WINNIPEG, MB, Nov. 21, 2013 /CNW/ - The Transportation Safety Board of
Canada (TSB) today released its investigation report (A12C0005) into
the crash of a Piper PA31-350 Navajo Chieftain on 10 January 2012. The
accident claimed the lives of the pilot and three passengers. A fourth
passenger was seriously injured.
The aircraft, operating as Keystone Air Service Ltd. Flight 213,
departed Winnipeg, Manitoba, en route to North Spirit Lake, Ontario,
with one pilot and four passengers on board. Just before 10 a.m.
Central Standard Time, on approach to the North Spirit Lake airport,
the aircraft struck the frozen lake surface about 1 mile from the
runway threshold. The aircraft was destroyed by the impact and
The investigation identified three findings as to the causes of the
accident. First, the decision to conduct an approach to an airport not
serviced by an instrument approach in adverse weather conditions was
likely the result of inexperience, and a desire to successfully
complete the flight. Second, the decision to descend into cloud and
continue in icing conditions was likely the result of inadequate
awareness of the aircraft's performance in icing conditions and
de-icing capabilities. Last, because of the time spent airborne in
icing conditions near the airport, the resulting ice accumulation on
the aircraft's critical surfaces would have led to an increase in the
aircraft's aerodynamic drag and stall speed, causing the aircraft to
stall during final approach at an altitude from which recovery was not
Since the accident, NAV CANADA has published an approved instrument
approach procedure for the North Spirit Lake airport. For its part,
Keystone Air Service has: revised its operations manual to better
reflect operational requirements in icing conditions; implemented a
multi-crew policy which applies to all instrument flights; amended its
flight training record-keeping procedures to make it easier and more
efficient to prove that all required training has been completed; and
revised its operational flight plan form to include the calculated
landing weight and centre of gravity.
Recently, the TSB issued a recommendation (A13-01) calling for the
installation of lightweight flight recording systems on board small
commercial aircraft. If onboard flight recorders are not available to
an investigation, this may preclude the identification and
communication of safety deficiencies to advance transportation safety.
The TSB is an independent agency that investigates marine, pipeline,
railway and aviation 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.
SOURCE: Transportation Safety Board of Canada
For further information:
Transportation Safety Board of Canada
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