A Culmination of Many Little Events
The Air Accident Investigation Unit (AAIU) of Ireland conducted a safety investigation into a serious incident involving a TECNAM P2006T aircraft, registration EI-WST, at Weston Airport, Co. Dublin, on 22 August 2023.
Incident Overview
Shortly after take-off from Runway 25 at Weston Airport, the Duty Air Traffic Controller informed the aircraft’s flight crew, consisting of an Instructor and a Student, that the aircraft’s towbar was still attached to the nose landing gear. The Instructor decided to return for an immediate landing. The aircraft landed with the towbar still attached, causing minor damage to the fuselage. Neither the Instructor nor the Student was injured, and there was no fire.
Pre-Flight Events
Due to distractions, Instructor and Student boarded the aircraft without removing the towbar”
On the day of the incident, the Student had completed a simulator training exercise with the Instructor, and was preparing for a flight to continue his training for a multi-engine piston rating. During the pre-flight walkaround inspection, the Student noticed the towbar attached to the aircraft but was interrupted by a pressing phone call. The Instructor, noticing the Student’s stress, offered to cancel the flight, but the Student declined. The Instructor completed the walkaround inspection while the Student continued his phone conversation. The Instructor moved the aircraft twice, using the towbar, to avoid the downwash from a departing helicopter. Due to these distractions, both the Instructor and the Student boarded the aircraft without removing the towbar.
Flight and Landing
The aircraft was cleared for take-off, and the Student, as the handling pilot, lifted off normally. Shortly after take-off, the Air Traffic Controller informed the crew about the towbar. The Instructor took control, requested landing clearance, and performed a left-hand circuit to land on Runway 25. During the landing, the towbar caused minor damage to the fuselage. The crew exited the aircraft, removed the towbar, and taxied back for further inspection.
Human Factors
The investigation highlighted the impact of distractions and interruptions on flight safety. The UK Civil Aviation Authority’s guidance on dealing with distractions emphasizes the importance of managing cognitive demands and maintaining focus. Personal issues and stress can significantly affect a pilot’s performance, leading to errors and omissions.
Case Study
A similar incident occurred in 2019 when a Cessna Centurion 210 aircraft departed with its towbar still attached, which later caused a collision with another aircraft. This incident underscored the importance of making ground equipment more visible to prevent such errors.
Operator's Response
Following the incident, the aircraft operator modified the towbar to make it visible from the cockpit, although this modification was later removed, as it proved impractical. The operator issued a new procedure requiring a final 360-degree visual inspection by the commander or instructor before boarding the aircraft.
Conclusion
The incident at Weston Airport was a result of multiple distractions and the fallibility of prospective memory. The investigation emphasized the need for highly visible colours, such as bright yellow, red or orange, for ground equipment, and thorough pre-flight checks. The operator’s revised procedure aims to prevent similar incidents in the future.
Read the full AAIU report here:
https://aaiu.ie/wp-content/uploads/2024/10/Report-2024-009.pdf