Canada

Findings as to causes and contributing factors:
1. The late initiation and subsequent management of the descent resulted in the aircraft turning onto final approach 600 feet above the glideslope, increasing the crew’s workload and reducing their capacity to assess and resolve the navigational issues during the remainder of the approach.
2. When the heading reference from the compass systems was set during initial descent, there was an error of −8°. For undetermined reasons, further compass drift during the arrival and approach resulted in compass errors of at least −17° on final approach.
3. As the aircraft rolled out of the turn onto final approach to the right of the localizer, the captain likely made a control wheel roll input that caused the autopilot to revert from VOR/LOC capture to MAN and HDG HOLD mode. The mode change was not detected by the crew.
4. On rolling out of the turn, the captain’s horizontal situation indicator displayed a heading of 330°, providing a perceived initial intercept angle of 17° to the inbound localizer track of 347°. However, due to the compass error, the aircraft’s true heading was 346°. With 3° of wind drift to the right, the aircraft diverged further right of the localizer.
5. The crew’s workload increased as they attempted to understand and resolve the ambiguity of the track divergence, which was incongruent with the perceived intercept angle and expected results.
6. Undetected by the pilots, the flight directors likely reverted to AUTO APP intercept mode as the aircraft passed through 2.5° right of the localizer, providing roll guidance to the selected heading (wings-level command) rather than to the localizer (left-turn command).
7. A divergence in mental models degraded the crew’s ability to resolve the navigational issues. The wings-level command on the flight director likely assured the captain that the intercept angle was sufficient to return the aircraft to the selected course; however, the first officer likely put more weight on the positional information of the track bar and GPS.
8. The crew’s attention was devoted to solving the navigational problem, which delayed the configuration of the aircraft for landing. This problem solving was an additional task, not normally associated with this critical phase of flight, which escalated the workload.
9. The first officer indicated to the captain that they had full localizer deflection. In the absence of standard phraseology applicable to his current situation, he had to improvise the go-around suggestion. Although full deflection is an undesired aircraft state requiring a go-around, the captain continued the approach.
10. The crew did not maintain a shared situational awareness. As the approach continued, the pilots did not effectively communicate their respective perception, understanding, and future projection of the aircraft state.
11. Although the company had a policy that required an immediate go-around in the event that an approach was unstable below 1000 feet above field elevation, no go-around was initiated. This policy had not been operationalized with any procedural guidance in the standard operating procedures.
12. The captain did not interpret the first officer’s statement of “3 mile and not configured” as guidance to initiate a go-around. The captain continued the approach and called for additional steps to configure the aircraft.
13. The first officer was task-saturated, and he thus had less time and cognitive capacity to develop and execute a communication strategy that would result in the captain changing his course of action.
14. Due to attentional narrowing and task saturation, the captain likely did not have a high- level overview of the situation. This lack of overview compromised his ability to identify and manage risk.
15. The crew initiated a go-around after the ground proximity warning system “sink rate” alert occurred, but there was insufficient altitude and time to execute the manoeuvre and avoid collision with terrain.
16. The first officer made many attempts to communicate his concerns and suggest a go-around. Outside of the two-communication rule, there was no guidance provided to address a situation in which the pilot flying is responsive but is not changing an unsafe course of action. In the absence of clear policies or procedures allowing a first officer to escalate from an advisory role to taking control, this first officer likely felt inhibited from doing so.
17. The crew’s crew resource management was ineffective. First Air’s initial and recurrent crew resource management training did not provide the crew with sufficient practical strategies to assist with decision making and problem solving, communication, and workload management.
18. Standard operating procedure adaptations on FAB6560 resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness. First Air’s supervisory activities did not detect the standard operating procedure adaptations within the Yellowknife B737 crew base.

Findings as to risk:
1. If standard operating procedures do not include specific guidance regarding where and how the transition from en route to final approach navigation occurs, pilots will adopt non-standard practices, which may introduce a hazard to safe completion of the approach.
2. Adaptations of standard operating procedures can impair shared situational awareness and crew resource management effectiveness.
3. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some first officers may feel inhibited from doing so.
4. If hazardous situations are not reported, they are unlikely to be identified or investigated by a company’s safety management system; consequently, corrective action may not be taken.
5. Current Transport Canada crew resource management training standards and guidance material have not been updated to reflect advances in crew resource management training, and there is no requirement for accreditation of crew resource management facilitators/instructors in Canada. This situation increases the risk that flight crews will not receive effective crew resource management training.
6. If initial crew resource management training does not develop effective crew resource management skills, and if there is inadequate reinforcement of these skills during recurrent training, flight crews may not adequately manage risk on the flight deck.
7. If operators do not take steps to ensure that flight crews routinely apply effective crew resource management practices during flight operations, risk to aviation safety will persist.
8. Transport Canada’s flight data recorder maintenance guidance (CAR Standard 625, Appendix C) does not refer to the current flight recorder maintenance specification, and therefore provides insufficient guidance to ensure the serviceability of flight data recorders. This insufficiency increases the risk that information needed to identify and communicate safety deficiencies will not be available.
9. If aircraft are not equipped with newer-generation terrain awareness and warning systems, there is a risk that a warning will not alert crews in time to avoid terrain.
10. If air carriers do not monitor flight data to identify and correct problems, there is a risk that adaptations of standard operating procedures will not be detected.
11. Unless further action is taken to reduce the incidence of unstable approaches that continue to a landing, the risk of controlled flight into terrain and of approach and landing accidents will persist.

Other findings:
1. It is likely that both pilots switched from GPS to VHF NAV during the final portion of the in-range check before the turn at MUSAT.
2. The flight crew of FAB6560 were not navigating using the YRB VOR or intentionally tracking toward the VOR.
3. There was no interference with the normal functionality of the instrument landing system for Runway 35T at CYRB.
4. Neither the military tower nor the military terminal controller at CYRB had sufficient valid information available to cause them to issue a position advisory to FAB6560.
5. The temporary Class D control zone established by the military at CYRB was operating without any capability to provide instrument flight rules separation.
6. The delay in notification of the joint rescue coordination centre did not delay the emergency response to the crash site.
7. The NOTAMs issued concerning the establishment of the military terminal control area did not succeed in communicating the information needed by the airspace users.
8. The ceiling at the airport at the time of the accident could not be determined. The visibility at the airport at the time of the accident likely did not decrease below approach minimums at any time during the arrival of FAB6560. The cloud layer at the crash site was surface-based less than 200 feet above the airport elevation.

Findings as to Causes and Contributing Factors:
Runway conditions, the pilot's takeoff technique, and possible shifting wind conditions combined to reduce the rate of the aircraft's acceleration during the takeoff roll and prevented it from attaining takeoff airspeed. The pilot rejected the takeoff past the point from which a successful rejected takeoff could be completed within the available stopping distance. The steep drop-off and sharp slope reversal at the end of Runway 33 contributed to the occupant injuries and fuel system damage that in turn caused the fire. This complicated passenger evacuation and prevented the rescue of the injured passenger. The deceased passenger was not wearing the available shoulder harness. This contributed to the serious injuries received as a result of the impact when the aircraft reached the bottom of the ravine and ultimately to his death in the post-impact fire.
Findings as to Risk:
If pilots are not aware of the increased aerodynamic drag during takeoff while using soft-field takeoff techniques they may experience an unexpected reduction in takeoff performance. Incomplete passenger briefings or inattentive passengers increase the risk that they will be unable to carry out critical egress procedures during an aircraft evacuation. When data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety. Although the runway at Pukatawagan and many other aerodromes are compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond the runway ends may increase the likelihood of damage to aircraft and injuries to crew and passengers in the event of an aircraft overrunning or landing short. TC's responses to TSB recommendations for action to reduce the risk of post-impact fires have been rated as Unsatisfactory. As a result, there is a continuing risk of post-impact fires in impact-survivable accidents involving these aircraft. The lack of accelerate stop distance information for aircraft impedes the crew's ability to plan the takeoff-reject point accurately.
Other finding:
Several anomalies were found in the engine's power control hardware. There was no indication that these anomalies contributed to the occurrence.

Findings as to Causes and Contributing Factors:
While manoeuvring at low level, the aircraft's critical angle of attack was likely exceeded and the aircraft stalled. The stall occurred at an altitude from which recovery was not possible.
Other Findings:
The separation of the propeller blade tip likely resulted from impact forces.
The investigation could not determine whether the fuel pressure warning light was illuminated prior to the accident.

Findings as to Causes and Contributing Factors:
1. The crew flew an unstabilized approach with excessive airspeed.
2. The lack of adherence to company standard operating procedures and crew resource management, as well as the non-completion of checklist items by the flight crew contributed to the occurrence.
3. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to follow the aural GPWS alerts and the missed approach call from the first officer.
4. The non-standard wording and the tone used by the first officer were insufficient to deter the captain from continuing the approach.
5. At touchdown, directional control was lost, and the aircraft veered off the runway with sufficient speed to prevent any attempts to regain control.
Finding as to Risk
1. Companies which do not have ground proximity warning system procedures in their standard operating procedures may place crews and passengers at risk in the event that a warning is received.

Conclusions
Findings as to Causes and Contributing Factors:
1. The right engine lost power when the intermediate spur gear on the torque sensor shaft failed. This resulted in loss of drive to the high-pressure engine-driven pump, fuel starvation, and immediate engine stoppage.
2. The ability of the left-hand No. 2 ejector pump to deliver fuel to the collector tank was compromised by foreign object debris (FOD) in the ejector pump nozzle.
3. When the fuel level in the left collector tank decreased, the left fuel level warning light likely illuminated but was not noticed by the crew.
4. The pilots did not execute the fuel level warning checklist because they did not perceive the illumination of the fuel level left tank warning light. Consequently, the fuel crossfeed valve remained closed and fuel from only the left wing was being supplied to the left engine.
5. The left engine flamed out as a result of depletion of the collector tank and fuel starvation, and the crew had to make a forced landing resulting in an impact with a concrete noise abatement wall.
Findings as to Risk:
1. Depending on the combination of fuel level and bank angle in single-engine uncoordinated flight, the ejector pump system may not have the delivery capacity, when the No. 1 ejector inlet is exposed, to prevent eventual depletion of the collector tank when the engine is operated at full power. Depletion of the collector tank will result in engine power loss.
2. The master caution annunciator does not flash; this leads to a risk that the the crew may not notice the illumination of an annunciator panel segment, in turn increasing the risk of them not taking action to correct the condition which activated the master caution.
3. When cockpit voice and flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
4. Because the inlets of the ejector pumps are unscreened, there is a risk that FOD in the fuel tank may become lodged in an ejector nozzle and result in a decrease in the fuel delivery rate to the collector tank.
Other Findings:
1. The crew’s decision not to recover or jettison the birds immediately resulted in operation for an extended period with minimal climb performance.
2. The composition and origin of the FOD, as well as how or when it had been introduced into the fuel tank, could not be determined.
3. The SkyTrac system provided timely position information that would have assisted search and rescue personnel if position data had been required.
4. Saskatoon police, firefighters, and paramedics responded rapidly to the accident and provided effective assistance to the survivors.

The aircraft departed controlled flight for reasons which could not be determined, and broke up due to high speed.

Findings as to Causes and Contributing Factors:
1. The conduct of the flight crew members during the instrument approach prevented them from effectively monitoring the performance of the aircraft.
2. During the descent below the minimum descent altitude, the airspeed reduced to a point where the aircraft experienced an aerodynamic stall and loss of control. There was insufficient altitude to effect recovery prior to ground impact.
3. For unknown reasons, the stall warning horn did not activate; this may have provided the crew with an opportunity to avoid the impending stall.
Findings as to Risk:
1. The use of company standard weights and a non-current aircraft weight and balance report resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.
2. Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.
3. Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.
4. Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance parameters of an instrument approach.

Findings As To Causes and Contributing Factors:
The bird strike occurred on take-off at an altitude of less than 50 feet. Gulls were ingested in the left engine, which then lost power.
After the loss of engine power, the flight crew had difficulty controlling the aircraft. The aircraft touched the ground, forcing the pilot flying to abort the take-off when the runway remaining was insufficient to stop the aircraft, resulting in the runway overrun.
Findings As To Risks:
Although a cannon was in place, it was not working on the day of the accident, which increased the risk of a bird strike.
The presence of a goose and duck farm outside the airport perimeter but near a runway increases the risk of attracting gulls.
Operators subject to Canadian Aviation Regulations Subpart 703 are not prohibited from having an aircraft take off from a runway that is shorter than the accelerate-stop distance of that aircraft as determined from the performance diagrams. Consequently, travellers carried by these operators are exposed to the risks associated with a runway overrun when a take-off is aborted.
The absence of a CVR makes it harder to ascertain material facts. Consequently, investigations can take more time, resulting in delays which compromise public safety.