Background
On the afternoon of 23 July 2010, passengers arrived at the Nordair Québec 2000 Inc. office in Radisson, Quebec, for a flight to l'Eau Claire Lake the next day. Their baggage was transported in two cars. The pilot inspected the baggage and agreed that loading it all on the aircraft would not be a problem. The passengers were to join a canoe expedition.
Accident Flight
On 24 July, the aircraft was fuelled at La Grande-Rivière Airport. It took on 374 litres of fuel, including three full belly tanks and two additional 20-litre containers. Four other 20-litre containers were filled with automotive fuel. Two containers were placed in the forward float compartments, and the other four were placed immediately behind the rear passenger seat in the cabin. Additionally, an 18-foot-long, 32-inch-wide canoe was tied directly to the right float struts.
The aircraft had two forward seats and one triple seat aft. The pilot loaded baggage behind the triple seat without weighing it. Passengers chose their own seats.
At 1051, the pilot informed the Flight Services Specialist (FSS) that he was ready to taxi for runway 31. The FSS advised that runway 13 was better due to wind, but the pilot elected runway 31. He used the full length of the runway, which was unusual; normally he took off from the taxiway Bravo intersection. The aircraft took off at 1053.
The take-off run was longer than usual. Once airborne, the aircraft could not gain altitude. Engine noise was constant and seemed normal. At approximately 50 feet above ground level near the runway end, the aircraft pitched up, banked left, then nosed down and crashed into a small shallow lake about 900 metres from the runway end, left of the centre line. The emergency locator transmitter activated on impact.
Rescue and Response
The FSS activated the crash alarm upon receiving the ELT signal but could not see the crash site. A misdial occurred when trying to call 911, and the call was made about 10 minutes after the crash. The airport prevention officer drove a fire truck to the runway 13 threshold and saw the aircraft in the lake but could not approach. An Air Inuit HS748 flew over and confirmed no movement. Two airport employees reached the wreckage by trail and wading. The pilot was conscious when they arrived. They rescued one rear-seat passenger and held the heads of the other two above water until first responders arrived. First responders were transported by helicopter; one injured was flown to Chisasibi, and the three rear-seat passengers were later flown to Montreal hospitals.
Wreckage and Investigation
The aircraft broke into three parts on impact. The cockpit rested on its right side in about 1 metre of water. Damage indicated a vertical impact with left bank. The engine compartment pushed upward and right; all float attachments failed. Both wings separated forward. The left float sustained compression damage; the nose wheel separated. The cabin floor was not severely damaged, but the triple seat legs broke, separating the seat from its attachments. Seatbelts were anchored to the seat. Baggage tie-down fittings were installed, but baggage was not secured and shifted forward.
Weight and balance calculations showed the aircraft was overweight on take-off, with a center of gravity aft of the limit prescribed in the supplemental type certificate for the amphibious floats. The aft CG increased stall speed and caused pitch-up characteristics that made recovery difficult. The carrier did not have approval to carry external loads; the canoe exceeded dimensions in the flight test permit. The aerodynamic effects of the oversized canoe were unknown.
The triple seat design met standards, but the forward shift of unsecured baggage was a major factor in the rear-seat passengers' injuries, as the seat pivoted forward on impact.
Transport Canada had conducted inspections since 2003, finding repeated non-conformances, including failure to use baggage tie-downs. Corrective action plans were approved, but anomalies persisted despite monetary penalties. Enhanced monitoring would have targeted repeated deficiencies. TC's actions did not ensure regulatory compliance; unsafe practices continued.
The 911 call delay and the fact that the crash occurred outside airport property meant the Municipality of Radisson was responsible for response, with an estimated 45-minute response time. The two employees who reached the site before first responders likely prevented the rear-seat passengers from drowning.
Probable Cause
The aircraft was overloaded and its centre of gravity was beyond the aft limit. The aircraft pitched up and stalled at an altitude that did not allow the pilot to execute the stall recovery manoeuvre.