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ASN Wikibase Occurrence # 230330
Last updated: 1 December 2021
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Date:27-OCT-2019
Time:22:47
Type:Silhouette image of generic B739 model; specific model in this crash may look slightly different
Boeing 737-958ER
Owner/operator:El Al - Israel Airlines
Registration: 4X-EHE
MSN: 41556/4840
Fatalities:Fatalities: 0 / Occupants: 170
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Paris Charles-de-Gaulle Airport (CDG) -   France
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:Paris-Charles de Gaulle Airport (CDG/LFPG)
Destination airport:Tel Aviv-Ben Gurion International Airport (TLV/LLBG)
Investigating agency: BEA
Narrative:
After checking in for flight LY326, the passenger kept his own electrical wheelchair in order to go to the boarding zone. Shortly before boarding the aeroplane, a gate agent installed him in a transfer wheelchair. The passenger folded his wheelchair himself and handed it to an EL AL security agent.
Following a lack of understanding and despite the instructions given by the agents during the check-in and in the departure lounge, the passenger supposed that one of the agents with whom he was dealing was going to remove the battery and that he did not have to do it. The wheelchair was then subject to checks which were not designed to identify the battery. The loading supervisor then took charge of the wheelchair but did not identify that the battery was still in place: he supposed that the red canvas pouch attached to the wheelchair contained the battery without being able to confirm this. He did not identify or did not know that the passenger should have carried the battery in the cabin.
After the wheelchair had been secured in the aft hold of the aeroplane, a short circuit occurred in the wheelchair’s electrical system for unknown reasons. The lithium battery, still connected, sustained this short circuit which resulted in incipient combustion. The battery was in immediate contact with the combustion zone which could have created thermal runaway inside the battery.
After the push-back from gate A38 of terminal 2A, the aeroplane was facing west on taxiway P1 with the engines operating while the tractor was uncoupled from the plane.
At that time, following the incipient combustion, a warning was activated in the cockpit. The crew then complied with the procedures, declared an emergency situation and constantly analysed the situation to adapt their actions until all the passengers and crew members had safely evacuated the plane.
The aircraft resumed service about 17 hours after the incident.

Contributing factors
The following factors may have contributed to the incident:
- Lack of understanding between the passenger and ground personnel, the passenger spoke French but visibly did not understand it very well.
- The “traffic” agent not checking that the battery had been removed, either when the passenger left his wheelchair or, in any case, before the “ramp” loading agent took charge of it.
- Incomplete or unsuitable procedures which did not ensure the continuous tracking of the battery information.
- Insufficiently effective training of the Alysia agents and in particular the loading supervisor which meant that he did not react to the presence of a battery which he thought was in the red pouch and which should have been carried by the passenger in the cabin.
- Checks solely focused on security and looking for explosives, not designed to detect the presence of the battery on the wheelchair before it is loaded in the hold.
- An unidentified internal fault which caused a short-circuit in the wheelchair’s electrical system

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-du-boeing-737-immatricule-4x-ehe-exploite-par-el-al-survenu-le-27102019-a-paris-cdg-95/

Accident investigation:
cover
  
Investigating agency: BEA
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report


Images:

Photo of 4X-EHE courtesy AirHistory.net


Frankfurt am Main (EDDF / FRA / FRF)
14 May 2019; (c) Sybille Petersen

Revision history:

Date/timeContributorUpdates
01-Nov-2019 09:22 harro Added
01-Nov-2019 09:23 harro Updated [Narrative]
09-Dec-2020 19:59 harro Updated [Time, Total occupants, Damage, Narrative, Accident report]

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