What happened
A Cessna 402 carrying five people was conducting an instrument flight rules (IFR) flight from Montreal to Schefferville, Quebec, with a planned stop in Wabush, Newfoundland. Due to poor weather conditions at the destination, the pilot diverted to the alternate airport at Wabush.
During an ILS approach for runway 01, the aircraft was too high to intercept the glide path, prompting the pilot to execute a missed approach. While performing the missed approach, the aircraft struck trees on a mountainside at an altitude of 2,460 feet. The aircraft decelerated over a 900-foot distance before coming to rest 23 nautical miles north of the airport. The crash occurred during the hours of darkness. All five occupants survived, though the pilot and one passenger sustained injuries.
The investigation
The investigation examined the aircraft's navigation settings and the pilot's flight planning. At the crash site, the navigation equipment showed the pilot had tuned the VOR frequency rather than the ILS frequency and was using parameters that did not align with the standard approach procedure.
Investigators also reviewed the pilot's operational status, noting that the pilot was not familiar with the Wabush airport and had been flying since early that morning. The aircraft was found to be properly maintained and equipped, with no mechanical failures or pre-impact malfunctions identified. The investigation also looked into the weather conditions, noting a strong tailwind during the initial approach attempt.
Findings
- The pilot did not follow the published missed approach procedure, specifically regarding the required minimum altitudes.
- The pilot failed to maintain the published minimum safe altitude during the maneuver.
- The pilot's planning for the approach was inadequate, as evidenced by the request for confirmation of minimum altitudes.
- A strong tailwind component during the initial descent modified the glide slope, making the aircraft too high and fast to intercept the localizer.
- The pilot lost the mental picture of the required flight path during the missed approach.
- Potential mental fatigue, resulting from a long period of duty and the complexities of a night approach at an unfamiliar airport, may have degraded performance.