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Edmonton, Alberta, 27 April 2015 — According to a Transportation Safety Board of Canada (TSB) investigation report (A13W0120) published today, a cylinder failure on the right engine, and the fact that the aircraft exceeded its maximum certified take-off weight, led to the wheels-up landing just after take-off of a Buffalo Airways DC-3C aircraft in August 2013. There were no injuries to the 21 passengers or the 3 crew members.
On 19 August 2013, the Buffalo Airways aircraft was operating as a scheduled passenger flight from Yellowknife to Hay River, Northwest Territories. After lift-off from Runway 16 at 1708 Mountain Daylight Time, there was a fire in the right engine. The crew performed an emergency engine shut-down and made a low altitude right turn towards Runway 10. The aircraft struck a stand of trees southwest of the threshold of Runway 10 and touched down south of the runway with the landing gear retracted.
The TSB investigation found that Buffalo Airways did not have an effective safety management system (SMS) in place to identify and mitigate risk in its operations. Along with the findings as to cause, the investigation also uncovered a number of findings as to risk, both for the air operation, and with regard to Transport Canada oversight. As for Transport Canada, the current approach to regulatory oversight, which focuses on an operator’s SMS processes almost to the exclusion of verifying compliance with the regulations, is at risk of failing to address unsafe practices and conditions. If Transport Canada does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified increasing the risk of accidents. This is an issue on the TSB Watchlist.
Buffalo Airways has begun to enforce the practice of weighing individual passengers and baggage in order to calculate a weight and balance prior to departure. The company has also contracted the development of Net Take-off Flight Path charts for its flights, and has revised its Company Operations Manual. The company has also made organizational changes such as: a comprehensive re-training of the Operations Manager; hiring of an operations consultant to assist with regulatory compliance; adjusting the Operations Manager’s responsibilities to identify and more effectively address non-compliance with regulations; and developing policies and procedures by the Accountable Executive and the Operations Manager to ensure regulatory compliance.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
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For more information:
Transportation Safety Board of Canada