Crash of a Canadair RegionalJet CRJ-100ER in Toronto

Date & Time: May 20, 2007 at 1235 LT
Operator:
Registration:
C-FRIL
Survivors:
Yes
Schedule:
Moncton – Toronto
MSN:
7051
YOM:
1994
Flight number:
AC8911
Country:
Crew on board:
37
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft, with 3 crew members and 37 passengers on board, was operating as Air Canada Jazz Flight 8911 from Moncton, New Brunswick, to Toronto/Lester B. Pearson International Airport, Ontario. At 1235 eastern daylight time, the aircraft landed on Runway 06R with a 90º crosswind from the left, gusting from 13 to 23 knots. The aircraft first contacted the runway in a left-wing-down sideslip. The left main landing gear struck the runway first and the aircraft sustained a sharp lateral side load before bouncing. Once airborne again, the flight and ground spoilers deployed and the aircraft landed hard. Both main landing gear trunnion fittings failed and the landing gear collapsed. The aircraft remained upright, supported by the landing gear struts and wheels. The aircraft slid down the runway and exited via a taxiway, where the passengers deplaned. There was no fire. There were no injuries to the crew; some passengers reported minor injuries as a result of the hard landing.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.
Final Report:

Crash of an Airbus A340-313X in Toronto

Date & Time: Aug 2, 2005 at 1602 LT
Type of aircraft:
Operator:
Registration:
F-GLZQ
Survivors:
Yes
Schedule:
Paris - Toronto
MSN:
289
YOM:
1999
Flight number:
AF358
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
297
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15411
Captain / Total hours on type:
1788.00
Copilot / Total flying hours:
4834
Copilot / Total hours on type:
2502
Aircraft flight hours:
28426
Aircraft flight cycles:
3711
Circumstances:
The Air France Airbus A340-313 aircraft (registration F-GLZQ, serial number 0289) departed Paris, France, at 1153 Coordinated Universal Time (UTC) as Air France Flight 358 on a scheduled flight to Toronto, Ontario, with 297 passengers and 12 crew members on board. Before departure, the flight crew members obtained their arrival weather forecast, which included the possibility of thunderstorms. While approaching Toronto, the flight crew members were advised of weather-related delays. On final approach, they were advised that the crew of an aircraft landing ahead of them had reported poor braking action, and Air France Flight 358’s aircraft weather radar was displaying heavy precipitation encroaching on the runway from the northwest. At about 200 feet above the runway threshold, while on the instrument landing system approach to Runway 24L with autopilot and autothrust disconnected, the aircraft deviated above the glideslope and the groundspeed began to increase. The aircraft crossed the runway threshold about 40 feet above the glideslope. During the flare, the aircraft travelled through an area of heavy rain, and visual contact with the runway environment was significantly reduced. There were numerous lightning strikes occurring, particularly at the far end of the runway. The aircraft touched down about 3800 feet down the runway, reverse thrust was selected about 12.8 seconds after landing, and full reverse was selected 16.4 seconds after touchdown. The aircraft was not able to stop on the 9000-foot runway and departed the far end at a ground speed of about 80 knots. The aircraft stopped in a ravine at 2002 UTC (1602 eastern daylight time) and caught fire. All passengers and crew members were able to evacuate the aircraft before the fire reached the escape routes. A total of 2 crew members and 10 passengers were seriously injured during the crash and the ensuing
evacuation.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew conducted an approach and landing in the midst of a severe and rapidly changing thunderstorm. There were no procedures within Air France related to distance required from thunderstorms during approaches and landing, nor were these required by regulations.
2. After the autopilot and autothrust systems were disengaged, the pilot flying (PF) increased the thrust in reaction to a decrease in the airspeed and a perception that the aircraft was sinking. The power increase contributed to an increase in aircraft energy and the aircraft deviated above the glide path.
3. At about 300 feet above ground level (agl), the surface wind began to shift from a headwind component to a 10-knot tailwind component, increasing the aircraft’s groundspeed and effectively changing the flight path. The aircraft crossed the runway threshold about 40 feet above the normal threshold crossing height.
4. Approaching the threshold, the aircraft entered an intense downpour, and the forward visibility became severely reduced.
5. When the aircraft was near the threshold, the crew members became committed to the landing and believed their go-around option no longer existed.
6. The touchdown was long because the aircraft floated due to its excess speed over the threshold and because the intense rain and lightning made visual contact with the runway very difficult.
7. The aircraft touched down about 3800 feet from the threshold of Runway 24L, which left about 5100 feet of runway available to stop. The aircraft overran the end of Runway 24L at about 80 knots and was destroyed by fire when it entered the ravine.
8. Selection of the thrust reversers was delayed as was the subsequent application of full reverse thrust.
9. The pilot not flying (PNF) did not make the standard callouts concerning the spoilers and thrust reversers during the landing roll. This further contributed to the delay in the PF selecting the thrust reversers.
10. Because the runway was contaminated by water, the strength of the crosswind at touchdown exceeded the landing limits of the aircraft.
11. There were no landing distances indicated on the operational flight plan for a contaminated runway condition at the Toronto/Lester B. Pearson International Airport (CYYZ).
12. Despite aviation routine weather reports (METARs) calling for thunderstorms at CYYZ at the expected time of landing, the crew did not calculate the landing distance required for Runway 24L. Consequently, they were not aware of the margin of error available for the landing runway nor that it was eliminated once the tailwind was experienced.
13. Although the area up to 150 m beyond the end of Runway 24L was compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond this point, along the extended runway centreline, contributed to aircraft damage and to the injuries to crew and passengers.
14. The downpour diluted the firefighting foam agent and reduced its efficiency in dousing the fuel-fed fire, which eventually destroyed most of the aircraft.
Findings as to Risk :
1. In the absence of clear guidelines with respect to the conduct of approaches into convective weather, there is a greater likelihood that crews will continue to conduct approaches into such conditions, increasing the risk of an approach and landing accident.
2. A policy where only the captain can make the decision to conduct a missed approach can increase the likelihood that an unsafe condition will not be recognized early and, therefore, increase the time it might otherwise take to initiate a missed approach.
3. Although it could not be determined whether the use of the rain repellent system would have improved the forward visibility in the downpour, the crew did not have adequate information about the capabilities and operation of the rain repellent system and did not consider using it.
4. The information available to flight crews on initial approach in convective weather does not optimally assist them in developing a clear idea of the weather that may be encountered later in the approach.
5. During approaches in convective weather, crews may falsely rely on air traffic control (ATC) to provide them with suggestions and directions as to whether to land or not.
6. Some pilots have the impression that ATC will close the airport if weather conditions make landings unsafe; ATC has no such mandate.
7. Wind information from ground-based measuring systems (anemometers) is critical to the safe landing of aircraft. Redundancy of the system should prevent a single-point failure from causing a total loss of relevant wind information.
8. The emergency power for both the public address (PA) and EVAC alert systems are located in the avionics bay. A less vulnerable system and/or location would reduce the risk of these systems failing during a survivable crash.
9. Brace commands were not given by the cabin crew during this unexpected emergency condition. Although it could not be determined if some of the passengers were injured as a result, research shows that the risk of injury is reduced if passengers brace properly.
10. Safety information cards given to passengers travelling in the flight decks of Air France Airbus A340-313 aircraft do not include illustrations depicting emergency exit windows, descent ropes or the evacuation panel in the flight deck doors.
11. There are no clear visual cues to indicate that some dual-lane slides actually have two lanes. As a result, these slides were used mostly as single-lane slides. This likely slowed the evacuation, but this fact was not seen as a contributing factor to the injuries suffered by the passengers.
12. Although all passengers managed to evacuate, the evacuation was impeded because nearly 50 per cent of the passengers retrieved carry-on baggage.
Other Findings:
1. There is no indication that the captain’s medical condition or fatigue played a role in this occurrence.
2. The crew did not request long aerodrome forecast (TAF) information while en route. This did not affect the outcome of this occurrence because the CYYZ forecast did not change appreciably from information the flight crew members received before departure, and they received updated METARs for CYYZ and Niagara Falls International Airport (KIAG).
3. The possibility of a diversion required the flight crew to check the weather for various potential alternates and to complete fuel calculations. Although these activities consumed considerable time and energy, there is no indication that they were unusual for this type of operation or that they overtaxed the flight crew.
4. The decision to continue with the approach was consistent with normal industry practice, in that the crew could continue with the intent to land while maintaining the option to discontinue the approach if they assessed that the conditions were becoming unsafe.
5. There is no indication that more sophisticated ATC weather radar information, had it been available and communicated to the crew, would have altered their decision to continue to land.
6. It could not be determined why door L2 opened before the aircraft came to a stop.
7. There is no indication that the aircraft was struck by lightning.
8. There is no information to indicate that the aircraft encountered windshear during its approach and landing.
9. The flight crew seats are certified to a lower standard than the cabin seats, which may have been a factor in the injuries incurred by the captain.
Final Report:

Crash of a Short 360-300 in Oshawa

Date & Time: Dec 16, 2004 at 2001 LT
Type of aircraft:
Operator:
Registration:
N748CC
Flight Type:
Survivors:
Yes
Schedule:
Toledo – Oshawa
MSN:
3748
YOM:
1988
Flight number:
SNC2917
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
400
Circumstances:
Air Cargo Carriers, Inc. Flight SNC2917, a Short Brothers SD3-60 aircraft (registration N748CC, serial number SH3748), was on a charter cargo flight from Toledo, Ohio, USA, to Oshawa, Ontario, with two pilots on board. The crew conducted an instrument flight rules approach to Oshawa Municipal Airport in night instrument meteorological conditions. At approximately 2000 eastern standard time, the aircraft landed on Runway 30, which was snow-covered. During the landing roll, the pilot flying noted poor braking action and observed the runway end lights approaching. He rejected the landing and conducted a go-around procedure. The aircraft became airborne, but it started to descend as it flew over lower terrain, striking an airport boundary fence. It continued until it struck rising terrain and then a line of forestation, where it came to an abrupt stop. The flight crew exited the aircraft and waited for rescue personnel to render assistance. The aircraft was substantially damaged, and both pilots sustained serious injuries. There was no post-crash fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
Other Finding:
1. The flight crew members were not advised that the potential Airworthiness Directive announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.
Final Report:

Crash of a Noorduyn Norseman VI in Birch Lake

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

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

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

Crash of a 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 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-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: