La Ronge

Findings as to Causes and Contributing Factors:
1. Contamination on the wings of the aircraft was not fully removed before take-off. It is likely that asymmetric contamination of the wings created a lift differential and a loss of lateral control.
2. Although the operator was not authorized for short take-off and landing (STOL) take-off on this aircraft, the crew conducted a STOL take-off, which reduced the aircraft’s safety margin relative to its stalling speed and minimum control speed.
3. As a result of the loss of lateral control, the slow STOL take-off speed, and the manipulation of the flaps, the aircraft did not remain airborne and veered right, colliding with obstacles beside the ski strip.
Findings as to Risk:
1. The out of phase task requirements regarding the engine vibration isolator assembly, as listed in the operator’s maintenance schedule approval, results in a less than thorough inspection requirement, increasing the likelihood of fatigue cracks remaining undetected.
2. The right engine inboard and top engine mounts had pre-existing fatigue cracks, increasing the risk of catastrophic failure.
Other Findings:
1. The cockpit voice recorder (CVR) contained audio of a previous flight and was not in operation during the occurrence flight. Minimum equipment list (MEL) procedures for logbook entries and placarding were not followed.
2. The Transwest Air Limited safety management system (SMS) did not identify deviations from standard operating procedures.

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.

Findings as to Causes and Contributing Factors:
1. The flight crew attempted a low-energy go-around after briefly touching down on the runway. The aircraft’s low-energy state contributed to its inability to accelerate to the airspeed required to accomplish a successful go-around procedure.
2. The rapid power lever advancement caused an inadvertent shutdown of the left engine, which exacerbated the aircraft’s low-energy status and contributed to the eventual loss of control.
3. The inadvertent activation of the autofeather system contributed to the crew’s loss of situational awareness, which adversely influenced the decision to go around, at a time when it may have been possible for the aircraft to safely stop and remain on the runway.
4. The shortage and ambiguity of information available on rejected landings contributed to confusion between the pilots, which resulted in a delayed retraction of the flaps. This departure from procedure prevented the aircraft from accelerating adequately.
5. Retarding the power levers after the first officer had exceeded maximum power setting resulted in an inadequate power setting on the right engine and contributed to a breakdown of crew coordination. This prevented the crew from effectively identifying and responding to the emergencies they encountered.
Findings as to Risk:
1. The design of the autofeather system is such that, when armed, the risk of an inadvertent engine shutdown is increased.
2. Rapid power movement may increase the risk of inadvertent activation of the negative torque sensing system during critical flight regimes.
Other Findings:
1. There were inconsistencies between sections of the Conair aircraft operating manual (AOM), the standard operating procedures (SOPs), and the copied AOM that the operator possessed. These inconsistencies likely created confusion between the training captain and the operator’s pilots.
2. The operator’s CV-580A checklists do not contain a specified section for circuit training. The lack of such checklist information likely increased pilot workload.

Findings as to Causes and Contributing Factors:
1. An incorrect roller of a smaller diameter and type was installed on the left main landing gear outboard bellcrank assembly, contrary to company and industry practice.
2. The smaller diameter roller reduced the required rigging tolerances for the bellcrank-to-cam assembly in the down-and-locked position and allowed the roller to eventually move beyond the cam cutout position, resulting in the collapse of the left landing gear.
3. A rigging check was not carried out after the replacement of the bellcrank roller. Such a check should have revealed that neither the inboard nor outboard bellcrank assembly met the minimum rigging requirements for proper engagement with the positioning cam.

Crashed after being stolen by an intoxicated 'pilot'.

After take-off, the left propeller was likely on its start locks, which, as the airspeed increased, allowed the propeller to overspeed. The pilot was unable to resolve the situation in time to prevent the aircraft from striking the surface of Wollaston Lake. Contributing to the severity of the patient's injuries were the inadequate restraint provided by the stretcher and its restraining strap, the lack of standards regarding stretchers used in aircraft, and the lack of standards as to the operation of MEDEVAC flights.

The following findings were reported:
- Aircraft control was lost for undetermined reasons.
- The pilot departed Wollaston Lake into known icing conditions in an aircraft that was not certified for flight into such conditions.
- There was no evidence of any airframe failure or system malfunction prior to or during the flight.
- The flight crew was certified and qualified for the flight in accordance with existing regulations.
- The aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures.
- The aircraft's weight and centre of gravity were within the prescribed limits.

Engine failure after takeoff.

Engine failure in flight.