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AVIATION INVESTIGATION REPORT A07Q0213 LOSS OF CONTROL AND COLLISION WITH TERRAIN AIR CREEBEC INC. BEECHCRAFT A100 C-FNIF CHIBOUGAMAU/CHAPAIS AIRPORT, QUEBEC 25 OCTOBER 2007 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 Loss of Control and Collision with Terrain Air Creebec Inc. Beechcraft A100 C-FNIF Chibougamau/Chapais Airport, Quebec 25 October 2007 Report Number A07Q0213 Summary The Beechcraft A100 (registration C-FNIF, serial number B-178), operated by Air Creebec Inc. on flight CRQ 501, was on a flight following instrument flight rules between Val-d’Or, Quebec, and Chibougamau/Chapais, Quebec, with two pilots on board. The aircraft flew a non-precision approach on Runway 05 of the Chibougamau/Chapais Airport, followed by a go-around. On the second approach, the aircraft descended below the cloud cover to the left of the runway centreline. A right turn was made to direct the aircraft towards the runway, followed by a steep left turn to line up with the runway centreline. Following this last turn, the aircraft struck the runway at about 500 feet from the threshold. A fire broke out when the impact occurred and the aircraft continued for almost 400 feet before stopping about 50 feet north of the runway. The first responders tried to control the fire using portable fire extinguishers but were not successful. The Chibougamau and Chapais fire departments arrived on the scene at about 0926 eastern daylight time, which was about 26 minutes after the crash. The aircraft was destroyed by the fire. The two pilots suffered fatal injuries. Ce rapport est également disponible en français. - 2 - Other Factual Information Company Information Air Creebec Inc. holds a valid operations certificate (number 8582). At the time of the occurrence, the company was operating a fleet of 18 aircraft: one Beechcraft 1900D, three Embraer 110s, three HS-748s, eight DHC-8s and three Beechcraft A100s. Depending on the type of aircraft used, operations are carried out in compliance with Subparts 3, 4, and 5 of Part VII of the Canadian Aviation Regulations (CARs) 1. In this occurrence, the aircraft was being used in compliance with Subpart 3. Aircraft Information The aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures. There was no evidence found of any airframe failure or system malfunction during the flight. The aircraft was equipped with a cockpit voice recorder (CVR), model Universal CVR 30B. The CVR was removed from the aircraft and sent to the TSB Engineering Laboratory for analysis. The recorded information and conversations made it possible to retrace the events of the last 30 minutes of the flight before the occurrence. Flight Crew Information The flight crew was certified and qualified for the flight in accordance with existing regulations. The pilot-in-command had been employed with the company since 05 July 2007. He had a total of about 1800 flying hours, including 122.9 hours on the Beechcraft A100 as pilot-in-command. He had performed his last line check on 23 September 2007. Prior to joining Air Creebec, he had worked in the West Indies as pilot-in-command on the BN 2A-26 and as co-pilot on the DHC-6, on which he had 403 and 530 flying hours, respectively, mainly in visual flight conditions. The co-pilot had been employed with the company since 11 June 2007 and had a total of about 1022 flying hours, including 71.9 hours on the Beechcraft A100. He had performed his line check on 22 August 2007. When he joined the company, he already had about 950 flying hours, including 31 hours on twin-engine aircraft. Almost all of his flying experience had been in visual flight conditions. Both pilots passed the initial pilot proficiency check (PPC) on the Beechcraft A100 as well as the renewal of their instrument flight rating on 25 July 2007. Also, they completed crew resource management (CRM) training on 11 June 2007. CRM training consists of a number of elements, notably communication, teamwork, decision making and judgment, workload management, and situational awareness. 1 See Appendix C, Glossary, for a list of abbreviations and acronyms. - 3 - There is a shortage of pilots in the aviation industry, not only in Canada but around the world. The International Air Transport Association has warned the world’s airlines of a serious lack of pilots if the industry and governments do not work together to change training and qualification methods. This shortage is making it increasingly difficult for operators to find experienced pilots. History of the Flight In the days leading up to the accident, the pilot-in-command had three days off and the co-pilot had six days off. They had worked together as flight crew members three times since they were hired. On the day of the accident, both pilots arrived at work at about 0445 2 or one hour before the initially scheduled departure time. There was no indication that the crew was not fit to fly. Because of the weather conditions in Chibougamau/Chapais, the dispatcher, jointly with the pilot-in-command, delayed the departure from Val-d’Or. The aircraft took off from Val-d’Or at 0800. According to the planned route, the crew was to go to Chibougamau/Chapais to pick up two passengers before going to Bagotville, Quebec. The return to Val-d’Or was scheduled for 1810. The aircraft took off from Val-d’Or with the two pilots on board and enough fuel to fly for about five hours. The weight and centre of gravity of the aircraft were within the limits prescribed by the manufacturer. Most of the flight was carried out above the cloud layer at an altitude of 15 000 feet above sea level (asl). No anomalies were reported by the crew. The co- pilot seated on the right was the pilot flying (PF) and the pilot-in-command was the pilot not flying (PNF). Before starting the descent, the flight crew had planned to fly an approach for Runway 23. The surface wind reported was 260 degrees at 5 knots. The pilot-in-command started programming the RNAV (GNSS) RWY 23 3 approach in one of the global positioning systems (GPSs) installed on board. The intent was to carry out an RNAV (GNSS) approach and monitor the raw data from the automatic direction finder (ADF) 4. A few minutes later, to shorten the flight, the flight crew opted for a direct approach to Runway 05 because the surface wind at Chibougamau/Chapais was light. At approximately 0833, on the en route frequency 126.7 MHz, the crew advised Propair 102, another King Air that was 21 miles behind it, that it was proceeding to Runway 05. Propair 102 confirmed that it would continue to Runway 23. The crew of CRQ 501 completed the briefing for the NDB/DME RWY 05 approach (see Appendix A) before starting the descent at about 2 All times are eastern daylight time (Coordinated Universal Time minus four hours). 3 Instrument approach procedure in which the global navigation satellite system (GNSS) is used. 4 Direction-finding equipment for obtaining a bearing to or from the radio beacon. - 4 - 0836. The aircraft was 47 nautical miles (nm) from Chibougamau/Chapais within an acceptable descent profile. The estimated arrival time at CHIBOO non-directional beacon (NDB) was at 0845 while Propair 102 estimated its arrival at Chibougamau/Chapais airport at 0901. Despite the briefing for the NDB/DME 05 approach, the pilot-in-command started programming the RNAV (GNSS) 05 approach (see Appendix B) in one of the GPSs. The investigation could not determine which GPS was used. Neither of the pilots was authorized nor trained to use the GPS as a primary source of navigation for an instrument approach. The programming was done during the descent over a period of about nine minutes. It was abandoned at about 15 nm from the runway threshold. At that time, the aircraft had a ground speed of about 210 knots and the crew had not started the aircraft’s approach configuration. The approach configuration was obtained when passing final approach fix (FAF) LEGER and the pre-landing checklist was completed when the aircraft was about 2 nm from the Runway 05 threshold. According to the standard operating procedures (SOPs), these actions must be completed when the final inbound course is intercepted before passing the FAF. Between 0847 and 0851, the Propair 102 crew broadcast four radio transmissions during which they indicated the aircraft was proceeding towards Runway 05. The first two transmissions were sent on the mandatory frequency (MF), which is 122.0 MHz. At this time, the crew of CRQ 501 had not yet tuned the frequency. The third transmission was sent on frequency 126.7 MHz, which was tuned by the crew of CRQ 501. This last transmission was sent as CRQ 501 reached the minimum descent altitude (MDA). At this time the PNF’s attention was focused on a visual scan of the exterior to locate the runway and its surroundings while the PF’s attention was focused on maintaining the desired track, airspeed, and the MDA. At 0849, when the aircraft was less than two miles from the runway threshold, the PNF made his first position report on final approach on 126.7 MHz. Section 602.104 of the CARs requires that an aircraft’s position be reported on the MF when the aircraft first intercepts the final approach course and when passing the FAF, which was not done.

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