Poor weather, unstable approach and other factors led to 2012 runway excursion in Blue River, British Columbia
Richmond, British Columbia, 7 February 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A12P0034) citing a number of factors that led a Northern Thunderbird Air Inc. Beechcraft 1900C to veer off the runway on 17 March 2012. There were no injuries.
The Northern Thunderbird Air Inc. Beechcraft 1900C left Vancouver International Airport on a charter flight to Blue River, British Columbia, with 2 crew members and 1 passenger on board. Arriving in the Blue River valley, the pilot commenced a straight-in visual approach to Runway 19. The aircraft touched down on the snow-covered runway, and the left main gear entered an area of deep snow. The aircraft veered left into the snow bank and came to a stop, sustaining substantial damage.
The issue of landing accidents and runway overruns was identified on the TSB's Watchlist in 2010. The TSB's concerns on this subject persist to this day. In this accident, investigators identified several contributing factors, including poor weather, an unstable approach and an unmarked and contaminated runway. Investigators also found that the crew did not request up-to-date weather and runway information and that the standard operating procedures for a stabilized approach were not followed.
The Board found that, although Northern Thunderbird Air had previously identified these hazards at Blue River, it did not produce an effective mitigation strategy in a timely manner. Also, if identified risks and mitigation strategies are not communicated to the people exposed to the risks, it is possible they will deem the risk as acceptable to management and continue operations.
To address these issues, Transport Canada will develop contemporary crew resource management (CRM) and pilot decision-making (PDM) training standards for small, medium and large aircraft operations, which will include the threat and error management (TEM) model.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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