The
Transportation Safety Board of Canada (TSB) released its
investigation report Thursday into the November 2017 loss
of control on landing involving an aircraft at Thompson Airport in
Manitoba, Canada.
On
Nov. 2, 2017, a Perimeter Aviation Fairchild Metro III (serial
number AC-756B, registration C-FLRY) was
operating on a ferry flight from Gods River Airport, Manitoba,
to Thompson Airport, Manitoba, to reposition the aircraft for
inspection and repair. As the aircraft neared the airport, the crew
advised air traffic control that they had received a low oil pressure
indication on the left engine. After consultation with maintenance,
the crew considered the risks associated with landing single engine
and without hydraulic pressure for the nose-wheel steering, and
decided to continue the flight with both engines running. After
touchdown, the aircraft suddenly veered to the right and exited the
runway. The aircraft was substantially damaged. The two crew members
received minor injuries.
The
investigation found that the low oil pressure indication was likely
the result of a steady oil leak past an air-oil seal in the left
engine. The loss of oil pressure thus resulted in a loss of propeller
control authority on landing and a runway excursion. The
investigation also found that the decision to continue the flight
with both engines running was not consistent with the quick reference
handbook procedures for low oil pressure indications.
The
aircraft was equipped with a cockpit voice recorder but was not
equipped with a flight data recorder, nor was one required by
regulation. The aircraft's integrated flight management system was
capable of capturing engine parameters, but it was not configured to
do so. If flight data, voice, and video recordings are not available
to an investigation, the identification and communication of safety
deficiencies to advance transportation safety may be precluded.
Following
the occurrence, the TSB issued an Aviation
Safety Advisory letter
suggesting that Transport Canada review the Fairchild Metro III
aircraft flight manual's emergency procedures for low engine oil
pressure indications. In addition, Perimeter Aviation installed
memory cards that store engine parameter data on its aircraft that
are equipped with an integrated flight management system. It has also
implemented crew resource management training for all of its air-taxi
and commuter flight crews.