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Air transportation safety investigation A17C0146

The TSB has completed this investigation. The report was published on 28 October 2021.

Table of contents

Loss of control and collision with terrain

West Wind Aviation L.P.
Avions de Transport Régional ATR 42-320, C-GWEA
Fond-du-Lac, Saskatchewan

View final report

The occurrence

On 13 december 2017, an Avions de Transport Régional ATR 42-320 aircraft (registration C-GWEA, serial number 240), operated by West Wind Aviation L.P. (West Wind), was scheduled for a series of instrument flight rules flights from Saskatoon through northern Saskatchewan as flight WEW282.

When the flight crew and dispatcher held a briefing for the day’s flights, they became aware of forecast icing along the route of flight. Although both the flight crew and the dispatcher were aware of the forecast ground icing, the decision was made to continue with the day’s planned route to several remote airports that had insufficient de-icing facilities.

The aircraft flew from Saskatoon/John G. Diefenbaker International (CYXE) to Prince Albert (Glass Field) Airport (CYPA) without difficulty, and, after a stop of about 1 hour, proceeded on toward Fond-du-Lac Airport (CZFD). On approach to Fond-du-Lac Airport, the aircraft encountered some in-flight icing, and the crew activated the aircraft’s anti-icing and de-icing systems.

Although the aircraft’s ice protection systems were activated, the aircraft’s de-icing boots were not designed to shed all of the ice that can accumulate, and the anti-icing systems did not prevent ice accumulation on unprotected surfaces. As a result, some residual ice began to accumulate on the aircraft.

The flight crew were aware of the ice; however, there were no handling anomalies noted during the approach. Consequently, they likely did not assess that the residual ice was severe enough to have a significant effect on aircraft performance. The crew continued the approach and landed at Fond-du-Lac Airport at 1724 Central Standard Time.

According to post-accident analysis of the data from the flight data recorder, the aircraft’s drag and lift performance was degraded by 28% and 10%, respectively, shortly before landing at Fond-du-Lac Airport. This indicated that the aircraft had significant residual ice adhering to its structure upon arrival. However, this data was not available to the flight crew at the time of landing.

The aircraft was on the ground at Fond-du-Lac Airport for approximately 48 minutes. The next flight was destined for Stony Rapids Airport (CYSF), Saskatchewan, with 3 crew members (2 pilots and 1 flight attendant) and 22 passengers on board.

Although there was no observable precipitation or fog while the aircraft was on the ground, weather conditions were conducive to ice or frost formation. This, combined with the residual mixed ice on the aircraft, which acted as nucleation sites that allowed the formation of ice crystals, resulted in the formation of additional ice or frost on the aircraft’s critical surfaces.

Once the passengers had boarded the aircraft, the First officer completed an external inspection of the aircraft. However, because the available inspection equipment was inadequate, the First officer’s ice inspection consisted only of walking around the aircraft and looking at the left wing from the top of the stairs at the left rear door, without the use of a flashlight on the dimly lit apron.

Figure S1. Ice contamination on leading edge of left horizontal stabilizer following the accident (Source: Royal Canadian Mounted Police, with TSB annotations)
Ice contamination on leading edge of left horizontal stabilizer following the accident (Source: Royal Canadian Mounted Police, with TSB annotations)

Although he was unaware of the full extent of the ice and the ongoing accretion, the First officer did inform the captain that there was some ice on the aircraft. The captain did not inspect the aircraft himself, nor did he attempt to have it de-iced; rather, he and the First officer continued with departure preparations.

Company departures from remote airports, such as Fond-du-Lac, with some amount of surface contamination on the aircraft’s critical surfaces had become common practice, in part due to the inadequacy of de-icing equipment or services at these locations. The past success of these adaptations resulted in this unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart.

Although the flight crew were aware of icing on the aircraft’s critical surfaces, they decided that the occurrence departure could be accomplished safely. Their decision to continue with the original plan to depart was influenced by continuation bias, as they perceived the initial and sustained cues that supported their plan as more compelling than the later cues that suggested another course of action. At 1812 Central Standard Time, in the hours of darkness, the aircraft began its take-off roll on Runway 28, and, 30 seconds later, it was airborne.

As a result of the ice that remained on the aircraft following the approach and the additional ice that had accreted during the ground stop, the aircraft’s drag was increased by 58% and its lift was decreased by 25% during the takeoff.

Despite this degraded performance, the aircraft initially climbed; however, immediately after liftoff, the aircraft began to roll to the left without any pilot input. This roll was as a result of asymmetric lift distribution due to uneven ice contamination on the aircraft.

Following the uncommanded roll, the captain reacted as if the aircraft was an uncontaminated ATR 42, with the expectation of normal handling qualities and dynamic response characteristics; however, due to the contamination, the aircraft had diminished roll damping resulting in unexpected handling qualities and dynamic response. Although the investigation determined that the ailerons had sufficient roll control authority to counteract the asymmetric lift, due to the unexpected handling qualities and dynamic response, the roll disturbance developed into an oscillation with growing magnitude and control in the roll axis was lost.

This loss of control in the roll axis, which corresponds with the known risks associated with taking off with ice contamination, ultimately led to the aircraft colliding with terrain 17 seconds after takeoff.

Figure S2. Aerial view of occurrence site (Source: Royal Canadian Mounted Police, with TSB annotations)
Aerial view of occurrence site (Source: Royal Canadian Mounted Police, with TSB annotations)

The aircraft collided with the ground in a relatively level pitch, with a bank angle of 30° left. As a result of the sudden vertical deceleration upon contact with the ground, the aircraft suffered significant damage, which varied in severity at different locations on the aircraft due to impact angle and variability in structural design.

The design standards for transport category aircraft in effect at the time the ATR 42 was certified did not specify minimum loads that a fuselage structure must be able to tolerate and remain survivable, or minimum loads for fuselage impact energy absorption. As a result, the ATR 42 was not designed with these crashworthy principles in mind.

The main landing gear at the bottom of the centre fuselage section was rigid, and, on impact, did not absorb or attenuate much of the load. The impact-induced acceleration was not attenuated because the landing gear housing did not deform. This unattenuated acceleration resulted in a large inertial load from the wing, causing the wing support structure to fail and the wing to collapse into the cabin.

The reduced survivable space between the floor above the main landing gear and the collapsed upper fuselage caused crushing injuries, such as major head, body, and leg trauma, to passengers in the middle-forward left section of the aircraft. Of the 3 passengers in this area, 2 experienced, serious life-changing injuries, and 1 passenger subsequently died.

Figure S3. Image of the displaced cabin seats (Source: TSB)
Image of the displaced cabin seats (Source: TSB)

The collapse of part of the floor structure compromised the restraint systems, limiting the protection afforded to the aircraft occupants when they were experiencing vertical, longitudinal, and lateral forces. This resulted in serious velocity-related injuries and impeded their ability to take post-crash survival actions in a timely manner. Unaware of the danger, most passengers in this occurrence did not brace for impact. Because their torsos were unrestrained, they received injuries consistent with jackknifing and flailing, such as hitting the seat in front of them.

As a result of unapproved repairs, the flight attendant seat failed on impact, resulting in injuries that impeded her ability to perform evacuation and survival actions in a timely manner.

Although the TSB has previously recommended the development and use of child restraints aboard commercial aircraft, planned regulations have yet to be implemented by Transport Canada. As a result, the occurrence aircraft was not equipped with these devices, and an infant passenger who was unrestrained received flailing and crushing injuries during the accident sequence.

By the time the aircraft came to a rest, all occupants had received injuries. Passengers began to call for help within minutes of the impact, using their cell phones. Numerous people from the nearby community received the messages and quickly set out to help.

The passengers and crew began to evacuate, but they experienced significant difficulties as a result of the aircraft damage. It took approximately 20 minutes for the first 17 passengers to evacuate, and the remaining passengers much longer; it took as long as 3 hours to extricate 1 passenger, who required rescuer assistance.

As a result of the accident, 9 passengers and 1 crew member received serious injuries, and the remaining 13 passengers and 2 crew members received minor injuries. One of the passengers who had received serious injuries died 12 days after the accident.

There was no post-impact fire, and the emergency locator activated on impact.

Early in this investigation, it became clear that more information was needed to determine whether the underlying factors identified in this occurrence were present elsewhere in the Canadian commercial aviation industry.

To assess the risks involved with winter operations at remote northern airports, and specifically the risk posed by aircraft taking off with frost, ice, or snow adhering to critical surfaces, the TSB conducted an online survey of pilots who were directly exposed to operations at remote airports throughout Canada.

The responses received to several questions showed that operations at these remote airports were routinely affected by the unavailability and inadequacy of equipment to inspect, de-ice, or anti-ice aircraft.

The combined probability and severity of this safety deficiency poses a high risk to transportation safety. The risk likely varies from airport to airport, depending somewhat on the frequency of operations; however, identifying high-risk locations for immediate mitigation can quickly reduce the likelihood of aircraft taking off with frost, ice, or snow adhering to any critical surface at those locations.

Transport Canada, air operators, and airport authorities have the capacity to identify high‑risk locations, analyze them for hazards and risks, and take mitigating action.

Therefore, in December 2018, the Board recommended that

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.
TSB Recommendation A18-02

The most notable information received from the survey showed that, in the past 5 years, 74% of pilots had seen aircraft take off with contaminated surfaces, in contravention of regulations and the clean aircraft concept. This majority indicates that the issue is systemic, rather than isolated to a small number of operators or a select few locations.

There are many defences in place to ensure the clean aircraft concept is followed, such as regulations, company operating manuals, and standard operating procedures. However, all of these defences rely singularly on flight crew compliance. As seen in this occurrence, when a single-point compliance adaptation is made, aircraft may depart with contaminated surfaces, despite several adequate administrative defences in place.

To mitigate this hazard, Transport Canada and air operators must take urgent action to ensure better compliance.

Accidents related to contaminated aircraft will continue to occur until the industry and the regulator approach the issue as systemic and take action to eliminate underlying factors that can negatively affect pilot compliance.

Therefore, in December 2018, the Board recommended that

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 A18-03

When West Wind commenced operations into CZFD in 2014, no effective risk controls were in place to mitigate the potential hazard of ground icing. Transportation companies have a responsibility to manage safety risks in their operations; however, compliance with regulations can provide only a baseline level of safety. When implemented properly, SMS enables companies to manage risk effectively and make operations safer. For SMS to be effective, it must be supported by a positive safety culture. If a company’s safety culture tolerates unsafe practices, there is a risk that these practices will continue and become a company norm.

Safety management is an issue on the TSB’s Watchlist 2020, which identifies the key safety issues that need to be addressed to make Canada’s transportation system even safer.

The investigation also revealed a number of instances in which Transport Canada’s surveillance policies and procedures were inconsistently applied to the oversight of West Wind. This is not the first time that such inconsistencies in Transport Canada’s oversight of commercial aviation in Canada have been identified. As detailed in the findings of several TSB investigations, there have been a number of past examples where Transport Canada has been slow to either identify or to rectify unsafe conditions at an operator. Transport Canada’s inconsistent application of its own policies and procedures for the 2016 assessment of West Wind and subsequent post-assessment corrective action plan verifications, as well as the ad hoc approach to enhanced monitoring, resulted in ineffective oversight of an operator that had a history of system-level (i.e., safety management system [SMS]) and systemic (e.g., operational control) non-compliance issues.

If the application of Transport Canada’s surveillance policies and procedures is inconsistent, there is a risk that resulting oversight will be ineffective at ensuring that operators are able to effectively manage the safety of their operations.

Regulatory surveillance is also an item on the TSB’s Watchlist 2020.


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

2021-10-28

TSB investigation into fatal 2017 plane crash in Fond-du-Lac, SK, highlights need for better de-icing equipment and practices in remote and northern airports
Read the 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

Video and audio materials

2021-10-28

A17C0146 – Fond du Lac air investigation summary
View on YouTube

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 Eric Vermette

Eric Vermette joined the TSB in 2014 as a Regional Senior Investigator – Operations, for the Central Region and works in Winnipeg, Manitoba. He holds a current airline transport pilot’s license and has accumulated over 5000 hours of flight time on various jet and propeller aircraft. He has been the Manager, Central Region Operations for the TSB Air Investigation Branch since 2015.

Prior to joining the TSB, Mr. Vermette worked for over 13 years in civil aviation including experience as a training pilot and as a check pilot. He also has over 5 years of experience as Chief Pilot in CAR 703, 704 and 705 operations. Mr. Vermette has flown in all parts of Canada and the USA and has extensive medevac flying experience.


Photos


  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

  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.