AVIATION Reports - 2004 - A04H0001

Table of Contents

1. 1.0 Factual Information
   1. 1.1 History of the Flight
   2. 1.2 Injuries to Persons
   3. 1.3 Personnel Information
   4. 1.3.1 General
   5. 1.3.2 Pilot's Seventy-Two Hour History
   6. 1.4 Aircraft Information
   7. 1.4.1 General
   8. 1.4.2 Weight and Balance
   9. 1.5 Meteorological Information
   10. 1.5.1 General
   11. 1.5.2 Forecast Weather
   12. 1.5.3 Observed Weather
   13. 1.5.4 Weather Briefing
   14. 1.5.5 Alternate Forecast Weather
   15. 1.6 Aircraft Performance
   16. 1.6.1 Take-off Procedure
   17. 1.6.2 Flight Performance
   18. 1.7 Aircraft Icing
   19. 1.7.1 Aircraft Certification
   20. 1.7.2 Cessna 208 Flight Manual Icing Information
   21. 1.7.3 Company Direction on Icing
   22. 1.7.4 Canadian Regulatory Policy Regarding Aircraft Icing
   23. 1.7.5 Historical Data on Cessna 208 Icing Accidents
   24. 1.7.6 National Transportation Safety Board Actions Regarding Cessna 208 Aircraft Icing
   25. 1.7.7 Aircraft De-icing Boot Activation
   26. 1.7.8 Cessna 208 De-icing Boot Coverage
   27. 1.8 Aids to Navigation
   28. 1.9 Aerodrome Information
   29. 1.10 Flight Recorders
   30. 1.11 Aircraft Wreckage and Impact Information
   31. 1.12 Medical Information
   32. 1.13 Survival Aspects
   33. 1.13.1 General
   34. 1.13.2 Door Placards and Safety Features Card
   35. 1.13.3 Animal Restraints
   36. 1.13.4 Emergency Locator Transmitter
   37. 1.14 Company Oversight
   38. 1.15 Regulatory Oversight
   39. 1.15.1 Oversight Process
   40. 1.15.2 Frequency of Inspections
   41. 1.15.3 Georgian Express Ltd. Audit History
   42. 1.15.4 Scheduled versus Chartered Service
   43. 1.16 Simulator Training Requirement
   44. 1.17 Standard Passenger Weights
   45. 1.18 Fatigue and Stress
2. 2.0 Analysis
   1. 2.1 Introduction
   2. 2.2 Use of Standard Passenger Weights
   3. 2.2.1 General
   4. 2.2.2 Validity of Standard Passenger Weights
   5. 2.2.3 Use of Standard Passenger Weights in Small Aircraft
   6. 2.3 Ice on the Aircraft
   7. 2.4 Aircraft De-icing Boot Activation
   8. 2.5 Cessna 208 De-icing Boot Coverage
   9. 2.6 Oversight by the Air Operator
   10. 2.7 Regulatory Oversight
   11. 2.8 Simulator Training Requirement
   12. 2.9 Pilot Decision Making
   13. 2.10 The Accident Flight
3. 3.0 Conclusions
   1. 3.1 Findings as to Causes and Contributing Factors
   2. 3.2 Findings as to Risk
4. 4.0 Safety Action
   1. 4.1 Action Taken
   2. 4.1.1 Georgian Express Ltd.
   3. 4.1.2 Transportation Safety Board of Canada
   4. 4.1.3 Transport Canada
   5. 4.1.4 Federal Aviation Administration
5. Appendices
   1. Appendix A - Map of the Crash Region
   2. Appendix B - Map of Pelee Island
   3. Appendix C - Graphic Area Forecast Chart
   4. Appendix D - Wreckage Recovery
   5. Appendix E - Crash Site Debris Field
   6. Appendix F - Passenger Door Placards
   7. Appendix G - List of Supporting Reports
   8. Appendix H - Glossary
6. Photos
   1. Photo 1 - USCG Ship Neah Bay
   2. Photo 2 - CCGS Samuel Risley
   3. Photo 3 - Exterior View of Cabin Passenger Door
   4. Photo 4 - Interior View of Upper Hatch in the Closed Position
   5. Photo 5 - Interior View of the Upper Hatch in the Open Position
   6. Photo 6 - Close-up of Placard Showing Direction of Rotation Opposite to Actual Handle Movement
7. Tables
   1. Table 1 - Calculated Take-off Weight Using Actual and A.I.P. Canada Weights
   2. Table 2 - Approximate Aircraft Stall Speed KIAS with Computed KCAS in Parentheses
   3. Table 3 - Stall Speeds with Reduced CLmax, Approximate KIAS with Computed KCAS in Parentheses
   4. Table 4 - A.I.P. Canada Section RAC 3.5: Published Standard Weights
   5. Table 5 - Amended A.I.P. Canada Standard Weights, 20 January 2005

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