News release

In its investigation report (A16A0041) released today, the Transportation Safety Board of Canada found that the lack of consideration of a combination of risks during a winter storm contributed to the April 2016 landing accident at Gander International Airport, Newfoundland and Labrador.

On the evening of 20 April 2016, Air Canada Express flight 7804, operated by Exploits Valley Air Services (EVAS), departed Goose Bay International Airport, Newfoundland and Labrador, for Gander International Airport with 14 passengers and two crew members on board. The weather forecast for the time of arrival in Gander was wind gusting to 55 knots, reduced visibility, and heavy blowing snow. At 2130, the aircraft touched down right of the runway centreline and almost immediately veered to the right. The nose wheel struck a compacted snow windrow on the runway, causing the nose landing gear to collapse. As the aircraft's nose dropped, the propeller blades struck the snow and runway surface. Most of the propeller blades separated at the root, and a portion of a blade penetrated the cabin wall. The aircraft slid further down the runway before coming to a stop. Three passengers sustained minor injuries.

The investigation found that the blowing snow made it difficult to identify the runway centreline markings, and that the situation was exacerbated by the absence of centreline lighting and a possible visual illusion caused by the blowing snow. 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 centreline lighting, was a hazard that may create additional risks. 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 take-off 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.

While there is no requirement for this operator to have a safety management system, it did have a flight safety program. Safety management and oversight is on the TSB Watchlist. The TSB has repeatedly emphasized the advantages of a safety management system to allow companies to effectively manage risk and make operations safer.

The investigation also found that neither pilot had received crew resource management (CRM) training at EVAS, nor was it required by regulation. CRM training is specifically designed to address interactions between crew members and fully prepare them to recognize and mitigate risks encountered during flights. Transport Canada intends to move ahead with implementation of the outstanding TSB Recommendation A09-02 and impose a mandatory requirement for operator CRM training.

See the investigation page for more information.