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ASN Wikibase Occurrence # 185997
Last updated: 22 February 2018
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Date:29-MAR-2016
Time:12:30
Type:Silhouette image of generic MU2 model; specific model in this crash may look slightly different
Mitsubishi MU-2B-60
Owner/operator:Marquise Aviation Corp Trustee (owner)
Registration: N246W
C/n / msn: 1552SA
Fatalities:Fatalities: 7 / Occupants: 7
Other fatalities:0
Airplane damage: Written off (damaged beyond repair)
Category:Accident
Location:2km SW Îles-de-la-Madeleine Airport -   Canada
Phase: Approach
Nature:Non Scheduled Passenger
Departure airport:Montreal-St. Hubert Airport, QC (YHU/CYHU)
Destination airport:Îles-de-la-Madeleine Airport, QC (YGR/CYGR)
Investigating agency: TSB Canada
Narrative:
A Mitsubishi Mu-2B-60 aircraft crashed while on approach to Îles-de-la-Madeleine Airport, Quebec, Canada killing former federal Liberal cabinet minister Jean Lapierre, four members of his family and the two pilots.
The wreckage was contained in a 150m x 150m field. The aircraft came to rest approximately 91m from the initial point of impact.
The aircraft was registered in the United States and was in the process of being purchased by the pilot.

On 13 July 2016 TSB stated:
The investigation has found that both the altitude and the speed of the aircraft's approach to CYGR were higher than recommended. On the MU-2 instrument-approach profile, the standard speed prior to the initial approach fix is 150 knots, slowing to a final approach speed of 125 knots past the final approach fix. In this instance, the aircraft's speed prior to the initial approach fix was 240 knots, and past the final approach fix the speed decreased below 175 knots, only 2.7 nm from Runway 07—much later than prescribed. The aircraft landing gear was lowered and approach flaps were selected at this point. Although not required by regulation, the occurrence aircraft was equipped with a lightweight recording system. The recorder will provide information critical to understanding the circumstances and events that led to the departure from controlled flight—information that would not have been available to the investigation if the aircraft had not been equipped with a recording system.

Findings:
Findings as to causes and contributing factors:
1. The pilot's inability to effectively manage the aircraft's energy condition led to an unstable approach.
2. The pilot "got behind" the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.
4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.
5. The pilot's high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.
6. It is unlikely that the pilot's flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU-2B for the conditions experienced during the occurrence flight.

10 jan 2018: TSB report , see link below

Sources:

http://www.lapresse.ca/actualites/justice-et-affaires-criminelles/faits-divers/201603/29/01-4965415-un-avion-secrase-aux-iles-de-la-madeleine.php
http://ici.radio-canada.ca/regions/est-quebec/2016/03/29/009-avion-accident-incident-aeroport-iles-madeleine.shtml
http://montreal.ctvnews.ca/plane-involved-in-deadly-crash-has-spotty-safety-record-1.2838309
http://www.thestar.com/news/canada/2016/03/29/small-plane-crashes-in-iles-de-la-madeleine-just-off-eastern-quebec.html

_____________________________
http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=246W
CADDORS 2016Q0513
http://www.tsb.gc.ca/eng/enquetes-investigations/aviation/2016/a16a0032/a16a0032.asp
https://www.flickr.com/photos/tsbcanada/sets/72157666465745621
http://www.tsb.gc.ca/eng/medias-media/communiques/aviation/2016/a16a0032-20160713.asp

Jan 2018 TSB report: http://www.tsb.gc.ca/eng/rapports-reports/aviation/2016/a16a0032/a16a0032.asp

Accident investigation:
cover
  
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 year and 9 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
29-Mar-2016 18:58 harro Added
29-Mar-2016 18:59 harro Updated [Aircraft type, Cn, Operator, Departure airport, Source, Embed code, Narrative]
29-Mar-2016 19:00 harro Updated [Aircraft type]
29-Mar-2016 19:03 harro Updated [Narrative]
29-Mar-2016 19:41 198.16.176.145 Updated [Total occupants]
29-Mar-2016 20:19 Louis Updated [Total occupants]
29-Mar-2016 23:19 Geno Updated [Aircraft type, Cn, Operator, Location, Nature, Source]
30-Mar-2016 05:38 yukonjack Updated [Source]
30-Mar-2016 05:44 Iceman 29 Updated [Embed code]
30-Mar-2016 09:13 Dmitriy Updated [Operator, Source]
30-Mar-2016 09:26 Aerossurance Updated [Time, Operator, Other fatalities, Location, Nature, Source, Narrative]
30-Mar-2016 19:15 Aerossurance Updated [Location, Nature, Source, Narrative]
31-Mar-2016 07:39 Aerossurance Updated [Source]
01-Apr-2016 11:11 Aerossurance Updated [Embed code]
01-Apr-2016 11:18 Aerossurance Updated [Time, Location, Narrative]
01-Apr-2016 17:50 96.20.200.56 Updated [Narrative]
13-Jul-2016 13:58 Aerossurance Updated [Source]
13-Jul-2016 14:01 Aerossurance Updated [Narrative]
21-Dec-2016 19:30 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
10-Jan-2018 16:06 Iceman 29 Updated [Source, Embed code]
10-Jan-2018 16:07 Iceman 29 Updated [Source]
10-Jan-2018 16:23 Iceman 29 Updated [Source, Damage, Narrative]
10-Jan-2018 18:48 Iceman 29 Updated [Embed code]
10-Jan-2018 19:56 harro Updated [Embed code, Narrative]

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