What happened
On the night of October 12, 1993, a twin-engine Cessna 310R, registered C-GILR, departed Sandy Bay, Saskatchewan, for a scheduled charter flight to La Ronge. Shortly after the aircraft took off from runway 05, it entered a very shallow climb and struck a line of trees approximately 2,400 feet beyond the end of the runway.
The impact with the trees, which were roughly 30 to 40 feet tall, caused the aircraft to lose control and enter a right-hand roll. The aircraft subsequently struck the rocky shoreline of the Churchill River in an inverted position. The collision and the resulting post-crash fire caused the destruction of the aircraft and resulted in four fatalities.
The investigation
Investigators examined the wreckage and confirmed that the flight control systems remained intact and functional up to the point of impact. A detailed teardown of both engines revealed no mechanical failures or pre-existing faults that would have caused a loss of power. The propellers were found to have been rotating at the time of the crash, and the aircraft's weight and balance were within legal limits.
Environmental factors were also scrutinized. At the time of the accident, there was very little ambient light from the sky or the ground, and the aircraft's landing lights were not in use. The investigation also looked into the pilot's training and medical history, noting that while the pilot held a commercial licence, previous training had indicated weak instrument flying performance. Additionally, the investigation considered the possibility of a somatogravic illusion affecting the pilot's perception during the acceleration phase of takeoff.
Findings
- The pilot maintained a very shallow climb angle after takeoff, which prevented the aircraft from clearing the trees.
- The aircraft was flying in a departure profile that deviated from the company's recommended night procedures.
- Poor illumination from both the sky and the ground made it difficult to maintain visual reference.
- The absence of landing light illumination contributed to the difficulty in navigating the departure path.
Safety action
- The Board recommended that the Department of Transport review pilot licences issued under medical flexibility options to ensure that a pilot's verified flying abilities are compatible with their operational privileges.