What happened
During a solo ferry flight from Quebec City to Peterborough, the pilot of a Beech King Air A1/100 was conducting an NDB RWY 09 instrument approach in low visibility and light drizzle. While descending toward the procedure turn altitude, the pilot's instrument approach chart, which was not secured to a knee pad, fell to the cockpit floor.
Attempting to continue the approach from memory, the pilot prematurely descended to 1,800 feet asl before turning to the final track. During the attempt to retrieve the fallen chart, the aircraft's altitude dropped further, resulting in the aircraft striking treetops at approximately 1,100 feet asl. Following the impact, the pilot applied full power, retracted the landing gear and flaps, and initiated a climb. After notifying air traffic control of the incident and a fuel leak in the right wing tank, the pilot diverted to the military aerodrome in Trenton, Ontario, where the single-pilot landing was completed safely with emergency services present.
The investigation
The investigation established that at the time of the approach, weather conditions were deteriorating, with visibility dropping to one mile and ceilings at 200 feet. The pilot was manually controlling the aircraft's power and altitude, as the autopilot altitude hold mode was not engaged.
Post-flight inspections of the aircraft revealed significant damage to the right propeller, engine cowl, right wing leading edge, fuel tanks, and the right outboard flap, along with evidence of multiple tree impacts on the landing gear and underside of the airframe.
Findings
- The pilot failed to adequately monitor flight instruments while performing a high-workload non-precision approach in instrument meteorological conditions.
- The pilot's decision to continue the approach procedure from memory after losing the approach chart contributed to the error.
- The loss of the approach chart due to it being unsecured led to a premature descent and a lack of reference to required altitudes.