FINAL REPORT Nr.

4-02/7-12/(6-13)
OF THE AIRCRAFT SERIOUS INCIDENT

CABIN DE-PRESSURIZATION of BOMBARDIER DHC-8-400 AIRCRAFT,

REGISTRATION YL-BAH ON SEPTEMBER 9, 2012
The Transport Accident and Incident Investigation Bureau of the Republic of Latvia is a
governmental, independent of all aviation authorities organization, established by law to
investigate and determine the cause or probable cause of accidents and serious incidents that
occurred in the civil aviation, as well, if necessary for enhancing flight safety, incidents.
The sole purpose of such investigation is to prevent accidents and incidents in accordance with
Annex 13 to the Convention on International Civil Aviation and REGULATION (EU) No
996/2010 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 20 October 2010
on the investigation and prevention of accidents and incidents in civil aviation and repealing
Directive 94/56/EC. If Bureau finds it appropriate, to issue safety recommendations. The purpose
of an investigation conducted under the responsibility of the Transport Accident and Incident
Investigation Bureau Republic of Latvia is not to apportion blame or liability.

Address:
58 Brivibas Str., Riga
LV-1011, Latvia
Phone. 67288140,
Fax. 67283339,
E-mail:[email protected]

Director of Transport Accident and

Incident Investigation Bureau

Ivars Alfreds Gaveika

FINAL REPORT Nr.4-02/7-12/(6-13)

ON THE AIRCRAFT SERIOUS INCIDENT

CABIN DE-PRESSURIZATION of BOMBARDIER DHC-8-400 AIRCRAFT,

REGISTRATION YL-BAH ON SEPTEMBER 9, 2012

TABLE OF CONTENTS
Synopsis
Investigation
1. FACTUAL INFORMATION
1.1. History of the incident
1.2. Injuries to persons
1.3. Damage to aircraft
1.4. Other damage
1.5. Personnel Information
1.6. Aircraft information
1.6.1. Air conditioning and pressurization
1.6.1.1. Air Cconditioning General
1.6.1.2. Pressurization
1.6.1.3. Bleed Air System
1.6.1.4.Pressuarization control
1.7. Meteorological information
1.8. Aids to Navigation
1.9. Communications
1.10. Aerodrome information
1.11. Flight recorders
1.12. Wreckage and impact information
1.13. Medical and pathological information
1.14. Fire
1.15. Survival aspects
1.16. Tests and research
1.17. Organizational and management information
1.18. Additional information
1.19. Useful or effective investigation techniques
2. ANALYSIS
2.1. Company procedures before flight
2.2. Sequence of Events and crew actions before the incident

3. CONCLUSIONS
2

3.1. Findings
3.2. Causes
4. SAFETY RECOMENDATIONS

Appendices:
1. air Baltic Flight Safety Report No306
2. Individual duty plan for PIC
3. Individual duty plan for FO
4. air Baltic Flight check Record for PIC
5. air Baltic Flight check Record for FO
6. Copy of PIC skill test and proficiency check on multipilot airplanes
7. Copy of Flight crew Licence issued CAA of Latvia
8. Copy of ATP Licence issued by Italian CAA
9. Copy of Medical Certificate class 1 No I-ATPL-A025378
10. Copy of Flight crew Licence issued by Swedish Transport Agency
11. Copy of Medical Certificate class 1 No SE-6510264853
12. Copies of airBaltic Tech logs, YL-BAH, SEQ Nr.01613-01616 un Nr.01593-01596
13. Flight crew recurrent training and check record for PIC
14. Flight crew recurrent training and check record for fo
15. FDR data records
16. Fueling record
17. Flight plan BT109/09 Seo/RIX-ARN
Abbreviations
CWP - Caution and Warning Panel
PF - Pilot Flying
PM - Pilot Monitoring
LP
- Left Pilot
RP
- Right Pilot
PIC - Pilot in Command
CPCS - Cabin Pressure Control System
PSEU - Proximity Sensor Electronic Unit
CWCP -The Caution and Warning Panel
ECU - Electronic Control Unit
ECS - Environmental Control System
ACU - Air Conditioning Unit
EFIS - Electronic Flight Info System
ED - Engine Display
QRH - Quick Reference Handbook
NSOV -Nacelle Shut-Off Valves

Synopsis
Unless stated otherwise the time in this Report is UTC

A serious incident occurred to an airBaltic Airlines, Bombardier Dash Q-400 aircraft,

registration YL-BAH on Sunday, September 9, 2012 at 16:55UTC. air Baltic was on a scheduled
3

passenger service, flight BT-109 from Riga International airport (EVRA), Latvia to Stocholm Arlanda airport (ESSA), Sweden.

Picture 1
BT 109 had four crew members and 67 (sixty seven) pasengers on board. At about 22000 FT the
crew got Cabin Pressure warning. Cabin ALTITUDE was indicating just above 8000 FT. The
crew initiated descent down to10000FT. Oxygen masks were put on when cabin altitude reached
10000 FT. AUTO and MANUAL mode was not operating. The crew decided to go back to Riga
International airport (EVRA), started emergency descent procedure, returned back and landed in
Riga International airport (EVRA).
Notification
The Transport Accident and Incident Investigation Bureau of the Republic of Latvia was
notified about the incident on Monday, September 10, 2012 at 17:13 local time by the quality
auditor of air Baltic.
TAIIB Authorities had evaluated the received information relevant to that case and
initiated formal investigation into this serious incident, under the provisions of Annex 13 to the
Convention on International Civil Aviation (Chicago 1944) and the Cabinet Regulation No 423,
Adopted 31 May 2011. There was forward request to airBaltic of providing flight recorder
recordings, documentation and any relevant available information regarding to the aircraft and
personal data of flight crew involved in the serious incident.
1. FACTUAL INFORMATION
1.1. History of the incident
A serious incident occurred on Sunday, September 9, 2012 at 16:55 UTC. air Baltic aircraft Dash
Q-400, registration YL-BAH was on a scheduled passenger service, flight BT-109 from Riga
International airport (EVRA), Latvia to Stocholm -Arlanda airport (ESSA), Sweden and had four
crew members and 67 (sixty seven) pasengers on board. The captain of BT109 was the Pilot
Flying (PF) and the First Oficer the Pilot Not Flying (PNF).
At 27 min. of flight at 22894FT on CAUTION AND WARNING PANEL (CWP) of aircraft
OVERHEAD CONSOLE CABIN PRESSURE warning light came on.

CAUTION AND WARNING PANEL (CABIN PRESSURE)

Picture 2 OVERHEAD CONSOLE

According to Captains statement in FSR 306 cabin altitude was indicating just 8000FT. The
crew commenced to decent and when cabin ALTITUDE reached 10000FT oxygen masks were
put on. QNH checklist was performed during decent. Switcing MAN mode as well as AUT mode
on CABIN PRESSURE CONTROL panel did not give results, neither of them system did not
operate.
The crew decided to go back to Riga International airport (EVRA). They informed passengers
and flight operational service, that due to pressurization problem unable to continue flight to
destination airport and flew back to departure airport.
1.2. Injuries to persons
NIL.
5

1.3. Damage to aircraft

NIL.
1.4. Other damage
NIL.
1.5. Personnel information

PIC: male, 47 years old;

Ratings: All necessary ratings were valid;
Total flight experience - 7121 hrs;
Flying experience as captain (PIC)- 6756 hrs;
Flight experience on aircraft DHC8-Q400-1147 hrs;
Flight time last 24 hours 06:59 BH (block hours);
Flight time last 7 days -15:53BH (block hours), (period 02SEP-08SEP);
Flaying hours last 28 days 53:53 BH, (period 12AUG-08SEP).

FO: male, 32 years old;

Ratings: All necessary ratings were valid;
Total flight experience -4872 hrs;
Flight experience on aircraft DHC8-Q400-991 hrs;
Flight time last 24 hours 03:33 BH (block hours);
Flight time last 7 days -08:08BH (block hours), (period 02SEP-08SEP);
Flaying hours last 28 days 57:17 BH, (period 12AUG-08SEP).
Rest time before flight BT109:
PIC -26:15hrs
FO -27:50hrs
Resrt time last 48 hrs:
PIC had 2 days off on 06-07 SEP, 09 SEP was his 2nd working day after days off.
1.6. AIRCRAFT INFORMATION
Aircraft type - DHC8-Q402; Registration - YL-BAH; serial No. 4296; TOW 29574 kg;
Owner of aircraft -Air Baltic Corporation;
Engines No1 PCE-FA0654 TSN 5951:07 CSN 4271 TSR 5951:07 CSR 4271;
No2 PCE-FA0655TSN 5951:07 CSN 4271 TSR 5951:07 CSR 4271;

1.6.1. AIR CONDITIONING AND PRESSURIZATION

1.6.1.1. AIR CONDITIONING GENERAL

The air conditioning pack conditions the bleed air to the proper temperature and humidity and
delivers it to the distribution system for environmental control of the cabin and flight deck. The
air conditioning pack is part of the Environmental Control System (ECS). It uses bleed air from
the engines or APU to supply conditioned air to the cabinand flight deck.

Picture 3 Air Conditioning Schematic

The air conditioning system receives bleed air when the BLEED switches 1 and 2 on the AIR
CONDITIONING control panel are selected in position BLEED.

Picture 4 Air conditioning control panel diagram

The air conditioning system is controlled by selecting the CABIN and FLT COMP PACKS
switches to the MAN or AUTO positions, and then adjusting the temperature using the TEMP
CONTROL knobs. These switch settings determine the bleed air source, manual or automatic
Environmental Control System (ECS) operation, and the air flow temperatures for the flight and
passenger compartments.
The ECS Electronic Control Unit (ECU) controls the two Nacelle Shut-Off Valves (NSOV). The
ECU also uses this data to control bleed airflow rate when APU bleed air is selected on.
1.6.1.2. PRESSURIZATION
The aeroplane is pressurized by engine bleed air supplied to and distributed by the air
conditioning system. Pressure is maintained and controlled by the cabin pressure control system,
which governs the rate of outflow from the pressurized areas of the aeroplane. An aft outflow
valve primarily controls the outflow of air and is assisted by two safety valves. The aft outflow
valve is controlled from the CABIN PRESSURE CONTROL panel on the flight deck
OVERHEAD CONSOLE. There are independent controls and indicators to operate and monitor
the system.The aft outflow valve and the aft safety valve are located on the aft pressure dome. A
forward safety outflow valve is located on the forward pressure bulkhead. If cabin altitude is too
high, a flight deck warning light comes on.

Picture 5 Pressurized Areas

Picture 6 Cabin Pressurization Controll panel

Cabin Pressurization Controll panel callouts:
9

1. Rear outflow valve contrpl switch (three position)

DUMP- releases pressure by fully opening the aft outflow valve;
MAN - turns off the cabin pressure controller.
-

Enables manual control of the outflow valve and the cabin differential pressure using the
MAN DIFF switch.

AUTO cabin altitude is controlled using the aft outflow valve which modulates to maintain a
pre-programmed cabin altitude Schedule.
2. FWD outflow valve rotary knob (rotary action)
CLSD decreases the cabin altitude by closing the forward safety valve.
OPN increases the cabin altitude by opening the forward safety valve.
-

usually set fully counterclockwise (CLSD) when in AUTO mode;

independent of rear outflow valve operation.

3. Man Diff Switch (three position, spring loaded to center)

INCR increases cabin pressure when AUTO/MAN/DUMP switch is in MAN position.
DECR decreases cabin pressure when AUTO/MAN/DUMP switch is in MAN position.
4. LDG ALT rotary switch (rotary action)
- selects the field elevation for take-off and landing as shown on the LDG ALT indicator.
Note:
The Cabin Indicator Module (CIM) is indicating according to QNE (1013.25hPa International
Standard Atmosphere at sea level) and has no barometric correction, therefore it will show
different cabin altitudes, at smae stationwith different pressure.
5. LDG ALT indicator
-

displays the landing altitude selected with the LDG ALT rotary switch.

6. Fault annunciator light (amber)

-

on continuously when the cabin pressure control system detects a fault;

on momentarily during the power up test mode.

10

Picture 7 Air Conditioning Controll panel

Air conditioning control panel callouts pertaining to pressurization are following:
1. BLEED 1 and 2 switches (two position)
1 or 2 starts bleed airflow from the No.1 and/or No. 2 engine to the airconditioning packs;
OFF - stops bleed airflow from the selected engine by closing the following.
2. BLEED SELECTOR (3 (three) position, rotary action)
MIN allows ECS controller to modulate the amount of bleed air from both engines at a
minimum level.
- The only selection permitted for take-off;
-

With the BLEED switches on, and NTOP or MTOP set, shows BLEED (white) on the
Engine Display.

NORM, MAX allows ECS controller to modulate the amount of bleed air from both engines at
increased levels.
- With the Bleed switches on, and NTOP set indicates BLEED (amber) on the Engine
Display;
- With the BLEED switches on and MTOP set rating display changes to and indicates
MCP.BLEED is not displayed.

Pressurization Indicator panel callouts:

11

1. Manual cabin ALT/DIFFERENTAL pressure schedule

-

used as a guide to set cabin differential pressure using the MAN DIFF switch in
MAN mode;

2. DIF Pressure indicator

-

shows the differential pressure between cabin and aeroplane flight altitude in
pounds per square inch.

3. Cabin Altitude indicator

- shows the cabin altitude in thousand of feet
- .
4. Cabin Altitude rate of climb indicator
-

shows cabin altitude rate of climb or descentin thousands of feet per minute.

Picture 8 Pressurization Indicator Panel diagramm

12

Layout of air conditioning and pressurization control and indication panels on the aeroplane
OVERHEAD CONSOLE

1. Pressurization Indicator Panel

2. Air conditioning control panel

3. Pressurization Controll panel
Picture 9 Overhead Console

1.6.1.3. Bleed Air System

The bleed air system supplies compressed air for:
- air conditioning
- airframe deicing
- door seal pressurization
- engine oil cooler ejectors
- cabin and flight compartment pressurization.
The bleed air system uses compressed air from either the engines or the Auxiliary Power Unit
(APU) and conditions it to acceptable pressure, flow and temperature levels. The bleed air
system then delivers the conditioned air to the air conditioning system, the deice system and the
oil cooler ejectors. Crew selection of the switches on the AIR CONDITIONING control
panel determine the bleed air source. The bleed air system is located within each engine
nacelle. The left nacelle bleed air system is identical to the right nacelle system.

13

Picture 10 Bleed Air System

Selection of the two Bleed Control switches on the AIR CONDITIONING control panel to
BLEED 1 and 2, turns on the related engine bleed air system. Two PACKS switches, labelled
OFF/MAN/AUTO, and a single rotary BLEED control selector are also on the AIR
CONDITIONING control panel. Together they regulate the quantity of air flowing into the
system.

high pressure stage

low pressure stage
Picture 11 Left EngineBleed Air System synoptoc chart (right engine similar)
14

The bleed air system collects compressed air from the high pressure (HP P3.0 stage) or low
pressure (LP P2.7 stage) bleed ports of each main engine. The use of either the HP port or the
LP port depends on the engine power setting. The Auxiliary Power Unit (APU) also supplies
compressed air to the bleed air system for ground operation. The bleed air system then
distributes the compressed air to the Environmental Control System (ECS), the deice system
(including the door seal pressurization system) and the oil cooler ejectors. The bleed air going to
the ECS is also used for flight compartment and cabin pressurization.
Selection of the BLEED 1 and/or BLEED 2 toggle switches on the flight compartment AIR
CONDITIONING control panel turns on the related engine bleed air system. The
Environmental Control System (ECS) Electronic Control Unit (ECU) selects which engine
bleed port (P3.0 or P2.7) is used. The two PACKS switches, OFF/MAN/AUTO, are used to
turn on the air conditioning packs in the automatic or manual control mode. The single rotary
BLEED control selector is used to regulate the quantity of air conditioning.
1.6.1.4. Pressuarization control
Limitations of aircraft Air Conditioning and Pressurization system are following:
- normal cabin pressure differential limit
- maximum cabin pressure differential limit
- maximum cabin pressure differential limit during taxiing, take-off and landing
- maximum cabin altitude (pressurized flight)

5.46 0.1 psi

5.95 psi
0.5 psi
8,000 ft

Picture12 Cabin Pressure Control System diagramm

The cabin pressure control system keeps a constant cabin pressure during the ground and flight
modes. The system controls the cabin altitude and the cabin rate of change. The Cabin Pressure
Control Panel controls the system in automatic and manual modes. The Cabin Indication Module
15

shows the data to monitor the system. When cabin altitude is too high, the cabin pressure and the
cabin indication module send the warning signal to the aircraft systems.
In the flight compartment the system shows:
- Cabin altitude;
- Cabin altitude rate of change;
- Differential pressure;
- Cabin altitude warning.
The aft outflow valve is for automatic and manual control of the pressurization. The aft outflow
valve can also be used to dump the pressurization. The forward safety valve is for emergency
operation and for smoke removal from the flight compartment. The aft safety valve and the
forward safety valve keep the positive and negative pressure relief constant.
The system functions in the modes that follow :
- Normal/Automatic
- On ground
- Take-off
- Landing
- Emergency/Smoke Removal
- Pressure dump.
Normal/Automatic:
The pressurization control system is electrically operated. The pressurized area of the fuselage is
supplied with a constant flow of conditioned air from the engine bleed air systems through the
Air Conditioning Unit (ACU). The pressure in the fuselage is controlled by system modulation
of the aft outflow valve, to control the amount of air let out of the fuselage. If the external
ambient pressure is more than the fuselage pressure, the safety valves will open for negative
pressure relief. When electrical power is first supplied to the system, a full electrical test of the
system is done. The FAULT alert light, on the Cabin Pressure Control Panel comes on during
the power up test mode. If there is a failure in the system, the light will stay on. The system
operation is fully automatic with the data programmed into the controller.

Picture 13 Pressurization System Control Panel diagramm

On ground:
When the aircraft is on the ground with the weight on the wheels and the No. 2 engine power
lever angle is set less than 60 degrees, electrical power is supplied through the open contacts of
the energized landing gear relay. The relay is energized through the Proximity Switch Electronic
Unit (PSEU). During the ground mode the aft outflow valve is at the fully open position to
prevent aircraft pressurization.

16

Take-off: When the No. 2 engine power lever angle is set to greater than 60 degrees the
controller sends a signal to the aft outflow valve to open or close, as necessary, to pressurize the
aircraft to 400 ft (121.9 m) less than ambient. The aft outflow valve moves from the fully open
position and starts to modulate to control the pressure changes that occur after take-off. When the
landing gear relay is de-energized after take-off (through the PSEU), the aft outflow valve
modulates to keep the set aircraft pressure.
The CABIN PRESS warning light on the Caution and Warning panel comes on when the cabin
altitude reaches 10,000 ft (3048 m), except when take-off or landing altitude is above 8000 ft
(2438.4 m). For take-off or landing altitudes above 8000 ft (2438.4 m) the warning light will
come on in the conditions that follow:
- The aircraft take-off altitude + 1000 ft (304.8 m)
- Landing altitude + 1000 ft (304.8 m)
Landing:
The aircraft depressurization is controlled automatically. If the set field altitude is higher than
actual field altitude, the aircraft will land unpressurized. If the field altitude is set less than actual
field altitude, the aircraft will land pressurized. On landing, cabin altitude will go back to field
altitude at the rate programmed into the controller, for one minute before cabin pressure is bled
to ambient.
Manual:
The manual mode is used if the automatic pressurization mode does not operate.
Pressurization can be controlled through the aft outflow valve, when the AUTO-MAN-DUMP
switch is set to MAN. The cabin pressure is set with the toggle switch moved and held to the
DECR position, to open the aft outflow valve and increase the cabin altitude. When the toggle
switch is moved and held to INCR, the aft outflow valve closes and the cabin altitude decreases.
1.7. Meteorological information
NIL
1.8. Aids to Navigation

NIL
1.9. Communications
NIL
1.10. Aerodrome information
NIL

17

1.11. Flight recorders

Flight recorder data of Flight - 89223: YL-BAH, 09 Sep 12 16:42 (Graph View), range +0135.595s to
+0135.595s
FDR data shows that BLEED switches position 1& 2 on Air conditioning control panel were on

position OFF from during flight, therefore bleed valves were off.
Cabin Pressure Warning on Caution and Warning Panel came on at 1565 sec of flight at
altitude 22874

Cabin Pressure Warning on Caution and Warning Panel came off at 1878 sec of flight at
altitude 10014

18

1.12. Wreckage and impact information

Not damage
1.13. Medical and pathological information
NIL
1.14. Fire
There was no fire
1.15. Survival aspects
NIL
1.16. Tests and research
NIL
1.17. Organizational and management information
NIL
1.18. Additional information
NIL
1.19. Useful or effective investigation techniques
NIL

19

2. Analysis
2.1. Company procedures before flight

The table with the phase of flight when the checklist shall be initiated and the crewmember
response.

20

BLEED OFF
Flight Deck Setup checklist
LP Items (black area)

RP Items (grey area)

Picture 13 Areas of Pilots Responsibility during Flight Deck Setup

21

According to Operators Operation Manual Part B Q400 Rev the crew before every flight should
performn the checklists and procedures according to Chapter 2 NORMAL CHECKLIST
The Normal checklist is a system developed and established by the Company for use by flight
crew in order to ensure proper airplane configuration, systems set-up and function prior to,
during and after all phases of flight.When the airplane is on ground, the RP should read the
checklist. When the airplane is airborne this is the duty of PM.
Bleeds at position OFF

Before Start checklist

Bleeds should be at position ON

After Start checklist

Line up checklist
22

Bleeds should be at position ON

After take-off checklist

Investigation has stated that according to Company OM Part B Q400 Rev.002 during performing
3 (three) checklists- After Start, Line up and After take-off the BLEED switches should be at
position ON. According to the respondent nominated in the third column of the checklists it is
responsibility of the Left Pilot. According to After take-off checklist it is responsibility of PF.

2.2. Sequence of Events and crew actions before the incident

According to Flight Plan for Flight BT109 on September 9, 2012 departure time from Riga
international airport (RVRA) was at 16:30UTC, that means departure as well as performed
procedures before was initiated at night time. Therefore, in opinion of investigation, it is not easy
visually to check position of BLEED switches on the Air Condition Control panel located on right
side of the OVERHEAD CONSOLE from LP seat position.

Picture 14 Controls and Idications

BLEED switches did not switch on, during performing After Start, Line up and After take-off
checklist. The position of BLEED switches was not checked by the finger touch.
23

In opinion of investigation the checklists according to Chapter 2 of OM Part B 400, Rev 2 were
performed carelesly by LP of crew. PF is responsible of performing after take-off checklist. PF
after take-off was LP Captain of aeroplane.
2.3. Company Abnormal and Emergency Procedures.
Abnormal/ Emergency Procedure- A procedure which shall be applied if a warning is received
or when appropriate conditions dictates.
Memory Items- Minimal vital actions, which shall be done as soon as the situation permits
without reference to the checklist.
Non-Normal checklist Abnormal or Emergency Procedures for which specific checklists are
developed. Could ne applied directly when in a nonnormal situation and/or upon warning have
been received.
2.3.1. Responsibility of the crew members during an abnormal or emergency situation.
Commander:
-

Set/change the priorities/course of actions;

Identify/confirm the applicableprocedure/non normal checklist
Brief crewmembers and coordinate their actions;
Direct and follow the procedure.

PF:
-

Control/navigate the airplane;

Initiate identified procedure/checklist;
Monitor PMs actions.

PM:
-

Carry out identified procedure/checklist;

Monitor and support PFs actions.

2.3.2. Emergency Descent

When unpressurized the airplane must be maintained at 10 000' feet or at the lowest safe
altitude, if higher.
Prolonged flight at altitudes above 14 000' shall be avoided and every opportunity shall be used,
including re-routing, to descent below the above- mentioned altitudes as soon as practicable.
Flight crew shall use OXYGEN when Cabin Altitude is above 10 000' with or without Cabin
Altitude warning.
Emergency (Rapid) Descent could be initiated when:
-

Cabin pressure cannot be controlled when the aeroplane is above 14000;

A rapid descent is required.

2.3.2.1. Crew actions and coordination

24

If Cabin Altitude Warning comes on both pilots shall compleete the Memory items of the
following non-normal checklist immediately:
RAPID DEPRESSURIZATION/EMERGENCY DESCENT

When those Memory Items are complete, the crew actions should be following:
1. STOP CLIMB; to assigned level or altitude above 10000;
- ALT HOLD;
- Level off;
- Report to ATC.
2. ENSURE SUPPLY;
- Bleeds- check ON/MAX;
- Packs Check AUTO.
3. ENSURE CONTROL;
- Auto/Man/Dump Check AUTO or MAN;
- Cabin Alt Fwd Outflow- Check Closed.
- Fwd Outflow Valve Ceck NORM
Pressurization problems may normally be fixed sometimes without the need for an immediate
Emergency Descent if proper actions are taken by crewmembers.
When the CABIN PRESS warning light comes on, LP did not check the BLEED position. He was
busy with performing actions to facilitate the readiness for an Emergencu Descent:
- LP should take control and ensure that A?P is used;
- LP should check airplane positionand traffic in vicinity that may affectthe descent
maneuver;
- LP should inform the Cabin Crew;
- RP should concentrate on regaining cabin pressure control.
During performing ENSURE SUPPLY checklist the position of BLEED switches No 1&2 were not
checked, therefore checklist was continued without the BLEED 1&2 ON/MAX.

The crew did not perform RAPID DEPRESSURIZATION/EMERGENCY DESCENT

procedure according to requirements of Item 3.6.2.3. CABIN ALTITUDE WARNING of
OM Part B, Rev. 002 of 16.07.2012.
As a result pressurization system did not operate at AUTO as MANUAL mode, because both
engine bleed air systems were turned off.
25

Therefore due to crew wrong actions pressurization problems were not normally fixed without the
need for an immediate Emergency Descent and due to false pressurization problem they were unable
to continue flight and returned to departure airport Riga International.
2.4. Threat and Error Management (TEM) analysis in Flight Operations
Investigation considered three basic components of the Threat and Error Management model,
regarding to flight BT109 crew: threats, errors and undesired aircraft states.
Threats and errors are part of everyday aviation operations that must be managed by flight crews,
since both threats and errors carry the potential to generate undesired aircraft states.
Flight crews must also manage undesired aircraft states, since they carry the potential for unsafe
outcomes. Undesired state management is an essential component of the TEM model, as
important as threat and error management. Undesired aircraft state management largely
represents the last opportunity to avoid an unsafe outcome and thus maintain safety margins
in flight operations.
2.4.1. Threats
Threats are defined as events or errors that occur beyond the influence of the flight crew,
increase operational complexity, and which must be managed to maintain the margins of safety.
During typical flight operations, flight crews have to manage various contextual complexities.
Such complexities would include, for example, dealing with adverse meteorological conditions,
airports surrounded by high mountains, congested airspace, aircraft malfunctions, errors
committed by other people outside of the cockpit, such as air traffic controllers, flight attendants
or maintenance workers, and so forth. The TEM model considers these complexities as threats
because they all have the potential to negatively affect flight operations by reducing margins of
safety.
2.4.2. Errors
Errors are defined actions or inactions by the flight crew that lead to deviations from
organisational or flight crew intentions or expectations. Unmanaged and/or mismanaged
errors frequently lead to undesired aircraft states. Errors in the operational context thus tend to
reduce the margins of safety and increase the probability of adverse events.
Errors can be spontaneous (i.e., without direct linkage to specific, obvious threats), linked to
threats, or part of an error chain.
Before flight there were the following crew errors:
- aircraft handling errors - incorrect BLEED switches setting on Air Conditioning
Control panel;
- procedural errors - performing non normal checklists carelessly.
Regardless of the type of error, an errors effect on safety depends on whether the flight crew
detects and responds to the error before it leads to an undesired aircraft state and to a
potential unsafe outcome. This is why one of the objectives of TEM is to understand error
management (i.e., detection and response), rather than solely focusing on error causality (i.e.,
causation and commission). From the safety perspective, operational errors that are timely
detected and promptly responded to (i.e., properly managed) do not lead to undesired aircraft
states, do not reduce margins of safety in flight operations, and thus become operationally
inconsequential. In addition to its safety value, proper error management represents an example
of successful human performance, presenting both learning and training value.
26

During flight BT109 the crew did not detect timely error, performing non normal checlist
when warning CABIN PRESS came on and therefore it lead to undesired aircraft state and as a
result to emergency decent and returning back to deperture airport.
2.4.3. Undesired Aircraft States
Undesired aircraft states are defined as flight crew-induced aircraft position or speed deviations,
misapplication of flight controls, or incorrect systems configuration, associated with a
reduction in margins of safety. Undesired aircraft states that result from ineffective threat and/or
error management may lead to compromising situations and reduce margins of safety in flight
operations. Often considered at the cusp of becoming an incident or accident, undesired aircraft
states must be managed by flight crews.
Events such as equipment malfunctions can also reduce margins of safety in flight operations,
but these would be considered threats. Undesired states can be managed effectively, restoring
margins of safety, or flight crew response(s) can induce an additional error, incident, or accident.
2.4.3.1. Incorrect systems configuration
An important learning and training point for flight crews is the timely switching from
error management to undesired aircraft state management. For example if a flight crew selects a
wrong BLEED switches settings and the flight crew subsequently identifies the error during a
performing non- normal checklist when warning CABIN PRESS came on.
The use of the TEM model assists in educating flight crews that, when the aircraft is in an
undesired state, the basic task of the flight crew is undesired aircraft state management instead of
error management.
The training and remedial implications of this differentiation are of significance. While at
the undesired aircraft state stage, the flight crew has the possibility, through appropriate TEM, of
recovering the situation, returning to a normal operational state, thus restoring margins of safety.
Once the undesired aircraft state becomes an outcome, recovery of the situation, return to a
normal operational state, and restoration of margins of safety is not possible.
Other countermeasures are more directly related to the human contribution to the safety
of flight operations. These are personal strategies and tactics, individual and team
countermeasures, that typically include canvassed skills, knowledge and attitudes developed by
human performance training, most notably, by Crew Resource Management (CRM) training.
There are basically three categories of individual and team countermeasures:
Planning countermeasures: essential for managing anticipated and unexpected threats
Execution countermeasures: essential for error detection and error response
Review countermeasures: essential for managing the changing conditions of a flight
Enhanced TEM is the product of the combined use of systemic-based and individual and team
countermeasures.
3. Conclusions

3.1. Findings
-

The flight crew was licensed and qualified for the flight in accordance with applicable
regulations;
The flight crew held valid medical certificates and was medically fit to operate the flight;
The flight crew was adequately rested and their flight and duty times were in compliance
with EU OPS Sub Part Q Flight and Duty Time Limitations and Rest Requirements;
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air Baltic OM Part B, rev 002 was approved by SVP Flight Operations and effective from
16.07.2013;

Procedures of OM Part B Q400 Rev 002 were adequate for performing task before flight
and during incident;

Pilot flying during flight BT109 was Captain;

Pilots used oxygen masks and initiated emergency descent procedure;

3 (three) checklists- After Start, Line up and After take-off were performed carelesly
by the crew mwmbers, without actual switching knob checking on pressurization control
and indication panels;

FDR data shows that BLEED switches position 1& 2 on Air conditioning control panel were on

position OFF during all flight, therefore both engine bleed air systems were turned off;
-

the bleed airflow sources- both main engine bleed air systems which distribute the
compressed air to the Environmental Control System and is also used for flight
compartment and cabin pressurization were switched off;

According to the respondent nominated in the third column of the checklists it is

responsibility of the Left Pilot to check position of air BLEED switches 1&2 on Air
Conditioning Control panel;
Cabin Pressure warning on Caution and Warning panel came on at 1565 sec of flight
at altitude 22874
The crew did not perform RAPID DEPRESSURIZATION/EMERGENCY
DESCENT procedure according to requirements of Item 3.6.2.3. CABIN
ALTITUDE WARNING of OM Part B, Rev. 002 of 16.07.2012;

During flight the crew did not detect timely error, performing RAPID
DEPRESSURIZATION/EMERGENCY DESCENT procedure when warning
CABIN PRESS came on.

3.2. Causes
Causes of the serious incident - cabin depressurization of aircraft DHC-8-402, registered YLBAH, flight BT109, were the following:

3.2.1. Proximate Cause

The source or origin of an event that caused this incident was the fact that the Pilot in Comand
did not switch BLEED switches 1&2 on the Air Conditioning Control Panel.
3.2.2. Root Cause
The factor that resulted this incident was that the bleed airflow sources- both main engine
bleed air systems which distribute the compressed air to the Environmental Control System
and is also used for flight compartment and cabin pressurization were switched off and did
not delivered flow of conditioned air through the Air Conditioning Unit (ACU).
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3.2.3. Contributing causes

Indistinguishably to check visually, without finger touch, position of BLEED switches on the Air
Condition Control panel on the OVERHEAD CONSOLE from LP seat position at night time.

3.2.4. Primary cause

The event after which incident became inevitable.
Performing
by
the
crew
in
improper
manner
procedure
RAPID
DEPRESSURIZATION/EMERGENCY DESCENT, when warning CABIN PRESS
came on, not corresponding to the requirements of Item 3.6.2.3. CABIN ALTITUDE
WARNING of OM Part B, Rev. 002 of 16.07.2012.

4. Safety Recommendations
As a result of the investigation of this accident, the Transport Accident and Incident Investigation
Bureau Republic of Latvia recommends the following:

Recommendation - 8-2013
Operator Air Baltic should provide incidents or serious incidents analysis where human factor
elements are involved and to consider oportunity to include in the crew training programms
section dedicated to human factors unsafe acts of operators and preconditions for unsafe acts.

October 18, 2012

Director of Transport Accident and Incident
Investigation Bureau

Ivars Alfreds Gaveika

Investigator in charge Head of Aircraft Accident and Incident

Investigation Department

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Visvaldis Trubs

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