Ground fire of a De Havilland DHC-2 Beaver off Minstrel Island

Date & Time: Aug 1, 2001
Type of aircraft:
Registration:
C-GNWS
Survivors:
Yes
MSN:
1382
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
he float-equipped aircraft had landed at Minstrel Island and was taxiing to the dock when the pilot of a company aircraft that was following C-GNWS to the dock radioed that he saw smoke coming from the lower right area of C-GNWS's engine cowling. The pilot of C-GNWS docked the aircraft, unloaded the three passengers and emptied a fire extinguisher onto the burning aircraft. The fire was not extinguished and the aircraft was pushed away from the dock where it burnt to the water.

Crash of a De Havilland DHC-2 Beaver near Nestor Falls: 1 killed

Date & Time: Jul 7, 2001 at 1530 LT
Type of aircraft:
Registration:
C-FNFO
Flight Phase:
Survivors:
No
Schedule:
Kakabikitchiwan Lake - Aremis Lake
MSN:
819
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1500
Captain / Total hours on type:
1300.00
Aircraft flight hours:
11843
Circumstances:
A de Havilland DHC-2 Beaver seaplane, registration C-FNFO, serial number 819, departed from Kakabikitchiwan Lake, Ontario, on a visual flight rules flight for Aremis Lake with only the pilot on board. Shortly after take-off, the aircraft was observed flying northbound at a very low altitude above Sabaskong Bay with the engine operating at a high power setting. The aircraft started to climb and bank to the left. The right wing struck the lower of two electrical wires strung across a channel between two islands. The aircraft was destroyed; the pilot sustained fatal injuries.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The power line running overhead the channel was invisible, except at very short range, and was not marked to indicate its presence.
2. The pilot was flying at a very low altitude and likely did not see the power line.
Findings as to Risk:
1. The Standards Obstruction Markings Manual allows for discretion in deciding whether to assess obstructions, making it possible for some obstructions to not be assessed and, consequently, to not be marked.
Final Report:

Crash of a Piper PA-31-310 Navajo in Charlottetown: 3 killed

Date & Time: Jun 5, 2001 at 1621 LT
Type of aircraft:
Operator:
Registration:
C-GMTT
Flight Phase:
Survivors:
Yes
Schedule:
Gander – Charlottetown – Natuashish
MSN:
31-7712004
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2085
Captain / Total hours on type:
185.00
Circumstances:
The flight took off on Runway 22 at Gander, Newfoundland and Labrador, at 1428 Newfoundland daylight time with the pilot and four passengers on board. Their destination was Sango Bay, Newfoundland and Labrador, with an intermediate stop in Charlottetown, Newfoundland and Labrador, to drop off one of the passengers. Radar data show that, on departure from Gander, the aircraft climbed at about 500 feet per minute at 125 knots ground speed to 2500 feet, then descended and proceeded en route to Charlottetown at 1900 feet and 150 knots. The aircraft landed at Charlottetown at 1615. After a brief stop, the flight continued to Sango Bay. The pilot broadcast his intention to take off on Runway 10, taxied the aircraft to the threshold of the runway, and commenced the take-off roll. Part-way down the runway, the pilot aborted the take-off. He then broadcast his intention to take off on Runway 28. Both radio broadcasts were acknowledged by a local pilot who was approaching the airport to land. Upon reaching the threshold of Runway 28, the aircraft turned and accelerated, without stopping, on the take-off roll. The aircraft lifted off shortly before the runway end and remained near treetop height until disappearing from view. After lift-off, the stall warning horn sounded intermittently until impact. The aircraft was unable to climb above the hilly terrain and struck the road 1.5 nautical miles from the departure end of the runway. A passing motorist spotted the downed aircraft and notified firefighters and medical personnel who were then dispatched to the scene. The accident occurred at about 1621 during daylight hours, at 58°45' N, 55°66' W, at 440 feet above sea level.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was over the maximum allowable take-off weight throughout its journey, reducing aircraft performance: the pilot apparently did not complete weight and balance calculations for
either of the flights.
2. The pilot did not use the proper short field take-off technique, and the aircraft was forced into the air before reaching sufficient flying speed.
3 The best angle of climb speed was not attained.
4. The unsecured cargo, some of which was found on top of the back of the rear passenger seat, most probably contributed to the severity of the injuries to the passenger in this seat.
Final Report:

Crash of a Boeing 737-210C in Yellowknife

Date & Time: May 22, 2001 at 1325 LT
Type of aircraft:
Operator:
Registration:
C-GNWI
Survivors:
Yes
Schedule:
Edmonton – Yellowknife
MSN:
21066
YOM:
1975
Flight number:
7F953
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
98
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16400
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
9500
Copilot / Total hours on type:
840
Circumstances:
First Air Flight 953, a Boeing 737-210C, serial number 21066, was on a scheduled flight from Edmonton, Alberta, to Yellowknife, Northwest Territories. On board were 2 flight crew, 4 cabin crew, and 98 passengers. The flight departed Edmonton at 1130 mountain daylight time, with an estimated time en route of 1 hour 35 minutes. As the aircraft approached Yellowknife, the spoilers were armed, and the aircraft was configured for a visual approach and landing on Runway 33. The computed Vref was 128 knots, and target speed was 133 knots. While in the landing flare, the aircraft entered a higher-than-normal sink rate, and the pilot flying (the first officer) corrected with engine power and nose-up pitch. The aircraft touched down on the main landing gear and bounced twice. While the aircraft was in the air, the captain took control and lowered the nose to minimize the bounce. The aircraft landed on its nose landing-gear, then on the main gear. The aircraft initially touched down about 1300 feet from the approach end of Runway 33. Numerous aircraft rubber scrub marks were present in this area and did not allow for an accurate measurement. During the third touchdown on the nose landing-gear, the left nose-tire burst, leaving a shimmy-like mark on the runway. The aircraft was taxied to the ramp and shut down. The aircraft was substantially damaged. There were no reported injuries to the crew or the passengers. The accident occurred at 1325, during the hours of daylight.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Incorrect bounced landing recovery procedures were carried out when the captain pushed forward on the control column to prevent a further bounce, and the aircraft landed nosewheel first.
2. The high sink rate on the initial flare was not recognized and corrected in time to prevent a bounced landing and a subsequent bounced landing.
Other Findings:
1. The power increase during the flair resulted in the speedbrake/spoilers retracting.
2. The captain had not received a line check of at least three sectors before returning to flight duties, although this check was required to regain competency after pilot proficiency check expiry.
Final Report:

Crash of a Beechcraft A100 King Air in Grande Prairie

Date & Time: Apr 7, 2001 at 0512 LT
Type of aircraft:
Operator:
Registration:
C-FWPN
Survivors:
Yes
Schedule:
Fort Saint John – Grande Prairie
MSN:
B-51
YOM:
1970
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Fort Saint John, the crew started a night approach to Grande Prairie Airport. The aircraft landed slightly to the left of the runway centerline. After touchdown on a snow covered runway (about two inches of snow), the left wing struck a windrow of snow. Out of control, the aircraft veered off runway and came to rest in snow. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Boeing 737-2E1F in Saint John's

Date & Time: Apr 4, 2001 at 0615 LT
Type of aircraft:
Operator:
Registration:
C-GDCC
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Montréal – Halifax – Saint John’s
MSN:
20681
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At 2320, Newfoundland daylight time, on 03 April 2001, the Royal Cargo flight, a Boeing 737-200, left Mirabel, Quebec, for a scheduled instrument flight rules cargo flight with two pilots on board. The flight was headed for Hamilton, Ontario; Mirabel; Halifax, Nova Scotia; St. John's, Newfoundland; and Mirabel. The flights from Mirabel to Halifax were uneventful. Before departure from Halifax, the pilot flying (PF) received the latest weather information for the flight to St. John's from the company dispatch; he did not ask for, or receive, the latest notices to airmen (NOTAMs). At 0545, the aircraft departed Halifax for St. John's. The PF was completing his line indoctrination training after having recently upgraded to captain. The training captain, who was the pilot not flying (PNF), occupied the right seat. After departure from Halifax, he contacted Halifax Flight Service Station (FSS) and received the latest weather report for St. John's, the 0530 aviation routine weather report (METAR). The weather was as follows: wind 050° magnetic (M) at 35, gusting to 40, knots; visibility 1 statute mile in light snow and blowing snow; ceiling 400 feet overcast; temperature -1°C; dew point -2°C; and altimeter 29.41 inches of mercury. The FSS passed runway surface condition (RSC) reports for both runways (11/29 and 16/34), including Canadian runway friction index (CRFI) readings of 0.25 for Runway 11/29 and 0.24 for Runway 16/34. The FSS specialist also provided the NOTAMs for St. John's, which included a NOTAM released more than five hours earlier advising of the unserviceability of the instrument landing system (ILS) for Runway 11. The flight crew had initially planned an ILS approach, landing on Runway 11 at St. John's. Because of the marginal weather, the loss of Runway 11/29, and his greater experience, the training captain decided to switch seats and assume the duties and full responsibilities as captain and PF. Returning to Halifax was not considered because the aircraft would be overweight for landing there. The option of diverting the flight to the alternate airport was also discussed by the crew; however, in the end, they felt that a safe landing was achievable in St. John's. At 0638:27, the PF contacted St. John's tower to ask if the approach to Runway 34 was still an option. The response indicated that Runway 34 was probably the only option because of the wind: 050°M (estimated) at 35, gusting to 40, knots. The ILS on Runway 11 was unserviceable, and the glidepath for Runway 29 was unserviceable. The only instrument approaches available were the localizer back course Runway 34 and the ILS Runway 16. Also, at about 0638, the Gander Area Control Centre (ACC) controller suggested to the crew that they obtain the 0630 automatic terminal information service (ATIS) for St. John's. The ATIS was reporting surface winds of 055°M at 20, gusting to 35, knots. The PNF attempted to obtain the ATIS information; however, because of a simultaneous radio transmission on the second VHF radio between the PF and St. John's tower, the ATIS information was not obtained. At 0641, the PNF contacted Gander ACC, which reported the winds at St. John's as 040°M at 13, gusting to 18, knots. The PNF pointed out the discrepancy in the two wind reports to the PF; however, there was no acknowledgement of the significance of the discrepancy. It was later determined that the discrepancy was an unserviceable anemometer at the St. John's airport due to ice accretion on the anemometer. The anemometer was providing a direct reading of the incorrect wind information to Gander ACC. Gander ACC was unaware of the unserviceability and unknowingly passed the incorrect wind information on to the flight crew. At 0644, Gander ACC transmitted a significant meteorological report (SIGMET), issued at 0412 and valid from 0415 to 0815, that included St. John's. The SIGMET forecast severe mechanical turbulence below 3000 feet due to surface wind gusts in excess of 50 knots. However, the crew may not have been listening to the SIGMET broadcast: while the ACC transmitted the SIGMET, the crew were discussing the application of an 18-knot quartering tailwind for the approach to Runway 16. This tailwind was well under the 50 knots described by the SIGMET. The crew did not acknowledge receipt of the SIGMET until prompted by the controller. Before the descent into St. John's, the crew discussed approach options. The approach to Runway 11 was discounted because of the unserviceability of the ILS, and Runway 34 was eliminated as an option because the weather was below its published approach minimums. The crew discussed the ILS approach to Runway 16. Although the PNF expressed concern about the tailwind, it was decided to attempt the approach because the wind reported by Gander ACC was within the aircraft's landing limits. In calculating the approach speed in preparation for the approach, there was confusion during the application of the tailwind and gust corrections to the landing reference speed (Vref ). The crew had correctly established a flap-30 Vref of 132 knots indicated airspeed (KIAS) and ultimately an approach speed of 142 KIAS. The approach speed calculations were derived using the incorrect wind information from Gander ACC; further, the crew added five knots for the gust increment to the nominal approach speed (Vref + 5 knots), that is, Vref + 10 knots. This incorrect calculation (adding the gust factor) was consistent with company practice at the time of the accident. During the descent, the crew also had difficulty completing the descent and approach checklists; there were several missteps and repeated attempts at completion of checks. Clearance for an ILS approach to Runway 16 was obtained from Gander ACC , and the crew was advised to contact St. John's tower. Just over two minutes before landing, the tower advised that the wind was 050°M (estimated) at 20, gusting to 35, knots and provided the following RSC report for Runway 16: Full length 170 feet wide, surface 30% very light dusting of snow and 70% compact snow and ice; remainder is 20% light snow, 80% compact snow and ice, windrow along the east side of the runway; friction index 0.20; and temperature -1°C at 0925. The aircraft crossed the final approach fix on the ILS glideslope at 150 KIAS. During the final approach, the airspeed steadily increased to 180 KIAS (ground speed 190 knots); the glidepath was maintained with a descent rate of 1000 feet per minute. From 1000 feet above sea level, no airspeed calls were made; altitude calls were made and responses were made. The Royal Boeing 737 operations manual states that the PNF shall call out significant deviations from programmed airspeed. In the descent, through 900 feet above sea level, the aircraft encountered turbulence resulting in uncommanded roll and pitch deviations and airspeed fluctuations of +/- 11 knots. At about 300 feet above decision height, the crew acquired visual references for landing. Approximately one minute before landing, St. John's tower transmitted the runway visual range, repeated the estimated surface wind (050°M [estimated] at 20, gusting to 35, knots), and issued a landing clearance to the aircraft; the PNF acknowledged this information. The aircraft touched down at 164 KIAS (27 KIAS above the desired touchdown speed of Vref), 2300 to 2500 feet beyond the threshold. Radar ground speed at touchdown was 180 knots. The wind at this point was determined to be about 050°M at 30 knots. Shortly after touchdown, the speed brakes and thrust reversers were deployed, and an engine pressure ratio (EPR) of 1.7 was reached 10 seconds after touchdown. Longitudinal deceleration was -0.37g within 1.3 seconds of touchdown, suggesting that a significant degree of effective wheel braking was achieved. With approximately 1100 feet of runway remaining, through a speed of 64 KIAS, reverse thrust increased to about 1.97 EPR on engine 1 and 2.15 EPR on engine 2. As the aircraft approached the end of the runway, the captain attempted to steer the aircraft to the right, toward the Delta taxiway intersection. Twenty-two seconds after touchdown, the aircraft exited the departure end of the runway into deep snow. The aircraft came to rest approximately 75 feet beyond and 53 feet to the right of the runway centreline on a heading of 235°M.
Probable cause:
Findings as to Causes and Contributing Factors:
1. A combination of excessive landing speed, extended touchdown point, and low runway friction coefficient resulted in the aircraft overrunning the runway.
Findings as to Risk:
1. Before departure from Halifax, the flight crew did not request nor did dispatch personnel inform the crew of the notice to airmen (NOTAM) advising of the instrument landing system's failure for Runway 11 at St. John's International Airport.
2. The St. John's dynamic wind information provided to the Gander Area Control Centre controller was inaccurate. The controller was not aware of this inaccuracy.
3. The crew applied tailwind corrections in accordance with company practices; however, these practices were not in accordance with those stated in the operations manual.
Final Report: