Homemade approach a path to disaster
RAYTHEON BEECH 1900D, SEPT-ILES, QUEBEC, AUG. 12, 1999–Two passengers and the first officer escaped from the wreckage of the Regionnair-operated turboprop, which crashed one mile short of its destination. The captain was killed in the accident. Canada’s Transportation Safety Board (TSB) concluded its investigation into Regionnair’s second crash in 1999, citing fatigue, poor judgment and corporate culture as factors.
Regionnair operates charter and scheduled air service from its main base in Chevery, Quebec. The company has held an operating certificate since September 1992.
Leading the flight crew, the captain was a 39-year-old entrepreneur who began his flying career in 1986 while working as a pilot and aircraft maintenance engineer (AME) for Aero Nord Est. He worked for a second aviation company, Alexander Inc., from November 1987 to September 1991. Alexander initially employed him as chief AME, then promoted him to chief pilot. Later he purchased Alexander, renaming the company Confortair. While attending the duties of running his new company, he began flying as a part-time captain on the Beech 1900 for Regionnair. He was properly licensed, possessed a valid medical and was current for the flight. The captain had more than 7,000 hr TT, 606 in type and 127 in the 30 days before the accident.
At 28, the first officer was a commercial pilot with eight years in the industry. In the summer of 1995 the first officer instructed at Quebec Transportair; the following summer he taught at Confortair. He began working for Regionnair five months before the accident and had an arrangement to fly for Confortair when his schedule allowed. The copilot had 2,600 hr TT, 179 in type and 181 in the preceding 30 days before the crash. In the days before the accident the copilot routinely worked 12- to 14-hr days; he flew more than eight hours each of those days. His last full day of rest was nearly one month prior.
On the day of the accident the captain and first officer left their homes at 0730 and 0630, respectively. The captain flew two 30-min flights for Confortair; one flight departed at 0900, the second at 1400. At 0700 the first officer began his day at Confortair and flew a five-leg trip, accruing 6.5 hr of flight time. Regionnair’s flight GIO347 originated in Sept-Iles at 2104. The captain and first officer flew to Port-Menier and Mont-Joli before heading home to Sept-Iles at 2334.
Weather in the Basse Cote-Nord (lower north shore) region of Quebec included widespread areas of low cloud and fog, with an upper trough of warm air moving through. Behind the trough towering cumulus and thunderstorms were expected. According to the TSB, “The airmass was nearly saturated.” Sept-Iles TAF for 1900 to 0700 called for winds from 090 deg at five knots, visibility one-half mile in light drizzle and fog and vertical visibility of 100 ft.
Meteorologists issued an airmet at 1829 for visibilities and ceilings near zero in an onshore flow. At 2000 the airport’s Metar indicated five-eighths mile visibility and a partially obscured ceiling of 100 ft. From the period between 1600 and 2357, eight pilots performed missed approaches to Runways 13 and 31 due to low ceilings and visibility. One Confortair Navajo made it in, after two missed approaches, at 1720. One Regionnair Twin Otter landed at 2059; no other commercial operator landed during that time.
Investigators found the crew planned a straight-in approach for Runway 31 “using solely the navigation guidance from the GPS set up to provide distance and track readouts relative to the runway threshold.” No GPS approach existed for the airport. The pilots entered coordinates that corresponded with the threshold as a waypoint. They agreed to fly an inbound track of 312 deg, crossing the ZV NDB (the final approach fix for the published NDB approach) at 400 ft agl, descending to 300 ft agl by two nautical miles out and crossing one nautical mile out at 100 ft agl. Once reaching 100 ft, the crew planned to fly a shallow descent angle until they could see the approach lights. The published NDB approach for Runway 31 has an MDA of 680 ft msl (506 ft agl). The TSB noted that had a GPS overlay approach been in use, the minimums would not have changed due to an antenna three nautical miles from the airport.
Compounding the fallacious approach plan, the first officer, who was flying the twin turboprop from the right seat, flew an unstabilized approach. Investigators found the copilot initiated his descent from cruise flight late, and the turboprop was high and fast during the approach segment. Nine miles outside the NDB the aircraft was at 10,000 ft and flew a descent rate that “generally exceeded 3,000 fpm.” The crew crossed the NDB at 600 ft and descended at 850 fpm for the last three miles, flying between 140 kt and 150 kt. Investigators noted the captain’s remarks regarding the excess speed and altitude on the CVR. He recommended a “shuttle type” maneuver, such as a 360-deg turn over the NDB, but the first officer didn’t believe that was necessary.
The GPWS sounded “minimums” with the 100-ft DH selected; the captain responded with directions to continue a slow descent. Eight seconds before the airplane crashed, “minimums, minimums” from the GPWS alerted the crew again but they continued the descent. At 2357 the crew hit trees in a “near-level attitude in an area of rising terrain.”
A post-crash fire ensued, destroying the wings, right engine and right center of the fuselage. However, the cabin remained intact. The cockpit separated and was crushed as the aircraft hit the trees, then rolled to the left, hitting the ground in a 50-deg left bank, nose-down attitude, after which it cartwheeled over the left wing.
According to the report, “The crumpled cockpit area was found lying on its right side, nestled between the fuselage and the right engine. The extensive crushing damage to the cockpit destroyed most of the livable space surrounding the occupants.” Releasing himself from his three-point lap belt and shoulder harness, the first officer crawled on his elbows through a hole at the rear of the cockpit and dragged himself a few feet away from the wreckage. The captain was not wearing his shoulder harness. Both passengers jumped out of the cabin, which remained mostly intact aft of the second row of seats, and walked toward the sound of traffic. An ambulance picked up the passengers and transported them to the Sept-Iles Hospital, where they were treated for minor injuries.
Regionnair’s turboprop was equipped with dual Bendix/King KLN 90B GPS receivers. Investigators removed them from the wreckage and returned them to the manufacturer for data retrieval. They found the waypoint coordinates corresponded to the Runway 31 threshold. The magnetic bearing and distance readouts left behind were 312 deg and one nautical mile, the location of the crash site. While the initial installation conformed to Technical Standard Order (TSO) C-129, the database was about one month out of date at the time of the accident. TSB drew no conclusion on the relationship between the currency of the database and the accident.
TSB investigators caution pilots against using self-made GPS approaches in instrument conditions. According to their investigation, RAIM alerts will not trigger when the aircraft is flying to a manually entered waypoint unless the signal degradation exceeds five nautical miles or if fewer than five satellites are received. This is true whether the approach is flown in the en route mode or if the pilot forces the sensitivity of the course indication to that of the approach mode.
TSB investigators are well aware that crews in the Basse Cote-Nord “routinely use GPS to conduct IFR approaches” at airports to descent minimums that are below those of published approaches. Investigators found at the accident site a data sheet printout containing latitude and longitude threshold coordinates, along with runway headings, for all the runways served by Regionnair. Following the accident on Jan. 4, 1999, involving the company’s other Beech 1900 (“Accident Recaps,” May 2001), Transport Canada (TC) revoked the PIC’s right to serve as chief pilot and the president’s right to serve as operations manager. Following the August 1999 accident, TC revoked Regionnair’s operating certificate but reinstated it five days later with the proviso that all crews undertake a Transport Canada CRM course and the company “replace the operations manager, put in place a flight-safety program and promptly correct any flight-safety deficiencies uncovered by the regulatory audit.”