Fraser River plane crash: No sign of student, flight instructor 1 year later

From CTV News – link to source story and video – Thanks CW

Alyse Kotyk, Reporter, CTVNewsVancouver.ca | Monday, June 7, 2021

(TSB graphic)

Sunday marks one year since a small plane crashed into the Fraser River between Maple Ridge and Langley. It still hasn’t been found.

VANCOUVER — The one-year mark passed over the weekend of a small plane going down in the Fraser River and there has still been no sign of the aircraft or the two people who were on board.

An instructor and a student were onboard the 1972 Cessna 172M for a local training flight from Boundary Bay Airport on June 6, 2020.

The plane took off just before 1 p.m. that day and minutes later, the instructor on board contacted an air traffic control tower in Pitt Meadows for permission to enter the control zone.

According to the Transportation Safety Board’s report into the incident, someone working in the tower said the aircraft couldn’t be accommodated, and directed the instructor and student to Langley instead. 

The TSB’s investigation showed that 12 minutes after takeoff, the plane started to descend as it flew over the Fraser River. The TSB says radar contact was lost three minutes later and, a minute after that, the plane struck a power transmission line that was strung across the Fraser River.

“Of course hitting a power line at cruising speed in a Cessna probably killed both occupants instantly and tore the airplane apart so that it wasn’t complete when it dropped into the Fraser River,” Keith Mackey, an aviation expert, told CTV News Vancouver on the anniversary of the plane going down.

Witnesses reported at the time seeing the plane crash into the river. Police searched with helicopters, boats and divers trying to locate the locate the aircraft.

An investigation into the crash is still ongoing.

With files from CTV News Vancouver’s Kendra Mangione 

Continued approach below required aerodrome operating visibility led to runway excursion in Kugaaruk, Nunavut

Winnipeg, Manitoba, 25 May 2021 – In its investigation report (A20C0037) released today, the Transportation Safety Board of Canada (TSB) identified the recurring issue of approaches continued in low visibility environments as a contributing factor in the 2020 Buffalo Airways Ltd runway excursion. The investigation found that the flight crew believed the landing was permitted given the absence of an approach ban, and landed even though the reported ground visibility was below the minimum aerodrome operating visibility.

On 28 April 2020, a Buffalo Airways Ltd. Beechcraft King Air A100 aircraft was conducting a charter flight under instrument flight rules, from the Cambridge Bay Airport, Nunavut to Kugaaruk, Nunavut, with two flight crew members and freight on board. Immediately after touchdown at the Kugaaruk Airport, the aircraft veered to the right and departed from the runway surface. The aircraft came to rest after colliding with a snowbank on the northwest side of the runway. The crew was uninjured and egressed the aircraft via the main cabin door. There was no fire, but the aircraft sustained substantial damage.

The investigation determined that during the later stages of the approach, a crosswind from the left, and the visual effects of blowing snow contributed to the aircraft being aligned with the right side of the runway. The aircraft touched down near the right edge of the runway and, when the right landing gear impacted the deeper snow along the runway edge, the aircraft veered to the right and departed the runway surface.

Approaches to airports north of 60°N latitude are not restricted by ground visibility and, as a result, the flight crew continued the approach when the reported visibility was ¼ statute mile, which is lower than the published advisory visibility of 1¾ statute miles for this approach. The flight crew believed that the lack of an approach ban permitted a landing, and landed at Kugaaruk Airport even though the reported ground visibility was below the minimum aerodrome operating visibility of ½ statute mile.

The rules that govern instrument approaches in Canada are too complex, confusing and ineffective at preventing pilots from conducting approaches that are not allowed, or banned, because they are below the minimum weather limits. In 2020, the TSB issued recommendations A20-01 and A20-02 calling on Transport Canada (TC) to review and simplify operating minima for approaches and landings at Canadian aerodromes and to introduce a mechanism to stop approaches and landings that are actually banned.

In a response to both recommendations, TC stated that it would be forming and leading an industry working group to draft a Notice of Proposed Amendment to update approach ban regulations, as well as the supporting documentation and guidance. Until these recommendations are fully addressed, there remains a risk that flight crews will initiate, or continue, approaches in weather conditions that do not permit a safe landing.

Following the accident, Buffalo Airways Ltd. conducted a survey among its pilots. The survey collected data regarding knowledge, understanding, and application of aerodrome visibility restrictions. It revealed that not all pilots realized that, in the absence of a published reduced visibility operations procedure in the Canada Flight Supplement, the minimum visibility for operating at an aerodrome is ½ SM. A review of the applicable regulations was carried out with company pilots and was also added to the company’s initial and recurrent flight training.

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.

January 2020 runway overrun in Halifax, Nova Scotia highlights longstanding TSB Watchlist issue

Dartmouth, Nova Scotia, 20 May 2021 – In its investigation report (A20A0001) released today, the Transportation Safety Board of Canada (TSB) found that changing runways without recalculating the landing distance required based on the changes in wind and runway surface conditions, led to a runway overrun in Halifax, Nova Scotia, in 2020.

On 5 January 2020, a WestJet Boeing 737-8CT aircraft was conducting flight WJA248 from Toronto/Lester B. Pearson International Airport, Ontario, to Halifax/Stanfield International Airport, Nova Scotia, with 172 passengers and six crew members on board. The flight crew had originally planned to conduct an approach for Runway 05. However, due to a lowering ceiling and reduced visibility, the crew requested to change to the Runway 14 instrument landing system approach, which allows for landing with lower minimum ceiling and visibility requirements than the approach to Runway 05. The aircraft then touched down with a tailwind component on the wet, snow-covered runway. The aircraft could not be stopped and it overran the end of Runway 14, coming to rest in snow with the nose wheel approximately 91m beyond the runway end. There were no injuries and no damage to the aircraft.

The investigation found that, while preparing for the runway change, the flight crew mentally assessed that the head wind for Runway 05 would become a crosswind for Runway 14. As a result, they did not recalculate the effects of the wind for the approach to Runway 14, but rather considered that the landing distance and the target approach speed calculated for Runway 05 were still appropriate. However, the reported wind speed and direction changed as the flight progressed, resulting in a tailwind component that exceeded the operator’s limitation, a lower required approach speed, and a landing distance that exceeded the runway length available. None of this was recognized by the flight crew and, as a result, they continued the approach to Runway 14. The unchanged target approach speed combined with the tailwind component resulted in the aircraft touching down at a faster groundspeed, thus requiring a longer stopping distance. The wet snow contamination on the runway reduced braking effectiveness, which also contributed to an increase in landing distance.

Runway overruns have been on the TSB Watchlist since 2010. 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. In this occurrence, the aircraft stopped within the 150m runway end safety area, which meets current international standards.

Following the occurrence, WestJet highlighted to its pilot group the importance of using the actual runway intended for landing when making pre-landing performance calculations. The company also revised its emergency response checklist to include the requirement to pull the cockpit voice recorder and flight data recorder circuit breakers after an incident, and is now monitoring for landings that exceed the maximum tailwind component in its flight data monitoring program.

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.

TSB releases investigation report about a 2020 landing accident in Calgary, Alberta

Edmonton, Alberta, 12 May 2021 — In its investigation report (A20W0016) released today, the Transportation Safety Board of Canada (TSB) found that a flap malfunction combined with the flight crew’s handling of the “flaps fail landing procedure” led to a loss of aircraft pitch control and subsequent contact of the rear fuselage with the runway while landing in Calgary, Alberta.

Rear fuselage damage (Source: Canadian Pacific Railway Company)

On 23 February 2020, a Bombardier Challenger 605 operated by the Canadian Pacific Railway Company (CP) departed Palm Beach International Airport, Florida, United States, for Calgary International Airport, Alberta, with three crew members and 10 passengers on board. During the descent, the flight crew attempted to deploy the flaps and immediately received a “FLAPS FAIL” caution message. The flight crew proceeded to complete the flap failure procedure from the Quick Reference Handbook (QRH).

The investigation found that after the nose wheel touched the ground during the landing, maximum reverse thrust was selected; however, insufficient pressure was applied to the control column to maintain the nose landing gear on the runway. As a result, the nose pitched up, and the rear fuselage contacted the runway. The aircraft’s stall protection system then commanded a rapid nose-down control input, leading to damage to the forward section of the aircraft when the nose wheel contacted the runway. Once the landing was completed, the aircraft continued to the intended parking area. There were no injuries to any of the aircraft occupants, although there was significant damage to the aircraft.

Occurrence aircraft’s failed flap flexible drive shaft (Source: Canadian Pacific Railway Company)

The flap failure occurred when one of the flap flexible drive shafts failed. Moisture entered the flap flexible drive shaft casing, likely through the undetected puncture holes and the drive shaft casing to flap actuator interface, which led to the subsequent corrosion and failure of the inner drive shaft. As the aircraft’s actual annual utilization was approximately half of that expected by the manufacturer, the calendar time interval between maintenance inspections increased. As a result, the corrosion that developed was not detected because the shaft had not yet reached the 2400 flight-hour maintenance interval.

The pilot monitoring did not read the cautions included on the flaps fail checklist out loud to the pilot flying during the completion of the QRH procedure. As a result, information critical to the safe operation of the aircraft was not brought to the pilot flying’s attention.

It was also found that the Challenger 605 flight simulator used for recurrent training did not accurately represent the zero-flap handling characteristics of the aircraft when the thrust reversers are deployed, nor was it required for certification. As a result, the flight crew was inadequately prepared to prevent, or recover from, the nose pitch-up that occurred when the thrust reversers were deployed.

Following the occurrence, CP amended its procedures to address the differences between the caution and warning notes published in the Aircraft Flight Manual and QRH. Bombardier issued a temporary revision to the QRH flap fail procedure. The TSB issued an Air Safety Information Letter (A20W0016-D1-L1) to highlight the Challenger 605 series flap system inspection interval, and a CL60 series cross-fleet product improvement observation.

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.

Unstable approach led to 2020 hard landing and rear fuselage strike in Schefferville, Quebec

Dorval, Quebec, 3 March 2021 — In its investigation report (A20Q0013) released today, the Transportation Safety Board of Canada (TSB) found that the January 2020 hard landing and rear fuselage strike in Schefferville, Quebec, was the result of an unstable approach.

From Air Inuit

On 20 January 2020, a de Havilland DHC-8-314 operated by Air Inuit Ltd. was conducting a flight from Québec/Jean Lesage Airport, Quebec, to Schefferville Airport, Quebec, with three crew members and 42 passengers on board. During the landing, the rear fuselage struck the runway as the wheels touched down. After landing, the aircraft taxied to the terminal to disembark the passengers. There were no injuries; however, the aircraft sustained substantial damage.

The investigation found that the flight crew forgot to perform the descent checklist and realized this at an inopportune time, while the captain (pilot monitoring) was providing a position report. Given ambiguities and contradictions in the company’s stabilized approach guidelines, the captain interpreted that he was allowed to continue the approach below 500 feet above aerodrome elevation, even though the aircraft had not been fully configured for the landing. When the aircraft passed this altitude, the pilots, who were dealing with a heavy workload, didn’t notice and continued the approach, which was unstable. At the time of the landing, the aircraft no longer had enough energy to arrest the descent rate solely by increasing pitch attitude. The pilot’s instinctive reaction to increase the pitch attitude during the flare, combined with the hard landing, resulted in the rear fuselage striking the runway, causing substantial damage to the aircraft’s structure.

The investigation also made findings as to risk related to Air Inuit’s standard operating procedures (SOPs) and training, and to Transport Canada’s (TC) oversight. Transport Canada assessed Air Inuit’s SOPs, but did not identify any specific issues with the operator’s stabilized approach guidelines. If TC does not assess the quality, consistency, accuracy conciseness, clarity, relevance, and content of SOPs, the procedures may be ineffective, increasing risks to flight operations.

Additionally, the captain had not received many of the required training elements during his recurrent training. If required training elements are not included in recurrent training, and if TC’s surveillance plan does not verify the content of crew training, there may be procedural deficiencies or deviations, increasing risks to flight operations.  

Following the occurrence, Air Inuit took a number of safety actions, including the revision of its SOPs to improve guidelines on several subjects, including stabilized approaches, and the revision of its training program to ensure that all training elements are covered within the two-year recurrent training cycle.

See the investigation page for more information.

Inaccurate Airborne Status Transmitted by Transponders and its Effect on Runway Monitoring and Conflict Alert Systems – Civil Aviation Safety Alert

Transport Canada

Purpose:

The purpose of this Civil Aviation Safety Alert (CASA) is to raise awareness to aircraft owners, operators and Air Navigation Services Providers (ANSP) on an issue related to operation of aircraft equipped with the Honeywell Primus Epic integrated avionics system transponders.

Background:

The Transportation Safety Board (TSB) recently advised Transport Canada of an occurrence at Toronto/Lester B. Pearson International Airport (CYYZ) where immediately following a rejected takeoff, an Embraer 190 (E190) equipped with a Honeywell Primus Epic integrated avionics system transponder incorrectly transmitted that the aircraft was in airborne status but remained on the runway.

A second aircraft, a Boeing 777-300 (B777) readying for take-off had been issued a take-off clearance while the E190 remained on the runway. Although the E190 flight crew made a radio call to the tower that they were aborting the takeoff, at the same time the B777 read back its take-off clearance on the same control tower frequency and commenced its take-off roll. The simultaneous radio transmissions went undetected and neither air traffic control nor the B777 flight crew heard the abort radio call of the E190.

Immediately after beginning its take-off roll the B777 flight crew observed that the E190 was still on the runway and initiated a rejected takeoff. The B777 came to within 3800 feet from the E190.

In the initial assessment in its investigation (TSB investigation A20O0029) the TSB has found that the Honeywell Primus Epic integrated avionics system in the E190 uses software logic that determines the aircraft to be airborne when the aircraft’s indicated airspeed exceeds 50 knots. The result being that the aircraft transponder may transmit that the aircraft is airborne when the aircraft may still be on the ground.

Additionally, the runway incursion monitoring and conflict alert system (RIMCAS) used by the air navigation service provider (ANSP) at CYYZ was configured to use data from the aircraft’s transponder transmission as the primary indication that an aircraft had become airborne. Therefore when the E190 exceeded 50 knots on its departure roll, the RIMCAS identified the aircraft as airborne even though it was not. As a result of this system logic, the RIMCAS did not detect a conflict when the B777 began its take-off roll, and did not issue an alert until well after both aircraft had initiated their respective rejected-takeoff procedures and decelerated.

In December 2020, NAV CANADA published an Urgent ATC Information Bulletin for all Toronto Tower personnel. The bulletin cautioned controllers that RIMCAS Stage 1 and Stage 2 alerts may not be generated when Embraer E-jets and some aircraft manufactured by Dassault, Gulfstream, Learjet, and Textron Aviation (formerly Cessna) are departing. The bulletin also advised that Stage 1 and Stage 2 alerts may not be produced for aircraft or vehicles approaching the active runway when one of these aircraft types is departing, and controllers were reminded to monitor these situations closely. NAV CANADA is investigating options for RIMCAS software mitigations.

Transport Canada is in the process of communicating with the original equipment manufacturer (OEM) to address the current software logic to identify aircraft airborne status. Additionally, Transport Canada is in the process of communicating with applicable ANSP who have similar RIMCAS that could yield a comparable outcome with aircraft with similarly configured transponders.

Recommended action

  1. Air operators currently operating aircraft equipped with Honeywell Primus Epic integrated avionics system should provide the information found in this CASA to staff and/or flight crew as a means of awareness.

Helicopter pilot killed in Nunavut crash was adventurous, lovable, remembers partner

From CBC News – link to source story

‘He was the most wonderful human I’ve met in my whole life’

Liny Lamberink · CBC News · May 01, 2021

Steven Page, 36, was one of three men who died after a helicopter belonging to Great Slave Helicopters went down outside of Resolute Bay, Nunavut. (Submitted by Sandra Soares)

A 36-year-old helicopter pilot, killed in last week’s crash in Nunavut, is being remembered as the kind of guy everyone would fall in love with. 

Steven Page was one of three men who died last Sunday, when the AS350-B3 aircraft they were travelling in crashed 22 kilometres southwest of Resolute Bay.

His partner, Sandra Soares, told CBC News she got the first phone call from Yellowknife-based Great Slave Helicopters that evening — alerting her that something had gone wrong.

“His boss, John, called me around 7:30 on Sunday and said Steve missed his check-in and they weren’t sure what was going on,” she said. “[I was] stirring and pacing and feeling pretty sick, but in the back of mind thinking, ‘Well, Steve’s always OK.'” 

Less than five hours later, she would find out that he wasn’t.

Sandra Soares, right, snapped this photo with Page on their first date together, when they bushwhacked up Grey Mountain outside of Whitehorse in search of a cave. (Submitted by Sandra Soares)

“I got the call around midnight that they found the crash site and there were no survivors.” 

Not only did Soares have to contend with her own grief, she also had to share the news with Page’s parents in Australia and her two sons, ages 7 and 9, who had “adored” him. 

“We’re all just devastated. He was the most wonderful human I’ve met in my whole life.”

The two other men aboard the Great Slave Helicopters aircraft have been identified as Benton Davie, a helicopter engineer from Yellowknife, and Marcus Dyck, a leading Canadian polar bear scientist.

The purpose of the trip had been to survey the Lancaster Sound polar bear population.

The first date and the last message

Soares said she and Page met in Whitehorse last summer, while he was working on contracts with Great Slave Helicopters. 

“We just hit it off right away and become best friends.” 

Soares said Page had lived in Yellowknife, but he started living with her in Whitehorse, with her boys, in between contracts. He moved to Canada about five years ago, she said.

“He had this passion for life and lust for adventure, and I know that he would be whispering in my ear right now telling me to get up and keep going. Go for a hike. Do yoga. Live your life,” she said. “So we’re all going to try and do that, to honour his memory.” 

Their first date, said Soares, had been up Grey Mountain near Whitehorse. 

Page had lived in Canada for five years, and grew up in Queensland, Australia. (Submitted by Sandra Soares)

“I wanted to show him where the cave was, but I wasn’t entirely sure where the cave was, which he kind of thought was hilarious being a pilot. He’s very good at navigation.” 

Soares said she went by the name “Lou,” with Steve, and it was in true “Lou and Steve fashion” that they ended up bushwhacking their way up and finding a second cave.

Sandra Soares said Page had been living with her and her two sons in Whitehorse between contracts with Great Slave Helicopters. (Submitted by Sandra Soares)

“So we wrote in that little notebook that, ‘There’s another cave! From Steve and Lou.’ So if anyone’s up there, that was us, breaking the news.” 

The pair messaged daily, using a satellite communication device when he didn’t have cell service, she said. The afternoon of the crash, he told her he was longing for better food at the camp where he’d been staying.

“He was looking forward to a hot breakfast,” she said. “Looking forward to a hot breakfast and that he was heading out to Resolute. That was the last time I heard from him.” 

Open-minded, non-judgmental

Soares said she’s thankful for the sense of courage she received from her partner, and for the way he would encourage adventure in her life and her sons’ lives. 

“Anyone he meets will fall in love with him. He has this smile that just lights up a room,” she said. “He was open to anything I wanted to talk about; I never felt judged. And I think that’s something he offered a lot of people — just an open space to be themselves.”

The Transportation Safety Board of Canada is investigating the April 25 crash. It said Thursday it would be deploying a team of investigators to gather information and assess what happened. 

The independent agency looks into incidents involving air, marine, pipeline and rail transportation with a goal of improving safety. It does not assign fault or determine civil or criminal liability.

With files from Jane Sponagle

Offshore helicopter crew recovers from inadvertent descent to 13 feet above water near Sable Island, Nova Scotia

Dartmouth, Nova Scotia, 27 April 2021 – In its investigation report (A19A0055) released today, the Transportation Safety Board of Canada (TSB) found that, while conducting a visual approach to an offshore helideck platform in instrument meteorological conditions (IMC), a Sikorsky S-92A helicopter inadvertently entered a low-energy state descent. The pilots were able to stop the descent and regain control within approximately 13 feet of the water.

On 24 July 2019, at 11:54 Atlantic Daylight Time, a Canadian Helicopters Offshore (CHO) Sikorsky S-92A helicopter departed Halifax/Stanfield International Airport, Nova Scotia, on an instrument flight rules flight. The helicopter was headed to the Thebaud Central Facility, an offshore platform southwest of Sable Island, Nova Scotia, with two pilots and 11 passengers on board. Two instrument approaches were attempted at the platform; however, landing was not possible due to low clouds and poor visibility.

Following the second approach, the flight crew acquired visual contact with the platform, visible above a fog layer, and elected to carry out a visual approach. Shortly after they commenced the visual approach, a high-rate-of-descent and low-airspeed condition developed in low-visibility conditions. During the descent, the helicopter’s engines were over-torqued, reaching a maximum value of 146%. The flight crew regained control of the aircraft at approximately 13 feet above the water. During the subsequent hand-flown climb, a second inadvertent descent occurred but the situation was rectified in a timely manner. The aircraft then returned to Halifax/Stanfield International Airport without further incident. The extent of the helicopter’s damage is unknown, as it has been removed from service. There were no injuries.

The investigation determined that instrument meteorological conditions existed at the time of the occurrence, which created a degraded visual environment that was highly conducive to spatial disorientation and provided inadequate cues to permit a visual approach to the Thebaud Central Facility. In an attempt to complete their assigned task within self-imposed time constraints, the pilots’ decision-making process was influenced by their past experience and ease with each other. As a result, they attempted a non-standard visual approach in a degraded visual environment, without thoroughly considering the risks or alternative options.

The investigation also found that CHO’s standard operating procedures provided flight crews with insufficient guidance to ensure that approaches were being conducted in accordance with industry-recommended stabilized approach guidelines.

The pilot flying’s workload increased during the approach when he depressed and held the cyclic trim release button, which contributed to the control difficulties that were encountered. If manufacturers’ flight manuals and operators’ standard operating procedures do not include guidelines for the use of the cyclic trim release button, it could lead to aircraft control problems in a degraded visual environment due to the sub-optimal use of the automatic flight control system.

The investigation also found that the S-92A’s enhanced ground proximity warning system (EGPWS) provides no warning of an inadvertent descent at airspeeds below 50 knots when the landing gear is down. As a result, the EGPWS did not alert the flight crew of the impending risk of controlled flight into terrain. Since there is currently no requirement for commercial helicopters to be equipped with an EGPWS, nothing prevents a manufacturer and/or operator from inhibiting modes of an installed EGPWS, which in turn degrades the system’s capabilities.

In 2016, the TSB issued Recommendation A16-10 calling for terrain awareness and warning systems for commercial helicopters that operate at night or in IMC. Until EGPWS / helicopter terrain awareness and warning systems become mandatory for Canadian commercial helicopters that operate at night or in IMC, flight crew and passengers aboard these flights are at increased risk of controlled flight into terrain.

Following the incident, CHO took several safety actions and subsequently requested the suspension of its air operator certificate since it no longer had any aircraft in its possession, nor did it have any ongoing contracts.

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.

Interrupted checklist procedures contributed to 2020 runway excursion in Dryden, Ontario

Winnipeg, Manitoba, 14 April 2021 — In its investigation report (A20C0016) released today, the Transportation Safety Board of Canada (TSB) found that an interruption while conducting checklist procedures and an incomplete checklist led to the February 2020 runway excursion involving an aircraft operated by Perimeter Aviation Ltd. at the Dryden Regional Airport, Ontario. One passenger sustained serious injuries.

Occurrence aircraft after coming to a stop (Source: Ontario Provincial Police)

Occurrence aircraft after coming to a stop (Source: Ontario Provincial Police)

On 24 February 2020, the Fairchild SA227-DC Metro 23 aircraft operated by Perimeter Aviation as Bearskin Airlines flight 344 was conducting a flight from Dryden Regional Airport, Ontario, to Sioux Lookout Airport, Ontario, with two crew members and six passengers on board. At 1610 local time, as the aircraft commenced its take-off roll, directional control was lost which caused the aircraft to exit the right side of the runway and come to rest approximately 18 m off the side in about 46 cm of snow. The aircraft was substantially damaged. The flight crew and passengers egressed through the main cabin door.

The investigation found that while the crew was carrying out the “Before Taxi” checklist, the task of disengaging the propeller start locks was initiated; however, it was interrupted and not completed. After the captain told the first officer to stand by, the crew’s focus shifted to other tasks. It is likely that this slip of attention resulted in the engine power levers not being pulled over the flight idle gate to release the start locks. The “Before Taxi” checklist did not contain a task to ensure that the start locks had been released and, as a result, the crew began taxiing unaware that the right propeller start locks were still engaged. It was determined that, during the takeoff roll, the power was advanced through 20%, but the “positive torque” call required by standard operating procedures was not made, and the engine torque differential was not noticed by the crew. As a result, power lever advancement continued although the right engine thrust remained near zero. The engaged start locks prevented the right propeller from producing the required thrust, which resulted in a significant thrust differential. With less thrust being generated by the right engine, the aircraft experienced a loss of directional control and exited the runway. The injuries to the passenger resulted from propeller blade fragments penetrating the cabin wall during impact with a frozen snowbank.

Following the occurrence, Perimeter Aviation changed its procedures and checklists to better ensure that the propeller start locks are disengaged before taxiing and to raise awareness and understanding of the Metro aircraft’s propeller start lock system. The company also enhanced training for less experienced flight crew members.

See the investigation page for more information.

Fatal accident near Racine, Quebec, highlights risks of flying under visual flight rules in deteriorating weather at night

Dorval, Quebec, 23 March 2021 — The Transportation Safety Board of Canada (TSB) today released its investigation report (A19Q0153) into a fatal loss of control and collision with terrain of a Cessna 172M aircraft near Racine, Quebec, in 2019. The investigation report highlights the risks of flying at night under visual flight rules (VFR), and the lack of clarity in Transport Canada (TC) regulations regarding visual references at night.

On 4 September 2019, a Cargair Ltd. Cessna 172M aircraft departed Montréal International (Mirabel) Airport, Quebec, for a night VFR training flight to Sherbrooke Airport, Quebec, with only the pilot on board. At approximately 19 nautical miles (NM) northwest of Sherbrooke Airport, the aircraft encountered instrument meteorological conditions (IMC) and disappeared from radar. The wreckage was found three days later, on 7 September 2019, in a heavily wooded area near Racine, Quebec. The aircraft had struck trees and had been destroyed by impact forces. The pilot received fatal injuries on impact.

The investigation found that when the plan for the night flight was reviewed by the flight instructor, the ceiling and visibility forecast were assessed as acceptable for the VFR night flight, and the training flight was authorized. Approximately 32 NM northwest of Sherbrooke Airport, the pilot lost visual reference to the surface and descended to 3000 feet above sea level to continue the flight towards Sherbrooke. This descent to regain visual reference, and then to remain clear of cloud, was the first indication that the weather ahead may be deteriorating. After entering IMC, the pilot was likely affected by an unconscious cognitive bias and her proximity to Sherbrooke Airport, Quebec, which led her to continue the VFR flight into deteriorating weather conditions.

As the aircraft neared the Sherbrooke Airport, the pilot inadvertently encountered IMC for a second time, which resulted in a loss of visual reference to the surface. Given the established correlation between loss of visual references and a loss of control, it is highly likely that the pilot, who had limited experience flying by sole reference to instruments, lost control of the aircraft as a result of spatial disorientation.

The TSB has previously investigated a number of similar occurrences, including its recently released investigation report into a loss of control and collision with terrain of a privately registered Piper PA-32-260 (A19O0178). In 2016, the Board issued a recommendation (A16-08) for TC to clearly define the visual references required to reduce the risks associated with night VFR flights. As shown in this occurrence, if the Canadian Aviation Regulations do not clearly define what is meant by “visual reference to the surface,” night flights may be conducted with inadequate visual references, which increases the risks associated with night VFR flight, including controlled-flight-into-terrain and loss-of-control accidents.

Following the occurrence, Cargair Ltd. revised its list of airports authorized for dual and solo night flights, and put in place restrictions on solo night flights for both licenced and non-licenced pilots training at Cargair Ltd.

See the investigation page for more information.