Casualties unknown

2015-11-30: Embraer E195 — b.d. (ND), PL

b.d. (ND), PL

On November 30, 2015, an Embraer E195 was involved in an aviation accident near b.d. (ND), PL. Investigators recorded the probable cause as: The crew's unauthorized, makeshift covering of monitor cooling system vents with newspapers. This summary draws on records from the Polish State Commission on Aircraft Accidents Investigation (PKBWL).

Sourcesthe Polish State Commission on Aircraft Accidents Investigation (PKBWL)Primary reportUpdated 1785092869Data APIEditorial standards

Maintenance personnel discovered newspapers stuffed around the air supply hose and covering display cooling vents in the cockpit of an Embraer E195. The makeshift modification, intended to reduce cold airflow, was removed and the system tested without anomalies.

Discovery and Removal

On November 30, 2015, technical staff of the maintenance organization received an email notification from the operator regarding an anomaly. Upon the aircraft's arrival at Warsaw Chopin Airport (WAW) around 18:40, a mechanic entered the cockpit and found newspapers stuffed under the instrument panel, wrapped around the air supply hose for cooling the displays (monitors), and covering the vents. The newspapers were removed, and a general visual inspection of the captain's monitor cooling air supply hose was performed. Tests in accordance with Embraer E195 AMM 21-24-00 showed no abnormalities.

Background and Crew Interviews

Interviews with Embraer fleet crews revealed that some pilots complained of cold air from the monitor cooling system blowing onto their legs and feet. In response, a few crew members had improvised by covering the vents with newspapers. The report notes that the newspaper found was dated November 17, suggesting the vents may have been covered from that date until detection on November 30. Crews also suggested that the operator contact the manufacturer to explore redirecting the airflow more appropriately.

Cause

The investigation determined that the primary cause of the incident was the flight crew's unauthorized, makeshift covering of the monitor cooling system vents with newspapers.

Corrective Actions

The maintenance organization issued Engineering Letter OTE/15/034 to MCC, Engineering, MRO, flight crews, and flight safety, describing the event and reminding personnel that such unauthorized modifications constitute a foreign object with serious safety implications and are unacceptable. The incident was also published in the December 2/2015 safety bulletin for the ERJ 170/175/190 fleet, emphasizing that any such findings must be immediately reported to supervisors and entered into the aircraft technical log (LDP-60) and a Technical Occurrence Report Form (TORF) submitted to the Quality Office. The Safety Action Group of the operator discussed the event on May 4, 2016, and decided to reiterate the prohibition against unauthorized modifications in the Embraer fleet safety bulletin.

The Commission did not issue any safety recommendations.

Probable cause

The crew's unauthorized, makeshift covering of monitor cooling system vents with newspapers.

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2015-2513/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.