Crash of a De Havilland DHC-6 Twin Otter 300 near Lac de Gras

Date & Time: Dec 27, 2023 at 1245 LT
Operator:
Registration:
C-GMAS
Survivors:
Yes
Schedule:
Margaret Lake - Lac de Gras
MSN:
438
YOM:
1974
Flight number:
TID601
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14300
Captain / Total hours on type:
8000.00
Copilot / Total flying hours:
400
Copilot / Total hours on type:
200
Aircraft flight hours:
51995
Circumstances:
The wheel-ski equipped airplane departed Margaret Lake at 1205LT on flight TID601 to Lac de Gras, carrying eight passengers and two crew members. Upon arriving over the Lac de Gras road camp, the flight crew conducted 4 approaches toward the desired landing area on the frozen lake surface, descending at times to heights below 50 feet above ground level. During the 4th and final approach attempt, the aircraft descended to below 50 feet above ground level, and the flight crew lost visual contact with the terrain. At 1245LT, the aircraft impacted the terrain 1,850 metres southeast from the desired landing site. Two passengers were seriously injured and were unable to egress. The remaining occupants, including one passenger who was ejected, sustained minor injuries. The airplane was damaged beyond repair.
Probable cause:
Findings as to causes and contributing factors:
- The oversight mechanisms employed by Air Tindi were unable to detect the drift away from standard operating procedures, and deviations by pilots, including the conduct of improvised instrument approaches in instrument meteorological conditions, were not addressed.
- The flight crew’s decision to depart on the day’s flights and continue flying in deteriorating weather was influenced by both the flight crew’s past successful experiences in similar conditions and by a plan continuation bias, which led to a reduced perception of risk associated with continuing this visual flight rules flight in instrument meteorological conditions.
- The flight crew’s overreliance on the electronic flight bags for situational awareness contributed to their decision to continue operating visually in instrument meteorological conditions.
- While conducting an improvised instrument approach in an area of reduced visibility, the flight crew intentionally descended below 50 feet above ground level without sufficient visual reference to the surface and the aircraft impacted rising terrain.
Final Report:

Crash of a Grumman G-21A Goose in Bella Bella

Date & Time: Dec 18, 2023 at 1429 LT
Type of aircraft:
Operator:
Registration:
C-GDDJ
Flight Phase:
Survivors:
Yes
Schedule:
Bella Bella - Port Hardy
MSN:
1184
YOM:
1942
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9297
Captain / Total hours on type:
1719.00
Aircraft flight hours:
26603
Circumstances:
The airplane departed Bella Bella (Campbell Island) Airport Runway 13 on a visual flight rules flight to Port Hardy Airport, carrying one pilot and four passengers. Shortly after takeoff, the aircraft experienced a dual engine failure and was unable to maintain altitude. The pilot transmitted a Mayday call on the radio before the aircraft collided with terrain some 1,5 km southeast from the airfield. All five occupants were injured and the airplane was damaged beyond repair.
Probable cause:
Findings as to causes and contributing factors:
1. The operator did not store fuel drums in a way that minimized the possibility of fuel contamination because the operator was not aware of Transport Canada’s fuel drum storage guidelines. As a result, the occurrence fuel drum was stored upright, and water likely entered via the vent or bung and contaminated the fuel.
2. The operator did not consider the hazards related to fueling from previously opened or contaminated fuel drums. As a result, physical defenses commonly used to detect contamination, such as filters or water detection paste, were not implemented.
3. Because drum fueling operations were new and in the process of changing, the operator delayed the communication of specific procedures describing how to safely perform the task.
4. Training was not provided on the equipment or procedures for drum fueling by the operator because it was perceived to be a simple task, and it was believed that company pilots would have prior experience with drum fueling.
5. Because there were no physical defenses, no specific procedures, and no training, water contamination was introduced into the fuel system when the aircraft was fueled.
6. Company guidance required fuel to be sampled only as part of the daily inspection, and the practice of omitting fuel sampling had become normalized. As a result, the contamination that was introduced into the fuel system was not detected before departure.
7. As a result of fuel contamination, the left and right engines lost power shortly after departure. The pilot performed a forced landing in a wooded area, which resulted in substantial damage to the aircraft and minor injuries to the 5 occupants.
Final Report:

Crash of a Mitsubishi MU-2B-60 in Wawa

Date & Time: Nov 27, 2023 at 0739 LT
Type of aircraft:
Operator:
Registration:
C-GYUA
Flight Type:
Survivors:
Yes
Schedule:
Thunder Bay – Wawa – Sault Sainte Marie
MSN:
1553
YOM:
1982
Flight number:
THU890
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2058
Captain / Total hours on type:
184.00
Copilot / Total flying hours:
1984
Copilot / Total hours on type:
44
Circumstances:
The crew was preparing for instrument flight rules (IFR) flight THU890 from Thunder Bay Airport (CYQT), Ontario, to Sault Ste. Marie Airport (CYAM), Ontario. The flight included a stop at Wawa Aerodrome (CYXZ), Ontario, to pick up a patient for a medical transfer to CYAM. As part of the pre-flight preparations, one of the flight crew members contacted CYXZ at 0549 to check the runway conditions and spoke with an aerodrome employee who was on duty for after-hour inquiries. During the call, the flight crew member learned of ongoing light snowfall and understood that the runway would be plowed by about 0730. At approximately 0653, during the hours of darkness, the aircraft departed CYQT for CYXZ with 2 flight crew members and a paramedic on board. The cruise portion of the flight was uneventful. The flight crew maintained radio contact with air traffic control (ATC) and received clearance for the approach to CYXZ. At about 0726, ATC instructed the flight crew to switch to the Wawa aerodrome traffic frequency (ATF). Between 0715 and 0730, aerodrome staff, including the employee to whom the flight crew member had spoken and a trainee, arrived at CYXZ. An ambulance carrying the patient who would be transferred also arrived at the aerodrome in that time. It had snowed overnight, and aerodrome staff were aware of the potential arrival of flight THU890, but had not yet plowed the runway. The staff began their morning duties, which included preparing the snow removal vehicles to clear the runway. There was no radio communication between aerodrome staff and the occurrence flight crew. The approach to CYXZ occurred during civil twilight,Footnote3 before sunrise. The flight crew activated the runway lights using the aircraft radio control of aerodrome lighting system and performed the RNAV (GNSS) [area navigation (global navigation satellite system)] approach to Runway 03. They visually spotted the runway when they were about 10 nautical miles away on final approach. As the aircraft approached the runway, the flight crew had a clear view of the runway lights and saw that the runway was covered in snow. The aircraft touched down on Runway 03 at 0739, and shortly after, it suddenly began sliding to the right. The flight crew attempted to correct this using rudder pedals, as well as differential propeller and power control, but were unsuccessful. The aircraft rotated almost 180° before sliding off the runway’s right side. The aircraft continued sliding sideways off the runway while facing the opposite direction of landing and came to rest on its left side in a drainage ditch, about 78 feet from the runway’s edge. The aircraft was extensively damaged; the right engine propeller blades penetrated the cabin before the engines were shut down. After the engines were shut down, the occupants began evacuating. The right emergency exit was damaged and would not open, so they egressed through the aircraft’s main door, which was located at the rear, on left side of the aircraft. A significant fuel leak was noted. The occupants walked the short distance to the runway, where the snow was between 6 to 8 inches deep on the runway surface. The flight crew called 911 and the London Flight Information Centre (FIC) to report the accident. The aerodrome staff observed the aircraft land and slide off the runway. They drove the snow removal vehicle down the runway, plowing snow along the way. They stopped to check on the occupants and then continued down the remaining runway length before turning around at the end and continuing to plow snow back toward the terminal building. Another vehicle transported the aircraft occupants to the terminal building, where they were assessed by emergency medical services and then transported to the local hospital for examination. There were only minor injuries.
Probable cause:
The investigation was unable to determine the aircraft’s exact touchdown point because the runway was plowed immediately after the occurrence. However, based on the available data, it was estimated that the aircraft touched down between 1000 feet and 1400 feet beyond the runway threshold, and began to slide to the right shorty after. The aircraft continued sliding to the right and rotated nearly 180° while on the runway surface. The aircraft then exited the side of the runway at an angle of about 45° to the runway edge. Shortly after the occurrence, Thunder Airlines Limited issued an operations bulletin to all flight crews, indicating that no flight crew shall depart until there is confirmation of suitable runway conditions (maximum ½ inch wet snow or 2 inches dry snow) from reliable sources on the ground. In addition, the bulletin states that if the communicated information includes a plan to clear the runway, confirmation of a cleared runway must be obtained before landing. The bulletin will be incorporated in the Thunder Airlines Limited standard operating procedures in the next revision.
Final Report:

Crash of a Pilatus PC-12/45 in Kasabonika

Date & Time: Nov 21, 2023 at 1938 LT
Type of aircraft:
Operator:
Registration:
C-GEOW
Survivors:
Yes
Schedule:
Sioux Lookout – Kasabonika
MSN:
244
YOM:
1999
Flight number:
BF712
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3133
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
690
Copilot / Total hours on type:
430
Circumstances:
The single engine airplane departed the Sioux Lookout Airport (CYXL), Ontario, at 1820LT on an instrument flight rules flight to the Kasabonika Airport (CYAQ), Ontario, with 2 pilots and 6 passengers on board. The captain was the pilot flying and the first officer (FO) was the pilot monitoring. On approach to CYAQ, the pilots conducted an area navigation approach to Runway 03, using the autopilot coupled with a GPS (global positioning system). The captain then turned off the autopilot at 1000 feet above ground level (AGL) per the aircraft’s pilot operating handbook (POH) limitation. The approach continued at 120 knots ground speed with the flaps set to 15°. The aircraft touched down approximately 1,200 feet beyond the threshold of Runway 03 at 102 knots ground speed. During the landing roll, the captain applied reverse thrust momentarily, which resulted in a slight yawing motion of the aircraft. The reverse thrust was returned to the idle position, and directional control was restored. The captain then fully applied the brakes; however, at 1938, the aircraft skidded and overshot the end of the runway. The aircraft came to rest approximately 350 feet beyond the runway surface. The aircraft cabin remained upright and intact. The passengers and crew were not injured and were able to egress though the main cabin door. The aircraft’s emergency locator transmitter activated.
Probable cause:
The weather conditions present and forecast during the occurrence showed winds moving westerly to become favorable for takeoffs and landings on Runway 21. The final approach was 120 knots ground speed during the last 500 feet of the approach. The aircraft crossed the threshold at 110 knots ground speed and touched down approximately 1200 feet beyond the threshold at 102 knots ground speed. The manufacturer’s landing performance specifications in the POH are provided for dry and paved runway conditions only. The Pilatus PC-12/45 aircraft’s normal approach speed for landing with 15° flaps is 98 KIAS. 14 However, the aircraft had an approach speed of 120 knots ground speed. Because the final approach ground speed exceeded the Pilatus PC-12’s landing performance charts found in the POH,15 it was not possible to calculate the distance the aircraft would have needed given these conditions. In addition, the charts in the POH do not provide compensation for gravel runways or for runway contaminants such as ice, rain, or snow. Based on calculations made using the aircraft’s landing performance charts, when landing with a 10-knot tailwind (the maximum charted tailwind) and without the use of reverse thrust, the aircraft would need 3458 feet of available runway.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Gold River

Date & Time: Jul 28, 2023 at 1720 LT
Type of aircraft:
Operator:
Registration:
C-FZVP
Flight Type:
Survivors:
Yes
Schedule:
Louie Bay - Gold River
MSN:
1033
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Circumstances:
The single engine airplane was conducting a visual flight rules repositioning flight from Louie Bay on Nootka Island, British Columbia (BC), to Gold River Water Aerodrome (CAU6), BC, with only the pilot on board. On arrival at CAU6, the pilot noted a rough sea state in the company’s primary landing area and elected to land in the secondary area, a tree-lined river to the east of the base. The aircraft was observed overflying the company dock to the north and then turning right, aligning with the southwest direction of the river. When descending on the alignment turn to final approach, the aircraft experienced an uncommanded yaw and roll. It
abruptly turned further right, heading west, and continued to descend toward the trees. It was reported that opposite aileron input, to try and arrest the uncommanded yaw and roll, increased the roll rate. At approximately 1720, the aircraft struck the forested area on the west side of the river, coming to rest approximately 75 feet from the river. There was no post-impact fire. The pilot received serious injuries, was extracted by local firefighting personnel, and attended to by local paramedics. He was then airlifted to hospital by a search and rescue helicopter.
Probable cause:
While on the right turn to final, the aircraft experienced an uncommanded yaw and roll. The application of aileron in the opposite direction made the condition worse. This is consistent with an aerodynamic stall.
Final Report:

Crash of a Quest Kodiak 100 near Tofino: 2 killed

Date & Time: Jun 21, 2023 at 1337 LT
Type of aircraft:
Registration:
C-GKTX
Flight Type:
Survivors:
Yes
Site:
Schedule:
Masset - Tofino
MSN:
100-0010
YOM:
2009
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1200
Captain / Total hours on type:
250.00
Circumstances:
At 1121LT on 20 June 2023, the privately registered Quest Kodiak 100 amphibious float-equipped aircraft (registration C-GKTX, serial number 100-0010) departed Masset Airport (CZMT), British Columbia (BC), on an instrument flight rules (IFR) flight to Tofino/Long Beach Airport (CYAZ), BC, with 1 pilot and 3 passengers on board. While enroute, at 1246, the pilot contacted air traffic control to cancel IFR and continued the flight under visual flight rules (VFR). The aircraft continued the flight to the planned final destination, which was a cabin approximately 60 nautical miles northwest of CYAZ. The aircraft followed an inlet (Tahsis Narrows) toward the destination and continued for a straight-in landing on the water, near the cabin. On initial touchdown, both floats touched the surface of the water simultaneously. The aircraft bounced and, as the aircraft approached the surface of the landing area the 2nd time in a level attitude, the left float reportedly made contact with either a boat wake or object. 2 The force of the contact resulted in the aircraft bouncing to a height of approximately 30 feet and banking to the right. The pilot initiated a go-around. At 1337, during the initial climb over land, the aircraft contacted trees and then impacted the terrain. The pilot and 1 passenger were fatally injured, 1 passenger received serious injuries, and 1 passenger received minor injuries. There was a post-impact fire. The aircraft was destroyed. The emergency locator transmitter signal was received by the Joint Rescue Coordination Centre in Victoria, BC. The Canadian Coast Guard, Canadian Armed Forces search and rescue, the RCMP (Royal Canadian Mounted Police), and fire personnel responded.
Probable cause:
It is possible that the accident was the consequence of wind shear and downdrafts.
Final Report:

Crash of a Pilatus PC-12/47E in Whitehorse

Date & Time: Apr 17, 2023 at 1138 LT
Type of aircraft:
Operator:
Registration:
C-GMPX
Flight Type:
Survivors:
Yes
Schedule:
Whitehorse – Yellowknife
MSN:
1017
YOM:
2008
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8700
Captain / Total hours on type:
3000.00
Aircraft flight hours:
11908
Circumstances:
At 1134 Mountain Standard Time on 17 April 2023, the Government of Canada, Royal Canadian Mounted Police Pilatus Aircraft Ltd. PC-12/47E (registration C-GMPX, serial number 1017) departed Whitehorse/Erik Nielsen International Airport (CYXY), Yukon, on an instrument flight rules flight to Yellowknife Airport (CYZF), Northwest Territories. The pilot was the sole occupant. Shortly after the aircraft lifted off from Runway 32L, its stall warning system activated, triggering an aural “STALL” warning and the activation of the stick shaker. The pilot informed the tower controller of the intention to return for landing. At 1138, while the pilot was visually manoeuvring to land on Runway 32L, the aircraft impacted the terrain approximately 520 feet west-southwest of the centre of the displaced threshold, in a right-wing-low attitude. The aircraft subsequently hit a pile of millings with its left wing, rolled onto its left side, and slid approximately 130 feet before coming to rest on an airport service road. The pilot, who was seriously injured, exited the aircraft through the emergency exit with assistance from aircraft rescue and firefighting personnel, who arrived within minutes of the accident. An emergency locator transmitter signal was received by the search and rescue satellite system. The aircraft was destroyed; there was no post-impact fire.
Probable cause:
Findings as to causes and contributing factors. These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. During the final moments of the flight, the aircraft’s right turn in excess of 45° of bank, while it was operating at a low height above the ground and just above the calculated stall speed, likely resulted in the aircraft entering an aerodynamic stall, with insufficient height to recover before impacting the terrain.
2. The stainless steel belt in the left AOA transmitter experienced a fatigue crack likely attributed to the wet-etch design process. Owing to the fact that the belt is an on condition component, the fatigue cracking went undetected until the belt failed at, or just before, takeoff on the occurrence flight, causing the AOA transmitter to transmit a false stall signal when the aircraft became airborne.
3. While attempting to align the aircraft for landing, the pilot experienced attentional narrowing due to an intense stress reaction in response to a surprise event. As a result, the pilot's attention was focused outside the aircraft, and the pilot unknowingly placed the aircraft in a flight regime that likely resulted in an aerodynamic stall at a very low height above ground.
4. The Royal Canadian Mounted Police's training for stall warning system malfunctions on the PC-12 focused solely on an inadvertent pusher activation. As a result, the occurrence pilot did not fully understand the symptoms of a false stall warning or the options available to mitigate the risks associated with this emergency.
5. The PC-12 pilot operating handbook provided limited guidance with regard to the potential use of the AURAL WARN INHIBIT switch during emergency situations. As a result, the occurrence pilot was unaware that this switch could be used during highworkload situations to quickly eliminate the false aural stall warning that was a distraction for the duration of the flight.
Final Report:

Crash of a Cessna 208B Grand Caravan near Nakina: 2 killed

Date & Time: Feb 28, 2023
Type of aircraft:
Operator:
Registration:
C-GMVB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nakina – Fort Hope
MSN:
208B-0317
YOM:
1992
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
325
Captain / Total hours on type:
103.00
Copilot / Total flying hours:
2570
Copilot / Total hours on type:
662
Aircraft flight hours:
28262
Circumstances:
On 28 February 2023, the Cessna 208B Caravan (208B) aircraft (registration C-GMVB) operated by 1401380 Ontario Limited, doing business as Wilderness North Air (WNA), was scheduled for 2 cargo flights from Nakina Airport (CYQN), Ontario, to Fort Hope Airport (CYFH), Ontario. The occurrence pilot, who had recently been promoted to pilot-in-command (PIC) on the 208B aircraft, was scheduled to fly alone in daytime visual flight rules (VFR) conditions. After reviewing the weather information with his colleagues at their morning briefing, he assessed that the weather was satisfactory for the flight and noted that the winds were forecast to be gusty. A pilot who was present at the briefing but was not scheduled for flight duty that day offered to accompany him. For all flights that day, the occurrence pilot would be the PIC and occupy the left seat, and the 2nd pilot went along as an extra crew member without any assigned duties, occupying the right seat. The cargo was loaded onto the aircraft, and the 1st flight of the day departed CYQN at 1020 and landed in CYFH at 1055. After unloading the cargo, they departed CYFH at 1120 and returned to CYQN at 1156. The pilots loaded the aircraft with cargo for their 2nd flight to CYFH. According to the load sheet, there were 3320 pounds of groceries and household goods on board. The pilots refuelled the aircraft and departed from Runway 27 at approximately 1245. A few minutes after departure, it was reported that they made a radio call on the aerodrome traffic frequency, indicating their location and an estimated time of arrival at CYFH of 1330. Approximately 30 minutes after the occurrence flight departed, a 2nd 208B aircraft (registration C-FUYC) operated by WNA departed also from CYQN to CYFH, with cargo for a different customer. The flight crew encountered snow showers en route, and shortly after they arrived at CYFH at 1400, there was a snow squall, which significantly reduced visibility. At that time, 2 customers were waiting at CYFH for their cargo, and it soon became apparent that the occurrence aircraft had not yet arrived. At approximately 1430, WNA personnel at CYQN were informed that the occurrence aircraft had not arrived at 1330 as expected. At 1445, management at WNA notified the Joint Rescue Coordination Centre (JRCC), in Trenton, Ontario, that the aircraft was overdue. WNA began its own aerial search along the flight path using C-FUYC, which departed CYFH at 1510 with 2 crew members on board, flew along the direct route of flight of the missing aircraft, and returned to CYQN at 1546. They refuelled the aircraft and departed on another search flight at 1620, with 2 additional pilots in the back to act as spotters. They searched along the route of flight until 1840 and returned to CYQN. JRCC had initiated its response at 1500, and the first tasked aircraft arrived in the search area at 1700. The search continued over the following 4 days. The occurrence aircraft was found on 04 March 2023, 30.8 nautical miles north-northwest of CYQN along the direct track to CYFH. Both pilots were fatally injured. The aircraft was destroyed by impact forces. There was no post-crash fire. There was no emergency locator transmitter (ELT) on the occurrence aircraft because it had been removed for recertification.
Probable cause:
During the en-route portion of the flight, over a remote area, the pilot lost control of the aircraft for an unknown reason, which resulted in the collision with terrain.
Final Report:

Crash of a Piper PA-46-350P Jetprop DLX in Goose Bay: 1 killed

Date & Time: Dec 14, 2022 at 1002 LT
Registration:
N5EQ
Flight Type:
Survivors:
Yes
Schedule:
Nashua – Goose Bay – Nuuk
MSN:
46-36051
YOM:
1996
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2260
Captain / Total hours on type:
1046.00
Circumstances:
The single engine airplane departed Nashua Airport, New Hampshire, on December 13 on a flight to Nuuk, Greenland, with an intermediate stop in Goose Bay. Due to poor weather conditions at destination, the pilot diverted to Seven Islands Airport, Quebec, where the couple passed the overnight. On the morning of December 14, the airplane departed Seven Islands Airport at 0820LT bound for Goose Bay. At about 0958LT, the aircraft crossed the final approach fix / final approach waypoint FAFKO at 2,800 feet ASL, travelling at a ground speed of 104 knots, and began the final descent. Although the descent remained steady on a 3° profile, the ground speed decreased continuously for about 60 seconds. At 1000:31, the occurrence pilot reported at waypoint SATAK, and the ground speed had increased to above 80 knots. The tower provided the pilot with updated wind information and cleared the aircraft to land on Runway 08. The pilot acknowledged the clearance at 1000:49. Soon after, the ground speed began to decrease at a rate similar to the previous rate. At 1002:47, it had decreased to 51 knots. The aircraft departed controlled flight and impacted terrain when it was about 2.5 NM southwest of the airport along the extended centreline for Runway 08. The 406 MHz emergency locator transmitter activated, and the signal was received by the Joint Rescue Coordination Centre in Halifax, Nova Scotia, at 1006. A helicopter search and rescue mission was launched from Canadian Forces Base 5 Wing Goose Bay at 1036; the helicopter arrived at the accident site 3 minutes later. Medical technicians extricated the 2 occupants, who were both seriously injured. The occupants were airlifted to a waiting ambulance and then transported to the local hospital. The pilot later died of his injuries. The aircraft was destroyed.
Probable cause:
Given the absence of data for the last minute of the occurrence flight, the investigation could not determine the complete sequence of events that led to the loss of control and collision with terrain.
Final Report:

Crash of a De Havilland DHC-3 Otter in Pluto Lake

Date & Time: Oct 13, 2022 at 0929 LT
Type of aircraft:
Operator:
Registration:
C-FDDX
Survivors:
Yes
Schedule:
Mistissini - Pluto Lake
MSN:
165
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1938
Captain / Total hours on type:
600.00
Aircraft flight hours:
17489
Circumstances:
On 12 October 2022, the True North Airways Inc. de Havilland DHC-3 Otter aircraft on floats (registration C-FDDX, serial number 165) was conducting a visual flight rules flight, with 1 pilot on board, from Mistissini Water Aerodrome (CSE6), Quebec, to Pluto Lake, Quebec, where it would deliver cargo and pick up passengers. At approximately 0929 Eastern Daylight Time, while manoeuvring for landing on Pluto Lake, the aircraft collided with the surface of the water. The pilot sustained serious injuries. The passengers, who had been waiting near the lake for the aircraft’s arrival, transported the pilot to a nearby cabin from where he was later taken to hospital by a search and rescue helicopter. The emergency locator transmitter activated. There was significant damage to the aircraft.
Probable cause:
3.1 Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
Due to the visual cues of the landing area that were visible to the pilot, the close proximity of the landing site where passengers were waiting, and the natural tendency to continue a plan under changing conditions, the pilot continued the approach despite visibility in the local area being below the minimum required for visual flight rules flight.
Owing to the reduced visibility, the pilot’s workload, while he was manoeuvring for landing, was high and his attention was focused predominantly outside the aircraft in order to keep the landing area in sight. As a result, a reduction in airspeed went unnoticed.
During the aircraft’s turn from base to final, the increased wing loading, combined with the reduced airspeed, resulted in a stall at an altitude too low to permit recovery.
The pilot was not wearing the shoulder harness while at the controls and operating the aircraft because he found it uncomfortable and other aircraft he flew were not equipped with one. As a result, during impact with the water, the pilot received serious injuries.

3.2 Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
If aircraft stall warning systems do not provide multiple types of alerts warning the pilot of an impending stall, there is an increased risk that a visual stall warning alone will not be salient enough and go undetected when the pilot’s attention is focused outside the aircraft or during periods of high workload.
If aircraft operators do not ensure that their contact information on file with the Canadian Beacon Registry is accurate, there is a risk that search and rescue operations may be delayed.
If companies do not employ robust flight-following procedures, there is a risk that, after an accident, potentially life-saving search and rescue services will be delayed.

3.3 Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
The occurrence aircraft was carrying dangerous goods on board, even though the operator was not authorized to do so on its DHC-3 Otter aircraft.
For unknown reasons, the pilot encountered difficulty inflating his personal flotation device, and because of his proximity to the shore, he removed it to make it easier to swim.
Final Report: