Pi­lots had no idea jet was too low un­til sec­onds be­fore Hal­i­fax crash: re­port

Cape Breton Post - - Province/ Atlantic -

As Air Canada Flight 624 made its fi­nal, ill-fated ap­proach to­ward Hal­i­fax’s main air­port in a raging bl­iz­zard, no one in the cock­pit was check­ing the plane’s alti­tude or dis­tance from the run­way.

The pi­lots had no idea the air­craft, car­ry­ing 133 pas­sen­gers and five crew, had strayed from its in­tended flight path and was fly­ing too low.

“It was only in the last few sec­onds of the flight, af­ter the pi­lots dis­en­gaged the au­topi­lot to land man­u­ally, that they then re­al­ized the air­craft was too low and too far back,’’ the Trans­porta­tion Safety Board of Canada con­cluded in a fi­nal in­ves­ti­ga­tion re­port re­leased Thurs­day, more than two years af­ter the crash land­ing.

The re­port cited sev­eral other fac­tors in the 2015 crash, in­clud­ing prob­lems with run­way light­ing and some­thing the board called “plan con­tin­u­a­tion bias.’’

And it de­scribed in grip­ping de­tail what hap­pened when the flight crew re­al­ized the air­craft was about to hit the ground.

The cap­tain poured on the thrust and pulled back on the stick to gain alti­tude for a goaround, but it was too late.

A sec­ond later, one of the jet’s tires hit an ap­proach light about 260 me­tres from the run­way thresh­old, and the air­craft clipped some power lines, knock­ing out power to the air­port. The jet’s main land­ing gear and left en­gine then struck a snow­bank and the Air­bus 320-211 smashed into an an­tenna ar­ray be­fore bounc­ing twice along the Run­way 05 for an­other 600 me­tres amid a

shower of sparks and leak­ing fuel.

The land­ing gear col­lapsed, an en­gine was torn off, but there was no fire.

The crash, de­scribed at the time as a “hard land­ing’’ by Air Canada, left 25 pas­sen­gers in­jured. The air­craft was de­stroyed.

“Be­cause no emer­gency was ex­pected, the pas­sen­gers and cabin crew were not in a brace po­si­tion at the time of the ini­tial im­pact,’’ the re­port says. “Most of the in­juries sus­tained by the pas­sen­gers were con­sis­tent with not adopt­ing a brace po­si­tion.’’

The board’s re­port says the air­craft,

en route from Toronto, was cir­cling the air­port just af­ter mid­night on March 29, 2015, when the crew re­ceived word from the tower that vis­i­bil­ity in the snow­storm had im­proved to just un­der one kilo­me­tre — the min­i­mum re­quire­ment for a land­ing.

As the plane ap­proached the air­port, it was placed in au­topi­lot mode. As well, the flight crew was re­ly­ing on the “lo­cal­izer’’ ra­dio beacon near the run­way, which pro­vides only lat­eral guid­ance to align the air­craft with the cen­tre line.

In this con­fig­u­ra­tion, the

au­topi­lot ad­justs the air­craft to main­tain its flight path ap­proach an­gle — in this case 3.5 de­grees — and the lo­cal­izer tells the pi­lots whether to steer left or right to keep in line with the run­way.

Nei­ther de­vice pro­vides in­for­ma­tion about alti­tude or dis­tance.

“What a lo­cal­izer does not pro­vide is ver­ti­cal guid­ance,’’ said se­nior in­ves­ti­ga­tor Doug McEwen. “That is up to the flight crew. They must re­fer to their in­stru­ments to en­sure they are at the cor­rect height rel­a­tive to the dis­tance from the run­way.’’

Kathy Fox, chair­woman of the TSB, said the pi­lots did not take into ac­count that a head­wind was push­ing the plane off of its in­tended flight path.

“Be­cause the wind was push­ing the air­plane back, it ended up be­ing lower and far­ther out,’’ she said. “They did not no­tice that they had moved away from where they needed to be.’’

Un­der Air Canada’s stan­dard op­er­at­ing pro­ce­dures, the cap­tain and first of­fi­cer were not re­quired to cross-check their alti­tude and dis­tance, which Fox de­scribed as a pro­ce­dural “gap’’ that has since been closed. Fox noted the flight crew op­er­at­ing man­u­als used by Air Canada and Air­bus do call for cross-check­ing of alti­tude and dis­tance.

“But) the pi­lots weren’t trained to do it,’’ she said in an in­ter­view. “It hap­pens. Some­times it takes some­thing like this to make peo­ple re­al­ize that there’s a gap.’’

The re­port said the pi­lots likely de­layed dis­con­nect­ing the au­topi­lot sys­tem be­cause of the chal­lenges they faced main­tain­ing the vis­ual cues from the air­port.

Air Canada has al­ready pro­vided its pi­lots with more guid­ance on vis­ual ref­er­ences, and it has is­sued ex­plicit warn­ings on the lim­i­ta­tions of the au­topi­lot sys­tem in a cer­tain mode. As well, Air Canada now re­quires in­stru­ment mon­i­tor­ing dur­ing all ap­proaches when be­low a cer­tain alti­tude, the TSB said.

In a state­ment re­leased Thurs­day, Air Canada con­firmed it has al­ready made many changes, in­clud­ing up­grades to some Air­bus air­craft, reach­ing out to other air­ports about im­prov­ing run­way light­ing, and re­view­ing emer­gency re­sponse plans.

CP PHOTO

The rear view of the air­craft on the run­way is shown in the day­time in this un­dated hand­out im­age pro­vided by Trans­porta­tion Safety Board of Canada. In its in­ves­ti­ga­tion re­port (A15H0002) re­leased Thurs­day, the Trans­porta­tion Safety Board of Canada (TSB) found that ap­proach pro­ce­dures, poor vis­i­bil­ity and air­field light­ing led to the 2015 col­li­sion with ter­rain of Air Canada Flight 624 at the Hal­i­fax/Stan­field In­ter­na­tional Air­port in Nova Sco­tia.

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