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News release

Investigation update: Collision with terrain of a Mitsubishi MU-2B-60
in Îles-de-la-Madeleine, Quebec (A16A0032)

Dorval, Quebec, 13 July 2016 – The Transportation Safety Board of Canada (TSB) team continues its investigation into the March 2016 collision with terrain of a Mitsubishi MU-2B-60 in Îles-de-la-Madeleine, Quebec.

The following update contains the facts that the TSB has been able to validate at this time.
It contains no conclusions about the factors that contributed to the accident.
The final investigation report will provide analysis of the accident and the findings of the Board.

The occurrence

On 29 March 2016, a private Mitsubishi MU-2B-60 aircraft (United States registration N246W), departed St. Hubert, Quebec, at 0931 local time (Eastern Daylight Time) on a flight to Îles-de-la-Madeleine, Quebec (CYGR). Onboard was the pilot-in-command, a pilot-passenger occupying the right-hand cockpit seat, and 5 passengers.

The autopilot was being used to control the aircraft throughout the flight.

At 1217 Atlantic Daylight Time (ADT), when the aircraft was at approximately 21 000 feet above sea level and 51 nautical miles (nm) from CYGR, the pilot initiated the descent. At 1225, Moncton Area Control Centre cleared the aircraft for an instrument flight rules approach (flying by reference to instruments rather than flying with visual reference to the ground) to CYGR. At 1229, 2.7 nm from Runway 07, the aircraft landing gear was lowered and approach flaps were selected.

Shortly after that, the autopilot was disconnected, and almost immediately the aircraft departed from controlled flight. It rolled quickly into a steep right bank and descended rapidly. The aircraft continued its rapid descent and impacted the ground in a near-level attitude. All 7 occupants were fatally injured.

Investigation teamwork

The Investigator-in-Charge, Mike Cunningham, is being assisted in this investigation by TSB investigators with backgrounds in flight operations, aircraft performance, aircraft systems and engines, human performance, and air traffic control. Representatives from Transport Canada, NAV CANADA, the Sûreté du Québec, the Bureau du coroner du Québec, the National Transportation Safety Board, the Federal Aviation Administration (FAA), the Mitsubishi Aircraft Corporation, Honeywell International Inc., and Hartzell Propeller Inc. are also providing assistance.

Work to date

A site survey was completed and the wreckage was transported to the TSB Engineering Laboratory (Lab) in Ottawa. The field phase of the investigation is complete and the examination and analysis phase is in progress.

TSB investigators have been in contact with the families of the aircraft's occupants to explain the role of the TSB and our investigation process.

A large number of technical and operational documents, weather reports, air traffic control communications, and incident reports have been gathered and reviewed by investigation team members.

Numerous interviews have been conducted with witnesses and individuals from various organizations.

Initial examination and documentation of aircraft systems, components and structural damage has been completed.

What we know

Aircraft

Lightweight recorder

Aircraft approach path

Figure 1. N246W actual approach (onboard recorder data), compared with the standard aproach

Pilot

Pilot-passenger

Weather

Next steps

The next steps of the investigation include the following work:

Outstanding safety issues

Approach-and-landing accidents

Every year, millions of successful landings occur on Canadian runways. However, there is a risk that accidents resulting in loss of life, injury, and aircraft damage can occur during the approach-and-landing phase of flight. In Canada, from 2009 to 2013, Canadian-registered aircraft were involved in an average of 150 approach-and-landing accidents every year. The TSB Watchlist identifies approach-and-landing accidents as one issue which poses the greatest risk to Canada's transportation system.

Stable approaches significantly increase the chances of a safe landing. Without improvements to stable-approach policy compliance, most unstable approaches will continue to a landing, increasing the risk of approach-and-landing accidents.

Lightweight flight recording systems

In 2013, following its investigation into the March 2011 loss of control/in-flight break-up occurrence, northeast of Mayo, Yukon (TSB Aviation Investigation Report A11W0048), the TSB found that if cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded. It further concluded that in the event that an accident does occur, recordings from lightweight flight recording systems will provide useful information to enhance the identification of safety deficiencies in the investigation. Therefore, the Board recommended that

The Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.
TSB Recommendation A13-01

TSB Recommendation A13-01 speaks about the benefits of lightweight flight recording systems for smaller commercial operations. However, this kind of system would also be equally beneficial for aircraft operated by private operators, for flight training and general aviation aircraft as demonstrated in this occurrence. As noted, in this investigation, valuable information was extracted and is being analyzed.

Communication of safety deficiencies

Should the investigation team uncover a safety deficiency that represents an immediate risk to aviation, the Board will communicate immediately so that it may be addressed quickly and the aviation system made safer.

Visit the investigation page for more information about this investigation.


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: 819-994-8053
Email: media@tsb.gc.ca