Crash of a Britten-Norman BN-2A-27 Islander in Pauingassi

Date & Time: Jan 25, 1995 at 1430 LT
Type of aircraft:
Operator:
Registration:
C-GSGK
Survivors:
Yes
MSN:
383
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Pauingassi, the twin engine aircraft was too low and struck the ground short of the airstrip. It came to rest in snow and was damaged beyond repair. Both occupants escaped uninjured.
Probable cause:
It is believed that the pilot misjudged the distance with the landing area and may have suffered a optical illusion caused by the reflection of the sun on the snow.

Crash of a Learjet 35 off Masset: 5 killed

Date & Time: Jan 11, 1995 at 0149 LT
Type of aircraft:
Operator:
Registration:
C-GPUN
Flight Type:
Survivors:
No
Schedule:
Vancouver - Masset
MSN:
35-058
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4550
Captain / Total hours on type:
2550.00
Copilot / Total flying hours:
2880
Copilot / Total hours on type:
61
Aircraft flight hours:
11676
Circumstances:
On 11 January 1995, at 0035 Pacific standard time (PST), the twin-engine Learjet 35 departed Vancouver International Airport, British Columbia, on a night, instrument flight rules (IFR), medical evacuation (MEDEVAC) flight to the Masset aerodrome, on the northern end of the Queen Charlotte Islands. On board the Learjet were a flight crew of two pilots, and a medical team consisting of two attendants and a doctor. Their mission was to evacuate a patient from Masset and deliver her to Prince Rupert for treatment; the aircraft was then to return to Vancouver. The flight-planned route was at flight level (FL) 390, direct to Sandspit then direct to Masset. Following routine communications with Air Traffic Services (ATS), at about 0144, the aircraft reported "outbound" from the Masset non-directional beacon (NDB) on the published NDB "A" instrument approach procedure to runway 12. Air Traffic Control (ATC) radar, situated near Sandspit, tracked the aircraft as it flew the approach. Radar data shows that the aircraft began a descent about 10 seconds after it had completed the procedure turn and was established on the final inbound approach track. Forty-three seconds later, at a point 8.8 nautical miles (nm) from the threshold of runway 12 and on the final, inbound track, the aircraft disappeared from radar. Department of National Defence (DND) Search and Rescue (SAR) aircraft began searching the area shortly after the aircraft was declared missing, and were later assisted by other private and military aircraft and vessels. On the second day of the search, flotsam from the aircraft was found in the area. Extensive underwater searching using sonar and underwater cameras found the aircraft wreckage on 31 January 1995, in 260 feet of water, near the last known position. The aircraft had been destroyed. The bodies of two occupants were found several days after the accident, but the other three occupants have not been found and are presumed to have been fatally injured. The accident occurred at latitude 54/08NN and longitude 131/58NW, at about 0149 PST, during the hours of darkness in unknown weather conditions.
Probable cause:
The crew most likely conducted the instrument approach with reference to an unintentionally mis-set altimeter of 30.17 in. Hg, and unknowingly flew the aircraft into the water. The circumstances leading to the incorrect altimeter setting could not be determined, nor was it determined why the crew did not detect the mis-set altimeter.
Final Report:

Crash of a Cessna 402B in Le Havre-Saint-Pierre

Date & Time: Nov 23, 1994 at 1714 LT
Type of aircraft:
Operator:
Registration:
C-FFAS
Flight Type:
Survivors:
Yes
Schedule:
Lourdes-de-Blanc-Sablon - Le Havre-Saint-Pierre
MSN:
402B-0820
YOM:
1975
Flight number:
ASJ638
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
689
Captain / Total hours on type:
29.00
Aircraft flight hours:
7012
Circumstances:
The Air Satellite Cessna 402B, flight 638, took off from Lourdes-de-Blanc-Sablon, Quebec, on an instrument flight rules (IFR) flight to Havre-Saint-Pierre, Quebec, with a load of mail. At 6,000 feet above sea level (asl), meteorological conditions were visual (VMC). About 35 nautical miles (nm) from Havre-Saint-Pierre, the pilot began his descent. At 25 nm from the airport and at an altitude of 5,000 feet asl, the pilot contacted the Flight Service Station (FSS) specialist at Sept-Îles, Quebec, via the remote communications outlet (RCO). He requested weather information for Havre-Saint-Pierre Airport. The specialist gave him the latest weather report available for the Havre-Saint-Pierre FSS. The report had been issued three hours previously by Environment Canada. The meteorological sequence indicated VMC. The pilot could see the town of Havre-Saint-Pierre when he commenced his back course approach for runway 27. During the descent, the aircraft flew into snow showers. The pilot contacted the company to check the weather at Havre-Saint-Pierre Airport, and he was told there was light snow. The pilot continued the approach to the MDA indicated on the Havre-Saint-Pierre approach chart, that is, 420 feet asl. There was moderate turbulence during the approach. The pilot tried to maintain control of the aircraft while operating the radio in an attempt to obtain more detailed weather information. One of the company pilots told him the snowfall was heavier. The aircraft then banked right. The pilot corrected, and, at the same time, the wheels touched the ground. The aircraft crashed and slid on its belly about 100 feet before coming to rest. The pilot sustained minor injuries; the aircraft sustained substantial damage. The accident occurred about 1.5 nm from the threshold of Havre-Saint-Pierre runway 27 on marshy ground. The pilot remained in radio contact with overflying aircraft and said he would stay on board the aircraft until rescuers arrived. Search and rescue crews walked toward the crash site, but they were unable to find the aircraft because of the rough terrain and reduced visibility. Five hours later, a Search and Rescue helicopter located the aircraft with the aid of the direction finder. The weak signal from the emergency locator transmitter (ELT) was still readable and was received. The pilot was transported to hospital for first aid treatment.The accident occurred during the hours of darkness.
Probable cause:
The pilot continued the descent below the MDA without the required visual references.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 in the Fish Egg Inlet: 3 killed

Date & Time: Sep 17, 1994 at 1148 LT
Operator:
Registration:
C-FDMR
Flight Phase:
Survivors:
Yes
Schedule:
Fish Egg Inlet - Pruth Bay
MSN:
36
YOM:
1967
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11725
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
150
Circumstances:
The captain, first officer, and two passengers departed from the Fish Egg Inlet logging camp, located 56 nautical miles (nm) north of Port Hardy, British Columbia, for a 16 nm visual flight rules (VFR) flight to Pruth Bay. This was the second leg of a flight which had originated at Port Hardy. The first officer, who occupied the left pilot seat and was handling the controls, taxied the aircraft a short distance away from the dock and took off. The captain occupied the right pilot seat. As the aircraft climbed through 100 feet, and just as the flaps were retracting, the aircraft pitched up violently and stalled. The pilots were unable to regain control of the aircraft, and it crashed into the water about 100 feet from the shore and sank immediately. The captain, who sustained serious injuries from the crash, escaped from the wreckage and swam to shore. The first officer and the two passengers remained in the aircraft and drowned. When the aircraft failed to arrive at Pruth Bay, personnel from Pacific Coastal Airlines (the company) notified the Rescue Coordination Centre and started their own search. A search pilot spotted debris in the water near the logging camp at about 1430 Pacific daylight saving time (PDT) that day. He landed to investigate, found the captain on the shore nearby, and transported him to the Port Hardy hospital. The accident occurred during daylight hours at approximately 1148 PDT, at latitude 51°36'N and longitude 127°41'W. There were no witnesses, other than the aircraft captain, to this accident.
Probable cause:
The down elevator control cable failed at station 376 due to corrosion, and, as a result, the pilot lost control of the aircraft. The corrosion was not detected by the maintenance personnel during the aircraft's last cable inspection.
Final Report:

Crash of a Grumman S-2F Tracker in Quesnel

Date & Time: Aug 28, 1994
Type of aircraft:
Operator:
Registration:
C-GHNU
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
351
YOM:
1957
Flight number:
Tanker 72
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 in the region of Quesnel. While cruising at an altitude of 6,500 feet, the pilot realized that the oil pressure on the left engine dropped while oil was leaking. He decided to shut down the left engine but mistakenly activated the fire extinguishing system on the right engine, causing the right engine to stop as well. In such conditions, he reduced his altitude and attempted to ditch the aircraft in the Fraser River near Quesnel. The aircraft was damaged beyond repair and the pilot was slightly injured.

Crash of a Piper PA-46-310P Malibu in Killarney: 6 killed

Date & Time: Aug 19, 1994 at 1230 LT
Operator:
Registration:
C-GSEV
Flight Type:
Survivors:
No
Schedule:
Windsor – Killarney
MSN:
46-8408035
YOM:
1984
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1322
Captain / Total hours on type:
122.00
Aircraft flight hours:
2019
Circumstances:
The flight was a private pleasure/travel flight for the purpose of transporting the pilot, his wife, and two other couples from Windsor to Killarney, Ontario, where they were to spend the weekend with friends. The flight had been planned in advance of the departure date. The pilot commenced taxiing at 1058 eastern daylight saving time (EDT), and was issued an instrument flight rules (IFR) clearance to Killarney via the routing "Windsor, radar vectors Sarnia, direct Wiarton, direct Killarney, to maintain 3,000" feet asl. The pilot took off at 1105. After take-off, the flight proceeded in a routine manner in accordance with the IFR clearance and was issued a final cruise altitude of 9,000 feet asl. The pilot reported level at 9,000 feet asl at 1125. At 1137, while the flight was 65 to 70 nm southwest of Wiarton, Ontario, the pilot was issued and acknowledged a clearance to fly direct to Killarney. At 1151, he requested and was issued a clearance to climb to 12,000 feet asl to get above a cloud layer, and reported level at 12,000 feet asl at 1155. The flight passed 20 nm to the west of Wiarton at 1203. At 1206, the pilot was given the Sudbury altimeter setting of 29.913 and was cleared to maintain 4,000 feet asl at his convenience. He acknowledged the clearance and commenced descent from 12,000 feet asl, 62 nm south of Killarney. Shortly after issuing the descent clearance, the air traffic services (ATS) controller advised the pilot that the IFR flight plan could be cancelled with the controller on his frequency while still airborne or with the Sault Ste. Marie flight service station (FSS) on the ground by a toll free telephone number. The ATS controller asked the flight crew of another aircraft on the same frequency to listen for an IFR cancellation from C-GSEV and to relay the cancellation to the controller. At 1221, the pilot of C-GSEV advised the ATS controller that he would be descending to 2,000 feet asl. The controller advised the pilot that the flight was in uncontrolled airspace and descent would be at the pilot's discretion. The pilot acknowledged the message, and this was the last direct controller/pilot communication (DCPC) between ATS and the aircraft. The last recorded radar position of the aircraft was at 1223:43, when it slowed to 180 knots ground speed and was descending out of 3,000 feet asl, 3 1/2 to 4 nm south of the Killarney airport. At about 1224, the flight crew from another aircraft on the frequency advised the ATS controller that C-GSEV had cancelled the IFR flight plan. There was no further communication with the flight after the pilot cancelled the IFR flight plan. The aircraft was reported missing to officials of the pilot's company the following morning by friends and family of the passengers. Search and rescue authorities were notified at approximately 0930, and the wreckage was located by search and rescue late that afternoon. The aircraft struck the rock face of a mountain at 1,321 feet asl in near level flight, on a northeast heading. The top of the mountain was 1,408 feet asl. The six occupants were fatally injured, and the aircraft was destroyed on impact. The accident occurred at about 1230 EDT during the hours of daylight, at latitude 46°02'N and longitude 081°26'W.
Crew:
Emidio Simone, pilot.
Passengers:
Laila Simone,
William and Lynne Bolton,
David and Pauline Moore.
Probable cause:
The pilot was operating the aircraft in instrument meteorological conditions and uncontrolled airspace while below a safe terrain clearance altitude, and the aircraft struck a mountain.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Charlevoix: 6 killed

Date & Time: Aug 3, 1994 at 1950 LT
Registration:
C-GVPB
Flight Phase:
Survivors:
No
Schedule:
Charlevoix - Trois-Rivières
MSN:
421C-0484
YOM:
1973
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
5261
Captain / Total hours on type:
1215.00
Aircraft flight hours:
3190
Circumstances:
Around 1950 eastern daylight saving time (EDT), the Cessna 421C aircraft, registration C-GVPB, operated by les Ailes de Charlevoix inc., took off on a visual flight rules (VFR) charter flight from Charlevoix Airport, Quebec, to Trois-Rivières, Quebec, with one pilot and five passengers on board. Shortly after take-off, witnesses saw greyish smoke emanating from the left engine. The aircraft entered a steep left turn followed by a descent. It then continued in the new direction. Shortly after, the aircraft yawed and entered an uncontrolled roll, nosed down, and crashed. The aircraft caught fire on impact. All six occupants were fatally injured during the impact. The aircraft was destroyed.
Probable cause:
It is probable that a loss of oil pressure in the left engine caused a loss of power just after take-off. The pilot was unable to maintain the minimum control speed (VMC) of the aircraft.
Final Report:

Crash of a Douglas C-47A-5-DK in Fort Simpson

Date & Time: Jun 26, 1994 at 1404 LT
Operator:
Registration:
C-FROD
Flight Type:
Survivors:
Yes
Schedule:
Big Trout Lake – Fort Simpson
MSN:
12307
YOM:
1942
Flight number:
BFL526
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
9000.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
850
Aircraft flight hours:
18456
Circumstances:
Buffalo Air Flight 526, a Douglas DC-3C freighter based in Yellowknife, was hauling jet fuel to Trout Lake from Fort Simpson, Northwest Territories, in support of forest fire suppression operations. Before the departure from Yellowknife to Trout Lake, the flight crew checked the en route weather and filed a company flight itinerary. Dispatch issued the flight crew an aircraft-fuel-load receipt which indicated that the aircraft had been fuelled the night before with a total fuel quantity of about 436 imperial gallons (imp. gal.): full main tanks (336 imp. gal.), and 50 gallons in each auxiliary tank (100 imp. gal.). The first officer confirmed this quantity with a fuel dip-stick borrowed from the refueller. At 07:40 mountain daylight saving time, the flight crew departed Yellowknife in accordance with visual flight rules (VFR). On board the aircraft were 17 full 45-imperial-gallon drums of Turbo-B jet fuel. At 09:25 the aircraft landed at Trout Lake, and the 17 drums of jet fuel were off-loaded; the aircraft then departed for Fort Simpson at 0945. The 82-nautical-mile (nm) flight to Fort Simpson was flown at an altitude of about 2,500 feet above sea level (asl); the flight crew reported encountering light headwinds. At 10:20 the aircraft landed at Fort Simpson. Once again 17 drums of jet fuel were loaded on board, then the aircraft departed at 10:49. The captain climbed the aircraft to an altitude of 3,500 feet asl. After he levelled off the aircraft, the captain adjusted the engines to 575 brake horsepower (bhp) settings. At 11:20, the aircraft landed at Trout Lake and the drums were off-loaded, and at 11:35 the aircraft was once again airborne on the second round-trip shuttle flight. Thirty-five minutes later the aircraft landed at Fort Simpson. While the cargo was being loaded on the aircraft, the flight crew discussed their different calculations regarding the aircraft's fuel quantity. The first officer indicated that the aircraft required fuel. The captain calculated that the aircraft had sufficient fuel remaining. The captain decided that they would refuel at Fort Simpson on the next shuttle flight; nonetheless, since the flight crew considered the cockpit fuel gauges unreliable, the captain requested that the first officer confirm the fuel quantity using a dip-stick. At 12:28, the aircraft departed Fort Simpson and climbed to 5,000 feet asl. About eight minutes later, the flight crew noticed that the fuel pressure was fluctuating, indicating that the auxiliary tanks were empty. The captain repositioned the fuel tank selectors to their respective main tanks and enquired about the dip-stick measurements. The first officer responded that he had not checked the fuel quantity because the fuel dip-stick was missing. The crew discussed the fuel quantity remaining and the captain calculated that the aircraft had approximately 45 minutes of fuel remaining. Following the 13:00 touchdown at Trout Lake, the cargo was unloaded and 31 empty fuel drums were loaded on board the aircraft for Fort Simpson. At 13:25 the aircraft departed Trout Lake. The first officer was the pilot flying (PF) the aircraft, and was in the right seat. The captain performed the duties of the pilot not flying (PNF). Twenty miles southwest of Fort Simpson, the PNF reported their position to Fort Simpson Flight Service Station (FSS). He also requested that the aircraft refueller be advised that they would require fuel on arrival. The flight crew then completed the descent checks and, at 10 miles southwest of the airport, the PNF updated FSS of their position and received the airport advisory. Approximately six miles from the airport, at an altitude of about 400 to 500 feet above ground level (agl), the PF advised the PNF that the left engine was losing fuel pressure. Shortly thereafter, the left engine lost power. Immediately, the PNF switched the left fuel boost pump to the ON position, and the left fuel selector from LEFT MAIN to LEFT AUXILIARY tank position. The engine resumed power momentarily, but lost power again. The PNF then switched the left fuel selector to the RIGHT AUXILIARY tank position and the engine regained power; however, it promptly lost power again. Realizing that the fuel had been depleted in three of the four tanks, the captain took control of the aircraft and headed straight for runway 31. As the captain called for the engine failure check for the left engine, the first officer advised the captain that the right engine was losing power. With a loss of power in both engines, and without sufficient altitude to glide to the airport, the first officer called the Fort Simpson FSS to advise that the flight crew would attempt a landing on the road (Mackenzie Highway) north of the Liard River. However, the approach to the road was unsuccessful and the aircraft crash-landed into a treed area. At about 14:03, several witnesses at the Liard River ferry crossing observed the aircraft flying low in a northwesterly direction. The aircraft was estimated to be at about 40 feet agl when it crossed overhead the ferry terminal and was descending. The witnesses reported that they heard the sound of the engines cutting in and out before the aircraft passed overhead their vantage points. They also reported seeing the landing gear being extended. The aircraft then disappeared from view behind the trees. Immediately thereafter, the aircraft struck trees near the road, and crashed about 1/2 nm short of runway 31. The aircraft had been flown for approximately 4 hours and 37 minutes since its last refuelling.
Probable cause:
The flight was commenced with a fuel quantity below the minimum requirements, resulting in loss of engine power because of fuel exhaustion. Contributing to the occurrence was the lack of flight crew coordination.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Hunter Point: 2 killed

Date & Time: Jun 23, 1994 at 1100 LT
Type of aircraft:
Operator:
Registration:
C-FDTI
Flight Phase:
Survivors:
No
Schedule:
Hunter Point – Sandspit
MSN:
37
YOM:
1949
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2586
Captain / Total hours on type:
1268.00
Aircraft flight hours:
11615
Circumstances:
The amphibious DHC-2 Beaver was being operated from the Harbour Air base at Sandspit, British Columbia, located on the Queen Charlotte Islands. On the first flight on the day of the accident, the aircraft carried baggage from the Sandspit Airport to a floating fishing resort at anchor in Givenchy Bay. This bay is located in the Kano Inlet on the west coast of the Queen Charlotte Islands, 28 nautical miles (nm) west of Sandspit. On board the aircraft with the pilot was a passenger who would remain with the flight for the return trip to Sandspit. The aircraft departed Sandspit under visual flight rules (VFR) at 1015 Pacific daylight time (PDT) and landed at the fishing resort at 1039. The pilot had taken the most direct route to the destination through a low pass and over Yakoun Lake. He advised the company dispatch on the company radio frequency that the weather was quite poor along that route and that he planned to take the Skidegate Channel for the return trip. On arrival at the Givenchy resort, the aircraft was loaded with the fish to be transported to Sandspit; it then departed Givenchy at 1051. When the aircraft did not arrive at Sandspit, a search was organized. The wreckage was located at 1245 at Hunter Point, about 7 nm from Givenchy, at latitude 53°15'N, longitude 132°42'W. The accident had occurred during the hours of daylight at approximately 1100. The aircraft was destroyed and the pilot and passenger were fatally injured upon impact.
Probable cause:
The aircraft likely stalled at an altitude insufficient to permit recovery. The reason why the aircraft may have stalled could not be determined.
Final Report:

Crash of a Cessna 441 Conquest in Fort Frances

Date & Time: Jun 18, 1994 at 0425 LT
Type of aircraft:
Operator:
Registration:
N441CA
Flight Phase:
Survivors:
Yes
Schedule:
Milwaukee – Fort Frances – God’s Lake Narrows
MSN:
441-0046
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
40.00
Aircraft flight hours:
2447
Circumstances:
The pilot of the Cessna 441 Conquest was conducting an international charter flight from General Mitchell International Airport in Milwaukee, Wisconsin, to Gods Lake Narrows, Manitoba. The pilot landed the aircraft at Fort Frances, Ontario, to clear customs and refuel, and then continued his visual flight rules (VFR) flight to Gods Lake Narrows. During the take-off at Fort Frances, the aircraft experienced a power loss in the left engine. The pilot elected to continue the take-off but was unable to control the aircraft after it became airborne. The aircraft veered to the left and crashed on the airfield. The accident occurred at 0425 central daylight time (CDT), at night, on the Fort Frances Municipal Airport. All seven occupants sustained minor injuries and the aircraft was damaged beyond repair.
Probable cause:
The pilot lost control of the aircraft during take-off when the left engine lost power as a result of bird ingestion. Contributing to the loss of aircraft control were a take-off weight in excess of the maximum allowable, and a centre of gravity aft of the centre of gravity limit.
Final Report: