Operational pressures, adverse weather conditions, and lack of experience factored in January 2012 accident at North Spirit Lake, Ontario
Winnipeg, Manitoba, 21 November 2013 – 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 post-impact fire.
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 possible.
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.
For more information, contact:
Transportation Safety Board of Canada
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