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Crash of a De Havilland DHC-3 Otter near Ivanhoe Lake: 1 killed

Date & Time: Aug 22, 2013 at 1908 LT
Type of aircraft:
Operator:
Registration:
C-FSGD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Scott Lake Lodge - Ivanhoe Lake
MSN:
316
YOM:
1959
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1600
Captain / Total hours on type:
248.00
Circumstances:
The float-equipped Transwest Air Limited Partnership DHC-3 turbine Otter (registration C-FSGD, serial number 316) departed Scott Lake, Northwest Territories, at approximately 1850 Central Standard Time on a 33-nautical mile, day, visual flight rules flight to Ivanhoe Lake, Northwest Territories. The aircraft did not arrive at its destination, and was reported overdue at approximately 2100. The Joint Rescue Coordination Centre Trenton was notified by the company. There was no emergency locator transmitter signal. A search and rescue C-130 Hercules aircraft was dispatched; the aircraft wreckage was located on 23 August 2013, in an unnamed lake, 10 nautical miles north of the last reported position. The pilot, who was the sole occupant of the aircraft, sustained fatal injuries.
Probable cause:
Findings as to causes and contributing factors:
1. During approach to landing on the previous flight, the right-wing leading-edge and wing tip were damaged by impact with several trees.
2. The damage to the aircraft was not evaluated or inspected by qualified personnel prior to take-off.
3. Cumulative unmanaged stressors disrupted the pilot’s processing of safety-critical information, and likely contributed to an unsafe decision to depart with a damaged, uninspected aircraft.
4. The aircraft was operated in a damaged condition and departed controlled flight likely due to interference between parts of the failing wing tip, acting under air loads, and the right aileron.
Findings as to risk:
Not applicable.
Other findings:
1. The emergency locator transmitter did not activate, due to crash damage and submersion in water.
2. The aircraft was not fitted with FM radio equipment that is usually carried by aircraft servicing the lodge. Lodge personnel did not have a means to contact the pilot once the aircraft moved away from the dock.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 in La Ronge

Date & Time: Feb 4, 2009 at 0915 LT
Operator:
Registration:
C-FCCE
Flight Phase:
Survivors:
Yes
Schedule:
La Ronge – Deschambeault Lake
MSN:
8
YOM:
1966
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
11000.00
Copilot / Total flying hours:
625
Copilot / Total hours on type:
425
Circumstances:
The aircraft was taking off from a ski strip east of and parallel to Runway 36 at La Ronge. After the nose ski cleared the snow, the left wing rose and the aircraft veered to the right and the captain, who was the pilot flying, continued the take-off. The right ski, however, was still in contact with the snow. The aircraft became airborne briefly as it cleared a deep gully to the right of the runway. The aircraft remained in a steep right bank and the right wing contacted the snow-covered ground. The aircraft flew through a chain link fence and crashed into trees surrounding the airport. The five passengers and two crewmembers evacuated the aircraft with minor injuries. There was a small fire near the right engine exhaust that was immediately extinguished by the crew.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Contamination on the wings of the aircraft was not fully removed before take-off. It is likely that asymmetric contamination of the wings created a lift differential and a loss of lateral control.
2. Although the operator was not authorized for short take-off and landing (STOL) take-off on this aircraft, the crew conducted a STOL take-off, which reduced the aircraft’s safety margin relative to its stalling speed and minimum control speed.
3. As a result of the loss of lateral control, the slow STOL take-off speed, and the manipulation of the flaps, the aircraft did not remain airborne and veered right, colliding with obstacles beside the ski strip.
Findings as to Risk:
1. The out of phase task requirements regarding the engine vibration isolator assembly, as listed in the operator’s maintenance schedule approval, results in a less than thorough inspection requirement, increasing the likelihood of fatigue cracks remaining undetected.
2. The right engine inboard and top engine mounts had pre-existing fatigue cracks, increasing the risk of catastrophic failure.
Other Findings:
1. The cockpit voice recorder (CVR) contained audio of a previous flight and was not in operation during the occurrence flight. Minimum equipment list (MEL) procedures for logbook entries and placarding were not followed.
2. The Transwest Air Limited safety management system (SMS) did not identify deviations from standard operating procedures.
Final Report:

Crash of a Beechcraft A100 King Air in Sandy Bay: 1 killed

Date & Time: Jan 7, 2007 at 2002 LT
Type of aircraft:
Operator:
Registration:
C-GFFN
Flight Type:
Survivors:
Yes
Schedule:
La Ronge – Sandy Bay
MSN:
B-190
YOM:
1974
Flight number:
TW350
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8814
Captain / Total hours on type:
449.00
Copilot / Total flying hours:
672
Copilot / Total hours on type:
439
Aircraft flight hours:
17066
Circumstances:
The aircraft departed La Ronge, Saskatchewan, at 1930 central standard time under instrument flight rules to Sandy Bay, with two flight crew members and two emergency medical technicians aboard. TW350 was operating under Part VII, Subpart 3, Air Taxi Operations, of the Canadian Aviation Regulations. At 1948, air traffic control cleared TW350 out of controlled airspace via the Sandy Bay Runway 05 non-directional beacon approach. The crew flew the approach straight-in to Runway 05 and initiated a go-around from the landing flare. The aircraft did not maintain a positive rate of climb during the go-around and collided with trees just beyond the departure end of the runway. All four occupants survived the impact and evacuated the aircraft. The captain died of his injuries before rescuers arrived. Both emergency medical technicians were seriously injured, and the first officer received minor injuries. The aircraft sustained substantial damage from impact forces and was subsequently destroyed by a post-impact fire. The accident occurred at 2002 during the hours of darkness.
Probable cause:
Findings as to Risk:
1. Some Canadian Air Regulations (CARs) subpart 703 air taxi and subpart 704 commuter operators are unlikely to provide initial or recurrent CRM training to pilots in the absence of a regulatory requirement to do so. Consequently, these commercial pilots may be unprepared to avoid, trap, or mitigate crew errors encountered during flight.
2. Transport Canada (TC) Prairie and Northern Region (PNR) management practices regarding the June 2006 replacement of the regional combined audit program, in order to manage safety management system (SMS) workload, did not conform to TC’s risk management decision-making policies. Reallocation of resources without assessment of risk could result in undetected regulatory non-compliance.
3. Although TC safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated by the PNR managers because of the limitations of the oversight system in place at that time.
4. It is likely that the National Aviation Company Information System (NACIS) records for other audits include inaccurate information resulting from data entry errors and wide use of the problematic audit tracking form, reducing the effectiveness of the NACIS as a management tracking system.
5. Self-dispatch systems rely on correct assessment of operational hazards by pilots, particularly in the case of unscheduled commercial service into uncertified aerodromes. Unless pilots are provided with adequate decision support tools, flights may be dispatched with defences that are less than adequate.
6. TWA King Air crews did not use any standard practice in applying cold temperature altitude corrections. Inconsistent application of temperature corrections by flight crews can result in reduction of obstacle clearance to less than the minimum required and reduced safety margins.
7. The practice of not visually verifying wind/runway conditions at aerodromes where this information is otherwise unavailable increases the risk of post-touchdown problems.
8. The company dispatched flights to Sandy Bay without a standard means for crews to deal with non-current altimeter settings. Use of non-current or inappropriate altimeter settings can reduce minimum obstacle clearance and safety margins.
9. The crew was likely unaware of their ¼ nautical mile (nm) error in the aircraft position in relation to the runway threshold resulting from use of the global positioning system (GPS). Unauthorized and informal use of the GPS by untrained crews during instrument flight rules (IFR) approaches can introduce rather than mitigate risk.
10. Widespread adaptations by the King Air pilots resulted in significant deviations from the company’s SOPs, notwithstanding the company’s disciplinary policy.
11. In a SMS environment, inappropriate use of punitive actions can result in a decrease in the number of hazards and occurrences reported, thereby reducing effectiveness of the SMS.
12. Pilot workload is increased and decision making becomes more complicated where limited visual cues are available for assessing aircraft orientation relative to runway and surrounding terrain.
13. Aerodromes with limited visual cues and navigational aids are not explicitly identified in flight information publications as hazardous for night/IFR approaches. Passengers and crews will continue to be exposed to this hazard unless aircraft and aerodrome operators carry out risk assessments to identify them and take mitigating action.
14. To properly assess applicants for pilot positions, operators need access to information on experience and performance that is factual, objective, and (preferably) standardized. Because some employers are unprepared to provide this information—fearing legal action—this may lead to the appointment of pilots to positions for which they are unsuited, thereby compromising safety.
Other Findings:
1. TWA’s safety management system was not yet capable or expected to be capable of detecting, analyzing, and mitigating the risks presented by the hazards underlying this occurrence.
2. The first officer and captain met competency standards on the completion of their initial flight training before they began employment as line pilots.
3. It is very likely that the captain became the pilot flying for the remaining 20 seconds of the flight. The scenario that neither pilot was controlling the aircraft at that time is considered very unlikely.
Final Report:

Crash of a Beechcraft A100 King Air in La Ronge

Date & Time: Dec 30, 2005 at 1500 LT
Type of aircraft:
Operator:
Registration:
C-GAPK
Flight Type:
Survivors:
Yes
Schedule:
Pinehouse Lake – La Ronge
MSN:
B-198
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Beechcraft A100 King Air, C-GAPK was inbound to La Ronge Airport, SK (YVC), from Pinehouse Lake on a medevac flight. On descent into La Ronge the crew noticed ice building on the wing leading edges. At approximately 6 miles back on final the crew operated the wing de-ice boots, however a substantial amount of residual ice remained after application of the boots. It was reported that in the landing flare at about 100 knots, the aircraft experienced an ice-induced stall from an altitude of about 20 feet followed by a hard landing. The right wing and nacelle buckled forward and downward from the landing impact forces to the extent that the right propeller struck the runway surface while the aircraft was taxiing off the runway.

Crash of a Beechcraft 99A Airliner in Prince Albert

Date & Time: Apr 23, 2003 at 1802 LT
Type of aircraft:
Operator:
Registration:
C-FDYF
Survivors:
Yes
Schedule:
Saskatoon – Prince Albert
MSN:
U-110
YOM:
1969
Flight number:
TW602
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was on a scheduled flight from Saskatoon, Saskatchewan, to Prince Albert, Saskatchewan, with two pilots and four passengers on board. The aircraft was approximately 4000 feet above sea level when the crew selected the flaps for the approach to Prince Albert. A bang was heard from the rear of the fuselage. The aircraft commenced an uncommanded pitch-up to a near-vertical attitude, then stalled, nosed over, and began a spin to the left. The crew countered the spin but the aircraft continued to descend in a near-vertical dive. Through the application of full-up elevator and the manipulation of power settings, the pilots were able to bring the aircraft to a near-horizontal attitude. The crew extended the landing gear and issued a Mayday call, indicating that they were conducting a forced landing. The aircraft struck a knoll, tearing away the belly cargo pod and the landing gear. The aircraft bounced into the air and travelled approximately 180 metres, then contacted a barbed-wire fence and slid to a stop approximately 600 metres from the initial impact point. The crew and passengers suffered serious but non-life-threatening injuries. All of the occupants exited through the main cabin door at the rear of the aircraft. The accident occurred during daylight hours at 1802 central standard time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. During flight, the horizontal stabilizer trim actuator worked free of the mounting structure, and as a result, the flight crew lost pitch control of the aircraft.
2. During replacement of the horizontal stabilizer trim actuator, the upper attachment bolts were inserted through the airframe structure but did not pass through the upper mounting lugs of the
trim actuator.
3. The improperly installed bolts trapped the actuator mounting lug assemblies, suspending the weight of the actuator and giving the false impression that the bolts had been correctly installed.
4. Dual inspections, ground testing, and flight testing did not reveal the faulty attachment.
Findings as to Risk:
1. The nature of the installation presents a risk that qualified persons may inadvertently install Beech 99 and Beech 100 horizontal stabilizer trim actuators incorrectly. There are no published warnings to advise installers that there is a potential to install the actuator incorrectly.
Final Report: