Occurrence
On 03 December 2019, a captain and first officer from North Star Air Ltd. were scheduled to conduct a daytime cargo flight from Red Lake Airport (CYRL) to Sachigo Lake Airport (CZPB), Ontario, aboard a Douglas DC3C Basler Turbo Conversions TP67 (DC3-TP67) aircraft, registration C-FKAL. During flight planning, the captain checked weather: at 0700 CST, CYRL reported an overcast ceiling at 700 feet AGL; Muskrat Dam Airport (CZMD), 30 NM southeast of CZPB, reported instrument meteorological conditions (IMC) with an overcast ceiling at 500 feet AGL. The forecast at CZMD was to improve to 1500 feet AGL with possible fluctuation to 700 feet AGL and decreased visibility by 0900 CST, the estimated time of arrival at CZPB. The flight departed CYRL under visual flight rules (VFR) at 0800 CST, with reported weather of broken ceiling at 1200 feet AGL and overcast layer at 2000 feet AGL.
Shortly after takeoff, the aircraft entered and climbed above the cloud layers before reaching planned cruising altitude, not in accordance with VFR regulations. Before descent to CZPB, pilots obtained the 0800 CST weather at CZMD, which had remained largely unchanged from 0700 CST, and elected a visual approach to Runway 10. The captain initiated descent through cloud layers by reference to flight instruments.
When the aircraft broke out of cloud at very low level, it was not positioned to continue the planned visual approach. The captain made low-level manoeuvres to attempt landing: a large 360° turn as low as 100 feet AGL (about 400 feet below required minimum altitude), then a left-hand circuit that brought the aircraft close to a 150-foot tall tower, all in conditions below VFR minimums. The captain had not briefed the first officer, who was unaware of intentions and began calling out airspeed and altitude. On the last attempt, during low-level downwind leg abeam the threshold of Runway 10, the captain initiated a left turn and descent. About 10 seconds later, the aircraft collided with terrain in a near wings-level attitude approximately 650 feet southwest of the threshold. It slid 350 feet southward before coming to rest on a southwesterly heading.
Injuries and Damage
The pilots evacuated uninjured via the right-hand cockpit window. The aircraft sustained substantial damage; no post-impact fire occurred.
Emergency Locator Transmitter
The 406-MHz ELT activated, but the whip antenna was ripped off during impact, and no signal was detected by search and rescue satellites. The TSB had previously recommended Transport Canada establish more rigorous ELT crash survivability requirements; TC has since implemented updated regulations for new designs, but they do not apply to legacy ELTs like the one on the occurrence aircraft.
Cockpit Voice Recorder
Although not required by regulation, North Star Air had installed a CVR in the aircraft. However, after repairs, a paperwork error caused the CVR to remain in inventory instead of being reinstalled. At the time of occurrence, it had been 329 days since removal, over 200 days beyond the maximum permissible time defined in the minimum equipment list. Without the CVR, valuable information was unavailable to the investigation.
Investigation Findings
The investigation revealed a result-oriented subculture among some of North Star Air's DC3-TP67 pilots, emphasizing mission completion over regulatory compliance, leading to VFR flights conducted in IMC. The captain had a history of conducting VFR flights in IMC; the decision to depart and continue a VFR flight in IMC was influenced by a distorted risk perception from successful past experiences. Company structure lacked operational management presence and day-to-day pilot supervision at remote bases, allowing considerable latitude in weather-related decisions. A culture of non-compliance developed undetected by management.
In December 2017, TC informed North Star Air of allegations regarding VFR flights in IMC. The company contacted captains verbally and by email reminding them of regulations but did not implement monitoring measures. A February 2018 reactive PI included three flight inspections deemed uneventful. The company's SMS created a hazard report but did not identify underlying factors; no additional monitoring was implemented. TC's November 2018 PI did not review the 2017 allegations. These previously identified unsafe practices persisted and played a direct role in this occurrence.
TC's surveillance approach led to approval of North Star Air's SMS even though several elements were not fully implemented. The TSB previously recommended regular SMS assessments; TC indicated measures to update surveillance methodology.
Post-Occurrence Actions
Following the occurrence, North Star Air implemented a flight operations quality assurance program. In December 2020, TC conducted a PI focusing on the long-term corrective action plan, concluding that the actions were effective.