Canada

Findings as to causes and contributing factors:
1. The captain commenced the flight with only a single headset on board, thereby preventing a shared situational awareness among the crew.
2. It is likely that the weather at the time of both approaches was such that the captain could not see the required visual references to ensure a safe landing.
3. The first officer was focused on locating the runway and was unaware of the captain’s actions during the descent.
4. For undetermined reasons, the captain initiated a steep descent 0.56 nautical mile from the threshold, which went uncorrected until a point from which it was too late to recover.
5. The aircraft contacted a road 0.25 nautical mile short of the runway and struck terrain.
6. The paramedic was not wearing a seatbelt and was not restrained during the impact sequence.
Findings as to risk:
1. If cockpit data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If crew members are unable to communicate effectively, then they are less likely to anticipate and coordinate their actions, which could jeopardize the safety of flight.
3. If crew resource management training is not provided, used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight.
4. If an actual weight and balance cannot be determined, then the aircraft may be operating outside of its approved limits, which could affect the aircraft’s performance characteristics.
5. If pre-computed weight and balance forms do not include standard items, then it increases the likelihood of omissions in weight and balance calculations, which increases the risk of inadvertently overloading or incorrectly loading the aircraft.
6. If organizations carry out a maintenance task that they consider to be elementary work and the task is not approved as an elementary work task, then there is a risk that the aircraft will not conform to its type design, which could jeopardize the safety of flight.
7. If individuals are performing maintenance tasks for which they have not received approved training, then there is a risk that the task will not be performed in accordance with the manufacturer’s instructions.
8. If components are not installed in accordance with the manufacturer’s instructions, then occupants are at a greater risk of injury or death during an incident or accident if these components are not properly secured.
9. If organizations do not record when maintenance is carried out, then the proper completion of tasks cannot be confirmed, and there is a risk that the aircraft will not conform to its type design, which could jeopardize the safety of flight.
10. If an aircraft is modified without regulatory approval and without supporting documentation, then the aircraft is not in compliance with all applicable standards of airworthiness, which could jeopardize the safety of flight.
11. If an operator undertakes unapproved changes to a supplemental type certificate, then there is a risk that the aircraft will not be airworthy, which could jeopardize the safety of flight.
12. If organizations do not use modern safety management practices, then there is an increased risk that hazards will not be identified and risks mitigated.
13. If Transport Canada does not adopt a balanced approach that combines thorough inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.
14. If organizations contract aviation companies to provide a service with which the organizations are not familiar, then there is an increased risk that safety deficiencies will go unnoticed, which could jeopardize the safety of the organizations’ employees.
15. If passengers are not provided with a regular safety briefing, then there is an increased risk that they will not use the available safety equipment or be able to perform necessary emergency functions in a timely manner to avoid injury or death.
16. If passengers are not properly restrained, then there is an increased risk of injuries and death to those passengers and the other occupants in the event of an accident.
17. If carry-on baggage, equipment or cargo is not restrained, then occupants are at a greater risk of injury or death if these items become projectiles in a crash.
18. If carry-on baggage, equipment or cargo is not restrained, then there is an increased risk that the occupants’ access to normal and emergency exits, and to safety equipment, will be completely or partially blocked.
19. If pilots continue an approach below published minimum descent altitudes without seeing the required visual references, then there is a risk of collision with terrain and/or obstacles.
20. If current charts and databases are not used, then navigational accuracy and obstacle avoidance cannot be assured.
21. If GPS (global positioning system) approaches are conducted without the approved Operations Specification, then there is a risk that the pilot’s training and knowledge will be inadequate to safely conduct the approach.
22. If medical symptoms/conditions are not reported to Transport Canada, then it negates some of the safety benefit of examinations and increases the risk that pilots will continue to fly with a medical condition that poses a risk to safety.
Other findings:
1. The pilot who installed the air ambulance system did not have approved training, nor was the pilot approved to carry out elementary work.
2. Atlantic Charters was not approved to install the air ambulance system as an elementary work task.
3. Atlantic Charters’ pre-computed weight and balance form did not include a line item to indicate nacelle fuel.
4. The semi-annual safety training offered to paramedics in lieu of safety briefings prior to flights did not meet regulatory requirements.

Prior to touchdown in a northerly direction, the aircraft encountered a gusty westerly crosswind and the associated turbulence. This initiated an un-commanded yaw and left wing drop indicating an aerodynamic stall. The pilot was unsuccessful in recovering full control of the aircraft and it impacted rising terrain on the shore approximately 30 feet above the water surface.

Failure of the right main gear for unknown reasons.

A first-stage turbine wheel blade in the left engine failed due to a combination of metallurgical issues and stator vane burn-through. As a result of the blade failure, the left engine continued to operate but experienced a near-total loss of power at approximately 500 feet above ground level, on final approach to Runway 26 at the Red Lake Airport. The crew were unable to identify the nature of the engine malfunction, which prevented them from taking timely and appropriate action to control the aircraft. The nature of the engine malfunction resulted in the left propeller being at a very low blade angle, which, together with the landing configuration of the aircraft, resulted in the aircraft being in an increasingly high drag and asymmetric state. When the aircraft’s speed reduced below minimum control speed (VMC), the crew lost control at an altitude from which a recovery was not possible.

The exact cause of the accident remains unknown.

Findings as to causes and contributing factors:
1. During approach to landing on the previous flight, the right-wing leading-edge and wing tip were damaged by impact with several trees.
2. The damage to the aircraft was not evaluated or inspected by qualified personnel prior to take-off.
3. Cumulative unmanaged stressors disrupted the pilot’s processing of safety-critical information, and likely contributed to an unsafe decision to depart with a damaged, uninspected aircraft.
4. The aircraft was operated in a damaged condition and departed controlled flight likely due to interference between parts of the failing wing tip, acting under air loads, and the right aileron.
Findings as to risk:
Not applicable.
Other findings:
1. The emergency locator transmitter did not activate, due to crash damage and submersion in water.
2. The aircraft was not fitted with FM radio equipment that is usually carried by aircraft servicing the lodge. Lodge personnel did not have a means to contact the pilot once the aircraft moved away from the dock.

Findings as to causes and contributing factors:
1. An accurate take-off weight and balance calculation was not completed prior to departure, resulting in an aircraft weight that exceeded its maximum certified takeoff weight.
2. The right engine number 1 cylinder failed during the take-off sequence due to a preexisting fatigue crack, resulting in an engine fire.
3. After the right propeller’s feathering mechanism was activated, the propeller never achieved a fully feathered condition likely due to a seized bearing in the feathering pump.
4. The windmilling right propeller caused an increase in drag which, combined with the overweight condition, contributed to the aircraft’s inability to maintain altitude, and the aircraft collided with terrain short of the runway.
5. The operator’s safety management system was ineffective at identifying and correcting unsafe operating practices.
6. Transport Canada’s surveillance activities did not identify the operator’s unsafe operating practices related to weight and balance and net take-off flight path calculations. Consequently, these unsafe practices persisted.
Findings as to risk:
1. If companies do not adhere to operational procedures in their operations manual, there is a risk that the safety of flight cannot be assured.
2. If Transport Canada does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.
3. If cockpit or data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Other findings:
1. Current Canadian Aviation Regulations permit a transport category piston-powered aircraft to carry passengers without a flight data recorder or cockpit voice recorder.
2. The crew resource management component of the flight attendant’s training had not been completed.

Findings as to causes and contributing factors:
1. The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others.
2. The pilot and 1 passenger did not exit the aircraft before it was consumed in the postimpact fire.
3. Air Nootka did not have effective methods to monitor its pilots’ in-flight decision making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behavior or poor decision making such as occurred on this flight.
Findings as to risk:
1. If aircraft are not fitted with technology to reduce fuel leakage or to eliminate ignition sources, the risk of post-impact fire is increased.
2. If aircraft are not equipped with shoulder harnesses for all seating positions then there is an increased risk of injuries.
3. If aircraft are not equipped with some alternate means of escape such as push-out windows, then there is a risk that post-crash structural deformation will jam doors shut and restrict exit for the occupants.
4. If companies operating under self-dispatch do not monitor their operations, they risk not being able to identify unsafe practices that are a hazard to flight crew and passengers.
5. If flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.