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AVIATION OCCURREN CE REPORT

CON TROLLED FLIGHT IN TO TERRAIN TRAN S PROVIN CIAL AIRLIN ES PIPER PA-31-350 CHIEFTAIN C-GKIY TERRACE, BRITISH COLUMBIA 39 nm N 22 OCTOBER 1990 REPORT N UMBER A90P0340

MANDATE OF THE TSB


The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework governing the TSB's activities. Basically, the TSB has a mandate to advance safety in the marine, pipeline, rail, and aviation modes of transportation by: ! ! ! ! ! conducting independent investigations and, if necessary, public inquiries into transportation occurrences in order to make findings as to their causes and contributing factors; reporting publicly on its investigations and public inquiries and on the related findings; identifying safety deficiencies as evidenced by transportation occurrences; making recommendations designed to eliminate or reduce any such safety deficiencies; and conducting special studies and special investigations on transportation safety matters.

It is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board must not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings.

INDEPENDENCE

To enable the public to have confidence in the transportation accident investigation process, it is essential that the investigating agency be, and be seen to be, independent and free from any conflicts of interest when it investigates accidents, identifies safety deficiencies, and makes safety recommendations. Independence is a key feature of the TSB. The Board reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be fully objective in arriving at its conclusions and recommendations.

The Transp ortation Safety Board of Canad a (TSB) investigated this occu rrence for the p u rp ose of ad vancing transp ortation safety. It is not the fu nction of the Board to assign fau lt or d eterm ine civil or crim inal liability.

Aviation Occurrence Rep ort

Controlled Flight into Terrain Trans Provincial Airlines Pip er PA-31-350 Chieftain C-GKIY Terrace, British Colu m bia 39 nm N 22 October 1990 Rep ort N u m ber A90P0340

Synopsis
The aircraft d ep arted on a flight from Bronson Creek to Terrace, British Colu m bia, bu t d id not arrive at its d estination. An air and ground search w as cond u cted , bu t the aircraft w as not fou nd , and the search w as aband oned . The aircraft w as fou nd by chance alm ost fou r years later. The aircraft stru ck the trees in controlled level flight w ith the engines prod u cing pow er. The pilot and three passengers d id not su rvive the im p act. The Board d eterm ined that the pilot likely attem p ted to continu e the visu al flight into an area of instru m ent m eteorological cond itions. N OTE: This rep ort su p ersed es the Board 's previous rep ort of the sam e nu m ber, released in Ap ril 1992. Find ing the aircraft provid ed some new evid ence, and this rep ort reflects all of the evid ence gathered . Ce rap p ort est galem ent d isp onible en franais.

TA BLE O F C O N TEN TS

Table of Contents
Page

1.0

Factu al Inform ation


1.1 1.2 1.3 1.4 1.5 1.6 1.7

..................................................

1 1 1 2 2 2 3 4

H istory of the Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inju ries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dam age to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Dam age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personnel Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aircraft Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meteorological Inform ation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.0

Analysis
2.1

................................................................

5 5

Controlled Flight into Terrain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.0

Conclu sions
3.1 3.2

...........................................................

7 7 7

Find ings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cau ses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.0 5.0

Safety Action Ap p end ices

..........................................................

Ap p end ix A - Rou te of Flight and Crash Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Ap p end ix B - List of Su p p orting Rep orts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Ap p end ix C - Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

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FA C TU A L IN FO RM A TIO N

1.0 Factual Information


1.1 History of the Flight

The aircraft w as on a sched u led visu al flight ru les (VFR)1 flight from Terrace to Isku t to Dease Lake to Bronson Creek and back to Terrace, British Colu m bia. The aircraft d ep arted Terrace abou t 1005 Pacific stand ard tim e (PST)2 and arrived Isku t abou t 1145, d eparted Isku t abou t 1155 and arrived Dease Lake about 1230, and d ep arted Dease Lake about 1250 and arrived Bronson Creek abou t 1340. All of these flights w ere com p leted w ithou t incid ent, and the aircraft d ep arted Bronson Creek for Terrace at abou t 1350 w ith the pilot and three passengers on board . Ten m inu tes later, the pilot sp oke on the rad io to a pilot w ho w as flying from Sm ithers to Bronson Creek w hen the tw o aircraft passed each other ap p roxim ately 20 m iles east of Bronson Creek. This w as in the Isku t River valley ju st east of the conflu ence of the Forest Kerr River and the Isku t River. This w as the last reported contact w ith the aircraft, and the pilot d id not report a problem at that tim e. An air and grou nd search w as started after the aircraft w as rep orted m issing, bu t the aircraft w as not fou nd and the search w as aband oned . N o em ergency locator transm itter (ELT) signal w as d etected . The w reckage w as fou nd by chance on 05 Au gu st 1994, nearly fou r years after the accid ent. (See Ap p end ix A.)

1.2

Injuries to Persons
Crew Passengers 3 3 Others Total 4 4

Fatal Serious Minor/ N one Total

1 1

See Glossary for all abbreviations and acronyms. All times are PST (Coordinated Universal Time [UTC] minus eight hours) unless otherwise indicated.
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FA C TU A L IN FO RM A TIO N

1.3

Damage to A ircraft

The aircraft w reckage w as found about 39 m iles north of Terrace, and about 5 m iles east of the Tseax River valley. The Tseax River valley is the m ain VFR rou te north of Terrace. The evid ence from the tree d am age and the w reckage pattern ind icated that the aircraft hit the trees in straight and level flight on a head ing of abou t 360 d egrees m agnetic. The accid ent site w as abou t 3,500 feet above sea level (asl), on steep ly slop ing terrain covered w ith su b-alpine vegetation. The aircraft broke up on im p act, and the accid ent w as not su rvivable. N o hu m an rem ains w ere fou nd at the site, ap art from a few sm all bones. A post-crash fire consu m ed the up p er p art of the fu selage; how ever, all of the other p arts of the aircraft w ere recovered . Dam age to the prop eller blad es ind icated that the engines w ere p rod u cing pow er at im pact. The ELT and the instru m ents that w ere not d estroyed by fire w ere sent to the TSB Engineering Branch laboratory for exam ination. The d u al engine fu el pressu re ind icator face and the d u al engine exhau st gas tem p eratu re ind icator face both had pointer imp rints in the norm al engine operating range. The exam ination of the ELT ind icated that it w as probably serviceable prior to im p act, but it failed to transm it a signal as the crystal w as d am aged by the im p act.

1.4

Other Damage

There w as no other significant d am age.

1.5

Personnel Information
Cap tain

Age Pilot Licence Med ical Exp iry Date Total Flying H ou rs H ou rs on Typ e H ou rs Last 90 Days H ou rs on Typ e Last 90 Days H ou rs on Du ty Prior to Occurrence H ours Off Du ty Prior to Work Period

67 ATPL 01 N ov 1990 13,000 1,000 218 212 5 8

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FA C TU A L IN FO RM A TIO N

The pilot w as qu alified for the flight and w as rep orted to have been healthy, w ell rested , and cheerfu l on that d ay. A review of his m ed ical history confirm ed his good health. The pilot had held an instru m ent rating since 1974 and had logged abou t 700 hou rs of instru m ent flight tim e; how ever, in the preced ing tw o years, he had flow n only in VFR w eather. The pilot had not been su ccessfu l in renew ing his instru m ent rating in Ju ne 1990, as he w as unable to m aintain control of the aircraft w ith reference to the instru m ents and d id not perform the necessary p roced u res to the required stand ard s. The pilot had flow n this aircraft for tw o years, and he w as very fam iliar w ith the area betw een Bronson Creek and Terrace, having flow n in the area for 20 years.

1.6

A ircraft Information

Manu factu rer Typ e Year of Manu factu re Serial N u m ber Certificate of Airw orthiness (Flight Perm it) Total Airfram e Tim e Engine Typ e (nu m ber of) Prop eller/ Rotor Typ e (nu m ber of) Maxim u m Allow able Take-off Weight Recom m end ed Fuel Typ e(s) Fuel Typ e Used

Pip er PA-31-350 Chieftain 1978 31-7852004 Valid 5,520 hr Lycom ing LTIO-540-J2BD (2) H artzell H C-E3YR (2) 7,000 lb 100/ 130, 100 LL 100/ 130

The aircraft m aintenance record s show ed that the aircraft w as certified , equ ip p ed , and m aintained in accord ance w ith existing regulations and app roved proced u res, and that there w as no ind ication of m echanical problem s. The instru m ents and avionics w ere serviceable, and the ELT had been recently checked . The aircraft w as equ ip p ed w ith an autop ilot, w hich w as serviceable prior to the flight; how ever, it is not know n if the pilot used the au top ilot. The w eight and centre of gravity w ere w ithin the prescribed lim its, and there w as su fficient fu el on board for the planned flight.

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FA C TU A L IN FO RM A TIO N

1.7

M eteorological Information

The forecast w eather for the area of the flight w as clou d 1,500 feet asl to 2,500 asl scattered , variable broken, top s 5,000 feet asl, a few broken cu m u lus and em bed d ed tow ering cu m u lus from 2,000 feet asl to 12,000 feet asl, giving light rain show ers, occasional visibility a half to tw o m iles in snow show ers above 2,000 feet asl. Ceilings locally w ere forecast to be 200 to 800 feet above grou nd level, and visibilities zero to three m iles in fog until 1700 Greenw ich Mean Tim e (UTC). There w ere to be light rain show ers and light snow show ers, becom ing isolated after 1500 UTC, surface w ind s from the sou theast at 25 knots, gu sting to 40 knots in exp osed areas, m od erate convective tu rbu lence w ith tow ering cum u lu s, and m od erate m echanical tu rbu lence below 4,000 feet asl. The ou tlook w as for m arginal visu al flight rules w eather ceilings, w ith rain and fog, w ith occasional instru m ent flight rules w eather ceilings, w ith rain and fog in the u p slop e areas. At the tim e of the accid ent, the reported w eather at Terrace (elevation 713 feet asl), the w eather station closest to the accid ent site, w as as follow s: scattered clou d based at 500 and 1,200 feet above grou nd level (agl), overcast ceiling estim ated 8,000 feet agl, visibility six m iles in very light rain and sm oke, temp eratu re 6C and d ew point 4C. The aftercast for the w eather in the area of the accid ent site ind icated that there w as heavy convective cloud based at 3,000 feet asl w ith m od erate turbu lence and patchy stratu s cloud below 3,000 feet asl. Also, the freezing level w as about 3,000 feet asl w ith heavy snow above and rain below , w ith the cond itions d eteriorating.

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A N A LYSIS

2.0 A nalysis
2.1 Controlled Flight into Terrain

The evid ence ind icates that the aircraft w as in straight and level controlled flight w ith both engines prod u cing cru ise pow er w hen it entered the trees. The w eather w as not su itable for VFR flight in the m ountainous terrain. The pilot w as p robably attem p ting to m aintain visu al flight below clou d and in poor visibility, and inad vertently flew into the trees. It w as not possible to d eterm ine w hy the aircraft, w hich w as going sou th to Terrace, crashed head ing north; how ever, it is possible that the pilot w as m anoeu vring to avoid cloud , and stru ck the trees w hile head ing north. The fact that the aircraft w as found in the m ountains five m iles from the m ain VFR route to Terrace su ggests that the pilot had either d iverted to avoid w eather, or had become lost w hile attem p ting to m aintain a navigation cou rse in the poor w eather.

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C O N C LU SIO N S

3.0 Conclusions
3.1
1.

Findings
The aircraft stru ck the trees in straight and level flight w ith the engines prod u cing cruise pow er. The pilot d id not pass his recent instru m ent rating check rid e. The aircraft w as airw orthy on d ep artu re from Terrace, and the ELT had been recently checked . The w eight and centre of gravity w ere w ithin the prescribed lim its, and there w as su fficient fu el for the flight. The ELT w as d am aged at im p act and d id not fu nction. The pilot w as probably trying to avoid bad w eather by flying low in the m ountainous terrain w hen he inad vertently stru ck the trees.

2. 3.

4.

5. 6.

3.2

Causes

The pilot likely attem p ted to continu e the visu al flight into an area of instru m ent m eteorological cond itions.

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SA FETY A C TIO N

4.0 Safety A ction


The Board has no aviation safety recom m end ations to issue at this tim e. This report concludes the Transportation Safety Board' s investigation into this occurrence. Consequently, the Board, consisting of Chairperson John W . Stants, and members Z ita Brunet and Hugh M acN eil, authorized the release of this report on 27 September 1995.

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A P P EN D IC ES

A ppendix A - Route of Flight and Crash Site

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A P P EN D IC ES

A ppendix B - List of Supporting Reports


The follow ing TSB Engineering Branch reports w ere com p leted : LP 122/ 94 - ELT & Instru m ents Exam ination; and LP 123/ 94 - Logbook Restoration. These rep orts are available up on requ est from the Transp ortation Safety Board of Canad a.

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A P P EN D IC ES

A ppendix C - Glossary
agl asl ATPL ELT hr lb nm PST TSB UTC VFR above grou nd level above sea level Airline Transp ort Pilot Licence em ergency locator transm itter hou r(s) p ou nd (s) nau tical m iles Pacific stand ard tim e Transp ortation Safety Board of Canad a Coord inated Universal Tim e visu al flight ru les

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