Astra SPX Strikes Trees During Night Approach at Fox Harbour

Incident Overview and Aircraft Status On a night visual approach to the private aerodrome at Fox Harbour, Nova Scotia, an Israel Aircraft Industries Astra SPX, registration C-FRJZ, struck the tops of trees while on short final. The crew initiated an overshoot just before impact, allowing the aircraft to climb away successfully. The flight subsequently diverted to Charlottetown, Prince Edward Island, approximately 30 nautical miles from Fox Harbour, and completed an uneventful landing. The aircraft sustained substantial damage, but neither the passengers nor the crew were injured. The aircraft was relatively new and records indicated it had been maintained in accordance with regulations, with no pre-occurrence deficiencies identified. Although the aircraft was equipped with a flight management system capable of providing vertical guidance, the crew was not trained or sufficiently familiar with this capability to have confidence in its use for approaches. ## Aerodrome and Environmental Conditions Fox Harbour is a privately owned, uncertified, single-runway aerodrome that was unregistered at the time of the accident. The paved runway 33/15 measured 4,885 feet in length and 75 feet in width, equipped with runway edge lights. The runway elevation was approximately 50 feet above sea level. The approach end of Runway 33 had been cleared to a tree line approximately 1,150 feet from the threshold, with an average treetop height of about 60 feet along the approach path. No approach lighting or visual approach slope indicating system (VASIS) was installed. The weather for the arrival was good and consistent with official forecasts. The night was clear and starlit, with a 90% illuminated moon positioned 24 degrees above the horizon and almost directly behind the crew on approach to Runway 33. No visibility restrictions were present. The aerodrome is located on a peninsula along the Northumberland Strait shore in a sparsely settled area of relatively featureless terrain. Only the runway lights were clearly visible to the crew. These conditions were conducive to a black-hole illusion, a phenomenon where the lack of ambient clues to orientation interferes with depth perception, often causing pilots to overestimate their altitude and fly along a descending arc that results in premature contact with the ground. The crew was not aware of the black-hole illusion. ## Crew Experience and Operational Context The captain, who was also the operations manager, was flying the aircraft from the left seat. The co-pilot, who was also the chief pilot, was in the right seat and responsible for pilot-not-flying duties. The captain had flown into Fox Harbour twice before, but never at night. The co-pilot had landed there about ten times, but only once before at night, and that previous night flight was in a Learjet using Runway 15. The departure and en route portions of the flight to Fox Harbour were unremarkable until preparation for the descent. The owner had made it clear to this crew, and to other crews on previous occasions, that he expected arrivals and approaches to be flown in minimum time. The operating crew and other employees confirmed this pressure, and the aircrew therefore planned and conducted their operations accordingly. In preparation for the arrival and the approach to Fox Harbour, the crew inserted a series of waypoints in the flight management system to guide them for a straight-in approach and landing on Runway 33. ## Approach Execution and Safety Deficiencies The company standard operating procedures (SOPs) require that prior to each approach and landing, the flight crew shall be briefed on the critical aspects of the procedure. The company had not developed a formal arrival procedure into Fox Harbour, and an approach briefing was not conducted. It is probable that the good weather and the absence of a formal approach procedure for Fox Harbour contributed to this omission. The aerodrome information available to the crew for the approach was a hand-drawn sketch of the aerodrome layout, with the latitude and longitude coordinates noted. The crew could not obtain current runway condition or wind information because the VHF radio at the aerodrome was not staffed. Air traffic control radar data provided good information about the aircraft descent track, altitudes, and approach speeds. In general, the descent was flown at high speed on a track following the navigation waypoints programmed in the flight management system by the crew. Speed brakes were required to slow the aircraft during the descent. Example speeds show that the aircraft was at 340 knots indicated airspeed (KIAS) at 10,000 feet, 310 KIAS at 5,000 feet, and 250 KIAS at 1,000 feet. At 1,000 feet, the aircraft was levelled and decelerated to configure for approach and landing. About this time, there was a slight quartering tailwind component, estimated to be about six knots. Because the speed was high throughout the descent, flaps and landing gear selections were delayed and, consequently, not fully extended until about three miles from the runway. At this time, the co-pilot went heads down to ensure that all checklist items were complete and to confirm that the aircraft was properly configured to land. When he next looked up, he observed that the aircraft was low in relationship to the runway and advised the captain, who corrected by levelling the aircraft. The aircraft altitude was recorded on radar to be between 200 and 300 feet above sea level while tracking inbound to the airport. A short distance before the tree line, the aircraft began descending again. The co-pilot saw trees between the aircraft and the runway and called for an overshoot. The captain had begun the overshoot on the co-pilot's call; however, the action was not taken in time to avoid striking the trees. There were no SOP calls relating to altitude during the approach. The regular defences provided by complete aerodrome information, a comprehensive approach briefing, altitude call-outs, final approach monitoring, and adherence to SOPs were not present on this flight. Further, this was the crew's first night flight into Fox Harbour with this aircraft and their first night flight to this runway, and visual conditions were conducive to a black-hole illusion. Without previous experience or other information to alert them to the potential of a black-hole illusion on approach, the crew were not adequately prepared to operate in this higher risk environment. Consequently, the crew, in the absence of these defences, were unable to detect their proximity to the terrain until just before the aircraft struck the trees. The descent and the approach were flown in a manner to minimize flying time. This manner resulted in high descent and intermediate approach speeds and delayed the pre-landing checks and the configuration of the aircraft for landing. Consequently, the co-pilot's attention was diverted inside the cockpit when approach monitoring was required. During the overshoot, the crew reverted to their training for a normal go-around and elected to raise the landing gear and the flaps. Under normal operating circumstances, this decision would have been appropriate; however, the decision created additional risk to safety because of the potential for an asymmetric flap or landing gear malfunction due to the damage to control surfaces and the landing gear. The extent of the damage was unknown to the crew. The flight was conducted under CARs section 604, when CARs section 704 applied. Since the runway length at Fox Harbour was sufficient for the flight to operate under either section, this did not affect the outcome of the occurrence. However, the Board is concerned that the company was unaware of the regulatory requirement to operate under the appropriate regulation. ## Findings and Subsequent Changes Findings as to causes and contributing factors: Conditions conducive to black-hole illusion were present during the night approach to the runway. In this situation, the crew did not recognize the potential hazard of the black-hole illusion and therefore did not compensate for it. The crew did not adhere to the required standard operating procedures for the preparation and execution of the approach. Consequently, the crew were inadequately prepared for the visual conditions on final approach. Findings as to risk: The high descent and intermediate approach speeds caused cockpit pre-landing checks to be delayed. This delay resulted in the co-pilot's attention being diverted inside the cockpit when approach monitoring should have been done. The crew's decision to raise the landing gear and the flaps on the overshoot after hitting the trees increased the risk to the flight. Other findings: The company was unaware that its operations into Fox Harbour were not done in accordance with the regulations. The following changes have been made at Fox Harbour: The runway has been surveyed and centreline markings have been made in accordance with accepted standards. A PAPI (precision approach path indicator) has been installed at both ends of the runway, and the calibration is confirmed weekly. ARCAL (aircraft radio control of aerodrome lighting system) has been installed to control runway lighting and the PAPI. The trees on the Runway 33 approach have been cut back to comply with the approach standards set out by Transport Canada. A rotating beacon has been installed on the hangar and comes on when the ARCAL is activated. A global positioning system approach is being developed by Approach Navigations Systems Inc. and Transport Canada approval is expected in the near future. Standard operating procedures have been put in place for all company aircraft operating in and out of the Fox Harbour aerodrome. Fuel is available at Fox Harbour, facilitating lower aircraft landing weights. Transport Canada has written a number of articles in its newsletter Aviation Safety Letter (ASL) - delivered to every valid Canadian licenced pilot - on night flying and the effects of black-hole illusion: Understanding Night VFR and the CFIT Risk (ASL 2/99); Spatial Disorientation at Night (ASL 3/2000); Night VFR Part I - Do You See the Hazard? (ASL 4/2000); and Night VFR Part II - The Dark Side of Night Flying (ASL 2/2001). Additionally, as part of an ambitious night visual flight rules (VFR) awareness campaign, Transport Canada (TC) produced a night VFR awareness briefing package for use by the regional System Safety offices during safety awareness presentations. This package includes a new video titled Black-holes and Little Grey Cells - Spatial Disorientation During Night VFR (TP13838), a night VFR awareness poster titled Hazards of Night Flying (TP13717), a slide presentation, and a questionnaire for participants to complete during presentations. In November 2001, the video was added to TC's Web site as a new item available for purchase. The poster was reproduced in ASL 3/2001 and has been listed on TC's Web site since July 2001. All these products have been made to raise pilots' awareness so as to prevent similar occurrences. This report concludes the Transportation Safety Board's investigation into this occurrence.