The Transportation Safety Board of Canada says multiple factors contributed to a fatal plane crash near Fort Smith in January 2024.
A British Aerospace Jetstream 3212, which was operated by Northwestern Air Lease and headed to the Diavik diamond mine, crashed shortly after taking off from the Fort Smith Airport on the morning of January 23, 2024.
The two pilots and four of the passengers on board were killed. A fifth passenger, who was ejected from the plane during the accident, sustained injuries.
The safety board released its investigation report on the collision on Thursday.
According to the report, the captain maintained a low pitch attitude and higher airspeed during departure to shed snow that had possibly accumulated on the aircraft, which caused the plane to fly closer to the ground than during a standard departure.
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When the flight crew attempted to retract the landing gear, the report says a combination of low outside air temperature and increased air load prevented one main landing gear unit from fully retracting. It said the crew reduced engine power to decrease airspeed in order to complete retracting the gear, which inadvertently caused the plane to descend at 140 feet above ground level.
The safety board said as the pilots were likely focused on the airspeed and landing gear issue, they did not detect the loss of altitude until immediately before impact. The plane hit trees and then the ground 10 seconds after the descent began.
The safety board said its investigation further identified “some broader operational and organizational factors that could pose risks to flight safety.”
That included the lack of a clear explanation of the roles and responsibilities of flight crew during departure in the airline’s manuals. It said the company’s guidance for the plane had also not been updated to include steps pilots should perform if the landing gear was not locked in the “up” position when selected “up.”
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The board’s investigation further found that Northwestern Air Lease pilots who flew the Jetstream aircraft were “well aware” that, in certain circumstances, the plane’s main landing gear would not lock in the retracted position.
As the issue did not occur during every flight, the board said the company determined it was not a flight safety concern that warranted being entered in the aircraft’s technical records. The board said if pilots do not record issues in the aircraft’s technical records, maintenance staff may not address them.
Pilots had developed a workaround to make the main landing gear lock in the retracted position. As that workaround had previously worked consistently without issues, the board said it “reinforced the benign nature” of the landing gear problem.
If adaptations of standard operating procedures are normalized but not formally implemented, the board said “there is a risk that inconsistent interpretation of procedures between pilots could impair shared situational awareness and crew management effectiveness.”
The board said Northwestern Air Lease amended the standard operating procedures manual for the Jetstream series 3100 and 3200 aircraft in October 2024 to clarify how and when pilots should address abnormal and emergency situations during a flight.
The airline ended scheduled service and Jetstream operations in January 2025.
The surviving passenger as well as the families and estates of the passengers who were killed in the crash are currently suing Northwestern Air Lease for damages.
