Seven dead in private plane crash in Quebec

[blues deville]

Well below standard altimeter and below zero temps? Not a great situation for a part time private pilot.

[Specs]

Plane carrying Jean Lapierre was flying higher, faster than recommended: TSB

By Morgan Lowrie

MONTREAL — The plane that crashed with former federal cabinet minister Jean Lapierre and six other people aboard on March 29 was travelling faster and at a higher altitude than recommended, the Transportation Safety Board said Wednesday.

The federal agency said the plane crashed short of the airport in Îles-de-la-Madeleine soon after the pilot turned off the autopilot and lowered the landing gear.

Almost immediately afterwards, the Mitsubishi MU-2B-60 aircraft “rolled quickly into a steep right bank and descended rapidly” before smashing to the ground, the TSB wrote in an investigation update.

According to the report, the aircraft’s mechanical systems all appeared to be working and the pilot was qualified for the flight.

“No mechanical deficiencies have been identified with the aircraft’s engines, flight controls, landing gear, and navigation systems,” it read.

The board said the plane that was carrying the seven victims of the crash was going nearly 90 knots faster than is standard — 240 knots instead of 150 knots — upon its initial approach for landing and reduced its speed to 175 knots upon final approach — 25 knots faster than the standard speed.

 

http://montrealgazette.com/news/quebec/speed-and-altitude-during-landing-at-fault-in-crash-that-killed-jean-lapierre

 

 

 

[blues deville]

This accident occurred in late March and the TSB is already releasing details to the general public?

[Airband]

4 hours ago, blues deville said:

This accident occurred in late March and the TSB is already is already releasing details to the general public?

Not sure that's a departure from past practice. Similar update was released on AC's accident in YHZ just 3 months after the incident.

[Canoehead]

At what point do you think 'yeah, might be time to try this again...' ?

About 800' high at 220kts and 1800fpm by the FAF going into Grindstone?  You've got to be kidding me.  Respectfully, that's just some of the ugliest flying I've ever heard of.  Brings a whole new meaning to unstable approaches.

Totally preventable. 

(Assuming there really was no mechanical failures of course)

[blues deville]

I believe this was a part time private pilot who owned or had access to this airplane. Apparently the person in the right side was was a low time pilot. Add some unusual weather with this high performance plane.....yikes. You end up with that data. 

[av8tor]

Information on the pilots' experience level can be found here:

http://www.tsb.gc.ca/eng/enquetes-investigations/aviation/2016/a16a0032/a16a0032.asp

[DEFCON]

And people want to believe an airliner can be landed with a little instruction provided from ground to air by radio?

 

[Guest]

Aviation Investigation A16A0032

Collision with terrain

Updated on 13 July 2016

The following update contains the facts that the TSB has been able to validate at this time. It contains no conclusions about the factors that contributed to the accident. The final investigation report will provide analysis of the accident and the findings of the Board.

 

The occurrence

On 29 March 2016, a private Mitsubishi MU-2B-60 aircraft (United States registration N246W), departed St. Hubert, Quebec, at 0931 local time (Eastern Daylight Time) on a flight to Îles-de-la-Madeleine, Quebec (CYGR). Onboard was the pilot-in-command, a pilot-passenger occupying the right-hand cockpit seat, and 5 passengers.

The autopilot was being used to control the aircraft throughout the flight.

At 1217 Atlantic Daylight Time (ADT), when the aircraft was at approximately 21 000 feet above sea level and 51 nautical miles (nm) from CYGR, the pilot initiated the descent. At 1225, Moncton Area Control Centre cleared the aircraft for an instrument flight rules approach (flying by reference to instruments rather than flying with visual reference to the ground) to CYGR. At 1229, 2.7 nm from Runway 07, the aircraft landing gear was lowered and approach flaps were selected.

Shortly after that, the autopilot was disconnected, and almost immediately the aircraft departed from controlled flight. It rolled quickly into a steep right bank and descended rapidly. The aircraft continued its rapid descent and impacted the ground in a near-level attitude. All 7 occupants were fatally injured.

A site survey was completed and the wreckage was transported to the TSB Engineering Laboratory (Lab) in Ottawa. The field phase of the investigation is complete and the examination and analysis phase is in progress.

TSB investigators have been in contact with the families of the aircraft's occupants to explain the role of the TSB and our investigation process.

A large number of technical and operational documents, weather reports, air traffic control communications, and incident reports have been gathered and reviewed by investigation team members.

Numerous interviews have been conducted with witnesses and individuals from various organizations.

Initial examination and documentation of aircraft systems, components and structural damage has been completed.

What we know

Aircraft

• The aircraft was certified and equipped to conduct the approved approach into CYGR.
• The investigation found that both the altitude and the speed of the aircraft's approach to CYGR were higher than recommended.
• On the MU-2 instrument-approach profile, the standard speed prior to the initial approach fix is 150 knots, slowing to a final approach speed of 125 knots past the final approach fix.
• In this instance, the aircraft's speed prior to the initial approach fix was 240 knots, and past the final approach fix the speed decreased below 175 knots, only 2.7 nm from Runway 07—much later than prescribed (Figure 1). The aircraft landing gear was lowered and approach flaps were selected at this point.
• No mechanical deficiencies have been identified with the aircraft's engines, flight controls, landing gear, and navigation systems.
• Communications with the aircraft throughout the flight were normal.
• In October 2005, the FAA began a safety evaluation of the MU-2's accident history. As a result, in 2008, it issued a Special Federal Air Regulation (SFAR 108) that requires MU-2 pilots to complete a standardized training program and to use a standardized checklist. At 29 March 2016, this was the third fatal MU-2 accident since SFAR 108's implementation.
• There are 263 MU-2 aircraft in service; 11 are in Canada.

Lightweight recorder

• Although not required by regulation, the occurrence aircraft was equipped with a lightweight recording system.
• It was recovered in good condition from the wreckage.
• TSB specialists at the Lab have extracted and continue to analyze data from the recorder.
• The recorder will provide information critical to understanding the circumstances and events that led to the departure from controlled flight—information that would not have been available to the investigation if the aircraft had not been equipped with a recording system.

Aircraft approach path

 

Figure 1. N246W actual approach (onboard recorder data), compared with the standard aproach

 

Pilot

• Records indicate the pilot was certified and qualified for the flight in accordance with existing regulations, and had completed the SFAR 108 standardized training program.
• The pilot had about 2500 hours total flight time, and about 140 hours on the MU-2.

Pilot-passenger

• The pilot-passenger occupying the right-hand cockpit seat was a commercial pilot and flight instructor.
• The pilot-passenger was not qualified to fly the MU-2.
• A second crew member was not required to fly the MU-2.
• The pilot-passenger was invited to come on the flight to help with some basic piloting functions.

Weather

• A detailed weather analysis for CYGR on the day of the accident has been completed. Between 0900 and 1500 ADT, visibility varied between 1½ and 3 statute miles. During this same period, ceilings (cloud base heights) varied between 200 and 400 feet above ground level (agl) and northeast winds varied between 20 to 30 knots with gusts as high as 35 knots.
• Weather forecast for CYGR indicated a potential for moderate mixed icing in cloud, particularly below 10 000 feet in the vicinity of Îles-de-la-Madeleine. There was also the potential for moderate mechanical turbulence below 3000 feet.
• In accordance with instrument flying rules, the Charlottetown airport (CYYG) had been selected as the alternate airport.

Next steps

The next steps of the investigation include the following work:

• Analyzing the accident flight profile to understand the approach phase of the flight and the challenges encountered by the pilot.
• Evaluating aircraft performance and determining if weather affected the performance.
• Evaluating pilot training and experience, and human performance aspects.
• Reviewing MU-2B aircraft handling and approach-and-landing issues.
• Evaluating the SFAR 108 standardized training, and other MU-2 safety action taken in the past.
• Conducting additional interviews as required.
• Completing the report phase of the investigation.

Outstanding safety issues

Approach-and-landing accidents

Every year, millions of successful landings occur on Canadian runways. However, there is a risk that accidents resulting in loss of life, injury, and aircraft damage can occur during the approach-and-landing phase of flight. In Canada, from 2009 to 2013, Canadian-registered aircraft were involved in an average of 150 approach-and-landing accidents every year. The TSB Watchlist identifies approach-and-landing accidents as one issue which poses the greatest risk to Canada's transportation system.

Stable approaches significantly increase the chances of a safe landing. Without improvements to stable-approach policy compliance, most unstable approaches will continue to a landing, increasing the risk of approach-and-landing accidents.

Lightweight flight recording systems

In 2013, following its investigation into the March 2011 loss of control/in-flight break-up occurrence, northeast of Mayo, Yukon (TSB Aviation Investigation Report A11W0048), the TSB found that if cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded. It further concluded that in the event that an accident does occur, recordings from lightweight flight recording systems will provide useful information to enhance the identification of safety deficiencies in the investigation. Therefore, the Board recommended that

The Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.

TSB Recommendation A13-01

 

TSB Recommendation A13-01 speaks about the benefits of lightweight flight recording systems for smaller commercial operations. However, this kind of system would also be equally beneficial for aircraft operated by private operators, for flight training and general aviation aircraft as demonstrated in this occurrence. As noted, in this investigation, valuable information was extracted and is being analyzed.

Communication of safety deficiencies

Should the investigation team uncover a safety deficiency that represents an immediate risk to aviation, the Board will communicate immediately so that it may be addressed quickly and the aviation system made safer.

Investigator-in-Charge

Bruce Mullen joined the TSB in May of 2010 with over 27 years and 8000 hours of flight experience in various types of aircraft. Prior to joining the TSB, he was a member of the Royal Canadian Mounted Police for almost 25 years; 9 of which were spent in Alberta as an RCMP investigator/Peace Officer.

Mr. Mullen also spent several years with the Department of Fisheries and Oceans as a research scientist and co – authored several Fisheries Research Publications.

 

Investigation teamwork

The Investigator-in-Charge, Bruce Mullen, is being assisted in this investigation by TSB investigators with backgrounds in flight operations, aircraft performance, aircraft systems and engines, human performance, and air traffic control. Representatives from Transport Canada, NAV CANADA, the Sûreté du Québec, the Bureau du coroner du Québec, the National Transportation Safety Board, the Federal Aviation Administration (FAA), the Mitsubishi Aircraft Corporation, Honeywell International Inc., and Hartzell Propeller Inc. are also providing assistance.

Photos

               

 

http://www.tsb.gc.ca/eng/enquetes-investigations/aviation/2016/a16a0032/a16a0032.asp

[DEFCON]

Thanks for bringing us back to this story Malcolm.

Interesting report. No matter whether ice, or other MU2 handling issues played a role, it's pretty clear that this pilot pushed the aircraft way beyond acceptable standards and killed everyone by doing so.

 

 

[Lakelad]

.

Unstable approach was key factor in plane crash that killed Jean Lapierre and family, TSB report finds

Transportation Safety Board reveals results of investigation into death of former cabinet minister

Wed Jan 10, 2018 -  CBC News
By Elias Abboud, Kalina Laframboise

The Transportation Safety Board of Canada says the pilot's decision to continue an unstable approach was the key factor in the plane crash that killed Jean Lapierre and his family in Quebec's Magdalen Islands almost two years ago.

The report says the loss of control occurred on the Mitsubishi MU-2B-60 aircraft "when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly."

While pilot Pascal Gosselin, who both owned and flew the plane, attempted to recover, there was insufficient altitude before the aircraft struck the ground.

The plane broke apart before coming to rest near a cluster of homes in the Magdalen Islands.

The report found Gosselin was trying to deal with too many tasks when he lost control, with little time to react.

"The pilot was in a very complex situation, in an unstable situation," said TSB investigations director Natacha Van Themsche.

"It's a mix of factors. The pilot, you have to understand, that most other pilots probably would have taken the same actions."

The TSB also found that while Gosselin had the number of required hours to fly the aircraft, he had only flown that aircraft for a total of four hours in the month prior to the crash.

The report found it was unlikely that his "flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU-2B for the conditions experienced during the occurrence flight."

Lapierre, his wife Nicole Beaulieu, his sister Martine Lapierre, and brothers Marc Lapierre and Louis Lapierre, all died in the crash on March 29, 2016. Lapierre was a political commentator and former Liberal federal cabinet minister.

Gosselin and crew member Fabrice Labourel also died when the plane went down.

The Lapierres were on their way to the Magdalen Islands to plan the funeral of the family patriarch, Raymond Lapierre, who had died a day earlier.

The Lapierre family said it will read the report before commenting with a written statement.

'Suitable, not ideal' weather

On the morning the flight took off from the Saint-Hubert airport, just south of Montreal, there were reports of fog on the islands, which are in the Gulf of St. Lawrence, close to P.E.I. Several commercial airlines cancelled flights because of the weather.

A weather report warned of limited visibility and a low cloud ceiling with the potential for icing in the air.

After the crash, some pilots and aviation experts questioned whether the twin-engine turboprop should have taken off in the first place, and whether Gosselin should have flown to an airport with better weather conditions.

The findings, however, did not point to weather conditions as a contributing factor to the fatal crash.

"The conditions under which the pilot operated were suitable, not ideal — but it was suitable and legal to take flight that day," said TSB chair Kathy Fox.

TSB Report

 

 

 

.

[Kip Powick]

10 minutes ago, Lakelad said:

"The pilot was in a very complex situation, in an unstable situation," said TSB investigations director Natacha Van Themsche.

"It's a mix of factors. The pilot, you have to understand, that most other pilots probably would have taken the same actions."

Say Whaaaaat ??????

Maybe I'm wrong but most other trained and competent  pilots would have "gone around" much earlier, especially when not one approach altitude or air speed was realized during the entire approach....I don't think he was overloaded...he was trying to salvage an extremely poor flown approach, an approach that should have been aborted long before he  was even 6-8 miles from the airport.

Many an accident has had serious consequences and only because the PF felt he could handle everything and  anything.... 

 

[Guest]

41 minutes ago, Kip Powick said:

Say Whaaaaat ??????

Maybe I'm wrong but most other trained and competent  pilots would have "gone around" much earlier, especially when not one approach altitude or air speed was realized during the entire approach....I don't think he was overloaded...he was trying to salvage an extremely poor flown approach, an approach that should have been aborted long before he  was even 6-8 miles from the airport.

Many an accident has had serious consequences and only because the PF felt he could handle everything and  anything.... 

 

Kip: here is what the actual report says, not sure where the quote came from that the press story used.

Quote

2.0 Analysis

2.1 Introduction The aircraft was equipped and maintained in accordance with regulations; no mechanical discrepancies were reported or found during the examination that would have prevented it from operating normally. The pilot had completed all required training to operate the MU-2B under the authority of his Federal Aviation Administration–issued private pilot certificate. The data and audio retrieved from the Wi-Flight was critical to understanding the events that led to the accident. Although not required by regulation, the installation and use of a lightweight flight recording system during the occurrence flight, as well as the successful retrieval of its data during the investigation, permitted a greater understanding of this accident. The analysis will focus on the events, conditions, and underlying factors that caused or contributed to this accident. It will include approach planning, descent and approach, workload management during final approach, situational awareness and “getting behind” the aircraft, the pilot’s experience on the aircraft type, and online flight planning. In addition, it will examine risks to the transportation system, with the objective of improving aviation safety.

2.2 Approach planning While in cruise flight, the pilot recognized there would be a strong tailwind during the descent. The pilot developed his approach plan, which included starting a 1500-feet-perminute (fpm) descent when prompted to do so by the aircraft’s global positioning system (GPS) in order to cross the initial approach waypoint (DAVAK) at 3000 feet above sea level (ASL). The minimum descent altitude (MDA) of 620 feet ASL was set on the radio altimeter, and the missed-approach altitude of 1900 feet ASL was noted. Other than the briefing on the minimum descent and missed approach altitudes, there was no briefing of when or under what conditions a go-around would be performed. The pilot subsequently decided to delay the descent to reduce fuel consumption and to minimize the time spent in cloud by adopting a higher airspeed and rate of descent. This led the pilot to further revise the plan to carry out the descent at 250 knots indicated airspeed and at a rate of 2000 fpm. This new plan would still have enabled the aircraft to reach DAVAK at or near 3000 feet. However, the faster and steeper descent would cause the aircraft to be in a high-energy condition, which would require more vigilant monitoring by the pilot. The broken ceiling at 200 feet was approximately 400 feet lower than the MDA; however, there was no discussion of the potential risks associated with continuing the approach. No 50 | Transportation Safety Board of Canada contingency plan, such as performing a go-around if circumstances dictated, was discussed. The pilot continued with his original plan to land at CYGR. If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.

2.3 Descent and approach The descent started when the aircraft was 51 nautical miles (nm) from CYGR. The descent checklist was started almost immediately after the descent began. While completing the checklist, the pilot engaged the passenger-pilot in non-essential communication, explaining aircraft systems and their operation. This interrupted the flow of the necessary cockpit activities and continued throughout the completion of the checklist. As a result, the actual descent rate began at 800 fpm, and more than 4 minutes later it had increased to only 1800 fpm, still 200 fpm below the briefed and planned descent rate of 2000 fpm. This placed the aircraft above the planned descent profile and further compressed the time available to complete subsequent checklist activities, thereby increasing the pilot’s workload. If pilots engage in non-essential communication during critical phases of flight, there is an increased risk that they will be distracted, which reduces the time available to complete cockpit activities and increases their workload. One of a pilot’s primary tasks is to maintain an energy condition appropriate to the phase of flight and, if deemed necessary, to recover the aircraft from a low- or high-energy condition. Approximately 6 minutes after starting the descent, the pilot recognized that the aircraft was too high and that the descent rate would have to be increased substantially to achieve his original plan of arriving at DAVAK at the correct altitude. To do so, the pilot reduced the engine power and increased the rate of descent to more than 2000 fpm. Just over a minute later, after the pilot reset the altimeter, effectively losing about 1000 feet of altitude, the aircraft was descending at 2500 fpm at 240 knots, which is considered a high-energy condition. When the aircraft crossed DAVAK, it was 1500 feet too high, about 100 knots too fast, and still descending at 1600 fpm. During the descent and approach, the airspeed constantly exceeded the MU-2B’s published values, and the rates of descent exceeded those typically defined by stabilized approach criteria. Although the pilot had properly briefed the passenger-pilot on the approach and realized he was high, fast, and not configured for landing, he continued the unstable approach. If pilots do not apply stable-approach criteria, there is a risk that they will continue an unstable approach to a landing, which can lead to an approach-and-landing accident. Aviation Investigation Report A16A0032 | 51

2.4 Workload management during final approach During the final approach, the pilot became primarily focused on individual tasks— alternating his attention among airspeed, rate of descent, and altitude—based on what he deemed critical at any one time, without planning and preparing for contingencies. This is consistent with attentional tunnelling. Specifically, the pilot initially focused on ensuring that the airspeed was reduced so that the aircraft could be configured for landing upon reaching the final approach waypoint IMOPA. However, as the aircraft crossed IMOPA, it was about 790 feet too high and 50 knots too fast, descending at 1900 fpm. At 2.7 nm from CYGR, the airspeed had been reduced to 175 knots, and the descent rate to 1200 fpm, when the aircraft flaps were selected to 5° and the landing gear was extended. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach. The pilot’s workload had significantly increased, which would have influenced his ability to make decisions; the pilot likely did not recognize that a go-around was an option available to reduce his workload. If pilots do not recognize that changing circumstances require a new plan, then plan continuation bias may lead them to continue with their original plan even though it may not be safe to do so. With less than 2.7 nm remaining to reach the runway, the pilot’s attention was diverted from monitoring airspeed to monitoring the altitude so that the aircraft would not descend below the MDA. The passenger-pilot stated that the ground could be seen on the right side of the aircraft, but at no time during the descent did the pilot indicate that he had the runway in sight. During the final moments of the flight, by the time the pilot had refocused his attention on the airspeed, the aircraft had already transitioned to a low-energy condition and the airspeed had decreased to 99 knots, within a few knots of the stall speed of 95 knots. At the time the pilot disconnected the autopilot, he recognized that the airspeed was critically low. While the aircraft was in a low-energy state and approaching the onset of a stall, the pilot rapidly advanced the power levers, causing a power-induced upset, resulting in the aircraft rolling sharply to the right and descending rapidly. The aircraft experienced a loss of control and responded in the manner described in MU-2B documents, which was consistent with the effects of the counterclockwise-rotating propellers. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.

2.5 Situational awareness and “getting behind” the aircraft Situational awareness requires a pilot to align the reality of a situation with his or her expectations. Maintaining situational awareness allows a pilot to plan and prepare for the 52 | Transportation Safety Board of Canada unexpected, thereby fostering more effective decision making. Any reduction in the pilot’s ability to effectively process information may result in a loss of situational awareness. The pilot recognized that the aircraft was high, fast, and not configured for landing as it passed the final approach waypoint. Plan continuation bias, overconfidence bias, attentional tunnelling, and framing bias contributed to the pilot’s continuing the approach. When the tasks required to fly an aircraft exceed the pilot’s capacity to conduct them, the aircraft starts to “get ahead” of the pilot—or the pilot “gets behind” the aircraft. This means that events or situations control the pilot’s actions. In this occurrence, inadequate approach planning and distraction caused by discussions not specific to the flight contributed to the pilot “getting behind” the aircraft, as demonstrated by the following signs: • late descent; • slow initial rate of descent; • late change of altimeter setting; • minimal corrections to rate of descent and airspeed; • failure to complete checklists; and • late landing configuration of the aircraft. The number of tasks that the pilot had to perform in the time remaining exceeded his capacity to perform them. As a result, there was no time available during the approach to conduct the approach checklist or the before-landing checklist. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.

2.6 Experience The occurrence aircraft was the first high-performance aircraft the pilot had flown, and the only aircraft he flew that was equipped with counterclockwise-rotating propellers. On final approach, the aircraft slowed to within a few knots of the stall speed before this was recognized by the pilot. The sudden addition of high power at low airspeed in the MU-2B produces a right-rolling tendency, which can lead to loss of control if not anticipated and corrected. The pilot was surprised by the right roll and delayed correcting it, which permitted the aircraft to roll more than 70° before returning to a near wings-level attitude at impact. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly. Aviation Investigation Report A16A0032 | 53 Although information was available to explain the aircraft’s characteristics when high power is applied at low airspeeds, it is unlikely that the pilot was familiar with this situation, based on his reaction during the occurrence. The pilot had about 2500 total flight hours and had held an airline transport pilot licence for about 6 years, but his flying experience was primarily on non–high performance single-engine and multi-engine aircraft. During the 20 months that the pilot had flown the occurrence aircraft, he had accumulated about 125 flight hours, of which at least 100 hours were flown underthe supervision of a qualified and experienced pilot. In the previous 3 months, he had logged only about 19 flight hours and, in the previous 30 days, only 4 flight hours. The investigation could not determine how many pilot-in-command (PIC) hours the pilot had flown with another pilot accompanying him. Skills are most effective when they are mastered during training and retrained on a regular basis. Degradation of skills is related to the level of proficiency obtained, the length of time since learning, and the repeated use of flight skills following training. The initial slow descent, the lack of effective aircraft energy management, getting behind the aircraft, and the low ceiling presented challenging flight conditions. Therefore, it is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the PIC for single-pilot operation on the MU-2B for the conditions experienced during the occurrence flight.

2.7 Online flight planning The use of Internet-based online flight planning providers is becoming more common. Information is transmitted electronically from the pilot to the flight-planning provider, and then to the area control centre (ACC) for the flight information region, via the aeronautical fixed telecommunications network. The search-and-rescue supplementary information (item 19) listed on a flight plan includes the amount of fuel on board, the number of occupants on board, the name of the PIC, and any emergency equipment on board in case of an off-airport forced or emergency landing. The transfer of search-and-rescue supplementary information is not regarded as mandatory when the flight plan is transmitted. Currently, that information is stored at the flightplanning provider’s base of operations, which could be in another country; therefore, attempts at retrieval of search-and-rescue information when required can be problematic. On the occurrence flight, search-and-rescue supplementary information (item 19) was not transmitted by the flight-planning provider via the aeronautical fixed telecommunications network and therefore was unavailable when the flight information region responsible for the accident location called the ACC to obtain it. The ACC did not have the telephone number of the flight-planning provider, since the pilot had removed it. The first responders did not know how many persons would need search and rescue or medical assistance until they were on scene and were extricating the occupants from the aircraft. 54 | Transportation Safety Board of Canada If a flight plan does not contain search-and-rescue supplementary information, and if that information is not transmitted or readily available, there is a risk that first responders will not have the information they need to respond adequately.

3.0 Findings

3.1 Findings as to causes and contributing factors

1. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach.

2. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.

3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.

4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.

5. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.

6. It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.

3.2 Findings as to risk

1. If the weight of an aircraft exceeds the certified maximum take-off weight, there is a risk of aircraft performance being degraded, which may jeopardize the safety of the flight.

2. If pilots engage in non-essential communication during critical phases of flight, there is an increased risk that they will be distracted, which reduces the time available to complete cockpit activities and increases their workload.

3. If flight, cockpit, or image/video data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

4. If pilots do not recognize that changing circumstances require a new plan, then plan continuation bias may lead them to continue with their original plan even though it may not be safe to do so.

5. If pilots do not apply stable-approach criteria, there is a risk that they will continue an unstable approach to a landing, which can lead to an approach-and-landing accident. 56 | Transportation Safety Board of Canada

6. If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.

7. If a flight plan does not contain search-and-rescue supplementary information, and if that information is not transmitted or readily available, there is a risk that first responders will not have the information they need to respond adequately

[Seeker]

Kip, you need to read the previous sentence: 

"The pilot was in a very complex situation, in an unstable situation," said TSB investigations director Natacha Van Themsche.

"It's a mix of factors. The pilot, you have to understand, that most other pilots probably would have taken the same actions."

I think what she's trying to say is that if you dropped a pilot into the "unstable situation" that he/she would have done the same thing - meaning that he/she would have done a go-around.  This completely ignores the fact that the go-around should have been initiated many miles sooner and that the vast majority of pilots would not have been in that situation in the first place.

I also like this part: 

The report says the loss of control occurred on the Mitsubishi MU-2B-60 aircraft "when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly."

While pilot Pascal Gosselin, who both owned and flew the plane, attempted to recover, there was insufficient altitude before the aircraft struck the ground.

No mention of the fact that this is a required skill and should easily been within the capabilities of a pilot qualified to fly that aircraft.

 

[mo32a]

You can always go around.....

 

 

[Kip Powick]

9 hours ago, seeker said:

I think what she's trying to say is that if you dropped a pilot into the "unstable situation" that he/she would have done the same thing - meaning that he/she would have done a go-around.  This completely ignores the fact that the go-around should have been initiated many miles sooner and that the vast majority of pilots would not have been in that situation in the first place.

Ok...That is basically what I was trying to say and my point is that he was unstable long before he "attempted to go around". and as you say, the vast majority of pilots would not attempt to salvage an unstable approach that late in the approach. He failed to recognize that the approach was fouled up as soon as he missed the numbers at the INITIAL APPROACH FIX and thought, wrongly, that he could salvage the approach. It was also apparent he was not fully cognizant of the quirks of the aircraft when applying full power onto counter rotating props.

The Air Force C-45 (Beech 18),had a similar quirk......during T/O when one pushed the tail up and were just riding on the mains, the prop wash,( clockwise rotating props) rolled under the aircraft, and came out pushing the two vertical stabs to the right  which caused the nose to head for the left ditch.......lots of rudder fun on every takeoff for the uninitiated !!

[Seeker]

Animation of the crash:

 

[Seeker]

6 hours ago, Kip Powick said:

 It was also apparent he was not fully cognizant of the quirks of the aircraft when applying full power onto counter rotating props.

 

Small point - the MU-2 does not have counter-rotating props.

From the report:

 

1.18.2 Effect of propeller performance on aircraft dynamics

1.18.2.1 P-factor

P-factor is the term for asymmetric propeller loading that causes the aircraft to yaw at a high angle of attack (AOA).

A propeller rotating counterclockwise (as viewed from the rear) causes the descending left side of the propeller, which has a higher AOA relative to the oncoming air, to generate more thrust than the ascending right side. As a result, the propeller’s aerodynamic centre is located left of the aircraft’s centreline. For this reason, when the AOA or power is increased, the aircraft responds by yawing to the right.

1.18.2.2 Propeller torque

Propeller torque causes the aircraft to roll on its longitudinal axis in the direction opposite to propeller rotation (Figure 5). Propeller torque is typically counteracted by the pilot moving or trimming the ailerons or spoilers. For example, to counter the aircraft rolling to the right, the pilot must apply the left spoiler. This correction induces adverse yaw, which is corrected by moving or trimming the rudder.

Figure 5. Effect of propeller torque

 

When there is a sudden increase in power, such as when a pilot advances the power levers quickly, there is also a sudden increase in torque. This situation can be critical when landing because the aircraft is at a relatively low speed. When the speed of the air passing over the wings and vertical stabilizer is low, the control surfaces are much less effective and may not be able to counteract the torque.50 This condition can be exacerbated in multi-engine aircraft.

 

[Kip Powick]

1 hour ago, seeker said:

Small point - the MU-2 does not have counter-rotating props.

???

[boestar]

Bot Props rotate counter clockwise.  Many other aircraft negate the torque effect by having one turn each way.  

[Seeker]

22 minutes ago, boestar said:

Bot Props rotate counter clockwise.  Many other aircraft negate the torque effect by having one turn each way.  

Both props on an MU-2 rotate counterclockwise but this is not the same as counter rotating props.  Actually very few aircraft have counter rotating props.  The only place a pilot might realistically encounter these today is on a light Piper; Seneca, Seminole, some Navajos. 

[Seeker]

33 minutes ago, Kip Powick said:

???

Don't understand.  What's your question?  Both props on a MU-2 rotate counterclockwise but this is not the same as counter-rotating props.

You said:

"It was also apparent he was not fully cognizant of the quirks of the aircraft when applying full power onto counter rotating props."

There is no "quirk" when the props are counter-rotating.  When the props are counter-rotating the P-factor and torque are cancelled out.  The "quirk" is when the props are not counter-rotating (as in this case).  The P-factor and torque effect is summed which can lead to an upset (as it did here).

 

 

[Kip Powick]

Oh man....semantics.....surely you understood what I meant.................. What you are saying is that I should have said " rotating counter clockwise"  props.......ok you win...

[Seeker]

41 minutes ago, Kip Powick said:

What you are saying is that I should have said " rotating counter clockwise"  props.......ok you win...

Sorry Kip, I didn't understand what you were saying.  I understand it now but, unfortunately, I think you actually still have this wrong.  The problem was not that the props were rotating counterclockwise it was that they were both rotating the same way.  If the props had been rotating clockwise the exact same issue would have existed except that the aircraft would have veered to the left instead of to the right.

This is the fault of the report.  It makes a big deal out of the props rotating one way, aircraft veering the other way.  This makes it sound as if it's something unique.  It's not.  The focus should have been on the pilot not being able to handle the application of high-power at low-speed not on which way the props were turning or which way the aircraft veered.

[Kip Powick]

Take a look at my comment  (small text)t re- the Mil C-45 -( B-18).......I am very familiar about what happens at low speed with any twin where both props rotate in the same direction be it clockwise or counter clockwise. Of course the reaction of the aircraft depends on speed and airframe design/structure.

41 minutes ago, seeker said:

This makes it sound as if it's something unique.  It's not.  The focus should have been on the pilot not being able to handle the application of high-power at low-speed not on which way the props were turning or which way the aircraft veered.

Look at it this way.....had one prop rotated one way and the other rotated the other way, his application of full power would probably dug him out of the hole he was entering. Better still if he was better aware of what would  happened at low speed with the prop./airframe config and the application of full power and had he  anticipated the roll, he could have corrected and 'possibly ' flown away unscathed..... When was the last time you flew any aircraft and let it roll 70 degrees before you corrected the roll?? 

He was not aware of the consequences of full power application at low airspeed which would result in a roll  and the contributing factor was the direction the props rotated...something perhaps many low-time twin engine jockeys are not aware of. At least this report does point out the consequences of flying an unstable approach and not being familiar with the flight envelope/characteristics  of the aircraft you are flying. I would put money on the fact that many low time twin prop drivers would find this report very enlightening, especially because of the consequences of NOT KNOWING your aircraft.