Canada’s TSB Points to Unstable Approach in MU2 Accident

Canada’s Transportation Safety Board released its final report regarding the March 2016 crash of a U.S-registered MU2 in Quebec. Transportation Safety Board of Canada

The Transportation Safety Board of Canada's final report of the March 2016 crash of a U.S-registered MU2 at Îles-de-la-Madeleine Airport (CYGR), Quebec, points to a pilot who let the aircraft get way ahead of him. Plagued by a high workload and unable to manage the aircraft's energy state, the approach became unstable and the pilot eventually lost control of the airplane. Just a few hundred feet above the ground, the pilot added full power inducing an upset that caused the aircraft to enter a severe right roll. At no time during the approach did the pilot ever attempt a missed approach. Seven people, including the pilot, perished in the accident.

The Board said, "It is unlikely that the pilot's flight skills and procedures were sufficiently practiced to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight."

While the pilot held an ATP certificate, the MU2 was the first truly high-performance aircraft he’d ever flown. The 2,500-hour pilot had logged approximately 125 hours in the MU2, 100 of which was under supervision required to meet insurance requirements. He’d flown the aircraft 19.1 hours in the past 90 days and just 4.3 in the 30 days prior to the accident.

The aircraft carried a General Aviation Safety Network34 Wi-Flight GTA02 FDR system based on a smartphone app that recorded the conversations during the flight used in the accident analysis. Another pilot manned the right seat, although he was unfamiliar with the MU2.

Following the sequence of events beginning 150 nm from the destination, the final minutes of the flight build a picture of a pilot who acted more like someone watching the airplane operate from a distance, than a pilot in command. While still about 145 nm from CYGR, the pilot advised the passenger-pilot he was delaying the descent to save fuel. Investigators believe the aircraft was carrying approximately 1,000 pounds (165 gal.) at the moment of impact. During the descent, the pilot also mentioned a 40-knot tailwind.

Because they would be closer to CYGR than originally planned, the pilot indicated that the aircraft would have to descend at 250 KIAS, which is the aircraft’s maximum operating limit speed (VMO). He later indicated that, in order to minimize time spent in cloud and avoid any icing, the descent would again be delayed. At 64 nm from CYGR, Moncton Center gave the pilot his discretion to 9,000 feet. At 51 nm, the pilot began a gradual descent of approximately 800 fpm, although it eventually reached 1,800 fpm and finally 2,000 fpm.

As the MU2 proceeded to the initial approach waypoint DAVAK, updated weather informed him the wind was 070° at 19 knots, gusting 24 knots, with 2 sm visibility. The ceiling reported was a broken layer at 200 feet and an overcast at 800. This should have caused a reaction by the pilot since the RNAV approach was now below minimums, although he said nothing. Through 12,000 feet the aircraft was indicating 245 knots and the power was reduced enough to cause the gear warning horn to sound, which the pilot silenced.

Once ATC cleared the MU2 for the approach, the pilot was asked to contact CYGR FSS. The passenger-pilot operating the radios told the FSS the aircraft was only 4.7 miles from DAVAK at 6,800 feet, 3,800 feet above the required 3,000-foot crossing altitude. Still indicating 240 knots in a 2,500-fpm descent, the aircraft crossed the initial fix 1,500 feet high while still descending at 1,600 fpm and nearly 100 knots faster than the recommended 140 knot approach speed. Because he was already behind the airplane, the pilot skipped both the approach and the before-landing checklist.

According to the TSB, “About 7 nm from the runway, as the aircraft descended from 3600 feet ASL to 2800 feet ASL, the wind shifted from a southerly component to a headwind of approximately 20 to 25 knots. At 5.8 nm from the runway, as the aircraft reached 3000 feet Agl, the pilot advised the passenger-pilot that, because the aircraft was very high, the rate of descent would have to be increased. About 1 minute later, the pilot indicated he was going to slow down to reach the flap and gear extension speed or the aircraft would not be able to land. The pilot also commented that the aircraft was too high.”

Almost immediately afterwards, the aircraft crossed IMOPA — the final approach waypoint, 4.2 nm from the runway at 2200 feet, some 800 feet above the published crossing altitude of 1410 feet. The aircraft was still descending at 1900 fpm at a speed of 188 knots, about 50 knots fast with the power levers at idle. When the aircraft was 2.7 nm from the runway, the airspeed had decreased to 175 knots and the descent rate had declined to just 1200 fpm. The pilot lowered the landing gear and set flaps to 5 degrees. The aircraft continued descending and slowing as the pilot said the rate of descent had to be further reduced and noted that the aircraft radio altimeter was set at 600 feet Agl.

A few seconds later, “when the aircraft was 1.6 nm from the runway at approximately 600 feet Agl, the passenger-pilot said he could see the ground out the right window. Although the pilot acknowledged this, he did not indicate that he had visual contact with the runway environment. Four seconds later, the pilot said he would continue the approach and fly the aircraft manually. At this point the aircraft had slowed to just a few knots above stall speed when the pilot apparently realizing his speed, advanced the power levers to full.

The aircraft quickly entered a 70-degree right bank and began to descend rapidly as the pilot attempted to right the airplane. While he did level the wings at 150 feet Agl, the rate of descent was not arrested and approached 4,600 fpm, allowing insufficient room to recover before the aircraft struck the ground 1.4 nm west-southwest of the airport.

The TSB added that, “At no time during the approach did the pilot discuss discontinuing the approach as an option available to reduce the workload. Additionally, neither the pilot nor the passenger-pilot indicated that the aircraft had encountered icing conditions, that the ice detector light was illuminated, or that additional de-icing or anti-icing systems should be selected ON.” Following the accident, the TSB determined weather reports had indicated the potential for moderate mixed icing in the clouds below 10,000 feet as well as for moderate turbulence.

The final report also said that investigators calculated a post-accident weight and balance on the aircraft and found it to have exceeded maximum allowable takeoff weight by approximately 200 pounds prior to takeoff, although the Board did not believe the overweight condition directly attributed to the accident.

Rob MarkAuthor
Rob Mark is an award-winning journalist, business jet pilot, flight instructor, and blogger.

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