Incident Overview
Description
The DH-125 corporate jet crashed while executing a night time approach to runway 14 at Churchill Falls Airport, NL (ZUM). The crew radioed that they could see the strobe lights and visual approach slope indicator system (VASIS). This was the last transmission. On December 11 the aircraft was located two miles short of the threshold of the runway at Churchill Falls. The aircraft was destroyed on ground impact, the wreckage scattered along a trail of 300 feet, and the two crew members and six passengers all lost their lives. Although the accident occurred only two miles out of the extended centre line of the runway, the wreckage was not located for two days due to extreme weather conditions. It was subsequently determined that two survivors of the crash lived for one to two hours after impact. A searching helicopter had flown over the site within fifteen minutes of the crash with a receiver tuned to a distress frequency. The emergency locator transmitters had been removed from the aircraft pursuant to an Airworthiness Directive. The final investigation report of the accident was published by Transport Canada, without approval of the Aircraft Accident Review Board. The Board disagreed on the 6th finding, which was published reading “6) On the assumptions that there had been at least one serviceable ELT on board, that it had been activated as a result of the impact or by other means, and that there was the capability at Churchill Falls of homing to the point of origin of the ELT signal, the rescue activity may have been expedited.” This finding had been changed compared to the initial report, which read: “The removal of the aircraft’s emergency locator transmitters seriously delayed the search and rescue activity and may have caused unnecessary loss of life.” In a May 1981 report by the Commission of Inquiry on Aviation Safety, it was concluded that in this case senior management unilaterally overruled the Aviation Safety Bureau and the Aircraft Accident Review Board in order to remove the criticism of the regulatory authority contained in the original accident report. CONCLUSIONS: 1) Cockpit discipline was inadequate as the approach entered the final phase. 2) Distractions in the cockpit degraded crew performance. 3) The pilots deprived themselves of essential altitude information by not effectively monitoring the flight instruments during the final approach. 4) The Captain, by relying on visual cues from the runway environment lighting in conditions where those cues were degraded, became exposed to visual illusions. 5) The pilots permitted the aircraft to deviate below the safe approach profile until it struck the terrain. 6) The removal of the aircraft’s emergency locator transmitters seriously delayed the search and rescue activity and may have caused unnecessary loss of life.
Source of Information
https://publications.gc.ca/collections/collection_2017/bcp-pco/T52-58-1-1981-eng.pdfhttps://publications.gc.ca/collections/collection_2017/bcp-pco/T52-58-1-1981-eng.pdfPrimary Cause
Uncontrolled departure of the aircraft’s emergency locator transmitters, leading to a significant delay in the search and rescue operation and potentially contributing to the loss of life.Uncontrolled departure of the aircraft’s emergency locator transmitters, leading to a significant delay in the search and rescue operation and potentially contributing to the loss of life.Share on:
