Montreal-Pierre-Elliott Trudeau (ex Dorval)

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Grumman G-159 Gulfstream I

Schedule:

Montreal - Bromont

MSN:

256006

YOM:

1973

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5000

Captain / Total hours on type:

550.00

Copilot / Total flying hours:

1700

Copilot / Total hours on type:

100

Circumstances:

The aircraft, operated by Scott Aviation, with two crew members and four passengers on board, took off from Montréal, Quebec, at 1756 eastern standard time, for a night instrument flight rules flight to Bromont, Quebec. Upon approaching Bromont, the co-pilot activated the lighting system and contacted the approach UNICOM (private advisory service). The flight crew was advised that the runway edge lights were out of order. However, the approach lights and the visual approach slope indicator did turn on. The flight crew executed the approach, and the aircraft touched down at 1818 eastern standard time, 300 feet to the left of Runway 05L and 1800 feet beyond the threshold. It continued on its course for a distance of approximately 1800 feet before coming to a stop in a ditch. The crew tried to stop the engines, but the left engine did not stop. The co-pilot entered the cabin to direct the evacuation. One of the passengers tried to open the emergency exit door, but was unsuccessful. All of the aircraft’s occupants exited through the main entrance door. Both pilots and one passenger sustained serious injuries, and the three remaining passengers received minor injuries. The aircraft suffered major damage.

Probable cause:

Findings as to Causes and Contributing Factors:
1. The flight crew attempted a night landing in the absence of runway edge lights. The aircraft touched down 300 feet to the left of Runway 05L and 1800 feet beyond the threshold.
2. The runway was not closed for night use despite the absence of runway edge lights. Nothing required it to be closed.
3. Poor flight planning, non-compliance with regulations and standard operating procedures (SOPs), and the lack of communications between the two pilots reveal a lack of airmanship on the part of the crew, which contributed to the accident.
Findings as to Risk:
1. Because they had not been given a safety briefing, the passengers were not familiar with the use of the main door or the emergency exit, which could have delayed the evacuation, with serious consequences.
2. The armrest of the side seat had not been removed as required and was blocking access to the emergency exit, which could have delayed the evacuation, with serious consequences.
3. Because they had not been given a safety briefing, the passengers seated in the side seats did not know that they should have worn shoulder straps and did not wear them, so they were not properly protected.
4. The possibility of flying to an airport that does not meet the standards for night use gives pilots the opportunity to attempt to land there, which in itself increases the risk of an accident.
5. The landing performance diagrams and the chart used to determine the landing distance did not enable the flight crew to ensure that the runway was long enough for a safe landing on a snow-covered surface.

Final Report:

Crash of a Grumman G-159 Gulfstream I in Montreal

Date & Time: Jul 27, 2000 at 2350 LT

Type of aircraft:

Operator:

Airwave Transport

Registration:

C-GPTG

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Montreal-Pierre-Elliott Trudeau (ex Dorval)

Schedule:

Toronto - Montreal

MSN:

189

YOM:

1968

Location:

Quebec

Country:

Canada

Region:

Grumman G-159 Gulfstream I

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Airwave flight 9806, a G-159 Gulfstream I, was flying IFR from Toronto (YYZ) to Montreal-Dorval (YUL). When it was on final for runway 06R, the pilot reported a problem with the landing gear. The crew recycled the gear and performed the emergency extension procedure unsuccessfully before trying various flight manoeuvres to free the gear. They then circled Montreal until minimum fuel was reached, declared an emergency and landed. On landing, the aircraft veered to the left and came to a halt 60 feet from the runway. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Probable cause:

Preliminary investigation revealed that an apprentice AME moved a line in the landing gear well prior to the flight. The work was neither scheduled nor required. The apprentice left the work unfinished when he went to do something else, then forgot that a fastener was not in place. There was no flag or note to inform the other technicians or the crew that the aircraft was not in an airworthy state. The apprentice has two years experience with this company. The management was satisfied with the quality of his work. Two other licensed AMEs were working in the hangar with the apprentice. He was the only apprentice they had to supervise. The apprentice attended a type training course for this aircraft.

Crash of a Grumman G-159 Gulfstream I in Linneus: 2 killed

Date & Time: Jul 19, 2000 at 0031 LT

Type of aircraft:

Operator:

Airwave Transport

Registration:

C-GNAK

Flight Phase:

Flight

Flight Type:

Postal (mail)

Survivors:

Site:

Plain, Valley

Schedule:

Moncton - Montreal

MSN:

154

YOM:

1965

Flight number:

AWV9807

Location:

Linneus

Maine

Country:

United States of America

Region:

Swearingen SA226 Metro II

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6000

Captain / Total hours on type:

500.00

Copilot / Total flying hours:

600

Copilot / Total hours on type:

300

Aircraft flight hours:

22050

Aircraft flight cycles:

15452

Circumstances:

The airplane was in cruise flight at 16,000 feet, in instrument meteorological conditions. About two minutes after the crew ceased cross-feeding due to a fuel imbalance, the left engine experienced a total loss of power. About one minute later, the co-pilot indicated to the pilot-in-command (PIC) that the airplane was losing airspeed, and about 15 seconds later, the co-pilot remarked "keep it up, keep it up." Shortly thereafter, the airplane departed controlled flight and impacted terrain. The airplane was destroyed by fire and impact forces. Examination of the left engine revealed no evidence of any pre-impact failures that would have accounted for an uncommanded in-flight shut-down. A SIGMET for potential severe clear icing was effective for airplane's flight path; however, the flight crew did not report or discuss any weather related problems around the time of the accident. At the time of the accident, the airplane was above its single-engine service ceiling. The PIC had accumulated approximately 6,000 hours of total flight experience, of which, about 500 hours were as PIC in make and model. The co-pilot had approximately 600 hours of total fight experience, of which, 300 hours were in make and model.

Probable cause:

The pilot-in-command's failure to maintain minimum control airspeed, which resulted in a loss of control. Factors in this accident were clouds, and a loss of engine power for undetermined reasons, while in cruise flight above the airplane's single engine service ceiling.

Final Report:

Crash of a Swearingen SA226AC Metro II in Montreal: 11 killed

Date & Time: Jun 18, 1998 at 0728 LT

Type of aircraft:

Operator:

Registration:

C-GQAL

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Beechcraft 200 Super King Air

Schedule:

Montreal - Peterborough

MSN:

TC-233

YOM:

1977

Flight number:

PRO420

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6515

Captain / Total hours on type:

4200.00

Copilot / Total flying hours:

2730

Copilot / Total hours on type:

Aircraft flight hours:

28931

Circumstances:

On the morning of 18 June 1998, Propair 420, a Fairchild-Swearingen Metro II (SA226-TC), C-GQAL, took off for an instrument flight rules flight from Dorval, Quebec, to Peterborough, Ontario. The aircraft took off from Runway 24 left (L) at 0701 eastern daylight time. During the ground acceleration phase, the aircraft was pulling to the left of the runway centreline, and the right rudder was required to maintain take-off alignment. Two minutes later, Propair 420 was cleared to climb to 16 000 feet above sea level (asl). At 0713, the crew advised the controller of a decrease in hydraulic pressure and requested to return to the departure airport, Dorval. The controller immediately gave clearance for a 180° turn and descent to 8000 feet asl. During this time, the crew indicated that, for the moment, there was no on-board emergency. The aircraft initiated its turn 70 seconds after receiving clearance. At 0713:36, something was wrong with the controls. Shortly afterward came the first perceived indication that engine trouble was developing, and the left wing overheat light illuminated about 40 seconds later. Within 30 seconds, without any apparent checklist activity, the light went out. At 0718:12, the left engine appeared to be on fire, and it was shut down. Less than one minute later, the captain took the controls. The flight controls were not responding normally: abnormal right aileron pressure was required to keep the aircraft on heading. At 0719:19, the crew advised air traffic control (ATC) that the left engine was shut down, and, in response to a second suggestion from ATC, the crew agreed to proceed to Mirabel instead of Dorval. Less than a minute and a half later, the crew informed ATC that flames were coming out of the 'engine nozzle'. Preparations were made for an emergency landing, and the emergency procedure for manually extending the landing gear was reviewed. At 0723:10, the crew informed ATC that the left engine was no longer on fire, but three and a half minutes later, they advised ATC that the fire had started again. During this time, the aircraft was getting harder to control in roll, and the aileron trim was set at the maximum. Around 0727, when the aircraft was on short final for Runway 24L, the landing gear lever was selected, but only two gear down indicator lights came on. Near the runway threshold, the left wing failed upwards. The aircraft then rotated more than 90° to the left around its longitudinal axis and crashed, inverted, on the runway. The aircraft immediately caught fire, slid 2500 feet, and came to rest on the left side the runway. When the aircraft crashed, firefighters were near the runway threshold and responded promptly. The fire was quickly brought under control, but all occupants were fatally injured.

Probable cause:

Findings as to Causes and Contributing Factors:
- The crew did not realize that the pull to the left and the extended take-off run were due to the left brakes' dragging, which led to overheating of the brake components.
- Dragging of the left brakes was most probably caused by an unidentified pressure locking factor upstream of the brakes on take-off. The dragging caused overheating and leakage, probably at one of the piston seals that retain the brake hydraulic fluid.
- When hydraulic fluid leaked onto the hot brake components, the fluid caught fire and initiated an intense fire in the left nacelle, leading to failure of the main hydraulic system.
- When the L WING OVHT light went out, the overheating problem appeared corrected; however, the fire continued to burn.
- The crew never realized that all of the problems were associated with a fire in the wheel well, and they did not realize how serious the situation was.
- The left wing was weakened by the wing/engine fire and failed, rendering the aircraft uncontrollable.
Findings as to Risk:
- Numerous previous instances of brake overheating or fire on SA226 and SA227 aircraft had the potential for equally tragic consequences. Not all crews flying this type of aircraft are aware of its history of numerous brake overheating or fire problems.
- The aircraft flight manual and the emergency procedures checklist provide no information on the possibility of brake overheating, precautions to prevent brake overheating, the symptoms that could indicate brake problems, or actions to take if overheated brakes are suspected.
- More stringent fire-blocking requirements would have retarded combustion of the seats, reducing the fire risk to the aircraft occupants.
- A mixture of the two types of hydraulic fluid lowered the temperature at which the fluid would ignite, that is, below the flashpoint of pure MIL-H-83282 fluid.
- The aircraft maintenance manual indicated that the two hydraulic fluids were compatible but did not mention that mixing them would reduce the fire resistance of the fluid.
Other Findings:
- The master cylinders were not all of the same part number, resulting in complex linkage and master cylinder adjustments, complicated overall brake system functioning, and difficult troubleshooting of the braking system. However, there was no indication that this circumstance caused residual brake pressure.
- The latest recommended master cylinders are required to be used only with specific brake assembly part numbers, thereby simplifying adjustments, functioning, and troubleshooting.
- Although the emergency checklist for overheating in the wing required extending the landing gear, the crew did not do this because the wing overheat light went out before the crew initiated the checklist.
- The effect of the fire in the wheel well made it difficult to move the ailerons, but the exact cause of the difficulty was not determined.

Final Report:

Crash of a Beechcraft 200 Super King Air in Seven Islands

Date & Time: Jan 28, 1997 at 1700 LT

Type of aircraft:

Operator:

Registration:

C-GCEV

Flight Phase:

Takeoff (climb)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Seven Islands - Montreal

MSN:

BB-153

YOM:

1976

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total hours on type:

1300.00

Circumstances:

The Propair Inc. Super King Air 200 (serial number BB-153), with two pilots and ten passengers on board, was preparing to make a charter flight under instrument flight rules from Sept-Îles to Dorval, Quebec. At 1700 eastern standard time (EST), the co-pilot, in the left seat, began the take-off roll on runway 09. At an indicated airspeed of about 90 knots, 5 knots below rotation speed (VR), the aircraft began to drift to the left, toward the runway edge. The copilot attempted unsuccessfully to correct the take-off track using the rudder. At around 100 knots, just before the aircraft exited the runway, the co-pilot pulled the elevator control all the way back and initiated a climb. At about the same moment, the pilot-in-command throttled back, believing that a collision with the snowbank at the runway edge was inevitable. The aircraft descended until it struck the snow-covered surface to the north of the runway and slid on its belly before coming to rest on a heading opposite to the take-off heading. The pilot-in-command was slightly injured. The aircraft sustained considerable damage. The occupants used the main door to evacuate the aircraft.

Probable cause:

The aircraft crashed as a result of the lack of cockpit co-ordination when the pilot-in-command took control of the aircraft as the aircraft was airborne. The following factors contributed to the occurrence: marginal environmental conditions; contaminated runway surface; poor cockpit management; ineffective briefing; and, inadequate training for rejected take-offs.

Final Report:

Crash of a Cessna 402C near Wabush

Date & Time: Oct 22, 1995 at 1907 LT

Type of aircraft:

Cessna 402

Operator:

Bowman Aviation

Registration:

N67850

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Auburn – Montreal – Schefferville

MSN:

402C-0410

YOM:

1980

Location:

Wabush

Newfoundland & Labrador

Country:

Canada

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The Cessna 402, with five persons on board, took off from Auburn, Indiana, USA, around 0630 local time (1130 Coordinated Universal Time (UTC)) for Schefferville, Quebec, with stops en route. Their final leg was from Montreal International (Dorval) to Schefferville, with Wabush, Newfoundland, as the alternate, and they took off at 1523 EDT (1923 UTC). The flights were conducted in accordance with instrument flight rules (IFR). While in cruising flight and west of Wabush, the pilot requested the weather conditions for Schefferville and Wabush. Because of poor conditions in Schefferville, the pilot decided to fly to his alternate, Wabush. During the ILS approach for runway 01, the aircraft was too high to complete the approach, and the pilot requested and received clearance to execute another one. During the missed approach, the pilot proceeded an unknown distance outbound and turned back toward the airport. During the inbound leg, the aircraft contacted trees on the side of a mountain, at an indicated altitude of 2,460 feet asl, and decelerated over a distance of about 900 feet. The aircraft came to rest 23 nautical miles north of the airport, on the extended centre line of runway 01, on a heading of 186 degrees magnetic. The aircraft crashed probably at just after 1907 ADT (2207 UTC) during the hours of darkness. All five occupants were injured.

Probable cause:

The pilot did not follow the missed approach procedure as published, particularly with regard to minimum altitudes, and the aircraft crashed on the side of a mountain.

Final Report:

Crash of a Piper PA-31T Cheyenne II in Montreal

Date & Time: Nov 12, 1993 at 1739 LT

Type of aircraft:

Piper PA-31 Cheyenne

Operator:

Allen J. Hicks

Registration:

C-GSWB

Flight Phase:

Flight Type:

Private

Survivors:

Site:

Montreal-Pierre-Elliott Trudeau (ex Dorval)

Schedule:

Ottawa - Montreal

MSN:

31-7720013

YOM:

1977

Location:

Quebec

Country:

Canada

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

On approach to Montreal-Dorval Airport, the pilot contacted ATC and reported longitudinal control problems. The aircraft started to roll left and right and the pilot maintained control using considerable aileron and rudder inputs. On short final, the twin engine aircraft crash landed short of runway 24L and came to rest in a grassy area. The pilot was injured and the aircraft was damaged beyond repair.

Crash of an Avro 748-215-2 in Dayton: 2 killed

Date & Time: Jan 12, 1989 at 0445 LT

Type of aircraft:

Avro 748

Operator:

Registration:

C-GDOV

Flight Phase:

Takeoff (climb)

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Dayton - Montreal

MSN:

1582

YOM:

1966

Location:

Dayton-James M. Cox

Ohio

Country:

United States of America

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5847

Captain / Total hours on type:

3200.00

Aircraft flight hours:

35817

Circumstances:

During night cargo operation, check captain (right seat) was evaluating the 1st officer (f/o, left seat) for possible upgrade to captain. Before departing, flight was cleared for right turn after takeoff to 020°. Takeoff began at 0441:11. Water/methanol injection was used (to 1st power reduction). At 0441:49, landing gear was retracted; 8 seconds later 1st power reduction was made, then a frequency change was approved. Captain noted they should climb to 1,500 feet msl (approximately 500 feet agl) before turning. At about 300 feet agl, aircraft entered overcast and began a steep right turn. CVR indicated captain was performing cockpit duties at this time and giving info to f/o about the departure. FDR showed aircraft reached max alt of 423 feet agl and began descending. At 0442:22, captain remarked to f/o, 'don't go down . . . Get up . . . Up up up . . . Up, oh!' At about that time, aircraft hit in an open field, but continued flying for approximately 3/4 mile. It then hit a tree and crashed in a wooded area. Investigation revealed that during several training flights and 2 check flights, the f/o demonstrated difficulty in performing instrument flight due to disorientation, narrow focus of attention, or lack of instrument scan (instrument fixation), especially during high task workload. Both pilots were killed.

Probable cause:

Improper IFR procedure by the first officer (copilot) during takeoff, his lack of instrument scan (improper use of flight/navigation instruments), his failure to maintain a positive rate of climb or to identify the resultant descent, and the captain's inadequate supervision of the flight. Contributing factors were: dark night, low ceiling, drizzle, the first officer's lack of total experience in the type of operation, and possible spatial disorientation of the first officer.
Occurrence #1: in flight collision with terrain/water
Phase of operation: takeoff
Findings
1. (f) light condition - dark night
2. (f) weather condition - low ceiling
3. (f) weather condition - drizzle/mist
4. (c) ifr procedure - improper - copilot/second pilot
5. (c) flight/navigation instrument(s) - improper use of - copilot/second pilot
6. (c) climb - not maintained - copilot/second pilot
7. (c) descent - not identified - copilot/second pilot
8. (f) spatial disorientation - copilot/second pilot
9. (f) lack of total experience in type operation - copilot/second pilot
10. (c) supervision - inadequate - pilot in command
----------
Occurrence #2: in flight collision with object
Phase of operation: other
Findings
11. Object - tree(s)

Final Report:

Crash of an Avro 748-2B-FAA in Cheney: 2 killed

Date & Time: Sep 15, 1988 at 1019 LT

Type of aircraft:

Avro 748

Operator:

Registration:

C-GFFA

Flight Phase: