ASN Wikibase Occurrence # 351894
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| Date: | Sunday 5 December 2010 |
| Time: | |
| Type: |  Bombardier DHC-8-402Q Dash 8 |
| Owner/operator: | AirBaltic |
| Registration: | YL-BAF |
| MSN: | 4293 |
| Year of manufacture: | 2010 |
| Total airframe hrs: | 884 hours |
| Cycles: | 684 flights |
| Fatalities: | Fatalities: 0 / Occupants: |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Riga -
 Latvia
|
| Phase: | En route |
| Nature: | Passenger |
| Departure airport: | Riga International Airport (RIX/EVRA) |
| Brussel-Zaventem Airport (BRU/EBBR) | |
| Investigating agency: | TAIIB |
| Confidence Rating: |  Accident investigation report completed and information captured |
AirBaltic flight BT603, a DHC-8-402Q , suffered a loss of cabin pressure.
After closing the passenger door prior to departure from Riga International Airport (RIX), the warning light “FUSELAGE DOORS” on the Caution and Warning Panel came on. Opening and closing passenger doors several times had no effect. The crew called technicians. MEL Item was open and after checking there was established that dispatch permitted according to MEL 52-10-5. The aircraft was released to service, Cabin Pressure Contol System INOP in “AUTO MODE” with time limit 1 (one) flight day. It was the first line training flight for the F/O. Pilot Flying was F/O. During climb “FUSELAGE DOORS” warning light disappeared and until FL 240 flight was normal in manual pressurization mode. After reaching FL 240 the PIC tried to stabilize cabin pressure and it was difficulty to set cabin rate at “0”. Because no more “FUSELAGE DOORS” warning light switched on, PIC decided to set Cabin Pressure Contol System back to Auto Mode. After that cabin started climbing and a rapid depressuarization occurred, then PIC switched Manual Mode again, but it was impossible to control Cabin pressure and shortly the cabin altitude reached 10000 Ft. The crew declared emergency, started emergency descent procedure, returned back and landed in Riga International airport (EVRA).
Proximate Cause
The source or origin of an event that caused this incident was the fact that the Pilot in Comand due to lack of experience of aircraft type (200 flying hours on aircraft DHC8-Q400) as well as competency of Cabin Pressure Control System algorithms set on system in MANUAL MODE.
Root Cause
The factors that resulted this incident are location of aircraft passenger doors proximity sensors, which is open for unfavourable environment - atmospheric precipitation, ice and snow contamination of sensors during weather conditions with low temperatures.
Contributing causes
Documentation of Bombardier Inc. DHC-8 Series 400 Rev 4 Jan 24/2008 did not consist strict rules or warning about consequences if Cabin Pressure Control System is set on in Auto Mode during flight.
Preliminary rev 002 in airBaltic OM Part B, about inadmissible to set Cabin Pressure Control System in Auto Mode and consequences of such operation, was made when serious incident occurred, despite first problems with DHC-8 Series 400 presurization system occurred and repeated since August 2010.
Insufficient experience of flight and technical services with maintaining new type aircraft.
Primary cause
The event after which incident became inevitable.
Not possibility to control cabin pressure (increasing of cabin altitude) regardless that system was switched back from auto to manual mode, because the algorithms of Cabin Pressure Control System are such that it would take some time till system stabilizes.
Accident investigation:
 |
|
Sources:
FINAL REPORT Nr.4-02/5-10/-2/2012
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 22-Feb-2024 08:10 | edijs1504 | Added |
| 22-Feb-2024 08:14 | ASN | Updated [Aircraft type, Cn, Location, Phase, Source, Narrative, Accident report] |
| 22-Feb-2024 08:16 | ASN | Updated [Narrative] |
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