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Accident
Last updated: 20 October 2017
Statuts:Enquête Officielle
Date:samedi 17 mars 2012
Heure:11:29
Type/Sous-type:Silhouette image of generic B190 model; specific model in this crash may look slightly different
Beechcraft 1900C
Compagnie:Northern Thunderbird Air
Immatriculation: C-GCMZ
Numéro de série: UC-61
Année de Fabrication: 1989
Equipage:victimes: 0 / à bord: 2
Passagers:victimes: 0 / à bord: 1
Total:victimes: 0 / à bord: 3
Dégats de l'appareil: Substantiels
Lieu de l'accident:Blue River Airport, BC (   Canada)
Phase de vol: A l'atterrissage (LDG)
Nature:Transport de Passagers Nat.
Aéroport de départ:Vancouver International Airport, BC (YVR/CYVR), Canada
Aéroport de destination:Blue River Airport, BC (CYCP), Canada
Détails:
A Beechcraft 1900C was damaged in a landing accident at Blue River Airport, BC, Canada. The aircraft sustained substantial damage.
The occurrence flight was chartered by a travel agency on behalf of a wilderness adventure ski lodge. It was a regularly occurring charter flight between Vancouver and Blue River, BC, Canada.
The travel agent verbally passed weather information to the flight crew. The captain understood that the runway had been plowed the previous day, and that the weather had been good that morning in Blue River.
Before departing Vancouver, the flight crew had also obtained official weather data from regular flight planning sources. It was noted that although current conditions at Blue River were good, a weather system was moving northbound, and conditions in the area of Kelowna, Kamloops (CYKA) (the alternate), and Blue River would begin to deteriorate. As the flight progressed, the ski lodge radio room operator overheard the flight crew discussing weather conditions with a local helicopter pilot on the ATF as the flight overflew Blue River, but the operator did not have any direct contact with the flight. The crew was satisfied with the information received from the helicopter pilot regarding local weather.
Because the Blue River aerodrome does not have a published instrument approach procedure, the intention was to fly over the aerodrome and proceed under visual flight rules (VFR) into the aerodrome. The flight progressed as planned until the aircraft passed overhead Blue River at the lowest useable IFR altitude, and the pilot was not able to descend under VFR into Blue River.
The pilot then climbed back up to an enroute IFR altitude and continued to Valemount Airport under IFR. After conducting the IFR approach into Valemount and finding the weather suitable for flight under VFR, the aircraft completed the 60-nautical mile (nm) trip back to Blue River visually. The aircraft slowly descended in steps as it flew south towards Blue River at a reduced cruise speed of approximately 175 knots. As the aircraft neared the aerodrome, the pilots descended to altitudes as low as 1100 feet above ground level (agl) to maintain visual contact with the ground in deteriorating weather. Approximately 4 nm from the aerodrome, and 85 seconds before touchdown, control was transferred from the first officer (FO) to the captain, who became the pilot flying (PF).
During the approach, the crew rushed to complete the pre-landing checks, visually acquire the runway, and manoeuvre the aircraft to land. The captain turned slightly to the left, away from the runway centreline. At this point, the FO called visual contact with the runway, and the captain turned right, back towards the runway centreline, and again passed through the runway centreline. The captain did not acknowledge that the runway was in sight.
The aircraft was configured for landing 25 seconds prior to touchdown. As viewed from the pilot's perspective, the aircraft was to the left of centreline. Several seconds later, the aircraft initiated a right turn to line up with the centreline of runway 19, but actually crossed to the right of the centreline. The aircraft then overflew several buildings on the right of the runway centreline, approximately 75 feet adjacent to the runway threshold. The aircraft then turned sharply to the left as it passed abeam the threshold, then sharply right to acquire the centreline before touching down approximately 2000 feet past the threshold. Immediately after touchdown, the aircraft veered left into the snow bank.
During the last 23 seconds of the flight, the FO broadcast a traffic advisory to indicate that the aircraft was on final, made 3 speed calls, and advised the captain that the runway was to the left. There were no remarks made by the captain since the request for the landing checklist. The FO did not declare an unstable approach, or prompt the captain to execute a missed approach.

Probable Cause:

Faits établis quant aux causes et aux facteurs contributifs

1. Bien que l’état dangereux de la piste ait été dépisté grâce au système de gestion de la sécurité de l’entreprise, le report du balisage de la piste a permis au risque de subsister.
2. Aucun renseignement n’a été fourni à l’équipage concernant les conditions météorologiques et l’état de la piste; l’équipage n’en a pas fait la demande non plus.
3. Le pilote a poursuivi l’approche malgré le fait que la visibilité était inférieure aux limites précisées dans les procédures d’utilisation normalisées de l’entreprise.
4. La détérioration des conditions météorologiques ainsi que l’absence d’aides à l’approche et de balises sur la piste ont empêché le pilote de déterminer si l’appareil était en approche finale stabilisée avant de franchir le seuil de piste.
5. L'équipage n'a pas respecté les procédures d’utilisation normalisées de l’entreprise en ce qui a trait aux approches stabilisées et a poursuivi l’approche non stabilisée.
6. Le pilote a été incapable d’aligner l’appareil sur l’axe de la piste au moment où il s’apprêtait à atterrir, puis le train d’atterrissage principal gauche est entré dans une couche de neige épaisse au bord de la piste, ce qui a fait virer l’avion dans le banc de neige.

Faits établis quant aux risques

1. Si les recommandations d’une entreprise visant à atténuer les risques ne sont pas mises en œuvre en temps opportun, les risques d’accident subsistent.
2. L'absence de critères et de procédures relatifs aux approches stabilisées dans les procédures d’utilisation normalisées (SOP) de l’entreprise ou leur non-respect accroît le risque d’accident à l’atterrissage.
3. Une piste couverte de neige, sans balises ou dispositifs permettant au pilote de reconnaître facilement la surface de la piste, augmente les risques de sorties de piste.
4. Si les risques dépistés et les stratégies d’atténuation ne sont pas communiqués aux personnes qui y sont exposées, ces personnes pourraient croire que la direction juge le risque acceptable et pourraient poursuivre les opérations

Accident investigation:
cover
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 year and 11 months
Accident number: A12P0034
Download report: Final report

Sources:
» SKYbrary 


Photos

photo of Beechcraft 1900C C-GCMZ
photo of Beechcraft 1900C C-GCMZ
photo of Beechcraft 1900C C-GCMZ
Estimated flight path of C-GCMZ
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Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Vancouver International Airport, BC et Blue River Airport, BC est de 423 km (264 miles).

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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