Unfavourable weather conditions and loss of engine power contributed to a 2021 fatal small plane crash in Montréal, Quebec

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.

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.

Unsuccessful visual scanning, operator task saturation factors in 2021 aircraft/drone collision near Toronto/Buttonville Municipal Airport, Ontario

Richmond Hill, Ontario, 19 January 2023 — The Transportation Safety Board of Canada (TSB) released its investigation report (A21O0069) into the August 2021 collision between a remotely piloted aircraft, commonly referred to as a drone, and a small aircraft that took place near the Toronto/Buttonville Municipal Airport, Ontario.

On 10 August 2021, a Cessna 172N aircraft operated by Canadian Flyers International Inc. was on final approach to the Toronto/Buttonville Municipal Airport, with a student pilot and flight instructor on board, when it collided with a York Regional Police DJI Matrice M210 remotely piloted aircraft (RPA) operated by a pilot located on the ground and a visual observer. Following the collision, the Cessna aircraft continued the approach and made an uneventful landing. After parking the aircraft, damage on the front left cowl under the propeller was observed. The York Regional Police RPA was destroyed. There were no injuries to either pilot on the Cessna 172N or to persons on the ground.

The investigation found that the Cessna pilots were unaware of the presence of airborne RPA traffic in the vicinity and, due to several factors, the active scanning that is part of the see-and-avoid principle was unsuccessful in identifying the conflict. Additionally, York Regional Police policy does not require that visual observers be trained crew members, and the RPA pilot did not brief the visual observer on his role and responsibilities before the operation. As a result, the visual observer was not aware of the requirement to maintain visual line-of-sight with the RPA, nor was he trained in visual scanning techniques or aircraft identification. Finally, the RPA pilot was tasked with operating the camera system, monitoring the status of the RPA, and communicating on multiple channels. As a result, he likely became task saturated, restricting his ability to visually monitor the RPA and hear radio calls on the control zone’s mandatory frequency and the sound of incoming aircraft, both of which preceded the collision. As a result of these factors, the conflict went unrecognized and the two aircraft collided.

Following the occurrence, the York Regional Police amended its directive to include the addition of a pre-flight risk assessment tool, and an updated RPA pilot checklist. There is also additional guidance for the role of the visual observer, including a quick reference card outlining their roles and responsibilities, as well as a requirement to have a visual observer present for all operational RPA flights. 

See the investigation page for more information.

Main rotor blade failure during emergency landing resulted in 2019 fatal helicopter accident in Campbell River, BC

Richmond, British Columbia, 8 December 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A19P0142) into the September 2019 loss of control and collision with terrain of a Bell helicopter in Campbell River, British Columbia (BC).

On 24 September 2019, an E & B Helicopter Ltd. Bell 206B helicopter was conducting a flight from Campbell River Heliport, BC, to Moat Lake, BC, with only the pilot on board. Shortly after departure, while flying southeast along the coastline, the helicopter briefly levelled off at 615 feet above sea level (ASL), then began a descent. When the aircraft was at 417 feet ASL, it entered a right-hand climbing turn toward land and, following the turn, it began to descend again. During this descent, control of the helicopter was lost when it was about 200 feet above ground level and the helicopter fell to the ground, striking a building and 2 vehicles. The pilot was fatally injured. The helicopter was destroyed by the impact forces and a post-impact fire.

The investigation found that an engine power anomaly likely occurred while the helicopter was in cruise flight and, as a result, the pilot reversed course and entered a descent consistent with an autorotation. At some point during the flight, the main rotors became deformed. Although indications of fatigue were present post-occurrence, the extent to which this fatigue contributed to the deformation could not be determined. In the last moments of the flight, likely as a result of the deformed blades, the main rotor rpm decreased to a point that could not sustain autorotational flight, and the helicopter fell vertically and impacted the ground. The investigation also revealed that the engine fuel system did not have the appropriate accumulators and double check valve for installation on the Bell 206 helicopter. During the installation of the engine, the company maintenance control system was ineffective at ensuring that the engine installation complied with the manufacturer’s recommendations. If maintenance procedures do not include a thorough review of all related instructions and bulletins, there is a risk that an aircraft will be released into service in a non-airworthy configuration.

The investigation examined the air operator’s safety culture. The pilot was the company’s owner, accountable executive, and operations manager, and direction on how the maintenance department was to respond to a partial loss of engine power that occurred a week before the occurrence came from him. The investigation revealed that many operational and maintenance-related decisions were being made based on a single opinion, rather than a process of validation by a hierarchy of independent and skilled supervisors. In addition, several opportunities to improve the safety of the flight had been missed. If company management routinely deviates from regulatory requirements, there is an increased risk that an unsupportive safety culture will develop, affecting the entire organization.

Finally, the investigation examined Transport Canada’s (TC’s) approach to managing cardiovascular health and hypertension in pilots. Using a variety of different risk calculators and all available medical information about the occurrence pilot, an independent cardiology review was conducted as part of this investigation and revealed that the pilot possessed many of the key indicators for a high-risk cardiac event. In this occurrence, TC’s civil aviation medical examination to assess pilot fitness did not identify the level of risk presented by the pilot. If TC guidance material and the civil aviation medical examination report do not require a Civil Aviation Medical Examiner to perform a global cardiovascular assessment, when appropriate, there is an increased risk that a pilot with high cardiovascular risk factors will be incapacitated while operating an aircraft as a result of a medical event.

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.


Main rotor blade failure and collision with terrain
E & B Helicopters Ltd.
Bell 206B (helicopter), C-GEBY
Campbell River, British Columbia
24 September 2019

Executive Summary

On 24 September 2019, the E & B Helicopters Ltd. Bell 206B helicopter (registration C-GEBY, serial number 3375) was conducting a visual flight rules flight from the operator’s base at Campbell River (E & B Heli) Heliport (CCR6) in Campbell River, British Columbia, to Moat Lake, British Columbia, with only the pilot on board.

Shortly after departure, while flying southeast along the coastline, the helicopter briefly levelled off at 615 feet above sea level, then began a descent. When the helicopter was at 417 feet above sea level, it entered a right-hand climbing turn toward land and, following the turn, it began to descend again. During this descent, at 1103 Pacific Daylight Time, control of the helicopter was lost when it was about 200 feet above ground level and the helicopter fell to the ground, striking a building and 2 vehicles. The pilot was fatally injured. No one on the ground was injured. The helicopter was destroyed by the impact forces and a post-impact fire.

The investigation found that an engine power anomaly likely occurred while the helicopter was in cruise flight and, as a result, the pilot reversed course and entered a descent consistent with an autorotation. Following the occurrence, a visual and microscopic examination of the main rotor blades revealed several indications of structural failure in flight. At some point during the flight, both main rotor blades became deformed. Although indications of fatigue were present post-occurrence on a small portion of the trailing edge of one of the main rotor blades, the extent to which this fatigue contributed to the deformation could not be determined. The investigation also found that in the last moments of the flight, likely as a result of the deformed blades, the main rotor rpm decreased to a point that could not sustain autorotational flight, and the helicopter fell vertically and impacted the ground.

The investigation also revealed that the engine fuel system did not have the appropriate accumulators and double check valve for the Bell 206 helicopter. During the installation of the engine, the company maintenance control system was ineffective at ensuring that the engine installation complied with the manufacturer’s recommendations, including having the correct accumulator and double check valve configuration for the Bell 206. If maintenance procedures do not include a thorough review of all related instructions and bulletins, there is a risk that an aircraft will be released into service in a non-airworthy configuration.

The investigation examined the air operator’s safety culture. Safety culture within a company can be summarized as “how we do things around here.” The pilot was the company’s owner, accountable executive, and operations manager, and direction on how the maintenance department was to respond to a partial loss of engine power that occurred a week before the occurrence came from him. The investigation revealed that many operational and maintenance-related decisions were being made based on a single opinion, rather than a process of validation by a hierarchy of independent and skilled supervisors. In addition, several opportunities to improve the safety of the flight had been missed. If company management routinely deviates from regulatory requirements, there is an increased risk that an unsupportive safety culture will develop, affecting the entire organization.

The investigation examined the certification process of composite main rotor blades. A structural fatigue test, completed as part of the primary structural element threat assessment, is intended to ensure the continuing airworthiness of a structural component, the failure of which could be catastrophic. A dynamic load assessment helps determine the maximum damage size to be introduced into the structural fatigue test specimen. The investigation determined that no dynamic assessment was carried out for the certification of the model of Van Horn composite blades installed on the occurrence helicopter. If data from a dynamic assessment is not available, the fatigue test may not discover structural responses associated with this damage. If a structural fatigue test does not include quantitative assessments and simulated damage that is of probable sizes and at critical locations as determined from a dynamic load assessment, the resulting airworthiness limitations may not be adequate to prevent failures or excessive structural deformations.

The Van Horn composite blades are certificated on the basis of the “no-growth” method. This method is used to show that “the structure, with damage present, is able to withstand repeated loads of variable magnitude without detectable damage growth within a specified replacement time.”Footnote1 However, Van Horn’s quality assurance process has no established inspection for internal defects following production, or criteria for the permissible size of internal defects. Therefore, it is possible that an unknown intrinsic flaw could exist following production that might exceed a predefined damage limit and would affect the structural integrity of the helicopter blades. If helicopter main rotor blade manufacturing processes do not include internal inspections for defects or criteria for permissible defects, there is a risk that defects that affect structural integrity will not be identified.

Finally, the investigation examined Transport Canada’s (TC’s) approach to managing cardiovascular health and hypertension in pilots. Using a variety of different risk calculators and all available medical information about the occurrence pilot, an independent cardiology review was conducted as part of this investigation and determined that the pilot’s actual annual risk for a sudden incapacitating cardiovascular event exceeded 5% per year. This surpasses the 2% threshold set by TC and the 1% threshold cardiologists recommend for single-pilot operations. Post-mortem results confirmed the presence of extensive atherosclerotic coronary artery disease in all 4 major coronary arteries, with significant (>75%) stenosis. This analysis revealed that the pilot possessed many of the key indicators for a high-risk cardiac event. In this occurrence, TC’s civil aviation medical examination to assess pilot fitness did not identify the level of risk presented by the pilot. If TC guidance material and the civil aviation medical examination report do not require a Civil Aviation Medical Examiner (CAME) to perform a global cardiovascular assessment, when appropriate, there is an increased risk that a pilot with high cardiovascular risk factors will be incapacitated while operating an aircraft as a result of a medical event.

The investigation determined that the pilot was not forthcoming with his CAMEs about conditions that were being followed by his family physician. In addition, the pilot’s family physician did not report the pilot’s conditions to TC, which contributed to TC’s incomplete understanding of the pilot’s health. If pilots do not declare all health issues to TC CAMEs and/or if pilots’ family physicians do not report medical conditions that are likely to constitute an aviation hazard, as required, TC may not be able to accurately assess the medical fitness of pilots, resulting in an increased risk that pilots will operate with diagnosed medical conditions that could affect flight safety.

Associated links (A19P0142)

TSB Investigation report: Fatal collision with obstacle on takeoff at Canton Aerodrome, Ontario

Richmond Hill, Ontario, 6 December 2022 —Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22O0118) into the 13 August 2022 fatal collision with obstacle on takeoff of a privately registered Piper PA-28-180 aircraft at the Canton Aerodrome, in 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 obstacle on takeoff
Privately registered
Piper Aircraft Corporation PA-28-180 (Cherokee), C-FYSZ
Canton Aerodrome, Ontario
13 August 2022

History of the flight

At approximately 2015Footnote1 on 13 August 2022, during daylight hours, the privately registered Piper Aircraft Corporation PA-28-180 (Cherokee) aircraft (registration C-FYSZ, serial number 285205) began its take-off roll on Runway 14 at Canton Aerodrome (CTN7), Ontario, for a visual flight rules (VFR) flight to Ottawa/Rockcliffe Airport (CYRO), Ontario, with the pilot and 1 passenger on board.

Shortly after becoming airborne, when the aircraft had travelled approximately 1400 feet down the runway and was at a height of approximately 26 feet above ground level, the left wing struck a tree located approximately 40 feet to the left of the runway centreline. Then, the aircraft was seen to veer to the left before disappearing from view. The aircraft then struck multiple additional trees before colliding with terrain,Footnote2 and came to rest approximately 220 feet to the left of the runway centreline (Figure 1).

At approximately 2045, bystanders reached the accident site and contacted emergency services, which arrived on site at 2100. Although both occupants were wearing safety belts with shoulder harnesses, they were fatally injured.

The aircraft’s 406 MHz emergency locator transmitterFootnote3 activated, and the signal was received by the Joint Rescue Coordination Centre (JRCC) in Trenton, Ontario. There was no post-impact fire.

Map showing the accident sequence (Source: Google Earth, with TSB annotations)
Figure 01. Map showing the accident sequence (Source: Google Earth, with TSB annotations)

Aerodrome information

CTN7 is private aerodrome at an elevation of 520 feet above sea level (ASL). It has 1 runway surface (Runway 14/32), which is asphalt and is 1958 feet long and 40 feet wide. Prior permission is required before landing at the aerodrome.

Mature trees are present on both sides of the runway, starting approximately 600 feet before the departure end of Runway 14. The grassy area along the runway edges was maintained up to the runway edge lights on both sides of the runway. The runway had not been used regularly for approximately 5 years. A review of historic Google Earth imagery and the conditions observed following the occurrence show that, over the past 4 years, the tree canopy has expanded toward the edges of the runway, likely reducing the opening over the Runway 14 departure end. On 14 September 2022, Transport Canada received written notice that CTN7 was closed. Transport Canada indicated that CTN7 would soon be removed from publications.

Aircraft information

The PA-28-180 aircraft is a 4-seat, low-wing aircraft equipped with a carbureted Lycoming O-360-A4A engine, a Sensenich all-metal, 2-bladed, fixed-pitch propeller, and fixed tricycle landing gear. The aircraft had accumulated approximately 4034 hours of total air time before the occurrence. It had been registered to the Outaouais Flying Club inc. (a private flying club) since April 2005. The last annual inspectionFootnote4 had been completed in March 2022.

Pilot information

The pilot held the appropriate licence and met the recency requirements for the flight in accordance with existing regulations. He had a private pilot licence — aeroplane with a night rating and a Group 3 instrument rating; his medical certificate was valid. He had accumulated approximately 600 total flying hours and approximately 190 of those hours were on the occurrence aircraft. The occurrence takeoff was the pilot’s third takeoff from Runway 14 at CTN7; the previous one was in October 2019.

Weather information

The weather was suitable for the VFR flight. The automatic hourly aerodrome routine meteorological report issued at 2000 for Peterborough Airport (CYPQ), Ontario, the closest aerodrome to the accident site, located 14 nautical miles north of CTN7, reported the winds from 200° true at 3 knots, visibility 9 statute miles, no clouds, temperature 20 °C, and dew point 10 °C. On the day of the occurrence, the sunset in Canton was at 2035.

Accident site and aircraft wreckage

Photo of the damage to the left wing (Source: TSB)
Figure 2. Photo of the damage to the left wing (Source: TSB)

The aircraft struck the ground in a nearly vertical, nose-down attitude; the nose and right wing impacted the ground first, followed by the lower right side of the fuselage. The right wing was nearly separated from the aircraft, and had folded back along the right side of the fuselage. The engine was displaced significantly to the left of the fuselage centreline, and the left wing was relatively undamaged by the ground impact. There were signs of tree strikes along both wing leading edges, the most significant of which was on the outboard leading edge of the left wing, approximately 2 feet inboard from the wing tip (Figure 2).

The aircraft systems were examined to the degree possible on site, and no indication of a malfunction was found. Damage to the propeller was consistent with power being produced at the time of impact, although the amount of power could not be determined. Due to the damage to the nose section, the position of the engine controls could not be determined with certainty.

The ignition key was found in the BOTH position. The stabilator was trimmed slightly nose up, which is consistent with a take-off configuration, and the flaps were found retracted. The fuel selector was selected to the right tank. Both the left and right fuel tanks were compromised and leaking fuel. Approximately 35 L of aviation fuel (AVGAS) were recovered from both tanks.

The aircraft was being operated within its weight and balance limitations.

The aircraft was not equipped with a lightweight data recorder, nor was it required to be by regulation. No data was available from the global positioning system on board the aircraft. Given the absence of data, the investigation could not determine the complete sequence of events that led to the aircraft deviating slightly to the left during takeoff, which resulted in the impact with a tree followed by a loss of control and 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 .

TSB Investigation Report: Fatal collision with communication tower at the Sandy Lake Water Aerodrome, ON

Winnipeg, Manitoba, 29 November 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22C0035) into the 26 May 2022 collision with a communication tower involving a Cessna U206G aircraft at the Sandy Lake Water Aerodrome, ON.

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 obstacle on approach
Sandy Lake Seaplane Service Ltd.
Cessna U206G, C-GBGJ
Sandy Lake First Nation, Ontario
26 May 2022

History of the flight

At 1545Footnote1 on 26 May 2022, the Sandy Lake Seaplane Service Ltd. float-equipped Cessna U206G aircraft (registration C-GBGJ, serial number U20605249) departed Sandy Lake Water Aerodrome (CKE5), Ontario, for a personal flightFootnote2 to an unnamed lake located 41 nautical miles (NM) north-northeast of CKE5. The purpose of the flight was to bring boat fuel and groceries to the pilot’s cabin located at the unnamed lake. The weather was suitable for the visual flight rules flight, with nearby weather stations reporting winds generally at 10 knots or less, visibility 9 statute miles, and scattered clouds above 5500 feet above ground level (AGL).

At approximately 1830, the aircraft departed the unnamed lake for the return flight to CKE5. As the aircraft approached CKE5, the pilot transmitted position reports on the aerodrome traffic frequency. At 1853, when the aircraft was flying over the community of Sandy Lake First Nation on final approach for a south-southwest direction landing at CKE5, it struck a 132-foot-tall communications tower located at the Nishnawbe Aski Police Service’s Sandy Lake First Nation detachment. The aircraft subsequently collided with terrain and a post-impact fire ensued. The pilot was fatally injured.

The emergency locator transmitter (ELT) activated as a result of the impact and the Joint Rescue Coordination Centre in Trenton, Ontario, received the signal at 1854. The Nishnawbe Aski Police Service and the Sandy Lake First Nation Fire Department responded to the scene.

Wreckage and impact information

During approach for landing on the lake, the occurrence aircraft struck the communications tower and then descended through a set of hydro lines before colliding with trees in a wooded area. The wreckage came to rest approximately 280 feet from the base of the communications tower. Approximately 80% of the airframe was consumed by the post-impact fire.

Damage to the propeller was indicative of contact with a metal object, suggesting that the propeller was rotating and the engine was producing power when the communications tower was struck. Antenna pieces found near the communications tower exhibited damage consistent with shear. This indicates that the aircraft hit the tower at approximately 126 feet AGL and laterally centered on the aircraft; in line with the propeller.

A portion of the right wing—near the wing tip and including the aileron—was found hanging from the hydro line. Damage to the wing tip was indicative of shear from the collision with the hydro line.

An inspection of all flight control cables did not reveal any pre-impact anomalies. Inspections of both control wheels and columns were inconclusive due to fire damage. Examination of the flap actuator jackscrew extension suggests a flap setting of approximately 24° at the time of impact; however, inspection of the flap system for continuity was also inconclusive due to fire damage.

The 406 MHz ELT emitted a signal before it was destroyed in the fire.

More on the report…

2021 forced landing of an aircraft due to fuel starvation highlights the importance of proper checklist usage

Edmonton, Alberta, 24 November 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21W0098) into the 2021 forced landing of an Air Tindi Ltd. de Havilland DHC-6-300 Twin Otter aircraft near Fort Providence, Northwest Territories (NWT), following fuel starvation. The investigation found that leading up to the event, there were several instances where checklists were not completed in accordance with company procedures.

On 01 November 2021, an Air Tindi Ltd. de Havilland DHC-6-300 Twin Otter aircraft departed Yellowknife Airport, NWT, on a visual flight rules flight to Fort Simpson Airport, NWT, with two flight crew and three passengers on board. Approximately 40 minutes into the flight, the crew realized that there was insufficient fuel to continue to Fort Simpson or to return to Yellowknife. The flight crew diverted the aircraft to Fort Providence Aerodrome and shut down the left engine to conserve fuel. Shortly after, the right engine flamed out. A forced landing onto muskeg was performed 6.7 nautical miles (14 km) northwest of Fort Providence Aerodrome. Approximately four hours after the forced landing, all occupants were recovered by rescue personnel. All occupants received minor injuries related to hypothermia. The aircraft sustained substantial damage.

The investigation determined that the aircraft had not been refuelled prior to departure. While conducting the Before Start checks from memory, the captain interrupted his routine by conversing with a passenger. Consequently, the fuel quantity check was missed and the preparation for flight continued without the captain being aware that the aircraft did not have sufficient fuel for the flight on board. While taxiing to the runway, the captain conducted the Taxi checks alone, silently, and from memory. Consequently, the fuel check on the checklist was missed and the aircraft departed with insufficient fuel for the flight. The first officer then completed the cruise checks silently and without reference to a checklist. As a result, the fuel state of the aircraft was not identified by either flight crew member.

A few of the experienced Air Tindi Ltd. DHC-6 captains within the company had developed the practice of performing some of the challenge and response checklists by memory only. This had become routine for most of their flights. Reporting is extremely important to a properly functioning safety management system (SMS). The investigation revealed that DHC-6 first officers who experienced deviations from company procedures tended to report informally rather than use the company SMS. As a result, company management, as a whole, was not fully aware of the deviation regarding checklist usage on the DHC-6 fleet, and did not have an opportunity to evaluate the risk and pursue a corrective action plan through the SMS. Safety management is an issue on TSB Watchlist 2022.

Following the occurrence, Air Tindi Ltd. enhanced checklist requirements and issued a company memo to flight crews emphasizing the requirement to follow all procedures and checklists. The company also enhanced fuelling procedures by requiring the captain to verify aircraft fuelling and sign an acknowledgement on every fuel slip before starting the engine. Flight crews are also required to communicate the fuel levels on board to the operations control centre before each departure.

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.


Fuel starvation
Air Tindi Ltd.
de Havilland DHC-6-300 Twin Otter, C-GNPS
Fort Providence, Northwest Territories, 6.7 NM NW
01 November 2021

Summary

At 1748 Mountain Daylight Time on 01 November 2021, the Air Tindi Ltd. de Havilland DHC-6-300 Twin Otter aircraft (registration C-GNPS, serial number 558) departed Yellowknife Airport (CYZF), Northwest Territories, as flight TIN223, a visual flight rules flight to Fort Simpson Airport (CYFS), Northwest Territories, with 2 flight crew and 3 passengers on board.

Approximately 40 minutes into the flight, the flight crew realized that there was insufficient fuel to continue to CYFS or to return to CYZF. The flight crew diverted the aircraft to Fort Providence Aerodrome (CYJP), Northwest Territories, and informed the company of their decision. The left engine was intentionally shut down to conserve fuel. The right engine then flamed out.

A forced landing onto muskeg was performed at 1851 Mountain Daylight Time, 6.7 nautical miles (14 km) northwest of CYJP. A signal from the emergency locator transmitter was received by the Canadian Mission Control Centre shortly after. Approximately 4 hours after the forced landing, all occupants were recovered by rescue personnel. All occupants received minor injuries related to hypothermia. The aircraft sustained substantial damage.

1.0 Factual information

1.1 History of the flight

On 01 November 2021, the Air Tindi Ltd. (Air Tindi) de Havilland DHC-6-300 Twin Otter aircraft (registration C-GNPS, serial number 558) was scheduled to depart Yellowknife Airport (CYZF), Northwest Territories, at 1030Footnote1 to conduct the following 3 return flights under visual flight rules (VFR):

  • The 1st return flight was from CYZF to Whatì Airport (CEM3), Northwest Territories: flight TIN218 out and flight TIN220 back.
  • The 2nd return flight was from CYZF to Wekweètì Airport (CYWE), Northwest Territories: flight TIN212 out and flight TIN213 back.
  • The 3rd return flight was from CYZF to CEM3: flight TIN220 out and flight TIN221 back.

Following those 3 return flights, the last trip of the day was flight TIN223 from CYZF to Fort Simpson Airport (CYFS), Northwest Territories (Figure 1; see Appendix A for greater detail). The same flight crew was to conduct all 7 flights and then overnight in Fort Simpson. This was the first time this flight crew had flown together. All flights consisted of a mix of passengers and cargo and were to be conducted under Canadian Aviation Regulations (CARs) Subpart 703 (Air Taxi Operations), except for flight TIN212, which was to be conducted under CARs Subpart 704 (Commuter Operations).Footnote2

Area map showing locations (Source: Google Earth, with TSB annotations)
Figure 1. Area map showing locations (Source: Google Earth, with TSB annotations)

During the last inbound flight of the day to CYZF (flight TIN221 on the day of the occurrence), it was typical for the flight crew to inform the flight coordinator how much fuel was required for the next flight. The flight coordinator would then place an order for fuel with the fuel company. The investigation was unable to confirm whether the flight crew had requested fuel from the flight coordinator for the occurrence flight; however, the flight coordinator did not call the fuel company with a fuel order. Flight TIN221 arrived at CYZF at 1725. The crew and passengers deplaned and entered the passenger boarding lounge. Then, the process of unloading and preparing for the last flight of the day (flight TIN223 to CYFS) began.

At 1738, the first officer returned to the aircraft from the passenger boarding lounge and began the external pre-flight inspection. Approximately 1 minute later, the captain returned to the aircraft and entered the cockpit through the front left door. While getting into his seat, the captain observed a fuel receipt in the door map pocket and assumed it was for the fuel he thought he had ordered for the flight to CYFS. He did not read the fuel receipt, which was from a flight 3 days prior.

Since landing, no fuel truck had arrived at the aircraft and consequently no fuel was added to the aircraft. According to the operational flight plan, the aircraft would have arrived in CYZF on flight TIN221 with approximately 533 pounds of fuel remaining. The operational flight plan for flight TIN223 to CYFS indicated that 2500 pounds of fuel were to be on board, which was standard for this flight.

The captain began preparing the aircraft for engine start by conducting the Before Start checks of the Air Tindi DHC6 Cockpit Checklist (Appendix B) using a geographic flow.Footnote3 At the same time, passengers started boarding the aircraft, and the captain interrupted the checks to converse with one of them with whom he used to work. After a short conversation, the captain resumed the checks.

At 1740, when passengers had finished boarding and the cargo had been loaded, the first officer briefed the passengers for the flight. The first officer then sat down in the cockpit and asked the captain if he would like to commence the Before Start checks. The captain declined and started the engines at 1743.

Unlike the first few legs of the day, the ensuing After Start, Taxi, and Line Up checks were completed by the captain from memory only. At 1747, the occurrence aircraft departed CYZF on flight TIN223, with the 2 pilots and 3 passengers on board. The aircraft climbed towards the planned cruising altitude of 6500 feet above sea level (ASL). The After Takeoff and Cruise checks were completed by the first officer without reference to the checklist. By this time in a typical flight, the flight crew would have been directed by Air Tindi DHC6 Cockpit Checkliston 3 separate occasions to observe the fuel quantity (see section 1.17.1.4 Checklists of this report).

At 1750, the fuel company at CYZF called the Air Tindi flight coordinator to ask whether the occurrence aircraft needed fuel. The flight coordinator informed the fuelling company that the aircraft was already airborne and on its way to CYFS.

Based on the fuel burn analysis (see section 1.16.1 Fuel quantity calculation of this report), the low-fuel-level caution light for the aft fuel tank illuminated at 1813. At this time, there were approximately 60 U.S. gallons of fuel left in the aircraft, including 8 U.S. gallons of fuel in the left-wing auxiliary tank and 9 U.S. gallons in the right-wing auxiliary tank. This would have given the aircraft about 40 minutes of flying time at cruise power before complete fuel exhaustion.

At 1826 (38 minutes after takeoff), when flight TIN223 was approximately halfway to CYFS, the flight crew noticed the illuminated low-fuel-level caution light for the aft fuel tank. The flight crew immediately realized that they had departed with insufficient fuel and began the process of determining where to divert to. It was decided that Fort Providence Aerodrome (CYJP), Northwest Territories, was the closest runway and, at 1829, flight TIN223 turned southbound towards it. During this time, the captain climbed the aircraft to 7000 feet ASL.

The captain informed the Air Tindi flight coordinator of the situation via the aircraft’s satellite radio. The flight coordinator relayed a suggestion from the chief pilot to consider shutting 1 engine down to conserve fuel, and the pilot agreed. At 1834, the captain began to draw fuel out of the auxiliary fuel tanks located in the wings,Footnote4 and the first officer briefed the passengers about the diversion. Shortly after, the captain commenced an intentional shutdown of the left engine and feathered the left propeller, which was completed at 1838. Power was then reduced on the right engine to conserve fuel and a slow descent was commenced. Fuel continued to be drawn from the right-wing auxiliary fuel tank. It was calculated during the investigation that an estimated 69 pounds of fuel remained in the forward fuel tank at this time and it is likely that the low-fuel-level caution light for the forward tank had illuminated.

At 1843, the captain noticed that the PUMP FAIL R TANK light had illuminated, indicating that the right-wing auxiliary fuel tank was nearly empty. The switch was then placed in the REFUEL position.

At 1847, flight TIN223 was about 11 nautical miles (NM) from CYJP, descending through 3300 feet ASL when the right engine began to surge. The flight crew shut down the engine and feathered the propeller, and the captain began slowing the aircraft to the optimal glide speed for maximum range of 86 knotsFootnote5 indicated airspeed. The first officer briefed the passengers for a forced approach to an off-airport landing. The captain looked for a suitable place to land. In the darkness, he was able to discern an area of muskeg and chose that area rather than a treed area.

Just before touchdown, the captain requested flaps to 10° and then full flap; the first officer selected those flap positions. The stall horn activated when the aircraft was just above the muskeg and seconds before touchdown. The aircraft touched down on the muskeg at 1851, 6.7 NM northwest of CYJP, and came to a stop in an upright position (Figure 2).

The Canadian Mission Control Centre, in Trenton, Ontario, received an emergency locator transmitter signal for the aircraft on frequency 406 MHz shortly after. Approximately 4 hours after the forced landing, all occupants were recovered by rescue personnel.

Photo of the occurrence aircraft after the forced landing in the muskeg, looking east (Source: Air Tindi Ltd.)
Figure 2. Photo of the occurrence aircraft after the forced landing in the muskeg, looking east (Source: Air Tindi Ltd.)

1.2 Injuries to persons

Two flight crew members and 3 passengers were on board the aircraft during the occurrence flight. All the occupants showed signs of and were treated for mild hypothermia. One passenger received a minor injury when walking out from the accident site.

Degree of injuryCrewPassengersPersons not on board the aircraftTotal by injury
Fatal000
Serious000
Minor235
Total injured235

1.3 Damage to aircraft

The aircraft remained upright during the landing and damage was limited to the nose bulkhead area at station 60. The nose landing gear was displaced rearward and there was associated wrinkling of nose skins and nose structure.

1.4 Other damage

There was no other damage.

More from the report…

TSB Investigation Report: Fatal collision with terrain near Sioux Lookout, Ontario

Winnipeg, Manitoba, 14 November 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22C0027) into the 29 April 2022 fatal collision with terrain involving a privately-registered Piper PA-28-140 aircraft near Sioux Lookout, ON.

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.


Air transportation safety investigation report A22C0027

Loss of control and collision with terrain
Privately registered
Piper Cherokee PA-28-140, C-GLKD
Sioux Lookout Airport, Ontario, 19 NM SSE
29 April 2022

The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

History of the flight

At 2102Footnote1 on 29 April 2022, the privately registered Piper Cherokee PA-28-140 (registration C-GLKD, serial number 28-23807) departed Dryden Regional Airport (CYHD), Ontario, bound for Marathon Aerodrome (CYSP), Ontario, with 1 pilot and 3 passengers on board. The aircraft was reported overdue at 0139 on 30 April 2022. The aircraft had last been observed on radar at 2145,Footnote2 flying a zig-zag route over an area with limited cultural lighting (Figure 1). A search was initiated and the wreckage was found approximately 19 nautical miles south-southeast of Sioux Lookout Airport (CYXL), Ontario. The aircraft had impacted terrain in a wooded area during the hours of darkness. The pilot and 3 passengers were fatally injured. The aircraft was destroyed. The emergency locator transmitter (ELT)Footnote3 activated on impact and the signal assisted search and rescue services in locating the accident site.

Map showing the flight path and accident location (Source: Google Earth, with TSB annotations)
Figure 1. Map showing the flight path and accident location (Source: Google Earth, with TSB annotations)

Pilot information

The pilot held a commercial pilot licence, which had been issued on 18 September 2019. His licence was endorsed for single- and multi-engine aircraft. He held a valid Category 1 medical certificate. He did not have an instrument rating; therefore, he was not qualified for flight in instrument meteorological conditions (IMC).

In accordance with the Canadian Aviation Regulations (CARs), the holder of a pilot licence is required to have completed 5 night takeoffs and 5 night landings within the 6 months preceding the flight to fly an aircraft with passengers on board at night.Footnote4 The investigation reviewed the pilot’s logbook and did not identify any night flight entries in the 6 months preceding the accident.

The passenger who was seated in the front right seat also held a commercial pilot licence.

Aircraft Information

The occurrence Piper PA-28-140 was manufactured by the Piper Aircraft Corporation in 1967. It was a single-engine, all-metal, low-wing aircraft, equipped with fixed tricycle landing gear. It was configured to carry 4 passengers and was certified for a maximum take-off weight of 2150 pounds. The aircraft weight at the time of the occurrence was calculated to be approximately 2320 pounds, which is 170 pounds over the aircraft’s maximum take-off weight.

The aircraft was privately registered and maintained on an annual inspection program as specified in CARs Standard 625.86, Appendix B, Part I. The aircraft had undergone a 50-hour inspection on 08 March 2022 and had a total airframe time of 4467 hours at the time of the occurrence.

The aircraft was originally equipped with a 150 hp Lycoming O-320-E2A carbureted engine. In March 2019, the engine and aircraft were modified to achieve an increased take-off power rating of 160 hp, under the authority of Supplemental Type Certificate numbers SE8987SW-D and SA2706SW-D, respectively.

A review of the aircraft technical records did not reveal any outstanding defects that may have contributed to the occurrence.

Impact and wreckage information

The aircraft struck trees in a heavily wooded area approximately 19 nautical miles south-southeast of Sioux Lookout, Ontario. The investigation determined that the aircraft entered the forest canopy in a 90° angle of bank, indicating that it had departed controlled flight. The aircraft came to rest approximately 100 feet from where it initially came into contact with trees. There was no post-impact fire.

The airframe broke apart in a manner consistent with a cartwheeling motion, and both fuel cells ruptured. Analysis of the aircraft components did not reveal any pre-existing anomalies and the engine was determined to have been operating normally. An inspection of the carburetor heat selector was inconclusive due to the nature of the impact damage. While the investigation did not reveal any signs of carburetor icing, the local weather conditions were consistent with those that could produce carburetor icing.Footnote5 Damage to the flight controls were consistent with overload failures, also a result of the impact.

More on the report…

March 2022 tail rotor strike and roll over in Kootenay Valley, British Colombia

March 2022 tail rotor strike and roll over in Kootenay Valley, British Colombia

Vancouver, British Colombia, 2 November 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22P0019) into the 16 March 2022 tail rotor strike and roll over involving an AS350 B3 helicopter in the Kootenay Valley, BC.

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.

Air transportation safety investigation report A22P0019

Collision with terrain
Kootenay Valley Helicopters Ltd.
Airbus Helicopters AS350 B3, C-GWTQ
Nelson, British Columbia, 35 NM N
16 March 2022

History of the flight

On 16 March 2022, the Kootenay Valley Helicopters Ltd. Airbus Helicopters AS350 B3 helicopter (registration C-GWTQ, serial number 7482), contracted by the British Columbia Ministry of Transportation and Infrastructure (MOTI), was conducting avalanche control operations north of Nelson Aerodrome (CZNL), British Columbia (BC), with the pilot and 2 avalanche technicians on board.

The occurrence flight was the second avalanche control flight of the day. The flight was in the London Ridge avalanche area, approximately 35 nautical miles (NM) north of CZNL, and consisted of dropping strategically placed explosive charges (12.5 kg bags of ammonium nitrate and fuel oil [ANFO] compound) and igniters onto the slope from a height of approximately 20 feet.

The occurrence aircraft took off from the staging area near New Denver, BC, at 1315Footnote1 under visual flight rules (VFR). The crew were the same as on the first flight, but the avalanche technicians exchanged roles and positions: the one who had fulfilled the duties of bombardier (or blaster of record) on the previous flight was the blasting assistant, and the former blasting assistant took on the role of bombardier and planned to deploy 15 explosive charges.

En route to London Ridge, the sky was overcast with scattered clouds at and below the ridgeline with calm to light winds from the southwest. The helicopter was being operated at an altitude of about 7000 feet above sea level (ASL), approximately 100 feet below the ridgeline. The pilot and technicians coordinated the placement of the charges and documented whether they detonated and triggered controlled releases of snowpack. The bombardier was seated on the right side of the rear bench wearing a high-visibility fall-arrest/restraint harness. His role was to deploy charges out of the right-side pocket door.Footnote2 He coordinated the placement of the helicopter with the pilot to achieve the best effect from the explosive charge. The role of the blasting assistant, who occupied the left front seat, was to document the operation.

The bombardier requested an adjustment to the initial target for the second explosive charge to be deployed, and the pilot climbed the helicopter up the slope, nearer to the ridge and close to the base of the clouds. The trees in the new location were more sparse and covered with more snow. The pilot assessed the new location and estimated that, as previously anticipated, his exit strategy to turn left and then fly downhill would be appropriate.

As the helicopter progressed along the mountainside near the upper treeline, the pilot positioned and stabilized it in a hover to allow the explosive charge to be deployed. Just as the pilot lost reference with the ground and flight visibilityFootnote3 was reduced, the bombardier deployed the second explosive charge. At this time, the main rotor downwash and prolonged hover over a layer of loose snow created whiteout conditions.Footnote4

The pilot, with reduced visibility, turned the helicopter to the left. During this manoeuvre the tail rotor contacted either a tree or the surface of the slope; this caused the helicopter to shudder. The high-frequency vibration rapidly worsened and the pilot performed a forced landing. At approximately 1331, the helicopter landed hard on its skids and tipped onto its right (the pilot’s) side (Figure 1). The main rotor and blades were fractured and the tail boom was partially severed. The helicopter came to rest about 3 to 5 m downslope of the second explosive charge deployed; the charge detonated approximately 2.5 minutes later, but did not trigger a release of the snowpack.

The occurrence aircraft, rolled over on its right side (Source: British Columbia Ministry of Transportation and Infrastructure)
Figure 1. The occurrence aircraft, rolled over on its right side (Source: British Columbia Ministry of Transportation and Infrastructure)

Snow entered the cabin through the gap where the pocket door had been removed and through several windows that had broken or popped out. The 3 occupants were initially disoriented and shaken, but were not injured. The bombardier was face down in the snow, still secured in the aircraft by his harness, with bags of unprimed ANFO on and around him. The blasting assistant was still belted in the front passenger seat and was disoriented due to being on his side. The pilot secured the electrical and fuel systems, and he, along with the blasting assistant, egressed from the helicopter.

The bombardier required some assistance to release his harness because his own knife was not easily accessible. He also experienced difficulty releasing his lap belt because the latch mechanism had been taped over.Footnote5 With the assistance of the other crew members, he was released and egressed from the aircraft. The required survival equipmentFootnote6 was on board the helicopter; however, because the helicopter was lying on its right side, the cargo door could not be opened and the crew could not access this equipment.

The pilot was able to remove the emergency locator transmitter (ELT) from its housing, attach the remote antenna, and turn it on manually to ensure that it was activated. The signal was received by the Canadian Mission Control Centre and relayed to the Joint Rescue Coordination Centre (JRCC) in Victoria, BC.

The technicians had a portable radio on board, but it was not readily available after the impact. It had been left on top of the instrument panel glareshield and was displaced during the accident sequence. After approximately a 15-minute search through the snow, it was found. The operator was contacted and informed of the accident, and transportation off the mountain was coordinated.

The JRCC then contacted the operator. It was determined that search and rescue resources were not required because a local helicopter operator could rescue the crew. The local helicopter arrived at the accident site at approximately 1430.

Pilot information

The pilot had a valid commercial pilot licence – helicopter for VFR flight and had completed a pilot proficiency check valid until 01 June 2022. He had accumulated about 11 000 total flight hours, mostly on the occurrence helicopter type. He had many years of experience flying avalanche control missions, and had previously flown similar missions in the same area. The pilot was certified for the transportation of dangerous goods by air. The occurrence flight was the third avalanche control mission in which he worked with these technicians.

Avalanche control operations

The BC MOTI’s Avalanche and Weather Programs unit has a published manual, Explosive Use Operational Plan,Footnote7 that specifies that the Ministry artificially triggers avalanches to reduce the threat of naturally triggered avalanches along provincial highways. As the manual states,

[p]redicting where and when avalanches could occur requires a thorough understanding of the interaction between weather, terrain, and the mountain snowpack. […] The decision to conduct explosive control is based on a complex analysis of current and future weather and snowpack conditions, and the effect these conditions may have on the avalanche hazard.Footnote8

Annual training had been conducted and procedures had been reviewed before the occurrence (during pre-season training in the fall of 2021). Both technicians had over 20 years of experience in avalanche control and were certified for the transportation of dangerous goods by air. Both also had current blasting certification with a helicopter deployment endorsement.

The blasting procedure requires that the deployment of the bag(s) be performed from an ideal height above the ground or slope because the bags could disappear from view under the helicopter, requiring the helicopter to break off the operation to track them and document whether or not they detonate.

The MOTI avalanche control personnel are provided with helicopter familiarization training, which is primarily focused on safety in and around helicopters. Training includes instruction on shutting off fuel and electrical systems and on access and operation of ELTs.

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Propeller malfunction led to 2020 runway excursion in Naujaat, NU

Winnipeg, Manitoba, 1 November 2022 — In its investigation report (A20C0107) released today, the Transportation Safety Board of Canada (TSB) identified multiple contributing factors leading to a 2020 runway excursion in Naujaat, Nunavut.

On 26 November 2020, a Calm Air International LP Avions de Transport Régional ATR 42-300 aircraft was conducting a flight from Rankin Inlet, Nunavut, to Naujaat, Nunavut, with three crew members on board. While on descent to Naujaat Airport, the crew observed abnormally low propeller rpm indications on the left engine. Shortly after touchdown, directional control was lost and the aircraft experienced a runway side excursion on the east side of the runway. The aircraft came to rest approximately 108 feet from the runway edge and sustained substantial damage. The captain received serious injuries.

The investigation determined that a contaminant inside the left propeller’s high-pressure pump caused its pressure relief valve to fail. As a result, the propeller entered a pitch-lock condition, which locks the blade pitch and prevents reverse thrust from activating. The propeller remained in that condition until the aircraft landed. The investigation also determined that because there is no indication in the cockpit of a pitch-lock condition in flight, the flight crew were not aware that the propeller had entered a pitch-lock condition. Immediately on touchdown, reverse thrust was selected by the pilot flying, resulting in the aircraft entering an asymmetric thrust state. Due to the asymmetric thrust, directional control of the aircraft could not be maintained, and the aircraft exited the landing surface of the runway.

Following the occurrence, the operator issued a Flight Operations Bulletin, which describes the condition known as pitch lock, possible causes for this condition, how to identify it, and the actions to be taken if this condition is suspected.

For more information, see the investigation page.


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 A20C0107

Runway excursion
Calm Air International LP
Avions de Transport Régional ATR 42-300, C-FAFS
Naujaat Airport, Nunavut
26 November 2020

Summary

On 26 November 2020, the Calm Air International LP Avions de Transport Régional ATR 42-300 aircraft (registration C-FAFS, serial number 298) was conducting flight CAV464 under instrument flight rules from Rankin Inlet, Nunavut, to Naujaat, Nunavut, with 3 crew members on board. While on descent, the crew observed abnormally low propeller rpm indications on the left engine. At 1326 Central Standard Time, shortly after touchdown on Runway 34 at Naujaat Airport, directional control was lost and the aircraft experienced a runway side excursion on the east side of the runway. The aircraft came to rest approximately 108 feet from the runway edge. The captain received serious injuries. The aircraft sustained substantial damage.

1.0 Factual information

1.1 History of the flight

On 26 November 2020, the flight crew reported for duty at Rankin Inlet Airport (CYRT), Nunavut, at 0745.Footnote1 Before departing on the occurrence flight, they conducted a cargo flight to Baker Lake Airport (CYBK), Nunavut, in another Avions de Transport Régional (ATR) 42 aircraft and returned to CYRT.

When the flight crew boarded the ATR 42-300 aircraft (registration C-FAFS, serial number 298) to conduct the occurrence flight, Calm Air International LP (Calm Air) flight CAV464, they noted, as part of their initial interior aircraft checks, that the left and right propeller feather solenoid circuit breakers were out and not collared.Footnote2 They called the maintenance supervisor, who informed them that the breakers had been pulled as part of a routine maintenance taskFootnote3 that had been carried out the night before. At the request of the maintenance supervisor, the flight crew then reset the breakers as instructed.

At 1217, the occurrence aircraft departed CYRT destined for Naujaat Airport (CYUT), Nunavut. On board were 2 pilotsFootnote4 and a flight attendant, as well as 3539 pounds of cargo. For this instrument flight rules (IFR) flight, 1272 L of Jet A fuel had been uploaded for a total fuel load of 5150 pounds. The departure, climb-out, and cruise portions of the flight were uneventful.

At approximately 1321, while the aircraft was on descent into CYUT, the flight crew observed that the left propeller was operating at a lower rpm than normal,Footnote5 while engine parameters remained normal. They briefly discussed the situation and made various attempts to troubleshoot and identify the problem, but did not consult the Quick Reference Handbook (QRH). They were unable to identify a specific malfunction and did not take any further action.

The captain considered his options: returning to CYRT, shutting down the left engine, or both. However, there was a crosswind at CYRT and he did not want to land on a runway with compacted snow in a crosswind or initiate a long return flight to CYRT in arctic conditions, particularly with only 1 engine operating. The captain believed that the propeller indications were related to the maintenance task that had been performed prior to the flight and did not discuss the options with the first officer. The flight crew continued the approach and monitored the situation.

During the approach, the captain advanced the condition leversFootnote6 to see if he could achieve 100% propeller rpm. This was successful at first, but as engine torque was reduced on descent, the left propeller rpm started to decay. On short final, the left propeller rpm continued to decrease, and the aircraft was becoming noticeably more difficult to control.

During the landing on Runway 34 at CYUT, the aircraft initially touched down 750 feet past the threshold and the pilot flying immediately selected reverse thrust on both power levers; however, only the right propeller went into reverse. Almost simultaneously with the selection of reverse thrust, only the “LO PITCH” light for the No. 2 engine illuminated, which went unnoticed by the flight crew.

At 1326, shortly after touchdown, the aircraft swerved to the right. In an effort to prevent a loss of control, the captain attempted to use asymmetric thrust and nose wheel steering. Although directional control was maintained momentarily for approximately 40 feet, lateral control was lost and the aircraft exited the right side of the runway in a north-easterly direction.

Wreckage site (Source: Naujaat Airport)
Figure 1. Wreckage site (Source: Naujaat Airport)

The aircraft travelled about 500 feet through the snow adjacent to the runway before coming to rest. At some point during the runway excursion, the captain’s safety belt released, and his head struck the forward cockpit area. The aircraft came to a stop approximately 108 feet from the edge of the runway, at which time the flight crew shut down the engines with the fire handles because the condition levers were jammed.

The captain received serious injuries and the 2 other crew members received minor injuries. The aircraft was substantially damaged (Figure 1). The emergency locator transmitter did not activate.

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TSB Investigation report: Fatal collision with terrain near Hope, British Columbia

Richmond, British Columbia, 27 October 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21P0124) into the fatal collision with terrain involving a privately-registered Cessna R182 aircraft near Hope, 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.


History of the flight

At 1346 on 15 November 2021, the privately registered Cessna R182 aircraft (registration C-FBKJ, serial number R18200149) departed on a visual flight rules (VFR) flight plan from Nanaimo Airport (CYCD), British Columbia (BC), to Glacier Park International Airport (KGPI), Montana, United States. The filed flight plan showed a direct route from CYCD to KGPI, flown at an altitude of 10 500 feet above sea level (ASL). The pilot and 1 passenger were on board.

The aircraft flew southeast from CYCD, crossing into U.S. airspace above the San Juan Islands at approximately 4000 feet ASL. The aircraft continued to travel southeast, climbing to approximately 10 700 feet ASL before beginning a series of turns and descents, then ultimately backtracking toward the north at an approximate altitude of 3000 feet ASL. At 1435, when the aircraft was 16 nautical miles (NM) east of Skajit Regional Airport (KBVS), Washington, United States, it turned to the southeast again and began to climb, reaching an altitude of approximately 9900 feet ASL.

At 1444, the aircraft began a 90° turn to the southwest at an approximate altitude of 8400 feet ASL. Three minutes later, the aircraft made a sharp turn to the north and began a slow climb to approximately 10 000 feet ASL. At 1451, the aircraft changed its heading to the northeast; it was at an approximate altitude of 10 100 feet ASL at the time.

At 1458, when the aircraft was 4 NM southeast of Bacon Peak, Washington, it began a tight turn to the west. At this time, the aircraft was at approximately 11 500 feet ASL. The aircraft began a slow descent to approximately 10 100 feet ASL before turning north at 1504 and climbing again.

As the aircraft passed 4 NM east of the summit of Mount Baker, Washington, it was at an approximate altitude of 12 000 feet ASL with a ground speed of 120 knots. The aircraft then turned to the northeast and continued to climb to approximately 13 700 feet ASL before turning north and then northwest at 1523. The aircraft then turned west and began a slow descent.

At 1526, the aircraft began a sequence of climbs, descents and heading changes that lasted several minutes. The aircraft climbed as high as 12 300 feet ASL, travelling southwest, before descending to approximately 9300 feet ASL and recovering on a northeast heading.

Occurrence aircraft’s flight path, with the intended flight path in inset (Source: Google Earth, with TSB annotations)
Figure 1. Occurrence aircraft’s flight path, with the intended flight path in inset (Source: Google Earth, with TSB annotations)

The aircraft began to climb as it travelled northeast, reaching approximately 12 100 feet ASL. During this time, the aircraft’s ground speed gradually decreased from approximately 150 knots to 40 knots. The aircraft had been travelling above 10 000 feet ASL for 47 minutes when it a entered descending spiral pattern from which it did not recover. The last recorded radar target was at 1541, at which time the aircraft was at an altitude of approximately 8700 feet ASL heading toward Needle Peak, BC (Figure 1).

The Canadian Mission Control Centre in Trenton, Ontario, received an emergency locator transmitter signal from the aircraft. The Joint Rescue Coordination Centre in Victoria, BC, initiated an aerial search; however, low clouds, poor visibility, and aircraft icing in the area hampered the search effort. A ground search was not possible due to road closures caused by flooding in the area.

At approximately 0140 on 16 November 2021, the crash site was discovered 18 NM northeast of Hope Aerodrome (CYHE), BC, near Needle Peak at an elevation of approximately 4400 feet ASL. Both of the aircraft’s occupants were fatally injured. The aircraft was destroyed on impact; there was no post-impact fire.

Previous flight

The investigation examined a previous flight conducted by the occurrence pilot in the same aircraft and with the same passenger on board. On 13 November 2021, the aircraft departed on a VFR flight plan from Lloydminster Airport (CYLL), Alberta, to CYCD. The flight included a planned fuel stop at Salmon Arm Airport (CZAM), BC.

While travelling between CYLL and CZAM, the aircraft was flown above 10 000 feet ASL continuously for approximately 1 hour and 34 minutes, reaching a maximum altitude of approximately 20 100 feet ASL.

Hypoxia

Flying unpressurized aircraft at high altitudes without the use of oxygen can lead to hypoxia.

Section 605.31 of the Canadian Aviation Regulations (CARs) stipulates that, for unpressurized aircraft such as the occurrence aircraft, a supply of oxygen must be available for the flight crew and at least 1 passenger for flights exceeding 30 minutes at cabin-pressure altitudes above 10 000 feet ASL but not exceeding 13 000 feet ASL. When the aircraft is operating at cabin-pressure altitudes above 13 000 feet ASL, a supply of oxygen must be available for all persons on board the aircraft.

In addition, section 605.32 of the CARs states the following regarding the use of oxygen:

(1)  Where an aircraft is operated at cabin-pressure-altitudes above 10,000 feet ASL but not exceeding 13,000 feet ASL, each crew member shall wear an oxygen mask and use supplemental oxygen for any part of the flight at those altitudes that is more than 30 minutes in duration.

(2)  Where an aircraft is operated at cabin-pressure-altitudes above 13,000 feet ASL, each person on board the aircraft shall wear an oxygen mask and use supplemental oxygen for the duration of the flight at those altitudes.

Pilot information

The pilot held a private pilot licence and his Category 3 medical certificate was valid. His licence had been issued in September 2021. The pilot had accumulated approximately 116 hours total flying time, approximately 55 hours of which were completed as pilot-in-command. Of the total time, approximately 42 hours were completed in the occurrence aircraft.

In addition to his private pilot licence training, the pilot had completed a 3.7 hour recreational mountain flying course in September 2021. The pilot did not hold an instrument rating.

Aircraft information

The occurrence aircraft was a Cessna R182 manufactured by the Cessna Aircraft Corporation in 1978. It was equipped with a 235-hp Avco Lycoming O-540-J3C5D engine. The aircraft was not equipped for flight in instrument meteorological conditions or in known icing conditions, and there was no supplemental oxygen system on board. The aircraft was not equipped with a flight data recorder or a cockpit voice recorder, nor was it required to be by regulation.

The aircraft’s last annual inspection was completed on 01 September 2021. At the time of the occurrence, the aircraft had accumulated approximately 8575 hours of total air time. The last entry in the aircraft journey logbook recovered from the site was completed on 30 October 2021. At least 2 flights had been completed since that entry, but they had not been recorded.

Records indicate that there were no outstanding defects at the time of the occurrence. There was no indication that a component or system malfunction played a role in this occurrence.

Wreckage and impact information

The aircraft was found upside down on a forested 39° slope (Figure 2). Damage to the aircraft was consistent with the aircraft striking trees in a steep nose-down attitude. Both wings and the engine had come off the main fuselage. The aircraft collided with the ground approximately 40 feet from where it first struck the trees. This impact is consistent with a loss of control of the aircraft.

Accident site (Source: Joint Rescue Coordination Centre)
Figure 2. Accident site (Source: Joint Rescue Coordination Centre)

The investigation determined there were no signs of pre-impact mechanical failure or system malfunction. The damage to the engine and propeller indicates that power was being produced during the impact sequence. There was no indication of fire in the wreckage.

Weather information

The investigation was unable to determine what weather information the pilot checked before departure. A VFR flight plan was filed electronically; however, there was no record that the pilot had received a weather briefing from NAV CANADA.

The aerodrome forecast (TAF), issued at 0941, indicated that conditions at CYCD at 1300 would be:

  • Winds from 340° true (T) at 10 knots, gusting to 20 knots
  • Visibility more than 6 statute miles (SM)
  • Scattered cloud at 2500 feet above ground level (AGL) and broken ceiling at 4000 feet AGL

Temporarily until 1800 on the day of the occurrence, the TAF indicated:

  • Visibility of 4 SM in light rain showers and mist
  • Broken ceiling at 2000 feet AGL

The TAF for KGPI, issued at 1233, indicated the following conditions until 1600:

  • Winds from 200°T at 10 knots
  • Visibility more than 6 SM
  • Broken ceiling at 25 000 feet AGL

The graphic area forecasts (GFA) issued at 0951, valid from 1000 in the occurrence area, indicated:

  • A cold front aloft moving northeast through the area
  • Overcast cloud layers with bases between 2000 and 4000 feet ASL and tops at 20 000 feet ASL
  • Visibility expected to be from 2 SM to more than 6 SM in rain or light rain and mist
  • Extensive ceilings between 500 and 1500 feet AGL
  • Isolated altocumulus castellanus clouds with tops at 24 000 feet ASL with visibility of ¾ SM in rain showers and mist

The freezing level was forecast to be between 5000 and 7500 feet ASL with moderate mixed icing from the freezing level up to 20 000 feet ASL. Lee waves and/or mechanical turbulence was expected to be moderate with local areas of severe turbulence.

According to the upper winds forecast for the area that was valid at the time of the occurrence, for the altitudes between 9000 and 12 000 feet ASL, the winds were forecast to be from 270°T at 37 knots, increasing steadily to 38 knots, with temperatures decreasing from −13 °C to −20 °C.

The closest aviation weather reporting station to the occurrence site is located at CYHE, 18 NM to the southwest. The automated weather observation system at CYHE recorded the following information at 1416, 84 minutes before radar contact with the aircraft was lost:

  • Winds from 300°T (varying between 250°T and 340°T) at 17 knots, gusting to 30 knots
  • Visibility 3 SM in rain and mist
  • Temperature 7 °C, dew point 5 °C
  • Altimeter setting 29.39 inches of mercury (inHg)
  • 0.8 mm of rain in the last hour

NAV CANADA operates automated weather cameras at CYHE. Figure 3 shows the southeast view taken by the cameras on both a clear day and on the day of the occurrence.

Southeast view taken at Hope Aerodrome on a clear day (left) and at approximately 1500 on the day of the occurrence (right) (Source: NAV CANADA)
Figure 3. Southeast view taken at Hope Aerodrome on a clear day (left) and at approximately 1500 on the day of the occurrence (right) (Source: NAV CANADA)

The Princeton Aerodrome (CYDC), BC, is 25 NM to the east of the occurrence site. Weather at the aerodrome was recorded at 1600 as:

  • Winds from 260° T (varying between 220° T and 300° T) at 17 knots, gusting to 25 knots
  • Visibility 10 SM in light rain showers
  • Few clouds at 800 feet AGL, few clouds at 2600 feet AGL, scattered clouds at 3700 feet AGL, a broken ceiling at 4300 feet AGL including cumulonimbus clouds, and broken clouds at 8800 feet AGL
  • Temperature 6 °C, dew point 2 °C
  • Altimeter setting 29.39 inHg

Terrain along the route

On the day of the occurrence, the aircraft passed over the Puget Sound region of Washington State. This area is a relatively low-lying coastal area characterized by an array of bays, islands, and peninsulas.

Travelling east, the aircraft quickly encountered the Cascade Mountain Range, which extends from Northern California to Southern BC. This mountain range is rugged and has numerous high peaks; many of those in the north Cascade area are over 9000 feet. Mount Baker is the highest peak in the vicinity of the occurrence flight at 10 786 feet (3286 m).

On the day of the occurrence, many of the mountain peaks along the route were above the cloud layers and would have been obscured to the pilot.

TSB laboratory reports

The TSB completed the following laboratory report in support of this investigation:

  • LP171/2021 – Radar data analysis

Safety messages

In this occurrence, the aircraft was flying in an area of forecast icing and instrument meteorological conditions at altitudes requiring the use of supplemental oxygen; however, the pilot did not hold an instrument rating, the aircraft was not equipped for flight in known icing conditions, and no supplemental oxygen system was on board.

TSB investigations continue to demonstrate that VFR flights into instrument meteorological conditions often result in a fatal collision with terrain or loss of control due to lost visual references.

It is important that pilots assess all available weather information before departure, plan routes to avoid weather hazards, and anticipate using alternate routes should unexpected weather be encountered.

Furthermore, pilots must operate within the limitations of their aircraft, the privileges of their licence, and their own experience-based limits.

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 .