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Report: Late touchdown causes runway excursion accident of DHC-6 Twin Otter in Canada
21 January 2016
The occurrence aircraft, after coming to rest beside the taxiway (TSB)

The occurrence aircraft, after coming to rest beside the taxiway (TSB)

The Transportation Safety Board of Canada (TSB) identified several factors which led to a late touchdown and runway excursion accident in September 2014 in La Tabatière, Quebec. 

On 28 September 2014, a de Havilland Canada DHC-6 Twin Otter 300, operated by Air Labrador, was on a charter flight from Lourdes-de-Blanc-Sablon to La Tabatière, Quebec, with 2 crew and 17 passengers on board. As the First Officer landed the aircraft, the captain determined that the aircraft would not stop before reaching the end of the runway, and took control and initiated a high-speed left turn onto the taxiway. The aircraft skidded to the right, and the right propeller struck a runway identification sign before the aircraft came to a stop.

The aircraft had floated for 6.3 seconds over the runway and touched down about 750 feet from the threshold, near the halfway point instead of the beginning of the runway, leaving not enough room to stop. The company had neither procedures nor a policy stating when to conduct go-arounds, and relied solely on pilot experience to determine when a go-around should be performed. If pilots are not prepared to conduct a go-around on every approach, there is a risk that they will not be ready to react to a situation that requires a go-around, the TSB stated.

Also, neither pilot had received CRM training at Air Labrador, nor was it required by regulation. TSB has an outstanding recommendation (A09-02) calling on contemporary CRM training for air taxi and commuter pilots. Transport Canada (TC) has recently developed CRM training standards for these operators and plans to publish them in 2016.

This accident highlights two issues on the TSB Watchlist: Approach-and-landing accidents and Safety management and oversight. As this occurrence demonstrates, landing accidents continue to occur at Canadian airports. The TSB has called on TC and operators to do more to reduce the number of unstable approaches that are continued to a landing. Additionally, a safety management system (SMS) is a comprehensive process for managing safety risks in an organization. In this case, the operator did not have an SMS, nor was it required to have one by regulation. However, if organizations do not use modern safety management practices, there is an increased risk that hazards will not be identified and mitigated. TSB also urges TC to implement regulations requiring all operators in the air industry to have formal safety management processes, and to oversee these processes.

Following the occurrence, Air Labrador issued a directive to all crews for modified procedures when landing on short runways. They also provided a landing-distance performance chart for each aircraft and amended their checklists.

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