Air transportation safety investigation A19Q0088

Table of contents

Loss of control during initial climb and collision with ground

Pitts S2E (amateur-built aircraft), C-GONV
Saint-Jean-Port-Joli, Quebec

View final report

The occurrence

On , a privately operated Pitts S2E aircraft impacted terrain shortly after take-off from Saint-Jean-Port-Joli, Quebec. A pilot and a passenger were on board. The pilot survived the accident and was transported to the hospital for serious injuries and the passenger was fatally injured. The aircraft was substantially damaged.


Media materials

News release

2020-03-03

Investigation report: June 2019 fatal collision with terrain after takeoff in Saint-Jean-Port-Joli, Quebec
Read the news release

Deployment notice

2019-06-17

TSB has deployed a team of investigators following an aircraft accident in Saint-Jean-Port-Joli, Quebec

The Transportation Safety Board of Canada (TSB) has deployed a team of investigators to Saint-Jean-Port-Joli, Quebec, following an accident involving a Pitts S2E aircraft. The TSB will gather information and assess the occurrence.


Investigation information

Map showing the location of the occurrence


Investigator-in-charge

Photo of Mr. Ledoux

Mr. Ledoux has 40 years of civil aviation experience. He joined the Transportation Safety Board (TSB) in April 1999 as an investigator in the Air Investigations Branch, in Dorval, Quebec, and has been the regional manager for the Quebec region since 2003. He has been the investigator-in-charge on several aviation investigations.

Mr. Ledoux worked as an airline pilot for different Canadian carriers, accumulating more than 15 000 flight hours in a wide variety of operations around the world. He flew different aircraft types, from small training aircraft to larger commuter aircraft, eventually piloting large jet aircraft such as, DC8, L1011, B747, and Airbus 310. He also holds a helicopter pilot license. Before joining the TSB, Mr. Ledoux worked at Transport Canada as inspector in the enforcement department.

Since joining the TSB, Mr. Ledoux has participated in several TSB investigations, and has also assisted numerous foreign investigation agencies in their investigations of accidents abroad. He is also a team member of the Universal Safety Oversight Audit Program (USOAP) with the International Civil Aviation Organization (ICAO).


Photos


  Download high-resolution photos from the TSB Flickr page.

Class of investigation

This is a class 4 investigation. These investigations are limited in scope, and while the final reports may contain limited analysis, they do not contain findings or recommendations. Class 4 investigations are generally completed within 220 days. For more information, see the Policy on Occurrence Classification.


TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

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.

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