Aviation Investigation Report A94O0056

• Table of contents

  1. Factual information
  2. Analysis
  3. Findings
  4. Safety action
  5. Appendices

Summary

The pilot was on a flight from Brampton to Hamilton Airport, Ontario, when he reported to the Hamilton tower controller that something had come through the windshield, that he could hardly see, and that he was disoriented. Six minutes later he made his last radio transmission. The aircraft was observed to go off radar about 14 miles northeast of Hamilton Airport over Lake Ontario. The pilot and aircraft are still missing.

The Board determined that an unknown object penetrated the aircraft windshield and incapacitated the pilot.

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1.0 Factual Information

1.1 History of the Flight

The pilot was on a visual flight rules (VFR^{Footnote 1}) flight from Brampton to Hamilton Airport, Ontario (See Appendix A.). At 1322 eastern standard time^{Footnote 2} (EST), he contacted Hamilton tower and requested special visual flight rules (SVFR) to land at Hamilton Airport. The pilot was instructed to hold over the bay (northeast of the control zone) because there was instrument flight rules (IFR) traffic in the control zone. The tower controller issued the latest weather to the pilot, and at 1328 approved SVFR operation into the control zone. At 1334 the pilot reported that something had come through the windshield and that he could not see. During and after this transmission, there was a loud background noise whenever the pilot transmitted. For the next six minutes the controller attempted, based on the tower radar, to assist the pilot by giving advice about the aircraft's position and headings to steer. The pilot was mostly unresponsive, repeating that something had come through the windshield, that he could barely see or could not see, and that he could not see the instruments. At one point he stated that he was disoriented. At 1340 the pilot made his last radio transmission, and further attempts to contact the pilot were unsuccessful; at about 1345 the aircraft disappeared from the radar screen. The aircraft was observed on radar to fly an S-pattern eastbound over Lake Ontario before it disappeared from the radar, approximately 14 miles northeast of Hamilton Airport. The pilot and aircraft are still missing.

Discussions with eye witnesses revealed that the aircraft was flying erratically as it flew out over Lake Ontario. No witnesses saw the aircraft strike the water surface.

1.2 Injuries to Persons

1.3 Damage to Aircraft

The aircraft is missing.

1.4 Other Damage

There was no other damage.

1.5 Personnel Information

The pilot was certified and qualified for the flight in accordance with existing regulations.

The pilot commenced pilot training in 1953, became a flying instructor in 1955, and in 1958 became the Chief Flying Instructor at Hamilton Airport. He also started to fly pipeline patrol in 1958; this later became the pilot's full-time employment. Most of the pilot's flying experience was low-level flying while conducting pipeline patrol.

1.6 Aircraft Information

The aircraft was certified, equipped and maintained in accordance with existing regulations and approved procedures. The weight and centre of gravity were estimated to be within the prescribed limits.

The aircraft had accumulated a total air time of 9,420.5 hours since it was manufactured in 1976.

1.7 Meteorological Information

The following weather reports are station actual (SA) reports for the time of the occurrence for Toronto and Hamilton, the two closest weather reporting stations relative to the aircraft's flight path.

Toronto - Measured ceiling 3,000 feet broken cloud, 7,000 feet overcast cloud, 15 miles visibility, temperature minus four ° C, dew point minus eight ° C, wind 280 ° at 20 knots gusting to 24 knots, altimeter setting 29.53.

Hamilton - Special at 1847 UTC - sky partially obscured, estimated ceiling 2,000 feet broken cloud, 3,000 feet broken cloud, one and one-half miles visibility in light snow showers with blowing snow, wind 280 ° at 20 knots gusting to 29 knots.

One witness, a pilot familiar with the occurrence aircraft, saw the aircraft in flight as he drove his car along highway 403, heading toward Hamilton. He observed the aircraft for about two minutes as it proceeded out over Lake Ontario. The witness reported that it was sunny, the visibility unlimited, with cloud bases at approximately 5,000 feet. Shortly before the pilot reported that the windshield had been hit, he stated that he had a visibility of at least eight miles.

1.8 The Search

A Transport Canada Beechcraft Kingair B90 was preparing for departure from Hamilton Airport at the time that the controller was giving the pilot his position and headings. The Kingair proceeded to the area where the Piper PA-28-140 was last observed on radar but was unsuccessful in locating the aircraft.

At 1355, the Rescue Coordination Centre (RCC) at Trenton, Ontario, was notified and a search was commenced. Search and Rescue (SAR) conducted air searches to no avail, and RCC closed the search at 2100 EST, 25 February 1994. Police forces also conducted an investigation.

2.0 Analysis

A large area of Lake Ontario was searched, but neither the pilot nor the aircraft was found. The last known position of aircraft C-GXGB is 14 miles northeast of Hamilton Airport over Lake Ontario.

The weather conditions where the pilot was holding were visual meteorological conditions (VMC).

The loud background noise in the pilot's radio transmissions, evident at the time the pilot announced his predicament and afterwards, was not evident on his initial communications with the tower controller. This audible change, accompanied by an erratic flight path, indicates that the aircraft's windshield was broken and that the pilot was incapacitated as a result. Because the aircraft and pilot are still missing, the nature of the object that broke the aircraft's windshield was not determined.

3.0 Findings

1. The pilot was qualified and competent.
2. The aircraft was being operated in visual meteorological conditions when the windshield was struck by an unknown object.
3. The object penetrated the windshield and caused the pilot to become incapacitated.
4. The aircraft was last observed on radar 14 miles northeast of Hamilton Airport over Lake Ontario.
5. An extensive search was conducted but neither the aircraft nor the pilot was found.

3.1 Causes

An unknown object penetrated the aircraft windshield and incapacitated the pilot.

4.0 Safety Action

The Board has no aviation safety recommendations to issue at this time.

This report concludes the Transportation Safety Board's investigation into this occurrence. Consequently, the Board, consisting of Chairperson, John W. Stants, and members Gerald E. Bennett, Zita Brunet, the Hon. Wilfred R. DuPont and Hugh MacNeil, authorized the release of this report on 26 October 1994.

Appendices

Appendix A - Radar Plot of Flight Path

Appendix B - Glossary

EST

eastern standard time

hr

hour(s)

IFR

instrument flight rules

RCC

rescue coordination centre

SA

station actual

SAR

search and rescue

SVFR

special visual flight rules

TSB

Transportation Safety Board of Canada

UTC

Coordinated Universal Time

VFR

visual flight rules

VMC

visual meteorological conditions