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Crash of a Beechcraft A100 King Air in Chibougamau: 2 killed

Date & Time: Oct 25, 2007 at 0859 LT
Type of aircraft:
Operator:
Registration:
C-FNIF
Flight Type:
Survivors:
No
Schedule:
Val d’Or – Chibougamau
MSN:
B-178
YOM:
1973
Flight number:
CRQ501
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1800
Captain / Total hours on type:
122.00
Copilot / Total flying hours:
1022
Copilot / Total hours on type:
71
Circumstances:
The Beechcraft A100 (registration C-FNIF, serial number B-178), operated by Air Creebec Inc. on flight CRQ 501, was on a flight following instrument flight rules between Val-d’Or, Quebec, and Chibougamau/Chapais, Quebec, with two pilots on board. The aircraft flew a non-precision approach on Runway 05 of the Chibougamau/Chapais Airport, followed by a go-around. On the second approach, the aircraft descended below the cloud cover to the left of the runway centreline. A right turn was made to direct the aircraft towards the runway, followed by a steep left turn to line up with the runway centreline. Following this last turn, the aircraft struck the runway at about 500 feet from the threshold. A fire broke out when the impact occurred and the aircraft continued for almost 400 feet before stopping about 50 feet north of the runway. The first responders tried to control the fire using portable fire extinguishers but were not successful. The Chibougamau and Chapais fire departments arrived on the scene at about 0926 eastern daylight time, which was about 26 minutes after the crash. The aircraft was destroyed by the fire. The two pilots suffered fatal injuries.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was configured late for the approach, resulting in an unstable approach condition.
2. The pilot flying carried out a steep turn at a low altitude, thereby increasing the load factor. Consequently, the aircraft stalled at an altitude that was too low to allow the pilot to carry out a stall recovery procedure.
Findings as to Risk:
1. The time spent programming the global positioning system reduced the time available to manage the flight. Consequently, the crew did not make the required radio communications on the mandatory frequency, did not activate the aircraft radio control of aerodrome lighting (ARCAL), did not make the verbal calls specified in the standard operating procedures (SOPs), and configured the aircraft for the approach and landing too late.
2. During the second approach, the aircraft did a race-track pattern and descended below the safe obstacle clearance altitude, thereby increasing the risk of a controlled flight into terrain. The crew’s limited instrument flight rules (IFR) experience could have contributed to poor interpretation of the IFR procedures.
3. Non-compliance with communications procedures in a mandatory frequency area created a situation in which the pilots of both aircraft had poor knowledge of their respective positions, thereby increasing the risk of collision.
4. The pilot-in-command monitored approach (PICMA) procedure requires calls by the pilot not flying when the aircraft deviates from pre-established acceptable tolerances. However, no call is required to warn the pilot flying of an approaching steep bank.
5. The transfer of controls was not carried out as required by the PICMA procedure described in the SOPs. The transfer of controls at the co-pilot’s request could have taken the pilot-in-command by surprise, leaving little time to choose the best option.
6. Despite their limited amount of IFR experience in a multiple crew working environment, the two pilots were paired. Nothing prohibited this. Although the crew had received crew resource management (CRM) training, it still had little multiple crew experience and consequently little experience in applying the basic principles of CRM.
Other Findings:
1. The emergency locator transmitter (ELT) had activated after the impact but due to circuit board damage its transmission power was severely limited. This situation could have had serious consequences had there been any survivors.
2. The Chibougamau/Chapais airport does not have an aircraft rescue and firefighting service. Because the fire station is 23 kilometres from the airport, the firefighters arrived at the scene 26 minutes after the accident.
3. Although this accident does not meet the criteria of a controlled flight into terrain (CFIT), it nonetheless remains that a stabilized constant descent angle (SCDA) non-precision approach (NPA) would have provided an added defence tool to supplement the SOPs.
4. After the late call within the mandatory frequency (MF) area, the specialist at the Québec flight information centre asked the crew about its familiarity with the MF area while the aircraft was in a critical phase of the first approach, which was approaching the minimum descent altitude (MDA). This situation could have distracted the flight crew while they completed important tasks.
5. The standard checklist used by the flight crew made no reference to the enhanced ground proximity warning system (EGPWS). Therefore, the crew was not prompted to check it to ensure that it was properly activated before departure.
Final Report:

Crash of a Beechcraft A100 King Air in Chibougamau

Date & Time: Apr 19, 2004 at 1018 LT
Type of aircraft:
Operator:
Registration:
C-FMAI
Survivors:
Yes
Schedule:
Quebec - Chibougamau
MSN:
B-145
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11338
Captain / Total hours on type:
2600.00
Copilot / Total flying hours:
1176
Copilot / Total hours on type:
400
Circumstances:
The Beechcraft A100, registration C-FMAI, operated by Myrand Aviation Inc., was on a chartered instrument flight rules flight from QuÈbec/Jean Lesage International Airport, Quebec, to Chibougamau/Chapais Airport, Quebec, with two pilots and three passengers on board. The copilot was at the controls and was flying a non-precision approach for Runway 05. The pilot-in-command took the controls less than one mile from the runway threshold and saw the runway when they were over the threshold. At approximately 1018 eastern daylight time, the wheels touched down approximately 1500 feet from the end of Runway 05. The pilot-in-command realized that the remaining landing distance was insufficient. He told the co-pilot to retract the flaps and applied full power, but did not reveal his intentions. The co-pilot cut power, selected reverse pitch and applied full braking. The aircraft continued rolling through the runway end, sank into the gravel and snow, and stopped abruptly about 500 feet past the runway end. The aircraft was severely damaged. None of the occupants were injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was positioned over the runway threshold at an altitude that did not allow a landing at the beginning of the runway, and this, combined with a tailwind component and the wet runway surface, resulted in a runway excursion.
2. Failure to follow standard operating procedures and a lack of crew coordination contributed to confusion on landing, which prevented the crew from aborting the landing and executing a missed approach.
3. The pilot-in-command held several management positions within the company and controlled the pilot hiring and dismissal policies. This situation, combined with the level of experience of the co-pilot compared with that of the pilot-in-command, had an impact on crew cohesiveness.
Findings as to Risk:
1. The pilot-in-command of C-FMAI decided to execute an approach for Runway 05 without first ensuring that there would be no possible risk of collision with the other aircraft.
2. The regulatory requirement to conform to or avoid the traffic pattern formed by other aircraft is not explicit as to how the traffic pattern should be avoided, in terms of either altitude or distance, which can result in risks of collision.
3. The regulations do not indicate whether the missed approach segment should be considered part of the traffic pattern; this situation can lead pilots operating in uncontrolled airspace to believe that they are avoiding another aircraft executing an instrument approach when in reality a risk of collision exists.
Final Report:

Crash of a De Havilland DHC-3 Otter in Camp Placer

Date & Time: Apr 20, 1987
Type of aircraft:
Operator:
Registration:
C-FRWK
Survivors:
Yes
Schedule:
Chibougamau – Camp Placer
MSN:
450
YOM:
1965
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Otter, with five occupants on board, was on a charter from its base at Chibougamau to Camp Placer, 206 miles to the north-east. At destination, a sand runway 2,200 feet in length and 100 feet in width had been built on an esker. On either side, there was a 100 foot gradient with a thirty degree slope. The wind speed was twenty knots. According to the operating manual, the wind exceeded the seven knot cross-wind limitation for the aircraft under such conditions. When the tail wheel touched down, the Otter turned nose to the wind, left the runway and came to rest at the bottom of the esker, in a sorry state. The Otter was destroyed in the accident.
Source: Karl E. Hayes

Crash of a Grumman G-21A Goose in Pointe-Claire

Date & Time: Jun 17, 1958
Type of aircraft:
Registration:
CF-EXA
Survivors:
Yes
Schedule:
Chibougamau - Montreal
MSN:
B050
YOM:
1944
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Dorval Airport, both engines failed. The seaplane stalled and crashed in a prairie located at Pointe-Claire, few dozen yards from the airfield. All six occupants were injured, some of them seriously, and the aircraft was written off.
Probable cause:
On final approach, the pilot mistakenly put the fuel selector in a wrong position (empty tank), causing both engines to stop.

Crash of a Fairchild FC-2W3 in Chibougamau

Date & Time: Jan 9, 1929
Type of aircraft:
Registration:
G-CAIQ
Flight Phase:
Survivors:
Yes
MSN:
49
YOM:
1928
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route, the pilot encountered technical problems and attempted to make an emergency landing. The aircraft landed on a snow covered road and skidded for few dozen metres before coming to rest against pine trees. Both occupants were uninjured and the aircraft was damaged beyond repair.
Probable cause:
Unknown technical failure.