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The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include only the TSB's synopsis and selected findings. For more information, contact the TSB or visit their Web site at http://www.tsb.gc.ca/. -Ed.

TSB Final Report A03P0332 -Maintenance Error-In-flight Fuel Leak

On November 6, 2003, an Airbus A330-300 departed Vancouver International Airport, B.C., at 14:23 Pacific Standard Time (PST) on a scheduled flight to Calgary, Alta., with 6 crew members and 92 passengers on board. Shortly after takeoff, the Vancouver tower informed the pilots that a substantial amount of smoke or vapour was coming from the No. 2 engine. Although the pilots did not receive any abnormal engine indications or cockpit warnings, they declared an emergency and advised that they were returning to Vancouver. After an uneventful landing, the pilots shut down the No. 2 engine. Aircraft rescue and firefighting (ARFF) services, following the aircraft, advised the pilots that fuel was leaking from the engine but there was no sign of fire. Eventually, the aircraft was towed back to the terminal where the passengers were deplaned. There were no injuries or damage to the aircraft.

Visible fuel leak from the Airbus A330
Visible fuel leak from the Airbus A330

Findings as to causes and contributing factors

  1. Because of an incorrect entry on the maintenance office duty board, and because technicians did not follow the troubleshooting manual (TSM), they unnecessarily removed the low-pressure (LP) fuel line from the fuel/oil heat exchanger.
  2. Because the technicians were unfamiliar with the coupling, because the retainer was hidden from view, and because they did not refer to the aircraft maintenance manual (AMM), the technicians did not properly reconnect the LP fuel line.
  3. Upon the application of take-off power, the fuel pressure, the fuel flow rate, and engine vibration caused the fuel/oil heat exchanger LP fuel line to detach, causing a substantial fuel leak from the No. 2 engine.

Findings as to risk

  1. A high-power engine run was not performed by the operator (nor was one required by the engine manufacturer), which would have produced conditions similar to those that caused the LP fuel line to detach from the fuel/oil heat exchanger on takeoff. A high-powered engine run could decrease the risk that a leak or mis-installed component would go undetected.
  2. Correct inspection of the fuel/oil heat exchanger would require the use of an elevated platform both prior to and after the actual engine run-up. A proper inspection of the LP fuel line connection was not accomplished after the engine run-up, increasing the risk that a leak or mis-installed component would go undetected.
  3. The operator had not implemented Airbus Service Bulletin (SB) A330-28-3080. Implementing this SB would reduce the risk that a fuel leak could go undetected, leading to fuel exhaustion, engine failure, or fire.

Other finding

  1. The removal and re-installation of the fuel/oil heat exchanger LP fuel line was not documented, as required by the operator's maintenance policy manual and Transport Canada regulation.


TSB Final Report A04P0057-In-flight Collision 

On March 12, 2004, two float-equipped Cessna 185 aircraft were conducting independent herring patrols on the northeast side of Vancouver Island, B.C.The pilot of the first C-185 was on a private business flight in support of his company's fishing vessels, located in the vicinity of Nanoose Bay, B.C.; he was monitoring radio frequencies 126.7 MHz and 122.9MHz.The pilot of the second C-185 was on a charter flight in support of the Department of Fisheries and Oceans Canada (DFO). The crew of this flight was to observe herring spawn size and location, and to conduct gear counts. This flight had originated at Comox, B.C., and had proceeded southeast along the shoreline toward Nanoose Bay, where the pilot was to land and pick up a second DFO officer from a boat that was regulating the fishing activity. The pilot of the second C-185 was monitoring frequency 123.2 MHz.

The second C-185 concluded the spawn count adjacent to the government wharf in Nanoose Bay, and the pilot began a left turn to land near the DFO boat. At the same time, the first C-185 was exiting Nanoose Bay, in level flight, at about 400 ft above ground level (AGL).The two aircraft collided in flight at approximately 09:48 PST. The pilot of the second C-185 had not seen the other aircraft. The pilot of the first C-185 did see the opposing aircraft, but had insufficient response time to avoid the collision. After the collision, both pilots were able to maintain control. They established radio contact and then inspected and assessed each other's damage. The first C-185 returned to and landed at Vancouver, B.C. The second C-185 flew back to Campbell River, B.C., and landed without further incident.The first C-185 received damage to the vertical fin and rudder while the second C-185 received damage to the forward compartment of the left float. There were no injuries.

Findings as to causes and contributing factors

  1. Both pilots were monitoring one or more radio frequencies that they considered appropriate for their location and intentions; however, neither pilot was on the same frequency, so any calls made were not heard by the other pilot.
  2. Neither pilot saw the other aircraft in time to avoid the collision and the two planes collided in flight.


TSB Final Report A04P0206 -Engine Power Loss

On June 11, 2004, an MD Helicopter (Hughes) 369D was lifting a 900-lb sling load when there was a loud bang accompanied by a partial engine power loss. The pilot performed a forced landing, and the aircraft hit the ground and rolled onto its right side with the main rotor blades still turning. The engine continued to operate on the ground and was shut down by the pilot. There was no post-impact fire. The pilot experienced accident-related
health issues some time after the occurrence

Compressor case half removed exposing damage to blades and vanes leading and trailing edges
Compressor case half removed exposing damage to blades and vanes leading and trailing edges

Finding as to causes and contributing factors

  1. The compressor failure resulted from the separation of a second stage rotor blade due to high cycle fatigue, which had initiated at or near the leading edge of the blade. Post-fracture mechanical damage in the origin area prevented determination of the cause of fatigue initiation.

Other finding

  1. Indications of foreign object damage (FOD) were observed, but the significance of FOD as a precursor to the second stage compressor rotor blade fracture initiation was inconclusive.


TSB Final Report A04H0002 -Collision with Water

On June 14, 2004, the pilot and sole occupant of the DHC-2 seaplane was on his first flight of the season on the Ottawa River at Gatineau, Que. This training flight, conducted according to visual flight rules (VFR), was to consist of about 12 touch-and-go landings. The aircraft took off at approximately 13:00 Eastern Daylight Time (EDT), and made several upwind touch-and-go landings in a westerly direction. At approximately 13:40 EDT, the aircraft was seen about 50 ft above the surface of the water proceeding downwind in an easterly direction, in a nose-down attitude of over 20°. The right float then struck the water and the aircraft tumbled several times, breaking up on impact. Despite the waves and gusting wind on the river, some riverside residents who witnessed the accident attempted a rescue, but the aircraft sank before they could reach it. Even though the pilot was wearing a seat belt, he sustained head injuries at impact and drowned.

Aircraft flight path
Aircraft flight path

Finding as to causes and contributing factors

  1. The aircraft struck the water for undetermined reasons.

Findings as to risk

  1. The certificate of airworthiness was not in effect at the time of the accident because of airworthiness directives that had not been completed.
  2. The distress signal emitted by the fixed, automatic emergency locator transmitter (ELT) was not received because of the reduced range of the signal once the ELT was submerged, which could have increased the response time of search and rescue units if there had been no witnesses to the accident.
  3. The pilot had not made a training flight with an instructor for more than 19 months, which could have resulted in a degradation of his skills and decision-making process.


TSB Final Report A04A0079-Aerodynamic Stall and Loss of Control 

On July 18, 2004, the pilot of an amateur-built Schreder HP 18 glider was prepared for a winch-assisted takeoff from the grass adjacent to Runway 02 at Stanley Airport, N.S.The wind was from the northwest at approximately 4 kt. At approximately 14:45 Atlantic Daylight Time (ADT), the pilot gave the signal to commence the launch. The winch was activated, and after a normal ground roll, the glider lifted off the surface. The glider then pitched up to an estimated angle of 45° and climbed steeply to about 100 ft AGL. The aircraft then rolled to the right, pitched nose-down, and completed one or two rolls before it struck the runway in a left-wing-low, nose-down attitude. The pilot was fatally injured and the glider was destroyed.

Aerodynamic Stall and Loss of Control

Finding as to causes and contributing factors

  1. Shortly after lifting off, the aircraft entered a steep climbing attitude and a wing stall ensued; there was insufficient altitude for the pilot to effect recovery.

Finding as to risk

  1. The shoulder harness straps were not latched prior to takeoff; however, it is unlikely that their use would have lessened injuries in this accident.


TSB Final Report A04Q0124-Risk of Collision  

On August 5, 2004 a Cessna 172 was returning to Québec, Que., following a VFR cross-country flight. The pilot contacted the Québec terminal control unit 28 NM west of the Québec/Jean Lesage International Airport while flying at approximately 3 000 ft above sea level (ASL). A Cessna 208 Caravan was on an instrument flight rules (IFR) flight from the Québec airport to Mirabel, Que., at a flight-planned altitude of 8 000 ft. The two aircraft passed within 200 ft vertically and 500 ft laterally of one another as the Cessna 208 was climbing through 3 000 ft ASL on departure from the Québec airport.

Findings as to causes and contributing factors

  1. The student pilot did not complete the entire "Line-up" portion of the aircraft checklist and omitted to turn the transponder to the altitude encoding position "ALT." Under these conditions, the transponder did not transmit information to the radar system, making the aircraft much less visible on the controller's radar situation display (RSiT).
  2. The Québec terminal controller did not radar-identify the Cessna 172 after issuing the transponder code, or request other information to determine the aircraft's position or altitude. As a result, the Cessna 172 was allowed to penetrate Class D airspace without the required level of radar service being provided. This placed the Cessna 172 at a risk of collision with the Cessna 208.
  3. The Québec terminal controller's attention was directed to controlling his IFR traffic inbound to the Québec airport and to coordinating the arrival sequence with the tower. He forgot about the Cessna 172 and did not notice the developing conflict between this aircraft and the Cessna 208.

Findings as to risk

  1. The RSiT software programming caused the flight plan data entry window to automatically close 30 seconds after the last keystroke. Once the window closed, it could no longer serve as a reminder to the Québec terminal controller that he still had some further action pending.
  2. In a radar environment, while in contact with air traffic services (ATS), pilots may expect to receive information on all aircraft in their vicinity and, when operating in visual meteorological conditions (VMC), may not search for conflicting traffic and take action to avoid a collision.


TSB Final Report A04AO111 -Loss of control-Collision with Terrain

On August 31, 2004, an AS-350D Astar helicopter was being operated in support of a geological survey crew, 45 NM northwest of Nain, N.L. At approximately 16:00 ADT, the pilot of the occurrence helicopter picked up a team of geologists and proceeded to reposition them 1.5 km further along the ridge line they had been sampling. While on short final for the landing site, the helicopter's rate of descent increased, and the pilot was unable to arrest the descent. The helicopter struck the ground in a gully, just left of the intended touchdown point. The helicopter came to rest on its right side, facing the direction of approach. The pilot and two passengers escaped with only minor injuries. The helicopter was substantially damaged, but there was no post-crash fire.

Loss of control - Collision with Terrain

Finding as to causes and contributing factors

  1. The reason for the sudden descent of the helicopter could not be determined.

Findings as to risk

  1. Some company helicopter pilots are operating in the mountainous terrain of northern Labrador without the benefit of mountain flying training.
  2. The pilot did not fly a reconnaissance of the intended landing site before attempting a landing.

Other finding

  1. Using a satellite phone to speedily notify company operations greatly improved the survival scenario.


TSB Final Report A04C0190-Collision with Terrain -

On October 30, 2004, a Bell 212 helicopter with two pilots and three passengers on board, departed from the radar facility at Shepherd Bay, N.U., at approximately 11:10 Mountain Daylight Time (MDT) on a day, defence VFR flight to another radar facility at Gjoa Haven, N.U. During takeoff from Shepherd Bay, the helicopter descended and crashed, in a nose-low, left-banked attitude, into the snow-covered terrain about 250 m from the departure helicopter pad. The captain and the three passengers were seriously injured, and the first officer died on impact. The survivors were able to return to the facility and alert search and rescue (SAR).The helicopter sustained substantial damage; there was no fire.

Findings as to causes and contributing factors

  1. The helicopter departed into environmental conditions conducive to white-out and loss of micro texture for attitude reference.
  2. The potential for entering white-out conditions was masked by the visibility of objects in the vicinity of the departure point.
  3. The crew did not maintain the priority of rate-of-climb during the rotation to forward flight, did not maintain an adequate instrument scan, and were not able to overcome the white-out conditions and establish a positive rate-of-climb.

Findings as to risk

  1. The helicopter was not equipped with an instantaneous vertical speed indicator, nor was one required. Transitory false indications of a climb were possible from the vertical speed indicator installed in the helicopter.
  2. The crew's training was conducted in a setting that did not demonstrate the effects of lack of micro texture, and the crew did not anticipate white-out other than the effects of re-circulating snow.
  3. The crew's training did not develop the rapid instrument scan required to compensate for the pilot flying's minimal experience on type and in arctic conditions.

Other finding

  1. The ELT was damaged and rendered inoperative when the main rotor struck the cockpit area.

Collision with Terrain



TSB Final Report A0400336 -Rejected Landing-Collision with Terrain

On December 16, 2004, a Short Brothers SD3-60 aircraft was on a charter cargo flight from Toledo, Ohio, USA, to Oshawa, Ont., with two pilots on board. The crew conducted an IFR approach to Oshawa Municipal Airport in night instrument meteorological conditions (IMC). At approximately 20:00 Eastern Standard Time (EST), the aircraft landed on Runway 30, which was snow-covered. During the landing roll, the pilot flying noted poor braking action and observed the runway end lights approaching. He rejected the landing and conducted a go-around procedure. The aircraft became airborne, but it started to descend as it flew over lower terrain, striking an airport boundary fence. It continued until it struck rising terrain and then a line of forestation, where it came to an abrupt stop. The flight crew exited the aircraft and waited for rescue personnel to render assistance. The aircraft was substantially damaged, and both pilots sustained serious injuries. There was no post-crash fire.

Findings as to causes and contributing factors

  1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
  2. The flight crew most likely did not reference the aircraft flight manual (AFM) performance chart "Effect of a Slippery Surface on Landing Distance Required" to determine that landing the aircraft on the 4 000-ft, snow-covered runway with flap-15 was inappropriate.
  3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
  4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
  5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on October 20, 2004, by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.

Other finding

  1. The flight crew members were not advised that the potential Airworthiness Directive (AD) announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.

Rejected Landing - Collision with Terrain



TSB Final Report A05P0154-Power Loss  

helicopter

On June 24, 2005, the pilot of a Robinson R22 Beta helicopter was operating in an area about 10 NM north of Courtenay, B.C., giving rides to volunteer interns at a local avian rescue society. He had completed four trips, then shut down and readied the helicopter for a flight to Courtenay Airpark, where he would refuel before returning to his home base at Boundary Bay Airport, B.C. On start-up, he ran the helicopter on the ground for about two minutes after re-engaging the clutch. At approximately 16:30 Pacific Daylight Time (PDT), the pilot lifted off, turned the helicopter 180° to point toward his departure path, and raised collective to perform a confined-space takeoff. The helicopter climbed to a height of about 60 ft AGL when there were abnormal engine sounds and an apparent detonation. The engine became quiet, and the main rotor blades were almost stopped. The helicopter rotated about 270° to the left in a rapid descent and struck the ground heavily with little or no forward speed. The pilot was severely injured. The helicopter was substantially damaged, but there was no post-crash fire.

Findings as to causes and contributing factors

  1. The pilot did not recall applying carburetor heat prior to departure or during takeoff. It is likely that carburetor ice adversely affected engine performance and caused the engine to stop operating.
  2. Following the loss of engine power, the main rotor RPM decayed rapidly to an unrecoverable speed and the pilot was unable to arrest the helicopter's descent.

Findings as to risk

  1. When replaced, the push-pull tube was found to have worn excessively. Failure of this primary flight control would render a helicopter uncontrollable.
  2. Incorrect over-current fuse protection of the belt tension actuator may lead to overloading of the drive belts.
  3. A global positioning system (GPS) unit was secured with clecos* onto the side of the instrument console. Failure of the temporary fastening could lead to an electrical fire. (*A "cleco" is a spring-loaded clamp used to temporarily hold parts together prior to the installation of rivets. Special pliers are used to insert clecos into holes.)

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