Zone

Crash of a Boeing 757-23N in Georgetown: 1 killed

Date & Time: Nov 9, 2018 at 0253 LT
Type of aircraft:
Operator:
Registration:
N524AT
Survivors:
Yes
Schedule:
Georgetown – Toronto
MSN:
30233/895
YOM:
1999
Flight number:
OJ256
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
120
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The airplane departed Georgetown-Cheddi Jagan Airport at 0209LT on an international schedule flight to Toronto-Lester Bowles Pearson Airport, carrying 120 passengers (118 adults and two children) and 8 crew members. At 0222LT, while climbing to 21,000 feet, the crew encountered technical problems with the hydraulic systems and was cleared to return. The captain made a 180 turn and followed a circuit and a holding pattern until he started the final approach to runway 06. After touchdown, the crew started the braking procedure but the airplane was apparently unable to stop within the remaining distance. Approaching the end of the runway, the aircraft veered to the right, lost its right main gear and came to rest in a sandy area with the right engine torn off and the right wing severely damaged. All 128 occupants evacuated and six of them were slightly injured. The aircraft was damaged beyond repair. A week after the accident, a 86 year old woman died from her injuries (fractured skull).

Crash of a Canadair RegionalJet CRJ-100ER in Toronto

Date & Time: May 20, 2007 at 1235 LT
Operator:
Registration:
C-FRIL
Survivors:
Yes
Schedule:
Moncton – Toronto
MSN:
7051
YOM:
1994
Flight number:
AC8911
Country:
Crew on board:
37
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft, with 3 crew members and 37 passengers on board, was operating as Air Canada Jazz Flight 8911 from Moncton, New Brunswick, to Toronto/Lester B. Pearson International Airport, Ontario. At 1235 eastern daylight time, the aircraft landed on Runway 06R with a 90º crosswind from the left, gusting from 13 to 23 knots. The aircraft first contacted the runway in a left-wing-down sideslip. The left main landing gear struck the runway first and the aircraft sustained a sharp lateral side load before bouncing. Once airborne again, the flight and ground spoilers deployed and the aircraft landed hard. Both main landing gear trunnion fittings failed and the landing gear collapsed. The aircraft remained upright, supported by the landing gear struts and wheels. The aircraft slid down the runway and exited via a taxiway, where the passengers deplaned. There was no fire. There were no injuries to the crew; some passengers reported minor injuries as a result of the hard landing.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.
Final Report:

Crash of an Airbus A340-313X in Toronto

Date & Time: Aug 2, 2005 at 1602 LT
Type of aircraft:
Operator:
Registration:
F-GLZQ
Survivors:
Yes
Schedule:
Paris - Toronto
MSN:
289
YOM:
1999
Flight number:
AF358
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
297
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15411
Captain / Total hours on type:
1788.00
Copilot / Total flying hours:
4834
Copilot / Total hours on type:
2502
Aircraft flight hours:
28426
Aircraft flight cycles:
3711
Circumstances:
The Air France Airbus A340-313 aircraft (registration F-GLZQ, serial number 0289) departed Paris, France, at 1153 Coordinated Universal Time (UTC) as Air France Flight 358 on a scheduled flight to Toronto, Ontario, with 297 passengers and 12 crew members on board. Before departure, the flight crew members obtained their arrival weather forecast, which included the possibility of thunderstorms. While approaching Toronto, the flight crew members were advised of weather-related delays. On final approach, they were advised that the crew of an aircraft landing ahead of them had reported poor braking action, and Air France Flight 358’s aircraft weather radar was displaying heavy precipitation encroaching on the runway from the northwest. At about 200 feet above the runway threshold, while on the instrument landing system approach to Runway 24L with autopilot and autothrust disconnected, the aircraft deviated above the glideslope and the groundspeed began to increase. The aircraft crossed the runway threshold about 40 feet above the glideslope. During the flare, the aircraft travelled through an area of heavy rain, and visual contact with the runway environment was significantly reduced. There were numerous lightning strikes occurring, particularly at the far end of the runway. The aircraft touched down about 3800 feet down the runway, reverse thrust was selected about 12.8 seconds after landing, and full reverse was selected 16.4 seconds after touchdown. The aircraft was not able to stop on the 9000-foot runway and departed the far end at a ground speed of about 80 knots. The aircraft stopped in a ravine at 2002 UTC (1602 eastern daylight time) and caught fire. All passengers and crew members were able to evacuate the aircraft before the fire reached the escape routes. A total of 2 crew members and 10 passengers were seriously injured during the crash and the ensuing
evacuation.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew conducted an approach and landing in the midst of a severe and rapidly changing thunderstorm. There were no procedures within Air France related to distance required from thunderstorms during approaches and landing, nor were these required by regulations.
2. After the autopilot and autothrust systems were disengaged, the pilot flying (PF) increased the thrust in reaction to a decrease in the airspeed and a perception that the aircraft was sinking. The power increase contributed to an increase in aircraft energy and the aircraft deviated above the glide path.
3. At about 300 feet above ground level (agl), the surface wind began to shift from a headwind component to a 10-knot tailwind component, increasing the aircraft’s groundspeed and effectively changing the flight path. The aircraft crossed the runway threshold about 40 feet above the normal threshold crossing height.
4. Approaching the threshold, the aircraft entered an intense downpour, and the forward visibility became severely reduced.
5. When the aircraft was near the threshold, the crew members became committed to the landing and believed their go-around option no longer existed.
6. The touchdown was long because the aircraft floated due to its excess speed over the threshold and because the intense rain and lightning made visual contact with the runway very difficult.
7. The aircraft touched down about 3800 feet from the threshold of Runway 24L, which left about 5100 feet of runway available to stop. The aircraft overran the end of Runway 24L at about 80 knots and was destroyed by fire when it entered the ravine.
8. Selection of the thrust reversers was delayed as was the subsequent application of full reverse thrust.
9. The pilot not flying (PNF) did not make the standard callouts concerning the spoilers and thrust reversers during the landing roll. This further contributed to the delay in the PF selecting the thrust reversers.
10. Because the runway was contaminated by water, the strength of the crosswind at touchdown exceeded the landing limits of the aircraft.
11. There were no landing distances indicated on the operational flight plan for a contaminated runway condition at the Toronto/Lester B. Pearson International Airport (CYYZ).
12. Despite aviation routine weather reports (METARs) calling for thunderstorms at CYYZ at the expected time of landing, the crew did not calculate the landing distance required for Runway 24L. Consequently, they were not aware of the margin of error available for the landing runway nor that it was eliminated once the tailwind was experienced.
13. Although the area up to 150 m beyond the end of Runway 24L was compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond this point, along the extended runway centreline, contributed to aircraft damage and to the injuries to crew and passengers.
14. The downpour diluted the firefighting foam agent and reduced its efficiency in dousing the fuel-fed fire, which eventually destroyed most of the aircraft.
Findings as to Risk :
1. In the absence of clear guidelines with respect to the conduct of approaches into convective weather, there is a greater likelihood that crews will continue to conduct approaches into such conditions, increasing the risk of an approach and landing accident.
2. A policy where only the captain can make the decision to conduct a missed approach can increase the likelihood that an unsafe condition will not be recognized early and, therefore, increase the time it might otherwise take to initiate a missed approach.
3. Although it could not be determined whether the use of the rain repellent system would have improved the forward visibility in the downpour, the crew did not have adequate information about the capabilities and operation of the rain repellent system and did not consider using it.
4. The information available to flight crews on initial approach in convective weather does not optimally assist them in developing a clear idea of the weather that may be encountered later in the approach.
5. During approaches in convective weather, crews may falsely rely on air traffic control (ATC) to provide them with suggestions and directions as to whether to land or not.
6. Some pilots have the impression that ATC will close the airport if weather conditions make landings unsafe; ATC has no such mandate.
7. Wind information from ground-based measuring systems (anemometers) is critical to the safe landing of aircraft. Redundancy of the system should prevent a single-point failure from causing a total loss of relevant wind information.
8. The emergency power for both the public address (PA) and EVAC alert systems are located in the avionics bay. A less vulnerable system and/or location would reduce the risk of these systems failing during a survivable crash.
9. Brace commands were not given by the cabin crew during this unexpected emergency condition. Although it could not be determined if some of the passengers were injured as a result, research shows that the risk of injury is reduced if passengers brace properly.
10. Safety information cards given to passengers travelling in the flight decks of Air France Airbus A340-313 aircraft do not include illustrations depicting emergency exit windows, descent ropes or the evacuation panel in the flight deck doors.
11. There are no clear visual cues to indicate that some dual-lane slides actually have two lanes. As a result, these slides were used mostly as single-lane slides. This likely slowed the evacuation, but this fact was not seen as a contributing factor to the injuries suffered by the passengers.
12. Although all passengers managed to evacuate, the evacuation was impeded because nearly 50 per cent of the passengers retrieved carry-on baggage.
Other Findings:
1. There is no indication that the captain’s medical condition or fatigue played a role in this occurrence.
2. The crew did not request long aerodrome forecast (TAF) information while en route. This did not affect the outcome of this occurrence because the CYYZ forecast did not change appreciably from information the flight crew members received before departure, and they received updated METARs for CYYZ and Niagara Falls International Airport (KIAG).
3. The possibility of a diversion required the flight crew to check the weather for various potential alternates and to complete fuel calculations. Although these activities consumed considerable time and energy, there is no indication that they were unusual for this type of operation or that they overtaxed the flight crew.
4. The decision to continue with the approach was consistent with normal industry practice, in that the crew could continue with the intent to land while maintaining the option to discontinue the approach if they assessed that the conditions were becoming unsafe.
5. There is no indication that more sophisticated ATC weather radar information, had it been available and communicated to the crew, would have altered their decision to continue to land.
6. It could not be determined why door L2 opened before the aircraft came to a stop.
7. There is no indication that the aircraft was struck by lightning.
8. There is no information to indicate that the aircraft encountered windshear during its approach and landing.
9. The flight crew seats are certified to a lower standard than the cabin seats, which may have been a factor in the injuries incurred by the captain.
Final Report:

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Burlington

Date & Time: Oct 12, 2000 at 0931 LT
Registration:
C-FAWF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Burlington – Toronto
MSN:
61-0629-7963287
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
30.00
Circumstances:
The pilot reported that after rotation, he obtained a positive rate of climb. At 110 knots, with the landing gear retracted and the wing flaps at 10 degrees, he noticed a right roll, a drop in climb performance, and a drop of manifold pressure on the right engine to at least 34 inches. The left engine maintained 42 inches. The pilot decided that, due to a "very minimum climb rate, rising terrain ahead, [and] airspeed not increasing," he would land the airplane in a small field about 1/4 mile and 50 degrees to the left. The pilot abruptly lowered the nose of the airplane and raised the flaps to gain airspeed, then landed with a nose-high attitude and the landing gear partially extended. Post-accident examination of the airplane revealed there was vertical compression to the belly area, the fuselage was spilt across the top at the aft end of the cabin, and both wings were damaged, with the left wing buckled downward just inboard of the engine. Examination also revealed that a clamp on the right engine intake manifold was loose. An estimated takeoff weight placed the airplane 74 pounds over the maximum allowed of 6,200 pounds. The type certificate holder estimated that with the airplane at 6,400 pounds, climbing at 110 kts, and with a partial power loss down to 26 inches on one engine, the rate of climb should have been 1,150 fpm with flaps and landing gear up, and 830 fpm with flaps 10 degrees and landing gear down. Higher terrain was to the east, and lower terrain was to the west. Terrain elevation for a straight-out departure was 25 feet above the runway at 0.5 nm, and 70 feet above the runway at 2.8 nm. The pilot reported his total flight experience as 15,000 hours, which included 13,000 hours in multi-engine airplanes, and 30 hours in make and model, all with the preceding 90 days.
Probable cause:
The pilot's improper in-flight decision to perform a precautionary landing, and his failure to maintain airspeed after he experienced a partial loss of power on one engine. A factor was the partial loss of power on one engine due to an induction air leak.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Montreal

Date & Time: Jul 27, 2000 at 2350 LT
Type of aircraft:
Registration:
C-GPTG
Flight Type:
Survivors:
Yes
Schedule:
Toronto - Montreal
MSN:
189
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Airwave flight 9806, a G-159 Gulfstream I, was flying IFR from Toronto (YYZ) to Montreal-Dorval (YUL). When it was on final for runway 06R, the pilot reported a problem with the landing gear. The crew recycled the gear and performed the emergency extension procedure unsuccessfully before trying various flight manoeuvres to free the gear. They then circled Montreal until minimum fuel was reached, declared an emergency and landed. On landing, the aircraft veered to the left and came to a halt 60 feet from the runway. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Preliminary investigation revealed that an apprentice AME moved a line in the landing gear well prior to the flight. The work was neither scheduled nor required. The apprentice left the work unfinished when he went to do something else, then forgot that a fastener was not in place. There was no flag or note to inform the other technicians or the crew that the aircraft was not in an airworthy state. The apprentice has two years experience with this company. The management was satisfied with the quality of his work. Two other licensed AMEs were working in the hangar with the apprentice. He was the only apprentice they had to supervise. The apprentice attended a type training course for this aircraft.

Crash of a Mitsubishi MU-2B-40 Solitaire in Parry Sound: 2 killed

Date & Time: May 24, 1999 at 2130 LT
Type of aircraft:
Registration:
N701K
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Parry Sound – Toronto
MSN:
410
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5500
Captain / Total hours on type:
400.00
Circumstances:
With one pilot and one passenger, the Mitsubishi MU-2B-40 Solitaire aircraft, serial number 410 S.A., departed on a night instrument flight rules flight from Parry Sound / Georgian Bay Airport, Ontario, destined for Toronto / Lester B. Pearson International Airport. Prior to departure, the pilot received his instrument flight rules clearance via telephone from the Sault Ste. Marie flight service station with a clearance valid time of 2118 eastern daylight time from Toronto Area Control Centre and a clearance cancel time of 2135. When the pilot did not establish communications with Toronto Area Control Centre within the clearance valid time, the Area Control Centre supervisor commenced a communication search. At 2151, he confirmed with Parry Sound / Georgian Bay Airport personnel that the aircraft had departed 10 to 15 minutes earlier. The aircraft was assumed missing and the Rescue Coordination Centre in Trenton, Ontario, was notified. Search and rescue was dispatched and three days later the aircraft wreckage was located one nautical mile west of the airport. Both of the aircraft occupants were fatally injured. The aircraft disintegrated as it cut a 306-foot swath through the poplar forest. The accident occurred at night in instrument meteorological conditions.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The accident flight was conducted at night in IMC, and the pilot, whose private pilot licence was not endorsed with an instrument rating, was not certified for the IFR flight.
2. The pilot may have been subjected to somatogravic illusion and allowed the aircraft to descend into terrain after a night take-off in IMC.
3. The pilot did not completely report his medical conditions to the civil aviation medical examiner.
Other Findings
1. The pilot was not certified to fly this model of aircraft as his private pilot licence was not endorsed with the appropriate high-performance aircraft rating.
2. The pilot conducted a downwind take-off.
3. While the aircraft was turning left for the on-course track, the aircraft flaps were retracting.
4. The aircraft struck trees while in a shallow descent. The integrity of the aircraft was compromised as it rolled inverted and entered the impact zone at high speed.
5. The aircraft engine teardown examination revealed no pre-impact failures of any component parts or accessories in either the left or right engine that would have precluded normal engine operation.
6. The propeller teardown examination revealed that both propellers were in a normal operating range and were rotating with power at the time of impact.
7. The ELT did not function due to the impact damage sustained by its various components.
Final Report:

Crash of a Canadair RegionalJet CRJ100 in Fredericton

Date & Time: Dec 16, 1997 at 2348 LT
Operator:
Registration:
C-FSKI
Survivors:
Yes
Schedule:
Toronto - Fredericton
MSN:
7068
YOM:
1995
Flight number:
AC646
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11020
Captain / Total hours on type:
1770.00
Copilot / Total flying hours:
3225
Copilot / Total hours on type:
60
Aircraft flight hours:
6061
Aircraft flight cycles:
5184
Circumstances:
Air Canada Flight 646, C-FSKI, departed Toronto-Lester B. Pearson International Airport, Ontario, at 2124 eastern standard time on a scheduled flight to Fredericton, New Brunswick. On arrival, the reported ceiling was 100 feet obscured, the visibility one-eighth of a mile in fog, and the runway visual range 1200 feet. The crew conducted a Category I instrument landing system approach to runway 15 and elected to land. On reaching about 35 feet, the captain assessed that the aircraft was not in a position to land safely and ordered the first officer, who was flying the aircraft, to go around. As the aircraft reached its go-around pitch attitude of about 10 degrees, the aircraft stalled aerodynamically, struck the runway, veered to the right and then travelled—at full power and uncontrolled—about 2100 feet from the first impact point, struck a large tree and came to rest. An evacuation was conducted; however, seven passengers were trapped in the aircraft until rescued. Of the 39 passengers and 3 crew members, 9 were seriously injured and the rest received minor or no injuries. The accident occurred at 2348 Atlantic standard time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Although for the time of the approach the weather reported for Fredericton—ceiling 100 feet and visibility c mile—was below the 200-foot decision height and the charted ½ -mile (RVR 2600) visibility for the landing, the approach was permitted because the reported RVR of 1200 feet was at the minimum RVR specified in CAR 602.129.
2. Based on the weather and visibility, runway length, approach and runway lighting, runway condition, and the first officer’s flying experience, allowing the first officer to fly the approach is questionable.
3. The first officer allowed the aircraft to deviate from the flight path to the extent that a go-around was required, which is an indication of his ability to transition to landing in the existing environmental conditions.
4. Disengagement of the autopilot at 165 feet rather than at the 80-foot minimum autopilot altitude resulted in an increased workload for the PF, allowed deviations
from the glide path, and deprived the pilots of better visual cues for landing.
5. In the occurrence environmental conditions, the lack of runway centre line and touchdown-zone lighting probably contributed to the first officer not being able to see the runway environment clearly enough to enable him to maintain the aircraft on the visual glide path and runway centre line.
6. The first officer’s inexperience and lack of training in flying the CL-65 in low-visibility conditions contributed to his inability to successfully complete the landing.
7. The situation of a captain being the PNF when ordering a go-around probably played a part in the uncertainty regarding the thrust lever advance and the raising of the flaps because there was no documented procedure covering their duties.
8. The go-around was attempted from a low-energy situation outside of the flight boundaries certified for the published go-around procedures; the aircraft’s low energy was primarily the result of the power being at idle.
9. The sequential nature of steps within the go-around procedures, in particular, in directing the pitch adjustment prior to noting the airspeed, the compelling nature of the command bars, and the high level of concentration required when initiating the go-around contributed to the first officer’s inadequate monitoring of the airspeed during the go-around attempt.
10. Following the command bars in go-around mode does not ensure that a safe flying speed is maintained, because the positioning of the command bars does not take into consideration the airspeed, flap configuration, and the rate of change of the angle of attack, considerations required to compute stall margin.
11. The conditions under which the go-arounds are demonstrated for aircraft certification do not form part of the documentation that leads to aircraft limitations or boundaries for the go-around procedure; this contributed to these factors not being taken into account when the go-around procedures were incorporated in aircraft and training manuals.
12. The published go-around procedure does not adequately reflect that once power is reduced to idle for landing, a go-around will probably not be completed without the aircraft contacting the runway (primarily because of the time required for the engines to spool up to go-around thrust).
13. The Air Canada stall recovery training, as approved by Transport Canada, did not prepare the crew for the conditions in which the occurrence aircraft stick shaker activated and the aircraft stalled.
14. The limitations of the ice-detection and annunciation systems and the procedures on the use of wing anti-ice did not ensure that the wing would remain ice-free during flight.
15. Ice accretion studies indicate that the aircraft was in an icing environment for at least 60 seconds prior to the stall, and that during this period a thin layer of mixed ice with some degree of roughness probably accumulated on the leading edges of the wings. Any ice on the wings would have reduced the safety margins of the stall protection system.
16. The implications of ice build-up below the threshold of detection, and the inhibiting of the ice advisory below 400 feet, were not adequately considered when the stall margin was being determined during the 1996 certification of the ice-detection system and associated procedures.
17. The stall protection system operated as designed: that it did not prevent the stall is related to the degraded performance of the wings.
18. The Category I approach was without the extra aids and defences required for Category II approaches.
19. Canadian regulations with respect to Category I approaches are more liberal than those of most countries and are not consistent with the ICAO International Standards and Recommended Practices (Annex 14), which defines visibility limits; in Canada, the visibility values, other than RVR, are advisory only.
20. Even though a Category I approach may be conducted in weather conditions reported to be lower than the landing minima specified for the approach, there is no special training required for any flight crew member, and there is no requirement that flight crew be tested on their ability to fly in such conditions.
21. Air Canada’s procedures required that the captain fly the aircraft when conducting a Category II approach, in all weather conditions; however, the decision as to who will fly low-visibility Category I approaches was left to the captain, who may not be in a position to adequately assess the first officer’s ability to conduct the approach.
22. The aircraft stalled at an angle of attack approximately 4.5 degrees lower, and at a CLmax 0.26 lower, than would be expected for the natural stall.
23. On final approach below 1000 feet agl, the wing performance on the accident flight was degraded over the wing performance at the same phase on the previous flight.
24. The engineering simulator comparison indicated two step reductions in aircraft performance, at 400 feet and 150 feet agl, as a result of local flow separation in the vicinity of wing station (WS) 247 and WS 253.
25. Pitting on the leading edges of the wings had a negligible effect on the performance of the aircraft.
26. The sealant on the leading edges of both wings was missing in some places and protruding from the surface 2 to 3 mm in others. Test flights indicate that the effect of the protruding chordwise sealant on the aircraft performance could have accounted for a reduction of 1.7 to 2.0 degrees in maximum fuselage angle of attack and of 0.03 to 0.05 in CLmax.
27. The maximum reduction in angle of attack resulting from ground effect is considered to be in the order of 0.75±0.5 degree: the aircraft angle of attack was influenced by ground effect during the go-around manoeuvre.
28. The performance loss caused by the protruding sealant and by ground effect was not great enough to account for the performance loss experienced; there is no apparent phenomenon other than ice accretion that could account for the remainder of the performance loss.
29. Neither Bombardier Inc., nor Transport Canada, nor Air Canada ensured that the regulations, manuals, and training programs prepared flight crews to successfully and consistently transition to visual flight for a landing or to go-around in the conditions that existed during this flight, especially considering the energy state of the aircraft when the go-around was commenced.
Other Findings:
1. Both the captain and the first officer were licensed and qualified for the duties performed during the flight in accordance with regulations and Air Canada training
and standards, except for minor training deficiencies with regard to emergency equipment.
2. The occurrence flight attendant was trained and qualified for the flight in accordance with existing requirements.
3. The aircraft was within its weight and centre-of-gravity limits for the entire flight.
4. Records indicate that the aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures.
5. There was no indication found of a failure or malfunction of any aircraft component prior to or during the flight.
6. When the stick shaker activated, it is unlikely that the crew could have landed the aircraft safely or completed a go-around without ground contact.
7. When power was selected for the go-around, the engines accelerated at a rate that would have been expected had the thrust levers been slammed to the go-around power setting.
8. The aircraft was not equipped with an emergency locator transmitter, nor was one required by regulation.
9. The lack of an emergency locator transmitter probably delayed locating the aircraft and its occupants.
10. Passengers and crew had no effective means of signaling emergency rescue services personnel.
11. The flight crew did not receive practical training on the operation of any emergency exits during their initial training program, even though this was required by
regulation.
12. Air Canada’s initial training program for flight crew did not include practical training in the operation of over-wing exits or the flight deck escape hatch.
13. Air Canada’s annual emergency procedures training for flight crew regarding the operation and use of emergency exits did not include practical training every third year, as required. Annual emergency exit training was done by demonstration only.
14. The flight crew were unaware that a pry bar was standard emergency equipment on the aircraft.
15. The four emergency flashlights carried on board were located in the same general area of the aircraft, increasing the possibility that all could be rendered inaccessible or unserviceable in an accident. (See section 4.1.6)
16. That there was a Flight Service Station specialist, as opposed to a tower controller, at the Fredericton airport at the time of the arrival of ACA 646 was not material to this occurrence.
Final Report:

Crash of a BAe Nimrod MR.2P off Toronto: 7 killed

Date & Time: Sep 2, 1995
Type of aircraft:
Operator:
Registration:
XV239
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toronto - Toronto
MSN:
8014
YOM:
1969
Location:
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The Nimrod display aircraft and crew had deployed to Canada on 23 August 1995 for displays at Canadian Forces Base Shearwater and the Canadian International Air Show (CIAS) at Toronto. In excellent weather, with a light on-shore wind, the aircraft took off on time for its display. Upon completion of the safety checks, it ran in for the standard Nimrod display sequence which features two orbits and two dumb-bell turns. The latter manoeuvres each involved a turn away from the display line, a climb to not above 1,000 feet, followed by a turn in the opposite direction and descent, to fly back parallel with the display line. Having completed the two orbits, the first dumb-bell turn was completed uneventfully. After a slow flypast with undercarriage down, the aircraft entered its final manoeuvre, the second dumb-bell turn. It was seen to turn away approximately 75° to starboard under full power before the flaps were retracted to 20° and the undercarriage raised. The nose was then pitched up into a climbing attitude of 24°. As the aircraft passed 950 feet, engine power was reduced to almost flight idle, following which the speed reduced rapidly to 122 knots, below the 150 knots recommended and taught for that stage of the display. The aircraft was rolled to 70° of port bank, shortly afterwards reducing to 45°, and the nose lowered to 5° below the horizon. During this turn the airspeed increased slightly and the G-loading increased to 1 .6 G. However, the combination of the low airspeed and the G-loading led the aircraft to stall, whereupon the port wing dropped to 85° of bank and the nose dropped to 18° below the horizon. Full starboard aileron and full engine power were applied in an attempt to recover the aircraft but, by this stage, there was insufficient height to recover and the aircraft hit the water. All seven crew members were killed.
Probable cause:
The Inquiry determined that the captain made an error of judgement in modifying one of the display manoeuvres to the extent that he stalled the aircraft at a height and attitude from which recovery was impossible. The Inquiry considered that contributory factors could have included deficiencies in the flight deck crew's training and in the method of supervision which could have allowed the captain to develop an unsafe technique without full appreciation of the consequences.

Crash of a Douglas DC-9-31 in Erie

Date & Time: Feb 21, 1986 at 0859 LT
Type of aircraft:
Operator:
Registration:
N961VJ
Survivors:
Yes
Schedule:
Toronto - Erie
MSN:
47506
YOM:
1970
Flight number:
US499
Crew on board:
5
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8900
Captain / Total hours on type:
5900.00
Aircraft flight hours:
42104
Circumstances:
During arrival, the crew of USAir flight 499 landed on runway 24, which was covered with snow. Reportedly, while landing, the aircraft touched down approximately 1,800 to 2,000 feet beyond the displaced threshold. Altho armed, the spoilers did not autodeploy, so the captain operated them manually. He lowered the aircraft's nose, actuated reverse thrust and applied brakes. The brakes were not effective. Subsequently, the aircraft continued off the end of the runway, ran over a runway end id light, struck a fence and came to rest straddling a road. The crew had planned on making an ILS approach to runway 06, but the RVR was only 2,800 feet and a minimum RVR of 4 000 feet was requested for that runway. The crew elected to land on runway 24, since 1/2 mile visibility was sufficient for that runway. However, the approach was made with a qtrg tailwind and approximately 10 knots above Vref. Tailwind landings were not authorized on runway 24 in wet/slippery conditions. The runway braking action was reported as fair-to-poor. The pilot's handbook cautioned the crew to monitor the spoilers when landing on slippery runways, since the spoilers auto-deploy only with wheel spin-up or when the nose wheel is on the ground. A passenger was slightly injured while 22 other occupants were uninjured.
Probable cause:
Occurrence #1: overrun
Phase of operation: landing - roll
Findings
1. (f) weather condition - low ceiling
2. (f) weather condition - snow
3. (f) weather condition - fog
4. (f) weather condition - tailwind
5. (c) planning/decision - improper - pilot in command
6. (f) airspeed(vref) - exceeded - pilot in command
7. (f) airport facilities, runway/landing area condition - displaced threshold
8. (f) proper touchdown point - not attained - pilot in command
9. (f) airport facilities, runway/landing area condition - snow covered
10. (c) go-around - not performed - pilot in command
----------
Occurrence #2: on ground/water collision with object
Phase of operation: landing - roll
Findings
11. (f) object - runway light
12. (f) object - fence
----------
Occurrence #3: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
13. (f) terrain condition - rough/uneven
Final Report:

Crash of a Piper PA-31T Cheyenne II in Toronto: 3 killed

Date & Time: Oct 17, 1984
Type of aircraft:
Registration:
C-GAPT
Flight Type:
Survivors:
No
MSN:
31-7620004
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On approach to Toronto-Lester Bowles Pearson Airport, the twin engine airplane struck the ground and crashed about 11 km short of runway threshold. All three occupants were killed.