What happened
On October 6, 2012, at 15:35 local time, an Air Europa Airbus A330-203, registration EC-JQQ, was undergoing a pushback maneuver from parking position T3 at Madrid-Barajas Airport (LEMD). The Apron Management Service (SDP) had issued a conditional instruction, allowing the crew to push back toward the north only once they were clear of another Airbus A330 that was expected to pass behind them.
Due to a communication failure between the flight crew and the ground handling staff, the conditional nature of the instruction was not properly conveyed. The crew attempted to use visual signals to communicate the instruction, but these were unsuccessful. Consequently, the ground personnel proceeded with the pushback without realizing the restriction.
Simultaneously, an Orbest Airbus A330-343, registration EC-JHP, was taxiing along taxiway I7. The crew of the Orbest aircraft did not perceive the pushback maneuver of the stationary aircraft. As a result, the left winglet of EC-JHP struck the tail cone and the right elevator of EC-JQQ. The impact caused a piece of the Orbest winglet to break off and land on the taxiway.
The investigation
The CIAIAC investigation examined the communications between the SDP and both aircraft, the ground handling procedures, and the visibility constraints at the airport. The investigation found that the SDP operator was focused on another aircraft at the time of the incident and that certain areas of the apron were not visible from the south tower.
Investigators also reviewed the technical damage to both aircraft. The Airbus A330-203 (EC-JQQ) sustained significant damage to its right elevator, including cracks and material loss, requiring the replacement of the elevator and its servo-actuators. The Airbus A330-343 (EC-JHP) suffered the loss of its left winglet tip, which required a replacement part from the manufacturer's production line.
Findings
- The primary cause was the failure of the Air Europa flight crew to communicate the conditional pushback instruction to their ground handling personnel.
- The ground personnel misinterpreted the situation, as they were not accustomed to the non-standard pushback trajectory being used.
- Visual obstructions at the south tower prevented the SDP operator from monitoring the maneuver effectively.
- The Air Europa crew utilized non-standard visual signals that were not understood by the ground team.
- The Orbest crew's attention may have been diverted due to a breach of sterile cockpit procedures.
- The fact that EC-JQQ was stationary at the moment of impact made it difficult for the Orbest crew to detect that the aircraft had encroached upon the protected area of taxiway I7.