Transportation Safety Board Reminds the Aviation Community to Always Consider Safety
GATINEAU, QC, April 5, 2012 /CNW/ - The Transportation Safety Board of Canada (TSB) released today its investigation report (A10Q0117) on the loss of control and collision with terrain of a De Havilland DHC-2 operated by Nordair Québec 2000 Inc. that occurred in La Grande Rivière, Quebec.
On 24 July 2010, the De Havilland DHC-2 departed the La Grande Rivière airport destined for l'Eau Claire Lake, Quebec. The aircraft became airborne, but was unable to gain altitude. At the runway end, about 50 feet above ground level, the aircraft pitched up and banked left, then nosed down and crashed in a small, shallow lake. The pilot and front-seat passenger were fatally injured; the 3 other passengers sustained serious injuries.
"We found that the aircraft was overloaded and its centre of gravity was beyond its limits. When the aircraft left the ground, it pitched up and stalled at an altitude that did not allow the pilot to recover," said Denis Deroy, TSB Investigator-in-charge. "The operation of an aircraft outside the limits and conditions under which a permit is issued increases the risk of an accident," he added.
On the day of the event, the pilot had refueled the aircraft and was carrying passengers, baggage, fuel containers and a canoe. The canoe was tied directly to the right float struts. The carrier operations manual states that the aircraft take-off weight must be reduced to 5160 pounds when carrying a canoe as external cargo. Based on the actual weight of the passengers and the weight of all other items, the overall weight of the aircraft was determined to be 6162 pounds, or 1002 pounds overweight. The centre of gravity was at 111.80 inches, which was 5.69 inches outside its limits.
The baggage was not secured and the shifting of the baggage at the time of the accident caused the triple seat to pivot forward, propelling the 3 rear-seat passengers against the pilot and front-seat passenger during impact. Although the design of the triple seat met aviation standards, it separated from the floor at the time of impact, principally due to the fact that the heavy cargo shifted. Since the beginning of Nordair Quebec 2000 Inc.'s operations, Transport Canada inspections had detected some safety deficiencies including noting on 4 occasions where the baggage tie-down system was not installed or not used.
The action taken by Transport Canada did not have the desired outcomes to ensure regulatory compliance; consequently, unsafe practices persisted. This was one of the six findings of the TSB investigation into this accident. The other findings can be read in the report at www.tsb.gc.ca.
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.
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