ASN Wikibase Occurrence # 321850
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| Date: | Thursday 25 October 2007 |
| Time: | 08:59 |
| Type: |  Beechcraft A100 King Air |
| Owner/operator: | Air Creebec |
| Registration: | C-FNIF |
| MSN: | B-178 |
| Year of manufacture: | 1973 |
| Fatalities: | Fatalities: 2 / Occupants: 2 |
| Aircraft damage: | Destroyed, written off |
| Category: | Accident |
| Location: | Chibougamau Airport, QC (YMT) -
 Canada
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Val-dOr Airport, QC (YVO/CYVO) |
| Chibougamau/Chapais Airport, QC (YMT/CYMT) | |
| Investigating agency: | TSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Beechcraft A100 King Air operated by Air Creebec as flight number CRQ501 was conducting an instrument flight rules (IFR) flight from Val-dOr Airport, QC (YVO) to Chibougamau Airport, QC (YMT). After its first NDB/DME05 approach, the flight crew conducted a missed approach. The crew conducted a second approach, and the aircraft crashed on the runway in a left-bank attitude. A fire started upon impact, and the aircraft continued its run for approximately 500 ft before coming to a stop nearly 50 ft off the end of the runway, 1 000 ft from the threshold of runway 05. The two crew members were fatally injured.
The winds were from the south-southwest (250°) at 4 kt, visibility was 1½ SM, there was light freezing drizzle and fog, and there was a covered ceiling at 500 ft.
Findings as to Causes and Contributing Factors:
1. The aircraft was configured late for the approach, resulting in an unstable approach condition.
2. The pilot flying carried out a steep turn at a low altitude, thereby increasing the load factor. Consequently, the aircraft stalled at an altitude that was too low to allow the pilot to carry out a stall recovery procedure.
Findings as to Risk:
1. The time spent programming the global positioning system reduced the time available to manage the flight. Consequently, the crew did not make the required radio communications on the mandatory frequency, did not activate the aircraft radio control of aerodrome lighting (ARCAL), did not make the verbal calls specified in the standard operating procedures (SOPs), and configured the aircraft for the approach and landing too late.
2. During the second approach, the aircraft did a race-track pattern and descended below the safe obstacle clearance altitude, thereby increasing the risk of a controlled flight into terrain. The crew's limited instrument flight rules (IFR) experience could have contributed to poor interpretation of the IFR procedures.
3. Non-compliance with communications procedures in a mandatory frequency area created a situation in which the pilots of both aircraft had poor knowledge of their respective positions, thereby increasing the risk of collision.
4. The pilot-in-command monitored approach (PICMA) procedure requires calls by the pilot not flying when the aircraft deviates from pre-established acceptable tolerances. However, no call is required to warn the pilot flying of an approaching steep bank.
5. The transfer of controls was not carried out as required by the PICMA procedure described in the SOPs. The transfer of controls at the co-pilot's request could have taken the pilot-in-command by surprise, leaving little time to choose the best option.
6. Despite their limited amount of IFR experience in a multiple crew working environment, the two pilots were paired. Nothing prohibited this. Although the crew had received crew resource management (CRM) training, it still had little multiple crew experience and consequently little experience in applying the basic principles of CRM.
Accident investigation:
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Sources:
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Revision history:
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