Perimeter Sanny accident report

[flyinhigh]

Just released couple hours ago, HOLY SHIT.

http://www.bst-tsb.gc.ca/eng/rapports-r ... 2Q0216.asp

[metal]

Thanks, I forgot it was coming out today.

[DanWEC]

Wow. Just, wow. Tragic as it was, glad it wasn't worse.

[TeePeeCreeper]

"The infant was found lodged in the footwell by the Captain's rudder petals"

The term "Horrific" doesn't begin to describe this one...

[esp803]

Left without the approach plates... PT on the wrong side.... No cold weather corrections...

Sad.

Condolences to the mother of the infant.

E

[metal]

Not discounting all the other errors, but cold corrections apparently were accounted for.

"The cold temperature correction was considered and applied to the minimum descent altitude (MDA) for NDB Runway 27 and the other procedure altitudes"

[Donald]

Not discounting all the other errors, but cold corrections apparently were accounted for.

"The cold temperature correction was considered and applied to the minimum descent altitude (MDA) for NDB Runway 27 and the other procedure altitudes"

Well actually....

The Canada Air Pilot General Pages (CAP GEN) Altitude Correction Chart shows that altimeter errors due to cold temperatures can occur at temperatures of 0°C and below. As the surface temperature was -5°C, a correction should have been made to the published procedure altitudes. A correction of 119 feet should have been added to the published sector altitude, a correction of 103 feet to the minimum published altitude for the procedure turn, and a correction of 37 feet to the MDA for the NDB Runway 27 approach, since that was the MDA used.

Since the procedure turn was executed on the opposite side of that published, and outside of the airspace to be protected, the MSA of 1600 feet asl should have been used and corrected. With the applicable cold temperature correction, the procedure turn should have been executed at 1719 feet. The MDA of 560 feet asl, when corrected, results in an indicated altitude of 597 feet. The crew had applied the required cold temperature correction only to the published MDA for the NDB Runway 27 approach and rounded it off to 600 feet asl; the circling MDA of 620 feet, which had not been obtained, was not used.

[Donald]

This whole report is brutal, how many 704 companies are operating this way?

[Rookie50]

..

[metal]

Not discounting all the other errors, but cold corrections apparently were accounted for.

"The cold temperature correction was considered and applied to the minimum descent altitude (MDA) for NDB Runway 27 and the other procedure altitudes"

Well actually....

The Canada Air Pilot General Pages (CAP GEN) Altitude Correction Chart shows that altimeter errors due to cold temperatures can occur at temperatures of 0°C and below. As the surface temperature was -5°C, a correction should have been made to the published procedure altitudes. A correction of 119 feet should have been added to the published sector altitude, a correction of 103 feet to the minimum published altitude for the procedure turn, and a correction of 37 feet to the MDA for the NDB Runway 27 approach, since that was the MDA used.

Since the procedure turn was executed on the opposite side of that published, and outside of the airspace to be protected, the MSA of 1600 feet asl should have been used and corrected. With the applicable cold temperature correction, the procedure turn should have been executed at 1719 feet. The MDA of 560 feet asl, when corrected, results in an indicated altitude of 597 feet. The crew had applied the required cold temperature correction only to the published MDA for the NDB Runway 27 approach and rounded it off to 600 feet asl; the circling MDA of 620 feet, which had not been obtained, was not used.

Well the report says they did corrections to all procedure altitudes that they had. They didn't have the circling MDA, which is why they didnt correct it.

[esp803]

My simple mistake shouldn't be the concern of this topic... There was also the Seeing the runway beyond the MAP and then diving into a crash...

E

[tbaylx]

Not discounting all the other errors, but cold corrections apparently were accounted for.

"The cold temperature correction was considered and applied to the minimum descent altitude (MDA) for NDB Runway 27 and the other procedure altitudes"

Well actually....

The Canada Air Pilot General Pages (CAP GEN) Altitude Correction Chart shows that altimeter errors due to cold temperatures can occur at temperatures of 0°C and below. As the surface temperature was -5°C, a correction should have been made to the published procedure altitudes. A correction of 119 feet should have been added to the published sector altitude, a correction of 103 feet to the minimum published altitude for the procedure turn, and a correction of 37 feet to the MDA for the NDB Runway 27 approach, since that was the MDA used.

Since the procedure turn was executed on the opposite side of that published, and outside of the airspace to be protected, the MSA of 1600 feet asl should have been used and corrected. With the applicable cold temperature correction, the procedure turn should have been executed at 1719 feet. The MDA of 560 feet asl, when corrected, results in an indicated altitude of 597 feet. The crew had applied the required cold temperature correction only to the published MDA for the NDB Runway 27 approach and rounded it off to 600 feet asl; the circling MDA of 620 feet, which had not been obtained, was not used.

The cold weather correction applied is the least of the issues here...

[DanWEC]

Everything possible done to put themselves into a corner, bit by bit, incrementally. Just brutal. Almost insidious. Switching to the tailwind approach capped it off and after all the stress they pooched it. Thank FVckin god they didn't all die. Lots to learn from a human standpoint.

[trey kule]

Trying to understand the various pressures here.

I felt that the particular issue should have been explored with the company and its other crews. Was get in itis a result of another sister company plane getting in? company culture? Or not real, but perceived pressure by the Captain to keep trying.
So many serious decision making errors, one can only shake their head at this sad situation.
On the other hand, if they had got in, it would have been another job well done, and an incentive to try it again.

[fish4life]

I'd imagine being in the arctic where they don't normally go coupled with the alternate weather going down added the pressure of needing to get in because maybe they felt the alternate was no better? Either way everything went wrong when they forgot to grab the approach plates.

[all_ramped_up]

Ugly.

Just shows how accurate the "Swiss Cheese" model really is. One or two errors... maybe three and you could have no serious problem but eventually all the holes line up and this happens.

The part about the infant though really tugs at the heart strings.

[55+]

The first two items under Findings indicates to me airlines/charter companiesof this nature shouldn't be in operation. I would hope the flight crew on this particular flight would have difficulty in employment prospects, this is just terrible, no other way to describe it.

[pelmet]

From what I remember, Saniqiluaq is as flat as a pancake(or nearly so). Regardless of the reasons, if you are in a situation where there is no alternate, it is time for alternative methods. Nothing wrong with initially circling but if it is too low, there really is only one way to go. A planned approach below minimums. Being familiar with the airport having been there more than once in the preceding days in good weather, they were likely familiar with the area.

Get the FO flying the aircraft, guide him in on the GPS at an appropriate altitude, preferably into wind to the airport reference point on runway track and be ready to take over and land. A PMA approach. A nice 3 to 1 descent can be done to the airport down to 100 feet. Or the old school guys might descend out over the water to a low altitude and proceed inbound. Based on the weather in the report, they would likely have had the runway in sight at 300 feet and 1 mile back. If it was dark(and it was dark season), light should have been easier to see. If the weather was really 400' and vis 1.5, it should have been straight forward actually. Following the regs exactly aren't necessarily safer.

It can be done. These guys in a 757 were in a worse situation and did it in the Antarctic onto an icestrip in a visibility of 1000 feet instead of 1.5 miles vis.

http://www.taic.org.nz/LinkClick.aspx?f ... uage=en-NZ

Unless the lighting was better on the other runway, I see no point in a downwind approach to a short runway followed by a ridiculously high descent rate to try and make it in. Might work on a long runway, doesn't work here.

[stef]

I agree with Pelmet. If you MUST land, get the f down into a position to land. Stay out of the position to begin with (looking at the conditions I'm 100% certain I wouldn't even have dispatched), but if you've got to land, minimums are out the window. Get into a position to see the runway.

Too bad this report took over three years to put out and is now completely irrelevant. It identifies some major issues at Perimeter that probably are no longer pertinent.

[Trematode]

A planned approach below minimums.

I agree with Pelmet

...uhhhh

[tbaylx]

A planned approach below minimums.

I agree with Pelmet

...uhhhh

Getting yourself into that situation is not desirable if you can avoid it...BUT if you do find yourself there, with no fuel to go to a suitable airport then you'd be pretty foolish to not go below minimums and land. The alternative is to what? go to your alternate and with worse weather, miss and run out if fuel?

Agree with Pelmet. However the thing to do would avoid getting yourself into that situation in the first place and divert en route if possible once you find you have no suitable alternate anymore.

[sstaurus]

Curious beyond checking the alt Wx much earlier in the flight, if they had a better option once in the descent for the primary. What could they do?

Assuming they weren't past any point of no return they still could have just turned back to ywg at that point.

I'm curious how prevalent 'granny gas' still is throughout the industry.

[xsbank]

The fundamental problem here was that the "Captain" didn't say "no."

Contemplating approaches below minima? With passengers? Professional Pilots? Holy crap. If that is the best you can come up with after reading this report...

[Big Pistons Forever]

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

[PositiveRate27]

He still wouldn't have had the approach plates for the RNAV. Makes me want to puke.