Winnipeg

Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.

A loss of control and subsequent in-flight breakup for reasons that could not be determined
based on the available information.

Findings as to causes and contributing factors:
1. Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
2. The fueling operation was not adequately supervised by the flight crew.
3. A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
4. The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.

Findings as to risk:
1. If administrative and physical defences against errors in aviation fuel operations are circumvented or disabled, there is a risk that the incorrect type of fuel will be delivered.
2. If a reduced-diameter spout is available to accommodate non-standard fuel filler openings, there is an increased risk that Jet-A1 fuel can be dispensed into an aircraft that requires AVGAS.

Other findings:
1. Aircraft that were manufactured prior to the current airworthiness standards, or that have been modified by the installation of turbine engines, may have fuel filler openings that do not meet the dimension requirements.
2. The airworthiness standards for rotorcraft do not specify the size of fuel filler openings.
3. The use of all of the available restraint systems in the aircraft contributed to the survival of the occupants.
4. There was no post-crash fire, likely due to the separation of the battery from the aircraft and to the rain-saturated crash site.
5. The absence of a post-impact fire contributed to the survival of all of the aircraft's occupants.

Findings as to causes and contributing factors:
1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a workaround solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq).
2. Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).
3. Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing and a shift away from welllearned, highly practised procedures.
4. Due to the lack of an instrument approach for the into-wind runway and the unsuccessful attempts at circling, the crew chose the option of landing with a tailwind, resulting in a steep, unstable approach.
5. The final descent was initiated beyond the missed approach point and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3- degree descent path.
6. Neither pilot heard the ground proximity warning system warnings; both were focused on landing the aircraft to the exclusion of other indicators that warranted alternative action.
7. During the final approach, the aircraft was unstable in several parameters. This instability contributed to the aircraft being half-way down the runway with excessive speed and altitude.
8. The aircraft was not in a position to land and stop within the confines of the runway, and a go-around was initiated from a low-energy landing regime.
9. The captain possibly eased off on the control column in the climb due to the low airspeed. This, in combination with the configuration change at a critical phase of flight, as called for in the company procedures, may have contributed to the aircraft’s poor climb performance.
10. A rate of climb sufficient to ensure clearance from obstacles was not established, and the aircraft collided with terrain.
11. The infant passenger was not restrained in a child restraint system, nor was one required by regulations. The infant was ejected from the mother’s arms during the impact sequence, and contact with the interior surfaces of the aircraft contributed to the fatal injuries.
Findings as to risk:
1. If instrument approaches are conducted without reference to an approach chart, there is a risk of weakened situational awareness and of error in following required procedures, possibly resulting in the loss of obstacle clearance and an accident.
2. If additional contingency fuel is not accounted for in the aircraft weight, there is a risk that the aircraft may not be operated in accordance with its certificate of airworthiness or may not meet the certified performance criteria.
3. If Transport Canada crew resource management (CRM) training requirements do not reflect advances in CRM training, such as threat and error management and assertiveness training, there is an increased risk that crews will not effectively employ CRM to assess conditions and make appropriate decisions in critical situations.
4. If a person assisting another is seated next to an emergency exit, there is an increased risk that the use of the exit will be hindered during an evacuation.
5. If a person holding an infant is seated in a row with no seatback in front of them, there is an increased risk of injury to the infant as no recommended brace position is available.
6. If young children are not adequately restrained, there is a risk that injuries sustained will be more severe.
7. If a lap-held infant is ejected from its guardian’s arms, there is an increased risk the infant may be injured, or cause injury or death to other occupants.
8. If more complete data on the number of infants and children travelling by air are not available, there is a risk that their exposure to injury or death in the event of turbulence or a survivable accident will not be adequately assessed and mitigated.
9. If temperature corrections are not applied to all altitudes on the approach chart, there is an increased risk of controlled flight into terrain due to a reduction of obstacle clearance.
10. If the missed approach point on non-precision instrument approaches is located beyond the 3-degree descent path, there is an increased risk that a landing attempt will result in a steep, unstable descent, and possible approach-and-landing accident.
11. If there is not sufficient guidance in the standard operating procedures, there is a risk that crews will not react and perform the required actions in the event that ground proximity warning system warnings are generated.
12. If standard operating procedures, the Airplane Flight Manual and training are not aligned with respect to low-energy go-arounds, there is a risk that crews may perform inappropriate actions at a critical phase of flight.
13. If non-compliant practices are not identified, reported, and dealt with by a company’s safety management system, there is a risk that they will not be addressed in a timely manner.
14. If Transport Canada’s oversight is dependent on the effectiveness of a company’s safety management system’s reporting of safety issues, there is a risk that important issues will be missed.
Other findings:
1. The quick response of the people on the ground reduced the exposure of passengers and crew to the elements.

Findings as to causes and contributing factors:
1. The aircraft departed Snow Lake overweight and with an accumulation of ice on the leading edges of its wings and tail from the previous flight. As a result, the aircraft had reduced take-off and climb performance and increased stall speed, and the protection afforded by its stall warning system was impaired.
2. A breakdown in the company’s operational control resulted in the flight not operating in accordance with the Canadian Aviation Regulations and the company operations manual.
3. As a result, shortly after departure, the aircraft stalled at an altitude from which recovery was not possible.
Findings as to risk:
1. If companies operate in instrument meteorological conditions for which they are not authorized, there is an increased risk that accidents may occur.
2. If Transport Canada does not provide the same degree of oversight for repetitive charter operations as it does for a scheduled operator, the risks in the operator’s activities may not be fully evaluated.
3. If passenger briefings are not provided and passengers are not properly seated and restrained, there is an increased risk of injuries to those passengers and the other occupants in the event of an accident.
4. If flights are conducted without ensuring an ice-free airframe, there is a risk of decreased aircraft performance and of loss of control and collision with terrain.
Other findings:
1. On impact, the aircraft’s seats and cabin deformed as designed, and this deformation partially attenuated the impact forces.

Findings as to causes and contributing factors:
1. The pilot's decision to conduct an approach to an aerodrome not serviced by an instrument flight rules approach in adverse weather conditions was likely the result of the pilot's inexperience, and may have been influenced by the pilot's desire to successfully complete the flight.
2. The pilot's decision to descend into cloud and continue in icing conditions was likely the result of inadequate awareness of the Piper PA31-350 aircraft's performance in icing conditions and of its de-icing capabilities.
3. While waiting for the runway to be cleared of snow, the aircraft held near North Spirit Lake (CKQ3) in icing conditions. The resulting ice accumulation on the aircraft's critical surfaces would have led to an increase in the aircraft's aerodynamic drag and stall speed, causing the aircraft to stall during final approach at an altitude from which recovery was not possible.
Findings as to risk:
1. Terminology contained in aircraft flight manuals and regulatory material regarding “known icing conditions,” “light to moderate icing conditions,” “flight in,” and “flight into” is inconsistent, and this inconsistency increases the risk of confusion as to the aircraft’s certification and capability in icing conditions.
2. If confusion and uncertainty exist as to the aircraft’s certification and capability in icing conditions, then there is increased risk that flights will dispatch into icing conditions that exceed the capability of the aircraft.
3. The lack of procedures and tools to assist pilots in the decision to self-dispatch leaves them at increased risk of dispatching into conditions beyond the capability of the aircraft.
4. When management involvement in the dispatch process results in pilots feeling pressure to complete flights in challenging conditions, there is increased risk that pilots may attempt flights beyond their competence.
5. Under current regulations, Canadian Aviation Regulations (CARs) 703 and 704 operators are not required to provide training in crew resource management / pilot decision-making or threat- and error-management. A breakdown in crew resource management / pilot decision-making may result in an increased risk when pilots are faced with adverse weather conditions.
6. Descending below the area minimum altitude while in instrument meteorological conditions without a published approach procedure increases the risk of collision with terrain.
7. If onboard flight recorders are not available to an investigation, this unavailability may preclude the identification and communication of safety deficiencies to advance transportation safety.

Findings as to Causes and Contributing Factors:
1. The gyro/horizon failed due to excessive wear on bearings and other components, resulting from a lack of maintenance and due to a vacuum system that was possibly not at minimum operating requirements for the instrument.
2. The gyro/horizon was reinstalled into the aircraft to complete the occurrence flight without the benefit of the recommended overhaul.
3. The autopilot became unusable when the attitude information from the gyro/horizon was disrupted.
4. The pilot had not practised partial panel instrument flying for a number of years, was not able to transition to a partial panel situation, and lost control of the aircraft while flying in instrument meteorological conditions.
5. The aircraft was loaded in excess of its certified gross weight and had a centre of gravity (C of G) that exceeded its aft limit. These two factors made the aircraft more difficult to handle due to an increase of the aircraft’s pitch control sensitivity and a reduction of longitudinal stability.
6. The structural limitations of the aircraft were exceeded during the uncontrolled descent; this resulted in the in-flight breakup.
7. There were a number of deficiencies with the company’s safety management system (SMS), in which the hazards should have been identified and the associated risks mitigated.
8. The company did not conduct an annual risk assessment as required by its SMS; this increased the risk that a hazard could go undetected.
9. The Canadian Business Aviation Association (CBAA) audit did not identify the risks in the company’s operations.
Findings as to Risk:
1. Lack of adequate instrument redundancy increases the risk of loss of control in single-pilot instrument flight rules (IFR) aircraft operations.
2. The pilot did not reduce his airspeed while attempting to maintain control of the aircraft; a lower speed would have allowed a greater margin to maximum operating speed (Vmo) while manoeuvring.
3. There were no quick-donning oxygen masks on board and the pilot was not wearing an oxygen mask at the time of the occurrence, as required by regulation.
4. If effective oversight of private operator certificate (POC) holders is not exercised by the regulator or its delegated organization, there is an increased risk that safety deficiencies will not be identified and properly addressed.
Other Finding:
1. The approved maintenance organization (AMO) that was maintaining the aircraft did not have the approval to maintain PA-46 turbine aircraft.

Findings as to Causes and Contributing Factors:
1. The left engine fuel control support assembly failed in fatigue and released one of three attachment bolts, which resulted in a slight displacement of the fuel control and changed the propeller control dimension. As a result, Beta pressure was achieved and propeller reverse was available for the left engine before it was available for the right engine.
2. The pilot selected thrust reverse without confirmation that the Beta lights were on for both engines, and the aircraft veered from the runway, most likely as a result of temporary asymmetric thrust.
Finding as to Risk:
1. There is no requirement to include the Beta light call as part of the pre-landing briefing. Briefing this item would remind the pilots of the need to confirm Beta light activation for both engines before application of thrust reverse.

Findings as to Causes and Contributing Factors:
1. The aircraft departed at a weight exceeding the maximum take-off weight and the maximum weight for operation in icing conditions.
2. After departure from Winnipeg, the aircraft encountered in-flight icing conditions in which the aircraftís performance deteriorated until the aircraft was unable to maintain altitude.
3. During the attempt to return to the Winnipeg International Airport, the pilot lost control of the aircraft, likely with little or no warning, at an altitude from which recovery was not possible.
Findings as to Risk:
1. Aviation weather forecasts incorporate generic icing forecasts that may not accurately predict the effects of icing conditions on particular aircraft. As a result, specific aircraft types may experience more significant detrimental effects from icing than forecasts indicate.
2. Bulk loading prevented determining the cargo weight in each zone, resulting in a risk that the individual zone weight limits could have been exceeded.
3. The aircraftís centre of gravity (CG) could not be accurately determined, and may have been in the extrapolated shaded warning area on the CG limit chart. Although it was determined that the CG was likely forward of the maximum allowable aft CG, bulk loading increased the risk that the CG could have exceeded the maximum allowable aft CG.
4. The incorrect tare weight on the Toronto cargo container presented a risk that other aircraft carrying cargo from that container could have been inadvertently overloaded.
Other Findings:
1. The pilotís weather information package was incomplete and had to be updated by a telephone briefing.
2. The operatorís pilots were not pressured to avoid using aircraft de-icing facilities or to depart with aircraft unserviceabilities.
3. The aircraft departed Winnipeg without significant contamination of its critical surfaces.
4. The biological material on board the aircraft was disposed of after the accident, with no indication that any of the material had been released into the ground or the atmosphere.
5. The fact that the aircraft was not equipped with flight data recorder or cockpit voice recorder equipment limited the information available for the occurrence investigation and the scope of the investigation.