Nine people were on board plane from Winnipeg to Nunavut when it overran runway in Sanikiluaq
Inclement weather, poor visibility, fatigue and a departure from established protocols all played factors in the crash-landing death of a six-month-old boy during a Perimeter Aviation flight 2½ years ago, investigators with the Transportation Safety Board (TSB) say.
At a news conference in Winnipeg Monday afternoon, TSB chair Kathy Fox explained the twin-engine turbo prop "came in too high, too steep, too fast" in its flight from Winnipeg to Sanikiluaq, Nunavut, three days before Christmas in 2012.
It was carrying seven passengers — plus a pilot and co-pilot — when it overran the runway in Sanikiluaq on its second landing attempt.
"The flight took off only for the flight crew to realize that they had forgotten the instrument procedure charts for approach and landing. Rather than return to the airport and extend the flight time even more, the captain instead radioed the company to obtain most of the required information," said Gayle Conners, who was in charge of the TSB investigation.
"By the time the captain tried to reject the landing, it was too late."
The plane came down hard, stopping about 200 metres past the end of the runway.
The child, Isaac Appaqaq, was thrown from his mother's lap and died of multiple injuries, Nunavut's chief coroner Padma Suramala stated a few days after the crash.
'Pressure to land'
Conners said the investigation revealed that stress and other issues affected decisions involved in making the landing.
"The crew began feeling a growing pressure to land. Crew communications started to break down. Stress, workload, frustration and fatigue combined to narrow their attention, and they shifted away from well-practised procedures," Conners said.
The eight other people on board suffered various injuries but none were life-threatening.
The TSB released two recommendations aimed at ensuring the safety of children and infants flying on commercial airliners.
"One: that commercial air carriers start routinely tracking and reporting data on the number of infants and children travelling," said Fox.
"And two, for the development and mandatory use of child-restraint systems so that infants and young children travelling on commercial aircraft will receive the same level of safety as adults."
Fox added that having more reliable information about the frequency and number of kids aboard flights will help inform efforts to make flying safer.
"What's needed is better data to conduct research to assess risks and to outline emerging trends related to the carriage of infants and children," said Fox.
She added Transport Canada and airlines are already aware of the risks and encourage families with kids or infants to travel using "an approved child-restraint system during flights."
"In the case of severe turbulence, a sudden deceleration or a crash such as this one, adults are not strong enough to adequately restrain an infant just by holding on," Fox said.
Following the release of the report, Canada's Transport Minister Lisa Raitt responded saying she expects the federal government will take a close look at the TSB's recommendations.
"Our thoughts and prayers continue to be with the victim's family," said Raitt. "We expect Transport Canada [will] review these recommendations on an expedited basis.
Sanikiluaq is an Inuit community of 850 residents, situated on the Belcher Islands in southeastern Hudson Bay.
Read more here: http://www.cbc.ca
Final Report: http://www.tsb.gc.ca
Low-energy rejected landing and collision with terrain
Perimeter Aviation LP
Fairchild SA227-AC Metro III,
C-GFWX
Sanikiluaq, Nunavut
22 December 2012
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