Crash of a Cessna 208B Grand Caravan in Nakina

Date & Time: Jan 3, 1997 at 1110 LT
Type of aircraft:
Operator:
Registration:
C-FTZF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nakina - Fort Hope
MSN:
208B-0389
YOM:
1994
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
1300.00
Circumstances:
At approximately 1110 eastern standard time (EST , the pilot commenced a scheduled cargo flight from Nakina, Ontario, to Fort Hope in a Cessna 208B Caravan, serial number 208B0389. The pilot reported that he selected the flaps to 20°, lined up on runway 09, and set the power at around 1,600 to 1,700 foot-pounds of torque. The torque redline is 1,865 foot-pounds. About 3/4 of the way through the take-off run, the aircraft began to yaw to the right, which the pilot initially compensated for by applying left rudder. As the airspeed increased and the nosewheel lifted off the runway, the right yaw became more pronounced, and the aircraft became more difficult to control. The aircraft became airborne at about 85 knots indicated airspeed (KIAS), with the pilot using left rudder and left aileron in his attempt to compensate for the yaw; however, he was not able to gain control of the aircraft. The aircraft touched down briefly on the runway, then became airborne again as the take-off continued. While flying at less than 20 feet above ground level over a small, frozen lake immediately off the end of the runway, the aircraft descended and struck the snow-covered surface of the lake. The aircraft was in a nose-high, right-wing-low attitude when it struck the ice. The aircraft flipped over and came to rest in an inverted position, approximately 1,000 feet past the end of the runway and 200 feet to the right of the extended right edge of the runway. The pilot received only minor injuries. He exited the aircraft and walked back to the flight office.
Probable cause:
The pilot experienced directional control difficulties during the take-off run, probably because the rudder trim was set at the near full left position. Because the rudder trim indicator could be moved without affecting the actual rudder trim, it is probable that it did not reflect the actual position of the rudder trim.
Final Report:

Crash of a Beechcraft D18S near Sioux Lookout

Date & Time: Jul 6, 1996
Type of aircraft:
Operator:
Registration:
C-FBGO
Flight Phase:
Survivors:
Yes
Schedule:
Fort Frances – Granite Lake
MSN:
A-865
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Fort Frances, Ontario, with the pilot and four passengers on a visual flight rules (VFR) flight to Granite Lake. The weather was overcast with good visibility on departure. However, about one-half of the way to Granite Lake, just north of Ignace, the pilot encountered an area of increasing rain and decreasing visibility. The pilot made several course deviations to find a route through the poor weather, but eventually could find neither a way out of the poor weather nor a lake with suitable conditions for landing. While manoeuvring at low level and with heavy rain obscuring the horizon, the pilot reported that the engines lost partial power because of carburettor icing. The pilot applied carburettor heat but was unable to restore engine power or sustain aircraft altitude. The pilot attempted to keep the aircraft level, and in a matter of seconds, the aircraft descended into the trees. The aircraft travelled approximately 500 feet through the trees; the left wing was torn off and a fuel-fed fire broke out almost immediately. All occupants survived the crash with minor injuries and exited the aircraft. The passenger occupying the copilot seat received burns to his upper body. The crash site was overflown about 15 minutes later by a second company pilot who transmitted a Mayday. The occupants were picked up by helicopter about one hour later
Probable cause:
The pilot continued the flight into adverse weather at low level and force-landed the aircraft into trees when the engines experienced a partial power loss that was probably caused by carburettor icing.
Final Report:

Crash of a De Havilland DHC-3 Otter near Cochenour

Date & Time: Jun 16, 1996 at 1914 LT
Type of aircraft:
Registration:
C-FMEL
Flight Phase:
Survivors:
Yes
Schedule:
Cochenour - Thunder Bay
MSN:
222
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The float-equipped DHC-3 (Otter), carrying the pilot and six passengers, departed the company's water base at Cochenour, Ontario, on a charter flight to Sandy Beach Lodge, located on Trout Lake approximately 25 miles to the east. The pilot levelled the aircraft and configured it for cruise flight at approximately 2,500 feet above sea level (asl). Shortly after level-off, the pilot heard a popping sound and noted a slight loss of engine power, and wisps of whitish-grey smoke entered the cabin. The aircraft instruments indicated normal engine operation, and the fire warning system did not activate. The pilot suspected that the engine had suffered a cylinder failure and turned to return to Cochenour. A passenger seated in the right front crew seat reported flames near the floor at the front, right corner of the cockpit. The pilot radioed the Thunder Bay Flight Service Station to advise of the emergency, had the passenger vacate the crew seat, and attempted to suppress the fire with a hand-held extinguisher. Thick, black smoke billowed into the cabin, restricting visibility and causing respiratory distress for all of the occupants. The pilot opened the left crew door in order to see ahead and landed the aircraft, still on fire, on McNeely Bay, the first available landing site. The aircraft landed hard but remained upright on the floats. The occupants left by the main door, with their life jackets, and were picked up almost immediately by nearby boats. The aircraft was consumed by fire within minutes after landing. The pilot suffered second degree burns to his face and right forearm, and the passenger in the right crew seat suffered burns to his right leg. The remaining five passengers escaped serious injury.
Probable cause:
Continued operation of the engine following an exhaust valve failure on the n°2 cylinder resulted in a flaming gas path near the right side of the firewall, an exhaust system overheat, and a subsequent cabin fire.
Final Report:

Crash of a De Havilland DHC-3 Otter in Salvesen Lake: 6 killed

Date & Time: Sep 20, 1995 at 1500 LT
Type of aircraft:
Operator:
Registration:
C-FGCV
Survivors:
No
Schedule:
Stewart Lake - Salvesen Lake
MSN:
2
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The single engine aircraft departed Stewart Lake, some 60 miles west of Dryden, on a charter flight to Salvesen Lake, carrying five anglers to a fishing camp. Upon landing on Salvesen Lake, the aircraft flipped over and became submerged. All six occupants were killed. It was reported that the landing was completed with a relative strong tailwind.

Crash of a BAe Nimrod MR.2P off Toronto: 7 killed

Date & Time: Sep 2, 1995
Type of aircraft:
Operator:
Registration:
XV239
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toronto - Toronto
MSN:
8014
YOM:
1969
Location:
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The Nimrod display aircraft and crew had deployed to Canada on 23 August 1995 for displays at Canadian Forces Base Shearwater and the Canadian International Air Show (CIAS) at Toronto. In excellent weather, with a light on-shore wind, the aircraft took off on time for its display. Upon completion of the safety checks, it ran in for the standard Nimrod display sequence which features two orbits and two dumb-bell turns. The latter manoeuvres each involved a turn away from the display line, a climb to not above 1,000 feet, followed by a turn in the opposite direction and descent, to fly back parallel with the display line. Having completed the two orbits, the first dumb-bell turn was completed uneventfully. After a slow flypast with undercarriage down, the aircraft entered its final manoeuvre, the second dumb-bell turn. It was seen to turn away approximately 75° to starboard under full power before the flaps were retracted to 20° and the undercarriage raised. The nose was then pitched up into a climbing attitude of 24°. As the aircraft passed 950 feet, engine power was reduced to almost flight idle, following which the speed reduced rapidly to 122 knots, below the 150 knots recommended and taught for that stage of the display. The aircraft was rolled to 70° of port bank, shortly afterwards reducing to 45°, and the nose lowered to 5° below the horizon. During this turn the airspeed increased slightly and the G-loading increased to 1 .6 G. However, the combination of the low airspeed and the G-loading led the aircraft to stall, whereupon the port wing dropped to 85° of bank and the nose dropped to 18° below the horizon. Full starboard aileron and full engine power were applied in an attempt to recover the aircraft but, by this stage, there was insufficient height to recover and the aircraft hit the water. All seven crew members were killed.
Probable cause:
The Inquiry determined that the captain made an error of judgement in modifying one of the display manoeuvres to the extent that he stalled the aircraft at a height and attitude from which recovery was impossible. The Inquiry considered that contributory factors could have included deficiencies in the flight deck crew's training and in the method of supervision which could have allowed the captain to develop an unsafe technique without full appreciation of the consequences.

Crash of a De Havilland DHC-2 Beaver in Pine Lake: 5 killed

Date & Time: Jun 18, 1995 at 1525 LT
Type of aircraft:
Operator:
Registration:
C-FGBC
Flight Phase:
Survivors:
No
Schedule:
Tukanee Lake – Pine Lake – White River – Wawa
MSN:
199
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Crashed in unknown circumstances shortly after takeoff from Pine Lake, killing all five occupants.

Crash of a Piper PA-31-350 Navajo Chieftain in Sioux Lookout: 5 killed

Date & Time: May 1, 1995 at 1330 LT
Operator:
Registration:
C-GYPZ
Flight Phase:
Survivors:
No
Schedule:
Sioux Lookout - Red Lake
MSN:
31-7652168
YOM:
1976
Flight number:
SNY3101
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1250
Captain / Total hours on type:
1000.00
Aircraft flight hours:
6784
Circumstances:
Bearskin flight 362, a Fairchild Swearingen Metro 23, departed Red Lake, Ontario, at 1300 central daylight saving time (CDT), with two pilots and one passenger on board, en route to Sioux Lookout on an instrument flight rules (IFR) flight plan. At approximately 30 nautical miles (nm) north of Sioux Lookout, the flight was cleared by the Winnipeg area control centre (ACC) for an approach to the Sioux Lookout airport. Air Sandy flight 3101, a Piper Navajo PA-31, departed Sioux Lookout at 1323 with one pilot and four passengers on board en route to Red Lake on a visual flight rules (VFR) flight. The pilot of Air Sandy 3101 reported clear of the Sioux Lookout control zone at 1326. No other communication was heard from the Air Sandy flight. At 1315 the Winnipeg ACC controller advised the Sioux Lookout Flight Service specialist that Bearskin 362 was inbound from Red Lake, estimating Sioux Lookout at 1332. At 1327, Bearskin 362 called Sioux Lookout Flight Service Station (FSS) and advised them they had been cleared for an approach and that they were cancelling IFR at 14 nm from the airport. At 1328, as Sioux Lookout FSS was giving an airport advisory to Bearskin 362, the specialist heard an emergency locator transmitter (ELT) emit a signal on the emergency frequencies. Moments later, the pilot of Bearskin 305, a Beechcraft B-99 in the vicinity of Sioux Lookout, advised the specialist that he had just seen a bright flare in the sky and that he was going to investigate. The pilot of Bearskin 305 stated that the flare had fallen to the ground and a fire was burning in a wooded area. A communications search was initiated to locate Bearskin 362, but the aircraft did not respond. A Search and Rescue aircraft from Trenton, Ontario, and an Ontario Ministry of Natural Resources (MNR) helicopter were dispatched to the site. The source of the fire was confirmed to be the Air Sandy aircraft. The MNR helicopter noticed debris and a fuel slick on a nearby lake, Lac Seul. It was later confirmed that Bearskin 362 had crashed into the lake. (See Appendix A.) The two aircraft collided in mid-air at 1328 during the hours of daylight at latitude 50º14'N and longitude 92º07'W, in visual meteorological conditions (VMC). All three persons on board the Bearskin aircraft and all five persons on board the Air Sandy aircraft were fatally injured.
Probable cause:
Neither flight crew saw the other aircraft in time to avoid the collision. Contributing to the occurrence were the inherent limitations of the see-and-avoid concept which preclude the effective separation of aircraft with high closure rates, the fact that neither crew was directly alerted to the presence of the other aircraft by the Flight Service specialist or by onboard electronic equipment, and an apparent lack of pilot understanding of how to optimize avoidance manoeuvring.
Final Report:

Crash of a Swearingen SA227CC Metro 23 in Sioux Lookout: 3 killed

Date & Time: May 1, 1995 at 1330 LT
Type of aircraft:
Operator:
Registration:
C-GYYB
Survivors:
No
Schedule:
Red Lake - Sioux Lookout
MSN:
CC-827B
YOM:
1993
Flight number:
BLS362
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7330
Captain / Total hours on type:
580.00
Copilot / Total flying hours:
2810
Copilot / Total hours on type:
355
Aircraft flight hours:
3200
Circumstances:
Bearskin flight 362, a Fairchild Swearingen Metro 23, departed Red Lake, Ontario, at 1300 central daylight saving time (CDT), with two pilots and one passenger on board, en route to Sioux Lookout on an instrument flight rules (IFR) flight plan. At approximately 30 nautical miles (nm) north of Sioux Lookout, the flight was cleared by the Winnipeg area control centre (ACC) for an approach to the Sioux Lookout airport. Air Sandy flight 3101, a Piper Navajo PA-31, departed Sioux Lookout at 1323 with one pilot and four passengers on board en route to Red Lake on a visual flight rules (VFR) flight. The pilot of Air Sandy 3101 reported clear of the Sioux Lookout control zone at 1326. No other communication was heard from the Air Sandy flight. At 1315 the Winnipeg ACC controller advised the Sioux Lookout Flight Service specialist that Bearskin 362 was inbound from Red Lake, estimating Sioux Lookout at 1332. At 1327, Bearskin 362 called Sioux Lookout Flight Service Station (FSS) and advised them they had been cleared for an approach and that they were cancelling IFR at 14 nm from the airport. At 1328, as Sioux Lookout FSS was giving an airport advisory to Bearskin 362, the specialist heard an emergency locator transmitter (ELT) emit a signal on the emergency frequencies. Moments later, the pilot of Bearskin 305, a Beechcraft B-99 in the vicinity of Sioux Lookout, advised the specialist that he had just seen a bright flare in the sky and that he was going to investigate. The pilot of Bearskin 305 stated that the flare had fallen to the ground and a fire was burning in a wooded area. A communications search was initiated to locate Bearskin 362, but the aircraft did not respond. A Search and Rescue aircraft from Trenton, Ontario, and an Ontario Ministry of Natural Resources (MNR) helicopter were dispatched to the site. The source of the fire was confirmed to be the Air Sandy aircraft. The MNR helicopter noticed debris and a fuel slick on a nearby lake, Lac Seul. It was later confirmed that Bearskin 362 had crashed into the lake. (See Appendix A.) The two aircraft collided in mid-air at 1328 during the hours of daylight at latitude 50º14'N and longitude 92º07'W, in visual meteorological conditions (VMC). All three persons on board the Bearskin aircraft and all five persons on board the Air Sandy aircraft were fatally injured.
Probable cause:
Neither flight crew saw the other aircraft in time to avoid the collision. Contributing to the occurrence were the inherent limitations of the see-and-avoid concept which preclude the effective separation of aircraft with high closure rates, the fact that neither crew was directly alerted to the presence of the other aircraft by the Flight Service specialist or by onboard electronic equipment, and an apparent lack of pilot understanding of how to optimize avoidance manoeuvring.
Final Report:

Crash of a Beechcraft A100 King Air in Big Trout Lake

Date & Time: Feb 21, 1995 at 1248 LT
Type of aircraft:
Operator:
Registration:
C-GYQT
Survivors:
Yes
Schedule:
Sioux Lookout - Big Trout Lake
MSN:
B-189
YOM:
1974
Flight number:
BLS324
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
800
Aircraft flight hours:
13739
Circumstances:
The crew of the Beechcraft A100, C-GYQT, were conducting a scheduled flight from Sioux Lookout, Ontario, to Big Trout Lake, Ontario, as Bearskin (BLS) 324. BLS324 departed Sioux Lookout with nine passengers and a crew of two at 1133 central standard time (CST) and arrived in the vicinity of Big Trout Lake at approximately 1240. The captain briefed an instrument approach with a circling procedure to runway 14. On descent to the radio beacon, the crew reportedly encountered flight visibilities of one mile and were in visual contact with the ground. When the aircraft was less than five miles from the airport, the crew heard a position report from another aircraft completing an approach to the airport. To ensure safe separation from the aircraft ahead, the captain elected to fly under visual flight rules to the southwest of the airport. Air Traffic Services radar data was obtained from the Big Trout Lake radar source. The radar data indicated that the crew descended to about 150 feet above ground level (agl) approximately 4.5 miles from the end of the landing runway and maintained 200 to 300 feet agl for some 50 seconds prior to impact. Immediately prior to impact, the radar data indicated that the aircraft was about 3 1/2 miles from the runway at about 300 feet agl and descending at more than 1,200 feet per minute. Throughout the approach, the first officer flew the aircraft visually with occasional reference to his instruments, while the captain navigated and maintained terrain clearance by visual reference to the terrain and issued instructions to the first officer. At approximately five miles from the runway, the crew turned onto the extended centre line of the runway and received a radio report from the other aircraft of local visibilities of less than 1/2 mile. The aircraft flew inbound over a wide expanse of lake, and the captain lowered the flaps in preparation for landing. Shortly thereafter, the captain became concerned with the reducing visibility and looked in the Company Approach Procedures binder that he held on his lap. The captain was aware of the danger of whiteout and intended to revert to instrument flight if whiteout were encountered. He had not previously removed the approach chart for Big Trout Lake and clipped it in the approach chart holder because he had discovered that the binder rings were broken and taped shut when he had performed his initial approach briefing. He intended to provide new approach information to the first officer so that a full instrument approach could be initiated from their current position. When the captain looked up from the binder, he observed the altimeter indicating a descent through 1,000 feet above sea level (asl) and called to the first officer, "Watch your altitude." Before a recovery could be initiated, the aircraft struck the frozen surface of the lake and bounced into the air. The captain initiated a recovery and then, concerned with the airworthiness of the aircraft, reduced power and attempted to land straight ahead. The aircraft crashed onto the frozen surface of the lake about 3/4 mile beyond the initial impact location. All passengers and crew survived the accident. However, the crew and several passengers sustained serious injuries. Rescuers from the local community reached the aircraft about two hours after the crash and all survivors were rescued within four hours. The more seriously injured were experiencing the effects of hypothermia when rescued. The accident occurred at 1248 CST, approximately three miles northwest of Big Trout Lake Airport, at latitude 53°49'N, longitude 089°53'W, at an elevation of 690 feet asl.
Probable cause:
While the crew were manoeuvring the aircraft to land and attempting to maintain visual flying conditions in reduced visibility, their workload was such that they missed, or unknowingly discounted, critical information provided by the altimeters and vertical speed indicators. Contributing factors were the whiteout conditions and the crew's decision to fly a visual approach at low altitude over an area where visual cues were minimal and visibility was reduced.
Final Report:

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: