What happened
On 0/December/2019, a Douglas DC3C Basler Turbo Conversions TP67, registered C-FKAL, was performing a daytime cargo flight from Red Lake Airport to Sachigo Lake Airport. The flight was operated by North Star Air Ltd. under visual flight rules (VFR). Although weather reports indicated low ceilings and instrument meteorological conditions (IMC) at the destination and nearby airports, the crew proceeded with the flight.
Shortly after departure, the aircraft climbed through cloud layers, which was a violation of VFR regulations. As the aircraft approached Sachigo Lake, the pilots attempted a visual approach despite the lack of visibility. The captain performed low-level maneuvers, including a 360-degree turn as low as 100 feet above ground level, bringing the aircraft dangerously close to a 150-foot tower. During a final attempt to land, the aircraft struck the ground approximately 650 feet from the runway threshold. The two uninjured pilots evacuated the wreckage, which sustained substantial damage.
The investigation
The TSB examined the flight operations, the company's safety management system, and the regulatory oversight provided by Transport Canada. The investigation looked into the lack of a cockpit voice recorder (CVR) on board, noting that while the aircraft was not required to have one, the company had failed to reinstall a CVR following repairs, leaving it in inventory for over 300 days. The investigation also reviewed the functionality of the aircraft's emergency locator transmitter (ELT), which failed to transmit a signal because the antenna was severed during the impact.
Findings
- The primary cause of the crash was the captain experiencing attentional narrowing during a high-workload, low-altitude approach in IMC, leading to an undetected descent into terrain.
- A company culture emerged among some pilots that prioritized mission completion over regulatory compliance, specifically regarding flying VFR in IMC.
- The lack of direct operational supervision at remote bases allowed a culture of non-compliance to persist undetected.
- The company's safety management system failed to identify the underlying causes of previous regulatory breaches.
- Regulatory oversight by Transport Canada was insufficient to ensure the operator's safety management system was fully implemented or to address prior allegations of non-compliance.