Crash of a De Havilland DHC-6 Twin Otter 300 in Lake Wicksteed

Date & Time: Jun 5, 2003 at 1800 LT
Operator:
Registration:
C-GOGC
Flight Type:
Survivors:
Yes
MSN:
750
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
8500.00
Circumstances:
The aircraft with a single pilot on board was performing firefighting operations in the vicinity of Lake Wicksteed, approximately 10 nautical miles north of Hornepayne, Ontario. The aircraft was scooping water from Lake Wicksteed for the nearby fire. The lake is approximately 7300 feet in length with gentle rising terrain along its shoreline. This was the third scooping from the lake, and the approach was flown in an easterly direction in light wind conditions. The pilot performed the inbound checks, lowered the water probes to begin filling the float water tanks, and touched down on the lake. Within a short time, he observed water spraying from the overflow vents located on top of the floats, indicating that the tanks were filled to capacity. He pressed a button on the yoke to retract the probes, and the aircraft immediately nosed over into the lake in a wings-level attitude and began to sink. The accident occurred at approximately 1800 eastern daylight time. The pilot extricated himself from the aircraft and held on to the side of the partially submerged aircraft. A witness to the occurrence immediately boarded a powered, aluminum boat and went to assist the pilot, while a second witness travelled to Hornepayne to notify the authorities and emergency services. Once the pilot reached the shore, he was taken to a nearby cottage where he remained until emergency services arrived. The aircraft came to rest on the bottom of the shallow lake in an inverted attitude with the floats above the surface of the water.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Ministry of Natural Resources DHC-6 SOPs were not followed, and the Vital Action checklist was not fully completed during the approach. As a result, the bomb door armed switch on the centre panel was not selected Off after the previous water bombing run and prior to the scooping operation.
2. After completing the water scooping operation, the pilot unintentionally selected the bomb door push button switch instead of the adjacent probe switch. Because the bomb door armed switch on the centre panel was left On, the bomb doors extended into the water. Drag from the doors and the water rushing into the door openings resulted in the aircraft nosing over in the water.
3. The hinged cover plate for the bomb door push button switch was not re-installed following maintenance to replace the push button switch. The push button was exposed, making an inadvertent selection more likely.
Final Report:

Crash of a Beechcraft 99A Airliner in Prince Albert

Date & Time: Apr 23, 2003 at 1802 LT
Type of aircraft:
Operator:
Registration:
C-FDYF
Survivors:
Yes
Schedule:
Saskatoon – Prince Albert
MSN:
U-110
YOM:
1969
Flight number:
TW602
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was on a scheduled flight from Saskatoon, Saskatchewan, to Prince Albert, Saskatchewan, with two pilots and four passengers on board. The aircraft was approximately 4000 feet above sea level when the crew selected the flaps for the approach to Prince Albert. A bang was heard from the rear of the fuselage. The aircraft commenced an uncommanded pitch-up to a near-vertical attitude, then stalled, nosed over, and began a spin to the left. The crew countered the spin but the aircraft continued to descend in a near-vertical dive. Through the application of full-up elevator and the manipulation of power settings, the pilots were able to bring the aircraft to a near-horizontal attitude. The crew extended the landing gear and issued a Mayday call, indicating that they were conducting a forced landing. The aircraft struck a knoll, tearing away the belly cargo pod and the landing gear. The aircraft bounced into the air and travelled approximately 180 metres, then contacted a barbed-wire fence and slid to a stop approximately 600 metres from the initial impact point. The crew and passengers suffered serious but non-life-threatening injuries. All of the occupants exited through the main cabin door at the rear of the aircraft. The accident occurred during daylight hours at 1802 central standard time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. During flight, the horizontal stabilizer trim actuator worked free of the mounting structure, and as a result, the flight crew lost pitch control of the aircraft.
2. During replacement of the horizontal stabilizer trim actuator, the upper attachment bolts were inserted through the airframe structure but did not pass through the upper mounting lugs of the
trim actuator.
3. The improperly installed bolts trapped the actuator mounting lug assemblies, suspending the weight of the actuator and giving the false impression that the bolts had been correctly installed.
4. Dual inspections, ground testing, and flight testing did not reveal the faulty attachment.
Findings as to Risk:
1. The nature of the installation presents a risk that qualified persons may inadvertently install Beech 99 and Beech 100 horizontal stabilizer trim actuators incorrectly. There are no published warnings to advise installers that there is a potential to install the actuator incorrectly.
Final Report:

Crash of a Cessna 550 Citation II in Sandspit

Date & Time: Nov 12, 2002 at 2052 LT
Type of aircraft:
Operator:
Registration:
C-GYCJ
Flight Type:
Survivors:
Yes
Schedule:
Vancouver - Sandspit
MSN:
550-0561
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4550
Captain / Total hours on type:
1450.00
Copilot / Total flying hours:
3300
Copilot / Total hours on type:
850
Circumstances:
The aircraft departed Vancouver International Airport, British Columbia, on a medical evacuation flight to the Sandspit Airport in the Queen Charlotte Islands, British Columbia. On board the aircraft were two pilots and a team of two Advanced Life Support Paramedics. When the aircraft arrived at Sandspit, the surface wind was strong, gusty, and across the runway. The crew conducted an instrument approach to Runway 30, and just before touchdown the aircraft's nose pitched down; the captain believed that the nosewheel, and then the main gear, collapsed as the aircraft slid on its belly. The crew carried out an evacuation and proceeded to the airport terminal building. When they returned to the aircraft to retrieve their belongings, the crew discovered that the gear was in the up position, as was the landing gear selector. The accident occurred at 2052 Pacific standard time. There were no injuries. The aircraft was substantially damaged.
Probable cause:
Findings as to causes and contributing factors:
1. The crew did not complete the before-landing checks, ignored aural warnings, and did not lower the landing gear, which resulted in a gear-up landing.
Findings as to risk:
1. The aircraft was not equipped with a GPWS, which could have prevented this accident.
2. The before-landing checklist in use did not reflect the AFM requirement that the speed brakes should be retracted prior to 50 feet.
Final Report:

Crash of a De Havilland DHC-3 Otter near Aguanish River: 3 killed

Date & Time: Sep 28, 2002 at 1135 LT
Type of aircraft:
Registration:
C-FLGA
Survivors:
Yes
Site:
Schedule:
Lake de l'Avion - Aguanish River
MSN:
279
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7980
Captain / Total hours on type:
7800.00
Circumstances:
A de Havilland DHC-3 Otter owned by Deraps Aviation Inc., registration C-FLGA, serial number 279, took off from Lake de l'Avion, Quebec, near Natashquan Airport at approximately 1050 eastern daylight time on a flight to a hunting camp 57 miles to the north along the Aguanish River. The pilot and three passengers were on board. Upon arriving at the destination at approximately 1135, the aircraft flew over part of the neighbouring forest before crashing upside down on rugged ground. The passengers were fatally injured on impact. The pilot survived and was evacuated to Sept-Îles by Canadian Forces Search and Rescue services at approximately 0400 on 29 September 2002.
Probable cause:
Because of the geographic and weather conditions, the pilot probably had trouble judging his horizontal and vertical distance with respect to the mountain, and the aircraft crashed.
Final Report:

Crash of a Douglas C-54E-15-DO Skymaster in Diavik

Date & Time: Aug 28, 2002 at 1650 LT
Type of aircraft:
Operator:
Registration:
C-GQIC
Flight Type:
Survivors:
Yes
Schedule:
Yellowknife – Diavik
MSN:
27343
YOM:
1944
Flight number:
BFL928
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Diavik Airport, the four engine aircraft was too low. This caused the undercarriage to struck the ground about one metre short of runway 10 threshold. On impact, the undercarriage were torn off and the aircraft slid on the runway for almost 300 metres then lost its right wing and rotated to the right before coming to rest, bursting into flames. Both pilots escaped with minor injuries and the aircraft was destroyed.

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

Date & Time: Aug 24, 2002 at 1308 LT
Type of aircraft:
Registration:
C-GUNE
Survivors:
Yes
Schedule:
Holinshead Lake - Kasshabog Lake
MSN:
1403
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was en route from Holinshead Lake to Kasshabog Lake when the pilot encountered deteriorating weather conditions. As the flight progressed, the ceiling became increasingly lower until it was nearly at tree top level. Shortly thereafter, the pilot located a cabin at the destination outpost camp. On final approach to the camp, the aircraft struck the water while in a turn, tearing off one float and it eventually sank. The pilot and four passengers exited the aircraft and attempted to swim ashore. While swimming, one of the passengers went missing and was not located. Ontario Provincial Police divers were dispatched to search for the missing passenger. Three people were slightly injured and one seriously.

Crash of a Rockwell Aero Commander 560F near London

Date & Time: Aug 20, 2002
Operator:
Registration:
N201KS
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
560-1066-22
YOM:
1961
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot attempted to take off from a private grass airstrip (2,400 feet long) located at 22678 Purple Hill Road, about 13,5 km north of London Airport, Ontario. The aircraft failed to get airborne and eventually came to rest in a cornfield. The aircraft was damaged beyond repair and both occupants were injured. A witness observed smoke coming from the aircraft's wheels and the pilot suspected that the parking brake was not fully disengaged.

Crash of a De Havilland DHC-3 Otter near Lake Cojibo

Date & Time: Jun 30, 2002 at 0900 LT
Type of aircraft:
Operator:
Registration:
C-GUTQ
Flight Phase:
Survivors:
Yes
Site:
MSN:
402
YOM:
1960
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Lake Cojibo with two passengers, one pilot and a full load of freight, destined for a fishing camp. Weather conditions were good but the OAT was high. After takeoff, the aircraft encountered difficulties to maintain a proper rate of climb due to the high temperature and the weight it was carrying. The pilot entered a valley and while trying to gain height to clear rising terrain, the aircraft struck the top of a mountain and crashed, bursting into flames. All three occupants were injured and the aircraft was destroyed by fire.

Crash of a Piper PA-31-350 Navajo Chieftain in Winnipeg: 1 killed

Date & Time: Jun 11, 2002 at 0920 LT
Operator:
Registration:
C-GPOW
Survivors:
Yes
Site:
Schedule:
Gunisao Lake - Winnipeg
MSN:
31-7305093
YOM:
1973
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3000
Circumstances:
The aircraft was on an instrument flight rules flight from Gunisao Lake, Manitoba, to Winnipeg. One pilot and six passengers were on board. At 0913 central daylight time, KEE208 began an instrument landing system approach to Runway 13 at Winnipeg International Airport. The captain flew the approach at a higher-than-normal approach airspeed and well above the glide path. When the aircraft broke out of the cloud layer, it was not in position to land safely on the remaining runway. The captain executed a missed approach at 0916 and, after switching to the approach frequency from tower frequency, requested an expedited return to the airport. The approach controller issued instructions for a turn back to the airport. Almost immediately, at 0918, the captain declared a 'Mayday' for an engine failure. Less than 20 seconds later the captain transmitted that the aircraft had experienced a double engine failure. The aircraft crashed at a major traffic intersection at 0920, striking traffic signals and several vehicles. All seven of the aircraft passengers and several of the vehicle occupants were seriously injured; one passenger subsequently died of his injuries. The aircraft experienced extensive structural damage, with the wings and engines tearing off along the wreckage trail. There was a small post-crash fire in the right wing and engine area.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot did not correctly calculate the amount of fuel required to accomplish the flight from Winnipeg to Gunisao Lake and return, and did not ensure that the aircraft carried sufficient fuel for the flight.
2. The ILS approach was flown above the glideslope and beyond the missed approach point, which reduced the possibility of a safe landing at Winnipeg, and increased the risk of collision with terrain.
3. During the missed approach, the aircraft's engines lost power as a result of fuel exhaustion, and the pilot conducted a forced landing at a major city intersection.
4. The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.
Findings as to Risk:
1. The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
2. The company operations manual did not reflect current company procedures.
3. The company did not provide an adequate level of supervision and allowed the flight to depart without adequate fuel reserves. The company did not have a safety system in place to prevent a fuel exhaustion situation developing.
Other Findings:
1. The pilot did not advise air traffic control of his critical situation in a timely fashion.
Final Report:

Crash of a Swearingen SA227AC Metro III in Goose Bay

Date & Time: Mar 4, 2002 at 0456 LT
Type of aircraft:
Operator:
Registration:
C-FITW
Flight Type:
Survivors:
Yes
Schedule:
Saint John's - Goose Bay
MSN:
AC-638
YOM:
1986
Flight number:
PB905
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was on a scheduled courier flight from St. John=s, Newfoundland and Labrador, to Goose Bay. The aircraft touched down at 0456 Atlantic standard time and, during the landing roll on the snow-covered runway, the aircraft started to veer to the right. The captain's attempt to regain directional control by the use of full-left rudder and reverse on the engines was unsuccessful. The aircraft continued to track to the right of the centreline, departed the runway, and struck a hard-packed snow bank. There were no injuries to the two crew members. The aircraft was substantially damaged.
Probable cause:
Findings as to Cause and Contributing Factors:
1. Aircraft directional control was lost, likely because of negative castering of the nosewheel when snow piled up in front of the nosewheel assembly.
Findings as to Risk:
1. The crew members were not aware of negative castering; the aircraft flight manual and emergency checklists do not address negative castering.
2. The emergency response to the occurrence was delayed by four minutes because of the lack of communication from the aircraft to the tower.
Final Report: