Investigation report: Unintentional gear-up landing on runway at the Sault Ste. Marie Airport, Ontario, in May 2021

Richmond Hill, Ontario, 4 November 2021 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21O0030) into the unintentional gear-up landing on runway that occurred on 2 May 2021 at the Sault Ste. Marie Airport, Ontario.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

See the investigation page for more information.

The occurrence

On May 2, 2021, a Canadair CL-215-6B11 (Series CL-415) aircraft operated by the Province of Ontario, Ministry of Natural Resources and Forestry, was conducting a local training flight at the Sault Ste. Marie Airport, ON. While conducting the third circuit on Runway 12, the flight crew inadvertently landed the aircraft with the landing gear retracted while conducting a flapless approach and landing exercise. The aircraft came to a stop on the runway surface. There was significant damage to the belly of the aircraft. There were no injuries.

Investigation information


Investigator-in-charge

Photo of Jon Douma

Jon Douma is a Senior Regional Investigator – Operations with the Ontario Region of the Air Investigations Branch. He joined the TSB in 2019 following 12 years in the business aviation sector, where he flew multiple jet and turboprop types and operated throughout North America, the Caribbean, and Eastern and Western Europe.

Prior to business aviation, he spent several years as a flight instructor, and has maintained an interest in general aviation since then, building and flying multiple amateur-built aircraft with his grandfather.


Class of investigation

This is a class 4 investigation. These investigations are limited in scope, and while the final reports may contain limited analysis, they do not contain findings or recommendations. Class 4 investigations are generally completed within 220 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

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.

Report details harrowing moments for passengers following northern Sask. plane crash

From CTV News – link to source story and video

WATCH: CTV Saskatoon’s Tyler Barrow explains the findings of a report into a 2017 plane crash in northern Saskatchewan.

Glimpse into crash chaos

A 16-year-old boy who was on a plane that crashed shortly after takeoff from Fond du Lac says the crash happened quickly.

Plane crash survivor recalls fall, aftermath

A class-action lawsuit on behalf of passengers on a West Wind Aviation airplane that crashed near Fond du Lac last month has been filed.

Cash to improve Fond-du-Lac airport

A passenger on board  a plane that crashed near Fond-du-Lac earlier this month has died. Cory Coleman reports.

Teen dies after being injured in plane crash

The Transportation Safety Board says a lack of de-icing equipment lead to the Fond du Lac plane crash.

TSB releases report into fatal plane crash

Josh Lynn, Digital News Editor CTV News Saskatoon | October 28, 2021

SASKATOON – 

A newly released report provides a glimpse into the terrifying moments experienced by passengers during a 2017 plane crash in northern Saskatchewan.

Twenty-five people were injured when an ATR 42-320 turboprop plane crashed shortly after taking off from the Fond du Lac airstrip on Dec. 13, 2017.

Nineteen-year-old Arson Fern Jr. later died in hospital from his injuries.

After a nearly four-year wait, the Transportation Safety Board released the results of its investigation into the crash on Thursday.

The TSB report outlines how a combination of lapses in safety procedures, poor weather and underlying issues facing many northern airports in Canada contributed to the crash.

While the plane, operated by West Wind Aviation initially climbed after takeoff, the aircraft began to roll due to ice build-up.

The pilot was unable to regain control and the plane crashed just 17 seconds after takeoff, according to the report. 

CHAOS AFTER CRASH

The plane’s rapid descent gave passengers little time to brace and damage to the plane at the moment of impact “compromised the restraint systems limiting the protection afforded to the aircraft occupants,” the report says.

In the chaotic moments following impact, due to their injuries, the people on board struggled to take “post-crash survival actions in a timely manner.”

Because of “unapproved repairs” the flight attendant seat “failed” on impact, making it difficult for her to initiate evacuation and survival procedures, the report says.

Everyone on the plane was injured in the crash and many passengers started calling for help using their cell phones.

A baby that wasn’t restrained “received flailing and crashing injuries” during the crash, according to the report.

Current TSB rules surrounding the use of child restraints had not yet come into effect at the time of the crash, the report says.

PASSENGERS TRAPPED

It took 20 minutes for the first 17 passengers to evacuate the downed plane. Getting those who remained out took “much longer,” the report says.

One passenger was trapped in the wreckage for three hours before being freed by rescuers.

In total, in addition to Fern’s death, nine passengers and one crew member were seriously injured. Thirteen passengers and two crew members came away with minor injuries, according to the report.

Three people were located in an area of the plane where damage was particularly severe.

Two of them experienced “serious life-changing injuries.”

Fern was the other passenger; he died 12 days later.  

While the TSB highlighted aspects inherent in the design of the ATR 42-320 that made it less “crashworthy,” the sprawling 240-page report is mainly focused on how the tragedy could have been avoided in the first place.

In April 2018, the TSB previously shared its preliminary findings, saying the aircraft was not de-iced before take-off and that ice had built up on the plane.

In their final report into the crash, TSB investigators lay out a series of questionable decisions going back to when the flight crew began their day in Saskatoon.

While the crew and dispatcher “were aware of the forecast ground icing” the decision was made to go ahead with the day’s planned route which included remote airports “that had insufficient de-icing facilities.”

The crew first flew from Saskatoon to Prince Albert “without difficulty.”

While approaching Fond du Lac on the second leg of the crew’s journey, the plane encountered in-flight icing and the crew activated the aircraft’s anti-icing and de-icing systems.

Due to the limitations of the two systems, some residual ice started to collect on the plane.

The ice didn’t noticeably change how the plane handled and the crew likely didn’t feel “the residual ice was severe enough to have a significant effect on aircraft performance.”

However, the flight data recorder showed the plane’s drag and lift performance was degraded by 28 per cent and 10 per cent respectively, the report says. 

‘DIMLY-LIT’ INSPECTION

The plane was on the ground in Fond du Lac for 48 minutes with more ice or frost forming on the plane’s “critical surfaces.”

Once the 22 passengers were on board, the first officer inspected the plane.

“Because the available inspection equipment was inadequate, the first officer’s ice inspection consisted only of walking around the aircraft and looking at the left wing from the top of the stairs at the left rear door, without the use of a flashlight on the dimly lit apron,” the report says.

The first officer who was “unaware of the full extent of the ice” told the captain there was some ice on the plane.

“The captain did not inspect the aircraft himself, nor did he attempt to have it de-iced; rather, he and the first officer continued with departure preparations,” the report says.

The TSB report says the crew was unconcerned because departures “with some amount of surface contamination” had become common practice due to the “inadequacy of de-icing” equipment at remote airports.

“The past success of these adaptations resulted in this unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart,” the report says.

By the time the aircraft took to the air again en route to Stony Rapids, the ice on the plane had increased its drag by 58 per cent and its lift had decreased by 25 per cent.

It soon hit the ground near the runway. 

WIDESPREAD ISSUES

As part of its investigation, the TSB surveyed pilots work regularly fly in and out of remote airports across Canada.

“The responses received to several questions showed that operations at these remote airports were routinely affected by the unavailability and inadequacy of equipment to inspect, de-ice, or anti-ice aircraft,” the TSB report says.

Based on its findings, which were first shared in December 2018, the TSB recommended that the Department of Transport identify locations where there is inadequate de-icing and anti-icing equipment and “take urgent action” to make sure it is available.

During a virtual media availability, TSB Chair Kathy Fox said while responsibility primarily rests with operators, passengers shouldn’t be shy about advocating for their safety.

“There’s nothing that stops a passenger from asking the operator what, you know, what actions do they take, especially if there’s more than one operator operating out there,” Fox said.

“They can question, you know, the airport authority, they can see themselves. I’m sure we’ve all been on an airplane at some point where it’s snowing or there’s icing conditions and we’re told ‘well we have to go to the de-icing bay to de-ice the aircraft and so there are ways that passengers can find that out,” Fox said.

She also emphasized that while the TSB report identified specific safety issues related to the Fond du Lac crash, thousands of flights safely land and take off from Canada’s remote airports every year.

HISTORY OF ‘NON-COMPLIANCE’

The investigators also found Transport Canada’s “surveillance policies and procedures were inconsistently applied to the oversight” of West Wind, which began operating under the name Rise Air earlier this year.

“We believe the TSB’s final report is fair in its findings. We acknowledge the issues it identifies and accept responsibility for them.,” Rise Air CEO Derek Nice said in a statement

.”We are sorry for the harm caused to the passengers and crew on that flight, their relatives and loved ones, and their communities, and we’re determined that something like this can never happen again.”

 “As detailed in the findings of several TSB investigations, there have been a number of past examples where Transport Canada has been slow to either identify or to rectify unsafe conditions at an operator,” the report says.

As an airline that “had a history of system-level and systemic non-compliance issues, the agency should have been more consistent in its approach to West Wind, the report argues.

West Wind was temporarily grounded following the crash. It was allowed to resume operations in May 2018.

As part of its December 2018 recommendations, the TSB said the Department of Transportation and air operators take action to “likelihood of aircraft taking off with contaminated critical surfaces.” 

TSB deploys team of investigators following October 18 collision between a floatplane and a water taxi in Tofino, BC

RICHMOND, BC, Oct. 27, 2021 /CNW/ – The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to Tofino, BC, following the October 18, 2021 collision between a De Havilland DHC-2 Beaver floatplane and the water taxi Rocky Pass. The TSB will gather information and assess the occurrence.

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.

The TSB is online at www.tsb.gc.ca.

Small plane crash near Old Montreal leaves one dead, one hospitalized

From City News 1130 – link to source story

BY ALY LAUBE | October 2, 2021

A Cessna 172 aircraft, the same model as the plane that crashed near Old Montreal on Saturday. (Courtesy of Flickr)

SUMMARY

  • A plane crash near Old Montreal has left one dead and one hospitalized
  • The Transportation Safety Board is investigating the incident and has a team on site
  • The plane, a Cessna 172 aircraft, was towing a banner when it went down

MONTREAL (NEWS 1130) — One person has died and another is in the hospital after a small plane crash near Old Montreal on Saturday.

It happened at around 6:00 pm on Île Sainte-Hélène, at a spot that’s home to an amusement park, casino, and other popular attractions.

The Transportation Safety Board (TSB) is investigating the incident and sent a team to the scene, says Chris Krepski with the TSB.

They believe the duo were only two people on the plane at the time of the accident.

The plane, a Cessna 172 aircraft, was towing a banner when it went down, says the TSB.

Police have not released further details on the people involved in the crash.

Crash of twin-engine plane at Thunder Bay airport leaves 1 dead

From CBC News – link to source story

TSB investigating after plane crashed following day of flying for Ontario ministry

CBC News · Posted: August 17, 2021

A number of flights into the Thunder Bay, Ont., airport from Toronto and Sioux Lookout were either cancelled or diverted as a result of the airport closure due to the small-plane crash Monday evening. (Michael Fox/Twitter)

A twin-engine airplane crashed Monday evening at Thunder Bay’s airport in northwestern Ontario, leaving one person dead.

In a written statement, airport president and chief executive officer Ed Schmidtke confirmed a twin-engine airplane crashed just after 9 p.m. ET and there was one fatality.

The name of the individual hasn’t been released.

Schmidtke said the airport’s operations specialists, along with Thunder Bay police, firefighters and paramedics,  responded to the incident.

The scene is being held for a Transportation Safety Board of Canada (TSB) investigation, he added.

Plane had finished day of work for ministry

TSB spokesperson Chris Krepski said Tuesday the crash occurred shortly after the plane — a Rockwell Commander 690 that was registered to MAG Aerospace — departed the Thunder Bay airport, heading for Dryden.

“Shortly after takeoff, the pilot … requested to return to the airport, and was returning to land on runway 07 at Thunder Bay,” Krepski said. “The aircraft lost control and struck the runway surface, and the Transportation Safety Board of Canada deployed a team of investigators this morning to gather information and assess the occurrence.”

MAG Aerospace is based in Dryden and provides a range of specialized aerial services, including fire management, airborne imagery and air charters, according to its website.

The plane’s wreckage was still sat on a runway at Thunder Bay International Airport on Tuesday morning. The scene was being held for Transportation Safety Board investigators to arrive. (Logan Turner/CBC)

In a statement Tuesday, a spokesperson for the Ministry of Northern Development, Mines, Natural Resources and Forestry said MAG Aerospace is one of the ministry’s long-term contract aircraft providers.

At the time of the crash, the plane was travelling to Dryden for routine maintenance after a completing a day of flying for the ministry. Further details were not provided.

A staff member with MAG Aerospace indicated the company will also likely issue a statement, but the timing is unclear.

Number of flights affected

A number of flights into the airport from Toronto and Sioux Lookout were either cancelled or diverted as a result of the airport closure on Monday night.

A Facebook post from Wasaya Airways said it had cancelled one flight from Sioux Lookout on Monday night, resulting in 37 passengers stranded in the northern town. At least two Air Canada flights from Toronto that were scheduled to land in Thunder Bay were rerouted after takeoff.

Just before nightfall, social media were filled with images showing a line of flames streaked across the runway with heavy smoke rising into the sky.

Krepski said two TSB investigators coming to Thunder Bay from Winnipeg are expected to be on the scene by early Tuesday evening.

“When they get there, they’re going to examine the accident site, examine the aircraft wreckage, identify components from the aircraft for further analysis at the TSB engineering lab in Ottawa,” Krepski said. “They’re also going to interview witnesses and gather information from air traffic control regarding communications and radar information, information about the weather, information about the aircraft’s maintenance records, pilot’s training records.

“It’s really about gathering as much information as we can about from the site and from other sources to begin our investigation.”

TSB deploys team of investigators to Roxton Falls, Quebec following an ultralight aircraft accident

DORVAL, QC, Aug. 15, 2021 /CNW/ – The Transportation Safety Board of Canada (TSB) has deployed a team of investigators to the site of an accident involving an ultralight aircraft in Roxton Falls, Quebec. The TSB will gather information and assess the occurrence.

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.

The TSB is online at www.tsb.gc.ca.

Canadian investigators take over probe into Air Baltic A220 engine incident

From Flight Global – link to source story

By David Kaminski-Morrow27 July 2021

Canadian investigators are to probe an engine-control incident involving an Air Baltic Airbus A220-300 during which both powerplants shut down after the aircraft touched down in Copenhagen.

Danish authorities have delegated the investigation into the 11 July incident to the Transportation Safety Board of Canada.

The board says the twinjet (YL-AAQ) had reached top-of-descent on its service from Riga to Copenhagen when the crew disengaged the autothrottle and deployed spoilers to reduce airspeed.

A few seconds after the autothrottle disengagement, a mast caution light illuminated for a right-hand throttle failure, and the crew completed an abnormal checklist for the throttle failure before continuing the approach.

“After touchdown with both main landing-gear on the ground, both engines shut down,” says the board, without elaborating.

“The aircraft came to a full stop on the taxiway and was towed to the gate.”

A220 YL-AAQ-c-Air Baltic

Source: Air Baltic

Pictured during an earlier flight, this aircraft (YL-AAQ) was involved in the incident

All A220s are powered by Pratt & Whitney PW1500G engines.

None of the 91 occupants was injured, says the safety board. The aircraft had landed on Copenhagen’s runway 04L.

Full circumstances of the incident have yet to be determined, with investigators still to identify whether the shutdown was the result of system logic or another cause.

Air Baltic took delivery of the aircraft in April 2019.

Pilot survives helicopter crash in Brantford, Ont., apparently hitting a power line

From The Toronto Star – link to source story

By The Canadian Press | Sun., July 25, 2021

BRANTFORD, Ont. – The Transportation Safety Board of Canada says a helicopter pilot has survived a crash in southwestern Ontario after she appears to have clipped some power lines.

A spokesman for the TSB says a Robinson R44 helicopter was conducting an aerial spray operation north of the airport in Brantford, Ont., at about 7 a.m., when it crashed.

Chris Krepski says preliminary information is that the helicopter collided with a power line.

He says the helicopter was substantially damaged.

Despite that, the Brantford paramedic service chief says the approximately 35-year-old pilot was conscious and appeared to only have fractures and minor injuries.

Russell King says his crews on scene said it was her day to buy a lottery ticket.

This report by The Canadian Press was first published July 25, 2021.

Limited visual cues and runway conditions contributed to runway excursion of passenger aircraft in Terrace, BC

Richmond, British Columbia, 22 July 2021 — In its investigation report (A20P0013) released today, the Transportation Safety Board of Canada (TSB) found that limited visual cues due to falling snow and a snow-covered runway contributed to the 2020 runway excursion involving a WestJet Encore De Havilland of Canada Ltd. DHC-8-402 in Terrace, British Columbia.

The occurrence aircraft on Runway 33 at Terrace Airport. Image taken approximately 9 hours after the occurrence (Source: Terrace Airport)

On 31 January 2020, a De Havilland Aircraft of Canada Ltd. DHC-8-402 aircraft was conducting WestJet Encore flight WEN3107 from Vancouver, BC to Terrace, BC with four crew members and 43 passengers on board. During the landing roll, the aircraft drifted left from the snow-cleared area of the runway and the left main landing gear exited the runway surface, travelling for approximately 400 feet before returning to the runway. During the runway excursion, the aircraft’s nose landing gear collapsed. The aircraft came to a stop in the centre of the runway. The passengers were transported to the airport terminal by bus approximately 30 minutes after landing. No injuries were reported. The damage to the aircraft included the collapsed nose landing gear and damaged right propeller blades.

The investigation found that, given the falling snow and the snow-covered runway, there were limited visual cues available to the flight crew, which decreased their ability to accurately judge the aircraft’s lateral position once it was beyond the runway threshold. Snow clearing operations cleared the centre 100 feet of the runway, which resulted in windrows that were approximately 18 inches high along the edges of the cleared area. This reduced the pilot’s lateral maneuvering room during the landing.

It was also determined that the aircraft initially touched down 10 feet left of the centreline due to control inputs and variable wind conditions and, while the aircraft was still in a light weight-on-wheels condition, a gust contributed to a further deviation to the left until the left main landing gear came into contact with the windrow. As a result, the aircraft was pulled to the left and travelled through the uncleared portion of the runway. During the runway excursion, snow and ice became packed in the nose landing gear bay and caused structural deformation. Consequently, the nose landing gear was no longer being held in place and collapsed rearward into the fuselage, causing substantial damage to the aircraft.

Finally, the investigation also determined that, if aircraft operators do not provide pilots with all the possible tools and relevant information to assess runway suitability for landing, pilots may not evaluate all potential threats and may make decisions based on incomplete or conflicting information.

Following the occurrence, WestJet Encore issued a revision to the Quick Reference Handbook on 14 February 2020 that included changes to contaminated runway operations. The Terrace-Kitimat Airport Society issued a memo informing staff of changes to its Winter Maintenance Plan, which aligned the procedures with Issue 04 of Transport Canada’s Advisory Circular 302-013: Airport Winter Maintenance and Planning.

See the investigation page for more information.

Investigation report: Loss of control and inadvertent descent near Upper Kananaskis Lake, Alberta, in January 2021

Calgary, Alberta, 13 July 2021 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21P0001) into the loss of control and inadvertent descent of a privately registered Mooney M20F that occurred on 3 January, 2021 near Upper Kananaskis Lake, Alberta.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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.