Zone

Crash of an Embraer ERJ-145LR in Ottawa

Date & Time: Sep 4, 2011 at 1529 LT
Type of aircraft:
Operator:
Registration:
N840HK
Survivors:
Yes
Schedule:
Chicago - Ottawa
MSN:
145-341
YOM:
2001
Flight number:
UA3363
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
4800
Copilot / Total hours on type:
3800
Aircraft flight hours:
25655
Aircraft flight cycles:
23335
Circumstances:
At 1406, United Express Flight 3363 (LOF3363), operated by Trans States Airlines LLC (TSA), departed Chicago O’Hare International Airport, Chicago, United States. Before commencing the descent into Ottawa/Macdonald-Cartier International Airport (CYOW), Ontario, the flight crew obtained the automatic terminal information service (ATIS) information Yankee for CYOW issued at 1411. Based on the reported wind speed and direction, the flight crew calculated the approach speed (VAPP) to be 133 knots indicated airspeed (KIAS). Runway 25 was identified in ATIS information Yankee as the active runway. However, as a result of a previous overrun on Runway 07/25 in August 2010, TSA prohibited its flight crews from landing or taking off on Runway 07/25 when the surface is reported as damp or wet. Because rain showers were forecast for CYOW and Runway 32 was the longest runway, the flight crew decided at 1506 to carry out an instrument landing system (ILS) approach to Runway 32. At 1524, the CYOW terminal air traffic controller (ATC) advised the flight crew that it was starting to rain heavily at CYOW. About 2 minutes later, the aircraft intercepted the glideslope for the ILS to Runway 32. Final descent was initiated, the landing gear was extended, and the flaps were selected to 22°. Upon contacting the CYOW tower controller, the flight crew was advised that moderate rain had just started at the airport and the wind was reported as 310° magnetic (M) at 10 knots. The aircraft crossed the GREELY (YYR) final approach fix at 4.3 nautical miles (nm), slightly above the glideslope at 174 KIAS. About 1528, the aircraft passed through 1000 feet above ground level (agl) at 155 knots. Moments later, the flaps were selected to 45°. The airspeed at the time was approximately 145 KIAS. The tower controller advised the flight crew that the wind had changed to 320°M at 13 knots gusting to 20 knots. To compensate for the increased wind speed, the flight crew increased the VAPP to 140 KIAS. About 1 minute later, at 1529, the aircraft crossed the threshold of Runway 32 at about 45 feet agl, at an airspeed of 139 KIAS. As the aircraft crossed the runway threshold, the intensity of the rain increased, so the flight crew selected the windshield wipers to high. When the aircraft was about 20 feet agl, engine power was reduced and a flare was commenced. Just before touchdown, the aircraft encountered a downpour sufficient to obscure the crew’s view of the runway. Perceiving a sudden increase in descent rate, at approximately 5 feet agl, the captain applied maximum thrust on both engines. The master caution light illuminated, and a voice warning stated that the flaps were not in a take-off configuration. Maximum thrust was maintained for 7 seconds. The aircraft touched down smoothly 2700 feet beyond the threshold at 119 KIAS; the airspeed was increasing, and the aircraft became airborne again. The aircraft touched down a second time at 3037 feet beyond the threshold, with the airspeed increasing through 125 KIAS. Airspeed on touchdown peaked at 128 KIAS as the nosewheel was lowered to the ground, and then the thrust levers were retarded to flight idle. The outboard spoilers almost immediately deployed, and about 8 seconds later, the inboard spoilers deployed. The aircraft was about 20 feet right of the runway centreline when it touched down for the second time. Once the nosewheel was on the ground, the captain applied maximum brakes. The flight crew almost immediately noted that the aircraft began skidding. The captain then requested the first officer to apply maximum brakes as well. The aircraft continued to skid, and no significant brake pressure was recorded until about 14 seconds after the outboard spoilers deployed, when brake pressure suddenly increased to its maximum. During this time, the captain attempted to steer the aircraft back to the runway centreline. As the aircraft skidded down the runway, it began to yaw to the left. Full right rudder was applied, but was ineffective in correcting the left yaw. Sufficient water was present on the runway surface to cause the aircraft tires to send a spray of water, commonly known as a rooster tail, to a height of over 22 feet, trailing over 300 feet behind the aircraft. At some point during the landing roll, the captain partially applied the emergency/parking brake (EPB), and when no braking action was felt, the EPB was engaged further. With no perceivable deceleration being felt, the EPB was stowed. The aircraft continued to skid down the runway until about 7500 feet from the threshold, at which point it started skidding sideways along the runway. At 1530, the nosewheel exited the paved surface, 8120 feet from the threshold, at approximately 53 knots, on a heading of 271°M. The aircraft came to rest on a heading of 211°M, just off the left side of the paved surface. After coming to a stop, the flight crew carried out the emergency shutdown procedure as per the company Quick Reference Handbook (QRH), and consulted with the flight attendant on the status of everyone in the passenger cabin. The flight crew determined that there was no immediate threat and decided to hold the passengers on board. When the aircraft exited the runway surface, the tower activated the crash alarm. The CYOW airport rescue and firefighting (ARFF) services responded, and were on scene approximately 3 minutes after the activation of the crash alarm. Once ARFF personnel had conducted a thorough exterior check of the aircraft, they informed the flight crew that there was a fuel leak. The captain then called for an immediate evacuation of the aircraft. The passengers evacuated through the main cabin door, and moved to the runway as directed by the flight crew and ARFF personnel. The evacuation was initiated approximately 12 minutes after the aircraft came to a final stop. After the evacuation was complete, the firefighters sprayed foam around the aircraft where the fuel had leaked.
Probable cause:
Findings as to causes and contributing factors:
1. Heavy rainfall before and during the landing resulted in a 4–6 mm layer of water contaminating the runway.
2. The occurrence aircraft’s airspeed during final approach exceeded the company prescribed limits for stabilized approach criteria. As a result, the aircraft crossed the runway threshold at a higher than recommended VREF airspeed.
3. A go-around was not performed, as per standard operating procedures, when the aircraft’s speed was greater than 5 knots above the appropriate approach speed during the stabilized portion of the approach.
4. The application of engine thrust just before touchdown caused the aircraft to touch down 3037 feet from the threshold at a higher than recommended airspeed.
5. The combination of a less than firm landing and underinflated tires contributed to the aircraft hydroplaning.
6. The emergency/parking brake was applied during the landing roll, which disabled the anti-skid braking system and prolonged the skid.
7. The aircraft lost directional control as a result of hydroplaning and veered off the runway.

Findings as to risk:
1. The typical and frequently used technique for differential braking that pilots are trained to use may not be effective when anti-skid systems require different techniques.
2. If aircraft electrical power is applied with an active fuel leak, there is a risk that an electrical spark could ignite the fuel and start a fire.
3. The use of non-grooved runways increases the risk of hydroplaning, which may result in runway excursions.
4. If there is an absence of information and training about non-grooved runways, there is a risk that crews will not carry out the appropriate landing techniques when these runways are wet.
5. The use of thrust reversers reduces the risk of runway excursions when landing on wet runways.
6. If pilots do not comply with standard operating procedures, and companies do not assure compliance, then there is a risk that occurrences resulting from such deviations will persist.

Other findings:
1. The central maintenance computer was downloaded successfully; however, there were no data present in the memory unit.
2. Although the Transportation Safety Board was able to download high-quality data from the flight data recorder, the parameters that were not recorded due to the model type and input to the flight data recorder made it more difficult to determine the sequence of events.
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 Piper PA-31T Cheyenne II in Montreal

Date & Time: Nov 12, 1993 at 1739 LT
Type of aircraft:
Operator:
Registration:
C-GSWB
Flight Type:
Survivors:
Yes
Schedule:
Ottawa - Montreal
MSN:
31-7720013
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Montreal-Dorval Airport, the pilot contacted ATC and reported longitudinal control problems. The aircraft started to roll left and right and the pilot maintained control using considerable aileron and rudder inputs. On short final, the twin engine aircraft crash landed short of runway 24L and came to rest in a grassy area. The pilot was injured and the aircraft was damaged beyond repair.

Crash of a Pilatus PC-6/C-H2 Turbo Porter in Ottawa

Date & Time: Jul 16, 1991
Operator:
Registration:
N285L
Flight Type:
Survivors:
Yes
MSN:
565
YOM:
1964
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
13463
Circumstances:
Crashed in unknown circumstances while on approach to Ottawa Airport. The pilot, sole on board, was injured. The aircraft was on a delivery flight.

Crash of a Fokker F27 Friendship 100 in New York

Date & Time: Jan 13, 1984 at 1442 LT
Type of aircraft:
Operator:
Registration:
N148PM
Flight Phase:
Survivors:
Yes
Schedule:
New York - Ottawa
MSN:
10108
YOM:
1958
Flight number:
PM035
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7012
Captain / Total hours on type:
799.00
Copilot / Total flying hours:
3151
Copilot / Total hours on type:
197
Aircraft flight hours:
42040
Aircraft flight cycles:
39945
Circumstances:
At 1442 on January 13, 1984, Pilgrim Airline Flight 35, a scheduled 14 CFR Part 121 flight with 21 passengers and a crew of three took off from runway 04L at John F. Kennedy International Airport, Jamaica, New York, en route to Ottawa, Canada. The weather was, in part, ceiling 2,700 feet overcast, visibility 7 miles; wind, 050° at I4 knots; and temperature 26°. As the captain raised the landing gear, the propeller on the left engine autofeathered. The captain initiated emergency procedures and told the first officer that he was retarding the power lever for the left engine. Concurrently, according to the cockpit voice recorder, the right engine experienced a power loss, and the airplane began to descend. The first officer, who was flying the airplane, maintained directional control, and the captain immediately put the landing gear lever down. however, the airplane struck the runway before the landing gear extended fully, and slid about 1,200 feet before stopping near the intersection of taxiway "G" and runway 04L. The captain and 13 passengers incurred minor injuries, and the flight attendant incurred a fracture of the spine. The airplane was damaged substantially; there was no postcrash fire.
Probable cause:
The flight crew's failure to use engine anti-ice on the inbound flight to JFK, the captain's failure to conduct a thorough pre-flight inspection, and the flight crew's decision to use engine anti-ice on take-off from JFK which led to power losses on both engines.
Final Report:

Crash of a De Havilland CC-123 Otter on Slide Mountain: 4 killed

Date & Time: Dec 19, 1980
Type of aircraft:
Operator:
Registration:
9407
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Norfolk - Newburgh - Ottawa
MSN:
367
YOM:
1960
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
En route from Newburgh-Stewart to Ottawa, the single engine airplane crashed in unknown circumstances on Slide Mountain, State of New York. The wreckage was found two days later and all four occupants were killed. The crew was returning to Ottawa following an exchange course at Norfolk NAS, Virginia.
Occupants:
Maj Eugene Ross,
Cpt Gilles Dessureault,
Cpt Jean Petit,
Lt Col D. R. Lawrence.

Crash of a Douglas DC-8-54F in Ottawa: 3 killed

Date & Time: May 19, 1967 at 1837 LT
Type of aircraft:
Operator:
Registration:
CF-TJM
Flight Type:
Survivors:
No
Schedule:
Montreal - Ottawa
MSN:
45653/178
YOM:
1963
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
19400
Captain / Total hours on type:
3700.00
Copilot / Total flying hours:
20748
Copilot / Total hours on type:
8
Aircraft flight hours:
9670
Circumstances:
The aircraft was on a conversion training flight from Montreal to Ottawa with three pilots on board. The aircraft departed Montreal at 1802 hours Eastern Standard Time on an instrument flight plan which was cancelled on reaching the Ottawa area. A hydraulic failure simulation was then carried out following which a touch-and-go landing on runway 32 was accomplished at 1825 hours. According to the recorded data the touch-and-go was accomplished with the ailerons in the manual mode, the flaps were raised to the 250 position during the landing roll and the ailerons were restored to the power mode during the turn following take-off while on a heading of about 260°. After about two minutes of flight on the downwind leg, No. 4 engine was retarded to flight idle and was kept at that setting for about two and a quarter minutes. During this period an average of about 30 left wing down bank was maintained, except at a point about halfway through that period the aircraft banked slowly 180 to the left, followed by a sharp reversal to 100 bank to the right. The length of the downwind leg was consistent with a planned two-engine asymmetric landing. Power was restored to No. 4 engine just before a left turn on to the base leg was started. During that turn No. 4 engine was again retarded to flight idle,then restored to normal power. No. 1 engine was then retarded to flight idle for about 20 seconds, then restored to normal power. The flaps remained at the 250 setting. While turning on to final approach, the pilot-in-command advised the tower that he was as yet undecided whether a landing would be carried out. When the aircraft had passed the UP beacon, about 84 miles from the runway threshold and approximately 200 sec from impact, rudder power was selected to the manual mode and power was reduced on all four engines. No. 4 engine was then retarded to the flight idle position and the other three engines advanced to approach power. About 171 sec before impact, the pilot-in-command advised the control tower that the aircraft would be making a full stop landing. The landing gear was extended 155 sec before impact and 120 sec before impact No. 3 engine was retarded to flight idle: at the same time power was increased on Nos. 1 and 2 engines. At that time the aircraft was at a height of 1 150 ft above the ground and its indicated airspeed was fairly steady around 165 kt. From 109 to 92 sec before impact, the aircraft turned to the right through 340 on to a heading of 3370. Power was reduced, bank applied and the aircraft returned to approximately the runway heading. The flaps were extended to 350, 69 sec before impact. At 54 sec before impact, the rudder was restored to the power mode for less than 6 sec and then returned to the manual mode. Through the period from 69 to 25 sec the rate of descent was relatively constant at about 700 ft/min with the aircraft tending to undershoot, and the airspeed decreasing from 163 to 152 kt. Power on Nos. 1 and 2 engines was progressively increased from 25 sec before impact until near maximum power was reached 8 sec before impact, following which they were retarded to flight idle. A yaw to the right had started 19 sec before impact and 12 sec before impact the throttles were advanced on engines 3 and 4 and they began to spool up. At 9 sec before impact and when some 200 ft above the ground, the left wing down condition could no longer be maintained and the aircraft entered a roll to the right. The roll rate to the right increased rapidly as did the yaw rate. The roll continued until the aircraft struck the ground in an inverted nose low attitude, 1 995 ft short of the threshold of runway 32 and 575 ft NE of its extended centre line. The accident occurred at 1837 hours. The aircraft was destroyed and all three crew members were killed.
Probable cause:
Failure to abandon a training manoeuvre under conditions which precluded the availability of adequate flight control. The following findings were reported:
- The decision to attempt an asymmetric approach with the rudder in the manual mode was improper,
- The information available to the crew in the Air Canada DC-8 Manual, concerning two engine operating procedures, was inadequate,
- The aircraft was tending to undershoot the runway,
- Control was lost when power to the left engines was increased late in the approach, at an airspeed too low for effective rudder control,
- The faulty check valve closed during the flight at least 54 seconds prior to impact.
Final Report:

Crash of a Noorduyn Norseman in Ottawa

Date & Time: Mar 10, 1959
Type of aircraft:
Operator:
Registration:
CF-HAD
Survivors:
Yes
MSN:
628
YOM:
1944
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Ottawa Airport, the single engine airplane deviated from the runway centerline to the left. The pilot increased engine power to attempt a go around when the aircraft struck a snow bank on the left shoulder and crashed upside down. Both occupants were seriously injured and the aircraft was destroyed.

Crash of a Beechcraft CT-128 Expeditor in Serpentine River: 7 killed

Date & Time: Apr 21, 1949
Type of aircraft:
Operator:
Registration:
1425
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Chatham – Ottawa – Presque Ile
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Crashed in unknown circumstances in Serpentine River, northwest of New Brunswick while performing a flight from Ottawa to Presque Ile, Maine. All seven occupants were killed.
Crew:
Wg Cdr Beverly Beck,
Sq Ldr Frederick William Darnell,
Wg Cdr John Harry Drury.

Crash of an Avro 652A Anson V in Ottawa

Date & Time: Oct 15, 1948
Type of aircraft:
Operator:
Registration:
CF-DTO
Flight Type:
Survivors:
Yes
MSN:
3091
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On touchdown in Ottawa Airport, the twin engine aircraft went out of control, veered off runway, lost its undercarriage and came to rest. There were no casualties but the aircraft was damaged beyond repair. The crew was performing a flight on behalf of the Canadian Department of Transport.