Perimeter SW4 at Sanikiluaq on Dec 22nd 2012, runway overrun on second approach

Last Update: July 1, 2015 / 15:25:36 GMT/Zulu time

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Incident Facts

Date of incident
Dec 22, 2012


Aircraft Registration

ICAO Type Designator

A Perimeter Aviation Swearingen SA-227 Metro III on behalf of Keewatin Air, registration C-GFWX performing charter flight 4B-993 from Winnipeg,MB to Sanikiluaq,NU (Canada) with 7 passengers and 2 crew, had gone around and was on its second final approach to Sanikiluaq's runway 27 when the aircraft touched down hard and overran the runway coming to a rest south of the runway about 150-200 meters past the end of the runway at 18:13L (23:13Z). An infant, 6 months old boy, amongst the passengers died, the first officer received serious injuries and was flown to Winnipeg for treatment, the captain received serious injuries and was treated in Sanikiluaq, the other 6 passengers received minor injuries and were treated in Sanikiluaq.

The airline confirmed their aircraft was involved in the accident, one infant died, the first officer was flown to Winnipeg for treatment of injuries, the captain and other passengers are treated on scene. None of the injuries are life-threatening.

Royal Canadian Mounted Police (RCMP) reported the aircraft was on final approach to Sanikiluaq when the crew decided to go around, but lost height and crashed.

Canada's Transportation Safety Board (TSB) said they were told the aircraft crashed on the runway on Saturday evening. They would decide during Sunday whether to dispatch an investigation team.

The TSB reported on Sunday (Dec 23rd 2012), that they have launched a full investigation into the accident including a team of investigators examining the occurrence site and wreckage and interviewing witnesses. The TSB reported the aircraft had gone around and was on its second final approach in blowing snow when the accident happened.

On Dec 24th 2012 the TSB reported the aircraft was on its second approach to runway 27 when the aircraft touched down hard and overran the western end of the runway by about 150-200 meters/500-650 feet.

Sanikiluaq features a gravel runway 09/27 of 3807 feet length, APAPIs (abbreviated PAPIs) are available for approaches to both runway 09 and 27.

On Jul 1st 2015 the Canadian TSB released their final report concluding the probable causes of the accident were:

- The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a work-around solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq).

- Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).

- Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing and a shift away from well-learned, highly practised procedures.

- Due to the lack of an instrument approach for the into-wind runway and the unsuccessful attempts at circling, the crew chose the option of landing with a tailwind, resulting in a steep, unstable approach.

- The final descent was initiated beyond the missed approach point and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3-degree descent path.

- Neither pilot heard the ground proximity warning system warnings; both were focused on landing the aircraft to the exclusion of other indicators that warranted alternative action.

- During the final approach, the aircraft was unstable in several parameters. This instability contributed to the aircraft being half-way down the runway with excessive speed and altitude.

- The aircraft was not in a position to land and stop within the confines of the runway, and a go-around was initiated from a low-energy landing regime.

- The captain possibly eased off on the control column in the climb due to the low airspeed. This, in combination with the configuration change at a critical phase of flight, as called for in the company procedures, may have contributed to the aircraft’s poor climb performance.

- A rate of climb sufficient to ensure clearance from obstacles was not established, and the aircraft collided with terrain.

- The infant passenger was not restrained in a child restraint system, nor was one required by regulations. The infant was ejected from the mother’s arms during the impact sequence, and contact with the interior surfaces of the aircraft contributed to the fatal injuries.

Findings as to risk

- If instrument approaches are conducted without reference to an approach chart, there is a risk of weakened situational awareness and of error in following required procedures, possibly resulting in the loss of obstacle clearance and an accident.

- If additional contingency fuel is not accounted for in the aircraft weight, there is a risk that the aircraft may not be operated in accordance with its certificate of airworthiness or may not meet the certified performance criteria.

- If Transport Canada crew resource management (CRM) training requirements do not reflect advances in CRM training, such as threat and error management and assertiveness training, there is an increased risk that crews will not effectively employ CRM to assess conditions and make appropriate decisions in critical situations.

- If a person assisting another is seated next to an emergency exit, there is an increased risk that the use of the exit will be hindered during an evacuation.

- If a person holding an infant is seated in a row with no seatback in front of them, there is an increased risk of injury to the infant as no recommended brace position is available.

- If young children are not adequately restrained, there is a risk that injuries sustained will be more severe.

- If a lap-held infant is ejected from its guardian’s arms, there is an increased risk the infant may be injured, or cause injury or death to other occupants.

- If more complete data on the number of infants and children travelling by air are not available, there is a risk that their exposure to injury or death in the event of turbulence or a survivable accident will not be adequately assessed and mitigated.

- If temperature corrections are not applied to all altitudes on the approach chart, there is an increased risk of controlled flight into terrain due to a reduction of obstacle clearance.

- If the missed approach point on non-precision instrument approaches is located beyond the 3-degree descent path, there is an increased risk that a landing attempt will result in a steep, unstable descent, and possible approach-and-landing accident.

- If there is not sufficient guidance in the standard operating procedures, there is a risk that crews will not react and perform the required actions in the event that ground proximity warning system warnings are generated.

- If standard operating procedures, the Airplane Flight Manual and training are not aligned with respect to low-energy go-arounds, there is a risk that crews may perform inappropriate actions at a critical phase of flight.

- If non-compliant practices are not identified, reported, and dealt with by a company’s safety management system, there is a risk that they will not be addressed in a timely manner.

- If Transport Canada’s oversight is dependent on the effectiveness of a company’s safety management system’s reporting of safety issues, there is a risk that important issues will be missed.

Other findings

- The quick response of the people on the ground reduced the exposure of passengers and crew to the elements.

The TSB reported that the captain (ATPL, 5,700 hours total, 2,300 hours on type) was pilot monitoring, the first officer (CPL, 1,250 hours total, 950 hours on type) was pilot flying. The aircraft departed Winnipeg 4 hours later than planned.

The TSB reported that although required by regulations no specific safety briefing was given to a mother holding her infant seated in seat 1L next to left main door, and the mother (passengers chose their seats, no predetermined seating) was not reseated.

The TSB reported: "Shortly after departure, the captain realized that the instrument approach charts for CYSK had been forgotten. The captain chose not to return to CYWG to obtain the instrument approach charts as this would delay the flight even more and add to the crew duty day. Instead, he obtained chart information pertaining to the non-directional beacon (NDB) Runway 27 instrument approach for CYSK via radio from a company pilot (Appendix A). Information obtained did not include the direction for the procedure turn or the minimum descent altitude (MDA)(620 feet above sea level [asl]) for the circling approach to Runway 09."

Approching the top of descent about 82nm out of Sanikiluaq the crew collected weather information for Sanikiluaq and the alternate aerodromes Kuujjuarapik,QC, 90nm from Sanikiluaq, and La Grande Riviera,QC, 260nm from Sanikiluaq. The weather conditions at Kuujjuarapik were poorer than predicted before departure and prevented a diversion there. The weather conditions at La Grande Riviera permitted a diversion there, the crew however determined that it was not possible to divert there and arrive with the final fuel reserve intact, and therefore ruled out a diversion there, too. The crew concluded they had sufficient fuel for several approaches to Sanikiluaq however.

Sanikiluaq has a gravel runway, and procedures by the airline required the captain to fly the aircraft onto gravel runways, hence the captain assumed the role as pilot flying and the first officer became pilot monitoring.

There is no published instrument procedure for runway 09, landing on runway 09 thus required to conduct the instrument approach to runway 27 and visually circle to land on runway 09. The crew planned, while inbound to Sanikiluaq's NDB arriving from the west, to maintain 1600 feet MSL and if they were able to see the runway fly a straight in visual approach to runway 09, if no visual contact was available to continue to the NDB and proceed with the instrument procedure to runway 27. The crew computed their Vref for the approach including wind corrections at 120 KIAS.

The crew did not acquire visual contact with the aerodrome while inbound to the NDB and thus continued to the NDB, performed a procedure turn to the south of the approach track (standard procedure is to perform the procedure turn to the north of the approach track), and set what the crew believed to be the final approach track towards the runway, however to the south of the approach track. The crew descended through 620 feet MSL (the circling approach altitude) and obtained visual contact at 600 feet MSL (MDA 560 feet MSL) and initiated a left hand circling approach to runway 09 and descended to 500 feet, but lost visual contact with the ground, the circling maneouver was continued in IMC conditions however, the go around was not called and the missed approach procedure was not initiated.

The aircraft, still in IMC conditions, continued the descent to 400 feet MSL, the wind pushed the aircraft further south of the aerodrome. While believed to be on finals, however on a track parallel to the extended runway centerline south of the aerodrome, the aircraft, still in IMC, overflew high terrain at 155 feet AGL, abeam of the runway the crew regained visual contact with the runway but were not in a position to even attempt a landing from there. Another circling to runway 09 was initiated, visual contact with the ground was lost again and the crew initiated a go-around, but the published missed approach procedure was not followed.

The first officer reminded the captain twice in quick succession that the minimum safe altitude was 1600 feet MSL.

The aircraft circled flew inbound the NDB a second time. The captain indicated that this was the final attempt to land in Sanikiluaq following the instrument approach to runway 27, not circling to runway 09 but accepting a 14 knots tailwind component (and 11 knots cross wind component). The GPS was setup to assist the crew with the approach to runway 27.

Following the procedure turn the aircraft joined the extended runway center line at 400 feet MSL, 197 feet below published MDA, at 3nm out, the crew obtained visual contact with the runway at 0.7nm out beyond the Missed Approach Point, full flaps were set and power selected to idle, the final descent commenced at 140 KIAS. The GPWS issued a "SINK RATE" caution when the rate of descent exceeded 1500 fpm, then a "PULL UP" warning when the rate of descent exceeded 1800 fpm, when the aircraft was about 200 feet ahead of the runway threshold at about 180 feet AGL, the PULL UP was repeated two more times, the last time when the aircraft was 600 feet past the runway threshold descending through 60 feet AGL. The rate of descent was reduced, the aircraft passed the runway midpoint between 20 and 50 feet AGL at 125 KIAS (135 knots over ground), two seconds later the captain called for a go-around, engine power was increased, the gear retracted and flaps reduced to 1/4 setting, the aircraft was about 2300 feet past the runway threshold at that point. The first officer called the speed at 105 KIAS, 4 seconds later the aircraft impacted terrain south of the runway center line and past the runway end. The aircraft slid over the ground rotating to the right and came to a stop facing in an easterly direction. The first officer initiated the evacuation of the aircraft, while the captain transmitted a MAYDAY call.

Airport staff and family members waiting for those aboard and other villagers waiting for the arrival of the aircraft rushed to the accident site to assist the occupants. The TSB wrote: "All occupants were transported to the community health centre. The quick response of the people on the ground reduced the exposure of passengers and crew to the elements. The flight crew were flown to Winnipeg for medical care the following day."

The TSB reported that all gear doors were open and torn away indicative that the gear was still retracting when the aircraft impacted terrain. The right main and nose gear was torn from the aircraft, the left main gear had already retracted into the gear well.

Both propellers were seriously damaged consistent with the engines at high power at the time of impact. The fuselage belly skin was ripped and cut open while sliding across sharp rocky terrain, the floor buckled, the fuselage fractured at the forward pressure bulkhead and rear baggage compartment, snow and gravel entered the cockpit, both wings were substantially damaged though remaining attached to the airframe.

The TSB analysed that the selection of the alternate aerodrome CYGW was suitable at the time of the briefing, the forecast did not suggest the weather might go below minima. The crew thus was surprised to learn upon approach to Sanikiluaq that the weather at CYGW was below minima. Although weather conditions at CYGL were suitable fuel was not sufficient to accomodate the diversion there. The TSB wrote: "This likely increased the pressure to land at CYSK."

The TSB analysed: "The winds were favouring an approach to Runway 09; however, CYSK did not have a published instrument approach procedure for this runway. The weather did not allow for visual manoeuvring to Runway 09, and the crew decided to land on Runway 27 with the associated risks of landing with a 14-knot tailwind on a 3807-foot runway. Lack of a published instrument approach for Runway 09 led to the crew’s decision to attempt a downwind landing."

The TSB wrote with respect to human factor's analysis: "Shortly after takeoff, the captain realized the instrument approach charts had been forgotten and chose not to return to Winnipeg (CYWG), as this would have resulted in further delay and necessitated addressing dispatch and management about extending the duty day or finding a replacement crew. This also would have had a negative impact on operations. The crew had received some of the approach chart information via radio from another pilot. However, without reference to the actual chart, the crew did not have a visual reminder of altitude limits or approach diagrams to assist with orientation of the aircraft in time and space. This made the crew more susceptible to error and loss of situational awareness, such as the incorrect direction of the procedure turn and incorrect turn on the missed approach. The lack of required flight documents, such as instrument approach charts, placed pressure on the captain to find a work-around solution during flight planning, and negatively affected the crew’s situational awareness during the approaches at CYSK."

The TSB added: "Several unforeseen issues arose during the flight preparation, which likely had a negative effect on the crew’s mental readiness for the flight. The aircraft did not have the required survival kit and this had to be obtained at the Keewatin Air hangar and properly stowed. The single redline limit minimum equipment list (SRL MEL) deferred maintenance issue was due to expire at midnight local time that night (0600 UTC on 23 December 2012). There was also the delay caused by the replacement of the cargo door handle position switch, which necessitated a re-filing of the flight plan. The change to the cargo load resulted in a change of fuel quantity and subsequent choice of alternate airport. All of these created additional work for the crew in this Type C dispatch environment. As the delay for departure was extended, the flight crew duty day was being stretched. Any additional extension to the duty day would have had to be addressed with management."

The TSB analysed the mood of the captain: "The captain felt frustrated as a result of the pre-flight preparation issues, and it is evident from analysis of his speech that signs of frustration persisted after takeoff. The captain’s use of 43 expletives in conversation with the first officer (FO) during the non emergency, non stressful, 2-hour period preceding the occurrence, showed a rate of approximately 21.5 swear words per hour. This type of behaviour was seen as being out of character for the captain." and added that the circadian rythm and long day added to the level of fatigue resulting from the acute sleep disruption, when prior to the flight the night's sleep was interrupted by a 1.5 hours wake period. The TSB wrote: "acute sleep disruption may have played a role in the captain’s behaviour during the flight by increasing the risk for fatigue and its associated performance decrements."

The TSB analysed that during the first approach the crew made the procedure turn to the right instead of the left, however, as they used the 25nm minimum safe altitude obstacle clearance was provided. The crew acquired visual contact with the city lights but were not in a position to land on runway 27, the captain therefore initiated a circling approach to runway 09 and the first officer agreed. The TSB wrote: "Shortly after initiating the circling procedure, the captain lost visual reference with the runway. A missed approach must be initiated when visual reference is lost; however, the crew continued to circle in instrument meteorological conditions (IMC). At this point, it was no longer a circling procedure, but rather a manoeuvre to position the aircraft to regain visual contact with the runway. At one point during this manoeuvre, the aircraft was as low as 155 feet agl. As the aircraft was returning towards the airport at an altitude of approximately 400 feet asl, the captain saw the runway, but again the aircraft was not in a position to land."

During the circling approach indications of stress became obvious, required calls were omitted, flight parameters were not corrected, decision making was impaired, deviations from regulations and standard procedures occurred. The TSB wrote: "Missed opportunities to manage threats and errors are a known reaction to stress. The accumulation of mismanaged threats and errors affected the level of stress experienced by the crew, and likely resulted in the required missed approach procedure not being executed when visual contact with the runway was lost during the circling procedure to Runway 09. Not initiating a missed approach at the point where visual reference to the runway was lost during the circling increased the risk of CFIT."

The TSB wrote that during the second approach to the NDB and the procedure turn the crew again did not follow published procedures but again maintained ther 25nm MSA, obstacle clearance therefore was assured.

The TSB analysed:

During the second approach, there were indications of the crew deviating even further from learned procedural norms and regulations:

- The procedure turn was flown at 1500 feet asl versus the briefed 1600 feet asl.

- The descent was 197 feet below published MDA without the required visual reference.

- Despite being high in relation to the runway threshold when visual references were established, the final descent was delayed.

- Excessive airspeed (VREF + 30) and rate of descent (>1800 feet per minute) were used once the decision to land was made.

- The threshold crossing height was high (approximately 180 feet agl).

The captain had indicated this was to be the last approach before proceeding to the alternate. The FO, however, was not convinced a diversion to the alternate airport was viable. Both pilots were very focused on landing on this approach as they did not feel they had another option. The captain chose to descend below MDA, likely in an attempt to be in a more favourable position to land. The FO advised of the deviation, but did not voice concern when a correction was not applied, indicating tacit acceptance of the captain’s action. Although the FO, at times, exhibited better situational awareness than the captain, he was not assertive in underlining important deviations from procedures and regulations.

The runway was sighted when the aircraft was approximately 0.7 nm from the threshold at a height of 253 feet agl (400 feet indicated). The captain called for full flaps 1 second after sighting the runway. The FO performed the remaining landing checklist items with no call or response from the captain. This omission of the required responses is evidence of task saturation and stress.

The captain flew beyond the MAP without visual reference to the runway although, procedurally, a missed approach was warranted. This was likely a conscious decision based on late sighting of the runway on the previous approach and lack of an alternate option. The crew felt pressured to land on this approach.

The descent for landing was initiated late. Engine power was decreased to idle 10 seconds after visual reference was acquired. It is not known why there was a delay between sighting the runway and initiating the descent. It is possible that the captain was starting to see some of the runway environment, but was not yet comfortable that there was sufficient visual reference to initiate the descent.

As a consequence, the aircraft had less distance in which to descend and a steeper approach angle was required to execute the landing within the confines of the runway. This resulted in a high rate of descent (>1800 ft/min) and high airspeed (150 knots) as the captain tried to reach the threshold of the runway. This attempt was exacerbated by the high ground speed due to the high airspeed and the strong tailwind. The final descent was initiated beyond the MAP and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3-degree descent path.

During this landing attempt, the first ground proximity warning system (GPWS) PULL UP warning was generated as the rate of descent exceeded 1800 ft/min. The aircraft approached the threshold of the runway at a height of approximately 180 feet agl and an estimated ground speed of 159 knots. The GPWS warning continued until the aircraft was approximately 900 feet past the threshold at a height of approximately 60 feet agl. The captain was focused on the landing despite the growing instability of the approach. The captain no longer had the overall perspective of the extent to which the approach and chance of landing safely had deteriorated.
The FO was monitoring airspeed and calling deviations, but did not express concern regarding aircraft speed and height at the threshold. The FO had also lost perspective regarding the aircraft’s state and the developing risks associated with the approach.

Both the captain and FO were concentrated on a very specific aspect of the approach, and lost sight of the threat associated with the high sink rate and airspeed as the aircraft crossed the threshold. This, and the lack of response to the GPWS warnings, are indications of attentional narrowing.

Both pilots were focused on landing the aircraft to the exclusion of other indicators that warranted alternative action.

With respect to the rejected landing the TSB analysed: "The crew used the go-around procedure described in the SOPs. The company procedure called for re-configuration of the aircraft (landing gear retracted, flaps ¼) prior to establishing a positive rate of climb. The action of raising the flaps resulted in a reduction of lift, a loss that would need to be compensated for by an increase in either speed or pitch attitude. This reduction in lift occurred during the critical transition from a low-energy landing regime to a stabilized climb. The TSB laboratory evaluated the effects of landing gear retraction on aircraft performance and concluded that this had no detrimental effects upon aircraft control and climb performance."

The TSB concluded flight performance analysis: "The configuration change at a critical phase of flight, possibly combined with a slight pitch reduction, may have contributed to the aircraft’s poor climb performance. A rate of climb sufficient to ensure clearance from obstacles was not established, and the aircraft collided with terrain."

With respect to cabin safety the TSB analysed: "The mother holding the infant chose to sit in seat 1L and had not been directed to sit elsewhere, although she was responsible for another. Without a seatback in front of seat 1L, the mother would not have been able to adopt the recommended bracing position had it been commanded. Additionally, the lack of a seat in front of the mother meant there was limited energy-absorbing material in front of her and her infant. Furthermore, the aircraft main doorstair was positioned directly in front of her seat, creating a hazard for the infant." and added: "Biomechanical research has found that, due to limitations in human clasping strength, it is not always possible for adults to restrain children adequately in their laps by holding onto them. Infants are therefore exposed to undue risks of injury when seated on an adult’s lap."

CYSK 230200Z 09012KT 10SM OVC016 M03/M04 A2915 REBLSN RMK ST7 CALL OUT SLP874
CYSK 230100Z 07014KT 3SM -SN BLSN OVC017 M03/M04 A2918 RMK SC8 CALL OUT SLP883
CYSK 222200Z 01017G25KT 2SM -SN BLSN OVC012 M05/M06 A2928 RMK SC8 CALL-OUT LAST OBS/NEXT 241300UTC SLP917
CYSK 222100Z 01015G23KT 2SM -SN BLSN OVC012 M05/M06 A2933 RMK SC8 CALL-OUT PRESFR SLP936
CYSK 222000Z 01015G22KT 4SM -SN DRSN OVC012 M05/M06 A2940 RMK SC8 CALL-OUT SLP958
CYSK 221900Z 02015G21KT 6SM -SN DRSN OVC012 M05/M06 A2945 RMK SC8 CALL-OUT SLP977
Incident Facts

Date of incident
Dec 22, 2012


Aircraft Registration

ICAO Type Designator

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