Perimeter Airlines Flight PAG962: Night Medevac Crash at Shamattawa (C-GYPA)

Incident Overview and Flight Details Perimeter Airlines Flight PAG962, a Fairchild SA226TC (Metroliner), departed Gods Lake Narrows, Manitoba, at approximately 2300 central daylight time on a medical evacuation (MEDEVAC) flight to Shamattawa. The aircraft was carrying two pilots and a flight nurse. ## Approach and Missed Approach While approaching Shamattawa, the crew initiated a descent to the 100-nautical-mile minimum safe altitude of 2,300 feet above sea level (ASL). After clearing an overcast cloud layer at approximately 3,000 feet ASL, the crew attempted a night visual approach to Runway 01. The aircraft was too high and too fast on final approach, prompting the crew to execute a missed approach. ## Impact and Wreckage Approximately 30 seconds after power was increased, at 2333, the aircraft struck trees slightly left of the runway centerline, about 2,600 feet from the departure end of Runway 01. The aircraft broke apart along a wreckage trail of approximately 850 feet, with only the cabin aft of the cockpit retaining some structural integrity. A post-crash fire was confined to the wings, which had separated from the cabin and cockpit wreckage. ## Casualties and Cockpit Voice Recorder The captain and first officer were fatally injured on impact. The flight nurse was seriously injured but managed to exit the wreckage. The aircraft's cockpit voice recorder (CVR) indicated that the crew remained in control of the aircraft and did not express concern prior to impact. ## Official Findings The official investigation determined that the aircraft was flown into terrain during an overshoot because the required climb angle was not set and maintained to ensure a positive rate of climb. During the go-around, conditions were present for somatogravic illusion, which most likely led to the captain losing situational awareness. The first officer did not monitor the aircraft instruments during a critical stage of flight; it is possible that he was affected by somatogravic illusion and/or distracted by the non-directional beacon to the extent that he lost situational awareness. Additional findings noted that the absence of approach aids likely decreased the crew's ability to fly an approach from which a landing could be executed safely, and that the company standard operating procedures (SOPs) did not define how positive rate is to be determined.