The federal agency that investigates air accidents is telling pilots to "maintain situational awareness" following its investigation into a fatal plane crash in Labrador last spring.
In May, a small Piper aircraft that was being ferried from the United States to the United Kingdom via Greenland crashed into the side of a hill outside Makkovik.
Alan Simpson, one of the two men piloting the plane, died in the crash. The other pilot, Samuel Rutherford, got out with minor injuries following a harrowing rescue by Makkovik's ground search and rescue team in blizzard-like conditions.
According to the findings of the investigation by the Transportation Safety Board, the plane crashed about 60 metres below the peak of a hill about 685 metres high.
While the highest point of elevation on the route was about a thousand metres, the flight plan showed the pilots would climb to about 600 metres, and then to climb to a higher altitude about midway through the flight where wind conditions were said to be more favourable.
The report said the pilots filed a visual flight plan — meaning using their eyes instead of instruments to see what's in front of them — before leaving so they could manoeuvre around weather and terrain while remaining clear of clouds.
"In this occurrence, the plan to initially fly VFR [visual flight rules] below the highest terrain elevation along the route introduced two hazards: flying over rising terrain in deteriorating weather conditions, and flying over snow-covered featureless terrain," the report says.
The TSB classified the crash as a "controlled flight Into terrain," which happens "when an airworthy aircraft under the control of the flight crew is flown unintentionally into terrain, obstacles, or water, usually with no prior awareness by the crew."
"In this occurrence, the altitude that was planned and flown was lower than the highest elevation of terrain along a route where visual references to the ground were reduced," reads the report.
"The ferry pilot knew the hill existed and had planned to fly around it or over the top if visual reference was lost; however, that plan was not executed, and impact occurred without warning."
Rutherford travelled back to Labrador last summer to thank the team that came to his rescue.
He says one of his main takeaways from the report was this line:
"It is important for pilots to operate aircraft with adequate clearance from obstacles and terrain along a VFR route. In such situations, it is important that pilots maintain situational awareness in order to reduce the risks associated with flight into rising terrain by using all available means."
That didn't happen in their crash, he told CBC in a Facebook message.
"The situational awareness was not maintained. Either visually by the handling pilot, or by use of the aircraft systems (the terrain database had not uploaded correctly)," he wrote
"The hill was the only place for miles around without any trees — until then, using visual cues to maintain situational awareness had worked perfectly (even without the terrain database)."
He said he believed Simpson thought the big white shape in front of him was a very long body of water.
"But it was was actually a rising hill with no trees. Visually identical, very different in reality," he said.
Rutherford again thanked the rescue crews who came to his aid.
"They gave Alan and myself a chance by putting their own lives on the line. Thank you," he said.