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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 A02Q0005 - Collision with Terrain

On January20, 2002, a Piper PA-28-161 took off from Gaspé, Que., at 16:30Eastern Standard Time (EST) on a flight to Québec, Que., making a night flight in accordance with VFR. At 16:35EST, the pilot notified the Québec flight service station (FSS) that he was 5NM west of the Gaspé airport and confirmed that he was going to the en route frequency. That was the last message received from the aircraft. The plane was reported missing after its flight plan expired. Almost 11 months later, on December8, 2002, an airliner flying high over the area of L'Ascension-de-Patapédia, N.B., picked up a signal from an emergency locator transmitter (ELT). The search and rescue (SAR) team dispatched to the site identified the missing aircraft. The two occupants were fatally injured; the aircraft was destroyed.

Collision with Terrain

Findings as to causes and contributing factors

  1. The pilot's lack of experience, combined with poor weather conditions, resulted in spatial disorientation that led to a loss of control.

Other findings

  1. The ELT did not transmit an emergency signal, probably because debris struck the reset button, interrupting transmission. This could have had serious consequences had there been any survivors.
  2. Having a global positioning system (GPS) on board possibly affected the pilot's decision to take off even though poor VFR conditions were forecast along the route.

TSB Final Report A03P0194 - Collision With Terrain

On July16, 2003, at about 12:10Mountain Standard Time (MST), a four-engine Lockheed L-188 Electra took off from Runway16 at the Cranbrook Airport, B.C. Two pilots were on board to conduct a fire-management mission on a small ground fire 2 NM southwest of the township of Cranbrook. Seven minutes earlier, the partner "bird dog" aircraft, a Turbo Commander, also departed Cranbrook to assess the appropriate aircraft flight path profiles and to establish the most suitable fire-retardant delivery program for the ground fire.

Following the flight path demonstrations by the bird dog aircraft, the Electra proceeded to carry out the retardant drop on the fire. After delivering the specified retardant load, the Electra was seen turning right initially then entering a turn to the left. At 12:21 MST, the Electra struck the terrain on the side of a steep ridge at about 3 900ft above sea level. The aircraft exploded on impact and the two pilots were fatally injured. An intense post-crash fire consumed much of the wreckage and started a forest fire at the crash site and in the surrounding area. The on-board ELT was damaged by the impact forces and did not activate.

The Electra seen delivering retardant to target fire moments prior to the accident
The Electra seen delivering retardant to target fire moments prior to the accident

Findings as to causes and contributing factors

  1. For undetermined reasons, the Electra did not climb sufficiently to avoid striking the rising terrain.
  2. Given the flight path and the rate of climb chosen, a collision with the terrain was unavoidable.
  3. The characteristics of the terrain were deceptive, making it difficult for the pilots to perceive their proximity and rate of closure to the rising ground in sufficient time to avoid it.

Other findings

  1. Performance calculations show that the Electra - in the absence of limiting mechanical malfunction - could have climbed at a rate that would have allowed the aircraft to avoid the terrain.
  2. Although a functional cockpit voice recorder (CVR) was installed in the aircraft, it was not required by regulation and it was not used; as a result, vital clues that could have shed light on the circumstances of this accident were not available.
  3. The ELT could not transmit a signal as a result of severe impact forces that exceeded the design criteria.

TSB Final Report A03P0199 - Collision with Terrain

On July18, 2003, a Cessna 172M departed Boundary Bay Airport, B.C., at 18:48Pacific Daylight Time (PDT). There was a flight instructor, a student pilot, and an observer on board to conduct mountain flying training in the areas around Stave Lake and Harrison Lake. About one hour later, during a practice forced approach conducted west of Harrison Lake, the aircraft struck the ground and was destroyed. There was no fire. The two front seat occupants were seriously injured, and the rear seat occupant received minor injuries. An emergency locator transmitter (ELT) signal was reported about three hours after the accident, and the aircraft was located about 24NM north-northwest of Harrison Hot Springs, B.C. All three occupants were evacuated from the site by helicopter.

Collision with Terrain

Findings as to causes and contributing factors

  1. The instructor did not brief the student on forced approach procedures and allowed the student to continue the forced approach to a height from which the aircraft could not avoid rising terrain.
  2. The aircraft was near gross weight, which, combined with the effects of altitude, outside air temperature, and aggressive manoeuvring, degraded the aircraft's ability to out-climb the terrain.

Other findings

  1. Shadows and lack of visual cues, such as trees, in the area of the forced approach may have adversely affected the pilot's ability to estimate the aircraft's height above ground.
  2. The risk of a fuel-fed post-crash fire was significant; ejection of the aircraft's battery eliminated one potential ignition source.

Safety action taken

As a result of this accident, the flight school has made the following changes:

  1. Aircraft will no longer be dispatched into the mountains in the evening;
  2. Safe flying limits for mountainous terrain have been established.

TSB Final Report A03H0002 - Collision with Terrain

On September11, 2003, at 20:57Eastern Daylight Time (EDT), a Cessna 208B Caravan departed Pickle Lake, Ont., for Summer Beaver, Ont., on a charter flight with seven passengers and one crew member. The flight proceeded on a direct routing to destination at 3 500ft above sea level, under night visual flight conditions. On approach to Summer Beaver, the aircraft joined the circuit on a downwind leg for a landing on Runway17. When the aircraft did not land, personnel at Summer Beaver contacted the Pickle Lake flight dispatch to inquire about the flight. The aircraft was declared missing following an unsuccessful radio search by the Pickle Lake flight dispatch staff. Search and rescue personnel found the wreckage in a wooded area 3 NM northwest of Summer Beaver. The aircraft had been nearly consumed by a post-crash fire. All eight people on board had been fatally injured.

TSB investigator analysing the Cessna Caravan's propeller
TSB investigator analysing the Cessna Caravan's propeller

Findings as to causes and contributing factors

  1. The aircraft departed controlled flight and struck terrain for undetermined reasons.

Findings as to risk

  1. The company's flight-following procedures for flights operating in remote areas were impractical and were not consistently applied; this could compromise timely search and rescue operations following an accident.

Other findings

  1. The aircraft did not carry flight recorders. Lack of information about the cause of this accident affects the TSB's ability to identify related safety deficiencies and to issue safety communications intended to prevent accidents that could occur under similar circumstances.

Safety action taken

  1. Flight instruments - The operator has provided maintenance personnel with additional training for handling gyro instruments.
  2. Emergency locator transmitter (ELT) maintenance requirements - The operator has revised its tracking of ELT maintenance requirements.
  3. Flight following capability - Prior to the accident, the company had started to equip their aircraft with an automatic tracking system. This system updates aircraft position every three minutes and allows operations dispatchers to track the location of an aircraft throughout the duration of its flight. Since the accident, this modification has been completed on all but two of the company's aircraft.
  4. Crew requirements on passenger flights - Although not required by regulation, the company has instituted a policy of crewing all passenger flights with two pilots.

TSB Final Report A03O0273 - Runway Excursion

On September26, 2003, an Astra SPX aircraft, with two crew and four passengers on board, was landed on Runway05 at Toronto/Lester B. Pearson International Airport at 18:26Eastern Daylight Time (EDT). As the nose wheel touched down, a severe nose wheel shimmy developed, and the flight crew had difficulty controlling the aircraft. As the flight crew attempted to steer the aircraft, an uncommanded full-left steering input was experienced, and the aircraft began to veer to the left. The first officer attempted to turn the steering control to the right, but was unable to move the control. The flight crew attempted to correct for the full-left input using differential braking and reverse thrust, but were unable to keep the aircraft on the runway. The aircraft skidded off the north side of the runway and came to rest in the infield between Runway05 and Taxiway Juliet, just before the intersection at Runway15R.

The captain contacted the tower and requested emergency services. Meanwhile, the first officer exited the aircraft to check for damage and to ensure there was no further danger to crew or passengers. Assessing the situation to be safe, the first officer re-entered the aircraft, and the flight crew and passengers waited for emergency services to arrive. There was minor damage to the aircraft.

Runway Excursion

Findings as to causes and contributing factors

  1. It is most likely that the occurrence aircraft was towed beyond the steering limits with the scissors connected, resulting in the fracture of the upper bracket.
  2. A nose wheel shimmy on landing stressed the remaining lower attachment bracket to overload and failure, which allowed the steering assembly and nose gear to rotate uncontrollably.
  3. The aircraft became uncontrollable and exited the runway after the steering assembly failed.

Findings as to risk

  1. Although the aircraft manuals caution against exceeding steering limitations with the scissors connected, there are no external markings which identify the steering limitations of the aircraft nose gear.

Other findings

  1. Although Service Bulletins (SB) were issued that might have prevented the initial failure, there was no regulatory requirement to comply with them.

Safety action taken

On October21, 2003, the State of Israel, Ministry of Transportation, Civil Aviation Administration, issued Airworthiness Directive (AD) 32-03-10-05, effective October28, 2003, requiring a one time inspection of the upper and lower steering assembly brackets within 50flight hours or 25landings, whichever comes first. This AD was endorsed by Transport Canada on November17, 2003.

TSB Final Report A03O0285 - Engine Power Loss - Forced Landing

On October9, 2003, at approximately 13:00EDT, a Cessna 172N aircraft departed from the Toronto/Buttonville Municipal Airport on a sightseeing flight over Toronto, Ont. The pilot and three passengers were on board. Before takeoff, an engine ground run revealed no anomalies. The pilot applied full power for the takeoff, climbed to an altitude of 2 000ft ASL (1 300 to 1 400ft above ground), levelled off, and selected the Toronto/City Centre Airport tower radio frequency. Shortly after that, the engine (Lycoming O-320-H2AD) began to lose power. The pilot informed the tower of the power loss and the intention to return to the Toronto/Buttonville Municipal Airport.

Trying to regain power, the pilot ensured that full throttle was selected, checked the positions of the primer and magnetos, and switched fuel tanks. When these attempts were unsuccessful, the pilot selected the carburettor heat to the hot position, observed a further decrease in engine power, and reset the carburettor heat to the cold position. The engine was not producing enough power to maintain level flight and return to the airport, so the pilot searched for a suitable location for a forced landing. The aircraft was over a densely populated area, and the only suitable clearing was surrounded with trees and nearby buildings. The engine lost power on final approach. The pilot selected the flaps to the full-down position, overflew the clearing, and stalled the aircraft into the trees. The aircraft was substantially damaged and one passenger received minor injuries.

Engine Power Loss - Forced Landing

Findings as to causes and contributing factors

  1. Ambient temperature and dew point conditions during the flight most likely resulted in carburettor icing, which caused the engine to lose power.
  2. When the engine began to lose power, the pilot applied carburettor heat, but noted it resulted in a further decrease in engine power and selected the carburetor heat off. The heat was not on long enough to remove any ice.

Other findings

  1. The pilot was unable to find a suitable landing area and intentionally stalled the aircraft into the trees, resulting in substantial damage to the aircraft.

TSB Final Report A03O0341 - Loss of Control After Takeoff

On December16, 2003, at approximately 09:00EST, the pilot arrived at the airstrip and prepared the ski-equipped de Havilland DHC-3 (Otter) aircraft for the morning flight. This Otter was equipped with a turbine engine. Two passengers, with enough supplies for an extended period of time, including a snowmobile and camping gear, were to be flown to a remote location. The pilot loaded the aircraft and waited for the weather to improve. At approximately 12:00EST, the pilot and passengers boarded the aircraft and took off in an easterly direction. The aircraft got airborne near the departure end of the airstrip, and shortly after takeoff, the right wing struck a number of small bushes and the top of a birch tree. The aircraft descended and struck the frozen lake surface, approximately 70ft below the airfield elevation in a steep, nose-down, right-wing-low attitude. When it came to rest, the aircraft was inverted and partially submerged, with only the aft section of the fuselage remaining above the ice. All of the occupants were wearing lap belts. The pilot and front seat passenger received fatal injuries. The rear seat passenger survived the impact and evacuated the aircraft with some difficulty due to leg injuries. The following morning, about 22 hr after the accident, a local air operator searching for the missing aircraft located and rescued the surviving passenger.

Loss of Control After Takeoff

Findings as to causes and contributing factors

  1. The pilot attempted to take off from an airstrip that was covered with approximately 18in. of snow, and the aircraft did not accelerate to take-off speed because of the drag; the aircraft was forced into the air and was unable to climb out of ground effect and clear the obstacles.
  2. The pilot did not abort the takeoff when it became apparent that the aircraft was not accelerating normally and before the aircraft became airborne.

Findings as to risks

  1. Unidirectional G switches, which are found on many types of ELTs, do not always activate the unit when impact forces are not aligned with the usual direction of flight.

Other findings

  1. The validity of the aircraft's certificate of airworthiness was affected while it flew more flights than allowed by the ferry permit issued by Transport Canada.
  2. The rear passenger seat was found to be installed incorrectly, contrary to de Havilland Alert Service Bulletin A3/49, dated 19July 1991.

TSB Final Report A04C0064 - In-flight Break-up/Collision With Terrain

On March20, 2004, the Baby Belle amateur-built helicopter departed from a farm located near Ralph, Sask., on a local VFR flight. The purpose of the flight was to inspect grid road and highway intersections for snow accumulation.

Shortly after takeoff, debris began to fall from the helicopter while it was flying in a northwesterly direction at approximately 500ft AGL. The helicopter dropped vertically; the nose pitched down; and the helicopter, while in a steep, nose-down attitude, crashed on a farm field. The pilot, the sole occupant, was fatally injured. The helicopter was destroyed by a post-impact fire. The accident occurred at approximately 10:00Central Standard Time (CST).

In-flight Break-up/Collission with Terrain

Findings as to causes and contributing factors

  1. Separation of the tail-rotor blade during a previous flight had induced an excessive amount of vibration in the stabilizer, resulting in bending of the horizontal stabilizer spar.
  2. Cold straightening the stabilizer spar, which was not a recommended maintenance practice, concentrated stresses at the first rivet hole, resulting in fatigue cracking. Subsequent tail-rotor strikes aggravated localized stress concentrations.
  3. Separation of the horizontal stabilizer resulted in a loss of control and in a sudden upward pitch of the tail boom, resulting in the bending of the rotor blades, and causing interference of the tail-boom structure with the rotor disc.

Findings as to risk

  1. Installation of the end cap at the root end of the stabilizer spar hid the fatigue crack.

Other findings

  1. No record of the stabilizer spar repair was found in the maintenance records, contrary to the Canadian Aviation Regulations (CARs).

Safety action taken

The TSB completed and distributed an occurrence bulletin to the manufacturer and to recreational aircraft organizations, advising of the stabilizer failure.

The manufacturer of the Baby Belle kit has issued a technical bulletin informing operators of the occurrence and of the recommended inspection criteria. The bulletin also advises operators to comply with the design by removing the end cap, if installed, at the root end.

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