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GL5T, Fox Harbour NS Canada, 2007

From SKYbrary Wiki

Summary
On 11 November 2007, a Bombardier BD-700 (Global 5000) operated by Canadian charter company Jetport touched down short of the runway at destination Fox Harbour in normal daylight visibility and then directional control was lost and the aircraft exited the side of the runway ending up having rotated 120° clockwise about its fore-aft axis and came to rest approximately 300metres from the threshold and approximately 50 meters from the runway edge. As a result, the co pilot and one of the passengers suffered serious injuries and the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.
Event Details
When November 2007
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Human Factors, Runway Excursion
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOMBARDIER Global 5000
Operator Jetport
Domicile Canada
Type of Flight Public Transport (Passenger)
Origin Hamilton/John C. Munro Hamilton International Airport
Intended Destination Fox Harbour
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Landing
LDG
Location - Airport
Airport Fox Harbour
General
Tag(s) Inadequate Aircraft Operator Procedures
CFIT
Tag(s) Undershoot on Landing
HF
Tag(s) Ineffective Monitoring,
Manual Handling
RE
Tag(s) Directional Control
EPR
Tag(s) RFFS Procedures
Outcome
Damage or injury Yes
Aircraft damage Major
Injuries Most or all occupants
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent

Description

On 11 November 2007, a Bombardier BD-700 (Global 5000) operated by Canadian charter company Jetport touched down short of the runway at destination Fox Harbour in normal daylight visibility and then directional control was lost and the aircraft exited the side of the runway ending up having rotated 120° clockwise about its fore-aft axis and came to rest approximately 300 metres from the threshold and approximately 50 meters from the runway edge. As a result, the co pilot and one of the passengers suffered serious injuries and the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.

GL5T point of dep RWY
GL5T point of departure RWY

Investigation

An Investigation was carried out by the Canadian Transport Safety Board. It found that the flight crew had low experience on a new and larger aircraft type than the similar one which they had previously operated and was operating to an aerodrome known for its multiple hazards on a day of strong gusting winds. Because the crew had both operated to this destination frequently in the past, they were comfortable with completing the flight. They flew the same profile they had flown on previous flights without taking into consideration the greater eye-to-wheel height of the aircraft they were flying compared to the previous smaller aircraft they had been used to or following the manufacturer’s recommended procedures for approach vertical profile and handling techniques. The Investigation considered that

“these deviations from recommended procedures increased crew workload and reduced the safety margin and the crew failed to appreciate that they were too low until the energy state of the aircraft made pitching up an ineffective recovery action.”

The Investigation also found that, although the Operator had declared having an SMS in place for the preceding three years, it had been ineffective, as had the traditional, reactive safety management process supposedly in place. Neither had identified many of the risks which contributed to the accident outcome.

The Investigation also found evidence that:

“although the Regulator, Transport Canada, had identified deficiencies in the operational safety oversight of the Canadian Business Aircraft Association, upon which they relied for audit of member’s Operational Standards, (the aircraft operator was a member) no effective follow up had occurred”

The Investigation considered that the misjudgment of the flight crew during the latter stages of the approach, which had led directly to the accident outcome, was related to a lack of appreciation of the implications of different pilot eye-to-wheel heights. It noted that information on this was not readily available to crews.

It also considered that there was a lack of appreciation by the accident flight crew of which visual landing system is most appropriate for their aircraft and of the implications of using a less than optimal one, as was provided at the airport in this case (an Abbreviated Precision Approach Path Indicator or APAPI). The Investigation noted that the APAPI had been installed as a result of an incident in 2000 in which an aircraft of the same Operator had struck trees whilst too low during a night visual approach. See http://www.skybrary.aero/bookshelf/books/2452.pdf

Causes and Contributing Factors

These included:

  1. In respect of the flight crew misjudgement of the approach profile that:
    • The crew planned a touchdown point within the first 500 feet of the runway to maximize the available roll-out. This required crossing the threshold at a height lower than the manufacturer’s recommended threshold crossing height (TCH).
    • The flight crew members flew the approach profile as they had done in the past on the smaller Bombardier Challenger 604, with no consideration for the Global 5000 greater aircraft eye-to-wheel height (EWH), resulting in a reduced TCH.
    • The abbreviated precision approach path indicator (APAPI) guidance, although not appropriate for this aircraft type, would have assured a reduced main landing gear clearance of eight feet above threshold. At 0.5 nm, the pilot flying (PF) descended below the APAPI guidance, further reducing the TCH.
    • The pilot used the wing-low crosswind technique, increasing his workload and resulting in pilot-induced oscillations.
    • With the aircraft in a low energy state, the pitch up to 10.6° without an associated thrust increase could not correct the flight profile, resulting in the impact with the sloped surface before the runway threshold.
  2. In respect of the absence of effective risk assessment at the Operator:
    • An inappropriate balance of responsibilities for oversight between the regulator, its delegated agency, and the operator resulted in Jetport’s inadequate risk assessment not being identified.
  3. In respect of evacuation hazards:
    • Not wearing shoulder harnesses during landings and take-offs increases the potential risk of passenger injuries.
    • Passengers not wearing footwear could impede evacuation, increase the risk of injury, and reduce post-crash mobility and (potentially) survival.

The Final Report of the Investigation was published on 23 September 2009 and may be seen in full at the SKYbrary bookshelf: Aviation Investigation Report A07A0134

It contained five Safety Recommendations as follows:

  • The Department of Transport ensure that eye-to-wheel height information is readily available to pilots of aircraft exceeding 12 500 pounds.
  • The Department of Transport require training on visual glide slope indicator (VGSI) systems so pilots can determine if the system in use is appropriate for their aircraft.
  • The Canadian Business Aviation Association set safety management system implementation milestones for its certificate holders.
  • The Department of Transport ensure that the Canadian Business Aviation Association implement an effective quality assurance program for auditing certificate holders.

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