Accident Boeing 747-428 CN-RGA,
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ASN Wikibase Occurrence # 18539
 
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Date:Saturday 21 January 1995
Time:16:52
Type:Silhouette image of generic B744 model; specific model in this crash may look slightly different    
Boeing 747-428
Owner/operator:Royal Air Maroc - RAM
Registration: CN-RGA
MSN: 25629/956
Year of manufacture:1992
Fatalities:Fatalities: 0 / Occupants: 114
Other fatalities:3
Aircraft damage: Unknown
Category:Accident
Location:Montreal (Mirabel) International Airport, Quebec -   Canada
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:Montreal (Mirabel) International Airport, Quebec
Destination airport:Casablanca
Investigating agency: TSB
Confidence Rating: Information verified through data from accident investigation authorities
Narrative:
"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 ""dégivrage terminé"" (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."

Accident investigation:
cover
  
Investigating agency: TSB
Report number: A95Q0015
Status: Investigation completed
Duration: 2 years 1 month
Download report: Final report

Sources:

1. CADORS Query 1995Q0032
2. http://web.archive.org/web/20080516223314/http://www.tsb.gc.ca:80/en/reports/air/1995/a95q0015/a95q0015.asp

Revision history:

Date/timeContributorUpdates
17-May-2008 11:10 ASN archive Added
08-Jul-2016 12:14 Dr.John Smith Updated [Source, Narrative]

Corrections or additions? ... Edit this accident description

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