Country

Crash of a De Havilland DHC-2 Beaver near Lake Boulene: 3 killed

Date & Time: Jul 12, 2019 at 1616 LT
Type of aircraft:
Operator:
Registration:
C-GRHF
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
St-Mathias - La Minerve - Barrage Goin - Weakwaten
MSN:
1123
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1028
Captain / Total hours on type:
314.00
Aircraft flight hours:
15040
Circumstances:
At approximately 1000LT on 12 July 2019, a private de Havilland DHC-2 Mk. 1 Beaver floatplane (registration C‑GRHF, serial number 1123) took off from the St-Mathias Water Aerodrome (CSV9), Quebec, with only the pilot on board, for a series of visual flight rules (VFR) flights. The aircraft landed at approximately 1130 on Désert Lake in La Minerve, Quebec, and came alongside a private dock where 3 individuals were waiting to board and fly to a fishing lodge. Once the baggage was stowed on the aircraft, the pilot provided a safety briefing to the passengers, who were all wearing a personal flotation device. The aircraft took off from Désert Lake at approximately 1215, bound for the Barrage Gouin Water Aerodrome (CTP3), Quebec, where the aircraft was scheduled to be refuelled. The aircraft landed at approximately 1430. Once the refuelling was complete, the aircraft took off once again around 1528, headed northwest to Weakwaten Lake, Quebec, where the fishing lodge was located. After approximately 48 minutes of flight, at around 1616, the aircraft collided with trees and struck the ground. There was no post-impact fire. The emergency locator transmitter was activated by the force of impact, and began transmitting a signal on frequency 121.5 MHz. This signal was detected by the flight crew of a commercial airliner at 1705 and reported to air traffic services. At 1850, the Joint Rescue Coordination Centre in Trenton dispatched a CC130 Hercules aircraft to try to locate the distress signal. The occurrence aircraft was found in a densely wooded area at 2032. Two search and rescue technicians were parachuted to rescue the aircraft occupants. Three of the 4 occupants received fatal injuries. The survivor was evacuated and transported to the hospital in Chibougamau, Quebec.
Probable cause:
Controlled flight into terrain following the pilot's decision to continue the flight at a relatively low speed and in a nose-up attitude, which reduced his field of vision.
Final Report:

Crash of a Piper PA-31-310 Navajo in Schefferville: 2 killed

Date & Time: Apr 30, 2017 at 1756 LT
Type of aircraft:
Operator:
Registration:
C-FQQB
Survivors:
No
Schedule:
Schefferville - Schefferville
MSN:
31-310
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
461
Captain / Total hours on type:
110.00
Copilot / Total flying hours:
1693
Copilot / Total hours on type:
650
Aircraft flight hours:
20180
Circumstances:
The Piper PA-31 (registration C-FQQB, serial number 31-310) operated by Exact Air Inc., with 2 pilots on board, was conducting its 2nd magnetometric survey flight of the day, from Schefferville Airport, Quebec, under visual flight rules. At 1336 Eastern Daylight Time, the aircraft took off and began flying toward the survey area located 90 nautical miles northwest of the airport. After completing the magnetometric survey work at 300 feet above ground level, the aircraft began the return flight segment to Schefferville Airport. At that time, the aircraft descended and flew over the terrain at an altitude varying between 100 and 40 feet above ground level. At 1756, while the aircraft was flying over railway tracks, it struck power transmission line conductor cables and crashed on top of a mine tailings deposit about 3.5 nautical miles northwest of Schefferville Airport. Both occupants were fatally injured. The accident occurred during daylight hours. Following the impact, there was no fire, and no emergency locator transmitter signal was captured.
Probable cause:
Findings:
Findings as to causes and contributing factors:
- Sensation seeking, mental fatigue, and an altered risk perception very likely contributed to the fact that, immediately after completing the magnetometric survey work, the pilot flying descended to an altitude varying between 100 and 40 feet above ground level and maintained this altitude until the aircraft collided with the wires.
- It is highly likely that the pilots were unaware that there was a power transmission line in their path.
- The pilot flying did not detect the power transmission line in time to avoid it, and the aircraft collided with the wires, which were 70 feet above the ground.
- Despite the warning regarding low-altitude flying in the Transport Canada Aeronautical Information Manua, and in the absence of minimum-altitude restrictions imposed by the company, the pilot chose to descend to a very low altitude on the return flight; as a result, this flight segment carried an unacceptable level of risk.

Findings as to risk:
- If pilots fly at low altitude, there is a risk that they will collide with wires, given that these are extremely difficult to see in flight.
- 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.
- If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, there is a risk that operators will be unable to proactively identify safety deficiencies before they cause an accident.
- If safety management systems are not required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will be unable to effectively identify and mitigate the hazards involved in their operations.
- Not wearing a safety belt increases the risk of injury or death in an accident.
- The current emergency locator transmitter system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search‑and‑rescue services will be delayed if an emergency locator transmitter antenna is damaged during an occurrence.
Final Report:

Crash of a Beechcraft A100 King Air in Saint-Frédéric

Date & Time: Dec 12, 2016 at 0730 LT
Type of aircraft:
Operator:
Registration:
C-FONY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Saint-Frédéric - Quebec
MSN:
B-154
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from runway 05 at Saint-Frédéric Airport, the twin engine deviated to the left. The pilot-in-command elected to correct the deviation and to maintain the airplane on the runway centerline but it veered off runway to the left and came to rest in the snow. Both pilots evacuated safely and the aircraft was damaged beyond repair.

Crash of a Mitsubishi MU-2B-60 Marquise in Le Havre-aux-Maisons: 7 killed

Date & Time: Mar 29, 2016 at 1230 LT
Type of aircraft:
Operator:
Registration:
N246W
Survivors:
No
Schedule:
Montreal - Le Havre-aux-Maisons
MSN:
1552
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
2500
Captain / Total hours on type:
125.00
Aircraft flight hours:
11758
Circumstances:
The twin engine aircraft left Montreal-Saint-Hubert Airport at 0930LT for a two hours flight to Le Havre-aux-Maisons, on Magdalen Islands. Upon arrival, weather conditions were marginal with low ceiling, visibility up to two miles, rain and wind gusting to 30 knots. During the final approach to Runway 07, when the aircraft was 1.4 nautical miles west-southwest of the airport, it deviated south of the approach path. At approximately 1230 Atlantic Daylight Time, aircraft control was lost, resulting in the aircraft striking the ground in a near-level attitude. The aircraft was destroyed and all seven occupants were killed, among them Jean Lapierre, political commentator and former Liberal federal cabinet minister of Transport. All passengers were flying to Magdalen Islands to the funeral of Lapierre's father, who died last Friday. The captain, Pascal Gosselin, was the founder and owner of Aéro Teknic.
Crew:
Pascal Gosselin, pilot.
Passengers:
Fabrice Labourel, acting as a copilot,
Jean Lapierre,
Nicole Beaulieu, Jean Lapierre's wife,
Martine Lapierre, Jean Lapierre's sister,
Marc Lapierre, Jean Lapierre's brother,
Louis Lapierre, Jean Lapierre's brother.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach.
2. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.
4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.
5. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.
6. It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.

Findings as to risk:
1. If the weight of an aircraft exceeds the certified maximum take-off weight, there is a risk of aircraft performance being degraded, which may jeopardize the safety of the flight.
2. If pilots engage in non-essential communication during critical phases of flight, there is an increased risk that they will be distracted, which reduces the time available to complete cockpit activities and increases their workload.
3. If flight, cockpit, or image/video data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
4. If pilots do not recognize that changing circumstances require a new plan, then plan continuation bias may lead them to continue with their original plan even though it may not be safe to do so.
5. If pilots do not apply stable-approach criteria, there is a risk that they will continue an unstable approach to a landing, which can lead to an approach-and-landing accident.
6. If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.
7. If a flight plan does not contain search-and-rescue supplementary information, and if that information is not transmitted or readily available, there is a risk that first responders will not have the information they need to respond adequately.

Other findings:
1. Transport Canada does not monitor or track the number of days foreign-registered aircraft are in Canada during a given 12-month period.
2. Turbulence and icing were not considered factors in this occurrence.
3. Transport Canada considers that the discretionary installation of an angle-of-attack system on normal-category, type-certificated, Canadian-registered aircraft is a major modification that requires a supplemental type certificate approval.
4. Although the aircraft was not in compliance with Airworthiness Directive 2006-17-05 at the time of the occurrence, there was no indication that it was operating outside of the directive’s specifications.
5. Although not required by regulation, the installation and use of a lightweight flight recording system during the occurrence flight, as well as the successful retrieval of its data during the investigation, permitted a greater understanding of this accident.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Les Bergeronnes: 6 killed

Date & Time: Aug 23, 2015 at 1127 LT
Type of aircraft:
Operator:
Registration:
C-FKRJ
Flight Phase:
Survivors:
No
Schedule:
Lac Long - Lac Long
MSN:
1210
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
5989
Captain / Total hours on type:
4230.00
Aircraft flight hours:
25223
Circumstances:
The float-equipped de Havilland DHC-2 Mk. 1 Beaver (registration C-FKRJ, serial number 1210), operated by Air Saguenay (1980) inc., was on a visual flight rules sightseeing flight in the region of Tadoussac, Quebec. At 1104 Eastern Daylight Time, the aircraft took off from its base on Lac Long, Quebec, for a 20-minute flight, with 1 pilot and 5 passengers on board. At 1127, on the return trip, approximately 2.5 nautical miles north-northwest of its destination (7 nautical miles north of Tadoussac), the aircraft stalled in a steep turn. The aircraft descended vertically and struck a rocky outcrop. The aircraft was substantially damaged in the collision with the terrain and was destroyed by the post-impact fire. The 6 occupants received fatal injuries. No emergency locator transmitter signal was captured.
Probable cause:
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.
Final Report:

Crash of a Beechcraft A100 King Air in Saint-Mathieu-de-Beloeil

Date & Time: Jun 10, 2013 at 1725 LT
Type of aircraft:
Operator:
Registration:
C-GJSU
Flight Type:
Survivors:
Yes
Schedule:
Montreal - Montreal
MSN:
B-88
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4301
Captain / Total hours on type:
1500.00
Aircraft flight hours:
13616
Aircraft flight cycles:
10999
Circumstances:
The aircraft took off from the Montréal/St-Hubert Airport, Quebec, on a local flight under visual flight rules with 1 pilot and 3 passengers on board. The purpose of the flight was to check the rudder trim indicator and to confirm a potential synchronization problem between the autopilot and the global positioning system (GPS). As the aircraft approached Runway 24R at the Montréal/St-Hubert Airport, both engines (Pratt & Whitney Canada, PT6A-28) stopped due to fuel exhaustion. The pilot diverted to the St-Mathieu-de-Beloeil Airport, Quebec, and then attempted a forced landing in a field 0.5 nautical mile west of the St-Mathieu-de-Beloeil Airport. The aircraft struck the ground 30 feet short of the selected field, at 1725 Eastern Daylight Time. The aircraft was extensively damaged, and the 4 occupants sustained minor injuries. The emergency locator transmitter activated during the occurrence. The flight took place during daylight hours, and there was no fire.
Probable cause:
Findings as to causes and contributing factors:
- The pilot relied exclusively on the gauge readings to determine the quantity of fuel on board, without cross-checking the fuel consumption since the last fueling to validate those gauge readings.
- The pilot misread the fuel gauges and assumed that the aircraft had enough fuel on board to meet the minimum fuel requirements of the Canadian Aviation Regulations for this visual flight rules flight, rather than adding more fuel to meet the greater reserves required by the company operations manual.
- The pilot did not monitor the fuel gauges while in flight and decided to extend the flight to carry out a practice instrument approach with insufficient fuel to complete the approach.
- The right engine stopped due to fuel exhaustion.
- The pilot did not carry out the approved engine failure procedure when the first engine stopped, and the propeller was not feathered, resulting in significant drag which reduced the aircraft's gliding range after the second engine stopped.
- The pilot continued flying toward Montréal/St-Hubert Airport (CYHU), Quebec, despite having advised air traffic control of the intention to divert to the St-Mathieu-de-Beloeil Airport (CSB3), Quebec, and without communicating the emergency. The priority given to communications resulted in the aircraft moving farther away from the intended diversion airport.
- The left engine stopped due to fuel exhaustion 36 seconds after the right engine stopped, when the aircraft was 7.4 nautical miles from Runway 24R at Montréal/St-Hubert Airport (CYHU), Quebec, and 2400 feet above sea level.
- The pilot's decision to lower the landing gear while the aircraft was still at 1600 feet above sea level further increased the drag, reducing the aircraft's gliding range. As a result, the aircraft was not able to reach the runway at St-Mathieu-de-Beloeil Airport (CSB3), Quebec.
- The operations manager was unable to perform the duties and responsibilities of the position related to monitoring and supervision of flight operations. As a result, the safety of more than half of the flights was compromised.
Findings as to risk:
- If the total fuel quantity required for a flight is not calculated and clearly displayed on the operational flight plan, there is an increased risk that aircraft will depart without the fuel reserves required by the Canadian Aviation Regulations.
- If flights are planned and carried out without the fuel reserves required by the Canadian Aviation Regulations, there is an increased risk of fuel exhaustion resulting from unanticipated situations that extend the duration of the flight.
- If pilots elect to extend flight without first determining whether sufficient fuel reserves are available to do so, there is an increased risk of fuel exhaustion.
- If pilots do not regularly check the quantity of fuel on board, there is an increased risk of fuel exhaustion.
- If pilots do not rule out a fuel leak before opening the crossfeed valve, they risk losing all of the remaining fuel on board.
- If a pilot does not maintain control of an aircraft until landing, the force of an impact following an aerodynamic stall is likely to be far greater, increasing the risk of injury or death during a forced landing.
- If a pilot does not declare an emergency to air traffic control in a timely manner, the pilot may be deprived of assistance and resources that could help deal with the emergency, increasing the risk of an accident.
- If pilots do not receive training in dealing with complex emergencies that require prioritizing tasks, there is a risk that they will not react effectively to emergencies, increasing the risk of an accident.
- If companies do not establish a process to monitor the performance of their pilots during training and testing, there is a risk that those companies will inadvertently assign pilots to carry out flights for which they are not proficient.
- If a flight is planned and authorized solely by the pilot, with no cross-check for compliance with existing regulations, there is a risk that deviations will continue undetected, reducing the safety of the flight.
- If pilots operate without regular supervision to ensure compliance with regulations and company procedures, coupled with effective training, there is a risk of procedural adaptations that result in reduced safety margins.
- If companies assign inexperienced personnel to key flight operations management positions, there is a risk that deviations in performance or from regulations will not be detected, reducing the safety of flight operations.
- If the pilot proficiency check requirements for a chief pilot are not more stringent than those for other pilots, there is a risk that the chief pilot will be unable to perform the duties required to ensure the safety of company training and operations.
- If the approval process for appointment of operations management personnel by companies is reduced to a compliance checklist based on the minimum standards in the Commercial Air Service Standards and on pilot proficiency checks that may be repeated an unlimited number of times, there is a risk that candidates who are unfit to perform the duties and responsibilities of their positions will be appointed.
- If Transport Canada does not take into consideration the combined knowledge and experience of a new operator's management team, there is a risk that the operator will lack the skills necessary to ensure the safety of flight operations.
- If process inspections carried out by Transport Canada do not examine factors related to a recent occurrence, there is a risk that those hazardous conditions will go undetected and will persist.
If process inspections carried by TC on newly certificated operators do not closely examine the outcomes of company processes, there is a risk that hazardous conditions will not be identified and will persist.
- If the inability of appointed individuals to perform their duties and responsibilities does not constitute grounds for suspending or revoking the ministerial approval of such appointments, there is a risk that operations management personnel who are not competent will remain in their positions, increasing the risk to flight safety.
Other findings:
- The chief pilot did not meet the requirements of the Canadian Aviation Regulations at the time of appointment.
- There was no indication that the aircraft's fuel gauges were not functioning properly at the time of the occurrence flight, and it is unlikely that a deviation of the fuel gauge indicator was a factor in the pilot's decision to take off.
- C-GJSU had approximately 260 pounds of fuel on board when it took off from Montréal/St-Hubert Airport (CYHU), Quebec, and did not experience a fuel leak during the occurrence flight.
Final Report:

Crash of a Beechcraft B100 King Air in Montmagny

Date & Time: Sep 22, 2010 at 1700 LT
Type of aircraft:
Operator:
Registration:
C-FSIK
Flight Phase:
Survivors:
Yes
Schedule:
Montmagny - Montreal
MSN:
BE-39
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
675
Circumstances:
The aircraft was operating as flight MAX100 on an instrument flight rules flight from Montmagny to Montreal/St-Hubert, Quebec, with 2 pilots and 4 passengers on board. At approximately 1700 Eastern Daylight Time, the aircraft moved into position on the threshold of 3010-foot-long runway 26 and initiated the take-off. On the rotation, at approximately 100 knots, the flight crew saw numerous birds in the last quarter of the runway. While getting airborne, the aircraft struck the birds and the left engine lost power, causing the aircraft to yaw and roll to the left. The aircraft lost altitude and touched the runway to the left of the centre line and less than 100 feet from the runway end. The take-off was aborted and the aircraft overran the runway, coming to rest in a field 885 feet from the runway end. All occupants evacuated the aircraft via the main door. There were no injuries. The aircraft was substantially damaged.
Probable cause:
Findings As To Causes and Contributing Factors:
The bird strike occurred on take-off at an altitude of less than 50 feet. Gulls were ingested in the left engine, which then lost power.
After the loss of engine power, the flight crew had difficulty controlling the aircraft. The aircraft touched the ground, forcing the pilot flying to abort the take-off when the runway remaining was insufficient to stop the aircraft, resulting in the runway overrun.
Findings As To Risks:
Although a cannon was in place, it was not working on the day of the accident, which increased the risk of a bird strike.
The presence of a goose and duck farm outside the airport perimeter but near a runway increases the risk of attracting gulls.
Operators subject to Canadian Aviation Regulations Subpart 703 are not prohibited from having an aircraft take off from a runway that is shorter than the accelerate-stop distance of that aircraft as determined from the performance diagrams. Consequently, travellers carried by these operators are exposed to the risks associated with a runway overrun when a take-off is aborted.
The absence of a CVR makes it harder to ascertain material facts. Consequently, investigations can take more time, resulting in delays which compromise public safety.
Final Report:

Crash of a De Havilland DHC-2 Beaver in La Grande: 2 killed

Date & Time: Jul 24, 2010 at 1053 LT
Type of aircraft:
Operator:
Registration:
C-FGYK
Flight Phase:
Survivors:
Yes
Schedule:
La Grande - Lac Eau Claire
MSN:
123
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3800
Captain / Total hours on type:
1000.00
Aircraft flight hours:
23808
Circumstances:
At approximately 1053 Eastern Daylight Time, de Havilland DHC-2 Mk. 1 amphibious floatplane (registration C-FGYK, serial number 123), operated by Nordair Québec 2000 Inc., took off from runway 31 at La Grande-Rivière Airport, Quebec, for a visual flight rules flight to l’Eau Claire Lake, Quebec, about 190 nautical miles to the north. The take-off run was longer than usual. The aircraft became airborne but was unable to gain altitude. At the runway end, at approximately 50 feet above ground level, the aircraft pitched up and banked left. It then nosed down and crashed in a small shallow lake. The pilot and 1 front-seat passenger were fatally injured and the 3 rear-seat passengers sustained serious injuries. The aircraft broke up on impact, and the forward part of the cockpit was partly submerged. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was overloaded and its centre of gravity was beyond the aft limit. The aircraft pitched up and stalled at an altitude that did not allow the pilot to execute the stall recovery manoeuvre.
2. The baggage was not secured. Shifting of the baggage caused the triple seat to pivot forward, propelling the 3 rear-seat passengers against the pilot and front-seat passenger during impact.
3. Although the design of the triple seat met aviation standards, it separated from the floor at the time of impact, principally due to the fact that the heavy cargo shifted.
4. The action taken by TC did not have the desired outcomes to ensure regulatory compliance; consequently, unsafe practices persisted.
Finding as to Risk:
1. Operating an aircraft outside the limits and conditions under which a permit is issued can increase the risk of an accident
Final Report:

Crash of a De Havilland DHC-2 Beaver near Chute des Passes: 4 killed

Date & Time: Jul 16, 2010 at 1117 LT
Type of aircraft:
Operator:
Registration:
C-GAXL
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Lac des Quatre - Lac Margane
MSN:
1032
YOM:
1957
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11500
Captain / Total hours on type:
9000.00
Aircraft flight hours:
17204
Circumstances:
The float-equipped de Havilland Beaver DHC-2 Mk.I (registration number C-GAXL, serial number 1032), operated by Air Saguenay (1980) Inc., was flying under visual flight rules from Lac des Quatre to Lac Margane, Quebec, with 1 pilot and 5 passengers on board. A few minutes after take-off, the pilot reported intentions of making a precautionary landing due to adverse weather conditions. At approximately 1117, Eastern Daylight Time, the aircraft hit a mountain, 12 nautical miles west-south-west of the southern part of Lac Péribonka. The aircraft was destroyed and partly consumed by the fire that broke out after the impact. The pilot and 3 passengers were killed; 1 passenger sustained serious injuries and 1 passenger sustained minor injuries. No ELT signal was received.
Probable cause:
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.
Final Report:

Crash of a Beechcraft A100 King Air in Québec: 7 killed

Date & Time: Jun 23, 2010 at 0559 LT
Type of aircraft:
Operator:
Registration:
C-FGIN
Flight Phase:
Survivors:
No
Schedule:
Québec - Seven Islands - Natashquan
MSN:
B-164
YOM:
1973
Flight number:
APO201
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
3046
Captain / Total hours on type:
372.00
Copilot / Total flying hours:
2335
Copilot / Total hours on type:
455
Aircraft flight hours:
19665
Aircraft flight cycles:
16800
Circumstances:
Aircraft was making an instrument flight rules flight from Québec to Sept-Îles, Quebec. At 0557 Eastern Daylight Time, the crew started its take-off run on Runway 30 at the Québec/Jean Lesage International Airport; 68 seconds later, the co-pilot informed the airport controller that there was a problem with the right engine and that they would be returning to land on Runway 30. Shortly thereafter, the co-pilot requested aircraft rescue and fire-fighting (ARFF) services and informed the tower that the aircraft could no longer climb. A few seconds later, the aircraft struck the ground 1.5 nautical miles from the end of Runway 30. The aircraft continued its travel for 115 feet before striking a berm. The aircraft broke up and caught fire, coming to rest on its back 58 feet further on. The 2 crew members and 5 passengers died in the accident. No signal was received from the emergency locator transmitter (ELT).
Probable cause:
Findings as to Causes and Contributing Factors:
1. After the take-off at reduced power, the aircraft performance during the initial climb was lower than that established at certification.
2. The right engine experienced a problem in flight that led to a substantial loss of thrust.
3. The right propeller was not feathered; therefore, the rate of climb was compromised by excessive drag.
4. The absence of written directives specifying which pilot was to perform which tasks may have led to errors in execution, omissions, and confusion in the cockpit.
5. Although the crew had the training required by regulation, they were not prepared to manage the emergency in a coordinated, effective manner.
6. The priority given to ATC communications indicates that the crew did not fully understand the situation and were not coordinating their tasks effectively.
7. The impact with the berm caused worse damage to the aircraft.
8. The aircraft’s upside-down position and the damage it sustained prevented the occupants from evacuating, causing them to succumb to the smoke and the rapid, intense fire.
9. The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.
10. The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Findings as to Risk:
1. Deactivating the flight low pitch stop system warning light or any other warning system contravenes the regulations and poses significant risks to flight safety.
2. The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.
3. Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.
4. The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.
5. The lack of an in-depth review by TC of SOPs and checklists of 703 operators poses a safety risk because deviations from aircraft manuals are not detected.
6. Conditions of employment, such as flight hours–based remuneration, can influence pilots’ decisions, creating a safety risk.
7. The absence of an effective non-punitive and confidential voluntary reporting system means that hazards in the transportation system may not be identified.
8. The lack of recorded information significantly impedes the TSB’s ability to investigate accidents in a timely manner, which may prevent or delay the identification and communication of safety deficiencies intended to advance transportation safety.
Final Report: