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Crash of a De Havilland DHC-2 Beaver near Lake Boulene: 3 killed

Date & Time: Jul 12, 2019
Type of aircraft:
Operator:
Registration:
C-GRHF
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
MSN:
1123
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine airplane departed La Minerve, in the Laurentides, in the afternoon, on a flight to a fishing camp located by a small lake northeast of Chibougamau. En route, the airplane crashed in unknown circumstances near Lake Boulène, about 100 km south of Chibougamau. The wreckage was spotted few hours later by the crew of a RCAF C-130 Hercules in a remote area. A passenger was injured while three other occupants, among them pilot Jim Duggan, were killed.

Crash of a Piper PA-31-310 Navajo near Schefferville: 2 killed

Date & Time: Apr 30, 2017 at 2015 LT
Type of aircraft:
Operator:
Registration:
C-FQQB
Flight Phase:
Survivors:
No
Site:
Schedule:
Schefferville - Schefferville
MSN:
31-310
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was flying over the territory bordering the Caniapiscau River on a geological mission on behalf of Geo Data Solution (GDS), a subcontractor of the Ministry of Natural Resources of Canada, looking for metals in the soils. Following an uneventful flight, the crew was returning to Schefferville Airport when the twin engine aircraft crashed in unknown circumstances in a snow covered field located north of the city. The wreckage was found few hours later and both occupants were killed. According to preliminary report, the left engine hit power cables that were found twisted around the left propeller.

Crash of a Mitsubishi MU-2B-60 Marquise in Le Havre-aux-Maisons: 7 killed

Date & Time: Mar 29, 2016 at 1230 LT
Type of aircraft:
Operator:
Registration:
N246W
Flight Type:
Survivors:
No
Schedule:
Montreal - Le Havre-aux-Maisons
MSN:
1552
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
2500
Captain / Total hours on type:
125.00
Copilot / Total flying hours:
834
Aircraft flight hours:
11758
Circumstances:
The twin engine aircraft left Montreal-Saint-Hubert Airport at 0930LT for a two hours flight to Le Havre-aux-Maisons, on Magdalen Islands. Upon arrival, weather conditions were marginal with low ceiling, visibility up to two miles, rain and wind gusting to 30 knots. During the final approach to Runway 07, when the aircraft was 1.4 nautical miles west-southwest of the airport, it deviated south of the approach path. At approximately 1230 Atlantic Daylight Time, aircraft control was lost,resulting in the aircraft striking the ground in a near-level attitude. The aircraft was destroyed and all seven occupants were killed, among them Jean Lapierre, political commentator and former Liberal federal cabinet minister of Transport. All passengers were flying to Magdalen Islands to the funeral of Lapierre's father, who died last Friday. The captain, Pascal Gosselin, was the founder and owner of Aérotechnik.
Crew:
Pascal Gosselin, pilot,
Fabrice Labourel, copilot.
Passengers:
Jean Lapierre,
Nicole Beaulieu, Jean Lapierre's wife,
Martine Lapierre, Jean Lapierre's sister,
Marc Lapierre, Jean Lapierre's brother,
Louis Lapierre, Jean Lapierre's brother.
Probable cause:
- The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach.
- The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
- A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.
- It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.
- The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.
- It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Les Bergeronnes: 6 killed

Date & Time: Aug 23, 2015 at 1340 LT
Type of aircraft:
Operator:
Registration:
C-FKRJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Lac Long - Lac Long
MSN:
1210
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
6000
Aircraft flight hours:
25000
Circumstances:
The single engine aircraft left Lac Long (Long Lake) located near Tadoussac for a sightseeing tour of 20 minutes. For unknown reason, control was lost and the Beaver crashed in a mountainous and wooded area located 6 km north of Les Bergeronnes. It was later confirmed that none of the six occupants survived. At the time of the accident, weather conditions were good with excellent visibility and no wind. While the pilot logged more than 6,000 flying hours and was with Air Saguenay since more than 14 years, the aircraft had about 25,000 flying hours.
Probable cause:
Findings as to causes and contributing factors:
- The pilot performed manoeuvres with a reduced safety margin at low altitudes. As a result, these flights involved a level of risk that was unnecessary to attain the objectives of sightseeing flights.
- With no restrictions on manoeuvres and no minimum altitude prescribed by the company prior to flight, the pilot flew according to his own limits and made a steep turn at approximately 110 feet above ground level.
- When the pilot made a steep left turn, aerodynamic stalling ensued, causing an incipient spin at an altitude insufficient to allow control of the aircraft to be regained prior to vertical collision with the terrain.
- The absence of an angle-of-attack indicator system and an impending stall warning device deprived the pilot of the last line of defence against loss of control of the aircraft.
Final Report:

Crash of a Beechcraft King Air 100 in Saint-Mathieu-de-Beloeil

Date & Time: Jun 10, 2013 at 1726 LT
Type of aircraft:
Operator:
Registration:
C-GJSU
Survivors:
Yes
Schedule:
Montreal - Saint-Mathieu-de-Beloeil
MSN:
B-088
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Saint-Mathieu-de-Beloeil Airport, while on a taxi flight from Montreal-Saint-Hubert Airport, both engine failed simultaneously and aircraft stalled and crashed half a mile short of runway. All four occupants were injured, one of them seriously. Aircraft was damaged beyond repair. Double engine failure due to fuel exhaustion or fuel system management failure suspected.

Crash of a Beechcraft King Air B100 in Montmagny

Date & Time: Sep 22, 2010 at 1700 LT
Type of aircraft:
Operator:
Registration:
C-FSIK
Flight Phase:
Survivors:
Yes
Schedule:
Montmagny - Montreal
MSN:
BE-39
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
675
Circumstances:
Aircraft was operating as flight MAX100 on an instrument flight rules flight from Montmagny to Montreal/St-Hubert, Quebec, with 2 pilots and 4 passengers on board. At approximately 1700 Eastern Daylight Time, the aircraft moved into position on the threshold of 3010-foot-long runway 26 and initiated the take-off. On the rotation, at approximately 100 knots, the flight crew saw numerous birds in the last quarter of the runway. While getting airborne, the aircraft struck the birds and the left engine lost power, causing the aircraft to yaw and roll to the left. The aircraft lost altitude and touched the runway to the left of the centre line and less than 100 feet from the runway end. The take-off was aborted and the aircraft overran the runway, coming to rest in a field 885 feet from the runway end. All occupants evacuated the aircraft via the main door. There were no injuries. The aircraft was substantially damaged.
Probable cause:
Findings As To Causes and Contributing Factors:
The bird strike occurred on take-off at an altitude of less than 50 feet. Gulls were ingested in the left engine, which then lost power.
After the loss of engine power, the flight crew had difficulty controlling the aircraft. The aircraft touched the ground, forcing the pilot flying to abort the take-off when the runway remaining was insufficient to stop the aircraft, resulting in the runway overrun.
Findings As To Risks:
Although a cannon was in place, it was not working on the day of the accident, which increased the risk of a bird strike.
The presence of a goose and duck farm outside the airport perimeter but near a runway increases the risk of attracting gulls.
Operators subject to Canadian Aviation Regulations Subpart 703 are not prohibited from having an aircraft take off from a runway that is shorter than the accelerate-stop distance of that aircraft as determined from the performance diagrams. Consequently, travellers carried by these operators are exposed to the risks associated with a runway overrun when a take-off is aborted.
The absence of a CVR makes it harder to ascertain material facts. Consequently, investigations can take more time, resulting in delays which compromise public safety.
Final Report:

Crash of a De Havilland DHC-2 Beaver in La Grande: 2 killed

Date & Time: Jul 24, 2010 at 1053 LT
Type of aircraft:
Operator:
Registration:
C-FGYK
Flight Phase:
Survivors:
Yes
Schedule:
La Grande - Lac Eau Claire
MSN:
0123
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3800
Captain / Total hours on type:
1000.00
Aircraft flight hours:
23808
Circumstances:
At approximately 1053 Eastern Daylight Time, de Havilland DHC-2 Mk. 1 amphibious floatplane (registration C-FGYK, serial number 123), operated by Nordair Québec 2000 Inc., took off from runway 31 at La Grande-Rivière Airport, Quebec, for a visual flight rules flight to l’Eau Claire Lake, Quebec, about 190 nautical miles to the north. The take-off run was longer than usual. The aircraft became airborne but was unable to gain altitude. At the runway end, at approximately 50 feet above ground level, the aircraft pitched up and banked left. It then nosed down and crashed in a small shallow lake. The pilot and 1 front-seat passenger were fatally injured and the 3 rear-seat passengers sustained serious injuries. The aircraft broke up on impact, and the forward part of the cockpit was partly submerged. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was overloaded and its centre of gravity was beyond the aft limit. The aircraft pitched up and stalled at an altitude that did not allow the pilot to execute the stall recovery manoeuvre.
2. The baggage was not secured. Shifting of the baggage caused the triple seat to pivot forward, propelling the 3 rear-seat passengers against the pilot and front-seat passenger during impact.
3. Although the design of the triple seat met aviation standards, it separated from the floor at the time of impact, principally due to the fact that the heavy cargo shifted.
4. The action taken by TC did not have the desired outcomes to ensure regulatory compliance; consequently, unsafe practices persisted.
Finding as to Risk:
1. Operating an aircraft outside the limits and conditions under which a permit is issued can increase the risk of an accident
Final Report:

Crash of a De Havilland DHC-2 Beaver in Chute des Passes: 4 killed

Date & Time: Jul 16, 2010 at 1117 LT
Type of aircraft:
Operator:
Registration:
C-GAXL
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lac des Quatre - Lac Margane
MSN:
1032
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11500
Captain / Total hours on type:
9000.00
Aircraft flight hours:
17204
Circumstances:
The float-equipped de Havilland Beaver DHC-2 Mk.I (registration number C-GAXL, serial number 1032), operated by Air Saguenay (1980) Inc., was flying under visual flight rules from Lac des Quatre to Lac Margane, Quebec, with 1 pilot and 5 passengers on board. A few minutes after take-off, the pilot reported intentions of making a precautionary landing due to adverse weather conditions. At approximately 1117, Eastern Daylight Time, the aircraft hit a mountain, 12 nautical miles west-south-west of the southern part of Lac Péribonka. The aircraft was destroyed and partly consumed by the fire that broke out after the impact. The pilot and 3 passengers were killed; 1 passenger sustained serious injuries and 1 passenger sustained minor injuries. No ELT signal was received.
Probable cause:
Causes and Contributing Factors:
1. The pilot took off in weather conditions that were below the minimum for visual flight rules, and continued the flight in those conditions.
2. After a late decision to carry out a precautionary alighting, the pilot wound up in instrument meteorological conditions (IMC). Consequently, the visual references were reduced to the point of leading the aircraft to controlled flight into terrain (CFIT).
3. The passenger at the rear of the aircraft was not seated on a seat compliant with aeronautical standards. The passenger was ejected from the plane at the moment of impact, which diminished his chances of survival.
Findings as to Risk:
1. The lack of training on pilot decision-making (PDM) for air taxi operators exposes pilots and passengers to increased risk when flying in adverse weather conditions.
2. In view of the absence of an ELT signal and the operator’s delay in calling, search efforts were initiated more than 3 ½ hours after the accident. That additional time lag can influence the seriousness of injuries and the survival of the occupants.
Final Report:

Crash of a Beechcraft King Air 100 in Quebec City: 7 killed

Date & Time: Jun 23, 2010 at 0603 LT
Type of aircraft:
Operator:
Registration:
C-FGIN
Flight Phase:
Survivors:
No
Schedule:
Quebec City - Seven Islands - Natashquan
MSN:
B-164
YOM:
1973
Flight number:
APO201
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
3046
Captain / Total hours on type:
372.00
Copilot / Total flying hours:
2335
Copilot / Total hours on type:
455
Aircraft flight hours:
19665
Aircraft flight cycles:
16800
Circumstances:
Aircraft was making an instrument flight rules flight from Québec to Sept-Îles, Quebec. At 0557 Eastern Daylight Time, the crew started its take-off run on Runway 30 at the Québec/Jean Lesage International Airport; 68 seconds later, the co-pilot informed the airport controller that there was a problem with the right engine and that they would be returning to land on Runway 30. Shortly thereafter, the co-pilot requested aircraft rescue and fire-fighting (ARFF) services and informed the tower that the aircraft could no longer climb. A few seconds later, the aircraft struck the ground 1.5 nautical miles from the end of Runway 30. The aircraft continued its travel for 115 feet before striking a berm. The aircraft broke up and caught fire, coming to rest on its back 58 feet further on. The 2 crew members and 5 passengers died in the accident. No signal was received from the emergency locator transmitter (ELT).
Probable cause:
Findings as to Causes and Contributing Factors:
1. After the take-off at reduced power, the aircraft performance during the initial climb was lower than that established at certification.
2. The right engine experienced a problem in flight that led to a substantial loss of thrust.
3. The right propeller was not feathered; therefore, the rate of climb was compromised by excessive drag.
4. The absence of written directives specifying which pilot was to perform which tasks may have led to errors in execution, omissions, and confusion in the cockpit.
5. Although the crew had the training required by regulation, they were not prepared to manage the emergency in a coordinated, effective manner.
6. The priority given to ATC communications indicates that the crew did not fully understand the situation and were not coordinating their tasks effectively.
7. The impact with the berm caused worse damage to the aircraft.
8. The aircraft’s upside-down position and the damage it sustained prevented the occupants from evacuating, causing them to succumb to the smoke and the rapid, intense fire.
9. The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.
10. The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Findings as to Risk:
1. Deactivating the flight low pitch stop system warning light or any other warning system contravenes the regulations and poses significant risks to flight safety.
2. The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.
3. Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.
4. The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.
5. The lack of an in-depth review by TC of SOPs and checklists of 703 operators poses a safety risk because deviations from aircraft manuals are not detected.
6. Conditions of employment, such as flight hours–based remuneration, can influence pilots’ decisions, creating a safety risk.
7. The absence of an effective non-punitive and confidential voluntary reporting system means that hazards in the transportation system may not be identified.
8. The lack of recorded information significantly impedes the TSB’s ability to investigate accidents in a timely manner, which may prevent or delay the identification and communication of safety deficiencies intended to advance transportation safety.
Final Report:

Crash of a Beechcraft King Air 100 in Chicoutimi: 2 killed

Date & Time: Dec 9, 2009 at 2250 LT
Type of aircraft:
Operator:
Registration:
C-GPBA
Survivors:
Yes
Schedule:
Val d'Or - Chicoutimi
MSN:
B-215
YOM:
1975
Flight number:
ET822
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
150
Circumstances:
The Beechcraft was on an instrument flight rules flight between Val-d’Or and Chicoutimi/Saint-Honoré, Quebec, with 2 pilots and 2 passengers on board. At 2240 Eastern Standard Time, the aircraft was cleared for an RNAV (GNSS) Runway 12 approach and switched to the aerodrome traffic frequency. At 2250, the International satellite system for search and rescue detected the aircraft’s emergency locator transmitter signal. The aircraft was located at 0224 in a wooded area approximately 3 nautical miles from the threshold of Runway 12, on the approach centreline. Rescuers arrived on the scene at 0415. The 2 pilots were fatally injured, and the 2 passengers were seriously injured. The aircraft was destroyed on impact; there was no post-crash fire.
Probable cause:
For undetermined reasons, the crew continued its descent prematurely below the published approach minima, leading to a controlled flight into terrain (CFIT).
Findings as to Risk:
1. The use of the step-down descent technique rather than the stabilized constant descent angle (SCDA) technique for non-precision instrument approaches increases the risk of an approach and landing accident (ALA).
2. The depiction of the RNAV (GNSS) Runway 12 approach published in the Canada Air Pilot (CAP) does not incorporate recognized visual elements for reducing ALAs, as recommended in Annex 4 to the Convention, thereby reducing awareness of the terrain.
3. The installation of a terrain awareness warning system (TAWS) is not yet a requirement under the Canadian Aviation Regulations (CARs) for air taxi operators. Until the changes to regulations are put into effect, an important defense against ALAs is not available.
4. Most air taxi operators are unaware of and have not implemented the FSF ALAR task force recommendations, which increases the risk of a CFIT accident.
5. Approach design based primarily on obstacle clearance instead of the 3° optimum angle increases the risk of ALAs.
6. The lack of information on the SCDA technique in Transport Canada reference manuals means that crews are unfamiliar with this technique, thereby increasing the risk of ALAs.
7. Use of the step-down descent technique prolongs the time spent at minimum altitude, thereby increasing the risk of ALAs.
8. Pilots are not sufficiently educated on instrument approach procedure design criteria. Consequently, they tend to use the CAP published altitudes as targets, and place the aircraft at low altitude prematurely, thereby increasing the risk of an ALA.
9. Where pilots do not have up-to-date information on runway conditions needed to check runway contamination and landing distance performance, there is an increased risk of landing accidents.
10. Non-compliance with instrument flight rules (IFR) reporting procedures at uncontrolled airports increases the risk of collision with other aircraft or vehicles.
11. If altimeter corrections for low temperature and remote altimeter settings are not accurately applied, obstacle clearance will be reduced, thereby increasing the CFIT risk.
12. When cockpit recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
13. Task-induced fatigue has a negative effect on visual and cognitive performance which can diminish the ability to concentrate, operational memory, perception and visual acuity.
14. Where an emergency locator transmitter (ELT) is not registered with the Canadian Beacon Registry, the time needed to contact the owner or operator is increased which could affect occupant rescue and survival.
15. If the tracking of a call to 911 emergency services from a cell phone is not accurate, search and rescue efforts may be misdirected or delayed which could affect occupant rescue and survival.
Other Findings:
1. Weather conditions at the alternate airport did not meet CARs requirements, thereby reducing the probability of a successful approach and landing at the alternate airport if a diversion became necessary.
2. Following the accident, none of the aircraft exits were usable.
Final Report: