Accident
Air Satellite Flight 501 was scheduled to fly from Baie-Comeau, Quebec, to Rimouski. After a five-hour delay due to adverse weather, the Britten-Norman aircraft (serial number 2028) took off at 11:09 Eastern Standard Time. On board were eight passengers and two pilots. The reported ceiling was 800 feet, the sky was obscured, and visibility was 0.5 statute mile in moderate snow showers.
Shortly after takeoff, while climbing at approximately 500 feet above sea level, the aircraft pitched up suddenly and became unstable when the flaps were retracted upon entering the cloud layer. The pilot-in-command pushed the control column down to level the aircraft. Deciding that the flight could not safely continue, he initiated a left turn to return to Baie-Comeau. During the turn, the aircraft rolled rapidly to the left and began to dive. It crashed into the St. Lawrence River about 0.5 nautical mile from shore and less than 1 nautical mile from the airport.
Four passengers were fatally injured in the crash. Two other passengers died while awaiting rescue, which arrived 98 minutes after takeoff. The co-pilot's body was carried away by the current and has not been recovered. The pilot-in-command and two passengers sustained serious injuries.
Probable Cause
The official investigation identified the following causes and contributing factors: 1. The aircraft took off with contaminated surfaces without an inspection by the pilot-in-command, contributing to reduced performance and the subsequent stall. 2. At takeoff, the aircraft was more than 200 pounds over the maximum allowable take-off weight, further reducing performance. 3. During initial climb, the pilot-in-command did not follow recommended procedures when entering an area of wind shear, causing additional speed loss and contributing to the stall. 4. Insufficient altitude was available for the pilot to recover from the stall and avoid striking the water. 5. The co-pilot's shoulder harness was not installed properly, resulting in serious head injuries from lack of restraint.
Additional Findings
- The crew's lack of experience in the existing conditions impaired pre-flight planning and flight decisions.
- The stall warning system was defective and could not have alerted the crew to an impending stall under other circumstances.
- No emergency message was transmitted after the decision to return, delaying rescue.
- The emergency signal was not received by Mont-Joli Flight Service Station because the Baie-Comeau remote communications outlet lacked the 121.5 MHz emergency frequency, which was not required.
- The emergency locator transmitter (ELT) was not installed per manufacturer instructions; its floor mounting increased damage risk, and it was ejected from its mounting plate upon impact, with the antenna contacting water, reducing the signal and preventing SARSAT validation.
- Transport Canada did not comply with audit standards for the operator, increasing risk of unidentified deficiencies.
- One occupant might have had a greater survival chance if life jackets had been on board; existing regulations did not require them.
- The aircraft had numerous mechanical deficiencies that should have been detected by Air Satellite staff.
- The Baie-Comeau airport emergency plan required confirmation of a water crash before helicopter use, prolonging response.
- The instrument panel configuration made reading flight instruments difficult from the co-pilot's seat.
- Air Satellite's standard operating procedures manual did not promote effective crew coordination.
- The pilot and co-pilot had not taken crew resource management or pilot decision-making courses, which were not required.
- High turnover of flight personnel and repeated changes in chief pilot hindered adequate supervision.