Aviation Safety Letter 1/2005

Recently Released TSB Reports

The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include only the TSB's synopsis and selected findings. For more information, contact the TSB or visit their Web site at http://www.tsb.gc.ca/ - Ed.

TSB Final Report A02Q0119 - Engine Failure and Loss of Control

Engine Failure and Loss of Control

On September 2, 2002, a Mooney M20E was to make a flight according to visual flight rules (VFR) from Québec City to Rimouski, Que. The aircraft took off from Runway 30 at 13:46 Eastern Daylight Time (EDT), with the pilot, a flight instructor, and a passenger on board. As the aircraft was climbing through 600 ft above sea level (ASL), the control tower received a radio message from the aircraft, indicating that the engine had failed and an emergency landing would be made. The aircraft was observed in a steep right turn before nosing down and crashing near a baseball field, less than 1 NM north of the end of Runway 30. The aircraft was destroyed on impact but did not catch fire. The three occupants were fatally injured.

Findings as to causes and contributing factors

  1. The pilot flying did not maintain the minimum flying speed after the engine stopped. The aircraft stalled at an altitude insufficient to allow the pilot to effect recovery.

  2. The engine stopped when the aircraft was at low altitude, allowing little time for the pilot flying to select a suitable landing area, place the aircraft at the gliding flight speed, and complete the emergency checklist.

  3. After the engine stopped, the pilot flying made a steep turn, thereby increasing the stall speed.

  4. The reason for the engine's failure was not determined.

Findings as to risk

  1. The pilot instructor did not know the flight characteristics of the aircraft any better than the pilot he was training. However, regulations permitted him to give flight instruction on aircraft types with which he was not familiar.

  2. The emergency locator transmitter (ELT) did not activate on impact, which might have had negative consequences if the aircraft had crashed in an uninhabited area.

Other findings

The fuel selector on Mooney M20 models A to G can be hard to reach without interfering with the flight controls, thereby adversely affecting the pilot's ability to control the aircraft.

TSB Final Report A03P0133 - Controlled Flight Into Terrain (CFIT)

Controlled Flight Into Terrain (CFIT)

On May 31, 2003, a Cessna 182 took off from a private airstrip near Chilliwack, B.C., with the pilot and four skydivers on board at approximately 18:40 Pacific Daylight Time (PDT). Two skydivers were released at 3 000 ft and two at 9 000 ft. The aircraft failed to return to the strip. No ELT signal was received. The Rescue Coordination Centre (RCC) at Victoria, B.C., was notified and a search was initiated. The aircraft was found six days later on a northwest-facing slope of the Skagit mountain range, 4 NM from the private airstrip, at an altitude of about 4 600 ft ASL. A fire had broken out on impact and consumed much of the cockpit area and left wing. The aircraft was destroyed. The pilot was fatally injured.

Findings as to causes and contributing factors

The pilot most likely entered cloud inadvertently and continued to descend in the expectation of breaking out of cloud, but flew into high terrain.

Findings as to risk

The armed ELT did not operate because of impact damage, hampering the search and rescue (SAR) operation.

TSB Final Report A03O0135 - Loss of Control on Water

On June 5, 2003, a de Havilland DHC-6-300 amphibious aircraft with a single pilot on board was performing firefighting operations in the vicinity of Lake Wicksteed, approximately 10 NM north of Hornepayne, Ont. The aircraft was scooping water from Lake Wicksteed for the nearby fire. The lake is approximately 7 300 ft in length, with gentle rising terrain along its shoreline. This was the third scooping from the lake, and the approach was flown in an easterly direction in light wind conditions. The pilot performed the inbound checks, lowered the water probes to begin filling the float water tanks, and touched down on the lake. Within a short time, he observed water spraying from the overflow vents located on top of the floats, indicating that the tanks were filled to capacity. He pressed a button on the yoke to retract the probes, and the aircraft immediately nosed over into the lake in a wings-level attitude and began to sink. The accident occurred at approximately 18:00 EDT. The pilot extricated himself from the aircraft and held on to the side of the partially submerged aircraft. A witness to the occurrence immediately boarded a powered aluminium boat and went to assist the pilot, while a second witness travelled to Hornepayne to notify the authorities and emergency services. Once the pilot reached the shore, he was taken to a nearby cottage where he remained until emergency services arrived. The aircraft came to rest on the bottom of the shallow lake, in an inverted attitude, with the floats above the surface of the water.

Loss of Control on Water

Findings as to causes and contributing factors

  1. The operator's DHC-6 standard operating procedures (SOP) were not followed, and the vital action checklist was not fully completed during the approach. As a result, the bomb door armed switch on the centre panel was not selected OFF after the previous water bombing run, and prior to the scooping operation.

  2. After completing the water scooping operation, the pilot unintentionally selected the bomb door push button switch instead of the adjacent probe switch. Because the bomb door armed switch on the centre panel was left ON, the bomb doors extended into the water. Drag from the doors and the water rushing into the door openings resulted in the aircraft nosing over in the water.

  3. The hinged cover plate for the bomb door push button switch was not re-installed following maintenance to replace the push button switch. The push button was exposed, making an inadvertent selection more likely.

Safety action

The operator has verified that every Twin Otter aircraft in their fleet is equipped with the cover plate over the bomb door push button switch. The operator will ensure that any future modifications to aircraft will be standardized to decrease the potential for inadvertent operation of systems.

TSB Final Report A03O0156 - Engine Failure and Forced Landing on Water

Engine Failure and Forced Landing on Water

On June 24, 2003, a Mooney M20E aircraft, with only the pilot on board, departed the Midland/Huronia Airport, Ont., at 07:15 EDT, on a VFR flight to Charleston, West Virginia. A few minutes after takeoff, the pilot transmitted a distress call to Toronto Buttonville flight service station (FSS), reporting that the engine had lost power and he was diverting to Collingwood airport for an emergency landing. Shortly afterwards, he reported a total loss of engine power and his intention to ditch the aircraft in Georgian Bay. At 07:23 EDT, he reported his position to Toronto Buttonville FSS as 7.5 SM from Collingwood at 3 000 ft ASL, and indicated that the ELT was armed. This was the last radio transmission from the aircraft. The aircraft struck the water shortly thereafter. Two pilots flying in the vicinity heard the distress call. Both pilots volunteered to divert to the last position reported by the Mooney, but their search for the aircraft was unsuccessful. The RCC was notified, and at 09:12 EDT, located the aircraft submerged in 58 ft of water, 5 mi. west-southwest of Wasaga Beach, Ont. Divers were requested, and brought to the site by helicopter. The divers entered the water at 09:32 EDT and examined the aircraft, but could not locate the pilot. Once search and rescue (SAR) personnel departed the site, police divers took over the search for the pilot; his body was found at approximately 19:30 EDT.

Findings as to causes and contributing factors

  1. Examination of the fuel servo revealed water contamination and corrosion in the fuel metering unit of the servo, resulting in reduced outlet fuel pressure to the fuel injectors. The engine quit as a result of the reduced fuel pressure, and the aircraft descended into the water.

  2. The ELT did not transmit an emergency signal after it was selected to the ON position. The absence of a signal from the transmitter likely increased the time required by SAR personnel to locate the aircraft.
Previous PageNext Page
Date modified: