What happened
On a flight from Saint-Hubert to Saint-Georges, Quebec, a Beech B300, registration C-FMHD, attempted to land under challenging winter conditions. During an initial instrument approach to Runway 06, the crew determined the aircraft was too high and executed a missed approach. The crew then transitioned to a Runway 24 RNAV (GPS) approach.
During the second approach, the aircraft's trajectory was not stabilized. The crew descended below the minimum descent altitude (MDA) without establishing the necessary visual references. As the aircraft touched down over 2400 feet past the threshold, it began to drift left on the snow-covered surface. The left main landing gear and subsequently the nose wheel struck a snow bank left by a recent clearing operation. The pilot attempted to use full right rudder to correct the direction, but the aircraft departed the runway and came to rest in a ditch. There were no injuries to the two pilots or the passenger on board.
The investigation
The TSB examined the crew's decision-making, the runway conditions, and the company's safety protocols. The investigation established that the crew operated with outdated information regarding the runway width, believing it was 60 feet wide when it had actually been reduced to 36 feet due to snow banks. Furthermore, the aircraft's altimeters were set incorrectly, displaying an altitude 100 feet lower than the actual height.
Investigators found that the crew failed to follow standard operating procedures, including incomplete flight planning and inadequate approach briefings. The investigation also noted that the ground personnel did not intervene despite several risk indicators, such as heavy snow showers and low visibility.
Findings
- The aircraft's path was not stabilized during the final phase of the approach, leading to a leftward drift at touchdown.
- The collision with a snow bank caused the loss of directional control.
- The crew failed to utilize cockpit resource management (CRM) principles, resulting in poor coordination and a failure to assess the deteriorating weather.
- The pilots did not adhere to company landing limits or runway contamination limits.
- The crew's decision to descend below the MDA without visual references increased the risk of an accident.