Aviation news release 2012

The TSB releases report into the February 2011 risk of collision involving two aircraft south of Puvirnituq, Quebec

Gatineau, Quebec, 21 August 2012 - The Transportation Safety Board of Canada (TSB) today released its investigation report (A11Q0028) into the 7 February 2011, risk of collision between a DHC-8-314 and a DHC-8-102, both operated by Air Inuit ltd, near Puvirnituq, Quebec.

The DHC-8-314 was flying between Puvirnituq and La Grande-Rivière, Quebec, at flight level 220 (22,000 feet above sea level). The DHC-8-102 was flying in the opposite direction at flight level 230 (23,000 feet above sea level). Both were flying in accordance with instrument flight rules. Approximately 117 nautical miles south of Puvirnituq, the two aircraft received a traffic advisory, followed by a resolution advisory from the traffic alert and collision avoidance system (TCAS). Avoidance manoeuvres were performed, and the 2 aircraft passed each other with a separation of 1500 vertical feet and 0.8 horizontal miles. They both continued toward their respective destinations, where they landed without incident. No one was injured.

The investigation found that the crew of the DHC-8-102 used aircraft instrumentation improperly. The operator has since issued a “safety alert” prohibiting pilots from using the instrumentation in this way.

Deficiencies with the crew's training, the checklists and company procedures contributed to the accident. While training met regulatory requirements, it did not prepare the crew to effectively manage the emergency. The emergency checklist was designed for use by a single pilot and there were no written directives specifying who was to preform which task during two-pilot operations. The checklists were also the same for all the company's King Airs, despite equipment differences in the fleet. These deficiencies may have led to confusion and omissions by the crew during the emergency.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca