Embarrassing Oops

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pelmet
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Embarrassing Oops

#1 Post by pelmet » Wed Jan 18, 2017 9:55 am

Any suggestions on how to prevent such a situation.

"C-GLWJ, a de Havilland DHC-8 400 aircraft operated by WestJet Encore, was conducting flight WEN3485 from Halifax/Stanfield Intl, NS (CYHZ) to Ottawa/MacDonald-Cartier Intl, ON (CYOW). As the flight crew levelled the aircraft at the cruising altitude of FL240, the check pressurization light illuminated. The QRH and QRC were performed, the flight crew declared an emergency and descended to enter a hold in order to burn fuel to attain the required landing weight at CYHZ.
Through 5000 feet, the flight crew noted the bleed air switches were in the off position. The flight landed without further event. The operator’s maintenance determined that no faults were present. The aircraft was returned to service."
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Rockie
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Re: Embarrassing Oops

#2 Post by Rockie » Wed Jan 18, 2017 9:59 am

Follow SOP's and do a proper pre-flight check. And don't rush...it's not a scramble.
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NotDirty!
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Re: Embarrassing Oops

#3 Post by NotDirty! » Wed Jan 18, 2017 10:19 am

pelmet wrote:Any suggestions on how to prevent such a situation.

"C-GLWJ, a de Havilland DHC-8 400 aircraft operated by WestJet Encore, was conducting flight WEN3485 from Halifax/Stanfield Intl, NS (CYHZ) to Ottawa/MacDonald-Cartier Intl, ON (CYOW). As the flight crew levelled the aircraft at the cruising altitude of FL240, the check pressurization light illuminated. The QRH and QRC were performed, the flight crew declared an emergency and descended to enter a hold in order to burn fuel to attain the required landing weight at CYHZ.
Through 5000 feet, the flight crew noted the bleed air switches were in the off position. The flight landed without further event. The operator’s maintenance determined that no faults were present. The aircraft was returned to service."
I'm a bit surprised that bleed air switches was not on the QRH for a check pressurization light. But even if it wasn't, I would like to think that if I were in the same situation, all that systems training we did in groundschool would come in useful for mentally working my way through the system to try to see if there was an easy to recognize (and hopefully correct) cause of the problem.

What Rockie said, too.
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rigpiggy
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Re: Embarrassing Oops

#4 Post by rigpiggy » Wed Jan 18, 2017 10:26 am

Is this covered in the after takeoff checks? Did they turn off bleed due to tailwind exhaust issue? Does WJE do a flow, and check list or a do list that got interrupted? is there a 10K check with check pressurization? Ad Nauseum etc..... Don't worry it will all come out in the SMS.
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skypirate88
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Re: Embarrassing Oops

#5 Post by skypirate88 » Wed Jan 18, 2017 10:29 am

I can't see how their QRH would be much different than mine at Jazz, but for a CABIN PRESS (warning light) the first item on the checklist is Bleed Air 1 and 2 - ON/Normal

We also have a pressurization confirmation through 10000 because of an incident we had. Perhaps they should consider the same.
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NotDirty!
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Re: Embarrassing Oops

#6 Post by NotDirty! » Wed Jan 18, 2017 10:33 am

rigpiggy wrote:Is this covered in the after takeoff checks? Did they turn off bleed due to tailwind exhaust issue? Does WJE do a flow, and check list or a do list that got interrupted? is there a 10K check with check pressurization? Ad Nauseum etc..... Don't worry it will all come out in the SMS.
I would think that it ought to be covered... my company has pressurization on the After Takeoff checklist, the 10,000 ft flows, the 18,000 ft checklist, and the Cruise checklist, etc. I was just working on the statement that they completed the QRH, so even if they skipped every other checklist up until that point, it should still have been covered.
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crazyaviator
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Re: Embarrassing Oops

#7 Post by crazyaviator » Wed Jan 18, 2017 10:34 am

The operator’s maintenance determined that no faults were present. The aircraft was returned to service."
I wonder if they initially tried to cover up their failure by sending the plane to maintenance/ for a release ?
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crazyaviator
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Re: Embarrassing Oops

#8 Post by crazyaviator » Wed Jan 18, 2017 10:35 am

The operator’s maintenance determined that no faults were present.
Was that after the subject pilots left for the day ? :lol:
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Re: Embarrassing Oops

#9 Post by skybaron » Wed Jan 18, 2017 11:55 am

Fatigue likely
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av8ts
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Re: Embarrassing Oops

#10 Post by av8ts » Wed Jan 18, 2017 1:13 pm

I find it hard to believe they could miss it in the after start checklist, then again at 10000 (if they have a check there) then again in the QRH.
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gimmepars
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Re: Embarrassing Oops

#11 Post by gimmepars » Wed Jan 18, 2017 2:10 pm

pelmet wrote:
"As the flight crew levelled the aircraft at the cruising altitude of FL240, the check pressurization light illuminated."
How'd they get to FL240 before the light came on if the bleeds were never turned on after takeoff?
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bobcaygeon
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Re: Embarrassing Oops

#12 Post by bobcaygeon » Wed Jan 18, 2017 2:49 pm

The Dash 8 has 2 Bleed Air Switches (On/Off) plus a Flow Rate selector (Min/Norm/Max).

Before Takeoff Checklist is usually
Bleeds......Min/Off

After Takeoff Checklist is usually
Bleeds......On/Norm

My guess is they turned the Bleeds On and left the rate at Min hence the delayed Pressurization light.

Just goes to show you what lower levels of experience brings you.

If I saw that light that would be the 1st thing I would have checked because I may know someone who has seen that light before :)
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Oxi
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Re: Embarrassing Oops

#13 Post by Oxi » Wed Jan 18, 2017 3:07 pm

Of note, I watched an Encore Q taxi out today to 17L in YYC with the left engine shut down. Is this now approved for operators?
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skypirate88
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Re: Embarrassing Oops

#14 Post by skypirate88 » Wed Jan 18, 2017 3:22 pm

Oxi wrote:Of note, I watched an Encore Q taxi out today to 17L in YYC with the left engine shut down. Is this now approved for operators?
It must be approved for them, or they wouldn't do it. At Jazz, we do not have approval for single engine taxi out, but we do for on the way in.
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pelmet
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Re: Embarrassing Oops

#15 Post by pelmet » Wed Jan 18, 2017 3:27 pm

Speaking of engine shutdown during operational procedures.....

I have seen a Jazz and an Encore Dash-8-400 beside each other getting de-iced. One had engines running, one had engines shut down.
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Oxi
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Re: Embarrassing Oops

#16 Post by Oxi » Wed Jan 18, 2017 3:35 pm

pelmet wrote:Speaking of engine shutdown during operational procedures.....

I have seen a Jazz and an Encore Dash-8-400 beside each other getting de-iced. One had engines running, one had engines shut down.
Okay, let me rephrase. De ice and taxi in to a gate/stop aside, speaking specifically taxi out to take off.
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Donald
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Re: Embarrassing Oops

#17 Post by Donald » Wed Jan 18, 2017 5:21 pm

Not the first time this sort of oops has happened:
Incident: Transat B738 near Hamilton on Feb 28th 2015, cabin pressure uncontrollable

An Air Transat Boeing 737-800, registration F-GZHA performing flight TS-832 from Hamilton,ON (Canada) to Varadero (Cuba), was climbing through 15,000 feet out of Hamilton when the cabin altitude horn sounded. The crw worked the related checklists but was unable to control the cabin pressure. The aircraft was cleared to descend and returned to Hamilton for a safe landing.

Canada's TSB reported: "Examination of the aircraft determined that both engine bleed air switches were in the off position. Normally, these switches are selected off for engine start."

The occurrence aircraft remained on the ground until Mar 3rd 2015.

A replacement Boeing 737-800 reached Varadero with a delay of 8 hours.
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GyvAir
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Re: Embarrassing Oops

#18 Post by GyvAir » Wed Jan 18, 2017 7:21 pm

Similar mistake presumed in this incident a few years back, only the outcome wasn’t so benign.

https://aviation-safety.net/database/re ... 20050814-0
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AuxBatOn
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Re: Embarrassing Oops

#19 Post by AuxBatOn » Wed Jan 18, 2017 8:05 pm

bobcaygeon wrote: Just goes to show you what lower levels of experience brings you.
You got some inside information suggesting the pilots were of low experience or just trying to promote an agenda?
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frog
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Re: Embarrassing Oops

#20 Post by frog » Wed Jan 18, 2017 8:16 pm

TSB typo ?

On engines start, bleed air switches are on on the 738, packs switches are off.
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Re: Embarrassing Oops

#21 Post by Canoehead » Wed Jan 18, 2017 11:18 pm

skypirate88 wrote: We also have a pressurization confirmation through 10000 because of an incident we had. Perhaps they should consider the same.
No need to wait for 10,000'. I also include the pressurization instruments (Diff and Alt) as a part of my after takeoff flow when I'm turning off exterior lights. If there's a problem with the system/configuration, I'll know about it long before 10K and or any Warning lights.
bobcaygeon wrote:The Dash 8 has 2 Bleed Air Switches (On/Off) plus a Flow Rate selector (Min/Norm/Max).

Before Takeoff Checklist is usually
Bleeds......Min/Off

After Takeoff Checklist is usually
Bleeds......On/Norm
On the Classic DH8 fleet this is standard (at Jazz), however the Q400 has a supplement for Bleeds ON takeoff. Jazz has this, I'm sure WJE must too. Although performance numbers may come back for a Bleeds OFF takeoff depending on various factors.
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Donald
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Re: Embarrassing Oops

#22 Post by Donald » Wed Jan 18, 2017 11:29 pm

frog wrote:TSB typo ?

On engines start, bleed air switches are on on the 738, packs switches are off.

No typo.

Think about the configuration for an engines running de-ice.

The Transat crew didn't re-configure properly after the de-ice, missed it in the after takeoff checklist, missed it in 10,000 checks, and didn't catch it with the QRH when the horn went off.
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JBI
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Re: Embarrassing Oops

#23 Post by JBI » Thu Jan 19, 2017 4:11 am

pelmet wrote:Speaking of engine shutdown during operational procedures.....

I have seen a Jazz and an Encore Dash-8-400 beside each other getting de-iced. One had engines running, one had engines shut down.
One was getting its props de-iced, one was not. Little hard to spray a spinning propeller.
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CAL
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Re: Embarrassing Oops

#24 Post by CAL » Thu Jan 19, 2017 9:33 am

you beat me to it!
gimmepars wrote:
pelmet wrote:
"As the flight crew levelled the aircraft at the cruising altitude of FL240, the check pressurization light illuminated."
How'd they get to FL240 before the light came on if the bleeds were never turned on after takeoff?
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pelmet
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Re: Embarrassing Oops

#25 Post by pelmet » Thu Jan 19, 2017 9:36 am

JBI wrote:
pelmet wrote:Speaking of engine shutdown during operational procedures.....

I have seen a Jazz and an Encore Dash-8-400 beside each other getting de-iced. One had engines running, one had engines shut down.
One was getting its props de-iced, one was not.
While they were getting wings sprayed at the time I saw this, de-icing the props does make sense as to the possible reason.
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