What happened
On 14 February 2003, a Cessna 210N, registration N104WF, was performing a ferry flight from Narsarsuaq, Greenland, to Goose Bay, Newfoundland and Labrador. The flight was part of a larger journey from Scotland to the United States. While conducting a straight-in precision radar approach to Runway 26 under instrument meteorological conditions, the pilot reported that the aircraft's attitude indicator had failed.
Shortly after this transmission, the aircraft entered a left-wing-down spiral dive. The aircraft struck the ice-covered surface of Hamilton Inlet at high speed. The impact resulted in two fatalities, involving the pilot and her daughter, and the total destruction of the aircraft. The accident occurred in darkness, approximately five nautical miles east of the airport.
The investigation
The investigation examined the mechanical state of the aircraft and the circumstances of the flight. Records indicated that while the aircraft had undergone recent maintenance, several mechanical deficiencies remained unaddressed at the time of departure. These included a malfunctioning cabin heater, an unserviceable turn coordinator, and an expired emergency locator transmitter (ELT) battery.
Engineers examined the wreckage and determined that while the vacuum system was producing suction, the attitude indicator's gyroscope had ceased to function with sufficient energy. The investigation also reviewed the flight planning, noting that the pilot had selected Churchill Falls as an alternate airport despite the aircraft lacking the necessary navigation equipment (ADF) to perform an approach there, and despite the forecast weather at the alternate being below legal limits. Furthermore, the aircraft's fuel reserves were insufficient to meet regulatory requirements for the planned alternate.
Findings
- The attitude indicator gyro stopped functioning for an unknown reason during the approach.
- The pilot was unable to recover from the spiral dive because the turn coordinator was unserviceable, leaving no secondary means to assess the aircraft's attitude.
- The aircraft was not equipped with the necessary navigation equipment to fly the approach at the filed alternate airport.
- The flight was conducted in extreme cold without functional cabin heating, which may have contributed to pilot fatigue or window frosting.
- The ELT was not in the armed position, and the battery was expired, which hindered the detection of the distress signal.
- The aircraft lacked the required fuel reserves to legally fly to and land at the designated alternate airport.