What happened
On January 21, 2012, a BA CityFlyer Embraer 190, registration G-LCYJ, arrived at Chambéry Aix-les-Bains Airport from London City. During the final approach to runway 18, the crew encountered wind shear, which led to difficulties controlling airspeed. After deploying full flaps, the aircraft experienced a slight overspeed, prompting the crew to perform a go-around. The aircraft successfully landed on a second approach.
Upon reaching the parking stand, the crew began the engine shutdown procedure but interrupted it to discuss the previous overspeed event and necessary maintenance actions. During this interruption, the commander turned off the anti-collision lights but failed to complete the shutdown of the engines.
Observing that the anti-collision lights were extinguished, the Ramp Area Supervisor (RZA) signaled to the ground crew that they could approach the aircraft. As a ground agent moved behind an engine to place chocks and cones, the still-functioning engine produced a jet blast that violently threw the worker backward. The error was discovered when a cockpit alert notified the crew that the engines were still running, and a cabin crew member entered the flight deck to report the same.
The investigation
The investigation focused on the discrepancy between the airline's shutdown checklist and the ground handling company's safety protocols. The airline's manual requires both the engines and anti-collision lights to be off before personnel approach. However, the ground handling company's procedures only required the lights to be extinguished.
Investigators found that ground agents, who must wear noise-canceling headsets, rely on visual cues—specifically the RZA's signal and the extinguishing of anti-collision lights—to determine if it is safe to approach. Because the headsets prevent them from hearing engine noise, they cannot independently verify if the engines have stopped.
Findings
- The primary cause was an inadequate ground handling procedure that allowed personnel to approach the aircraft based solely on the extinguishing of anti-collision lights, creating a false sense of security.
- The crew's failure to complete the engine shutdown procedure contributed to the incident.
- The preceding overspeed event during the approach likely distracted the crew during the arrival procedures.
- The ground agent was unable to detect the running engine due to the mandatory use of hearing protection.
Safety action
Following the incident, the ground handling company implemented a new procedure requiring radio communication between the RZA and the flight crew to confirm that engines are fully shut down before ground staff approach.
The BEA has issued a recommendation to the DGAC and EASA to ensure that arrival procedures for both operators and ground handling companies guarantee that personnel only approach an aircraft once engines are effectively stopped.