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| Date: | Monday 29 November 2021 |
| Time: | 18:42 LT |
| Type: |  Bombardier CRJ-900LR |
| Owner/operator: | Air Canada Express, opb Jazz Aviation |
| Registration: | C-GJZV |
| MSN: | 15424 |
| Engine model: | GE CF34-8C5 |
| Fatalities: | Fatalities: 0 / Occupants: 73 |
| Other fatalities: | 0 |
| Aircraft damage: | Minor, repaired |
| Category: | Serious incident |
| Location: | San Diego International Airport, CA (SAN/KSAN) -
 United States of America
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | San Diego International Airport, CA (SAN/KSAN) |
| Vancouver International Airport, BC (YVR/CYVR) | |
| Investigating agency: | TSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
A CRJ-900LR operated by Jazz Aviation, was conducting Air Canada Express flight AC787 from San Diego International (KSAN), CA to Vancouver International (CYVR), BC with 4 crew members and 69 passengers.
At 18:42 hours local time (02:42 UTC, Nov. 30) the aircraft began its take-off roll left of the center line on runway 27, the flight crew noticed they were left of center line and corrected the trajectory.
During cruise at approximatively 110 nm NNW of Los Angeles International (KLAX), CA, a fuel imbalance was noticed, the checklist was followed and the right hand engine was shutdown. An emergency was declared and the aircraft diverted to KLAX.
At 19:46 (03:46 UTC), during the landing roll out at KLAX, the flight crew noticed that the airplane was pulling to the left. The aircraft was stopped on the runway. The AARF advised that the no.1 tire from the left main landing gear was deflated and some smoke was coming out of the wheel. The ARFF sprayed the left main landing gear due to the brake overheat. Passengers were disembarked and transported to the terminal.
The left hand flap was punctured by an impact with the runway edge lights on takeoff at KSAN. The maintenance in KLAX temporary repaired the left hand flap, and replaced the the no.1 tire. The aircraft was flown to Calgary International (CYYC), on December 4 under the authority of a ferry flight permit for further repairs.
Findings as to causes and contributing factors:
1. The aircraft was operating at night and in fog, in an area where visibility was between ¼ statute mile and ½ statute mile. As a result, there were few visible cues available to the flight crew to identify and verify the aircraft’s position on Runway 27 at San Diego International Airport.
2. When taxiing to position on the runway, the captain taxied the aircraft off the taxiway centreline in order to increase the runway distance available for takeoff. As a result, he had to rely on other visual cues to determine the aircraft’s position on the runway.
3. When the aircraft was turning left to establish the runway heading in preparation for takeoff, the limited and ambiguous visual cues that were available likely met the captain’s expectations. As a result, he perceived the left runway edge as the runway centreline and aligned the aircraft laterally with the left edge of the runway, rather than its centre.
4. The complexity of instrument flight rules operations on a single runway surface, with arrivals on one end and departures from the other end, created an environment where the flight crew perceived a time pressure for the takeoff. As a result, the first officer was completing the line-up checks while the captain taxied to position, and the first officer therefore did not monitor the progress of the taxi.
5. Due to the reduced visual cues and perceived time pressure felt by the first officer, he did not recognize that the aircraft’s nose was aligned with the left edge of the runway when he assumed the role of pilot flying shortly before the take-off roll commenced.
6. During the take-off roll, the aircraft’s left main landing gear wheels contacted and severed 3 runway edge lights, causing damage to the aircraft’s tires and flaps.
7. The aircraft’s contact with the runway edge lights was not recognized by the flight crew because they perceived the sounds and vibrations to be normal contact with the embedded runway centreline lights and consequently continued with the departure.
8. During the completion of either the before-takeoff or after-takeoff checklists, it is likely that the flight crew inadvertently pressed the gravity crossflow push-button switch instead of the co-located crossflow auto override push-button switch. As a result, during the flight, fuel periodically transferred between the aircraft’s wing tanks by gravity when the aircraft was banked left or right, leading to a worsening fuel imbalance condition.
9. While operating at night with the autopilot on, the aircraft was placed in a sideslip toward the wing tank with the greater quantity of fuel, and this opposite bank was not recognized by the flight crew. As a result, the lateral fuel imbalance was not controlled, and continued to increase.
10. The fuel imbalance, which was unrelated to the damage sustained during the take-off roll, led the flight crew to declare an emergency and divert to a nearby airport for an emergency landing.
11. The checklists did not require the flight crew to close the gravity crossflow valve following the attempted Gravity Crossfeed Procedure. As a result, the open valve occasionally made the fuel imbalance worse during the subsequent manoeuvring and was at one point more than 3 times the maximum permissible.
Weather reported during takeoff from San Diego (0242Z, 30 Nov.)
KSAN 300156Z 00000KT 4SM BR SCT002 16/15 A3003 RMK AO2 VIS S-W 1 T01560150
KSAN 300304Z 34003KT 1/4SM R09/2000V3000FT FG VV002 14/14 A3005 RMK AO2 T01390139
Accident investigation:
 |
|
Sources:
TSB A21F0210
https://www.flightradar24.com/data/aircraft/c-gjzv#2a073b2c
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 08-Dec-2021 18:42 | harro | Added |
| 08-Dec-2021 18:45 | harro | Updated [Date, Time, Operator, Location, Narrative, ] |
| 08-Dec-2021 18:48 | harro | Updated [Time, Narrative, ] |
| 07-Jul-2024 06:47 | ASN | Updated [Narrative, Accident report, ] |
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