Investigation Summary
The flight departed Montreal at 09:31 EDT, carrying Jean Lapierre, his wife, and three siblings to the Magdalen Islands for their father's funeral. As the aircraft approached Îles-de-la-Madeleine Airport, weather conditions were challenging, featuring a 200-foot ceiling, 2 miles of visibility, and gusty winds. The Transportation Safety Board of Canada (TSB) investigation determined that the pilot failed to maintain a stabilized approach. The high-stress environment and the pilot's insufficient proficiency on the MU-2 type contributed to a breakdown in decision-making. When the pilot attempted to correct the approach by increasing power at a critical low-speed, low-altitude state, the aircraft's aerodynamic characteristics led to an upset. The MU-2 is known for sensitive handling characteristics, particularly during power changes at low speeds. The TSB found that the pilot's skills were not adequate for the complexities of the operation in those specific conditions.
Final Conclusions
The TSB final report, released on 10 January 2018, concluded that the accident resulted from an unstable approach and subsequent loss of control. The pilot's high workload reduced situational awareness and hindered effective decision-making. The investigation highlighted that the pilot's flight skills and procedures were insufficient for the pilot-in-command requirements of the MU-2B-60, especially during the demanding conditions of the accident flight.
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Mitsubishi MU-2 Flight Controls
The MU-2 uses spoilers rather than ailerons for roll control, which can lead to unique handling characteristics during low-speed, high-power transitions.
Onboard Recording Device
Although not a standard FDR/CVR, this device provided investigators with critical data to reconstruct the flight path and engine performance.
Interesting Facts
- 01The aircraft was not equipped with flight data or cockpit voice recorders, as they were not required for light aircraft.
- 02A non-required onboard recording device was recovered intact and used by investigators.
- 03Weather at the time included a 200-foot ceiling, light rain, mist, and winds gusting to 24 knots.
- 04The aircraft slid for 91 meters after the initial impact before coming to a stop.
- 05Examination of the wreckage confirmed both engines were running until the moment of impact.
Safety Actions & Advisories
TSB Recommendation on Lightweight Flight Recorders
Source ↗Following the investigation, the TSB reiterated the need for the Department of Transport to require the installation of lightweight flight recording systems on commercial and private aircraft not currently required to carry them.
Focus on Unstable Approaches
Source ↗The TSB highlighted the ongoing risk of unstable approaches and encouraged operators to implement stable approach policies and monitoring to reduce the risk of approach-and-landing accidents.