Communiqués

TSB # A 06/2001

(Hull, Quebec, 13 July 2001) - A mechanically sound aircraft was inadvertently flown into the frozen sea while the crew was executing a second attempt to land, in inclement weather, at Davis Inlet, Labrador, on 19 March 1999. The copilot was killed and the captain seriously injured. The aircraft was destroyed.

The Transportation Safety Board of Canada (TSB) concluded that the crew did not follow company standard operating procedures (SOPs), such as altitude calls, and flew below minimum descent altitude (MDA) without the required visual references, thus increasing their exposure to risk during the flight. The Board also noted that there were lapses in the company's management of its Goose Bay operation that were not detected by Transport Canada's safety oversight activities.

The findings, from this and other TSB accident investigations, indicate that, in certain areas of commercial operations, the safety oversight efforts of Transport Canada have been somewhat ineffective. The Board recommended that:

Non-adherence to standard operating procedures is recognized as a frequent causal factor in approach and landing accidents. In this flight, SOPs, especially altitude calls, would have heightened the crew's awareness about their proximity to terrain. In addition, operating the aircraft in weather and visibility conditions that were below requirements for the visual flight rules (VFR) flight plan contravened the company operations manual and Canadian Aviation Regulations. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments, allowing the aircraft to fly into the frozen sea.

There was no weight and balance documentation left at the departure point, as required by regulation, a normal company/pilot practice, and the cargo was not properly secured before take-off.

The report notes that the TSB has observed similar deficiencies in the conduct of business in other organizations, as demonstrated by five other similar occurrences(A00H0001, A99Q0005, A98Q0007, A97C0236, A97P0207,). Each of these six occurrences exhibited one or more of the following findings relating to regulatory oversight:

• descent below MDA without adequate visual references;
  
• non-adherence to SOPs;
  
• operating under visual flight rules when in instrument meteorological conditions;
  
• operating the aircraft in an overweight condition; and
  
• inadequate company supervision of operations or maintenance.

These serious accidents indicate that some operators and crews have disregarded safety regulations and, consequently, put passengers and themselves at an unnecessary and unacceptably high level of risk.

After the accident, Transport Canada conducted a regulatory audit of the operator and increased the frequency of in-flight checks and general inspection of the Goose Bay operation.

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

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