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Crash of a Britten-Norman BN-2A-27 Islander in Port Hope Simpson: 1 killed

Date & Time: Jun 7, 2009 at 0830 LT
Type of aircraft:
Operator:
Registration:
C-FJJR
Flight Type:
Survivors:
No
Schedule:
Lourdes-de-Blanc-Sablon - Port Hope Simpson
MSN:
424
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13500
Captain / Total hours on type:
600.00
Circumstances:
The pilot was tasked with a medical evacuation flight to take a patient from Port Hope Simpson to St. Anthony, Newfoundland and Labrador. The aircraft departed the company’s base of operations at Forteau, Newfoundland and Labrador, at approximately 0620 Newfoundland and Labrador daylight time. At approximately 0650, he made radio contact with the airfield attendant at the Port Hope Simpson Airport, advising that he was four nautical miles from the airport for landing. The weather in Port Hope Simpson was reported to be foggy. There were no further transmissions from the aircraft. Although the aircraft could not be seen, it could be heard west of the field. An application of power was heard, followed shortly thereafter by the sound of an impact. Once the fog cleared about 30 minutes later, smoke was visible in the hills approximately four nautical miles to the west of the Port Hope Simpson Airport. A ground search team was dispatched from Port Hope Simpson and the wreckage was found at approximately 1100. The sole occupant of the aircraft was fatally injured. The aircraft was destroyed by impact forces and a severe post-crash fire. There was no emergency locator transmitter signal.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The aircraft departed controlled flight, likely in an aerodynamic stall, and impacted terrain for undetermined reasons.
Other Finding:
1. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.
Final Report:

Crash of a Beechcraft 1900C-1 off Saint-Augustin

Date & Time: Jan 4, 1999 at 0859 LT
Type of aircraft:
Operator:
Registration:
C-FGOI
Survivors:
Yes
Schedule:
Lourdes-de-Blanc-Sablon – Saint-Augustin
MSN:
UC-085
YOM:
1989
Flight number:
RH1707
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Copilot / Total flying hours:
4000
Copilot / Total hours on type:
500
Circumstances:
The Régionnair Inc. Beechcraft 1900C, serial number UC-85, with two pilots and 10 passengers on board, was making an instrument flight rules (IFR) flight between Lourdes-de-Blanc-Sablon, Quebec, and Saint-Augustin, Quebec. Just before initiation of descent, the radiotelephone operator of the Saint-Augustin Airport UNICOM (private advisory service) station informed the crew that the ceiling was 300 feet, visibility a quarter of a mile in snow flurries, and the winds from the southeast at 15 knots gusting to 20 knots. The crew made the LOC/DME (localizer transmitter / distance-measuring equipment) non-precision approach for runway 20. The approach proceeded normally until the minimum descent altitude (MDA). When the first officer reported sighting the ground beneath the aircraft, the captain decided to continue descending below the MDA. Thirty-five seconds later, the ground proximity warning system (GPWS) AMINIMUMS@ audible alarm sounded. Three seconds later, the aircraft flew into the frozen surface of the Saint-Augustin River. The occupants escaped the accident unharmed. The aircraft was heavily damaged.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew did not follow the company's SOPs for the briefing preceding the approach and for a missed approach.
2. In the approach briefing, the captain did not specify the MDA or the MAP, and the first officer did not notice these oversights, which shows a lack of coordination within the crew.
3. The captain continued descent below the MDA without establishing visual contact with the required references.
4. The first officer probably had difficulty perceiving depth because of the whiteout.
5. The captain did not effectively monitor the flight parameters because he was trying to establish visual contact with the runway.
6. The chief pilot (the captain of C-FGOI) set a bad example to the pilots under him by using a dangerous method, that is, descending below the MDA without establishing visual contact with the required references and using the GPWS to approach the ground.
Findings as to Risks:
1. The operations manager did not effectively supervise air operations.
2. Transport Canada did not detect the irregularities that compromised the safety of the flight before the occurrence.
3. Régionnair had not developed GPWS SOPs for non-precision approaches.
Other Findings:
1. The GPWS 'MINIMUMS' alarm sounded at a height that did not leave the captain time to initiate pull-up and avoid striking the ground because of the aircraft=s rate of descent and other flight
parameters.
2. Neither the captain nor the first officer had received PDM training or CRM training.
3. At the time of the approach, the ceiling and visibility unofficially reported by the AAU were below the minima published on the approach chart.
4. The decision to make the approach was consistent with existing regulations because runway 02/20 was not under an approach ban.
5. Some Régionnair pilots would descend below the MDA and use the GPWS to approach the ground if conditions made it impossible to establish visual contact with the required references.
Final Report:

Crash of a Cessna 402B in Le Havre-Saint-Pierre

Date & Time: Nov 23, 1994 at 1714 LT
Type of aircraft:
Operator:
Registration:
C-FFAS
Flight Type:
Survivors:
Yes
Schedule:
Lourdes-de-Blanc-Sablon - Le Havre-Saint-Pierre
MSN:
402B-0820
YOM:
1975
Flight number:
ASJ638
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
689
Captain / Total hours on type:
29.00
Aircraft flight hours:
7012
Circumstances:
The Air Satellite Cessna 402B, flight 638, took off from Lourdes-de-Blanc-Sablon, Quebec, on an instrument flight rules (IFR) flight to Havre-Saint-Pierre, Quebec, with a load of mail. At 6,000 feet above sea level (asl), meteorological conditions were visual (VMC). About 35 nautical miles (nm) from Havre-Saint-Pierre, the pilot began his descent. At 25 nm from the airport and at an altitude of 5,000 feet asl, the pilot contacted the Flight Service Station (FSS) specialist at Sept-Îles, Quebec, via the remote communications outlet (RCO). He requested weather information for Havre-Saint-Pierre Airport. The specialist gave him the latest weather report available for the Havre-Saint-Pierre FSS. The report had been issued three hours previously by Environment Canada. The meteorological sequence indicated VMC. The pilot could see the town of Havre-Saint-Pierre when he commenced his back course approach for runway 27. During the descent, the aircraft flew into snow showers. The pilot contacted the company to check the weather at Havre-Saint-Pierre Airport, and he was told there was light snow. The pilot continued the approach to the MDA indicated on the Havre-Saint-Pierre approach chart, that is, 420 feet asl. There was moderate turbulence during the approach. The pilot tried to maintain control of the aircraft while operating the radio in an attempt to obtain more detailed weather information. One of the company pilots told him the snowfall was heavier. The aircraft then banked right. The pilot corrected, and, at the same time, the wheels touched the ground. The aircraft crashed and slid on its belly about 100 feet before coming to rest. The pilot sustained minor injuries; the aircraft sustained substantial damage. The accident occurred about 1.5 nm from the threshold of Havre-Saint-Pierre runway 27 on marshy ground. The pilot remained in radio contact with overflying aircraft and said he would stay on board the aircraft until rescuers arrived. Search and rescue crews walked toward the crash site, but they were unable to find the aircraft because of the rough terrain and reduced visibility. Five hours later, a Search and Rescue helicopter located the aircraft with the aid of the direction finder. The weak signal from the emergency locator transmitter (ELT) was still readable and was received. The pilot was transported to hospital for first aid treatment.The accident occurred during the hours of darkness.
Probable cause:
The pilot continued the descent below the MDA without the required visual references.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Lourdes-de-Blanc-Sablon: 2 killed

Date & Time: Jan 11, 1994 at 1854 LT
Type of aircraft:
Operator:
Registration:
C-GDOU
Flight Type:
Survivors:
No
Schedule:
Saint Anthony - Lourdes-de-Blanc-Sablon
MSN:
31-7612033
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Captain / Total hours on type:
1550.00
Copilot / Total flying hours:
1079
Copilot / Total hours on type:
650
Aircraft flight hours:
11050
Circumstances:
On 11 January 1994, the crew were on a chartered round-robin flight on a PA-31 Navajo, between Lourdes-de-Blanc-Sablon airport, Quebec, and St. Anthony, Newfoundland, in accordance with visual flight rules (VFR) . During the return flight, at night, the crew advised the St. Anthony flight service station (FSS) that they departed at 1813 Newfoundland standard time (NST). At 1846 NST, the crew transmitted that they were flying at 2,500 feet and that they were 32 nautical miles (nm) and 13 minutes southeast of Blanc-Sablon. Seven minutes later, the crew called the Sept-Iles FSS through the Blanc-Sablon repeater. They requested airport information and reported being 16 nm and six minutes from the airport. After receiving information on the winds and the altimeter setting, the crew reported that they would use runway 05 and would call back on final. No further transmissions were received from the crew. Fishermen found the wreckage seven months later.
Probable cause:
The cause of the occurrence could not be determined; however, it is probable that the pilots did not monitor the altimeter properly and allowed the aircraft to descend until it struck the surface of the ice.
Final Report:

Crash of a Douglas C-47A-1-DK in Lourdes-de-Blanc-Sablon

Date & Time: Mar 16, 1965 at 1730 LT
Operator:
Registration:
CF-PQG
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
12055
YOM:
1943
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
6500.00
Copilot / Total flying hours:
2400
Copilot / Total hours on type:
1000
Circumstances:
During the takeoff roll, the visibility decreased because of the glare of the landing lights on the falling snow. The aircraft deviated 10° or 15° to the left without the crew being aware that this deviation had occurred and, after rolling for about 750 ft, it left the north side of the runway. The attempt to take off was continued. However, adequate speed could not be obtained. After a series of impacts, the aircraft came to rest about 3,150 feet from the start of takeoff and about 700 feet short of the base of a sharply rising hill. All 9 occupants were uninjured while the aircraft was damaged beyond repair. It was operated on behalf of the Département des Transports et des Communications du Québec.
Probable cause:
Loss of directional control during takeoff at night from an unlighted aerodrome.
Final Report:

Crash of a Douglas DC-3A in Lourdes-de-Blanc-Sablon

Date & Time: Nov 21, 1964
Type of aircraft:
Operator:
Registration:
CF-GOC
Survivors:
Yes
MSN:
7362
YOM:
1942
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach, the airplane was too low and struck the ground short of runway threshold. It continued for several yards, causing the right propeller to struck the ground as well. It flew for several hundred yards before crashing 1,400 meters past the runway end. All four occupants were injured while the aircraft was damaged beyond repair.
Probable cause:
On final approach, the crew misjudged the distance with ground.