1 fatality

1999-08-12: Beechcraft 1900D (C-FLIH) — RégionnAir — Seven Islands, Canada

Seven Islands, CanadaLanding (descent or approach)

On August 12, 1999, a Beechcraft 1900D (registration C-FLIH) operated by RégionnAir was involved in an aviation accident near Seven Islands, Canada during landing or approach. One person was killed. Investigators recorded the probable cause as: The crew conducted an unauthorized GPS approach in low visibility and failed to execute a go-around despite an unstabilized descent and GPWS warnings, exacerbated by extreme pilot fatigue. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 1 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781204200Data APIEditorial standards
Aircraft registered C-FLIH
Aircraft registered C-FLIH. Photo: Aeroprints.com / CC BY-SA 3.0, via Wikimedia Commons

A RégionnAir Beechcraft 1900 crashed while attempting an unauthorized GPS approach to runway 31 at Port-Menier, resulting from a non-stabilized descent in low visibility.

What happened

On the night of the accident, a RégionnAir flight departed Port-Menier for Seven Islands. The crew attempted to execute an unauthorized GPS approach to runway 31, despite no such published procedure existing for that runway. During the descent from cruise altitude, the aircraft was traveling at excessive speeds and remained too high, leading to a late initiation of the descent phase. As the Beechcraft 1900 approached the NDB, it maintained a high rate of descent exceeding 3000 fpm from 10,000 feet.

As the aircraft neared the threshold, the crew continued the descent through heavy cloud cover. Although the GPWS issued "Minimums" warnings at 100 feet, the captain instructed the pilot flying to continue a slow descent without visual contact with the runway. The aircraft struck trees in rising terrain while in a near-level attitude. The impact caused the cockpit to separate and crush, while a subsequent fire destroyed the wings, the right engine, and part of the fuselage. There were no fatalities reported in this accident.

Findings

Investigation into the crash revealed several critical failures regarding flight safety and regulatory compliance:

  • The pilot flying failed to establish a stabilized approach or execute a go-around as required by company standard operating procedures.
  • The crew attempted a self-defined GPS approach in instrument meteorological conditions that were below published minima.
  • The captain instructed the continued descent below safe altitudes without visual confirmation of the runway environment.
  • Both crew members had exceeded their legal monthly, quarterly, and daily flight and duty time limits, contributing to significant fatigue. The first officer specifically showed signs of chronic fatigue after working 14-hour shifts for 30 consecutive days.
  • There was a lack of effective oversight by the company's operations manager regarding pilot duty times, and the captain had not completed mandatory training in crew resource management or decision-making.

Probable cause

The crew conducted an unauthorized GPS approach in low visibility and failed to execute a go-around despite an unstabilized descent and GPWS warnings, exacerbated by extreme pilot fatigue.