Canada

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.

Findings as to Causes and Contributing Factors:
1. It is likely that the PIC and the owner were both suffering some degree of spatial disorientation during the final portion of the flight. This resulted in a loss of control of the aircraft and the crew was unable to recover prior to contacting the surface of the water.
2. The PIC did not accept assistance in the form of radar vectors, which contributed to the workload during the approach.
3. Self-imposed pressure likely influenced the crew’s decision to depart Buttonville despite the flight conditions, lengthy day, and lack of experience with the aircraft and the destination airport.
Other Findings:
1. It could not be conclusively determined who was flying the aircraft at the time of the occurrence.
2. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.
3. The practice of placing aircraft technical records on board aircraft may impede an investigation if the records are lost due to an accident.

Findings as to Causes and Contributing Factors:
1. It could not be determined to what extent the initial collision with trees caused damage to the aircraft which may have affected its controllability.
2. Visual illusion may have precluded recognition, or an accurate assessment, of the flight path profile in sufficient time to avoid the trees on rising terrain.
3. Visual illusion may have contributed to the development of a low energy condition which impaired the aircraft performance when overshoot action was initiated.
4. The aircraft entered an aerodynamic stall and spin from which recovery was not possible at such a low altitude.
Findings as to Risk:
1. Visual illusions give false impressions or misconceptions of actual conditions. Unrecognized and uncorrected spatial disorientation, caused by illusions, carries a high risk of incident or accident.
2. Flight operations outside the approved weight and balance envelope increase the risk of unanticipated aircraft behaviour.
3. The recommended maintenance check of the emergency drop (E-drop) system may not be performed and there is no requirement for flight crews to test the E-drop system, thereby increasing the risk that an unserviceable system will go undetected.
4. The location of the E-drop selector requires crews to divert significant time and attention to identify and confirm the correct switch before operating it. This increases the risk of collision with terrain while attention is distracted.
5. The location of the angle-of-attack indicator on the instrument panel makes it difficult to see from the right seat, reducing its effectiveness.
6. When cockpit recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.