Canadair CL-415

Findings as to causes and contributing factors:
- It is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to the MANUAL selection when the centre pedestal cover was removed.
- The PROBES AUTO/MANUAL switch position check was not included on the Newfoundland and Labrador Government Air Services CL-415 checklist.
- The flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity.
- The flight crew decided to continue the take-off with the aircraft in an overweight condition.
- The extended period with the probes deployed on the water resulted in a longer take-off run, and the pilot flying decided to alter the departure path to the left.
- The left float contacted the surface of the lake during initiation of the left turn. Aircraft control was lost and resulted in collision with the water.
Findings as to risk:
- If safety equipment is installed in a manner that hampers its access and removal, then there is an increased risk that occupants may not be able to retrieve the safety equipment in a timely manner to ensure their survival.
- If individuals are not trained on safety equipment installed on the aircraft, then there is an increased risk that the individuals may not be aware of how to effectively use the equipment.
- If a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that that item will be missed, which could jeopardize the safety of flight.
- If flight crews do not adhere to standard operating procedures, then there is a risk that errors and omissions can be introduced, which could jeopardize the safety of flight.
- If a person is not restrained during flight and the aircraft either makes an abrupt manoeuvre or loses control, then that person is at a much greater risk of injury or death.
- If an overweight take-off is carried out, there may be an adverse effect on the aircraft’s performance, which could jeopardize the safety of flight.
- If companies do not have procedures for recording overweight take-offs and flight crews do not report them, then the overall condition of the aircraft’s structures will not be accurately known, which could jeopardize the safety of flight.
- If organizations do not use formal and documented processes to manage operational risks, there is an increased risk that hazards will not be identified and mitigated.
- If organizations do not have measures in place to raise awareness of the potential impact of stress on performance or to promote the early recognition and mitigation of stress, then there is an increased risk that errors will occur when an individual is affected by stress that has become chronic.
Other findings:
- Utilizing the locking position of the PROBES AUTO/MANUAL switch for the MANUAL selection allows the switch to be inadvertently moved from the AUTO to the MANUAL position.

Even if it was not possible to define with certainty why the aircraft impacted against the ground, it is nevertheless considered reasonable that the impact occurred as a result of improper management of the manoeuvre by the crew, the result of an inadequate assessment by the crew of the flight altitude with respect to the top of the hill and the critical environmental conditions, characterized by the presence of strong turbulence, strong wind and visibility affected by the presence of smoke. (The cause of the accident would therefore be substantially due to human and environmental factors).

Environmental area:
The load case studied during the investigations did not explain the observed fuselage failure. However, the characteristics of the upward aerological disturbance caused by the fire are likely to have generated airframe stresses of an order of magnitude close to that of the loads capable of causing the fuselage to fail. Given the uncertainties encountered during the evaluation of the parameters of the rising air column that affected the accuracy of the research results concerning the effects of the stresses on the airframe, the aerological phenomenon encountered represents a possible cause of the event.
Technical Area:
The research undertaken to find in-flight loads capable, in the context of the event, of breaking the intact fuselage without damaging the empennage was unsuccessful. Detailed observation of the airframe did not reveal any damage prior to the occurrence. However, the results of these investigations do not rule out the existence of such damage, so the hypothesis of prior damage to the airframe cannot be totally rejected.

The accident was the consequence of an in-flight collision with a power line because the crew adopted a wrong approach configuration to the fire area. The following contributing factors were identified:
- Poor decision making in attacking the fire, causing the crew to focus their attention on obstacles (pylons) of power line n°500, without considering the presence of the cable guard line n°550,
- The reduced visibility of obstacles resulting from the smoke of the forest,
- The inadequate reporting of electricity pylons and associated overhead lines,
- Non-activation of the required radio links, so the crew could not receive reports on the presence of obstacles,
- Short and discontinuous experience of the captain in that role, coming from the institution of the "PIC Frozen",
- The combination of to similar qualified pilots ("PIC Frozen") in the cockpit for the operation of a flight, one just rehabilitated to a high command function, the other still employed in the role of co-pilot: This condition could have a negative impact in terms of crew integration, obscuring decision making,
- The existence of criticality in corporate manuals used at the date of the accident,
- Reduced operational capacity of the crew in the last phase of flight, resulting from the strong heat of the fire under the left wing which penetrated the airplane through an opening created by the separation of a porthole.

The cause of the accident is attributable to the human factor and can be identified in the impact of the aircraft against certain trees following the setting of an inadequate escape manoeuvre.
The following causal factors may have contributed to the dynamics of the accident:
- The crew's failure to strictly comply with the Operator's Manual of Operations, which provided that the route of attack and escape should not be made uphill, unless there were very limited differences in level that could be overcome without power fluctuations,
- The failure to carry out, as a precautionary measure, since the trajectory of the attack route has changed (from descending to ascending), a new reconnaissance with subsequent briefing by the crew, in order to properly assess the different perspective of all the elements of interest (orography, escape route, etc..), even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in unstabilized conditions, therefore not in line with what is previewed from the operating manual, even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in not stabilized conditions, therefore not in line with what is previewed from the operating manual;
- The existence of communication problems within the cockpit, deriving from the fact that there was no information flow between the co-pilot (depositary of the information necessary for the assumption of the most appropriate operational decisions) and the commander, responsible for the final decisions; in this regard, it should be noted that radio communications with the DOCFS were made by the co-pilot in Italian, as the latter was not known by the commander, of Canadian nationality,
- The significant difference in experience and age between the two crew members, with possible negative effects in terms of crew coordination,
- The presence of critical points in the operating manuals, partly eliminated after the accident,
- The presence of locally significant turbulence.

It was reported that the hatches were open when the aircraft landed on the sea, causing severe vibrations and the subsequent loss of control.