The wreckage of an airplane lies in a field in in Havre-aux-Maison, Que., on March 29, 2016. Among those killed was former federal cabinet minister and political commentator Jean Lapierre.David Noel/The Associated Press
The plane crash that killed prominent Quebec commentator and former federal politician Jean Lapierre along with four family members rushing home to attend their father's funeral was the result of an inexperienced and overwhelmed pilot whose difficult aircraft got away from him, a Transportation Safety Board report has concluded.
The TSB report released on Wednesday describes a cascading series of faulty decisions that ended with the Mitsubishi MU-2B twin-engine turboprop slamming into the ground nearly two kilometres short of the runway at the Îles-de-la-Madeleine.
On March 29, 2016, Mr. Lapierre, 59, had pilot Pascal Gosselin fly him, his wife, Nicole Beaulieu, his sister, Martine, and his brothers Marc and Louis, from a Montreal suburb to their father's funeral at the family's home archipelago. Fabrice Labourel was a passenger-pilot who Mr. Gosselin brought along to assist on the flight, which did not require a co-pilot. All on board died in the crash.
Small aircraft such as the 11-seat MU-2B are not required to carry flight data or voice recorders, but Mr. Gosselin voluntarily installed a basic unit in the aircraft. His recorder provided vital insight into the series of decisions he made leading to the crash, the TSB report said.
The events started near noon at a cruising altitude of 21,000 feet and about 145 nautical miles from the island airport where Mr. Gosselin informed Mr. Labourel he would delay his initial descent in order to save fuel and minimize time in thick clouds. The decision also compressed the time the pilot would have to reduce altitude and speed and make other preparations to land.
In the 12 minutes and 12 seconds between the start of the descent and the crash, the report described how Mr. Gosselin was constantly correcting errors, leaving his aircraft flying an unstable zigzag pattern, at times too high or too low, while also hitting the top and bottom of the aircraft's airspeed limits.
"The pilot 'got behind' the aircraft by allowing events to control his actions," the report concludes.
The aircraft arrived at the first approach marker at nearly double the planned 125-knot approach speed and 1,500 feet too high. The pilot's effort to reduce speed and altitude ended up with the aircraft too low and slow. As he hit full throttle to try to recover, torque from the engines caused the aircraft to "upset," the report said, banking the plane 70 degrees to the right and losing lift in the wings. The plane levelled off five seconds later, just before striking open ground among some houses.
The pilot never discussed a go-around – a reset manoeuvre where a pilot in an unstable situation flies back to higher altitude to restart a calm and stable approach toward the runway.
"The pilot was juggling multiple tasks and reacting to the situation rather than controlling events in a deliberate, measured manner," said Natacha Van Themsche, the TSB's director of air investigations.
TSB chair Kathy Fox said instances of pilots persisting through unstable approaches to land is a recurring problem. "We have seen too many of these unstable approaches in the past lead to tragic accidents," she said. The TSB also stressed the importance of the recorder installed in the aircraft. The board recommended requiring such recorders several years ago.
The weather was cloudy and windy with a visibility of two nautical miles – "difficult conditions," Ms. Fox said, but within legal limits.
Marie-Anne Lapierre, Jean Lapierre's daughter, released a statement on behalf of family members saying they hope recommendations such as the use of recorders will be implemented by Transport Canada.
They also thanked "everyone who helped shed light on this terrible accident. Their work brings up painful memories but is necessary for our grieving process," Ms. Lapierre wrote.
The MU-2B can be tricky to fly. Fourteen accidents, including 10 fatal crashes, from 2002 to 2005 prompted the Federal Aviation Administration in the United States to conduct a complete safety evaluation of the aircraft.
The FAA found the aircraft was increasingly being flown by less-experienced pilots in cargo and private operations and ordered specific training on the aircraft, which Mr. Gosselin had received.
The TSB report says Mr. Gosselin had 2,500 hours of total flying experience and had received required training on the MU-2B but had only flown the aircraft 25 hours as pilot-in-command.
"It is unlikely that the pilot's flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU-2B for the conditions experienced during the occurrence flight," the TSB report concludes.
Les Perreaux