On July 7, 2003, at approximately 09:58 Eastern Daylight Time (EDT), a Beech 58TC Baron aircraft crashed into Lake Ontario, Ont., approximately 3 NM southeast of the Toronto City Centre Airport. The privately owned and operated aircraft was carrying out a localizer/distance measuring equipment (LOC/DME) B instrument approach to Toronto City Centre Airport, after a flight from Lansing Municipal Airport, in Chicago, Illinois. When the aircraft did not arrive at the airport, and failed to respond to transmissions from the tower, a search was commenced. Patchy fog in the area resulted in ceilings variable from zero to unlimited, and visibility from 1/8 mile to more than one mile. Several hours later, the Metropolitan Toronto Police Marine Unit found debris on the surface of Lake Ontario. The aircraft was located the following day by the Ontario Provincial Police, using a sidescan sonar. The aircraft was essentially intact, resting vertically on its nose at a depth of 220 ft. The deceased pilot was located in the aft cabin of the aircraft. He received minor injuries in the impact, but failed to egress the aircraft for unknown reasons, and died as a result of drowning.

Findings as to causes and contributing factors

1. During the latter stages of a non-precision instrument approach, the pilot lost situational awareness, specifically of his altitude. As a result, he descended below the minimum descent altitude (MDA) and continued a controlled descent in instrument meteorological conditions (IMC) until the aircraft struck the water.
2. Factors that contributed to the loss of situational awareness were non-precision approach, poor visibility, rushed or incomplete checks, level of instrument proficiency and visual illusion created by surface-based fog.

Finding as to risk

Minimum altitudes on Canada Air Pilot (CAP) approach plates are presented differently from minimum altitudes on U.S. Federal Aviation Administration/National Aeronautical Charting Office (FAA/NACO) approach plates, which could create confusion and contribute to an unsafe approach.