Crash of a De Havilland DHC-3 Otter in Otter Creek

Date & Time: Sep 12, 2001 at 1100 LT
Type of aircraft:
Operator:
Registration:
C-FQOS
Flight Phase:
Survivors:
Yes
MSN:
398
YOM:
1960
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Otter Creek near Goose Bay on a charter flight to a fishing lodge with three passengers and one pilot on board. The pilot reported he was in climb mode when the aircraft pitched forward and then nosed up before entering an uncontrollable nose-down descent, although it did not exhibit characteristics normally associated with an aerodynamic stall. It impacted the water hard, resulting in structural failure of the float supports and extensive damage to the fuselage. 'Lab Air 911', a Twin Otter medevac flight bound for Nain witnessed the incident and raised the alarm. All four occupants were rescued by boat while the aircraft sank in 55 feet of water.
Source: http://www.dhc-3archive.com/DHC-3_398.html

Crash of a Boeing 737-2E1F in Saint John's

Date & Time: Apr 4, 2001 at 0615 LT
Type of aircraft:
Operator:
Registration:
C-GDCC
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Montréal – Halifax – Saint John’s
MSN:
20681
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At 2320, Newfoundland daylight time, on 03 April 2001, the Royal Cargo flight, a Boeing 737-200, left Mirabel, Quebec, for a scheduled instrument flight rules cargo flight with two pilots on board. The flight was headed for Hamilton, Ontario; Mirabel; Halifax, Nova Scotia; St. John's, Newfoundland; and Mirabel. The flights from Mirabel to Halifax were uneventful. Before departure from Halifax, the pilot flying (PF) received the latest weather information for the flight to St. John's from the company dispatch; he did not ask for, or receive, the latest notices to airmen (NOTAMs). At 0545, the aircraft departed Halifax for St. John's. The PF was completing his line indoctrination training after having recently upgraded to captain. The training captain, who was the pilot not flying (PNF), occupied the right seat. After departure from Halifax, he contacted Halifax Flight Service Station (FSS) and received the latest weather report for St. John's, the 0530 aviation routine weather report (METAR). The weather was as follows: wind 050° magnetic (M) at 35, gusting to 40, knots; visibility 1 statute mile in light snow and blowing snow; ceiling 400 feet overcast; temperature -1°C; dew point -2°C; and altimeter 29.41 inches of mercury. The FSS passed runway surface condition (RSC) reports for both runways (11/29 and 16/34), including Canadian runway friction index (CRFI) readings of 0.25 for Runway 11/29 and 0.24 for Runway 16/34. The FSS specialist also provided the NOTAMs for St. John's, which included a NOTAM released more than five hours earlier advising of the unserviceability of the instrument landing system (ILS) for Runway 11. The flight crew had initially planned an ILS approach, landing on Runway 11 at St. John's. Because of the marginal weather, the loss of Runway 11/29, and his greater experience, the training captain decided to switch seats and assume the duties and full responsibilities as captain and PF. Returning to Halifax was not considered because the aircraft would be overweight for landing there. The option of diverting the flight to the alternate airport was also discussed by the crew; however, in the end, they felt that a safe landing was achievable in St. John's. At 0638:27, the PF contacted St. John's tower to ask if the approach to Runway 34 was still an option. The response indicated that Runway 34 was probably the only option because of the wind: 050°M (estimated) at 35, gusting to 40, knots. The ILS on Runway 11 was unserviceable, and the glidepath for Runway 29 was unserviceable. The only instrument approaches available were the localizer back course Runway 34 and the ILS Runway 16. Also, at about 0638, the Gander Area Control Centre (ACC) controller suggested to the crew that they obtain the 0630 automatic terminal information service (ATIS) for St. John's. The ATIS was reporting surface winds of 055°M at 20, gusting to 35, knots. The PNF attempted to obtain the ATIS information; however, because of a simultaneous radio transmission on the second VHF radio between the PF and St. John's tower, the ATIS information was not obtained. At 0641, the PNF contacted Gander ACC, which reported the winds at St. John's as 040°M at 13, gusting to 18, knots. The PNF pointed out the discrepancy in the two wind reports to the PF; however, there was no acknowledgement of the significance of the discrepancy. It was later determined that the discrepancy was an unserviceable anemometer at the St. John's airport due to ice accretion on the anemometer. The anemometer was providing a direct reading of the incorrect wind information to Gander ACC. Gander ACC was unaware of the unserviceability and unknowingly passed the incorrect wind information on to the flight crew. At 0644, Gander ACC transmitted a significant meteorological report (SIGMET), issued at 0412 and valid from 0415 to 0815, that included St. John's. The SIGMET forecast severe mechanical turbulence below 3000 feet due to surface wind gusts in excess of 50 knots. However, the crew may not have been listening to the SIGMET broadcast: while the ACC transmitted the SIGMET, the crew were discussing the application of an 18-knot quartering tailwind for the approach to Runway 16. This tailwind was well under the 50 knots described by the SIGMET. The crew did not acknowledge receipt of the SIGMET until prompted by the controller. Before the descent into St. John's, the crew discussed approach options. The approach to Runway 11 was discounted because of the unserviceability of the ILS, and Runway 34 was eliminated as an option because the weather was below its published approach minimums. The crew discussed the ILS approach to Runway 16. Although the PNF expressed concern about the tailwind, it was decided to attempt the approach because the wind reported by Gander ACC was within the aircraft's landing limits. In calculating the approach speed in preparation for the approach, there was confusion during the application of the tailwind and gust corrections to the landing reference speed (Vref ). The crew had correctly established a flap-30 Vref of 132 knots indicated airspeed (KIAS) and ultimately an approach speed of 142 KIAS. The approach speed calculations were derived using the incorrect wind information from Gander ACC; further, the crew added five knots for the gust increment to the nominal approach speed (Vref + 5 knots), that is, Vref + 10 knots. This incorrect calculation (adding the gust factor) was consistent with company practice at the time of the accident. During the descent, the crew also had difficulty completing the descent and approach checklists; there were several missteps and repeated attempts at completion of checks. Clearance for an ILS approach to Runway 16 was obtained from Gander ACC , and the crew was advised to contact St. John's tower. Just over two minutes before landing, the tower advised that the wind was 050°M (estimated) at 20, gusting to 35, knots and provided the following RSC report for Runway 16: Full length 170 feet wide, surface 30% very light dusting of snow and 70% compact snow and ice; remainder is 20% light snow, 80% compact snow and ice, windrow along the east side of the runway; friction index 0.20; and temperature -1°C at 0925. The aircraft crossed the final approach fix on the ILS glideslope at 150 KIAS. During the final approach, the airspeed steadily increased to 180 KIAS (ground speed 190 knots); the glidepath was maintained with a descent rate of 1000 feet per minute. From 1000 feet above sea level, no airspeed calls were made; altitude calls were made and responses were made. The Royal Boeing 737 operations manual states that the PNF shall call out significant deviations from programmed airspeed. In the descent, through 900 feet above sea level, the aircraft encountered turbulence resulting in uncommanded roll and pitch deviations and airspeed fluctuations of +/- 11 knots. At about 300 feet above decision height, the crew acquired visual references for landing. Approximately one minute before landing, St. John's tower transmitted the runway visual range, repeated the estimated surface wind (050°M [estimated] at 20, gusting to 35, knots), and issued a landing clearance to the aircraft; the PNF acknowledged this information. The aircraft touched down at 164 KIAS (27 KIAS above the desired touchdown speed of Vref), 2300 to 2500 feet beyond the threshold. Radar ground speed at touchdown was 180 knots. The wind at this point was determined to be about 050°M at 30 knots. Shortly after touchdown, the speed brakes and thrust reversers were deployed, and an engine pressure ratio (EPR) of 1.7 was reached 10 seconds after touchdown. Longitudinal deceleration was -0.37g within 1.3 seconds of touchdown, suggesting that a significant degree of effective wheel braking was achieved. With approximately 1100 feet of runway remaining, through a speed of 64 KIAS, reverse thrust increased to about 1.97 EPR on engine 1 and 2.15 EPR on engine 2. As the aircraft approached the end of the runway, the captain attempted to steer the aircraft to the right, toward the Delta taxiway intersection. Twenty-two seconds after touchdown, the aircraft exited the departure end of the runway into deep snow. The aircraft came to rest approximately 75 feet beyond and 53 feet to the right of the runway centreline on a heading of 235°M.
Probable cause:
Findings as to Causes and Contributing Factors:
1. A combination of excessive landing speed, extended touchdown point, and low runway friction coefficient resulted in the aircraft overrunning the runway.
Findings as to Risk:
1. Before departure from Halifax, the flight crew did not request nor did dispatch personnel inform the crew of the notice to airmen (NOTAM) advising of the instrument landing system's failure for Runway 11 at St. John's International Airport.
2. The St. John's dynamic wind information provided to the Gander Area Control Centre controller was inaccurate. The controller was not aware of this inaccuracy.
3. The crew applied tailwind corrections in accordance with company practices; however, these practices were not in accordance with those stated in the operations manual.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter in Davis Inlet: 1 killed

Date & Time: Mar 19, 1999 at 0945 LT
Operator:
Registration:
C-FWLQ
Flight Type:
Survivors:
Yes
Schedule:
Goose Bay - Davis Inlet
MSN:
724
YOM:
1980
Flight number:
PB960
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1600
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
70
Aircraft flight hours:
30490
Circumstances:
The flight was a pilot self-dispatched, non-scheduled cargo flight from Goose Bay to Davis Inlet, Newfoundland, and was operating as Speed Air 960 under a defence visual flight rules flight plan. Before the flight, the captain received weather information from the St. John's, Newfoundland, flight service station (FSS) via telephone and fax. The aircraft departed for Davis Inlet at 0815 Atlantic standard time (AST). The captain was the pilot flying (PF). During the first approach, the first officer (FO) had occasional visual glimpses of the snow on the surface. The captain descended the aircraft to the minimum descent altitude (MDA) of 1340 feet above sea level (asl). When the crew did not acquire the required visual references at the missed approach point, they executed a missed approach. On the second approach, the captain flew outbound from the beacon at 3000 feet asl until turning on the inbound track. It was decided that if visual contact of the surface was made at any time during the approach procedure, they would continue below the MDA in anticipation of the required visual references. The captain initiated a constant descent at approximately 1500 feet per minute with 10 degrees flap selected. The FO occasionally caught glimpses of the surface. At MDA, in whiteout conditions, the captain continued the descent. In the final stages of the descent, the FO acquired visual ground contact; 16 seconds before impact, the captain also acquired visual ground contact. At 8 seconds before impact, the crew selected maximum propeller revolutions per minute. The aircraft struck the ice in controlled flight two nautical miles (nm) from the airport (see Appendix B). During both approaches, the aircraft encountered airframe icing. The crew selected wing de-ice, which functioned normally by removing the ice.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain decided to descend below the minimum descent altitude (MDA) without the required visual references.
2. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice.
Findings as to Risk:
1. The flight crew did not follow company standard operating procedures.
2. Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present.
3. Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight.
4. The cargo was not adequately secured before departure, which increased the risk of injury to the crew.
5. The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight.
6. There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities.
7. The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation.
8. Records establish that the aircraft departed approximately 500 pounds overweight.
Other Findings:
1. The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training.
2. During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions.
3. There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches.
4. It was determined that an ice-contaminated tailplane stall did not occur.
5. The fuel weight was not properly recorded in the journey logbook.
6. The wreckage pattern was consistent with a controlled, shallow descent.
7. The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable.
Final Report:

Crash of a Pilatus PC-12/45 in Clarenville

Date & Time: May 18, 1998 at 1741 LT
Type of aircraft:
Registration:
C-FKAL
Survivors:
Yes
Schedule:
Saint John’s – Goose Bay
MSN:
151
YOM:
1996
Flight number:
FKL151
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4700
Captain / Total hours on type:
800.00
Aircraft flight hours:
3913
Circumstances:
The aircraft, a Pilatus PC-12, serial number 151, was on a scheduled domestic flight from St. John's, Newfoundland, to Goose Bay, Labrador, with the pilot, a company observer, and eight passengers on board. Twenty-three minutes into the flight, the aircraft turned back towards St. John's because of a low oil pressure indication. Eight minutes later, the engine(Pratt & Whitney PT6A-67B) had to be shut down because of a severe vibration. The pilot then turned towards Clarenville Airport, but was unable to reach the airfield. The aircraft was destroyed during the forced landing in a bog one and a half miles from the Clarenville Airport. The pilot, the company observer, and one passenger sustained serious injuries. The Board determined that the pilot did not follow the prescribed emergency procedure for low oil pressure, and the engine failed before he could land safely. The pilot's decision making was influenced by his belief that the low oil pressure indications were not valid. The engine failed as a result of an interruption of oil flow to the first-stage planet gear assembly; the cause of the oil flow interruption could not be determined.
Probable cause:
The pilot did not follow the prescribed emergency procedure for low oil pressure, and the engine failed before he could land safely. The pilot's decision making was influenced by his belief that the low oil pressure indications were not valid. The engine failed as a result of an interruption of oil flow to the first-stage planet gear assembly; the cause of the oil flow interruption could not be determined.
Final Report:

Crash of a Learjet 36A in Stephenville: 2 killed

Date & Time: Dec 6, 1996 at 0238 LT
Type of aircraft:
Operator:
Registration:
N14TX
Flight Type:
Survivors:
No
Schedule:
Grand Rapids – Stephenville – Shannon
MSN:
36-033
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5700
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
2800
Copilot / Total hours on type:
400
Circumstances:
Learjet L36A (serial number 033), N14TX, was on an instrument flight rules (IFR) flight from Grand Rapids, Michigan, to Stephenville, Newfoundland. At 0216 Newfoundland standard time (NST1), N14TX was cleared by Gander Area Control Centre (ACC) for an approach to the Stephenville airport. The co-pilot contacted the St. John=s Flight Service Station (FSS) and advised that they would be conducting an approach to runway 28. The FSS specialist relayed the latest Stephenville weather observation and runway surface condition report to the aircraft and requested that the crew advise St. John=s FSS when they had landed. When the crew of N14TX did not report after landing at Stephenville, the St. John=s FSS specialist advised Gander ACC that the aircraft was missing, and a search was begun. Initial information received by the agencies searching for the missing aircraft did not include the aircraft=s last recorded radar position. The wreckage was located approximately three hours and ten minutes after the aircraft was reported missing, within the airport perimeter, close to the last observed aircraft radar position. The aircraft struck a service road embankment in an inverted, wings-level attitude. The two crew members were fatally injured. The accident occurred during the hours of darkness at approximately 0238 NST.
Probable cause:
Shortly after crossing the runway threshold, the aircraft began moving to the left of the runway. The motion probably was undetected by the pilot until the aircraft touched down off the left side of the runway surface. The pilot did not maintain the proper aircraft attitude during an attempted missed approach, and the aircraft struck the terrain.
Final Report:

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

Date & Time: Sep 30, 1996
Type of aircraft:
Registration:
C-FFHF
Flight Phase:
Survivors:
No
Schedule:
Ugly Lake - Goose Bay
MSN:
19
YOM:
1949
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
894
Circumstances:
The pilot of C-FFHF, a float-equipped de Havilland DHC-2 Beaver, departed the company camp at Ugly Lake, Labrador, en route to Goose Bay. Prior to arriving at Goose Bay, the pilot contacted an overflying Air Labrador flight and advised them that he had landed on a pond and that he needed the SAR (search and rescue) time extended on his flight plan. The pilot also said that he would be departing the pond shortly, en route to Goose Bay. When C-FFHF did not arrive at the destination by the SAR time of 2030 Atlantic daylight saving time (ADT), a search was commenced. Seven days later, an oil slick and a paddle with the company name on it were identified on a pond about 66 nautical miles (nm) north of Goose Bay. Divers located the aircraft wreckage in 120 feet of water. The aircraft was destroyed and the bodies of the pilot and passenger were located inside the wreckage.
Probable cause:
It is probable that the pilot was unable to maintain visual reference with the surface sometime after take-off from the pond. The aircraft struck the water either during the pilot's attempt to regain visual reference or because the pilot lost control of the aircraft in reduced visibility.
Final Report:

Crash of a Douglas DC-3C in Kenty Lake

Date & Time: May 5, 1996 at 1400 LT
Type of aircraft:
Operator:
Registration:
C-GCZG
Flight Type:
Survivors:
Yes
MSN:
17118/34385
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing on the icy Kenty Lake, the right ski struck a snowbank, causing the gear to collapse. All three occupants were evacuated safely while the aircraft was damaged beyond repair.

Crash of a Cessna 402C near Wabush

Date & Time: Oct 22, 1995 at 1907 LT
Type of aircraft:
Registration:
N67850
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Auburn – Montreal – Schefferville
MSN:
402C-0410
YOM:
1980
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Cessna 402, with five persons on board, took off from Auburn, Indiana, USA, around 0630 local time (1130 Coordinated Universal Time (UTC)) for Schefferville, Quebec, with stops en route. Their final leg was from Montreal International (Dorval) to Schefferville, with Wabush, Newfoundland, as the alternate, and they took off at 1523 EDT (1923 UTC). The flights were conducted in accordance with instrument flight rules (IFR). While in cruising flight and west of Wabush, the pilot requested the weather conditions for Schefferville and Wabush. Because of poor conditions in Schefferville, the pilot decided to fly to his alternate, Wabush. During the ILS approach for runway 01, the aircraft was too high to complete the approach, and the pilot requested and received clearance to execute another one. During the missed approach, the pilot proceeded an unknown distance outbound and turned back toward the airport. During the inbound leg, the aircraft contacted trees on the side of a mountain, at an indicated altitude of 2,460 feet asl, and decelerated over a distance of about 900 feet. The aircraft came to rest 23 nautical miles north of the airport, on the extended centre line of runway 01, on a heading of 186 degrees magnetic. The aircraft crashed probably at just after 1907 ADT (2207 UTC) during the hours of darkness. All five occupants were injured.
Probable cause:
The pilot did not follow the missed approach procedure as published, particularly with regard to minimum altitudes, and the aircraft crashed on the side of a mountain.
Final Report:

Crash of a Swearingen SA226T Merlin IV in Deer Lake

Date & Time: Dec 6, 1993 at 0919 LT
Type of aircraft:
Operator:
Registration:
C-GVCY
Flight Type:
Survivors:
Yes
Schedule:
Saint John's - Deer Lake
MSN:
AT-003
YOM:
1974
Flight number:
AG601
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 25 at Deer Lake Airport, the aircraft deviated to the right and veered off a snow covered runway. It lost its undercarriage and came to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair. It is believed that the crew encountered technical problems with the reverse system on the right engine.

Crash of a Cessna 208B Grand Caravan near Postville: 1 killed

Date & Time: Feb 8, 1991 at 0812 LT
Type of aircraft:
Operator:
Registration:
C-FPEZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nain - Goose Bay
MSN:
208B-0120
YOM:
1988
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While on a cargo flight from Nain to Goose Bay, the pilot reported problems to ATC and was cleared to descend from 7,500 to 3,500 feet. Shortly later, the aircraft entered an uncontrolled descent and stuck the ground in a 55° nose-down attitude some 51 southwest of Postville. The pilot, sole on board was killed. At the time of the accident, weather conditions were considered as good without any icing conditions or atmospheric turbulences.
Probable cause:
The exact cause of the accident could not be determined.