Date:	Thursday 26 October 2023
Time:	17:15 LT
Type:	de Havilland Canada DHC-8-106
Owner/operator:	Air Creebec
Registration:	C-FLSX
MSN:	285
Year of manufacture:	1991
Engine model:	P&W Canada PW120
Fatalities:	Fatalities: 0 / Occupants: 31
Other fatalities:	0
Aircraft damage:	None
Category:	Serious incident
Location:	1.46 nm from Val-d’Or Airport, QC (YVO) -   Canada
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Chisasibi Airport (CSU2), Quebec
Destination airport:	Val-d’Or Airport, QC (YVO/CYVO)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Air Creebec flight YN238, a DHC-8-106, was involved in a near collision with terrain incident during an approach to Val-d’Or Airport (YVO).

few moments after beginning a descent from flight level 200, the flight crew received an instruction to hold at the initial approach waypoint IKDOB because an aircraft was going to land at YVO before them.
The occurrence aircraft had been holding at 6000 feet above sea level for 12 minutes when it was cleared to conduct an area navigation approach to Runway 18 at YVO using the global navigation satellite system. The aircraft exited the hold and ended up on a track that diverged from the approach. The pilot not flying reprogrammed the flight management system to rejoin the approach. A 2nd track divergence occurred at the final approach waypoint and, after terrain awareness and warning system alerts sounded, the flight crew conducted a go-around. The aircraft ended up 405 feet above ground level, 0.98 nautical miles to the right of the final approach path and 1.46 nautical miles from the runway threshold. A 2nd approach was conducted, and the aircraft landed on Runway 18 without further incident.

Findings as to causes and contributing factors
1. When the holding pattern was being programmed at the IKDOB waypoint before the area navigation approach to Runway 18 at Val-d’Or Airport using the global navigation satellite system, by default, the flight management system suggested the preprogrammed holding pattern at the IKDOB waypoint that was the last waypoint of the flight plan. Therefore, when the DTO HOLD [direct to hold] function was activated, given that there were no further waypoints on the flight management system flight plan after the holding pattern, the aircraft was going to maintain its last heading, unbeknownst to the pilots, rather than conduct the approach.
2. Given that there were no further waypoints on the flight plan when the aircraft exited the holding pattern, the flight management system maintained the aircraft on its current course, which diverged from the final approach path by 48°, complicating the manoeuvre needed to re-establish the aircraft on the approach path.
3. When the approach was being reprogrammed in the flight management system, maintaining a divergent heading for 44 seconds, combined with a late descent, resulted in the aircraft arriving at the final approach waypoint at 180 KIAS in a clean configuration (flaps and landing gear retracted). At that point, it was no longer possible to slow down the aircraft to the 120 knots indicated airspeed meet the company’s stabilized approach criteria at 1000 feet above ground level.
4. After the aircraft passed the final approach waypoint, it continued to turn right on a divergent vertical and lateral track and left the obstacle clearance area, risking a collision with obstacles or terrain.
5. Given the high workload and the loss of shared situational awareness regarding the change in the approach plan, the pilot not flying asked the area control centre for clearance to conduct a go-around, while the pilot flying was continuing the descent at approximately 1300 fpm as the aircraft passed the company’s stabilized approach gate at 187 knots indicated airspeed, i.e., 67 knots faster than the target speed.
6. Approximately 25 seconds after communications began with the area control centre, alerts were generated by the terrain awareness and warning system and a go-around was initiated. At its lowest point, the aircraft was 405 feet above ground level, flying at an airspeed of 192 knots indicated airspeed (i.e., 72 knots above the target speed), in a clean configuration, approximately 1 nautical mile to the right of the approach path, and 1 nautical mile from the runway threshold.
7. Initial and recurrent training on the flight management system did not enable the flight crew to recognize the particular subtleties of the system programming, causing a discrepancy between the flight crew’s expectations and the aircraft’s behaviour, and causing difficulties with in-flight programming, all leading to a delay in completing critical flight actions.

CYVO 262000Z 05006KT 2 1/4SM -DZ BR OVC003 07/07 A3007 RMK ST8 SLP197
CYVO 262106Z 06004KT 5SM BR OVC003 07/07 A3006 RMK ST8 SLP194
CYVO 262221Z 06005KT 4SM -RA BR OVC003 08/08 A3003 RMK NS8 SLP186

TSB

Date/time	Contributor	Updates
28-Oct-2025 17:38	ASN	Added
28-Oct-2025 17:42	ASN	Updated [Time, Narrative, ]