Incident Overview

Date: Friday 23 March 2018
Aircraft Type: Boeing 737-8K5 (WL)
Owner/operator: SmartWings, opf Israir
Registration Number: OK-TVP
Location: Budapest Ferenc Liszt International Airport (BUD/LHBP) – ÿ Hungary
Phase of Flight: Standing
Casualties: Fatalities: 0 / Occupants: 167
Component Affected: Rear slides of the Boeing 737-800 aircraft.Rear slides of the Boeing 737-800 aircraft.
Investigating Agency: TSB HungaryTSB Hungary
Category: Accident
A Boeing 737-800, operated by Israir Airlines, experienced a significant evacuation at Budapest Ferenc Liszt International Airport due to smoke entering the cabin during a flight from Budapest to Tel Aviv. The aircraft’s tow truck emitted smoke, which entered the cabin, leading to the opening of rear emergency exits. The unstable rear slides caused a delay in engine shutdown, resulting in a passenger falling from the slides and sustaining a serious head injury. Investigation revealed a lack of communication from the galley crew regarding the situation, compounded by passenger anxiety, misjudgment of the smoke’s origin, inadequate emergency procedures, delayed crew response, and an unauthorized evacuation.A Boeing 737-800, operated by Israir Airlines, experienced a significant evacuation at Budapest Ferenc Liszt International Airport due to smoke entering the cabin during a flight from Budapest to Tel Aviv. The aircraft’s tow truck emitted smoke, which entered the cabin, leading to the opening of rear emergency exits. The unstable rear slides caused a delay in engine shutdown, resulting in a passenger falling from the slides and sustaining a serious head injury. Investigation revealed a lack of communication from the galley crew regarding the situation, compounded by passenger anxiety, misjudgment of the smoke’s origin, inadequate emergency procedures, delayed crew response, and an unauthorized evacuation.

Description

A Boeing 737-800 was evacuated at Budapest Ferenc Liszt International Airport, Hungary when smoke had entered the cabin. The aircraft was performing Israir Airlines flight 6H716 from Budapest to Tel Aviv, Israel. During pushback the tow truck reportedly began emitting smoke, which supposedly entered the aircraft cabin. Cabin crew members opened the rear emergency exit(s) to allow evacuation through slides. During the evacuation, the rear slides were unstable because of the jet blast of the operating engines. Approximately 2.5 minutes passed from the opening of the slide to the shutdown of the engines. One passenger fell from the evacuation slide and suffered a serious head injury. Causes In the course of its investigation, the IC concluded that the direct cause of the accident was the lack of communication from the cabin crew on duty in the aft galley to the rest of the crew, and identified the presence of the panic on board as an indirect cause, which was caused by the misjudgement of the origin of the smoke. In addition to those above, the IC presumes the following contributing factors: ? passengers? fatigue; ? malfunction of the pushback tug; ? ambiguity of the emergency procedures; ? initiation of an evacuation without approval; ? late reaction of the flight crew to the situation.

Source of Information

http://airportal.hu/veszcsuszdakon-uritettek-ki-egy-repulogepet-ferihegyen/, https://mno.hu/belfold/sulyos-incidens-a-ferihegyen-2455450, http://www.kbsz.hu/j25/hu/legi-kozlekedes/kbsz-altal-vizsgalt-esemenyek-2014/22-legi-kozlekedes/legi-kozlekedes/2344-20180323http://airportal.hu/veszcsuszdakon-uritettek-ki-egy-repulogepet-ferihegyen/, https://mno.hu/belfold/sulyos-incidens-a-ferihegyen-2455450, http://www.kbsz.hu/j25/hu/legi-kozlekedes/kbsz-altal-vizsgalt-esemenyek-2014/22-legi-kozlekedes/legi-kozlekedes/2344-20180323

Primary Cause

Lack of communication from the cabin crew regarding the situation and the presence of passenger anxiety.Lack of communication from the cabin crew regarding the situation and the presence of passenger anxiety.

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