De Havilland DHC-2 Beaver

Findings as to causes and contributing factors:
1. The pilot performed manoeuvres with a reduced safety margin at low altitudes. As a result, these flights involved a level of risk that was unnecessary to attain the objectives of sightseeing flights.
2. With no restrictions on manoeuvres and no minimum altitude prescribed by the company prior to flight, the pilot flew according to his own limits and made a steep turn at approximately 110 feet above ground level.
3. When the pilot made a steep left turn, aerodynamic stalling ensued, causing an incipient spin at an altitude insufficient to allow control of the aircraft to be regained prior to vertical collision with the terrain.
4. The absence of an angle-of-attack indicator system and an impending stall warning device deprived the pilot of the last line of defence against loss of control of the aircraft.

Findings as to risk:
1. If lightweight flight data recording systems are not used to closely monitor flight operations, there is a risk that pilots will deviate from established procedures and limits, thereby reducing safety margins.
2. If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring, operators may not be able to proactively identify safety deficiencies before they cause an accident.
3. If pilots do not obtain at least the regulatory rest periods, there is a risk that flights will be conducted when pilots are fatigued.
4. Unless all flights made are recorded in the pilot’s logbook and monitored by the company, it is possible that the pilot will not receive the required rest periods, which increases the risk of flights being conducted when the pilot is fatigued.
5. If flights made are not recorded in the aircraft’s journey logbook, it is possible that inspection and maintenance schedules and component lifetimes will be exceeded, increasing the risk of failure.
6. Unless safety management systems are required, assessed, and monitored by Transport Canada in order to ensure continual improvement, there is an increased risk that companies will not be able to identify and effectively mitigate the hazards involved in their operations.
7. If pilots do not receive stall training that demonstrates the aircraft’s actual behaviour in a steep turn under power, there is a high risk of loss of control.

Other findings:
1. The replacement of the ventral fin with Seafins on C-FKRJ was in compliance with the requirements of Kenmore Air Harbor Inc.’s supplemental type certificate.
2. The control wheel was in the left-hand position (pilot side) at the moment of impact.
3. Angle-of-attack indicator systems have been recognized as contributing to flight safety by improving pilot awareness of the stall margin at all times, thereby allowing pilots to react in order to prevent loss of control of the aircraft.
4. Stall warning systems have been recognized as a means of improving flight safety by providing a clear, unambiguous warning of an impending stall.

Causes:
- According to the ITSB calculations the airplane was well over the maximum gross weight and the airplane’s performance was considerably degraded due to its overweight condition.
Weather
- VFR flight was executed, with the knowledge of IMC at the planned flight route across Tröllaskagi. The airplane was turned around before it entered IMC on two occasions and it crashed when the PF attempted to turn it around for the third time.
- Favorable weather on for the subsequent flight between Keflavik Airport and Greenland on August 10th may have motivated the pilots to fly the first leg of the flight in poor weather conditions on August 9th.
Terrain
- The pilots failed to take into account the geometry of the valley of Barkárdalur, namely its narrow width and the fast rising floor in the back of the valley.
Contributing factors:
CRM - Inadequate planning
- The W&B calculations performed by the PF prior to the flight were insufficient, as the airplane’s weight was well over the maximum gross weight of the airplane.
- The plan was to look for an opening (in the weather), first in the head of the valley of Öxnadalur, then the head of Hörgárdalur and finally in the head of Barkárdalur.
- The decision to fly into the valley of Barkárdalur was taken spontaneously, when flying out of the valley of Hörgárdalur and the pilots noticed what looked like a break in the cloud cover over the head of the valley of Barkárdalur.
CRM – Failed to conduct adequate briefing
- A failure of CRM occurred when the PNF did not inform the PF of the amount of fuel he added to the airplane prior to the flight.
Overconfidence
- The special ferry flight permit the pilots received for the ferry flight to Iceland in 2008 may have provided the pilots with a misleading assumption that such loading of the airplane in 2015 was also satisfactory.
Continuation bias
- The pilots were determined to continue with their plan to fly to Keflavik Airport, over the peninsula of Tröllaskagi, in spite of bad weather condition.
Loss of situational awareness
- The pilots were not actively managing the flight or staying ahead of the aircraft, taking into account various necessary factors including performance, weather and terrain.
- The airplane most likely incurred severe carburetor icing in Barkárdalur.

Prior to touchdown in a northerly direction, the aircraft encountered a gusty westerly crosswind and the associated turbulence. This initiated an un-commanded yaw and left wing drop indicating an aerodynamic stall. The pilot was unsuccessful in recovering full control of the aircraft and it impacted rising terrain on the shore approximately 30 feet above the water surface.