Investigation Summary
The flight departed St. Andrews under visual flight rules (VFR) but encountered a ceiling of only 200 feet and one mile visibility at the destination. After an initial missed approach, the crew attempted a second approach following a report from another company aircraft that had just landed. During this second attempt, the Bandeirante was observed flying at approximately 150 feet above the lake surface, well below the MDA of 555 feet above airport elevation. As the aircraft approached the shoreline, it encountered a fog bank that blended with frost-covered trees, eliminating external visual references. The pilot increased power, which likely induced a somatogravic illusion of climbing, and performed rapid left and right banks, possibly to avoid a 93-foot fire tower, before impacting the forest. The investigation revealed the aircraft was overweight and the crew had not completed all required training, including right-seat conversion for the captain and emergency equipment training.
Final Conclusions
The Transportation Safety Board of Canada (TSB) concluded that the primary cause was controlled flight into terrain resulting from the decision to continue the approach below minimum safe altitudes in marginal weather. Contributing factors included the aircraft being 1,000 pounds overweight, the use of an unapproved GPS as a primary navigational aid, and the pilot's potential spatial disorientation (somatogravic illusion) following a power increase. The TSB also cited inadequate safety oversight by Transport Canada, which had deferred a post-certification audit. The investigation was significantly hindered by the lack of a CVR and FDR, which left many facts unknown and reduced the opportunity to uncover further safety risks.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Had not completed required training to operate the aircraft from either pilot seat (right seat conversion).
First Officer
Systems & Failure Modes
GPS
The aircraft was equipped with a GPS that was not approved as a primary navigational aid, yet evidence suggested the crew used it for navigation during the final approach.
ELT
The Emergency Locator Transmitter failed to provide an adequate signal because the antenna cable was installed with insufficient slack and detached during the crash.
GPWS
The aircraft was not equipped with a Ground Proximity Warning System, nor was it required by Canadian regulations for this type of operation at the time.
Interesting Facts
- 01The aircraft was approximately 1,000 pounds (450 kg) over its maximum allowable weight at both takeoff and landing.
- 02The captain had 15,000 total flight hours but only 114 hours on the EMB-110 type.
- 03The aircraft was not equipped with a Cockpit Voice Recorder (CVR) or Flight Data Recorder (FDR) due to regulatory exemptions.
- 04The ELT signal was weak because the antenna cable pulled out of its fitting during the impact due to lack of slack.
- 05The aircraft was flying at approximately 150 feet above the lake, while the Minimum Descent Altitude (MDA) was 555 feet above airport elevation.
- 06Post-mortem tests found carbon monoxide and diphenhydramine in the captain's system, though their effect on his performance could not be definitively determined.
Safety Actions & Advisories
Pilot Decision Making Training
Transport Canada prepared a Notice of Proposed Amendment to require annual Pilot Decision Making (PDM) training for operators authorized for reduced visibility operations.
Approach Ban Review
A joint study group was formed to review safety data regarding approaches in poor weather, leading to regulatory recommendations for approach bans.
Marginal Weather Awareness
Transport Canada increased national aviation safety promotional efforts focusing on the risks of operating in marginal VFR conditions.
Location
ACCIDENT SITE · Coordinates taken from the official investigation report.