TSB Watchlist issues highlighted in September 2014 runway excursion in La Tabatière, Quebec
Dorval, Quebec, 20 January 2016 – In its investigation report (A14Q0148) released today, the Transportation Safety Board of Canada (TSB) identified several factors which led to the September 2014 runway excursion in La Tabatière, Quebec. Although the aircraft sustained substantial damage, no occupants were injured.
On 28 September 2014, a de Havilland DHC-6-300 Twin Otter, operated by Air Labrador Limited, was on a charter flight from Lourdes-de-Blanc-Sablon to La Tabatière, Quebec, with 2 crew and 17 passengers on board. As the First Officer landed the aircraft, the captain determined that the aircraft would not stop before reaching the end of the runway, and took control and initiated a high-speed left turn onto the taxiway. The aircraft skidded to the right, and the right propeller struck a runway identification sign before the aircraft came to a stop.
The aircraft had floated for 6.3 seconds over the runway and touched down about 750 feet from the threshold, near the halfway point instead of the beginning of the runway, leaving not enough room to stop. The company has neither procedures nor a policy stating when to conduct go-arounds, and relies solely on pilot experience to determine when a go-around should be performed. If pilots are not prepared to conduct a go-around on every approach, there is a risk that they will not be ready to react to a situation that requires a go-around.
Crew resource management (CRM) training is specifically designed to address interactions between flight crew members. Neither pilot had received CRM training at Air Labrador, nor is it required by regulation. This training could have served as an aid by requiring crew members to monitor the other crew member's performance and to identify any deviation, bringing it to their attention as soon as practicable. The Board has an outstanding recommendation (A09-02) calling on contemporary CRM training for air taxi and commuter pilots. Transport Canada (TC) has recently developed CRM training standards for these operators and plans to publish them in 2016.
This accident highlights two issues on the TSB Watchlist: Approach-and-landing accidents and Safety management and oversight. The TSB publishes the Watchlist to focus the attention of industry and regulators on the safety issues posing the greatest risk to Canada's transportation system. As this occurrence demonstrates, landing accidents continue to occur at Canadian airports. The TSB has called on TC and operators to do more to reduce the number of unstable approaches that are continued to a landing. Additionally, a safety management system (SMS) is a comprehensive process for managing safety risks in an organization. In this case, the operator did not have an SMS, nor was it required to have one by regulation. However, if organizations do not use modern safety management practices, there is an increased risk that hazards will not be identified and mitigated. TSB also urges TC to implement regulations requiring all operators in the air industry to have formal safety management processes, and to oversee these processes.
Following the occurrence, Air Labrador issued a directive to all crews for modified procedures when landing on short runways. They also provided a landing-distance performance chart for each aircraft and amended their checklists.
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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