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Crash of a Swearingen SA227AC Metro III in Thompson

Date & Time: Nov 2, 2017 at 1920 LT
Type of aircraft:
Operator:
Registration:
C-FLRY
Flight Type:
Survivors:
Yes
Schedule:
Gods River – Thompson
MSN:
AC-756
YOM:
1990
Flight number:
PAG959
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1400
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
950
Copilot / Total hours on type:
700
Aircraft flight hours:
24672
Circumstances:
On 02 November 2017, a Perimeter Aviation LP Fairchild SA227-AC Metro III (serial number AC-756B, registration C-FLRY) was operating as flight 959 (PAG959) from Gods River Airport, Manitoba, to Thompson Airport, Manitoba, with 2 flight crew members on board. When the aircraft was approximately 40 nautical miles southeast of Thompson Airport, the crew informed air traffic control that they had received a low oil pressure indication on the left engine that might require the engine to be shut down. The crew did not declare an emergency, but aircraft rescue and firefighting services were put on standby. After touchdown on Runway 24 with both engines operating, the aircraft suddenly veered to the right and exited the runway. The aircraft came to rest in snow north of the runway. The captain and first officer exited the aircraft through the left side over-wing emergency exit and were taken to hospital with minor injuries. The aircraft was substantially damaged. The 406-MHz emergency locator transmitter did not activate. The occurrence took place during the hours of darkness, at 1920 Central Daylight Time.
Probable cause:
Findings as to causes and contributing factors:
1. The left engine low oil pressure indications during the previous and the occurrence flights were likely the result of a steady oil leak past the rear turbine air-oil seal assembly.
2. The loss of engine oil pressure resulted in a loss of propeller control authority on landing and the upset of the aircraft.
3. After consultation with maintenance, the crew considered the risks associated with landing single engine and without hydraulic pressure for the nose-wheel steering, and decided to continue the flight with both engines running, even though this was not consistent with the QRH procedures for low oil pressure indications.
4. Carbon deposits that accumulated within the inside diameter of the bellows convolutions interfered with the bellows’ ability to expand and to provide a positive seal against the rotor seal.

Findings as to risk:
1. If Canadian Aviation Regulations (CARs) subparts 703 and 704 operators do not provide initial or recurrent crew resource management training to pilots, these pilots may not be prepared to avoid, trap, or mitigate crew errors encountered during flight.
2. If operators of the SA227-AC Metro III aircraft rely solely on the emergency procedures listed in the aircraft flight manual, continued engine operation with low oil pressure may result in loss of control of the aircraft.
3. If an engine is not allowed to sufficiently cool down prior to shutdown, oil that remains trapped within hot areas of the engine may heat up to a point where the oil decomposes, creating a carbon deposit.
4. If flight data, voice, and video recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Other findings:
1. The investigation was unable to determine the length of cooldown periods for the occurrence aircraft. However, a random sampling of engine shutdowns for similar company aircraft showed that 50% had not completed the full 3-minute cooldown period.
2. Despite having received limited crew resource management (CRM).
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Thompson

Date & Time: Sep 15, 2015 at 1821 LT
Operator:
Registration:
C-FXLO
Flight Phase:
Survivors:
Yes
Schedule:
Thompson – Winnipeg
MSN:
31-8052022
YOM:
1980
Flight number:
KEE208
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
446
Copilot / Total hours on type:
120
Circumstances:
At 1817 Central Daylight Time, the Keystone Air Service Ltd. Piper PA-31-350 (registration C-FXLO, serial number 31-8052022) departed Runway 06 at Thompson Airport, Manitoba, on an instrument flight rules flight to Winnipeg/James Armstrong Richardson International Airport, Manitoba, with 2 pilots and 6 passengers on board. Shortly after rotation, both engines began to lose power. The crew attempted to return to the airport, but the aircraft was unable to maintain altitude. The landing gear was extended in preparation for a forced landing on a highway southwest of the airport. Due to oncoming traffic, the forced landing was conducted in a forested area adjacent to the highway, approximately 700 metres south of the threshold of Runway 06. The occupants sustained varying serious injuries but were able to assist each other and exit the aircraft. The emergency locator transmitter activated, and there was no fire. Emergency services were activated by a 911 call and by the Thompson flight service station. Initial assistance was provided by sheriffs of the Manitoba Department of Justice after a crew member flagged down their vehicle on the highway.
Probable cause:
Findings as to causes and contributing factors:
1. Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
2. The fueling operation was not adequately supervised by the flight crew.
3. A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
4. The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.

Findings as to risk:
1. If administrative and physical defences against errors in aviation fuel operations are circumvented or disabled, there is a risk that the incorrect type of fuel will be delivered.
2. If a reduced-diameter spout is available to accommodate non-standard fuel filler openings, there is an increased risk that Jet-A1 fuel can be dispensed into an aircraft that requires AVGAS.

Other findings:
1. Aircraft that were manufactured prior to the current airworthiness standards, or that have been modified by the installation of turbine engines, may have fuel filler openings that do not meet the dimension requirements.
2. The airworthiness standards for rotorcraft do not specify the size of fuel filler openings.
3. The use of all of the available restraint systems in the aircraft contributed to the survival of the occupants.
4. There was no post-crash fire, likely due to the separation of the battery from the aircraft and to the rain-saturated crash site.
5. The absence of a post-impact fire contributed to the survival of all of the aircraft's occupants.
Final Report:

Crash of an ATR42-300 in Churchill

Date & Time: Mar 9, 2014 at 1015 LT
Type of aircraft:
Operator:
Registration:
C-FJYV
Survivors:
Yes
Schedule:
Thompson – Churchill
MSN:
216
YOM:
1991
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Thompson, the crew completed the approach and landing at Churchill Airport. After touchdown, the crew started the braking procedure and was vacating the runway when the right main gear collapsed. This caused the right propeller and the right wing to struck the ground. The aircraft was stopped and all five occupants evacuated safely. The aircraft was damaged beyond repair.
Probable cause:
Failure of the right main gear for unknown reasons.

Crash of a Beechcraft 100 King Air in Island Lake

Date & Time: Jan 16, 2009 at 2110 LT
Type of aircraft:
Operator:
Registration:
C-GNAA
Flight Type:
Survivors:
Yes
Schedule:
Thompson - Island Lake
MSN:
B-24
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
620
Circumstances:
The crew was on a re-positioning flight from Thompson to Island Lake, Manitoba. On arrival in the Island Lake area, the crew commenced an instrument approach to Runway 12. On the final approach segment, the aircraft descended below the minimum descent altitude and the crew initiated a missed approach. During the missed approach, the aircraft struck trees. The crew was able to return for a landing on Runway 12 at Island Lake without further incident. The two crew members were not injured; the aircraft sustained damage to its right wing and landing gear doors. The accident occurred during hours of darkness at approximately 2110 Central Standard Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew conducted an Area Navigation (RNAV) approach for which they were not trained, with an aircraft that was not properly equipped nor approved for such purpose.
2. The aircraft descended 300 feet below the minimum descent altitude (MDA) as a result of a number of lapses, errors and adaptations which, when combined, resulted in the mismanaged approach.
3. The aural warning on the aircraft’s altitude alerter had been silenced prior to the approach, which precluded it from alerting the crew when the aircraft descended below minimum descent altitude.
4. The SkyNorth standard operating procedures for conducting a non-precision approach were not followed, which resulted in the aircraft descending below the minimum descent altitude. During the ensuing missed approach, the aircraft struck trees.
Findings as to Risk:
1. The lack of a more-structured training environment and the type of supervisory flying provided increased the risk that deviations from standard operating procedures (SOPs) would not be identified.
2. There are several instrument approach procedures in Canada that contain step-down fixes that are not displayed on global positioning system (GPS) units. This may increase the risk of collision with obstacles during step-downs on approaches.
Final Report:

Crash of a Beechcraft A100 King Air in Gods Lake Narrows

Date & Time: Nov 22, 2008 at 2140 LT
Type of aircraft:
Operator:
Registration:
C-FSNA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Gods Lake Narrows – Thompson
MSN:
B-227
YOM:
1976
Flight number:
SNA683
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
1850.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
500
Circumstances:
The Sky North Air Ltd. Beechcraft A100 (registration C-FSNA, serial number B-227) operating as SN683 departed Runway 32 at Gods Lake Narrows, Manitoba, for Thompson, Manitoba with two pilots, a flight nurse, and two patients on board. Shortly after takeoff, while in a climbing left turn, smoke and then fire emanated from the pedestal area in the cockpit. The crew continued the turn, intending to return to Runway 14 at Gods Lake Narrows. The aircraft contacted trees and came to rest in a wooded area about one-half nautical mile northwest of the airport. The accident occurred at 2140 central standard time. All five persons onboard evacuated the aircraft; two received minor injuries. At approximately 0250, the accident site was located and the occupants were evacuated. The aircraft was destroyed by impact forces and a post-crash fire. The emergency locator transmitter was consumed by the fire and whether or not it transmitted a signal is unknown.
Probable cause:
Findings as to Causes and Contributing Factors:
1. An electrical short circuit in the cockpit pedestal area produced flames and smoke, which induced the crew to take emergency action.
2. The detrimental effects of aging on the wires involved may have been a factor in this electrical arc event.
3. The crew elected to return to the airport at low level in an environment with inadequate visual references. As a result, control of the aircraft was lost at an altitude from which a recovery was not possible.
Findings as to Risk:
1. The actions specified in the standard operating procedures (SOP) do not include procedures for an electrical fire encountered at low altitude at night, which could lead to a loss of control.
2. Visual inspection procedures in accordance with normal phase inspection requirements may be inadequate to detect defects progressing within wiring bundles, increasing the risk of electrical fires.
3. In the event of an in-flight cockpit pedestal fire, the first officer does not have ready access to available fire extinguishers, reducing the likelihood of successfully fighting a fire of this nature.
4. Sealed in plastic containers and stored behind each pilot seat, the oxygen masks and goggles are time consuming to access and cumbersome to apply and activate. This could increase the probability of injury or incapacitation through extended exposure to smoke or fumes, or could deter crews from using them, especially during periods of high cockpit workload.
Other Finding:
1. A failure of the hot-mic recording function of the cockpit voice recorder (CVR) had gone undetected and information that would have been helpful to the investigation was not available.
Final Report:

Crash of a Swearingen SA226TC Metro II in Thompson

Date & Time: May 10, 2005 at 1030 LT
Type of aircraft:
Operator:
Registration:
C-FKEX
Survivors:
Yes
Schedule:
York Landing – Thompson
MSN:
TC-332
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
erimeter Aviation flight 914, a Metro II with 17 people on board, was on approach at Thompson, MB. The first officer flew the aircraft during the approach, and encountered turbulence and fluctuating airspeed. The captain took control at 200 feet agl. The aircraft was high and left of centreline. The captain added power, continued the approach and landed hard on runway 23 near the intersection with runway 32. After the aircraft arrived at the apron, a fuel leak was noted. The aircraft was inspected and damage was found in the wheel wells, wing leading edge, engine mounts and a wing-fuselage attachment point. No injuries were reported. Reported winds at 1400Z were 010 at 15-20 kts; 1500Z winds were 350 at 9 kts.

Crash of a Swearingen SA26T Merlin IIA in Thompson: 2 killed

Date & Time: Jun 1, 1994 at 0001 LT
Type of aircraft:
Operator:
Registration:
C-FFYC
Flight Type:
Survivors:
Yes
Schedule:
Coral Harbour – Churchill – Thompson
MSN:
T26-36
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
20000
Captain / Total hours on type:
3160.00
Copilot / Total flying hours:
3700
Copilot / Total hours on type:
375
Aircraft flight hours:
12633
Circumstances:
The twin-engine turboprop aircraft had just completed a medical evacuation (MEDEVAC) flight from Coral Harbour, Northwest Territories (NWT), to Churchill, Manitoba. At 2257 central daylight saving time (CDT), the aircraft departed Churchill for a night, instrument flight rules (IFR) flight to return to the aircraft's base of operations at Thompson, Manitoba. The en route portion of the return leg was conducted at an altitude of 18,000 feet above sea level (asl). Approximately one hour after take-off, the aircraft commenced an approach to the Thompson Airport. The crew remained in radio contact with air traffic control (ATC) personnel until approximately 2359 CDT. Just after midnight (0001 CDT), the Hotel non-directional beacon (NDB), which is located 3.4 miles northeast of the Thompson Airport, stopped transmitting. Ninety minutes later, the search and rescue satellite system (SARSAT) picked up an emergency locator transmitter (ELT) signal to the northeast of the airport. Thompson Airport staff, who had been dispatched to the site of the failed navigation beacon, found the wreckage of the aircraft in and around the NDB transmitter compound. Emergency responses were initiated by various airport and local authorities.
Probable cause:
The flight crew lost altitude awareness during the localizer back course approach and allowed the aircraft to descend below a mandatory level-off altitude. Contributing factors to this occurrence were the crew's deviation from a published approach procedure, ineffective in-flight monitoring of the approach, rapidly developing localized fog conditions, and, probably, pilot fatigue.
Final Report:

Crash of a Douglas C-54A-5-DO Skymaster in Thompson

Date & Time: Jun 1, 1979
Type of aircraft:
Operator:
Registration:
C-FQIX
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
7476
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Thompson Airport, the engine n°1 caught fire. The crew initiated a turn and was able to complete a safe landing. While both occupants escaped uninjured, the airplane was partially destroyed by fire. It was reported that the fire extinguisher system failed, causing the fire to spread to the entire left wing.
Probable cause:
Fire in engine n°1 after takeoff and failure of the fire extinguisher system.

Crash of a Curtiss C-46F-1-CU Commando near Thompson

Date & Time: Sep 29, 1977
Type of aircraft:
Operator:
Registration:
CF-CZH
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
22515
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minutes after takeoff from Thompson Airport, the crew encountered engine problems and elected to return. The airplane lost speed and height and the crew was eventually forced to attempt an emergency landing. The airplane struck trees and crashed 24 km southeast of Thompson. Both pilots were rescued while the aircraft was damaged beyond repair.
Probable cause:
Engine problems of unknown origin.

Crash of a Bristol 170 Freighter 31E in Rankin Inlet: 2 killed

Date & Time: May 31, 1974
Type of aircraft:
Operator:
Registration:
CF-QWJ
Flight Type:
Survivors:
No
Schedule:
Thompson - Rankin Inlet
MSN:
13078
YOM:
1951
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On final approach to Rankin Inlet, while completing a cargo flight from Thompson, the airplane went out of control and crashed. Both pilots were killed.
Probable cause:
Loss of control on final caused by an engine failure.