aThe release said not considering a combination of risks during a winter storm contributed to the crash of the flight carrying 16 people including 14 passengers and two crewmembers.
The plane attempted to land at around 8:30 p.m. on Runway No. 3 in winds gusting to 55 knots. The visibility was heavily reduced on the runway that has no centre-line lighting in Gander.
“Neither pilot had considered that the combination of landing at night, in reduced visibility, with a crosswind and blowing snow, on a runway with no centre-line lighting, was a hazard that may create additional risks,’’ the TSB release said.
In addition, the report said: “The crew also did not recognize that the gusty crosswind conditions had caused the aircraft to drift to the right during landing. The operator did not have defined crosswind limits that would have restricted the maximum crosswind allowed for takeoff and landing, nor was it required to do so. Rather, it relied on aircraft captains to determine their own personal limits for crosswind landings. If operators do not have defined crosswind limits, there is a risk that pilots may land in crosswinds that exceed their abilities, which could jeopardize the safety of flight.”
As the plane touched down offline, it veered to the right striking a snowbank that caused the landing gear to collapse. As the nose of the plane dipped, the propellers struck both the snow and the surface of the runway and sheared off the left-side propeller blades and three of the right-side blades separated from their mount.
A portion of a right-side blade went through the side of the plane that slid to a stop on the runway.
The 16 occupants were evacuated from the plane with three passengers sustaining minor injuries.
The TSB made several recommendations for the operator to enhance the safety of its passengers including having a safety management system in place to effectively manage risk.
Also, the TSB is seeking to implement mandatory operator CRM training designed to address interactions between crewmembers and fully prepare them to recognize and mitigate risks encountered during flights.