Recently Released TSB Reports

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The following summaries are extracted from final reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include the TSB’s synopsis and selected findings. Some excerpts from the analysis section may be included, where needed, to better understand the findings. For the benefit of our readers, all the occurrence titles below are now hyperlinked to the full TSB report on the TSB Web site. —Ed.

TSB Final Report A09W0026—Runway Incursion/Risk of Collision

On February 9, 2009, at 21:11 MST, a Beech 1900D aircraft, with two crew members and eighteen passengers on board, was taking off from Runway 25 at Fort McMurray Airport, Fort McMurray, Alta. Visibility at the time was reported as 5/8 SM in light snow. Just before reaching the takeoff decision speed/rotation speed, the crew noticed headlights on the runway in front of them and rotated immediately. The aircraft passed about 100 to 150 ft over a snowplow operating on the runway. The snowplow operator had been cleared by the flight service specialist to continue snow clearing operations on Runway 25 after a previous departure. The snowplow operator had not been instructed to vacate the runway prior to the Beech 1900's departure, and the crew of the aircraft had not been advised of the presence of the snowplow on the runway. The Beech 1900 crew was communicating with the flight service station (FSS) on the mandatory frequency (MF) of 118.1 MHz, whereas the snowplow operator was communicating on the ground frequency of 121.9 MHz.

Fort McMurray Airport diagram
Fort McMurray Airport diagram

Analysis

The consequences of a collision between ground vehicles and aircraft taking off or landing can be catastrophic. As a result, several defences are used to prevent ground vehicles and aircraft from conflicting with each other.

The specialist was relatively busy, communicating with airport traffic and coordinating with the area control centre (ACC). The specialist did not remember clearing the vehicle back onto the runway after the previous departure. It is likely that the other tasks, at around the same time the specialist was clearing the vehicle onto the runway, interrupted the specialist's normal use of available aide memoires. Furthermore, the position of the vehicle in and around Taxiway C likely confirmed in the specialist's mind that the vehicle had not moved since the previous departure, and that a clearance had not been given to the vehicle to proceed back onto the runway.

Transport Canada regulations require pilots to ensure that the runway is clear of obstacles prior to departure. This can be done by visual observation or through radio communications. In this case, it was night with reduced visibility in snow, which limited the effectiveness of visual observation.

Having both the aircraft pilot and the vehicle operator on the same radio frequency would have likely enhanced each other's awareness of their respective positions on the runway.

Findings as to causes and contributing factors

  1. Likely due to the interruption from other tasks at the same time the specialist was clearing the vehicle onto the runway, the flight service specialist did not use any aide memoires as a reminder that the snowplow had been cleared onto the runway.

  2. The flight service specialist's visual scan was defeated by reduced visibility.

  3. The reduced visibility due to darkness and falling snow resulted in neither the vehicle operator nor the pilot accurately determining the other's position on the runway.

  4. The snowplow and the Beech 1900 were operating on different frequencies, removing an opportunity for the flight crew or the vehicle operator to be aware of the other's presence on the runway.

 

Safety action taken

Transportation Safety Board of Canada

On August 13, 2009, the Transportation Safety Board of Canada issued to Transport Canada an Aviation Safety Advisory A09W0026-D1-A1, entitled Communication Frequency Assignment for Vehicle Advisory Services. This advisory suggests that Transport Canada may want to work with NAV CANADA to explore the feasibility of a single frequency for the aircraft and vehicles occupying the manoeuvring areas.

NAV CANADA
In response to the above-mentioned Safety Advisory, NAV CANADA provided the following:

  • On February 26, 2009, NAV CANADA published Squawk 7700 (2009-2) titled Reducing the risk of runway incursions. It provides the latest runway incursion statistics and reminders on some of the actions that air traffic services (ATS) personnel can take to reduce the likelihood of being involved in a runway incursion.

  • NAV CANADA conducted an Operational Safety Investigation (OSI) into the event. In the weeks following the release of its investigation report, NAV CANADA examined the possibility of implementing cross coupling 1 capability at FSS as a potential mitigation to reduce the likelihood of similar occurrences.

  • On April 27, 2009, a memorandum on the implementation of cross coupling was distributed. It provided directions to unit managers of FSS facilities to implement the cross coupling capability, proceed with an on-site implementation safety review, include procedures on the use of cross coupling in the Unit Operations Manual (UOM) and provide a mandatory briefing for specialists. Flight Services (FS) evaluations and investigations inspectors are verifying the implementation of cross coupling in all units as part of their routine unit evaluations.

  • Since the incident, there have been changes in the ATS provision at the Fort McMurray Airport (YMM). An air traffic control (ATC) tower has been established and, outside the tower’s hours of operation, a remote airport advisory service (RAAS) through Peace River FSS is available. With respect to RAAS, vehicle advisory service is provided on the MF, which is a single frequency for both vehicle operators and aircraft.

Decorative line

1 Cross coupling of frequencies allows aircraft and vehicles to hear communications coming from each other and the specialists even when these communications take place on the frequency that they do not monitor, thus increasing their situational awareness of other vehicle and aircraft relative positions and intentions.

TSB Final Report A09P0249—Loss of Control—Collision with Water

On August 14, 2009, a Bell 212 helicopter was engaged in firefighting operations about 20 NM south of Lillooet, B.C. At approximately 16:02 PDT, the accident helicopter approached the Fraser River to pick up water. Shortly before reaching the pickup location, the helicopter descended unexpectedly and its water bucket, on a 150-ft longline, touched down in a fast flowing section of the river. As the helicopter continued forward, it was dragging the water bucket. Moments later, the helicopter pitched nose-down, yawed to the left, struck the river surface, broke up, and sank. The pilot escaped the wreckage and was swimming in the fast flowing water. Repeated attempts to rescue the pilot by other helicopters in the area proved unsuccessful. The pilot's body was found downstream five days later. Some pieces of the wreckage, including the longline and water bucket, were retrieved, but the majority of the wreckage was not recovered.

Accident sequence (VRS followed by bucket anchoring)
Accident sequence (VRS followed by bucket anchoring)

Analysis

The helicopter was not recovered; however, it is believed that mechanical malfunctions were not a factor in this accident. Therefore, the analysis focuses on the canyon winds, helicopter aerodynamics, operational factors and post-crash survival.

Because of the local topography, the wind direction changed 180º in a short time. This may have happened without a decrease in wind speed and, because of the barren land and rough water, the wind direction would have been hard to identify.

The tight circuit just before final approach—likely for spacing—put the helicopter in a position that would have necessitated a steep approach, requiring careful power management. It is likely that the accident pilot's approach was unknowingly conducted with a tailwind, due to the sudden change in wind direction. This would have caused the helicopter to lose translational lift early on the approach, likely producing a sudden increase in the rate of descent. To counter this descent, the pilot would have to add power. The combination of a steep approach, unknowingly conducted downwind at slow speed with power applied, likely caused the helicopter to descend into its own downwash. This would have caused the helicopter to enter a vortex ring state (VRS) and produced a rapid descent. The VRS condition and/or the attempt to recover by gaining airspeed or lowering the collective caused the water bucket to drop into the river before reaching the back eddy (see image, position A).

In an attempt to recover from VRS, the pilot would have pushed the cyclic forward to gain airspeed. However, the water bucket would have been full and drifting downstream, opposite to the direction of flight. This would have produced an anchor-like effect on the helicopter, causing it to pitch nose-down (see image, position B). The pilot would have quickly run out of aft cyclic travel while trying to raise the nose, causing the helicopter to fly in a descending arc until it collided with the water.

If the pilot had released the longline before he ran out of aft cyclic travel, he would likely have been able to fly away without losing control.

It is impossible to ascertain whether or not the pilot attempted to release the water bucket before the crash. Because he was known to disarm the release switch, the pilot would not have been able to electrically release the water bucket. The left yaw that occurred just prior to impact could be attributed to a last second attempt to jettison the longline and water bucket. In doing so, the pilot probably took his right foot off the right anti-torque control pedal to activate the manual belly hook release. This would make it very easy to induce a left pedal input that caused the helicopter to yaw left.

Findings as to causes and contributing factors

  1. The combination of a steep approach, unknowingly conducted downwind at slow speed with power applied, likely caused the helicopter to enter a VRS.

  2. During the pilot's attempt to recover, the water bucket dropped into the flowing river and acted as an anchor, causing the helicopter to pitch nose-down and collide with the water.

  3. The helicopter was likely being operated with the belly hook electrically disarmed, limiting the pilot's ability to jettison the water bucket before losing control.

  4. Although the pilot was able to escape the helicopter wreckage in the water without injury, he was not wearing a personal flotation device (PFD) and drowned.

 

Findings as to risk

  1. The helicopter's manual emergency release for an external load requires the pilot to remove one foot from the anti-torque control pedals. As a result, there is an increased risk of loss of anti-torque control at a critical time of flight.
  1. Operations in deep canyons may be subject to turbulent airflow and winds that rapidly flip from one direction to the opposite. Without adequate warning, helicopter pilots may be placed at risk.

 

Safety action taken

Operator

Immediately following the accident, the helicopter operator instituted policies requiring pilots to fly with the belly hook armed and to wear PFDs when water bucketing.

TSB Final Report A10Q0019—Cabin Fire

On January 2, 2010, a Beech 200, with two pilots and four passengers on board, conducted an IFR medical evacuation (MEDEVAC) flight between La Romaine Airport and Sept-Îles Airport in Quebec. While the aircraft was approximately 5 NM from landing on Runway 09 at Sept-Îles, one of the passengers informed the flight crew that there was smoke in the cabin. The crew switched off the fluorescent lights in the cabin, the ordinance lights and the two air bleed systems. The smoke appeared to dissipate. The aircraft touched down at 12:39 EST and taxied to the company's facilities. Once the aircraft came to a stop, some smoke reappeared. Emergency services were alerted. The crew was unable to locate the source of the fire until it became visible from outside the cabin, on the top left of the fuselage. The crew extinguished the fire using portable fire extinguishers. There were no injuries. The aircraft was significantly damaged.afforded by adherence to published instrument procedures and associated company standard operating procedures (SOP).

Damage as seen from outside the aircraft
Damage as seen from outside the aircraft

Analysis

The flight crew was notified of the presence of smoke while performing an approach in instrument flight conditions. The crew was faced with an emergency during a critical phase of flight. Although the crew had little time to assess the situation and take appropriate action before landing, the first officer went to the rear of the aircraft to better assess the situation. He observed the presence of grey smoke, normally associated with an electrical problem, but the applicable emergency procedures were not followed. Two factors may have influenced the flight crew to not follow the emergency procedures:

  • The smoke appeared to dissipate as a result of the initial actions taken, namely the switching off of the fluorescent lights, the ordinance sign lights and the closing of the two air bleed systems;
  • The crew had little time to locate and apply the emergency procedures before landing.

It is difficult to predict what the outcome would have been had the flight crew applied the emergency procedures on a timely basis. However, in the case of this occurrence, shutting off non‑essential electrical equipment, such as fluorescent lights and ordinance sign lights, was done as soon as the passenger informed the crew of the presence of smoke. Therefore, electrical power was cut sooner than if the crew had taken the time to read the paragraph to identify the source of the smoke and get to point 7, which states to cut the electrical power to non‑essential equipment.
Declaring an emergency at the right time and clearly indicating the nature of the problem allows crews to get the best possible assistance when faced with an abnormal or emergency situation. Without this information, unexpected and undesirable consequences could occur, for example, a pilot being unable to comply with requests from air traffic control and being forced to execute a missed approach or any other manoeuvre that could delay the landing. In this occurrence, the crew did not deem it necessary to declare an emergency, likely because they thought that they had isolated the source of the problem. However, if the smoke appeared to have dissipated, it was impossible for the crew to know the magnitude of the situation behind the panels.
 

Findings as to causes and contributing factors

  • Arcing between the connector and electrical power supply of panel LH/4 produced overheating to the point of igniting the fire.
  • The strip of fabric ignited and spread the fire to the air outlet, melted it and burned it completely.

Findings as to risk

  • The surrounding material can ignite in seconds when it is in direct contact with a flame.
  • Not declaring an emergency and omitting to clearly indicate the nature of a problem could produce unexpected and undesirable consequences, which would likely delay landing.

Other finding

  • The manufacturer, Beech Aircraft Corporation, issued a press release informing operators of the possibility of arcing between the connector and power supply of the fluorescent lights.

TSB Final Report A10A0056—Controlled Flight Into Terrain

On May 26, 2010, at 08:35 ADT, a Piper Navajo PA31-350 departed on a round trip flight from Goose Bay to Cartwright and Black Tickle before returning to Goose Bay, N.L. The pilot was to deliver freight to Cartwright as well as a passenger and some freight to Black Tickle. At approximately 09:05, the pilot made a radio broadcast advising that the aircraft was 60 NM west of Cartwright. No further radio broadcasts were received. The aircraft did not arrive at destination and, at 10:10, was reported as missing. The search for the aircraft was hampered by poor weather. On May 28, 2010, at about 22:00, the aircraft wreckage was located on a plateau in the Mealy Mountains. Both occupants of the aircraft were fatally injured. The aircraft was destroyed by impact forces and a post-crash fire. There was no emergency locator transmitter (ELT) on board and, as such, no signal was received.

aircraft was destroyed by impact forces and a post-crash fire

Route

The pilot planned and flew the most common route from Goose Bay to Cartwright, which is direct. However, weather conditions may require flying around the Mealy Mountains. Pilots who routinely fly the coast of Labrador choose any one of the following alternate routes:

  • Alternate Route 1: Follow the Kenamu River Valley until south of the Mealy Mountains, then proceed eastward and follow the Eagle River.
  • Alternate Route 2: Proceed northeast from Goose Bay along the south shore of Lake Melville to Frenchman Point, then follow the English River to the North River, which can be tracked to the coast.
  • Alternate Route 3: Fly to Lake Melville and through the Narrows to the coast proceeding down the shoreline to Cartwright.

aircraft route
The pilot was flying VFR direct to Cartwright in weather conditions where he would have encountered lowering ceilings and reduced visibility en route towards the Mealy Mountains.

 

Analysis

The aircraft had no deficiencies that precluded normal operation. Pilot incapacitation was ruled out; there was no indication of any health-related matters during the pilot's last radio communication, just prior to the aircraft impacting the terrain.

The investigation also determined that turbulence was not a factor contributing to the aircraft striking the ground. If turbulence forced the aircraft down into the mountain, the debris field would consist of an initial impact point with debris spread about in multiple directions. In this occurrence, the left engine cowling was dragged through the snow for 40 ft, and the aircraft continued in a straight line for an additional 370 ft before coming to a stop. The majority of the debris was contained within a confined area.

At the time of departure, the pilot was aware that the altimeter setting was 29.93 in-Hg in Goose Bay and 29.71 in-Hg in Cartwright. The planned route would take the aircraft over rising terrain and toward an area of lower pressure. Therefore, if left untouched, the altimeter would have read approximately 200 ft higher than the actual altitude of the aircraft. The last radar return showed the aircraft at 3 600 ft ASL. If the altimeter was reading 200 ft higher than the actual altitude, as a result of the pilot not having adjusted it to Cartwright's setting, then the aircraft would have been flying at an actual altitude of about 3 400 ft.

Although the aircraft was extensively damaged, there was no evidence suggesting a problem with the flight controls or engines. Initial impact signatures and the debris field suggest that there was no attempt made to avoid the terrain. The pilot was flying VFR direct to Cartwright in weather conditions where he would have encountered lowering ceilings and reduced visibility en route towards the Mealy Mountains. If the pilot entered cloud or an area of low visibility, then he likely would have lost visual reference with the horizon due to the snow covered mountains, and would have had to rely on his altimeter to maintain clearance with terrain. The aircraft initially struck the ground at about 3 450 ft, which is consistent with the altitude of the last radar contact if the pilot had not set the altimeter to Cartwright's setting. The aircraft flew into the rising terrain in a straight and level attitude with the engines running, consistent with controlled flight into terrain (CFIT).

The pilot had extensive experience flying in Labrador, and the forecast weather conditions for the en route portion of the flight were marginal VFR. It could not be determined why the pilot chose to fly this route when alternatives were available.

Findings as to causes and contributing factors

  1. The pilot conducted a VFR flight into deteriorating weather in a mountainous region.

  2. The pilot lost visual reference with the ground and the aircraft struck the rising terrain in level, controlled flight.

 

Findings as to risk

  1. When an aircraft is not equipped with a functioning ELT, the ability to locate the aircraft in a timely manner is hindered.

  2. Not applying current altimeter settings along a flight route, particularly from an area of high to low pressure, may result in reduced obstacle clearance.

  3. Without a requirement for terrain awareness warning systems, there will be a continued risk of accidents of this type.

TSB Final Report A10Q0087—Collision with Water

On June 3, 2010, at approximately 19:00 EDT, a privately operated Lake Buccaneer LA-4-200 amphibious aircraft, with the pilot and a passenger on board departed on a VFR flight from Lac de la Marmotte II to Baie Comeau, Que. The 98-NM flight was to take approximately 1.3 hr. When the aircraft did not arrive at its destination by the end of day on June 4, a search was started on the morning of June 5. Using sonar, the aircraft was located on June 26 by the Sûreté du Québec police dive team at a depth of 230 ft in Lac Berté, 5 NM south of Lac de la Marmotte II. The aircraft and occupants were recovered on July 2 and 3, 2010, with the assistance of a remotely operated vehicle with underwater camera. The aircraft was substantially damaged on impact with the surface of the water. The pilot and passenger were seriously injured and drowned. No emergency locator transmitter (ELT) signal was detected by the search and rescue system.

Lake Buccaneer
Lake Buccaneer

 

Analysis

Two possible scenarios resulting in the collision with water were considered: a missed precautionary or emergency landing due to aircraft operation difficulties and glassy water conditions, or a loss of control of the aircraft due to pilot or passenger impairment. Risk factors that may have increased the likelihood of sudden impairment were considered for both the pilot and the passenger; both were at risk of a sudden medical event.

The first possible scenario is that the aircraft had some system malfunction that was not determined during the post-accident examination. However, this scenario would not explain why the pilot, with much experience landing on water, and with ample space on Lac Berté to make a precautionary landing, was not able to land the aircraft safely on the water. The pilot's experience and skill level should have been sufficient to handle such an event.

The second scenario is a sudden medical event resulting in pilot or passenger impairment while in flight over Lac Berté. Both the pilot and the passenger had pre-existing health risk factors, making it possible that either one of them may have experienced a medical event resulting in some degree of impairment, possibly leading to distraction and/or a loss of control of the aircraft. The investigation could not determine if either the pilot or the passenger experienced an incapacitating medical event, and there was insufficient factual information to conclusively state why the aircraft descended and impacted the water.

Findings as to causes and contributing factors

  1. It could not be determined why the aircraft descended and struck the surface of the water.

  2. The pilot and passenger seats failed when the aircraft floor was torn open on impact. The lack of effective occupant restraint during the impact sequence likely contributed to the severity of their injuries, rendering them unconscious and unable to survive the post-crash water environment.

 

Findings as to risk

  1. Once an ELT is submerged, a signal cannot be transmitted through water, delaying initiation of rescue efforts.

  2. Not wearing shoulder harnesses increases the risk of serious injury to the head and upper torso in the event of an accident, which in turn may prevent a safe exit from the aircraft.

TSB Final Report A10W0171—Stall on Approach/Loss of Control

On October 25, 2010, a Beech 100 was on an IFR flight from Edmonton City Centre Airport to Kirby Lake, Alta. At approximately 11:14 MDT, during the approach to Runway 08 at Kirby Lake Airport, the aircraft struck the ground, 174 ft short of the threshold. The aircraft bounced and came to rest off the edge of the runway. There were two flight crew members and eight passengers on board. The captain sustained fatal injuries. Four occupants, including the co-pilot, sustained serious injuries. The five remaining passengers sustained minor injuries. The aircraft was substantially damaged. A small, post impact electrical fire in the cockpit was extinguished by survivors and first responders. The emergency locator transmitter (ELT) was activated on impact.

the aircraft struck the ground

Analysis

The analysis focuses on crew performance inside the cockpit, while engaged in non-operational conversation, and outside of the cockpit, in particular with regard to both pilots' attention being on obtaining visual reference to the runway at the expense of monitoring the aircraft.

During the initial stages of the approach to Kirby Lake, the crew was engaged in a conversation that did not directly pertain to the operation of the flight. The casual nature of the conversation between the pilot flying (PF) and pilot not flying (PNF) suggests that they were not overly concerned with the approach and may not have been at a heightened level of attention. While a majority of the standard operating procedure (SOP) and checklist items were completed during the approach, a number of critical items, such as descending below the minimum sector altitude while diverting to the XIKIB waypoint and failing to announce/confirm arrival at the minimum descent altitude (MDA), were indicative of lapses in cockpit discipline.

Beyond the distraction within the cockpit, the crew was faced with the additional task of identifying the runway. Although the company SOP did not specify when the PNF should look outside, the automated weather observation system at Kirby Lake indicated that the visibility was 4 SM in light snow. This likely prompted the PNF to look outside of the cockpit at a GPS distance of 4 NM and to identify the runway. This declaration prompted the PF to look up from monitoring the flight instruments in an attempt to identify the runway. For the remainder of the flight, both crew members were focused outside the cockpit. With neither pilot monitoring the airspeed and altitude, the aircraft continued to descend. From the initial identification of the runway, the airspeed decreased to a point that it entered an aerodynamic stall. The aircraft was, however, too low to effect a recovery, despite attempts by the crew to do so.

The loss of control of the aircraft was likely the result of a stall or near stall condition. The ground speed determined by the propeller marks and the high engine power setting during the attempted recovery indicate that the aircraft was in a low energy state. The aircraft's close proximity to the ground prevented a full recovery from the loss of control.

Pilots are often expected to perform a number of concurrent activities. In this case, this involved flying and monitoring the aircraft as well as visually acquiring the runway. During these multi-tasking situations, the crew may prioritize activities based on their perceived level of importance. In this case, the act of visually finding the runway was categorized as being of primary importance. As such, the crew's cognitive efforts were directed to this activity at the expense of monitoring the aircraft's flight profile.

The aircraft was equipped with a stall warning system, which did not activate prior to the aircraft entering a low energy state. The aircraft's wing de-icing system appeared to be functional throughout the approach, and the post impact inspection of the aircraft did not indicate an accumulation of ice on the critical flight surfaces. The investigation was unable to determine why the stall warning system did not activate.

Findings as to causes and contributing factors

  1. The conduct of the flight crew members during the instrument approach prevented them from effectively monitoring the performance of the aircraft.

  2. During the descent below the minimum descent altitude, the airspeed reduced to a point where the aircraft experienced an aerodynamic stall and loss of control. There was insufficient altitude to effect recovery prior to ground impact.

  3. For unknown reasons, the stall warning horn did not activate; the horn could have provided the crew with an opportunity to avoid the impending stall.

Findings as to risk

  1. The use of company standard weights and a non-current aircraft weight and balance report resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.

  2. Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.

  3. Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.

  4. Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance parameters of an instrument approach.

 

Safety action taken

The operator has taken the following safety actions:

  • Amended the weight and balance calculation procedure to require flight crews to confirm the correct aircraft configuration and passenger weights.

  • Implemented a company line check program that includes Canadian Aviation Regulations 703 and 704 operations to ensure adherence to SOP, including sterile cockpit procedures.

  • Developed and implemented a procedures review exam for flight crew, emphasizing SOP and company procedures for stabilized approaches, sterile cockpit, and crew roles and duties during non-precision approaches at remote airports with limited services.

  • Amended company SOP and placarded aircraft equipped with a Garmin 155XL regarding conducting GPS approaches. These approaches will be flown from the left seat only.

TSB Final Report A11O0098—Runway Excursion

On June 17, 2011, a Dassault Falcon 10 was on a flight from Toronto/Lester B. Pearson International Airport to Toronto/Buttonville Municipal Airport, Ont., with two pilots on board. Air traffic control (ATC) cleared the aircraft for a contact approach to Runway 33. During the left turn on to final, the aircraft overshot the runway centreline. The pilot then compensated with a tight turn to the right to line up with the runway heading and touched down just beyond the threshold markings. Immediately after touchdown, the aircraft exited the runway to the right, and continued through the infield and the adjacent Taxiway Bravo, striking a runway/taxiway identification sign, but avoiding aircraft that were parked on the apron. The aircraft came to a stop on the infield before Runway 21/03. The aircraft remained upright, and the landing gear did not collapse. The aircraft was substantially damaged. There was no fire, and the flight crew was not injured. The Toronto/Buttonville tower controller observed the event as it progressed and immediately called for emergency vehicles from the nearby municipality. The accident occurred at 15:06 EDT.

 Dassault Falcon 10

Analysis

The investigation determined that the aircraft was serviceable and that there were no maintenance defects that affected the aircraft during the flight. Also, crew fatigue and weather conditions did not contribute to this occurrence. Therefore, the investigation focused on the manner in which the aircraft was flown prior to touchdown on Runway 33, and the procedures followed by the crew in this occurrence.
Considering the entire flight was approximately 6 min in duration and below 4 000 ft ASL, there was no need to fly at the speeds attained during the flight. Although radar indications provided ground speed values, it was determined that, even after the conversions to indicated airspeed values, the aircraft was flown in excess of the current regulations and the operator’s standard operating procedure (SOP).

The excessive speed and the fact that the crew did not routinely fly this route or other short routes reduced the amount of time available to perform all the tasks dictated by the company SOP, the required checklist items and the approach briefing. This resulted in the crew flying an unstabilized approach.
ATC requested that the flight crew keep the circuit tight. Because of its excessive speed, however, the aircraft overshot the final approach track. The radar display indicated that the aircraft transitioned through the final approach course at approximately 140 kt. Consequently, a left turn was performed exceeding 30° of bank, well above the SOP limit and outside the Flight Safety Foundation (FSF) criteria for a stabilized approach. The distance to the runway threshold continued to reduce quickly, and manoeuvres to regain runway heading became more aggressive and non-standard.

The first officer (FO) called for a missed approach using non-standard wording. The ground proximity warning system (GPWS) aural alert sounded twice. Either of these should have prompted the captain to perform a missed approach. The non-standard wording and the tone used by the FO were insufficient to deter the captain from continuing the approach. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to conduct a missed approach.

Full flaps were called for by the captain on final approach and subsequently selected by the FO. The flaps reached full extension approximately 13 s afterwards, when the aircraft was about 40 ft above the runway.

Just prior to touchdown, the FO called for engine power, likely to arrest the high rate of descent. The captain did not increase engine power, and the aircraft touched down hard. Attempts at rudder steering and braking were ineffective in reducing speed and providing directional control, as tire traction would have been greatly reduced on the grass surface.

As the aircraft exited the infield and entered the paved Taxiway Bravo, the brakes regained effectiveness. However, directional control was not fully regained, and the aircraft struck the runway/taxiway identification sign before exiting Taxiway Bravo onto the grass infield.

Runway excursion diagram
Runway excursion diagram

Findings as to causes and contributing factors

  1. The crew flew an unstabilized approach with excessive airspeed.

  2. The lack of adherence to company SOP and crew resource management, as well as the non-completion of checklist items by the flight crew contributed to the occurrence.

  3. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to follow the aural GPWS alerts and the missed approach call from the FO.

  4. The non-standard wording and the tone used by the FO were insufficient to deter the captain from continuing the approach.

  5. At touchdown, directional control was lost, and the aircraft veered off the runway with sufficient speed to prevent any attempts to regain control.

Finding as to risk

  1. Companies which do not have GPWS procedures in their SOP may place crews and passengers at risk in the event that a warning is received.

Additional info 
The TSB provided as an annex to the report the following FSF recommended elements of a stabilized approach:

All flights must be stabilized by 1 000 ft above airport elevation in instrument meteorological conditions (IMC) and by 500 ft above airport elevation in visual meteorological conditions (VMC).

An approach is stabilized when all of the following criteria are met:

  1. The aircraft is on the correct flight path;
  2. Only small changes in heading/pitch are required to maintain the correct flight path;
  3. The aircraft speed is not more than reference landing approach speed (Vref) + 20 kt indicated airspeed and not less than Vref;
  4. The aircraft is in the correct landing configuration;
  5. Sink rate is no greater than 1 000 ft/min; if an approach requires a sink rate greater than 1 000 ft/min, a special briefing should be conducted;
  6. Power setting is appropriate for the aircraft configuration and is not below the minimum power for approach as defined by the aircraft operating manual;
  7. All briefings and checklists have been conducted;
  8. Specific types of approaches are stabilized if they also fulfill the following: instrument landing system (ILS) approaches must be flown within one dot of the glide slope and localizer; a Category II or Category III ILS approach must be flown within the expanded localizer band; during a circling approach, wings should be level on final when the aircraft reaches 300 ft above airport elevation; and
  9. Unique approach procedures or abnormal conditions requiring a deviation from the above elements of a stabilized approach require a special briefing. An approach that becomes unstabilized below 1 000 ft above airport elevation in IMC, or below 500 ft above airport elevation in VMC requires an immediate go-around.

Unstabilized approaches are attributed to:

  • Fatigue;
  • Pressure of flight schedule (making up for delays);
  • Any crew-induced or ATC-induced circumstances resulting in insufficient time to plan, prepare and conduct a safe approach. This includes accepting requests from ATC to fly higher/faster or to fly shorter routings than desired;
  • ATC instructions that result in flying too high/too fast during the initial approach;
  • Excessive altitude or excessive airspeed (e.g., inadequate energy management) early in the approach;
  • Late runway change (lack of ATC awareness of the time required by the flight crew to reconfigure the aircraft for a new approach);
  • Excessive head-down work (e.g., flight management system [FMS] reprogramming);
  • Short outbound leg or short downwind leg (e.g., because of traffic in the area);
  • Late takeover from automation (e.g., because the auto pilot [AP] fails to capture the glide slope);
  • Premature descent or late descent caused by failure to positively identify the final approach fix (FAF);
  • Inadequate awareness of wind conditions, including:
    • Tail-wind component;
    • Low-altitude wind shear;
    • Local wind gradient and turbulence (because of terrain or buildings).
  • Recent weather along the final approach path (e.g., wind shift or downdrafts caused by a descending cold air mass following a rain shower);
  • Incorrect anticipation of aircraft deceleration characteristics in level flight or on a 3° glide path;
  • Failure to recognize deviations or failure to adhere to the excessive-parameter-deviation limits;
  • Belief that the aircraft will be stabilized at the minimum stabilization height or shortly thereafter;
  • Excessive confidence by the pilot not flying (PNF) that the pilot flying (PF) will achieve a timely stabilization;
  • PF-PNF too reliant on each other to call excessive deviations or to call for a go-around; and
  • Visual illusions.

TSB Final Report A11W0151—Controlled Flight Into Terrain

On October 4, 2011, a Cessna 208B Caravan departed Yellowknife, N.W.T. at 11:03 MDT under VFR as a regularly scheduled flight to Lutsel K’e, N.W.T. When the aircraft did not arrive at its scheduled time, a search was initiated, and the aircraft was found 26 NM west of Lutsel K’e, near the crest of Pehtei Peninsula. The pilot and one passenger were fatally injured, and two passengers were seriously injured. There was no post-impact fire, and no emergency locator transmitter (ELT) signal was received by the Joint Rescue Coordination Centre or search aircraft.

Cessna 208B

Analysis

When the aircraft departed for Lutsel K'e, the weather at Yellowknife was marginal for VFR flight. Low cloud persisted for the entire flight, which was flown at low level so the pilot could maintain visual contact with the ground. The descent during the last 2 min of the flight suggests that the ceiling had become lower.

The conduct of the flight and the nature of the impact were characteristic of a controlled flight into terrain (CFIT) event. The aircraft struck rising terrain under the pilot's control at cruise speed with a wings-level attitude and a heading generally consistent with the direct track to the destination. Because no effective evasive manoeuvres were made before impact, it is likely that the crest of the Pehtei Peninsula was obscured in fog and not visible to the pilot. The application of increased engine power immediately before impact was likely made when the terrain in front of the aircraft suddenly became visible.

When the pilot transmitted a position report 6 NM closer to Lutsel K'e than the actual position, it is possible that he believed that the shoreline of Great Slave Lake had been crossed and that open water at about 500 ft ASL lay ahead. Since the global positioning system (GPS) was likely the primary navigational aide, there should have been little ambiguity in position, unless the unit was set to a waypoint associated with the area navigation (RNAV) approach at Lutsel K'e. However, the location of the site and the wreckage trail track indicate that the aircraft was proceeding directly to the airport. If an instrument approach had been planned, the aircraft should have been navigating toward a waypoint associated with the approach at an altitude no lower than 3 100 ft, in accordance with the company-published route.

A terrain awareness warning system (TAWS) installation in the aircraft could have warned of the impending collision with the ground, possibly in sufficient time to prevent the accident.

Route and accident site
Route and accident site

VFR flight in marginal weather

It could not be determined why the pilot chose to fly the trip under VFR. Conditions were suitable to enable operation under IFR at altitudes providing safe terrain clearance. The pilot, the aircraft and the company were qualified to operate the trip under IFR. The en route weather was suitable. With the freezing level well above the minimum IFR route altitude, icing was not a factor to preclude IFR flight. The cloud base was above the minimums required for successful completion of an approach and landing at Lutsel K'e. Before departure, the forecast weather was such that Yellowknife could be filed as an IFR alternate.

The fuel load was not considered to be a factor in the pilot's decision to fly the trip under VFR rather than IFR. Fuel was readily available at Yellowknife, and there was adequate time between the arrival from Fort Simpson and the departure for Lutsel K'e to bring the fuel quantity to IFR requirements under the supervision of dispatch personnel.

Although the pilot had gained experience in an IFR environment during his flying as a co-pilot in multi-engine aircraft, he had limited experience in single-pilot IFR operations. This may have led to reluctance to file an IFR flight plan on the accident flight, and the decision to remain visual in marginal VFR weather conditions. The route lay mostly in uncontrolled airspace. When flight visibility deteriorated, the pilot had the option of climbing without ATC clearance to a safe altitude and conducting an instrument approach at Lutsel K'e. The pilot was apparently willing to fly in cloud as indicated by the earlier flight from Fort Simpson to Yellowknife, albeit on a VFR flight plan in controlled airspace.

Pilot decision-making and THC effects

On the day of the accident, aspects of the pilot's planning, flying technique and decision-making were inconsistent with regulatory and administrative requirements, the company operations manual policy and safe flying practices. These included VFR flight in marginal visual weather conditions, flight in instrument meteorological conditions (IMC) on a VFR flight plan and overwater flight beyond gliding distance of land. The quantity of psychoactive components in the pilot's system is considered to have been sufficient to have resulted in impairment of cognitive processes. This would likely have had an effect on the planning and conduct of the accident flight. It is possible that the pilot, under the influence of cannabis, avoided the higher workload of IFR flight in IMC, choosing to remain visual for the trip to Lutsel K'e. Random testing of employees in safety-sensitive positions may mitigate this risk.

Overwater flight risk

The company did not provide personal floatation devices in the land-plane fleet, and management expected single-engine aircraft to remain within gliding distance of land at all times. The pilot was familiar with the route. Given the low cloud en route and the current weather at Lutsel K'e, it is likely that a diversion to the south to remain within gliding distance of land would have to be made well before arriving at the shoreline near the accident location. The direct flight track flown toward Lutsel K'e suggests that, after crossing the Pehtei Peninsula, the pilot was prepared to overfly 11 NM of open water at low level, increasing the risk to the aircraft and its occupants. Overflight of Great Slave Lake on the earlier flight from Fort Simpson to Yellowknife indicated a willingness on the part of the pilot to accept that risk.

ELT

Due to a loosely fastened hook and loop retention strap on the ELT installation, the ELT was ejected from its mounting tray during impact. Since instructions do not describe a method for determining the required degree of tightness to retain the ELT in its mount, the installer's own judgment is relied upon to determine this. As a result, a wide variation in the quality of installation of ELTs that are retained by this method could increase the possibility of inadequate retention. In this accident, in the absence of a transmitted 406 MHz signal, the on-board GPS-based flight-following equipment (SkyTrac) was effective in directing the search party to the accident site and reduced the time for the search and rescue of the survivors.

Impact point on Pehtei Peninsula
Impact point on Pehtei Peninsula
 

Findings as to causes and contributing factors

  • The aircraft was flown at low altitude into an area of low forward visibility during a day VFR flight, which prevented the pilot from seeing and avoiding terrain.

  • The concentrations of cannabinoids were sufficient to have caused impairment in pilot performance and decision-making on the accident flight.

 

Findings as to risk

  • Installation instructions for the ELT did not provide a means of determining the degree of strap tightness necessary to prevent the ELT from being ejected from its mount during an accident. Resultant damages to the ELT and antenna connections could preclude transmission of an effective signal, affecting search and rescue of the aircraft and occupants.

  • Flying beyond gliding distance of land without personal floatation devices on board exposes the occupants to hypothermia and/or drowning in the event of a ditching.

Safety action taken

Transportation Safety Board of Canada (TSB)
On April 19, 2012, the TSB promulgated Safety Advisory 825-A11W0151-D1-A1, Loose Attachment of Kannad 406 AF-Compact (ER) ELT, suggesting that Transport Canada may wish to inform owners, operators and maintainers of aircraft with ELTs featuring fabric hook and loop retention systems of the necessity to ensure adequate retention of the ELT in the event of an accident.

Also on April 19, 2012, TSB Safety Advisory 825-A11W0151-D1-A2 was sent to ELT manufacturers utilizing fabric loop and hook retention systems, advising that they may wish to develop and publish methods of determining the degree of strap tightness and inform maintenance personnel of the necessity of proper installation.

U.S. Federal Aviation Administration (FAA)
On May 23, 2012, the FAA issued Special Airworthiness Information Bulletin HQ-12-32, addressed to ELT manufacturers, installers and aircraft maintenance personnel. The bulletin expressed concerns with the ability of hook and loop style fasteners to retain their designed capability to restrain ELTs during accident impact and with the quality of installation instructions to ensure adequate tightness of the fasteners.

Operator
On October 7, 2011, the operator issued a company directive which initiated the following policies for scheduled services operations:

Dispatch limitations:

  • All scheduled flights will be dispatched under IFR. VFR flight may only be conducted if authorized by operations management personnel.
  • No company aircraft may be operated on any scheduled passenger flight when the observed weather is at, or forecast to be lower than, the alternate minima for the destination airport.

 

The operator instituted changes to the operational control system of scheduled passenger flights to ensure adequate flight following and timely reporting of departure and arrival times to the company system operations control centre (SOCC).

In order to facilitate incident and accident investigations, the operator has commenced installation of Appareo Vision 1000 Systems cockpit imaging and flight data monitoring devices in the Cessna 208B fleet.

In order to improve operational oversight, the company has consolidated most management personnel at the airport base.

The company has revised the existing drug and alcohol policy to include random testing of employees in safety-sensitive positions. These positions include pilots, maintenance engineers and dispatch personnel.

Kannad Aviation
Kannad Aviation (Orolia Group) has developed a new type of ELT called Integra, which has received European Aviation Safety Agency (EASA), FAA and Transport/Industry Canada certification. The ELT is equipped with an internal integral antenna. When circuits detect a low standing wave ratio due to a lost connection with the external antenna, as in this occurrence, the ELT automatically switches to the internal antenna. To enhance accuracy in position detection, the Integra ELT is also equipped with an internal GPS antenna and receiver.

On June 12, 2012, Kannad Aviation (Orolia Group) issued Service Bulletin S1800000-25-04 that outlines the instructions for properly securing the ELT during installation and reinstallation and the instructions for inspecting fasteners of mounting brackets. It also defines the replacement interval for the mounting bracket fasteners.

On February 11, 2013, Kannad Aviation issued Service Bulletin SB1840501-25-25-05 Rev01, entitled “Kannad 406 AF-Compact, Kannad 406 AF-Compact (ER) Integra ELTs Family - Guidelines for Periodic Inspection”. On February 19, 2013, Kannad Aviation issued Safety Letter SL18XX502-25-12 Rev02, entitled “Kannad 406 ELTs – Guidelines for Periodic Inspection”. These documents describe usual operations for periodic checks required by major aviation authorities.

Transport Canada
An article highlighting the importance of following the manufacturer's installation and retention requirements for ELT installations featuring hook and loop retention systems is included in the “Maintenance and Certification” section of this issue of the Aviation Safety Letter.

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