News release

Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A23Q0038) into the 2023 accident where a Bell 206L helicopter collided with the surface of a frozen lake near Vallillee Lake, Quebec.

In the morning of April 7, 2023, the helicopter, carrying one pilot and three passengers, was flying from Port-Cartier, Quebec, to a work camp under visual flight rules (VFR). The investigation found that the weather forecast for the flight did not indicate any concerning conditions for that day. However, over the course of the flight, the weather changed, leading to unexpected snow showers and a lower ceiling that caused visibility to rapidly deteriorate. As a result, the pilot unexpectedly lost visual references, also known as inadvertent flight into instrument meteorological conditions (IIMC). Seeing the contour of the lake and confident that visibility was going to improve, the pilot continued flying in the snow shower while descending, unknowingly experiencing deteriorating spatial awareness. A third of the way across the lake, the snow shower intensified, further affecting his ability to visually determine his height. As the pilot turned to the right where he could momentarily see a tree line, the helicopter collided with the lake’s frozen surface and rolled onto its side. All the occupants were able to exit the wreckage and were transported to the hospital.

It's important to note that even when flights are conducted within regulatory visibility requirements and visual references are available, flight safety can be compromised in situations of low visibility or when flying over a surface without contrasts. These two conditions decrease the quality of the visual information pilots have and affect their ability to accurately determine height, distance, and speed visually. Simply meeting regulations may not be enough to guarantee safety.

As previously highlighted by the TSB, loss of visual references can occur unexpectedly and rapidly. When pilots rely on subjective elements when deciding whether to continue a VFR flight despite deteriorating weather conditions, the flight may continue into conditions that are no longer safe, increasing the risk of accidents due to IIMC. To mitigate this risk, Helicopter Association International proposes that operators establish objective criteria for decision-making, such as using enroute decision triggers like airspeed and height. These triggers seek to prompt pilots to take corrective action when conditions worsen, ensuring that decisions are made based on safety rather than relying on their personal comfort level or perceived operational pressures.

Since the occurrence, the operator, Canadian Helicopters Limited, has taken many steps to address the issues raised in the investigation, including issuing a memo clarifying company weather limits, holding an operations and safety update meeting, and updating specific sections of their flight operations manual.

See the investigation page for more information.