Churchill Falls | Bureau of Aircraft Accidents Archives

The corporate jet HS-125 aircraft departed Montreal at 2123 (GMT), 9 December 1977 with Churchill Falls as destination. The estimated time en route was 1 hour 45 minutes. The flight proceeded normally and was in contact with Air Traffic Services en route. When in range of Churchill Falls the flight received a clearance for the approach from Moncton ATC. At 2228Z the pilot acknowledged the clearance to the Churchill Falls airport and received the latest weather. The aircraft left cruising altitude shortly thereafter; the descent was normal to the minimum initial altitude for the instrument approach. The flight reported outbound to Churchill Falls advisory at approximately 2252Z. The final transmission from the crew was that they were two miles back on final with a confirmation that they could see the strobe lights and the VASIS. Moncton Centre was alerted shortly after 2300Z when it was evident that the aircraft had not landed. A local search was initiated with two helicopters from the airport but because of deteriorating weather, the search had to be discontinued and the aircraft was not found that night. Search and Rescue were alerted at 2314Z. Near blizzard conditions occurred that night and the next day, December 10. It wasn't until 11 December that the air search was resumed and the aircraft was located two miles short of the threshold of runway 14. There was no sign of life.

Probable cause:

It was determined that the accident was the consequence of the combination of the following findings:
- Cockpit discipline was inadequate as the approach entered the final phase,
- Distractions in the cockpit degraded crew performance,
- The pilots deprived themselves of essential altitude information by not effectively monitoring the flight instruments during the final approach,
- The Captain, by relying on visual cues from the runway environment lighting in conditions where those cues were degraded, became exposed to visual illusions,
- The pilots permitted the aircraft to deviate below the safe approach profile until it struck the terrain,
- On the assumptions that there had been at least one serviceable ELT on board, that it had been activated as a result of the impact or by other means, and that there was the capability at Churchill Falls of homing to the point of origin of the ELT signal, the rescue activity may have been expedited.

Final Report:

Crash of a BAe 125-400A in Wabush: 8 killed

Date & Time: Nov 11, 1969 at 1832 LT

Type of aircraft:

BAe 125

Operator:

Registration:

CF-CFL

Flight Phase:

Landing (descent or approach)

Flight Type:

Executive/Corporate/Business

Survivors:

Site:

Airport (less than 10 km from airport)

Schedule:

Churchill Falls - Wabush - Montreal

MSN:

25193/NA725

YOM:

1969

Location:

Wabush

Newfoundland & Labrador

Country:

Canada

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4800

Captain / Total hours on type:

1200.00

Copilot / Total flying hours:

350

Copilot / Total hours on type:

Aircraft flight hours:

Circumstances:

The twin engine aircraft departed Churchill Falls Airport at 1800LT on a 20-minute flight to Wabush. As it neared destination, Moncton Centre cleared the aircraft to the Wabush airport to perform an ADF approach on the WK beacon, a cancelled procedure. This clearance was acknowledged and read back by the copilot. The WK is an airway beacon; however, the only currently approved instrument approach procedure at Wabush was based on the WZ beacon. At 1829LT, the pilot reported to the tower that he had crossed the beacon and was on the final approach to the runway. Minutes later, eyewitnesses saw the aircraft north of the WK beacon clear of cloud on a northerly heading. Figure 1 shows that flying the approved approach procedure on the WK beacon rather than on the WZ resulted in a 6-mile northward displacement of the approach pattern. Having crossed over a beacon that the pilot apparently assumed incorrectly to be south of the field, he was now flying at his minimum approach altitude expecting to see the runway ahead. Routine transmissions from the aircraft were heard before the impact. The aircraft crashed 5,5 miles north of the WK beacon into the rock face of a lighted open-pit mine, killing all eight persons on board, among them Donald J. McParland, President of Churchill Falls (Labrador) Corporation, his assistant John Lethbridge, Eric Lambert and three employees of the Acres Canadian Bechtel.

Probable cause:

The following findings were identified:
- The ATC agency cleared the pilot to perform an approach procedure cancelled six months before, a procedure of which he, as an itinerant pilot with an up-to-date approach publication, would probably have no knowledge.
- One of the aircraft's two ADF sets had been unserviceable during this and preceding flights. The flight plan specified a fuel endurance limiting the flight to a region in which there were only non-directional navigation aids. For this flight, under instrument flight rules two serviceable ADFs are required.
- The copilot received and accepted the incorrect clearance. Since the copilot did not hold an instrument rating, there was no proof of competence relevant to instrument flight procedures. His effectiveness as a copilot on an IFR night flight, in a high speed jet aircraft, could have been limited as a result of his relative inexperience.
- There was evidence of uncertainty among some pilots and the ATC centre staff as to whether the WK procedure had in fact been cancelled. The cancelled procedure page of the Canada Air Pilot had been retained and used routinely by the ATC centre and some pilots.
Assigned causes:
- The pilot was cleared by the ATC centre to perform a cancelled approach procedure.
- The pilot performed the currently approved procedure on the wrong beacon.

Final Report: