Communiqués

TSB #A03-2002

RELEASE OF TRANSPORTATION SAFETY BOARD REPORT A99Q0151
ACCIDENT OF A RÉGIONNAIR AIRCRAFT IN SEPT-ÎLES, QUEBEC,
ON 12 AUGUST 1999

(Gatineau, Quebec, xx March 2002) - The Transportation Safety Board of Canada (TSB) today released its report on the investigation of the crash of a Régionnair Inc. Beech 1900D on 12 August 1999 in Sept-Îles, Quebec. The TSB has identified safety deficiencies and is making two recommendations.

The aircraft was on a scheduled flight from Port-Menier, Quebec to Sept-Îles with two pilots and two passengers on board. It departed under instrument flight rules in controlled airspace. The take-off and en route portions of the flight were uneventful. An approach using solely the navigation guidance from the global positioning system (GPS) was planned. The Beech 1900D crashed one mile short of the runway while on approach to the Sept-Îles airport. The weather conditions were low cloud and fog, with a ceiling of 200 feet and visibility of one-quarter mile. A post-crash fire destroyed the wings, the engines, and the right mid-side of the fuselage. The captain was fatally injured, the first officer was seriously injured, and the two passengers sustained minor injuries.

In its investigation, the TSB found that some of the company's standard operating procedures were not followed; the aircraft was allowed to descend well below the published Canada Air Pilot minimum descent altitude; no visual contact with the ground was established; and a user-defined GPS approach was used contrary to regulations and safe practices.

A number of accidents occur during the approach and landing phase. From January 1994 to December 2001, the Board has investigated 24 such accidents where low visibilities and/or low ceilings likely contributed to the occurrence. These accidents resulted in 34 fatalities and 28 serious injuries, as well as loss of property and damage to the environment. Therefore, the need for additional restrictions related to instrument approaches in poor weather is pressing.

In September 1999, Transport Canada initiated regulatory action to implement new approach ban regulations based on visibility in the form of a notice of proposed amendment to the Canadian Aviation Regulations. These regulations should reduce the likelihood of accidents involving instrument approaches in low-visibility conditions. However, this process has been ongoing for two years now. Until these regulations are promulgated, there will continue to be inadequate defences against this risk. Consequently, accidents have continued to occur and will likely continue to occur. The Board therefore recommended that:

The Department of Transport expedite the approach ban regulations prohibiting pilots from conducting approaches in visibility conditions that are not adequate for the approach to be conducted safely. [A02-01]

The proposed approach ban addresses the visibility issue to a large extent, but it does not address the ceiling issue. Although regulations exist to prohibit pilots from descending below the applicable decision height / minimum descent altitude for their approach, these regulations are not enforceable. In recent years, the Board has investigated a number of accidents where the visibility was reasonable, but the ceiling was below the limits stated in Canada Air Pilot for the particular approach flown. Therefore, the Board recommended that:

The Department of Transport take immediate action to implement regulations restricting pilots from conducting approaches where the ceiling does not provide an adequate safety margin for the approach or landing. [A02-02]

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.