Accident Dornier 228-202 C-FYEV,

ASN Wikibase Occurrence # 321598

Date:	Saturday 13 December 2008
Time:	01:43
Type:	Dornier 228-202
Owner/operator:	Summit Air Charters
Registration:	C-FYEV
MSN:	8133
Year of manufacture:	1987
Engine model:	Garrett TPE331-5-252D
Fatalities:	Fatalities: 0 / Occupants: 14
Aircraft damage:	Substantial, written off
Category:	Accident
Location:	2,5 km SE of Cambridge Bay Airport, NU (YCB) - Canada
Phase:	Landing
Nature:	Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:	Resolute Airport, NU (YRB/CYRB)
Destination airport:	Cambridge Bay Airport, NU (YCB/CYCB)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Dornier 228 with 14 people on board operated by Summit Air Charters, was on approach at Cambridge Bay (YCB) after a flight from Resolute Bay (YRB) when the aircraft collided with terrain about 2,5 km short of the runway. One flight crew member and one passenger received minor injuries.
The aircraft departed Resolute Bay with 12 passengers on December 12 at 23:45. The aircraft cruised en route to Cambridge Bay at flight level 100, with the crew using a global positioning system (GPS) as the primary navigation aid.
At 01:17 the captain briefed the first officer that they would proceed direct to the LEXUP waypoint and conduct a straight-in visual approach to Runway 31 True. At 01:34, 16 nm from Cambridge Bay, the crew contacted Cambridge Bay Airport Radio with a position report and estimated time of arrival of five minutes. Airport Radio advised that there was no reported traffic, the wind was at 300° True (T) at 15 knots gusting to 20.
At 01:38, five nm north of LEXUP, the aircraft descended out of cloud to 2100 feet asl. Ground features of dark rocks against white snow were intermittently visible to the crew. A descent was then begun to 1200 feet asl. At one nm from LEXUP, the landing gear was selected down, and pre-landing checks were commenced by the first officer.
Shortly after crossing LEXUP, the captain noticed that the GPS equipment had not automatically sequenced to the missed approach waypoint at the threshold of Runway 31 True. While the first officer reprogrammed the GPS for a direct course to the threshold, the aircraft proceeded southbound on a track approximately 90° to the inbound course to the runway. The GPS indicated the direct course to the runway threshold of 319°T, or 11° greater than the published approach final approach course (308°T). At about 1.3 nm south of the extended runway centre-line, a right turn was commenced, and the aircraft was directed toward the diffused lights from the settlement of Cambridge Bay on a track varying between about 332°T and 020°T. A descent of 400 to 500 feet per minute was initiated at this time. The last available radar altitude data at 0140:53 indicated 810 feet asl when the aircraft was 5.8 nm from the threshold. At 0141:30, the radar altitude 500-foot alert activated, and the first officer brought this to the attention of the captain. There was no further reference made by either crew member in regard to actual or published approach altitudes, and neither pilot monitored the aircrafts altimeters during the remainder of the approach.
The aircraft crossed the extended runway centreline for the second time, 2.8 nm from the runway threshold; at 2.1 nm, a left turn was made toward the runway centreline. When the runway lead-in strobe lights became dimly visible, the captain turned toward the runway. The precision approach path indicator system (PAPI), positioned on the left side of the runway, 1000 feet from the threshold, was not visible to the crew. Due to reflected glare from falling and blowing snow, the captain requested that the aircrafts landing lights be turned off, and confirmed with Cambridge Bay Airport Radio that the runway lights were at maximum illumination level. A maximum of two runway lights were visible to the captain. Fifteen seconds before ground impact, the propellers were set to SPEEDS HIGH and flaps were set to FLAPS 1. The aircraft contacted the ground in a shallow descent with wings level, on a track of 310°T. It came to rest on flat, snow-covered terrain near the extended runway centreline, 542 feet from the initial point of contact at 70 feet asl.
The occupants evacuated the aircraft immediately through the main cabin door and the emergency window exits. After an evaluation of the state of the aircraft, the crew and passengers re-entered the cabin to reduce exposure to the elements. The crew notified Cambridge Bay Airport Radio of the occurrence and ground rescue personnel found the site within 30 minutes utilizing snow machines. The pilots illuminated the aircrafts landing lights occasionally to help the rescue team find the aircraft.

FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS:
1. An abbreviated visual approach was conducted at night in instrument meteorological conditions, which resulted in the flight crews inability to obtain sufficient visual reference to judge their height above the ground.
2. The flight crew did not monitor pressure altimeter readings or reference the minimum altitude requirements in relation to aircraft position on the approach, resulting in controlled flight into terrain.
3. The pilots had not received training and performance checks for the installed global positioning system (GPS) equipment, and were not fully competent in its use.
4. The attempts at adjusting the settings likely distracted the pilots from maintaining the required track and ground clearance during the final approach.

Accident investigation: