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Associated links (A21Q0087)

TSB releases investigation report into 2021 runway overrun at Sept- Îles Airport, Quebec

Dorval, Quebec, 6 June 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21Q0087) into the 2021 runway overrun at Sept-Îles Airport, Quebec.

On 12 September 2021, an Airmédic Inc. Pilatus PC-12/47E aircraft was flying from Québec/Jean Lesage International Airport, Quebec, to Sept-Îles Airport, Quebec, with two crew members on board. The aircraft landed approximately 2525 feet beyond the threshold of Runway 09, which was wet, and ended up overrunning the runway by approximately 590 feet in the grass before making a right turn around an approach light and returning to the runway. No one was injured. There was no damage to the aircraft.

The investigation found that during the flight, the captain, who was paired with a first officer with little experience on the Pilatus PC-12, decided to demonstrate a high-speed final approach, decelerating just before reaching the runway. During the high-speed approach, the first officer had doubts that the aircraft could land successfully; however, he deferred to the captain’s experience and did not feel comfortable making the actionable go-around call. When the aircraft was approximately 1.7 nautical miles from the runway, flying at an airspeed of 238 knots at 500 feet above ground level, it was no longer possible to decelerate and continue the descent to reach the runway threshold in a stabilized landing configuration. However, perceiving that it was still possible to land within the first third of the runway, the captain continued with the approach.

The aircraft crossed the runway threshold at 200 feet above ground level at 180 knots indicated airspeed, with a rate of descent of 2000 fpm, the landing gear in transit and the flaps in the fully retracted position. Under such conditions, it was impossible to stop the aircraft on the wet runway. The aircraft landed on the runway approximately 2525 feet from the threshold at an airspeed of 159 knots. Given that the excessive speed, combined with other factors, increased the landing distance, the aircraft overran the runway.

The report also cites findings as to risk with regards to company standard operating procedures (SOPs). If SOPs and training do not incorporate runway overrun risk factors, they may not be taken into consideration during approach. Also, if SOPs do not include mandatory and actionable go-around calls when approaches become unstable, pilots may choose to continue with an unstable approach, increasing the risk of a runway overrun. If operators do not have lightweight data recorders and flight data monitoring systems, they may not be able to oversee compliance with policies, procedures, and operational limits. Finally, if Transport Canada does not assess the quality, consistency, accuracy, conciseness, clarity, and relevance of an operator’s SOPs, these procedures may not be effective, increasing the risks to flight operations.

Runway overruns have been on the TSB Watchlist since 2010. Despite the actions taken to date, the number of runway overruns in Canada has remained constant since 2005 and demands a concerted effort to be reduced.

Following the occurrence, Airmédic Inc. amended its SOPs to reduce ambiguities and to respond to observations made by Transport Canada during the reactive process inspection. For its part, the Sept-Îles Airport authority established a procedure to notify pilots when there is more than 1/8 inch of rain or standing water on the runway and includes runway condition checks in its daily inspection records.

See the investigation page for more information.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. 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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-360-4376