safe, wearing a hi-viz jacket. No doubt he needed ear protection after the event..

[ANCDU]

Outsourcing ground functions is commonplace throughout the world, it’s certainly not just the domain of LCC’s. Qantas only really has its own ramp staff at major Australian airports. Even gate staff may be in Qantas uniforms but they are external contractors...it’s a sign of the times.

[ricardian]

Forgetful ground staff (http://www.news.com.au/travel/travel-updates/uh-oh-forgotten-something-jetstar/news-story/437bc65baf11665cd07f50e1a00b8bf4)

[MATELO]

During the (subsequent) walk-around the dispatcher noticed the clipboard in the right engine but, believing it would be retrieved prior to the aircraft departing

:uhoh: Goodness Me.

[Herod]

Nice to see that the Captain "scrambled". I should think after landing, he probably boiled, and if he had found the culprit, that man would have been fried.

[Chronic Snoozer]

I have read the ATSB report and have to say I am disappointed in the findings.
Not once does the report mention training, and the solution is to bark a bit louder at the employees , no mention of training whatsoever.
The Leading Hand placed the clipboard in the engine.....training ?
The dispatcher did a walk around and saw the clipboard but she thought it didn’t qualify as FOD as it was the aircrafts loading paperwork......training?
The problem wasn’t that the manuals had the wrong words in them, the problem is that the employees are ill equipped to hold the responsibility of their roles. That’s not their fault, they haven’t been trained properly because it costs too much.

Completely agree. All the layers of OHS and risk management BS that companies force us to endure can't replace common sense. Abject failure of the training system - which always sucks the hind teat of the sow that aviation has become.

[framer]

How much training is needed to learn you don't use a jet engine intake as a desk??

Well, if you offer a low hourly rate and employ people who may or may not have experience in the aviation environment then you need to provide more training ( initial and ongoing) than if you pay more and get aviation folk who stick around the industry for decades and mentor their co-workers without even knowing it.
There is no free lunch.
My disappointment lay in the fact that the ATSB doesn’t have the courage to identify the real cause and is satisfied with supporting the way things are currently done even when safety is impacted. Or are the ATSB so inept now days that they believe what they wrote?

[GA Driver]

Wonder how long before the clipboards will need to be made from the hi vis vest material with reflective racing stripes. :rolleyes:

[The Banjo]

Wonder how long before the clipboards will need to be made from the hi vis vest material with reflective racing stripes. :rolleyes:


With a red ASIC:sad:

[ruprecht]

From Pravda:

1. ATSB report – A report into a Sydney-bound Jetstar flight that returned to Auckland in October last year has been released. The aircraft returned after a clipboard was ingested into one of the A320’s engines. The report by the Australian Transport Safety Bureau (ATSB) found the plastic clipboard was inadvertently left on the aircraft’s engine cowl by the ground handler at Auckland Airport just prior to departure. The incident did not impact the safe operation of the flight, and procedures have since been updated to include a specific warning about placing items in the engine cowling.

Well, that fixes everything. :rolleyes:

[itsnotthatbloodyhard]

Excellent news. They can put stuff in the pack inlets instead.

If it’s the same mob we use in Auckland, then they come across as more of a mature-age work experience program.

[jugofpropwash]

Wonder how long before the clipboards will need to be made from the hi vis vest material with reflective racing stripes. :rolleyes:

Perhaps a warning label on the clipboard: "Do not place inside engine!"

[MarkerInbound]

Or a label on the inlet - No Storage Here.

[Traffic_Is_Er_Was]

They just need "Remove Before Flight" flags hung on them.

[ozziekiwi]

Excellent news. They can put stuff in the pack inlets instead.

If it’s the same mob we use in Auckland, then they come across as more of a mature-age work experience program.


Jetstar and Aerocare, which manages ground crews in New Zealand, released a notice saying engines must not be used for the placement of any foreign objects.
On Tuesday, a Jetstar spokesman said while the incident "didn't impact the safe operation of the aircraft, we take it very seriously".
"Since this occurred we have updated our procedures which includes a specific warning about not placing items in the engine cowling and improved detail around checks and responsibilities of the aircraft dispatch process."


https://www.stuff.co.nz/travel/travel-troubles/101831252/aussie-safety-agency-reports-on-auckland-airport-jetstar-flight-clipboard-scare

[belowMDA]

There is a lot about this incident that concerns me. However if we put aside the fact that it happened, why the hell did the Captain have to do all the leg work to find out the details from various sources. Surely Jetstar has an operations centre that should have bent over backwards to investigate and inform the crew what had happened. How does it make it better to impede the Captains ability to make a sound decision but not proactively giving him/her all the details up front?
I had heard Jetstar don't have ACARS, but surely they have a bloody sat-phone? Or is it just an old HF patch?

[HOOROO]

Jetstar definitely do have ACARS, Sat Phones only on the new A321’s and yes a very annoying HF patch.
Unfortunately it’s not uncommon to have issues trying to get through to Maintenance Watch which may have happened in this case

[Ollie Onion]

In his case they were having to converse with the Company on HF which is hard to do at the best of times. Also the real-time engine data isn’t controlled by Jetstar and has to be sourced from Qantas so takes forever.

[Ascend Charlie]

The pilot checklist will be amended to read:
Before Starting Engines:
*Ask ground crew to hold up their clipboards, and conduct a count of those who do not have a clipboard showing.
*If the count is Zero, proceed with engine start.

[havick]

Excellent news. They can put stuff in the pack inlets instead.


You win the internet this week.

[megan]

The engine damage was caused by silica gel dessicant bags which were accidentally left inside the air intakes for the port engines. When the take off run was initiated, the gel bags were unfortunately sucked through the engines and caused major internal compressor and combustion chamber damage.

https://www.youtube.com/watch?v=YzkQ7sSpATU

[michigan j]

Wouldn't it be easier to re-certify the engine to accept clipboard ingestion?

[Icarus2001]

No mention of the despatch/starter who probably called clear to start two?

[Sue Ridgepipe]

“While this incident didn’t impact the safe operation of the aircraft Really?.....

[glad rag]

Nice to see that the Captain "scrambled". I should think after landing, he probably boiled, and if he had found the culprit, that man would have been fried.

So dispatchers are trained to examine aircraft for serviceability now....

[Uplinker]

Everybody involved around an aircraft should keep aircraft servicability in mind, and if something odd is noticed, they should bring it to the crew’s or push chief's attention. Over the years, I have occasionally been called out by a loader to check a hold door, or an oil/hyd leak, and I never mind checking.

The incident in this thread reminds me of the BA double cowl unlocked incident.

What ever happened to:

“Ground from flight deck, can I have your checks please?”

“Yes flight deck; all equipment removed, all hatches and holds secure. All intakes clear, beacon rotating, tug connected, chocks removed, standing by”.

?

[framer]

So dispatchers are trained to examine aircraft for serviceability now....
Anyone who works on the ramp around operating airliners should be trained on the basics. This is the basics. When was the last time you saw anyone other than an Engineer or Pilot picking up FOD? It’s rare even with the trained folk now days. The ramp culture of times past has been diluted to the point that it’s rare to see it raise its head. Don’t worry though, you can fly to the Goldie for $98.

[Boe787]

This type of incident is the end result when you have Poorly paid/poorly trained Ground Staff!

[Bend alot]

Surprised passengers did not report confetti.


Surprised the pilots pressed on for a "considerable time" if they had concerns about the engine that was indicating and operating normally.


- Serious question, What is the procedure for keeping the paperwork dry for the ground crews when it is raining?

[GA Driver]

Serious question, What is the procedure for keeping the paperwork dry for the ground crews when it is raining?
There isn't one, its common through winter to be handed 3 or 4 sheets of dripping wet paper that by this stage often resembles toilet paper.

[framer]

Don’t get wound up, the safety of the flight was never effected.

[tdracer]

Really?.....
Sue, modern engines are certified to ingest much larger/harder items than a clipboard - bird ingestion tests are far more challenging.
Perhaps some small deformation of a few fan blades where they impacted the metal clip on the clipboard and some impact damage to the acoustic lining aft of the fan after the big bits got flung outward.
Now, if he'd left a large wrench in the inlet....

[framer]

This could easily have caused enough damage to cause an accident and it did impact on the safety of the flight. Anyone who says differently is either lying or doesn’t understand what safety is.

[Piltdown Man]

It was brave of the guy to admit leaving the clipboard in the engine intake. Judging by the comments of the “hang him high” brigade, this might be the last time that anyone will admit to making a mistake, and who could blame them? May I make a suggestion to the punishment brigade? The next time someone fouls up, gets it wrong, forgets something etc. don’t rip their ears off, even if you think it is deserved. That is the reaction of a bully who deserves a proper punishment, if for no other reason than your actions endanger my flights. You are given the responsibility of ensuring the safety of the aircraft and everyone and everything on and around it. So make sure you creatte the environment around you to that will enable you to play your part in the process.

And the solution is NOT:

What ever happened to:

“Ground from flight deck, can I have your checks please?”

“Yes flight deck; all equipment removed, all hatches and holds secure. All intakes clear, beacon rotating, tug connected, chocks removed, standing by”.


That is just their creed. Those words are little more than hot air and a way of shifting the blame. I want people to REALLY look and give me something in their own words that we are ready for a pushback (but I also don’t want a engineering check unless the guy or girl is an engineer).

Safe flying,

PM

[framer]

I think you’ve misread the tone of the thread PM. Who wants to ‘hang em high’? I’m advocating for the ground crew, not against them.

[Piltdown Man]

I agree, you are part if the solution. But the same can not be said of others. Poor training of ground crew and useless, unserviceable, poorly designed equipment are major factors that result in unnecessary incidents. Shouting at the poor sod who cocked up will bring about the wrong sort of change. And as many have pointed out above, the main problem is the result pernicious penny pinching by greedy senior management. Only when they become criminally liable for their company’s performance will there be change. A few weeks avoiding prison showers often brings about change in their outlook.

In this instance, the provision of a lightweight waterproof document box might have prevented this dispatcher from using the engine intake as a rain cover. Another solution is a car set up as a mobile office.

PM

[Bend alot]

Site Office vans sounds like a perfect idea to me Piltdown Man - helps in high wind too.


Personally in this case I don't see much safety issue after the fact of take-off and a delay to be notified of FOD being a clip board. A tool kit maybe if no sockets found on tarmac or runway.

- Another serious question. Do twins on ETOPS require instant and continues access to live engine data from a secondary or tertiary provider?

[ruprecht]

Maybe there should be an all ranks FOD walk, joined by senior management.

:p

[tdracer]

This could easily have caused enough damage to cause an accident and it did impact on the safety of the flight. Anyone who says differently is either lying or doesn’t understand what safety is.
I guess 40 years experience working high bypass turbine engines, and 25 years on the Boeing Propulsion Safety Board means I don't understand what safety is. :*
Leaving FOD in the inlet is certainly bad, but it's quite a stretch to say a single clipboard was going to cause an accident. The engine is certified to keep operating after taking 6 large birds going 200+ knots - all at the same time. A clipboard sucked out of the inlet is far less challenging to the engine.

[Tankengine]

I guess 40 years experience working high bypass turbine engines, and 25 years on the Boeing Propulsion Safety Board means I don't understand what safety is. :*
Leaving FOD in the inlet is certainly bad, but it's quite a stretch to say a single clipboard was going to cause an accident. The engine is certified to keep operating after taking 6 large birds going 200+ knots - all at the same time. A clipboard sucked out of the inlet is far less challenging to the engine.

On the other hand I sucked in a crow (classified as one small bird?) on a 737-400 and the engine needed two new fan blades. No accident, In fact no change to engine parameters and damage not confirmed until looking at the engine after landing but a reduction in safety for sure.

[framer]

I guess 40 years experience working high bypass turbine engines, and 25 years on the Boeing Propulsion Safety Board means I don't understand what safety is.
Maybe, maybe not.
Do you think that leaving the clipboard in the intake impacted the safety of the flight? If you don’t, then you don’t understand safety (in my opinion of course). I’m sure you understand engines.

[tdracer]

This could easily have caused enough damage to cause an accident
I was specifically responding to this statement. Leaving a clipboard in the inlet is bad. It can cause damage and reduce the margin of safety. "Easily cause an accident"? Not by a long shot. Engine are tested and certified to survive far worse and keep running.
As for impacting safety of the flight - perhaps by a small amount. But several other holes in the cheese would need to have aligned before it could possibly become meaningful.
MMEL dispatch also results in a small reduction in safety and aircraft depart under MMEL restrictions all the time. Or are you suggesting MMEL dispatch be banned since it impacts safety of the flight?

[framer]

I was specifically responding to this statement.
Fair enough. It’s very likely that I worded it in an ambiguous way ( English/grammar not my strong suite).
I was more focussed on the Airline putting out a statement that the safety of the flight was never impacted/ effected, whatever they said. It irks me that they cut costs to the extent that ground handlers don’t get the training they ( and the public) deserve and then roll out trite statements which are not true. The safety of the flight was effected.
You have a lot of engineering experience, do you think it is possible that the airflow could have been affected to the point that a surge or stall occurred during the take off roll?
I remember a rolls Royce engine stopping after a single rivet head bounced around the intake for a bit before making its way past the first stage. Admittedly that was over 20 years ago and the engine wasn’t high bypass.
I also remember an A320 having an engine shut down due to a single black backed gull, I imaging a metal clip could do more damage than a black backed gull.
On 20 June 2012 an Air New Zealand Airbus A320 was landing at Wellington International Airport when it suffered a bird strike to its right engine. The bird strike did not affect the landing. The bird was later identified as a black-backed gull.
1.2. Maintenance engineers inspected the engine in accordance with the Airbus aircraft maintenance manual and released it back into revenue service later the same day for a flight to Auckland with 172 persons on board, including five crew members.
1.3. The Airbus aircraft maintenance manual required parts of the engine to be inspected using a borescope.2 However, as the bird strike had involved only one engine and no damage had been observed, the aeroplane was allowed to continue in service for up to 10 hours’ flying or one more sector (one more take-off and landing), whichever came first. The engine was then required to undergo the borescope inspection. The aeroplane was released to fly to Auckland under this “continued operating allowance”.3
1.4. On approach to land at Auckland International Airport the same engine suffered a failure. The captain reduced the engine thrust to idle and continued with the landing. Although damaged internally, the engine continued to run and was used during the landing.
1.5. An inspection of the failed engine revealed damage to components caused by the bird being ingested down the core of the engine.4 This damage had led to cracking in a compressor blade in the third-stage compressor. The crack in this blade grew further under the stress of continued engine operation in a damaged state. It finally fractured completely and caused significant damage to other components as it passed through other compressor stages in the jet engine.
I’m not sure how that ties in with The engine is certified to keep operating after taking 6 large birds going 200+ knots - all at the same time. A clipboard sucked out of the inlet is far less challenging to the engine.
Another thing to keep in mind is that during the last ten of your 40+ years things have changed, it’s not just the ground handlers who have been on the receiving end of a complete lack of quality training and investment. There is every chance that the guy or girl pulling back on the side stick is up to their eyeballs in debt with a nauseating roster behind them and absolute minimum number of sims and ground classes with both their type rating and recurrent training.
But several other holes in the cheese would need to have aligned before it could possibly become meaningful.
Those holes are in layers of defence.
At the Industry level, the regulators are handing over the monitoring and regulating of safety to the Airlines themselves as long as the Airline can point to systems in manuals that would work if human nature was out of the equation. The slice of cheese is thinner and has more holes.
At a Company level, management earn bonuses for hitting KPI’s that are almost exclusively cost related. Their kids school fees literally depend on them cutting costs. You can still smell the cheese but it’s so thin you can’t see it.
At an Operational level, we have the problems we see here, communication is difficult, systems don’t work well ( why was the tug not there, why was there nowhere to keep the paperwork dry, why did the dispatcher not have a sound understanding of what FOD is?) The cheese has more holes than last decade.
At an Individual level we have people not trained as well as they used to be. In addition, they have less experience than in days of old ( 1990) their workload has increased and their shift work has got shiftier, their pay checks don’t go as far and they see little security in their jobs and as a result have less loyalty, and strive ( on average) for a lower bar. More holes, thin cheese.
That’s my thoughts anyway :)
Have a good day.

[Icarus2001]

https://s3-ap-southeast-1.amazonaws.com/a2.datacaciques.com/00/MTI5OTk/b1b818a9409dd852/a3d04b4e8e3b6be4.jpg

Very cheap solution as used...elsewhere.

[Bend alot]

Looks like they double as a rain water gauge, if any ground staff need to actually fill out any paperwork on the ground!

[Icarus2001]

What is wrong with standing under a wing out of the rain, being in the hold or shock horror, fill out the paperwork once on the aerobridge or in the aircraft.

Have you seen these...

https://cdn.shopify.com/s/files/1/0227/0033/products/Davek_Umbrella_Elite_Open_Straight.jpg?v=1487711086

[GA Driver]

They’re all great ideas but you’re confusing common sense and ‘reasonableness’ with the Jetstar business model......
Aerobridge? What’s that??? Sydney yes, almost all other ports no.

Umberella? Fantastic idea, but all banned as FOD from anyone on the apron. I’ve seen many pax berated by ground staff because they had the audacity to open their umberella and endanger all the other people and engines around them. :rolleyes:

Flight deck is a great idea, but most pilots have kicked them out due to the ongoing distractions and radio they carry that needs to be at 300db.......

[Icarus2001]

Flight deck is a great idea, but most pilots have kicked them out due to the ongoing distractions and radio they carry that needs to be at 300db.......

I specifically did NOT say on the flight deck, so do not misquote me.

[GA Driver]

Sorry.... accident.
You said on the aircraft, which leaves nowhere else BUT the flightdeck on a JQ sardine can.