Perimeter Sanny accident report

[AOW]

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.

This is what bugs me with this whole scenario. They dispatched with sufficient fuel to get to YSK, shoot an approach and missed approach, fly to YGW, shoot an approach and land, plus 45 minutes of reserve fuel. On top of that, they claim to have had 200 lbs of "granny gas". YGL is less than 100 miles further from YSK than YGW, which is probably pretty close to 200 lbs more fuel burn to get to, in this machine! Even without the granny gas, I would have considered diverting to YGL after the first approach, knowing that another approach was likely not going to work out any better, and knowing that YGW was below limits. Yes, this would be cutting into my reserve fuel, but isn't this exactly the reason why we carry reserve fuel? With the extra 200 lbs, we probably would land in YGL with close to 45 minutes left in the tanks... that sounds like a much better option to me! A better airport, with better weather, and better approaches.

[JoeShmoe]

I also find it shocking that the lack of a straight in approach to both runways was not even included as a risk factor in this report. They must secretly admit that this is a risk factor if an rnav approach appeared there soon after the accident. I remember about a month after the keystone accident in north spirit an rnav approach suddenly appeared there as well. It drives me a little crazy that the only way we get upgraded approaches in these isolated areas is for someone to die. I personally have just sent an email to navcanada requesting what I am sure many of you have already done, and that is to install an rnav approach at every northern airport and to do so quickly. I hope many of you will do the same.

I realize that the lack of rnav approach is not the only cause of this crash, probably not even the main reason for this crash, but it is something that we can actually do something about. This is a forum for pilots, it would be nice if we could get together to advocate for safer flying conditions.

[FICU]

I have done more trips than I can remember from YWG to Sani and I always checked wx enroute. You cannot trust Kuj as an good alternate when Sani is in the shitter because Kuj would probably be in the same system. Always plan to go somewhere else or divert if necessary while enroute. All this talk of approaches is moot when the crew didn't keep themselves updated on weather and plan for a contingency.

[Johnny#5]

Shoulda, coulda, woulda....

[FL7377]

As for the granny gas....

You'll notice the AC took off at 15993 lbs (max 16000) on PAPER + 200 lbs granny gas. And the only comment the NTSB had about it was adding extra fuel "may invalidate the C of A". The NTSB did NOT suggest to TC that the "well known practice within the company" of adding granny gas should be changed. The NTSB mentioned without criticism the use of granny gas, this flight took off 200 lbs overweight invalidating the C of A... and no one cares. And nor should they!

Perimeter's Metro's are what, 30-40 years old? Go drive a car from that era and ask yourself how accurate the fuel guage is. In fact I think if Perimeter's pilots DON'T add 200 lbs to every flight, that's a problem!

I fly up north in a little twin turbo-prop. In my AC I never take off without a little extra fuel on board, so I KNOW I have the minimum.... usually around %10 more. If I'm on my way south, or flying around civilization, maybe a little less.

That is very common in my company to take a little extra, and by the sounds of it its common at Perimeter as well.

[FL7377]

I also find it shocking that the lack of a straight in approach to both runways was not even included as a risk factor in this report. They must secretly admit that this is a risk factor if an rnav approach appeared there soon after the accident. I remember about a month after the keystone accident in north spirit an rnav approach suddenly appeared there as well. It drives me a little crazy that the only way we get upgraded approaches in these isolated areas is for someone to die. I personally have just sent an email to navcanada requesting what I am sure many of you have already done, and that is to install an rnav approach at every northern airport and to do so quickly. I hope many of you will do the same.

I realize that the lack of rnav approach is not the only cause of this crash, probably not even the main reason for this crash, but it is something that we can actually do something about. This is a forum for pilots, it would be nice if we could get together to advocate for safer flying conditions.

Couldn't agree more! We need more infrastructure up north!

What is the College of Professional Pilots doing about this????

Oh right, nothing, because they don't legally exist yet......

[FL7377]

As a low time private here -- hence my handle -- circling approaches scare me. At night? Ugggggggg. Just did my first one actually -- during the day. Prepped for minimums -- per the metar - but comfortably above. Anticlimactic, An LNAV, and I had a first class alternate 20 min away, tons of fuel.

Night NDB circling? No thanks for me SP. But I'm zero experience essentially.

Circling approaches at night scare me to! Lets never do them!

Then all of a sudden the company gets a $20k charter to somewhere like Sanny, the only way in with the winds that night is to circle, and every one expects you to get in, if you don't you'll have a torrent of angry managers breathing down your neck when you get back. SO what do you do? Chicken out and hope you get to keep your job, or bite the bullet and learn to circle....

The level of infrastructure up north in the 21st century is embarrassing!

[CID]

They must secretly admit that this is a risk factor if an rnav approach appeared there soon after the accident.

This is one of a few comments on this thread that is disturbing. A risk factor is one that contributed to the accident. The lack of specific approaches is NOT a risk factor. As a pilot, you are supposed to plan and operate within the established parameters and limitations and that includes the available published approaches.

If you are not capable or able and you attempt the flight anyway, THAT is the risk factor, not the lack of an approach. Next we'll be reading about how the airplane would have made it if the fuel tank was bigger or if it was able to fly with a few thousand extra pounds.

And here's a thought for you RNAV flag wavers. If a straight-in RNAV approach would have saved the day, why didn't the flight crew build one? Yes, somewhat dangerous but you can't tell me that nobody does that or that the airplane wasn't equipped. Of course it would have been easier if they had the charts which was one of the more significant screw-ups in this mess.

The point here however is don't make decisions based on what SHOULD BE. Make them on reality and you may avoid killing anyone.

[Rookie50]

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[Diadem]

Now people are advocating taking "a little extra" fuel and knowingly taking off overweight? What the hell has happened to this industry? If your gauges aren't accurate and you think you need more fuel, bump some freight; if you take off overweight and lose an engine, there's a good chance someone could die, likely you. Don't start breaking laws just to get the job done.

[CID]

Yes I know it's money, the U.S. has 3500 LPV approaches now. We have a few hundred at most, with a lot less alternates than the U.S. has. We need them even more for that reason.

The US has 10 times the population and more than 10 times the airports. Out of 15,000 airports in the US, about 1500 have LPV approaches. About 10%. In order to design an approach to LPV minima (or any WAAS approach for that matter) the airport needs to lie within the coverage area of a WAAS ground station.

Out of about 35 WAAS ground stations in North America, 4 are located in Canada at Winnipeg, Iqaluit, Goose Bay and Gander. Here is a map of the population density of Canada.

http://www12.statcan.gc.ca/census-recen ... z01-en.gif

So tell me genius, (in all your shame) how can you say that our country isn't progressing in a reasonable time? How much do you think we need to pile together to provide about 1% of the population with all weather approaches? Should we put up our own satellites?

And no, you need to wrap your head around what a risk factor in an accident is. Coulda-woulda-shoulda doesn't cut it. The lack of instrument approaches isn't something that happened over night. People have been flying in the north for decades. WAY before the existence of GPS, never mind GPS based approaches. I don't recall any accident reports from the 60s that mention a risk factor of "lack of GPS approach". But I bet there are a few where a factor was an outdated star almanac.

And please...don't give me that "in the real world" bullshit. If you screw up for real, you screw up on paper. If you break the rules and get away with it you're not a hero. You're a lucky moron.

[fish4life]

It may only be 1% of the population but for that 1% the airports are a lifeline for everything in and out of the community. For the cost of a few medevacs missing because they only have an NDB approach it would easily pay for an LPV built on either end or at least an RNAV. As for the safety things try make a circling approach fit into flight safety's stabilized approach criteria. Also in the 60's nobody complained about not having / using accelerate stop distance charts either but we sure use them now RNAV should be no different

[Rookie50]

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[CID]

"If you screw up on paper you screw up for real"

In some ivory towers, because attempting the approach is illegal in paper, to conform to the Regs flight crews should just fly around in pretty circles until they run out of fuel and crash.

Therefore, no regs were violated.

Legal, but dead.

I'm not endorsing the flight crews pre - takeoff or on route decisions, but once you are there what do you do. Follow paper or try to get your butt on the ground?

Are you trying to quote me? I stated "If you screw up for real, you screw up on paper." Much different sentiment.

[Diadem]

"If you screw up on paper you screw up for real"

In some ivory towers, because attempting the approach is illegal in paper, to conform to the Regs flight crews should just fly around in pretty circles until they run out of fuel and crash.

Therefore, no regs were violated.

Legal, but dead.

I'm not endorsing the flight crews pre - takeoff or on route decisions, but once you are there what do you do. Follow paper or try to get your butt on the ground?

So you're saying that instead of going to their alternate, which was forecast to improve, and hope that the improvement had occurred, or hold until they were min fuel to see if the improvement occurred, that they should just chop and drop below mins to get on the ground? Don't climb up nice and high to minimize fuel burns while they re-evaluated and got updated weather, just plop it down below mins and hope you get it inside the boundary of the runway? We're not talking about an airplane that was running on fumes, or in 0/0 weather with no other airport in range, or had a mechanical issue that precluded them from flying anymore; they took a perfectly functional airplane, with 200 lbs more fuel than they needed, and ran it off the end of the runway. They rushed, and they fixated on landing in YSK rather than gathering more info and coming up with a plan. The ultimate reason that they went off the end of the runway was that the captain continued the approach at ref+30 and tried to force it down, because he was fixated on completing that landing.

[Rookie50]

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[pelmet]

All these scenarios I have discussed are based on no viable alternate. Someone mentioned that they would go for YGL and could make it. I am not familiar enough with the aircraft, approaches, fuel burns etc to comment on that. I am just going on the TSB statement that it was no longer viable to go to YGL and their filed alternate was down to one-half mile with no precision approaches available which is a non-starter for me based on the present weather in YSK which wasn't that bad as lights could be seen multiple times during this event.

So, why would you climb all the way back up to some high altitude to re-evaluate and get weather. Are you really going to save any fuel by burning a lot more to get up to where you are burning somewhat less. If you have decided to hold for a while then perhaps at 3000 feet somewhere near where you will initiate your next approach seems logical to me.

If you really want a weather update, for YGW which would be nice to have, get the weather from the CARS guy at YSK, perhaps during the initial descent from cruise altitude. It might take him a while but he does have a phone and can call FSS to see if there has been any change. If it turns out to be reasonable at YGW you have your fuel for an approach, missed approach, two hundred pounds extra and then the required fuel beyond that. Then you can decide whether to divert right away or try YSK.

[Mr. North]

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[Diadem]

Rookie, what I'm trying to say is that busting mins may not have had any impact on their ability to see the runway; on the first approach, they had it in sight at the straight-in MDA, they just chose to circle for that approach. It was their inability to line up properly with the runway and maintain a proper approach speed that caused the accident. The same thing could have happened in day VMC, and busting mins wouldn't have made any difference. The METAR shows 2SM and a ceiling of 1200 feet, so I really don't see how busting mins would have helped them. Descending below the safe altitude on a constant descent, especially if the wind isn't exactly what you expect, is going to get pilots killed a lot more frequently than trying to find somewhere else to land, and it's irresponsible of you to endorse that. I hope you never become an instructor or training captain.
Pelmet, YGL wasn't down to 1/2SM, YGW was. YGL was 1 1/2SM and VV013. I don't have a CAP for Quebec available, but I would bet that there's an approach that meets those mins. Hell, those meet alternate mins. The TSB didn't say that it wasn't viable to go to YGL, the flight crew decided that because they didn't take the time to gather all of the info and make a decision, they just acted hastily. They could have reached YGL by using some of their reserve fuel, which is what it's there for; their legal alternate crapped out after they took off, and they were under no obligation to land with 45 minutes of usable fuel remaining. I've run into a surprising number of pilots who think that reserve is untouchable, but this is precisely the situation for which it's intended.
Mr. North, those 20 minutes are more than enough to collect new weather info and make a better decision. Regardless, the important point is the attitude of the pilots in taking fuel that wasn't on the flight plan and departing overweight. In this situation, they only had one legal alternate within range, and it had a marginal forecast at that; every time I've been uncertain about the weather at both my destination and alternate, I've taken enough fuel to reach a third airport, and sometimes that's meant bumping some freight. The crew in the accident wasn't willing to do that, either because of self-imposed pressure or because of fear of management, and they ran out of options. Alternates aren't there just to tick a box on a form, they need to be good enough that to use if the destination craps out.

[pelmet]

Pelmet, YGL wasn't down to 1/2SM, YGW was. YGL was 1 1/2SM and VV013. I don't have a CAP for Quebec available, but I would bet that there's an approach that meets those mins. Hell, those meet alternate mins.

First I think you need to re-read what I posted before responding. I never said YGL was 1/2 mile. I said.... "I am just going on the TSB statement that it was no longer viable to go to YGL and their filed alternate was down to one-half mile with no precision approaches available"

The TSB didn't say that it wasn't viable to go to YGL, the flight crew decided that because they didn't take the time to gather all of the info and make a decision, they just acted hastily. They could have reached YGL by using some of their reserve fuel, which is what it's there for; their legal alternate crapped out after they took off, and they were under no obligation to land with 45 minutes of usable fuel remaining. I've run into a surprising number of pilots who think that reserve is untouchable, but this is precisely the situation for which it's intended.

Second, I think you need to re-read the report. The second finding says...."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."

YGL wasn't down to 1/2SM, YGW was. YGL was 1 1/2SM and VV013. I don't have a CAP for Quebec available, but I would bet that there's an approach that meets those mins. Hell, those meet alternate mins.

Alternates aren't there just to tick a box on a form, they need to be good enough that to use if the destination craps out.

Third, I appreciate the advice but you might want to check again to see if this is above the alternate minima for YGL?

Descending below the safe altitude on a constant descent, especially if the wind isn't exactly what you expect, is going to get pilots killed a lot more frequently than trying to find somewhere else to land, and it's irresponsible of you to endorse that. I hope you never become an instructor or training captain.

Fourth, there was nowhere else to land. Based on the report, I suspect a properly flown circling approach actually would have gotten them in but failing that, there only viable choice was a straight in approach using the GPS and descending on a 3 to 1(or slightly above) as they were familiar with the terrain and knew that it was only some downsloping terrain to fly over.

What you say about the wind doesn't make sense. They would have known their groundspeed from their GPS and their distance back as well. What is the Metro approach speed? 130 knots perhaps minus a 15 knot headwind. 115 on approach for groundspeed. A 600 fpm descent started at 8 miles back at 2400 feet AAE. Every mile a target altitude would have been checked, if above or below the descent path, an adjustment would have been made to the descent rate. PAPI's would have been picked up at 500 feet or so in this case allowing a safe landing. Radalt would have been monitored when close in. It works extremely well. Just ask the 757 pilots of the NZ Air Force who did the same under worse weather conditions. Report link on page 1.