What happened
On a flight originally scheduled from Port Menier to Du Rocher-Percé, a Piper PA-3/1-350, registration C-GBYL, diverted to Gaspé, Quebec, due to unfavorable weather at the initial destination. The aircraft, operated by Aéropro, was carrying one pilot and four passengers. After an initial missed approach at Gaspé, the pilot attempted a second approach to Runway 29.
During this second attempt, the pilot executed a manual approach without the use of the aircraft's autopilot. As the aircraft neared the threshold, the pilot mistook the left row of runway lights for the right row and decided to land. The aircraft touched down 2400 feet past the runway threshold and 60 feet to the left of the centerline on a surface covered in approximately 60 cm of snow. The impact caused the nosewheel to separate, and the aircraft subsequently overturned. While the crew and passengers were rescued by airport staff, the accident resulted in one serious injury and four minor injuries.
The investigation
The investigation examined the flight's history, the pilot's workload, and the environmental conditions at Gaspé. Investigators found that the pilot's flight schedule for the day was unrealistic, involving ten flights over nearly eight hours. On the second approach, the pilot's speed was significantly above the landing reference speed, and the approach was unstable.
Technical analysis of the aircraft revealed that the cargo, which included frozen meat and baggage, was not secured with straps or nets. Upon the aircraft's rapid deceleration, this cargo shifted forward, destroying utility cabinets and obstructing the evacuation of the occupants. Additionally, while the aircraft was equipped with a functional autopilot, the pilot chose to fly the approach manually, significantly increasing his cognitive workload during deteriorating visibility.
Findings
- The pilot mistook the left runway lights for the right and proceeded to land without sufficient visual references.
- The pilot's decision to execute a manual approach increased his workload, preventing him from effectively monitoring deviations from the runway centerline.
- The airport environment lacked sufficient visual contrast because the runway markings were obscured by snow and the aircraft was positioned left of the centerline.
- The pilot utilized medium-intensity runway lighting when high-intensity lighting would have been more effective for the conditions.
- The lack of secured cargo contributed to the obstruction of the emergency evacuation.