Narrative:The NorOntair flight was scheduled to proceed from Red Lake to Kenora, and then to Thunder Bay. There were no passengers for the leg to Kenora, but there were passengers scheduled to fly out of Kenora to Thunder Bay. During the taxi to the runway, the pre-takeoff checks were completed and the captain conducted the briefing for a standard ten-degree flap takeoff. He then decided to practice a short takeoff and landing (STOL) type takeoff. He informed the first officer, and selected the flaps to 30 degrees. The captain lined up on the button of runway 08. The engines were set to takeoff power and after approximately 300 feet of ground roll, the aircraft became airborne. Initially the aircraft climbed, and then it began to descend. It then climbed again, more steeply than before. Suddenly, at approximately 150 feet agl, the aircraft stopped climbing, descended in a steep nosedown attitude, and crashed half-way down the runway.
Probable Cause:
PROBABLE CAUSE: "The Board determined that inappropriate short take-off and landing (STOL) take-off procedures were applied, which placed the aircraft in a flight regime outside of the aircraft performance envelope for sustained flight. The aircraft stalled at an altitude from which recovery was not possible.
Contributing to the occurrence was the general acceptance of the use of STOL techniques as an approved procedure."
Classification:
Loss of control
Follow-up / safety actions
TSB issued 2 Safety Recommendations
Issued: -- | To: DoT Canada | A94-13 |
The Department of Transport promulgate guidelines regarding the use of "non-approved" material contained in aircraft flight manuals, including related operational information issued by aircraft manufacturers. (Satisfactory in part) |
Issued: -- | To: Bombardier | A94-17 |
The Bombardier Corporation amend the Twin Otter (DHC-6) Aircraft Flight Manual (PSM 1-63-1A) and Supplementary Operating Data Manual (PSM 1-63-1) to include appropriate warnings regarding any safety limitations associated with the operation of the aircraft in the "maximum performance" STOL configuration. (Fully satisfactory) |
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Photos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Red Lake Airport, ON to Kenora Airport, ON as the crow flies is 147 km (92 miles).
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.