AVIATION INVESTIGATION REPORT.pdf

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AVIATION INVESTIGATION REPORT A11P0149 LOSS OF CONTROL AND COLLISION WITH GROUND NORTHERN THUNDERBIRD AIR INC. BEECHCRAFT KING AIR 100, C-GXRX VANCOUVER INTERNATIONAL AIRPORT RICHMOND, BRITISH COLUMBIA 27 OCTOBER 2011 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liabil
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    AVIATION INVESTIGATION REPORT   A11P0149 LOSS OF CONTROL AND COLLISION WITH GROUND NORTHERN THUNDERBIRD AIR INC. BEECHCRAFT KING AIR 100, C-GXRX VANCOUVER INTERNATIONAL AIRPORT RICHMOND, BRITISH COLUMBIA 27 OCTOBER 2011  The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Investigation Report Loss of Control and Collision with Ground Northern Thunderbird Air Inc. Beechcraft King Air 100, C-GXRX Vancouver International Airport Richmond, British Columbia 27 October 2011 Report Number A11P0149 Summary The Northern Thunderbird Air Incorporated Beechcraft King Air 100 (serial number B-36, registration C-GXRX) departed Vancouver International Airport for Kelowna, British Columbia, with 7 passengers and 2 pilots on board. About 15 minutes after take-off, the flight diverted back to Vancouver because of an oil leak. No emergency was declared. At 1611 Pacific Daylight Time, when the aircraft was about 300 feet above ground level and about 0.5 statute miles from the runway, it suddenly banked left and pitched nose-down. The aircraft collided with the ground and caught fire before coming to rest on a roadway just outside of the airport fence. Passersby helped to evacuate 6 passengers; fire and rescue personnel rescued the remaining passenger and the pilots. The aircraft was destroyed, and all of the passengers were seriously injured. Both pilots succumbed to their injuries in hospital. The aircraft’s emergency locator transmitter had been removed. Ce rapport est également disponible en français.    Table of Contents 1.0   Factual Information .................................................... 2   1.1   History of the Flight......................................................................................................... 2   1.1.1   Sequence of Events Before the Flight ............................................................................ 2   1.1.2   Accident Sequence ........................................................................................................... 2   1.2   Injuries to Persons ............................................................................................................ 4   1.3   Damage to Aircraft .......................................................................................................... 4   1.4   Other Damage .................................................................................................................. 5   1.5   Personnel Information ..................................................................................................... 5   1.6   Aircraft Information ........................................................................................................ 5   1.6.1   Aircraft ............................................................................................................................... 5   1.6.2   Airworthiness ................................................................................................................... 6   1.6.3   Raisbeck Modification ..................................................................................................... 6   1.6.4   Service Bulletins ............................................................................................................... 6   1.6.5   Transport Canada Service Difficulty Advisory ........................................................... 7   1.6.6   Weight and Balance ......................................................................................................... 7   1.7   Meteorological Information ............................................................................................ 8   1.8   Aids to Navigation ........................................................................................................... 8   1.9   Communications .............................................................................................................. 8   1.10   Aerodrome Information .................................................................................................. 8   1.11   Flight Recorders ............................................................................................................... 8   1.12   Wreckage and Impact Information ............................................................................... 9   1.13   Medical and Pathological Information ......................................................................... 9   1.14   Fire ..................................................................................................................................... 9   1.15   Survival Aspects ............................................................................................................. 10   1.16   Tests and Research ......................................................................................................... 10   1.16.1   Wreckage Examination ................................................................................................. 10   1.16.2   Acoustic Examinations .................................................................................................. 11   1.16.3   Engine Oil System (Pratt & Whitney PT6 series)....................................................... 12   1.16.4   Propeller Control System .............................................................................................. 12   1.16.5   Asymmetrical Thrust ..................................................................................................... 12   1.16.6   Single-engine Control .................................................................................................... 13   1.16.7   Aerodynamic Stall ......................................................................................................... 14   1.17   Organizational and Management Information .......................................................... 14   1.17.1   Company Flight Operations ......................................................................................... 14   1.17.2   Weight and Balance ....................................................................................................... 14   1.17.3   Standard Operating Procedures .................................................................................. 14   1.17.3.1   Pre-flight Inspections ................................................................................................. 14   1.17.3.2   Checklists ..................................................................................................................... 15   1.17.3.3   Stabilized Approaches ............................................................................................... 15   1.17.4   Flight Operations Training ........................................................................................... 15   1.17.5   Company Maintenance Practices ................................................................................. 16   1.17.6   Safety Management System.......................................................................................... 16   1.18   Additional Information ................................................................................................. 16   1.18.1   Previously Identified Post-crash Fire Issues .............................................................. 16      1.19   Useful or Effective Investigation Techniques ............................................................ 18   2.0   Analysis ...................................................................... 19   2.1   Engine Oil Leak .............................................................................................................. 19   2.2   Service Bulletin ............................................................................................................... 19   2.3   Northern Thunderbird Air Beechcraft King Air 100 Standard Operating Procedures .................................................................................................................................... 19   2.4   Diversion Choice ............................................................................................................ 20   2.5   Emergency/Non-emergency ........................................................................................ 21   2.6   Aircraft Configuration and Control Speeds ............................................................... 21   2.7   Passenger Safety ............................................................................................................. 21   2.8   Post-impact Fire ............................................................................................................. 21   2.9   Weight-and-balance Calculations ................................................................................ 22   3.0   Findings...................................................................... 23   3.1   Findings as to Causes and Contributing Factors ....................................................... 23   3.2   Findings as to Risk ......................................................................................................... 24   4.0   Safety Action ............................................................. 25   4.1   Safety Action Taken ....................................................................................................... 25   4.1.1   Northern Thunderbird Air Inc. .................................................................................... 25   4.1.2   Transport Canada .......................................................................................................... 25   4.2   Safety Concern ................................................................................................................ 25   4.2.1   Post- crash−fire Risk Reduction  .................................................................................... 25   5.0   Appendices ................................................................ 28   Appendix A: List of Transportation Safety Board Laboratory Reports .............................. 28   Appendix B: Final Flight Profile and Events ........................................................................... 29   Appendix C: Enlarged Diagram of Final Flight Path............................................................. 30   Appendix D: Weight-and-balance Calculations ..................................................................... 31   Table of Photos Photo 1.  Left-engine oil leak ..................................................................................................................... 2   Photo 2.  C-GXRX ........................................................................................................................................ 5   Photo 3. Oil reservoir cap, left engine ................................................................................................... 11   Photo 4.  Oil remaining, left engine ........................................................................................................ 11   Photo 5.  Oil cap hidden from normal view .......................................................................................... 16   Table of Figures Figure 1.  “Abnormal” checklist for low oil pressure (Source: Northern Thunderbird [NT] Air Quick Reference Handbook ) .......................................................................................................................... 3  
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