Runway Excursion Highlights Importance of Safety Management Systems and Regulatory Surveillance

The Transportation Safety Board of Canada (TSB) has published its report A23Q0145 on a recent runway excursion incident involving an aircraft operated by Propair Inc. The Beech King Air A100, conducting a medical evacuation flight to Wemindji Airport in Quebec, experienced a lateral runway excursion when the propeller and left main landing gear struck a snow windrow during landing on the night of November 4, 2023.

The aircraft came to rest approximately 45 feet from the edge of the landing surface, with one member of the mission personnel receiving minor injuries. An investigation revealed that the runway had been cleared asymmetrically, leaving two snow windrows, one on each side of the runway.

The operator of the snow removal vehicle had not received training on winter maintenance plans or specific procedures for the airport. This lack of knowledge led to the reduced width of the runway not being reported, causing the crew to presume it was sufficiently cleared.

The previous flight's normal landing reinforced their mental model, and they failed to take action in response to actual conditions. The investigation also found that several components of the airport's safety management system had not been compliant with requirements since its implementation, potentially compromising its effectiveness and increasing operational and aviation safety risks.

These findings highlight the importance of effective safety management systems and regulatory surveillance in preventing such incidents. Despite the TSB issuing recommendations in 2016 regarding these issues, they remain active due to Transport Canada's responses still not addressing the Board's concerns.

Nearly a decade later, these two issues remain on the TSB Watchlist.