What happened
On 15 February 2015, a flydubai Boeing 737-800, registration A6-FDC, was parked at Dubai International Airport, prepared for a scheduled flight to Bagram. During the ground handling process, two mobile conveyor belts (MCBs) were being deployed to the aircraft's cargo holds by dnata personnel.
As one operator approached the aircraft, he discovered that another MCB had already been positioned at the aft cargo door. Attempting to redirect his vehicle toward the vacant forward cargo door, the operator stopped the MCB and released the brake pedal to steer. During this maneuver, the MCB unexpectedly moved forward and struck the right engine. The collision resulted in damage to the engine shroud, the acoustic panel, and the inlet cowl. There were no injuries to any personnel during the incident.
The investigation
The UAE Air Accident Investigation Sector (AAIS) examined the operational procedures and organizational management of the ground handling agent. The investigation focused on the coordination between equipment operators and the adequacy of existing safety management systems. Investigators reviewed the training records of the operator, the meteorological conditions at the time of the event, and the recent changes to staff duty rosters. The inquiry also looked into the communication protocols between the ground handling provider and the airport operator regarding safety oversight.
Findings
- The investigation identified that dnata's procedures lacked specific instructions for allocating equipment to specific cargo doors when multiple units are servicing the same aircraft.
- The lack of a predefined task assignment left the decision of equipment positioning to the discretion of individual operators, creating potential for uncoordinated movements.
- The MCB operator likely experienced a loss of situational awareness due to distraction when encountering the other vehicle, or potentially misapplied the accelerator instead of the brake.
- There was no formal risk assessment conducted regarding recent changes to the airside operators' duty rosters, which could have introduced latent fatigue hazards.
- The ground handling agent's risk management system failed to detect the possibility of uncoordinated equipment positioning.
Safety action
Following the incident, dnata implemented several control measures, including the introduction of marshalling for all equipment positioning, specialized marshalling training for staff, and revised work instructions for approaching aircraft holds. The AAIS also issued recommendations for the GCAA to mandate risk assessments for any changes to procedures or rosters, and for Dubai Airports to enhance its oversight of ground handling safety systems.