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Aviation Investigation Report A15c0163

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Aviation Investigation Report A15c0163 AVIATION INVESTIGATION REPORT A15C0163 Icing encounter, loss of control, and collision with terrain Wasaya Airways Limited Partnership Cessna 208B, C-FKDL Pickle Lake, Ontario, 10 nm N 11 December 2015 Transportation Safety Board of Canada Place du Centre 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2017 Aviation investigation report A15C0163 Cat. No. TU3-5/15-0163E-PDF ISBN 978-0-660-09510-3 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. 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 Investigation Report A15C0163 Icing encounter, loss of control, and collision with terrain Wasaya Airways Limited Partnership Cessna 208B, C-FKDL Pickle Lake, Ontario, 10 nm N 11 December 2015 Summary The Wasaya Airways Limited Partnership Cessna 208B Caravan (registration C-FKDL, serial number 208B0240) departed Pickle Lake Airport, Ontario, on 11 December 2015 at 0900 Eastern Standard Time under visual flight rules as flight WSG127 to Angling Lake / Wapekeka Airport, Ontario, with the pilot and a load of cargo on board. At 0908, the flight levelled off at about 4600 feet above sea level. At 0909, WSG127 descended and turned about 120° to the right, then collided with the southeast side of Tarp Hill at an elevation of 1460 feet above sea level. The pilot was fatally injured, and the aircraft was destroyed. There was no post-impact fire. The 406-megahertz emergency locator transmitter activated on impact, but no signal was emitted. Le présent rapport est également disponible en français. Aviation Investigation Report A15C0163 | iii Table of contents 1.0 Factual information.......................................................................... 1 1.1 History of the flight ............................................................................................ 1 1.2 Injuries to persons............................................................................................... 2 1.3 Damage to aircraft .............................................................................................. 2 1.4 Other damage ..................................................................................................... 2 1.5 Personnel information......................................................................................... 2 1.6 Aircraft information............................................................................................ 4 1.6.1 General ......................................................................................................................................4 1.6.2 Automatic flight control system ..........................................................................................5 1.6.3 Aircraft payload extender modification.............................................................................5 1.6.4 Icing certification .....................................................................................................................5 1.6.5 ICEX II .......................................................................................................................................7 1.6.6 Aircraft performance ..............................................................................................................7 1.6.7 Emergency locator transmitter .......................................................................................... 10 1.6.8 Satellite tracking system ..................................................................................................... 11 1.7 Meteorological information ............................................................................... 11 1.7.1 General ................................................................................................................................... 11 1.7.2 Pre-flight wea ther................................................................................................................. 11 1.7.3 Enroute weather experienced by another Wasaya Cessna 208B flight..................... 14 1.7.4 Current Icing Product ......................................................................................................... 15 1.7.5 Pickle Lake Airport upper-air meteorological conditions........................................... 16 1.7.6 Onta rio–Quebec graphical area forecast for 09 and 10 December 2015 ................... 17 1.8 Aids to navigation ............................................................................................ 17 1.9 Communications .............................................................................................. 17 1.10 Aerodrome information .................................................................................... 18 1.11 Flight recorders ................................................................................................ 18 1.12 Wreckage and impact information .................................................................... 19 1.13 Medical and pathological information ............................................................... 23 1.14 Fire................................................................................................................... 23 1.15 Survival aspects ................................................................................................ 24 1.15.1 Occupant restraint system.................................................................................................. 24 1.15.2 Emergency locator transmitter .......................................................................................... 24 1.15.3 Search and rescue ................................................................................................................. 25 1.16 Tests and research............................................................................................. 26 1.16.1 WSG127 flight data analysis .............................................................................................. 26 1.16.2 TSB Engineering Laboratory reports ............................................................................... 27 1.17 Organizational and management information ................................................... 27 1.17.1 Wasa ya.................................................................................................................................... 27 1.17.2 Transport Canada................................................................................................................. 34 1.18 Additional information ..................................................................................... 37 1.18.1 Decision support systems................................................................................................... 37 1.18.2 Risk posed by flight in icing conditions .......................................................................... 38 1.19 Useful or effective investigation techniques ....................................................... 39 iv | Transportation Safety Board of Canada 2.0 Analysis ......................................................................................... 40 2.1 Introduction ..................................................................................................... 40 2.2 Wasaya risk mitigation and Cessna 208B operations .......................................... 40 2.3 Flight authorization and release ........................................................................ 42 2.4 Decision support tools ...................................................................................... 44 2.5 Icing and aircraft performance .......................................................................... 45 2.6 In-flight pilot decision making .......................................................................... 48 2.7 ICEX II application interval ............................................................................... 48 2.8 Wasaya initial technical ground training ........................................................... 49 2.9 Cessna 208B loading documentation at CYPL .................................................... 50 2.10 Emergency locator transmitters and satellite flight-following ............................. 50 3.0 Findings......................................................................................... 52 3.1 Findings as to causes and contributing factors ................................................... 52 3.2 Findings as to risk ............................................................................................. 52 3.3 Other findings .................................................................................................. 53 4.0 Safety action .................................................................................. 54 4.1 Safety action taken ............................................................................................ 54 4.1.1 Wasa ya.................................................................................................................................... 54 4.1.2 Transport Canada................................................................................................................
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