Incident Overview

Date: Saturday 21 January 1995
Aircraft Type: Boeing 747-428
Owner/operator: Royal Air Maroc – RAM
Registration Number: CN-RGA
Location: Montreal (Mirabel) International Airport, Quebec – ÿ Canada
Phase of Flight: Taxi
Status: Unknown
Casualties: Fatalities: 0 / Occupants: 114
Component Affected: The Boeing 747-400 aircraft, specifically its de-icing vehicles and the cherry-pickers.The Boeing 747-400 aircraft, specifically its de-icing vehicles and the cherry-pickers.
Investigating Agency: TSBTSB
Category: Accident
A Royal Air Maroc Boeing 747-400 experienced a catastrophic accident during a scheduled flight from Montreal (Mirabel) to Casablanca, Morocco. The aircraft was operating with four engines running, and the crew received the signal ‘d‚givrage termin‚’ indicating de-icing was complete. The pilot then requested the apron controller to inform the aircraft was ready for taxi, leading to a series of events including the overturning of de-icing vehicles and resulting fatal injuries to the cherry-pickers. The incident stemmed from inadequate de-icing procedures, communication failures, and a lack of oversight by Royal Air Maroc and its contracted airlines.A Royal Air Maroc Boeing 747-400 experienced a catastrophic accident during a scheduled flight from Montreal (Mirabel) to Casablanca, Morocco. The aircraft was operating with four engines running, and the crew received the signal ‘d‚givrage termin‚’ indicating de-icing was complete. The pilot then requested the apron controller to inform the aircraft was ready for taxi, leading to a series of events including the overturning of de-icing vehicles and resulting fatal injuries to the cherry-pickers. The incident stemmed from inadequate de-icing procedures, communication failures, and a lack of oversight by Royal Air Maroc and its contracted airlines.

Description

“The Royal Air Maroc Boeing 747-400 was parked in the de-icing centre of Montreal (Mirabel) International Airport, Quebec. The aircraft was being prepared for a scheduled flight from Mirabel to Casablanca, Morocco, with a stop at New York, New York. The four engines were running during the de-icing operation. The crew heard “”d‚givrage termin‚”” (de-icing completed), and the captain asked the co-pilot to inform the apron controller that the aircraft was ready to taxi. Taxi instructions were issued. The aircraft started to move forward and overturned the two de-icing vehicles that were still in front of the aircraft’s horizontal stabilizers. The two vehicle drivers sustained minor injuries; the three occupants of the cherry-pickers received fatal injuries. The Board determined that the flight crew started to taxi the aircraft before its perimeter was clear, following confusion in the radio communications. The following factors contributed to the accident: a lack of de-icing procedures within Royal Air Maroc; non-compliance with procedures on the part of the Canadian Airlines International Ltd. de-icing crew; inadequate or inappropriate communications equipment; incomplete training of Snowman 1 (the chief de-icing attendant); a regulatory framework less demanding of foreign air carriers than of Canadian carriers; a lack of operational supervision; and a lack of adherence to radio protocol.”

Source of Information

http://web.archive.org/web/20080516223314/http://www.tsb.gc.ca:80/en/reports/air/1995/a95q0015/a95q0015.asphttp://web.archive.org/web/20080516223314/http://www.tsb.gc.ca:80/en/reports/air/1995/a95q0015/a95q0015.asp

Primary Cause

Inadequate de-icing procedures, communication failures, and insufficient oversight by Royal Air Maroc and its contracted airlines.Inadequate de-icing procedures, communication failures, and insufficient oversight by Royal Air Maroc and its contracted airlines.

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