Map showing the occurrence aircraft’s take-off path, point of initial impact, and final resting position at Thunder Bay Airport (Source: Google Earth, with TSB annotations)

The Transportation Safety Board of Canada on February 2, 2023, released its investigation report (A21C0078) into the 2021 loss of control and collision with terrain of an aircraft at the Thunder Bay Airport, Ontario.

On the evening of August 16, 2021, TSB explains a Rockwell International Aero Commander 690B aircraft, operated by MAG Aerospace Canada Corp., was conducting a visual flight rules flight from Thunder Bay Airport, Ontario, to Dryden Regional Airport, Ontario, with only the pilot on board.

The aircraft began to takeoff on Runway 12, according to the TSB report, and shortly after rotation, it entered a left bank, continued to roll, and then struck the surface of Runway 07 in an inverted attitude. The pilot was fatally injured, and the aircraft was destroyed by the impact and post-impact fire.

The TSB investigation found that the pilot’s decision to conduct the rapid, low-level, climbing steep turn was likely influenced by an altered perception of risk from previous similar takeoffs that did not result in any adverse consequences. TSB explains its investigation also determined that if air traffic controllers engage in communications that may be perceived by pilots to encourage unusual flight manoeuvres, pilots may perceive this encouragement as a confirmation that the manoeuvres are acceptable to perform, increasing the risk of an accident.

Following the occurrence, TSB explains MAG Aerospace Canada suspended all flight operations to hold a company-wide Safety Stand-Down meeting to discuss safety policies, compliance with standard operating procedures and safe practices, and reiterate the company’s anonymous, non-punitive safety reporting program. The company also updated its crew resource management training materials, explains TSB, to include more information on managing stress and internal/external pressures as well as the normalization of deviance, which refers to the acceptance of unsafe practices.