7 fatalities

2016-03-29: Mitsubishi MU-2 Marquise (N246W) — Aéro Teknic — Le Havre-aux-Maisons (Magdalen Islands), Canada

Le Havre-aux-Maisons (Magdalen Islands), CanadaLanding (descent or approach)

On March 29, 2016, a Mitsubishi MU-2 Marquise (registration N246W) operated by Aéro Teknic was involved in an aviation accident near Le Havre-aux-Maisons (Magdalen Islands), Canada during landing or approach. 7 people were killed. Investigators recorded the probable cause as: The pilot’s inability to manage energy led to an unstable approach; cognitive biases led to continuation; loss of control from power-induced upset at low altitude and airspeed; pilot not prepared for upset; high workload reduced situational awareness;… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781192489Data APIEditorial standards

A twin-engine aircraft crashed during approach to Le Havre-aux-Maisons, killing all seven occupants, including former Canadian minister Jean Lapierre. The pilot lost control in marginal weather conditions, according to investigation findings.

Occurrence

On the day of the accident, the twin-engine aircraft departed Montreal-Saint-Hubert Airport at 0930 local time for a two-hour flight to Le Havre-aux-Maisons on the Magdalen Islands. Upon arrival, weather conditions were marginal with low ceiling, visibility up to two miles, rain, and wind gusting to 30 knots. During final approach to Runway 07, when the aircraft was 1.4 nautical miles west-southwest of the airport, it deviated south of the approach path. At approximately 1230 Atlantic Daylight Time, aircraft control was lost, resulting in the aircraft striking the ground in a near-level attitude. The aircraft was destroyed and all seven occupants were killed.

Aircraft and Crew

The aircraft was a twin-engine aircraft operated by Aéro Teknic. The pilot-in-command was Pascal Gosselin, founder and owner of Aéro Teknic. Also on board was Fabrice Labourel, acting as copilot. The passengers were Jean Lapierre, a political commentator and former Liberal federal cabinet minister of Transport; his wife Nicole Beaulieu; his sister Martine Lapierre; and his brothers Marc Lapierre and Louis Lapierre. All were traveling to the funeral of Jean Lapierre's father.

Investigation Findings

The official investigation identified the following causes and contributing factors:

1. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach. 2. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach. 3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly. 4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground. 5. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making. 6. It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.

The investigation also noted several findings as to risk, including risks associated with exceeding maximum takeoff weight, non-essential communication during critical phases, lack of flight recordings, plan continuation bias, unstable approach criteria, go-around preparedness, and search-and-rescue information. Other findings included that Transport Canada does not monitor foreign-registered aircraft duration, turbulence and icing were not factors, and that installation of an angle-of-attack system requires supplemental type certificate approval.

Probable cause

The pilot’s inability to manage energy led to an unstable approach; cognitive biases led to continuation; loss of control from power-induced upset at low altitude and airspeed; pilot not prepared for upset; high workload reduced situational awareness; insufficient proficiency for single-pilot MU2B operations.