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Crash of a Curtiss C-46A-45-CU Commando in Déline

Date & Time: Sep 25, 2015 at 1203 LT
Type of aircraft:
Operator:
Registration:
C-GTXW
Flight Type:
Survivors:
Yes
Schedule:
Yellowknife – Norman Wells
MSN:
30386
YOM:
1944
Flight number:
BFL525
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Buffalo Airways Curtiss C-46A (C-GTXW) was operating as flight 525 from Yellowknife, NT (YZF) to Norman Wells, NT (YVQ). While en route, approximately 140 nautical miles southeast of Norman Wells at 6500 feet above sea level, the crew noticed a drop in the right engine oil quantity indicator in conjunction with a propeller overspeed. The propeller pitch was adjusted to control the overspeed however, oil quantity indication continued to drop rapidly. A visual confirmation of the right engine nacelle confirmed that oil was escaping via the engine breather vent at an abnormally high rate. The right propeller speed became uncontrollable and the crew completed the "Prop overspeed drill". However, the propeller did not feather as selected. Several additional attempts were made to feather the propeller before it eventually feathered. The engine was secured and the shutdown checklist completed. The crew elected to divert to Tulita, NT (ZFN), but quickly determined that the descent rate would not permit that as an option. The only other option for diversion was Déline, NT (YWJ) where weather was reported at half a mile visibility and 300 feet ceiling. An emergency was declared with Déline radio. BFL525 was able to land at Déline however, the landing gear was not selected down to prevent further loss of airspeed resulting in a belly landing approximately midpoint of runway 08. The aircraft continued off the end of the runway coming to a stop approximately 700 feet beyond the threshold. The crew evacuated the aircraft sustaining no injuries however, the aircraft was destroyed.
Probable cause:
Buffalo Airways’ initial investigation revealed the engine oil scavenge pump had failed. No TSB-BST investigation was conducted on the event.

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 Douglas C-54G-15-DO Skymaster in Norman Wells

Date & Time: Jan 5, 2006 at 1704 LT
Type of aircraft:
Operator:
Registration:
C-GXKN
Flight Type:
Survivors:
Yes
Schedule:
Norman Wells – Yellowknife
MSN:
36090
YOM:
1946
Flight number:
BFL1405
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Buffalo Airways Limited Douglas C-54G-DC (DC-4), registration C-GXKN, serial number 36090, departed from Norman Wells, Northwest Territories, at 1749 mountain standard time for a visual flight rules flight to Yellowknife, Northwest Territories, with a crew of four and 2000 pounds of cargo. While climbing through an altitude of approximately 3500 feet above sea level, the crew experienced a failure of the number 2 engine and a nacelle fire. The crew carried out the Engine Fire Checklist, which included discharging the fire bottles and feathering the number 2 propeller. The fire continued unabated. During this period, an uncommanded feathering of the number 1 propeller and an uncommanded extension of the main landing gear occurred. The crew planned for an emergency off-field landing, but during the descent to the landing area, the fuel selector was turned off as part of the Engine Securing Checklist, and the fire self-extinguished. A decision was made to return to the Norman Wells Airport where a successful two-engine landing was completed at 1804 mountain standard time. The aircraft sustained substantial fire damage, but there were no injuries to the four crew members on board.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Airworthiness Directive AD 48-12-01 mandates the replacement of the potentially hazardous fuel line, but the line had not been replaced on this aircraft.
2. A fuel leak from the main fuel inlet line in the engine compartment of this cargo DC-4 caused an in-flight fire that spread into the nacelle and wing.
3. The fuel-fed fire burned for an extended period of time because turning the fuel selector off is not required as part of the primary Engine Fire Checklist.
Final Report:

Crash of a Douglas C-54G-10-DO Skymaster in Ulu

Date & Time: Aug 2, 2003 at 0800 LT
Type of aircraft:
Operator:
Registration:
C-GBSK
Flight Type:
Survivors:
Yes
MSN:
36049
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was completing a cargo flight to Ulu, carrying four crew members and a load consisting of 45 oil drums. On final approach, the crew realized his speed was too high so he reduced engine power and selected full flaps. The aircraft lost height so power was added. But the aircraft continued to descent and struck the ground short of runway threshold. Upon impact, the undercarriage were torn off. The aircraft slid on its belly, lost its both wings and came to rest few hundred feet further. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Douglas C-54E-15-DO Skymaster in Diavik

Date & Time: Aug 28, 2002 at 1650 LT
Type of aircraft:
Operator:
Registration:
C-GQIC
Flight Type:
Survivors:
Yes
Schedule:
Yellowknife – Diavik
MSN:
27343
YOM:
1944
Flight number:
BFL928
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Diavik Airport, the four engine aircraft was too low. This caused the undercarriage to struck the ground about one metre short of runway 10 threshold. On impact, the undercarriage were torn off and the aircraft slid on the runway for almost 300 metres then lost its right wing and rotated to the right before coming to rest, bursting into flames. Both pilots escaped with minor injuries and the aircraft was destroyed.

Crash of a Douglas C-47A-5-DK in Fort Simpson

Date & Time: Jun 26, 1994 at 1404 LT
Operator:
Registration:
C-FROD
Flight Type:
Survivors:
Yes
Schedule:
Big Trout Lake – Fort Simpson
MSN:
12307
YOM:
1942
Flight number:
BFL526
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
9000.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
850
Aircraft flight hours:
18456
Circumstances:
Buffalo Air Flight 526, a Douglas DC-3C freighter based in Yellowknife, was hauling jet fuel to Trout Lake from Fort Simpson, Northwest Territories, in support of forest fire suppression operations. Before the departure from Yellowknife to Trout Lake, the flight crew checked the en route weather and filed a company flight itinerary. Dispatch issued the flight crew an aircraft-fuel-load receipt which indicated that the aircraft had been fuelled the night before with a total fuel quantity of about 436 imperial gallons (imp. gal.): full main tanks (336 imp. gal.), and 50 gallons in each auxiliary tank (100 imp. gal.). The first officer confirmed this quantity with a fuel dip-stick borrowed from the refueller. At 07:40 mountain daylight saving time, the flight crew departed Yellowknife in accordance with visual flight rules (VFR). On board the aircraft were 17 full 45-imperial-gallon drums of Turbo-B jet fuel. At 09:25 the aircraft landed at Trout Lake, and the 17 drums of jet fuel were off-loaded; the aircraft then departed for Fort Simpson at 0945. The 82-nautical-mile (nm) flight to Fort Simpson was flown at an altitude of about 2,500 feet above sea level (asl); the flight crew reported encountering light headwinds. At 10:20 the aircraft landed at Fort Simpson. Once again 17 drums of jet fuel were loaded on board, then the aircraft departed at 10:49. The captain climbed the aircraft to an altitude of 3,500 feet asl. After he levelled off the aircraft, the captain adjusted the engines to 575 brake horsepower (bhp) settings. At 11:20, the aircraft landed at Trout Lake and the drums were off-loaded, and at 11:35 the aircraft was once again airborne on the second round-trip shuttle flight. Thirty-five minutes later the aircraft landed at Fort Simpson. While the cargo was being loaded on the aircraft, the flight crew discussed their different calculations regarding the aircraft's fuel quantity. The first officer indicated that the aircraft required fuel. The captain calculated that the aircraft had sufficient fuel remaining. The captain decided that they would refuel at Fort Simpson on the next shuttle flight; nonetheless, since the flight crew considered the cockpit fuel gauges unreliable, the captain requested that the first officer confirm the fuel quantity using a dip-stick. At 12:28, the aircraft departed Fort Simpson and climbed to 5,000 feet asl. About eight minutes later, the flight crew noticed that the fuel pressure was fluctuating, indicating that the auxiliary tanks were empty. The captain repositioned the fuel tank selectors to their respective main tanks and enquired about the dip-stick measurements. The first officer responded that he had not checked the fuel quantity because the fuel dip-stick was missing. The crew discussed the fuel quantity remaining and the captain calculated that the aircraft had approximately 45 minutes of fuel remaining. Following the 13:00 touchdown at Trout Lake, the cargo was unloaded and 31 empty fuel drums were loaded on board the aircraft for Fort Simpson. At 13:25 the aircraft departed Trout Lake. The first officer was the pilot flying (PF) the aircraft, and was in the right seat. The captain performed the duties of the pilot not flying (PNF). Twenty miles southwest of Fort Simpson, the PNF reported their position to Fort Simpson Flight Service Station (FSS). He also requested that the aircraft refueller be advised that they would require fuel on arrival. The flight crew then completed the descent checks and, at 10 miles southwest of the airport, the PNF updated FSS of their position and received the airport advisory. Approximately six miles from the airport, at an altitude of about 400 to 500 feet above ground level (agl), the PF advised the PNF that the left engine was losing fuel pressure. Shortly thereafter, the left engine lost power. Immediately, the PNF switched the left fuel boost pump to the ON position, and the left fuel selector from LEFT MAIN to LEFT AUXILIARY tank position. The engine resumed power momentarily, but lost power again. The PNF then switched the left fuel selector to the RIGHT AUXILIARY tank position and the engine regained power; however, it promptly lost power again. Realizing that the fuel had been depleted in three of the four tanks, the captain took control of the aircraft and headed straight for runway 31. As the captain called for the engine failure check for the left engine, the first officer advised the captain that the right engine was losing power. With a loss of power in both engines, and without sufficient altitude to glide to the airport, the first officer called the Fort Simpson FSS to advise that the flight crew would attempt a landing on the road (Mackenzie Highway) north of the Liard River. However, the approach to the road was unsuccessful and the aircraft crash-landed into a treed area. At about 14:03, several witnesses at the Liard River ferry crossing observed the aircraft flying low in a northwesterly direction. The aircraft was estimated to be at about 40 feet agl when it crossed overhead the ferry terminal and was descending. The witnesses reported that they heard the sound of the engines cutting in and out before the aircraft passed overhead their vantage points. They also reported seeing the landing gear being extended. The aircraft then disappeared from view behind the trees. Immediately thereafter, the aircraft struck trees near the road, and crashed about 1/2 nm short of runway 31. The aircraft had been flown for approximately 4 hours and 37 minutes since its last refuelling.
Probable cause:
The flight was commenced with a fuel quantity below the minimum requirements, resulting in loss of engine power because of fuel exhaustion. Contributing to the occurrence was the lack of flight crew coordination.
Final Report:

Crash of a Boeing 707-351C in Kansas City: 4 killed

Date & Time: Apr 13, 1987 at 2155 LT
Type of aircraft:
Operator:
Registration:
N144SP
Flight Type:
Survivors:
No
Schedule:
Oklahoma City – Wichita – Kansas City – Fort Wayne
MSN:
19209
YOM:
1966
Flight number:
BV721
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
10000
Captain / Total hours on type:
3500.00
Circumstances:
Buffalo Airways flight 721, a regularly scheduled cargo flight, was operating between Oklahoma City, OK, and Fort Wayne, IN (FWA), with en route stops at Wichita, KS (ICT), and Kansas City, MO (MCI). The flight to Wichita was routine. En route to Kansas City, the crew deviated from course to avoid thunderstorms, but the descent into the terminal area was routine. At 21:42 flight 721 contacted the TRACON arrival radar controller. The controller directed the flight to turn to 060 degrees and told the flightcrew that they were being vectored to the ILS localizer for the ILS approach to runway 1. About 21:47 while the airplane was descending through about 6,500 feet, the first officer, who had been flying the airplane, turned the controls over to the captain. Buffalo Airways' regulations required captains to make all the approaches and landings whenever the ceilings and visibilities were less than 400 feet and 1 mile, respectively. At 21:50, after several intermediate descent clearances, flight 721 was cleared to descend to 2,400 feet. At 21:51, the controller told flight 721 that it was "five miles from DOTTE (the LOM), turn left zero four zero, maintain two thousand four hundred until established, cleared ILS runway one approach." The crew had completed the before-landing checklist, the landing gear was down and locked, and the flaps had been extended to 25 degrees, as required, for landing. At 21:52:40, the local controller advised flight 721 that it was No. 2 to land and that the winds were zero four zero at eight knots, and that the RVR on runway 1 was more than 6,000 feet. At 21:52:47, the first officer stated, "Localizer alive." The first office reported the airplane's altitude during the descent in 100-foot increments above "minimums (DH)" until the airplane reached the decision height. At 21:53:07, the first officer called, "Marker inbound." The flightcrew then received ATIS information "Sierra" which stated that the weather at the airport was in part: ceiling--100 feet, overcast; visibility 1/2 mile, fog; wind 40° at 8 knots. At 21:53:24, the captain remarked, "Already started the approach." At 21:53:32, 4 seconds after reporting that the airplane was 200 feet above minimums, the first officer told the local controller that, "Seven twenty-one is the marker inbound." The local controller acknowledged receipt of the message. At 21:53:41, after receiving a low-altitude alert generated by the Automated Radar Tracking System III (ARTS III) computer's Minimum Safe Altitude Warning (MSAW) function, the local controller warned flight 721 to "check altitude immediately should be two thousand four hundred, altimeter two nine six one." Flight 721 did not respond. However, the captain said "Call the radar (radio) altimeter please." At 21:53:46, the first officer responded, "Okay, there's twelve hundred on the (radio) altimeter." At 21:53:50, the local controller again called the flight and warned, "I have a low altitude alert, climb and maintain two thousand four hundred." Again, the flightcrew did not acknowledge receipt of the warning. At 21:53:51, a crewmember called out "pull it up," and at 2153:52, the captain applied power followed almost simultaneously by sounds of initial impact. Flight 721 struck the tops of trees on a 950-foot-high ridge about 3 nmi short of the approach end of runway 1. The airplane cut a relatively level 750- to 800-foot-long swath through the tree tops about 20 to 30 feet above the ground. The swath ended as the ridge and tree tops sloped downward. The airplane then rolled and turned to the right as it descended into the main impact area 2,000 feet beyond the initial impact site. All four occupants were killed.
Probable cause:
The Safety Board determines that the probable cause of this accident was the captain’s intentional descent below the DH. Contributing to the accident was the breakdown in flightcrew coordination procedures which contributed to the failure of the captain and the first officer to detect that the airplane had not intercepted and was below the ILS glideslope. Also contributing to the accident was the failure, for unknown reasons, of the airplane’s GPWS to provide an unsafe deviation below the ILS glideslope warning.
Final Report:

Crash of a De Havilland DHC-3 Otter at Salkeld Lake

Date & Time: Apr 17, 1977
Type of aircraft:
Operator:
Registration:
CF-QOR
Survivors:
Yes
Schedule:
Fort Smith - Salkeld Lake
MSN:
375
YOM:
1960
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane was on a flight that day from its base at Fort Smith to Salkeld Lake, Northwest Territories. The pilot, after intentionally planning to land as close to the end of the lake as possible, overshot the selected landing area. In an attempted go-around, the aircraft could not out-climb the rising terrain. A tailwind condition prevailed at the time and the Otter was five hundred pounds over gross weight. It collided with the trees, crashed and burned, seriously injuring the two on board.
Source: http://www.dhc-3archive.com/DHC-3_375.html and Karl E. Hayes.

Crash of a Noorduyn Norseman in Thubun Lake

Date & Time: Oct 6, 1970
Type of aircraft:
Operator:
Registration:
CF-NJV
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
564
YOM:
1944
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Thubun Lake, while climbing, the airplane lost height, crashed and came to rest upside down. The pilot was injured and the aircraft was damaged beyond repair.
Probable cause:
It was determined that the pilot failed to prepare the flight according to published procedures and positioned the fuel selector on an empty tank. In such conditions, the engine stopped shortly after rotation.