What happened
On April 19, 2019, at Adolfo Suárez Madrid-Barajas Airport, a Bombardier CL-600-2E25, registration EC-MSB, was preparing for a scheduled flight to Casablanca. While the aircraft was parked at stand 618 in the T4S remote apron, a refueling operation was underway with passengers already boarded.
During the engine start sequence, the flight crew requested permission to start the engines. The ground operations coordinator authorized the start of engine number 1 and subsequently engine number 2, despite the fuel truck still being positioned within the Equipment Restriction Area (ERA). Following the engine start, the crew requested taxi clearance. As the aircraft began to move, the right wing struck the fuel truck, which had not yet vacated the area. The impact caused minor damage to the aircraft's right wing tip and the truck's cabin. There were no injuries among the 84 passengers, 4 crew members, or the ground personnel involved.
The investigation
The CIAIAC investigation focused on the sequence of ground operations, specifically the refueling process with passengers on board and the authorization of engine start and taxi. The investigation examined the communication between the flight crew and the ground coordinator, as well as the adherence to safety protocols regarding the Equipment Restriction Area (ERA).
Investigators found that the ground coordinator had delivered the load sheet to the crew before the refueling was actually complete. Furthermore, the investigation noted that the ground coordinator's visibility was compromised by heavy rain and his specific positioning. While moving to a new position to signal the crew, the coordinator lost visual contact with the fuel truck and mistakenly believed a different, similar truck parked nearby was the one involved in the refueling.
Findings
- The primary cause of the incident was that the ground operations coordinator failed to ensure the area was clear of equipment before authorizing the aircraft's movement.
- The ground coordinator lost visual contact with the fuel truck, and the presence of another similar vehicle in a nearby stand led him to misidentify the truck's location.
- The coordinator provided the engine start authorization from a position where the fuel truck was obscured from his line of sight.
- The flight crew requested the engine start despite being aware that the fuel truck was still present in the ERA.
- The crew performed the 'after start checklist' during taxi, which the investigation noted can act as a distraction in congested apron areas.
- Adverse weather conditions, including rain, reduced visibility and contributed to the loss of situational awareness.
Safety action
- REC 10/19: It is recommended that Air Nostrum reinforce training for flight crews regarding strict adherence to procedures during refueling and engine start operations.
- REC 11/19: It is recommended that Iberia Airport Services reinforce training for ground personnel regarding strict adherence to procedures during refueling and engine start operations.