Perimeter Sanny accident report

[RatherBeFlying]

How many folks check the satellite IR?

It gives you a very good idea of what the weather systems are up to. Agreed you can't check it enroute, but isn't that what's dispatch is for?

Heading to an isolated airport with iffy wx, I'd be insisting on an iron clad alternate and keeping a watchful eye on it. Dispatch should be looking after this.

[lostaviator]

It's been a few years since I have had my hands on the company SOP's over there, but once upon a time, stabilized approaches were not something that could be accomplished as a result of the SOP's themselves.

Speeds below 140 (or 130) and flaps greater then half were not permitted until landing was assured. This alone had you at REF + 30 (give or take). This often gets you into a situation where you are level at MDA, powering along with large amounts of high torque inertia, see the runway at a 1 or 1 1/2 from the runway and now need to flight idle, select landing flap, slow while descending all while managing what we would now refer to as an unstabilized approach.

There was a lot of bad decisions, and what I consider real sloppy flying. But the thought of the situation they were in makes me sick to think about.

For me, this should have ended with the realization there was no charts. This should have ended in one of those go home with the tail between your legs days, admitting you made a mistake and try again tomorrow. Plus... there would not have been time to start over so this would have solved all the crew concerns of a tight duty day. Not only were you missing the approach charts, but also charts for your alternate and enoute. Given this was not a scheduled flight for Perimter, these guys were flying in unfamiliar territory and having charts for every airport along the way (or knowing where they are for that matter due to lack of maps) doesn't sit well with me.

[pelmet]

For me, this should have ended with the realization there was no charts. This should have ended in one of those go home with the tail between your legs days, admitting you made a mistake and try again tomorrow. Plus... there would not have been time to start over so this would have solved all the crew concerns of a tight duty day. Not only were you missing the approach charts, but also charts for your alternate and enoute. Given this was not a scheduled flight for Perimter, these guys were flying in unfamiliar territory and having charts for every airport along the way (or knowing where they are for that matter due to lack of maps) doesn't sit well with me.

I think the charts issue is a red herring. They had the approach information as relayed to them by another aircraft. There is no reason to think that this would have turned out differently if they had brought the appropriate charts along. The report states that this increased the pressure on them but unless the TSB were to do the right thing and release CVR info, we will never be able to know. We do know that he swore more than usual on the flight. Having a bad day shouldn't lead to what happened here. Bad days happens to all of us at some point.

Bottom line, you don't need approach charts to know that once visual and not in a position to land on a runway with tight tolerances for type, diving down with a big tailwind is obviously not going to work. Same for being able to do a go-around at the appropriate time do it successfully.

The report states "As there were several MEDEVAC and charter flights to areas in Nunavut that day, there was an insufficient number of available instrument approach charts for Nunavut at the flight planning/flight following office during pre-flight planning. It was arranged that a set of charts would be picked up at Keewatin Air prior to departure." They had the Quebec charts and likely had en route charts as well. In reality, YSK should also be out into the Quebec CAP by Navcanada as it is so far away from the rest of Nunavut and so close to Quebec. Something else Navcanada could try being proactive about.

The captain was not in unfamiliar territory. According to the report, "(a) During his previous years of employment with Perimeter, the captain had gained experience flying in the North. (b)Since being rehired, he had been to CYSK twice before the day of the occurrence, once by day and once by night."

[ReserveTank]

I think the charts issue is a red herring. They had the approach information as relayed to them by another aircraft. There is no reason to think that this would have turned out differently if they had brought the appropriate charts along.

It's OK to depart without the proper charts? Just point to the reg or the COM page that says it.

[A346Dude]

How many folks check the satellite IR?

It gives you a very good idea of what the weather systems are up to. Agreed you can't check it enroute, but isn't that what's dispatch is for?

Heading to an isolated airport with iffy wx, I'd be insisting on an iron clad alternate and keeping a watchful eye on it. Dispatch should be looking after this.

The flight was operating under CARs 704 and thus had no Dispatcher, only a flight follower. Many (most?) flight followers have limited training and knowledge on how to read and interpret weather, required minimums, etc. The Captain had sole authority over flight planning and flight watch.

[CID]

Pelmet there absolutely is reason to believe the lack of charts is a factor. They not only had no charts for the destination, they had no charts for alternates. Furthermore, it's not enough to just have what a particular pilot considers the highlights of an approach. He didn't have enough descent info.

And visiting an airport a couple of times in your career now qualifies as familiarity? How long ago did the pilot fly there? What was the weather like? Were they visual? Did he have charts?

[Rockie]

Instrument procedures carry their own unique blend of risks even with the proper charted information. Instrument procedures up north - in winter, in lousy weather, with lousy alternates, with insufficient gas to return south - without proper charted information is bad, bad, BAD decision making.

Risk assessment is our job, and every risk associated with operating airplanes must have mitigating measures in place to bring it into acceptable range or we don't do it. As the risks piled up on this flight where were the mitigating measures or decision making that should have put them into the "unacceptable" category - before they were committed?

[pelmet]

Pelmet there absolutely is reason to believe the lack of charts is a factor. They not only had no charts for the destination, they had no charts for alternates. Furthermore, it's not enough to just have what a particular pilot considers the highlights of an approach. He didn't have enough descent info.

And visiting an airport a couple of times in your career now qualifies as familiarity? How long ago did the pilot fly there? What was the weather like? Were they visual? Did he have charts?

I think some people need to read the report carefully before commenting. They had no charts for destination because it was in the Nunavut CAP. I already showed the quote for this. Their alternate was in Quebec. Nowhere in the report does it say anything other than that their destination charts were not on board. Those familiar with the area know that YSK, located adjacent to Quebec is far, far away from mainland Nunuvat but has its approach charts located in the Nunuvut CAP.

As the report says, he had been to YSK twice since he RETURNED to Perimeter which was two months prior to the accident. As the report says, both times were VMC. Please read the report carefully and read posts carefully prior to commenting.

But seeing that some people seem to feel that this made all the difference in the world despite the fact that they were inbound on what appears to be the approximate published track to the NDB please explain how having the published chart would have made a difference in this accident. Well, on second thought, perhaps they would have flown the procedure turn on the published side making a big difference.

I'm not saying that they should have continued without charts, but if they had returned the following day in the exact same weather scenario with their Nunavut CAP in hand, this accident would have happened the following day. It is always interesting that people will get caught up in side issues as a cause distracting them from the big picture when it is not the cause. If we go with this line of thinking then perhaps if they had decided to break a regulation and departed with their inoperative item that caused the 3 hour delay, this accident wouldn't have happened. Therefore, following the regulations is dangerous and caused this accident.

It has been more than 5 years since I was at YSK. If I ever head back and find myself in the same situation as these guys, I am confident that I can do a straight in to 09 and do a 3 to1 descent(perhaps slightly higher gradient and get in if the weather conditions are exactly the same as that night.

[Rockie]

please explain how having the published chart would have made a difference in this accident.

Having it would have put them closer to the good side of risk mitigation and been one less worry for them. Not having it put them very much to the negative side. Careful planning and preparation make the successful outcome of any flight more certain on every level, while not being prepared in any aspect has a negative influence on all the rest. This crew was not prepared, it all added up, and ended badly.

Who knows, maybe the time spent getting incomplete approach procedure information on the radio and fretting over that would otherwise have been spent checking weather and thinking about what they should have been thinking about, and resulted in a return to Winnipeg.

[pelmet]

please explain how having the published chart would have made a difference in this accident.

Having it would have put them closer to the good side of risk mitigation and been one less worry for them. Not having it put them very much to the negative side. Careful planning and preparation make the successful outcome of any flight more certain on every level, while not being prepared in any aspect has a negative influence on all the rest. This crew was not prepared, it all added up, and ended badly.

If that was not carefully planned like this causes you to crash in the circumstances that happened at YSK then you shouldn't be in the cockpit. It is not unusual for a flight somewhere to have to divert on short notice to an unexpected airport due to some sort of occurrence, meaning that what was carefully planned did not pan out. Hundreds of pilots did it on Sep 11. None of them crashed because they had not carefully planned their flight to end the way it did.

These guys going to YSK had 3 hours to plan what to do. If they had brought their charts, diligently checked their weather every hour and had great alternate weather for the first 3/4 of the flight, and then discovered just prior to top of descent that special weather reports had been issued 15 minutes earlier resulting in what they really did encounter, the final outcome would almost certainly been the same.

Who knows, maybe the time spent getting incomplete approach procedure information on the radio and fretting over that would otherwise have been spent checking weather and thinking about what they should have been thinking about, and resulted in a return to Winnipeg.

A 5 minute radio conversation caused them to not update their weather on a 3 hour flight? Come on. Do you really believe that?

Anyways, all my posts have been or were meant to be, as originally stated, not on what they should have done enroute but what should be done when at a familiar fairly flat airport with no alternate and a situation similar to this with marginal but not flat weather.

[Maynard]

Looks like Doc hit the nail on the head back in 2012...

But, by all means, lets let the "experts" tell us what happened, say around the middle of 2015?

[pelmet]

Looks like Doc hit the nail on the head back in 2012...

Whatever happened to him?

[Rockie]

It is not unusual for a flight somewhere to have to divert on short notice to an unexpected airport due to some sort of occurrence meaning that what was carefully planned did not pan out.

Nor is it common. The rare time I've had to divert short notice to an unplanned alternate the act of diverting becomes your primary focus and is greatly eased by the level of preparation you have on all the rest of the flight. As always, the more gas you have the more time you have to sort things out. With regards to 9/11, planes near their destination landed at their destination, planes not near their destination had lots of gas and therefore lots of time to sort things out. Where it was most critical was on the North Atlantic track system where they turned most of those airplanes around. That was a triumph of flexibility and quick thinking to accomplish something unprecedented without serious incident.

A 5 minute radio conversation caused them to not update their weather on a 3 hour flight? Come on. Do you really believe that?

A preoccupation with that situation is what may have prevented adequate thought towards more normal inflight activities. Don't tell me preoccupation with something has never distracted you before in flight. If not, you don't fly very much.

These guys going to YSK had 3 hours to plan what to do. If they had brought their charts had great alternate weather for the first 3/4 of the flight, checked their weather just prior to top of descent and then discovered that special weather reports issued 15 minutes earlier had been what they really did encounter, the scenario would have been the same.

No it wouldn't. They would have had charts for one thing and been certain what their MDA was and that they were completing the proper procedure. That knowledge may have led them to divert before leaving cruise altitude to get to alternate with even more gas and better approaches into wind even with crappy weather. Lots of things could have happened differently with a crew properly prepared and making better decisions.

[grimey]

Looks like Doc hit the nail on the head back in 2012...

Whatever happened to him?

He became the man from UNCLE.

[CID]

please explain how having the published chart would have made a difference in this accident.

Please read the report carefully and read posts carefully prior to commenting.

[pelmet]

A preoccupation with that situation is what may have prevented adequate thought towards more normal inflight activities. Don't tell me preoccupation with something has never distracted you before in flight. If not, you don't fly very much.

These guys going to YSK had 3 hours to plan what to do. If they had brought their charts had great alternate weather for the first 3/4 of the flight, checked their weather just prior to top of descent and then discovered that special weather reports issued 15 minutes earlier had been what they really did encounter, the scenario would have been the same.

No it wouldn't. They would have had charts for one thing and been certain what their MDA was and that they were completing the proper procedure. That knowledge may have led them to divert before leaving cruise altitude to get to alternate with even more gas and better approaches into wind even with crappy weather. Lots of things could have happened differently with a crew properly prepared and making better decisions.

Rockie.....You are making excuses for the cause of the accident on the fly. Obviously, they knew the minimum altitudes. Why do you think that they did not ask the other aircraft for these altitudes? Because they forgot? No, they didn't ask for minimum altitude information because they already knew the minimum altitudes. They just needed the inbound track.

I have never advocated continuing on once it was discovered that they had no plates but....based on their decision to continue, three hours should be enough time on a flight to come up with a plan. They should have known that a circling approach was the only legal option at YSK prior to departure and briefed it during their 2 hour cruise segment.

A preoccupation with that situation is what may have prevented adequate thought towards more normal inflight activities. Don't tell me preoccupation with something has never distracted you before in flight. If not, you don't fly very much.

Yes Rockie....I have been distracted before in flight as we all have.

I guess then we can now conclude that the reason for the extremely poor circling maneuver is distraction from a short conversation with another aircraft a couple of hours earlier. And the reason for the attempted high dive to a really short downwind runway when it was in sight below their nose was this earlier distraction shortly after departure which prevented their ability to come up with a plan or make other considerations while enroute. If only they had their charts he wouldn't have done that last second dive and screwed up the go-around by pushing forward on the control column. Perhaps we should all divert if there is any sort of distraction earlier in the flight.

As you stated in your previous post

" With regards to 9/11, planes near their destination landed at their destination, planes not near their destination had lots of gas and therefore lots of time to sort things out.

The YSK guys had lots of time as well. I believe in reality, a lot of 9/11 guys were told to land NOW. None crashed, and none of the guys with lots of time crashed due to preoccupation such as finding out that certain elements of the attack that was going on. Some guys no doubt lived in NYC and DC. So the idea of distraction due to a brief radio conversation much earlier on the flight leading to an inability of pilots in general to update weather or properly plan an approach is, to put it mildly, implausible.

Once again, my real emphasis in earlier posts on this thread is a suggestion of what to consider when caught out in a situation like this with no alternate(which can happen), not the decisions made prior to getting the weather near top of descent so, I'll just agree with the analysis of others for that portion of the flight.

With no alternate available and the weather similar to what was reported in YSK, only two approaches were required here, a properly briefed and flown circling approach and if the weather was below that, a 3 to 1 straight-in descent on runway track.

[Rockie]

Obviously, they knew the minimum altitudes. Why do you think that they did not ask the other aircraft for these altitudes? Because they forgot? No, they didn't ask for minimum altitude information because they already knew the minimum altitudes. They just needed the inbound track.

From the TSB report, and this is despite the fact the wind reports at the beginning of the flight indicated at least a good chance for a circling approach:

"Information obtained did not include the direction for the procedure turn or the minimum descent altitude (MDA)(620 feet above sea level [asl]) for the circling approach to Runway 09."

I guess then we can now conclude that the reason for the extremely poor circling maneuver is distraction from a short conversation a couple of hours earlier. And the reason for the attempted high dive to a really short downwind runway when it was in sight below their nose was distraction enroute which prevent their ability to come up with a plan or make other considerations enroute. If only they had their charts he wouldn't have done that last second dive and screwed up the go-around by pushing forward on the control column. Perhaps we should all divert if there is any sort of distraction earlier in the flight.

These are the first three causal findings of the TSB report:

"1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a work-around solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq).

2. Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).

3. Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing and a shift away from well-learned, highly practised procedures."



Doesn't look like the TSB agrees with you either.

[pelmet]

Obviously, they knew the minimum altitudes. Why do you think that they did not ask the other aircraft for these altitudes? Because they forgot? No, they didn't ask for minimum altitude information because they already knew the minimum altitudes. They just needed the inbound track.

From the TSB report, and this is despite the fact the wind reports at the beginning of the flight indicated at least a good chance for a circling approach:

"Information obtained did not include the direction for the procedure turn or the minimum descent altitude (MDA)(620 feet above sea level [asl]) for the circling approach to Runway 09.".

If you read the report thoroughly and put things together you will understand that it is jumping to a conclusion to believe that because they didn't ask the other aircraft for minimum altitude info, they didn't know the minimum altitudes.

Do you really think that it didn't occur to them to ask what were the minimum altitudes and therefore did not have this info? Simply forgot perhaps. Did you wonder why, despite the fact that they did not ask the other aircraft for minimum altitudes, they still flew the initial arrival direction to the airport for a hoped landing on 09 at the appropriate MSA minimum altitude of 1600 feet? They then flew their Procedure turn at 1600 feet, 200 feet above published(which is only a minimum altitude and there is no need to actually be at this altitude) and then descended down to 600 feet when inbound which was the MDA(actually 560). It wasn't an incredible coincidence. It was because they knew their minimum altitudes. Perhaps they didn't know the PT altitude but 1600 feet is fine as they were above their MSA and it is quite safe to maneuver as desired. Direction of the procedure turn has no bearing on the accident. It is over the ocean and being familiar with the airport, they would have known this was over the ocean.

As stated in the report "Twice in quick succession during this procedure, the FO reminded the captain that the MSA was 1600 feet." So lets put the minimum altitude thing to rest.

Once he decided to circle, things completely fell apart as seen by the resulting ground track and altitude excursions.

These are the first three causal findings of the TSB report:

"1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a work-around solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq).

2. Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).

3. Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing

Maybe you should contact the TSB and grace them with your insights, they'll be happy to be set straight.

The reality is this. If you go by the conclusions of the TSB and your suggestions, earlier events made it improbable that the pilot could make it in at all. The reality is that any experienced, competent pilot with the same background experience as the captain would have gotten into YSK in such a situation even if they made a mistake to get into this situation in the first place.

Based on all the issues that happened on the flight and your suggestion that I grace the TSB with my insights, I think I would grace them with some insight to investigate pilot competence and put that as one of the causal findings. After all, aside from all the earlier events, who dives down onto a runway in the manner they did and then crashes on the go-around. And plenty of us have to deal with fatigue on a regular basis(I'm sure they had plenty of adrenaline at this point and were not sleepy), frustrations and workload(like in the sim), and stresses.

The TSB put fatigue in as being part of the cause. This is after stating that "The captain was off duty the 2 days preceding 22 December. He had a fairly good sleep the night before reporting for duty; he woke once and had taken 1.5 hours before falling back to sleep but eventually managed to do so. He felt rested prior to beginning the work shift. He had been on duty for approximately 9.5 hours when the occurrence took place." Hardly an exhausting day compared to a lot of other flying.

There were alternatives as I suggested earlier. By the way, none of these suggested alternatives in this situation includes what Diadem has suggested such as climbing back to a nice and high altitude to get a weather update and re-evaluate, holding until min fuel for improving weather or actually going to your below minimums alternate with 1/2 mile vis with a forecast to improve but is an amended forecast.

[Rockie]

A department of highly trained and experienced professional accident investigators spent a very long time meticulously dissecting every aspect of the circumstances leading up to this accident. These investigators are specialists in every applicable field including operations and human factors who no doubt spent hours and hours exhaustively interviewing the crew. This team of experts spent months more compiling their findings in an extremely detailed and thorough report.

But you, pelmet, disagree with their findings.

Makes one wonder why we even have a TSB....

[Heliian]

A department of highly trained and experienced professional accident investigators

You are giving them way too much credit. They are still humans that make decisions, sometimes even poor ones.