Crash of a Swearingen SA227AC Metro III in La Ronge

Date & Time: Sep 21, 2004 at 1410 LT
Type of aircraft:
Operator:
Registration:
C-FIPW
Survivors:
Yes
Schedule:
Stony Rapids - La Ronge
MSN:
AC-524
YOM:
1982
Flight number:
KA1501
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Northern Dene Airways Ltd. Metro III (registration C-FIPW, serial number AC524), operating as Norcanair Flight KA1051, departed Stony Rapids, Saskatchewan, with two crew members and nine passengers on a day, visual flight rules flight to La Ronge, Saskatchewan. On arrival in La Ronge, at approximately 1410 central standard time, the crew completed the approach and landing checklists and confirmed the gear-down indication. The aircraft was landed in a crosswind on Runway 18 and touched down firmly, approximately 1000 feet from the threshold. On touchdown, the left wing dropped and the propeller made contact with the runway. The aircraft veered to the left side of the runway, despite full rudder and aileron deflection. The crew applied maximum right braking and shut down both engines. The aircraft departed the runway and travelled approximately 200 feet through the infield before the nose and right main gear were torn rearwards; the left gear collapsed into the wheel well. The aircraft slid on its belly before coming to rest approximately 300 feet off the side of the runway. Three of the passengers suffered minor injuries from the sudden stop associated with the final collapsing of the landing gear; the other passengers and the pilots were not injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. An incorrect roller of a smaller diameter and type was installed on the left main landing gear outboard bellcrank assembly, contrary to company and industry practice.
2. The smaller diameter roller reduced the required rigging tolerances for the bellcrank-to-cam assembly in the down-and-locked position and allowed the roller to eventually move beyond the cam cutout position, resulting in the collapse of the left landing gear.
3. A rigging check was not carried out after the replacement of the bellcrank roller. Such a check should have revealed that neither the inboard nor outboard bellcrank assembly met the minimum rigging requirements for proper engagement with the positioning cam.
Final Report:

Crash of a Douglas A-26C-45-DT Invader in Rainbow Lake

Date & Time: Aug 12, 2004
Type of aircraft:
Operator:
Registration:
C-FCBK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rainbow Lake - High Level
MSN:
28940
YOM:
1944
Flight number:
Tanker 11
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was engaged in a fire fighting mission and was supposed to leave Rainbow Lake for High Level. During the takeoff roll, at a speed of 90 knots, one of the engine lost power. The pilot rejected takeoff and released the load of fire retardant. Unable to stop within the remaining distance, the aircraft overran, rolled for about 1,200 feet then struck a drainage ditch and came to rest. The pilot was seriously injured and the aircraft was damaged beyond repair.

Crash of a Beechcraft A100 King Air in Fort Vermilion

Date & Time: Jul 13, 2004 at 0001 LT
Type of aircraft:
Registration:
C-FQOV
Flight Type:
Survivors:
Yes
Schedule:
Grande Prairie – Fort Vermilion
MSN:
B-38
YOM:
1970
Flight number:
LRA913M
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crew twin engine aircraft was performing an ambulance flight from Grande Prairie to his base in Fort Vermilion with one patient, one doctor, one accompanist and two pilots on board. On final approach, the aircraft was too high and eventually landed hard. Upon touchdown, the right main gear collapsed and the aircraft veered off runway to the right and and came to rest. All five occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:

Crash of a De Havilland DHC-6 Twin Otter 300 in Mile 222 (Canol Road)

Date & Time: Jul 4, 2004 at 1730 LT
Operator:
Registration:
C-FMOL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mile 222 - Mile 170
MSN:
303
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The North-Wright Airways Ltd. DHC-6 Twin Otter, registration C-FMOL, was departing from an approximately 1,500 foot long gravel strip at Mile 222 of the Canol Road (near the Tsichu River), Canada. The takeoff was initiated to the north and into wind. Immediately after becoming airborne, the aircraft encountered a strong right cross-wind and settled back onto the strip. The left wheel contacted willows that had overgrown the edge of the strip. The aircraft veered left into the willows at about 60 knots, and began to decelerate. Prior to flying speed being regained, the aircraft rolled off the end of the strip and come to rest in a shallow creek. The right wing partially separated from the fuselage at impact and the forward fuselage, nose gear and right main gear sustained substantial damage. The pilot and first officer were uninjured. The purpose of the trip was to move hunting gear and outfitter supplies back to an airstrip at Mile 170 of the Canol Road (Godlin Lake). The aircraft was at or near gross weight at the time of the occurrence.

Crash of a Noorduyn Norseman VI in Birch Lake

Date & Time: Jul 3, 2004
Type of aircraft:
Operator:
Registration:
C-FOBE
Survivors:
Yes
MSN:
480
YOM:
1944
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing on Birch Lake, the second compartment of the right float ruptured. The aircraft nosed down and sank. All five occupants were able to evacuate the cabin and to swim to the shore. The aircraft was written off.
Probable cause:
Failure of the right float on landing that was leaking probably due to a crack located in the second compartment.

Crash of a De Havilland DHC-2 Beaver near Gatineau: 1 killed

Date & Time: Jun 14, 2004 at 1340 LT
Type of aircraft:
Registration:
C-GJST
Flight Type:
Survivors:
No
Schedule:
Gatineau - Gatineau
MSN:
1368
YOM:
1959
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1709
Captain / Total hours on type:
700.00
Circumstances:
The pilot and sole occupant of the DHC-2 seaplane, registration C-GJST, serial number 1368, was on his first flight of the season on the Ottawa River at Gatineau, Quebec. This training flight, conducted according to visual flight rules, was to consist of about 12 touch-and-go landings. The aircraft took off at approximately 1300 eastern daylight time, and made several upwind touch-and-go landings in a westerly direction. At approximately 1340 eastern daylight time, the aircraft was seen about 50 feet above the surface of the water proceeding downwind in an easterly
direction, in a nose-down attitude of over 20 degrees. The right float then struck the water and the aircraft tumbled several times, breaking up on impact. Despite the waves and gusting wind on the river, some riverside residents who witnessed the accident attempted a rescue, but the aircraft sank before they could reach it. Even though the pilot was wearing a seat-belt, he sustained head injuries at impact and drowned.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The aircraft struck the water for undetermined reasons.
Findings as to Risk:
1. The certificate of airworthiness was not in effect at the time of the accident because of the airworthiness directives that had not been completed.
2. The distress signal emitted by the fixed, automatic emergency locator transmitter (ELT) was not received because of the reduced range of the signal once the ELT was submerged, which could have increased the response time of search and rescue units if there had been no witnesses to the accident.
3. The pilot had not made a training flight with an instructor for more than 19 months, which could have resulted in a degradation of his skills and decision-making process.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Fawcett Lake: 4 killed

Date & Time: May 18, 2004 at 1800 LT
Type of aircraft:
Registration:
C-GQHT
Survivors:
No
Schedule:
Pickeral Arm Camp - Fawcett Lake
MSN:
682
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1688
Captain / Total hours on type:
344.00
Circumstances:
Pickerel Arm Camps is located about 22 km south of Sioux Lookout, Ontario. It operates a main campsite at its water base and several remote fishing lodges. The company operates two float equipped de Havilland DHC-2 Beaver aircraft to fly guests and supplies to their remote sites. Seven guests of the company arrived at the water base on 18 May 2004, the day before their scheduled four-day fishing trip at Fawcett Lake, one of the remote lodges. Because the remote lodge was available, a decision was made to fly in that afternoon. The group was divided in two, and a group of three guests and all the supplies for the seven guests were to go in the first aircraft. The second group of four, with their personal baggage, was to follow in the company’s other Beaver. The occurrence aircraft, a de Havilland DHC-2 Beaver (C-GQHT, serial number 682) with one pilot and three camp guests on board, departed the company water base at approximately 1700 eastern daylight time on a day visual flight rules flight to Fawcett Lake. At approximately 1930, the pilot and the other four guests arrived in the second aircraft to discover that the first group had not arrived. The guests later found the accident aircraft overturned in the lake. Ontario Provincial Police divers recovered the bodies of the pilot and the three passengers. The aircraft sustained substantial damage. There was no fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot flew a high-drag approach configuration for which his proficiency was not established.
2. The pilot most likely allowed the airspeed to decrease to the point that the aircraft stalled on approach at an altitude at which recovery was unlikely.
3. The impact was non-survivable because of the high impact forces.
Findings as to Risk:
1. The emergency locator transmitter (ELT) airframe antenna was broken off above the fuselage; however, the flight was within the 30-day period allowed by regulation for flight with an unserviceable ELT.
2. The pilot did not secure the cargo prior to flight, which allowed the cargo to shift forward on impact.
3. The weight and centre of gravity (C of G) were not indicated in the operational flight plan and load record, and the aircraft’s weight and C of G could only be estimated.
Final Report:

Crash of a Beechcraft A100 King Air in Chibougamau

Date & Time: Apr 19, 2004 at 1018 LT
Type of aircraft:
Operator:
Registration:
C-FMAI
Survivors:
Yes
Schedule:
Quebec - Chibougamau
MSN:
B-145
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11338
Captain / Total hours on type:
2600.00
Copilot / Total flying hours:
1176
Copilot / Total hours on type:
400
Circumstances:
The Beechcraft A100, registration C-FMAI, operated by Myrand Aviation Inc., was on a chartered instrument flight rules flight from QuÈbec/Jean Lesage International Airport, Quebec, to Chibougamau/Chapais Airport, Quebec, with two pilots and three passengers on board. The copilot was at the controls and was flying a non-precision approach for Runway 05. The pilot-in-command took the controls less than one mile from the runway threshold and saw the runway when they were over the threshold. At approximately 1018 eastern daylight time, the wheels touched down approximately 1500 feet from the end of Runway 05. The pilot-in-command realized that the remaining landing distance was insufficient. He told the co-pilot to retract the flaps and applied full power, but did not reveal his intentions. The co-pilot cut power, selected reverse pitch and applied full braking. The aircraft continued rolling through the runway end, sank into the gravel and snow, and stopped abruptly about 500 feet past the runway end. The aircraft was severely damaged. None of the occupants were injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was positioned over the runway threshold at an altitude that did not allow a landing at the beginning of the runway, and this, combined with a tailwind component and the wet runway surface, resulted in a runway excursion.
2. Failure to follow standard operating procedures and a lack of crew coordination contributed to confusion on landing, which prevented the crew from aborting the landing and executing a missed approach.
3. The pilot-in-command held several management positions within the company and controlled the pilot hiring and dismissal policies. This situation, combined with the level of experience of the co-pilot compared with that of the pilot-in-command, had an impact on crew cohesiveness.
Findings as to Risk:
1. The pilot-in-command of C-FMAI decided to execute an approach for Runway 05 without first ensuring that there would be no possible risk of collision with the other aircraft.
2. The regulatory requirement to conform to or avoid the traffic pattern formed by other aircraft is not explicit as to how the traffic pattern should be avoided, in terms of either altitude or distance, which can result in risks of collision.
3. The regulations do not indicate whether the missed approach segment should be considered part of the traffic pattern; this situation can lead pilots operating in uncontrolled airspace to believe that they are avoiding another aircraft executing an instrument approach when in reality a risk of collision exists.
Final Report:

Crash of a Cessna 208B Grand Caravan off Pelée Island: 10 killed

Date & Time: Jan 17, 2004 at 1638 LT
Type of aircraft:
Operator:
Registration:
C-FAGA
Flight Phase:
Survivors:
No
Schedule:
Pelée Island – Windsor
MSN:
208B-0658
YOM:
1998
Flight number:
GGN125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3465
Captain / Total hours on type:
957.00
Aircraft flight hours:
7809
Circumstances:
On 17 January 2004, the occurrence pilot started his workday in Toronto, Ontario, reporting for duty at 0445 eastern standard time. In the morning, he completed flights in the Cessna 208B Caravan from Toronto to Windsor, Ontario, Windsor to Pelee Island, Ontario, and then Pelee Island to Windsor where the aircraft landed at 0916. At approximately 1500, the pilot received local weather and passenger information by telephone from the Pelee Island office personnel. The 1430 weather was reported as follows: ceiling 500 feet obscured, visibility two miles. There were eight male passengers for pick up at Pelee Island. One additional passenger was travelling with the pilot. There was no discussion concerning the amount of cargo to be carried or the passenger weights. At 1508, the pilot received a faxed weather package that he had requested from the Flight Information Centre (FIC) in London, Ontario. At 1523, the aircraft was refuelled in preparation for the scheduled 1600 departure to Pelee Island. The passengers were loaded earlier than usual to allow time for aircraft de-icing, as wet snow had accumulated on the fuselage and wings since the previous flight. At 1555, the aircraft was de-iced with Type 1 de-icing fluid, and it departed for Pelee Island at 1605 on an instrument flight rules (IFR) flight plan as Flight GGN125. At 1615, the pilot advised the Cleveland Control Centre, Ohio, United States, that he had Pelee Island in sight, was cancelling IFR, and was descending out of 5000 feet. The pilot also advised Cleveland that he would be departing IFR out of Pelee Island in about 20 minutes as GGN126 and asked if a transponder code could be issued. The Cleveland controller issued a transponder code and requested a call when GGN126 became airborne. The pilot advised that the flight would depart on Runway 27 then turn north. These were the last recorded transmissions from the aircraft. The aircraft landed at 1620. While on the ramp, two individuals voiced concern to the pilot that there was ice on the wing. Freezing precipitation was falling. The pilot was observed to visually check the leading edge of the wing; however, he did not voice any concern and proceeded with loading the passengers and cargo. At approximately 1638, GGN126 departed Pelee Island for Windsor. After using most of the runway length for take-off, the aircraft climbed out at a very shallow angle. No one on the ground observed the aircraft once it turned toward the north; however, witnesses who were not at the airport reported that they heard the sound of a crash, then no engine noise. A normal flight from Pelee Island to Windsor in the Cessna Caravan takes 15 to 20 minutes. Shortly after the aircraft departed, the ticket agent in Windsor received a call from Pelee Island reporting that a crash had been heard. At 1705, when the aircraft had not arrived, the ticket agent called Windsor tower. The pilot had not made contact with any air traffic services (ATS) facility immediately before or after departure, so there was nothing in the ATS system to indicate that the aircraft had taken off. It was, therefore, unaccounted for. There was no signal heard from the emergency locator transmitter (ELT). At 1710, the Windsor tower controller contacted the Rescue Coordination Centre in Trenton, Ontario, and a search was initiated. At 1908, the aircraft empennage and debris were spotted by a United States Coast Guard (USCG) helicopter on the frozen surface of the lake, about 1.6 nautical miles (nm) from the departure end of the runway. There were no survivors. The empennage sank beneath the surface some four hours later. The wreckage recovery was not fully completed until 13 days later.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At take-off, the weight of the aircraft exceeded the maximum allowable gross take-off weight by at least 15 per cent, and the aircraft was contaminated with ice. Therefore, the aircraft was being flown significantly outside the limitations under which it was certified for safe flight.
2. The aircraft stalled, most likely when the flaps were retracted, at an altitude or under flight conditions that precluded recovery before it struck the ice surface of the lake.
3. On this flight, the pilotís lack of appreciation for the known hazards associated with the overweight condition of the aircraft, ice contamination, and the weather conditions was inconsistent with his previous practices. His decision to take off was likely adversely affected by some combination of stress and fatigue.
Findings as to Risk:
1. Despite the abbreviated nature of the September 2001 audit, the next audit of Georgian Express Ltd. was not scheduled until September 2004, at the end of the 36-month window.
2. The internal communications at Transport Canada did not ensure that the principal operations inspector responsible for the air operator was aware of the Pelee Island operation.
3. The standard passenger weights available in the Aeronautical Information Publication at the time of the accident did not reflect the increased average weight of passengers and carry-on baggage resulting from changes in societal-wide lifestyles and in travelling trends.
4. The use of standard passenger weights presents greater risks for aircraft under 12 500 pounds than for larger aircraft due to the smaller sample size (nine passengers or less) and the greater percentage of overall aircraft weight represented by the passengers. The use of standard passenger weights could result in an overweight condition that adversely affects the safety of flight.
5. The Cessna Caravan de-icing boot covers up to a maximum of 5% of the wing chord. Research on this wing has shown that ice accumulation beyond 5% of the chord can result in degradation of aircraft performance.
6. At the Pelee Island Airport, the air operator did not provide the equipment that would allow an adequate inspection of the aircraft for ice during the pre-flight inspection and did not provide adequate equipment for aircraft de-icing.
7. Repetitive charter operators are not considered to be scheduled air operators under current Transport Canada regulations, and, therefore, even though the charter air operator may provide a service with many of the same features as a scheduled service, Transport Canada does not provide the same degree of oversight as it does for a scheduled air operator.
8. A review of the Canadian Aviation Regulations regarding simulator training requirements indicates that there is no requirement to conduct recurrent simulator training if currency and/or pilot proficiency checks do not lapse.
9. Commercial Air Service Standard 723.91(2) does not clearly indicate whether there is a requirement for simulator training following expiration of a pilot proficiency check.
10. Incorrect information on the passenger door placards, an incomplete safety features card, and the fact that the operating mechanisms and operating instructions for the emergency exits were not visible in darkness could have compromised passenger egress in the event of a survivable accident.
11. The dogs being carried on the aircraft were not restrained, creating a hazard for the flight and its occupants.
Final Report:

Crash of a Beechcraft A100 King Air in Terrace Bay

Date & Time: Jan 1, 2004
Type of aircraft:
Operator:
Registration:
C-GFKS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Terrace Bay – Thunder Bay
MSN:
B-247
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off roll on runway 25 at dusk, left wing struck a snowbank on left side of the runway. Aircraft veered off runway and came to rest in snow with its nose gear sheared off and several damages to the fuselage. Both pilots were uninjured.
Probable cause:
A NOTAM stated that there were windrows four feet high, 10 feet inside the runway lights on both sides of the runway. This NOTAM also stated that the cleared portion of the runway was covered with ¼ inch of loose snow over 60 percent compacted snow and 40 percent ice patches and that braking action was fair to poor. The take-off was being conducted at dusk in conditions of poor lighting and contrast. Crosswind was not a factor.