What happened
On a flight from Toronto-Lester B. Pearson International Airport to Toronto/Buttonville Municipal Airport, a Dassault Falcon 10, registration C-GRIS, was cleared for a contact approach to Runway 33. During the approach, the aircraft was flying at speeds exceeding both regulatory limits and company standard operating procedures.
As the aircraft transitioned through the final approach course, it overshot the runway centerline. The pilot attempted to correct this with a sharp right turn to realign with the runway heading. The aircraft touched down just beyond the threshold markings with a high rate of descent. Immediately following touchdown, the aircraft exited the runway to the right, traveling through the infield and across taxiway Bravo, where it struck a runway/taxiway identification sign. The aircraft eventually came to a stop in the infield near Runway 21/03. The aircraft sustained substantial damage, but there were no injuries to the two crew members and no fire occurred.
The investigation
The investigation focused on the flight dynamics and crew procedures leading up to the excursion. Investigators determined that the aircraft was mechanically sound and that neither weather conditions nor crew fatigue were contributing factors.
It was established that the aircraft was operated at excessive speeds for the short flight duration. This high speed, combined with the crew's lack of familiarity with this specific short route, left insufficient time to complete necessary checklists, briefings, and standard operating procedures. Furthermore, the investigation found that the approach was unstabilized, with the aircraft performing a bank exceeding 30 degrees during the correction maneuver.
Findings
- The crew conducted an unstabilized approach characterized by excessive airspeed.
- A lack of adherence to company standard operating procedures and crew resource management contributed to the event.
- The captain's decision to continue the landing was influenced by a potential lack of understanding regarding the instability of the flight path or a commitment to landing, despite receiving a missed approach call from the first officer and hearing two GPWS aural alerts.
- The first officer's use of non-standard wording and tone during the missed approach call failed to effectively prompt the captain to abort the landing.
- Loss of directional control occurred immediately upon touchdown, preventing effective use of braking or rudder steering on the grass surface.