Aviation news release 2012

Deficiencies in training, operating procedures and company safety culture led to fatal Aéropro accident

Québec, Quebec, 15 August 2012 - Highlighting several causal factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (A10Q0098) into the crash of a Beech A100 King Air operated by Aéropro that killed 7 people on 23 June 2010 in Quebec City.

"We found numerous safety deficiencies in the areas of pilot training, company operating procedures, maintenance documentation and the company's safety culture," said André Turenne, Investigator-in-Charge. "And while inspections performed by Transport Canada (TC) revealed unsafe practices, the measures TC took to ensure compliance with regulations were not effective. As such, the unsafe practices continued."

The aircraft departed the Quebec City airport with a reduced engine power setting; a procedure established by the company but not endorsed by the manufacturer. As such, the aircraft's performance during the takeoff was lower than that established during the aircraft's type certification. Within seconds after takeoff, the crew reported a problem with the right engine and stated their intention to return to land. But because the right engine's propeller blades were not feathered (placed parallel to airflow after an engine failure), there was excessive aerodynamic drag, which compromised the aircraft's ability to climb or maintain level flight. The aircraft descended and struck the terrain at the end of the runway. The aircraft hit a berm and the 5 passengers and 2 crew members perished in the post-impact fire.

Deficiencies with the crew's training, the checklists and company procedures contributed to the accident. While training met regulatory requirements, it did not prepare the crew to effectively manage the emergency. The emergency checklist was designed for use by a single pilot and there were no written directives specifying who was to preform which task during two-pilot operations. The checklists were also the same for all the company's King Airs, despite equipment differences in the fleet. These deficiencies may have led to confusion and omissions by the crew during the emergency.

Since this accident, Transport Canada has made improvements to its surveillance program. These changes include updates to methods used for the surveillance planning process and the introduction of tools that provide an improved capacity for the monitoring and analysis of risk indicators within the aviation system.

"Air taxi companies operate in a challenging environment: serving smaller airports with less infrastructure and flying smaller aircraft equipped with less sophisticated navigation and warning systems, among other factors," added Turenne. "The risks posed by these challenges can be mitigated with a proactive and robust company safety culture."

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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca