What happened
On July 7, 2003, a privately owned Beech 58TC Baron, registered N6058T, crashed into Lake Ontario approximately 3 nautical miles southeast of the Toronto City Centre Airport. The flight originated from Lansing Municipal Airport in Illinois and was conducting a LOC/DME B instrument approach to Toronto.
During the approach, the pilot was cleared to descend to 3000 feet at the TILEL fix. Radar data indicated that after passing the fix, the aircraft's descent rate and airspeed began to increase. While the aircraft had previously leveled off at 2900 feet, it eventually crossed the VOKUB 5 DME fix at 1000 feet with a high rate of descent. The aircraft continued to descend until it struck the water at approximately 3.6 DME, well below the minimum descent altitude (MDA) of 760 feet.
The pilot sustained minor injuries upon impact but died from drowning after the aircraft settled on the lake floor at a depth of 220 feet. The wreckage was recovered on July 21, 2003.
The investigation
The TSB examined the wreckage, radar data, and communication records. The investigation confirmed that the aircraft was in a normal approach configuration, with the landing gear down and flaps extended. There were no signs of mechanical failure or structural anomalies that would have prevented controlled flight.
Investigators also reviewed the pilot's recent flight history, noting that while the pilot held an instrument rating, he had very limited recent experience in actual instrument meteorological conditions (IMC). The investigation also looked into the weather conditions, which included patchy fog and variable visibility during the approach.
Findings
- The pilot lost situational awareness regarding the aircraft's altitude during the final stages of a non-precision approach.
- The pilot descended below the MDA while unaware of the proximity to the water surface.
- Contributing factors included poor visibility, the use of a non-precision approach, and potential visual illusions caused by surface-based fog.
- The pilot's low level of recent instrument proficiency and the possibility of rushed or incomplete pre-landing checks further eroded situational awareness.
- The investigation noted that differences in how minimum altitudes are presented on Canadian versus U.S. approach plates could potentially cause confusion.