What happened
On 28 December 2005, an A330-300, registration EI-ORD, operating a public transport flight from Dublin to New York, was involved in a serious ground incident. During the loading process, a baggage loading shift leader entered the aircraft's cargo hold to retrieve a piece of luggage that had been incorrectly loaded into a Unit Loading Device (ULD) intended for a different flight. While the leader was working in Hold 4, other members of the loading crew, unaware of his presence, proceeded to close the bulk cargo door.
As the aircraft commenced its pushback from the stand, the leader realized he was trapped inside the hold. Although the cargo holds were illuminated, the leader did not notice the aircraft moving until the engines had powered up. He was able to contact the base supervisor's office via a mobile phone, which led Air Traffic Control to notify the flight crew. The aircraft subsequently returned to Stand 55, where the door was reopened and the staff member was safely released. There were no injuries and no damage to the aircraft.
The investigation
The investigation focused on the sequence of events leading to the entrapment and the communication gaps between ground personnel. It was established that while the shift leader had informed a ramp agent and one crew member of his intent to retrieve the bag, this information was not passed to the specific loaders responsible for closing the cargo door.
Investigators found that the crew used a "thumbs up" signal to indicate the aircraft was ready for closure, but the leader was out of sight in a different compartment at the time. Furthermore, the investigation noted that the shift leader's training and the airline's existing protocols did not include specific procedures for closing up an aircraft or managing the late removal of items from the holds. The investigation also highlighted that there was no dedicated communication system in place for a loading leader to immediately alert a ramp agent of an emergency.
Findings
- The aircraft was pushed back and began taxiing while the loading shift leader was still inside the No. 4 cargo hold.
- A breakdown in communication between the loading staff meant the crew members closing the door were unaware the leader was still inside the aircraft.
- There were no formal written procedures for the aircraft close-up process or for handling the late removal of baggage from the holds.
- The shift leader was unable to alert the ramp agent directly due to the lack of an immediate communication system.
Safety action
Following the incident, the following safety recommendations were issued to the operator:
- Development of a formal procedure for the aircraft close-up process.
- Establishment of procedures for the late removal of items from cargo holds.
- Implementation of a communications system to allow loading leaders to alert ramp agents of emergencies immediately.