Most Canadian pilots are unaware of the limitations of certain guidance systems that help them land their aircraft, the Transportation Safety Board said Tuesday in a report that examined the 2007 crash of a business jet in northern Nova Scotia.
The jet, carrying Tim Hortons co-founder Ron Joyce and seven other passengers, was en route from Hamilton to Joyce's private airstrip at Fox Harb'r Resort when it started its final approach in a gusty crosswind.
The plane landed two metres short of the runway, and the right landing gear plowed into a flower bed at 189 kilometres per hour and collapsed when it hit the edge of the pavement.
The jet's right wing slammed into the tarmac, and the aircraft skidded on its belly for 300 metres, veering off Runway 33 and bouncing over a number of earthen mounds before grinding to a halt near a row of luxury condos.
Joyce suffered two fractured vertebrae. The aircraft's first officer also injured his back. The captain and the other passengers suffered minor injuries.
The two pilots had limited experience flying the 14-passenger jet and were unaware that the visual, ground-based guidance system they were using wasn't suitable for the aircraft, the report said.
This is a common mistake made by pilots, the report said.
"Although most pilots are aware that different … systems are in use, they are not aware of what the limitations of those [systems] are," the report said.
"Many flight crews do not know which visual landing system is appropriate for their aircraft."
Indicators incorrectly calibrated
The system, known as a glide slope indicator, uses red and white signal lights to show approaching pilots when they are too high or too low when coming in for a landing.
The independent agency found that the indicators at the Fox Harb'r airstrip were calibrated for aircraft smaller than Joyce's gleaming jet, a Bombardier Global 5000.
Joyce had purchased it only a month earlier.
The pilots, who had flown to the resort many times before, chose an approach profile based on the smaller Bombardier Challenger, the report said.
Even though pilots should know the distance between the cockpit and the landing gear on final approach — the so-called eye-to-wheel height — that information is rarely available, the board said.
"No consideration had been given to the Global 5000's greater eye-to-wheel height and the implications of the larger aircraft flying the accustomed flight profile," the report said.
"It was determined that, in general, pilots are not aware of the [eye-to-wheel height] of the aircraft they operate .… Furthermore, the topic of EWH is rarely addressed in any type of pilot training."
To complicate matters, the captain tried to cope with the crosswind by using a complex manoeuvre that isn't recommended for the Global 5000, and he let the aircraft fall below the minimum altitude for a safe approach, the report said.
The board also found ineffective oversight of safety regulations was a key factor behind the crash.
'Critical oversight' lacking
Private aircraft operators regulated by the Canadian Business Aviation Association were not held to the same standard as commercial airlines regulated by Transport Canada, the report said.
The federal department transferred regulatory responsibility for some aviation operators to the private association in 2003, then failed to exercise effective oversight, the board said.
While Transport Canada requires commercial airlines to implement safety management systems on a fixed timeline, the association was not held to any deadlines, the board found.
"This is a serious problem," board member Kathy Fox said in a statement.
"Safety can be compromised when … deadlines are flexible, and critical oversight is lacking."
The safety board is recommending the association set "implementation milestones" and establish an audit system.
Patrick Charette, a Transport Canada spokesman, said the department will review the TSB report and respond within 90 days, as required.
He said Transport Canada has already addressed, or is addressing, some of the concerns expressed by the TSB in regards to the Canadian Business Aviation Association.
"This is a process," Charette said in an email. "As it unfolds, we make changes as required.
"We continue to work to make improvements in areas identified by the TSB, including in assuring quality in the CBAA's audit program."