APRIL 27, 2015
EDMONTON, ALBERTA
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.