What happened
During the pre-departure phase of operations, a failure in the communication process between the flight crew and ground personnel occurred. The captain and engineer did not complete the verbal exchange required by the Stand-Off Bay Despatch Using Intercom challenge-and-response checklist. Because this procedure was bypassed, the tail strut remained attached to the aircraft as it began its movement.
As the aircraft commenced taxiing, the engineer attempted to use various methods to notify the flight crew of the hazard. However, the engineer lacked an effective procedure or means of communication to reach the cockpit once the aircraft was in motion. Consequently, the crew remained unaware of the attached equipment until after the error had occurred.
The investigation
Investigators examined the communication protocols used during the dispatch process. The inquiry focused on why the tail strut was not identified during the initial checks and why the ground engineer was unable to interrupt the taxiing process to signal the danger. The investigation looked into the effectiveness of the existing intercom-based checklist as a risk control mechanism.
Findings
- The verbal exchange between the captain and the engineer was not conducted according to the prescribed challenge-and-response checklist.
- The omission of the checklist steps was likely due to the task being viewed as a routine procedure, which negated the checklist's ability to function as an effective risk control.
- The engineer possessed no reliable method or established procedure to contact the flight crew once the aircraft had begun taxiing.
- The failure to complete the full checklist resulted in a missed opportunity to detect the presence of the tail strut before departure.