Air transportation safety investigation A17C0146

Updated November 2019: This ongoing investigation is in the report phase.

Table of contents

Collision with terrain

The occurrence

On 13 December 2017, an ATR 42-320 aircraft operated by West Wind Aviation as flight WEW282 departed Fond-du-Lac Airport, Saskatchewan (CZFD) for Stony Rapids, Saskatchewan (CYSF) with 22 passengers and 3 crew on board. At 1812 central standard time, shortly after takeoff, the aircraft collided with trees and terrain less than a mile west of the end of Runway 28. The aircraft was destroyed. Nine occupants were reported to have sustained serious injuries. Sixteen other aircraft occupants were also injured. One of the seriously injured passengers subsequently died. The TSB is investigating.

Families, loved ones, survivors and the community of Fond-du-Lac

The TSB offers its condolences to the family who lost a loved one and we understand that this accident has been traumatic to those involved. The TSB investigation team is mindful of the survivors and the community of Fond-du-Lac, who want answers rapidly. We continue our work to determine how accidents like this one can be prevented in the future.

What we know based on initial examinations

A significant amount of work has been completed so far, but much remains to be done. An investigation team including air investigators from various TSB offices and technical experts from the TSB laboratory in Ottawa were deployed to the accident site. A site survey was completed and the wreckage was transported to an off-site location for further investigation. The examination and analysis phase is in progress.

Sequence of events

  • On 13 December 2017, an ATR 42-320 aircraft operated by West Wind Aviation arrived at Fond-du-Lac Airport at 1725 central standard time.
  • During the descent, the aircraft encountered icing conditions and the anti-icing and de-icing systems were activated. When the de-icing and anti-icing systems were turned off, residual ice remained on portions of the aircraft.
  • The aircraft stayed at the Fond-du-Lac Airport to board new passengers and cargo.
  • The operator, West Wind Aviation, had some de-icing equipment in the terminal building (see photos) at the airport. The de-icing equipment that was available to WestWind Aviation in Fond-du-Lac consisted of two ladders, a hand-held spray bottle with electric blanket and wand, and a container of de-icing fluid. However, the aircraft was not de-iced before takeoff, and the takeoff was commenced with ice contamination on the aircraft.
  • The aircraft departed Fond-du-Lac Airport at 1811 for Stony Rapids.
  • At 1812, shortly after takeoff, the aircraft collided with trees and terrain less than a mile west of the end of Runway 28.

The aircraft

  • The wreckage path through trees and across terrain was at least 750 feet long. The aircraft came to rest with the forward cabin and cockpit rotated 90° to the right, and the remainder of the fuselage rotated about 35° to the right.
  • Engines were operating up to the point of impact.
  • There are 30 ATR 42 aircraft registered in Canada.

Pilots

  • Records indicate the captain and first officer were certified and qualified for the flight in accordance with existing regulations.

Aircraft performance

  • Investigators determined the flight's takeoff weight was about 35 370 pounds, below the maximum structural takeoff weight and the centre of gravity was within limits.
  • Investigators are now analyzing the aircraft performance based on the aircraft weight and balance, and weather and runway conditions on the day of the occurrence.

Flight data recorder and cockpit voice recorder (FDR/CVR)

  • The aircraft was equipped with an FDR and CVR as required by regulation. The FDR/CVR were recovered in good condition from the wreckage.
  • TSB specialists have extracted data from the recorders and continue to analyze it.

Weather conditions

  • A detailed weather analysis for the area on the day of the accident has been completed.
  • Weather information for the Fond-du-Lac area indicates the presence of patchy moderate rime icing in cloud from 3000 to 7000 feet above sea level. Rime ice is rough, opaque, and crystalline ice.
  • The surface temperature at Stony Rapids, 75 kilometres east of Fond-du-Lac, was −10°C.

Next steps

The next steps of the investigation include the following work:

  • Examine the factors underlying why the aircraft was not de-iced before takeoff
  • Examine the adequacy of ground de-icing equipment
  • Evaluate aircraft performance to determine the effects of weather and runway surface conditions
  • Gather and analyze data about aircraft operations in remote locations in Canada
  • Review operational policies, procedures and regulatory requirements
  • Examine aircraft maintenance records
  • Further examine the wreckage for crashworthiness and survivability
  • Conduct examination of flight controls
  • Compare the actual behavior of the aircraft with the theoretical performance through engineering simulation
  • Evaluate pilot training and experience, and human performance aspects
  • Examine previous similar occurrences and subsequent safety action taken in Canada, the United States, France and other jurisdictions
  • Conduct additional interviews as required
  • Complete the analysis and report production phases of the investigation

Investigation teamwork

The Investigator-in-Charge, David Ross, is being assisted in this investigation by TSB investigators with backgrounds in flight operations, engineering, aircraft performance, aircraft systems and engines, and human factors.

The TSB conducts independent investigations. Representatives from Transport Canada, Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile – BEA (France's accident investigation authority), and ATR (aircraft manufacturer) are providing assistance with this investigation.

We would also like to recognize the contributions of the local Canadian Rangers and of the Royal Canadian Mounted Police (RCMP) who provided assistance at the accident site to the investigation team.

Communication of safety deficiencies

Investigations are complex and we take the time needed to complete a thorough investigation. However, should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay.

It is important not to speculate, or draw conclusions as to causes at this time. There are often many factors that can contribute to an accident.


Safety communications

Recommendations

2018-12-14

Letter to the Minister of Transport: Air transportation safety recommendations in advance of final report publication (A18-02, A18-03)

2018-12-14

TSB Recommendation A18-03: the Department of Transport and air operators take action to increase compliance with Canadian Aviation Regulations subsection 602.11(2) and reduce the likelihood of aircraft taking off with contaminated critical surfaces.

TSB Recommendation A18-02: the Department of Transport collaborate with air operators and airport authorities to identify locations where there is inadequate de-icing and anti-icing equipment and take urgent action to ensure that the proper equipment is available to reduce the likelihood of aircraft taking off with contaminated critical surfaces.


Media materials

Speeches and presentations

2018-12-14

A17C0146: Fond du Lac opening remarks
Kathy Fox, TSB Chair
and
David Ross, Investigator-in-charge, TSB
Read the opening remarks

News release

2018-12-14

TSB calls for adequate aircraft de-icing equipment, greater compliance with de-icing regulations at remote northern airports
Read the news release

2018-04-23

TSB provides update on investigation into Fond-du-Lac accident, expands data collection on aircraft operations in remote areas
Read the news release

Media advisories

2018-12-12

TSB will issue recommendations as part of its ongoing investigation into the 12 December 2018 aircraft accident in Fond-du-Lac, Saskatchewan
Read the media advisory

2017-12-19

TSB will provide a news briefing on its investigation into the airplane accident in Fond-du-Lac, Saskatchewan
Read the media advisory

Deployment notice

2017-12-13

TSB deploys a team of investigators to an aircraft accident near Fond-du-Lac, Saskatchewan

Winnipeg, Manitoba, 13 December 2017 - The Transportation Safety Board is deploying a team of investigators to an aircraft accident near Fond-du-Lac, Saskatchewan. The TSB will gather information and assess the occurrence.


Investigation information

Map showing the location of the occurrence

Investigator-in-charge

Photo of

David Ross has been a TSB operations investigator in the Central Region since 1999.

His background includes three years experience as a weather observer, twenty years military service in the Canadian Forces, and one year as a regional airline pilot in western Canada.

Mr. Ross has extensive worldwide air transport flight operations experience and worked as a training pilot, check pilot, and flight operations supervisor.

Mr. Ross holds a current airline transport pilot licence and he has accumulated 7750 hours flight time.


Photos


  Download high-resolution photos from the TSB Flickr page.

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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