Mountains

Controlled flight into terrain. Combining instrument flight (IFR), with visual flight (VFR), the crew lost situational awareness, deviating 29.8 miles to the right of the Victor 3 airway due to bad weather, when the weather conditions imposed the application of the instrument flight rules (IFR), causing collision of the aircraft with the mountain at 6200 feet of elevation without loss of control (CFIT).
The following contributing factors were identified:
- Severe weather conditions en route,
- Persistence of the pilot in command, to continue the instrument flight (IFR) on visual flight (VFR),
- Inconsistency in cockpit resource management (CRM),
- Loss of situational awareness of the flight crew and the controllers, due to numerous deviations from the route, due to severe weather conditions and poor communication between the parties.
- inadequate preparation of the flight plan, since in view of the very probable need to circumnavigate severe meteorological conditions, the flight altitudes that would continue outside of the controlled airspace (outside the v-3 airway) were not verified.

The failure of the pilot-in-command to ensure adequate airspeed for flight during a forced descent due to airframe icing, resulting in a stall. Factors included: freezing rain conditions, airframe icing, an improper decision by the pilot-in-command to turn toward mountainous terrain (where a turn toward lower and level terrain was a viable option), mountainous terrain, and insufficient altitude available for stall recovery.

A descent below the surrounding terrain, by the pilot, in IMC conditions. Factors were high mountainous terrain, clouds, inaccurate weather evaluation by the pilot, and the pilot's flight into IMC conditions.

Controlled flight into terrain after the crew decided to continue the descent under VFR mode in IMC conditions. It was reported that both pilots have the qualifications for IFR flight but were never trained to fly in such conditions.

Findings as to Causes and Contributing Factors:
1. The aircraft probably stalled with insufficient altitude for the pilot to execute a recovery.
2. The prevailing conditions were conducive to optical illusions associated with low-altitude flight over rising terrain.
3. The aircraft was not equipped with a stall warning system, nor was it required by regulation.
4. The pilot's decision to fly at low altitude and probably use cutback power for the climb did not allow for safe obstacle clearance.
5. The pre-flight safety briefing did not inform passengers where to find the survival equipment on board the aircraft. Consequently, they could not use the sleeping bags to protect themselves from exposure and thereby delay hypothermia.
6. Rescue was late because the mostly white aircraft blended into the snowy ground, making it difficult to locate, and the ELT antenna was broken, reducing the range of the signal. Consequently, the survivors' exposure time was increased.
Other Findings:
1. The pilot was certified and qualified for the flight.
2. The autopsy and toxicological test results revealed no indication that physiological factors affected the pilot's performance.
3. Records indicate that the aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures.
4. The aircraft's weight and centre of gravity were within the limits specified in the aircraft fight manual.
5. There is no indication that there was an emergency situation or that the aircraft experienced problems prior to impact.
6. The ready-to-use weight and balance calculation form is not consistent with the standard. Transport Canada reported this irregularity in 1992, but no change was made in the form, which is still part of the company operations manual approved by Transport Canada on 23 October 1999.
7. The weather conditions were suitable for visual flight.