News releases
TSB # A09/2005
THE TRANSPORTATION SAFETY BOARD IDENTIFIES THE LOSS OF SITUATIONAL AWARENESS AS A FACTOR IN FATAL AIR CRASH
(Gatineau, Quebec, May 24, 2005) - The Transportation Safety Board of Canada (TSB) today releases its final report (A03O0171) into the fatal crash of a Beech Baron into the waters of Lake Ontario off the Toronto City Centre Airport, Ontario, on July 7, 2003.
In its investigation, the TSB found that it is most likely that, while in an area of patchy dense fog, the pilot lost situational awareness, specifically of his altitude. As a result, he continued a controlled descent until the aircraft struck the water.
The TSB investigation also identified a risk associated with minimum altitudes on approach plates. These are publications that provide pilots with information on the altitudes that should be used when approaching an airfield. Some altitude information on Canadian approach plates is presented differently from that displayed on U.S. plates. Although not a factor in this accident, this lack of standardization could create confusion and contribute to an unsafe approach for pilots using an unfamiliar approach plate layout.
On the morning of July 7, 2003, a Beech Baron aircraft crashed into Lake Ontario, approximately three miles southeast of the Toronto City Centre Airport. The privately owned and operated aircraft was on an instrument approach to the airport after a flight from Lansing Municipal Airport in Illinois, U.S. When the aircraft did not arrive at the airport and failed to respond to calls from the tower, a search began. Several hours later, the Metropolitan Toronto Police Marine Unit found debris on the surface of Lake Ontario. The aircraft was located the following day by the Ontario Provincial Police. The aircraft was found essentially intact at a depth of 220 feet. The pilot did not survive the accident.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
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The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053
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