Air transportation safety recommendation A18-03
Assessment of the response to TSB Recommendation A18-03
Compliance with Canadian Aviation Regulations subsection 602.11(2)
On 13 December 2017, an Avions de Transport Régional (ATR) 42-320 aircraft (registration C-GWEA, serial number 240), operated by West Wind Aviation LP (West Wind) as flight 282 (WEW282), departed from Fond-du-Lac (CZFD), Saskatchewan, on an instrument flight rules flight to Stony Rapids (CYSF), Saskatchewan. On board were 3 crew members (2 pilots and 1 flight attendant) and 22 passengers. Shortly after takeoff from Runway 28 at CZFD, WEW282 collided with trees and terrain approximately 1400 feet west of the departure end of Runway 28. Nine 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. The aircraft was destroyed.
At this time, the TSB investigation into this accident (A17C0146) is ongoing and the investigation team is completing its analysis of the information collected. However, the investigation team identified safety deficiencies in need of urgent attention. As a result, the Board is making the following recommendation in advance of final report publication.
TSB Recommendation A18-03 (December 2018)
The duration of cold weather and icing conditions varies widely across Canada. Many remote northern airports have an icing season of 10 months or more. Icing conditions can be both severe and persistent.
Thousands of flights take off every year from remote northern airports. Some airports serve as hubs, experience higher traffic volumes, and may have better equipment.
The absence of adequate equipment increases the likelihood that pilots will conduct a takeoff in an aircraft that has frost, ice, or snow adhering to any of its critical surfaces. Additionally, in the absence of adverse consequences, taking off with contamination on critical surfaces is a deviation that has become normalized. Therefore, providing adequate de-icing and anti-icing equipment may not be sufficient to reduce the likelihood of aircraft taking off with contaminated critical surfaces.
Some of the current defences used by the Canadian air transportation system to prevent aircraft from taking off with frost, ice, or snow adhering to any critical surface are less than adequate. Takeoffs with contaminated critical surfaces occur in substantial numbers across the spectrum of aircraft and operating categories at remote northern airports.
Non-compliance with Canadian Aviation Regulations subsection 602.11(2), flight crew operating manuals, company operations manuals, and company standard operating procedures can be a single point of failure of defence framework. To mitigate this, Transport Canada and air operators must take urgent action to ensure better compliance.
Organizations can audit equipment (to inspect, de-ice, and anti-ice aircraft), policies (such as ground icing operations programs and contingencies for situations where resources are not available), training (for pilots and ground staff), and operations (procedures, compliance, deviations). Air operators could incorporate questions in before-start and before-takeoff checklists with a requirement for a clean aircraft or a mitigation response from the pilot-in-command.
Accidents related to contaminated aircraft will continue to occur until the industry and the regulator approach the issue as systemic and take action to eliminate underlying factors that can negatively affect pilot compliance.
Therefore, the Board recommends that
the Department of Transport and air operators take action to increase compliance with Canadian Aviation Regulations subsection 602.11(2) and reduce the likelihood of aircraft taking off with contaminated critical surfaces.
Transportation Safety Recommendation A18-03
In accordance with section 24(6) of the Canadian Transportation Accident Investigation and Safety Board Act, Transport Canada is required to respond to the Board in writing within the next ninety days of any action taken or proposed to be taken in response to Recommendation A18-03.
For more information, see the investigation page.
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