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News release

Associated links (A19Q0128)

Fatal collision with terrain highlights the risks of continued visual flight rules flights in adverse weather conditions

Gatineau, Quebec, 10 December 2020 — In its investigation report A19Q0128 released today, the Transportation Safety Board of Canada (TSB) determined that flying in a degraded visual environment likely led to the pilot experiencing spatial disorientation and the aircraft subsequently colliding with terrain.

On 29 July 2019, at 15:55 (Eastern Daylight Time), a Beechcraft Bonanza V35B aircraft registered in the U.S. departed Wittman Regional Airport, Wisconsin, U.S., for a daytime visual flight rules (VFR) flight to Danbury Municipal Airport, Connecticut, U.S., with only the pilot on board. Shortly after takeoff, the aircraft began to deviate north of the planned route and subsequently flew into Canadian airspace. At 19:12, while in the vicinity of a line of rain showers, thunderstorms and lightning, the aircraft entered a right turn, descended rapidly and collided with terrain approximately seven nautical miles northeast of Senneterre, Quebec.

At 23:31, the Joint Rescue Coordination Centre (JRCC) in Trenton, Ontario, was notified of a missing aircraft and initiated search and rescue operations. The accident site was found four days later, on 2 August 2019. The pilot was fatally injured and the aircraft was destroyed. There was no post-impact fire and no signal was detected from the aircraft’s emergency locator transmitter.

The flight profile and weather data suggest that the pilot deviated over 350 nautical miles north from his intended flight path in an attempt to bypass or outrun a moving line of thunderstorms and lightning. Numerous heading deviations and corrections all proved unsuccessful in either crossing the line of weather or regaining a suitable track toward the original destination. The commitment to the original plan indicates that the pilot’s decision making was likely affected by plan continuation bias, which led him to continue a VFR flight in adverse weather conditions. The final flight path also suggest that the pilot likely experienced spatial disorientation from a visual or vestibular illusion and, as a result, the aircraft entered a spiral dive and collided with terrain.

The investigation also highlights that if pilots do not have recent experience flying in instrument meteorological conditions, they may not possess the skills and proficiency required to do so, increasing the risk of loss of control and accident.

Canadian space-based ADS-B network. It was also determined that the knowledge level of ADS-B, including space-based ADS-B, was limited within the search and rescue (SAR) community. At the time of the occurrence, JRCC Trenton was aware that ADS-B technology had been available in Canada since March 2019, but also that not all aircraft operating in Canada were equipped with this technology. As a result, JRCC did not include ADS-B data in its data requests to NAV CANADA.

As such, if SAR authorities do not access or use data from emerging technologies, such as space-based automatic dependent surveillance – broadcast, in a timely manner, there is a risk that following an accident, potentially life-saving search and rescue services will be delayed. In this particular case, however, the accident was not survivable. Eventually, access to spaced-based ADS-B data helped in reducing the search area, locating the downed aircraft, and allowed the TSB to reconstruct the flight path.

Since this accident, the Department of National Defence SAR stakeholders were made aware of an ADS-B aircraft locating emergency response tracking service and the requirement to specifically request ADS-B data. Coordinators now routinely include such queries when investigating overdue or missing aircraft.

The TSB is an independent agency that investigates air, marine, pipeline, and rail 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
Telephone: 819-360-4376