Narrative:Nearing the Peterborough in IMC, the flight crew received a clearance to conduct an NDB runway 09 approach. The flight crew did not acquire the runway environment during this approach and conducted a missed approach procedure. They obtained another clearance for the same approach from Toronto Area Control Centre. During this approach, the flight crew acquired the runway environment and manoeuvred the aircraft for landing on runway 09. The aircraft touched down near the runway midpoint, and the captain elected to abort the landing. The captain then conducted a left visual circuit to attempt another landing. As the aircraft was turning onto the final leg, the approach became unstabilized, and the flight crew elected to overshoot; however, the aircraft pitched nose-down, banked left, and struck terrain. As it travelled 400 feet through a ploughed farm field, the aircraft struck a tree line and came to rest about 2000 feet before the threshold of runway 09, facing the opposite direction.
FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS:
1) The captain's attempt to continue the landing during the second approach was contrary to company standard operating procedures and Federal Aviation Regulations, in that the approach was unstable and the aircraft was not in a position to land safely.
2) Following the aborted landing, the flight crew proceeded to conduct a circling approach to runway 09, rather than the missed approach procedure as briefed.
3) The pilot lost situational awareness during the overshoot after the third failed attempt to land, likely when he was subjected to somatogravic illusion.
4) Breakdown in crew coordination after the aborted landing, lack of planning and briefing for the subsequent approach, operating in a dark, instrument meteorological conditions environment with limited visual cues, and inadequate monitoring of flight instruments contributed to the loss of situational awareness
Official accident investigation report
PH-ILX was sold in 1994 and went to the U.S. as N4115B. It was later registered N184GA.
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 Detroit-Willow Run Airport, MI to Peterborough Airport, ON as the crow flies is 470 km (294 miles).