Beechcraft 100 King Air

The loss of engine power due to fuel exhaustion as a result of the pilot's inadequate fuel management.

Controlled flight into terrain after the crew started the descent prematurely. The lack of visibility was considered as a contributing factor.

Findings as to Causes and Contributing Factors:
1. The crew conducted an Area Navigation (RNAV) approach for which they were not trained, with an aircraft that was not properly equipped nor approved for such purpose.
2. The aircraft descended 300 feet below the minimum descent altitude (MDA) as a result of a number of lapses, errors and adaptations which, when combined, resulted in the mismanaged approach.
3. The aural warning on the aircraft’s altitude alerter had been silenced prior to the approach, which precluded it from alerting the crew when the aircraft descended below minimum descent altitude.
4. The SkyNorth standard operating procedures for conducting a non-precision approach were not followed, which resulted in the aircraft descending below the minimum descent altitude. During the ensuing missed approach, the aircraft struck trees.
Findings as to Risk:
1. The lack of a more-structured training environment and the type of supervisory flying provided increased the risk that deviations from standard operating procedures (SOPs) would not be identified.
2. There are several instrument approach procedures in Canada that contain step-down fixes that are not displayed on global positioning system (GPS) units. This may increase the risk of collision with obstacles during step-downs on approaches.

Findings as to Causes and Contributing Factors:
1. An electrical short circuit in the cockpit pedestal area produced flames and smoke, which induced the crew to take emergency action.
2. The detrimental effects of aging on the wires involved may have been a factor in this electrical arc event.
3. The crew elected to return to the airport at low level in an environment with inadequate visual references. As a result, control of the aircraft was lost at an altitude from which a recovery was not possible.
Findings as to Risk:
1. The actions specified in the standard operating procedures (SOP) do not include procedures for an electrical fire encountered at low altitude at night, which could lead to a loss of control.
2. Visual inspection procedures in accordance with normal phase inspection requirements may be inadequate to detect defects progressing within wiring bundles, increasing the risk of electrical fires.
3. In the event of an in-flight cockpit pedestal fire, the first officer does not have ready access to available fire extinguishers, reducing the likelihood of successfully fighting a fire of this nature.
4. Sealed in plastic containers and stored behind each pilot seat, the oxygen masks and goggles are time consuming to access and cumbersome to apply and activate. This could increase the probability of injury or incapacitation through extended exposure to smoke or fumes, or could deter crews from using them, especially during periods of high cockpit workload.
Other Finding:
1. A failure of the hot-mic recording function of the cockpit voice recorder (CVR) had gone undetected and information that would have been helpful to the investigation was not available.

Gear up landing for undetermined reason.

The pilot’s failure to maintain terrain clearance during takeoff for undetermined reasons.

The pilot's failure to maintain a positive climb rate during an instrument takeoff. Contributing to the accident was the low visibility.

Findings as to Causes and Contributing Factors:
1. The aircraft was configured late for the approach, resulting in an unstable approach condition.
2. The pilot flying carried out a steep turn at a low altitude, thereby increasing the load factor. Consequently, the aircraft stalled at an altitude that was too low to allow the pilot to carry out a stall recovery procedure.
Findings as to Risk:
1. The time spent programming the global positioning system reduced the time available to manage the flight. Consequently, the crew did not make the required radio communications on the mandatory frequency, did not activate the aircraft radio control of aerodrome lighting (ARCAL), did not make the verbal calls specified in the standard operating procedures (SOPs), and configured the aircraft for the approach and landing too late.
2. During the second approach, the aircraft did a race-track pattern and descended below the safe obstacle clearance altitude, thereby increasing the risk of a controlled flight into terrain. The crew’s limited instrument flight rules (IFR) experience could have contributed to poor interpretation of the IFR procedures.
3. Non-compliance with communications procedures in a mandatory frequency area created a situation in which the pilots of both aircraft had poor knowledge of their respective positions, thereby increasing the risk of collision.
4. The pilot-in-command monitored approach (PICMA) procedure requires calls by the pilot not flying when the aircraft deviates from pre-established acceptable tolerances. However, no call is required to warn the pilot flying of an approaching steep bank.
5. The transfer of controls was not carried out as required by the PICMA procedure described in the SOPs. The transfer of controls at the co-pilot’s request could have taken the pilot-in-command by surprise, leaving little time to choose the best option.
6. Despite their limited amount of IFR experience in a multiple crew working environment, the two pilots were paired. Nothing prohibited this. Although the crew had received crew resource management (CRM) training, it still had little multiple crew experience and consequently little experience in applying the basic principles of CRM.
Other Findings:
1. The emergency locator transmitter (ELT) had activated after the impact but due to circuit board damage its transmission power was severely limited. This situation could have had serious consequences had there been any survivors.
2. The Chibougamau/Chapais airport does not have an aircraft rescue and firefighting service. Because the fire station is 23 kilometres from the airport, the firefighters arrived at the scene 26 minutes after the accident.
3. Although this accident does not meet the criteria of a controlled flight into terrain (CFIT), it nonetheless remains that a stabilized constant descent angle (SCDA) non-precision approach (NPA) would have provided an added defence tool to supplement the SOPs.
4. After the late call within the mandatory frequency (MF) area, the specialist at the Québec flight information centre asked the crew about its familiarity with the MF area while the aircraft was in a critical phase of the first approach, which was approaching the minimum descent altitude (MDA). This situation could have distracted the flight crew while they completed important tasks.
5. The standard checklist used by the flight crew made no reference to the enhanced ground proximity warning system (EGPWS). Therefore, the crew was not prompted to check it to ensure that it was properly activated before departure.