What happened
On November 27, 2015, at Warsaw Chopin Airport (EPWA), a ground service operation involving a Dash Q-400 resulted in safety equipment being left in a hazardous position during engine start-up. Following the completion of baggage loading, the flight coordinator performed a walk-around inspection. During this process, a conveyor belt was moved away from the rear cargo hold, and the coordinator instructed ground personnel to clear the area under the aircraft.
While one ground worker removed warning cones from the right side of the aircraft, another worker, moving along the left side, bypassed the cones while heading toward a ground power unit (GPU). After the inspection, the coordinator used interphone communication to authorize the start of engine number 2, followed shortly by engine number 1. During this sequence, the GPU was disconnected and towed away from the aircraft.
A ground crew supervisor noticed the remaining cones near the engine nacelle and the left wingtip and attempted to alert the personnel towing the conveyor belt. Simultaneously, a "Follow Me" vehicle driver noticed the hazard and positioned the vehicle in front of the aircraft wing to alert the coordinator and prevent ground staff from approaching the running engine. Upon noticing the cones, the flight crew shut down the engine. The cones were subsequently removed, and the engine was restarted.
The investigation
The investigation established that all ground personnel involved were properly trained and held valid qualifications, though they possessed relatively short service experience in their current roles. The technical condition of the equipment was not a factor in the incident.
Findings
- Improper communication between the flight coordinator and the crew responsible for removing equipment led to the failure to remove the warning cones from beneath the left wing and engine nacelle.
- A human factor involving ineffective monitoring of engine number 1 during the authorization of the start-up sequence.