Region
Crash of a De Havilland DHC-2 Beaver into Mistastin Lake: 7 killed
Date & Time:
Jul 15, 2019
Operator:
Registration:
C-FJKI
Survivors:
No
Schedule:
Crossroads Lake - Mistastin Lake
MSN:
992
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total hours on type:
16000.00
Circumstances:
The single engine airplane was chartered by a provider based in Crossroads Lake (near Churchill Falls reservoir) to fly four fisherman and two guides to Mistastin Lake, Labrador. The aircraft was supposed to leave Crossroads Lake at 0700LT but the departure was postponed to 1000LT due to low ceiling. Several attempts to contact the pilot failed during the day and the SAR center based in Trenton was alerted. SAR operations were initiated and four days later, the location of the accident was reached but only four bodies were found. The body of the pilot and two passengers were never recovered as well as the wreckage.
Probable cause:
The aircraft had been seen floating in Mistastin Lake and later sank. To date, the wreckage has not been found. There is no radar coverage at low altitudes in the area, and the aircraft was flying in uncontrolled airspace and not in communication with air traffic services. Without any witnesses and without key pieces of the aircraft, the TSB is unable to conduct a full investigation into this accident. If the aircraft is found, the TSB will assess the feasibility of investigating the accident further.
Final Report:
Crash of a De Havilland DHC-2 Beaver near Lake Boulene: 3 killed
Date & Time:
Jul 12, 2019 at 1616 LT
Registration:
C-GRHF
Survivors:
Yes
Schedule:
St-Mathias - La Minerve - Barrage Goin - Weakwaten
MSN:
1123
YOM:
1957
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total hours on type:
314.00
Aircraft flight hours:
15040
Circumstances:
At approximately 1000LT on 12 July 2019, a private de Havilland DHC-2 Mk. 1 Beaver floatplane (registration C‑GRHF, serial number 1123) took off from the St-Mathias Water Aerodrome (CSV9), Quebec, with only the pilot on board, for a series of visual flight rules (VFR) flights. The aircraft landed at approximately 1130 on Désert Lake in La Minerve, Quebec, and came alongside a private dock where 3 individuals were waiting to board and fly to a fishing lodge. Once the baggage was stowed on the aircraft, the pilot provided a safety briefing to the passengers, who were all wearing a personal flotation device. The aircraft took off from Désert Lake at approximately 1215, bound for the Barrage Gouin Water Aerodrome (CTP3), Quebec, where the aircraft was scheduled to be refuelled. The aircraft landed at approximately 1430. Once the refuelling was complete, the aircraft took off once again around 1528, headed northwest to Weakwaten Lake, Quebec, where the fishing lodge was located. After approximately 48 minutes of flight, at around 1616, the aircraft collided with trees and struck the ground. There was no post-impact fire. The emergency locator transmitter was activated by the force of impact, and began transmitting a signal on frequency 121.5 MHz. This signal was detected by the flight crew of a commercial airliner at 1705 and reported to air traffic services. At 1850, the Joint Rescue Coordination Centre in Trenton dispatched a CC130 Hercules aircraft to try to locate the distress signal. The occurrence aircraft was found in a densely wooded area at 2032. Two search and rescue technicians were parachuted to rescue the aircraft occupants. Three of the 4 occupants received fatal injuries. The survivor was evacuated and transported to the hospital in Chibougamau, Quebec.
Probable cause:
Controlled flight into terrain following the pilot's decision to continue the flight at a relatively low speed and in a nose-up attitude, which reduced his field of vision.
Final Report:
Crash of a De Havilland DHC-2 Beaver in Hawk Junction: 2 killed
Date & Time:
Jul 11, 2019 at 0853 LT
Operator:
Registration:
C-FBBG
Survivors:
No
Schedule:
Hawk Junction - Oba Lake
MSN:
358
YOM:
1952
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total hours on type:
409.00
Aircraft flight hours:
17804
Circumstances:
On 11 July 2019, at approximately 0852 Eastern Daylight Time, the float-equipped de Havilland DHC-2 Mk. I Beaver aircraft (registration C-FBBG, serial number 358), operated by Hawk Air, departed from the Hawk Junction Water Aerodrome, on Hawk Lake, Ontario. The aircraft, with the pilot and 1 passenger on board, was on a daytime visual flight rules charter flight. The aircraft was going to drop off supplies at an outpost camp on Oba Lake, Ontario, approximately 35 nautical miles north-northeast of the Hawk Junction Water Aerodrome. The aircraft departed heading northeast. Shortly after takeoff, during the initial climb out, just past the northeast end of Hawk Lake, the aircraft crashed in a steep nose-down attitude, severing a power line immediately before impact, and coming to rest next to a hydro substation. The pilot and the passenger received fatal injuries. The aircraft was destroyed as a result of the impact, but there was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The aircraft likely departed with the fuel selector set to the rear tank position,which did not contain sufficient fuel for departure. As a result, the engine lost power due to fuel starvation shortly after takeoff during the initial climb.
2. After a loss of engine power at low altitude, a left turn was likely attempted in an effort to either return to the departure lake or head toward more desirable terrain for a forced landing. The aircraft stalled aerodynamically, entered an incipient spin, and subsequently crashed.
Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If aircraft are not equipped with a stall warning system, pilots and passengers who travel on these aircraft will remain exposed to an elevated risk of injury or death as a result of a stall at low altitude.
2. If air-taxi training requirements do not address the various classes of aircraft and operations included in the sector, there is a risk that significant type-, class-, or operation-specific emergency procedures will not be required to be included in training programs.
3. If seasonal air operators conduct recurrent training at the end of the season rather than at the beginning, there is a risk that pilots will be less familiar with required emergency procedures.
4. If air operators do not tailor their airborne training programs to address emergency procedures that are relevant to their operation, there is a risk that pilots will be unprepared in a real emergency.
5. If pilots and passengers do not use available shoulder harnesses, there is an increased risk of injury in the event of an accident.
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. The aircraft likely departed with the fuel selector set to the rear tank position,which did not contain sufficient fuel for departure. As a result, the engine lost power due to fuel starvation shortly after takeoff during the initial climb.
2. After a loss of engine power at low altitude, a left turn was likely attempted in an effort to either return to the departure lake or head toward more desirable terrain for a forced landing. The aircraft stalled aerodynamically, entered an incipient spin, and subsequently crashed.
Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If aircraft are not equipped with a stall warning system, pilots and passengers who travel on these aircraft will remain exposed to an elevated risk of injury or death as a result of a stall at low altitude.
2. If air-taxi training requirements do not address the various classes of aircraft and operations included in the sector, there is a risk that significant type-, class-, or operation-specific emergency procedures will not be required to be included in training programs.
3. If seasonal air operators conduct recurrent training at the end of the season rather than at the beginning, there is a risk that pilots will be less familiar with required emergency procedures.
4. If air operators do not tailor their airborne training programs to address emergency procedures that are relevant to their operation, there is a risk that pilots will be unprepared in a real emergency.
5. If pilots and passengers do not use available shoulder harnesses, there is an increased risk of injury in the event of an accident.
Final Report:
Crash of a Piper PA-46-350P Malibu near Makkovik: 1 killed
Date & Time:
May 1, 2019 at 0816 LT
Operator:
Registration:
N757NY
Survivors:
Yes
Schedule:
Goose Bay - Narsarsuaq
MSN:
46-36657
YOM:
2015
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total hours on type:
20.00
Copilot / Total hours on type:
0
Circumstances:
On 01 May 2019 at 0723, the aircraft departed CYYR on a VFR flight plan direct to BGBW. The ferry pilot, who was the pilot-in-command, occupied the left seat while the co-owner occupied the right seat. The aircraft climbed to 2000 feet ASL and proceeded on a direct track to destination. The altitude and heading did not change significantly along the route, therefore it is likely that the autopilot was engaged. At 0816, the aircraft collided with a snow-covered hill 2250 feet in elevation, located 35 nautical miles (NM) southeast of Makkovik Airport (CYFT), Newfoundland and Labrador. The impact happened approximately 200 feet below the top of the hill. The aircraft came to rest in deep snow on steep sloping terrain. The aircraft sustained significant damage to the propeller, nose gear, both wings, and fuselage. Although the cabin was crush-damaged, occupiable space remained. There was no post-impact fire. The ferry pilot was seriously injured and the co-owner was fatally injured. The Joint Rescue Coordination Centre (JRCC) in Halifax received an emergency locator transmitter (ELT) signal from the aircraft at 0823. The ferry pilot carried a personal satellite tracking device, a personal locator beacon (PLB) and a handheld very high frequency (VHF) radio, which allowed communication with search and rescue (SAR). Air SAR were dispatched to the area; however, by that time, the weather had deteriorated to blizzard conditions and aerial rescue was not possible. Ground SAR then deployed from the coastal community of Makkovik and arrived at the accident site approximately 4 hours later because of poor weather conditions and near zero visibility. The ferry pilot and the body of the co-owner were transported to Makkovik by snowmobile. The following day, they were airlifted to CYYR.
Probable cause:
Controlled flight into terrain.
Final Report:
Crash of a Beechcraft B200 Super King Air in Gillam
Date & Time:
Apr 24, 2019 at 1823 LT
Operator:
Registration:
C-FRMV
Survivors:
Yes
Schedule:
Winnipeg – Churchill – Rankin Inlet
MSN:
BB-979
YOM:
1982
Flight number:
KEW202
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1100.00
Copilot / Total hours on type:
1350
Circumstances:
On 24 April 2019, the Keewatin Air LP Beechcraft B200 aircraft (registration C‑FRMV, serial number BB979), equipped to perform medical evacuation flights, was conducting an instrument flight rules positioning flight (flight KEW202), with 2 flight crew members and 2 flight nurses on board, from Winnipeg/James Armstrong Richardson International Airport, Manitoba, to Rankin Inlet Airport, Nunavut, with a stop at Churchill Airport, Manitoba. At 1814 Central Daylight Time, when the aircraft was cruising at flight level 250, the flight crew declared an emergency due to a fuel issue. The flight crew diverted to Gillam Airport, Manitoba, and initiated an emergency descent. During the descent, both engines flamed out. The flight crew attempted a forced landing on Runway 23, but the aircraft touched down on the frozen surface of Stephens Lake, 750 feet before the threshold of Runway 23. The landing gear was fully extended. The aircraft struck the rocky lake shore and travelled up the bank toward the runway area. It came to rest 190 feet before the threshold of Runway 23 at 1823:45 Central Daylight Time. None of the occupants was injured. The aircraft sustained substantial damage. The 406 MHz emergency locator transmitter activated. Emergency services responded. There was no fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.
Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.
Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.
Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.
Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.
Final Report:
Crash of a Beechcraft B200 Super King in Whatì: 2 killed
Date & Time:
Jan 30, 2019 at 0915 LT
Operator:
Registration:
C-GTUC
Survivors:
No
Schedule:
Yellowknife – Whatì – Wekweèti – Ekati
MSN:
BB-268
YOM:
1977
Flight number:
8T503
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total hours on type:
1712.00
Copilot / Total hours on type:
330
Aircraft flight hours:
20890
Aircraft flight cycles:
18863
Circumstances:
At 0851 Mountain Standard Time on 30 January 2019, the Air Tindi Ltd. Beechcraft King Air 200 aircraft (registration C-GTUC, serial number BB-268) departed Yellowknife Airport (CYZF), Northwest Territories, as flight TIN503, on an instrument flight rules flight itinerary to Whatì Airport (CEM3), Northwest Territories, with 2 crew members on board. At 0912, as the aircraft began the approach to CEM3, it departed controlled flight during its initial descent from 12 000 feet above sea level, and impacted terrain approximately 21 nautical miles east-southeast of CEM3, at an elevation of 544 feet above sea level. The Canadian Mission Control Centre received a signal from the aircraft’s 406 MHz emergency locator transmitter and notified the Joint Rescue Coordination Centre in Trenton, Ontario. Search and rescue technicians arrived on site approximately 6 hours after the accident. The 2 flight crew members received fatal injuries on impact. The aircraft was destroyed.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- For undetermined reasons, the left-side attitude indicator failed in flight.
- Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
- The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
- The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
- The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
- The captain and first officer likely experienced spatial disorientation.
- Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.
Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
- If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.
Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- For undetermined reasons, the left-side attitude indicator failed in flight.
- Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
- The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
- The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
- The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
- The captain and first officer likely experienced spatial disorientation.
- Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.
Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
- If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.
Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.
Final Report:
Crash of a Cessna 340A in Ponoka
Date & Time:
Nov 13, 2018 at 1815 LT
Registration:
C-GMLS
Survivors:
Yes
MSN:
340A-0771
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Ponoka-Labrie Field, the pilot encountered technical problems with the autopilot and decided to make a go-around. While in the circuit pattern, the autopilot failed to disconnect properly so the pilot attempted an emergency landing in a field. The airplane belly landed then contacted trees. Upon impact, the tail was torn off and the aircraft came to rest. The pilot was seriously injured.
