Gatineau, Quebec, 2 May 2012 – The TSB today released its investigation report (A09Q0203) into the December 2009 accident where a Beech King Air 100, operated by Exact Air Inc., crashed three nautical miles short of the runway while landing at the Chicoutimi/St-Honoré airport in Quebec.
The aircraft was flying a non-precision approach procedure (one where only horizontal guidance is provided electronically) at night, in adverse weather conditions. The aircraft descended below the minimum descent altitude on approach and struck trees while in controlled flight.The two pilots were fatally injured and the two passengers were seriously injured.
“During step-down approaches, aircraft are flown at minimum altitudes for a longer time, exposing people to increased risks of approach and landing accidents (ALAs).To avoid ALAs, commercial operators must fly stabilized constant descent angle approaches, above the minimum altitudes,” said Board Member Kathy Fox. “To help them do that, approach charts must show the optimal flight path for safe descent to the runway. This is the focus of the two recommendations the Board is making from this investigation.”
In short, the TSB is asking Transport Canada (TC) to require that approach charts used by pilots depict the optimal path to be flown rather than the line joining the obstacle clearance altitudes currently shown (A12-01) and that the stabilized constant descent angle approach technique be used by Canadian operators that conduct non-precision instrument approach procedures (A12-02).
This occurrence is an example of an approach and landing accident (ALA). ALAs take place most often at airports where only non-precision approaches are available, and these airports are served most often by air taxi operations, such as Exact Air. Because of this, air taxi operations are most at risk, and 70 per cent of ALAs involve air taxi operations.
The Flight Safety Foundation has produced and distributed the Approach and Landing Accident Reduction Toolkit, which incorporates recommendations to reduce and prevent ALAs. However most Canadian Air Taxi operators have not reviewed these recommendations, thus they have not been implemented into their operations. The Board is concerned that despite past efforts, recognized strategies to reduce approach and landing accidents are not being implemented into commercial operations.
The final investigation report A09Q0203 and all related materials are available on the TSB website at www.tsb-bst.gc.ca.
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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.
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TSB Media Relations
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