Findings from TSB investigation A18Q0030 – February 2018 runway overrun in Havre-Saint-Pierre, Quebec
Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the Havre-Saint-Pierre, Quebec, accident on 26 February 2018 several factors led to the runway overrun. The eight findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made 13 findings as to risk.
Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- The captain continued the approach beyond the final approach fix when the reported visibility was below the approach ban minima.
- During the approach, runway lighting was reduced to medium intensity, which was 30% of maximum strength, thereby reducing the probability of seeing the visual references required to conduct the landing on the runway.
- The captain proceeded with the landing sequence, without seeing or knowing the length of the remaining runway ahead and unable to accurately assess the aircraft’s position.
- The aircraft landed approximately 3800 feet past the threshold, 700 feet from the end of the runway, and stopped its landing roll in a snowbank, 220 feet beyond the runway.
- The deviation from standard operating procedures at a critical moment of flight was a source of confusion between the flight crew members, to the point where the aircraft was not configured for a landing, which increased the landing distance required.
- The captain, focused on the landing manoeuvre and experiencing narrowed attention, was unable to make the decision to conduct a go-around. He lost the notion of time and flew over the runway for 20 seconds, not realizing that it was now impossible to touch down and come to a stop before the end of the runway.
- Without policies, clear procedures and training, the first officer did not have the tools necessary to shift from a passive advisory role to proactive assertiveness strong enough to convince the captain to conduct a go-around.
- The approach ban was ineffective in preventing this approach while visibility on the ground was below the minimum required for an approach ban.
Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If Transport Canada does not clarify the application of operating visibility and visibility minima for approach bans, flight crews may proceed with an approach that is actually banned, thereby increasing the risk of an approach-and-landing accident.
- If flight crew members do not have shared situational awareness, they cannot anticipate or coordinate their actions, which increases the risk of an approach-and-landing accident.
- If pilots continue their approach below the minimum descent altitude with only one visual reference, they risk continuing their landing without having established the additional visual references required to land safely.
- If a safety briefing is not provided to passengers before landing to remind them to fasten their safety belt, some of them may not fasten their safety belt before landing, which increases the risk of injury in the event of an accident.
- If the passenger seats on small aircraft are not equipped with a shoulder harness, passengers face a greater risk of injury, more or less serious, perhaps even fatal, in the event of an accident.
- If the airport emergency response plan is interrupted and fire protection services are not contacted quickly to secure the accident site in the event of a fuel spill or fire, there is a risk of injury to the people at the accident site, and damages to airport facilities and the environment.
- If runways 1200 m or longer do not have a runway end safety area that is at least 150 m long, or some other arresting system that provides aircraft with an equivalent level of safety, there is a risk of injury to the aircraft occupants in the event of a runway overrun.
- If airport operators are not required to close a runway when one of the criteria stated in their snow clearance plan has been exceeded, there is a greater risk of a runway overrun.
- If standard operating procedures approach briefings do not cover all of the restrictive elements for an approach, pilots may conduct an approach outside the prescribed limits, increasing the risk of an approach-and-landing accident.
- If pilots are not properly prepared for a go-around on every approach, they may not be ready to react promptly when this manoeuvre becomes imperative, thereby increasing the risk of an approach-and-landing accident.
- If cockpit voice recordings are not available, it is impossible to accurately assess crew resource management, standard operating procedure execution and compliance, and workload management, which may limit the identification of safety deficiencies and the advancement of safety
- If Transport Canada does not provide oversight of flight operations to assess the effectiveness of crew resource management, threat and error management, decision making and standard operating procedures, including application and compliance, these standard operating procedures may not be effective, increasing the risk of an accident, particularly an approach-and-landing accident.
- If a mechanism is not implemented in Canada to prevent an approach that is in fact banned, there is an increased risk of an ALA.