Pilot error may be to blame for upside-down Endeavor Air accident
March 21, 2025
The Transportation Safety Board of Canada (TSB) has issued a preliminary report into its investigation of the 17 February incident in which an Endeavor Air-operated aircraft flipped over onto its roof whilst landing at Toronto Pearson Airport. Although encountering a gust of “performance-increasing” wind during the descent (and accordingly pulling back the thrust), it appears the pilots did not increase power or pitch to address the situation; neither did the aircraft exhibit the expected 3-8 degrees of flare, instead coming in at just 1 degree nose-up.
The Bombardier CRJ-900 LR had been coming in to land on instruments on runway 23, descending through 500ft AGL at an airspeed of 150kts and a rate of descent of 720 fpm (feet per minute). After disengaging the autopilot, at a height of 50ft agl, the airspeed was 145kts and the rate of descent 1114 fpm. A second later, the enhanced ground proximity warning system (EGPWS) ‘sink rate’ alert sounded, indicating a high rate of descent, with the bank angle increasing to 4.7 degrees of right bank. Less than a second before touchdown, the rate of descent was recorded as 1110 fpm, with the aircraft in a 7.5 degree bank to the right at the point its right landing gear made contact with the runway.
The first officer, who had 418 hours on type (and 1422 hours total flight time) was in command at the time of the incident. The captain, who had about 3570 hours total flight time (including 764 on type) did not apparently increase the power or step in to mitigate the rate of descent.
At touchdown, the sidestay attached to the right main landing gear fractured, causing the gear to fold into the retracted position. The wing root fractured between the fuselage and the landing gear and the wing detached from the fuselage. “The exact sequence of these events is still to be determined by further examination of the fracture surfaces,” confirmed the TSB. As it slid along the runway, the fuselage rolled right until fully inverted, veering off the right side of the runway about 75 feet later on runway 15L. The right wing and main landing gear, having become fully detached from the body of the aircraft, slid around 215ft further along runway 23.
21 of the 80 occupants (comprising four crew and 76 passengers) were confirmed to have been injured, two reported to have sustained “serious injuries”. Some of these were sustained when passengers, hanging inverted in their seats, unbuckled their seat belts and fell to the ceiling. Deformation of the forward fuselage prevented the flight deck door from opening, necessitating the pilots to use the cockpit escape hatch on the cabin ceiling (now close to the ground).
Examination of the wreckage indicated the landing gear and tyres had been in serviceable condition, with no pre-existing damage found to flight control cables, or elevator and aileron control units and mechanisms. No abnormalities were found within the engines. No caution or warning messages pertaining to the flight controls were noted by the flight data recorder data.
The right wing, sections of the left wing, and the wing box structure (to which the wings are attached) will now undergo further examination at the TSB Engineering Laboratory. Further analysis will also be performed on the emergency locator transmitter (which did not activate during the accident sequence) and its applicable components. The cause of an explosion, occurring “outside of the aircraft in the area of the left wing root” shortly after the evacuation of occupants and the ingress of ARFF personnel, has also yet to be determined.
An ongoing investigation is expected to take around a year, with further areas of focus to include “landing techniques, hard landings, and pilot training”. Evacuation procedures, cabin obstructions and impediments once inverted, the flight deck secondary egress route, flight deck door structure and design, and emergency coordination will also be subject to assessment.
