News release

The Transportation Safety Board of Canada (TSB) released its investigation report (A23Q0143) into the near collision with terrain of an aircraft operated by Air Creebec Inc. during final approach at Val-d’Or Airport, Quebec.

On 26 October 2023, as a De Havilland DHC-8-106 aircraft began its descent toward Val-d’Or Airport, the flight crew received an instruction to enter a holding pattern at the initial approach waypoint. Shortly after, the crew was cleared to conduct an approach to the designated runway. When exiting the holding pattern, the aircraft ended up on a track that diverged from the final approach path. After the flight management system was reprogrammed, a second track divergence occurred at the final approach waypoint. Moments later, the terrain awareness and warning system alerts sounded, and the crew conducted a go-around when the aircraft was at a height of 405 feet above ground level. A second approach was conducted and the aircraft landed without further incident.

The investigation revealed that when the holding pattern before the approach was programmed, the flight management system suggested, by default, the preprogrammed holding pattern at the last waypoint of the flight plan. Because the “direct to hold” function was activated without other waypoints, when the aircraft exited the holding pattern, it maintained its last heading, unbeknownst to the pilots.

With the aircraft maintaining the heading when exiting the holding pattern, it deviated from the final approach path, complicating the realignment with the final approach path. The flight management system took several seconds to be reprogrammed to realign its heading; this plus the late descent resulted in the aircraft arriving at the final approach waypoint at a speed where it was no longer possible to meet the stabilized approach criteria. The aircraft then entered a second track divergence and left the obstacle clearance area, increasing the risk of collision with terrain.

If holding patterns are not aligned with the final approach path, the manoeuvre to conduct the final approach is more complex. When an unexpected situation arises, as in this occurrence, the increase in workload can reduce situational awareness, creating a risk that critical tasks will not be performed.

After the occurrence, Air Creebec Inc. initiated numerous safety actions, such as the release of memoranda as well as changes to the standard operating procedures and to the simulator training.

See the investigation page for more information.