Investigation Summary
The investigation by the Transportation Safety Board of Canada (TSB) focused on the performance limitations of the Cessna 208B on unpaved surfaces. The aircraft encountered soft spots on the gravel runway, which had been saturated by recent heavy rains. At the time of takeoff, the prevailing temperature was approximately 25 degrees C and the aircraft's gross weight was calculated at 8050 pounds. The pilot utilized a company-taught soft-field technique that involved raising the nose wheel early; however, this increased aerodynamic drag and further hindered acceleration. When the airspeed stopped increasing, the pilot rejected the takeoff, but the aircraft's accelerate-stop distance under the prevailing conditions exceeded the remaining runway. The TSB noted that the Cessna 208B Pilot Operating Handbook (POH) did not provide accelerate-stop distance calculations, leaving the pilot without a clear reference for a safe reject point. The crash was survivable, but the steep terrain at the runway end caused severe structural damage to the fuel system, leading to a rapid fire. The sole fatality was attributed to the passenger not wearing the available shoulder harness, resulting in a loss of consciousness upon impact that prevented escape from the fire.
Final Conclusions
The TSB concluded that the accident was caused by a combination of environmental factors and operational decisions. The primary factors were the reduced acceleration due to runway conditions and pilot technique, and the delayed decision to reject the takeoff past the point of no return. The severity of the outcome was exacerbated by the lack of a Runway End Safety Area (RESA) and the passenger's failure to use a shoulder harness. The final report, Aviation Investigation Report A11C0102, was released in June 2012.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
The pilot held a valid commercial pilot license and had been with the company since May 2010.
Systems & Failure Modes
Shoulder Harness
Safety restraints available to all passengers; the failure to use one by the deceased passenger was cited as a factor in their inability to evacuate.
Event Recorder
A non-mandatory device designed to store engine parameters; it was too heavily damaged by fire to provide usable data.
Power Lever Assembly
Post-crash examination found an incorrect bolt (AN3-14 instead of AN3-16) and a missing spacer, though these did not contribute to the accident.
Interesting Facts
- 01The aircraft's Manufacturer Serial Number (MSN) was 208B1114.
- 02The aircraft was modified with a kit to increase the maximum takeoff weight to 9,062 pounds.
- 03The actual gross weight of the aircraft at the time of the accident was approximately 8,050 pounds.
- 04The Cessna 208B type is certified without published accelerate-stop or accelerate-go distance calculations.
- 05The deceased passenger was not wearing the available shoulder harness, which contributed to their loss of consciousness.
- 06The runway at Pukatawagan was compliant with existing standards (TP 312E) despite the steep drop-off at the end.
- 07Transport Canada twice suspended Missinippi Airways' air operator's certificate following the accident due to safety and operational concerns.
Safety Actions & Advisories
Operator Procedure Revision
Missinippi Airways implemented a new short-field takeoff procedure and increased emphasis on short/soft field training.
Regulatory Oversight
Transport Canada conducted inspections of the operator's Operational Control System, leading to temporary suspensions of their Air Operator Certificate until deficiencies were corrected.