Canada

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.

Findings as to Causes and Contributing Factors:
1. The seaplane stalled at an altitude that did not allow the pilot time to recover from the stall.
2. The stall occurred in circumstances conducive to illusions created by drift.
Findings as to Risks:
1. The aircraft was not equipped with a stall warning device, which could have alerted the pilot to the onset of a stall.
2. The chances of surviving the impact would have been improved if the front seat occupants had been wearing their shoulder harnesses as prescribed by aviation regulations.
3. Life jackets were available, but the occupants who evacuated the aircraft do not seem to have had time to find, retrieve, and don them.
4. The emergency locator transmitter was not capable of emitting a distress signal because a short circuit occurred when the antenna came into contact with the water.

Findings as to Causes and Contributing Factors:
1. The meat was loaded into the aircraft on a slippery surface and not adequately secured.
2. The manner in which the meat was loaded and secured most likely allowed the load to shift to the rear of the cabin during take-off. This rearward shift resulted in the loss of pitch control and an aerodynamic stall from which the pilot could not recover.
Other Findings:
1. The aircraft's C of G was most likely at or aft of the aft limit before engine start.

Findings as to Causes and Contributing Factors:
1. The pilot abandoned his attempt to fly through the pass because of unsuitable weather conditions. He flew into a confined area that required him to manoeuvre the aircraft aggressively to avoid the rising terrain, causing the aircraft to stall.
2. The aircraft weight exceeded the certificated MAUW, and the CG was outside the floatplane aft limit. The out-of-limit weight and balance aggravated aerodynamic stall and produced rapid and
uncontrolled aircraft attitudes from which the pilot could not recover before striking the trees.
3. Basic weight and balance of the aircraft was incorrectly recorded in several aircraft documents, leading to remarkable discrepancies in take-off weight and CG calculations. As a result, a pilot could not calculate an accurate weight and balance. In certain conditions, calculations erroneously showed that the aircraft was below maximum allowable gross weight.
Findings as to Risk:
1. The practice of using a non-standard passenger weight led to inaccurate take-off weight calculations and provided an estimated total passenger weight that was 185 pounds less than actual.
2. Weight and balance calculations performed using inaccurate figures would not have revealed that the aircraft was overloaded until it was approximately 450 pounds beyond the maximum limit.
3. Aircraft weight exceeded the maximum allowable gross weight, and the CG was outside the aft CG limit. This weight and balance combination placed the aircraft outside the manufacturer’s
original design envelope, to where slow speed and stall handling characteristics are neither proven nor certificated.
4. Cargo was not secured by the available cargo restraint and might have shifted during aircraft manoeuvring. Such cargo movement would have exacerbated the effects of the existing aft CG and likely increased the level of injury to the occupants.
Other Findings:
1. The pilot chose to fly above cloud in accordance with the visual flight rules and could not descend through the cloud at his intended landing site.
2. The Alaska cargo door installation increases the volume of the cargo compartment. The installation is thereby conducive to larger loads being stowed farther aft and possible overloading of the cargo compartment.
3. The DHC-2 Beaver is not equipped with an aural or visual stall warning system, nor is it required by regulation. Warning of an impending stall is dependent on juddering or some other aerodynamic indication.