Read the case study throughly and covered the following parameters

a) Brief description of the occurrence

b)Stake holders involved

B739, Paris CDG France, 2019

Description

On 27 October 2019, a Boeing 737-900 (4X-EHE) being operated by El Al on a scheduled international passenger flight from Paris CDG to Tel Aviv as LY326 was about to begin taxiing after pushback and engine start when an under-floor hold fire was annunciated in the flight deck. Since there were no signs of fire in the passenger cabin or during an emergency services external inspection, a non-emergency disembarkation of all occupants was made. The hold concerned was then opened and fire damage sourced to the overheated lithium battery in a passenger wheelchair was discovered.

Investigation

An Investigation was carried out by the French Civil Aviation Accident Investigation Agency, the BEA. The Investigation was conducted by use of statements and reference to applicable procedures. Since the aircraft electrical power system had remained on, any relevant data on the CVR would have been overwritten and it was not downloaded.

How and Why It Happened

It was noted that transport of powered mobility aids is described in ICAO Doc 9284 Technical Instructions for the Safe Transport of Dangerous Goods by Air on which the IATA Dangerous Goods Regulations (DGR) are based. The El Al procedures for the transport of dangerous goods were found to replicate these international requirements and stated that the transport of electrical wheelchairs equipped with removable lithium batteries was only authorised subject to the following conditions: the aircraft operator must be advised of its presence the battery must be removed by the passenger before the wheelchair is placed in the hold the battery must be protected from impacts the battery must be carried in the cabin by the passenger the aircraft Captain must be informed of the presence, number and location of the batteries

It was also noted that applicable DGR also placed specific responsibilities on ground handling agents who provide services on behalf of the operator which include the acceptance, handling, loading, unloading, transferring or other processing of cargo or mail and the processing of passengers by requiring that their personnel must be trained in the requirements commensurate with their responsibilities.

It was found that although aircraft operators are responsible for the check in of their passengers, El Al subcontracted this function to Alysia which, in the case of a PRM, required the recording of the presence of any mobility aid being carried on a flight electronically along with information about the type of any battery involved (its serial number, technology and whether it is fixed or removable). This information is transmitted to their Traffic Coordinator who must remind the passenger in the departure lounge if they are required to remove a battery and take it into the aircraft cabin with them. The same Traffic Coordinator must also advise the Ramp Handling Supervisor of the presence of and type of any mobility aid. The procedure which Alysia was using allowed a passenger wheelchair to be accepted at check-in or, if a passenger so requested, subsequently when they are about to board the aircraft. It was noted that in all cases, the procedure stipulated that the passenger must declare the presence of a battery when the wheel chair is handed over and then remove, isolate and carry any battery with them into the passenger cabin. It was also noted that the airport operator provides assistance to PRMs and that the provision of such assistance for this flight was subcontracted to a service provider called Samsic whose personnel do not take charge of the personal effects of these passengers.

It was found that on check in, the passenger involved had wanted to keep his wheelchair so as to go from check-in to the departure gate unaided. During check-in, the Alysia Check-in Agent had reportedly questioned the passenger about the type of battery powering his wheelchair and informed him that he would have to remove the battery himself before boarding the aircraft. The Alysia Traffic Coordinator reportedly further questioned the passenger who it was stated had replied, in non native French yes, Ill do as [when] I came by plane. When boarding, the passenger was accompanied by the Samsic agent onto the airbridge being used for boarding and this agent had then, as per their procedures, and without the Alysia Traffic Coordinator being present), moved the passenger to a transfer wheelchair. The passenger had then folded and handed over their own wheelchair to an El Al security agent who had then taken it down onto the apron and, after required security checks had been carried out, handed it over to the Alysia Ramp Handling Supervisor. The latter reported having seen a red pouch attached to the wheelchair which he thought appeared to be full and heavy. He said he had supposed that the wheelchair battery was in this pouch but was unable to check as his procedures prohibited him from opening passengers personal effects. The wheelchair was then loaded and secured in the aeroplanes aft hold.

After the incident, an Alysia manager stated that they had spoken to the passenger but he had not seemed to understand the questions being asked and gave contradictory answers. In a statement given to investigators, the passenger said that during boarding, the agents told him that they knew what to do with the wheelchair and that he did not have to do anything (so) he had handed over the wheelchair as it was, with the battery in place. He added that on the flight from Tel-Aviv to Paris, he had been asked to remove the battery but not on the return flight.

The Investigation found that the presence of the battery had indeed been recorded by Alysia but not its location or the possibility of there being several batteries. It was noted that two- yearly dangerous goods training for Alysia staff, which included specific coverage of the lithium battery risk, was conducted separately for Check-in Agents, Traffic Coordinators and Ramp Handling Supervisors and found that all those involved in this event were recorded as having completed training that was still current