Zone

Crash of a Cessna 208B Grand Caravan off Pelée Island: 10 killed

Date & Time: Jan 17, 2004 at 1638 LT
Type of aircraft:
Operator:
Registration:
C-FAGA
Flight Phase:
Survivors:
No
Schedule:
Pelée Island – Windsor
MSN:
208B-0658
YOM:
1998
Flight number:
GGN125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
3465
Captain / Total hours on type:
957.00
Aircraft flight hours:
7809
Circumstances:
On 17 January 2004, the occurrence pilot started his workday in Toronto, Ontario, reporting for duty at 0445 eastern standard time. In the morning, he completed flights in the Cessna 208B Caravan from Toronto to Windsor, Ontario, Windsor to Pelee Island, Ontario, and then Pelee Island to Windsor where the aircraft landed at 0916. At approximately 1500, the pilot received local weather and passenger information by telephone from the Pelee Island office personnel. The 1430 weather was reported as follows: ceiling 500 feet obscured, visibility two miles. There were eight male passengers for pick up at Pelee Island. One additional passenger was travelling with the pilot. There was no discussion concerning the amount of cargo to be carried or the passenger weights. At 1508, the pilot received a faxed weather package that he had requested from the Flight Information Centre (FIC) in London, Ontario. At 1523, the aircraft was refuelled in preparation for the scheduled 1600 departure to Pelee Island. The passengers were loaded earlier than usual to allow time for aircraft de-icing, as wet snow had accumulated on the fuselage and wings since the previous flight. At 1555, the aircraft was de-iced with Type 1 de-icing fluid, and it departed for Pelee Island at 1605 on an instrument flight rules (IFR) flight plan as Flight GGN125. At 1615, the pilot advised the Cleveland Control Centre, Ohio, United States, that he had Pelee Island in sight, was cancelling IFR, and was descending out of 5000 feet. The pilot also advised Cleveland that he would be departing IFR out of Pelee Island in about 20 minutes as GGN126 and asked if a transponder code could be issued. The Cleveland controller issued a transponder code and requested a call when GGN126 became airborne. The pilot advised that the flight would depart on Runway 27 then turn north. These were the last recorded transmissions from the aircraft. The aircraft landed at 1620. While on the ramp, two individuals voiced concern to the pilot that there was ice on the wing. Freezing precipitation was falling. The pilot was observed to visually check the leading edge of the wing; however, he did not voice any concern and proceeded with loading the passengers and cargo. At approximately 1638, GGN126 departed Pelee Island for Windsor. After using most of the runway length for take-off, the aircraft climbed out at a very shallow angle. No one on the ground observed the aircraft once it turned toward the north; however, witnesses who were not at the airport reported that they heard the sound of a crash, then no engine noise. A normal flight from Pelee Island to Windsor in the Cessna Caravan takes 15 to 20 minutes. Shortly after the aircraft departed, the ticket agent in Windsor received a call from Pelee Island reporting that a crash had been heard. At 1705, when the aircraft had not arrived, the ticket agent called Windsor tower. The pilot had not made contact with any air traffic services (ATS) facility immediately before or after departure, so there was nothing in the ATS system to indicate that the aircraft had taken off. It was, therefore, unaccounted for. There was no signal heard from the emergency locator transmitter (ELT). At 1710, the Windsor tower controller contacted the Rescue Coordination Centre in Trenton, Ontario, and a search was initiated. At 1908, the aircraft empennage and debris were spotted by a United States Coast Guard (USCG) helicopter on the frozen surface of the lake, about 1.6 nautical miles (nm) from the departure end of the runway. There were no survivors. The empennage sank beneath the surface some four hours later. The wreckage recovery was not fully completed until 13 days later.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At take-off, the weight of the aircraft exceeded the maximum allowable gross take-off weight by at least 15 per cent, and the aircraft was contaminated with ice. Therefore, the aircraft was being flown significantly outside the limitations under which it was certified for safe flight.
2. The aircraft stalled, most likely when the flaps were retracted, at an altitude or under flight conditions that precluded recovery before it struck the ice surface of the lake.
3. On this flight, the pilotís lack of appreciation for the known hazards associated with the overweight condition of the aircraft, ice contamination, and the weather conditions was inconsistent with his previous practices. His decision to take off was likely adversely affected by some combination of stress and fatigue.
Findings as to Risk:
1. Despite the abbreviated nature of the September 2001 audit, the next audit of Georgian Express Ltd. was not scheduled until September 2004, at the end of the 36-month window.
2. The internal communications at Transport Canada did not ensure that the principal operations inspector responsible for the air operator was aware of the Pelee Island operation.
3. The standard passenger weights available in the Aeronautical Information Publication at the time of the accident did not reflect the increased average weight of passengers and carry-on baggage resulting from changes in societal-wide lifestyles and in travelling trends.
4. The use of standard passenger weights presents greater risks for aircraft under 12 500 pounds than for larger aircraft due to the smaller sample size (nine passengers or less) and the greater percentage of overall aircraft weight represented by the passengers. The use of standard passenger weights could result in an overweight condition that adversely affects the safety of flight.
5. The Cessna Caravan de-icing boot covers up to a maximum of 5% of the wing chord. Research on this wing has shown that ice accumulation beyond 5% of the chord can result in degradation of aircraft performance.
6. At the Pelee Island Airport, the air operator did not provide the equipment that would allow an adequate inspection of the aircraft for ice during the pre-flight inspection and did not provide adequate equipment for aircraft de-icing.
7. Repetitive charter operators are not considered to be scheduled air operators under current Transport Canada regulations, and, therefore, even though the charter air operator may provide a service with many of the same features as a scheduled service, Transport Canada does not provide the same degree of oversight as it does for a scheduled air operator.
8. A review of the Canadian Aviation Regulations regarding simulator training requirements indicates that there is no requirement to conduct recurrent simulator training if currency and/or pilot proficiency checks do not lapse.
9. Commercial Air Service Standard 723.91(2) does not clearly indicate whether there is a requirement for simulator training following expiration of a pilot proficiency check.
10. Incorrect information on the passenger door placards, an incomplete safety features card, and the fact that the operating mechanisms and operating instructions for the emergency exits were not visible in darkness could have compromised passenger egress in the event of a survivable accident.
11. The dogs being carried on the aircraft were not restrained, creating a hazard for the flight and its occupants.
Final Report:

Crash of a Piper PA-46-310P Malibu in Killarney: 6 killed

Date & Time: Aug 19, 1994 at 1230 LT
Operator:
Registration:
C-GSEV
Flight Type:
Survivors:
No
Schedule:
Windsor – Killarney
MSN:
46-8408035
YOM:
1984
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1322
Captain / Total hours on type:
122.00
Aircraft flight hours:
2019
Circumstances:
The flight was a private pleasure/travel flight for the purpose of transporting the pilot, his wife, and two other couples from Windsor to Killarney, Ontario, where they were to spend the weekend with friends. The flight had been planned in advance of the departure date. The pilot commenced taxiing at 1058 eastern daylight saving time (EDT), and was issued an instrument flight rules (IFR) clearance to Killarney via the routing "Windsor, radar vectors Sarnia, direct Wiarton, direct Killarney, to maintain 3,000" feet asl. The pilot took off at 1105. After take-off, the flight proceeded in a routine manner in accordance with the IFR clearance and was issued a final cruise altitude of 9,000 feet asl. The pilot reported level at 9,000 feet asl at 1125. At 1137, while the flight was 65 to 70 nm southwest of Wiarton, Ontario, the pilot was issued and acknowledged a clearance to fly direct to Killarney. At 1151, he requested and was issued a clearance to climb to 12,000 feet asl to get above a cloud layer, and reported level at 12,000 feet asl at 1155. The flight passed 20 nm to the west of Wiarton at 1203. At 1206, the pilot was given the Sudbury altimeter setting of 29.913 and was cleared to maintain 4,000 feet asl at his convenience. He acknowledged the clearance and commenced descent from 12,000 feet asl, 62 nm south of Killarney. Shortly after issuing the descent clearance, the air traffic services (ATS) controller advised the pilot that the IFR flight plan could be cancelled with the controller on his frequency while still airborne or with the Sault Ste. Marie flight service station (FSS) on the ground by a toll free telephone number. The ATS controller asked the flight crew of another aircraft on the same frequency to listen for an IFR cancellation from C-GSEV and to relay the cancellation to the controller. At 1221, the pilot of C-GSEV advised the ATS controller that he would be descending to 2,000 feet asl. The controller advised the pilot that the flight was in uncontrolled airspace and descent would be at the pilot's discretion. The pilot acknowledged the message, and this was the last direct controller/pilot communication (DCPC) between ATS and the aircraft. The last recorded radar position of the aircraft was at 1223:43, when it slowed to 180 knots ground speed and was descending out of 3,000 feet asl, 3 1/2 to 4 nm south of the Killarney airport. At about 1224, the flight crew from another aircraft on the frequency advised the ATS controller that C-GSEV had cancelled the IFR flight plan. There was no further communication with the flight after the pilot cancelled the IFR flight plan. The aircraft was reported missing to officials of the pilot's company the following morning by friends and family of the passengers. Search and rescue authorities were notified at approximately 0930, and the wreckage was located by search and rescue late that afternoon. The aircraft struck the rock face of a mountain at 1,321 feet asl in near level flight, on a northeast heading. The top of the mountain was 1,408 feet asl. The six occupants were fatally injured, and the aircraft was destroyed on impact. The accident occurred at about 1230 EDT during the hours of daylight, at latitude 46°02'N and longitude 081°26'W.
Crew:
Emidio Simone, pilot.
Passengers:
Laila Simone,
William and Lynne Bolton,
David and Pauline Moore.
Probable cause:
The pilot was operating the aircraft in instrument meteorological conditions and uncontrolled airspace while below a safe terrain clearance altitude, and the aircraft struck a mountain.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Pelée Island: 3 killed

Date & Time: Jun 24, 1989 at 2300 LT
Registration:
C-GSWC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pelée Island - Windsor
MSN:
31-7305067
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft was dispatched at Pelée Airport to evacuate to Windsor a patient. On board were one patient, his spouse, one ambulance officer and two pilots. Shortly after a night takeoff from runway 28, while climbing, the aircraft went out of control and crashed in Lake Erie. The copilot and the patient survived while three other occupants were killed.

Crash of a Beechcraft C-45F Expeditor near Windsor: 6 killed

Date & Time: May 19, 1947
Type of aircraft:
Operator:
Registration:
44-87142
Flight Phase:
Flight Type:
Survivors:
No
MSN:
8401
YOM:
1945
Location:
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
While approaching the Selfridge Air National Guard Base from the south, the twin engine aircraft crashed in unknown circumstances two miles south of Windsor, Ontario. All six occupants were killed.