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Crash of a Beechcraft 100 King Air in Kirby Lake: 1 killed

Date & Time: Oct 25, 2010 at 1120 LT
Type of aircraft:
Operator:
Registration:
C-FAFD
Survivors:
Yes
Schedule:
Calgary - Edmonton - Kirby Lake
MSN:
B-42
YOM:
1970
Flight number:
KBA103
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was on an instrument flight rules flight from the Edmonton City Centre Airport to Kirby Lake, Alberta. At approximately 1114 Mountain Daylight Time, during the approach to Runway 08 at the Kirby Lake Airport, the aircraft struck the ground, 174 feet short of the threshold. The aircraft bounced and came to rest off the edge of the runway. There were 2 flight crew members and 8 passengers on board. The captain sustained fatal injuries. Four occupants, including the co-pilot, sustained serious injuries. The 5 remaining passengers received 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 was activated on impact. All passengers were BP employees.
Probable cause:
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; this may 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.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage near Wainwright: 5 killed

Date & Time: Mar 28, 2008 at 0811 LT
Operator:
Registration:
C-FKKH
Flight Phase:
Survivors:
No
Schedule:
Edmonton – Winnipeg
MSN:
46-22092
YOM:
1989
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The privately operated Piper PA-46-350P Jetprop DLX (registration C-FKKH, serial number 4622092) had departed from Edmonton, Alberta, at about 0733 mountain daylight time en route to Winnipeg, Manitoba, on an instrument flight rules flight plan. Shortly after the aircraft levelled off at its cleared altitude of flight level (FL) 270, the aircraft was observed on radar climbing through FL 274. When contacted by the controller, the pilot reported autopilot and gyro/horizon problems and difficulty maintaining altitude. Subsequently, he transmitted that his gyro/horizon had toppled and could no longer be relied upon for controlling the aircraft. The aircraft was observed on radar to make several heading and altitude changes, before commencing a right turn and a steep descent, after which the radar target was lost. An emergency locator transmitter signal was received by the Lloydminster, Alberta, Flight Service Station for about 1 ½ minutes before it stopped. The wreckage was found by the Royal Canadian Mounted Police about 16 nautical miles northeast of Wainwright at about 1205. None of the five people on board survived.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The gyro/horizon failed due to excessive wear on bearings and other components, resulting from a lack of maintenance and due to a vacuum system that was possibly not at minimum operating requirements for the instrument.
2. The gyro/horizon was reinstalled into the aircraft to complete the occurrence flight without the benefit of the recommended overhaul.
3. The autopilot became unusable when the attitude information from the gyro/horizon was disrupted.
4. The pilot had not practised partial panel instrument flying for a number of years, was not able to transition to a partial panel situation, and lost control of the aircraft while flying in instrument meteorological conditions.
5. The aircraft was loaded in excess of its certified gross weight and had a centre of gravity (C of G) that exceeded its aft limit. These two factors made the aircraft more difficult to handle due to an increase of the aircraft’s pitch control sensitivity and a reduction of longitudinal stability.
6. The structural limitations of the aircraft were exceeded during the uncontrolled descent; this resulted in the in-flight breakup.
7. There were a number of deficiencies with the company’s safety management system (SMS), in which the hazards should have been identified and the associated risks mitigated.
8. The company did not conduct an annual risk assessment as required by its SMS; this increased the risk that a hazard could go undetected.
9. The Canadian Business Aviation Association (CBAA) audit did not identify the risks in the company’s operations.
Findings as to Risk:
1. Lack of adequate instrument redundancy increases the risk of loss of control in single-pilot instrument flight rules (IFR) aircraft operations.
2. The pilot did not reduce his airspeed while attempting to maintain control of the aircraft; a lower speed would have allowed a greater margin to maximum operating speed (Vmo) while manoeuvring.
3. There were no quick-donning oxygen masks on board and the pilot was not wearing an oxygen mask at the time of the occurrence, as required by regulation.
4. If effective oversight of private operator certificate (POC) holders is not exercised by the regulator or its delegated organization, there is an increased risk that safety deficiencies will not be identified and properly addressed.
Other Finding:
1. The approved maintenance organization (AMO) that was maintaining the aircraft did not have the approval to maintain PA-46 turbine aircraft.
Final Report:

Crash of a Cessna T207A Turbo Stationair 7 II in Pemberton: 1 killed

Date & Time: May 18, 2006 at 1506 LT
Operator:
Registration:
C-GGQR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Pemberton – Edmonton
MSN:
207-0499
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1500
Circumstances:
The aircraft departed from Pemberton Airport, British Columbia, at about 1500 Pacific daylight time on a visual flight rules flight to Edmonton, Alberta. The aircraft initially climbed out to the east and subsequently turned northeast to follow a mountain pass route. The pilot was alone on this aircraft repositioning flight. The pilot had been conducting air quality surveys for Environment Canada’s Air Quality Research Section in the Pemberton area. The aircraft was operating on a flight permit and was highly modified to accept various types of probes in equipment pods suspended under the wings, a camera hatch type provision in the centre belly area, and carried internal electronic equipment. About 30 minutes after the aircraft took off, the Coastal Fire Service responded to a spot fire and discovered the aircraft wreckage in the fire zone. A post-crash fire consumed most of the airframe, and the pilot was fatally injured. The accident occurred at about 1506 Pacific daylight time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot entered the valley at an altitude above ground that did not provide sufficient terrain clearance given the aircraft’s performance.
2. The pilot encountered steeply rising terrain, where false horizon and relative scale illusions in the climb are likely. Realizing that the aircraft would not likely be able to out-climb the approaching terrain, he turned to reverse his course.
3. The aircraft’s configuration, relatively high weight, combined with the effects of increased drag from the equipment, density altitude, down-flowing winds, and manoeuvring resulted in the aircraft colliding with terrain during the turn.
Findings as to Risk:
1. A detailed flight plan was not filed and special equipment, such as laser radiation emitting devices and/or hazardous substances were not reported. The absence of flight plan information regarding these devices could delay search and rescue efforts and expose first responders to unknown risks.
2. Transport Canada (TC) does not issue a rating/endorsement for mountain flying training. There are no standards established to ascertain the proficiency of a pilot in this environment. Pilots who complete a mountain flying course may not acquire the required skill sets.
3. There was no emergency locator transmitter (ELT) signal received. The ELT was destroyed in the impact and subsequent fire. Present standards do not require that ELTs resist crash damage.
4. “Flight permits – specific purpose” are issued for aircraft that do not perform as per the original type design but are deemed capable of safe flight. Placards are not required; therefore, pilots and observers approved to board may be unaware of the limitations of the aircraft and the associated risks.
5. The TC approval process allowed the continued operation of this modified aircraft for sustained environmental research missions under a flight permit authority. This circumvented the requirement to meet the latest airworthiness standards and removed the risk mitigation built into the approval process for a modification to a type design.
Other Findings:
1. The fuel system obstruction found during disassembly was a result of the post-crash fire.
2. The aircraft was operated at an increased weight allowance proposed by the design approval representative (DAR). Such operation was to be approved only in accordance with a suitably worded flight permit and instructions contained in the proposed document CN-MSC-011; however, this increased weight allowance was not incorporated to any flight authority issued by TC.
Final Report:

Crash of a Boeing 737-210C in Yellowknife

Date & Time: May 22, 2001 at 1325 LT
Type of aircraft:
Operator:
Registration:
C-GNWI
Survivors:
Yes
Schedule:
Edmonton – Yellowknife
MSN:
21066
YOM:
1975
Flight number:
7F953
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
98
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16400
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
9500
Copilot / Total hours on type:
840
Circumstances:
First Air Flight 953, a Boeing 737-210C, serial number 21066, was on a scheduled flight from Edmonton, Alberta, to Yellowknife, Northwest Territories. On board were 2 flight crew, 4 cabin crew, and 98 passengers. The flight departed Edmonton at 1130 mountain daylight time, with an estimated time en route of 1 hour 35 minutes. As the aircraft approached Yellowknife, the spoilers were armed, and the aircraft was configured for a visual approach and landing on Runway 33. The computed Vref was 128 knots, and target speed was 133 knots. While in the landing flare, the aircraft entered a higher-than-normal sink rate, and the pilot flying (the first officer) corrected with engine power and nose-up pitch. The aircraft touched down on the main landing gear and bounced twice. While the aircraft was in the air, the captain took control and lowered the nose to minimize the bounce. The aircraft landed on its nose landing-gear, then on the main gear. The aircraft initially touched down about 1300 feet from the approach end of Runway 33. Numerous aircraft rubber scrub marks were present in this area and did not allow for an accurate measurement. During the third touchdown on the nose landing-gear, the left nose-tire burst, leaving a shimmy-like mark on the runway. The aircraft was taxied to the ramp and shut down. The aircraft was substantially damaged. There were no reported injuries to the crew or the passengers. The accident occurred at 1325, during the hours of daylight.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Incorrect bounced landing recovery procedures were carried out when the captain pushed forward on the control column to prevent a further bounce, and the aircraft landed nosewheel first.
2. The high sink rate on the initial flare was not recognized and corrected in time to prevent a bounced landing and a subsequent bounced landing.
Other Findings:
1. The power increase during the flair resulted in the speedbrake/spoilers retracting.
2. The captain had not received a line check of at least three sectors before returning to flight duties, although this check was required to regain competency after pilot proficiency check expiry.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Stony Rapids

Date & Time: Feb 27, 2000 at 2200 LT
Operator:
Registration:
C-FATS
Survivors:
Yes
Schedule:
Edmonton - Stony Rapids
MSN:
31-7952072
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7850
Captain / Total hours on type:
1450.00
Circumstances:
The Piper Navajo Chieftain PA-31-350, serial number 31-7952072, departed Edmonton, Alberta, on an instrument flight rules charter flight to Stony Rapids, Saskatchewan, with one pilot and six passengers on board. The pilot conducted a non-directional beacon approach at night in Stony Rapids, followed by a missed approach. He then attempted and missed a second approach. At about 2200 central standard time, while manoeuvring to land on runway 06, the aircraft struck trees 3.5 nautical miles west of the runway 06 button and roughly one quarter nautical mile left of the runway centreline, at an altitude of 1200 feet above sea level. The aircraft sustained substantial damage, but no fire ensued. The pilot and one passenger were seriously injured, and the remaining five passengers sustained minor injuries. Canadian Forces search and rescue specialists were air-dropped to the site at 0300 and provided assistance to the pilot and passengers. Local ground search parties later assisted with the rescue.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot executed a missed approach on his first NDB approach, and, during the second missed approach, after momentarily seeing the runway, he decided to conduct a visual approach, descending below MDA in an attempt to fly under the cloud base.
2. In flying under the cloud base during the visual portion of his approach, the pilot likely perceived the horizon to be lower on the windscreen than it actually was.
3. There was no indication that there was any form of pressure from management to influence the pilot to land at the destination airport. However, the pilot may have chosen to land in Stony Rapids because he had an early flight the following day, and he did not have the keys for the accommodations in Fond-du-Lac.
Findings as to Risk:
1. No scale was available to the pilot in Edmonton for weighing aircraft loads.
2. The maximum allowable take-off weight of the aircraft was exceeded by about 115 pounds, and it is estimated that at the time of the crash, the aircraft was 225 pounds below maximum landing weight. The aircraft's centre of gravity was not within limits at the time of the crash.
3. The rear baggage area contained 300 pounds of baggage, 100 pounds more than the manufacturer's limitation.
4. Two screws were missing from each section of the broken seat track to which the anchor points were attached.
5. Cargo net anchorage system failure contributed to passenger injuries.
6. The stitching failed on the seat belt's outboard strap that was mounted on the right, middle, forward-facing cabin seat.
Other Findings:
1. Hand tools were required to access the ELT panel, since the cockpit remote switch could not be accessed.
Final Report:

Crash of an IAI-1124A Westwind in Meadow Lake: 2 killed

Date & Time: Jan 27, 1994 at 0855 LT
Type of aircraft:
Operator:
Registration:
C-FMWW
Flight Type:
Survivors:
No
Schedule:
Edmonton - Meadow Lake
MSN:
380
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
15600
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
3200
Copilot / Total hours on type:
1500
Aircraft flight hours:
4810
Circumstances:
The privately owned Israel Aircraft Industries (IAI) Westwind II aircraft was en route from the Edmonton Municipal Airport, Alberta, to the Meadow Lake aerodrome, Saskatchewan. Low ceilings and reduced visibility were reported in the vicinity of the destination aerodrome. The crew completed a straight-in instrument approach to runway 08 at Meadow Lake, and began a circling procedure to the south of the aerodrome in order to set up to land on runway 26. The aircraft passed overhead the aerodrome at an altitude of approximately 400 feet above ground level (agl). It then turned and proceeded in level flight towards the southeast. Approximately two and one-half miles from the aerodrome, the aircraft entered a number of steep-banked rolling manoeuvres. Immediately following these manoeuvres, the aircraft descended and struck the ground in a nose-high, slightly right-wing-low attitude. The ground-strike produced very high deceleration forces. The aircraft broke into several sections, internal fuel tanks ruptured, and fuel was sprayed forward and outward from the initial impact point. A severe post-crash fire erupted and engulfed the entire wreckage trail. Emergency medical service and firefighting crews responded from the town of Meadow Lake and were on the scene within minutes of the accident. Both pilots died in the crash.
Probable cause:
While circling to land on runway 26, the aircraft performed a non-typical circling procedure at a lower than published circling altitude, leading to loss of control consistent with an accelerated stall, and descended into terrain before recovery could be completed. Whiteout conditions may have contributed to this occurrence.
Final Report:

Crash of a Lockheed C-130 Hercules near Alert: 5 killed

Date & Time: Oct 30, 1991 at 1640 LT
Type of aircraft:
Operator:
Registration:
130322
Flight Type:
Survivors:
Yes
Schedule:
Edmonton - Thule - Alert
MSN:
4192
YOM:
1967
Flight number:
Boxtop22
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Every year, in the cold and darkness of late October, personnel at Canadian Forces Station Alert on Ellesmere Island, Nunavut, gather at a cairn near the runway to remember the crew and passengers of Hercules 130322 who lost their lives during a resupply mission to the station. On October 30, 1991, at approximately 4:40 p.m., flight 22 of Operation Boxtop – as the biannual resupply mission is called – was on its final approach to the station from Thule Air Force Base in Greenland. As the CC-130 Hercules from 435 Transport and Rescue Squadron, loaded with 3,400 litres of diesel fuel, began its descent, the pilot flying lost sight of the runway. Moments later, radar contact and communication were lost as the aircraft crashed approximately 16 km south of the station. The crew of another CC-130 Hercules, also bound for Alert, saw the fires of the crash and identified the location of Boxtop 22. The crash took the lives of five Canadian Armed Forces members – four died in the crash and one perished before help arrived – and led to the boldest and most massive air disaster rescue mission ever undertaken by the Canadian military in the High Arctic. Thirteen lives were saved. Within a half hour of the rescue call, a Hercules carrying 12 search and rescue technicians from 440 Search and Rescue Squadron in Edmonton, Alberta, was in the air. It reached the crash site seven and a half hours later, but the SAR technicians couldn’t descend due to the weather. Another Hercules from 413 Search and Rescue Squadron in Greenwood, Nova Scotia, soon joined the search. Meanwhile, search and rescue technicians formed a ground rescue team at Alert and set out overland for the crash site, guided through the darkness and horrendous weather conditions by a Hercules. The survivors, some soaked in diesel fuel, endured high winds and temperatures between -20C and -30C. Many sheltered in the tail section of the downed aircraft but others were more exposed to the elements. Finally, the 413 Squadron team finally got a break in the weather and six SAR technicians parachuted into the site more than 32 hours after the crash and began looking for survivors. They were joined soon after by more SAR technicians. When the ground rescue team finally arrived – 21 hours after it had set out – 26 rescuers were on the ground. They warmed and treated the injured and prepared them for medical evacuation. A Twin Huey helicopter from Alert made three trips to bring the survivors back to the station. Once again this year, personnel at Alert will conduct a parade on October 30 to commemorate the crash. The parade will begin at 4:30 p.m. and continue through the 4:40 p.m. timing when the crash occurred.
Those killed were:
Cpt John Couch, pilot,
Cpt Judy Trépanier, logistics officer,
M/WO Tom Jardine, regional services manager CANEX,
W/O Robert Grimsley, supply technician,
M/Cpl Roland Pitre, traffic technician.
Those who survived were:
Robert Thomson,
Susan Hillier,
Cpt Richard Dumoulin, logistics officer,
Cpt Wilma DeGroot, doctor,
Lt Joe Bales, pilot,
Lt Mike Moore, navigator,
M/WO Marc Tremblay, supply technician,
Sgt Paul West, flight engineer,
M/Cpl Tony Cobden, communications researcher,
M/Cpl David Meace, radio technician,
M/Cpl Mario Ellefsen, communications researcher,
M/S “Monty” Montgomery, communications researcher,
Pvt Bill Vance, communications researcher.
Source:
http://www.rcaf-arc.forces.gc.ca/en/article-template-standard.page?doc=remembering-the-crash-of-boxtop-flight-22/ig9v1k0t
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near High Prairie: 6 killed

Date & Time: Oct 19, 1984
Operator:
Registration:
C-GXUC
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Edmonton - Peace River
MSN:
31-7405136
YOM:
1974
Flight number:
3Y402
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
En route from Edmonton to Peace River, while cruising by night, the crew encountered marginal weather conditions. Due to interferences, the crew was unable to receive the signal from the Whitecourt VOR and thought he already overflew the mountain range located southeast of High Prairie. Too low, the aircraft struck tree tops, stalled and crashed in a wooded area covered by snow and located on Mt Swan, southwest of Lesser Slave Lake. The wreckage was found the following day in an isolated area. A pilot and three passengers were injured while six other occupants were killed, among them the Canadian politician Walter Grant Notley aged 45.

Crash of a Boeing 737-275 in Calgary

Date & Time: Mar 22, 1984 at 0742 LT
Type of aircraft:
Operator:
Registration:
C-GQPW
Flight Phase:
Survivors:
Yes
Schedule:
Calgary - Edmonton
MSN:
22265/755
YOM:
1981
Flight number:
PW501
Location:
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
114
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7447
Circumstances:
Pacific Western Airlines scheduled early morning flight 501 to Edmonton was pushed-back from the gate at 07:35. After engine start the aircraft taxied to runway 34 for departure. Takeoff was begun at 07:42 from the intersection of runway 34 and taxiway C-1. About 20 seconds into the takeoff roll, at an airspeed of approximately 70 knots, the flightcrew heard a loud bang which was accompanied by a slight veer to the left. The captain immediately rejected the takeoff using brakes and reverse thrust. Both the crew members suspected a tire on the left main landing gear had blown. The captain decided to taxi clear of the runway at taxiway C-4. Approaching C-4, the crew a.o. noted that left engine low pressure unit rpm was indicating 0 per cent. Twenty-three seconds after the initiation of the rejected takeoff, the first officer called clear of the runway on tower frequency: "501 clear here on Charlie 4". The purser then entered the flight deck and reported a fire on the left wing. The control tower then confirmed that there was a fire: "Considerable amount off the back - on the left side engine there - and - eh - it's starting to diminish there. Eh - there's a fire going on the left side." One minute and two seconds had passed since the initiation of the rejected takeoff. Immediately after this the purser further stated that "the whole left-hand side, the whole back side of it is burning". The captain discharged a fire bottle into the engine and the first officer requested emergency equipment. At an elapsed time of 1 minute 36 seconds, the cockpit fire warning bell activated. Simultaneously, the purser re-entered the cockpit and reported that it was getting bad at the back. The captain stopped the aircraft the crew then carried out the procedures for an emergency evacuation, which was initiated at an elapsed time of 1 minute 55 seconds. All 119 occupants were evacuated, among them 29 were injured. The aircraft was destroyed.
Probable cause:
The accident was the consequence of the combination of the following factors:
- An uncontained rupture of the left engine thirteenth stage compressor disc occurred approximately 1,300 feet into the take-off roll,
- Failure of the disc was the result of fatigue cracking at three main locations in the rear snap and adjacent to 6 of the 12 tie-bolt holes,
- Fatigue cracking initiated as a result of an unidentified combination of factors which developed progressively over an undefined period of time, following the last major overhaul in May 1981,
- Some stator repair procedures carried out at the last major overhaul were not in accordance with the provisions of the Pratt & Whitney JT8D engine overhaul manual; as a result, deficiencies in the thirteenth stage stator assembly occurred,
- The ruptured piece of the compressor disc exited the engine and penetrated the left lower inboard wing skin, puncturing a fuel cell,
- Fuel leaking from the punctured fuel cell was ignited instantaneously,
- The fuel-fed fire increased in size and engulfed the left wing and aft section of the aircraft.

Crash of a Mitsubishi MU-2B-35 Marquise in Edmonton: 1 killed

Date & Time: Dec 6, 1981 at 1805 LT
Type of aircraft:
Registration:
C-GLOW
Survivors:
Yes
Site:
Schedule:
Fort McMurray – Edmonton
MSN:
624
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to Edmonton Airport runway 30, the airplane lost height and crashed on the roof of the Royal Alexandra Hospital. The airplane was destroyed and both occupants were seriously injured. A day later, the pilot died from his injuries.
Probable cause:
It appears that both engines stopped on approach for undetermined reasons.