Canada

Controlled flight into terrain.

Findings as to Causes and Contributing Factors:
- The engine quit operating because the aircraft fuel system was contaminated with a large amount of water.
- The most likely source of the water contamination was the drums from which the aircraft was refuelled.
- A proper filter to prevent water contamination was not used when the aircraft was refuelled.
- The nose-level aircraft attitude when beached and the freezing of water probably prevented the water contamination from being drained from the front tank during the pilot's pre-flight checks.
Other Findings:
- The aircraft's maintenance records indicate that the aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures.
- The use of the available shoulder harnesses probably prevented serious injury to the pilot and engineer.

Findings as to Causes and Contributing Factors:
1. The number three cylinder lower forward through stud was missing its base nut, which allowed the lower rear base nut of the number two cylinder to loosen.
2. The missing base nut of the through stud indicates that the base nut did not have sufficient clamping force; however, it could not be determined if the base nut did not receive the required torque during installation or if the base nut lost its clamping force during engine operation.
3. The d-inch studs and the 2-inch through studs of the number two cylinder failed in fatigue, and the number two cylinder of the left engine separated from the crankcase.
4. The left propeller could not be feathered because of interference between the propeller governor control and the separated number two cylinder.
5. The drag from the unfeathered left propeller and the deformed left engine cowling resulted in the aircraft being incapable of maintaining its altitude.
Other Findings:
1. The pilot was certified and qualified for the accident flight.
2. The aircraft's weight and balance were within the specified limits at the time of the accident.
3. The ELT was not readily accessible without tools.

Findings as to causes and contributing factors:
1. The pilot flying did not establish a maximum performance climb profile, although required by the company's standard operating procedures (SOPs), when the ground proximity warning system (GPWS) "Terrain, Terrain" warning sounded during the descent, in cloud, to the non-directional beacon (NDB).
2. The pilot flying did not fly a stabilized approach, although required by the company's SOPs. The crew did not carry out a go-around when it was clear that the approach was not stabilized.
3. The crew descended the aircraft well below safe minimum altitude while in instrument meteorological conditions.
4. Throughout the approach, even at 100 feet above ground level (agl), the captain asked the pilot flying to continue the descent without having established any visual contact with the runway environment.
5. After the GPWS "Minimums, Minimums" voice activation at 100 feet agl, the aircraft's rate of descent continued at 850 feet per minute until impact.
6. The crew planned and conducted, in cloud and low visibility, a user-defined global positioning system approach to Runway 31, contrary to regulations and safe practices.
Findings as to risk:
1. At the time of the approach, the reported ceiling and visibility were well below the minima published on the approach chart.
2. Because the runway was not equipped with a reporting runway visual range system, flying the NDB approach was allowable under the existing regulations.
3. The crew did not follow company SOPs for the approach and missed-approach briefings.
4. Both crew members had surpassed their maximum monthly and quarterly flight times and maximum daily flight duty times. They were thus at increased risk of fatigue, which leads to judgement and performance errors.
5. The first officer likely suffered from chronic fatigue, having worked an average of 14 hours a day for the last 30 days, with only 1 day of rest.
6. Transport Canada was not aware that the company's pilots were exceeding the flight and duty times.
7. The company operations manager did not effectively supervise the flight and duty times of company pilots.
8. The captain had not received the mandatory training in pilot decision making or crew resource management.
Other findings:
1. The emergency locator transmitter activated on initial impact but ceased to transmit shortly thereafter when its antenna cable was severed.

Findings as to Causes and Contributing Factors:
1. The most likely accident scenario during the second take-off is that water contamination migrated from the centre fuel tank to the engine, resulting in a loss of engine power.
2. The engine stopped at a point from which there was insufficient time for the engine to restart, nor from which a safe landing could be made.
3. Indications of water contamination were found in the fuel system after the occurrence; however, the source(s) of the water contamination could not be identified.
Other Findings:
1. Examination of the aircraft and testing of the engine and components did not identify any pre-occurrence structural, mechanical, or electrical defects or malfunctions that would have
contributed to this occurrence.
2. The post-crash fire in the carburettor most likely resulted from uncontaminated fuel brought forward by the windmilling engine and the pilot's efforts to clear contamination from the fuel
system.
3. The pilot's use of his shoulder harness likely prevented more serious injuries during the impact sequence.
4. The engineer's injuries likely would have been less severe had he been using both his seat belt and shoulder harness.
5. The pilot was certified and qualified for the flight.
6. The aircraft's weight and centre of gravity were within approved limits.
7. The aircraft's records indicated that the aircraft had been certified and maintained in accordance with existing regulations.
8. The aircraft's engine power loss during the first attempted take-off was likely due to water contamination in the fuel.

The flight crew lost pitch control of the aircraft on take-off when the stabilizer trim actuators became disconnected because they had not been properly reinstalled by the AME during maintenance work conducted before the flight. The crew chief responsible for the inspection did not ensure correct assembly of the stabilizer trim actuators, which contributed to the accident.

Findings as to Causes and Contributing Factors:
1. The accident flight was conducted at night in IMC, and the pilot, whose private pilot licence was not endorsed with an instrument rating, was not certified for the IFR flight.
2. The pilot may have been subjected to somatogravic illusion and allowed the aircraft to descend into terrain after a night take-off in IMC.
3. The pilot did not completely report his medical conditions to the civil aviation medical examiner.
Other Findings
1. The pilot was not certified to fly this model of aircraft as his private pilot licence was not endorsed with the appropriate high-performance aircraft rating.
2. The pilot conducted a downwind take-off.
3. While the aircraft was turning left for the on-course track, the aircraft flaps were retracting.
4. The aircraft struck trees while in a shallow descent. The integrity of the aircraft was compromised as it rolled inverted and entered the impact zone at high speed.
5. The aircraft engine teardown examination revealed no pre-impact failures of any component parts or accessories in either the left or right engine that would have precluded normal engine operation.
6. The propeller teardown examination revealed that both propellers were in a normal operating range and were rotating with power at the time of impact.
7. The ELT did not function due to the impact damage sustained by its various components.

The pilot continued the take-off run with the left ski firmly adhering to the slushy surface beyond a point at which a reject could have been made safely. Contributing to the occurrence was the decrease in engine rpm during take-off.

Findings as to Causes and Contributing Factors:
1. The captain decided to descend below the minimum descent altitude (MDA) without the required visual references.
2. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice.
Findings as to Risk:
1. The flight crew did not follow company standard operating procedures.
2. Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present.
3. Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight.
4. The cargo was not adequately secured before departure, which increased the risk of injury to the crew.
5. The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight.
6. There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities.
7. The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation.
8. Records establish that the aircraft departed approximately 500 pounds overweight.
Other Findings:
1. The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training.
2. During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions.
3. There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches.
4. It was determined that an ice-contaminated tailplane stall did not occur.
5. The fuel weight was not properly recorded in the journey logbook.
6. The wreckage pattern was consistent with a controlled, shallow descent.
7. The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable.