Canada

Findings as to causes and contributing factors:
1. The crew did not complete the before-landing checks, ignored aural warnings, and did not lower the landing gear, which resulted in a gear-up landing.
Findings as to risk:
1. The aircraft was not equipped with a GPWS, which could have prevented this accident.
2. The before-landing checklist in use did not reflect the AFM requirement that the speed brakes should be retracted prior to 50 feet.

Because of the geographic and weather conditions, the pilot probably had trouble judging his horizontal and vertical distance with respect to the mountain, and the aircraft crashed.

Findings as to Causes and Contributing Factors:
1. The pilot did not correctly calculate the amount of fuel required to accomplish the flight from Winnipeg to Gunisao Lake and return, and did not ensure that the aircraft carried sufficient fuel for the flight.
2. The ILS approach was flown above the glideslope and beyond the missed approach point, which reduced the possibility of a safe landing at Winnipeg, and increased the risk of collision with terrain.
3. During the missed approach, the aircraft's engines lost power as a result of fuel exhaustion, and the pilot conducted a forced landing at a major city intersection.
4. The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.
Findings as to Risk:
1. The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
2. The company operations manual did not reflect current company procedures.
3. The company did not provide an adequate level of supervision and allowed the flight to depart without adequate fuel reserves. The company did not have a safety system in place to prevent a fuel exhaustion situation developing.
Other Findings:
1. The pilot did not advise air traffic control of his critical situation in a timely fashion.

Findings as to Cause and Contributing Factors:
1. Aircraft directional control was lost, likely because of negative castering of the nosewheel when snow piled up in front of the nosewheel assembly.
Findings as to Risk:
1. The crew members were not aware of negative castering; the aircraft flight manual and emergency checklists do not address negative castering.
2. The emergency response to the occurrence was delayed by four minutes because of the lack of communication from the aircraft to the tower.

Findings as to Causes and Contributing Factors:
1. For undetermined reasons, the pilot did not maintain adequate altitude during a night circling approach in IMC and the aircraft struck the ground.
2. The pilot and front seat passenger were not wearing available shoulder harnesses, as required by regulation, which likely contributed to the severity of their injuries.
Findings as to Risk:
1. The aircraft was not fitted with, and was not required to be fitted with, a GPWS or a radio altimeter.
2. The pilot used an unauthorized remote altimeter setting that would have resulted in the cockpit altimeters reading approximately 200 feet higher than the actual altitude.
3. The pilot did not meet the night recency requirements necessary to carry passengers, as specified in CAR 401.05 (2).
4. Risk management responsibilities had been placed almost entirely on the pilot.
5. While the company had taken the voluntary initiative to appoint a safety officer, and appeared to have a safety program in place, the program may not have been directed at the needs.
Other Findings:
1. Approximately 28 hours of flight time that the pilot had logged as multi-engine dual would not have qualified as flight experience for the issue of a higher license.
2. CAR do not define 'flight familiarization', 'flight experience', or 'dual', and therefore do not address flight time 'quality'.
3. Opportunities for local community searchers to identify and access the accident site earlier were hampered by initial inaccurate SARSAT location information, by the time required to locate SAR aircraft to the Fort Liard area, and by darkness and poor weather conditions.
4. The decreased time required to alert the SAR system and the higher degree of accuracy permitted by the utilization of a 406 MHz ELT, particularly one interfaced with the onboard GPS, would have likely permitted rescuers to access the site in a more timely manner.
5. 703 Air Taxi operations continue to have a much higher accident rate than 704 Commuter and 705 Airline operations.

Findings as to Causes and Contributing Factors:
1. The aircraft was flown into terrain during an overshoot because the required climb angle was not set and maintained to ensure a positive rate of climb.
2. During the go-around, conditions were present for somatogravic illusion, which most likely led to the captain losing situational awareness.
3. The first officer did not monitor the aircraft instruments during a critical stage of flight; it is possible that he was affected by somatogravic illusion and/or distracted by the non-directional
beacon to the extent that he lost situational awareness.
Other Findings:
1. The absence of approach aids likely decreased the crew=s ability to fly an approach from which a landing could be executed safely.
2. The company standard operating procedures (SOPs) did not define how positive rate is to be determined.