Canada

Finding as to Causes and Contributing Factors:
1. The aircraft departed controlled flight, likely in an aerodynamic stall, and impacted terrain for undetermined reasons.
Other Finding:
1. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.

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 Causes and Contributing Factors:
1. The crew conducted an Area Navigation (RNAV) approach for which they were not trained, with an aircraft that was not properly equipped nor approved for such purpose.
2. The aircraft descended 300 feet below the minimum descent altitude (MDA) as a result of a number of lapses, errors and adaptations which, when combined, resulted in the mismanaged approach.
3. The aural warning on the aircraft’s altitude alerter had been silenced prior to the approach, which precluded it from alerting the crew when the aircraft descended below minimum descent altitude.
4. The SkyNorth standard operating procedures for conducting a non-precision approach were not followed, which resulted in the aircraft descending below the minimum descent altitude. During the ensuing missed approach, the aircraft struck trees.
Findings as to Risk:
1. The lack of a more-structured training environment and the type of supervisory flying provided increased the risk that deviations from standard operating procedures (SOPs) would not be identified.
2. There are several instrument approach procedures in Canada that contain step-down fixes that are not displayed on global positioning system (GPS) units. This may increase the risk of collision with obstacles during step-downs on approaches.

Findings as to Causes and Contributing Factors:
1. An abbreviated visual approach was conducted at night in instrument meteorological conditions, which resulted in the flight crew’s inability to obtain sufficient visual reference to judge their height above the ground.
2. The flight crew did not monitor pressure altimeter readings or reference the minimum altitude requirements in relation to aircraft position on the approach, resulting in controlled flight into terrain.
3. The pilots had not received training and performance checks for the installed global positioning system (GPS) equipment, and were not fully competent in its use. The attempts at adjusting the settings likely distracted the pilots from maintaining the required track and ground clearance during the final approach.
Findings as to Risk:
1. The precision approach path indicator systems (PAPI) at Cambridge Bay had not been inspected in accordance with the Airport Safety Program Manual. Although calibration of the equipment did not have a bearing on this occurrence, there was an increased risk of aircraft misalignment from the proper glide path, especially during night and reduced visibility conditions.
2. The flight crew’s cross-check of barometric altimeter performance was not sufficient to detect which instrument was inaccurate. As a result, reference was made to a defective altimeter, which increased the risk of controlled flight into terrain.
3. Operators’ maintenance organizations normally do not have access to the troubleshooting information contained in Component Maintenance Instruction Manuals for the Intercontinental Dynamics Corporation altimeters. Therefore, aircraft could be dispatched with damaged instruments with the potential for developing a loss of calibration during flight.
4. The flight was conducted during a period in which the crew’s circadian rhythm cycle could result in cognitive and physical performance degradation unless recognized and managed.

Findings as to Causes and Contributing Factors:
1. Though icing conditions were encountered, the airframe de-icing boots were not cycled nor was the Vref speed increased to offset the effects of aircraft icing.
2. An abrupt change in aircraft configuration, which included a reduction in power to flight idle and the addition of 35° flap, caused the aircraft’s speed to rapidly decrease.
3. The aircraft entered an aerodynamic stall due to the decreased performance caused by the icing. There was insufficient altitude to recover the aircraft prior to impact with the runway.
Finding as to Risk:
1. The company had not incorporated the British Aerospace Notice to Aircrew into its standard operating procedures (SOP) at the time of the occurrence. Therefore, crews were still required to make configuration changes late in the approach sequence, increasing the risk of an unstabilised approach.

Findings as to Causes and Contributing Factors:
1. An electrical short circuit in the cockpit pedestal area produced flames and smoke, which induced the crew to take emergency action.
2. The detrimental effects of aging on the wires involved may have been a factor in this electrical arc event.
3. The crew elected to return to the airport at low level in an environment with inadequate visual references. As a result, control of the aircraft was lost at an altitude from which a recovery was not possible.
Findings as to Risk:
1. The actions specified in the standard operating procedures (SOP) do not include procedures for an electrical fire encountered at low altitude at night, which could lead to a loss of control.
2. Visual inspection procedures in accordance with normal phase inspection requirements may be inadequate to detect defects progressing within wiring bundles, increasing the risk of electrical fires.
3. In the event of an in-flight cockpit pedestal fire, the first officer does not have ready access to available fire extinguishers, reducing the likelihood of successfully fighting a fire of this nature.
4. Sealed in plastic containers and stored behind each pilot seat, the oxygen masks and goggles are time consuming to access and cumbersome to apply and activate. This could increase the probability of injury or incapacitation through extended exposure to smoke or fumes, or could deter crews from using them, especially during periods of high cockpit workload.
Other Finding:
1. A failure of the hot-mic recording function of the cockpit voice recorder (CVR) had gone undetected and information that would have been helpful to the investigation was not available.

Findings as to Causes and Contributing Factors
1. The pilot likely departed and continued flight in conditions that were below visual
flight rules (VFR) weather minima.
2. The pilot continued his VFR flight into instrument meteorological conditions (IMC),
and did not recognize his proximity to terrain until seconds before colliding with
Thormanby Island, British Columbia.
3. The indication of a marginal weather improvement at Powell River, British Columbia,
and incorrect information from Merry Island, British Columbia, may have
contributed to the pilot’s conclusion that weather along the route would be sufficient
for a low-level flight.
Findings as to Risk:
1. The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received.
2. Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety.
3. The lack of pilot decision making (PDM) training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions.
4. Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions.
5. Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions.
6. Incremental growth in Pacific Coastal’s support to Kiewit did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected.
7. Transport Canada’s guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows.
8. Previous discussions between Pacific Coastal and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk.
9. There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart.
10. Because the aircraft’s emergency locator transmitter (ELT) failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed.
11. On a number of flights, pilots on the Vancouver–Toba Inlet route, British Columbia, departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits.
12. The over-reliance on global positioning system (GPS) in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers.
Other Finding:
1. The SPOT Satellite Messenger data transmitted before the crash helped to narrow the search area and reduce the search time to find the aircraft. The fact that the wrong data were consulted caused an initial delay in reporting the missing aircraft.

Gear up landing for undetermined reason.

Findings as to Causes and Contributing Factors:
1. The general condition of the aircraft, the engine time before overhaul (TBO) over-run and the missed inspection items demonstrated inadequate maintenance that was not detected by regulatory oversight.
2. The TBO over-run and missed inspections resulted in excessive spline wear in the left engine-driven fuel pump going undetected.
3. The left engine lost power due to mechanical failure of the engine fuel pump drive splines.
4. The horizontal engine instrument arrangement and the lack of recent emergency training made quick engine malfunction identification difficult. This resulted in the pilot shutting down the wrong engine, causing a dual-engine power loss and a forced landing.
5. Not using the restraint devices contributed to the seriousness of injuries to some passengers.
Finding as to Risk:
1. There is a risk to passengers if Transport Canada does not verify that holders of Canadian Foreign Air Operator Certificates-Free Trade Agreement meet airworthiness and operational requirements.

Findings as to Causes and Contributing Factors:
1. While likely climbing to fly above a cloud-covered ridge and below the overcast ceiling, the aircraft stalled aerodynamically at a height from which full recovery could not be made before striking the trees.
2. The aircraft broke apart upon impact, and electrical arcing from exposed wires in the presence of spilled fuel caused a fire that consumed most of the aircraft.
Findings as to Risk:
1. While the company’s established communications procedures and infrastructure met the regulatory requirements, they were not effective in ascertaining an aircraft’s position and flight progress, which delayed critical search and rescue (SAR) action.
2. The emergency locator transmitter was destroyed in the crash and failed to operate, making it difficult for SAR to find the aircraft. This prolonged the time the injured survivors had to wait for rescue and medical attention.