Canada

Findings as to Causes and Contributing Factors:
1. The take-off was attempted at an aircraft weight that did not meet the performance capabilities of the aircraft to clear an obstacle and, as a result, the aircraft struck a telephone pole and a telephone cable during the initial climb.
2. A take-off and climb to 50 feet performance calculation was not completed prior to take-off; therefore, the flight crew was unaware of the distance required to clear the telephone cable.
3. The southeast end of the airstrip was not clearly marked; as a result, the take-off was initiated with approximately 86 feet of usable airstrip behind the aircraft.
4. The take-off was attempted in an upslope direction and in light tailwind, both of which increased the distance necessary to clear the existing obstacles.
Findings as to Risk:
1. Operational control within the company was insufficient to reduce the risks associated with take-offs from the lodge airstrip.
2. The take-off weight limits for lodge airstrip operations were not effectively communicated to the flight crew.
3. Maximum performance short take-off and landing (MPS) techniques may have been necessary in order to accomplish higher weight Twin Otter take-offs from the lodge airstrip; however, neither the aircraft nor the company were approved for MPS operations.
4. The first officer’s shoulder harness assembly had been weakened by age and ultraviolet (UV) light exposure; as a result, it failed within the design limits at impact.
5. The SeeGeeTM calculator operating index (OI) values being used by Liard Air Twin Otter pilots was between 0.5 and 1.0 units greater than the correct SeeGeeTM OI values; therefore, whenever the SeeGeeTM calculator was used for flight planning, the actual centre of gravity (c of g) of the aircraft would have been forward of the calculated CofG.
6. There are no airworthiness standards specifically intended to contain fuel and/or to prevent fuel ignition in crash conditions in fixed-gear United States Civil Aviation Regulation 3 and United States Federal Aviation Regulation 23 aircraft.

Findings as to Causes and Contributing Factors:
1. The aircraft was loaded in a manner that resulted in the centre of gravity being aft of the rearward limit.
2. Because the cargo was not properly secured, it shifted towards the rear of the aircraft, resulting in the centre of gravity moving further aft, causing the aircraft to pitch up and stall.

Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.

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 engine stopped as a result of fuel starvation; the amount of fuel in the wings was less than the amount estimated by the pilot, the fuel senders gave an incorrect reading, and the low fuel pressure warning light could illuminate randomly.
2. The engine stopped at low altitude, which reduced the time needed to complete the emergency procedure. The pilot was unable to glide to the lake and made a forced landing on an unsuitable terrain, causing significant damage to the aircraft and injuries to the occupants.
Findings as to Risk:
1. The wing tank selection system was subject to icing in cold weather, and the pilots adopted the practice to place the wing tank selector in the middle position, which is contrary to the aircraft flight manual supplement instructions and a placard posted on the instrument panel.
2. When the change to the type design was approved through issuance of the Supplementary Type Certificate (STC), Transport Canada did not notice the fact that the fuel senders and triple fuel level gauge did not meet airworthiness standards; Transport Canada issued an STC that contained several deficiencies. 3. Storage of the shoulder harnesses underneath the aircraft interior covering made them inaccessible; since the pilot and the front seat passenger did not wear their shoulder harness, their protection was reduced.

Findings as to Causes and Contributing Factors:
1. A late full flap selection at 300 feet above ground level (agl) likely destabilized the aircraft’s pitch attitude, descent rate and speed in the critical final stage of the precision approach, resulting in an increased descent rate before reaching the runway threshold.
2. After the approach lights were sighted at low altitude, both pilots discontinued monitoring of instruments including the glide slope indicator. A significant deviation below the optimum glide slope in low visibility went unnoticed by the crew until the aircraft descended into the approach lights.
Finding as to Risk:
1. The crew rounded the decision height (DH) figure for the instrument landing system (ILS) approach downward, and did not apply a cold temperature correction factor. The combined error could have resulted in a descent of 74 feet below the DH on an ILS approach to minimums, with a risk of undershoot.
Other Finding:
1. The cockpit voice recorder (CVR) was returned to service following an intelligibility test that indicated that the first officer’s hot boom microphone intercom channel did not record. Although the first officer voice was recorded by other means, a potential existed for loss of information, which was key to the investigation.

Findings as to Risk:
1. Some Canadian Air Regulations (CARs) subpart 703 air taxi and subpart 704 commuter operators are unlikely to provide initial or recurrent CRM training to pilots in the absence of a regulatory requirement to do so. Consequently, these commercial pilots may be unprepared to avoid, trap, or mitigate crew errors encountered during flight.
2. Transport Canada (TC) Prairie and Northern Region (PNR) management practices regarding the June 2006 replacement of the regional combined audit program, in order to manage safety management system (SMS) workload, did not conform to TC’s risk management decision-making policies. Reallocation of resources without assessment of risk could result in undetected regulatory non-compliance.
3. Although TC safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated by the PNR managers because of the limitations of the oversight system in place at that time.
4. It is likely that the National Aviation Company Information System (NACIS) records for other audits include inaccurate information resulting from data entry errors and wide use of the problematic audit tracking form, reducing the effectiveness of the NACIS as a management tracking system.
5. Self-dispatch systems rely on correct assessment of operational hazards by pilots, particularly in the case of unscheduled commercial service into uncertified aerodromes. Unless pilots are provided with adequate decision support tools, flights may be dispatched with defences that are less than adequate.
6. TWA King Air crews did not use any standard practice in applying cold temperature altitude corrections. Inconsistent application of temperature corrections by flight crews can result in reduction of obstacle clearance to less than the minimum required and reduced safety margins.
7. The practice of not visually verifying wind/runway conditions at aerodromes where this information is otherwise unavailable increases the risk of post-touchdown problems.
8. The company dispatched flights to Sandy Bay without a standard means for crews to deal with non-current altimeter settings. Use of non-current or inappropriate altimeter settings can reduce minimum obstacle clearance and safety margins.
9. The crew was likely unaware of their ¼ nautical mile (nm) error in the aircraft position in relation to the runway threshold resulting from use of the global positioning system (GPS). Unauthorized and informal use of the GPS by untrained crews during instrument flight rules (IFR) approaches can introduce rather than mitigate risk.
10. Widespread adaptations by the King Air pilots resulted in significant deviations from the company’s SOPs, notwithstanding the company’s disciplinary policy.
11. In a SMS environment, inappropriate use of punitive actions can result in a decrease in the number of hazards and occurrences reported, thereby reducing effectiveness of the SMS.
12. Pilot workload is increased and decision making becomes more complicated where limited visual cues are available for assessing aircraft orientation relative to runway and surrounding terrain.
13. Aerodromes with limited visual cues and navigational aids are not explicitly identified in flight information publications as hazardous for night/IFR approaches. Passengers and crews will continue to be exposed to this hazard unless aircraft and aerodrome operators carry out risk assessments to identify them and take mitigating action.
14. To properly assess applicants for pilot positions, operators need access to information on experience and performance that is factual, objective, and (preferably) standardized. Because some employers are unprepared to provide this information—fearing legal action—this may lead to the appointment of pilots to positions for which they are unsuited, thereby compromising safety.
Other Findings:
1. TWA’s safety management system was not yet capable or expected to be capable of detecting, analyzing, and mitigating the risks presented by the hazards underlying this occurrence.
2. The first officer and captain met competency standards on the completion of their initial flight training before they began employment as line pilots.
3. It is very likely that the captain became the pilot flying for the remaining 20 seconds of the flight. The scenario that neither pilot was controlling the aircraft at that time is considered very unlikely.

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.