Air transportation safety investigation A17C0146
Updated January 2020: This ongoing investigation is in the report phase.
Collision with terrain
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.
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 West Wind 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 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.
- Records indicate the captain and first officer were certified and qualified for the flight in accordance with existing regulations.
- 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 analyzed 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 and analyzed data from the recorders.
- 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.
Steps completed so far
The following investigation steps have been completed:
- Examined the factors underlying why the aircraft was not de-iced before takeoff
- Examined the adequacy of ground de-icing equipment
- Gathered and analyzed data about aircraft operations in remote locations in Canada
- Reviewed operational policies, procedures and regulatory requirements
- Examined aircraft maintenance records
- Further examined the wreckage for crashworthiness and survivability
- Evaluated pilot training and experience, and human performance aspects
- Examined previous similar occurrences and subsequent safety action taken in Canada, the United States, France and other jurisdictions
- Issued two TSB recommendations regarding aircraft icing. For more information, please see Safety Communications
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.
Letter to the Minister of Transport: Air transportation safety recommendations in advance of final report publication (A18-02, A18-03)
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.
Speeches and presentations
A17C0146: Fond du Lac opening remarks
Kathy Fox, TSB Chair
David Ross, Investigator-in-charge, TSB
Read the opening remarks
TSB calls for adequate aircraft de-icing equipment, greater compliance with de-icing regulations at remote northern airports
Read the news release
TSB provides update on investigation into Fond-du-Lac accident, expands data collection on aircraft operations in remote areas
Read the news release
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
TSB will provide a news briefing on its investigation into the airplane accident in Fond-du-Lac, Saskatchewan
Read the media advisory
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.
Map showing the location of the occurrence
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.
Download high-resolution photos from the TSB Flickr page.
Class of investigation
This is a class 2 investigation. These investigations are 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
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- 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.
- 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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