Runway excursion Serious incident Pilatus PC-12/47E C-GIOX, Sunday 12 September 2021
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Date:Sunday 12 September 2021
Time:17:09
Type:Silhouette image of generic PC12 model; specific model in this crash may look slightly different    
Pilatus PC-12/47E
Owner/operator:Airmédic
Registration: C-GIOX
MSN: 1237
Year of manufacture:2010
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Sept-Îles Airport, QC (YZV/CYZV) -   Canada
Phase: Landing
Nature:Unknown
Departure airport:Québec City Jean Lesage International Airport, QC (YQB/CYQB)
Destination airport:Sept-Îles Airport, QC (YZV/CYZV)
Investigating agency: TSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The Airmédic Pilatus PC-12/47E aircraft (registration C-GIOX) was conducting flight AM237 under instrument flight rules from Québec/Jean Lesage International Airport, Quebec, to Sept-Îles Airport, Quebec, with only 2 crew members on board. During final approach for Runway 09 at Sept-Îles Airport, when the aircraft was 1.6 nautical miles from the runway threshold, it was flying at 242 knots indicated airspeed. The aircraft crossed the runway threshold at 200 feet above ground level, at 180 knots indicated airspeed (ground speed of 191 knots); its rate of descent was 2000 fpm, the landing gear was in transit and the flaps were in the fully retracted position.

At 17:09 Eastern Daylight Time, the aircraft landed approximately 2525 feet beyond the threshold of Runway 09, which was wet, at 159 knots indicated airspeed. Approximately 20 seconds later, the aircraft overran the runway at a ground speed of 57 knots and travelled approximately 590 feet in the grass before making a right turn around an approach light and returning to the runway. No one was injured. There was no damage to the aircraft.


Findings as to causes and contributing factors
1. During the occurrence flight, the captain, who was paired with a first officer with little experience on the Pilatus PC-12, decided to demonstrate a high-speed final approach, decelerating just before reaching the runway. As a result, the stabilized approach gate indicated in the standard operating procedures (1000 feet above ground level) was crossed in clean configuration at 236 knots indicated airspeed.
2. During the high-speed approach, the first officer had doubts that the aircraft could land successfully; however, due to the authority gradient, he deferred to the captain’s experience and did not feel comfortable making the actionable go-around call.
3. When the aircraft was approximately 1.7 nautical miles from the runway, flying at an airspeed of 238 knots indicated airspeed at 500 feet above ground level, it was no longer possible to decelerate and continue the descent to reach the runway threshold at 50 feet above ground level in a stabilized landing configuration at the landing reference speed of 95 knots indicated airspeed. However, perceiving that it was still possible to land within the first third of the runway, the captain continued with the approach.
4. When the aircraft was approximately 0.5 nautical miles from the runway at 500 feet above ground level, the captain was focused on conducting the landing within the first third of the runway, and insisted on the landing gear being extended even though the aircraft’s speed exceeded the maximum landing gear operating speed at the time. The first officer followed the order, and the landing gear was extended, which allowed the landing to continue.
5. The aircraft crossed the runway threshold at 200 feet above ground level at 180 knots indicated airspeed, with a rate of descent of 2000 fpm, the landing gear in transit and the flaps in the fully retracted position. Under such conditions, it was impossible to stop the aircraft on the wet runway. However, the captain continued the approach, influenced by plan continuation bias and focused on conducting the landing within the first third of the runway.
6. The aircraft landed on the runway approximately 2525 feet from the threshold at 159 knots indicated airspeed, i.e., a ground speed of 167 knots. Given that the excessive speed, combined with other factors, increased the landing distance, the aircraft overran the runway 21 seconds later, at a ground speed of 57 knots.

Accident investigation:
cover
  
Investigating agency: TSB
Report number: A21Q0087
Status: Investigation completed
Duration: 1 year and 8 months
Download report: Final report

Sources:

TSB

Revision history:

Date/timeContributorUpdates
06-Jun-2023 14:42 harro Added
06-Jun-2023 14:44 harro Updated

Corrections or additions? ... Edit this accident description

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