AVIATION INVESTIGATION REPORT A10Q0098 ENGINE PROBLEM - COLLISION WITH TERRAIN AÉROPRO (2550-4330 QUÉBEC INC.) BEECHCRAFT A100 KING AIR C-FGIN QUÉBEC, QUEBEC 23 JUNE 2010 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 Engine Problem - Collision with Terrain Aéropro (2550-4330 Québec Inc.) Beechcraft A100 King Air C-FGIN Québec, Quebec 23 June 2010 Report Number A10Q0098 Synopsis On 23 June 2010, the Beechcraft A100 King Air (registration C-FGIN, serial number B-164) operated by Aéropro (2550-4330 Québec Inc.) as flight APO201 was making an instrument flight rules flight from Québec to Sept-Îles, Quebec. At 0557 Eastern Daylight Time, the crew started its take-off run on Runway 30 at the Québec/Jean Lesage International Airport; 68 seconds later, the co-pilot informed the airport controller that there was a problem with the right engine and that they would be returning to land on Runway 30. Shortly thereafter, the co-pilot requested aircraft rescue and fire-fighting (ARFF) services and informed the tower that the aircraft could no longer climb. A few seconds later, the aircraft struck the ground 1.5 nautical miles from the end of Runway 30. The aircraft continued its travel for 115 feet before striking a berm. The aircraft broke up and caught fire, coming to rest on its back 58 feet further on. The 2 crew members and 5 passengers died in the accident. No signal was received from the emergency locator transmitter (ELT). Ce rapport est également disponible en français. 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 the Aircraft .................................................................................................................. 2 1.4 Other Damage................................................................................................................................. 3 1.5 Personnel Information ................................................................................................................... 3 1.5.1 Pilot-in-Command ..................................................................................................................... 3 1.5.2 Co-pilot ........................................................................................................................................ 4 1.6 Aircraft Information ...................................................................................................................... 5 1.6.1 General ......................................................................................................................................... 5 1.6.2 Aircraft Weight and Balance .................................................................................................... 5 1.6.3 Review of Aircraft Maintenance Records ............................................................................... 5 1.6.4 Beechcraft A100 King Aircraft Flight Manual ........................................................................ 7 1.6.5 Normal, Abnormal and Emergency Procedures ................................................................... 9 1.7 Meteorological Information ........................................................................................................ 17 1.8 Telecommunications .................................................................................................................... 17 1.8.1 Communications Between APO201 and Quebec Airport Control .................................... 17 1.8.2 Internal Communications ....................................................................................................... 18 1.8.3 Analysis of Communications from APO201 ........................................................................ 18 1.9 Aerodrome Information .............................................................................................................. 18 1.10 Recorders ....................................................................................................................................... 19 1.10.1 Flight Data Recorder ................................................................................................................ 19 1.10.2 Cockpit Voice Recorder ........................................................................................................... 19 1.10.3 Guardian Skytrax 3 .................................................................................................................. 20 1.11 Wreckage and Impact Information ............................................................................................ 20 1.11.1 Accident Site ............................................................................................................................. 20 1.11.2 Wreckage Distribution ............................................................................................................ 21 1.11.3 Examination of the Wreckage ................................................................................................ 22 1.11.4 Examination of the Annunciator Panel ................................................................................. 22 1.11.5 Examination of the Propellers ................................................................................................ 22 1.11.6 Examination of the Engines .................................................................................................... 23 1.11.7 Examination of the Propulsion Control System .................................................................. 24 1.11.8 Examination of the Flight Low Pitch Stop System .............................................................. 25 1.12 Medical Information .................................................................................................................... 25 1.13 Survival Aspects ........................................................................................................................... 26 1.14 Training Information ................................................................................................................... 26 1.14.1 Pilot Training on the Beechcraft A100 King Air .................................................................. 26 1.15 Information on the Operator and Management ...................................................................... 28 1.15.1 General ....................................................................................................................................... 28 1.15.2 Management ............................................................................................................................. 28 1.15.3 Conditions of Employment for Pilots.................................................................................... 29 1.15.4 Safety Management at Aéropro ............................................................................................. 30 1.16 Transport Canada Oversight ...................................................................................................... 31 1.16.1 General ....................................................................................................................................... 31 1.16.2 Surveillance of Aéropro Operations by Transport Canada ............................................... 33 1.16.3 Program Validation Inspection Interviews .......................................................................... 38 1.16.4 Aéropro Approved Maintenance Organization .................................................................. 38 1.17 Safety Programs ........................................................................................................................... 39 1.17.1 Voluntary Reporting Programs .............................................................................................. 39 1.17.2 Safety Culture and Management ........................................................................................... 41 1.18 Air Taxi Operations Under CARs Subpart 703 ........................................................................ 42 2.0 ANALYSIS .................................................................................................................................... 45 2.1 Introduction .................................................................................................................................. 45 2.2 Condition of the Aircraft Before Take-off ................................................................................. 45 2.3 Take-off Run ................................................................................................................................. 45 2.4 Climb .............................................................................................................................................. 46 2.5 Problem Reported in Flight ........................................................................................................ 46 2.5.1 General ......................................................................................................................................