Beechcraft 100 King Air

Findings as to Risk:
1. Some Canadian Air Regulations (CARs) subpart 703 air taxi and subpart 704 commuter operators are unlikely to provide initial or recurrent CRM training to pilots in the absence of a regulatory requirement to do so. Consequently, these commercial pilots may be unprepared to avoid, trap, or mitigate crew errors encountered during flight.
2. Transport Canada (TC) Prairie and Northern Region (PNR) management practices regarding the June 2006 replacement of the regional combined audit program, in order to manage safety management system (SMS) workload, did not conform to TC’s risk management decision-making policies. Reallocation of resources without assessment of risk could result in undetected regulatory non-compliance.
3. Although TC safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated by the PNR managers because of the limitations of the oversight system in place at that time.
4. It is likely that the National Aviation Company Information System (NACIS) records for other audits include inaccurate information resulting from data entry errors and wide use of the problematic audit tracking form, reducing the effectiveness of the NACIS as a management tracking system.
5. Self-dispatch systems rely on correct assessment of operational hazards by pilots, particularly in the case of unscheduled commercial service into uncertified aerodromes. Unless pilots are provided with adequate decision support tools, flights may be dispatched with defences that are less than adequate.
6. TWA King Air crews did not use any standard practice in applying cold temperature altitude corrections. Inconsistent application of temperature corrections by flight crews can result in reduction of obstacle clearance to less than the minimum required and reduced safety margins.
7. The practice of not visually verifying wind/runway conditions at aerodromes where this information is otherwise unavailable increases the risk of post-touchdown problems.
8. The company dispatched flights to Sandy Bay without a standard means for crews to deal with non-current altimeter settings. Use of non-current or inappropriate altimeter settings can reduce minimum obstacle clearance and safety margins.
9. The crew was likely unaware of their ¼ nautical mile (nm) error in the aircraft position in relation to the runway threshold resulting from use of the global positioning system (GPS). Unauthorized and informal use of the GPS by untrained crews during instrument flight rules (IFR) approaches can introduce rather than mitigate risk.
10. Widespread adaptations by the King Air pilots resulted in significant deviations from the company’s SOPs, notwithstanding the company’s disciplinary policy.
11. In a SMS environment, inappropriate use of punitive actions can result in a decrease in the number of hazards and occurrences reported, thereby reducing effectiveness of the SMS.
12. Pilot workload is increased and decision making becomes more complicated where limited visual cues are available for assessing aircraft orientation relative to runway and surrounding terrain.
13. Aerodromes with limited visual cues and navigational aids are not explicitly identified in flight information publications as hazardous for night/IFR approaches. Passengers and crews will continue to be exposed to this hazard unless aircraft and aerodrome operators carry out risk assessments to identify them and take mitigating action.
14. To properly assess applicants for pilot positions, operators need access to information on experience and performance that is factual, objective, and (preferably) standardized. Because some employers are unprepared to provide this information—fearing legal action—this may lead to the appointment of pilots to positions for which they are unsuited, thereby compromising safety.
Other Findings:
1. TWA’s safety management system was not yet capable or expected to be capable of detecting, analyzing, and mitigating the risks presented by the hazards underlying this occurrence.
2. The first officer and captain met competency standards on the completion of their initial flight training before they began employment as line pilots.
3. It is very likely that the captain became the pilot flying for the remaining 20 seconds of the flight. The scenario that neither pilot was controlling the aircraft at that time is considered very unlikely.

The inadequate in-flight decision to continue the approach to land, directional control not maintained, and the contaminated runway. Contributing factors were flight to destination alternate not performed, a notice to airman not issued by airport personnel relating to snow/slush contamination of the runway, and the snow bank that the airplane impacted during the landing.

Findings as to Causes and Contributing Factors:
1. The aircraft was positioned over the runway threshold at an altitude that did not allow a landing at the beginning of the runway, and this, combined with a tailwind component and the wet runway surface, resulted in a runway excursion.
2. Failure to follow standard operating procedures and a lack of crew coordination contributed to confusion on landing, which prevented the crew from aborting the landing and executing a missed approach.
3. The pilot-in-command held several management positions within the company and controlled the pilot hiring and dismissal policies. This situation, combined with the level of experience of the co-pilot compared with that of the pilot-in-command, had an impact on crew cohesiveness.
Findings as to Risk:
1. The pilot-in-command of C-FMAI decided to execute an approach for Runway 05 without first ensuring that there would be no possible risk of collision with the other aircraft.
2. The regulatory requirement to conform to or avoid the traffic pattern formed by other aircraft is not explicit as to how the traffic pattern should be avoided, in terms of either altitude or distance, which can result in risks of collision.
3. The regulations do not indicate whether the missed approach segment should be considered part of the traffic pattern; this situation can lead pilots operating in uncontrolled airspace to believe that they are avoiding another aircraft executing an instrument approach when in reality a risk of collision exists.

A NOTAM stated that there were windrows four feet high, 10 feet inside the runway lights on both sides of the runway. This NOTAM also stated that the cleared portion of the runway was covered with ¼ inch of loose snow over 60 percent compacted snow and 40 percent ice patches and that braking action was fair to poor. The take-off was being conducted at dusk in conditions of poor lighting and contrast. Crosswind was not a factor.

The flight crew's failure to maintain adequate airspeed, which led to an aerodynamic stall from which they did not recover.

The pilot decided to continue the approach in a flapless configuration and at an insufficient speed, which caused the aircraft to stall on short final.