Transportation Safety Board Bureau de la sécurité des transports of Canada du Canada AVIATION OCCURRENCE REPORT A97H0011 LOSS OF CONTROL ON GO-AROUND (REJECTED LANDING) AIR CANADA CANADAIR CL-600-2B19 C-FSKI FREDERICTON AIRPORT, NEW BRUNSWICK 16 DECEMBER 1997 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 Occurrence Report Loss of Control on Go-around (Rejected Landing) Air Canada Canadair CL-600-2B19 C-FSKI Fredericton Airport, New Brunswick 16 December 1997 Report Number A97H0011 Synopsis Air Canada Flight 646, C-FSKI, departed Toronto-Lester B. Pearson International Airport, Ontario, at 2124 eastern standard time on a scheduled flight to Fredericton, New Brunswick. On arrival, the reported ceiling was 100 feet obscured, the visibility one-eighth of a mile in fog, and the runway visual range 1200 feet. The crew conducted a Category I instrument landing system approach to runway 15 and elected to land. On reaching about 35 feet, the captain assessed that the aircraft was not in a position to land safely and ordered the first officer, who was flying the aircraft, to go around. As the aircraft reached its go-around pitch attitude of about 10 degrees, the aircraft stalled aerodynamically, struck the runway, veered to the right and then travelled—at full power and uncontrolled—about 2100 feet from the first impact point, struck a large tree and came to rest. An evacuation was conducted; however, seven passengers were trapped in the aircraft until rescued. Of the 39 passengers and 3 crew members, 9 were seriously injured and the rest received minor or no injuries. The accident occurred at 2348 Atlantic standard time. 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TABLE OF CONTENTS 1.0 Factual Information.................................... 1 1.1 History of the Flight................................................... 1 1.2 Injuries to Persons .................................................... 3 1.3 Damage to Aircraft.................................................... 3 1.4 Other Damage........................................................ 4 1.5 Personnel Information................................................. 4 1.5.1 General.............................................................. 4 1.5.2 Captain.............................................................. 4 1.5.3 First Officer .......................................................... 5 1.5.4 Cabin Crew .......................................................... 5 1.6 Aircraft Information................................................... 6 1.6.1 General.............................................................. 6 1.6.2 Aircraft Systems ...................................................... 6 1.6.2.1Flight Director........................................................ 6 1.6.2.2 Stall Protection System ................................................ 7 1.6.2.3Airspeed Indications .................................................. 8 1.6.2.4Flaps ................................................................ 9 1.7 Meteorological Information ........................................... 10 1.7.1 General............................................................. 10 1.7.2 Forecast Weather .................................................... 10 1.7.3 Actual Weather...................................................... 11 1.7.4 Icing Conditions..................................................... 11 1.8 Aids to Navigation................................................... 12 1.9 Communications..................................................... 12 1.10 Aerodrome Information .............................................. 13 1.10.1General............................................................. 13 1.10.2Runway Lighting and Runway Visual Range............................ 13 1.10.3Runway Condition................................................... 13 1.10.4Air Traffic Services ................................................... 14 1.11 Flight Recorders ..................................................... 15 1.11.1General............................................................. 15 1.11.2Flight Data Recorder ................................................. 15 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 1.11.3Cockpit Voice Recorder............................................... 15 1.11.4Flight Reconstruction................................................. 16 1.12 Wreckage and Impact Information .................................... 16 1.13 Medical Information ................................................. 18 1.14 Fire ................................................................ 18 1.15 Survival Aspects..................................................... 18 1.15.1General............................................................. 18 1.15.2The Aircraft ......................................................... 18 1.15.3Air Canada Emergency Procedures..................................... 19 1.15.4Training—Emergency Equipment and Procedures....................... 20 1.15.5Occurrence Flight.................................................... 21 1.15.6Emergency Response................................................. 23 1.15.7Emergency Locator Transmitter........................................ 24 1.16 Tests and Research................................................... 25 1.17 Organizational and Management Information........................... 26 1.17.1Air Canada Regional Jet Training Program.............................. 26 1.17.1.1Introduction........................................................ 26 1.17.1.2Pilot Training....................................................... 26 1.17.1.3Line Indoctrination and Command Training............................ 26 1.17.2Crew Pairing........................................................ 27 1.18 Other Information ................................................... 27 1.18.1Conduct of the Flight................................................. 27 1.18.1.1General ............................................................ 27 1.18.1.2Assignment of Flying Duties.......................................... 27 1.18.1.3Final Approach to Go-around Command............................... 28 1.18.1.4The Go-around ..................................................... 31 1.18.1.5Stall Prevention..................................................... 39 1.18.1.6Runway Length..................................................... 41 1.18.2 Approach and Landing Issues ......................................... 42 1.18.2.1Category I and Category II Approaches ................................ 42 1.18.2.2Approach Bans...................................................... 43 1.18.2.3Approach Criteria ................................................... 44 1.18.2.4Loss of Visual References after Deciding to Land........................ 46 iv TRANSPORTATION SAFETY BOARD TABLE OF CONTENTS 1.18.2.5Approach Procedures................................................ 46 1.18.2.6Weather-related Occurrences......................................... 48 1.18.3Aircraft Performance ................................................. 49 1.18.3.1General ............................................................ 49 1.18.3.2Stall Protection System Activation..................................... 49 1.18.3.3Coefficient of Lift Curve.............................................. 50 1.18.3.4Flight Data Recorder Data from Previous Flight......................... 50 1.18.3.5Flight Data Recorder Data from Aircraft 104 ............................ 51 1.18.3.6Simulator Comparison............................................... 51 1.18.3.7Wing Condition..................................................... 52 1.18.3.8Ground Effect....................................................... 53 1.18.3.9 Ice Accretion ....................................................... 53 1.18.3.10Ice Detection and Protection......................................... 55 2.0 Analysis............................................. 57 2.1 Introduction......................................................... 57 2.2 Survival Aspects..................................................... 57 2.2.1 Training on Evacuation and Emergency Equipment...................... 57 2.2.2 Survival Equipment—Signalling Tools .................................. 58 2.2.3 Emergency Equipment—Location of Flashlights......................... 58 2.2.4 Passenger Preparedness for Post-Evacuation Survival .................... 59 2.2.5 Emergency Response................................................. 59 2.3 Operational Issues ................................................... 59 2.3.1 Approach and Transition to Land...................................... 59 2.3.1.1Approach Ban Weather Limits......................................... 59 2.3.1.2Weather Conditions and Effects on this Flight........................... 60 2.3.1.3Low-Weather Procedures............................................. 61 2.3.2 Assigning First Officer Pilot-Flying Duties............................... 61 2.3.3 Captain Duties on Approach .......................................... 62 2.3.4 Go-around Issues .................................................... 63 2.3.4.1Low-Energy Rejected Landing Considerations .......................... 63 2.3.4.2Flight Director Guidance.............................................. 64 2.3.4.3Go-around Procedure and Training...................................