Date: 5th April 2022
Location: Melbourne Airport, Victoria, Australia
Aircraft: Saab 340B, registration VH-ZRK
Operator: REX Regional Express
Flight Number: ZL-3937
Route: Melbourne to King Island, Tasmania
Occupants: 23 passengers, 3 crew
Injuries: 2 minor injuries
Damage: None reported
Summary of Events
On 5th April 2022, REX Regional Express flight ZL-3937, a Saab 340B, was preparing for departure from Melbourne Airport to King Island. During the engine start sequence, flames and smoke were observed from the left-hand engine, leading the captain to initiate an evacuation. While no substantial damage to the aircraft was found, the incident highlighted several procedural and communication shortcomings.
Sequence of Events
1. Engine Start Sequence:
• The right-hand engine was successfully started.
• During the left-hand engine start, ground staff disconnected the ground power unit (GPU) prematurely, interrupting the start sequence.
• The captain initiated the motoring process to remove residual fuel from the left-hand engine.
2. Emergence of Flames and Smoke:
• As the left propeller began to rotate, the ground marshaller observed flames and smoke emanating from the rear of the left-hand engine.
• The marshaller attempted to signal the crew to stop the engine start using non-standard hand signals.
3. Crew Response:
• The captain stopped motoring the engine but observed the interstage turbine temperature (ITT) rising, prompting a second motoring attempt.
• After further signals from the marshaller, the captain decided to perform the engine fire checklist and initiated an evacuation through the right-hand door.
4. Evacuation Process:
• The captain signalled the flight attendant with seatbelt chimes to evacuate the aircraft, but the signal was not immediately recognised.
• The R1 door was used for the evacuation, with all passengers and crew exiting the aircraft within four minutes.
• Two passengers sustained minor injuries during the evacuation process.
5. Aftermath:
• Post-incident inspection revealed no damage to the engine or the aircraft.
• Emergency services were delayed by approximately two minutes due to a lack of immediate communication with air traffic control.
Initial Findings
Contributing Factors
1. Premature GPU Disconnection:
• A ground crew member disconnected the GPU without proper communication, leading to an interrupted engine start and the development of a tailpipe fire.
2. Crew Coordination Challenges:
• The captain did not effectively coordinate with the first officer regarding the engine start issue or the fire signals, limiting collaborative problem-solving.
3. Stress and Urgency:
• Increased stress and urgency led the captain to evacuate without fully assessing the situation.
Safety Risks
1. Non-Standard Communication:
• The marshaller used non-standard hand signals, increasing the risk of miscommunication during critical events.
2. Evacuation Challenges:
• Passengers were not directed to all available exits, and some took cabin baggage, delaying the evacuation.
3. Delayed Emergency Services:
• Lack of immediate notification to air traffic control delayed the arrival of emergency services.
Recommendations
1. Training Enhancements:
• Provide recurrent training for flight and ground crews on standard hand signals, emergency protocols, and communication procedures.
2. Emergency Preparedness:
• Reinforce crew training on evacuation drills and ensure cabin crew are familiar with all evacuation signals.
3. Passenger Awareness:
• Educate passengers on evacuation protocols, emphasising the importance of leaving baggage behind.
4. Operational Coordination:
• Improve coordination between flight and ground crews to ensure GPU disconnection occurs only upon explicit instruction.
5. ATC Communication:
• Emphasise the importance of immediate communication with air traffic control in emergencies to expedite emergency response.
Safety Lessons
This incident highlights the importance of adhering to standard operating procedures, effective crew coordination, and comprehensive training for both flight and ground crews. Quick and decisive actions are vital, but they must be based on accurate situational assessments and clear communication.
Disclaimer
If you are the rightful owner of the photo and wish it to be taken down, please email takedown@cockpitking.com.
Our investigation reports are based on all the evidence and facts available at the time of writing and posting. We apologise if any details are missed or are not fully accurate.
