The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
The pilots flew a Piper PA31-350 aircraft (registration C-FTNS, serial number 31-7652009) from Québec, Quebec, to Saint John, New Brunswick, on an instrument flight rules flight, with Fredericton, New Brunswick, as their alternate airport. On arrival, they flew a radar-vectored, instrument landing system approach in low-visibility conditions to Runway 23 at the Saint John Airport. Radio contact was lost while the aircraft was on the approach and a brief emergency locator transmitter signal was heard at 2234:30 Atlantic daylight time. The aircraft had crashed on final approach, and the two pilots sustained serious burn injuries in the ensuing post-crash fire.
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History of the flight
The en route portion of the flight from Québec was uneventful. Approach clearance was given by Moncton Centre for the instrument landing system (ILS) Runway 23 approach to the Saint John Airport (CYSJ). Radar showed that C-FTNS was established on the localizer with a stable flight profile, at least until 1500 feet above ground level (agl) when radar coverage was lost due to terrain interference. The pilot-in-command was the pilot not flying (PNF) and was in the right-hand seat. The other pilot was the pilot flying (PF).
A regional airline Beech 1900 flight crew had attempted an approach on the same runway just before the approach by the occurrence aircraft. The crew members of the Beech 1900 were flying a pilot-monitored approachFootnote 1 with the first officer flying. When adequate visual reference with the runway environment was acquired, the captain took control from the first officer and continued the approach down to 100 feet agl. The first officer continued to monitor the instruments and the approach, observed that the aircraft was misaligned with the runway, and called for a missed approach.
Shortly after the Beech 1900 started the missed approach, the PNF of C-FTNS established contact with the CYSJ Flight Service Station (FSS) specialist. The specialist observed on radar that the Beech 1900 was conducting the missed approach, told C-FTNS to stand by and instructed the crew of the Beech 1900 to contact Moncton Centre. Before instructing the crew to contact Moncton, the FSS specialist did not ask the Beech 1900 crew to provide a pilot report (PIREP) on the weather they encountered during their approach and attempted landing, nor did the pilots offer to provide a PIREP. Paragraph 234.1 of the NAV CANADA Flight Service Station Manual of Operations (FSS MANOPS) states in part:
Solicit PIREP from pilots during a pilot briefing and from aircraft when:
A. poor weather conditions exist;
B. necessary to remain aware of flight conditions;
234.1 Note: PIREPs contain useful information for aviation forecasters and may be an important factor in another pilot's decision. PIREPs are especially useful when they contain critical information on low clouds, reduced visibility. . . .
The FSS specialist did not advise C-FTNS of the Beech 1900's missed approach, nor was there a requirement to do so, and the pilots of C-FTNS were unaware that the Beech 1900 had not successfully completed the approach.
The FSS specialist advised C-FTNS that the reported 2200 Atlantic daylight timeFootnote 2 weather at CYSJ was as follows: wind 220º magnetic (M) at 13 knots gusting to 18 knots, visibility ½ statute mile (sm) in fog, vertical visibility 200 feet, runway visual range (RVR) 2000 feet with the runway lights on strength five.
Moderate turbulence was encountered by the accident aircraft during the latter stages of the approach to Runway 23. During this encounter, the aircraft went above the glideslope and drifted left of the localizer. The PF, manually flying the approach, corrected for the deviations and continued the approach. A short time later, the PNF called the approach lights coming into view and shortly thereafter called minimums (decision height [DH]). The PF discontinued his instrument scan, observed the runway lights at the two o'clock position in the windscreen, and attempted to correct. The PNF called for an overshoot, but the aircraft continued to descend until it struck the terrain. Because of the absence of radar and flight recorder data, the exact path and correlation of the crew's observations during the approach could not be established.
The last radio transmission from the aircraft was when it was established on the final approach to Runway 23. After the impact, a two-second emergency locator transmitter (ELT) signal was heard by the FSS specialist at 2234:30. Twenty minutes later, an airport fire response vehicle located the aircraft inverted and on fire at the southeast edge of the Clover Valley Road, about one-half nautical mile from the threshold of Runway 23 and 650 feet to the southeast of the extended runway centreline (Figure 1). The pilots had