Country

Crash of a De Havilland DHC-2 Beaver into Mistastin Lake: 7 killed

Date & Time: Jul 15, 2019
Type of aircraft:
Operator:
Registration:
C-FJKI
Survivors:
No
Schedule:
Crossroads Lake - Mistastin Lake
MSN:
992
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
18800
Captain / Total hours on type:
16000.00
Circumstances:
The single engine airplane was chartered by a provider based in Crossroads Lake (near Churchill Falls reservoir) to fly four fisherman and two guides to Mistastin Lake, Labrador. The aircraft was supposed to leave Crossroads Lake at 0700LT but the departure was postponed to 1000LT due to low ceiling. Several attempts to contact the pilot failed during the day and the SAR center based in Trenton was alerted. SAR operations were initiated and four days later, the location of the accident was reached but only four bodies were found. The body of the pilot and two passengers were never recovered as well as the wreckage.
Probable cause:
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.
Final Report:

Crash of a Piper PA-46-350P Malibu near Makkovik: 1 killed

Date & Time: May 1, 2019 at 0816 LT
Operator:
Registration:
N757NY
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Goose Bay - Narsarsuaq
MSN:
46-36657
YOM:
2015
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Captain / Total hours on type:
20.00
Copilot / Total flying hours:
1300
Copilot / Total hours on type:
0
Circumstances:
On 01 May 2019 at 0723, the aircraft departed CYYR on a VFR flight plan direct to BGBW. The ferry pilot, who was the pilot-in-command, occupied the left seat while the co-owner occupied the right seat. The aircraft climbed to 2000 feet ASL and proceeded on a direct track to destination. The altitude and heading did not change significantly along the route, therefore it is likely that the autopilot was engaged. At 0816, the aircraft collided with a snow-covered hill 2250 feet in elevation, located 35 nautical miles (NM) southeast of Makkovik Airport (CYFT), Newfoundland and Labrador. The impact happened approximately 200 feet below the top of the hill. The aircraft came to rest in deep snow on steep sloping terrain. The aircraft sustained significant damage to the propeller, nose gear, both wings, and fuselage. Although the cabin was crush-damaged, occupiable space remained. There was no post-impact fire. The ferry pilot was seriously injured and the co-owner was fatally injured. The Joint Rescue Coordination Centre (JRCC) in Halifax received an emergency locator transmitter (ELT) signal from the aircraft at 0823. The ferry pilot carried a personal satellite tracking device, a personal locator beacon (PLB) and a handheld very high frequency (VHF) radio, which allowed communication with search and rescue (SAR). Air SAR were dispatched to the area; however, by that time, the weather had deteriorated to blizzard conditions and aerial rescue was not possible. Ground SAR then deployed from the coastal community of Makkovik and arrived at the accident site approximately 4 hours later because of poor weather conditions and near zero visibility. The ferry pilot and the body of the co-owner were transported to Makkovik by snowmobile. The following day, they were airlifted to CYYR.
Probable cause:
Controlled flight into terrain.
Final Report:

Crash of a Beechcraft 1900D in Gander

Date & Time: Apr 20, 2016 at 2130 LT
Type of aircraft:
Operator:
Registration:
C-FEVA
Survivors:
Yes
Schedule:
Goose Bay – Gander
MSN:
UE-126
YOM:
1994
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2381
Captain / Total hours on type:
1031.00
Copilot / Total flying hours:
1504
Copilot / Total hours on type:
174
Aircraft flight hours:
32959
Circumstances:
The Exploits Valley Air Services Beechcraft 1900D (registration C-FEVA, serial number UE-126), operating as Air Canada Express flight EV7804, was on a scheduled passenger flight from Goose Bay International Airport, Newfoundland and Labrador, to Gander International Airport, Newfoundland and Labrador. At 2130 Newfoundland Daylight Time, while landing on Runway 03, the aircraft touched down right of the centreline and almost immediately veered to the right. The nosewheel struck a compacted snow windrow on the runway, causing the nose landing gear to collapse. As the aircraft’s nose began to drop, the propeller blades struck the snow and runway surface. All of the left-side propeller blades and 3 of the right-side propeller blades separated at the blade root. A portion of a blade from the right-side propeller penetrated the cabin wall. The aircraft slid to a stop on the runway. All occupants on board — 14 passengers and 2 crew members — were evacuated. Three passengers sustained minor injuries. The aircraft was substantially damaged. There was no post-impact fire. There were insufficient forward impact forces to automatically activate the 121.5 MHz emergency locator transmitter. The accident occurred during the hours of darkness.
Probable cause:
Findings as to causes and contributing factors:
1. Neither pilot had considered that the combination of landing at night, in reduced visibility, with a crosswind and blowing snow, on a runway with no centreline lighting, was a hazard that may create additional risks.
2. The blowing snow made it difficult to identify the runway centreline markings, thereby reducing visual cues available to the captain. This situation was exacerbated by the absence of centreline lighting and a possible visual illusion caused by blowing snow.
3. Due to the gusty crosswind conditions, the aircraft drifted to the right during the landing flare, which was not recognized by the crew.
4. It is likely that the captain had difficulty determining aircraft position during the landing flare.
5. The flight crew’s decision to continue with the landing was consistent with plan continuation bias.
6. During landing, the nosewheel struck the compacted snow windrow on the runway, causing the nose landing gear to collapse.

Findings as to risk:
1. If aircraft are not equipped with a 406 MHz-capable emergency locator transmitter, flight crews and passengers are at increased risk of injury or death following an accident because search-and-rescue assistance may be delayed.
2. If operators do not have defined crosswind limits, there is a risk that pilots may land in crosswinds that exceed their abilities, which could jeopardize the safety of flight.
3. If composite propeller blades contact objects and separate, and then strike or penetrate the cabin, there is a risk of injury or death to occupants seated in the propeller’s plane of rotation.
4. If modern crew resource management training is not a regulatory requirement, then it is less likely to be introduced by operators and, as a result, pilots may not be fully prepared to recognize and mitigate hazards encountered during flight.
5. If organizations do not use modern safety management practices and do not have a robust safety culture, then there is an increased risk that hazards will not be identified and mitigated.
6. When testing an emergency locator transmitter’s (ELT) automatic activation system, a sticking g-switch may go undetected if more than 1 football throw is necessary to activate the ELT. As a result, the ELT might not activate during an accident, and search-and-rescue assistance may be delayed, placing flight crews and passenger at an increased risk for injury or death.
Final Report:

Crash of a Canadair CL-415 in Moosehead Lake

Date & Time: Jul 3, 2013 at 1415 LT
Type of aircraft:
Operator:
Registration:
C-FIZU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wabush - Wabush
MSN:
2076
YOM:
2010
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12500
Captain / Total hours on type:
120.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
138
Aircraft flight hours:
461
Circumstances:
On 03 July 2013, at about 1415 Atlantic Daylight Time, the Government of Newfoundland and Labrador Air Services Division Bombardier CL-415 amphibious aircraft (registration C-FIZU, serial number 2076), operating as Tanker 286, departed Wabush, Newfoundland and Labrador, to fight a nearby forest fire. Shortly after departure, Tanker 286 touched down on Moosehead Lake to scoop a load of water. About 40 seconds later, the captain initiated a left-hand turn and almost immediately lost control of the aircraft. The aircraft water-looped and came to rest upright but partially submerged. The flight crew exited the aircraft and remained on the top of the wing until rescued by boat. There was an insufficient forward impact force to activate the onboard 406-megahertz emergency locator transmitter. There were no injuries to the 2 crew members. The aircraft was destroyed. The accident occurred during daylight hours.
Probable cause:
Findings as to causes and contributing factors:
- It is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to the MANUAL selection when the centre pedestal cover was removed.
- The PROBES AUTO/MANUAL switch position check was not included on the Newfoundland and Labrador Government Air Services CL-415 checklist.
- The flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity.
- The flight crew decided to continue the take-off with the aircraft in an overweight condition.
- The extended period with the probes deployed on the water resulted in a longer take-off run, and the pilot flying decided to alter the departure path to the left.
- The left float contacted the surface of the lake during initiation of the left turn. Aircraft control was lost and resulted in collision with the water.
Findings as to risk:
- If safety equipment is installed in a manner that hampers its access and removal, then there is an increased risk that occupants may not be able to retrieve the safety equipment in a timely manner to ensure their survival.
- If individuals are not trained on safety equipment installed on the aircraft, then there is an increased risk that the individuals may not be aware of how to effectively use the equipment.
- If a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that that item will be missed, which could jeopardize the safety of flight.
- If flight crews do not adhere to standard operating procedures, then there is a risk that errors and omissions can be introduced, which could jeopardize the safety of flight.
- If a person is not restrained during flight and the aircraft either makes an abrupt manoeuvre or loses control, then that person is at a much greater risk of injury or death.
- If an overweight take-off is carried out, there may be an adverse effect on the aircraft’s performance, which could jeopardize the safety of flight.
- If companies do not have procedures for recording overweight take-offs and flight crews do not report them, then the overall condition of the aircraft’s structures will not be accurately known, which could jeopardize the safety of flight.
- If organizations do not use formal and documented processes to manage operational risks, there is an increased risk that hazards will not be identified and mitigated.
- If organizations do not have measures in place to raise awareness of the potential impact of stress on performance or to promote the early recognition and mitigation of stress, then there is an increased risk that errors will occur when an individual is affected by stress that has become chronic.
Other findings:
- Utilizing the locking position of the PROBES AUTO/MANUAL switch for the MANUAL selection allows the switch to be inadvertently moved from the AUTO to the MANUAL position.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain near Cartwright: 2 killed

Date & Time: May 26, 2010 at 0930 LT
Operator:
Registration:
C-FZSD
Flight Phase:
Survivors:
No
Site:
Schedule:
Goose Bay - Cartwright - Black Tickle - Goose Bay
MSN:
31-7405233
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9000
Circumstances:
Aircraft departed on a round trip flight from Goose Bay to Cartwright and Black Tickle before returning to Goose Bay, Newfoundland and Labrador. The pilot was to deliver freight to Cartwright as well as a passenger and some freight to Black Tickle. At approximately 0905, the pilot made a radio broadcast advising that the aircraft was 60 nautical miles west of Cartwright. No further radio broadcasts were received. The aircraft did not arrive at destination and, at 1010, was reported as missing. The search for the aircraft was hampered by poor weather. On 28 May 2010, at about 2200, the aircraft wreckage was located on a plateau in the Mealy Mountains. Both occupants of the aircraft were fatally injured. The aircraft was destroyed by impact forces and a post-crash fire. There was no emergency locator transmitter on board and, as such, no signal was received.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot conducted a visual flight rules (VFR) flight into deteriorating weather in a mountainous region.
2. The pilot lost visual reference with the ground and the aircraft struck the rising terrain in level, controlled flight.
Findings as to Risk:
1. When an aircraft is not equipped with a functioning emergency locator transmitter (ELT), the ability to locate the aircraft in a timely manner is hindered.
2. Not applying current altimeter settings along a flight route, particularly from an area of high to low pressure, may result in reduced obstacle clearance.
3. Without a requirement for terrain awareness warning systems, there will be a continued risk of accidents of this type.
Final Report:

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 De Havilland DHC-2 Beaver in Crossroads Lake

Date & Time: Jul 14, 2008 at 0816 LT
Type of aircraft:
Operator:
Registration:
C-FPQC
Flight Phase:
Survivors:
Yes
Schedule:
Crossroads Lake - Schefferville
MSN:
873
YOM:
1956
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7885
Captain / Total hours on type:
1000.00
Circumstances:
The Labrador Air Safari (1984) Inc. float-equipped de Havilland DHC-2 (Beaver) aircraft (registration C-FPQC, serial number 873) departed Crossroads Lake, Newfoundland and Labrador, at approximately 0813 Atlantic daylight time with the pilot and six passengers on board. About three minutes after take-off as the aircraft continued in the climb-out, the engine failed abruptly. When the engine failed, the aircraft was about 350 feet above ground with a ground speed of about 85 miles per hour. The pilot initiated a left turn and, shortly after, the aircraft crashed in a bog. The pilot and four of the occupants were seriously injured; two occupants received minor injuries. The aircraft was substantially damaged, but there was no post-impact fire. The impact forces activated the onboard emergency locator transmitter.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The linkpin plugs had not been installed in the recently overhauled engine, causing inadequate lubrication to the linkpin bushings, increased heat, and eventually an abrupt engine failure.
2. Immediately following the engine failure, while the pilot manoeuvred the aircraft for a forced landing, the aircraft entered an aerodynamic stall at a height from which recovery was not possible.
Finding as to Risk:
1. The failure to utilize available shoulder harnesses increases the risk and severity of injury.
Final Report:

Crash of a Swearingen SA227AC Metro III in Goose Bay

Date & Time: Mar 4, 2002 at 0456 LT
Type of aircraft:
Operator:
Registration:
C-FITW
Flight Type:
Survivors:
Yes
Schedule:
Saint John's - Goose Bay
MSN:
AC-638
YOM:
1986
Flight number:
PB905
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was on a scheduled courier flight from St. John=s, Newfoundland and Labrador, to Goose Bay. The aircraft touched down at 0456 Atlantic standard time and, during the landing roll on the snow-covered runway, the aircraft started to veer to the right. The captain's attempt to regain directional control by the use of full-left rudder and reverse on the engines was unsuccessful. The aircraft continued to track to the right of the centreline, departed the runway, and struck a hard-packed snow bank. There were no injuries to the two crew members. The aircraft was substantially damaged.
Probable cause:
Findings as to Cause and Contributing Factors:
1. Aircraft directional control was lost, likely because of negative castering of the nosewheel when snow piled up in front of the nosewheel assembly.
Findings as to Risk:
1. The crew members were not aware of negative castering; the aircraft flight manual and emergency checklists do not address negative castering.
2. The emergency response to the occurrence was delayed by four minutes because of the lack of communication from the aircraft to the tower.
Final Report:

Crash of a Beechcraft 1900C in Saint John's

Date & Time: Sep 14, 2001 at 2118 LT
Type of aircraft:
Operator:
Registration:
C-GSKC
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
UB-27
YOM:
1984
Flight number:
SLQ621
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off from runway 11 at St. John's, the crew felt the nose of the aircraft rise to a high-pitch attitude. The aircraft climbed to about 150 to 200 feet, and was about to enter cloud when the crew reduced power. The crew lowered the nose, and force-landed the aircraft on the runway. The main gear, wings, engines and fuselage sustained substantial structural damage. Weather conditions at the time of the crash were reported as: winds 090° at 25 knots gusting to 35 knots, horizontal visibility 1/2 statute mile in light rain and fog, vertical visibility 100 feet, temperature 15° Celsius, dew point 15° Celsius, altimeter 29.31 Hg., pressure dropping.

Crash of a De Havilland DHC-3 Otter in Otter Creek

Date & Time: Sep 12, 2001 at 1100 LT
Type of aircraft:
Operator:
Registration:
C-FQOS
Flight Phase:
Survivors:
Yes
MSN:
398
YOM:
1960
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Otter Creek near Goose Bay on a charter flight to a fishing lodge with three passengers and one pilot on board. The pilot reported he was in climb mode when the aircraft pitched forward and then nosed up before entering an uncontrollable nose-down descent, although it did not exhibit characteristics normally associated with an aerodynamic stall. It impacted the water hard, resulting in structural failure of the float supports and extensive damage to the fuselage. 'Lab Air 911', a Twin Otter medevac flight bound for Nain witnessed the incident and raised the alarm. All four occupants were rescued by boat while the aircraft sank in 55 feet of water.
Source: http://www.dhc-3archive.com/DHC-3_398.html