Flugunfall 09 DEC 1977 einer de Havilland DH-125-400A CF-CFL - Churchill Falls Airport, NL (ZUM)
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Status:Accident investigation report completed and information captured
Datum:Freitag 9 Dezember 1977
Zeit:22:55 UTC
Flugzeugtyp:Silhouette image of generic H25A model; specific model in this crash may look slightly different
de Havilland DH-125-400A
Fluggesellschaft:Churchill Falls Co.
Kennzeichen: CF-CFL
Werknummer: 25213/NA741
Baujahr: 1970
Triebwerk: 2 Rolls-Royce Viper 522
Besatzung:Todesopfer: 2 / Insassen: 2
Fluggäste:Todesopfer: 6 / Insassen: 6
Gesamt:Todesopfer: 8 / Insassen: 8
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:3 km (1.9 Meilen) NW of Churchill Falls Airport, NL (ZUM) (   Kanada)
Flugphase: Annäherung (APR)
Betriebsart:Geschäftsflug
Flug von:Moncton-Metropolitan Area Airport, NB (YQM/CYQM), Kanada
Flug nach:Churchill Falls Airport, NL (ZUM/CZUM), Kanada
Unfallbericht:
The DH-125 corporate jet crashed while executing a night time approach to runway 14 at Churchill Falls Airport, NL (ZUM).
The crew radioed that they could see the strobe lights and visual approach slope indicator system (VASIS). This was the last transmission.

On December 11 the aircraft was located two miles short of the threshold of the runway at Churchill Falls. The aircraft was destroyed on ground impact, the wreckage scattered along a trail of 300 feet, and the two crew members and six passengers all lost their lives. Although the accident occurred only two miles out of the extended centre line of the runway, the wreckage was not located for two days due to extreme weather conditions. It was subsequently determined that two survivors of the crash lived for one to two hours after impact. A searching helicopter had flown over the site within fifteen minutes of the crash with a receiver tuned to a distress frequency. The emergency locator transmitters had been removed from the
aircraft pursuant to an Airworthiness Directive.

The final investigation report of the accident was published by Transport Canada, without approval of the Aircraft Accident Review Board. The Board disagreed on the 6th finding, which was published reading "6) On the assumptions that there had been at least one serviceable ELT on board, that it had been activated as a result of the impact or by other means, and that there was the capability at Churchill Falls of homing to the point of origin of the ELT signal, the rescue activity may have been expedited."
This finding had been changed compared to the initial report, which read: "The removal of the aircraft's emergency locator transmitters seriously delayed the search and rescue activity and may have caused unnecessary loss of life."

In a May 1981 report by the Commission of Inquiry on Aviation Safety, it was concluded that in this case senior management unilaterally overruled the Aviation Safety Bureau and the Aircraft Accident Review Board in order to remove the criticism of the regulatory authority contained in the original accident report.

Probable Cause:

CONCLUSIONS:
1) Cockpit discipline was inadequate as the approach entered the final phase.
2) Distractions in the cockpit degraded crew performance.
3) The pilots deprived themselves of essential altitude information by not effectively monitoring the flight instruments during the final approach.
4) The Captain, by relying on visual cues from the runway environment lighting in conditions where those cues were degraded, became exposed to visual illusions.
5) The pilots permitted the aircraft to deviate below the safe approach profile until it struck the terrain.
6) The removal of the aircraft's emergency locator transmitters seriously delayed the search and rescue activity and may have
caused unnecessary loss of life.

Informationsquelle:
» ICAO Circular 153-AN/56 (Accident Digest 23, p.181-193)
» Dubin Report


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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 Moncton-Metropolitan Area Airport, NB to Churchill Falls Airport, NL as the crow flies is 823 km (515 miles).
Accident location: Exact; deduced from official accident report.

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.
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HS-125

  • 290 built
  • 13th loss
  • 11th Fataler Unfall
  • 2nd worst accident (Zu diesem Zeitpunkt)
  • 4th worst accident (Momentan)
» safety profile

 Kanada
  • 39th worst accident (Zu diesem Zeitpunkt)
  • 49th worst accident (Momentan)
» safety profile

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