What happened
On 6 December 2013, a Boeing 737-800, registration A6-FEB, operated by Flydubai, arrived at Dubai International Airport following a ferry flight from Amman, Jordan. The aircraft had been at a maintenance facility in Jordan for a C-Check and a cabin reconfiguration project. During the modification, which involved changing the forward cabin from economy to business class, several Passenger Service Unit (PSU) assemblies were removed from the aircraft. These units contained chemical oxygen generators, which are strictly prohibited from being carried on passenger aircraft. The units were packed into cardboard boxes and loaded into the cargo hold of the aircraft without being identified as hazardous material.
The investigation
An investigation by the GCAA AAIS focused on how prohibited materials were loaded onto a flight without proper declaration. Investigators examined the maintenance procedures at the Jordanian Aircraft Maintenance Organization (AMO), the engineering orders used for the cabin modification, and the contractual agreements between the operator and the maintenance provider. The inquiry looked into the handling of removed parts, the labeling of the PSU assemblies, and the oversight provided by both the operator and the regulatory authorities regarding the management of dangerous goods during maintenance and return logistics.
Findings
- The primary cause of the incident was that the chemical oxygen generators inside the PSU assemblies were not labeled as dangerous goods.
- Maintenance staff at the AMO failed to follow specific instructions regarding oxygen systems found in the Aircraft Maintenance Manual (AMM).
- The Engineering Order provided by the STC holder did not sufficiently address the dangerous goods risks associated with the removed units.
- Personnel at both the operator and the maintenance organization were unaware that the components contained hazardous material.
- The contract between the operator and the AMO lacked a distinction between standard aircraft parts and dangerous goods when returning materials by air.
- There were systemic failures in the quality and safety management systems, including a lack of oversight regarding the maintenance provider's safety protocols.