Blame Culture and Just Culture in Aviation Safety

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The Transportation Safety Board of Canada (TSB) has released a preliminary report into the recent accident involving an Endeavor Air CRJ-900LR aircraft at Toronto Pearson International Airport. The report outlines initial findings on the runway incident that occurred on 17 February 2025, where the MHI RJ Aviation Group. CL-600-2D24 aircraft (CRJ-900LR) (registration N932XJ, serial number 15194) was operating as Endeavor Air flight EDV4819 from Minneapolis-Saint Paul International/Wold-Chamberlain Airport (KMSP), Minnesota, United States, to Toronto/Lester B. Pearson International Airport (CYYZ), Ontario. During the landing on Runway 23, the aircraft impacted the runway, the right wing detached, and a fire ensued. The aircraft overturned and slid down the runway inverted, coming to rest near the intersection of Runway 23 and Runway 15L. Aircraft rescue and fire fighting responded, and All 80 occupants evacuated the aircraft, though 21 sustained injuries, including 2 serious cases.
Aircraft Information
The aircraft, manufactured by Bombardier Inc. in 2008, had accumulated 35,335 total airframe hours. It was powered by two CF34-8C5 engines. The maximum allowable take-off weight was 84,500 lbs. The aircraft was within weight and balance limits at landing.
Flight History
At 12471 on 17 February 2025, the MHI RJ Aviation Group. CL-600-2D24 aircraft (CRJ 900LR) operated by Endeavor Air (doing business as Delta Connection) departed Minneapolis-St. Paul International/Wold-Chamberlain Airport (KMSP), Minnesota, United States, on flight EDV4819, an instrument flight rules flight to Toronto/Lester B. Pearson International Airport (CYYZ), Ontario, with 2 flight crew members, 2 cabin crew members, and 76 passengers on board. The captain was seated in the left seat and was the pilot monitoring for the flight. The first officer was seated in the right seat and was the pilot flying (PF).
The flight was uneventful until the approach phase at CYYZ. The crew executed an instrument landing system approach to Runway 23 under gusty wind conditions. At approximately 500 feet AGL, the autopilot was disconnected. The approach speed was increased to account for gusts, but a high descent rate developed. Less than one second before touchdown, the aircraft was descending at approximately 1110 fpm. Upon touchdown, the right main landing gear collapsed, the right wing detached, and fuel ignited. The aircraft rolled to the right, became inverted, and slid to a stop.
Crew Information
The captain had 3570 total flight hours, including 764 on type, and was working his first flight in seven days. The first officer had 1422.3 total flight hours, with 418.7 on type. She was on day 5 of a 5-day work cycle. The flight attendants had 3 and 11 years of experience, respectively.
Weather
At the time of the occurrence, winds were from 270°T at 28 knots, gusting to 35 knots, with 6 SM visibility in blowing snow. The runway visual range on Runway 24L varied between 3000 and over 6000 feet. Temperature was −9 °C with a dew point of −14 °C.
Wreckage and Impact Information
The aircraft initially impacted 420 feet past the Runway 23 threshold. It came to rest inverted on Runway 15L, approximately 1800 feet from the threshold and 75 feet to the right of the runway edge. The right wing detached and slid approximately 215 feet further. The left wing was severely damaged but remained attached. Significant fire damage was noted on the right wing.
Landing Gear
The right main landing gear outboard side-stay fractured, leading to gear collapse. The right MLG and its components were recovered for further examination.
Flight Controls
The flaps and slats were fully deployed (flaps at 45° and slats at 25°). Control continuity was verified up to the severed locations, with no pre-existing faults found.
Engines
Both engines were free to rotate post-accident, and no abnormalities were detected. The auxiliary power unit was operating due to a deferred right engine generator.
Flight Recorders
The CVR and FDR were recovered and sent to the TSB Engineering Laboratory. Both captured data from the approach and impact sequence.
Emergency Response and Evacuation
The aircraft came to rest inverted; as a result, passengers were hanging upside down in their seats, suspended by their safety belts, and many of the carry-on baggage and other items ended up on the aircraft ceiling. Some passengers had difficulty releasing the buckles on their safety belts due to being inverted. Some of the injuries sustained by the passengers occurred when they unbuckled their safety belts and fell to the ceiling.
The investigation focuses on metallurgical analysis of the wing, landing gear certification, egress procedures, pilot training, and organizational factors, among others. The TSB is collaborating with several agencies and organizations.
The investigation is ongoing, examining flight crew actions, aircraft systems, environmental conditions, and emergency response. Further readings on the preliminary report may be found Here
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