SH36, vicinity Oshawa ON Canada, 2004
From SKYbrary Wiki
|On 16 December 2004, an Air Cargo Carriers Shorts SD3-60 attempted to land at Oshawa at night on a runway covered with 12.5mm of wet snow which did not offer the required landing distance. After unexpectedly poor deceleration despite selection of reverse propeller pitch, full power was applied and actions for a go around were taken. Although the aircraft then became airborne in ground effect, it subsequently failed to achieve sufficient airspeed to sustain a climb and an aerodynamic stall was followed by impact with terrain and trees beyond the end of the runway. The aircraft was substantially damaged and both pilots sustained serious injuries but there was no post-crash fire|
|Actual or Potential
|Human Factors, Loss of Control|
|Operator||Air Cargo Carriers|
|Type of Flight||Public Transport (Cargo)|
|Intended Destination||Oshawa Municipal Airport|
|Take off Commenced||Yes|
|Flight Phase||Missed Approach|
|Location - Airport|
|Airport vicinity||Oshawa Municipal Airport|
|Tag(s)||Inadequate Aircraft Operator Procedures|
|Tag(s)||Inappropriate crew response - skills deficiency,|
Plan Continuation Bias,
Procedural non compliance,
|Tag(s)||Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,|
|Damage or injury||Yes|
|Aircraft damage||Hull loss|
|Injuries||Most or all occupants|
|Causal Factor Group(s)|
On 16 December 2004 a Shorts SD3-60 being operated by Air Cargo Carriers on a cargo flight from Toledo OH USA to Oshawa ON Canada rejected an attempt to land at night on a runway contaminated with snow after poor deceleration but failed to transition to a climb and subsequently impacted rising terrain and trees beyond the end of the runway. The aircraft was substantially damaged and both pilots sustained serious injuries but there was no post-crash fire.
An Investigation was carried out by the Canadian TSB. It was noted that the aircraft had not been fitted with a Flight Data Recorder (FDR) or Cockpit Voice Recorder (CVR) and neither was required to be fitted under the prevailing regulations. There was provision for the generation of METARs for Oshawa but TWR ATC had advised, approximately 11 minutes before the landing, that there was a layer of cloud at about 100 feet agl and surface visibility was about 800 metres. The crew had subsequently had requested a Runway Condition Report (RCR) and just over two minutes before landing, TWR stated the RCR had just been completed and gave the runway as “snow-covered and slippery underneath” and gave landing clearance.
It was established that after radar vectors from ATC, the aircraft had commenced a straight in LLZ back course/DME approach to runway 30 with the First Officer as PF. During this approach, still in Instrument Meteorological Conditions (IMC), the First Officer had difficulty maintaining track and at between 3 and 4 miles from touchdown, the aircraft commander had taken over as PF. The approach thereafter after was stable and upon obtaining visual reference approximately 70 feet above the applicable MDA, a slight realignment onto the runway extended centreline was made.
Touchdown with 15 flap selected was found not to have occurred until about one-third of the way down the 1220 metre runway. After selection of full reverse pitch, which was contrary to AFM limitations, deceleration was less than expected and after between 5 and 8 seconds of full reverse, a go around was called and maximum take-off power set. As the end of the runway approached, the aircraft was rotated to a take-off attitude and had became airborne in Ground Effect but it had been impossible to transition to a sustained climb in free air before the control was lost and the aircraft impacted terrain approximately 170 metres beyond the end of the runway.
It was noted that the flap 15 approach, which the crew would have been aware would result on a longer landing roll than a full flap (30) approach, was in compliance with an Operator Instruction prohibiting full flap approaches. However, although this was current, it was based on aircraft manufacturer advice that had been withdrawn some two months earlier. In the light of the contaminated runway conditions, it was considered that the flight crew would have been aware of the need for an early touchdown but it concluded that they “most likely did not reference the AFM performance chart ‘Effect of a Slippery Surface on Landing Distance Required’ to determine that landing the aircraft on the 1220 metre, snow-covered runway with flap-15 was inappropriate”.
The Investigation also concluded that “with the runway end lights rapidly approaching, (the Captain) called for a go-around at a point on the runway where it would have been prudent to continue full braking and remain on the ground”.
In summary, it was considered that the flight crew had made a number of “questionable decisions during the preparation and execution of the approach and landing”, including attempting a landing on a runway which, with Flap 15, would have marginally more than the LDA even if it had been dry and uncontaminated runway as well as continuing when they had a suitable alternate and, ultimately, attempting a go around after selecting reverse propeller pitch first.
The Investigation recorded its ‘Findings as to Causes and Contributing Factors’ as follows:
- The crew planned and executed a landing on a runway that did not provide the required landing distance.
- The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
- After landing long on the snow-covered runway and applying full reverse thrust, the Captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
- The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar
- The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
The Final Report of the Investigation A04O0336 was authorised for release on 18 October 2005. No Safety Recommendations were made.