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SOMBA K'E/YELLOWKNIFE
The September 2011 crash of an Arctic Sunwest Charters Twin Otter float plane in Old Town that took the lives of two pilots was caused by a bounced landing and improper recovery techniques, the Transportation Safety Board of Canada has concluded.

Matthew Grogono was one of the many witnesses to the accident on Sept. 22, 2011, in which an Arctic Sunwest floatplane crashed on McDonald Drive. Grogono was among the first people to arrive at the scene to help evacuate passengers. - NNSL file photo

Confused crew co-ordination in the seconds after aborting the landing on a choppy Great Slave Lake might have been a factor in the loss of control of the aircraft, states the board's report, released Wednesday. The report includes a detailed account of the moments and conditions leading up to the Sept. 22 tragedy on McDonald Drive.

Winds were gusting up to 30 knots southwest as the aircraft, being flown by the first officer, approached the lake just after 1 p.m.

As witnesses watched from the shore, the aircraft, carrying seven passengers from a mining camp at Thor Lake, touched down on the water and bounced, then contacted the water again - right float first. As the Twin Otter moved unsteadily toward the shore, the report states the captain placed his right hand on the power lever over the first officer's hand, initiating full power for a go-around.

The aircraft lifted off, nose-high, right-wing-low, over the shore and toward the buildings in Old Town, reaching just 15 metres above the ground before colliding with power lines and dropping nose down. The bottom of the floats hit the Aurora Geosciences building before the aircraft nosedived, then cart-wheeled left into an adjacent parking lot.

The two pilots, Trevor Jonasson and first officer Nicole Stacey, were fatally injured in the collision. Four passengers were seriously injured, and three sustained minor injuries.

After reading the report, Ray Jonasson, father of Trevor Jonasson, said he did not think the crew could have done anything more than they did to save the lives of everyone on board.

"He was a good pilot and he did everything he could. They both did," Jonasson said. "There were seven other passengers on board. They all survived. We'd just like to remember him as being a hero."

The total elapsed time from the initiation of the go-around to the final impact was 10 seconds, the report found.

The captain did not declare that he was taking control before attempting the go-around, investigators added, stating that the improper go-around techniques led to loss of control of the aircraft.

Both pilots possessed commercial licences. Jonasson had 5,817 hours of flight experience while Stacey had 570 hours.

The report analysis took into account data from the cockpit voice recorder, witness accounts from the ground and on Pilot's Monument, photographs, flight crew training, the wreckage, and the weather situation, said senior investigator Wray Tsuji.

The report is disseminated for the public and pilots to learn from the sequence of events, he said.

"The idea is that pilots, especially those flying Twin Otters, could read the report, keeping in the back of their minds what can happen under those conditions so that we don't have to come up with formal recommendations to say 'this is what you should do or have to do,' because every situation is different. Every landing is different."

The Northern Air Transportation Association was not in a position to comment on the landing techniques used in the fatal crash, executive director Stephen Nourse told Yellowknifer, because Arctic Sunwest is a member of the association.

The Vancouver-based Ledcor Group of Companies, which purchased Arctic Sunwest last summer, declined to comment on the incident because it occurred before the Northern aviation company was acquired from RTL-Westcan Group of Companies in 2012, said spokesman David Hoff.

"Ledcor bought the brand and aircraft but we weren't responsible for Arctic Sunwest at the time of the accident. We weren't the owners or operators then," he said.

"We are aware of the report, we've received a copy of it and we're glad that the Transportation Safety Board has completed its work but we weren't involved in 2011."

The report was released to a number of parties of interest for comment before being released to the public, Tsuji said, including Arctic Sunwest, Transport Canada, and next of kin of the pilots.

Don Bubar, president of Avalon Rare Metals Inc., the company which chartered the flight, said the report describes the events "as they unfolded, with good clarity and detail."

"We didn't see anything in it that was inconsistent with the observations of our people," he said. "As far as we're concerned, it really doesn't leave any unanswered questions either."

The three Avalon employees and four visitors injured in the crash have since recovered, he added.

A Trevor Jonasson Memorial Fund and bursary has been set up by his family online to continue Trevor's passion for flying in the North."

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