Perimeter Sanny accident report

[CID]

and the only reason that this option was not available was because of a generalized unwillingness on the part of governments at all levels, and industry, to make the investments necessary to make flying safer.

I think that's unfair. There are a LOT of airports out there and the government has a set level of resources to implement these approaches. It's far too simple to say that it's an "unwillingness" especially when you consider the airport in question now has an LNAV approach to both runways.

[JigglyBus]

The accident statistics are clear. In order of probability of a most to least fatal outcomes. (Note: for all approach types circling at night is the most likely to result in a fatal accidents, followed by circling during the day, followed by night straight in followed by day straight in.)

1) NDB (no distance information)
2) NDB (with distance information)
3) Other Non Precision (LOC or VOR with no DME)
4) Other Non Precision (LOC or VOR with DME, LNAV)
5) Other Non Precision (LNAV with VNAV)
6)ILS or LPV or RNP.

Out of curiosity, where are you getting these statistics?

I'm not saying that they are incorrect, just wondering where you came across them.

[PROC_HDG]

I am pretty sure there would have been no accident if there had been a proper LNAV approach to both ends of the runway. This would have allowed an into the wind CDA procedure to be carried out. There is no question that this is a much safer procedure than a NDB to circling limits.

In this day and age there is no excuse for public use airports to only have an NDB approach

So...the lack of an LNAV approach caused the accident? If they didn't bring charts for the NDB approach what makes you think they'd have charts for any LNAV approach? Besides, if they crashed by screwing up an LNAV approach would you then be stating that they wouldn't have crashed if they had a CAT III ILS?

The point is that you need to use what is available and you must respect the associated limitations. If you don't then you can't cite the lack of "extra" that doesn't exist.

Bingo.

The accident wouldn't have happened if the runway was made out of cotton candy either... You gotta play the game with the field that's available.

Accidents never have only one cause. Having an RNAV at CYSK may have been the malaligned hole in the swiss cheese model required to prevent a lot of the other major errors causing a crash. Whether they had charts or not, having a t-bar approach with lower minimums to both runway ends almost certainly would have made a difference in this case.

PROC_HDG

[Crusty]

I think a secondary interesting discussion from an ethics discussion is this:

Your buddy calls you on the radio 10 minutes after he takes off and asks you to read him an approach plate for his destination so he can make notes because he forgot his plates. Do you do it?

[pelmet]

I am pretty sure there would have been no accident if there had been a proper LNAV approach to both ends of the runway. This would have allowed an into the wind CDA procedure to be carried out. There is no question that this is a much safer procedure than a NDB to circling limits.

In this day and age there is no excuse for public use airports to only have an NDB approach

So...the lack of an LNAV approach caused the accident? If they didn't bring charts for the NDB approach what makes you think they'd have charts for any LNAV approach? Besides, if they crashed by screwing up an LNAV approach would you then be stating that they wouldn't have crashed if they had a CAT III ILS?

The point is that you need to use what is available and you must respect the associated limitations. If you don't then you can't cite the lack of "extra" that doesn't exist.

Bingo.

The accident wouldn't have happened if the runway was made out of cotton candy either... You gotta play the game with the field that's available.

What makes me think that they would have had the information for an RNAV approach despite having forgotten their charts is that they had the information for an NDB approach despite having forgotten their charts. They would have gotten their info from the same source.

It is silly to bring in the question of a CAT III ILS into the conversation but it is not unreasonable at all to expect a straight in RNAV approach at an airport that is the most qualified type to get one. An airport with no terrain of significance and no straight-in approach available with traditional navaids to a runway that is frequently into wind.

We hear from so many posters after an accident on how the pilots should not be the only ones taking blame, that we need to look at the higher echelons such as management and regulating authorities and their role. Well how about the role of NavCanada who(now that I see YSK has two RNAV approaches) waited who knows how many years to finally put in RNAV approaches.

It is nice to say that pilots play with what is available to them and there is something to be said about that but why are pilots being still given so few tools to play with about a quarter century after GPS approaches started. A massive amount has been spent by them on ADS and CPDLC by Nav Canada but I don't think it has prevented one death. It is a well known fact that circling approaches, especially into tight dark holes like this on old aircraft are much higher risk with many, many accidents over the years.

So coincidentally, two straight in RNAV approaches are installed after the accident. The equivalent of the so-called "Tombstone technology" where it took a significant amount of deaths to push for regulatory/technological change.

[Diadem]

For those who think a stabilised approach below mins would be an appropriate solution, I'd like to point out that the crew had the runway in sight on both approaches. They were also below mins on both. At one point on the second approach, the FO commented that the runway looked good. This wasn't a CFIT where they flew into the ground without seeing it; the captain flew a shitty approach at ref+30 with a tailwind, and touched down 3000' past the threshold. It wasn't a matter of not seeing the runway, and not having any other options, it was his poor decision making and inability to judge that he was fucking up. Taking off with 200 lbs of granny gas, not having the approach plates, and utilising an alternate that was marginal even on the best forecasts were indications that his decision-making was poor, but ultimately it came down to shitty flying.

[stef]

Ok. Point taken Diadem.

[Rookie50]

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[pelmet]

For those who think a stabilised approach below mins would be an appropriate solution, I'd like to point out that the crew had the runway in sight on both approaches. They were also below mins on both.

Isn't that why they had the runway in sight, because of their further descent. They just did it in an improper manner

the captain flew a shitty approach at ref+30 with a tailwind, and touched down 3000' past the threshold. It wasn't a matter of not seeing the runway, and not having any other options, it was his poor decision making and inability to judge that he was fucking up. Taking off with 200 lbs of granny gas, not having the approach plates, and utilising an alternate that was marginal even on the best forecasts were indications that his decision-making was poor, but ultimately it came down to shitty flying.

I agree the flying was pretty bad. For the circling, all they had to do was circle to the south. While I haven't flown a Metro, my guess would be with runway in sight, a turn to the left for 20 to 30 seconds depending on the winds, past the threshold for 30 seconds or so depending on the winds, using an appropriate wind correction angle backed up by GPS track display and then a turn onto final. It is fairly simple and works well. The captain appears to have wanted to fly and be the one looking outside as he kept the airport to his left.

Why not just fly and let the FO help guide you around with a proper briefing on what calls to make. I find that calls in this situation can be helpful or not helpful depending on what is said. Instead of the PNF saying things on the turn inbound that may not be particularly useful, how about a call such as "20 degrees bank" and "500 fpm descent" instead of your a little bit tight and start descending" leaving you having to guess on how much correction to make. Exact commands can be very easy to follow promptly. They also had PAPI's on this runway which are very useful once they come into view. Once on the descent and the PF has the airport in view, the PNF can be really useful by calling out "ref plus ____ sink 800" as the PF is concentrating 100% looking outside.

To try to dive into a very short for type runway at 1800 fpm and ref plus 30 with a 15 knot tailwind(and according to the report, a significant number of seconds delayed prior to initiating this approach from almost the MAP) makes no sense.

Then there is the go-around, Why would you wait until being at the very end of the runway to go around at 50 or less feet when you know you would overrun even if you landed halfway down the runway. But a go-around should not be a big deal. If I remember correctly, the PNF made a call that they were 5 knots slow and according to the report, the captain likely pushed forward on the control column. I suspect quite a bit. Something like this typically happens in what are known as Somotogravic effect accidents where the acceleration gives the pilot the sense of pitching up excessively when in fact this is not the case. The best defense against this is a good scan. I notice that the captain had flown widebody jets at two carriers previously to this. Typically they have modern EFIS flight displays that are known for reducing pilots instrument scanning skills over the long term.

I'm surprised that the TSB didn't look further into this as a go-around even at low energy should not be a big deal, especially in cooler temperatures like that day with plenty of power available, assuming that plenty of power was applied of course.

[PositiveRate27]

I agree that having an RNAV approach would have reduced the chance of this accident from happening, but that is not the lesson that should be interpreted here. We as pilots can't just say "hey, the government didn't give us the best equipment available so it's out of our control."

The fact is these pilots demonstrated alarmingly poor decision making and we as a group need to look at this and ask ourself how we can avoid putting ourselves in these types of situations.

[AOW]

CYSK 2200 UTC METAR: wind 010°T at 17 knots gusting 25 knots, visibility 2 sm in light snow and blowing snow, cloud ceiling overcast 1200 feet agl, temperature −5°C, dewpoint −6°C, altimeter setting 29.28 in. Hg.

CYGW 2200 UTC METAR: wind 030°T at 8 knots, visibility ½ sm in moderate snow, vertical visibility 400 feet, temperature −4°C, dewpoint −5°C, altimeter setting 29.18 in. Hg.

CYGL 2200 [UTC] METAR: wind 290°T at 10 knots gusting 17 knots, visibility 1½ sm in light snow and drifting snow, vertical visibility 1300 feet, temperature −7°C, dew point −9°C, altimeter setting 29.17 in. Hg. In remarks, visibility was noted as variable from 1 to 2 sm.

This is what bugs me with this whole scenario. They dispatched with sufficient fuel to get to YSK, shoot an approach and missed approach, fly to YGW, shoot an approach and land, plus 45 minutes of reserve fuel. On top of that, they claim to have had 200 lbs of "granny gas". YGL is less than 100 miles further from YSK than YGW, which is probably pretty close to 200 lbs more fuel burn to get to, in this machine! Even without the granny gas, I would have considered diverting to YGL after the first approach, knowing that another approach was likely not going to work out any better, and knowing that YGW was below limits. Yes, this would be cutting into my reserve fuel, but isn't this exactly the reason why we carry reserve fuel? With the extra 200 lbs, we probably would land in YGL with close to 45 minutes left in the tanks... that sounds like a much better option to me! A better airport, with better weather, and better approaches.

[JoeShmoe]

I also find it shocking that the lack of a straight in approach to both runways was not even included as a risk factor in this report. They must secretly admit that this is a risk factor if an rnav approach appeared there soon after the accident. I remember about a month after the keystone accident in north spirit an rnav approach suddenly appeared there as well. It drives me a little crazy that the only way we get upgraded approaches in these isolated areas is for someone to die. I personally have just sent an email to navcanada requesting what I am sure many of you have already done, and that is to install an rnav approach at every northern airport and to do so quickly. I hope many of you will do the same.

I realize that the lack of rnav approach is not the only cause of this crash, probably not even the main reason for this crash, but it is something that we can actually do something about. This is a forum for pilots, it would be nice if we could get together to advocate for safer flying conditions.

[FICU]

I have done more trips than I can remember from YWG to Sani and I always checked wx enroute. You cannot trust Kuj as an good alternate when Sani is in the shitter because Kuj would probably be in the same system. Always plan to go somewhere else or divert if necessary while enroute. All this talk of approaches is moot when the crew didn't keep themselves updated on weather and plan for a contingency.

[Johnny#5]

Shoulda, coulda, woulda....

[FL7377]

As for the granny gas....

You'll notice the AC took off at 15993 lbs (max 16000) on PAPER + 200 lbs granny gas. And the only comment the NTSB had about it was adding extra fuel "may invalidate the C of A". The NTSB did NOT suggest to TC that the "well known practice within the company" of adding granny gas should be changed. The NTSB mentioned without criticism the use of granny gas, this flight took off 200 lbs overweight invalidating the C of A... and no one cares. And nor should they!

Perimeter's Metro's are what, 30-40 years old? Go drive a car from that era and ask yourself how accurate the fuel guage is. In fact I think if Perimeter's pilots DON'T add 200 lbs to every flight, that's a problem!

I fly up north in a little twin turbo-prop. In my AC I never take off without a little extra fuel on board, so I KNOW I have the minimum.... usually around %10 more. If I'm on my way south, or flying around civilization, maybe a little less.

That is very common in my company to take a little extra, and by the sounds of it its common at Perimeter as well.

[FL7377]

I also find it shocking that the lack of a straight in approach to both runways was not even included as a risk factor in this report. They must secretly admit that this is a risk factor if an rnav approach appeared there soon after the accident. I remember about a month after the keystone accident in north spirit an rnav approach suddenly appeared there as well. It drives me a little crazy that the only way we get upgraded approaches in these isolated areas is for someone to die. I personally have just sent an email to navcanada requesting what I am sure many of you have already done, and that is to install an rnav approach at every northern airport and to do so quickly. I hope many of you will do the same.

I realize that the lack of rnav approach is not the only cause of this crash, probably not even the main reason for this crash, but it is something that we can actually do something about. This is a forum for pilots, it would be nice if we could get together to advocate for safer flying conditions.

Couldn't agree more! We need more infrastructure up north!

What is the College of Professional Pilots doing about this????

Oh right, nothing, because they don't legally exist yet......

[FL7377]

As a low time private here -- hence my handle -- circling approaches scare me. At night? Ugggggggg. Just did my first one actually -- during the day. Prepped for minimums -- per the metar - but comfortably above. Anticlimactic, An LNAV, and I had a first class alternate 20 min away, tons of fuel.

Night NDB circling? No thanks for me SP. But I'm zero experience essentially.

Circling approaches at night scare me to! Lets never do them!

Then all of a sudden the company gets a $20k charter to somewhere like Sanny, the only way in with the winds that night is to circle, and every one expects you to get in, if you don't you'll have a torrent of angry managers breathing down your neck when you get back. SO what do you do? Chicken out and hope you get to keep your job, or bite the bullet and learn to circle....

The level of infrastructure up north in the 21st century is embarrassing!

[CID]

They must secretly admit that this is a risk factor if an rnav approach appeared there soon after the accident.

This is one of a few comments on this thread that is disturbing. A risk factor is one that contributed to the accident. The lack of specific approaches is NOT a risk factor. As a pilot, you are supposed to plan and operate within the established parameters and limitations and that includes the available published approaches.

If you are not capable or able and you attempt the flight anyway, THAT is the risk factor, not the lack of an approach. Next we'll be reading about how the airplane would have made it if the fuel tank was bigger or if it was able to fly with a few thousand extra pounds.

And here's a thought for you RNAV flag wavers. If a straight-in RNAV approach would have saved the day, why didn't the flight crew build one? Yes, somewhat dangerous but you can't tell me that nobody does that or that the airplane wasn't equipped. Of course it would have been easier if they had the charts which was one of the more significant screw-ups in this mess.

The point here however is don't make decisions based on what SHOULD BE. Make them on reality and you may avoid killing anyone.

[Rookie50]

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[Diadem]

Now people are advocating taking "a little extra" fuel and knowingly taking off overweight? What the hell has happened to this industry? If your gauges aren't accurate and you think you need more fuel, bump some freight; if you take off overweight and lose an engine, there's a good chance someone could die, likely you. Don't start breaking laws just to get the job done.

[CID]

Yes I know it's money, the U.S. has 3500 LPV approaches now. We have a few hundred at most, with a lot less alternates than the U.S. has. We need them even more for that reason.

The US has 10 times the population and more than 10 times the airports. Out of 15,000 airports in the US, about 1500 have LPV approaches. About 10%. In order to design an approach to LPV minima (or any WAAS approach for that matter) the airport needs to lie within the coverage area of a WAAS ground station.

Out of about 35 WAAS ground stations in North America, 4 are located in Canada at Winnipeg, Iqaluit, Goose Bay and Gander. Here is a map of the population density of Canada.

http://www12.statcan.gc.ca/census-recen ... z01-en.gif

So tell me genius, (in all your shame) how can you say that our country isn't progressing in a reasonable time? How much do you think we need to pile together to provide about 1% of the population with all weather approaches? Should we put up our own satellites?

And no, you need to wrap your head around what a risk factor in an accident is. Coulda-woulda-shoulda doesn't cut it. The lack of instrument approaches isn't something that happened over night. People have been flying in the north for decades. WAY before the existence of GPS, never mind GPS based approaches. I don't recall any accident reports from the 60s that mention a risk factor of "lack of GPS approach". But I bet there are a few where a factor was an outdated star almanac.

And please...don't give me that "in the real world" bullshit. If you screw up for real, you screw up on paper. If you break the rules and get away with it you're not a hero. You're a lucky moron.

[fish4life]

It may only be 1% of the population but for that 1% the airports are a lifeline for everything in and out of the community. For the cost of a few medevacs missing because they only have an NDB approach it would easily pay for an LPV built on either end or at least an RNAV. As for the safety things try make a circling approach fit into flight safety's stabilized approach criteria. Also in the 60's nobody complained about not having / using accelerate stop distance charts either but we sure use them now RNAV should be no different

[Rookie50]

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[CID]

"If you screw up on paper you screw up for real"

In some ivory towers, because attempting the approach is illegal in paper, to conform to the Regs flight crews should just fly around in pretty circles until they run out of fuel and crash.

Therefore, no regs were violated.

Legal, but dead.

I'm not endorsing the flight crews pre - takeoff or on route decisions, but once you are there what do you do. Follow paper or try to get your butt on the ground?

Are you trying to quote me? I stated "If you screw up for real, you screw up on paper." Much different sentiment.

[Diadem]

"If you screw up on paper you screw up for real"

In some ivory towers, because attempting the approach is illegal in paper, to conform to the Regs flight crews should just fly around in pretty circles until they run out of fuel and crash.

Therefore, no regs were violated.

Legal, but dead.

I'm not endorsing the flight crews pre - takeoff or on route decisions, but once you are there what do you do. Follow paper or try to get your butt on the ground?

So you're saying that instead of going to their alternate, which was forecast to improve, and hope that the improvement had occurred, or hold until they were min fuel to see if the improvement occurred, that they should just chop and drop below mins to get on the ground? Don't climb up nice and high to minimize fuel burns while they re-evaluated and got updated weather, just plop it down below mins and hope you get it inside the boundary of the runway? We're not talking about an airplane that was running on fumes, or in 0/0 weather with no other airport in range, or had a mechanical issue that precluded them from flying anymore; they took a perfectly functional airplane, with 200 lbs more fuel than they needed, and ran it off the end of the runway. They rushed, and they fixated on landing in YSK rather than gathering more info and coming up with a plan. The ultimate reason that they went off the end of the runway was that the captain continued the approach at ref+30 and tried to force it down, because he was fixated on completing that landing.