Narrative:A Swearingen SA227-AC Metro III passenger plane was involved in an accident at Sanikiluaq Airport, NU (YSK), Canada. The flight crew sustained serious injuries, 6 passengers sustained minor injuries and one passenger, an infant, was fatally injured.
The route from Winnipeg to Sanikiluaq is normally operated by Keewatin Air, a Perimeter Aviation sister company. The normally scheduled flight on the previous day (Friday, 21 December 2012) had been cancelled due to poor weather in Sanikiluaq. With extra cargo and passengers needing to travel to Sanikiluaq before Christmas, Keewatin Air completed a flight on the morning of 22 December 2012 and had chartered Perimeter to complete an additional flight. The Perimeter flight crew had been notified in the early evening of 21 December 2012 that they would be operating flight PAG993 the next morning.
Following an attempted visual approach to runway 09, a non-precision non-directional beacon (NDB) runway 27 approach was conducted. Visual contact with the runway environment was made and a circling for runway 09 initiated. Visual contact with the runway 09 environment was lost and a return to the Sanikiluaq NDB was executed. A second NDB runway 27 approach was conducted with the intent to land on runway 27. Visual contact with the runway environment was made after passing the missed approach point. Following a steep descent, a rejected landing was initiated at 20 to 50 feet above the runway; the aircraft struck the ground approximately 525 feet beyond the departure end of runway 27.
Probable Cause:Findings as to causes and contributing factors:
1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a work-around solution during flight planning. It also negatively affected the crew's situational awareness during the approaches at CYSK (Sanikiluaq).
2. Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).
3. Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing and a shift away from well-learned, highly practised procedures.
4. Due to the lack of an instrument approach for the into-wind runway and the unsuccessful attempts at circling, the crew chose the option of landing with a tailwind, resulting in a steep, unstable approach.
5. The final descent was initiated beyond the missed approach point and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3-degree descent path.
6. Neither pilot heard the ground proximity warning system warnings; both were focused on landing the aircraft to the exclusion of other indicators that warranted alternative action.
7. During the final approach, the aircraft was unstable in several parameters. This instability contributed to the aircraft being half-way down the runway with excessive speed and altitude.
8. The aircraft was not in a position to land and stop within the confines of the runway, and a go-around was initiated from a low-energy landing regime.
9. The captain possibly eased off on the control column in the climb due to the low airspeed. This, in combination with the configuration change at a critical phase of flight, as called for in the company procedures, may have contributed to the aircraft's poor climb performance.
10. A rate of climb sufficient to ensure clearance from obstacles was not established, and the aircraft collided with terrain.
11. The infant passenger was not restrained in a child restraint system, nor was one required by regulations. The infant was ejected from the mother's arms during the impact sequence, and contact with the interior surfaces of the aircraft contributed to the fatal injuries.
Controlled Flight Into Terrain (CFIT) - Ground
METAR Weather report:
01:00 UTC / 21:00 local time: CYSK 230100Z 07014KT 3SM -SN BLSN OVC017 M03/M04 A2918 RMK SC8 CALL OUT SLP883
Wind 070 degrees at 14 knots; Visibility: 3 miles; blowing snow, light snow; overcast cloud deck at 1700 feet AGL; Temperature: -3°C; Dewpoint -4°C; Pressure 988.2 mb
22:00 UTC / 17:00 local time: CYSK 222200Z 01017G25KT 2SM -SN BLSN OVC012 M05/M06 A2928 RMK SC8 CALL-OUT LAST OBS/NEXT 241300UTC SLP917
Wind 010 degrees at 17 knots, gusting to 25 knots; Visibility: 2 miles; blowing snow, light snow; overcast cloud deck at 1200 feet AGL; Temperature: -5°C; Dewpoint -6°C; Pressure 991.6 mb
Official accident investigation report
|investigating agency: ||Transportation Safety Board (TSB) - Canada |
|report status: ||Final|
|report number: ||A12Q0216|
|report released:||29 June 2015|
|duration of investigation: ||2 years and 6 months|
|download report: ||
Flight path profile
Compilation of all flight trajectories during the attempted landings at Sanikiluaq
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This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Winnipeg International Airport, MB to Sanikiluaq Airport, NU as the crow flies is 1389 km (868 miles).