Accident Beechcraft A100 King Air C-GFFN, Sunday 7 January 2007
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Date:Sunday 7 January 2007
Time:20:02
Type:Silhouette image of generic BE10 model; specific model in this crash may look slightly different    
Beechcraft A100 King Air
Owner/operator:Transwest Air
Registration: C-GFFN
MSN: B-190
Year of manufacture:1974
Total airframe hrs:17066 hours
Engine model:Pratt & Whitney Canada PT6A-28
Fatalities:Fatalities: 1 / Occupants: 4
Other fatalities:0
Aircraft damage: Destroyed, written off
Category:Accident
Location:Sandy Bay Airport, SK -   Canada
Phase: Approach
Nature:Ambulance
Departure airport:La Ronge Airport, SK (YVC/CYVC)
Destination airport:Sandy Bay Airport, SK
Investigating agency: TSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Transwest Air Flight 350 (TW350), a Beechcraft A100 King Air, registration C-GFFN, departed La Ronge, Saskatchewan, at 19:30 under instrument flight rules to Sandy Bay, with two flight crew members and two emergency medical technicians aboard. At 19:48, air traffic control cleared TW350 out of controlled airspace via the Sandy Bay runway 05 non-directional beacon approach. The crew flew the approach straight-in to runway 05 and initiated a go-around from the landing flare. The aircraft did not maintain a positive rate of climb during the go-around and collided with trees just beyond the departure end of the runway. All four occupants survived the impact and evacuated the aircraft. The captain died of his injuries before rescuers arrived. Both emergency medical technicians were seriously injured, and the first officer received minor injuries. The aircraft sustained substantial damage from impact forces and was subsequently destroyed by a post-impact fire.

FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS:
1. The crew was unable to work effectively as a team to avoid, trap, or mitigate errors and safely manage the risks associated with flight TW350.
2. Transwest Air (TWA) managers had identified and addressed some crew pairing issues with respect to this crew, but were unaware of the degree to which these factors could impair their effective crew coordination.
3. The crew's lack of coordination was, in part, because they had not received recent crew resource management (CRM) training.
4. Contrary to company policy, the approach to Sandy Bay, Saskatchewan, was flown by the less experienced crew member.
5. The crew members did not assess the aircraft performance and did not identify runway length as a threat. Consequently, they did not discuss and agree on a point at which a safe landing was no longer possible and were unprepared to make and execute a timely go-around decision.
6. The first officer suggested a go-around at an appropriate time. However, inadequate preparation and coordination by the crew members resulted in the captain rejecting this suggestion and they continued the approach past the point at which the aircraft could be safely stopped on the runway.
7. The captain decided to initiate a go-around, but his communication of this decision to the first officer was non-standard and did not have the desired effect of triggering the correct sequence of go-around actions required.
8. The captain very likely took control of the aircraft from the first officer using the non-standard transfer of control practice the crew had developed, thereby causing confusion, which further eroded the limited opportunity to achieve a positive climb.
9. The discrepancy in the standard operating procedures (SOPs) describing the selection of flaps during go-around likely led to both pilots independently operating the flap control lever, distracting them from monitoring the climb performance during the go-around.
10. It is likely that a somatogravic illusion caused the pilot flying (PF) to lower the nose of the aircraft. Consequently, the aircraft did not maintain a positive rate of climb and collided with the trees.
11. Deficiencies in TWA's supervisory activities permitted the undetected development and persistence of substantial and widespread deviations from SOPs within the King Air operation.
12. The company management structure and workload, combined with the location of managers away from the remote bases of operations, reduced the effectiveness of operational control.

Accident investigation:
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Investigating agency: TSB
Report number: A07C0001
Status: Investigation completed
Duration: 2 years and 7 months
Download report: Final report

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