Air Saguenay

The aircraft had been seen floating in Mistastin Lake and later sank. To date, the wreckage has not been found. There is no radar coverage at low altitudes in the area, and the aircraft was flying in uncontrolled airspace and not in communication with air traffic services. Without any witnesses and without key pieces of the aircraft, the TSB is unable to conduct a full investigation into this accident. If the aircraft is found, the TSB will assess the feasibility of investigating the accident further.

Findings as to causes and contributing factors:
1. The pilot performed manoeuvres with a reduced safety margin at low altitudes. As a result, these flights involved a level of risk that was unnecessary to attain the objectives of sightseeing flights.
2. With no restrictions on manoeuvres and no minimum altitude prescribed by the company prior to flight, the pilot flew according to his own limits and made a steep turn at approximately 110 feet above ground level.
3. When the pilot made a steep left turn, aerodynamic stalling ensued, causing an incipient spin at an altitude insufficient to allow control of the aircraft to be regained prior to vertical collision with the terrain.
4. The absence of an angle-of-attack indicator system and an impending stall warning device deprived the pilot of the last line of defence against loss of control of the aircraft.

Findings as to risk:
1. If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
2. If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, operators may not be able to proactively identify safety deficiencies before they cause an accident.
3. If pilots do not obtain at least the regulatory rest periods, there is a risk that flights will be conducted when pilots are fatigued.
4. Unless all flights made are recorded in the pilot’s logbook and monitored by the company, it is possible that the pilot will not receive the required rest periods, which increases the risk of flights being conducted when the pilot is fatigued.
5. If flights made are not recorded in the aircraft’s journey logbook, it is possible that inspection and maintenance schedules and component lifetimes will be exceeded, increasing the risk of failure.
6. Unless safety management systems are required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will not be able to identify and effectively mitigate the hazards involved in their operations.
7. If pilots do not receive stall training that demonstrates the aircraft’s actual behaviour in a steep turn under power, there is a high risk of loss of control.

Other findings:
1. The replacement of the ventral fin with Seafins on C-FKRJ was in compliance with the requirements of Kenmore Air Harbor Inc.’s supplemental type certificate.
2. The control wheel was in the left-hand position (pilot side) at the moment of impact.
3. Angle-of-attack indicator systems have been recognized as contributing to flight safety by improving pilot awareness of the stall margin at all times, thereby allowing pilots to react in order to prevent loss of control of the aircraft.
4. Stall warning systems have been recognized as a means of improving flight safety by providing a clear, unambiguous warning of an impending stall.

Causes and Contributing Factors:
1. The pilot took off in weather conditions that were below the minimum for visual flight rules, and continued the flight in those conditions.
2. After a late decision to carry out a precautionary alighting, the pilot wound up in instrument meteorological conditions (IMC). Consequently, the visual references were reduced to the point of leading the aircraft to controlled flight into terrain (CFIT).
3. The passenger at the rear of the aircraft was not seated on a seat compliant with aeronautical standards. The passenger was ejected from the plane at the moment of impact, which diminished his chances of survival.
Findings as to Risk:
1. The lack of training on pilot decision-making (PDM) for air taxi operators exposes pilots and passengers to increased risk when flying in adverse weather conditions.
2. In view of the absence of an ELT signal and the operator’s delay in calling, search efforts were initiated more than 3 ½ hours after the accident. That additional time lag can influence the seriousness of injuries and the survival of the occupants.