Edmonton, Alberta, 29 March 2023 — In its investigation report (A21W0090) released today, the Transportation Safety Board of Canada (TSB) highlights the importance of taking appropriate measures when encountering an unstable approach and ensuring that items in the cabin are secured.
On 10 October 2021, a privately registered Daher TBM700 N was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers.
At the time of occurrence, one pilot and three passengers were on board. Following an unstable visual approach at the Westlock Aerodrome, the aircraft bounced, and the pilot initiated a go-around. During the application of engine power, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side.
The investigation identified issues with the execution of the approach, touchdown, and go-around as causes and contributing factors for this accident. It also identified that the passengers did not receive a safety briefing before departure or before landing, and multiple items in the cabin were not secured. While all passengers were wearing the lap belts, only one was wearing the available shoulder harness. As a result, one passenger sustained serious injuries due their unrestrained upper torso and the loose items that were thrown around in the cabin during the accident. The pilot was also only wearing the lap belt but not the available airbag-equipped shoulder harness; as a result, he sustained serious injuries.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Air transportation safety investigation report A21W0090
Loss of control during landing Privately registered Daher TBM700 N (TBM 910), C-FFYM Westlock Aerodrome, Alberta 10 October 2021
Summary
On 10 October 2021, the privately registered Daher TBM700 N (registration C-FFYM, serial number 1190) was conducting an instrument flight rules flight from Vernon Airport, British Columbia, to Westlock Aerodrome, Alberta, with a stop at Calgary/Springbank Airport, Alberta, to pick up passengers, after which 1 pilot and 3 passengers were on board. At 1102:26 Mountain Daylight Time, while the aircraft was landing on Runway 28 at Westlock Aerodrome, the aircraft bounced and the pilot initiated a go-around. During the application of engine power for the go-around, the aircraft rolled to the left, struck the runway inverted, and came to rest on the runway’s south side.
The 3 passengers exited the aircraft through the main cabin door with the assistance of persons nearby. One passenger received serious injuries, and the other 2 had minor injuries. The pilot, who was seriously injured, was trapped in the cockpit for approximately 2 hours before first responders could safely rescue him from the wreckage. An emergency locator transmitter signal was received by the search and rescue satellite system. The aircraft was significantly damaged and there was no post-impact fire.
1.0 Factual information
1.1 History of the flight
On 10 October 2021, the privately registered Daher TBM700 N (TBM 910) aircraft was conducting an instrument flight rules (IFR) flight from Vernon Airport (CYVK), British Columbia. The planned destination was Edmonton/Villeneuve Airport (CZVL), Alberta, with a brief intermediate stop at Calgary/Springbank Airport (CYBW), Alberta. The pilot and 1 passenger were on board for the first leg of the flight, and 2 additional passengers boarded at CYBW.
During the stopover at CYBW, the aircraft stopped at the end of an uncontrolled taxiway to pick up the 2 passengers. The pilot remained in the cockpit with the engine running and the propeller turning. Given that the aircraft was on an uncontrolled taxiway, there was no ramp safety supervision or marshallers present. There is no regulation precluding loading an aircraft in this manner.
The 2 passengers approached the aircraft and opened the main cabin door. They unloaded a bike before boarding the aircraft, and then they loaded their baggage primarily into the passenger compartment. The baggage was not secured.
The pilot then phoned a family member to report that he and the passengers would be arriving in an hour. One of the 3 passengers was seated in the mid-cabin, rear-facing seat on the right side of the aircraft, and only secured the lap belt. One passenger was seated in the aft cabin forward-facing seat on the left side of the aircraft, beside the main cabin door. This passenger secured both the lap belt and shoulder harness. The third passenger was seated in the aft cabin forward-facing seat on the right side of the aircraft and only secured the lap belt.
The passengers had routinely flown with the pilot on the occurrence aircraft and were familiar with boarding the aircraft, operating and locking the main cabin door, stowing baggage, and fastening safety harnesses.
The aircraft departed CYBW at 1013 on an IFR flight plan and proceeded to CZVL at 16 000 feet above sea level (ASL).
Thirty minutes into this leg of the flight, the pilot requested that the flight-planned destination be amended from CZVL to Westlock Aerodrome (CES4), Alberta, because weather conditions at that location met visual meteorological conditions, which would permit a visual flight rules (VFR) approach. At the time of the occurrence, CES4 did not have any instrument approach procedures. The Edmonton terminal controller approved the change, and the flight was cleared to proceed visually, direct to CES4.
The aircraft approached CES4 from the south (Figure 1), and at 1059:40, it crossed over the aerodrome mid-field at approximately 1250 feet above ground level (AGL) and 126 knots indicated airspeed (KIAS), configured with the landing gear extended and the flaps set to the take-off position (10°). The aircraft then banked right to join the mid-right downwind leg.
Figure 1. Image showing the occurrence approach to Westlock Aerodrome; the circled letters correspond to those in Figure 2 (Source: Google Earth, with TSB annotations)
Edmonton, Alberta, 14 March 2023 — Today, the Transportation Safety Board of Canada (TSB) is issuing a recommendation aimed at improving the Civil Aviation Medical Examiners’ guidelines. It is being issued as part of investigation (A21W0089) in which an amateur-built Cavalier SA102.5 aircraft entered into an aerodynamic stall and collided with terrain, in Lacombe, Alberta, on 09 October 2021, resulting in the death of the pilot.
The Office of the Chief Medical Examiner in Alberta reported that the cause of death was attributed to blunt force trauma, with cardiovascular disease as a significant contributing factor. The report also noted that the pilot had evidence of a heart attack, although it was not possible to determine the exact time of this event.
Since 2000, TSB has investigated eight accidents, including this one,involving commercial pilots in which cardiovascular disease was identified as a finding as to risk or finding as to cause.
Recommendation to Transport Canada
Following a loss of control and collision with terrain that took place in Miramichi, New Brunswick, on 23 April 2010 (investigation report A10A0041), the Board issued a safety concern indicating that medical practitioners may not always be aware of the need or importance of transmitting reportable medical conditions and, further, that deficiencies exist in the guidelines designed to screen for cardiovascular risks.
If Transport Canada guidance material and the civil aviation medical examination report do not include up-to-date cardiovascular screening methods to perform a global cardiovascular assessment when appropriate, there is an increased risk that cardiovascular disease will remain unidentified and pilots may become incapacitated while operating an aircraft.
Therefore, the Board recommends that the Department of Transport establish a framework for routine review and improvement to the Handbook for Civil Aviation Medical Examiners to ensure it contains the most effective screening tools for assessing medical conditions such as cardiovascular health issues. (TSB Recommendation A23-01)
These updated screening guidelines would reduce the likelihood of pilots becoming incapacitated while operating an aircraft and mitigate the risk of another accident such as this one.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Collision with terrain Privately registered Cavalier SA102.5 (amateur-built aircraft), C-FBWF Lacombe Aerodrome, Alberta, 14 NM E 09 October 2021
Summary
On 09 October 2021, the privately registered, amateur-built Cavalier SA102.5 aircraft (registration C-FBWF, serial number 6958) was conducting a local recreational flight from Lacombe Aerodrome, Alberta, with 1 pilot and 1 passenger on board. When the aircraft was 14 nautical miles east of the aerodrome, it entered an aerodynamic stall, resulting in a left-hand spin and collision with terrain. The pilot, who was seated in the left seat, was fatally injured; the passenger received serious injuries. The aircraft was substantially damaged; there was no post-impact fire. The 406 MHz emergency locator transmitter activated. A satellite tracking device also helped locate the aircraft.
1.0 Factual information
1.1 History of the flight
At approximately 1516 on 09 October 2021, the privately registered, amateur-built Cavalier SA102.5 aircraft (registration C-FBWF, serial number 6958) departed Lacombe Aerodrome (CEG3), Alberta, for a local recreational flight with the owner/pilot and 1 passenger on board.
After departing CEG3, the aircraft flew generally eastward. Details of the flight path (Figure 1) were captured every 10 minutes by a SPOT satellite tracking device on board. The last recorded position of the aircraft while it was airborne was at 1556, at an approximate altitude of 5095 feet above sea level (ASL). Following this, the aircraft changed direction to a south-southeast heading and at some point between this position and the accident site, the aircraft entered an aerodynamic stall, resulting in a spin and collision with terrain. The accident site was approximately 14 nautical miles east of Lacombe Aerodrome, Alberta, at an elevation of 2644 feet ASL.
Figure 1. Map showing the aircraft’s position plots recorded by the SPOT satellite tracking device (Source: Google Earth, with TSB annotations)
At 1605, the 406 MHz emergency locator transmitter (ELT) activated and a signal was detected by the Canadian Mission Control Centre, which relayed the information to the Joint Rescue Coordination Centre in Trenton, Ontario. The Joint Rescue Coordination Centre contacted first responders within 2 minutes.
First responders arrived at the site approximately 1 hour and 46 minutes after the accident. The pilot was fatally injured, and the passenger was seriously injured.
Richmond Hill, Ontario, 2 March 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22O0125) into the 23 August 2022 fatal collision with terrain of a privately registered Grumman G44 Widgeon aircraft at the Stratford Municipal Airport, Ontario.
The TSB conducted a limited-scope, class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Collision with terrain Privately registered Grumman Aircraft Engineering Corp. G44 (Widgeon), C-FNGD Stratford Municipal Airport, Ontario, 1.3 NM ENE 23 August 2022
History of the flight
At approximately 0830Footnote1 on 23 August 2022, the privately registered Grumman Aircraft Engineering Corp. G44 (Widgeon) aircraft (registration C-FNGD, serial number 1210) departed Sarnia (Chris Hadfield) Airport (CYZR), Ontario, for a visual flight rules (VFR) flight to Stratford Municipal Airport (CYSA), Ontario. The pilot was alone on board. The purpose of the flight was to bring the aircraft to a maintenance facility at CYSA to have an annual inspection performed.
The cruise portion of the flight was conducted at about 3000 feet above sea level and the aircraft approached CYSA from the southwest. The pilot’s last radio transmission on the CYSA aerodrome traffic frequency (122.8 MHz) indicated that he was turning onto the right base leg for Runway 23.
At about 0910, the aircraft was observed flying in low-visibility conditions, entering and exiting areas of low cloud cover in a steep right angle of bank. The aircraft then disappeared from sight and, a few seconds later, an impact sound was heard. Although the actual impact was not observed, smoke from the fire could be seen from a nearby field, and observers called 911. The aircraft had crashed in a cultivated field, 1.3 nautical miles (NM) east-northeast of the Runway 23 threshold (Figure 1). There was a significant post-impact fire and the aircraft was destroyed. The pilot was fatally injured.
Figure 1. Map showing the accident site in relation to the intended destination (Runway 23), and assumed direction of flight (right base leg for Runway 23) (Source: Google Earth, with TSB annotations)
Pilot information
The pilot held the appropriate licence for the planned flight in accordance with existing regulations. He held a private pilot licence – aeroplane and a valid Category 3 medical certificate. His licence was endorsed with a VFR over-the-top rating; he did not hold an instrument rating. The pilot had accumulated approximately 1146 hours total flying time, 133.6 hours of which were on the occurrence aircraft, including 26.8 hours in the last 12 months. Over the last 90 days, he had flown a total of 2.8 hours.
Weather information
The weather at CYZR before departure was suitable for VFR flight. The 0800 automated weather observation system (AWOS) report at CYZR showed the visibility was 9 statute miles (SM) with no clouds, the temperature was 19°C and dew point 17°C. The 0900 AWOS report indicated similar conditions. There is no weather reporting available at CYSA; however, local observers reported the weather as poor visibility, low ceilings with fog at the airport and surrounding area.
Weather reports for nearby airports indicated the following:
At 0800, the Kitchener/Waterloo Airport (CYKF), Ontario, AWOS (24 NM east of the accident site) indicated a visibility of 9 SM, overcast ceiling at 8100 feet, temperature 18°C, and dew point 17°C. Similar conditions were reported at 0900.
At 0800, the London Airport (CYXU), Ontario, aerodrome routine meteorological report (METAR) (25 NM south-southwest of the accident site) indicated a visibility of ½ SM in fog and a broken ceiling at 100 feet, temperature and dew point were both 18°C. At 0900, the METAR indicated a visibility of 10 SM, scattered clouds at 600 feet and 8000 feet, temperature and dewpoint were both 20°C.
The investigation was unable to determine what weather information the pilot had reviewed before the flight.
Aircraft information
The Grumman Aircraft Engineering Corp. G44 (Widgeon) is a high-wing, twin-engine, flying boat amphibious aircraft, equipped with 6 seats. The occurrence aircraft was manufactured in 1941, and was retrofitted with Teledyne Continental IO-470-E engines and McCauley 3AF32C528/82 NEA-4 constant speed propellers. The aircraft had accumulated approximately 3226 hours of total air time before the occurrence.
Aerodynamic stall
An aerodynamic stall occurs when a wing’s angle of attack exceeds the critical angle at which the airflow begins to separate. When a wing stalls, the airflow breaks away from the upper surface and the amount of lift is reduced to below that needed to keep the wing flying. While stalls occur at a given angle of attack, they can happen at any speed. The speed at which a stall occurs depends on a number of things, including the load factor, the weight of the aircraft, and the centre of gravity.
Increasing the angle of bank increases the load factor and the aircraft’s stalling speed because it causes the aircraft to perform as if it is heavier. At a 60° angle of bank, the load factor is 2, meaning that the aircraft performs as if it is twice as heavy as it would be in level flight. The stall speed is increased by about 40% at a 60° angle of bank. At a 45° angle of bank, the load factor is 1.4 and the stall speed is increased by about 18%. The investigation was unable to determine the aircraft’s actual speed during the flight or during the steep turn that was observed shortly before the accident.
Wreckage information
The disposition of the wreckage at the accident site and lack of wreckage trail indicate that the aircraft struck the ground in a nearly vertical attitude. The 2 propellers were embedded in the ground and the wing leading edges were crushed rearward by impact forces. The damage to the propellers is consistent with the engines producing power at impact. A post-impact fire consumed the entire fuselage. The wings and flight controls were also damaged in the fire, which prevented verification of flight control continuity.
The aircraft was not equipped with a lightweight data recorder, nor was it required to be by regulation. Given the absence of data, the investigation could not determine the complete sequence of events that led to the collision with terrain.
This report concludes the Transportation Safety Board of Canada’s investigation into this occurrence. The Board authorized the release of this report on . It was officially released on .
EDMONTON, AB, March 3, 2023 /CNW/ – The Transportation Safety Board of Canada (TSB) is deploying an investigator to Kelowna, British Columbia, to investigate an inflight engine fire that resulted in the diversion of a WestJet Encore De Havilland DHC-8-402 aircraft on 02 March 2023. The TSB will gather information and assess the occurrence.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Richmond Hill, Ontario, 28 February 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21O0127) into a runway overrun in Kingston, Ontario in 2021.
On 30 November 2021, at 17:54 EST, an Embraer EMB-505 aircraft, operated by I.M.P. Group Limited, departed Montréal/Pierre Elliott Trudeau International Airport (CYUL), Quebec, for an instrument flight rules flight to Kingston/Norman Rogers Airport (CYGK), Ontario, with two pilots on board.
Upon landing in Kingston CYGK on Runway 19, the pilots applied maximum braking. Although the braking system was working properly, the pilots did not feel the expected deceleration. The aircraft departed the runway’s end while skidding slightly to the left and came to a stop in a grassy area approximately 440 feet beyond the runway threshold. Neither pilot was injured, the aircraft was undamaged, and there was no damage to airport fixtures.
The investigation determined that the surface friction on Runway 19 at the time of the occurrence was consistent with that of an ice-covered runway. The aerodrome routine meteorological reports (METARs) issued during the hours leading up to the occurrence indicated both that snow had been falling steadily and that the temperature had dropped below freezing. Despite the snowfall, the runways still appeared bare and wet at the time of the occurrence.
The most recent runway surface condition NOTAM (Notice to Airmen) reviewed by the crew reported good braking conditions with a wet runway surface. As a result, they determined that a safe landing was possible. However, during the time between the issuance of the runway surface condition NOTAM and the occurrence landing, some of the moisture on the runway surface had frozen, resulting in an icy surface with limited friction available for braking.
While the aircraft touched down at the planned speed within the touchdown zone and the brakes were applied immediately, the decreased braking effectiveness resulted in the runway overrun.
Runway overruns are a Watchlist 2022 issue. As this occurrence demonstrates, when a runway overrun occurs during landing, it is important that the aircraft have an adequate safety area beyond the end of the runway to reduce adverse consequences.
Following the occurrence, the aircraft operator, I.M.P. Group Limited, updated its procedures to include the task of notifying the airport operator of planned arrivals when environmental conditions may be affecting the runway condition and to require pilots to request updated runway condition reports if conditions warrant.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Summary
On 30 November 2021, at 1754 Eastern Standard Time, the Embraer EMB-505 (Phenom 300E) (registration C-GRIA, serial number 50500566) aircraft, operated by I.M.P. Group Limited, departed Montréal/Pierre Elliott Trudeau International Airport (CYUL), Quebec, for an instrument flight rules flight to Kingston/Norman Rogers Airport (CYGK), Ontario, with 2 pilots on board.
At 1829, the aircraft landed on Runway 19 following an instrument landing system approach. The second-in-command, who was the pilot flying, applied full braking within seconds of touchdown but did not feel the expected aircraft deceleration. The pilot-in-command also attempted to stop the aircraft once it was apparent that the expected braking was not taking place; this had no added effect on the deceleration of the aircraft. The aircraft departed the runway’s end at a speed of 61 knots, entering a grassy area. It continued for approximately 440 feet before coming to a stop.
Neither pilot was injured, the aircraft was undamaged, and there was no damage to airport fixtures.
1.0 Factual information
1.1 History of the flight
At approximately 1700Footnote1 on 30 November 2021, the 2 pilots scheduled on the occurrence flight met at a fixed-base operatorFootnote2 at Montréal/Pierre Elliott Trudeau International Airport (CYUL), Quebec, for a pre-flight briefing. The flight was to be a nightFootnote3 instrument flight rules (IFR) flight between CYUL and Kingston/Norman Rogers Airport (CYGK), Ontario, that would last approximately 35 minutes and cover a distance of 144 nautical miles (NM). The flight crew were familiar with the route, having landed on Runway 19 at CYGK before on more than one occasion. The aircraft was an Embraer EMB-505 (Phenom 300E), which was operated by I.M.P. Group Limited (I.M.P. Group) under Canadian Aviation Regulations (CARs) Subpart 604—Private Operators.
The pilot-in-command, seated in the right seat, was the pilot monitoring, while the second-in-command, seated in the left seat, was the pilot flying (PF). The flight proceeded uneventfully until the aircraft touched down on Runway 19 at CYGK following the instrument landing system approach.
At 1829, the main landing gear (MLG) of the aircraft touched down within the touchdown zone at an indicated airspeed of 113 knots approximately 1200 feet beyond the displaced threshold of Runway 19. The PF began braking within 2 seconds of touchdown, with maximum braking occurring after approximately 8 seconds. The aircraft did not decelerate appreciably during these 8 seconds, and the crew did not feel pulsing or shuddering through the braking system, which is typically felt when the anti-skid engages. After a brief verbal exchange between the pilots about the insufficient deceleration, the pilot monitoring also applied his brakes, with no added effect. Following 24 seconds of full brake application, during which braking performance did not improve, and with approximately 200 feet of runway remaining, the PF pulled the emergency parking brake in an effort to increase the braking effectiveness. The emergency parking brake application did not alter or improve the deceleration of the aircraft.
The aircraft overran the runway while skidding slightly to the left, with the nose to the right of the aircraft track. The overrun began approximately 45 feet left of the centreline at a speed of 61 knots. The aircraft continued to slide onto the soft grassy area beyond the runway’s end for approximately 400 feet before coming to a stop 30 feet left of the runway extended centreline and 48 feet short of the approach lighting structure for Runway 01 (Figure 1), remaining within the runway-end safety area (RESA) throughout the overrun.
Figure 1. The occurrence aircraft taken the morning after the overrun (Source: TSB)
1.2 Injuries to persons
There were no injuries.
1.3 Damage to aircraft
There was no damage to the aircraft resulting from the runway overrun.
Dorval, Quebec, 21 February 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22Q0084) into a July 2022 fatal collision with a power line cable of a privately registered, float-equipped, Bellanca 7GCBC (Citabria) aircraft in Shawinigan, Quebec.
The TSB conducted a limited-scope class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
History of the flight
At approximately 1530 on 17 July 2022, the privately registered, float-equipped, single-engine Bellanca 7GCBC (Citabria) aircraft (registration C-GOQZ, serial number 74174) took off for a local visual flight rules (VFR) flight from Trois-Rivières Airport (CYRQ), Quebec, to Shawinigan, Quebec. The purpose of the flight was for the pilot, who was alone on board, to position his aircraft on the Saint-Maurice River, near downtown Shawinigan, for the summer season. Given that the aircraft was not equipped with amphibious floats, the departure from CYRQ was conducted by towing the aircraft on a trailer behind a pickup truck. Less than an hour after departure, the aircraft was seen flying over the Saint-Maurice River, from west to east, in Shawinigan. Approximately 10 minutes later, the aircraft was seen flying over the river once again, near the same location, but this time it was flying from east to west at low altitude, until it collided with the lower cable of a power line, which was at a height of about 20 m. After the impact, the aircraft fell into the river in an inverted position. The pilot was fatally injured.
Weather information
According to the aerodrome routine meteorological report (METAR) issued at 1500 for CYRQ, which is situated 10 nautical miles (NM) south-southeast of the accident site, the weather conditions were favourable for this VFR flight and were not considered to be a contributing factor in this accident.
Pilot information
The pilot held a Canadian private pilot licence – aeroplane, issued in July 2009, and a medical certificate which, according to Transport Canada (TC) records, had expired on 01 March 2020. The investigation was unable to determine whether the pilot had renewed his certificate after that date.
He had the ratings needed to fly single-engine landplanes and seaplanes. He had accumulated approximately 575 hours on the occurrence aircraft since he became the owner, in 2013.
Although the pilot was quite familiar with the Shawinigan area, this was the first time he was using this particular portion of the Saint-Maurice River to dock his aircraft.
According to information gathered during the investigation, there was no indication that the pilot’s performance was degraded by medical or physiological factors.
Aircraft information
The Bellanca 7GCBC (Citabria) is a single-engine 2-seat tandem aircraft that is commonly equipped with floats. At the time of the occurrence, the aircraft had accumulated about 2474.6 hours of air time, including approximately 1 hour for the occurrence flight. A review of the aircraft’s journey log and technical records did not reveal any outstanding defects that could have contributed to the occurrence. According to the wreckage examination, there was no indication that an aircraft system or component malfunction had contributed to this occurrence .
Accident site
The accident occurred over the Saint-Maurice River in Shawinigan, not far from the destination dock, where a Hydro-Québec power line crosses the river, 3.5 NM west of a hydro dam. While flying over the landing site, the aircraft struck the lower cable on this power line (Figure 1).
Figure 1. Image of the occurrence site, the aircraft’s known route, and the point of collision with the cable (Source: Google Earth, with TSB annotations)
The damage to the lower cable matched the damage to the aircraft wreckage (Figure 2). Clear signs of contact with the cable were visible on the propeller blades, the left windshield post (Figure 3) and the left-wing strut (Figure 4).
Figure 2. Photo of the damage to the lower cable of the power line (Source: TSB)Figure 3. Photo of the damage to the left windshield post caused by the collision with the cable (Source: TSB)Figure 4. Photo of the damage to the left-wing strut caused by the collision with the cable (Source: TSB)
Low-altitude flight
Intentionally flying at low altitude increases the risk of an accident: the pilot’s field of vision is reduced and consequently, the pilot has less time to take action to avoid obstacles and terrain. It is also recognized that flying at low altitude reduces the margin of safety in the event of engine failure, a loss of control, or any other unexpected circumstances, while increasing the risk of an impact with the ground or an obstacle. The Canadian Aviation Regulations (CARs) and other publications make specific mention of these risks., Furthermore, over the years, the TSB has investigated numerous occurrences in which low-altitude flight was identified as a contributing factor.
Under certain circumstances and for a variety of reasons, a pilot may decide to fly over a point of interest on the ground at low altitude. For instance, the pilot may wish to inspect a planned landing area and the potential obstacles near a destination dock. If the pilot’s attention is fully focused on observing this point of interest on the ground, the pilot stops watching where the aircraft is heading and may not detect obstacles along the route.
Richmond, British Columbia, 16 February 2023 —Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22P0061) into the 24 July 2022 collision with terrain of a privately registered Cessna 172P aircraft at the Qualicum Beach Airport, British Columbia.
The TSB conducted a limited-scope class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Collision with terrain Privately registered Cessna 172P, C-GGSN Qualicum Beach Airport, British Columbia 24 July 2022
History of the flight
On 24 July 2022, the privately registered Cessna 172P aircraft (registration C-GGSN, serial number 17274207) was conducting a recreational visual flight rules flight from Victoria International Airport (CYYJ), British Columbia (BC), to Qualicum Beach Airport (CAT4), BC. Before the flight, 18 U.S. gallons of 100LL aviation grade fuel were added to the aircraft at CYYJ, after which a total of 30 U.S. gallons of fuel was onboard.
At approximately 1857,cafter the pilot had conducted the walkaround inspection and run-up checks, the aircraft departed CYYJ with only the pilot on board. The aircraft flew at a cruising altitude between 2300 and 2500 feet above ground level (AGL) for approximately 27 minutes. During the approach to CAT4 from the southeast, the pilot conducted a reduced power descent, first to 2000 feet AGL, then to 1300 feet AGL. Shortly after the aircraft had levelled off at 1300 feet AGL, the pilot increased throttle and the engine began to sputter and its speed decreased from approximately 2300 rpm to 1200 rpm. The pilot further increased throttle, but the engine did not respond. The engine fuel mixture was set to full rich for the duration of the flight and carburetor heat was not applied at any time.
The pilot had been manoeuvring to join the downwind leg for Runway 29, but opted to conduct an emergency landing on Runway 11 and announced his intention on the airport’s mandatory frequency. The pilot initiated a left turn, reduced throttle, added full flaps, and entered a forward slip in a steep descent. At 1938:28, the aircraft briefly contacted the surface of Runway 11 beyond Taxiway C (at which point less than 1850 feet of runway remained) and became airborne again. The pilot initiated a go-around and increased the throttle to full power, raised the flaps, and the aircraft entered a climb. Approximately 19 seconds after the initial touchdown, the pilot initiated a steep right turn immediately before reaching tree-covered, down-sloping terrain, and the aircraft began a rapid descent in a right bank and nose-down attitude. The pilot declared a MAYDAY on the airport’s mandatory frequency and the aircraft impacted terrain in the trees along the edge of a farmer’s field (Figure 1).
Figure 1. Accident site, approximately 1880 feet east-southeast of the end of Runway 11 (Source: Parksville Fire Department)
The 406 MHz emergency locator transmitter activated and local emergency services arrived on scene shortly after. The pilot received serious injuries and was transported to hospital by air ambulance. The aircraft was substantially damaged.
Pilot information
The pilot held a commercial pilot licence – aeroplane, issued on 13 March 2022, and had a valid Category 1 medical certificate.
The pilot had accumulated 289.7 total flying hours, 116.2 hours of which were as pilot-in-command. He had flown 11.8 hours in the 90 days before the occurrence flight, which was his first flight since 27 June 2022. The pilot had last flown a Cessna 172 aircraft on 24 April 2022.
Aircraft information
The Cessna 172P aircraft is a single-engine, high-wing, all-metal monoplane equipped with a carbureted Avco Lycoming O-320-D2J engine, a McCauley all-metal, 2-bladed, fixed-pitch propeller, and fixed tricycle landing gear.
The occurrence aircraft had accumulated approximately 21 463.2 total air time hours and was being rented by the pilot.
The investigation revealed that a pilot had reported a rough-running engine on the right magneto 52.9 air time hours before the occurrence. However, an aircraft maintenance engineer was unable to duplicate the fault during an engine run-up on the ground, and the aircraft was returned to service.
The aircraft had undergone an annual inspection, including the removal and repair of the No. 2 and No. 3 cylinders, 8.3 hours before the occurrence.
The aircraft was being operated within its weight and balance limitations.
Meteorological information
Environment and Climate Change Canada’s weather station at CAT4 records hourly weather information. The information recorded at 2000 indicated the following:
Winds from 300° true (T) at 7 knots
Temperature 23.5 °C, dew point 12.4 °C
Relative humidity 50%
An aerodrome routine meteorological report (METAR) for Nanaimo Airport (CYCD), BC, located 26 nautical miles east-southeast of the accident site, indicated the following weather at 2000:
Winds from 330°T, variable to 030°T, at 3 knots
Visibility 30 statute miles
Broken ceiling at 25 000 feet AGL
Temperature 27 °C, dew point 11 °C
Density altitude 1400 feet
Aerodrome information
CAT4 has 1 runway surface (Runway 11/29), which is 3564 feet long and has thresholds that are displaced by 485 feet and 200 feet respectively. The abbreviated precision approach path indicator (APAPI) angle is set at 4.5° for both ends of the runway.
The Canada Flight Supplement entry for CAT4 includes a caution note informing pilots that 100-foot-tall trees are located approximately 3000 feet beyond the threshold of Runway 29.
Wreckage and impact information
The aircraft was found approximately 1880 feet from the end of Runway 11, at the edge of a privately owned famer’s field that is approximately 100 feet below the runway elevation (Figure 2).
Figure 2. Map showing the approximate accident site and elevation profile between the end of the runway and the field (Source: Google Earth, with TSB annotations)
The aircraft initially contacted trees at approximately 22 feet AGL. It came to rest on the sloped bank on a west-southwest heading, at a 62° nose-down attitude in a water-filled ditch that was approximately 12 to 24 inches deep.
The forward fuselage was significantly deformed from the impact and 3 of the 4 engine mounts were severed. The remainder of the aircraft was largely intact; however, the right-wing strut had separated from the fuselage and the right landing gear had rotated 180°. Both wing flaps were found retracted. The propeller was embedded in the ditch with 1 blade significantly bent aft and no damage to the second blade. This type of damage is consistent with the engine producing low power or not operating on impact. Continuity of the flight and engine controls was confirmed.
First responders noted that fuel was initially leaking from the right wing; TSB investigators recovered approximately 4.5 U.S. gallons of fuel that remained in the aircraft and noted the fuel as being 100LL aviation grade fuel, which was clean and bright.
Engine examination
The engine was removed from the aircraft for a detailed examination and teardown. Despite minor impact damage, the overall condition of the assembled engine was unremarkable and the crankshaft rotated normally. The magnetos were synchronized with each other, the engine timing was correct, and all spark plugs operated normally. The carburetor was disassembled with no faults found. The filters and the screens from the oil and fuel systems were found clean and unobstructed. The examination found 2 anomalies of note:
The right magneto was firing intermittently below 1800 rpm.
The oil sump contained significant magnetic metal particles.
The right magneto was disassembled and signs of wear were evident on the carbon brush, distributor block electrodes, and contact points. It was also noted that the centre brass electrode was found loose on the centre steel shaft. The impulse coupling was operating normally. It is unlikely that the intermittent firing of the magneto would have significantly degraded engine operation.
The metal particles found in the oil sump could not be sourced to the failure or absence of an internal engine component. There were no signs that the particles caused secondary damage to the internal engine components or precluded the engine from operating.
Survival aspects
In this occurrence, the aircraft remained upright and the fuselage maintained a survivable space for the pilot.
Both of the occurrence aircraft’s front seats were fitted with a safety belt consisting of a lap belt and a shoulder harness. First responders found the pilot’s seat (left side) secured to the floor and the pilot secured with the lap belt only. Upon further examination, the investigation determined that the shoulder harness was secured to the lap belt buckle, but the stitching of the harness webbing had failed at the aft anchor bracket. As a result, the shoulder harness webbing pulled through the bracket during the impact sequence.
In accordance with the Canadian Aviation Regulations, safety belts are to be inspected every 12 months “for poor condition, fraying, and any other apparent defects.” The occurrence aircraft’s safety belts were inspected 10 days before the occurrence, during the aircraft’s annual inspection. There is no service life limit for the safety belts installed on the occurrence aircraft.
The Canadian Aviation Regulations also require that “each separate part of the safety belt assembly must be permanently and legibly marked.” The occurrence aircraft’s lap belts each had an attached label that included the rated strength of the belt; however, the shoulder harness did not have a label.
Carburetor icing
The Cessna 172P Pilot Operating Handbook (POH) states that carburetor ice may result in “[a] gradual loss of RPM and eventual engine roughness.” To prevent carburetor icing, the POH includes the application of carburetor heat on various checklists. In the Normal Procedures section of the POH, carburetor heat is included on both the Descent and the Before Landing checklists. In the Emergency Procedures section of the POH, it is included on the Engine Failure During Flight checklist. For the duration of the occurrence flight, the carburetor heat was in the OFF position.
The Transport Canada Aeronautical Information Manual provides guidance material and a reference chart for weather conditions that can induce carburetor icing (Figure 3). The formation of carburetor ice can occur at all engine power settings and can vary with specific engine installations.
Based on the weather conditions recorded closest to the time of the occurrence at CAT4, carburetor icing was charted as moderate icing during cruise power and serious icing during descent power.
Figure 3. Chart providing weather conditions that can induce carburetor icing based on temperature, dew point, and humidity with the CAT4 weather conditions plotted (Source: Transport Canada, TP 14371E, Transport Canada Aeronautical Information Manual (TC AIM), AIR – Airmanship (24 March 2022), section 2.3, figure 2.2, with TSB annotations)
Environmental impact
The water-filled ditch where the aircraft came to rest was part of the neighbouring French Creek watershed. Following the release of oil and fuel from the aircraft, the area underwent an extensive environmental rehabilitation that included removal of contaminated water and soil.
TSB laboratory report
The TSB completed the following laboratory report in support of this investigation:
LP065/2022 – NVM Recovery – iPad
Safety message
Based on the conditions at the time of the occurrence, there was a potential for serious carburetor icing at descent power. Even though the investigation was unable to determine if carburetor icing was a factor in this occurrence, pilots are reminded that carburetor icing can occur even in warm temperatures. Pilots should follow the guidance in their aircraft’s POH with respect to the application of carburetor heat.
This report concludes the Transportation Safety Board of Canada’s investigation into this occurrence. The Board authorized the release of this report on . It was officially released on .
Richmond Hill, Ontario, 15 February 2023 —Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22O0140) into the 24 September 2022 fatal collision with terrain of a privately registered Quad City Challenger II advanced ultralight aircraft near Westport, Ontario.
The TSB conducted a limited-scope, class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Winnipeg, Manitoba, 2 February 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21C0078) into the 2021 loss of control and collision with terrain of an aircraft at the Thunder Bay Airport, Ontario.
On the evening of 16 August 2021, the Rockwell International Aero Commander 690B aircraft, operated by MAG Aerospace Canada Corp., was conducting a visual flight rules flight from Thunder Bay Airport, Ontario, to Dryden Regional Airport, Ontario, with only the pilot on board. The aircraft began to takeoff on Runway 12. Shortly after rotation, it entered a left bank, continued to roll, and then struck the surface of Runway 07 in an inverted attitude. The pilot was fatally injured, and the aircraft was destroyed by the impact and post-impact fire.
The investigation found that the pilot’s decision to conduct the rapid, low-level, climbing steep turn was likely influenced by an altered perception of risk from previous similar takeoffs that did not result in any adverse consequences. The investigation also determined that if air traffic controllers engage in communications that may be perceived by pilots to encourage unusual flight manoeuvres, pilots may perceive this encouragement as a confirmation that the manoeuvres are acceptable to perform, increasing the risk of an accident.
Following the occurrence, MAG Aerospace Canada Corp. suspended all flight operations to hold a company-wide Safety Stand-Down meeting to discuss safety policies, compliance with standard operating procedures and safe practices, and reiterate the company’s anonymous, non-punitive safety reporting program. The company also updated its crew resource management training materials to include more information on managing stress and internal/external pressures as well as the normalization of deviance, which refers to the acceptance of unsafe practices.See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Dorval, Quebec, 25 January 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21Q0092) into a fatal 2021 occurrence where a Cessna 172M banner towing aircraft lost engine power and collided with terrain in Montréal, Quebec. The investigation found that unfavourable weather conditions along with loss of engine power contributed to the occurrence.
On 2 October 2021, a Cessna 172M aircraft operated by Publicité AERO-GRAMME Inc. took off from St-Mathieu-de-Laprairie Aerodrome, Quebec, with one pilot and one passenger on board, to conduct a visual flight rules (VFR) aerial advertising flight in the region of Montréal, Quebec. While the aircraft was flying over the St. Lawrence River near the Concorde bridge, a loss of engine power occurred. The pilot was attempting an emergency landing, when the aircraft’s left wing grazed some treetops, causing the aircraft to cartwheel before colliding with terrain. A post-impact fire occurred and the aircraft was destroyed. The passenger was unable to evacuate the aircraft and was fatally injured, while the pilot sustained serious injuries.
The investigation found that during flight planning, weather forecasts indicated unfavourable conditions, making it difficult to meet the minimum requirements for a VFR flight; however, the pilot decided to take off and proceed with the flight at an altitude of 500 feet above sea level (ASL), likely under the influence of an unconscious cognitive bias and the time constraints to complete the flight.
Additionally, atmospheric conditions conducive to carburetor icing most likely caused ice to develop, which would have reduced the engine’s ability to produce enough power to maintain the aircraft’s altitude. Given the amount of ice that was quite likely in the carburetor when the carburetor heat was turned on, the melted ice entered the engine causing an additional loss of power. To remain within VFR conditions, the pilot continued the flight at an altitude of 500 feet ASL, flying over built-up areas. Consequently, when the engine lost power, the possible locations for a safe landing were considerably limited.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Canadian Aviation News 
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