What happened
At 2140 CST, a Sky North Air Ltd. Beechcraft A100, registration C-FSNA, was performing a flight from Gods Lake Narrows to Thompson, Manitoba. The aircraft was carrying two pilots, a flight nurse, and two patients. Shortly after departing Runway 32, the crew observed smoke and flames emerging from the cockpit pedestal area during a climbing left turn.
In an attempt to return to the airport via Runway 14, the captain continued the turn at approximately 400 feet above ground level. During this maneuver, the aircraft's bank angle increased significantly. As the landing gear was extended, a stall warning activated. The pilot attempted to level the wings and apply full power, but the aircraft descended into trees approximately one-half nautical mile northwest of the airport. The impact and subsequent fire destroyed the aircraft. All five occupants successfully evacuated the wreckage, though two individuals sustained minor injuries.
The investigation
The investigation focused on the electrical failure and the crew's response during the emergency. Investigators examined the cockpit electrical distribution system and the aircraft's age, noting the plane was 32 years old. The investigation also reviewed the operator's Standard Operating Procedures (SOP) and pilot training protocols.
Technicians analyzed the cockpit pedestal and wiring, while the laboratory examined the emergency locator transmitter (ELT), which was too damaged by fire to determine if it had functioned. The investigation also looked into the environmental conditions, noting the flight occurred in total darkness with no visual horizon, creating a high risk for the 'black hole' illusion.
Findings
- An electrical short circuit in the cockpit pedestal area caused the initial flames and smoke.
- The aging of the wiring may have contributed to the electrical arc event.
- The crew attempted an emergency return at a low altitude without sufficient visual references, leading to a loss of control from which recovery was impossible.
- The operator's SOPs lacked specific instructions for managing an electrical fire at low altitudes during night operations.
- The lack of flight simulator training meant the crew had not practiced these specific emergency scenarios in a controlled environment.