On 15th July 2026, the Transportation Safety Board of Canada published their final report on the accident involving a Perimeter Aviation Fairchild SA227-DC Metro 23 (C GJVW) at Detour Lake Aerodrome, Ontario, on 7 September 2023.
After experiencing a pressurisation problem en route, the crew initially diverted towards Timmins but, after restoring manual pressurisation, decided to continue to Detour Lake. During the first RNAV approach, the aircraft became misaligned with the runway and a missed approach was flown.
On the second approach, conducted in poor weather with a significant crosswind, the aircraft became unstable, with descent rates of 1,000–2,000 ft/min and Ground Proximity Warning System alerts including “sink rate” and “pull up”.
While attempting to land, the captain inadvertently selected BETA mode (reverse thrust) before touchdown. This caused a loss of control. The aircraft rolled right, struck the runway with the right wing, collapsed the nose and right main landing gear, and departed the runway before coming to rest down an embankment approximately 47 m from the runway.
The aircraft was substantially damaged. Three passengers and one flight crew member sustained minor injuries.
Findings as to Causes and Contributing Factors
The crew's attention narrowed on the goal of landing at Detour Lake. High workload, operational pressures, proximity to destination, the previous missed approach, and challenging weather influenced their decision to continue the second approach despite signs it was unstable.
The captain expected to need aggressive braking because of the aircraft's speed and his training regarding gravel runways. Combined with high workload and the highly practised nature of selecting BETA mode, this led to reverse thrust being selected before touchdown. The premature selection of BETA mode caused a loss of control and impact with the runway.
Findings as to Risk
Stabilised approach criteria were not sufficiently specific, creating a risk that unstable approaches may not be recognised during high-workload situations. Passengers evacuated before receiving a crew command and could have entered a hazardous environment. Operators may fail to identify hazards if they do not conduct formal risk assessments following operational changes. Traditional hazard identification methods may miss complex, multi-dimensional hazards. Industry-wide pilot inexperience remains a growing risk that may not be adequately mitigated by current training and procedures.
Safety Actions
Following the accident, Perimeter Aviation implemented a range of safety improvements. They added a new Instrument Approach Policy requiring the published instrument approach to be programmed and flown regardless of weather conditions. Introduced mandatory re-briefing and Threat and Error Management (TEM) discussion after a missed approach before conducting another approach. Enhanced approach briefings to include landing distance available (LDA), TEM considerations and non-standard approach features. Revised stabilised approach procedures with standardised call-outs and mandatory stabilisation by 1,000 ft AAE in IMC.
They implemented an operational flight risk assessment tool for aerodromes served or being considered for service. Installed Garmin 750Xi avionics in Metro 23 aircraft, providing synthetic vision and flight-data monitoring capability.
They added stabilised approach training to recurrent training. Introduced six monthly Line-Oriented Flight Training (LOFT) scenarios. Created a command course for captain upgrades. Established recurring meetings focused on pilot recruitment, training progression, and upgrades.
A permanent Flight Operations Safety Officer role was created. Flight Data Monitoring (FDM) with unstable approach alerts and a Line Operations Safety Audit (LOSA) programme was introduced. They also implemented routine pilot route checks to monitor SOP compliance.
Engineering conducted a fleet-wide review of Emergency Locator Transmitter (ELT) installations and updated annual inspection procedures.
Photo source from the official TSB Report