Crash of a Bombardier BD-700-1A11 Global Express 5000 in Fox Harbour

Date & Time: Nov 11, 2007 at 1434 LT
Operator:
Registration:
C-GXPR
Survivors:
Yes
Schedule:
Hamilton – Fox Harbour
MSN:
9211
YOM:
2006
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9188
Captain / Total hours on type:
64.00
Copilot / Total flying hours:
6426
Copilot / Total hours on type:
9
Aircraft flight hours:
92
Aircraft flight cycles:
26
Circumstances:
The aircraft, operated by Jetport Inc., departed Hamilton, Ontario, for Fox Harbour, Nova Scotia, with two crew members and eight passengers on board. At approximately 1434 Atlantic standard time, the aircraft touched down seven feet short of Runway 33 at the Fox Harbour aerodrome. The main landing gear was damaged when it struck the edge of the runway, and directional control was lost when the right main landing gear collapsed. The aircraft departed the right side of the runway and came to a stop 1000 feet from the initial touchdown point. All occupants evacuated the aircraft. One crew member and one passenger suffered serious injuries; the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.
Probable cause:
Findings as to Risk:
1. Because aircraft EWH information is not readily available to pilots, crews may continue to conduct approaches with an aircraft mismatched to the visual glide slope indicator (VGSI) system, increasing the risk of a reduced TCH safety margin.
2. Due to limited knowledge of the various VGSI systems in operation and their limitations, flight crews will continue to follow visual guidance that might not provide for safe TCH.
3. Jetport did not develop an accurate company risk profile. This precluded identification of systemic safety deficiencies and development of appropriate mitigation strategies.
4. If adequate safety oversight of POC operators is not maintained by the regulator, or the delegated organization, especially during SMS implementation, there is an increased risk that safety deficiencies will not be identified.
5. The fact that the Canadian Business Aviation Association (CBAA) did not insist that milestones for SMS implementation and development be followed may result in some POC operators never reaching full SMS compliance.
6. If Transport Canada does not ensure that the CBAA fulfills its responsibilities for adequate oversight of the Canadian Aviation Regulations (CARs) subpart 604 community, safety deficiencies will not be identified and addressed.
7. The audit of Jetport’s SMS, conducted by the CBAA–accredited auditor, did not identify the deficiencies in the program or make any suggestions for improvement. Without a comprehensive audit of an operator’s SMS, deficiencies could exist resulting in the operator’s inability to implement an effective mitigation strategy.
8. Contrary to the recommendations made in the Transport Canada/CBAA feasibility studies, the CBAA did not have a quality assurance program for its audit process. As a result, there is a risk that the CBAA will fail to identify weaknesses in the POC audit program.
9. At the time of the accident, no one at Fox Harbour (CFH4) had been assigned responsibility for regular maintenance of the APAPI, therefore preventing timely identification of APAPI equipment misalignment.
10. Jetport’s risk analysis before the introduction of the Global 5000 did not identify the incompatibility between the EWH of the aircraft and the APAPI at CFH4.
11. Not wearing shoulder harnesses during landings and take-offs increases the potential risk of passenger injuries.
12. Passengers not wearing footwear could impede evacuation, increase the risk of injury, and reduce post-crash mobility and (potentially) survival.
Other Findings:
1. A SMS integrates sound risk management policies, practices, and procedures into day-to-day operations and, properly implemented, offers great potential to reduce accidents.
2. Contrary to its own assessment protocol, Transport Canada did not document its decision to close off the CBAA assessment even though the CBAA had not submitted an acceptable corrective action plan.
3. Depiction of the different types of VGSIs differs, depending on the publication.
Final Report:

Crash of a Swearingen SA226TC Metro II in Ottawa

Date & Time: Jun 13, 1997 at 1248 LT
Type of aircraft:
Registration:
C-FEPW
Flight Type:
Survivors:
Yes
Schedule:
Hamilton - Ottawa
MSN:
TC-294
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2240
Captain / Total hours on type:
1930.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
55
Circumstances:
The flight crew were properly licensed and certified to conduct the flight. The pilot had a total flying time of approximately 2,240 hours, of which 1,930 were on the occurrence aircraft type. The co-pilot received his commercial pilots license in 1988 and had approximately 500 hours total flying time. He completed his instrument rating on 15 December 1996 and his initial training on the SA226-TC was completed in March 1997 in British Columbia with a different company. He had not flown for 44 days at the time his recurrent training was completed on 09 June 1997. This was the co-pilot=s third day of operational flying for the company; he had accumulated approximately 55 hours total time on the aircraft type. The co-pilot was flying the aircraft for a radar-vectored, localizer/back-course approach to runway 25 of the Ottawa/Macdonald-Cartier airport. Descending out of 10,000 feet above sea level, the crew completed a briefing for the approach. The weather conditions at the time did not necessitate a full instrument approach briefing because the crew expected to fly the approach in visual conditions. Air traffic control requested that the crew fly the aircraft at a speed of 180 knots or better to the Ottawa non-directional beacon (NDB), which is also the final approach fix (FAF) for the approach to runway 25. At approximately eight nautical miles from the airport the aircraft was clear of cloud and the crew could see the runway. In order to conduct some instrument approach practice, the pilot, who was also the company training pilot, placed a map against the co-pilot=s windscreen to temporarily restrict his forward view outside the aircraft. The approach briefing was not amended to reflect the simulated instrument conditions for the approach. The co-pilot accurately flew the aircraft on the localizer to the FAF, at which point, he began to slow the aircraft to approximately 140 knots and requested that the pilot set 2 flap, which he did. Once past the FAF, the copilot=s workload increased, and he had difficulty flying the simulated approach. On short final to runway 25, the pilot removed the map from the co-pilot=s windscreen. The co-pilot noted that the aircraft was faster and higher than normal and he tried to regain the proper approach profile. By the time the aircraft reached the threshold of the runway 25, it was approximately 500 feet above ground, and at a relatively high speed, so the pilot took control of the aircraft for the landing. The pilot attempted to descend and slow the aircraft as it proceeded down the length of the runway and stated that he had just initiated an overshoot when he heard the first sounds of impact. Runway 25 is 8,000 feet long. The first signs of impact on the runway were made by the propellers, with propeller marks beginning about 4,590 feet from the threshold of runway 25. The aircraft came to rest about 6,770 feet from the threshold, and a fire broke out in the area of the right engine. The co-pilot opened the main door of the aircraft while the pilot shut down the aircraft systems, and both exited the aircraft uninjured. The maximum speed for extending the landing gear on this aircraft is 176 knots, and the company standard operating procedures (SOPs) for a normal instrument approach stipulate that the aircraft should cross the final approach fix at a speed of 140 knots, with a 2-flap setting, and with the landing gear lowered. The company SOPs require that all checklist items, from the after start checks through to the after landing checks inclusive, be actioned through a challenge and response method with each item called individually. The first item of the before landing checks is a landing gear .....Down/3 greens@. The co-pilot did not recall being challenged for the landing gear check, and the pilot could not remember selecting the landing gear switch to the down position. Neither pilot checked for the three green lights prior to the occurrence. The pilot stated that it was his habit to check if the landing lights were on prior to landing because it was his habit to turn them on only after the landing gear had been extended. He remembered checking to see that the landing lights were on and so was satisfied that the gear was down. The co-pilot assumed that, because the aircraft had passed the NDB, the before landing checks had been completed; they are normally completed before or at that point during an approach. Neither pilot recalled hearing a gear warning horn prior to the impact. When the aircraft systems were inspected, the landing gear selector was found in the up position. Tests were conducted on the landing gear warning system which revealed that the gear warning horn did not function. A closer examination of the system revealed a faulty diode. The diode was replaced and when the warning system was checked again, it functioned properly. The pilot stated that the gear warning horn on the aircraft had functioned properly during the training for the co-pilot one week earlier.
Probable cause:
The aircraft was landed with the landing gear retracted because the flight crew did not follow the standard operating procedures and extend the landing gear. Contributing to the occurrence were the lack of planning, coordination, and communication on the part of the crew; and the failure of the landing gear warning system.
Final Report:

Crash of a Swearingen SA226AC Metro II off Hamilton: 2 killed

Date & Time: Feb 11, 1988 at 0332 LT
Type of aircraft:
Operator:
Registration:
C-GJDX
Flight Type:
Survivors:
No
Schedule:
Toronto - Hamilton
MSN:
TC-211EE
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Toronto-Lester Bowles Pearson Airport on a short night cargo flight to Hamilton. While descending in good weather conditions, the airplane went out of control and crashed into Lake Ontario, few km off Hamilton. Both pilots were killed.

Crash of a Convair T-29D near Hamilton AFB: 13 killed

Date & Time: May 4, 1970 at 0804 LT
Type of aircraft:
Operator:
Registration:
52-5822
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Hamilton - Spokane
MSN:
52-21
YOM:
1954
Flight number:
Visco 57
Crew on board:
3
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
Shortly after takeoff from runway 30 at Hamilton AFB (Novato, CA), the crew was cleared to climb at his discretion, following heading 360 till 2,600 feet then heading 340. Few seconds later, the airplane struck trees and crashed on a mountain slope located eight miles from the airbase. The aircraft was totally destroyed by impact forces and a post crash fire. A passenger was seriously injured while 13 other occupants were killed. The crew from the 26th Division was completing a flight to Spokane, Washington. At the time of the accident, weather conditions were considered as good with three cloud layers at 900, 15,000 and 25,000 feet, a visibility of about 8 miles and a light wind from 340 at 2 knots.
Probable cause:
A second flight was completed in similar conditions few hours later and the investigators were unable to determine the exact cause of the accident.

Crash of a Douglas VC-47A on Mt Yale: 12 killed

Date & Time: Sep 24, 1956
Operator:
Registration:
43-48146
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ent - Hamilton
MSN:
13962/25407
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The aircraft departed Ent AFB in Colorado Springs and continued to the west. After passing over Buena Vista, the airplane hit the north face of Mt Yale (4,328 meters high) and disintegrated on impact, killing all 12 occupants.
Crew:
Col Charles Arthur Miller, pilot,
Cpt James Joseph Richardson, copilot.
Passengers:
Col Frederick W. Ledeboer,
S/Sgt William E. MacKenzie Jr.,
Oscar M. Rupert (civilian),
A1c William R. Carpenter,
Sgt Phillip Lenz,
M/Sgt Helen M. Schuyler,
Cpt David C. Jacobs,
1st Lt David W. Gill,
Sp3 William L. Simpson,
Pvt William R. Rooney.
Probable cause:
It is believed that the accident was the consequence of a controlled flight into terrain.

Crash of a Douglas C-54G-5-DO Skymaster into the Atlantic Ocean

Date & Time: Jan 26, 1955 at 1658 LT
Type of aircraft:
Operator:
Registration:
45-0569
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lajes – Hamilton
MSN:
36022
YOM:
1945
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a transatlantic flight from Lajes to Hamilton, Bermuda. Enroute, the captain informed ground that he was short of fuel and was unable to reach Hamilton. He reduced his altitude and ditched the airplane near the Echo weather station. A USCG crew was able to evacuate all eight crew members while the aircraft sank and was lost.
Probable cause:
Fuel exhaustion.

Crash of a Lockheed RC-121C Super Constellation off Hamilton AFB

Date & Time: Nov 21, 1953 at 2130 LT
Operator:
Registration:
51-3838
Flight Type:
Survivors:
Yes
Schedule:
McClellan - Hamilton
MSN:
4114
YOM:
1953
Crew on board:
13
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a flight from McClellan AFB. On final approach to Hamilton AFB by night, the crew encountered foggy conditions when the four engine airplane hit the water surface and crashed into the San Pablo Bay about two miles southeast of the airbase. All 13 occupants were rescued while the aircraft was considered as damaged beyond repair. USAF headquarter reported that the aircraft suffered a loss of engine power on final.

Crash of a Douglas C-47B-15-DK near Fairfield

Date & Time: Apr 15, 1951 at 2300 LT
Operator:
Registration:
43-49527
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
March - Hamilton
MSN:
15343/26788
YOM:
1944
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While cruising by night at an insufficient height, the airplane hit the slope of a hill located in the region of Fairfiled, Solano County. The aircraft was destroyed and all three crew members were injured, one of them seriously.

Crash of a Lockheed 10A Electra in Mt Ruapehu: 13 killed

Date & Time: Oct 23, 1948 at 1415 LT
Type of aircraft:
Operator:
Registration:
ZK-AGK
Flight Phase:
Survivors:
No
Site:
Schedule:
Palmerston North – Hamilton
MSN:
1128
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
En route, the crew encountered marginal weather conditions with strong winds and rain showers. In low visibility, the aircraft christened 'Kaka' hit the slope of Mt Ruapehu and disintegrated on impact, killing all 13 occupants. The aircraft was off course at the time of the accident.
Probable cause:
Failure of the crew to take the appropriate measures to follow the correct track. However, strong winds and the lack of radio navigational beacon was considered as a contributory factor.