Canada

Findings as to Causes and Contributing Factors:
1. The crew conducted an approach and landing in the midst of a severe and rapidly changing thunderstorm. There were no procedures within Air France related to distance required from thunderstorms during approaches and landing, nor were these required by regulations.
2. After the autopilot and autothrust systems were disengaged, the pilot flying (PF) increased the thrust in reaction to a decrease in the airspeed and a perception that the aircraft was sinking. The power increase contributed to an increase in aircraft energy and the aircraft deviated above the glide path.
3. At about 300 feet above ground level (agl), the surface wind began to shift from a headwind component to a 10-knot tailwind component, increasing the aircraft’s groundspeed and effectively changing the flight path. The aircraft crossed the runway threshold about 40 feet above the normal threshold crossing height.
4. Approaching the threshold, the aircraft entered an intense downpour, and the forward visibility became severely reduced.
5. When the aircraft was near the threshold, the crew members became committed to the landing and believed their go-around option no longer existed.
6. The touchdown was long because the aircraft floated due to its excess speed over the threshold and because the intense rain and lightning made visual contact with the runway very difficult.
7. The aircraft touched down about 3800 feet from the threshold of Runway 24L, which left about 5100 feet of runway available to stop. The aircraft overran the end of Runway 24L at about 80 knots and was destroyed by fire when it entered the ravine.
8. Selection of the thrust reversers was delayed as was the subsequent application of full reverse thrust.
9. The pilot not flying (PNF) did not make the standard callouts concerning the spoilers and thrust reversers during the landing roll. This further contributed to the delay in the PF selecting the thrust reversers.
10. Because the runway was contaminated by water, the strength of the crosswind at touchdown exceeded the landing limits of the aircraft.
11. There were no landing distances indicated on the operational flight plan for a contaminated runway condition at the Toronto/Lester B. Pearson International Airport (CYYZ).
12. Despite aviation routine weather reports (METARs) calling for thunderstorms at CYYZ at the expected time of landing, the crew did not calculate the landing distance required for Runway 24L. Consequently, they were not aware of the margin of error available for the landing runway nor that it was eliminated once the tailwind was experienced.
13. Although the area up to 150 m beyond the end of Runway 24L was compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond this point, along the extended runway centreline, contributed to aircraft damage and to the injuries to crew and passengers.
14. The downpour diluted the firefighting foam agent and reduced its efficiency in dousing the fuel-fed fire, which eventually destroyed most of the aircraft.
Findings as to Risk :
1. In the absence of clear guidelines with respect to the conduct of approaches into convective weather, there is a greater likelihood that crews will continue to conduct approaches into such conditions, increasing the risk of an approach and landing accident.
2. A policy where only the captain can make the decision to conduct a missed approach can increase the likelihood that an unsafe condition will not be recognized early and, therefore, increase the time it might otherwise take to initiate a missed approach.
3. Although it could not be determined whether the use of the rain repellent system would have improved the forward visibility in the downpour, the crew did not have adequate information about the capabilities and operation of the rain repellent system and did not consider using it.
4. The information available to flight crews on initial approach in convective weather does not optimally assist them in developing a clear idea of the weather that may be encountered later in the approach.
5. During approaches in convective weather, crews may falsely rely on air traffic control (ATC) to provide them with suggestions and directions as to whether to land or not.
6. Some pilots have the impression that ATC will close the airport if weather conditions make landings unsafe; ATC has no such mandate.
7. Wind information from ground-based measuring systems (anemometers) is critical to the safe landing of aircraft. Redundancy of the system should prevent a single-point failure from causing a total loss of relevant wind information.
8. The emergency power for both the public address (PA) and EVAC alert systems are located in the avionics bay. A less vulnerable system and/or location would reduce the risk of these systems failing during a survivable crash.
9. Brace commands were not given by the cabin crew during this unexpected emergency condition. Although it could not be determined if some of the passengers were injured as a result, research shows that the risk of injury is reduced if passengers brace properly.
10. Safety information cards given to passengers travelling in the flight decks of Air France Airbus A340-313 aircraft do not include illustrations depicting emergency exit windows, descent ropes or the evacuation panel in the flight deck doors.
11. There are no clear visual cues to indicate that some dual-lane slides actually have two lanes. As a result, these slides were used mostly as single-lane slides. This likely slowed the evacuation, but this fact was not seen as a contributing factor to the injuries suffered by the passengers.
12. Although all passengers managed to evacuate, the evacuation was impeded because nearly 50 per cent of the passengers retrieved carry-on baggage.
Other Findings:
1. There is no indication that the captain’s medical condition or fatigue played a role in this occurrence.
2. The crew did not request long aerodrome forecast (TAF) information while en route. This did not affect the outcome of this occurrence because the CYYZ forecast did not change appreciably from information the flight crew members received before departure, and they received updated METARs for CYYZ and Niagara Falls International Airport (KIAG).
3. The possibility of a diversion required the flight crew to check the weather for various potential alternates and to complete fuel calculations. Although these activities consumed considerable time and energy, there is no indication that they were unusual for this type of operation or that they overtaxed the flight crew.
4. The decision to continue with the approach was consistent with normal industry practice, in that the crew could continue with the intent to land while maintaining the option to discontinue the approach if they assessed that the conditions were becoming unsafe.
5. There is no indication that more sophisticated ATC weather radar information, had it been available and communicated to the crew, would have altered their decision to continue to land.
6. It could not be determined why door L2 opened before the aircraft came to a stop.
7. There is no indication that the aircraft was struck by lightning.
8. There is no information to indicate that the aircraft encountered windshear during its approach and landing.
9. The flight crew seats are certified to a lower standard than the cabin seats, which may have been a factor in the injuries incurred by the captain.

Findings as to Causes and Contributing Factors:
1. The aircraft was flown up a narrow canyon into rapidly rising terrain for reasons that could not be determined. The aircraft’s proximity to terrain and the narrowness of the canyon precluded a turn, and the aircraft’s climb rate was insufficient to clear the rising terrain.
2. The pilot decision-making training received by the crew members was ineffective because they were unprepared for the unique hazards and special operating techniques associated with flying low in mountainous terrain.
Finding as to Risk:
1. The company operations manual (COM) gave no guidance to the crew for the operation of a visual flight rules (VFR) flight, except for the provision that it should not be conducted closer to obstacles than 500 feet vertically and horizontally.

Findings as to Causes and Contributing Factors:
1. The aircraft was loaded in such a manner that the C of G was beyond the rearward limit. This resulted in the aircraft’s aerodynamic pitch control limitation being exceeded.
2. A weight and balance report was not completed by the pilot prior to departure and, as a consequence, he was unaware of the severity of the aft C of G position.
Finding as to Risk:
1. The weight of the passengers was underestimated due to the use of standard weights. This increased the potential of inadvertently loading the aircraft in excess of its maximum certified take-off weight.

Findings as to Causes and Contributing Factors:
1. At some point after 01 April 1999, a bad gasket (P/N LW-13388) was installed in the accident engine.
2. The requirement of Airworthiness Directive 2002-12-07 (to ensure that old converter plate gaskets were removed and replaced by new parts) was not carried out on the accident engine.
3. The improper oil filter converter plate gasket in the right engine compartment failed, allowing pressurized oil to spray into the engine compartment and ignite on contact with hot turbocharger and exhaust components.
4. The firewall fuel shut-off valve remained in the OPEN position, allowing pressurized fuel to be delivered to the engine-driven fuel pump by the aircraft’s boost pumps.
5. The initial oil-fed fire generated considerable heat, which melted the casing of the engine-driven fuel pump, allowing pressurized fuel to intensify the fire.
6. The flames breached the main fuel tank, inboard of the engine, causing the aircraft to become engulfed in flames.
Findings as to Risk:
1. Inappropriate converter plate gaskets, identified by part number LW-13388, are known to have remained in the aviation system after the date of the terminating action required by Airworthiness Directive (AD) 2002-12-07.
2. Compliance with the full requirements of AD 2002-12-07 is not always being accomplished with respect to vibro-peening and proper gluing procedures.

Findings as to Causes and Contributing Factors:
1. The flight crew attempted a night landing in the absence of runway edge lights. The aircraft touched down 300 feet to the left of Runway 05L and 1800 feet beyond the threshold.
2. The runway was not closed for night use despite the absence of runway edge lights. Nothing required it to be closed.
3. Poor flight planning, non-compliance with regulations and standard operating procedures (SOPs), and the lack of communications between the two pilots reveal a lack of airmanship on the part of the crew, which contributed to the accident.
Findings as to Risk:
1. Because they had not been given a safety briefing, the passengers were not familiar with the use of the main door or the emergency exit, which could have delayed the evacuation, with serious consequences.
2. The armrest of the side seat had not been removed as required and was blocking access to the emergency exit, which could have delayed the evacuation, with serious consequences.
3. Because they had not been given a safety briefing, the passengers seated in the side seats did not know that they should have worn shoulder straps and did not wear them, so they were not properly protected.
4. The possibility of flying to an airport that does not meet the standards for night use gives pilots the opportunity to attempt to land there, which in itself increases the risk of an accident.
5. The landing performance diagrams and the chart used to determine the landing distance did not enable the flight crew to ensure that the runway was long enough for a safe landing on a snow-covered surface.

Findings as to Causes and Contributing Factors:
1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
Other Finding:
1. The flight crew members were not advised that the potential Airworthiness Directive announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.

Findings as to Causes and Contributing Factors:
1. The Bradley take-off weight was likely used to generate the Halifax take-off performance data, which resulted in incorrect V speeds and thrust setting being transcribed to the take-off data card.
2. The incorrect V speeds and thrust setting were too low to enable the aircraft to take off safely for the actual weight of the aircraft.
3. It is likely that the flight crew member who used the Boeing Laptop Tool (BLT) to generate take-off performance data did not recognize that the data were incorrect for the planned take-off weight in Halifax. It is most likely that the crew did not adhere to the operatorís procedures for an independent check of the take-off data card.
4. The pilots of MKA1602 did not carry out the gross error check in accordance with the company's standard operating procedures (SOPs), and the incorrect take-off performance data were not detected.
5. Crew fatigue likely increased the probability of error during calculation of the take-off performance data, and degraded the flight crewís ability to detect this error.
6. Crew fatigue, combined with the dark take-off environment, likely contributed to a loss of situational awareness during the take-off roll. Consequently, the crew did not recognize the inadequate take-off performance until the aircraft was beyond the point where the take-off could be safely conducted or safely abandoned.
7. The aircraftís lower aft fuselage struck a berm supporting a localizer antenna, resulting in the tail separating from the aircraft, rendering the aircraft uncontrollable.
8. The company did not have a formal training and testing program on the BLT, and it is likely that the user of the BLT in this occurrence was not fully conversant with the software.
Findings as to Risk:
1. Information concerning dangerous goods and the number of persons on board was not readily available, which could have jeopardized the safety of the rescue personnel and aircraft occupants.
2. Failure of one of the airport emergency power generators to provide backup power prevented the operation of some automatic functions at the fire hall after the crash alarm was activated, increasing the potential for a delayed response.
3. Grid map coordinates were not used to direct units responding to the crash and some responding units did not have copies of the grid map. The non-use of grid coordinates during an emergency could lead to confusion and increase response times.
4. Communication difficulties encountered by the emergency response agencies complicated coordination and could have hampered a rescue attempt or quick evacuation of an injured person.
5. A faulty aircraft cargo loading system prevented the proper positioning of a roll of steel, resulting in the weight limits of positions LR and MR being exceeded by 4678 kg (50 per cent).
6. The company increase of the maximum flight duty time for a heavy crew from 20 to 24 hours increased the potential for fatigue.
7. Regulatory oversight of MK Airlines Limited by the Ghana Civil Aviation Authority (GCAA) was not adequate to detect serious non-conformances to flight and duty times, nor ongoing non-adherence to company directions and procedures.
8. The delay in passing the new Civil Aviation Act, 2004 hindered the GCAAís ability to exercise effective oversight of MK Airlines Limited.
9. Company planning and execution of very long flight crew duty periods substantially increased the potential for fatigue.
10. The company expansion, flight crew turnover, and the MK Airlines Limited recruitment policy resulted in a shortage of flight crew; consequently, fewer crews were available to meet operational demands, increasing stress and the potential for fatigue.
11. There were no regulations or company rules governing maximum duty periods for loadmasters and ground engineers, resulting in increased potential for fatigue-induced errors.
12. The MK Airlines Limited flight operations quality and flight safety program was in the early stages of development at the time of the accident; consequently, it had limited effectiveness.
13. The berms located at either end of runways 06 and 24 were not evaluated as to whether they were a hazard to aircraft in the runway overrun/undershoot areas.
14. The operating empty weight of the aircraft did not include 1120 kg of personnel and equipment; consequently, it was possible that the maximum allowable aircraft weights could be exceeded unknowingly.
15. The ground handling agent at Halifax International Airport did not have the facilities to weigh built-up pallets that were provided by others. Incorrect load weights could result in adverse aircraft performance.
16. Some MK Airlines Limited flight crew members did not adhere to all company SOPs; company and regulatory oversight did not address this deficiency.
Other Findings:
1. An incorrect slope for Runway 24 was published in error and not detected; the effect of this discrepancy was not a significant factor in the operation of MKA1602 at Halifax.
2. The occurrence aircraft was within the weight and centre of gravity limits for the occurrence flight, although the allowable cargo weights on positions LR and MR were exceeded.
3. Based on engineering simulation, the accident aircraft performance was consistent with that expected for the configuration, weight and conditions for the attempted take-off at Halifax International Airport.
4. There have been several examples of incidents and accidents worldwide where non-adherence to procedures has led to incorrect take-off data being used, and the associated flight crews have not recognized the inadequate take-off performance. 5. No technical fault was found with the aircraft or engines that would have contributed to the accident.