Perimeter Sanny accident report

[StandingBy]

Pelmet and those who agree with him are totally missing the point if your issues with the crew's actions start at the accident airport, or worse yet if you think this was an acceptable scenario. I hope you are not in a position that others can learn from you.

Adam Dyck

[PROC_HDG]

Notwithstanding the mistakes made by the crew and operator, which were obviously considerable, this does raise the question, as these accidents always do: Why isn't there at least one GNSS WAAS approach to every single runway everywhere north of Gimli? Unfortunately we all know the an$$wer.

PROC_HDG

[tbaylx]

Pelmet and those who agree with him are totally missing the point if your issues with the crew's actions start at the accident airport, or worse yet if you think this was an acceptable scenario. I hope you are not in a position that others can learn from you.

Adam Dyck

No one said the issues started at the approach..you are the only one that suggested that. Pelmet simply said IF you find yourself in a situation where you must land at an airport it is better to descend below minimums on profile and land than to run our of fuel and crash. Seems like a good plan to me.

Don't confuse that with condoning the whole decision making process that got them there in the first place.

[Rookie50]

..

[pelmet]

Contemplating approaches below minima? With passengers? Professional Pilots? Holy crap. If that is the best you can come up with after reading this report...

Well, what would you have done once in the situation where you had no alternate and were over YSK.

Not interested in a I wouldn't have departed. What would you do if you had departed with good weather and now were at YSK with no alternate.

Or even better, read the 757 report I posted and tell me what you would have done if you found yourself in their situation.

Any one of us could get caught out with amended forecasts(or are they really aftercasts) that are a not unusual experience in the arctic.
I see the captain had flown widebodies overseas prior to returning to Perimeter. It is nice having CAT IIIB autoland as the way out, but that doesn't work here I'm afraid.

To be honest, I think that lots of varied flying such as what Perimeter does is good background experience for some aspects of the international stuff, but not that much of the international airline stuff is helpful for the Perimeter style stuff. That being said, he flew there before so I would assume that he was quite familiar with this type of operation in general.

We have two reports on this thread for two crew who got caught at an airport below minimums and no alternate. Both crews made errors to get into this situation. However, one crew survived and one did not. I suggest that those who disagree with me on what to do in this situation fully read both reports and ask yourself who made the better decisions in the end.

So please reply, what would you have done. Diverted to your alternate that has bad weather as well and arrive with hardly any fuel for multiple approaches? Ditch? Stay above your minimums with no possibility of seeing anything with continuous approaches til you ran out of gas? Dive down to the relatively short runway like was done from very close in with no hope of landing within the confines of the runway? Call dispatch?

What is the professional thing to do with pax onboard in this situation. And what did you come away with from this report once established in the situation they were in.

[Big Pistons Forever]

Pelmet and those who agree with him are totally missing the point if your issues with the crew's actions start at the accident airport, or worse yet if you think this was an acceptable scenario. I hope you are not in a position that others can learn from you.

Adam Dyck

Don't agree at all with the crews actions before arrival.

I'm just interested in the views here on how a crew handles a no - win scenario, which could happen with or without approach plates. You're approaching your primary, and the primary goes below minima, and the alternate MAY be below Minima but you burn a chunk of fuel getting there to find out. Fluctuating, lets say, which modifies the accident scenario a little.

Do you go to the alternate knowing you will have less fuel to hold and approach, or do what this crew (tried) to do?

I know lots of variables maybe too many, lets say NP approach only at both and flat terrain.

There are so many variables I think you have asked a question impossible to answer. The only comment I can make as somebody who once let themselves get caught in the trap of a min fuel, crap weather approach with all the other options gone, is the urge to rush is almost overwhelming. This is the time where you have to force yourself to slow down and get all your ducks in a row. Take a second lap in the hold to nail the winds and extend the turn to final so you have lots of room to get down. Slow down and get configured early.

Then when you make it and your knees have stopped shaking, keep that heartfelt vow to never let yourself get in that kind of a jam again.

My significant emotional event occurred over 20 years ago, but is still a vivid memory which keeps me grounded, no pun intended, when it is decision time

[pelmet]

Pelmet and those who agree with him are totally missing the point if your issues with the crew's actions start at the accident airport, or worse yet if you think this was an acceptable scenario. I hope you are not in a position that others can learn from you.

Adam Dyck

Don't agree at all with the crews actions before arrival.

I'm just interested in the views here on how a crew handles a no - win scenario, which could happen with or without approach plates. You're approaching your primary, and the primary goes below minima, and the alternate MAY be below Minima but you burn a chunk of fuel getting there to find out. Fluctuating, lets say, which modifies the accident scenario a little.

Do you go to the alternate knowing you will have less fuel to hold and approach, or do what this crew (tried) to do?

I know lots of variables maybe too many, lets say NP approach only at both and flat terrain.

. The only comment I can make as somebody who once let themselves get caught in the trap of a min fuel, crap weather approach with all the other options gone, is the urge to rush is almost overwhelming. This is the time where you have to force yourself to slow down and get all your ducks in a row. Take a second lap in the hold to nail the winds and extend the turn to final so you have lots of room to get down. Slow down and get configured early.

Very true with down wind approaches. Set yourself up much further away(done safely of course with respect to terrain), even in normal circumstances to get configured and stable as the wind is working against you in both directions.

[StandingBy]

Apologies for a bit of an inflammatory post earlier. I think the conversation would be better off concentrating on the decision making andd risk management that can prevent accidents like these rather than the pilotage that can get you out of them once you've flown through the previously mentioned 'Swiss cheese'.

[stef]

For sure. Like I said before, I'd have refused the trip. Dark. Shit weather. Northern strip. That's a no brainer to me.

If you're ever in a position where you have to land, you have to get yourself into a position to land. Sitting at minima until it's too late and diving for it is not the answer. That is very very dangerous and was ultimately their final mistake in a calamity of errors.

[fish4life]

If you never left with the forecast they had when they left then you would never go flying up north. It wasn't bad weather until after they left.

[stef]

I've actually got around 20000 landings under my belt "up north" as you say, and being more careful about the weather after dark has been working out pretty well for me so far. That's a marginal forecast at destination with an unusable alternate.

[CpnCrunch]

I've actually got around 20000 landings under my belt "up north" as you say, and being more careful about the weather after dark has been working out pretty well for me so far. That's a marginal forecast at destination with an unusable alternate.

The alternate was usable when they departed. However that was based on a forecast saying that the weather was going to improve, which is always a risky gamble.

[fish4life]

After they left it was a poor forecast and alternate but BEFORE the forcast wasn't bad. Should have they checked the forcast along the way and then made a diversion? Probably. All I'm saying is the original forcast had nothing to stay grounded for.

[xsbank]

Correct me if I'm wrong, I don't want to reread the report but wasn't there a comment made that they did not check weather enroute? Arriving at destination to find the weather was a surprise?

I learned very early in my career that you always need an out. They didn't have one. They operated to a destination where the alternate was no use because it was in the same w/x system and had no better approach facilities than the destination and even with the illegal fuel they loaded, they didn't have enough. If the aircraft could not get to a suitable alternate with adequate fuel, they should have not gone.

To the person who made the comment about Arctic ops who suggested that you would never complete a trip unless you broke a rule, pick one? Is it worth somebody's life to "get 'er done?"

I have refused Whitehorse trips because Watson wasn't good enough or it was after hours for w/x reporting and the a/c couldn't carry enough fuel for anywhere else; the passengers were po'd but we waited for better w/x. I landed in Jordan for an unexpected fuel stop because the aircraft was new and the paperwork for RVSM had not returned, the fuel burn was too high and we would have only had enough fuel for a miss and one attempt at the alternate. Jordan was interesting because it was not on the flight plan and Tel Aviv was out because of the nationality of some passengers. Canadian Embassy on speed-dial! You are paid to make the tough decisions and if you wish to be considered professional, those decisions need to abide by ALL the rules. CARS, Limitations, SOPs, QRH, all the rules. You cannot depart with contingency plans that are illegal!

Returning to pick up plates and being embarrassed, (did they even have the plates for their alternate?) maybe being called some names or maybe scrubbing the trip for duty day issues is really no different than a mechanical issue and would have been better than a dead baby jammed under their rudders, don't you think?

Good night ladies and gentlemen. Happy Canada Day, especially those of you in Quebec. Before you nod off tonight read over your limitations and your SOPs. Maybe recite your Engine Fire After Takeoff memory items. I'll bet many of you haven't done that since your last recurrent?

[stef]

I didn't say it was illegal. I said it was unusable. That's too much wet snow even on a quick turn and the piss pack would not suffice. Not a suitable 'out.'

[Heliian]

Sani can be a brutal place. THERE IS NOTHING FLAT ABOUT IT. Sure, there isn't any mountains but since one end of the runway ends in rocks, sea and village and the other ends in rocks, it's not to be reckoned with. It's short and gravel, this is not a place you push weather. These clowns (whether it be the company or the PIC who decided to continue with a second approach) are completely at fault, they could have gone to an alternate, just like many other trips in there. I spent time there, I saw many types struggle with it but never saw a metro go in there, why would they even try to get that crap a/c in there?

[pelmet]

These clowns (whether it be the company or the PIC who decided to continue with a second approach) are completely at fault, they could have gone to an alternate, just like many other trips in there.

So you would have gone to the alternate then? It was 1/2 mile in snow at YGW. Here is the weather they got at top of descent.

CYSK 2200 UTC METAR: wind 010°T at 17 knots gusting 25 knots, visibility 2 sm in light snow and blowing snow, cloud ceiling overcast 1200 feet agl, temperature −5°C, dewpoint −6°C, altimeter setting 29.28 in. Hg.

CYGW 2200 UTC METAR: wind 030°T at 8 knots, visibility ½ sm in moderate snow, vertical visibility 400 feet, temperature −4°C, dewpoint −5°C, altimeter setting 29.18 in. Hg.

CYGL 2200 [UTC] METAR: wind 290°T at 10 knots gusting 17 knots, visibility 1½ sm in light snow and drifting snow, vertical visibility 1300 feet, temperature −7°C, dew point −9°C, altimeter setting 29.17 in. Hg. In remarks, visibility was noted as variable from 1 to 2 sm.

I say the clown would be the one to go to their alternate which was YGW, although I see in the report that the pilot planned to do so if the approaches at YSK didn't work out(I am assuming that YGW only has a non-precision approach). At 1200' and 2 miles vis, the weather at YSK is above the minimums of 600 feet and 1.5 miles. Your destination just became your alternate in my opinion. Easy decision(remember, YGL is too far away according to the report).

If caught in that situation, I would have continued with another approach. But first of all, they circled to the north with a tailwind on base leg. That is why it failed both times. It is quite possible that they lost sight of the runway strictly because they were so far off course in a turn well south of the runway having blown well through final approach. Look how far south of the runway the diagram of the circling track shows them to be. They were never close to being in a position to land. If the plan is to circle, then why not circle to the south and have the wind in your favour.

Second, if the circling does not work and it was because of low cloud or whatever obscuring visibility then work on plan B. Look at the track where they circled. It is over water and the water extends for quite a few miles. Why not just set yourself up on final at about ten miles back over the water and be aligned with the runway, corrected for wind, using the GPS with the NDB showing on course and fly inbound. Stay at circling minimums if you like and see what you see. If it doesn't work, try lower on a 3 to 1. Trust me, if you go to YGW at 1/2 mile in snow, you won't get in from the MDA if only a non-precision approach is available and will have to do the same in even worse weather.

The bottom line is that regardless of whatever mistakes were made to get into a situation where the destination and alternate are below minimums, once in that situation, you are in an emergency. Now that you have an emergency, the PIC has the legal right to break whatever regulation needs to be broken as long as it can be justified as being required to be broken to get in. It appears that that this accident happened due to an attempt to stay legal in terms of approach track flown.

I spent time there, I saw many types struggle with it but never saw a metro go in there, why would they even try to get that crap a/c in there?

Bearskin operates Metros on a bunch of 3500 foot runways in northern Ontario. This one is 3800, so why is there any problem with going into YSK?

Sani can be a brutal place. THERE IS NOTHING FLAT ABOUT IT. Sure, there isn't any mountains but since one end of the runway ends in rocks, sea and village and the other ends in rocks, it's not to be reckoned with.

There are lots of airports that end in rocks, sea or drop offs that are relatively short. That doesn't seem to stop operations. It was winter so it was likely hard pack snow, not gravel. Here is a picture. Slopes down on final so a 3 to 1 or slightly higher is the best profile.

http://www.panoramio.com/photo/83770756

Last, I would like to point out that I believe that Nav Canada should be considered in this accident. I sent a letter to them over 15 years ago complaining about the lack of approaches to airports just like this creating unsafe conditions due to circling only approaches on some runways. It appears that this situation still exists. There should be a straight in approach to 09, preferably an RNAV one. It baffles me why the TSB doesn't consider this to be a risk.

[Crusty]

The shortest strip in Bearskin's network is Fort Frances which is just under 4500 feet long.

[BTD]

As said above Bearskin does not operate into gravel or that short of strips. They are governed by accelerate stop distances etc, which are not a metro 3/23 s best quality.

Former Bear pilot.

[pelmet]

Ok, I thought they used to go into a bunch of 3500 foot strips prior to the routes being taken over by Wasaya.

[fish4life]

Perimeter goes into a ton of 3-4000' stripes all over MB, runway length wasn't the issue in this crash. As to whoever said the metro was a crap aircraft I would have to say it' held up extremely well in this crash I'm not sure a king air would have kept the passengers in the same shape.

[CID]

I am pretty sure there would have been no accident if there had been a proper LNAV approach to both ends of the runway. This would have allowed an into the wind CDA procedure to be carried out. There is no question that this is a much safer procedure than a NDB to circling limits.

In this day and age there is no excuse for public use airports to only have an NDB approach

So...the lack of an LNAV approach caused the accident? If they didn't bring charts for the NDB approach what makes you think they'd have charts for any LNAV approach? Besides, if they crashed by screwing up an LNAV approach would you then be stating that they wouldn't have crashed if they had a CAT III ILS?

The point is that you need to use what is available and you must respect the associated limitations. If you don't then you can't cite the lack of "extra" that doesn't exist.

[PositiveRate27]

I am pretty sure there would have been no accident if there had been a proper LNAV approach to both ends of the runway. This would have allowed an into the wind CDA procedure to be carried out. There is no question that this is a much safer procedure than a NDB to circling limits.

In this day and age there is no excuse for public use airports to only have an NDB approach

So...the lack of an LNAV approach caused the accident? If they didn't bring charts for the NDB approach what makes you think they'd have charts for any LNAV approach? Besides, if they crashed by screwing up an LNAV approach would you then be stating that they wouldn't have crashed if they had a CAT III ILS?

The point is that you need to use what is available and you must respect the associated limitations. If you don't then you can't cite the lack of "extra" that doesn't exist.

Bingo.

The accident wouldn't have happened if the runway was made out of cotton candy either... You gotta play the game with the field that's available.

[Big Pistons Forever]

I am pretty sure there would have been no accident if there had been a proper LNAV approach to both ends of the runway. This would have allowed an into the wind CDA procedure to be carried out. There is no question that this is a much safer procedure than a NDB to circling limits.

In this day and age there is no excuse for public use airports to only have an NDB approach

So...the lack of an LNAV approach caused the accident? If they didn't bring charts for the NDB approach what makes you think they'd have charts for any LNAV approach? Besides, if they crashed by screwing up an LNAV approach would you then be stating that they wouldn't have crashed if they had a CAT III ILS?

The point is that you need to use what is available and you must respect the associated limitations. If you don't then you can't cite the lack of "extra" that doesn't exist.

The accident statistics are clear. In order of probability of a most to least fatal outcomes. (Note: for all approach types circling at night is the most likely to result in a fatal accidents, followed by circling during the day, followed by night straight in followed by day straight in.)


1) NDB (no distance information)
2) NDB (with distance information)
3) Other Non Precision (LOC or VOR with no DME)
4) Other Non Precision (LOC or VOR with DME, LNAV)
5) Other Non Precision (LNAV with VNAV)
6)ILS or LPV or RNP.

So the aircraft was performing what is the most dangerous possible approach, a night circling NDB. I get that there was a ton of bad decisions made on the accident flight, but there is no doubt in my mind that the accident would have been less likely to have occurred if they could have flown a straight in, into the wind LNAV approach, and the only reason that this option was not available was because of a generalized unwillingness on the part of governments at all levels, and industry, to make the investments necessary to make flying safer.

I am discouraged that all the reporting on this event seems to be about baby seats in the cabin, not about addressing a systemic lack of approach aids in the North.

[126.75]

I would like some mature conversation on whether pilots who duck things up this poorly should be charged criminally. Continuing the flight without IFR approach charts? Sure their alternate crapped out, but they did not call YWG or YXU radio for updates? In my opinion these guys could have a case argued against them for negligence causing death and bodily harm.

Would knowingly flying past airports like YRL where they could duck in to print off the approach plates, be the same as waking up after a bender, still drunk and going flying? Or a pilot taking a bong hit before check in?

I used to work at Perimeter and there was not this type of pressure, and it was most of the same managers at the time. Leads me to believe it was more pilot induced get there itis than say from the company (like Keystone).

Scary Shit

As for taking the metro in and out of 3500 strips. It is easy as long as you respected the airplane, you could not treat it much like a Navajo. Perhaps that is not "easy" but I'd consider it to be, does not mean every approach worked out. Had to be on the numbers, on slope and put the airplane down in the first few hundred feet. If it wasnt looking like you would go around and try again.