DH4 Better do a final door check yourself

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pelmet
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DH4 Better do a final door check yourself

Post by pelmet »

Looks like you can't count on the aircraft systems to properly warn you about the cargo doors not being properly closed. Bit of a pain but better check 'em yourself. Four incidents in five weeks.

Occurrence No.: A17O0262 Occurrence Type: INCIDENT REPORTABLE
Class: CLASS 5 Reportable Type: EMERGENCY/PRIORITY (xi)
Date: 2017-12-11 Time: 20:00:00 EDT
Region of
Responsibility:
ONTARIO
Location: CYYZ - Lester B. Pearson Intl - Toronto
Country: CANADA Province: ONTARIO
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: C-GVEN Operator: WESTJET ENCORE
Manufacturer: DE HAVILLAND Operator Type: COMMERCIAL
Model: DHC-8-400 CARS Sub Part: 705 - AIRLINER
Injuries: Fatal: 0 Minor: 0
Serious: 0 None: 49
Unknown: 0
Occurrence Summary:
C-GVEN, a Bombardier DHC-8-402 aircraft operated by WestJet Encore, was conducting flight
WEN3606 from Toronto/Lester B. Pearson Intl, ON (CYYZ) to Boston/General Edward Lawrence
Logan Intl, MA (KBOS) with 4 crew members and 45 passengers on board. As the aircraft was
climbing through approximately 400 feet AGL on the departure from CYYZ, the flight crew
observed a Master Warning and a Fuselage Door lights illuminate. A cabin depressurization also
occurred simultaneously. The flight crew consulted the QRH, returned to CYYZ and declared an
emergency. The aircraft landed without further incident and stopped on the runway to have the
doors inspected by ARFF. It was noted that the aft baggage door was closed, however the handle
was out and not locked.

Occurrence No.: A17Q0196 Occurrence Type: INCIDENT REPORTABLE
Class: CLASS 5 Reportable Type: EMERGENCY/PRIORITY (xi)
Date: 2017-12-23 Time: 19:30:00 EST
Region of
Responsibility:
QUEBEC
Location: 80.00 Nautical miles W From CYQB - Jean Lesage Intl - Quebec City
Country: CANADA Province: QUEBEC
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: C-GSJZ Operator: JAZZ AVIATION LP
Manufacturer: DE HAVILLAND Operator Type: COMMERCIAL
Model: DHC-8-400 CARS Sub Part: 705 - AIRLINER
Injuries: Fatal: 0 Minor: 0
Serious: 0 None: 76
Unknown: 0
Occurrence Summary:
C-GSJZ, a Bombardier DHC-8-400 aircraft operated by Jazz Aviation LP, was conducting flight
JZA8722 from Montreal/Pierre Elliott Trudeau Intl, QC (CYUL) to Quebec/Jean Lesage Intl, QC
(CYQB) with 4 crew members and 72 passengers on board. While descending through 5000 feet,
a fuselage door warning light illuminated. The flight crew executed the Quick Reference Handbook
(QRH) checklist and declared a PAN PAN. The aircraft landed without further incident.
Ramp personnel noticed that the door handle was protruding by about 2 inches.


Occurrence No.: A17O0271 Occurrence Type: INCIDENT REPORTABLE
Class: CLASS 5 Reportable Type: EMERGENCY/PRIORITY (xi)
Date: 2017-12-25 Time: 21:19:00 UTC
Region of
Responsibility:
ONTARIO
Location: CYYZ - Lester B. Pearson Intl - Toronto
Country: CANADA Province: ONTARIO
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: C-GVEN Operator: WESTJET ENCORE
Manufacturer: DE HAVILLAND Operator Type: COMMERCIAL
Model: DHC-8-400 CARS Sub Part: 705 - AIRLINER
Injuries: Fatal: 0 Minor: 0
Serious: 0 None: 75
Unknown: 0
Occurrence Summary:
C-GVEN, a Bombardier DHC-8-402 aircraft operated by WestJet Encore, was conducting flight
WEN3511 from Toronto/Lester B. Pearson Intl, ON (CYYZ) to London, ON (CYXU) with 4 crew
members and 71 passengers on board. During climb, when at 6000 feet the flight crew received a
master warning, and a fuselage door warning. The aircraft was levelled at 7000 feet and the QRH
was actioned. The crew declared an emergency and returned to CYYZ. The aircraft performed an
uneventful landing with ARFF standing by.
The operator’s maintenance found the aft baggage door handle disengaged. A operational check
of the door revealed no further faults, and the aircraft was returned to service

Occurrence No.: A18A0005 Occurrence Type: INCIDENT REPORTABLE
Class: CLASS 5 Reportable Type: EMERGENCY/PRIORITY (xi)
Date: 2018-01-16 Time: 11:52:00 UTC
Region of
Responsibility:
ATLANTIC
Location: 10.00 Nautical miles N From CYHZ - Stanfield Intl - Halifax
Country: CANADA Province: NOVA SCOTIA
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: C-GDEN Operator: WESTJET ENCORE
Manufacturer: DE HAVILLAND Operator Type: COMMERCIAL
Model: DHC-8-400 CARS Sub Part: 705 - AIRLINER
Injuries: Fatal: 0 Minor: 0
Serious: 0 None: 26
Unknown: 0
Occurrence Summary:
C-GDEN, a Bombardier DHC-8-402 aircraft operated by WestJet Encore, was conducting flight
WEN3483 from Sydney/J.A. Douglas McCurdy airport, NS (CYQY) to Halifax/Stanfield Intl., NS
(CYHZ) with 4 crew members and 22 passengers on board. After departing CYQY, the fuselage
doors warning light illuminated. The flight crew referred to the QRH, pressurization remained
normal, and the crew elected to continue with the flight. During descent, about 10 nm north of
CYHZ at an altitude of 4000 feet the aircraft depressurized, and the crew declared a PAN PAN.
WEN3483 landed on runway 05 without further incident; emergency response services responded.
The operator’s maintenance inspected the aircraft, and observed that the AFT cargo door was in
the unlocked position, with the AFT cargo canted panel blown out. The AFT cargo was locked, the
door seal and indication system was function checked, and the canted bulkhead blow out panel
was secured. An aircraft pressurized/leak check was carried with no faults found. The aircraft
returned to service.
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

Like I said......

Occurrence No.: A18O0020 Occurrence Type: INCIDENT REPORTABLE
Class: CLASS 5 Reportable Type: EMERGENCY/PRIORITY (xi)
Date: 2018-02-01 Time: 23:47:00 UTC
Region of
Responsibility:
ONTARIO
Location: CYTZ - Billy Bishop Toronto City - Toronto
Country: CANADA Province: ONTARIO
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: C-GLQN Operator: PORTER AIRLINES INC.
Manufacturer: DE HAVILLAND Operator Type: COMMERCIAL
Model: DHC-8-400 CARS Sub Part: 705 - AIRLINER
Injuries: Fatal: 0 Minor: 0
Serious: 0 None: 39
Unknown: 0
Occurrence Summary:
C-GLQN, a Porter Airlines DHC-8-400 aircraft was being operated as flight POE 616, from Timmins, (Victor M. Power) (CYTS) to Billy Bishop Toronto City - Toronto (CYTS). During the climb out a master warning for an unsafe door indication was received. The crew followed the QRH procedures and continued to destination uneventfully. Upon descent to CYTZ, the crew noted the cabin altitude climbing at 3000 feet/min and cabin pressure differential decreasing. QRH procedures were re-actioned, and instructions were to land at the nearest suitable airport which was CYTZ. The crew declared a PanPan and the aircraft landed uneventfully with ARFF standing by. The post flight walk around noted that the baggage door handle was unseated preventing the door seal from inflating and affecting pressurization. The door handle in this position does not unlock the door but does trigger a cockpit indication.
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Heliian
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Re: DH4 Better do a final door check yourself

Post by Heliian »

I would expect an a.d. at this point. Are there any info letters from bbd about this already? It's quite obvious the system does not indicate properly.
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PostmasterGeneral
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Re: DH4 Better do a final door check yourself

Post by PostmasterGeneral »

Heliian wrote: Sat Mar 03, 2018 4:25 pm I would expect an a.d. at this point. Are there any info letters from bbd about this already? It's quite obvious the system does not indicate properly.
It indicates properly, with failsafes as well. Each door has 4-6 microswitches. Some in the handle, some on the door itself. (Depending on which door.) if a micro switch fails closed, it’s automatically excluded from operation, with nothing noticeable to the pilots. This is strictly a maintenance function through the laptop (they can diagnose and disable individual sensors).

If a sensor indicates an open, it’s presented to the flight crew as a “fuselage door” warning light. The DOOR page of the MFDs will display which one. It’s up to the pilots to determine which door is indicating open, and act accordingly.

When I’ve had this indication in flight, I first check the pressurization panel. Is it indicating properly? The Q has some pretty good bleed air, even a small leak will go unnoticed most times. If it’s holding, most likely an indication.

Every time I’ve seen it, it’s been in a fin that’s sat in the humid Vancouver air for a couple days. Then, when it’s flown to Calgary that’s sitting at -20 OAT, you’ll see the microswitches frost up and refuse to close.

Just a quirk of the airplane.
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plhought
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Re: DH4 Better do a final door check yourself

Post by plhought »

The only "quirk" is people not pushing the cargo door enough to really drive the handle flush. Usually a new rampy will try and close the door by pushing the handle closed when you actually have to press on the bottom of the door inboard and up FORCEFULLY and the handle will retract into it's place. You are right though that moisture and crud accumulating behind the handle may not allow it to retract into it's 'receptacle'
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Re: DH4 Better do a final door check yourself

Post by Canoehead »

DH4 fellas:

Image
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justwork
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Re: DH4 Better do a final door check yourself

Post by justwork »

Canoehead wrote: Sun Mar 04, 2018 10:15 am DH4 fellas:

Image
I was waiting for this. :prayer:
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Mach .28
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Re: DH4 Better do a final door check yourself

Post by Mach .28 »

DH4
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Heliian
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Re: DH4 Better do a final door check yourself

Post by Heliian »

DH4
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

justwork wrote: Sun Mar 04, 2018 10:34 am
Canoehead wrote: Sun Mar 04, 2018 10:15 am DH4 fellas:

Image
I was waiting for this. :prayer:
Actually, you are both wrong, the aircraft in question is really a DHC-8-400 while the Caribou is a DHC-4. The DH.4 is a famous WWI aircraft designed by Mr. de Havilland with more info found at this link...

https://en.wikipedia.org/wiki/Airco_DH. ... s_variants

......Almost 5000 built in the US.
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J31
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Re: DH4 Better do a final door check yourself

Post by J31 »

DeHavilland Dash 8-400Q

ICAO: DH8D
IATA: DH4
Transport Canada: DH8

------------------------------

DeHavilland Caribou

ICAO: DHC4
IATA: DHC
Transport Canada: DH4
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

Thanks for the clarification.

Any DH4 drivers out there that are checking this particular door yourself?
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Re: DH4 Better do a final door check yourself

Post by co-joe »

I find it somewhat alarming that a door can be unlocked and not give a cockpit indication.
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Re: DH4 Better do a final door check yourself

Post by av8ts »

co-joe wrote: Thu Mar 29, 2018 11:13 pm I find it somewhat alarming that a door can be unlocked and not give a cockpit indication.
In every one of those incidents the crew had a cockpit indication. It appears to me that the handle is not staying in the flush locked position. Ground crew are pushing the handle in ( cockpit door warning goes out) but for some reason the handle is popping out in flight
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Re: DH4 Better do a final door check yourself

Post by SmokinJoe »

I had an incident such as this a while back, although for us it was the service door.

What was determined was that the caterers are trained to close the service door from the outside. Once the caterers have come and gone, if the door is opened and closed from the inside of the cabin, the handle and vent on the outside of the door may not be in the fully closed position.

So in flight, the inside door handle becomes “loosened” and may vibrate enough to set off the micro switch. In our case the door unsafe indication would illuminate and extinguish on its own, and the inside handle moved on its own from the “locked” position to the “unlocked” position as we were descending for a landing at the “nearest suitable airport”. (Just to describe how the door handle works. The handle is rotated from the left “open” position to the right “closed” position. Then the handle is pushed inwards to the “locked” position.)

After this, I pay particular attention to when the doors are opened and closed, brief the FA’s that if they choose to open the doors for airflow when it’s hot, and the caterers have come and gone, to at least advise the flight crew. That way I can either go outside my self and visually check the door, or advise the ramp crew to ensure they check the door outside on their final walk around.
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

Just out of curiosity, have any of our DH4 operators changed any procedures since I suggested that the pilots might want to do a final check?

"C-GLQN, a Bombardier DHC-8-400 aircraft operated by Porter Airlines, was conducting flight POE943 from Toronto/Billy Bishop Toronto City, ON (CYTZ). During the climb after the departure from CYTZ, the flight crew received a door open indication and was unable to pressurize aircraft. The flight crew declared a PAN PAN and returned to CYTZ where the aircraft landed without further incident with ARFF standing by.

A visual inspection of the aircraft determined that the cargo door handle had popped out or was inadvertently left unlocked by ground personnel during the previous stop. The operator’s maintenance inspected and lubricated the door handle and subsequent operational checks revealed no further faults."
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

"C-GLQO, a Bombardier DHC-8-400 aircraft operated by Porter Airlines, was conducting flight POE229 from Halifax/Stanfield Intl, NS (CYHZ) to St. John’s Intl, NL (CYYT). As the flight climbed through 11 000 feet after the departure, the flight crew received a message that the cargo door was unsafe. The flight crew contacted ATC and initiated a return for CYHZ. When descending through 4000 feet, the cabin depressurized rapidly. The flight crew requested emergency vehicles on stand by for the landing, and the aircraft landed without further incident.

The operator’s maintenance found that the cargo door handle had moved out of its flush, latched position, which allowed the cargo compartment pressurization to decrease. The aft cabin bulkhead blowout panel became dislodged because of the cargo compartment pressure loss."


Not much a pilot can do if the handle is really dislodging by itself.
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

I wonder if an AD will come out on this....

"C-GLQN, a Bombardier DHC-8-400 aircraft operated by Porter Airlines, was conducting flight POE486 from Montreal/Pierre Elliott Trudeau Intl (CYUL), QC to Toronto/Billy Bishop Toronto City (CYTZ), ON with 4 crew members and 17 passengers on board. Just prior to levelling off at FL220, the flight crew received a Fuselage Door warning, associated with a gradual climb indication in the cabin altitude. The flight crew decided to begin a descent to 14 000 feet, and declared a PAN PAN. During the descent, the cabin altitude began to increase. The flight crew decided to divert to Ottawa/MacDonald-Cartier Intl (CYOW), ON, and declared an emergency. As the aircraft descended through 12 000 feet, the aircraft experienced a complete loss of pressurization. The flight crew briefed the passengers and proceeded to land uneventfully on Runway 07 with ARFF standing by. The operator’s maintenance found the cargo door handle had become unstowed in flight, which deflated the door seal and depressurized the aircraft. The aircraft has been returned to service without further incident."

Interesting to see the this particular registration has had it happen three times since I started the thread nine months ago.....C-GLQN. It may not be convenient for the pilot to do a last minute outside door handle check on every flight but....maybe on this particular aircraft, it would be a good idea.

Did it ever have a tail strike which perhaps could have resulted in a permanent a slight doorframe misalignment?
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Last edited by pelmet on Thu Nov 15, 2018 8:49 pm, edited 1 time in total.
wrenchturner
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Re: DH4 Better do a final door check yourself

Post by wrenchturner »

There is a Service Bulletin out to rework the door handle that gives you a more visual indication that the handle is properly and fully locked and stowed, and a positive latch engagement. I'm curious if any handles that have been modified have popped open in flight
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pelmet
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Re: DH4 Better do a final door check yourself

Post by pelmet »

wrenchturner wrote: Thu Nov 15, 2018 7:12 pm There is a Service Bulletin out to rework the door handle that gives you a more visual indication that the handle is properly and fully locked and stowed, and a positive latch engagement. I'm curious if any handles that have been modified have popped open in flight
I wonder if this airline has followed the SB......

"C-FWEP, a Bombardier DHC-8-400 aircraft operated by WestJet Encore, was conducting flight WEN3265 from Calgary Intl (CYYC), AB to Kelowna (CYLW), BC. During cruise flight, the flight crew received a fuselage door warning light. Subsequently, a loud bang was heard and pressurization was lost during the descent. The flight crew declared an emergency, and continued to destination where ARFF met the flight. The aircraft landed without further event. The operator’s maintenance inspected the aft cargo door and found the lateral door handle in the extended position on arrival to the gate. The door handle had not been secured properly."
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