ASN Wikibase Occurrence # 23296
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Date: | Monday 24 May 1999 |
Time: | 21:30 |
Type: | Mitsubishi MU-2B-40 Solitaire |
Owner/operator: | Lucky Landings Charter Inc |
Registration: | N701K |
MSN: | 410SA |
Year of manufacture: | 1979 |
Fatalities: | Fatalities: 2 / Occupants: 2 |
Aircraft damage: | Destroyed |
Category: | Accident |
Location: | 1nm W of Parry Sound/Georgian Bay Airport, Parry Sound, Ontario -
Canada
|
Phase: | Initial climb |
Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
Departure airport: | Parry Sound/Georgian Bay Airport, Ontario |
Destination airport: | Toronto/Lester B. Pearson International Airport |
Investigating agency: | TSB |
Confidence Rating: | Information verified through data from accident investigation authorities |
Narrative:The aircraft was destroyed when it crashed shortly after take-off from Runway 35 at Parry Sound, coming down among trees about 1 nautical mile from the airport. The accident happened in darkness (21:30 Local Time) and in IMC; weather, wind southwest at 5 to 10 knots., visibility 3 to 4 miles in rain and overcast ceiling at 500 feet. The aircraft was operating a flight to Toronto. Both persons on board (pilot and one passenger) were killed
CARs require pilots flying this model of aircraft to have their pilot's licence endorsed for high-performance aircraft. Similarly, a valid instrument rating is required by any pilot filing and flying under IFR. The pilot's private pilot licence was not endorsed with an instrument rating, nor did he have an aircraft high-performance type rating. TC pilot records indicate that, on several occasions, the pilot attempted, but never successfully completed, the instrument rating examination.
A U.S. pilot certificate was issued on the basis of, and valid only when accompanied by, a valid Canadian licence. The pilot provided the U.S. training provider with licensing documentation that indicated that he held an instrument rating when, in fact, he did not hold this rating. Furthermore, the pilot did not obtain a high-performance type rating on his licence for this model of aircraft.
There are inconsistencies between the facts recorded on the pilot's last civil aviation medical examination with respect to medical conditions and current prescribed medications, and those learned during the investigation. TC CAM could not declare with any certainty that the combination of medical conditions experienced by this pilot would or would not have met all the criteria to allow a valid medical certificate to be issued, since the required medical investigations were either not available or had not been done for some of the conditions of interest.
There are numerous indicators that the departure may have been rushed. The pilot and passenger arrived late at the airport due to busy highway traffic during the holiday weekend. The aircraft take-off was conducted downwind. Since the pilot was trained, and it was his practice, to conduct all take-offs using 20 degrees of trailing edge flap extended, and the flaps were found in the zero to five degrees range, the pilot most likely made a left turn shortly after take-off and raised the flaps in the turn.
Finally, the occurrence site is only 1 nautical mile west of the airport, and the aircraft had turned through more than 180 degrees prior to striking the first trees, which are also indicators that the departure may have been rushed.
After becoming airborne at night, in rain, with little outside visual reference, the pilot would have been required to rapidly shift his scan from outside the aircraft to the flight instruments in the cockpit. This transition is a critical stage of flight and demands positive, deliberate action and the pilot's full attention. While the aircraft was at low altitude, the landing gear was retracted. Moments after landing gear retraction, the pilot turned the aircraft left for the on-course track and the flaps were raised.
The aircraft's rate of climb would have been degraded when the flaps were retracted while the aircraft was banked in the left turn. The tasks of moving the gear selector and raising the flaps, although not demanding, would divert some of the pilot's attention away from monitoring the flight instruments. This diversion during the transition from visual flight to instrument flight may have caused the pilot to become disoriented and to misinterpret or improperly scan the flight instruments.
The pilot may have also been subjected to somatogravic illusion. The overall result was that the pilot allowed the aircraft to commence a shallow descent until it struck trees, which compromised the integrity of the aircraft. With critical flight controls missing from the aircraft, it rolled inverted and entered the impact zone. Due to the severity of the impact sequence, many of the avionics components and instruments did not reveal conclusive information. The airspeed indicator imprint and the length of the wreckage trail through the heavily-wooded area indicate that
the aircraft entered the impact zone at high speed.
Accident investigation:
|
| |
Investigating agency: | TSB |
Report number: | A99O0126 |
Status: | Investigation completed |
Duration: | 1 year |
Download report: | Final report |
|
Sources:
1. CADORS 1999O0482
2.
http://web.archive.org/web/20080625063644/http://www.tsb.gc.ca:80/en/reports/air/1999/a99o0126/a99o0126.asp? 3. NTSB Identification: NYC99WA121 at
https://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20001212X18882&ntsbno=NYC99WA121&akey=1 4.
http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?omni=Home-N-Number&nNumberTxt=701K Revision history:
Date/time | Contributor | Updates |
27-Sep-2008 01:00 |
ASN archive |
Added |
07-Mar-2016 12:00 |
Dr.John Smith |
Updated [Time, Operator, Location, Nature, Departure airport, Destination airport, Source, Narrative] |
07-Mar-2016 12:01 |
Dr.John Smith |
Updated [Narrative] |
07-Mar-2016 12:02 |
Dr.John Smith |
Updated [Narrative] |
21-Dec-2016 19:14 |
ASN Update Bot |
Updated [Time, Damage, Category, Investigating agency] |
21-Dec-2016 19:16 |
ASN Update Bot |
Updated [Time, Damage, Category, Investigating agency] |
21-Dec-2016 19:20 |
ASN Update Bot |
Updated [Time, Damage, Category, Investigating agency] |
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