Crash of a Socata TBM-850 near Calabogie: 1 killed

Date & Time: Oct 8, 2012 at 1219 LT
Type of aircraft:
Registration:
C-FBKK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Carp - Goderich
MSN:
621
YOM:
2012
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19200
Captain / Total hours on type:
700.00
Aircraft flight hours:
64
Circumstances:
The privately owned SOCATA TBM 700N (registration C-FBKK, serial number 621) departed from Ottawa/Carp Airport, Ontario, on an instrument flight rules flight plan to Goderich, Ontario. Shortly after takeoff, the pilot and sole occupant altered the destination to Wiarton, Ontario. Air traffic control cleared the aircraft to climb to flight level 260 (FL260). The aircraft continued climb through FL260 and entered a right hand turn, which quickly developed into a spiral dive. At approximately 1219 Eastern Daylight Time, the aircraft struck the ground and was destroyed. Small fires broke out and consumed some sections of the aircraft. The pilot was fatally injured. The 406 MHz emergency locator transmitter on board the aircraft was damaged and its signal was not sensed by the search and rescue satellite-aided tracking (SARSAT) system.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot lost control of the aircraft for undetermined reasons and the aircraft collided with terrain.
Findings as to Risk:
1. Operating an aircraft above 13 000 feet asl without an available emergency oxygen supply increases the risk of incapacitation due to hypoxia following depressurization.
Other Findings:
1. The avionics system had the capability to record data essential to the accident investigation but the recording medium was destroyed in the accident.
Final Report:

Ground fire of an Avro 748-264-2A in Sandy Lake

Date & Time: Jun 12, 2012 at 1343 LT
Type of aircraft:
Operator:
Registration:
C-FTTW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pickle Lake – Sandy Lake
MSN:
1681
YOM:
1970
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was parked on the ramp at Sandy Lake Airport. The flight crew had disembarked and were off-loading the cargo (JET A-1 jet fuel drums) from the aircraft to fuel tanks adjacent to the ramp. A fire broke out and the flight crew used the available fire extinguishers but the fire spread and consumed most of the aircraft that was totally destroyed. There were no injuries.
Probable cause:
A leak occurred in a hose downstream of the pumps (located on the ground beside the aircraft). The ambient wind blew vapors toward the pumps and a fire broke out. No official investigation was conducted by the TSB on this event.

Crash of a De Havilland DHC-2 Beaver in Lillabelle Lake: 2 killed

Date & Time: May 25, 2012 at 1408 LT
Type of aircraft:
Operator:
Registration:
C-FGBF
Survivors:
Yes
Schedule:
Edgar Lake - Lillabelle Lake
MSN:
168
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1100
Captain / Total hours on type:
300.00
Aircraft flight hours:
22000
Circumstances:
The Cochrane Air Service de Havilland DHC-2 Mk.1 Beaver floatplane (registration C-FGBF, serial number 168) departed Edgar Lake, Ontario, with 2 passengers and 300 pounds of cargo on board. The aircraft was destined for the company’s main base located on Lillabelle Lake, Ontario, approximately 77 miles to the south. On arrival, a southwest-bound landing was attempted across the narrow width of the lake, as the winds favoured this direction. The pilot was unable to land the aircraft in the distance available and executed a go-around. At 1408, Eastern Daylight Time, shortly after full power application, the aircraft rolled quickly to the left and struck the water in a partially inverted attitude. The aircraft came to rest on the muddy lake bottom, partially suspended by the undamaged floats. The passenger in the front seat was able to exit the aircraft and was subsequently rescued. The pilot and rear-seat passenger were not able to exit and drowned. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On the windward side of the landing surface, there was significant mechanical turbulence and associated wind shear caused by the passage of strong gusty winds over surface obstructions.
2. During the attempted overshoot, the rapid application of full power caused the aircraft to yaw to the left, and a left roll quickly developed. This movement, in combination with a high angle of attack and low airspeed, likely caused the aircraft to stall. The altitude available to regain control before striking the water was insufficient.
3. The pilot survived the impact, but was unable to exit the aircraft, possibly due to difficulties finding or opening an exit. The pilot subsequently drowned.
4. The rear-seat passenger did not have a shoulder harness and was critically injured. The passenger’s head struck the pilot’s seat in front; this passenger did not exit the aircraft and drowned.
Findings as to Risk:
1. Without a full passenger safety briefing, there is increased risk that passengers may not use the available safety equipment or be able to perform necessary emergency functions in a timely manner to avoid injury or death.
2. Not wearing a shoulder harness can increase the risk of injury or death in an accident.
3. Not having a stall warning system increases the risk that the pilot may not be aware of an impending aerodynamic stall.
4. Commercial seaplane pilots who do not receive underwater egress training are at increased risk of being unable to exit the aircraft following a survivable impact with water.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in North Spirit Lake: 4 killed

Date & Time: Jan 10, 2012 at 0957 LT
Operator:
Registration:
C-GOSU
Survivors:
Yes
Schedule:
Winnipeg - North Spirit Lake
MSN:
31-7752148
YOM:
1977
Flight number:
KEE213
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2400
Captain / Total hours on type:
95.00
Circumstances:
The Piper PA31-350 Navajo Chieftain (registration C-GOSU, serial number 31-7752148), operating as Keystone Air Service Limited Flight 213, departed Winnipeg/James Armstrong Richardson International Airport, Manitoba, enroute to North Spirit Lake, Ontario, with 1 pilot and 4 passengers on board. At 0957 Central Standard Time, on approach to Runway 13 at North Spirit Lake, the aircraft struck the frozen lake surface 1.1 nautical miles from the threshold of Runway 13. The pilot and 3 passengers sustained fatal injuries. One passenger sustained serious injuries. The aircraft was destroyed by impact forces and a post-impact fire. After a short period of operation, the emergency locator transmitter stopped transmitting when the antenna wire was consumed by the fire.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot's decision to conduct an approach to an aerodrome not serviced by an instrument flight rules approach in adverse weather conditions was likely the result of the pilot's inexperience, and may have been influenced by the pilot's desire to successfully complete the flight.
2. The pilot's decision to descend into cloud and continue in icing conditions was likely the result of inadequate awareness of the Piper PA31-350 aircraft's performance in icing conditions and of its de-icing capabilities.
3. While waiting for the runway to be cleared of snow, the aircraft held near North Spirit Lake (CKQ3) in icing conditions. The resulting ice accumulation on the aircraft's critical surfaces would have led to an increase in the aircraft's aerodynamic drag and stall speed, causing the aircraft to stall during final approach at an altitude from which recovery was not possible.
Findings as to risk:
1. Terminology contained in aircraft flight manuals and regulatory material regarding “known icing conditions,” “light to moderate icing conditions,” “flight in,” and “flight into” is inconsistent, and this inconsistency increases the risk of confusion as to the aircraft’s certification and capability in icing conditions.
2. If confusion and uncertainty exist as to the aircraft’s certification and capability in icing conditions, then there is increased risk that flights will dispatch into icing conditions that exceed the capability of the aircraft.
3. The lack of procedures and tools to assist pilots in the decision to self-dispatch leaves them at increased risk of dispatching into conditions beyond the capability of the aircraft.
4. When management involvement in the dispatch process results in pilots feeling pressure to complete flights in challenging conditions, there is increased risk that pilots may attempt flights beyond their competence.
5. Under current regulations, Canadian Aviation Regulations (CARs) 703 and 704 operators are not required to provide training in crew resource management / pilot decision-making or threat- and error-management. A breakdown in crew resource management / pilot decision-making may result in an increased risk when pilots are faced with adverse weather conditions.
6. Descending below the area minimum altitude while in instrument meteorological conditions without a published approach procedure increases the risk of collision with terrain.
7. If onboard flight recorders are not available to an investigation, this unavailability may preclude the identification and communication of safety deficiencies to advance transportation safety.
Final Report:

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 Dassault Falcon 10 in Toronto

Date & Time: Jun 17, 2011 at 1506 LT
Type of aircraft:
Operator:
Registration:
C-GRIS
Flight Type:
Survivors:
Yes
Schedule:
Toronto-Lester Bowles Pearson - Toronto-Buttonville
MSN:
02
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
7100
Copilot / Total hours on type:
475
Aircraft flight hours:
12697
Circumstances:
Aircraft was on a flight from Toronto-Lester B. Pearson International Airport to Toronto-Buttonville Municipal Airport, Ontario, with 2 pilots on board. Air traffic control cleared the aircraft for a contact approach to Runway 33. During the left turn on to final, the aircraft overshot the runway centerline. The pilot then compensated with a tight turn to the right to line up with the runway heading and touched down just beyond the threshold markings. Immediately after touchdown, the aircraft exited the runway to the right, and continued through the infield and the adjacent taxiway Bravo, striking a runway/taxiway identification sign, but avoiding aircraft that were parked on the apron. The aircraft came to a stop on the infield before Runway 21/03. The aircraft remained upright, and the landing gear did not collapse. The aircraft sustained substantial damage. There was no fire, and the flight crew was not injured. The Toronto-Buttonville tower controller observed the event as it progressed and immediately called for emergency vehicles from the nearby municipality. The accident occurred at 1506 Eastern Daylight Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew flew an unstabilized approach with excessive airspeed.
2. The lack of adherence to company standard operating procedures and crew resource management, as well as the non-completion of checklist items by the flight crew contributed to the occurrence.
3. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to follow the aural GPWS alerts and the missed approach call from the first officer.
4. The non-standard wording and the tone used by the first officer were insufficient to deter the captain from continuing the approach.
5. At touchdown, directional control was lost, and the aircraft veered off the runway with sufficient speed to prevent any attempts to regain control.
Finding as to Risk
1. Companies which do not have ground proximity warning system procedures in their standard operating procedures may place crews and passengers at risk in the event that a warning is received.
Final Report:

Crash of a Rockwell Aero Commander 500B near Armstrong

Date & Time: Nov 30, 2007 at 0917 LT
Operator:
Registration:
C-GETK
Flight Phase:
Survivors:
Yes
Schedule:
Dryden – Geraldton
MSN:
500-1093-56
YOM:
1961
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed from Dryden, Ontario, en route to Geraldton, Ontario. The flight was conducted under visual flight rules at 5500 feet above sea level with ambient temperatures aloft of -33°C. Approximately 40 minutes into the flight, the crew observed an abnormal right engine fuel flow indication. While troubleshooting the right engine, the engine rpm and fuel flow began to decrease and the crew diverted toward Armstrong, Ontario. A short time later, the left engine rpm and fuel flow began to decrease and the crew could no longer maintain level flight. At 0917 central standard time, the crew made a forced landing 20 nautical miles southwest of Armstrong, into a marshy wooded area. The captain sustained serious injuries and the co-pilot and passenger sustained minor injuries. The aircraft was substantially damaged. The crew and passenger were stabilized and transported to Thunder Bay, Ontario, for medical assistance.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Suspended water in the fuel system precipitated out of solution and froze in the fuel distributor valve. This blocked the fuel supply to the fuel nozzles and led to the loss of engine power.
2. The aircraft was being operated without a fuel additive icing inhibiter. Use of such an additive would have inhibited ice formation in the aircraft’s fuel system and would likely have prevented the fuel system blockage.
Findings as to Risk:
1. The fuel distributor valve on the Aero Commander 500B is exposed directly to the cooling blast of the outside air, which under extremely cold conditions, can lead to the freezing of super-cooled water droplets present in the fuel stream.
2. The operator did not have procedures to describe how fuel additive icing inhibiter should be used during winter operations.
Final Report:

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 Short 360-300 in Oshawa

Date & Time: Dec 16, 2004 at 2001 LT
Type of aircraft:
Operator:
Registration:
N748CC
Flight Type:
Survivors:
Yes
Schedule:
Toledo – Oshawa
MSN:
3748
YOM:
1988
Flight number:
SNC2917
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
400
Circumstances:
Air Cargo Carriers, Inc. Flight SNC2917, a Short Brothers SD3-60 aircraft (registration N748CC, serial number SH3748), was on a charter cargo flight from Toledo, Ohio, USA, to Oshawa, Ontario, with two pilots on board. The crew conducted an instrument flight rules approach to Oshawa Municipal Airport in night instrument meteorological conditions. At approximately 2000 eastern standard time, the aircraft landed on Runway 30, which was snow-covered. During the landing roll, the pilot flying noted poor braking action and observed the runway end lights approaching. He rejected the landing and conducted a go-around procedure. The aircraft became airborne, but it started to descend as it flew over lower terrain, striking an airport boundary fence. It continued until it struck rising terrain and then a line of forestation, where it came to an abrupt stop. The flight crew exited the aircraft and waited for rescue personnel to render assistance. The aircraft was substantially damaged, and both pilots sustained serious injuries. There was no post-crash fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
Other Finding:
1. The flight crew members were not advised that the potential Airworthiness Directive announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.
Final Report: