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
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
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.
SOURCE TRANSPORTATION SAFETY BOARD OF CANADA
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