Incident Overview

Date: Monday 8 March 2004
Aircraft Type: Canadair CL-215-6B11 (CL-415)
Owner/operator: Securit‚ Civile
Registration Number: F-ZBEZ
Location: Lac Sainte Croix – ÿ France
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 3
Component Affected: Aircraft Control System (specifically, the flight controls, including flaps and the pilot’s control inputs).Aircraft Control System (specifically, the flight controls, including flaps and the pilot’s control inputs).
Investigating Agency: BEADBEAD
Category: Accident
At 09:30, a Canadair (Pelican 41) with callsign Pelican 41 took off from Marseille-Provence Airport for a Lac Sainte-Croix training flight. After 1:20 of flight, the first trainee completed their initial training. During the flight, the two co-pilots switched places, and the second trainee took control, initiating hydroplaning training. The instructor emphasized the speed limit of 55 kt, reminding the trainee to maintain it. The trainee extended flaps to 10ø, initiating takeoff, and accelerated, causing the aircraft to tilt to the right. The instructor directed the trainee to lose the right-hand float, which resulted in the aircraft striking the water. The crew felt a shock, and the aircraft continued to move, causing the instructor to point out the loss of the right-hand float. The trainee in the center seat suggested manual control, which the instructor refused. The instructor initiated descent, directing the trainee to the landing configuration of the flaps. The aircraft, still banked and descending, hit the water with its right wing. The instructor and trainee in the center seat died. The trainee in training was seriously injured.At 09:30, a Canadair (Pelican 41) with callsign Pelican 41 took off from Marseille-Provence Airport for a Lac Sainte-Croix training flight. After 1:20 of flight, the first trainee completed their initial training. During the flight, the two co-pilots switched places, and the second trainee took control, initiating hydroplaning training. The instructor emphasized the speed limit of 55 kt, reminding the trainee to maintain it. The trainee extended flaps to 10ø, initiating takeoff, and accelerated, causing the aircraft to tilt to the right. The instructor directed the trainee to lose the right-hand float, which resulted in the aircraft striking the water. The crew felt a shock, and the aircraft continued to move, causing the instructor to point out the loss of the right-hand float. The trainee in the center seat suggested manual control, which the instructor refused. The instructor initiated descent, directing the trainee to the landing configuration of the flaps. The aircraft, still banked and descending, hit the water with its right wing. The instructor and trainee in the center seat died. The trainee in training was seriously injured.

Description

At 09:30, the Canadair with callsign Pelican 41 took off from Marseille-Provence Airport for the Lac Sainte-Croix which is one of the water bodies usually used for training flights. After 01:20 of flight, the instruction phase for the first trainee was completed. When the Canadair stopped on the lake, the two co-pilots switched places. The second trainee took the controls and began his training session with hydroplaning in accordance with the training program. Before starting the next exercise, the instructor reminded the trainee of the actions to be taken to achieve this phenomenon. He reminded that the speed must remain below 55 kt. The trainee, still at the controls, extended the flaps to 10ø, the takeoff configuration. He then proceeded to accelerate the aircraft by advancing the throttle to obtain an engine torque close to that required for takeoff. As the Canadair accelerated, the trainee applied elevator to initiate the porpoise. The airspeed continued to increase and the Canadair took off without the porpoising phenomenon having occurred. The trainee moved the power levers to minimum. The aircraft struck the water and the crew felt a shock. As the aircraft continued to move through the water in deceleration, the instructor pointed out to the trainee the loss of the right-hand float. The instructor decided to abort the training mission and took over the controls to return to the Marseille-Provence Airport. The instructor then undertook to take off. As soon as the aircraft took off, it slowly tilted to the right even though the control column was positioned to the left. The instructor then positioned the control column to the left, but the bank continued to increase. The instructor told the two co-pilots that he was having difficulty controlling the aircraft. The co-pilot trainee, sitting in the middle seat, suggested switching to manual control. The instructor did not accept this option and put the aircraft in descent. He asked the trainee in the right seat to put the flaps in the 25ø position which corresponded to the landing configuration. The aircraft, still banked and descending, hit the water with its right wing. The instructor and the trainee in the center seat died. The trainee in training was seriously injured. CAUSES OF THE ACCIDENT (translation from French report) The accident is the consequence of a chain of causes of human origin which lead to the loss of control in roll of the aircraft: The accident can be broken down into 2 phases: – A first phase that leads to the damage of the flight controls during the impact with the water following the stall of the aircraft. The stall is the result of the trainee’s failure to execute the flight controls, which was not countered by the instructor. The trainee’s failure to perform at the very beginning of Canadair training was part of a context of: — a failure to comply with the training framework: Contrary to what the progression booklet states, the instructor did not demonstrate the porpoising. He entrusted the commands to the trainee. — pedagogical error: The instructor did not follow a trainee who was performing an exercise for the first time. — lack of control of the parameters (speed) by the crew. – A second phase that lead to the loss of the aircraft and part of its crew. It resulte from an underestimation of the damage to the aircraft during the impact with the water and from the decision of the captain to take off without checking the flight controls. It is common practice for crews to continue flying loss of a float during a scoop. The instructor assimilated the circumstances of the float loss he was confronted with to those already encountered during scooping operations. He proceeded with the takeoff without checking the flight controls that were damaged during the stall.

Primary Cause

A chain of human actions leading to loss of control during the aircraft’s stall, initiated by the trainee’s failure to execute flight controls and the instructor’s lack of proper guidance. The failure to respond to the instructor’s instructions and the trainee’s lack of awareness of the critical speed limit contributed to the accident.A chain of human actions leading to loss of control during the aircraft’s stall, initiated by the trainee’s failure to execute flight controls and the instructor’s lack of proper guidance. The failure to respond to the instructor’s instructions and the trainee’s lack of awareness of the critical speed limit contributed to the accident.

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