West Wind AT42 at Fond-du-Lac on Dec 13th 2017, descended into terrain shortly after takeoff
Last Update: October 28, 2021 / 17:51:44 GMT/Zulu time
Incident Facts
Date of incident
Dec 13, 2017
Classification
Accident
Airline
West Wind Aviation
Flight number
WEW-282
Departure
Fond-du-Lac, Canada
Destination
Stony Rapids, Canada
Aircraft Registration
C-GWEA
Aircraft Type
ATR ATR-42
ICAO Type Designator
AT42
Royal Canadian Mounted Police reported all occupants have been accounted for and have been taken to hospitals.
On Dec 27th 2017 the family of one of the seriously injured passengers reported, the passenger succumbed to his injuries and died on Dec 27th 2017.
The Canadian TSB have dispatched investigators on site.
On Dec 14th 2017 the TSB reported that both flight data and cockpit voice recorder are being sent to the TSB lab in Ottawa.
On Dec 15th 2017 the TSB reported: "On 13 December 2017, a ATR42-320 operated by West Wind Aviation with 22 passengers and 3 crew on board collided with terrain shortly after take-off from the Fond-du-Lac Airport, Saskatchewan (ZFD) for a flight to Stony Rapids, Saskatchewan (YSF). The aircraft sustained substantial damage. A number of passengers and one crew member sustained serious injuries. The TSB is investigating."
On Dec 16th 2017 the TSB reported that the aircraft lost height and descended into trees and terrain leaving a wreckage trail of 800 feet length. The aircraft came to rest in an upright position steeply tilted to the right, the worst damage occurred to the left side of the airframe, the fuselage ruptured at seat row 3. West Wind have taken all their ATRs out of service for the time being. The French BEA, ATR, Pratt & Whitney are participating in the investigation.
On Dec 20th 2017 the TSB reported 6 passengers and one member of the crew sustained serious injuries, 18 other occupants received minor injuries. Both engines were operating normally up to impact. The flight data and cockpit voice recorders were recovered and sent for analysis.
On Dec 22nd 2017 Transport Canada, Civil Aviation Authority of Canada, suspended the Air Operator Certificate of West Wind stating: "The department took this serious action in the interest of public safety because the department identified deficiencies in the company’s Operational Control System. An Operational Control System ensures that a company’s day-to-day actions are compliant with safety requirements for things such as, for example, the dispatching of personnel and aircraft. On December 13, 2017, a West Wind Aviation aircraft, with 25 people onboard, crashed in Fond-du-Lac, Saskatchewan. Transport Canada identified deficiencies during a post-accident inspection of West Wind Aviation from December 18 to 20, 2017. As a result, in the interest of public safety, Transport Canada suspended West Wind Aviation’s Air Operator Certificate and will not allow the company to resume its commercial air service until it demonstrates compliance with aviation safety regulations."
On Jan 5th 2018 the TSB confirmed one of the passengers died 12 days after the accident. The investigation determined the aircraft collided with trees about 1400 feet (420m) past the runway end during initial climb.
On Apr 24th 2018 the TSB reported the aircraft had encountered icing conditions during the approach to Fond-du-Lac, the crew had activated the anti-icing and de-icing systems on board of the aircraft. After landing, when the anti-icing and de-icing systems were turned off, residual ice remained on portions of the aircraft. Although manual de-icing equipment was available at the terminal, the aircraft departed with ice contamination still present and lost height shortly after takeoff. The manual de-icing equipment available at the terminal consisted of two ladders, a hand-held spray bottle with electric blanekt and wand and a container of de-icing fluid.
Local volunteer fire fighter Raymond Sanger wrote: "Quite a show tonight. Thank to all the helpers rangers. Black lake rescued teams. And everyone that helped out. I guess we’re not alone. We’ve been looked after by garden Engels tonight. And thank you God for being there with us all. All that fuel was like raining. Still nothing happened. FDL. Beautiful team work."
On Oct 28th 2021 the TSB released their final report releasing following findings but not releasing any conclusions to cause(s) or contributing factors:
Findings as to causes and contributing factors
- When West Wind commenced operations into Fond-du-Lac Airport (CZFD) in 2014, no effective risk controls were in place to mitigate the potential hazard of ground icing at CZFD.
- 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.
- Although the aircraft’s ice-protection systems were activated on the approach to CZFD, 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.
- Although the flight crew were aware of the ice, there were no handling anomalies noted on the approach. Consequently, the crew likely did not assess that the residual ice was severe enough to have a significant effect on aircraft performance. Subsequently, without any further discussion about the icing, the crew continued the approach and landed at CZFD.
- Weather conditions on the ground were conducive to ice or frost formation, and this, combined with the nucleation sites provided by the residual mixed ice on the aircraft, resulted in the formation of additional ice or frost on the aircraft’s critical surfaces.
- Because the available inspection equipment was inadequate, the first officer’s ice inspection consisted only of walking around the aircraft on a dimly lit apron, without a flashlight, and looking at the left wing from the top of the stairs at the left rear entry door (L2). As a result, the full extent of the residual ice and ongoing accretion was unknown to the flight crew.
- Departing from remote airports, such as CZFD, 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 the 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.
- 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.
- During the takeoff, despite the degraded performance, the aircraft initially climbed; however, immediately after lift off, 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 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.
- The aircraft collided with the ground in 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 because of the impact angle and the 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.
- On impact, the 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 died.
- The collapse of part of the floor structure compromised the restraint systems, limiting the protection afforded to the occupants when they were experiencing vertical, longitudinal, and lateral forces. This resulted in serious velocity-related injuries and impeded their ability to take post-impact survival actions in a timely manner.
- Most passengers in this occurrence did not brace before impact. Because their torsos were unrestrained, they received injuries consistent with jackknifing and flailing, such as hitting the seat in front of them.
- Given that regulations requiring the use of child-restraint systems have yet to be implemented, the aircraft was not equipped with these devices. As a result, the infant passenger was unrestrained and received flail and crushing injuries.
- 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.
Findings as to risk
- If weather forecasting guidance does not allow for the forecasting of icing that can occur in the absence of precipitation or fog, there is an increased risk that pilots will not have advance warning of foreseeable ground icing conditions.
- If ground icing operations programs do not clearly define a procedure to identify ground icing conditions, flight crews may not initiate inspection and de-icing procedures, increasing the risk of aircraft taking off with contaminated surfaces.
- If guidance material that requires the inspection of aircraft surfaces that are not visible from the ground does not detail a procedure to conduct this inspection, there is a risk that the inspection will not be completed, and surface contamination will go undetected.
- If staff who are aware of deficiencies in de-icing procedures, or the availability of equipment, do not report these hazards through the company’s safety management system, there is a risk that the hazards will not be documented, assessed, and mitigated.
- When a trans-cockpit authority gradient is relatively flat, communications may be less effective and pilots may make erroneous assumptions concerning the other pilot’s situational awareness and decision-making, increasing the risk that hazards to flight will not be identified and addressed by the crew.
- Although threat and error management briefings are helpful, if they are relied upon to mitigate threats or errors that are systemic adaptations, there is a risk that the hazards will continue, especially if the threat itself is non-compliance with the mitigation method.
- If adequate de-icing equipment is unavailable, especially at locations with routine operations, there is a risk that, if ice is detected, the perceived pressure from causing extensive delays may lead flight crews to make adaptations to the clean aircraft concept and depart with contamination on the aircraft’s critical surfaces.
- Until actions are implemented to address the availability of anti-icing and de-icing equipment (TSB Recommendation A18-02) and compliance (TSB Recommendation A18-03), there remains a persistent risk that pilots will not comply with the clean aircraft concept and will continue to take off with contaminated aircraft.
- If the guidance provided to pilots to help them determine when to select take-off icing speeds is not clear and well-defined, flight crews may select a take-off speed or operating weight that will result in the aircraft being unable to meet the minimum performance requirements set by certification standards, thereby increasing the risk of an accident.
- If flight crews do not apply the take-off performance calculation penalties required for contaminated or unpaved runways, they might operate at take-off weights or on runway lengths that do not meet their aircraft’s capabilities, increasing the risk of a runway excursion or accident.
- When the wing collapsed, the integral fuel became uncontained and leaked out, significantly increasing the risk of a post-impact fire at a time when passengers were unable to evacuate.
- Following the wing collapse, the leaked fuel entered the survivable space, and with the outside temperature of approximately −10 °C, the passengers who were soaked in fuel faced an increased risk of hypothermia.
- The collapse also resulted in structural and terrain hazards entering the cabin survivable space. These intrusions increased the risk of injuries for those occupants flailing in their seats during the accident sequence, and also to evacuating passengers who had to climb through the cabin, over seats and hazards, to evacuate the aircraft.
- As shown in this occurrence, on aircraft certified to older standards, there is a risk that displacement of cargo restraint systems and cabin partitions that are positioned adjacent to an evacuation route could impede the evacuation route for survivors.
- If company risk profiles maintained by the regulator are not up to date and accurate, changes in a company’s risk profile may go undetected and surveillance activities might be reduced, allowing unsafe conditions to develop or persist.
- If the regulator does not create and follow a plan for enhanced monitoring, as required by its internal procedures, there is a risk that the enhanced monitoring will be ineffective in helping return companies to regulatory compliance.
- If the application of Transport Canada’s surveillance policies and procedures is inconsistent, there is a risk that resulting oversight will not ensure that operators are able to effectively manage the safety of their operations.
- If Transport Canada’s oversight guidance material for its inspectors is distributed among several different documents, and Transport Canada does not ensure that amendments to this guidance are received and understood, inspectors may not follow the latest guidance, and as a result, will not achieve the intended safety objectives.
- If a company’s safety culture tolerates unsafe practices, there is a risk that these practices will continue and become a company norm.
- If organizations do not adequately identify hazards and analyze risks, potential mitigation methods can be overlooked, increasing the risk of an adverse consequence.
- If mitigations that are determined following risk assessments are not formalized and properly disseminated, they may not be widely implemented in a sustained fashion, increasing the risk of accidents.
Other findings
- Transport Canada’s inconsistent application of its own policies and procedures for the 2016 assessment and post-assessment corrective action plan verifications, as well as the ad hoc approach to enhanced monitoring, resulted in ineffective oversight of an operator that had a history of system-level (i.e., safety management system) and systemic (e.g., operational control) non-compliance issues.
The TSB summarized the sequence of events:
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.
West Wind Aviation currently operates three ATR-42s: C-GWEA, C-GWWD and C-GWWC. On Dec 13th 2017 C-GWEA was seen departing Saskatoon,SK for Prince Albert,SK (Canada), the first segment of flight WEW-280, and departing Prince Albert for Fond-du-Lac, the second segment of flight WEW-280. The aircraft left radar coverage about half way into Fond-du-Lac and has not re-entered radar coverage since.
No weather data are available for Fond-du-Lac, the next station at Stony Rapids, located 41nm east of Fond-du-Lac, showed:
CYSF 140200Z AUTO 30003KT 270V340 9SM -SN OVC019 M09/M11 A3008 RMK SLP210=
CYSF 140125Z AUTO 34005KT 310V010 9SM -SN OVC017 M09/M11 A3008 RMK SLP210=
CYSF 140116Z AUTO 33005KT 300V010 9SM OVC017 M09/M10 A3008 RMK SLP210=
CYSF 140100Z AUTO 30003KT 280V360 9SM -SN OVC017 M09/M10 A3007 RMK SLP209=
CYSF 140051Z AUTO 29004KT 9SM -SN OVC017 M09/M10 A3007 RMK SLP208=
CYSF 140050Z AUTO 29005KT 9SM OVC017 M09/M10 A3007 RMK SLP208=
CYSF 140009Z AUTO 27004KT 9SM -SN OVC019 M09/M10 A3006 RMK SLP203=
CYSF 140000Z AUTO 27004KT 9SM OVC019 M10/M10 A3006 RMK ICG PAST HR SLP203=
CYSF 132355Z AUTO 27004KT 6SM BR BKN017 OVC023 M10/M10 A3006 RMK ICG PAST HR SLP202=
CYSF 132350Z AUTO 28003KT 3SM BR OVC019 M10/M10 A3006 RMK ICG PAST HR SLP202=
CYSF 132347Z AUTO 28003KT 3SM -SN OVC019 M10/M10 A3005 RMK ICG PAST HR SLP201=
CYSF 132341Z AUTO 28003KT 3SM -SN OVC019 M10/M10 A3005 RMK ICG INTMT SLP201=
CYSF 132335Z AUTO 28003KT 2 1/2SM -SN OVC019 M10/M10 A3005 RMK ICG INTMT SLP200=
CYSF 132322Z AUTO 27002KT 2SM -SN FEW014 OVC019 M10/M10 A3005 RMK ICG SLP199=
CYSF 132321Z AUTO 27002KT 3SM -SN FEW014 OVC019 M10/M10 A3005 RMK SLP199=
CYSF 132316Z AUTO 28003KT 4SM BR FEW014 OVC019 M10/M10 A3005 RMK SLP199=
CYSF 132314Z AUTO 27003KT 6SM BR FEW014 OVC021 M10/M10 A3005 RMK SLP200=
CYSF 132305Z AUTO 27003KT 6SM -SN FEW014 OVC021 M10/M10 A3005 RMK SLP200=
CYSF 132300Z AUTO 26003KT 3SM -SN FEW011 OVC021 M10/M10 A3005 RMK SLP199=
CYSF 132256Z AUTO 26003KT 3SM -SN FEW014 OVC021 M10/M10 A3004 RMK SLP198=
CYSF 132254Z AUTO 26003KT 2 1/2SM -SN FEW014 BKN023 OVC037 M10/M10 A3004 RMK SLP198=
CYSF 132240Z AUTO 28002KT 2 1/4SM -SN FEW013 OVC023 M10/M10 A3004 RMK SLP197=
CYSF 132236Z AUTO VRB02KT 2 1/2SM -SN FEW013 OVC023 M10/M10 A3004 RMK SLP197=
CYSF 132235Z AUTO VRB02KT 2 1/2SM -SN FEW013 OVC025 M10/M10 A3004 RMK SLP197=
CYSF 132219Z AUTO 29002KT 5SM -SN OVC027 M10/M11 A3004 RMK SLP197=
CYSF 132210Z AUTO 28005KT 9SM -SN OVC027 M10/M11 A3004 RMK SLP196=
CYSF 132200Z AUTO VRB02KT 9SM FEW012 OVC029 M10/M11 A3003 RMK SLP194=
CYSF 132146Z AUTO 29003KT 270V340 9SM SCT012 OVC031 M10/M11 A3003 RMK SLP192=
CYSF 132102Z AUTO 29003KT 7SM -SN SCT046 BKN060 OVC070 M10/M11 A3000 RMK SLP185=
CYSF 132100Z AUTO 28003KT 5SM -SN SCT044 BKN055 OVC070 M10/M11 A3000 RMK SLP183=
CYSF 132047Z AUTO 26003KT 5SM -SN BKN037 BKN055 OVC071 M10/M11 A3000 RMK SLP183=
CYSF 132042Z AUTO 25002KT 9SM -SN BKN039 BKN055 OVC073 M10/M11 A3000 RMK SLP182=
CYSF 132027Z AUTO 00000KT 9SM BKN036 BKN075 M10/M11 A3000 RMK SLP182=
CYSF 132000Z AUTO 00000KT 9SM -SN BKN038 OVC070 M10/M11 A3000 RMK SLP183=
Aircraft Registration Data
Aircraft registration data reproduced and distributed with the permission of the Government of Canada.
Incident Facts
Date of incident
Dec 13, 2017
Classification
Accident
Airline
West Wind Aviation
Flight number
WEW-282
Departure
Fond-du-Lac, Canada
Destination
Stony Rapids, Canada
Aircraft Registration
C-GWEA
Aircraft Type
ATR ATR-42
ICAO Type Designator
AT42
This article is published under license from Avherald.com. © of text by Avherald.com.
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