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Accident description
Last updated: 20 October 2017
Status:Final
Date:Sunday 28 September 2014
Time:15:12
Type:Silhouette image of generic DHC6 model; specific model in this crash may look slightly different
de Havilland Canada DHC-6 Twin Otter 300
Operator:Air Labrador
Registration: C-GKSN
C/n / msn: 493
First flight: 1976-06-03 (38 years 4 months)
Crew:Fatalities: 0 / Occupants: 2
Passengers:Fatalities: 0 / Occupants: 17
Total:Fatalities: 0 / Occupants: 19
Airplane damage: Substantial
Airplane fate: Repaired
Location:La Tabatičre Airport, QC (ZLT) (   Canada)
Phase: Landing (LDG)
Nature:Domestic Non Scheduled Passenger
Departure airport:Lourdes-de-Blanc-Sablon Airport, QC (YBX/CYBX), Canada
Destination airport:La Tabatičre Airport, QC (ZLT), Canada
Flightnumber: 401
Narrative:
A DHC-6 Twin Otter airplane was damaged in a landing accident at La Tabatičre Airport, QC (ZLT) in Canada. No one was injured in the accident.
The flight departed at 14:37 under visual flight rules (VFR). The captain conducted the takeoff and, shortly after the aircraft became airborne, handed over the control to the FO. For the remainder of the flight, the FO was the pilot flying (PF), and the captain was the pilot not flying (PNF). At about 15:10, the FO conducted an approach briefing.
Ninety seconds later, the FO called for the initial landing checks to be completed and, 10 seconds after that, for the final landing checks to be completed. The flaps were at 20°, and the aircraft was configured for landing.
At 15:12:17, at an altitude of approximately 200 feet above ground level (agl), the captain asked the FO a non-operational question. About 10 seconds later, the radar altimeter annunciated 10 feet.
At 15:12:32, after floating for 6.3 seconds, the aircraft touched down about 750 feet from the threshold of runway 23, which is 1649 feet long. On touchdown, the captain took control of the aircraft, immediately selected reverse thrust, and applied the brakes. The captain determined that the aircraft could not be stopped before the end of the runway and initiated an aggressive left turn onto the taxiway.
During the turn, a tire hit a runway edge light, and the right propeller struck a runway identification sign before the aircraft came to a stop. Debris from the sign penetrated the fuselage just aft of the right cockpit door. As the aircraft was skidding, it came within 3 feet of sliding off the taxiway surface and going down a significant drop.
The crew shut down the aircraft and exited at the same time as the passengers.

Probable Cause:

Findings as to causes and contributing factors
1. The aircraft floated for 6.3 seconds over the runway and touched down about 750 feet from the threshold, which reduced the length of runway available for stopping.
2. The captain took control almost halfway down the runway with insufficient runway remaining in which to stop, requiring an aggressive left turn onto the taxiway that resulted in significant damage to the aircraft.

Findings as to risk
1. If pilots are not prepared to conduct a go-around on every approach, there is a risk that they will not be ready to react to a situation that requires a go-around.
2. If performance charts are not consulted, there is a risk that the required landing distance will be greater than the actual length of the runway.
3. If flight crews do not adhere to sterile flight deck procedures, they may be distracted during critical phases of flight, which could jeopardize the safety of flight.
4. If crew resource management training is not a regulatory requirement, it is less likely to be introduced by operators, and as a result their crew coordination may be less effective.
5. If crew resource management training is not provided, pilots may be unprepared to respond to situations that may jeopardize the safety of flight.
6. If pilots do not focus on the task at hand, there is a risk that they will not react to conditions that could affect the safety of flight.
7. If organizations do not use modern safety management practices, there is an increased risk that hazards will not be identified and mitigated.
8. If flight data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Other findings
1. The crew used 20° flaps for landing, which did not permit them to meet the calculated landing distance requirement of the Aircraft Flight Manual and the 10% factor required by regulation for landings on unprepared surfaces.

Accident investigation:
cover
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 year and 4 months
Accident number: A14Q0148
Download report: Final report

Classification:

Sources:
» CADORS


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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Lourdes-de-Blanc-Sablon Airport, QC to La Tabatičre Airport, QC as the crow flies is 141 km (88 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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