Aviation safety investigations & reports

Smoke in the cockpit involving Bombardier DHC-8-315VH-SBG, 56 km from Canberra Airport, ACT, on 29 July 2013

Investigation number:
AO-2013-120
Status: Completed
Investigation completed

Final Report

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What happened

On 29 July 2013, about 64 NM (119 km) from Sydney the captain of Bombardier DHC-8-315 (Dash 8) aircraft, registered VH‑SBG and operated by QantasLink on a scheduled flight from Sydney to Wagga Wagga, New South Wales noticed a blank area in the centre of the flight management system (FMS) screen. About 10 minutes later the screen went completely blank and thick, light-grey smoke was observed coming from the unit.

The flight crew commenced the quick reference handbook Fuselage Fire or Smoke checklist, donning oxygen masks and smoke goggles. The crew found communication difficult while wearing their masks and, as a result, removed the masks for the remainder of the flight. The aircraft was diverted to Canberra, Australian Capital Territory. The flight crew were taken to hospital for observation and later released without needing treatment. No injuries were reported by the cabin crew or passengers. The aircraft sustained no other damage.

What the ATSB found

Examination of the FMS unit found that two capacitors failed, resulting in the smoke and failure of the unit. The unit was manufactured in 1997 and, in 1998, the FMS manufacturer introduced a modification to replace those capacitors in all subsequently-manufactured units. However, there was no recall or retrofit program for unmodified FMS units already in service.

The ATSB also found that, at the time of the occurrence, the approved QantasLink training did not provide sufficient familiarity to first officers in the use of oxygen masks and smoke goggles. The more-experienced captain’s familiarity with the equipment was enhanced by completion of additional mask and goggles training sessions.

What's been done as a result

In October 2013, as a result of this occurrence, the FMS manufacturer issued a service bulletin for the optional incorporation of different capacitors to unmodified in-service FMS units.

QantasLink undertook a number of safety actions in response to this occurrence. This included installing modified FMS units to all aircraft in its Dash 8 fleet. QantasLink has also implemented a number of improvements to crew training, including improved oxygen mask and smoke goggle training and identifying alternate stowage for the flight deck fire extinguisher.

Safety message

This occurrence highlights the importance of flight crew familiarising themselves with the operation of the onboard emergency equipment. It also reminds crews that inhalation of fumes can have an adverse effect on an individual’s ability to function. Flight crew need to fully consider the implications of removing their emergency breathing equipment when in an environment where smoke and fumes are, or have been, present.

Download Final Report
[Download  PDF: 1.95MB]
 
 
Alternate: [Download  DOCX: 808KB]
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

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Safety Issue

Go to AO-2013-120-SI-01 -

Emergency oxygen mask and smoke goggles training

At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.

Safety issue details
Issue number: AO-2013-120-SI-01
Who it affects: All QantasLink DHC-8-315 pilots
Status: Adequately addressed
General details
Date: 29 July 2013   Investigation status: Completed  
Time: 12:30 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 56 km NNE Canberra Airport    
State: Australian Capital Territory   Occurrence type: Smoke  
Release date: 07 April 2017   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8-315  
Aircraft registration VH-SBG  
Serial number 575  
Operator Eastern Australia Airlines  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Wagga Wagga, NSW  
Last update 14 November 2018