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Aviation Investigation Report A93H0023

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Aviation Investigation Report A93H0023 AVIATION OCCURRENCE REPORT CONTROLLED FLIGHT INTO TERRAIN AIR MANITOBA LIMITED HAWKER SIDDELEY, HS 748 SERIES 2A C-GQTH SANDY LAKE, ONTARIO 1 nm NW 10 NOVEMBER 1993 REPORT NUMBER A93H0023 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. Aviation Occurrence Report Controlled Flight into Terrain Air Manitoba Limited Hawker Siddeley, HS 748 Series 2A C-GQTH Sandy Lake, Ontario 1 nm NW 10 November 1993 Report Number A93H0023 Synopsis The flight departed Winnipeg, Manitoba, at 1438 central standard time (CST) for Sandy Lake, Ontario. On arrival at Sandy Lake at approximately 1549 CST, the crew attempted to land but were unable to because of the low ceiling and visibility. They then diverted to St. Theresa Point, Manitoba, landing at 1630 CST. After a normal turnaround, the flight returned to Sandy Lake and landed at approximately 1745 CST. The aircraft took off from runway 29 at Sandy Lake at approximately 1805 CST and immediately entered a right turn. After turning through about 120 degrees, the aircraft descended into 100-foot trees and crashed. All seven occupants of the aircraft were fatally injured, and the aircraft was destroyed. The Board determined that, after take-off, the crew most likely lost situational awareness and, as a result, did not detect the increasing deviation from their intended flight path. Contributing to the loss of situational awareness was the lack of AC power to some of the flight instruments; the reason for the lack of AC power could not be determined. Ce rapport est également disponible en français. TABLE OF CONTENTS Table of Contents Page 1.0 Factual Information ................................................... 1 1.1 History of the Flight ................................................. 1 1.2 Injuries to Persons................................................... 1 1.3 Damage to Aircraft .................................................. 1 1.4 Other Damage ...................................................... 2 1.5 Personnel Information ............................................... 2 1.5.1 General ............................................................ 2 1.5.2 The Captain ........................................................ 2 1.5.2.1 General ............................................................ 2 1.5.2.2 Flying History ...................................................... 2 1.5.3 First Officer ........................................................ 3 1.5.3.1 General ............................................................ 3 1.5.3.2 Flying History ...................................................... 3 1.5.4 Flight Attendant .................................................... 4 1.5.5 Pilot at the Controls ................................................. 4 1.5.6 Company Training on the HS 748 Aircraft .............................. 5 1.5.6.1 General ............................................................ 5 1.5.6.2 Simulator Training .................................................. 5 1.5.7 Flight Crew Working Conditions ...................................... 5 1.5.8 Crew Resource Management Training ................................. 6 1.6 Aircraft Information ................................................. 6 1.6.1 Aircraft Data ....................................................... 6 1.6.2 Aircraft History ..................................................... 6 1.6.3 Weight and Balance ................................................. 6 1.6.4 Flight Controls...................................................... 7 1.6.4.1 General ............................................................ 7 1.6.4.2 Aileron Control System .............................................. 7 1.6.4.3 Gust Locks ......................................................... 8 1.6.4.4 Flaps .............................................................. 8 1.6.5 Electrical System .................................................... 8 1.6.5.1 General ............................................................ 8 1.6.5.2 DC Power System ................................................... 9 1.6.5.3 Inverter System ..................................................... 9 1.6.5.4 Other Electrical Determinations ....................................... 11 1.6.6 Hydraulic System ................................................... 12 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 1.6.7 Fuel System ........................................................ 12 1.6.8 Air Conditioning System ............................................. 13 1.6.9 Powerplants and Propellers .......................................... 13 1.6.9.1 General ............................................................ 13 1.6.9.2 Powerplants ........................................................ 13 1.6.9.3 Propellers .......................................................... 13 1.6.10 Flight Instruments .................................................. 14 1.6.10.1 Attitude Indicators .................................................. 14 1.6.10.3 Radio Altimeter ..................................................... 15 1.6.10.4 Altimeters.......................................................... 15 1.6.11 Ice and Rain Protection .............................................. 15 1.6.12 Global Positioning System (GPS) ...................................... 15 1.6.13 Ground Proxim ity Warning System (GPWS) . 15 1.6.14 Minimum Equipment List (MEL)...................................... 16 1.6.15 Aircraft Checklists - Applicable to C-GQTH . 16 1.6.16 Aircraft Performance ................................................ 17 1.7 Meteorological Information........................................... 18 1.7.1 Weather Forecasts ................................................... 18 1.7.2 Weather Reports .................................................... 18 1.8 Aids to Navigation .................................................. 19 1.9 Communications .................................................... 19 1.10 Aerodrome Information.............................................. 19 1.11 Flight Recorders .................................................... 20 1.11.1 General ............................................................ 20 1.11.2 Flight Data Recorder................................................. 20 1.11.2.1 General ............................................................ 20 1.11.2.2 FDR Data .......................................................... 20 1.11.3 Cockpit Voice Recorder (CVR) ........................................ 22 1.12 Wreckage and Impact Information .................................... 22 1.13 Medical Information ................................................. 22 1.14 Fire ............................................................... 23 1.15 Survival Aspects .................................................... 23 1.15.1 Emergency Response ................................................ 23 1.15.2 Crew Seats and Harnesses............................................ 23 1.16 Tests and Research - Flight Path Calculations (Reference LP 148/ 93) . 24 1.17 Additional Information .............................................. 24 1.17.1 Aircraft Contamination .............................................. 24 1.17.2 Air Manitoba ....................................................... 25 iv TRANSPORTATION SAFETY BOARD TABLE OF CONTENTS 1.17.2.1 Organizational and Management Information . 25 1.17.2.2 Operations ......................................................... 27 1.17.2.3 Maintenance ....................................................... 27 1.17.3 Transport Canada and Air Manitoba................................... 31 1.17.4 Controlled Flight into Terrain ......................................... 32 1.17.5 Situational Awareness ............................................... 32 1.17.6 Misorientation (Unrecognized Disorientation) . 32 2.0 Analysis ................................................................ 35 2.1 General ............................................................ 35 2.2 The Flight .......................................................... 35 2.3 Possible Scenarios ................................................... 36 2.3.1 General ............................................................ 36 2.3.2 Number 1 AC Bus Not Powered ...................................... 36 2.3.3 Both AC Buses Not Powered ......................................... 37 2.4 Minimum Equipment List ............................................ 38 2.5 Decision Making .................................................... 38 2.6 Standby Attitude Indicator ........................................... 38 2.7 Ground Proximity Warning System ................................... 38 2.8 CL2 Compass....................................................... 39 2.9 Disorientation ...................................................... 39 2.9.1 Vestibular Sensing .................................................. 39 2.9.2 Loss of Situational Awareness ........................................ 39 2.10 Air Manitoba and Regulations ........................................ 40 2.11 Flight Crew Performance............................................. 40 2.12 Crew Resource Management Training ................................. 40 2.13 Returning to Land at Sandy Lake...................................... 41 2.14 Summary .........................................................
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