Final Report: Icing and overload downed Caravan

 - September 20, 2006, 6:43 AM

Cessna Caravan 208B, Pelee Island, Ontario, Jan. 17, 2004–The Canadian Transportation Safety Board has released its final report of the Georgian Express Caravan that crashed in Lake Erie, near Pelee Island. The airplane was 1,270 pounds overweight and was laden with ice. The ATP-rated pilot’s decision to take off in icing
conditions was “likely adversely affected by some combination of stress and fatigue,” said the report. The pilot and all nine passengers were killed.

The Caravan used most of the 3,300-foot Runway 27 at Pelee Island for its departure. Climbout was at a very shallow angle while turning north toward Windsor, Ontario. The aircraft struck the frozen surface of the lake 1.6 nm from the departure end of the runway. It was en route to Windsor.

The pilot reported for work at 4:45 a.m. in Toronto, after an estimated five hours’ sleep. The report noted that between January 13 and 16, he had flown to Los Angeles and back, with three time changes each way. The report concluded that it was “likely that the pilot was exposed to an increased risk of fatigue due to circadian rhythm disruptions.”

On January 17 he flew the Caravan to Windsor, then to Pelee Island and back to Windsor. At 3 p.m., planning to fly back to Pelee, he received the weather briefing of a 500-foot ceiling and two miles visibility. The airplane was refueled and
de-iced, as wet snow had accumulated on the wings. The pilot departed for Pelee at 4:05 p.m. on an IFR flight plan and landed at 4:20 p.m. in freezing precipitation. Two people pointed to the ice on the wing, but the pilot inspected the leading edge of the wings, loaded the passengers without voicing concern and took off at 4:38 p.m.

Coworkers described the 3,465-hour pilot as conscientious and professional. He had worked for Georgian Express since November 2000, flying as captain on the Caravan since the fall of 2003. He had taken the complete company ground school and flight training program, including a three-hour lecture on winter operations.

After the accident, Georgian Express installed an aircraft de-icing machine on Pelee Island and the company now employs a second crewmember on all passenger flights.