Crash of an Avro 748-2B-FAA in Cheney: 2 killed

Date & Time: Sep 15, 1988 at 1019 LT
Type of aircraft:
Operator:
Registration:
C-GFFA
Flight Type:
Survivors:
No
Schedule:
Montreal - Ottawa
MSN:
1789
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5500
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
1750
Copilot / Total hours on type:
200
Aircraft flight hours:
10004
Aircraft flight cycles:
14733
Circumstances:
A BAe-748 cargo plane was destroyed when it crashed while on approach to Ottawa International Airport, ON (YOW), Canada. Both pilots were killed. The airplane had arrived at Montreal-Dorval International Airport, QC (YUL) following a cargo flight from Dayton, OH, USA. All the cargo was unloaded in Montreal and the aircraft departed at 09:58 for Ottawa on an instrument flight rules (IFR) flight plan. The en route phase of the flight were uneventful. At about 10:19, while the aircraft was in level cruise flight at 3000 feet at approximately 200 knots indicated airspeed (KIAS), the flight data recorder (FDR) recorded a full-up deflection of the left aileron and a full-down deflection of the right aileron, and the aircraft began a roll to the left at a high rate. The right aileron remained at the fully-deflected position for a period of three seconds, and then, over the next seven seconds, the deflection gradually decreased by about five degrees. During the same 10-second period, the left aileron remained nearly fully deflected for the first eight seconds, then the deflection decreased by about five degrees during the next two seconds. By this time, the aircraft had rolled through approximately 460 degrees, and the aircraft nose had dropped 20 to 30 degrees below the horizon. At this point, the ailerons suddenly returned to about the neutral position and remained there for the last three seconds of the flight. The aircraft bank angle remained at approximately 90 degrees of left bank with a maximum vertical g of 4.7 recorded. The aircraft struck the ground at an airspeed of approximately 290 KIAS after a heading change of about 75 degrees left of the cruise heading. At impact, the aircraft bank angle was nearly 90 degrees left and the pitch angle was 41 degrees down. The time from the initial aileron deflection to ground impact was approximately 18 seconds.
Probable cause:
The Board determined that the aileron control system was asymmetrically rigged, making it susceptible to aerodynamic overbalance. The operator did not conduct the required post-maintenance flight tests of the aileron control response. When the ailerons were held at full deflection by aerodynamic forces, following a large control-wheel input by the pilot, the subsequent control reaction by the pilot was inappropriate. Contributing to the accident were the design of the aileron system; ambiguous and incomplete maintenance instructions; a lack of published information for flight crew concerning aileron system performance and possible emergencies; and the presence of factors which may have led to the development of flight crew fatigue.
Final Report:

Crash of a Canadair CL-215-1A10 in Montreal

Date & Time: Sep 29, 1983
Type of aircraft:
Operator:
Registration:
C-GKEE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Montreal - Montreal
MSN:
1078
YOM:
1983
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a demo flight at Montreal-Dorval Airport for federal politicians and Canadair officials. Following a single engine low pass over the runway, the crew lost control of the airplane that crashed near the runway end. Both pilots were injured and the aircraft was destroyed.

Crash of a Beechcraft 65-90 King Air near Sherrington: 2 killed

Date & Time: May 1, 1979 at 1805 LT
Type of aircraft:
Operator:
Registration:
C-FCAS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Montreal - Montreal
MSN:
LJ-23
YOM:
1965
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13000
Copilot / Total flying hours:
4400
Aircraft flight hours:
5466
Circumstances:
The crew was engaged in a calibration flight on behalf of Transport Canada. The twin engine airplane departed Montreal-Dorval Airport at 1741LT to proceed with the calibration of a radar antenna. After contact was established with ATC, the crew initiated an orbit 20 NM from the antenna at an altitude of 1,700 feet. After crossing the 165 radial, the airplane entered an uncontrolled descent and crashed in a field located near Sherrington. The airplane was totally destroyed and both occupants were killed. It was determined that the outside section of the right wing, after the right engine nacelle, separated in flight and was found 640 metres from the main wreckage.
Probable cause:
The following findings were identified:
- The right hand lower forward outboard wing attachment fitting of C-FCAS had developed a progressive crack of sufficient magnitude to cause in-flight fracture, and consequent immediate wing separation outboard of the right hand engine nacelle, under normal flight loads.
- The laboratory analysis revealed the Progressive cracking was complex and of mixed modes in the initiation and early growth stages. The latter stages appeared to be essentially all due to fatigue cracking, driven by cyclic stresses generated in flight. The failed fitting exhibited a manufacturing deficiency in the form of gas bubbles located on the grain boundaries. Much of the early cracking appeared to be strongly influenced by the presence of these bubbles.
- It was not possible to precisely evaluate the mode or rate of crack propagation since insufficient basic data exists to determine the adverse influence of the gas bubbles on the performance of such flawed material.
- The fitting met all relevant specifications. It is not considered any typical quality control procedure would have detected the gas bubble deficiency. The available evidence suggests that only some fittings in a relatively small production batch of P/N 50-110057 fittings are defective in this manner, and that cracking similar to that in C-FCAS only occurs in this batch of fittings.
- The evidence indicates that the fitting was inspected in accordance with Airworthiness Directive 70-25-04 and Service Instruction 0394-018 at 4,907 hours, and that no crack was detected at that time.
- Since the accident the FAA and the manufacturer have affirmed that the dye penetrant inspection should have been made at 5,407 hours on the basis of a 500 hour inspection interval. This inspection was not made - if it had been made it is most probable that a crack would have been detected.
- There is a lack of clarity in AD 70-25-04 that resulted in the DOT and other maintenance personnel interpreting the AD as meaning that a 500 hour aye penetrant inspection was not mandatory if wing skin cracks were not found at the regular 100 hour skin inspections, which were carried out.
Final Report:

Crash of a Fairchild F27 in Quebec: 17 killed

Date & Time: Mar 29, 1979 at 1845 LT
Type of aircraft:
Operator:
Registration:
C-FQBL
Flight Phase:
Survivors:
Yes
Schedule:
Quebec - Montreal
MSN:
47
YOM:
1959
Flight number:
QB255
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
5200
Captain / Total hours on type:
565.00
Copilot / Total flying hours:
4787
Copilot / Total hours on type:
687
Aircraft flight hours:
41077
Aircraft flight cycles:
53052
Circumstances:
Shortly after liftoff from Quebec-Ancienne Lorette Airport, en route to Montreal-Dorval Airport, the right engine caught fire. The captain contacted ATC, declared an emergency and was cleared to return for an emergency landing. He initiated a turn to the right when the airplane lost height, struck the ground and crashed in flames about 1,300 meters short of runway. Seven passengers were seriously injured while 17 other occupants were killed.
Probable cause:
It was determined that during initial climb, the low pressure impeller from the right (n°2) engine burst, causing the forward part of the engine to separate. The gear couldn't be raised because of engine debris damage to the electronic gear selection circuitry. This, including the exposed engine and lower cowl, increased the drag. In this configuration the aircraft wasn't capable of out-climbing obstacles straight ahead nor capable of maintaining altitude during the right hand turn. Engine separation and passenger movement resulted in the center of gravity shifting beyond its aft limit. The airspeed then decreased until the aircraft struck the ground at or below the minimum control speed (Vmc). Investigations revealed that the low pressure impeller burst due to the presence of fatigue cracks that had not been detected by the technicians in charge of the aircraft's maintenance.
Final Report:

Crash of a Swearingen SA226T Merlin III in Montreal

Date & Time: Apr 10, 1973
Registration:
N5296M
Survivors:
Yes
MSN:
T-219
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Montreal-Dorval Airport, the crew encountered poor weather conditions and a limited visibility due to snow falls. Unable to locate the runway, the captain decided to abandon the approach and initiated a go-around manoeuvre. Few minutes later, a second attempt to land was also abandoned for similar reasons. During a third attempt, the crew descended below the glide to establish a visual contact with the ground when the airplane struck the ground. On impact, the undercarriage were torn off and the airplane slid in an open field before coming to rest few dozen meters short of runway. All eight occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The crew descended below the MDA in marginal weather conditions.

Crash of a Douglas DC-8-54F in Ottawa: 3 killed

Date & Time: May 19, 1967 at 1837 LT
Type of aircraft:
Operator:
Registration:
CF-TJM
Flight Type:
Survivors:
No
Schedule:
Montreal - Ottawa
MSN:
45653/178
YOM:
1963
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
19400
Captain / Total hours on type:
3700.00
Copilot / Total flying hours:
20748
Copilot / Total hours on type:
8
Aircraft flight hours:
9670
Circumstances:
The aircraft was on a conversion training flight from Montreal to Ottawa with three pilots on board. The aircraft departed Montreal at 1802 hours Eastern Standard Time on an instrument flight plan which was cancelled on reaching the Ottawa area. A hydraulic failure simulation was then carried out following which a touch-and-go landing on runway 32 was accomplished at 1825 hours. According to the recorded data the touch-and-go was accomplished with the ailerons in the manual mode, the flaps were raised to the 250 position during the landing roll and the ailerons were restored to the power mode during the turn following take-off while on a heading of about 260°. After about two minutes of flight on the downwind leg, No. 4 engine was retarded to flight idle and was kept at that setting for about two and a quarter minutes. During this period an average of about 30 left wing down bank was maintained, except at a point about halfway through that period the aircraft banked slowly 180 to the left, followed by a sharp reversal to 100 bank to the right. The length of the downwind leg was consistent with a planned two-engine asymmetric landing. Power was restored to No. 4 engine just before a left turn on to the base leg was started. During that turn No. 4 engine was again retarded to flight idle,then restored to normal power. No. 1 engine was then retarded to flight idle for about 20 seconds, then restored to normal power. The flaps remained at the 250 setting. While turning on to final approach, the pilot-in-command advised the tower that he was as yet undecided whether a landing would be carried out. When the aircraft had passed the UP beacon, about 84 miles from the runway threshold and approximately 200 sec from impact, rudder power was selected to the manual mode and power was reduced on all four engines. No. 4 engine was then retarded to the flight idle position and the other three engines advanced to approach power. About 171 sec before impact, the pilot-in-command advised the control tower that the aircraft would be making a full stop landing. The landing gear was extended 155 sec before impact and 120 sec before impact No. 3 engine was retarded to flight idle: at the same time power was increased on Nos. 1 and 2 engines. At that time the aircraft was at a height of 1 150 ft above the ground and its indicated airspeed was fairly steady around 165 kt. From 109 to 92 sec before impact, the aircraft turned to the right through 340 on to a heading of 3370. Power was reduced, bank applied and the aircraft returned to approximately the runway heading. The flaps were extended to 350, 69 sec before impact. At 54 sec before impact, the rudder was restored to the power mode for less than 6 sec and then returned to the manual mode. Through the period from 69 to 25 sec the rate of descent was relatively constant at about 700 ft/min with the aircraft tending to undershoot, and the airspeed decreasing from 163 to 152 kt. Power on Nos. 1 and 2 engines was progressively increased from 25 sec before impact until near maximum power was reached 8 sec before impact, following which they were retarded to flight idle. A yaw to the right had started 19 sec before impact and 12 sec before impact the throttles were advanced on engines 3 and 4 and they began to spool up. At 9 sec before impact and when some 200 ft above the ground, the left wing down condition could no longer be maintained and the aircraft entered a roll to the right. The roll rate to the right increased rapidly as did the yaw rate. The roll continued until the aircraft struck the ground in an inverted nose low attitude, 1 995 ft short of the threshold of runway 32 and 575 ft NE of its extended centerline. The accident occurred at 1837 hours. The aircraft was destroyed and all three crew members were killed.
Probable cause:
Failure to abandon a training manoeuvre under conditions which precluded the availability of adequate flight control. The following findings were reported:
- The decision to attempt an asymmetric approach with the rudder in the manual mode was improper,
- The information available to the crew in the Air Canada DC-8 Manual, concerning two engine operating procedures, was inadequate,
- The aircraft was tending to undershoot the runway,
- Control was lost when power to the left engines was increased late in the approach, at an airspeed too low for effective rudder control,
- The faulty check valve closed during the flight at least 54 seconds prior to impact.
Final Report:

Crash of a Douglas DC-8-54F in Sainte-Thérèse-de-Blainville: 118 killed

Date & Time: Nov 29, 1963 at 1833 LT
Type of aircraft:
Operator:
Registration:
CF-TJN
Flight Phase:
Survivors:
No
Schedule:
Montreal - Toronto
MSN:
45654
YOM:
1963
Flight number:
TCA831
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
111
Pax fatalities:
Other fatalities:
Total fatalities:
118
Captain / Total flying hours:
17206
Captain / Total hours on type:
561.00
Copilot / Total flying hours:
8302
Copilot / Total hours on type:
390
Aircraft flight hours:
2174
Circumstances:
The Douglas DC-8 aircraft was on a regular scheduled flight Montreal-Dorval Airport (YUL) to Toronto (YYZ), Canada, scheduled to leave Montreal at 18:10. There were some delays in the boarding of the passengers and Flight 831 started its takeoff roll on runway 06R at approximately 18:28. Weather was reported as overcast, light rain and fog, visibility 4 miles, surface wind NE at 12 mph. The flight was instructed to report passing 3000 feet and 7000 feet on the climb-out from the airport. The aircraft took off normally, reported in at 3,000 feet and acknowledged a clearance for a left turn to St. Eustache. This was the last radio contact with the flight. The aircraft then deviated from its normal flight path about 55 degrees to the right and began a quick descent. At 18:33, 16.9 miles from the airport, the DC-8 struck the ground at a speed of 470-485 knots descending at an angle of about 55 degrees (+/- 7deg). The airplane plunged into the ground and totally disintegrated upon impact. There were no survivors among the 118 occupants.
Probable cause:
It is concluded that the actual cause of the accident cannot be determined with certainty. It is concluded that the most probable chain of events which occasioned the crash can be identified as follows. For one of the reasons which are set forth below, the pilot applied the near maximum available Aircraft Nose Down Trim to the horizontal stabilizer. The aircraft then commenced a diving descent building up speed at such a rate that any attempted recovery was ineffective because the stabilizer hydraulic motor had stalled, thus making it impossible within the altitude available to trim the aircraft out of the extreme AND position.
(a) The first reason which might have indicated to the pilot the necessity for applying, nose down trim could have been icing of the Pitot system as discussed in the Analysis of Evidence. While the experience and competency of the crew would likely have led them to recognize the fault in time to take corrective action, the possibility that this condition caused the application of AND trim cannot be dismissed.
(b) The second reason could have been a failure of a vertical gyro. The evidence indicated that it was possible to have a failure of a vertical gyro without an associated warning flag. If such a failure occurred and the aircraft was being flown with reference to the associated artificial horizon instrument it is likely that the pilot would be misled by the erroneous indication and could have applied nosedown trim. Aircraft CF-TJN was equipped with a standby artificial horizon located on the Captain's instrument panel and this cross reference together with the experience and competency of the crew would likely have led them to recognize the fault in time to take corrective action. Again, the possibility that this condition caused the application of AND trim cannot be dismissed.
(c) The third reason could have been an unprogrammed and unnoticed extension of the Pitch Trim Compensator. This would have had the effect of moving the control column back, the elevators up and the aircraft to a nose up condition. The pilot would likely have counteracted the pitch up force of the elevators by trimming the horizontal stabilizer to or near to the limit of the Aircraft Nose Down setting. The evidence shows that the simultaneous application of up elevator from the PTC and the application of as little as 0.5 degrees of Aircraft Nose Down trim on the horizontal stabilizer has an adverse effect on aircraft stability and can create a difficult control problem. The problems of instability and control are more serious as further AND trim is applied. In aircraft CF-TJN 2.0 degrees of AND trim was available and it appears that the pilot applied at least 1.6 degrees of the available trim. It is unlikely that the flight crew were aware of the serious stability and-control problems that we now know can result from the combination of extended PTC and AND trim, even if they had been aware that the PTC had extended. The aircraft would then be in a condition where a slight displacement from its trim point would lead to divergent oscillations. In other words, a minor change. of attitude, easily caused by the existing turbulence, would build up into large displacements. The inadequate control available to the pilot and the lack of an external horizon reference would likely result in the aircraft eventually assuming a dive attitude.
It is concluded that an unprogrammed extension of the Pitch Trim Compensator is the most probable cause for the pilot having applied Aircraft Nose Down Trim, which initiated the chain of events that culminated in the crash.
Final Report:

Crash of a Douglas C-54A-15-DC Skymaster in Saint-Cléophas-de-Brandon: 5 killed

Date & Time: Nov 4, 1959 at 2307 LT
Type of aircraft:
Operator:
Registration:
CF-ILI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Montreal – Hall Beach
MSN:
10360
YOM:
1944
Flight number:
WH1658
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
30357
Circumstances:
Flight 1658 took off from Montreal-Dorval runway 10 at 2244LT on a cargo flight to Hall Beach, NWT. Following takeoff the aircraft continued runway heading and climbed to 6,000 feet. Course was then changed and the aircraft climbed to the assigned altitude of 9,000 feet, reaching this altitude at 2259LT. Some 3 and a half minutes later the crew reported that they were in an emergency descent because of a no. 2 engine fire. Last radio contact was at 2307LT when the crew reported that the plane had lost its left wing and "was in a spin and going straight in". The DC-4 broke up in midair, causing wreckage to cover a 1,25 x 0,75 mile area. All five crew members were killed.
Probable cause:
A fire of undetermined origin started in no.2 engine nacelle during the climb and developed to the stage where fire extinguishing equipment was inadequate to extinguish it. The following are considered to be primary contributing factors:
- The deteriorated condition of the exhaust collector ring,
- The probable deteriorated condition of the flexible wire braid hose assemblies,
- The probable use of high power during the climb,
- The possible failure of the fire detection and warning system to inform the pilot of the existence of a fire before it had penetrated the firewall and ignited the fuel feed system and oil tank to the rear of no.2 engine. During the rapid letdown, stresses were imposed on the weekened left wing by manoeuvre and/or gusts which were sufficient to sever the left wing spar. No subsequent action by the pilot could have brought the aircraft safely to the ground; neither was it possible to determine what effect a less rapid letdown would have had.

Crash of a Vickers 724 Viscount in New York

Date & Time: Nov 10, 1958 at 1101 LT
Type of aircraft:
Operator:
Registration:
CF-TGL
Flight Phase:
Survivors:
Yes
Schedule:
New York - Montreal
MSN:
43
YOM:
1955
Flight number:
TCA604
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Viscount was parked at gate to board passengers when it was struck by a Seaboard & Western Airlines' Lockheed L-1049D Super Constellation which was performing training flight LN800 at Idlewild Airport. The Constellation began its takeoff run on runway 31R of the New York International Airport at 1100. When an airspeed of 117 knots (V 2) was reached, the aircraft became airborne and climbed to an altitude of approximately 25 feet. At this altitude severe control difficulty was encountered, causing the aircraft to veer suddenly to the left and the left wing to lower 20 to 30 degrees. This wing struck the runway and from this point on directional control of the aircraft was lost. The aircraft skidded In a westerly direction into a temporary terminal area and came to rest after striking the Viscount. All five crew members from the Constellation were injured while the Viscount was empty. Both aircraft were totally destroyed by fire.
Probable cause:
The Board determines that the probable cause of this accident was an unwanted propeller reversal at a low altitude occurring immediately after takeoff. A contributing factor was the inadequate overhaul procedure employed by the propeller manufacturer.
Final Report:

Crash of a Grumman G-21A Goose in Pointe-Claire

Date & Time: Jun 17, 1958
Type of aircraft:
Registration:
CF-EXA
Survivors:
Yes
Schedule:
Chibougamau - Montreal
MSN:
B050
YOM:
1944
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Dorval Airport, both engines failed. The seaplane stalled and crashed in a prairie located at Pointe-Claire, few dozen yards from the airfield. All six occupants were injured, some of them seriously, and the aircraft was written off.
Probable cause:
On final approach, the pilot mistakenly put the fuel selector in a wrong position (empty tank), causing both engines to stop.