Dorval, Quebec, 4 May 2021 — In its investigation report (A20Q0013) released today, the Transportation Safety Board of Canada (TSB) found that the January 2020 hard landing and rear fuselage strike in Schefferville, Quebec, was the result of an unstable approach.

On 20 January 2020, a de Havilland DHC-8-314 operated by Air Inuit Ltd. was conducting a flight from Québec/Jean Lesage Airport, Quebec, to Schefferville Airport, Quebec, with three crew members and 42 passengers on board. During the landing, the rear fuselage struck the runway as the wheels touched down. After landing, the aircraft taxied to the terminal to disembark the passengers. There were no injuries; however, the aircraft sustained substantial damage.

The investigation found that the flight crew forgot to perform the descent checklist and realized this at an inopportune time, while the captain (pilot monitoring) was providing a position report. Given ambiguities and contradictions in the company’s stabilized approach guidelines, the captain interpreted that he was allowed to continue the approach below 500 feet above aerodrome elevation, even though the aircraft had not been fully configured for the landing. When the aircraft passed this altitude, the pilots, who were dealing with a heavy workload, didn’t notice and continued the approach, which was unstable. At the time of the landing, the aircraft no longer had enough energy to arrest the descent rate solely by increasing pitch attitude. The pilot’s instinctive reaction to increase the pitch attitude during the flare, combined with the hard landing, resulted in the rear fuselage striking the runway, causing substantial damage to the aircraft’s structure.

The investigation also made findings as to risk related to Air Inuit’s standard operating procedures (SOPs) and training, and to Transport Canada’s (TC) oversight. Transport Canada assessed Air Inuit’s SOPs, but did not identify any specific issues with the operator’s stabilized approach guidelines. If TC does not assess the quality, consistency, accuracy conciseness, clarity, relevance, and content of SOPs, the procedures may be ineffective, increasing risks to flight operations.

Additionally, the captain had not received many of the required training elements during his recurrent training. If required training elements are not included in recurrent training, and if TC’s surveillance plan does not verify the content of crew training, there may be procedural deficiencies or deviations, increasing risks to flight operations.  

Following the occurrence, Air Inuit took a number of safety actions, including the revision of its SOPs to improve guidelines on several subjects, including stabilized approaches, and the revision of its training program to ensure that all training elements are covered within the two-year recurrent training cycle.

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.

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Author: Editor
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