On 4 April 2003, an Airbus A330-200, registered VH-EBA, was
being readied for departure for a flight from Sydney to Melbourne.
The flight crew was provided with the load sheet based on
information about the intended number of passengers and the amount
of freight to be carried onboard the aircraft. The two forward left
aircraft doors (DL1 and DL2) were closed in preparation for the
pushback from the terminal, and the airbridges providing access to
doors DL1 and DL2 were retracted clear of the aircraft. The flight
crew notified the ground engineer that departure was imminent. They
completed the `Before Pushback or Start' checklist, and verified
that the aircraft doors were closed on the `DOOR/OXY' page on the
system display of the electronic centralised aircraft monitoring
(ECAM) system.
The passenger and baggage counts were lower than had been
expected, and the aircraft weight and balance data differed from
the load sheet that had been provided to the flight crew. The
assigned load controller reconciled those differences by
reassigning seating of passengers to restore the aircraft into an
`in trim' configuration, and transmitted the final load sheet to
the flight crew. However, although the seating reallocation had
been performed in the computer system, those passengers had yet to
be physically moved to their reassigned seats.
The airbridge servicing door DL2 was returned to the aircraft to
allow the ground-based service agents to supervise the movement of
the passengers to their reassigned seats. The cabin crew customer
service manager (CSM) reopened DL2 to allow the ground-based
service agents to board the aircraft without seeking permission
from the pilot in command. The operator's procedures specified
that: `If a door must be re-opened, the Customer Service Manager
must request permission from the captain prior to re-opening a
door'.
The ground engineer supervising the dispatch of the aircraft was
standing at the nose of the aircraft, and did not notice that the
airbridge had been returned to door DL2. The operator's procedures
specified that: `If access is required to the cabin once the
aircraft has been cleared to the dispatching engineer, clearance
must be sought from the captain through the engineer'.
The ground engineer was not informed that the airbridge had been
returned to door DL2, and clearance to open the door was not
sought. When door DL2 was re-opened, the DL2 door symbol on the
ECAM `DOOR/OXY' synoptic would have changed from green (closed and
locked) to amber (door not locked). The amber door indication (door
not locked), which was suppressed when the door was closed, would
also have appeared on the ECAM `DOOR/OXY' synoptic. Those were the
only visual indications available to the flight crew to indicate
that door DL2 had been re-opened. No aural warning would have
accompanied those changes to the ECAM `DOOR/OXY' synoptic, because
the aircraft engines had not been started. The flight crew had
previously verified that the aircraft doors were closed, and there
was no requirement for them to conduct another check of the doors
before commencement of the pushback.
The flight crew obtained clearance for pushback from air traffic
control and the pushback from the terminal was commenced. As the
aircraft moved rearwards, the opened door DL2 impacted the
airbridge. The door and airbridge were deflected into the aircraft
fuselage, causing significant damage to the fuselage skin and
associated structure. Damage to the airbridge was limited to
surface scraping and associated paint loss.
None of the passengers, crewmembers or ground personnel were
injured.
The operator conducted an investigation into the incident, and
determined that a number of individual/team actions,
task/environmental conditions and organisational factors had
contributed to the development of the occurrence. In addition, the
operator's investigation identified a number of procedural and
training deficiencies, particularly in the areas of
cross-functional communication and coordination.
As a result of its investigation into this occurrence, the
operator conducted a fleet-wide review of its airbridge return and
aircraft door opening procedures. That review has resulted in
amended procedures that ensure improved communication and
coordination between departments sharing responsibility for the
dispatch of company aircraft.