Aviation Investigation A16A0032

Collision with terrain

The occurrence

On 29 March 2016, a private Mitsubishi MU-2B-60 aircraft (United States registration N246W), departed St. Hubert, Quebec, at 0931 local time (Eastern Daylight Time) on a flight to Îles-de-la-Madeleine, Quebec (CYGR). Onboard was the pilot-in-command, a pilot-passenger occupying the right-hand cockpit seat, and 5 passengers.

The autopilot was being used to control the aircraft throughout the flight.

At 1217 Atlantic Daylight Time (ADT), when the aircraft was at approximately 21 000 feet above sea level and 51 nautical miles (nm) from CYGR, the pilot initiated the descent. At 1225, Moncton Area Control Centre cleared the aircraft for an instrument flight rules approach (flying by reference to instruments rather than flying with visual reference to the ground) to CYGR. At 1229, 2.7 nm from Runway 07, the aircraft landing gear was lowered and approach flaps were selected.

Shortly after that, the autopilot was disconnected, and almost immediately the aircraft departed from controlled flight. It rolled quickly into a steep right bank and descended rapidly. The aircraft continued its rapid descent and impacted the ground in a near-level attitude. All 7 occupants were fatally injured.

Map of the area

Work to date

A site survey was completed and the wreckage was transported to the TSB Engineering Laboratory (Lab) in Ottawa. The field phase of the investigation is complete and the examination and analysis phase is in progress.

TSB investigators have been in contact with the families of the aircraft's occupants to explain the role of the TSB and our investigation process.

A large number of technical and operational documents, weather reports, air traffic control communications, and incident reports have been gathered and reviewed by investigation team members.

Numerous interviews have been conducted with witnesses and individuals from various organizations.

Initial examination and documentation of aircraft systems, components and structural damage has been completed.

What we know

Aircraft

• The aircraft was certified and equipped to conduct the approved approach into CYGR.
• The investigation found that both the altitude and the speed of the aircraft's approach to CYGR were higher than recommended.
• On the MU-2 instrument-approach profile, the standard speed prior to the initial approach fix is 150 knots, slowing to a final approach speed of 125 knots past the final approach fix.
• In this instance, the aircraft's speed prior to the initial approach fix was 240 knots, and past the final approach fix the speed decreased below 175 knots, only 2.7 nm from Runway 07—much later than prescribed (Figure 1). The aircraft landing gear was lowered and approach flaps were selected at this point.
• No mechanical deficiencies have been identified with the aircraft's engines, flight controls, landing gear, and navigation systems.
• Communications with the aircraft throughout the flight were normal.
• In October 2005, the FAA began a safety evaluation of the MU-2's accident history. As a result, in 2008, it issued a Special Federal Air Regulation (SFAR 108) that requires MU-2 pilots to complete a standardized training program and to use a standardized checklist. At 29 March 2016, this was the third fatal MU-2 accident since SFAR 108's implementation.
• There are 263 MU-2 aircraft in service; 11 are in Canada.

Lightweight recorder

• Although not required by regulation, the occurrence aircraft was equipped with a lightweight recording system.
• It was recovered in good condition from the wreckage.
• TSB specialists at the Lab have extracted and continue to analyze data from the recorder.
• The recorder will provide information critical to understanding the circumstances and events that led to the departure from controlled flight—information that would not have been available to the investigation if the aircraft had not been equipped with a recording system.

Aircraft approach path

Pilot

• Records indicate the pilot was certified and qualified for the flight in accordance with existing regulations, and had completed the SFAR 108 standardized training program.
• The pilot had about 2500 hours total flight time, and about 140 hours on the MU-2.

Pilot-passenger

• The pilot-passenger occupying the right-hand cockpit seat was a commercial pilot and flight instructor.
• The pilot-passenger was not qualified to fly the MU-2.
• A second crew member was not required to fly the MU-2.
• The pilot-passenger was invited to come on the flight to help with some basic piloting functions.

Weather

• A detailed weather analysis for CYGR on the day of the accident has been completed. Between 0900 and 1500 ADT, visibility varied between 1½ and 3 statute miles. During this same period, ceilings (cloud base heights) varied between 200 and 400 feet above ground level (agl) and northeast winds varied between 20 to 30 knots with gusts as high as 35 knots.
• Weather forecast for CYGR indicated a potential for moderate mixed icing in cloud, particularly below 10 000 feet in the vicinity of Îles-de-la-Madeleine. There was also the potential for moderate mechanical turbulence below 3000 feet.
• In accordance with instrument flying rules, the Charlottetown airport (CYYG) had been selected as the alternate airport.

Next steps

The next steps of the investigation include the following work:

• Analyzing the accident flight profile to understand the approach phase of the flight and the challenges encountered by the pilot.
• Evaluating aircraft performance and determining if weather affected the performance.
• Evaluating pilot training and experience, and human performance aspects.
• Reviewing MU-2B aircraft handling and approach-and-landing issues.
• Evaluating the SFAR 108 standardized training, and other MU-2 safety action taken in the past.
• Conducting additional interviews as required.
• Completing the report phase of the investigation.

Outstanding safety issues

Approach-and-landing accidents

Every year, millions of successful landings occur on Canadian runways. However, there is a risk that accidents resulting in loss of life, injury, and aircraft damage can occur during the approach-and-landing phase of flight. In Canada, from 2009 to 2013, Canadian-registered aircraft were involved in an average of 150 approach-and-landing accidents every year. The TSB Watchlist identifies approach-and-landing accidents as one issue which poses the greatest risk to Canada's transportation system.

Stable approaches significantly increase the chances of a safe landing. Without improvements to stable-approach policy compliance, most unstable approaches will continue to a landing, increasing the risk of approach-and-landing accidents.

Lightweight flight recording systems

In 2013, following its investigation into the March 2011 loss of control/in-flight break-up occurrence, northeast of Mayo, Yukon (TSB Aviation Investigation Report A11W0048), the TSB found that if cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded. It further concluded that in the event that an accident does occur, recordings from lightweight flight recording systems will provide useful information to enhance the identification of safety deficiencies in the investigation. Therefore, the Board recommended that

The Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.

TSB Recommendation A13-01

TSB Recommendation A13-01 speaks about the benefits of lightweight flight recording systems for smaller commercial operations. However, this kind of system would also be equally beneficial for aircraft operated by private operators, for flight training and general aviation aircraft as demonstrated in this occurrence. As noted, in this investigation, valuable information was extracted and is being analyzed.

Communication of safety deficiencies

Should the investigation team uncover a safety deficiency that represents an immediate risk to aviation, the Board will communicate immediately so that it may be addressed quickly and the aviation system made safer.

Investigator-in-Charge

Bruce Mullen joined the TSB in May of 2010 with over 27 years and 8000 hours of flight experience in various types of aircraft. Prior to joining the TSB, he was a member of the Royal Canadian Mounted Police for almost 25 years; 9 of which were spent in Alberta as an RCMP investigator/Peace Officer.

Mr. Mullen also spent several years with the Department of Fisheries and Oceans as a research scientist and co – authored several Fisheries Research Publications.

Investigation teamwork

The Investigator-in-Charge, Bruce Mullen, is being assisted in this investigation by TSB investigators with backgrounds in flight operations, aircraft performance, aircraft systems and engines, human performance, and air traffic control. Representatives from Transport Canada, NAV CANADA, the Sûreté du Québec, the Bureau du coroner du Québec, the National Transportation Safety Board, the Federal Aviation Administration (FAA), the Mitsubishi Aircraft Corporation, Honeywell International Inc., and Hartzell Propeller Inc. are also providing assistance.

Photos

Select image to see it in full size.

Transportation Safety Board investigation process

There are 3 phases to a TSB investigation:

1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

Media