Canada

The Sky Lease Cargo Boeing 747-412F aircraft (U.S. registration N908AR, serial number 28026) was conducting flight 4854 (KYE4854) from Chicago/O’Hare International Airport, Illinois, U.S., to Halifax/Stanfield International Airport, Nova Scotia, with 3 crew members, 1 passenger, and no cargo on board. The crew conducted the Runway 14 instrument landing system approach. When the aircraft was 1 minute and 21 seconds from the threshold, the crew realized that there was a tailwind; however, they did not recalculate the performance data to confirm that the landing distance available was still acceptable, likely because of the limited amount of time available before landing. The unexpected tailwind resulted in a greater landing distance required, but this distance did not exceed the length of the runway. The aircraft touched down firmly at approximately 0506 Atlantic Standard Time, during the hours of darkness. After the firm touchdown, for undetermined reasons, the engine No. 1 thrust lever was moved forward of the idle position, causing the speed brakes to retract and the autobrake system to disengage, increasing the distance required to bring the aircraft to a stop. In addition, the right crab angle (4.5°) on initial touchdown, combined with the crosswind component and asymmetric reverser selection, caused the aircraft to deviate to the right of the runway centreline. During the landing roll, the pilot monitoring’s attention was focused on the lateral drift and, as a result, the required callouts regarding the position of the deceleration devices were not made. Although manual brake application began 8 seconds after touchdown, maximum braking effort did not occur until 15 seconds later, when the aircraft was 800 feet from the end of the runway. At this position, it was not possible for the aircraft to stop on the runway and, 5 seconds later, the aircraft departed the end of the runway at a speed of 77 knots and came to a stop 270 m (885 feet) past the end. The aircraft struck the approach light stanchions and the localizer antenna array. The No. 2 engine detached from its pylon during the impact sequence and came to rest under the left horizontal stabilizer, causing a fire in the tail section following the impact. The emergency locator transmitter activated. Aircraft rescue and firefighting personnel responded. All 3 crew members received minor injuries and were taken to the hospital. The passenger was not injured. During the overrun, the aircraft crossed a significant drop of 2.8 m (9 feet) approximately 166 m (544 feet) past the end of the runway and was damaged beyond repair.

The vintage de Havilland DH-89A MKIV Dragon Rapide biplane (U.S. registration N683DH, serial number 6782) operated by Historic Flight Foundation was part of the static aircraft display at the Abbotsford International Airshow at Abbotsford Airport (CYXX), British Columbia. Following the conclusion of the airshow that day, the aircraft was being used to provide air rides. At approximately 1731 on 11 August 2018, the aircraft began its takeoff from Runway 25 with the pilot and 4 passengers on board for a local flight to the southeast. During the takeoff, the aircraft encountered strong, gusting crosswinds. It climbed to about 30 feet above ground level before descending suddenly and impacting the runway, coming to rest on its nose immediately off the right edge of the runway. Within 2 minutes, 2 aircraft rescue firefighting trucks arrived on the scene along with an operations/command vehicle. About 10 minutes later, 2 St. John Ambulances arrived. A representative of the HFF was escorted to the scene to ensure all electronics on the aircraft were turned off. Shortly thereafter, 2 BC Ambulance Service ground ambulances arrived, followed by 2 City of Abbotsford fire trucks. Two BC Ambulance Service air ambulances arrived after that. The fire trucks stabilized the aircraft, and the first responders who arrived with the fire truck finished evacuating the occupants. The pilot and 1 passenger received serious injuries; the other 3 passengers received minor injuries. All of the aircraft occupants were taken to the hospital. The aircraft was substantially damaged. There was a fuel spill, but no fire. The emergency locator transmitter activated.

On 01 August 2018, after completing 2 hours of survey work near Penticton, British Columbia (BC), an Aries Aviation International Piper PA-31 aircraft (registration C-FNCI, serial number 31-8112007) proceeded on an instrument flight rules flight plan from Penticton Airport (CYYF), BC, to Calgary/Springbank Airport (CYBW), Alberta, at 15 000 feet above sea level. The pilot and a survey technician were on board. When the aircraft was approximately 40 nautical miles southwest of CYBW, air traffic control began sequencing the aircraft for arrival into the Calgary airspace and requested that the pilot slow the aircraft to 150 knots indicated airspeed and descend to 13 000 feet above sea level. At this time, the right engine began operating at a lower power setting than the left engine. About 90 seconds later, at approximately 13 500 feet above sea level, the aircraft departed controlled flight. It collided with terrain near the summit of Mount Rae at 1336 Mountain Daylight Time. A brief impact explosion and fire occurred during the collision with terrain. The pilot and survey technician both received fatal injuries. The Canadian Mission Control Centre received a 406 MHz emergency locator transmitter signal from the occurrence aircraft and notified the Trenton Joint Rescue Coordination Centre. Search and rescue arrived on site approximately 1 hour after the accident.

Weather conditions at Abbotsford at the time of departure consisted of a temperature of -2°C in moderate to heavy snowfall with winds of approximately 10 knots. Prior to the departure, the fuel tanks were filled to capacity and the pilot and passengers boarded the aircraft inside the operator's heated hangar. The aircraft was towed outside of the hangar without being treated with anti-ice fluid, and taxied for the departure on runway 07. Due to an inbound arrival at Abbotsford, C-GIAE was delayed for departure. Once cleared for takeoff, the aircraft had been exposed to snow and freezing conditions for approximately 14 minutes. After becoming airborne, the aircraft experienced power and control issues shortly after the landing gear was retracted. The aircraft collided with terrain within the airport perimeter. Four passengers and the pilot sustained serious injuries as a result of the accident which destroyed the aircraft.

On 13 December 2017, an Avions de Transport Régional ATR 42-320 aircraft (registration C-GWEA, serial number 240), operated by West Wind Aviation L.P. (West Wind), was scheduled for a series of instrument flight rules flights from Saskatoon through northern Saskatchewan as flight WEW282. When the flight crew and dispatcher held a briefing for the day’s flights, they became aware of forecast icing along the route of flight. Although both the flight crew and the dispatcher were aware of the forecast ground icing, the decision was made to continue with the day’s planned route to several remote airports that had insufficient de-icing facilities. The aircraft flew from Saskatoon/John G. Diefenbaker International (CYXE) to Prince Albert (Glass Field) Airport (CYPA) without difficulty, and, after a stop of about 1 hour, proceeded on toward Fond-du-Lac Airport (CZFD). On approach to Fond-du-Lac Airport, the aircraft encountered some in-flight icing, and the crew activated the aircraft’s anti-icing and de-icing systems. Although the aircraft’s ice protection systems were activated, the aircraft’s de-icing boots were not designed to shed all of the ice that can accumulate, and the anti-icing systems did not prevent ice accumulation on unprotected surfaces. As a result, some residual ice began to accumulate on the aircraft. The flight crew were aware of the ice; however, there were no handling anomalies noted during the approach. Consequently, they likely did not assess that the residual ice was severe enough to have a significant effect on aircraft performance. The crew continued the approach and landed at Fond-du-Lac Airport at 1724 Central Standard Time. According to post-accident analysis of the data from the flight data recorder, the aircraft’s drag and lift performance was degraded by 28% and 10%, respectively, shortly before landing at Fond-du-Lac Airport. This indicated that the aircraft had significant residual ice adhering to its structure upon arrival. However, this data was not available to the flight crew at the time of landing. The aircraft was on the ground at Fond-du-Lac Airport for approximately 48 minutes. The next flight was destined for Stony Rapids Airport (CYSF), Saskatchewan, with 3 crew members (2 pilots and 1 flight attendant) and 22 passengers on board. Although there was no observable precipitation or fog while the aircraft was on the ground, weather conditions were conducive to ice or frost formation. This, combined with the residual mixed ice on the aircraft, which acted as nucleation sites that allowed the formation of ice crystals, resulted in the formation of additional ice or frost on the aircraft’s critical surfaces. Once the passengers had boarded the aircraft, the first officer completed an external inspection of the aircraft. However, because the available inspection equipment was inadequate, the first officer’s ice inspection consisted only of walking around the aircraft and looking at the left wing from the top of the stairs at the left rear door, without the use of a flashlight on the dimly lit apron. Although he was unaware of the full extent of the ice and the ongoing accretion, the first officer did inform the captain that there was some ice on the aircraft. The captain did not inspect the aircraft himself, nor did he attempt to have it de-iced; rather, he and the first officer continued with departure preparations. Company departures from remote airports, such as Fond-du-Lac, with some amount of surface contamination on the aircraft’s critical surfaces had become common practice, in part due to the inadequacy of de-icing equipment or services at these locations. The past success of these adaptations resulted in this unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart. Although the flight crew were aware of icing on the aircraft’s critical surfaces, they decided that the occurrence departure could be accomplished safely. Their decision to continue with the original plan to depart was influenced by continuation bias, as they perceived the initial and sustained cues that supported their plan as more compelling than the later cues that suggested another course of action. At 1812 Central Standard Time, in the hours of darkness, the aircraft began its take-off roll on Runway 28, and, 30 seconds later, it was airborne. As a result of the ice that remained on the aircraft following the approach and the additional ice that had accreted during the ground stop, the aircraft’s drag was increased by 58% and its lift was decreased by 25% during the takeoff. Despite this degraded performance, the aircraft initially climbed; however, immediately after liftoff, the aircraft began to roll to the left without any pilot input. This roll was as a result of asymmetric lift distribution due to uneven ice contamination on the aircraft. Following the uncommanded roll, the captain reacted as if the aircraft was an uncontaminated ATR 42, with the expectation of normal handling qualities and dynamic response characteristics; however, due to the contamination, the aircraft had diminished roll damping resulting in unexpected handling qualities and dynamic response. Although the investigation determined that the ailerons had sufficient roll control authority to counteract the asymmetric lift, due to the unexpected handling qualities and dynamic response, the roll disturbance developed into an oscillation with growing magnitude and control in the roll axis was lost. This loss of control in the roll axis, which corresponds with the known risks associated with taking off with ice contamination, ultimately led to the aircraft colliding with terrain 17 seconds after takeoff. The aircraft collided with the ground in a relatively level pitch, with a bank angle of 30° left. As a result of the sudden vertical deceleration upon contact with the ground, the aircraft suffered significant damage, which varied in severity at different locations on the aircraft due to impact angle and variability in structural design. The design standards for transport category aircraft in effect at the time the ATR 42 was certified did not specify minimum loads that a fuselage structure must be able to tolerate and remain survivable, or minimum loads for fuselage impact energy absorption. As a result, the ATR 42 was not designed with these crashworthy principles in mind. The main landing gear at the bottom of the centre fuselage section was rigid, and, on impact, did not absorb or attenuate much of the load. The impact-induced acceleration was not attenuated because the landing gear housing did not deform. This unattenuated acceleration resulted in a large inertial load from the wing, causing the wing support structure to fail and the wing to collapse into the cabin. The reduced survivable space between the floor above the main landing gear and the collapsed upper fuselage caused crushing injuries, such as major head, body, and leg trauma, to passengers in the middle-forward left section of the aircraft. Of the 3 passengers in this area, 2 experienced, serious life-changing injuries, and 1 passenger subsequently died. The collapse of part of the floor structure compromised the restraint systems, limiting the protection afforded to the aircraft occupants when they were experiencing vertical, longitudinal, and lateral forces. This resulted in serious velocity-related injuries and impeded their ability to take post-crash survival actions in a timely manner. Unaware of the danger, most passengers in this occurrence did not brace for impact. Because their torsos were unrestrained, they received injuries consistent with jackknifing and flailing, such as hitting the seat in front of them. As a result of unapproved repairs, the flight attendant seat failed on impact, resulting in injuries that impeded her ability to perform evacuation and survival actions in a timely manner. Although the TSB has previously recommended the development and use of child restraints aboard commercial aircraft, planned regulations have yet to be implemented by Transport Canada. As a result, the occurrence aircraft was not equipped with these devices, and an infant passenger who was unrestrained received flailing and crushing injuries during the accident sequence. By the time the aircraft came to a rest, all occupants had received injuries. Passengers began to call for help within minutes of the impact, using their cell phones. Numerous people from the nearby community received the messages and quickly set out to help. The passengers and crew began to evacuate, but they experienced significant difficulties as a result of the aircraft damage. It took approximately 20 minutes for the first 17 passengers to evacuate, and the remaining passengers much longer; it took as long as 3 hours to extricate 1 passenger, who required rescuer assistance. As a result of the accident, 9 passengers and 1 crew member received serious injuries, and the remaining 13 passengers and 2 crew members received minor injuries. One of the passengers who had received serious injuries died 12 days after the accident. There was no post-impact fire, and the emergency locator activated on impact.

On 02 November 2017, a Perimeter Aviation LP Fairchild SA227-AC Metro III (serial number AC-756B, registration C-FLRY) was operating as flight 959 (PAG959) from Gods River Airport, Manitoba, to Thompson Airport, Manitoba, with 2 flight crew members on board. When the aircraft was approximately 40 nautical miles southeast of Thompson Airport, the crew informed air traffic control that they had received a low oil pressure indication on the left engine that might require the engine to be shut down. The crew did not declare an emergency, but aircraft rescue and firefighting services were put on standby. After touchdown on Runway 24 with both engines operating, the aircraft suddenly veered to the right and exited the runway. The aircraft came to rest in snow north of the runway. The captain and first officer exited the aircraft through the left side over-wing emergency exit and were taken to hospital with minor injuries. The aircraft was substantially damaged. The 406-MHz emergency locator transmitter did not activate. The occurrence took place during the hours of darkness, at 1920 Central Daylight Time.

The twin engine airplane departed North Bay on an ambulance flight to Arnprior, carrying two pilots and a doctor. Following an uneventful flight, the crew was cleared for a VOR/DME approach to runway 28 under VFR conditions. On short final, the aircraft descended too low and impacted ground 50 metres short of runway. Upon impact, the nose gear collapsed and the airplane slid for about 600 metres before coming to rest. All three occupants evacuated safely and the aircraft was damaged beyond repair.

The Piper PA-31 (registration C-FQQB, serial number 31-310) operated by Exact Air Inc., with 2 pilots on board, was conducting its 2nd magnetometric survey flight of the day, from Schefferville Airport, Quebec, under visual flight rules. At 1336 Eastern Daylight Time, the aircraft took off and began flying toward the survey area located 90 nautical miles northwest of the airport. After completing the magnetometric survey work at 300 feet above ground level, the aircraft began the return flight segment to Schefferville Airport. At that time, the aircraft descended and flew over the terrain at an altitude varying between 100 and 40 feet above ground level. At 1756, while the aircraft was flying over railway tracks, it struck power transmission line conductor cables and crashed on top of a mine tailings deposit about 3.5 nautical miles northwest of Schefferville Airport. Both occupants were fatally injured. The accident occurred during daylight hours. Following the impact, there was no fire, and no emergency locator transmitter signal was captured.

During the takeoff roll from runway 05 at Saint-Frédéric Airport, the twin engine deviated to the left. The pilot-in-command elected to correct the deviation and to maintain the airplane on the runway centerline but it veered off runway to the left and came to rest in the snow. Both pilots evacuated safely and the aircraft was damaged beyond repair.

The pilot and 3 passengers boarded the aircraft. At 2126, the pilot obtained an IFR clearance from the CYLW ground controller for the KELOWNA SEVEN DEP standard instrument departure (SID) procedure for Runway 34. The instructions for the runway 34 KELOWNA SEVEN DEP SID were to climb to 9000 feet ASL, or to an altitude assigned by air traffic control (ATC), and to contact the Vancouver Area Control Centre (ACC) after passing through 4000 feet ASL. The aircraft was then to climb and track 330° magnetic (M) inbound to the Kelowna non-directional beacon (LW). From LW, the aircraft was to climb and track 330°M outbound for vectors to the filed or assigned route. At 2127, C-GTNG began to taxi toward Runway 34. At 2131, the CYLW tower controller cleared the aircraft to take off from the intersection of Runway 34 and Taxiway D. The pilot acknowledged the clearance and began the take-off roll on Runway 34 about 1 minute later. Radar data showed that, at 2133:41, the aircraft was 0.5 nautical miles (nm) beyond the departure end of the runway and was climbing at more than 4000 feet per minute (fpm) through 2800 feet ASL, at a climb angle of approximately 16°. In that time, it had deviated laterally by about 3° to the right of the 330°M track associated with the SID. At 2134:01, when the aircraft was 1.2 nm beyond the runway, it had climbed through 3800 feet ASL and deviated further to the right of the intended routing. The aircraft’s rate of climb decreased to about 1600 fpm, and its ground speed was 150 knots. A short time later, the aircraft’s rate of climb decreased to 600 fpm, its climb angle decreased to 2°, and its ground speed had increased to 160 knots. At 2134:22, the aircraft was 2.1 nm beyond the departure end of the runway, and it was climbing through approximately 4800 feet ASL. The aircraft had deviated about 13° to the right of the intended track, and its rate of climb reached its maximum value of approximately 000 fpm, 3 with a climb angle of about 22°. The ground speed was roughly 145 knots. At 2134:39, the aircraft was 2.7 nm beyond the departure end of the runway, passing through 5800 feet ASL, and had deviated about 20° to the right of the intended routing. The rate of climb was approximately 2000 fpm, with a climb angle of about 7°. According to the SID, the pilot was to make initial contact with the ACC after the aircraft had passed through 4000 feet ASL.Initial contact was made when the aircraft was passing through 6000 feet ASL, at 2134:42. At 2134:46, the ACC acknowledged the communication and indicated that the aircraft had been identified on radar. The aircraft was then cleared for a right turn direct to the MENBO waypoint once it was at a safe altitude, or once it was climbing through 8000 feet ASL. The aircraft was also cleared to follow the flight-planned route and climb to 10 000 feet ASL. At 2134:55, the pilot read back the clearance as the aircraft climbed through 6400 feet ASL, with a rate of climb of approximately 2400 fpm. The aircraft was tracking about 348°M at a ground speed of about 170 knots. At 2135:34, the aircraft began a turn to the right, which was consistent with the instruction from the ACC. Flying directly to the MENBO waypoint required the aircraft to be on a heading of 066°M, requiring a right turn of about 50°. At this point, the aircraft was still climbing and was passing through 8300 feet ASL. The rate of climb was about 3000 fpm. The aircraft continued the right turn and was tracking through 085°M. After reaching a peak altitude of approximately 8600 feet ASL, the aircraft entered a steep descending turn to the right, consistent with the characteristics of a spiral dive. At 2135:47, the ACC controller cleared C-GTNG to climb to FL 250. The lack of radar returns and radio communications from the aircraft prompted the controller to initiate search activities. At 2151, NAV CANADA notified first responders, who located the accident site in forested terrain at about midnight. The aircraft had been destroyed, and all of the occupants had been fatally injured.