Crash of a Douglas DC-3C in Yellowknife

Date & Time: Aug 19, 2013 at 1712 LT
Type of aircraft:
Operator:
Registration:
C-GWIR
Survivors:
Yes
Schedule:
Yellowknife - Hay River
MSN:
9371
YOM:
1943
Flight number:
BFL168
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
4300.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
125
Circumstances:
On 19 August 2013, a Buffalo Airways Ltd. Douglas DC-3C (registration C-GWIR, serial number 9371) was operating as a scheduled passenger flight from Yellowknife, Northwest Territories, to Hay River, Northwest Territories. After lift-off from Runway 16 at 1708 Mountain Daylight Time, there was a fire in the right engine. The crew performed an emergency engine shutdown and made a low-altitude right turn towards Runway 10. The aircraft struck a stand of trees southwest of the threshold of Runway 10 and touched down south of the runway with the landing gear retracted. An aircraft evacuation was accomplished and there were no injuries to the 3 crew members or the 21 passengers. There was no post-impact fire and the 406 MHz emergency locator transmitter did not activate.
Probable cause:
Findings as to causes and contributing factors:
1. An accurate take-off weight and balance calculation was not completed prior to departure, resulting in an aircraft weight that exceeded its maximum certified takeoff weight.
2. The right engine number 1 cylinder failed during the take-off sequence due to a preexisting fatigue crack, resulting in an engine fire.
3. After the right propeller’s feathering mechanism was activated, the propeller never achieved a fully feathered condition likely due to a seized bearing in the feathering pump.
4. The windmilling right propeller caused an increase in drag which, combined with the overweight condition, contributed to the aircraft’s inability to maintain altitude, and the aircraft collided with terrain short of the runway.
5. The operator’s safety management system was ineffective at identifying and correcting unsafe operating practices.
6. Transport Canada’s surveillance activities did not identify the operator’s unsafe operating practices related to weight and balance and net take-off flight path calculations. Consequently, these unsafe practices persisted.
Findings as to risk:
1. If companies do not adhere to operational procedures in their operations manual, there is a risk that the safety of flight cannot be assured.
2. If Transport Canada does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.
3. If cockpit or data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Other findings:
1. Current Canadian Aviation Regulations permit a transport category piston-powered aircraft to carry passengers without a flight data recorder or cockpit voice recorder.
2. The crew resource management component of the flight attendant’s training had not been completed.
Final Report:

Crash of a BAe 3112 Jetstream 31 in Fort Smith

Date & Time: Nov 27, 2008 at 1515 LT
Type of aircraft:
Operator:
Registration:
C-FNAY
Survivors:
Yes
Schedule:
Hay River - Fort Smith
MSN:
768
YOM:
1987
Flight number:
PLR734
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Northwestern Air BAe Jetstream 31 was operating as PLR734 on an instrument flight rules (IFR) flight from Hay River to Fort Smith, Northwest Territories. After conducting an IFR approach to Runway 11, PLR734 executed a missed approach and flew a full procedure approach for Runway 29. At approximately 0.2 nautical miles from the threshold, the crew sighted the approach strobe lights and continued for a landing. Prior to touchdown, the aircraft entered an aerodynamic stall and landed hard on the runway at 1515 mountain standard time. The aircraft remained on the runway despite the left main landing gear collapsing. The two flight crew members and three passengers were uninjured and evacuated the aircraft through the left main cabin door. There was no post-impact fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Though icing conditions were encountered, the airframe de-icing boots were not cycled nor was the Vref speed increased to offset the effects of aircraft icing.
2. An abrupt change in aircraft configuration, which included a reduction in power to flight idle and the addition of 35° flap, caused the aircraft’s speed to rapidly decrease.
3. The aircraft entered an aerodynamic stall due to the decreased performance caused by the icing. There was insufficient altitude to recover the aircraft prior to impact with the runway.
Finding as to Risk:
1. The company had not incorporated the British Aerospace Notice to Aircrew into its standard operating procedures (SOP) at the time of the occurrence. Therefore, crews were still required to make configuration changes late in the approach sequence, increasing the risk of an unstabilised approach.
Final Report:

Crash of a Bristol 170 Freighter 31M in Hay River: 1 killed

Date & Time: Nov 20, 1977
Type of aircraft:
Operator:
Registration:
C-FWAD
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
13253
YOM:
1956
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After takeoff from Hay River, while climbing to a height of 200 feet, the crew lost control of the airplane that crashed near the airport. A pilot was killed while the second occupant was seriously injured.
Probable cause:
It was determined that the crew lost control of the airplane after the cargo shifted during initial climb. It is believed that the cargo was not properly stowed.

Crash of a Canadian Vickers PBV-1A Canso in Pine Point: 2 killed

Date & Time: Sep 3, 1971
Operator:
Registration:
CF-IDS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hay River - Hay River
MSN:
CV-311
YOM:
1943
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The Canso departed Hay River with two pilots on a firefighting mission in the region of Pine Point. While flying at low height, circling around the wreckage of a helicopter that crashed in the same area, the Canso collided with a Field Aviation Catalina registered CF-HTN. Two pilots were on board the Catalina and were also engaged in a firefighting mission. Following the collision, both aircraft crashed and were destroyed, killing all four crew members.

Crash of a Consolidated PBY-5A Catalina in Pine Point: 2 killed

Date & Time: Sep 3, 1971
Type of aircraft:
Operator:
Registration:
CF-HTN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hay River - Hay River
MSN:
1637
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The Catalina departed Hay River with two pilots on a firefighting mission in the region of Pine Point. While flying at low height, circling around the wreckage of a helicopter that crashed in the same area, the Catalina collided with a Norcanair Canadian Vickers PBV-1A Canso registered CF-IDS. Two pilots were on board the Canso and were also engaged in a firefighting mission. Following the collision, both aircraft crashed and were destroyed, killing all four crew members.

Crash of a Noorduyn Norseman in Hay River

Date & Time: Dec 29, 1962
Type of aircraft:
Registration:
CF-SAH
Flight Phase:
Survivors:
Yes
MSN:
21
YOM:
1938
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Hay River Airport, the single engine aircraft stalled and crashed. All four occupants were unhurt while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the loss of control was the consequence of an excessive accumulation of ice on wings and fuselage. For unknown reason, the aircraft has not been deiced prior to takeoff.