Issued June 2020 REPORT SL 2020/14 REPORT ON THE AIR ACCIDENT AT OSLO AIRPORT GARDERMOEN, NORWAY ON 18 DECEMBER 2018 WITH BOEING 787-9 DREAMLINER, ET-AUP OPERATED BY ETHIOPIAN AIRLINES The Accident Investigation Board has compiled this report for the sole purpose of improving flight safety. The object of any investigation is to identify faults or discrepancies which may endanger flight safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board's task to apportion blame or liability. Use of this report for any other purpose than for flight safety shall be avoided. Accident Investigation Board Norway • P.O. Box 213, N-2001 Lillestrøm, Norway • Phone: + 47 63 89 63 00 • Fax: + 47 63 89 63 01 www.aibn.no • [email protected] This report has been translated into English and published by the AIBN to facilitate access by international readers. As accurate as the translation might be, the original Norwegian text takes precedence as the report of reference. Photos: AIBN and Trond Isaksen/OSL The Accident Investigation Board Norway Page 2 INDEX ACCIDENT NOTIFICATION ............................................................................................................ 3 SUMMARY ......................................................................................................................................... 3 1. FACTUAL INFORMATION .............................................................................................. 4 1.1 History of the flight .............................................................................................................. 4 1.2 Injuries to persons .............................................................................................................. 10 1.3 Damage to aircraft .............................................................................................................. 10 1.4 Other damage ..................................................................................................................... 10 1.5 Personnel information ........................................................................................................ 11 1.6 Aircraft information: .......................................................................................................... 12 1.7 Meteorological information ............................................................................................... 13 1.8 Aids to navigation .............................................................................................................. 14 1.9 Communications ................................................................................................................ 14 1.10 Airport information ............................................................................................................ 14 1.11 Flight recorders .................................................................................................................. 15 1.12 Wreckage and impact information ..................................................................................... 16 1.13 Medical and pathological information ............................................................................... 18 1.14 Fire ..................................................................................................................................... 18 1.15 Survival aspects ................................................................................................................. 18 1.16 Tests and research .............................................................................................................. 18 1.17 Organizational and management information .................................................................... 18 1.18 Additional information ....................................................................................................... 21 1.19 Useful or effective investigation techniques ...................................................................... 28 2. ANALYSIS ........................................................................................................................ 29 2.1 Introduction ........................................................................................................................ 29 2.2 Allocation of incorrect de-icing stand ................................................................................ 29 2.3 The aircraft's entry into the “Bravo North” de-icing area .................................................. 30 2.4 The crew's actions at the de-icing stand 991 ...................................................................... 31 2.5 Indirect communication between de-icing vehicle No. 11 and the pilots on ETH715 ...... 31 2.6 Introduction of new technology to be used during taxiing. ............................................... 32 2.7 New pan-European regulations .......................................................................................... 32 3. CONCLUSIONS ................................................................................................................ 33 4. SAFETY RECOMMENDATIONS ................................................................................... 34 APPENDICES ................................................................................................................................... 35 2 The Accident Investigation Board Norway Page 3 AIR ACCIDENT REPORT Type of aircraft: Boeing Commercial Airplane Group, Boeing 787-9 Dreamliner Nationality and registration: Ethiopian, ET-AUP Owner: Ethiopian Airlines Operator: Same as owner Crew: 10 (three pilots + seven cabin crew members) Passengers: 59 (including one passive crew member) Accident site: Oslo Airport Gardermoen, Norway (ENGM), de-icing platform “Bravo North”, de-icing stand 991 Time of the incident: Tuesday 18 December 2018 19:10:05 hours All times given in this report are local time (UTC + 1 hour) if not otherwise stated. ACCIDENT NOTIFICATION The Accident Investigation Board Norway (AIBN) was not notified of the air accident. However, when the AIBN the day after learned of the accident through the media, the on-call accident inspector contacted Avinor Oslo airport. Three accident inspectors mobilized and started their investigation. In accordance with ICAO, Annex 13 (Aircraft Accident and Incident Investigation), the AIBN submitted notifications to the National Transportation Safety Board (NTSB), the European Aviation Safety Agency (EASA) and the Ethiopian Civil Aviation Authority. SUMMARY On 18 December 2018, a Boeing 787-9 operated by Ethiopian Airlines (flight ETH715) collided with a light mast at a de-icing platform at Oslo Airport Gardermoen. There was considerable damage to the outer section of the aircraft’s right wing, but there was no fuel leakage. ETH715 was by a slip-up from the de-icing coordinator instructed to taxi to a de-icing stand only authorized for smaller wingspan aircraft. The assigned stand was designed for aircraft up to Category C (Max. 36 meter wingspan). Boeing 787 is a Category E aircraft with a wingspan of 60.12 meters. The investigation showed that the de-icing coordinators did not have adequate technical aids to ensure correct de-icing stand allocation, based on aircraft category. Moreover, SAS Ground Handling was until spring 2020 unable to present work instructions for the de-icing coordinators relating to allocation of de-icing stand for each aircraft category. As the ET-AUP turned into the Bravo North de-icing area, there were no markings, lights, signage or other technical barriers to indicate to the crew that they had been assigned the wrong de-icing stand. Thus, the crew were unable to stop the aircraft before it hit the light mast to the right. Moreover, the ET-AUP crew did not have details about which de-icing stands at Gardermoen were 3 The Accident Investigation Board Norway Page 4 authorized for this type of aircraft, as it was not specified in the Aeronautical Information Publication Norway, or in the NOTAM. As the aircraft approached the light mast, the commander thought that clearance was marginal. The crew decided to rely on the given instructions to taxi to de-icing stand 991. The Accident Investigation Board is of the opinion that some type of anti-collision aid, such as a wing tip camera, would have clearly indicated to the crew that there was insufficient clearance between the wing and the light mast, thus preventing a collision. The AIBN is issuing three safety recommendations based on this investigation. 1. FACTUAL INFORMATION 1.1 History of the flight 1.1.1 Ethiopian Airlines had six weekly flights from Oslo via Stockholm to Ethiopia's capital Addis Abeba. Normally, a Boeing 787 Dreamliner is used for this flight (ETH715). 1.1.2 On Tuesday 18 December 2018, flight ETH715 was operated with a Boeing 787-9 Dreamliner with registration ET-AUP. 1.1.3 While the aircraft was at the gate, using datalink, the crew requested de-icing of the aircraft. Data from the A-CDM1 system entails that air traffic controllers and de-icing personnel receive relevant information about aircraft that need de-icing before departure. The request from ETH715 was submitted approximately 30 minutes prior to the aircraft arriving at the de-icing platform. 1.1.4 There are three dedicated de-icing platforms at Gardermoen. On the day in question, the “Bravo North” de-icing platform at the north-eastern end of the airport was in use. The de-icing platforms are located outside the designated airport maneuvering