A PERTH airport worker warned a flight crew six times in five seconds to check their brakes after their aircraft started rolling, according to an Australian Transport Safety Bureau report released today.
The Cobham Aviation Avro RJ85 charter flight was carrying two cabin crew and 62 passengers when it rolled into stairs and a light pole on July 30 last year.
The report said there was not a chock on the nose wheel and the flight crew did not check the brake system during two separate pre-flight checklists.
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READ NOWThe aircraft had been parked for several hours after its previous flight and its braking system did not have enough pressure.
The ATSB report said when the aircraft started rolling the dispatch engineer warned the crew several times over his headset, with an “increasingly urgent tone”.
The report found the captain did not perform checklist items as required and the first officer did not monitor the captain or check the brake pressure systems.
When the main wheel landing gear chocks were removed there was nothing to stop the aircraft rolling forward.
The combined thrust of the aircraft’s four engines at idle power and the slight apron slope caused the aircraft to inadvertently roll forward.
The crew attempted to apply the aircraft brakes but they were ineffective.
The report said the close proximity of the edge of the apron and the surprise associated with the unexpected roll-forward reduced the crew’s ability to respond before it collided with portable aircraft stairs.
The aircraft then collided with a bollard in front of a light pole and then the light pole itself.
“This investigation highlights the importance of ensuring all checklist items are addressed,” ATSB executive director transport safety Nat Nagy said.
“As highlighted in this accident, individuals can be vulnerable to omitting checklist items and this can lead to accidents.
“Aviation safety relies on a resilient safety system involving multiple defences.
“One of the key defences against this type of accident is the other pilot monitoring and cross-checking the pilot who is completing the checklist. This can provide a last line of defence to trap individual errors.”
Cobham has reiterated to their check and training captains the importance of vigilance during checklists.
It is also planning to update procedures to require the use of nose-wheel chocks when dispatching aircraft from stand-off bays.