Air transportation safety investigation A12Q0216

Update: The TSB has completed this investigation. The report was published on 29 June 2015.

Table of contents

Low-energy rejected landing and collision with terrain

Perimeter Aviation LP
Fairchild SA227-AC Metro III, C-GFWX
Sanikiluaq, Nunavut

View final report

The occurrence

Perimeter Aviation Flight 993 was originally scheduled to depart Winnipeg, Manitoba, for Sanikiluaq, Nunavut, on the morning of December 22, 2012, but several issues, including repairs to the cargo door, caused a four-hour delay. After finally taking off, the crew realized they'd forgotten key published information for the approach and landing at Sanikiluaq. Rather than return to Winnipeg and lengthen the flight, the captain radioed the company to obtain most of the required information.

The crew's initial plan was to come in on a straight-in visual approach to land eastbound, into the wind on Runway 09 at Sanikiluaq. Weather conditions, however, did not permit this. As there was no published instrument approach procedure for Runway 09, they used the published procedure for Runway 27 and circled around visually to land on Runway 09, as wind favored landing in that direction. But visibility was insufficient, so they circled a second time, only to once more lose sight of the runway.

En route, a weather update had revealed that the alternate destination of Kuujjuarapik was no longer feasible. Since the weather was still technically acceptable for landing, the crew decided to continue attempting to land at Sanikiluaq. With the crew feeling increasing pressure to land, there was an increase in stress, workload, frustration and fatigue, resulting in attentional narrowing and a breakdown in crew communication. They made a second attempt, this time to land westbound on Runway 27. A tailwind, however, increased the aircraft's groundspeed, and they came in too high, too steep, and too fast, sighting the runway later than expected. By the time the captain decided to reject the landing it was too late, and the aircraft struck the ground. This is considered an approach-and-landing accident.

Read the complete Executive summary

Safety communication

Recommendations

2015-06-29

TSB Recommendation A15-01: The Board recommends that the Department of Transport require commercial air carriers to collect and report, on a routine basis, the number of infants (under 2 years old), including lap-held, and young children (2 to 12 years old) travelling.

2015-06-29

TSB Recommendation A15-02: The Board recommends that the Department of Transport work with industry to develop age- and size-appropriate child restraint systems for infants and young children travelling on commercial aircraft, and mandate their use to provide an equivalent level of safety compared to adults.

Media materials

News release

2015-06-29

December 2012 accident in Sanikiluaq, Nunavut, highlights need for improved safety for infants and children onboard aircraft
Read the news release

2012-12-23

TSB is investigating an accident at Sanikiluaq Airport in Nunavut
Read the news release

Backgrounders

Speeches

2015-06-29

News conference for the release of Aviation Investigation Report A12Q0216: Opening remarks
Kathy Fox, TSB Chair
Gayle Conners, TSB Investigator-in-Charge
Read the opening remarks

Media advisory

2015-06-25

TSB will hold a news conference on its report into the December 2012 Perimeter Aviation aircraft accident in Sanikiluaq, Nunavut
Read the media advisory

Animations

2015-06-29

A12Q0216: Apparent weight of a lap-held infant

Other resources

Information on travelling with young children

Investigation information

Map showing the location of the occurrence


Investigator-in-charge

Photo of Gayle Conners

Gayle Conners graduated from the University of Ottawa, obtaining a Bachelor of Arts degree in Psychology in 1985. Ms. Conners obtained her commercial helicopter pilot’s license from Canadore College in North Bay, Ontario in 1986. She flew for a commercial helicopter operator in northern Quebec prior to joining the Transportation Safety Board (TSB), with over 4000 hours of helicopter flying experience. She also holds single-engine fixed-wing aircraft and glider pilot licenses. Most of her fixed-wing aircraft experience was obtained while towing gliders for the Air Cadets’ glider school.

Ms. Conners has been employed with the TSB Montreal regional office for 23 years, initially working as a Human Performance Specialist/Investigator, then as a Senior Investigator Operations (Air). She has been the investigator-in-charge of many occurrences over the years spent with the TSB.


Photos


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Class of investigation

This is a class 2 investigation. These investigations are particularly complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates air, marine, pipeline, and rail 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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