Unstable approach led to 2021 aircraft accident in Westlock, Alberta

Unstable approach led to 2021 aircraft accident in Westlock, Alberta

Time Stamp: March 30, 2023 1:50 AM
Source Node: 2039062

Edmonton, Alberta, 29 March 2023 — In its investigation report (A21W0090) released today, the Transportation Safety Board of Canada (TSB) highlights the importance of taking appropriate measures when encountering an unstable approach and ensuring that items in the cabin are secured.

On 10 October 2021, a privately registered Daher TBM700 N was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers.

At the time of occurrence, one pilot and three passengers were on board. Following an unstable visual approach at the Westlock Aerodrome, the aircraft bounced, and the pilot initiated a go-around. During the application of engine power, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side.

The investigation identified issues with the execution of the approach, touchdown, and go-around as causes and contributing factors for this accident. It also identified that the passengers did not receive a safety briefing before departure or before landing, and multiple items in the cabin were not secured. While all passengers were wearing the lap belts, only one was wearing the available shoulder harness. As a result, one passenger sustained serious injuries due their unrestrained upper torso and the loose items that were thrown around in the cabin during the accident. The pilot was also only wearing the lap belt but not the available airbag-equipped shoulder harness; as a result, he sustained serious injuries.

See the investigation page for more information.

The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.

Air transportation safety investigation report A21W0090

Loss of control during landing
Privately registered
Daher TBM700 N (TBM 910), C-FFYM
Westlock Aerodrome, Alberta
10 October 2021

Summary

On 10 October 2021, the privately registered Daher TBM700 N (registration C-FFYM, serial number 1190) was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers, after which 1 pilot and 3 passengers were on board. At 1102:26 Mountain Daylight Time, while the aircraft was landing on Runway 28 at Westlock Aerodrome, the aircraft bounced and the pilot initiated a go-around. During the application of engine power for the go-around, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side.

The 3 passengers exited the aircraft through the main cabin door with the assistance of persons nearby. One passenger received serious injuries, and the other 2 had minor injuries. The pilot, who was seriously injured, was trapped in the cockpit for approximately 2 hours before first responders could safely rescue him from the wreckage. An emergency locator transmitter signal was received by the search and rescue satellite system. The aircraft was significantly damaged and there was no post-impact fire.

1.0 Factual information

1.1 History of the flight

On 10 October 2021, the privately registered Daher TBM700 N (TBM 910) aircraft was conducting an instrument flight rules (IFR) flight from Vernon Airport (CYVK), British Columbia. The planned destination was Edmonton/Villeneuve Airport (CZVL), Alberta, with a brief intermediate stop at Calgary/Springbank Airport (CYBW), Alberta. The pilot and 1 passenger were on board for the first leg of the flight, and 2 additional passengers boarded at CYBW.

During the stopover at CYBW, the aircraft stopped at the end of an uncontrolled taxiway to pick up the 2 passengers. The pilot remained in the cockpit with the engine running and the propeller turning. Given that the aircraft was on an uncontrolled taxiway, there was no ramp safety supervision or marshallers present. There is no regulation precluding loading an aircraft in this manner.

The 2 passengers approached the aircraft and opened the main cabin door. They unloaded a bike before boarding the aircraft, and then they loaded their baggage primarily into the passenger compartment. The baggage was not secured.

The pilot then phoned a family member to report that he and the passengers would be arriving in an hour. One of the 3 passengers was seated in the mid-cabin, rear-facing seat on the right side of the aircraft, and only secured the lap belt. One passenger was seated in the aft cabin forward-facing seat on the left side of the aircraft, beside the main cabin door. This passenger secured both the lap belt and shoulder harness. The third passenger was seated in the aft cabin forward-facing seat on the right side of the aircraft and only secured the lap belt.

The passengers had routinely flown with the pilot on the occurrence aircraft and were familiar with boarding the aircraft, operating and locking the main cabin door, stowing baggage, and fastening safety harnesses.

The aircraft departed CYBW at 1013 on an IFR flight plan and proceeded to CZVL at 16 000 feet above sea level (ASL).

Thirty minutes into this leg of the flight, the pilot requested that the flight-planned destination be amended from CZVL to Westlock Aerodrome (CES4), Alberta, because weather conditions at that location met visual meteorological conditions, which would permit a visual flight rules (VFR) approach. At the time of the occurrence, CES4 did not have any instrument approach procedures. The Edmonton terminal controller approved the change, and the flight was cleared to proceed visually, direct to CES4.

The aircraft approached CES4 from the south (Figure 1), and at 1059:40, it crossed over the aerodrome mid-field at approximately 1250 feet above ground level (AGL) and 126 knots indicated airspeed (KIAS), configured with the landing gear extended and the flaps set to the take-off position (10°). The aircraft then banked right to join the mid-right downwind leg.

Image showing the occurrence approach to Westlock Aerodrome; the circled letters correspond to those in Figure 2 (Source: Google Earth, with TSB annotations)
Figure 1. Image showing the occurrence approach to Westlock Aerodrome; the circled letters correspond to those in Figure 2 (Source: Google Earth, with TSB annotations)

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