Narrative:A Maritime Air Charter Beech A100 was to carry out a charter flight from Halifax Stanfield International Airport (CYHZ), to Margaree Aerodrome (CCZ4), Nova Scotia, Canada with 2 passengers on board.
MAC's operations manager determined that the flight would be carried out with the company's Beechcraft A100 King Air. This decision was primarily based on personnel availability, as well as the knowledge that the company had landed at Margaree in the A100 on two previous occasions and that, with the expected landing weight, the calculated landing distance would be 1700 feet, 800 feet shorter than the runway.
The operations manager assigned a part-time employed pilot to be the captain and a full-time employed pilot to be the first officer (FO). Although these pilots had flown together before, neither had previously flown into Margaree.
In preparation for the flight, the operations manager and the captain discussed hazards that the crew should be aware of, primarily the possibility that people or animals could be on the runway, and that, if required, a diversion to Port Hawkesbury Airport (CYPD) was an option. The operations manager expected the captain to make the decision as to whether a safe landing could be carried out.
Neither the captain nor the FO indicated that he had any concerns about undertaking the flight. The crew discussed landing on runway 01 and noted that it was shorter than the runways that they had typically flown into. The crew agreed that the final approach would be carried out at 120 knots and that they wanted to touch down as close as possible to the threshold. Due to high terrain near Margaree, the crew planned to stay high and descend at a steeper rate during final approach.
Prior to departure, even though this was the first flight of the day for the aircraft, the crew did not perform the required Engine Run-up checklist.
At 15:29, the aircraft departed Halifax Stanfield International Airport under visual flight rules (VFR). The captain was the pilot flying (PF) and occupied the left seat, and the FO was the pilot not flying (PNF).
At 15:51, a descent from the enroute altitude of 9500 feet above sea level (ASL) was initiated.
The crew re-confirmed that, based on the wind reported by the automated weather observation system at Port Hawkesbury Airport, they would land on runway 01.
At 16:00, the PNF made an advisory transmission on the aerodrome traffic frequency (ATF) informing any traffic in the area that the aircraft would be joining a left base leg for runway 01.
At 16:04, the crew performed the Descent Checks checklist in accordance with the company standard operating procedures (SOP), with the exception of the approach briefing, which was abbreviated and described the approach as being visual for runway 01.
At 16:07, the PNF reported on the ATF that the aircraft was at 2700 feet ASL and about 20 nautical miles (nm) from Margaree. No other aircraft reported being in the area.
When the aircraft was at 2500 feet ASL, the PNF made an advisory transmission on the ATF indicating that the aircraft was joining the circuit on a left base for runway 01.
At 16:13, about 5 nm from the runway, the power was reduced to 600 foot-pounds of torque, and approach flaps were selected to initiate a steep rate of descent.
The crew observed a tower along the flight path, and the PNF focused his attention on ensuring that clearance was maintained.
At about 16:14, the PF reduced the power to idle to further increase the rate of descent. The engine auto-ignition system igniters activated, indicating that engine power was below 400 foot-pounds of torque. The igniters remained on until the aircraft touched down.
The landing gear was selected down and, once the PNF had confirmed that the aircraft was clear of the tower, full flaps were selected. The crew did not complete the Landing Checks checklist as required by the SOPs. About 20 seconds later, the aircraft was descending through 1900 feet ASL (about 1700 feet above runway elevation) and 2.1 nm from the runway threshold.
At about 16:15:34, the PNF indicated that the airspeed was below the planned speed. The PF indicated that he was making the appropriate correction and began to increase the airspeed by pitching the aircraft down; there was no change in engine power. This correction was followed by automated calls of "SINK RATE," "PULL UP, PULL UP," and "FIVE HUNDRED" (indicating 500 feet above ground elevation) in very quick succession from the terrain awareness and warning system (TAWS). The PF acknowledged the TAWS calls and began to reduce the rate of descent by pitching the aircraft up; there was no change in engine power.
At 16:15:56, when the aircraft was about 120 feet above the runway elevation, the PNF began to move the propellers toward full while asking the PF if the propellers should be advanced. Almost immediately, the PF acknowledged the PNF's statement by replying "check." There was no change in engine power, and the aircraft's rate of descent increased.
At 16:16:06, the propellers reached the full position; 4 seconds later, the PF requested that the propellers be selected to full. Almost immediately following this, the aircraft touched down hard in a flat attitude about 263 feet beyond the runway threshold. The right main landing gear (MLG) collapsed, and 82 feet further down the runway, the right propeller contacted the runway. The aircraft settled onto its right wing and engine nacelle, and subsequently veered to the right and departed the runway. The aircraft came to rest about 1850 feet from the threshold and 22 feet from the runway edge, on a heading of approximately 090°.
There were no injuries and there was no post-impact fire. The crew and passengers evacuated the aircraft through the cabin door.
Probable Cause:Findings as to causes and contributing factors:
1. Neither pilot had considered that landing on a short runway at an unfamiliar aerodrome with known high terrain nearby and joining the circuit directly on a left base were hazards that may create additional risks, all of which would increase the crew's workload.
2. The presence of the tower resulted in the pilot not flying focusing his attention on monitoring the aircraft's location, rather than on monitoring the flight or the actions of the pilot flying.
3. The crew's increased workload, together with the unexpected distraction of the presence of the tower, led to a reduced situational awareness that caused them to omit the Landing Checks checklist.
4. At no time during the final descent was the engine power increased above about 400 foot-pounds of torque.
5. Using only pitch to control the rate of descent prevented the pilot flying from precisely controlling the approach, which would have ensured that the flare occurred at the right point and at the right speed.
6. Neither pilot recognized that the steep rate of descent was indicative of an unstable approach.
7. Advancing the propellers to full would have increased the drag and further increased the rate of descent, exacerbating the already unstable approach.
8. The aircraft crossed the runway threshold with insufficient energy to arrest the rate of descent in the landing flare, resulting in a hard landing that caused the right main landing gear to collapse.
Findings as to risk:
1. If data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If organizations do not use modern safety management practices, then there is an increased risk that hazards will not be identified and risks will not be mitigated.
3. If passenger seats installed in light aircraft are not equipped with shoulder harnesses, then there is an increased risk of passenger injury or death in the event of an accident.
4. If the experience and proficiency of pilots are not factored into crew selection, then there is a risk of suboptimal crew pairing, resulting in a reduction of safety margins.
5. If pilots do not carry out checklists in accordance with the company's and manufacturer's instructions, then there is a risk that a critical item may be missed, which could jeopardize the safety of the flight.
6. If crew resource management is not used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight.
7. If organizations do not have a clearly defined go-around policy, then there is a risk that flight crews will continue an unstable approach, increasing the risk of an approach-and-landing accident.
8. If pilots are not prepared to conduct a go-around on every approach, then there is a risk that they may not respond to situations that require a go-around.
9. If operators do not have a stable approach policy, then there is a risk that an unstable approach will be continued to a landing, increasing the risk of an approach-and-landing accident.
10. If an organization's safety culture does not fully promote the goals of a safety management system, then it is unlikely that it will be effective in reducing risk.
1. There were insufficient forward impact forces to automatically activate the emergency locator transmitter.
» Transport Canada
Official accident investigation report
|investigating agency: ||Transportation Safety Board (TSB) - Canada |
|report status: ||Final|
|report number: ||A15A0054|
|report released:||22 April 2017|
|duration of investigation: ||1 year and 8 months|
|download report: ||
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 Halifax International Airport, NS to Margaree Airport, NS as the crow flies is 253 km (158 miles).