Saab Aircraft AB SF-340B , VH-KDV

Investigation number

199901614

Occurrence date

28/03/1999

Location

Bindook, (VOR)

Report release date

26/10/1999

Report status

Final

Investigation type

Occurrence Investigation

Investigation status

Completed

Aviation occurrence type

Flight crew incapacitation

Occurrence category

Incident

Highest injury level

Minor

Safety Action Summary

As a result of the Regional Airlines Safety Study, the Bureau of
Air Safety Investigation issued the following Interim
Recommendation to the Civil Aviation Safety Authority on 6 July
1998.

IR 19980098

"The Bureau of Air Safety Investigation recommends that the Civil
Aviation Safety Authority develop standards and implement
regulations which:

require Australian airlines to develop industry-consistent
cabin baggage control programs that will prevent passengers from
bringing inappropriate cabin baggage onto aircraft; and
ensure correct on-board stowage of approved cabin baggage. Such
programs should be approved and monitored by CASA".

The following response was received from CASA on 6 August
1998:

"As acknowledged in the BASI document, the recommendation made
by the Cabin Safety and Carriage of Persons project team to adopt
the Canadian rule 705.42 for carry-on baggage is intended to be
implemented by CASA

A Notice of Proposed Rule Making (NPRM) is currently being
prepared in CASA's Regulatory Framework program office for
publication by September 1998. The proposed new rule for carry-on
baggage expands CAO 20.16.3, subsection 9, adopts Canadian rule
705.42 and similarly covers the requirements for FAR121/589, and
responds directly to the safety deficiency identified by BASI".

CASA Notice of Proposed Rule Making 9809RP, was subsequently
issued in November 1998. The NPRM proposal requires that every
operator establish a carry-on baggage program, acceptable to CASA,
that will ensure that baggage that cannot be correctly stowed is
prevented from carriage in the cabin, and once accepted as cabin
baggage, is correctly stowed (NPRM. 121.AK). The CASA NPRM process
is currently in progress.

Following discussions within CASA, and between CASA and the
operator, the operator has subsequently issued a company
requirement prohibiting the practice of securing cabin baggage on
passenger seats.

The flight attendant was preparing the cabin for landing when an
area of severe air turbulence was encountered, causing the flight
attendant to strike his head on the cabin roof. He received minor
injuries, and was relieved from further duty that day. The flight
attendant has since returned to flight duties.

During the investigation, it was revealed that after striking
his head, the flight attendant was unable to occupy a nearby spare
aisle seat during the turbulence encounter, as another passenger's
hand luggage had been secured to the seat with the seat belt. The
flight attendant returned to his seat at the front of the aircraft.
It was further revealed that it was common company practice to
secure passenger cabin baggage on spare passenger seats due to the
problem of stowage on smaller aircraft types.

Civil Aviation Safety Authority (CASA) regulations required
cabin baggage to be stowed securely so that movement of cabin
baggage would not cause injury to any person or damage to the
aircraft, during turbulence or unusual aircraft accelerations or
manoeuvres. The regulations also required that cabin baggage be
stowed whenever the seat belt sign was on, and specified that
luggage be stowed under a passenger seat with approved
forward-movement restraint, or in an approved overhead locker or
rack (Civil Aviation Order 20.16.3, subsection 9).

Following the occurrence, the operator sought clarification of
the regulation regarding the stowage of cabin baggage from CASA.
CASA had initially agreed with the operator that soft bags could be
stowed with a seat belt through the straps, on a window seat that
was not an emergency exit.

The Bureau conveyed its concerns to CASA that seat belts were
designed primarily to restrain the human form and that bag handles
were not stressed to take loads that could occur under turbulent
conditions or impact forces. Bags so secured on a passenger seat by
a seat belt might become loose during turbulence or impact, or
could swing about the seat belt, presenting injury or evacuation
obstruction hazards.

Aircraft Details

Model

340

Registration

VH-KDV

Serial number

340B-322

Operation type

Air Transport Low Capacity

Departure point

Canberra, ACT

Destination

Sydney, NSW

Damage

Nil