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Crash of a Canadair CL-415 in Moosehead Lake

Date & Time: Jul 3, 2013 at 1415 LT
Type of aircraft:
Operator:
Registration:
C-FIZU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wabush - Wabush
MSN:
2076
YOM:
2010
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
120.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
138
Aircraft flight hours:
461
Circumstances:
On 03 July 2013, at about 1415 Atlantic Daylight Time, the Government of Newfoundland and Labrador Air Services Division Bombardier CL-415 amphibious aircraft (registration C-FIZU, serial number 2076), operating as Tanker 286, departed Wabush, Newfoundland and Labrador, to fight a nearby forest fire. Shortly after departure, Tanker 286 touched down on Moosehead Lake to scoop a load of water. About 40 seconds later, the captain initiated a left-hand turn and almost immediately lost control of the aircraft. The aircraft water-looped and came to rest upright but partially submerged. The flight crew exited the aircraft and remained on the top of the wing until rescued by boat. There was an insufficient forward impact force to activate the onboard 406-megahertz emergency locator transmitter. There were no injuries to the 2 crew members. The aircraft was destroyed. The accident occurred during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
- It is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to the MANUAL selection when the centre pedestal cover was removed.
- The PROBES AUTO/MANUAL switch position check was not included on the Newfoundland and Labrador Government Air Services CL-415 checklist.
- The flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity.
- The flight crew decided to continue the take-off with the aircraft in an overweight condition.
- The extended period with the probes deployed on the water resulted in a longer take-off run, and the pilot flying decided to alter the departure path to the left.
- The left float contacted the surface of the lake during initiation of the left turn. Aircraft control was lost and resulted in collision with the water.
Findings as to risk:
- If safety equipment is installed in a manner that hampers its access and removal, then there is an increased risk that occupants may not be able to retrieve the safety equipment in a timely manner to ensure their survival.
- If individuals are not trained on safety equipment installed on the aircraft, then there is an increased risk that the individuals may not be aware of how to effectively use the equipment.
- If a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that that item will be missed, which could jeopardize the safety of flight.
- If flight crews do not adhere to standard operating procedures, then there is a risk that errors and omissions can be introduced, which could jeopardize the safety of flight.
- If a person is not restrained during flight and the aircraft either makes an abrupt manoeuvre or loses control, then that person is at a much greater risk of injury or death.
- If an overweight take-off is carried out, there may be an adverse effect on the aircraft’s performance, which could jeopardize the safety of flight.
- If companies do not have procedures for recording overweight take-offs and flight crews do not report them, then the overall condition of the aircraft’s structures will not be accurately known, which could jeopardize the safety of flight.
- If organizations do not use formal and documented processes to manage operational risks, there is an increased risk that hazards will not be identified and mitigated.
- If organizations do not have measures in place to raise awareness of the potential impact of stress on performance or to promote the early recognition and mitigation of stress, then there is an increased risk that errors will occur when an individual is affected by stress that has become chronic.
Other findings:
- Utilizing the locking position of the PROBES AUTO/MANUAL switch for the MANUAL selection allows the switch to be inadvertently moved from the AUTO to the MANUAL position.
Final Report:

Crash of a Canadair CL-415-6B11 near Acciano: 1 killed

Date & Time: Jul 23, 2007 at 1806 LT
Type of aircraft:
Operator:
Registration:
I-DPCX
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Pescara - Pescara
MSN:
2045
YOM:
2000
Flight number:
CAN19
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6240
Captain / Total hours on type:
1321.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
55
Aircraft flight hours:
2742
Circumstances:
The crew departed Pescara-Liberi Airport at 1719LT on a fire fighting mission in the Sirente-Velino Regional Natural Park under callsign CAN19. While approaching the area under fire, the aircraft initiated a slight turn to the right when it collided with the top of a hill and disintegrated, bursting into flames. The wreckage was found at an altitude of 1,155 metres near Acciano. While the copilot was seriously injured, the captain was killed.
Probable cause:
Even if it was not possible to define with certainty why the aircraft impacted against the ground, it is nevertheless considered reasonable that the impact occurred as a result of improper management of the manoeuvre by the crew, the result of an inadequate assessment by the crew of the flight altitude with respect to the top of the hill and the critical environmental conditions, characterized by the presence of strong turbulence, strong wind and visibility affected by the presence of smoke. (The cause of the accident would therefore be substantially due to human and environmental factors).
Final Report:

Crash of a Canadair CL-415-6B11 in Diliso: 2 killed

Date & Time: Jul 23, 2007 at 1546 LT
Type of aircraft:
Operator:
Registration:
2055
Flight Phase:
Flight Type:
Survivors:
No
MSN:
2055
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a fire fighting mission in the region of Diliso, on the Evia Island, with four other water bomber and two helicopters. While approaching the zone under fire, the aircraft struck the ground and crashed, killing both occupants.

Crash of a Canadair CL-415 in Calvi: 2 killed

Date & Time: Aug 1, 2005 at 1005 LT
Type of aircraft:
Operator:
Registration:
F-ZBEO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ajaccio - Ajaccio
MSN:
2011
YOM:
1995
Flight number:
Pélican 36
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After take-off from Ajaccio Airport and a first scooping, the fleet composed of three planes with respective callsigns Pelican 44, Pelican 36 and Pelican 37 intervened on a fire at Piétramaggiore, near Calvi, Corsica, France. A first sector of the fire zone was treated by six passes. During the two following passages, the fleet dropped on another sector of the fire. Pelican 36 began its last scooping in the Gulf of Revellata at heading 250°, three minutes and fourteen seconds before the accident. At the end, it gained height and continued the circuit to arrive on the drop axis. The "doubling" action consists of releasing the water load at the precise location of the previous aircraft's release. During the last turn, it reached an altitude of 2,160 feet. Pelican 36 was observed on a trajectory estimated to be consistent by the crew of the following aircraft (Pelican 37) a few seconds before it passed over the drop site. However, video evidence shows that the track of Pelican 36 is further west than that of Pelican 44, which preceded it, and over higher terrain. One and a half seconds before the flight recorder stopped, the aircraft was in a right turn at an altitude of 1,360 feet. The angle of roll to the right and increasing was then 17°. While the elevators were nearly stable, the altitude stored by the flight recorder increased to 1,500 feet in one and a half seconds. After that the tail section of the aircraft separated from the fuselage. The aircraft then impacted the side of a mountain and broke up.
Crew:
Ludovic Piasentin, pilot,
Jean-Louis de Bénédict, copilot.
Probable cause:
Environmental area:
The load case studied during the investigations did not explain the observed fuselage failure. However, the characteristics of the upward aerological disturbance caused by the fire are likely to have generated airframe stresses of an order of magnitude close to that of the loads capable of causing the fuselage to fail. Given the uncertainties encountered during the evaluation of the parameters of the rising air column that affected the accuracy of the research results concerning the effects of the stresses on the airframe, the aerological phenomenon encountered represents a possible cause of the event.
Technical Area:
The research undertaken to find in-flight loads capable, in the context of the event, of breaking the intact fuselage without damaging the empennage was unsuccessful. Detailed observation of the airframe did not reveal any damage prior to the occurrence. However, the results of these investigations do not rule out the existence of such damage, so the hypothesis of prior damage to the airframe cannot be totally rejected.

Crash of a Canadair CL-415 in Forte dei Marmi: 2 killed

Date & Time: Mar 18, 2005 at 1805 LT
Type of aircraft:
Operator:
Registration:
I-DPCK
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rome - Rome
MSN:
2051
YOM:
2001
Flight number:
Tanker 22
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
1232
Aircraft flight hours:
1733
Circumstances:
The crew departed Rome-Ciampino Airport in the afternoon on a fire fighting mission in Forte dei Marmi, north of Pisa. Following two successful missions, the crew was attacking the fire in hilly terrain and low altitude when the aircraft collided with power cables. A fire erupted on the right side of the aircraft and the crew lost control of the airplane that crashed in a residential area. Both pilots were killed while there were no injuries on the ground.
Probable cause:
The accident was the consequence of an in-flight collision with a power line because the crew adopted a wrong approach configuration to the fire area. The following contributing factors were identified:
- Poor decision making in attacking the fire, causing the crew to focus their attention on obstacles (pylons) of power line n°500, without considering the presence of the cable guard line n°550,
- The reduced visibility of obstacles resulting from the smoke of the forest,
- The inadequate reporting of electricity pylons and associated overhead lines,
- Non-activation of the required radio links, so the crew could not receive reports on the presence of obstacles,
- Short and discontinuous experience of the captain in that role, coming from the institution of the "PIC Frozen",
- The combination of to similar qualified pilots ("PIC Frozen") in the cockpit for the operation of a flight, one just rehabilitated to a high command function, the other still employed in the role of co-pilot: This condition could have a negative impact in terms of crew integration, obscuring decision making,
- The existence of criticality in corporate manuals used at the date of the accident,
- Reduced operational capacity of the crew in the last phase of flight, resulting from the strong heat of the fire under the left wing which penetrated the airplane through an opening created by the separation of a porthole.
Final Report:

Crash of a Canadair CL-415 off Les Salles-sur-Verdon: 2 killed

Date & Time: Mar 8, 2004 at 1100 LT
Type of aircraft:
Operator:
Registration:
F-ZBEZ
Flight Type:
Survivors:
Yes
Schedule:
Marseille - Marseille
MSN:
2018
YOM:
1996
Flight number:
Pélican 41
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
One instructor and two pilots under supervision departed Marseille-Marignane Airport on a training flight. Several scooping manoeuvres were completed on the Sainte-Croix Lake located about 85 km northeast of Marseille. While completing a new scooping procedure, the aircraft approached in a high nose attitude and disintegrated upon landing. The main wreckage sank to a depth of 31 metres off Les Salles-sur-Verdon. One pilot was found alive but seriously injured due to hypothermia (the water temperature was 6° C) while both other occupants, Jean Beauvais and Jean-Pierre Laty, were killed.

Crash of a Canadair CL-415-6B11 in Esine

Date & Time: Aug 16, 2003 at 1548 LT
Type of aircraft:
Operator:
Registration:
I-DPCN
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Verona - Verona
MSN:
2008
YOM:
1995
Flight number:
Tanker 9
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15700
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
2200
Copilot / Total hours on type:
400
Aircraft flight hours:
1186
Circumstances:
The aircraft was dispatched over the region of Esine to fight a forest fire under call sign Tanker 9. The area under fire was located on the southern slope of the Val Camonica, about 8 NM northeast from Lake Iseo. While approaching the zone to be treated, the aircraft struck trees and crashed on the mountain slope. Both pilots were injured, one seriously, and the aircraft was destroyed.
Probable cause:
The cause of the accident is attributable to the human factor and can be identified in the impact of the aircraft against certain trees following the setting of an inadequate escape manoeuvre.
The following causal factors may have contributed to the dynamics of the accident:
- The crew's failure to strictly comply with the Operator's Manual of Operations, which provided that the route of attack and escape should not be made uphill, unless there were very limited differences in level that could be overcome without power fluctuations,
- The failure to carry out, as a precautionary measure, since the trajectory of the attack route has changed (from descending to ascending), a new reconnaissance with subsequent briefing by the crew, in order to properly assess the different perspective of all the elements of interest (orography, escape route, etc..), even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in unstabilized conditions, therefore not in line with what is previewed from the operating manual, even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in not stabilized conditions, therefore not in line with what is previewed from the operating manual;
- The existence of communication problems within the cockpit, deriving from the fact that there was no information flow between the co-pilot (depositary of the information necessary for the assumption of the most appropriate operational decisions) and the commander, responsible for the final decisions; in this regard, it should be noted that radio communications with the DOCFS were made by the co-pilot in Italian, as the latter was not known by the commander, of Canadian nationality,
- The significant difference in experience and age between the two crew members, with possible negative effects in terms of crew coordination,
- The presence of critical points in the operating manuals, partly eliminated after the accident,
- The presence of locally significant turbulence.
Final Report:

Crash of a Canadair CL-415-6B11 off La Ciotat: 1 killed

Date & Time: Nov 17, 1997 at 1030 LT
Type of aircraft:
Operator:
Registration:
F-ZBFQ
Flight Type:
Survivors:
Yes
Schedule:
Marseille - Marseille
MSN:
2025
YOM:
1996
Flight number:
Pélican 43
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew departed Marseille-Marignane Airport with three other similar aircraft to conduct a training mission in the bay of La Ciotat. Following several scooping manoeuvres, the crew simulated an engine failure and then performed a complete landing when the aircraft suffered severe vibrations. The crew increased engine power in an attempt to take off when the seaplane overturned and came to rest upside down. The copilot was seriously injured while the captain was killed.
Probable cause:
It was reported that the hatches were open when the aircraft landed on the sea, causing severe vibrations and the subsequent loss of control.