Air Accident Investigation Unit

Ireland

IncIdent RepoRt Boeing 737-8AS, eI-enB

Kerry Airport (eIKY), co. Kerry, Ireland 21 december 2010

Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010

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Air Accident Investigation Unit Report 2012-004

AAIU Report No: 2012-004

State File No: IRL00910128

Published: 29/02/2012 In accordance with the provisions of SI 460 of 2009, the Chief Inspector of Air Accidents, on 22 December 2010, appointed Paddy Judge as the Investigator-in-Charge to carry out a Field Investigation into this Incident and prepare a Report. The sole purpose of this Investigation is the prevention of aviation Accidents and Incidents. It is not the purpose of the Investigation to apportion blame or liability.

Aircraft Type and Registration: Boeing 737-8AS, EI-ENB

No. and Type of Engines: 2 x CFM56-7B

Aircraft Serial Number: 40289

Year of Manufacture: 2010

Date and Time (UTC): 21 December 2010 @ 09.13 hrs

Location: Kerry Airport (EIKY), Co. Kerry, Ireland

Type of Flight: Public Transport, Scheduled

Persons on Board: Crew - 7 Passengers - 170

Injuries: Crew - Nil Passengers - Nil

Nature of Damage: None

Commander’s Licence: JAA ATPL(A)1

Commander’s Details: Male, aged 47 years

Commander’s Flying Experience: 13,000 hours, of which 6,100 were

on type

Notification Source: ATC Duty Manager Shannon

Information Source: AAIU Field Investigation

AAIU Report Form submitted

by Commander

1 JointAviationAuthoritiesAirTransportPilotLicence(Aeroplane)

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SYNoPSIS

Shortlyafterlanding,smokewasobservedinboththecockpitandcabin.Theaircraftwasstopped,theengineswereshutdownandanevacuationwascarriedout.Notechnicaldefectwasfoundduringthesubsequentexamination.Itisprobablethatthesmokewascausedbytheenginesingestinggranularurea,whichhadbeenusedtode-icetherunwayduringaverycoldweatherperiod.

NoTIFICATIoN

TheAirAccidentInvestigationUnit(AAIU)wasfirstinformedoftheoccurrencebytheAirTrafficControl(ATC)StationManageratShannon.AnAAIUResponseTeamoftwoInspectorsdispatchedbyrailinmoderatesnowtoEIKYandarrivedat18.30hrs.

1 FACTUAL INFoRMATIoN

1.1 History of the Flight

TheflightdepartedfromStanstedAirport(EGSS)intheU.K.andflewdirectlytoEIKY.ThecockpitcrewconsistedofaCommander,whowasaninstructorpilot,anewlyqualifiedFirstOfficer(FO),whowasmakinghisfirstlandingwithpassengersonboardandaSafetyPilot(SP)occupyingthejumpseat.TheFOwasthePilotFlying(PF)andtheCommanderwasthePilotNon-Flying(PNF).

Theweatherconditionsweregoodfortheapproachandtherunwaysurfacewasreporteddry.Thedescent,approachandlandingwerereportednormal.Afterlandingreversethrustwasselected.AstheaircraftdeceleratedtheSPreportedsmokeontherighthandsideofthecockpit.Theaircraftwasturnedofftherunwayandbroughttoahaltonthetaxiwayadjacenttotheramp.ShortlyafterwardstheCabinServicesSupervisor(CSS)alsoreportedsmokeinthecabin.

Theengineswereshutdownandanevacuationwasimmediatelycommencedfollowingwhichthepassengerswalkedtotheairportterminalbuilding,ashortdistanceaway.

1.2 Commander

TheCommanderreportedthatafteranuneventfullandingbytheFOonRunway(RWY)26hetookcontroloftheaircraftatabout60kts,aspernormalprocedure.Atabout50ktstheSPreportedsmokeontherighthandsideofthecockpit.ThiswasfollowedbyacallfromtheCSSthattherewassmokeinthecabin.Atthetimetheaircraftwasturningofftherunwayontothetaxiway.

HereportedthatthesmokecontinuedtothickenontheflightdeckandhetoldtheFOtodonhisoxygenmaskasthesmokewasdenseontherighthandsideofthecockpit.OnhearingthecallfromthecabinheaskedtheSPtoansweritandtoopenthecockpitdoortoviewthecabin.Hestatedthathewasunabletoseethebackofthecabinclearlydueto“grey/blue slightly acrid smoke”.Basedonthisassessmenthedecidedtoimmediatelyevacuatetheaircraft,thisbeingthesafestoption.Hethenshutdowntheenginesandcarriedouttheevacuationprocedures.

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Air Accident Investigation Unit Report 2012-004

Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010

1.3 Safety Pilot (SP) TheSPstatedthatATChadreportedthattherunwaywasdryforlanding.Thelanding,whichwas

conductedwithflapsat40andauto-brakesettingat3,wassmoothandnormalreversethrustwasused.

Duringthelandingrollhesawblue/violetsmokeontherighthandsideoftheflightdeck,whichhereported.Thesmokeormistwasacridandaffectedthebackofhisthroat.

HeansweredacallfromtheCSSwhotoldhimthattherewassmokeinthecabin.Whentheaircrafthadstoppedheopenedthedoorandlookedbackdownthecabin.Hestatedthathecouldseeabouthalf-waydownthecabin.

Hemadea“PAN2”transmissiontoATCandsaidthattheFireServicesreactedverypromptlytothiscall.HestatedthattheAuxiliaryPowerUnit(APU)wasnotstartedaftershutdown.

1.4 Cabin Services Supervisor (CSS)

TheCSSreportedthatwhenheobservedvapourlikesteamalloverthecabinafterlandinghecalledthecockpit.Hesaidthatthevapourappearedverydenseintheflightdeckwhenthecockpitdoorwasopenedandthatitseemedtobegettingdenserinthecabinatthetime.

Hesaidthathehadneverseenthisamountofvapourinthecabinbeforebutthathehadheardthatanincidentofasimilarnaturehadhappenedtoacompanyaircraftsomeweekspreviously,whichhebelievedmighthavebeenduetode-icingfluid.HehadtriedtocommunicatethistotheSPwhoansweredhiscallfromthecockpit.

FollowingtheCommander’sordertoevacuate,whichwasgivenoverthepublicaddress(PA)system,heandthecrewimmediatelycommencedanevacuationusingallexits.

Hestatedthatduringtheevacuationallfourdoorslideswereusedaswellasthreeofthefourover-wingexitsandthattheevacuationwascompletedinabout30seconds.TheCSSreportedthatapassengerhadbeenunabletoopenoneover-wingexit,whichwasthereforeunused.However,itwassubsequentlyfoundtobeserviceablewhenchecked.Theover-wingexitswerenotmannedbythecabincrewbutapassengerclosetoeachhadbeenearlierbriefedonhowtoopenit.

Hereportedthatitwasverydifficulttodealwiththosepassengerswhobroughtcarry-onbaggagewiththemduringtheevacuation,eventhoughtheyhadbeentoldnottobringanything.Hesaidthatitwasnotpossibletoremovehandbaggagefromindividualsduringtheevacuationwithoutdisruptingtheevacuationflowandreducingtherateofegressofpassengers.Hestatedthatcrowdcontroloutsidetheaircraftwasdifficult,eventhoughheusedaloudhailer.

1.5 Injuries to Persons NoinjurieswerereportedtotheInvestigation.

1.6 Damage to Aircraft Theaircraftwasnotdamaged.

2 PAN: Whena“PAN-PAN”radiotransmissionisrepeatedthreetimesitindicatesthatanurgentmessageaboutthesafetyoftheaircraftisbeing

transmitted.

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1.7 Licences

TheCommander’slicencewasaJointAviationAuthorities(JAA)AirlineTransportPilotLicence(ATPL),issuedbytheCivilAviationAuthority(CAA)UK.

Hislicence,typeratingandClassOnemedicalcertificatewerevalid.Hehadatotalof13,000flyinghoursofwhich6,100hourswereontheB737-800type.

TheSPheldaJAAATPLlicence,issuedbytheIrishAviationAuthority(IAA).Hislicence,typeratingandClassOnemedicalcertificatewerevalid.Hehadatotalof2,600flyinghoursofwhich2,300hourswereontheB737-800type.

TheFOheldaJAACommercialPilotLicence(CPL),issuedbytheIAA.Hislicence,typeratingandClassOnemedicalcertificatewerevalid.Hehadatotalof322flyinghoursofwhich2.5hourswereontheB737-800type.

Thetrainingrecordforeachcabincrewmemberwasfoundtobecurrent.

1.8 Hand Baggage

AirportsecuritycamerasrecordedthatthefirstFireServiceappliancearrivedattheaircraft22secondsaftertheaircraftcametoahalt.Oneminuteandfivesecondslatertheportdoorsopened,theslidesinflatedandpassengersimmediatelybegantoleavetheaircraft.Thesecuritycameras(Photo No. 1)recordedthatasignificantnumberofthepassengerscarriedhandbaggageastheywalkedtowardstheairportterminalbuilding.

Photo No. 1: Passengers after emergency evacuation.

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Air Accident Investigation Unit Report 2012-004

Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010

TheInternationalCivilAviationOrganisation(ICAO)TrainingManual,Document7192,PartD-3containsproceduresregardingcarry-on/handbaggage.However,theNationalTransportationSafetyBoard(NTSB)oftheUnitedStates,inaSafetyStudy3of46emergencyevacuationspublishedin2000,identifiedthatnearly50percentofpassengerswhobroughtcarry-onluggageonboardattemptedtoremoveabagduringemergencyevacuations.Reportsissuedbyotherinvestigativeauthoritiesonotherevacuationshavefoundthatsomepassengershaveresistedtheremovalofcarry-onbaggagebycabincrew,therebydisruptingorderlyevacuation.

1.9 Weather

TheweatherreportforEIKYatthetimeoftheincidentwasthatthewindwascalm;thevisibilitywasinexcessof10km.Therewassomecloudat3,000ftwithatemperatureof-9ºCandadewpointof-11ºC.

ThemonthofDecember2010inIreland,duringwhichtheincidentoccurred,wasthecoldestsinceweatherrecordscommenced,consequentlythenormalsuppliesofrunwayde-icingfluidhadbeenexhausted.

TheAirportinformedtheInvestigationthatalthoughsnowhadbeenexpectedduringtheearlymorningperiodthishadnotoccurred.

1.10 Site Inspection

Theaircraftwasinspectedandnodefectortechnicalanomalywasfoundwhichcouldexplainthepresenceofsmokeduringthelandingroll.

TherunwayandtaxiwaywereinspectedbytheInvestigationthefollowingmorning.Thesehadbeensweptclearofsnow,whichhadbeenremovedtothesidesoftherunway.Thecentresectionoftherunwaywasbareandclearbutfoundtobelightlycoveredbysignificantamountsofgranularureathathadbeenspreadontherunwaybyamechanicalspreader.

1.11 Runway Anti-Icing Agents

1.11.1 General

Olderrunwayde-icing/anti-icingmethods,suchastheapplicationofureaorglycol,arenolongerusedastheyhavebeenreplacedbymoremodernmethodsthataremoreenvironmentallyfriendlyinthemain.Inaddition,chloridesalts,commonlyusedonroadsetc.,cannotbeusedwhereaircraftmoveduetotheircorrosiveeffectonaircraftstructuresandsystems.

1.11.2 Urea

Ureagranulesarecolourless,odourlessandhaveameltingpointof132.7ºC.Asampleofthegranularureausedontherunwaywasobtained,whichwasheatedusinghotair.Itinitiallymeltedtoaclearliquidthatsubsequentlyboiledwithanacridandpungentsmell(ammoniaisreleasedoncontactwiththewatervapourintheair).Agreyhuewasobservedintheairandapowderyresidueremainedaftertheliquidhadevaporated.

Whenureaisusedasananti-iceformationagent,precipitation(snoworrain)fallingontheureadissolvesit.Theresultingmixturehasalowerfreezingpoint.Thougheffectivedownto-9.5ºCitisoflimiteduseattemperaturesbelow-4ºC.

3 NTSB/SS-00/01,titledEmergency Evacuation of Commercial Airplanes

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1.12 Cockpit Voice Recorder (CVR)

TheCVRwasdownloadedandwasfoundtobeofgoodquality,butitwasdifficulttodecipherduetothesoundofbreathingsubsequenttotheFOdonninghisoxygenmask.TheCVRconfirmedtheaccuracyoftheflightandcabincrew’srecollections.However,itterminatedwhiletheengineswerespoolingdownanddidnotrecordthesubsequentevacuationorder,PAannouncementsortheconductofassociatedprocedures.

TheCVRelectricalpowersourceonthisaircraftisfromthe115VACTransferBusNo.2.ThisBusisde-energisedwhentheenginesareshutdownunlesstheAuxiliaryPowerUnit(APU)isrunningwithitsgeneratoronlineorexternalpowerhasbeenconnected;insuchcasestheCVRwillthenrunforanadditional5minutes.

IfneitherexternalnorAPUelectricalpowerisavailable,theCVRceasesrecordingwhentheelectricalpowersupplyfromtheenginesislostduringshutdown.

1.13 AAIB Safety Recommendation (SR) 2005-075

FollowinganinvestigationintoanincidentinvolvingaUnitedKingdomregisteredaircraftin2005theUKAirAccidentInvestigationBranch(AAIB)issuedSafetyRecommendationNo.2005-075,whichstated:

For newly manufactured aircraft, the Joint Airworthiness Authorities should require that the cockpit voice recorder and cockpit area microphone are provided with an independent 10 minute back-up power source, to which the cockpit voice recorder and cockpit area microphone are switched automatically, in the event that normal power is interrupted.

1.14 CVR Power Supply

TheInvestigationnotesthat,inresponsetoAAIBSR2005-075, theEuropeanAviationSafetyAuthority(EASA)currentRulemakingProgrammefor2012-2015,TaskNo.RMT.0268proposesarevisionofFDRandCVRcertificationspecifications.However,notimingorworkmethodforthisTaskisscheduledintheProgramme.

TheInvestigationnotesthattheFederalAviationAdministration(FAA)2010RuleOptionrequiresthatCVRsofnewB737aircraftmusthaveOption2371B628B41CVRPower–RIPS4,whichprovidesforanindependentpowersupplytopowertheCVRforanadditional10minutesintheeventthatnormalpowerislostorinterrupted.HoweverthisoptionisonlymandatoryforaircraftregisteredintheUnitedStates.ThereisnoequivalentrulingintheEuropeanUnion.

On31January2011theInternationalCivilAviationOrganisation(ICAO)issuedStateLettersproposingthatAnnex6Part1,(CommercialAirTransport–Aeroplanes),Section6.3.4.1,incorporatesaprovisionthatanalternateCVRpowersupplyengagesfor10minuteswhennormalpowertotheCVRislost,whetherbyenginesshutdownorbyanyotherlossofpower.Thisproposalwouldbecomemandatoryforaircraftover27,000kgsforwhichtheapplicationfortypecertificationissubmittedonorafterthe1January2018.

4 RIPS:RecorderIndependentPowerSupply

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Air Accident Investigation Unit Report 2012-004

Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010

1.15 Previous Incident

AsimilarincidenthadoccurredononeoftheOperator’sflightstoGirona(Spain)threeweekspreviously.Thepilotsubsequentlyreportedthatduringthelandingrollbluesmokeappearedintheflightdeckaccompaniedbysmokeinthecabin.A“PAN”callwasmade,butasthedistancetotheairportterminalwasshorttheaircraftwastaxiedtowardsthestand.Thesmokeclearedanddidnotreturn.

Whentheaircraftarrivedonstandtheengineswereshutdownandthepassengersdisembarkednormally.Followingthisthesubsequentengineeringinvestigationfoundnocausefortheincidentandtheaircraftwasreleasedbacktoservice.Itoperatedthereafternormallywithnofurtherreportofsmoke.

1.16 De-icing and Anti-icing

IAAguidanceonmovementareade-icing/anti-icingtoairportoperatorsisprovidedinALM002ofwhichSection7.3.12referstoICAOAirportServicesManual,Part2(Doc9137).Chapter7.1.1ofthisdocumentaddressestheissuesofsnowandiceremovalfromthemovementareaandstates:

It is impossible to decide, in advance, on the measures that should be adopted in order to improve the friction coefficient (μ value) on a movement area where ice, snow, slush, water and other contaminants result in impaired friction characteristics since, at a particular airport, the meteorological conditions can lead to a number of different situations demanding entirely different countermeasures.

Ingeneralliquidpotassiumacetate(KAc)isusedatIrishAirportsasananti-icingagent.Thiscanalsobespreadinconjunctionwithurea(hopperspreadbeforehand),inwhichcaseKAcdissolvestheureagranules.SincesuppliesofKAcwereexhaustedbythetimeoftheincidentureawasusedonitsown.

TheIAAsubsequentlyinformedtheInvestigationthatairportshaveincreasedtheirstocksofKActoensuretheywillhavesufficientstockanditisnotanticipatedthatureawillbeusedwithanyleveloffrequency.

2. ANALYSIS

2.1 General

ThetechnicalexaminationoftheaircraftbytheInvestigationfoundnofaultintheaircraftoritssystems.Theaircraftwaslaterreleasedtoserviceandthereafteroperatednormally.

AtthetimeoftheincidenttheweatherinIrelandhadbeenunseasonablycoldforthepreviousmonth.Becauseofthis,thesuppliesofrunwayde-icingfluidhadbeenexhaustedatEIKYand,ifairportoperationsweretocontinue,granularureawasoneofthefewalternativesavailable.Thiswasspreadontherunwayasananti-icingmeasureinordertoallowcontinuedsafeoperationofflightsfromtherunway.Inthiscase,althoughsomesnowhadbeenexpected,nonehadfallenandconsequentlytheureahadnotdissolvedandsignificantamountsremainedingranularformonthecentreoftherunway,whichwasbareandclearofsnow.

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Afterlanding,theenginesspooledupduetoreversethrustbeingselected,aspernormalprocedures.Itisprobablethattheureaontherunwaywastheningestedintotheenginesandrapidlyheatedtoahightemperaturebyenginecompressionbeforebeingdispensedbytheairconditioningsystemthroughouttheflightdeckandcabin.

Thiswouldhaveresultedintheacridsmokeobservedinboththecockpitandcabin.

2.2 Evacuation Order

Whensmokewasreportedinthecockpit,theaircraftwasdeceleratingandapproachingashorttaxiwaythatledtotheramp.CCTVrecordedtheaircraftcomingtoastopontherampandlaterthedoorsopeningandtheevacuationcommencing.ItisunclearatwhatpointtheorderwasmadetoevacuatetheaircraftastheCVRrecordingstoppedduringengineshutdown.

AlthoughtheSCMmentionedapreviousincidenttotheSP,whoansweredhiscall,thisinformationwasnotconveyedtotheCommander.Inanycase,asnodetailsofthecauseofthatincidentwereavailable,itisunlikelythatitwouldhavebeenafactorintheCommander’sdecisionmakinghadhebeeninformed,asitsrelevancewasunknown.

Fireinanaircraftisamostseriousoccurrenceandifsuspectedmustbeaddressedimmediately.Thefirstpriorityisthesafetyofpassengersandcrew;iftheycanbeevacuatedsafelyitiscriticalthatthisisdoneassoonaspossible.Thereforewhenfacedwithacridsmokeinboththecockpitandcabinfromanunknownsourceandpossiblyafire,theCommandercorrectlydecidedtoshuttheenginesdownandorderanevacuation.

TheInvestigationnotesthat,althoughapassengerclosetoeachover-wingexithadbeenearlierbriefedonhowtoopenit;oneover-wingexitwasnotopenedduringtheevacuation.Neverthelesstheotherthreeexitswereopenedand,astheseover-wingexitswerenotmannedbythecabincrew,theevidencefromthisandotherevacuationssupportstheimportanceofbriefingpassengersatsuch“self-helpexits”.

Historicallyureawasoncecommonlyusedasananti-icingagentonrunwaysandtaxiways.Currently,itisrarelyusedandconsequentlyitsfumesandsmellarenotrecognisedwhenflightcrewareexposedtoitsaffectsforthefirsttime.Consequently,ifitisspreadonrunwayortaxiways,pilotsshouldbeadvisedaccordinglyandaSafetyRecommendationisissuedinthisregard.

2.3 Passenger Hand Baggage

TheairportCCTVrecordedpassengersleavingtheaircraftandapproachingtheterminalbuildingwithhandbaggage.TheSCMreportedthatsomepassengershadbroughttheirhandbaggagewiththemduringtheevacuationeventhoughtheyhadbeentoldnottodosointheevacuationannouncementmadebythecabincrew.

Passengerswhotakecarry-onbaggageofftheaircraftduringanemergencyevacuationimpedetheevacuationbecauseitrestrictstheevacuationflowrate,whichiscriticalespeciallyintheeventofafireorthesuspicionofone.Furthermore,aircraftemergencyslidesarenotdesignedtoaccommodatehandbaggageandcanthereforebedamaged.Thereisalsoasignificantriskthatapassengerwithhandbaggagecanlosebalancewhiledescendingtheslideandconsequentlysufferinjuryoncontactwiththeground.Inaddition,itdelaystheevacueeclearingawayfromtheslideafterdescent.Finally,itnegatesthecertificationprocessthatgovernsaircraftdesignandsafeevacuationprocedures.

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Air Accident Investigation Unit Report 2012-004

Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010

Thereasonsgivenbypassengersfortakingoffcarry-onbaggageincludethatvaluablessuchaswallets,passportsandkeysareintheluggage.Althoughitcanbearguedthatthefourcabinstaffcouldhaveforciblytakenthecarry-onbaggagefrompassengersduringtheevacuation,thiswasonlypossibleatthepassengerdoors,wherethecabincrewwerelocated.However,previousinvestigationshaveshownthatitwouldhavereducedevacuationflowratesaspassengersresistedand,bearinginmindtheextentoftheproblemrecordedinPhoto No. 1,itwouldnothavebeenpossibletosubsequentlystoreitwithoutblockingtheoppositeemergencyexit.Therefore,itwasnotpossible.

TheInvestigationbelievesthattheonlypracticaloptionforcabincrewistorepeatedlyandvigorouslyorderpassengersnottoremovecarry-onbaggageduringtheevacuation.

TheInvestigationisoftheopinionthatthisissueappliestomostCommercialAirTransport(CAT)aeroplaneoperationsthathaveanunplannedemergencyevacuationandtheNTSBstudyin2000hasshownthatalmost50%ofpassengerswithcarry-onbaggagetakeitwiththemduringanemergencyevacuation.TheInvestigationthereforeconsidersthatthisissueshouldbeexaminedbytheinternationalcivilaviationcommunityinordertopreventlossoflifeduringafutureemergencyevacuationwherespeedofevacuationisessential.AlthoughtheICAOTrainingManual,Document7192,PartD-3indicatestrainingrequirementsregardingcarry-on/handbaggage,thisisinthecontextofgeneraloperations.TheInvestigationisoftheopinionthatguidanceregardingemergencyproceduresshouldalsobegivenandconsequentlyaSafetyRecommendationisissuedtotheInternationalCivilAviationOrganisation(ICAO)inthisregard.

2.4 Cockpit Voice Recorder (CVR) Power Supply

BecausetheCVRrecordingstoppedduringengineshutdownitwasnotpossibletoclarifywhathappenedsubsequently,astheCVRnolongerrecordedactivitiesinthecockpitduetothefailureoftheelectricalpowersupplyfromtheengines.TheInvestigationnotesthatin2010theFAAintroducedarequirementthataCVRshouldcontinuetorecordintheeventofnormalpowerfailurefornewaircraftregisteredintheUnitedStates.However,thereisnosuchrequirementforaircraftregisteredintheEuropeanUnion.

TheInvestigationnotesthat,inresponsetoaUKAirAccidentInvestigationBranch(AAIB)SRNo.2005-075regardingCVRpowersupply,ataskwasallocatedinEASA’scurrentRulemakingprogrambutnotimeconstraintorurgencyisidentifiedforthisfuturework.

ThisInvestigationbelievesthisissueshouldbeaddressedandmakesaSafetyRecommendationtoEASAaccordingly.

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3 CoNCLUSIoNS

(a) Findings

1. Duringdecelerationfollowinganormallanding,acridsmokewasobservedinthecockpitandcabin.

2. Thesourceofthesmokewasnotidentified.

3. Theaircraftwasstoppedontherampandtheengineswereshutdown.

4. Anemergencyevacuationwassuccessfullyconducted.

5. Depositsofgranularurea,whichhadbeenusedasananti-iceprecaution,werefoundontherunway.

6. Theflightcrewhadnotbeenadvisedthatureawasbeingusedasananti-icingagent.

7. TheCVRrecordingceasedwhiletheengineswereshuttingdown.

8. Passengerstookcarry-onbaggageofftheaircraftduringtheemergencyevacuation.

(b) Probable Cause

Ingestionofgranularureawhileusingreversethrust.

(c) Contributory Factor(s)

Aprolongedspellofcoldweatherresultedingranularureabeingusedtoanti-icetherunwayafternormalde-icingfluidstockshadbeenexhausted.

4. SAFETY RECoMMENDATIoNS

It is recommended that:

1. TheIrishAviationAuthorityshouldrequireairportoperatorstoadvisepilots,viaNOTAM,ATISorVHFtransmission,whenureaisbeingusedasananti-icingagentonrunwaysortaxiways.IRLD201202

2. EuropeanAviationSafetyAgency(EASA)shouldintroducearequirementthattheCVRshouldcontinuetorecordintheeventofpowerfailure. IRLD201203

3. TheInternationalCivilAviationOrganisation(ICAO)shouldexaminetheissueofpassengerstakingoffcarry-onbaggageduringanemergencyevacuationandprovideguidanceforcabincrewinsuchsituations.IRLD201204

-END-

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and Investigation of Accidents, Serious Incidents and Incidents) Regulation, 2009, the sole purpose of these investigations is to prevent aviation accidents and serious incidents. It is not the purpose of any such accident investigation and the associated

investigation report to apportion blame or liability.

A safety recommendation shall in no case create a presumption of blame or liability for an occurrence.

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