What happened
On the night of August 12, 1999, a Régionnair Inc. Raytheon Beech 1900D, registration UE-347, was conducting a scheduled flight from Port-Menier to Sept-Îles, Quebec. The aircraft was carrying two pilots and two passengers. During the approach to Sept-Îles Airport, the aircraft struck trees in an area of rising terrain approximately one nautical mile short of the runway.
The weather at the time of the accident was characterized by dense fog, with a reported ceiling of only 200 feet and visibility of one-quarter statute mile. The crew had planned an approach using GPS coordinates to navigate toward the runway threshold, despite there being no published GPS approach for Runway 3-1. During the descent, the aircraft was noted to be high and fast. Although the ground proximity warning system (GPWS) activated with "Minimums" alerts, the descent continued. The impact occurred at 23:57 EDT, resulting in one fatality (the captain), one serious injury (the first officer), and two minor injuries (the passengers). A post-crash fire damaged the engines, wings, and part of the fuselage.
The investigation
The investigation examined the flight profiles, the crew's recent work history, and the meteorological conditions. Investigators found that the aircraft's engines were functioning normally prior to impact and that the aircraft was within weight and balance limits. The investigation also reviewed the crew's flight duty records and the company's oversight of pilot hours.
Findings
- The reported weather conditions were significantly below the published minimums for the approach.
- The crew failed to adhere to company standard operating procedures regarding approach and missed-approach briefings.
- Both crew members had exceeded their maximum allowable monthly, quarterly, and daily flight duty times.
- The first officer was likely suffering from chronic fatigue, having worked an average of 14 hours per day over the preceding month with only one day of rest.
- The company's management failed to effectively supervise or record the flight and duty hours of its pilots.
- The captain had not undergone mandatory training in crew resource management (CRM) or pilot decision-making.