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AVIATION INVESTIGATION REPORT A15H0002 Collision with Terrain Air

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AVIATION INVESTIGATION REPORT A15H0002 Collision with Terrain Air AVIATION INVESTIGATION REPORT A15H0002 Collision with terrain Air Canada Airbus Industrie A320-211, C-FTJP Halifax/Stanfield International Airport Halifax, Nova Scotia 29 March 2015 Transportation Safety Board of Canada Place du Centre 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2017 Aviation Investigation Report A15H0002 Cat. No. TU3-5/15-0002E-PDF ISBN 978-0-660-08379-7 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Investigation Report A15H0002 Collision with terrain Air Canada Airbus Industrie A320-211, C-FTJP Halifax/Stanfield International Airport Halifax, Nova Scotia 29 March 2015 Summary On 29 March 2015, an Air Canada Airbus Industrie A320-211 (registration C-FTJP, serial number 233), operating as Air Canada flight 624, was on a scheduled flight from Toronto/Lester B. Pearson International Airport, Ontario, to Halifax/Stanfield International Airport, Nova Scotia, with 133 passengers and 5 crew members on board. At approximately 0030 Atlantic Daylight Time, while conducting a non-precision approach to Runway 05, the aircraft severed power lines, then struck the snow-covered ground about 740 feet before the runway threshold. The aircraft continued airborne through the localizer antenna array, then struck the ground twice more before sliding along the runway. It came to rest on the left side of the runway, about 1900 feet beyond the threshold. The aircraft was evacuated; 25 people sustained injuries and were taken to local hospitals. The aircraft was destroyed. There was no post-impact fire. The emergency locator transmitter was not activated. The accident occurred during the hours of darkness. Le présent rapport est également disponible en français. Aviation Investigation Report A15H0002 | i Table of contents 1.0 Factual information.......................................................................... 1 1.1 History of the flight ............................................................................................ 1 1.2 Injuries to persons............................................................................................... 7 1.3 Damage to aircraft .............................................................................................. 7 1.4 Other damage ..................................................................................................... 7 1.5 Personnel information......................................................................................... 8 1.5.1 Flight crew ................................................................................................................................8 1.5.2 Ca bin crew ................................................................................................................................9 1.6 Aircraft information............................................................................................ 9 1.6.1 General ......................................................................................................................................9 1.6.2 Airbus A320 systems and operation ................................................................................ 10 1.6.3 Electrical power .................................................................................................................... 11 1.6.4 Cabin doors and over-wing exits...................................................................................... 12 1.6.5 Bulk cargo compartment .................................................................................................... 13 1.6.6 Passenger seats ..................................................................................................................... 13 1.6.7 Flight crew shoulder-harness assembly .......................................................................... 14 1.6.8 Coffee-maker assemblies .................................................................................................... 15 1.6.9 Passenger address system .................................................................................................. 16 1.6.10 Cabin emergency lighting system .................................................................................... 16 1.7 Meteorological information ............................................................................... 16 1.7.1 General ................................................................................................................................... 16 1.7.2 Halifax weather forecasts received by the flight crew before departure ................. 16 1.7.3 Halifax weather forecasts issued before departure ...................................................... 17 1.7.4 Halifax weather forecasts issued while AC624 was enroute ...................................... 17 1.7.5 Halifax weather forecasts issued after the accident...................................................... 17 1.8 Aids to navigation ............................................................................................ 18 1.9 Communications .............................................................................................. 18 1.10 Aerodrome information .................................................................................... 18 1.10.1 General ................................................................................................................................... 18 1.10.2 Approach and runway lighting ........................................................................................ 19 1.11 Flight recorders ................................................................................................ 21 1.11.1 Independent power source for cockpit voice recorders .............................................. 21 1.12 Wreckage and impact information .................................................................... 22 1.12.1 Impact ..................................................................................................................................... 22 1.12.2 Wrecka ge................................................................................................................................ 24 1.13 Medical and pathological information ............................................................... 27 1.13.1 Obstructive sleep apnea...................................................................................................... 27 ii | Transportation Safety Board of Canada 1.13.2 Transport Canada guidance for civil aviation medical examiners on obs tructive s leep apnea....................................................................................................... 28 1.13.3 Transport Canada management of obstructive sleep apnea ...................................... 28 1.13.4 Federal Aviation Administration management of obstructive sleep apnea ........... 30 1.13.5 Australian Civil Aviation Safety Authority management of obstructive sleep a pnea ....................................................................................................................................... 30 1.13.6 United Kingdom’s Civil Aviation Authority management of obstructive s leep apnea ............................................................................................................................ 30 1.13.7 Air Canada management of obstructive sleep apnea................................................... 31 1.13.8 Fatigue .................................................................................................................................... 32 1.14 Fire................................................................................................................... 32 1.15 Survival aspects ................................................................................................ 32 1.15.1 Occupant injuries ................................................................................................................. 32 1.15.2 Child-restraint systems ....................................................................................................... 33 1.15.3 Passenger safety and emergency information ............................................................... 34 1.15.4 Evacuation ............................................................................................................................. 37 1.15.5 Planned or prepared emergency landing ....................................................................... 38 1.15.6 Minimum number of flight attendants............................................................................ 38 1.15.7 Transport Canada: What to wear on the plane.............................................................. 39 1.16 Tests and research............................................................................................. 40 1.16.1 TSB laboratory reports ........................................................................................................ 40 1.17 Organizational and management information ................................................... 40 1.17.1
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