Country
Crash of a De Havilland DHC-2 Beaver I in Lumby
Date & Time:
May 10, 2016 at 1030 LT
Operator:
Registration:
C-FMPV
Survivors:
Yes
MSN:
1304
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from a private airstrip in Lumby, the airplane suffered engine problems. The pilot elected to make an emergency landing when the aircraft crashed in a prairie located 300 feet from a house, bursting into flames. All three occupants evacuated with minor injuries and the aircraft was destroyed by a post crash fire. The pilot and both passengers were en route to the south of the province when the accident occurred.
Crash of a De Havilland DHC-2 Beaver near Les Bergeronnes: 6 killed
Date & Time:
Aug 23, 2015 at 1127 LT
Operator:
Registration:
C-FKRJ
Survivors:
No
Schedule:
Lac Long - Lac Long
MSN:
1210
YOM:
1958
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total hours on type:
4230.00
Aircraft flight hours:
25223
Circumstances:
The float-equipped de Havilland DHC-2 Mk. 1 Beaver (registration C-FKRJ, serial number 1210), operated by Air Saguenay (1980) inc., was on a visual flight rules sightseeing flight in the region of Tadoussac, Quebec. At 1104 Eastern Daylight Time, the aircraft took off from its base on Lac Long, Quebec, for a 20-minute flight, with 1 pilot and 5 passengers on board. At 1127, on the return trip, approximately 2.5 nautical miles north-northwest of its destination (7 nautical miles north of Tadoussac), the aircraft stalled in a steep turn. The aircraft descended vertically and struck a rocky outcrop. The aircraft was substantially damaged in the collision with the terrain and was destroyed by the post-impact fire. The 6 occupants received fatal injuries. No emergency locator transmitter signal was captured.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot performed manoeuvres with a reduced safety margin at low altitudes. As a result, these flights involved a level of risk that was unnecessary to attain the objectives of sightseeing flights.
2. With no restrictions on manoeuvres and no minimum altitude prescribed by the company prior to flight, the pilot flew according to his own limits and made a steep turn at approximately 110 feet above ground level.
3. When the pilot made a steep left turn, aerodynamic stalling ensued, causing an incipient spin at an altitude insufficient to allow control of the aircraft to be regained prior to vertical collision with the terrain.
4. The absence of an angle-of-attack indicator system and an impending stall warning device deprived the pilot of the last line of defence against loss of control of the aircraft.
Findings as to risk:
1. If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
2. If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, operators may not be able to proactively identify safety deficiencies before they cause an accident.
3. If pilots do not obtain at least the regulatory rest periods, there is a risk that flights will be conducted when pilots are fatigued.
4. Unless all flights made are recorded in the pilot’s logbook and monitored by the company, it is possible that the pilot will not receive the required rest periods, which increases the risk of flights being conducted when the pilot is fatigued.
5. If flights made are not recorded in the aircraft’s journey logbook, it is possible that inspection and maintenance schedules and component lifetimes will be exceeded, increasing the risk of failure.
6. Unless safety management systems are required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will not be able to identify and effectively mitigate the hazards involved in their operations.
7. If pilots do not receive stall training that demonstrates the aircraft’s actual behaviour in a steep turn under power, there is a high risk of loss of control.
Other findings:
1. The replacement of the ventral fin with Seafins on C-FKRJ was in compliance with the requirements of Kenmore Air Harbor Inc.’s supplemental type certificate.
2. The control wheel was in the left-hand position (pilot side) at the moment of impact.
3. Angle-of-attack indicator systems have been recognized as contributing to flight safety by improving pilot awareness of the stall margin at all times, thereby allowing pilots to react in order to prevent loss of control of the aircraft.
4. Stall warning systems have been recognized as a means of improving flight safety by providing a clear, unambiguous warning of an impending stall.
1. The pilot performed manoeuvres with a reduced safety margin at low altitudes. As a result, these flights involved a level of risk that was unnecessary to attain the objectives of sightseeing flights.
2. With no restrictions on manoeuvres and no minimum altitude prescribed by the company prior to flight, the pilot flew according to his own limits and made a steep turn at approximately 110 feet above ground level.
3. When the pilot made a steep left turn, aerodynamic stalling ensued, causing an incipient spin at an altitude insufficient to allow control of the aircraft to be regained prior to vertical collision with the terrain.
4. The absence of an angle-of-attack indicator system and an impending stall warning device deprived the pilot of the last line of defence against loss of control of the aircraft.
Findings as to risk:
1. If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
2. If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, operators may not be able to proactively identify safety deficiencies before they cause an accident.
3. If pilots do not obtain at least the regulatory rest periods, there is a risk that flights will be conducted when pilots are fatigued.
4. Unless all flights made are recorded in the pilot’s logbook and monitored by the company, it is possible that the pilot will not receive the required rest periods, which increases the risk of flights being conducted when the pilot is fatigued.
5. If flights made are not recorded in the aircraft’s journey logbook, it is possible that inspection and maintenance schedules and component lifetimes will be exceeded, increasing the risk of failure.
6. Unless safety management systems are required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will not be able to identify and effectively mitigate the hazards involved in their operations.
7. If pilots do not receive stall training that demonstrates the aircraft’s actual behaviour in a steep turn under power, there is a high risk of loss of control.
Other findings:
1. The replacement of the ventral fin with Seafins on C-FKRJ was in compliance with the requirements of Kenmore Air Harbor Inc.’s supplemental type certificate.
2. The control wheel was in the left-hand position (pilot side) at the moment of impact.
3. Angle-of-attack indicator systems have been recognized as contributing to flight safety by improving pilot awareness of the stall margin at all times, thereby allowing pilots to react in order to prevent loss of control of the aircraft.
4. Stall warning systems have been recognized as a means of improving flight safety by providing a clear, unambiguous warning of an impending stall.
Final Report:
Crash of a De Havilland DHC-2 Beaver near Barkárdal: 1 killed
Date & Time:
Aug 9, 2015 at 1445 LT
Operator:
Registration:
N610LC
Survivors:
Yes
Schedule:
Akureyri – Keflavik
MSN:
1446
YOM:
1960
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total hours on type:
250.00
Circumstances:
At 14:01 on August 9th, 2015, a pilot along with a friend, a contracted ferry flight pilot, planned to fly airplane N610LC, which is of the type De Havilland DHC-2 Beaver, under Visual Flight Rules (VFR) from Akureyri Airport to Keflavik Airport in Iceland. The purpose of the flight was to ferry the airplane from Akureyri to Minneapolis/St. Paul in the United States, where the airplane was to be sold. The airplane was initially flown in Eyjafjörður in a northernly direction from Akureyri, over Þelamörk and then towards and into the valley of Öxnadalur. The cloud ceiling was low and it was not possible to fly VFR flight over the heath/ridge of Öxnadalsheiði. The airplane was turned around in the head of the valley of Öxnadalur and flown towards the ridge of Staðartunguháls, where it was then flown towards the heath/ridge of Hörgárdalsheiði at the head of the valley of Hörgárdalur. In the valley of Hörgárdalur it became apparent that the cloud base was blocking off the heath/ridge of Hörgárdalsheiði, so the airplane was turned around again. The pilots then decided to fly around the peninsula of Tröllaskagi per their original backup plan, but when they reached the ridge of Staðartunguháls again the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur. A spontaneous decision was made by the pilots to fly into the valley of Barkárdalur. The valley of Barkárdalur is a long narrow valley with 3000 – 4500 feet high mountain ranges extending on either side. At the head of the valley of Barkárdalur there is a mountain passage at an elevation of approximately 3900 ft. About 45 minutes after takeoff the airplane crashed in the head of the valley of Barkárdalur at an elevation of 2260 feet. The pilot was severely injured and the ferry flight pilot was fatally injured in a post crash fire.
Probable cause:
Causes:
- According to the ITSB calculations the airplane was well over the maximum gross weight and the airplane’s performance was considerably degraded due to its overweight condition.
Weather
- VFR flight was executed, with the knowledge of IMC at the planned flight route across Tröllaskagi. The airplane was turned around before it entered IMC on two occasions and it crashed when the PF attempted to turn it around for the third time.
- Favorable weather on for the subsequent flight between Keflavik Airport and Greenland on August 10th may have motivated the pilots to fly the first leg of the flight in poor weather conditions on August 9th.
Terrain
- The pilots failed to take into account the geometry of the valley of Barkárdalur, namely its narrow width and the fast rising floor in the back of the valley.
Contributing factors:
CRM - Inadequate planning
- The W&B calculations performed by the PF prior to the flight were insufficient, as the airplane’s weight was well over the maximum gross weight of the airplane.
- The plan was to look for an opening (in the weather), first in the head of the valley of Öxnadalur, then the head of Hörgárdalur and finally in the head of Barkárdalur.
- The decision to fly into the valley of Barkárdalur was taken spontaneously, when flying out of the valley of Hörgárdalur and the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur.
CRM – Failed to conduct adequate briefing
- A failure of CRM occurred when the PNF did not inform the PF of the amount of fuel he added to the airplane prior to the flight.
Overconfidence
- The special ferry flight permit the pilots received for the ferry flight to Iceland in 2008 may have provided the pilots with a misleading assumption that such loading of the airplane in 2015 was also satisfactory.
Continuation bias
- The pilots were determined to continue with their plan to fly to Keflavik Airport, over the peninsula of Tröllaskagi, in spite of bad weather condition.
Loss of situational awareness
- The pilots were not actively managing the flight or staying ahead of the aircraft, taking into account various necessary factors including performance, weather and terrain.
- The airplane most likely incurred severe carburetor icing in Barkárdalur.
- According to the ITSB calculations the airplane was well over the maximum gross weight and the airplane’s performance was considerably degraded due to its overweight condition.
Weather
- VFR flight was executed, with the knowledge of IMC at the planned flight route across Tröllaskagi. The airplane was turned around before it entered IMC on two occasions and it crashed when the PF attempted to turn it around for the third time.
- Favorable weather on for the subsequent flight between Keflavik Airport and Greenland on August 10th may have motivated the pilots to fly the first leg of the flight in poor weather conditions on August 9th.
Terrain
- The pilots failed to take into account the geometry of the valley of Barkárdalur, namely its narrow width and the fast rising floor in the back of the valley.
Contributing factors:
CRM - Inadequate planning
- The W&B calculations performed by the PF prior to the flight were insufficient, as the airplane’s weight was well over the maximum gross weight of the airplane.
- The plan was to look for an opening (in the weather), first in the head of the valley of Öxnadalur, then the head of Hörgárdalur and finally in the head of Barkárdalur.
- The decision to fly into the valley of Barkárdalur was taken spontaneously, when flying out of the valley of Hörgárdalur and the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur.
CRM – Failed to conduct adequate briefing
- A failure of CRM occurred when the PNF did not inform the PF of the amount of fuel he added to the airplane prior to the flight.
Overconfidence
- The special ferry flight permit the pilots received for the ferry flight to Iceland in 2008 may have provided the pilots with a misleading assumption that such loading of the airplane in 2015 was also satisfactory.
Continuation bias
- The pilots were determined to continue with their plan to fly to Keflavik Airport, over the peninsula of Tröllaskagi, in spite of bad weather condition.
Loss of situational awareness
- The pilots were not actively managing the flight or staying ahead of the aircraft, taking into account various necessary factors including performance, weather and terrain.
- The airplane most likely incurred severe carburetor icing in Barkárdalur.
Final Report:
Crash of a De Havilland DHC-2 Beaver near Saint John Harbour
Date & Time:
Jul 11, 2014 at 1550 LT
Registration:
C-FFRL
Survivors:
Yes
Schedule:
St John Harbour - Sandspit
MSN:
482
YOM:
1953
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Saint John Harbour, the single engine aircraft went out of control and crashed on the shore of the Athlone Island, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all four occupants were injured.
Crash of a De Havilland DHC-2 Beaver near Kennedy Lake
Date & Time:
Jun 25, 2014 at 1425 LT
Operator:
Registration:
C-FHVT
Survivors:
Yes
Schedule:
Sudbury - Kennedy Lake
MSN:
284
YOM:
1952
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1000.00
Circumstances:
The Sudbury Aviation Limited float-equipped de Havilland DHC-2 Beaver aircraft (registration C-FHVT, serial number 284) was on approach to Kennedy Lake, Ontario, with the pilot and 2 passengers on board, when the aircraft rolled to the left prior to the flare. The pilot attempted to regain control of the aircraft by applying full right rudder and right aileron. The attempt was unsuccessful and the aircraft struck rising tree-covered terrain above the shoreline. The aircraft came to a stop on its right side and on a slope. The pilot and the passenger in the rear seat received minor injuries. The passenger in the right front seat was not injured. All were able to walk to the company fishing camp on the lake. There was no fire and the 406 megahertz emergency locator transmitter (ELT) was manually activated by one of the passengers. One of the operator's other aircraft, a Cessna 185, flew to the lake after C-FHVT became overdue. A search and rescue aircraft, responding to the ELT, also located the accident site. Radio contact between the Cessna 185 and the search and rescue aircraft confirmed that their assistance would not be required. The accident occurred at 1425 Eastern Daylight Time.
Probable cause:
Prior to touchdown in a northerly direction, the aircraft encountered a gusty westerly crosswind and the associated turbulence. This initiated an un-commanded yaw and left wing drop indicating an aerodynamic stall. The pilot was unsuccessful in recovering full control of the aircraft and it impacted rising terrain on the shore approximately 30 feet above the water surface.
Final Report:
Crash of a De Havilland DHC-2 Beaver I in Hesquiat Lake: 2 killed
Date & Time:
Aug 16, 2013 at 1023 LT
Operator:
Registration:
C-GPVB
Survivors:
Yes
Schedule:
Hesquiat Lake - Gold River
MSN:
871
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
At 1015 Pacific Daylight Time, the de Havilland DHC-2 (Beaver) floatplane (registration CGPVB, serial number 871), operated by Air Nootka Ltd., departed Hesquiat Lake, British Columbia, with the pilot and 5 passengers for Air Nootka Ltd.’s water aerodrome base near Gold River, British Columbia. Visibility at Hesquiat Lake was about 2 ½ nautical miles in rain, and the cloud ceiling was about 400 feet above lake and sea level. Approximately 3 nautical miles west of the lake, while over Hesquiat Peninsula, the aircraft struck a tree top at about 800 feet above sea level and crashed. Shortly after the aircraft came to rest, a post-crash fire developed. All 6 persons on board survived the impact, but the pilot and 1 passenger died shortly after. A brief 406 megahertz emergency locator transmitter signal was transmitted, and a search and rescue helicopter recovered the survivors at about 1600.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others.
2. The pilot and 1 passenger did not exit the aircraft before it was consumed in the postimpact fire.
3. Air Nootka did not have effective methods to monitor its pilots’ in-flight decision making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behavior or poor decision making such as occurred on this flight.
Findings as to risk:
1. If aircraft are not fitted with technology to reduce fuel leakage or to eliminate ignition sources, the risk of post-impact fire is increased.
2. If aircraft are not equipped with shoulder harnesses for all seating positions then there is an increased risk of injuries.
3. If aircraft are not equipped with some alternate means of escape such as push-out windows, then there is a risk that post-crash structural deformation will jam doors shut and restrict exit for the occupants.
4. If companies operating under self-dispatch do not monitor their operations, they risk not being able to identify unsafe practices that are a hazard to flight crew and passengers.
5. If flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
1. The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others.
2. The pilot and 1 passenger did not exit the aircraft before it was consumed in the postimpact fire.
3. Air Nootka did not have effective methods to monitor its pilots’ in-flight decision making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behavior or poor decision making such as occurred on this flight.
Findings as to risk:
1. If aircraft are not fitted with technology to reduce fuel leakage or to eliminate ignition sources, the risk of post-impact fire is increased.
2. If aircraft are not equipped with shoulder harnesses for all seating positions then there is an increased risk of injuries.
3. If aircraft are not equipped with some alternate means of escape such as push-out windows, then there is a risk that post-crash structural deformation will jam doors shut and restrict exit for the occupants.
4. If companies operating under self-dispatch do not monitor their operations, they risk not being able to identify unsafe practices that are a hazard to flight crew and passengers.
5. If flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Final Report:
