Final Report Jazz DHC-8 CYYB Runway Overrun

[Intentional Left Bank]

TSB Report A08O0333

Findings as to Causes and Contributing Factors

1. 1. The approach speed of the aircraft was higher than outlined in the Air Canada Jazz standard operating procedures (SOPs). Because the aircraft could not be configured for landing until it slowed to the appropriate speed, commencement of the final descent to the minimum descent altitude (MDA) was delayed.

• 2. The final descent to the MDA was not initiated at the final approach fix (FAF). Therefore, even though the flight path angle (FPA) of the aircraft was about 3° and the rate of descent was constant, the aircraft was well above the desired vertical profile, resulting in the aircraft reaching the MDA well beyond the missed approach point (MAP).

• 3. The flight crew was not cognizant of the distance or time to the MAP during the approach. Therefore, the aircraft crossed the MAP before arriving at the MDA, but a missed approach was not conducted.

• 4. When the runway edge lights came into view, the flight crew continued the approach and began the landing sequence without being able to accurately assess the aircraft position and rate of change of position. This assessment may also have been hindered by a windrow obscuring the runway end lights.

• 5. Air Canada Jazz had not provided the flight crew members with adequate initial stabilized constant descent angle (SCDA) training, or any recurrent SCDA training and they were therefore unfamiliar with many aspects of SCDA approaches.

• 6. Transport Canada approved the Air Canada Jazz training program without data to indicate that the SCDA training met the requirements of the Canadian Aviation Regulations (CARs) and the Commercial Air Service Standards (CASS). This resulted in flight crews not receiving all the required training to safely conduct this type of approach.

[Maynard]

Maybe people can take back their remarks about the 200 hour FO that was on board......

[Hedley]

So the crew did everything right?

[scopiton]

The captain joined Air Canada Jazz in January 2000, transitioned to the DHC-8 in November 2007 and was subsequently appointed captain. The captain had approximately 9500 hours' total time including 4000 hours on the DHC-8, 500 hours as pilot-in-command.

The FO had been employed with Air Canada Jazz since September 2006 and had approximately 4500 hours' total time of which 1300 hours were second in command on the DHC-8.

[teacher]

So the crew did everything right?

Exactly. Some Jazz folks on here were telling us to wait for the report, once we knew the details we'd see that 'this could have happened to anyone'. What a load...

.............and it could, unless you're a super pilot in which case I'd be even more careful as they're the ones that usually end up in these reports because they can NEVER be wrong. These guys have flown to this airport a million times and once made a mistake flying an approach they NEVER do with outdated weather and this happened. It CAN happen to anyone which is why we train and improve our skills every year.

Did you even read the report? The 10000 foot strip with obscured lighting is probably what prompted them to continue the landing not knowing they had traveled further than they thought.

[The Other Kind]

I get that....I'm not posting here as a high brow elitist. I understand that things can happen to any of us. I was expecting something of substance to be in this report..something more than just a poorly flown approach...and it's NOT there. I will not fly my airplane off a 10000 foot runway under the same conditions, ever. Add some sort of system failure...even something unrelated that would add to the work load and give at least some sort of reason...but there's nothing of the sort. You folks talked like there was a REASON we would all understand once the report was released. The fact is these guys flew a Dash 8 off a very long runway, because...well, they pooched it. Unfuckingacceptable.

[J31]

And it descends into a pissing contest.... You guys need to cool off a bit.

[square]

.

[Mclovin]

Yes the guys screwed up, we all know it, and there is no way to justify it. It happened they fucked up, and we should all be happy no one was seriously injured of killed. And hopefully we learned something from this and it won't happen again.

What bothers me the most is "The Other Kind" spouting off the BS about "you get what you pay for". This statement is totally ignorant and obviously mean spirited. Most likely made to get under the skin of Jazz employees because he has nothing better to do with his time then insult his fellow pilot. Insulting over 1500 current pilots at Jazz I might add, and anyone else who has ever worked there.

"The Other Kind" I invite you to come to one our bases, meet some of our pilots and then form an opinion. We have some very talented people working in both seats up front and I am sure they would love to hear your opinion about us face to face, I know I would.

Pissing matches like this should be put into that other thread about "this is what's wrong with Canadian aviation". People constantly criticizing, taking jabs, people hoping for certain companies downfall, you see it all the time on this website its disgusting. We all do the same job, we need to grow up and stop pointing fingers at each other!

[RFN]

If you truly believe that your are immune to making stupid mistakes then you have already proven yourself incorrect.

[Cat Driver]

I guess as the senior poster here I may as well put in my thoughts on this event.

When it first happened and for months after no one could make any comment without bringing down a rain of indignant protest from some of the Jazz pilots claiming there were extenuating circumstances that contributed to the runway over run that anyone of us could have been a victim of.

It will be interesting to read their comments now that the report is out.

[teacher]

This isn't a pissing contest and I'm not defending the actions of the crew. There's no doubt they made a series of mistakes. It's not because, in your opinion, that they were under paid or stupid it's because of a group of factors listed in the first post of this thread. There were reasons and all pilots who do SCDA approaches should read the report and be aware of them. Insulting fellow aviators after an accident is extremely unprofessional. Learn from their mistakes and make sure this kind of accident does not happen again.

One thing that hasn't really been mentioned here is the tail wind on final. Their approach as botched due to late configuration of the aircraft. With the FSS being closed no up to date weather information was available and it went unnoticed that they had a 50 knot tailwind on approach and 30 knots on the tail at the FAF. Also on the dash we NEVER do SCDA approaches since we have coupled VNAV with the FMS but that's useles when doing a LOC app as it's not engaged. Because of this the training was minimal (which has been changed). The only information they had was surface winds which were much different than the winds aloft.

Yes they could have double checked their ground speed on the FMS
Yes they should have just gone around at the MAP
Yes they should have started configuring earlier than the FAF

My thoughts on the matter:

They were focused on flying an unfamiliar type of approach and trusted the VS numbers they came up with
and didn't think of double checking GS when the surface winds were so low. The tail wind skewed their calculations

Focusing on rate of decent and time rather than distance from the runway had them see the runway on time but further down than they expected knowing that "it's a dash" and that "it's 10000 feet long" as well as the runway end lights being covered with snow didn't help their perception of where they broke out

Configuring earlier doesn't happen often since flying at 120 from the FAF inbound holds up traffic at a large majority of the airports we fly to. It's alway "hold 170" or "160 to the FAF"

The time of day probably didn't help as these guys were probably pretty tired this being their last flight of the day

This isn't defending their actions it is learning from someone elses mistakes. These aren't excuses but reasons (and my opinions). Coming in here and saying these guys are idiots and you get what you pay for is just ignorant.

I suggest you review the following:

Hazardous Attitude: Invulnerability
'Nah I dont think it'll happen to me!'
Despite the fact that mishaps in aviation do have a rather low percentage probability, many still rest assured on this fact and oft take it for granted. Such attitudes would compromise vigilance and cause pilots to overlook certain issues that they feel are of less importance (going thru checklist twice, good lookout). Remember accidents can happen to ANYONE!

And this http://www.airlinepilotcentral.com/airl ... z_air.html

You're not gonna get rich working at Jazz (or as a pilot in general) but the payscales are not horrible. I guess it depends on who you talk to, some folks will call us bottom feeders, others will say we're over paid and over priced. I guess it all depends on your motivation.

Safe flying to all!

[dream_big]

What is everyone getting bent out of shape about. Everyone with a brain knows mistakes were made here with a bad chain of events.

[KAG]

Mistakes were made, the crew screwed up. Also having flown SCDA's at Jazz personally I thought the training was good.

Never say never...A lot of smart, careful pilots are not here today due to the right set of circumstances at the wrong time.
Stay vigilant.

[xsbank]

What the posters are annoyed at is the superior attitude that was displayed by Jazz proponents when this accident happened, many threads were locked or discarded and we were told to wait for the great unveiling of the accident report which would explain what really happened. Well, the report is out and the crew simply pooched it. There was no great event that happened to make our comments unreasonable, there was no earth-shattering ground breaking events that justified shutting us up, being rude to us and p*ssing us off back then, just a bunch of Jazz apologists on their hind legs.

The crew just pooched it as the majority of the posters back then suggested.

The end result was a total change in the character of this site and many long-time posters saw the writing on the wall and abandoned it. All because of this accident and the draconian response by the mods.

THEY POOCHED IT!

[TopperHarley]

Not exactly. What "annoyed" most Jazz pilots was that people were using this incident as a means to make fun of Jazz, often seeming happy that it happened. I lost count at how many times XXX made references to this incident. I know he wasn't intentionally trying to bring down the pilots/company, but it still rubs people the wrong way when you make fun of something that happened to one of your fellow coworkers.

Even now people bring up their payscale... that has absolutely nothing to do with the incident.

[TopperHarley]

I assure you nobody at Jazz thinks they're immune to anything. The FO who worked this flight is a CRM instructor now and was my instructor when I did my recurrent last year. He spent the better part of the day discussing the incident. It was a very informative class and I assure you it mustve taken a lot of guts for him to be doing that. He was very humble about it and very open about everything that happened. By far the least boring CRM class Ive ever had.

[Doc]

Just one comment here from me. I feel there is an inbred fear, not a fear really, more an aversion to, the missed approach. If we see something. Anything. By Gawd, we are going to get her down. The amount of "bacon and eggs" that could be saved in this industry by simply missing the bloody approach. Here's the "dumbed" down lesson here. When things, ANY thing, doesn't look quite right, execute a missed approach. Perfect example here. See the runway, but not the threshold? Miss.

[fish4life]

Although the length or runway doesn't really matter lets be happy it happened where it did, had they done this same approach into somewhere in the mountains and ended up 2 miles further down the approach then they thought they were and then went missed things could have gotten really ugly. I CAN easily see how this could happen to most pilots if they were unfamiliar with the SCDA approach, oddly enough had they stuck with your standard approach with step downs instead of doing the "safer" SCDA they would have probably been fine.

[Plim Sole]

Doc,

I guarantee you that when you touch down 8000' into a 10,000' runway... its only 2000' long!
Yes Yes, if they had done it correctly, it would have been 10,000' long, but they didn't.
The issue here was the SCDA and not, as some would explain it, the crews ability to stop a Dash8 on a 10,000' runway!

The very simple fact is that the crew made a series of errors which lead them to touch down way too far down a suitable runway.

I find the attitude of those who think a similar incident could never happen to them quite alarming.
Been doing this for 22 years now and the one thing I have learnt is that 'surprise' can race up and bite you on the arse anytime, anyplace and anywhere!

Plim

[xsbank]

"Plim sole" is Brit terminology for a running shoe.

All bets are off if you go noodling past the missed approach point and you are not in a position to land. Like Doc says (Hi Doc!) its not rocket science, not even Dash 8 science, you execute a missed approach. Try doing such a fool maneuver in the rocks or somewhere that is less forgiving?

Another thing, WTF is this going into an airport where there is no current weather reporting, not even wind, at night in sh*tty weather with a load of trusting passengers in the back? Snow covered some of the lights? These guys are damn lucky they are not up to their Raybans in lawsuits. Jazz may be a paragon of aviation virtue in some of your eyes but in my not humble opinion, this accident started when they decided to leave from wherever they left from; "shooting in the dark" springs to mind.

I'm glad that all you Jazzers are feeling all warm and touchy-feely about the CRM in this case, but you are so damn lucky you didn't kill everyone.

Rant Switch...........................OFF

[teacher]

By weather I meaned the FSS station was not maned. I believe there is an auto station there but getting up to date weather on approach was not available nor had anyone been there or was there to advise the crew of 30 knot tailwinds on final. That has been changed and they remain there until the last scheduled flight arrives. Again, not excuses but contributing factors to an incident caused by pilot error. Just one of many "holes" in the cheese that lined up that night. Agreed though, a MAP is a MAP regardless of doing an SCDA or not. Repeating myself though, it is possible to fixate on your VS and time when doing an SCDA and forget about the actual MAP of the approach. A lesson for everyone to learn and THAT is what's important.

[Cat Driver]

By weather I meaned the FSS station was not maned. I believe there is an auto station there but getting up to date weather on approach was not available nor had anyone been there or was there to advise the crew of 30 knot tailwinds on final.

There was no other means of knowing there was a 30 knot tailwind during that trip and approach?

[Hedley]

I guess their GPS doesn't have the capability to display groundspeed, on final.

[bawlsdeep]

This is an awesome opportunity to look an the many unconnected factors that came into this and most are not posted in that initial post as contributing factors. This website could function as a place to come and feel like you have learned something instead you have bonehead posts by some other kinds and back seat drivers.

Transport Canada issued lower approach ban minimums for doing an SCDA approach than the traditional step down, which I think is wrong. If you start missing a series of step downs you are more likely to reconsider your ability to recover the approach. The fact that the runway was 10 000 feet long was probably another huge contributing factor. Had in been a few thousand feet you'd be thinking more about the end of it. My understanding is that they thought they were somewhere that they were not, I'm referring to visual clues once they had the airport environment. I've had that happen flying coastal floats in marginal wx and have to say is probably one of the most dangerous situations that I have come across.

Another issue that I would like to see changed is let the training briefing that Jazz pilots went through after the fact be published, instead of the couple points mentioned in the first post. I don't remember all the details but do remember thinking that there were a lot of things going on with that flight.

This isn't the first or last airplane to go off the end. Look around at other industries and their safety records. The aviation industry has done a great deal of work creating a safe environment. It's nice to have high standards and training to keep it safe.