Foreign Object Debris (FOD)

Article Information

Category: Ground Operations

Content source: SKYbrary

Content control: SKYbrary

Contents
• 1 Description
• 2 Effects
• 3 Contributory Factors
• 4 Responsibility
• 5 Defences
o 5.1 Constant inspection systems
o 5.2 FOD Control Program
• 6 Accidents & Incidents
o 6.1 Runway FOD
o 6.2 Taxiway/Apron FOD
o 6.3 Maintenance FOD
• 7 Related Articles
• 8 Further Reading

Description
Foreign Object Debris (FOD) at airports includes any object found in an inappropriate
location that, as a result of being in that location, can damage equipment or injure
personnel. FOD includes a wide range of material, including loose hardware,
pavement fragments, catering supplies, building materials, rocks, sand, pieces of
luggage, and even wildlife. FOD is found at terminal gates, cargo aprons, taxiways,
runways, and run-up pads.

The three main areas that require specific attention are:

• Runway FOD - this relates to various obects (fallen from aircraft or vehicles,
broken ground equipment, birds, etc.) that are present on a runway that may
adversely affect fast-moving aircraft (during take-off and landing). Runway
FOD has the greatest potential of causing damage.
• Taxiway/Apron FOD - while this type of FOD may seem less harmful than the
previous one, it should be noted that jet blast can easily move small objects onto
the runway.
• Maintenance FOD - this relates to various objects, such as tools, materials or
small parts) that are used in maintenance activities (e.g. aircraft maintenance,
construction works, etc.) and can cause damage to aircraft.

Effects
FOD can cause damage in a number of ways, the most notable being:

• Damaging aircraft engines if ingested;

• Cutting aircraft tyres;
• Lodging in aircraft mechanisms preventing them from operating properly;
• Injuring people afer being propelled by a jet blast or prop wash.
The resulting damage is estimated to cost the aerospace industry $4 billion a year.

A dramatic example of FOD damage is the loss of the Air France Concorde, which
struck FOD on the runway during take-off from Paris Charles de Gaulle Airport in
2000 (see Accidents & Incidents section for details).

Contributory Factors
A number of factors can affect the presence and handling of FOD, e.g.:

• Poor maintenance of buildings, equipment and aircraft.

• Inadequate staff training.
• Pressure on staff not to delay movements for inspection.
• Weather (e.g. FOD may be created by strong winds or may be blown onto the
airfield or its detection can be hampered by adverse weather).
• Presence of uncontrolled (e.g. contractors') vehicles on the airfield.

Responsibility
FOD-prevention and clearance is the responsibility of all all airport users; however,
specific responsibility must be allocated to appropriate persons who must be suitably
trained and supervised. Quality assurance is an essential tool to ensure that
responsible organisations and personnel carry out their allotted tasks correctly.

While the airport authority is responsible for the runways, taxiways and general
manoeuvring areas, airline representatives or handling agents are normally responsible
for ensuring that the gate and its approaches are clear of FOD, including ground
equipment, and are free of ice, snow or other contaminant capable of affecting braking
action. Handling contracts must specify the extent of agents' responsibilities and
agents' procedures must specify how these responsibilities are to be exercised.

Defences
Defences against FOD include the following activities:

• Regular and frequent inspection of the airfield, including aircraft manoeuvring

areas and adjacent open spaces.
• Suspension of runway operations upon notification to ATC about FOD on or
near the runway until FOD has been removed and the runway inspected, as
necessary.
• Regular and frequent inspection of the airfield buildings and equipment and
immediate repair or withdraw from service of items likely to create FOD.
• Inspection of the parking gate to ensure that it is free of FOD, including ground
equipment, and of ice, snow or other material capable of reducing braking action
(normally the responsibility of the airline representatives).
• Removal of FOD as soon as it is identified.
• Use of constant inspection systems (see subsection below for details).
• Implementing a FOD control program (see subsection below for details).

Constant inspection systems

Constant inspection systems use a combination of radar and electro-optical sensors
which facilitate FOD detection 24/7 under all weather conditions. Such systems are
used at some of the busiest aerodromes in the world,
including Heathrow, Vancouver, Dubai, Doha and others. The benefits of such a
system over conventional vehicle inspections are:

• Constant monitoring, including night time and low visibility conditions.

• Detection of FOD is faster and more reliable.
• More efficient (uninterrupted by inspections) traffic flow.
• Reduced risk of runway incursions (by the inspecting vehicle e.g. due to a
controller error)
• Reduced risk of birdstrikes (birds are recognised by the optical sensors)

FOD Control Program

A program to control airport FOD is most effective when it addresses four main areas:

• Training. All airport and airline personnel and airport tenants should receive
training in the identification and elimination of FOD, including the potential
consequences of ignoring it. This training can supplement the general FOD
awareness incorporated into the airside driver-training curriculum at many
airports. FOD training for flight crews includes following the recommended
procedures identified in the Flight Crew Operating Manual and pre- and post-
flight inspection procedures covered during line training. Effective training
include procedures for removing and eliminating FOD at its source, and should
be reinforced through the use of posters and signs. Recurrent training is
necessary to help maintain an awareness of FOD.
• Inspection by airline, airport, and airplane handling agency personnel. Airline
personnel, when feasible, should join the airport staff in daily airside
inspections. This practice helps increase familiarity with local airfield
conditions, and promotes effective communication between the airport and
airlines. The International Civil Aviation Organisation (ICAO) requires a daily,
daylight inspection of aircraft manoeuvring areas and removal of FOD. In
addition to performing these inspections at the beginning of the day or shift,
personnel on the airside should look for FOD during their normal shifts. On-
going construction requires more frequent inspections. It may even be necessary
to assign dedicated personnel to continually inspect for FOD during major
construction activities. Flight crews should report to air traffic control and
station operations any FOD they observe on runways and taxiways. Aircraft
operators and handling agents should designate individuals to inspect aircraft
parking stands prior to aircraft movement onto or off them.
• Maintenance, which includes:
o Sweeping. This may be done manually or with the airfield sweeper, which
is the most effective equipment for removing FOD from airside. The
sweeper removes debris from cracks and pavement joints, and should be
used in all areas except for those that can be reached only with a hand
broom. All airside areas, including aircraft manoeuvring areas, aprons and
gates and the areas adjacent to them, should be swept routinely. The areas
in which ground support equipment (GSE) is staged should be swept
periodically.
o Magnetic bars. These can be suspended beneath tugs and trucks to pick up
metallic material. However, the bars should be cleaned regularly to prevent
 them from dropping the collected debris. Vehicles operating on the airside
should be inspected periodically to ensure that they have no loose items
that can fall off.
o Rumble strips. Driving over rumble strips can dislodge FOD from the
underside of vehicles. The strips, which are between 10 ft and 15 ft long,
can be moved and used at transitions from the landside to the airside, or
adjacent to airside construction areas.
o FOD containers. These should be placed at all gates for the collection of
debris. The containers should be emptied frequently to prevent them from
overflowing and becoming a source of FOD themselves. In addition,
airport personnel can wear waist pouches to collect debris. Evaluating the
debris collected in containers and pouches can identify its sources and
indicate where personnel and equipment should be deployed for more
effective control.
o Other means for preventing FOD damage include wind barriers and
netting to restrict the movement of airborne FOD, fencing to prevent
animals from entering the airfield, and well-maintained paved surfaces. If
damaged pavement cannot be repaired immediately, aircraft should use an
alternate route.
• Coordination. Airports with a FOD committee of airport tenant representatives
tend to control FOD more successfully than those without such a committee
because the representatives can address local conditions and specific problems.
At airports served by multiple airlines, the airlines should have these
representatives as well as an airport user's committee to coordinate FOD control
efforts among themselves. Both airside and landside construction activities, as
well as scheduled maintenance, should be communicated to airport users as early
as possible. Airport preconstruction planning should include a means for
controlling and containing FOD generated by the construction. This is especially
true in high-wind environments where debris is more likely to become airborne.
Access to and from construction sites should avoid areas of aircraft operation.
Contractors must fully understand the requirements and penalties incorporated in
their contracts regarding the control and removal of FOD.

Accidents & Incidents

Runway FOD
• CONC, vicinity Paris Charles de Gaulle France, 2000 - On 25th July 2000, an
Air France Concorde crashed shortly after take-off from Paris CDG following
loss of control after debris from an explosive tyre failure between V1 and VR
attributed to runway FOD ruptured a fuel tank and led to a fuel-fed fire which
 quickly resulted in loss of engine thrust and structural damage which made the
aircraft impossible to fly. It was found that nothing the crew failed to do,
including rejecting the take off after V1 could have prevented the loss of the
aircraft and that they had been faced with entirely unforeseen circumstances.
• RJ85, Helsinki Finland 2010 - On 12 June 2010, a requested 22R runway
inspection at Helsinki in normal daylight visibility carried out after a severe
engine failure during the take off roll had led an Avro RJ85 being operated by
Finnish Airline Blue1 on a scheduled passenger flight to Copenhagen to reject
that take off at high speed. This inspection had not detected significant debris
deposited on the runway during the sudden and severe engine failure. Two
passenger aircraft, one being operated by Finnair to Dubrovnik, Croatia and the
other being operated by Swedish airline TUIfly Nordic to Rhodes, Greece then
departed the same runway before a re-inspection disclosed the debris and it was
removed. Neither of the aircraft which used the runway prior to debris removal
were subsequently found to have suffered any damage but both were advised of
the situation en route.
• E190, Oslo Norway, 2010 - On 23 October 2010, an Embraer 190 commenced
its night rolling takeoff from runway 01L at Oslo with the aircraft aligned with
left runway edge lights instead of the lit centreline before correcting to the
runway centreline and completing the takeoff and flight to destination. Engine
damage caused by ingestion of broken edge light fittings, which was sufficient
to require replacement of one engine before the next flight, was not discovered
until after completion of an otherwise uneventful flight. Tyre damage requiring
wheel replacement was also sustained. The Investigation concluded that
"inadequate CRM" had been a Contributing Factor.
• Vehicle / B712, Perth Western Australia, 2014 - On 26 July 2014, the crew of a
Boeing 717 which had just touched down on the destination landing runway at
Perth in normal day visibility as a heavy shower cleared the airport area after
previously receiving and acknowledging a landing clearance saw the rear of a
stationary vehicle on the runway centreline approximately 1180 metres from the
landing threshold. An immediate go around was called and made and the aircraft
cleared the vehicle by about 150 feet. The same experienced controller who had
issued the landing clearance was found to have earlier given runway occupancy
clearance to the vehicle.
• B734, Aberdeen UK, 2005 - Significant damage was caused to the tailplane and
elevator of a Boeing 737-400 after the pavement beneath them broke up when
take off thrust was applied for a standing start from the full length of the runway
at Aberdeen. Although in this case neither outcome applied, the Investigation
noted that control difficulties consequent upon such damage could lead to an
overrun following a high speed rejected takeoff or to compromised flight path
control airborne. Safety Recommendations on appropriate regulatory guidance
 for marking and construction of blast pads and on aircraft performance, rolling
take offs and lead-on line marking were made.
• MD82, Copenhagen Denmark, 2013 - On 30 January 2013, the crew of a Boeing
MD82 successfully rejected its take off at Copenhagen after sudden explosive
failure of the left hand JT8D engine occurred during the final stage of setting
take off thrust. Full directional control of the aircraft was retained and the failure
was contained, but considerable engine debris was deposited on the runway. The
subsequent Investigation concluded that a massive failure within the low
pressure turbine had been initiated by the fatigue failure of one blade, the reason
for which could not be established.

Taxiway/Apron FOD
• E170, Nuremberg Germany, 2013 - On 13 March 2013, smoke and fumes were
immediately evident when the cable of an external GPU was connected to an
ERJ170 aircraft on arrival after flight with passengers still on board. A
precautionary rapid disembarkation was conducted. The Investigation found that
a short circuit had caused extensive heat damage to the internal part of the
aircraft GPU receptacle and minor damage to the surrounding structure and that
the short circuit had occurred due to metallic FOD lodged within the external
connecting box of aircraft GPU receptacle.
• B772, Singapore, 2013 - On 19 December 2013, the left engine of a Boeing 777-
200 taxiing onto its assigned parking gate after arrival at Singapore ingested an
empty cargo container resulting in damage to the engine which was serious
enough to require its subsequent removal and replacement. The Investigation
found that the aircraft docking guidance system had been in use despite the
presence of the ingested container and other obstructions within the clearly
marked 'equipment restraint area' of the gate involved. The corresponding
ground handling procedures were found to be deficient as were those for
ensuring general ramp awareness of a 'live' gate.

Maintenance FOD
• B738, Auckland New Zealand, 2013 - On 7 June 2013, stabiliser trim control
cable, pulley and drum damage were discovered on a Boeing 737-800
undergoing scheduled maintenance at Auckland. The Investigation found the
damage to have been due to a rag which was found trapped in the forward cable
drum windings and concluded that the integrity of the system which provided for
stabiliser trim system manual control by pilots had been compromised over an
extended period. The rag was traced to a specific Australian maintenance facility
 which was run by the Operator's parent company and which was the only user of
the particular type of rag.

Related Articles
• Jet Efflux Hazard
• Prop Wash
• Airport Bird Hazard Management
• Flight Crew Pre Flight External Check

Further Reading
• FAA Advisory Circular 150/5210-24 "Airport Foreign Object Debris (FOD)
Management", September 2010
• FAA Advisory Circular 150/5020-24 "Airport Foreign Object Debris (FOD)
Detection Equipment", September 2009
• NTSB Safety Alert 054 "Control Foreign Object Debris", June 2016
• UK CAA CAP 1010 Ramp/ Aircraft Loading Operations Checklist, February
2014
• ACI Airside Safety Handbook, 4th edition, 2010
• Foreign Object Debris Characterization at a Large International Airport, FAA,
Edwin E. Herricks, DAvid Mayer and Sidney Majumdar, 8 Feb. 2015.
• FOREIGN OBJECT DAMAGE (FOD) PREVENTION GUIDANCE
DOCUMENT, Aerospace Industries Association, NAS412, 2nd Edition, 30
April 2018.

CONC, vicinity Paris Charles de Gaulle

France, 2000
Summary

On 25th July 2000, an Air France Concorde crashed shortly after take-off

from Paris CDG following loss of control after debris from an explosive tyre

failure between V1 and VR attributed to runway FOD ruptured a fuel tank

and led to a fuel-fed fire which quickly resulted in loss of engine thrust and
structural damage which made the aircraft impossible to fly. It was found

that nothing the crew failed to do, including rejecting the take off after V1

could have prevented the loss of the aircraft and that they had been faced

with entirely unforeseen circumstances.

Event Details

When July 2000

Actual or
Airworthiness, Fire Smoke and Fumes, Ground
Potential
Event Type Operations, Loss of Control

Day/Night Day

Flight
Conditions VMC

Flight Details

AEROSPATIALE - BRITISH AEROSPACE

Aircraft
Concorde

Operator Air France

Domicile France

Type of Flight Public Transport (Passenger)

Origin Paris/Charles de Gaulle Airport

Intended
Destination New York/John F Kennedy International Airport

Take off
Commenced Yes

Flight Airborne Yes

Flight Completed No

Flight Phase Take Off

TOF

Location En-Route

Origin Paris/Charles de Gaulle Airport

Destination New York/John F Kennedy International Airport

Location - Airport

Airport vicinity Paris/Charles de Gaulle Airport

General

Tag(s) Ineffective Regulatory Oversight

FIRE

Fire-Fuel origin,
Tag(s)
Fire-Wing

LOC

Tag(s) Loss of Engine Power

AW

Fuel,
System(s)
Landing Gear

Contributor(s) OEM Design fault

 Outcome

Damage or injury Yes

Aircraft damage Hull loss

Non-aircraft damage Yes

Non-occupant casualties Yes ()

Fatalities Most or all occupants ()

Causal Factor Group(s)

Aircraft Technical,
Group(s)
Airport Operation

Safety Recommendation(s)

Aircraft Operation,
Group(s) Aircraft Airworthiness,

Airport Management

Investigation Type

Type Independent

Contents
• 1 Description
• 2 Investigation
• 3 Safety Recommendations
• 4 Related Articles

Description
On 25th July 2000, a Concorde being operated by Air France on a passenger charter
flight from Paris CDG to New York JFK caught fire as it rotated for take off from
runway 26R in normal daylight visibility and subsequently failed to maintain altitude
as the fire continued. The aircraft soon lost height and was destroyed by impact with a
hotel situated just over 3 nm from the upwind end of the runway. All 109 occupants
and four other persons on the ground were killed and 6 other people on the ground
were injured.

Investigation
An Investigation was carried out by the French Bureau d'Enquêtes et d'Analyses
(BEA) with specific assistance from the UK AAIB because of the unusual shared
responsibility for the aircraft type certificate between the UK and France. A
preliminary report was published on 31 August 2000 followed by Interim Reports on
15 December 2000 and 10 July 2001.

In addition to the BEA "Technical Investigation" on July 26 2000, the French

Government established a special “Commission of Inquiry” which “assisted the BEA
in its work”. It was noted that eleven meetings had been held at which the
Commission was informed of the progress of the BEA Investigation and, following
discussion, it had then “approved the reports”. Also, in accordance with French law, a
Judicial Inquiry in respect of the Accident took precedence over the BEA
investigation and so all BEA activity at the accident site and examination of the
various parts of the aircraft “were performed in coordination with those responsible
for the judicial inquiry, strictly adhering to the procedures of that inquiry”. In this
connection, “the accident site and the various parts of the aircraft (had remained)
constantly under the control of the judicial authorities”.

The BEA investigation established that about 1700 metres along the runway, shortly
after the aircraft had passed V1, and whilst accelerating through 175 KCAS, the front
right tyre of the left main landing gear had run over a strip of metal which had fallen
from another aircraft five minutes earlier. The explosive failure of this tyre had
thrown tyre debris against the wing structure causing a rupture of fuel tank 5. Fire,
fuelled by the leak, broke out almost immediately under the left wing. As rotation was
begun at a speed of 183 KCAS some 15 kt before VR, marks on the runway showed
that the aircraft was deviating to the left of the runway centreline. The crew were
advised by the ATC that there were "large flames behind them". Almost
simultaneously, thrust was suddenly lost from engine 2 as a consequence of debris
ingestion and/or disruption of the intake airflow. The aircraft became airborne 2900
metres along the runway some ten seconds after rotation had begun, but the crew then
found that, in addition to asymmetric thrust, they were unable to retract the landing
gear. The aircraft flew for around a minute at a speed of 200 kt and at a radio altitude
of 200 feet but, with only intermittent thrust from Engine 1, was unable to gain height
or speed. When Engine 1 suffered a final loss of thrust, the aircraft "adopted a very
pronounced angle of attack and roll attitude". Loss of thrust on engines 3 and 4 then
followed as "a combination of deliberate selection of idle and by a surge due to
excessive airflow distortion". Control was not regained.

The Investigation noted that:

" The crew had no way of grasping the overall reality of the situation. They reacted
instinctively when they perceived an extremely serious but unknown situation, which
they were evaluating by way of their sensory perceptions. Each time the situation
allowed, they applied the established procedure in a professional way."

" (A) simulation (during the investigation) showed that a rejected take off would have
led to a high-speed runway excursion. Under these conditions, the landing gear would
have collapsed and with the fire that was raging under the left wing, the aircraft
would probably have burst into flames immediately."

" Many pieces of the aircraft found along the track indicate that severe damage to the
aircraft’s structure was caused in flight by the fire. Even with the engines operating
normally, the significant damage caused to the aircraft’s structure would have led to
the loss of the aircraft."

On the subject of the cause and effects on aircraft structure of tyre failure - in this case
just a single tyre failure being the direct cause of a level of structural damage which
resulted in a major fuel leak near a ready source of ignition - the investigation noted
that:

"On Concorde, nineteen of the fifty-seven known cases of bursts/punctures were

caused by foreign objects. All of this clearly shows that in addition to increased
surveillance of runways and taxiways, it is becoming necessary to improve
the resistance of tyres to damage. It is useful to note that certification imposes no
dynamic destructive tests on tyres, which means that there is no indication of burst
modes, the weight and size of debris. Nevertheless, with these factors, it would be
possible to evaluate the energies released and to deduce the possible consequences on
the aircraft’s structure."

The Causes of the Accident determined by the Investigation were as follows:

• High-speed passage of a tyre over a part lost by an aircraft that had taken off five
minutes earlier and the destruction of the tyre.
• The ripping out of a large piece of tank in a complex process of transmission of
the energy produced by the impact of a piece of tyre at another point on the tank,
this transmission associating deformation of the tank skin and the movement of
the fuel, with perhaps the contributory effect of other more minor shocks and /or
a hydrodynamic pressure surge.
• Ignition of the leaking fuel by an electric arc in the landing gear bay or through
contact with the hot parts of the engine with forward propagation of the flame
causing a very large fire under the aircraft’s wing and severe loss of thrust on
engine 2 then engine 1.
In addition, it was noted that “the impossibility of retracting the landing gear probably
contributed to the retention and stabilisation of the flame throughout the flight.”

Safety Recommendations
Following an initial assessment of the circumstances of the accident, the BEA and the
UK AAIB issued the following Safety Recommendation on 16 August 2000:

• that the Certificates of Airworthiness for Concorde be suspended until

appropriate measures have been taken to guarantee a satisfactory level of safety
with regard to the risks associated with the destruction of tyres.”
This Interim Recommendation was subsequently rendered no longer applicable as a
result of further progress in the Investigation about which full details were provided to
the two manufacturers, the two operators and the jointly responsible airworthiness
authorities, the UK CAA and DGAC. The latter two agencies then defined a list of
requirements for a return of the aircraft type to service as follows:

• Installation of flexible linings in fuel tanks 1,4,5,6,7 and 8.

• Reinforcement of the electrical harnesses in the main landing gear bays.
• Modification of Aircraft Flight Manual (AFM) procedures so as to inhibit power
supply to the brake ventilators during critical phases of flight and revision of
the MEL to ensure that technical operational limitations cannot be applied for
the tyre under-pressure detection system.
• Installation of Michelin NZG tyres and modification of the anti-skid computer.
• Modification of the shape of the water deflector and removal of the retaining
cable.
• A ban on the use of volatile fuels and an increase in the minimum quantity of
fuel required for a go-around.
Four further Safety Recommendations “specific to Concorde” were subsequently
published having been brought directly to the attention of the airworthiness authorities
and these were taken into account in the context of the aircraft’s return to service. One
of these was applicable to both operators of the type (British Airways and Air France)
as follows:

• that the airworthiness authorities, the manufacturers and the operators of

Concorde reinforce the means available for the analysis of the functioning of
aircraft systems and in-service events and for the rapid definition of corrective
actions.
The other three were specific to the operation of the type by Air France:

• that Air France ensure that the emergency procedures in the section on
Concorde utilisation in its Operations Manual be coherent with the Flight
Manual.
• that Air France equip its Concorde aircraft with recorders capable of sampling
at least once a second the parameters that allow engine speed to be determined
on all of the engines.
• that the DGAC undertake an audit of Concorde operational and maintenance
conditions within Air France.
Ten other Safety Recommendations described as ‘general’ were also made as a
result of the investigation as follows:

• that the DGAC, in liaison with the appropriate regulatory bodies, study the
reinforcement of the regulatory requirements and demonstrations of conformity
with regard to aviation tyres.
• that the DGAC, in liaison with the appropriate regulatory bodies, modify the
regulatory certification requirements so as to take into account the risks of tank
damage and the risk of ignition of fuel leaks.
• that the DGAC ensure the rapid implementation of programmes for the
prevention of debris on aerodromes. These programmes should involve all
organisations and personnel operating on the movement area.
• that the ICAO study the technical feasibility of an automatic detection system
for foreign objects on runways.
• that the FAA carry out an audit of Continental Airlines maintenance both in the
United States and at its foreign sub-contractors.
• that the ICAO fix a precise timetable for the FLIREC group to establish
propositions on the conditions for the installation of video recorders on board
aircraft undertaking public transport flights.
• that the ICAO study the procedures for recording specific exchanges between
cabin crew members and exchanges between the cockpit and the cabin.
• that the DGAC, in liaison with the appropriate regulatory bodies, study the
possibility of installing devices to visualise parts of the structure hidden from the
crew’s view or devices to detect damage to those parts of the aircraft.
• that the DGAC, in liaison with the appropriate regulatory bodies, study the
possibility of modifying the regulatory requirements relating to new flight
simulators so that they accurately reproduce the accelerations really experienced
in the cockpit.
• that the ICAO put recommendation 8/1 of the AIG 99 meeting into practice in
the shortest possible time and, while waiting for the results of this work, that the
primary certification authorities ask manufacturers to immediately identify all
potentially dangerous substances in case of an accident which are used in the
manufacture of aircraft under their responsibility and to mention them in an
explicit manner in documentation.
The Final Report of the Investigation was made public on 16 January 2002.

Editor's Note: This report is quite large (16Mb) and may therefore take some time to
download depending on the speed of your internet connection.

B772, Singapore, 2013

Summary

On 19 December 2013, the left engine of a Boeing 777-200 taxiing onto its

assigned parking gate after arrival at Singapore ingested an empty cargo

container resulting in damage to the engine which was serious enough to

require its subsequent removal and replacement. The Investigation found

that the aircraft docking guidance system had been in use despite the

presence of the ingested container and other obstructions within the clearly

marked 'equipment restraint area' of the gate involved. The corresponding

ground handling procedures were found to be deficient as were those for

ensuring general ramp awareness of a 'live' gate.

Event Details
When December 2013

Actual or Potential
Event Type Ground Operations, Human Factors

Day/Night Day

Flight Conditions On Ground - Normal Visibility

Flight Details

Aircraft BOEING 777-200 / 777-200ER

Operator Singapore Airlines

Domicile Singapore

Type of Flight Public Transport (Passenger)

Origin Chhatrapati Shivaji International Airport

Intended Destination Singapore Changi Airport

Take off Commenced Yes

Flight Airborne Yes

Flight Completed Yes

Flight Phase Taxi

TXI

Location - Airport

Airport Singapore Changi Airport

 General

Airport Layout,
Tag(s)
Inadequate Airport Procedures

HF

Ineffective Monitoring,
Tag(s)
Procedural non compliance

GND

On gate collision,
Tag(s)
Aircraft / Object or Structure conflict

Outcome

Damage or injury Yes

Aircraft damage Major

Non-aircraft damage Yes

Causal Factor Group(s)

Aircraft Operation,
Group(s)
Airport Operation

Safety Recommendation(s)

Aircraft Operation,
Group(s)
Airport Management

Investigation Type

Type Independent
Description
On 19 December 2013, a Boeing 777-200 (9V-SRP) being operated by Singapore
Airlines in a scheduled passenger flight from Mumbai to Singapore ingested an empty
cargo container into the left engine as it taxied onto the designated arrival gate at
Terminal 2 at Singapore with normal daylight visibility. The engine sustained serious
damage and had to be replaced. No persons on the aircraft or on the ground were
injured.

Investigation
An Investigation was carried out by the Singapore Air Accident Investigation Bureau.

It was established that the ingested container and two attached baggage trailers had
been wholly within the designated Equipment Restraint Area (ERA) of the designated
arrival gate F37 at the time the gate entry guidance system had been switched on by
the ground service provider personnel covering the arrival of the accident aircraft.
They were located just clear of the red hatched area marking the extent of the
Passenger Loading Bridge (PLB) safety zone.

The empty container dolly and attached baggage containers after the ingestion (reproduced
from the Official Report)

It was also noted that the commander of the arriving aircraft had observed that the
aircraft docking guidance system was not switched on as the gate area was
approached and had stopped the aircraft prior to gate entry for approximately 20
seconds until it was.

It was found that the Ground Service Provider's arrival crew - two technicians - had
arrived at the gate about 25 minutes prior to the expected arrival of the aircraft. The
technician in charge of the crew was a 'Certifying Technician' (CT) and the other
technician was a 'Lead Technician' (LT) under training to himself qualify as a CT.
Whilst the CT checked the correct function of the PLB, the LT "inspected the ERA to
ensure that it was clear of obstructions and equipment" They then waited below the
PLB for the aircraft to arrive and no further inspection of the area was carried out as it
was not required by procedures. About 15 minutes prior to the actual arrival of the
aircraft, another CT joined the arrival crew and was assigned to act as the chock
bearer.

Meanwhile, an A330 was due to arrive at the adjacent gate F42 shortly after the 777
had arrived on F37. An Equipment Operator (EO) from different Ground Service
Provider arrived driving a tractor towing two baggage containers which, on seeing
that the ESA for gate F42 was already full, he then left just within the ESA of gate
F37, returning few minutes later to attach an empty cargo container on a dolly to the
two baggage trailers so that all three trailers were within the F37 ESA. The EO then
waited for an A320 to depart from gate F42, expecting that when it did, some of the
handling equipment serving the A320 would be moved which would release some
ESA space. However, with the A320 still on the gate after about 10 minutes, he
decided to try and rearrange equipment in the gate F36 ESA to make room for his
trailers in the gate F42 ESA. Just as the aircraft docking guidance system had been
activated and the 777 was proceeding into gate F37, he left the area, leaving the
baggage trailers and the cargo container behind.

The LT acting as chock bearer walked slowly towards the approaching aircraft
and "only then … noticed the cargo container and baggage trailers". He reported
having called out to the technician in charge who was operating the PLB to try to get
him to stop the aircraft using the guidance system but the noise of the engine drowned
out his voice and the cargo container had been sucked into the left engine before the
aircraft reached the stop line.

The Investigation noted that the aircraft commander, although he had not announced
verbally that the left side of the gate area was clear, reported that "he had done a
visual sweep of the area from his position and did not notice any obstructions". In
order to understand what the chances of pilots detecting obstructions on a gate area
which they would not expect if the aircraft docking guidance system was 'live', the
Investigation team set up a simulation on the gate concerned using a towed 777
aircraft. This exercise (see the picture below) led to the conclusion that "it was not
easy to judge" whether the cargo container and the two baggage trailers would have
been in the ERA or not, although "one could infer, from the fact that the PLB safety
zone could not be seen", that the cargo container and the baggage trailers were in the
ERA because they were partially obscuring the marked PLB safety zone and the
wheels of the airbridge.

A pilot's eye view of the cargo container and the baggage trailers during a reconstruction of the
accident scenario (reproduced from the Official Report)

The Conclusion of the Investigation was that the ingestion incident was the result of
the incorrect positioning of the cargo container/dolly and the baggage trailers in the
ERA and:

• the failure of the Ground Service Provider's arrival crew to continue to monitor
the ERA to ensure that it remained clear of obstructions and equipment, after
they had done one round of inspection.
• the failure of the inbound aircraft flight crew to detect that there was equipment
within the ERA.
It was noted that in the light of the findings of the Investigation, "it may be useful for
flight crews to check for tell-tale signs that might suggest an abnormal situation in the
ERA, for example, when the hatched lines of the PLB safety zone or the wheels of the
aerobridge are not visible".

Safety Action taken by the Aerodrome Operator whilst the Investigation was in
progress was recorded as including the following:

• increased the frequency of airside inspections and safety audits on Ground

Service Providers
• has limited the use of gate involved to smaller aircraft to allow provision of a
bigger equipment storage area for both this and the adjacent gate and service
vehicle access.
• initiated a comprehensive review of the aircraft parking bay layout at the airport.
• replaced all remaining 30-key aircraft docking guidance system operator panels
with the 54-key alternative to standardise operating procedures.
Also, the Aviation Regulatory Authority found that "there was no one organisation
or person who was overall in-charge and responsible for the various ground handling
activities conducted by multiple parties at the bay" and has since required that the
aerodrome operator "to ensure that there is an overall person-in-charge of the
operations at the bay for each arrival flight so as to ensure that the operations are
carried out safely at the bay".

Three Safety Recommendations were made as a result of the Investigation as

follows:

• that the Aerodrome Operator should look into having a system that can clearly
indicate to all working in the bay and adjacent areas the operational status of a
bay. (R-2015-005)
• that the Airline Operator should remind its flight crews that if the view of the
hatch lines of the PLB safety zone or the wheels of the aerobridge were
obscured, it could suggest an abnormal situation in the ERA. (R-2015-006)
• that the Ground Service Provider (responsible for the operation of the gate area
during the arrival of the incident aircraft) review its procedures to ensure that
there will be continuous surveillance of the parking bays by its arrival crews
until the aircraft arrive. (R-2015-007)
The Final Report of the Investigation was published on 30 July 2015.