What happened
On a flight from Points North Landing, Saskatchewan, to Ennadelle Lake, Nunavut, a Douglas DC-3, registration C-FNTF, attempted a go-around following a landing on an ice strip. During the maneuver, the aircraft entered a steep, nose-up attitude, banked sharply to the left, and descended into the ice. The left wing struck the surface first, causing the aircraft to rotate and strike the ground approximately 400 feet from the end of the runway. The impact resulted in 2 fatalities, as both the pilot and first officer were killed instantly.
The investigation
Investigators examined the aircraft's configuration and the cargo load, which included construction materials such as plywood, insulation, and 2x4 lumber. The investigation revealed that the aircraft was configured for a go-around with the right flap partially extended and the landing gear retracted.
Analysis of the weight and balance documentation showed that the crew had not recalculated the load sheet for the second flight of the day, instead reusing data from an earlier trip. This led to a significant error: the actual center of gravity (C of G) was calculated to be 32.3 inches beyond the allowable aft limit. Furthermore, the 2x4 lumber was inadequately secured to wall attachment points rather than floor tie-downs, and it may have shifted rearward during the aircraft's acceleration.
Additionally, investigators found that the Janitrol heater had leaks that allowed exhaust gas to enter the cockpit. Toxicological tests confirmed elevated carbon monoxide levels in both crew members, with the captain's carboxyhaemoglobin level at 17.9 per cent.
Findings
- The pilot lost control of the aircraft during a go-around maneuver.
- The aircraft's center of gravity was significantly beyond the aft limit.
- The crew failed to recalculate the weight and balance for the second flight, using an inaccurate index number.
- The 2x4 lumber was not properly secured and likely shifted during the maneuver.
- Leaks in the cabin heater allowed carbon monoxide to contaminate the cockpit air.
- Elevated carbon monoxide levels in the captain may have impaired his decision-making and visual acuity.