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Report: Hydraulic leak caused A320 runway excursion on landing, Bulgaria
18 February 2021

Report: Hydraulic leak caused A320 runway excursion on landing, Bulgaria

Early power reduction caused C-130J hard landing at Ramstein Air Base

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‘High-risk piloting’ caused fatal JU-52 accident, Switzerland

Report: USAF Global Express crew shut down wrong engine after failure

DHC-8, fuel truck collision shows passengers need to pay more attention to safety instructions

The Transportation Safety Board of Canada (TSB) released its investigation report into the May 2019 collision between a fuel truck and a DHC-8-300 at Toronto/Lester B. Pearson International Airport, Canada. The investigation highlights the importance of passengers familiarizing themselves with safety information and following instructions from flight attendants during emergencies.

On 10 May 2019, at 01:33 local time, a Jazz Aviation DHC-8-300 operated as flight JZA8615, and a fuel tanker collided on the apron at the Toronto Airport. The aircraft was carrying 56 occupants. The passengers and crew evacuated the aircraft and were guided to the terminal building by the first responders. There was no fire and no fuel spillage. Fifteen minor injuries were reported, including one infant and one crew member.

The fuel tanker had crossed an aircraft warning sign painted on the apron surface just before the connecting corridor. These signs serve as a reminder for drivers that they are about to cross an aircraft taxilane, and to exercise vigilance. Drivers are not required to slow or stop in the absence of aircraft traffic. The fuel tanker did not slow or stop near the aircraft warning sign, and continued southbound at a speed of approximately 40 km/h, which is the speed limit.

The investigation determined that the limited field of view to the right of the fuel tanker driver’s cab caused by the front elevating service platform, along with the condensation on the windows, resulted in the driver being unable to see the aircraft in time to avoid the collision. While taxiing, the captain’s attention was focused primarily on the intended path of the aircraft to maintain the taxilane centreline and scan for traffic or obstacles ahead. The captain had a clear field of view in the direction of the oncoming fuel tanker, but the visibility was limited due to darkness, rain, and reflected light. Therefore, he did not see the oncoming tanker during the critical moments before the collision.

The investigation also highlighted several factors related to the aircraft evacuation following the collision. It is important that passengers pay attention to the pre-flight safety briefings, review the safety features card, and follow directions from flight attendants in order to be prepared and to evacuate safely during an emergency. In this occurrence, one passenger was injured because she removed her seatbelt before the collision, despite the seatbelt light being illuminated and being told by the flight attendant to keep her seatbelt on. Two other passengers were injured after opening a rear emergency exit without instruction and jumping from the exit, which was not compliant with the safety features card instructions to sit on the sill of the emergency exit opening before exiting the aircraft. Some passengers also tried to retrieve carry-on items during the evacuation, which created delays. One infant was injured during the collision, reinforcing the need to address the outstanding TSB recommendation (A15-02) to require child restraint systems for infants and young children, to provide an equivalent level of safety to adults aboard commercial aircraft.

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Pilot decision-making in poor weather contributed to fatal CFIT accident in Canada

TSB Canada found that pilot decision-making was a factor in a fatal controlled flight into terrain accident involving a Cessna 208B in 2019 near Mayo, Yukon.

On 6 August 2019, a Cessna 208B Supervan 900 operated by Alkan Air was on a visual flight rules (VFR) flight from Rau Airstrip to Mayo Airport, Canada, with one pilot and one passenger on board. While enroute, the aircraft entered an area of low visibility and low cloud ceilings. The aircraft departed from the intended route, turned into a box canyon and struck rising terrain, fatally injuring the pilot and passenger. The aircraft was destroyed and there was a brief post-impact fire.

The investigation found that the pilot’s decision to continue a low altitude flight into poor weather conditions in mountainous terrain was influenced by several factors. The pilot had recently completed a flight along the same route, in similar weather conditions. The pilot’s decision-making would have been affected by his familiarity with the route and, consequently, he likely did not consider an alternate route to avoid the poor weather conditions.

The high speed at low altitude and low visibility reduced the opportunities for the pilot to take alternative action to avoid terrain. Within the box canyon, the canyon floor elevation increased abruptly within less than one nautical mile and the low visibility prevented the pilot from detecting this and taking sufficient actions to prevent a collision. Additionally, the aircraft’s terrain awareness and warning system aural alerts were ineffective in warning the pilot of the rising terrain because he had already heard multiple similar alerts in the preceding minutes of flight, or had silenced these alerts.

Following the occurrence, Alkan Air made changes to its Caravan operations, including requiring a second flight crew member for Cessna 208B Grand Caravan captains with less than 2000 hours. Before becoming a captain on the Caravan, candidates must perform as a second crew member on the Caravan for 1 season. The company has also made modifications to its emergency response plan.