08/03/2026
On 07 September 2023, the Fairchild SA227-DC Metro 23 (Metro 23) aircraft was being operated by Perimeter Aviation LP (Perimeter Aviation) as Bearskin Airlines flight 4330 (BLS 4330), on an instrument flight rules (IFR) flight from Toronto/Lester B. Pearson International Airport (CYYZ) to Detour Lake Aerodrome (CDT9), with a stop at North Bay Airport (CYYB) on the way.
The flight crew arrived at CYYZ at 0545 and began preparing for a planned 0630 departure to CYYB. Due to a minor administrative issue, the flight incurred a 49-minute delay at CYYZ.
The flight crew consisted of 2 members: the captain and the first officer. Seven passengers boarded the aircraft at CYYZ, and the first officer provided a safety briefing. The aircraft departed CYYZ at 0719 and arrived at CYYB at 0800, where an additional passenger boarded the aircraft. The first officer provided another safety briefing before the departure from CYYB.
For the flight from CYYB to CDT9, the captain was the pilot flying (PF) and occupied the left seat. The first officer was the pilot monitoring (PM) and occupied the right seat. The aircraft was not equipped with any automation features, such as an autopilot system or en route vertical navigation (VNAV); therefore, the flight crew flew the aircraft manually.
The aircraft departed CYYB at 0820 and was cleared direct to CDT9. At 0855, the Toronto Area Control Centre (ACC) cleared the flight out of high-level controlled airspace and provided a contact number for the flight crew to call to close the flight plan once the aircraft was on the ground at CDT9.
At 0901, when the aircraft was 46 nautical miles (NM) south of CDT9 and descending through approximately 16 000 feet above sea level (ASL), the cabin pressurization differential gauge indicated a loss of pressurization, and the CABIN ALTITUDE annunciator illuminated.
The passengers detected a change in pressurization in their ears and those passengers seated near the rear of the aircraft could also hear a squealing noise coming from the rear bulkhead.
The flight crew initiated an emergency descent and donned their oxygen masks. The aircraft levelled off at approximately 8900 feet ASL, and the flight crew removed their oxygen masks and then prepared to divert to Timmins (Victor M. Power) Airport (CYTS).
The flight crew began following the Emergency Descent and Cabin Low Pressure Malfunction checklists in the quick reference handbook (appendices A and B). The cabin pressurization controller was placed in manual mode and the pressurization began to return to normal, with the cabin differential increasing and the cabin altitude decreasing. The remaining items on the 2 checklists were not completed after this point. The captain briefed the first officer on the deviation from the standard operating procedures (SOPs) as required.
Using the aircraft’s satellite-based text-messaging device, the first officer contacted company operations to report that there had been a pressurization issue and that the flight was diverting to CYTS. Company operations acknowledged the text. The flight crew obtained updated weather for CYTS from the Toronto ACC because the automatic terminal information service (ATIS) was not operational.
After coordinating with Toronto ACC on diverting the flight, the minimum equipment list (MEL) was reviewed by the flight crew. The MEL indicated that the pressurization issue could be deferred if the cabin pressurization controller was maintained in the manual position.
At 0918, when the aircraft was 16 NM north of CYTS, the flight crew informed Toronto ACC that the pressurization issue was resolved and that they wished to continue to the original destination of CDT9. The first officer sent a text message to company operations providing an update on the situation. This text message was acknowledged. The captain informed the passengers that the aircraft would be landing at CDT9 as originally planned.
At 0922, wind information was obtained from the automated weather observation system (AWOS) based at CDT9, which indicated that winds were from 360° magnetic (M) at 15 knots, gusting to 20 knots.
Based on a 100° crosswind and the direction of the aircraft, the captain, as the PF, briefed the area navigation approach using the global navigation satellite system (RNAV [GNSS]) Y for Runway 10 approach via the DUGRO transition. The planned level of service was localizer performance with vertical guidance (LPV)
With this approach, there are 3 different segments and a 3.6° glide path, which is intercepted at a minimum of 2300 feet ASL at the final approach waypoint (FAWP). The approach then has a 15° right turn to the final approach segment, with a distance of 3.4 NM.
On final approach, a higher descent rate is required (based on a ground speed of 140 knots, and a descent rate of 890 fpm with no wind) to reach a minimum descent altitude of 250 feet above ground level (AGL).
After the captain completed the approach briefing, the first officer noticed the ground speed was low and realized that the flaps had remained in the quarter position after the emergency descent. The flaps were then fully retracted.
On the approach, when the flight crew obtained visual contact with the runway, they realized that the aircraft was not aligned with the runway centreline. The first officer called for a missed approach.
The captain actioned the call and then flew the published missed-approach procedure, which calls for the aircraft to continue straight ahead (on the runway heading) to 1400 feet ASL and then turn right to a waypoint to the south, with a published holding procedure at 2500 feet ASL.
In the early part of the missed approach, ground support at the aerodrome radioed the flight crew and asked if they would be returning for a 2nd approach. The flight crew responded in the affirmative.
The first officer completed the after-takeoff checklist. The captain decided to conduct a pilot monitored approach (PMA) because of the low ceiling (overcast at 300 feet). The first officer reactivated the RNAV (GNSS) Y RWY 10 approach using the DUGRO transition and re-briefed the approach. The flight crew did not complete the step in the SOPs that requires a PMA review. At this point, control of the aircraft was transferred to the first officer, who became the PF. The captain, who then became the PM, planned to take back control to land once the aircraft had reached the approach minima and the flight crew had obtained visual contact with the runway.
At 1004:26, when the aircraft was on the final segment of the 2nd approach (2.4 NM to 0.7 NM from the runway threshold), the rate of descent varied from 1000 to 2000 fpm and, simultaneously, a ground proximity warning system (GPWS) “sink rate” aural alert sounded. After receiving this alert, the PF reduced the aircraft’s rate of descent. The flight crew had briefed the approach speed, which was based on the landing weight. The planned approach speed was 140 knots indicated airspeed (KIAS), which would gradually be reduced to 115 KIAS to achieve the required landing reference speed (Vref) for touchdown.
At 1005:05, with the runway in sight, the captain took control of the aircraft and became the PF. He asked for flaps to be set to full. When the aircraft was 0.75 NM from the runway threshold, a “pull up” alert from the GPWS sounded. The aircraft’s descent rate was approximately 2000 fpm.
According to the AWOS, the winds at 1003 were from 340°M at 9 knots, gusting to 19 knots, with a variable direction from 300° to 360°.
At 1005:13, the aircraft was at 171 feet above the touchdown zone elevation (TDZE) and 0.5 NM from the runway threshold at a speed of approximately 150 KIAS.
At 1005:18, when the aircraft was at 98 feet above the TDZE, the flight data recorder (FDR) recorded a negative torque value, indicating that the engine was in reverse thrust (Appendix E). The first officer informed the captain that BETA was selected, which the captain acknowledged and, 1 second later, a positive torque value was recorded. A 2nd negative torque value was recorded on the right and left engines just before touchdown.
When the aircraft was at 11 feet above the TDZE, at 1005:25, the aircraft’s roll angle was recorded as 15.4° to the right, and the aircraft was in a nose-down attitude. As a result, the right wing impacted the runway (Figure 2), and the nose gear and right main landing gear collapsed. The right propeller was the 1st to contact the runway surface approximately 305 m (1000 feet) past the runway threshold.
The aircraft veered to the right (south) of the runway centreline, leaving the runway surface laterally and sliding down an embankment. The left main landing gear collapsed, and the aircraft came to rest in an upright position approximately 47 m (154 feet) from the runway, facing south-southwest on a heading of 210°M
While the flight crew was conducting the emergency shutdown, the passengers, of their own volition, began egressing the aircraft through the main cabin door and the over-wing exits. The engines were still operating at the time.
When the first officer opened the main cabin door and realized that the engines were still operating, he returned to the cockpit and pulled the engine start/stop buttons to shut down the engines. Both flight crew members then egressed. Aerodrome ground service personnel responded within several minutes of the occurrence and, at 1019, Agnico Eagle Mines Limited’s volunteer firefighters and medical personnel responded.
The emergency locator transmitter (ELT) did not activate.
At 1014, Perimeter Aviation contacted a NAV CANADA air traffic operations specialist who then informed Toronto ACC that the aircraft had impacted the runway.
The aircraft was substantially damaged. Three passengers and 1 flight crew member received minor injuries.
There were 2 flight crew members and 8 passengers on board.
Damage to aircraft:
The occurrence aircraft was substantially damaged during the accident sequence.
Neither the aircraft’s cabin nor cockpit was compromised. However, the fuselage’s underside was wrinkled and punctured at numerous places along its length, including the wing centre structure. The aircraft fuel tanks were damaged from the impact with loose rock off the side of the runway. The nose landing gear and the left main landing gear were completely detached, while the right main landing gear was displaced but remained attached.
Both propellers shed all composite blades and exhibited damage to each hub. Both engines received significant damage from ingesting runway surface material and propeller blade particles.
Captain - ATPL 2688 TT, 658 On type
First Officer - CPL 542.2 TT, 282.9 On type
The captain joined Perimeter Aviation in August 2022 as a first officer and completed upgrade training to become a captain on the Fairchild SA227 Metro 23 aircraft in March 2023.
The first officer joined Perimeter Aviation in April 2023 and completed initial training and a pilot proficiency check (PPC) on the Fairchild SA227 Metro 23 aircraft in April 2023.
When the captain and first officer were hired by Perimeter Aviation, they had no previous experience working for a Canadian Aviation Regulations (CARs) Subpart 703 (Air Taxi Operations) or Subpart 704 (Commuter Operations) operation. The flight crew held the appropriate licences and current medical certificates, in accordance with existing regulations.
Findings as to causes and contributing factors:
These are the factors that were found to have caused or contributed to the occurrence.
The proximity to the intended destination and the high workload experienced by the flight crew resulted in a narrowing of attention and, when combined with various operational pressures, influenced the flight crew’s decision to continue the 2nd approach and attempt to land.
The captain developed a strong expectancy for aggressive braking action based on his gravel runway training and on the aircraft’s speed. When this expectancy combined with the captain’s high workload and the reflexive nature of initiating BETA mode, he inadvertently engaged BETA mode before the aircraft had touched down, resulting in a loss of control and the aircraft impacting the runway.
Findings as to risk:
These are the factors in the occurrence that were found to pose a risk to the transportation system. These factors may or may not have been causal or contributing to the occurrence but could pose a risk in the future.
If stabilized instrument approach criteria are not specific with regards to how flight crews evaluate the stability of an approach, there is a risk that flight crews will not identify an approach as being unstable during this high-workload phase of flight.
If passengers do not wait for a command from the flight crew before evacuating an aircraft, they may exit into a hazardous situation where there is a possibility of injury.
If air operators do not consider potential hazards and complete a formal risk assessment when there are operational changes (e.g., a new non-standard approach or changes of equipment used), there is a possibility that a hazard may be overlooked and, as a result, its risk not mitigated.
If hazard identification processes are unable to recognize multi-dimensional hazards, there is a possibility that these complex hazards will not be identified, resulting in an incomplete understanding of the level of risk in an operation.
If the hazards related to crew inexperience are not better understood, operators may be unable to develop training and procedures to mitigate the risks of these hazards and crew experience will become a more frequent contributing factor to aviation accidents.
Safety action taken:
After the occurrence, Perimeter Aviation LP (Perimeter Aviation) made the following revisions to its standard operating procedures (SOPs) for the Fairchild SA227-DC Metro 23 (Metro 23):
Added an Instrument Approach Policy that states, “the appropriate Instrument Approach procedure shall be programmed into the aircraft’s navigation system and flown regardless of the weather conditions reported or observed at the destination aerodrome.”
Added direction on Multiple Approach Attempts that states that after a missed approach, the subsequent approach must be fully briefed again, including a threat and error management (TEM) discussion.
Amended the Instrument Approach Briefing section to include a requirement to brief on landing distance available (LDA), TEM, and non-standard approach elements.
Revised the Stabilized Approach Factors and Unstable Approach sections to include stable approach standard callouts and require the approach to be stabilized by 1000 feet above aerodrome elevation (AAE) in instrument meteorological conditions (IMC).
Perimeter Aviation has made the following system and process improvements:
An operational flight risk assessment tool has been implemented to support risk assessment of the aerodromes the company serves or is considering serving through charter or expansion.
Garmin 750Xi units have been installed on Metro 23 aircraft, supporting fleet commonality and synthetic vision for flight crews, and allowing aircraft to provide flight data monitoring (FDM) parameters.
Perimeter Aviation has made the following adjustments to its flight crew training:
Stabilized approach factors/criteria are now covered in the ground briefing done before the annual recurrent sessions for all flight crew members.
A line-oriented flight training (LOFT) scenario is now completed on a 6-month recurrence cycle for Metro 23 flight crew members.
A command course has been implemented for all flight crew upgrades, including upgrades made in the 12 months preceding the course creation.
Recurring meetings have been scheduled for hiring pilots, training progression, and potential upgrades of first officers.
Perimeter Aviation has made the following investments in oversight programs and initiatives:
Created a permanent flight operations safety officer position.
Implemented an FDM program, which includes ongoing monitoring and daily alerting for unstable approach criteria on its Dash 8 and Metro 23 fleet.
Implemented a line operations safety audit (LOSA).
Introduced a Pilot Performance Monitoring Policy where route checks are performed on a routine basis for SOP compliance and oversight.
Perimeter Aviation has taken the following action regarding aircraft maintenance:
Conducted a fleet campaign to ensure emergency locator transmitters (ELTs) were installed in accordance with manufacturer instructions.
Amended the applicable Annual Inspection Check Sheet.
