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.

Crash of a De Havilland DHC-3 Otter in Jellicoe: 2 killed

Date & Time: Dec 16, 2003 at 1200 LT
Type of aircraft:
Operator:
Registration:
C-GOFF
Flight Phase:
Survivors:
Yes
MSN:
65
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5016
Captain / Total hours on type:
540.00
Circumstances:
At approximately 0900 eastern standard time (EST), the pilot arrived at the airstrip and prepared the ski-equipped de Havilland DHC–3 (Otter) aircraft (registration C–GOFF, serial number 65) for the morning flight. This Otter was equipped with a turbine engine. Two passengers, with enough supplies for an extended period of time, including a snowmobile and camping gear, were to be flown to a remote location. The pilot loaded the aircraft and waited for the weather to improve. At approximately 1200 EST, the pilot and passengers boarded the aircraft and took off in an easterly direction. The aircraft got airborne near the departure end of the airstrip, and, shortly after take-off, the right wing struck a number of small bushes and the top of a birch tree. The aircraft descended and struck the frozen lake surface, approximately 70 feet below the airfield elevation in a steep, nose-down, right-wing-low attitude. When it came to rest, the aircraft was inverted and partially submerged, with only the aft section of the fuselage remaining above the ice. All of the occupants were wearing lap belts. The pilot and front seat passenger received fatal injuries. The rear seat passenger survived the impact and evacuated the aircraft with some difficulty due to leg injuries. The following morning, about 22 hours after the accident, a local air operator searching for the missing aircraft located and rescued the surviving passenger.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot attempted to take off from an airstrip that was covered with approximately 18 inches of snow, and the aircraft did not accelerate to take-off speed because of the drag; the aircraft was forced into the air and was unable to climb out of ground effect and clear the obstacles.
2. The pilot did not abort the take-off when it became apparent that the aircraft was not accelerating normally and before the aircraft became airborne.
Findings as to Risk:
1. Unidirectional G switches, which are found on many types of ELTs, do not always activate the unit when impact forces are not aligned with the usual direction of flight.
Other Findings:
1. The validity of the aircraft’s certificate of airworthiness was affected while it flew more flights than allowed by the ferry permit issued by Transport Canada.
2. The rear passenger seat was found to be installed incorrectly, contrary to de Havilland Alert Service Bulletin A3/49, dated 19 July 1991.
Final Report:

Crash of a Piper PA-31-310 Navajo in Gaspé: 3 killed

Date & Time: Sep 27, 2003 at 1857 LT
Type of aircraft:
Registration:
C-FARL
Survivors:
No
Schedule:
Le Havre-aux-Maisons - Gaspé
MSN:
31-306
YOM:
1968
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5262
Captain / Total hours on type:
3000.00
Circumstances:
The PA-31-310, registration C-FARL, serial number 31306, operated by Les Ailes de Gaspé Inc., with one pilot and two passengers on board, was on a visual flight rules flight from Îles-de-la-Madeleine, Quebec to Gaspé, Quebec. While en route to Gaspé, the pilot was informed about weather conditions at his destination, which were a ceiling at 500 feet and visibility of ¾ mile in fog. The pilot requested clearance for an instrument approach, which he received at approximately 1857 eastern daylight time. A few seconds later the pilot switched on the aerodrome lights with his microphone button. That was the last radio transmission received from the aircraft. When the aircraft did not arrive at its destination, emergency procedures were initiated to find it. The wreckage was found the next day at 1028 eastern daylight time on a hilltop 1.2 nautical miles (nm) north-east of the airport. The aircraft was destroyed, but did not catch fire. The three occupants were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot descended to the minimum descent altitude (MDA) without being established on the localizer track, thereby placing himself in a precarious situation with respect to the approach and to obstruction clearance.
2. On an instrument approach, the pilot continued his descent below the MDA without having the visual references required to continue the landing, and he was a victim of CFIT (controlled flight into terrain).
Findings as to Risk:
1. The aircraft was not, nor was it required to be, equipped with a ground proximity warning system (GPWS) or a radio altimeter, either of which would have allowed the pilot to realize how close the aircraft was to the ground.
2. The presence of a co-pilot would have allowed the pilots to share tasks, which undoubtedly would have facilitated identification of deviations from the approach profile.
3. The existing regulations do not provide adequate protection against the risk of ground impact when instrument approaches are conducted in reduced visibility conditions.
Other Findings:
1. The emergency locator transmitter (ELT) could not emit a distress signal because the battery disconnected on impact. Location of the aircraft was delayed until the day after the accident, which could have had serious consequences if there had been any survivors.
Final Report:

Crash of a Cessna 414A Chancellor near Calgary: 1 killed

Date & Time: Sep 23, 2003 at 1936 LT
Type of aircraft:
Operator:
Registration:
C-GVZE
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cranbrook – Calgary
MSN:
414A-0219
YOM:
1979
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4375
Captain / Total hours on type:
2780.00
Aircraft flight hours:
8377
Circumstances:
The Alta Flights Cessna 414A (registration C-GVZE, serial number 414A0219) departed Cranbrook, British Columbia, at approximately 1910 mountain daylight time (MDT) on a visual flight rules cargo flight to Calgary, Alberta. The aircraft disappeared from the Calgary area radar at 1936 MDT, at an indicated altitude of 9000 feet above sea level (asl) in the Highwood Range mountains, approximately 49 nautical miles southwest of Calgary. The aircraft wreckage was found on a mountain ridge at 8900 feet asl some 40 hours later. The flight was in controlled descent to Calgary when the impact occurred. There was a total break-up of the aircraft, and the pilot, the lone occupant, was fatally injured. There was a brief fireball at the time of impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot lost situational awareness most likely believing he was over lower terrain.
2. The aircraft was very likely flown into cloud during a day VFR flight, which prevented the pilot from seeing and avoiding the terrain.
Findings as to Risk:
1. The aircraft was not required by regulation to have terrain avoidance equipment installed, leaving the pilot with no last defence for determining the aircraft's position relative to the terrain. This is a risk for all aircraft operated in similar conditions.
Other Findings:
1. The flight plan was prematurely closed by NAV CANADA, which caused the early stoppage of SAR activities and delayed the recommencement of those searches by two hours.
Final Report:

Crash of a Cessna 208B Grand Caravan near Summer Beaver: 8 killed

Date & Time: Sep 11, 2003 at 2130 LT
Type of aircraft:
Operator:
Registration:
C-FKAB
Survivors:
No
Schedule:
Pickle Lake - Summer Beaver
MSN:
208B-0305
YOM:
1992
Flight number:
WSG125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2351
Captain / Total hours on type:
946.00
Aircraft flight hours:
16770
Circumstances:
The aircraft departed Pickle Lake to Summer Beaver, Ontario, on a charter flight with seven passengers and one crew member. The flight proceeded on a direct routing to destination at 3500 feet above sea level under night visual flight conditions. On approaching Summer Beaver, the aircraft joined the circuit on a downwind leg for a landing on Runway 17. When the aircraft did not land, personnel at Summer Beaver contacted the Pickle Lake flight dispatch to inquire about the flight. The aircraft was declared missing following an unsuccessful radio search by the Pickle Lake flight dispatch staff. Search and rescue personnel found the wreckage in a wooded area three nautical miles northwest of Summer Beaver. The aircraft had been nearly consumed by a post-crash fire. All eight people on board had been fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
The aircraft departed controlled flight and struck terrain for undetermined reasons.
Findings as to Risk:
The company's flight-following procedures for flights operating in remote areas were impractical and were not consistently applied; this could compromise timely search and rescue operations following an accident.
Other Findings:
The aircraft did not carry flight recorders. Lack of information about the cause of this accident affects TSB's ability to identify related safety deficiencies and to issue safety communications intended to prevent accidents that could occur under similar circumstances.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Penticton: 3 killed

Date & Time: Aug 29, 2003 at 1427 LT
Type of aircraft:
Registration:
C-GHAF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nanaimo - Penticton - Calgary
MSN:
1408
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
915
Captain / Total hours on type:
615.00
Aircraft flight hours:
9029
Circumstances:
The aircraft left Nanaimo, British Columbia, and landed at Penticton Airport at 1232 Pacific daylight time (PDT). The aircraft was fueled with 184 litres of fuel, filling all three belly tanks. At this time, the rear portion of the aircraft cabin was observed to be loaded with luggage and cargo. The pilot/aircraft owner was planning his flight to Calgary (Springbank), Alberta, and spent at least an hour flight planning and talking with the Kamloops Flight Information Centre by telephone. He had some difficulty determining a route to fly to Springbank, because of airspace restrictions due to forest fires, but decided on a routing of Penticton, Kelowna, Vernon, Revelstoke, and Springbank. The aircraft took off from Penticton Airport at 1420 PDT, with the pilot and two passengers on board and crashed approximately seven minutes later in a ravine of Penticton Creek, 11 nautical miles northeast of Penticton Airport. A post-impact fire broke out and consumed most of the fuselage area. The fire caused a small forest fire, seen by a firefighting aircraft crew. There were no radio calls from the occurrence aircraft, and the three occupants were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. As the aircraft approached high terrain in a climb, the pilot, for undetermined reasons, did not turn away from the terrain; the aircraft struck tree tops and crashed.
2. The aircraft’s climb performance was adversely affected by density altitude and the relatively high aircraft weight, so that the aircraft was unable to clear the high terrain ahead.
Findings as to Risk:
1. The licensed passenger had not informed the TC medical examiner who conducted her last medical that she had been diagnosed with coronary artery disease, posing the risk that she could pilot an aircraft while not medically fit to do so.
2. The aircraft was being operated at a higher weight than was justified by the STC, under which it was converted to an amphibian. Some of the structural modifications called for by the STC for the higher weight had not been carried out.
Other Findings:
1. It could not be determined who was piloting the aircraft on the occurrence flight.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Sully Lake: 1 killed

Date & Time: Aug 2, 2003 at 1700 LT
Type of aircraft:
Registration:
C-GUXW
Flight Type:
Survivors:
Yes
Schedule:
Pelican Narrows - Sully Lake
MSN:
611
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft departed Pelican Narrows with two passengers and one pilot on board. While approaching Sully Lake, the engine lost power. The aircraft lost height and crashed in Sully Lake. Both passengers exited the cabin and were seriously injured while the pilot was killed. They spent a night on the shore and were rescued and evacuated to hospital a day later.
Probable cause:
A cracked cylinder resulted in a loss of engine power and the pilot attempted a force landing on a small lake. The altitude at which the event began may have given the pilot very little time to successfully complete a forced landing.

Crash of a Douglas C-54G-10-DO Skymaster in Ulu

Date & Time: Aug 2, 2003 at 0800 LT
Type of aircraft:
Operator:
Registration:
C-GBSK
Flight Type:
Survivors:
Yes
MSN:
36049
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was completing a cargo flight to Ulu, carrying four crew members and a load consisting of 45 oil drums. On final approach, the crew realized his speed was too high so he reduced engine power and selected full flaps. The aircraft lost height so power was added. But the aircraft continued to descent and struck the ground short of runway threshold. Upon impact, the undercarriage were torn off. The aircraft slid on its belly, lost its both wings and came to rest few hundred feet further. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Lockheed L-188A Electra in Cranbrook: 2 killed

Date & Time: Jul 16, 2003 at 1221 LT
Type of aircraft:
Operator:
Registration:
C-GFQA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cranbrook - Cranbrook
MSN:
1040
YOM:
1959
Flight number:
Tanker 86
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
38775
Circumstances:
The aircraft took off from Runway 16 at the Cranbrook Airport, British Columbia. Two pilots were on board to conduct a fire-management mission on a small ground fire (designated N10156) two nautical miles southwest of the township of Cranbrook. Seven minutes earlier, the partner “bird dog” aircraft, a Turbo Commander, also departed Cranbrook to assess the appropriate aircraft flight path profiles and to establish the most suitable fire-retardant delivery program for the ground fire. Following the flight path demonstrations by the bird dog aircraft, Tanker 86 proceeded to carry out the retardant drop on the fire. After delivering the specified retardant load, Tanker 86 was seen to turn right initially then entered a turn to the left. At 1221 MST, the Electra struck the terrain on the side of a steep ridge at about 3900 feet above sea level. The aircraft exploded on impact and the two pilots were fatally injured. An intense post-crash fire consumed much of the wreckage and started a forest fire at the crash site and the surrounding area. The on-board emergency locator transmitter was damaged by the impact forces and did not activate.
Probable cause:
Findings as to Causes and Contributing Factors:
1. For undetermined reasons, the Electra did not climb sufficiently to avoid striking the rising terrain.
2. Given the flight path and the rate of climb chosen, a collision with the terrain was unavoidable.
3. The characteristics of the terrain were deceptive, making it difficult for the pilots to perceive their proximity and rate of closure to the rising ground in sufficient time to avoid it.
Other Findings:
1. Performance calculations show that the Electra—in the absence of limiting mechanical malfunction—could have climbed at a rate that would have allowed the aircraft to avoid the terrain.
2. Although a functional cockpit voice recorder was installed in the aircraft, it was not required by regulation and it was not used; as a result, vital clues that could have shed light on the circumstances of this accident were not available.
3. The emergency locator transmitter could not transmit a signal as a result of severe impact forces that exceeded the design criteria.
Final Report: