An Australian Transport Safety Bureau report into the October incident states Jetstar has updated its aircraft dispatch procedures after a leading hand placed his clipboard into the engine cowling to protect paperwork from wind and rain.
"While preparing the aircraft for departure the leading hand placed a clipboard in the right engine which was subsequently ingested during start-up," the ATSB report released on Tuesday found.
"During the walk-around, the dispatcher noticed the clipboard in the right engine but, believing it would be retrieved prior to the aircraft departing, the dispatcher did not notify the leading hand or supervisor of the foreign object debris as per company procedures."
Tuesday's report reveals the leading hand realized he was missing his clipboard as the Airbus was taxiing but thought the dispatcher had it.
When he asked her about it the pair quickly realised it was missing.
"The ground crew returned to where they were preparing the aircraft and noticed paper debris on the ground," the ATSB report states, adding ground crew then organized for their operations area to contact the flight crew.
But 12 minutes after the leading hand first realized his mistake the plane took off.
A short time later the pilot was told the paperwork may have been sucked into the right-hand engine. The captain asked if there was also a clipboard involved and was advised by a company engineer on the ground that a piece of sheared metal had been found.
At that point, the flight crew decided to return to Auckland, landing an hour after the Airbus had taken off.
"The engine was inspected by engineers and paper was found throughout the engine. They also found minor damage to an engine fan blade and attrition liner," Tuesday's report states.
The ATSB found at the time there was no procedure in place for the ground crew to contact the flight crew in the event of a "non-normal or emergency situation" prior to or after departure.
There were no rules on how paperwork should be prepared and managed during adverse weather.
Jetstar workers are now given a specific warning about not placing items in the engine cowling and greater detail on checks and responsibilities.
Ground crew staff are told how to re-establish communication with the cockpit "such as visually gaining the attention of the flight or contacting them via radio".
Original article can be found here ➤ https://www.sbs.com.au
Foreign object debris on the ground behind the aircraft (circled)
Investigation number: AO-2017-108
Final Report: https://www.atsb.gov.au
Foreign object damage involving Airbus A320, VH-VGY, Auckland International Airport, New Zealand, on October 27, 2017
What happened
On 27 October 2017, at about 1900 Coordinated Universal Time, a Jetstar Airways Airbus A320 aircraft, registered VH-VGY, was being prepared for a scheduled passenger service from Auckland International Airport, New Zealand to Sydney, Australia. The captain was designated as the pilot flying and the first officer was the pilot monitoring.
At about 1909, the leading hand had finished loading the last container into the aircraft hold and was organising his paperwork. As it was raining, he decided to put the clipboard in the right engine (No. 2) cowling to stop his paperwork from becoming wet and blown by the wind, with the intention to retrieve it later. The leading hand went to the flight deck, gave some paperwork to the flight crew, and returned to the ground to organise the aircraft’s push back.
At about 1919, the dispatcher cleared the ground and servicing equipment from the aircraft and conducted the ‘duty of care’ walk-around. During the walk-around, she noticed the clipboard in the right engine and thought that the leading hand would return for it, so she continued with the walk-around. Soon after, the engines reportedly started normally.
At about 1925, when the aircraft was taxiing, the leading hand realised his clipboard with the paperwork was missing and thought the dispatcher had the paperwork. The leading hand asked the dispatcher about the clipboard and she mentioned she saw it in the right engine during the walk-around. The ground crew returned to where they were preparing the aircraft and noticed paper debris on the ground. The ground crew organised for their operations area to contact the flight crew.
At about 1937, the aircraft departed. Shortly after, when on climb through flight level 150, the flight crew received a radio call from the Auckland Approach air traffic controller to contact the surface movement controller. The captain handed control of the aircraft to the first officer and contacted the surface movement controller who advised that the ground crew had lost their paperwork and it may have been placed on the engine. The captain requested further information about the paperwork, specifically whether the paper was on top of the engine or inside the inlet. The flight crew checked the engine instruments and there were no abnormal indications. The surface movement controller confirmed that the paperwork was placed within the inlet and paper debris was found on the tarmac. The captain then contacted the company engineer at the airport and asked whether it was just paperwork or a clipboard with a metal clip. The engineer advised that a piece of sheared metal had been found. The flight crew decided to return to Auckland.
After landing at about 2048, the engine was inspected by engineers and paper was found throughout the engine. They also found minor damage to an engine fan blade and attrition liner.
Additional comments
The leading hand stated that, due to the wind and rain, he felt the need to shelter the paperwork. Normally, staff use the pushback tractor for shelter during adverse weather and to prepare paperwork for the flight. There is a metal box on the loader to store the folder. However, as the pushback tractor was not yet present at the bay, he used the engine cowling. He recalled that he did not feel pressured to rush the departure.
The dispatcher stated that she did not view the clipboard as a foreign object as it belonged to the leading hand and had the paperwork for the flight. She assumed that the leading hand would retrieve it later, prior to engine start-up.
The captain stated that, to obtain more information about the incident, numerous calls were made to other agencies, which took considerable time. Further, due to poor communications, he was unable to contact the operator’s maintenance controller to discuss the engine’s status.
Final Report: https://www.atsb.gov.au
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