Created Friday, May 10th 2019 22:11Z, last updated Wednesday, Sep 2nd 2020 15:11Z

A Jazz de Havilland Dash 8-300, registration C-FJXZ performing flight QK-8615 (dep May 9th) from Toronto,ON to Sudbury,ON (Canada) with 54 passengers and 3 crew, had flown to Subbury and had entered a hold due to weather before the crew decided to return to Toronto, where the aircraft landed safely about 2.5 hours after departure. While taxiing to the apron a fuel truck drove into the aircraft causing substantial damage to the aircraft (believed to be beyond repair) including nose, left fuselage, the left hand propeller as well as to the fuel truck. Fuel leaked, however, no fire broke out. 5 occupants of the aircraft including both flight crew needed medical treatment at the airport, 3 of the injured were taken to hospitals.

Passengers reported the aircraft suddenly spun around and came to stop, then the smell of fuel occurred in the cabin causing panic and a rapid evacuation. After jumping out of the aircraft a lot of fuel was seen on the tarmac.

Airport police reported the fuel truck driver has been charged with dangerous driving. The aircraft appears to be a write off.

The airport reported 3 people were taken to hospitals.

The Canadian TSB dispatched investigators on site and opened an investigation.

On May 24th 2019 the TSB reported the aircraft had returned to Toronto due to bad weather in Sudbury. While taxiing towards the terminal a collision with a fuel truck occurred. Both aircraft and the fuel truck received substantial damage. Passengers and crew evacuated the aircraft. Five people were taken to hospitals with minor injuries. The collision occurred in the hours of darkness and in rainy weather. The TSB is conducting a Class 4 investigation.

On Jun 20th 2019 the TSB reported the investigation is now a Class 3 investigation (usually completed in 450 days). There were injuries to 3 passengers and 2 crew.

On Jun 11th 2020 the TSB reported there had been 15 minor injuries.

On Sep 2nd 2020 the TSB released their final report concluding the probable causes were:

Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

1. The limited field of view to the right of the fuel tanker drivers cab caused by the front elevating service platform and its structural elements, along with the condensation on the windows, resulted in the driver being unable to see the aircraft in time to avoid the collision.

2. The captain had a clear field of view in the direction of the oncoming fuel tanker but the visibility was limited due to darkness, rain, and reflected light, and he did not see the oncoming tanker during the critical moments before the collision.

Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.

1. If drivers and flight crews do not remain vigilant to the potential for other vehicles to cross designated apron manoeuvring areas, regardless of airport activity level or vehicle right-of-way rules, there is an increased risk of collision.

2. If passengers open emergency exits before an evacuation order is given, the suitability of the exit may not be assessed and a premature evacuation could occur, increasing the risk of passengers being exposed to hazardous conditions.

3. If passengers attempt to retrieve personal belongings during an evacuation, they will impede or delay passengers and crew exiting the aircraft, increasing the risk of injury or death.

4. If passengers remove their seat belts while the aircraft is in motion, or while the seat belt sign is illuminated, they put themselves and others at risk of injury.

5. If passengers do not familiarize themselves with the briefing card for the specific aircraft on which they are travelling, they may not know how to operate and correctly use an emergency exit, increasing the risk of injury.

6. If new regulations on the use of child-restraint systems are not implemented, lap-held infants and young children will continue to be exposed to undue risk and will not be provided with a level of safety equivalent to that of adult passengers.

7. If flight attendants are unable to directly supervise passengers for reasons of proximity or visibility, there is a risk that unsafe action or non-compliance by passengers during emergency procedures will increase the potential for injury.

8. If vehicle operators do not follow airport traffic directives with regard to vehicle corridors, there is a higher potential for traffic conflicts, increasing the risk of ground collisions.

Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.

1. One passenger seated at the front of the aircraft had removed her seat belt before the collision, despite the flight attendant directing her to keep her seat belt fastened, and the seat belt sign being illuminated.


The TSB described the collision:

At 0133:48, the aircraft was taxiing at a speed of approximately 18.5 km/h (10 knots) along the centreline of Lane 6 and the fuel tanker was travelling at a speed of approximately 40 km/h (21.5 knots) when the aircraft and fuel tanker collided. The collision occurred at the intersection of the southbound lane of the connecting corridor and the Lane 6 centreline.

As a result of the collision, the aircraft spun approximately 120 to the right before the rear of the aircraft collided with the back of the fuel tanker and rebounded slightly. The aircraft came to a stop facing approximately 100 to the right of the original direction of travel.


The TSB analysed:

The investigation determined that the limited field of view to the right of the fuel tanker drivers cab caused by the front elevating service platform and its structural elements, along with the condensation on the windows, resulted in the driver being unable to see the aircraft in time to avoid the collision. This limited field of view at the time of the occurrence would not have allowed the driver an opportunity to perceive the presence of the aircraft until the final 3 seconds before the collision, and only then if he had been leaning forward and looking to the right.

The weather conditions at the time of the collision would only serve to exacerbate the difficulties encountered in operating a vehicle with a poor field of view. The high humidity and rainfall resulted in mist, which also reflects light, and reduced visibility. In the case of the fuel tanker, these conditions caused condensation to form on the inside surfaces of the cab windows. The defog controls were not being used to maximum effect.

The investigation did not uncover any information to indicate that the captain, who was in control of the aircraft, had obstructions to his field of view that would have prevented him from seeing the fuel tanker following his turn onto Taxiway AK, 30 seconds before the collision.
While taxiing, the captains attention was focused primarily on the intended path of the aircraft to maintain the centreline of the taxilane and scan for traffic or obstacles ahead.

The captain had a clear field of view in the direction of the oncoming fuel tanker but the visibility was limited due to darkness, rain, and reflected light, and he did not see the oncoming tanker during the critical moments before the collision.

Expectations

The pilots of the occurrence aircraft and the driver of the fuel tanker all had experience operating at Toronto/Lester B. Pearson International Airport (CYYZ). They were aware that, at the time of the occurrence, there would have been very little activity on the airport manoeuvring areas.

The drivers and flight crews familiarity and previous experience operating on the apron at that time of night and the expectation that it was unlikely to encounter an aircraft or ground vehicle crossing the connecting corridor may have contributed to a lower level of vigilance.
In addition, the flight crews previous experience operating at CYYZ, and at other busy airports, coupled with their understanding of the rules governing right-of-way, may have led to the expectation that ground vehicles would yield to their aircraft in all situations.

If drivers and flight crews do not remain vigilant to the potential for other vehicles to cross designated apron manoeuvring areas, regardless of airport activity level or vehicle right-of-way rules, there is an increased risk of collision.

Evacuation

Following the collision, because the fuel tanker was not visible from the flight deck or from the flight attendants position in the cabin, both the flight crew and the flight attendant needed a few moments to assess what had occurred and decide on the best course of action regarding a rapid deplanement or evacuation. In addition, the flight crew required some time to shut down the engines and allow for the propellers to stop turning before passengers could safely exit the aircraft.

After the flight crew shut down the engines, the captain called the flight attendant via the interphone and instructed her to initiate a rapid deplanement. The flight attendant answered the call, but had difficulty hearing the captain over the noise of the passengers. At that time, the smell of fuel and/or engine exhaust reached the cockpit, and the captain gave the order over the passenger address system to evacuate.
However, nobody on the aircraft reported hearing the captains evacuation order, possibly due to the passenger address system being damaged by the impact, , and/or passenger noise in the cabin. Due in part to increasing pressure from the passengers, including verbal threats from one of them, the flight attendant opened the main door (exit L1) slowly. When the flight attendant smelled fuel, she decided to initiate an emergency evacuation.

The hazards that existed were all closer to the rear of the aircraft, which made the use of the front exits an appropriate choice; however, the decision to block the right-hand front emergency exit door (exit R1) because of the risk of injury to passengers increased the evacuation time.

Passenger behaviour

Some passengers seated along the left side of the aircraft had seen the oncoming fuel tanker and were aware that a collision was imminent. Approximately 30 seconds after impact, while the propellers were still turning, some passengers near the rear of the aircraft decided to act on their own by opening the rear emergency window exits without waiting for directions from the flight crew or flight attendant.

The passenger who opened the left-hand rear emergency window exit (exit L2) closed it immediately, as the fuel tanker was nearby. The passenger who opened the right-hand rear emergency window exit (exit R2) threw the hatch outside and then jumped from the exit. A 2nd passenger followed. A total of 4 passengers exited through this emergency exit window.
If passengers open emergency exits before an evacuation order is given, the suitability of the exit may not be assessed and a premature evacuation could occur, increasing the risk of passengers being exposed to hazardous conditions.

When the rear emergency window exits were opened, the smell of exhaust and noise of the engines entered the cabin and may have been interpreted by the passengers as a significant risk of fire and/or explosion, which resulted in an increase in panic.

Many passengers were ignoring the flight attendants instructions to remain seated and calm. Some were gathering their bags or items from their bags, which were located in the overhead compartments; some were escalating the panic by yelling that they needed to get out of the aircraft. Others reboarded or attempted to reboard the aircraft during and after the evacuation. If passengers attempt to retrieve personal belongings during an evacuation, they will impede or delay passengers and crew exiting the aircraft, increasing the risk of injury or death.

Injuries

One passenger seated at the front of the aircraft had removed her seat belt before the collision, despite the flight attendant directing her to keep her seat belt fastened and the seat belt sign being illuminated. During impact, the passenger fell to the ground near the right-hand front emergency exit (exit R1) and received injuries as a result. This injured passenger then became an obstacle to the flight attendant, who needed to access the window beside seat 1A to assess the hazards outside the aircraft. If passengers remove their seat belts while the aircraft is in motion, or while the seat belt sign is illuminated, they put themselves and others at risk of injury.

On the DHC-8-300 series of aircraft, the correct procedure for deplaning the aircraft through the rear emergency window exits is to first sit down on the edge of the opening and then jump to the ground; this reduces the effective height of the jump. This information was available to all passengers and detailed in the passenger briefing cards located in the pocket of each seat back.

The 4 passengers who exited the right-hand rear emergency window exit (exit R2) during this occurrence jumped from the full sill height of the exit, approximately 65 inches above the pavement; 2 of them were injured as a result of this jump. If passengers do not familiarize themselves with the briefing card for the specific aircraft on which they are travelling, they may not know how to operate and correctly use an emergency exit, increasing the risk of injury.

Carriage of infants

As a result of the collision, the 2 lap-held infants became separated from the adults who were holding them and came into contact with parts of the aircraft or nearby passengers. One of the infants received significant bruising.

The infant who was held in the baby carrier was not injured; however, the adult wearing the baby carrier received injuries to her back and ribcage due to twisting forces resulting from the momentum of the child strapped into the carrier. There is no requirement for operators of passenger aircraft, such as the DHC-8-311, to incorporate child restraint systems for infants and children.

If new regulations on the use of child-restraint systems are not implemented, lap-held infants and young children will continue to be exposed to undue risk and will not be provided with a level of safety equivalent to that of adult passengers.

Minimum cabin crew complement

The occurrence flight was operating according to minimum cabin crew regulations, with the required cabin crew of 1 flight attendant for 50 passenger seats.

In this occurrence, the sole flight attendant had to coordinate the evacuation of 52 passengers (49 adults and 3 infants), initially by herself, following a sudden collision. Noise in the cabin caused by shouting passengers and unruly passenger behaviour made it difficult to communicate with anybody near the rear of the cabin.

In addition, passengers standing in the aisle and holding their personal belongings prevented the flight attendant from being able to observe and assess the suitability of the exits at the rear of the aircraft. The blocked aisle also prevented her from ensuring that the exits were being used as intended, resulting in at least 2 injuries during egress.

If flight attendants are unable to directly supervise passengers for reasons of proximity or visibility, there is a risk that unsafe action or non-compliance by passengers during emergency procedures will increase the potential for injury.


Metars Sudbury:
CYSB 100600Z 19007KT 1 1/2SM -RA BR OVC005 09/09 A2968 RMK SF8 SLP063=
CYSB 100541Z 19008KT 1SM R22/3000V5500FT/U -RA BR OVC002 09/09 A2969 RMK SF8 SLP066=
CYSB 100500Z 17003KT 1/4SM R22/2200FT/N FG VV001 09/09 A2966 RMK FG8 SLP054=
CYSB 100443Z 21003KT 150V230 1/4SM R22/2000FT/N FG VV001 09/09 A2966 RMK FG8 SLP054=
CYSB 100400Z 18006KT 1/8SM R22/1200FT/N FG VV001 09/09 A2968 RMK FG8 SLP064=
CYSB 100300Z 17009KT 1/8SM R22/1200FT/N -DZ FG VV001 08/08 A2968 RMK FG8 SLP063=
CYSB 100200Z 17006KT 1/8SM R22/1200FT/N -DZ FG VV001 08/08 A2969 RMK FG8 SLP067=
CYSB 100100Z CCA 14006KT 1/4SM R22/1600FT/N -DZ FG VV001 07/07 A2968 RMK FG8 SLP064=
CYSB 100000Z 13009KT 1/4SM R22/2800FT/N -RA FG VV001 07/07 A2969 RMK FG8 SLP066=

Track Related Flights on Airportia: QK8615