Seven Islands

Given the absence of data for the last minute of the occurrence flight, the investigation could not determine the complete sequence of events that led to the loss of control and collision with terrain.

Findings as to Causes and Contributing Factors:
1. After the take-off at reduced power, the aircraft performance during the initial climb was lower than that established at certification.
2. The right engine experienced a problem in flight that led to a substantial loss of thrust.
3. The right propeller was not feathered; therefore, the rate of climb was compromised by excessive drag.
4. The absence of written directives specifying which pilot was to perform which tasks may have led to errors in execution, omissions, and confusion in the cockpit.
5. Although the crew had the training required by regulation, they were not prepared to manage the emergency in a coordinated, effective manner.
6. The priority given to ATC communications indicates that the crew did not fully understand the situation and were not coordinating their tasks effectively.
7. The impact with the berm caused worse damage to the aircraft.
8. The aircraft’s upside-down position and the damage it sustained prevented the occupants from evacuating, causing them to succumb to the smoke and the rapid, intense fire.
9. The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.
10. The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Findings as to Risk:
1. Deactivating the flight low pitch stop system warning light or any other warning system contravenes the regulations and poses significant risks to flight safety.
2. The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.
3. Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.
4. The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.
5. The lack of an in-depth review by TC of SOPs and checklists of 703 operators poses a safety risk because deviations from aircraft manuals are not detected.
6. Conditions of employment, such as flight hours–based remuneration, can influence pilots’ decisions, creating a safety risk.
7. The absence of an effective non-punitive and confidential voluntary reporting system means that hazards in the transportation system may not be identified.
8. The lack of recorded information significantly impedes the TSB’s ability to investigate accidents in a timely manner, which may prevent or delay the identification and communication of safety deficiencies intended to advance transportation safety.

Finding as to Causes and Contributing Factors:
1. The aircraft stalled at an altitude that was too low for the pilot to recover.
Findings as to Risk:
1. The aircraft was flying at an altitude that could lead to a collision with an obstacle and that did not allow time for recovery.
2. The steep right bank of the aircraft considerably increased the aircraft’s stall speed.
3. The form used to record the pilot’s flight time, flight duty time, and rest periods had not been updated for over a month; this did not allow the company manager to monitor the pilot’s hours.
4. At the time of the occurrence, the Aéropro company operations manual did not make provision for the restrictions on daytime VFR flights prescribed in Section 703.27 of the Canadian Aviation Regulations.
Other Findings:
1. The fact that the aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice recorder (CVR) limited the information available for the investigation and limited the scope of the investigation.
2. Since the aircraft was on a medical evacuation (MEDEVAC) flight, the company mistakenly advised the search and rescue centre that there were two pilots on board the aircraft when it was reported missing.

Findings as to causes and contributing factors:
1. The pilot flying did not establish a maximum performance climb profile, although required by the company's standard operating procedures (SOPs), when the ground proximity warning system (GPWS) "Terrain, Terrain" warning sounded during the descent, in cloud, to the non-directional beacon (NDB).
2. The pilot flying did not fly a stabilized approach, although required by the company's SOPs. The crew did not carry out a go-around when it was clear that the approach was not stabilized.
3. The crew descended the aircraft well below safe minimum altitude while in instrument meteorological conditions.
4. Throughout the approach, even at 100 feet above ground level (agl), the captain asked the pilot flying to continue the descent without having established any visual contact with the runway environment.
5. After the GPWS "Minimums, Minimums" voice activation at 100 feet agl, the aircraft's rate of descent continued at 850 feet per minute until impact.
6. The crew planned and conducted, in cloud and low visibility, a user-defined global positioning system approach to Runway 31, contrary to regulations and safe practices.
Findings as to risk:
1. At the time of the approach, the reported ceiling and visibility were well below the minima published on the approach chart.
2. Because the runway was not equipped with a reporting runway visual range system, flying the NDB approach was allowable under the existing regulations.
3. The crew did not follow company SOPs for the approach and missed-approach briefings.
4. Both crew members had surpassed their maximum monthly and quarterly flight times and maximum daily flight duty times. They were thus at increased risk of fatigue, which leads to judgement and performance errors.
5. The first officer likely suffered from chronic fatigue, having worked an average of 14 hours a day for the last 30 days, with only 1 day of rest.
6. Transport Canada was not aware that the company's pilots were exceeding the flight and duty times.
7. The company operations manager did not effectively supervise the flight and duty times of company pilots.
8. The captain had not received the mandatory training in pilot decision making or crew resource management.
Other findings:
1. The emergency locator transmitter activated on initial impact but ceased to transmit shortly thereafter when its antenna cable was severed.

The aircraft crashed as a result of the lack of cockpit co-ordination when the pilot-in-command took control of the aircraft as the aircraft was airborne. The following factors contributed to the occurrence: marginal environmental conditions; contaminated runway surface; poor cockpit management; ineffective briefing; and, inadequate training for rejected take-offs.

Engine failure for unknown reasons. The aircraft stalled during the last turn because its speed was insufficient.

Failure or malfunction of both engines after takeoff in icing conditions. The following contributing factors were reported:
- Failed to use anti-icing/deicing systems.

Overheating of the starter selector relay during starting of no.1 and 2 engines. The proximity of a wire bundle to the relay provided a source of combustibles for the initial fire.