What happened
On 28 February 2010, at approximately 0654 hours, an Airbus A320, registration 9M-AHA, arrived at gate D38 of Singapore Changi Airport. As the aircraft taxied into its parking bay, the engines remained at idle and had not yet been shut down by the flight crew.
A ground handling team was present to receive the aircraft, consisting of a flight supervisor and two equipment operators. Following the aircraft's stop at the designated line, one equipment operator approached the aircraft to place safety cones around the engine hazard zone. While the operator was in the process of placing the first cone in front of the No. 2 engine, the second cone was pulled from his hand by the engine suction and ingested into the turbine. The ingestion caused a loud popping sound and resulted in the cone being shredded by the engine blades.
The investigation
The investigation focused on the sequence of ground operations and the adherence to safety protocols. It was established that the flight supervisor was using the Aircraft Docking Guidance System (ADGS) to assist the arrival. While the ADGS indicated "stop," the engines were still operational.
Investigators reviewed the ground handling agent's (GHA) standard operating procedures and training records. The investigation found that while the equipment operator had previously completed a ramp safety course, he had approached the aircraft before receiving the required clearance. The investigation also confirmed that there were no injuries and no damage to the Airbus A320 following the inspection of the No. 2 engine.
Findings
- The primary cause of the incident was that the equipment operator approached the aircraft before the engines were shut down and before receiving the official "thumbs up" signal from the flight supervisor.
- The operator mistakenly interpreted the ADGS "stop" display as a signal that it was safe to approach the engine hazard zone.
- This action was a deviation from the GHA's work instruction manual, which mandates that all ground activities should only commence once anti-collision lights are off and the headset man provides clearance.
Safety action
Following the incident, the ground handling agent implemented several safety measures:
- Immediate refresher training on airside safety was provided to all handling staff, specifically focusing on arrival procedures.
- The GHA established a new policy of recurrent training, requiring all ramp staff to undergo safety retraining every two years.
- Safety lessons learned from the event were distributed among all ground handling personnel to prevent recurrence.