Air transportation safety investigation A19Q0088

The TSB has completed this investigation. The report was published on 3 March 2020.

Table of contents

    Loss of control during initial climb and collision with ground
    Pitts S2E (amateur-built aircraft), C-GONV
    Saint-Jean-Port-Joli, Québec

    The occurrence

    On , a privately operated Pitts S2E aircraft impacted terrain shortly after take-off from Saint-Jean-Port-Joli, Quebec. A pilot and a passenger were on board. The pilot survived the accident and was transported to the hospital for serious injuries and the passenger was fatally injured. The aircraft was substantially damaged.


    Media materials

    News release

    2020-03-03

    Investigation report: June 2019 fatal collision with terrain after takeoff in Saint-Jean-Port-Joli, Quebec
    Read the news release

    Deployment notice

    2019-06-17

    TSB has deployed a team of investigators following an aircraft accident in Saint-Jean-Port-Joli, Quebec

    The Transportation Safety Board of Canada (TSB) has deployed a team of investigators to Saint-Jean-Port-Joli, Quebec, following an accident involving a Pitts S2E aircraft. The TSB will gather information and assess the occurrence.


    Investigation information

    Map showing the location of the occurrence

    A19Q0088

    Loss of control during initial climb and collision with ground
    Pitts S2E (amateur-built aircraft), C-GONV
    Saint-Jean-Port-Joli, Québec

    Investigator-in-charge

    Image
    Photo of Jean-Marc Ledoux

    Mr. Ledoux has 40 years of civil aviation experience. He joined the Transportation Safety Board (TSB) in April 1999 as an investigator in the Air Investigations Branch, in Dorval, Quebec, and has been the regional manager for the Quebec region since 2003. He has been the investigator-in-charge on several aviation investigations.

    Mr. Ledoux worked as an airline pilot for different Canadian carriers, accumulating more than 15 000 flight hours in a wide variety of operations around the world. He flew different aircraft types, from small training aircraft to larger commuter aircraft, eventually piloting large jet aircraft such as, DC8, L1011, B747, and Airbus 310. He also holds a helicopter pilot license. Before joining the TSB, Mr. Ledoux worked at Transport Canada as inspector in the enforcement department.

    Since joining the TSB, Mr. Ledoux has participated in several TSB investigations, and has also assisted numerous foreign investigation agencies in their investigations of accidents abroad. He is also a team member of the Universal Safety Oversight Audit Program (USOAP) with the International Civil Aviation Organization (ICAO).


    Photos


      Download high-resolution photos from the TSB Flickr page.

    Class of investigation

    This is a class 4 investigation. These investigations are limited in scope, and while the final reports may contain limited analysis, they do not contain findings or recommendations. Class 4 investigations are generally completed within 220 days. For more information, see the Policy on Occurrence Classification.

    TSB investigation process

    There are 3 phases to a TSB investigation

    1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
    2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
    3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

    For more information, see our Investigation process page.

    The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.