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ASN Wikibase Occurrence # 197990
Last updated: 5 June 2019
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Date:15-DEC-2008
Time:00:01
Type:Silhouette image of generic DH8A model; specific model in this crash may look slightly different
de Havilland Canada DHC-8-102
Owner/operator:Jazz
Registration: C-GTBP
C/n / msn: 066
Fatalities:Fatalities: 0 / Occupants: 18
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:North Bay Jack Garland Airport, Ontario -   Canada
Phase: Landing
Nature:Domestic Scheduled Passenger
Departure airport:Toronto/Lester B. Pearson International Airport, Ontario
Destination airport:North Bay Jack Garland Airport, Ontario
Investigating agency: TSB Canada
Narrative:
The Air Canada Jazz DHC-8-100 (registration C-GTBP, serial number 066) operating as flight JZA7779 departed Toronto/Lester B. Pearson International Airport, Ontario, under instrument flight rules for a regularly scheduled flight to North Bay, Ontario. The flight crew planned a stabilized constant descent angle non-precision approach to Runway 08 at the North Bay Jack Garland Airport. The aircraft touched down approximately 8900 feet past the threshold of Runway 08, which is 10 000 feet in length, and overran the end at 2348 Eastern Standard Time. The aircraft came to rest approximately 260 feet past the end of the runway in two to three feet of snow. There were no injuries and the aircraft sustained minor damage.


Findings as to Causes and Contributing Factors

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.

Sources:

http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2008/a08o0333/a08o0333.asp


Revision history:

Date/timeContributorUpdates
13-Aug-2017 20:22 harro Updated [Aircraft type, Registration, Cn, Location, Departure airport, Destination airport, Source, Narrative]

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