Question NW2217 to the Minister of Transport

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30 September 2021 - NW2217

Profile picture: Lees, Mr RA

Lees, Mr RA to ask the Minister of Transport

Whether (a) the investigation and (b) report into the SA Airways (SAA) Alpha Floor incident that occurred during the SAA flights to and/or from Brussels on or about the 24 February 2021 have been concluded; if not, (i) what are the reasons for non-completion and (ii) by what date will the investigation and report be completed; if so, what are the details of the (aa) findings and (bb) recommendations?

Reply:

The investigation and (b) report into the SA Airways (SAA) Alpha Floor incident that occurred during the SAA flights to and/or from Brussels on or about the 24 February 2021 have been concluded (i) N/A (ii) The investigation was completed on 08 June 2021. The report was handed over to the operator and they were given a time to respond to the report addressing the contents of identified issues.

(aa) The findings of the investigations were as follows:

Similar occurrences happened in 2014 and in 2015 and were never reported to the SACAA.

Relating to this specific incident of February 2021, when performing the engine run Procedure Aircraft Maintenance Manual (AMM) _71-00-00-860-845-A_Engine_Automatic_Start) the reset of the Fuel Control and Monitoring Computers (FCMC) 1&2 was not performed. Because the FCMC 1&2 was not performed and the AC remained powered since the engine run, the Zero Fuel Weight (ZFW) inserted at the time of the engine run was still present in the FCMC when the engines were started again at 21:59 Coordinated Universal Time (UTC).

If the crew entered the ZFW, in the Multi-Function Display Unit (MCDU) INIT B page, as per “Cockpit preparation” Specific Operating Procedure (SOP), this new ZFW was necessarily different from the one actually recorded in the FCMC (107,9T) leading to the display of the amber scratchpad message - REENTER WEIGHT/CENTER OF GRAVITY (CG) - on the MCD and the request to re-enter the ZFW and the ZFWCG even if they were correct. Had this been performed, the new ZFW value would have been taken into account by the FCMC.

The pre-departure check of the Gross Weight (Comparison of the load sheet Gross Weight with the Electronic Centralized Aircraft Monitor (ECAM) Gross Weight (GW)) included in the “Before Eng Start” SOP was not performed. If done, the discrepancy would have been identified and the ZFW entered for the second time in the MCDU INIT B page, would have forced the new ZFW to be taken into account by the FCMC.

Although the Flight crew correctly assessed the situation and actioned the appropriate measures to contain the very short Alpha Floor alert that occurred, it is evident that both the flight crew and the ground crew did not execute any of the two procedures in place which are established to prevent this occurrence.

(bb) recommendations include the following:

  1. SAA to document and record aircraft de-energizing methods and sessions as an occurrence.
  2. The procedure of weight review before engine start, must be added into the pre-flight checklist.
  3. SAA to create a SOP compliance procedure/checklist.
  4. Ground and flight crew to attend CRM course together.
  5. SAA to report any safety jeopardising action to the SACAA within a 12-hour period.
  6. SAA to report to SACAA as to why previous Alpha-Floor incidents were not reported and propose how the organisation intends to rectify this shortcoming.
  7. SACAA to consider taking enforcement action against SAA for failing to report these since 2014. (This recommendation has been implemented - Operator was issued with a financial penalty).

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