Narrative:Flight 960 operated under a defense visual flight rules flight plan and departed Goose Bay for Davis Inlet at 08:15 AST. During the first approach, the first officer had occasional visual glimpses of the snow on the surface. The captain descended the aircraft to the minimum descent altitude (MDA) of 1340 feet asl. When the crew did not acquire the required visual references at the missed approach point, they executed a missed approach. On the second approach, the captain flew outbound from the beacon at 3000 feet asl until turning on the inbound track. It was decided that if visual contact of the surface was made at any time during the approach procedure, they would continue below the MDA in anticipation of the required visual references. The captain initiated a constant descent at approximately 1500 feet per minute with 10 degrees flap selected. The FO occasionally caught glimpses of the surface. At MDA, in whiteout conditions, the captain continued the descent. In the final stages of the descent, the FO acquired visual ground contact; 16 seconds before impact, the captain also acquired visual ground contact. At 8 seconds before impact, the crew selected maximum propeller revolutions per minute. The aircraft struck the ice in controlled flight two nm from the airport. The aircraft was destroyed with wing and partial fuselage separation, and other incursion damage. The tail section where the ELT was mounted was badly damaged. Aircraft parts and cargo were scattered over the ice. The co-pilot was found approximately 20 feet from the main wreckage. He had expired before searchers reached the scene. The pilot was located in the rear of the aircraft, apparently thrown there during the crash sequence. He was semi-conscious with serious injuries. There was no fire.
Probable Cause:
Findings as to Causes and Contributing Factors: "1) The captain decided to descend below the minimum descent altitude (MDA) without the required visual references; 2) After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice."
Accident investigation:
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Investigating agency: | TSB Canada |
Status: | Investigation completed |
Duration: | 2 years and 2 months | Accident number: | A99A0036 | Download report: | Final report
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Classification:
Controlled Flight Into Terrain (CFIT) - Ground
Follow-up / safety actions
After the accident, Transport Canada (TC) conducted a regulatory audit of the operator and increased the frequency of in-flight checks and general inspection of the Goose Bay operation.
TSB issued 1 Safety Recommendation
Issued: -- | To: DoT Canada | A01-01 |
The Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those operators who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations. (Fully satisfactory) |
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Photos
accident date:
19-03-1999type: de Havilland Canada DHC-6 Twin Otter 300
registration: N914MA
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Goose Bay Airport, NL to Davis Inlet Airport, NL as the crow flies is 286 km (179 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.