Incident Overview

Date: Thursday 16 December 2004
Aircraft Type: Shorts 360-300
Owner/operator: Air Cargo Carriers
Registration Number: N748CC
Location: Oshawa Municipal Airport, ON (YOO) – ÿ Canada
Phase of Flight: Landing
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 2
Component Affected: The aircraft’s flight control system, including the flaps, airspeed indicator, and control inputs. Specifically, the flap setting and airspeed were critical to the aircraft’s stability and descent control.The aircraft’s flight control system, including the flaps, airspeed indicator, and control inputs. Specifically, the flap setting and airspeed were critical to the aircraft’s stability and descent control.
Investigating Agency: TSBTSB
Category: Accident
A serious aviation incident occurred during a localizer approach on Toledo to Oshawa. The first officer experienced a significant difficulty maintaining the backcourse localizer, leading to a controlled go-around. The captain effectively regained control of the aircraft, resulting in a ground effect landing. The aircraft sustained damage due to a combination of factors including a miscalculated landing distance, inadequate airspeed and flap settings, and a failure to properly manage the aircraft’s descent. The incident highlights a critical error in procedure and a lack of sufficient situational awareness.A serious aviation incident occurred during a localizer approach on Toledo to Oshawa. The first officer experienced a significant difficulty maintaining the backcourse localizer, leading to a controlled go-around. The captain effectively regained control of the aircraft, resulting in a ground effect landing. The aircraft sustained damage due to a combination of factors including a miscalculated landing distance, inadequate airspeed and flap settings, and a failure to properly manage the aircraft’s descent. The incident highlights a critical error in procedure and a lack of sufficient situational awareness.

Description

The first officer was the pilot flying for the flight from Toledo to Oshawa. The crew were cleared for a localizer backcourse runway 30 approach. The flight crew members were given radar vectors and then cleared for the straight-in approach. During the approach, the first officer had difficulty maintaining the backcourse localizer, and the captain took control when the aircraft was 3 to 4 miles from touchdown. While descending on the approach, the flight crew selected 15ø of flap and maintained VREF + 10 knots, that is 110 knots indicated airspeed (KIAS). At approximately 440 feet above ground level, the flight crew observed the runway edge lights to the right of the aircraft. The captain realigned the aircraft to the runway centreline and continued the approach. The aircraft touched down approximately one-third of the way down the runway. After touchdown, the captain selected full reverse. He noted that the rate of deceleration was slower than expected and observed the end of the runway approaching. After 5 to 8 seconds of full-reverse application, he called for a go-around, and the power levers were advanced to maximum takeoff power. With little runway remaining and without referencing the airspeed indicator, the captain rotated to a takeoff attitude; the aircraft became airborne prior to the end of the runway. The captain attempted to fly the missed approach; however, after the aircraft flew past level terrain at the end of the runway, it descended and the tail struck the airport perimeter fence. The aircraft flew over a marshy area, the landing gear struck rising, hilly terrain, and the aircraft then struck a line of forestation, coming to an abrupt stop. The cockpit area was wedged between two cedar trees. FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS: “1. The crew planned and executed a landing on a runway that did not provide the required landing distance. 2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate. 3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed. 4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees. 5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.”

Primary Cause

The crew’s failure to accurately assess the landing distance and to properly utilize the Aircraft Flight Manual performance chart, specifically the flap-15 approach recommendation, contributed significantly to the incident. The incorrect flap setting and lack of sufficient airspeed resulted in a miscalculation of the required landing distance, leading to the go-around.The crew’s failure to accurately assess the landing distance and to properly utilize the Aircraft Flight Manual performance chart, specifically the flap-15 approach recommendation, contributed significantly to the incident. The incorrect flap setting and lack of sufficient airspeed resulted in a miscalculation of the required landing distance, leading to the go-around.

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