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Aviation Investigation Report A07c0001 Collision with Terrain Transwest Air

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Aviation Investigation Report A07c0001 Collision with Terrain Transwest Air AVIATION INVESTIGATION REPORT A07C0001 COLLISION WITH TERRAIN TRANSWEST AIR BEECH A100 KING AIR C-GFFN SANDY BAY, SASKATCHEWAN 07 JANUARY 2007 Collision with Terrain Transwest Air OCCURRENCE SUMMARY • Beech A100 King Air C-GFFN Sandy Bay, Saskatchewan A07C0001 EVENT On the evening of 07 January 2007, a Transwest Air Beech King Air medical evacuation flight heading for Sandy Bay, Saskatchewan, abandoned its landing attempt, but failed to climb sufficiently, and hit trees beyond the end of the runway. While all four occupants evacuated the aircraft, the captain died of injuries before rescuers arrived. Two passengers (medical technicians) were seriously injured and the first officer had minor injuries. The aircraft was destroyed by fire. SAFETY ISSUES Many airports in Canada are surrounded by unlit areas (“black holes”) which present hazards. Pilots need better information about locations where these hazards exist. Training in crew resource management (CRM) teaches flight crews to avoid errors, by working together to use all available resources. This training is not currently required for Canadian air taxi and commuter operations. TSB RECOMMENDATION The Department of Transport require commercial air operators to provide contemporary crew resource management (CRM) training for Canadian Aviation Regulations (CARs) subpart 703 air taxi and CARs subpart 704 commuter pilots. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Investigation Report Collision with Terrain Transwest Air Beech A100 King Air C-GFFN Sandy Bay, Saskatchewan 07 January 2007 Report Number A07C0001 Synopsis Transwest Air Flight 350 (TW350), a Beech A100 King Air (registration C-GFFN, serial number B190), departed La Ronge, Saskatchewan, at 1930 central standard time under instrument flight rules to Sandy Bay, with two flight crew members and two emergency medical technicians aboard. TW350 was operating under Part VII, Subpart 3, Air Taxi Operations, of the Canadian Aviation Regulations. At 1948, air traffic control cleared TW350 out of controlled airspace via the Sandy Bay Runway 05 non-directional beacon approach. The crew flew the approach straight-in to Runway 05 and initiated a go-around from the landing flare. The aircraft did not maintain a positive rate of climb during the go-around and collided with trees just beyond the departure end of the runway. All four occupants survived the impact and evacuated the aircraft. The captain died of his injuries before rescuers arrived. Both emergency medical technicians were seriously injured, and the first officer received minor injuries. The aircraft sustained substantial damage from impact forces and was subsequently destroyed by a post-impact fire. The accident occurred at 2002 during the hours of darkness. Ce rapport est également disponible en français. © Minister of Public Works and Government Services Canada 2009 Cat. No. TU3-5/07-2E ISBN 978-1-100-13884-8 TABLE OF CONTENTS 1.0 Factual Information .............................................................................. 1 1.1 History of the Flight ..................................................................................................... 1 1.1.1 Pre-Flight Preparation.................................................................................................. 1 1.1.2 Departure, En Route, and Descent ............................................................................. 1 1.1.3 Approach ....................................................................................................................... 2 1.1.4 Go-Around..................................................................................................................... 2 1.2 Injuries to Persons......................................................................................................... 3 1.3 Damage to Aircraft ....................................................................................................... 3 1.4 Other Damage ............................................................................................................... 3 1.5 Personnel Information ................................................................................................. 4 1.5.1 General ........................................................................................................................... 4 1.5.2 The Captain ................................................................................................................... 4 1.5.3 The First Officer ............................................................................................................ 6 1.5.4 Captain and First Officer Interaction ......................................................................... 7 1.6 Aircraft Information ..................................................................................................... 8 1.6.1 General ........................................................................................................................... 8 1.6.2 Weight and Balance...................................................................................................... 8 1.6.3 Global Positioning System........................................................................................... 9 1.6.4 Aircraft Flight Manual ................................................................................................. 9 1.7 Meteorological Information ........................................................................................ 9 1.8 Aids to Navigation ....................................................................................................... 10 1.9 Communications........................................................................................................... 11 1.10 Aerodrome Information............................................................................................... 11 1.11 Flight Recorders ............................................................................................................ 12 1.12 Wreckage and Impact Information ............................................................................ 12 1.13 Medical and Pathological Information ...................................................................... 13 1.13.1 The Captain ................................................................................................................... 13 1.13.2 The First Officer ............................................................................................................ 13 1.14 Fire .................................................................................................................................. 13 1.15 Survival Aspects ........................................................................................................... 14 1.16 Tests and Research........................................................................................................ 15 1.17 Organizational and Management Information ........................................................ 15 1.17.1 Transwest Air ................................................................................................................ 15 1.17.1.1 General ........................................................................................................................... 15 1.17.1.2 Air Operator Certificate and Operations Specification 99 ...................................... 15 1.17.1.3 Flight Operations Manual ........................................................................................... 16 1.17.1.4 Pilot Self-Dispatch ........................................................................................................ 17 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 1.17.1.5 Pairing Policy ................................................................................................................ 17 1.17.1.6 Unscheduled Service to Registered Aerodromes..................................................... 18 1.17.1.7 Global Positioning System Approaches .................................................................... 18 1.17.1.8 Flight Crew Training Manual ..................................................................................... 18 1.17.1.9 Director of Flight Operations/Safety Manager........................................................ 19 1.17.1.10 Southern Chief Pilot ..................................................................................................... 19 1.17.1.11 Northern Chief Pilot..................................................................................................... 20 1.17.1.12 Pilot Hiring ....................................................................................................................21 1.17.1.13 Company Response to Repeated Flight Crew Regulatory Infractions ................. 22 1.17.1.14 Safety Management System Implementation........................................................... 22 1.17.1.15 Supervision of TW350 Crew ....................................................................................... 23 1.17.1.16 TW350 Crew Pairing and Scheduling........................................................................ 25 1.17.1.17 Operations Directives and Safety Directives ............................................................ 25 1.17.1.18 Beech A100 King Air Standard Operating Procedures ..........................................
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