What happened
On a scheduled instrument flight from Lourdes-de-Blanc-Sablon to Saint-Augustin, Quebec, a Beechcraft 1900C (registration C-FGOI) was performing a LOC/DME approach for runway 20. Before the descent, the crew received information from a private advisory service indicating low ceilings, poor visibility due to snow flurries, and gusting winds.
During the approach, the captain decided to descend below the minimum descent altitude (MDA) after the first officer reported seeing the ground. The crew had established a practice of using the ground proximity warning system (GPWS) as a safety margin, setting the radio altimeter to 100 feet above ground level. As the aircraft continued its descent, the GPWS "MINIMUMS" alarm sounded, but three seconds later, the aircraft impacted the snow-covered, frozen surface of the Saint-Augustin River. Despite the heavy damage to the aircraft, all 12 occupants escaped without injury.
The investigation
The investigation examined the crew's adherence to standard operating procedures (SOPs) and the company's training and supervisory structures. It was established that the captain had failed to conduct a proper pre-flight briefing, omitting critical information such as the MDA and missed-approach point. Furthermore, the investigation found that the crew was operating in conditions conducive to whiteout, which likely impaired depth perception.
Investigators also looked into the company's operational culture, finding that some pilots within the operator were in the habit of descending below the MDA without visual references. The investigation also noted that the company's management and regulatory oversight had failed to detect significant irregularities in training and operational control.