What happened
On an instrument flight following route from Val-d'Or to Chibougamau/Chapais, a Beechcraft A100, registration C-FNIF, operated by Air Creebec Inc., experienced a fatal accident during its second approach to Runway 05. After an initial missed approach, the crew attempted a second approach using a pilot-in-command monitored approach (PICMA) procedure.
During this second attempt, the aircraft performed a race-track pattern that descended below the minimum sector altitude. As the aircraft attempted to realign with the runway centerline, the pilot flying executed a steep left turn. This maneuver, combined with a high rate of descent and increased load factor, caused the aircraft to stall at an altitude of less to than 100 feet above the ground. The aircraft struck the runway approximately 500 feet from the threshold, triggering a fire that destroyed the aircraft. The two fatalities involved were both pilots on board.
The investigation
The TSB examined the flight crew's actions, the aircraft's mechanical state, and the operational procedures in place. The investigation confirmed that the aircraft was properly maintained and that no mechanical failures or airframe issues contributed to the crash. Analysis of the cockpit voice recorder allowed investigators to reconstruct the final 30 minutes of the flight.
The investigation also looked into the crew's navigation methods, noting that the pilot-in-command had attempted to program a GPS for the approach despite not being trained or authorized to use it as a primary navigation source. The investigation also reviewed the communication between the crew and the Québec Flight Information Centre, as well as radio transmissions from another aircraft, Propair 102, which was operating in the same area.
Findings
- The aircraft was configured late for the approach, which led to an unstable approach condition.
- The pilot flying performed a steep turn at a low altitude, which increased the load factor and caused the aircraft to stall at an altitude too low for recovery.
- High workloads, driven by time spent programming the GPS, resulted in several procedural omissions, including failure to activate aerodrome lighting (ARCAL) and late radio communications on the mandatory frequency.
- The crew's limited experience in instrument flight rules (IFR) and multi-crew environments contributed to a poor interpretation of approach procedures and deficiencies in crew resource management (CRM).
- The decision to continue the approach despite the unstable condition may have been influenced by flight delays and the unexpected transfer of controls during the maneuver.