What happened
On a night flight from Pikangikum, Ontario, to Poplar Hill, a Beech 99, registration C-GHVI, experienced a loss of control shortly after takeoff. The flight, operated by Bearskin Lake Air Service, was carrying two pilots and three passengers under visual flight rules. Following a normal takeoff from Runway 21, the pilot flying, seated in the right-hand seat, initiated a climbing right turn at approximately 400 feet above ground level.
During the maneuver, the pilot flying struggled to discern the artificial horizon due to inadequate instrument lighting. As the aircraft banked, a high rate of descent developed, reaching 2000 feet per minute. The first officer identified the descent and took control of the aircraft. Despite efforts by both crew members to pull up, the aircraft struck the frozen surface of a lake. The impact caused the aircraft to bounce, but the damage to the engines and propellers necessitated an immediate forced landing. The crew successfully landed the aircraft on the snow-covered lake surface about 1.5 nautical miles from the departure runway. There were no injuries to the five people on board, though the aircraft sustained substantial damage.
The investigation
The investigation examined the cockpit configuration, crew training records, and environmental conditions. It was determined that a recent crew change had placed the captain in the right-hand seat. While company policy allows qualified pilots to operate from the right seat with annual training, the captain had not completed the required right-seat training.
Investigators also reviewed the cockpit lighting settings. During the previous flight leg, the captain had reduced the brightness of the right-side instrument lighting. This setting was not adjusted prior to the departure from Pikanglykum. Furthermore, the investigation looked into the visibility conditions, noting that the night was extremely dark with no moonlight, and the lack of ground lighting made maintaining visual reference to the surface difficult.
Findings
- The captain elected to operate the aircraft from the right seat despite not being current in that position.
- Inadequate instrument lighting prevented the pilot flying from effectively using the artificial horizon, leading to a loss of situational awareness.
- The flight was effectively operating under instrument conditions despite being filed as a visual flight rules flight.
- The lack of ambient light and ground references made maintaining visual reference to the surface nearly impossible.