Date & Time: May 25, 2012 at 1408 LT
Operator:
Registration:
C-FGBF
Survivors:
Yes
Schedule:
Edgar Lake - Lillabelle Lake
MSN:
168
YOM:
1952
Country:
Canada
Crew on board:
1
Crew fatalities:
1
Pax on board:
2
Pax fatalities:
1
Other fatalities:
0
Total fatalities:
2
Captain / Total flying hours:
1100
Captain / Total hours on type:
300
Aircraft flight hours:
22000
Circumstances:
The Cochrane Air Service de Havilland DHC-2 Mk.1 Beaver floatplane (registration C-FGBF, serial number 168) departed Edgar Lake, Ontario, with 2 passengers and 300 pounds of cargo on board. The aircraft was destined for the company’s main base located on Lillabelle Lake, Ontario, approximately 77 miles to the south. On arrival, a southwest-bound landing was attempted across the narrow width of the lake, as the winds favoured this direction. The pilot was unable to land the aircraft in the distance available and executed a go-around. At 1408, Eastern Daylight Time, shortly after full power application, the aircraft rolled quickly to the left and struck the water in a partially inverted attitude. The aircraft came to rest on the muddy lake bottom, partially suspended by the undamaged floats. The passenger in the front seat was able to exit the aircraft and was subsequently rescued. The pilot and rear-seat passenger were not able to exit and drowned. The emergency locator transmitter activated on impact.
Causes:
The investigation determined that the aircraft was maintained in accordance with existing rules and regulations, and that the company was operating within the rules and guidelines laid out in the Canadian Aviation Regulations (CARs) and the company operations manual. The analysis will therefore focus on the pilot, on the particular circumstances that led to the aircraft impacting the water, and on the underlying systemic safety issues within the floatplane industry. The wind at the time of the occurrence was very strong and gusty. While these conditions were known to the pilot, changes in wind speed and direction, as well as the mechanical turbulence caused by the wind’s passage over obstacles on the windward side of the approach, would have made for challenging landing conditions. There likely was an increase in headwind, which in turn increased the float time of the aircraft while in the landing flare. As the available landing distance was used up in this landing flare, the pilot decided to conduct a missed approach, applied power, and increased the aircraft angle of attack. It is possible that the pilot inadvertently allowed the aircraft speed to bleed off, or perhaps a change in the headwind component due to the gusty winds (wind shear) resulted in a sudden drop in airspeed below the stall speed. The rapid application of full power caused the aircraft to yaw to the left, and a left roll quickly developed. This movement, in combination with a high angle of attack and low airspeed, likely caused the aircraft to stall. The altitude available to regain control before striking the water was insufficient. The aircraft was not equipped with a stall warning system, which may have given the pilot additional warning of an impending stall.
Final Report:
C-FGBF.pdf304.3 KB