Ambulance

The rupture of two teeth of the sprocket of the control cylinder of the left main landing gear caused the cylinder to be locked and thus caused the mechanical system to extend the landing gear. This blockage prevented the complete extension and locking of the landing gear. This rupture and other damage to the two main landing gear actuators was probably the result of improper installation of the toothed gear and / or improper adjustment of the assembly.

The misfueling of the airplane with jet fuel instead of the required aviation fuel, and the resultant detonation and a total loss of engine power during initial climb. Contributing to the accident were the line service technician's inadvertent misfueling of the airplane, the pilot's inadequate supervision of the fuel servicing, and the fixed-base operator's use of a small fuel nozzle on its jet fuel truck.

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.

The following factors were identified:
- The lack of technical knowledge published in the POH for the execution of the pertinent actions during the failure of the engine in flight, together with the unwise decisions made by the crew in that situation.
- The haste of the crew members to land caused them to act in an uncoordinated manner and without the assertiveness required for the execution of the procedures contemplated by the manufacturer, the navigation charts and the published approach procedures.
- The omissions, reactions and deviations inappropriate to conduct the flight safely to the runway.
- The turning to the runway on the same side of the inoperative (critical) engine and maximum power on the operational engine during the unstabilized approach to the runway threshold which led to loss of control of the aircraft in low altitude flight.

Double engine failure in flight due to carburetor icing. The following contributing factors were identified:
- Erroneous assessment of the risk factors specific to the conduct of this flight,
- Lack of crew experience on this type of aircraft,
- Erroneous decision of the captain to continue the flight in meteorological conditions that caused the carburetor icing,
- Erroneous decision of the captain to continue to fly for a long period of time in icing conditions,
- Erroneous decision of the captain to continue the mission under the AMA, under conditions of BMI flight according to IFR flight rules,
- Erroneous decision of the crew to initiate the flight while the total weight of the aircraft was above MTOW and the CofG was outside the prescribed limits.

The following factors were identified:
- The utilization of an aircraft not included in the Operating Specifications and of a runway neither registered nor approved, with a pilot who did not have the amount of hours necessary nor specific training, disclose a culture based on informal practices, which led to operation below the minimum safety requirements.
- It is possible that the pilot forgot to verify the quantity of fuel in the tanks of the aircraft before takeoff.
- The lack of specific training for the pilot and for the coordinator who, possibly, assumed the function of instructor may have compromised their operational performance during the preparation and conduction of the flight, since they were not effectively prepared for the activity.
- It is possible that the pilot failed to comply with the prescriptions of the legislation relatively to the minimum amount of fuel required for the flight leg. The operation of the aircraft by a pilot with expired qualifications and without the required training goes against the prescriptions at the time, but it was not determined whether this pilot (coordinator) was in the aircraft controls at the moment of the accident. The transport of a cylinder onboard the aircraft also configures flight indiscipline, since it goes against the legislation which prohibits the transport of such material.
- The lack of training of the differences may have contributed to the forgetting to verify the fuel tanks, a procedure that is prescribed in the aircraft manual. Likewise, lack of training may have deprived the pilots from acquiring proficiency for the operation of the aircraft in a single engine condition.
- The fact of conducting a flight to provide assistance in an emergency situation may have contributed to the pilot having forgotten to check safety parameters, such as the amount of fuel necessary.
- The pilot’s intention to earn his operational promotion may have stimulated him excessively, to the point of disregarding the minimum safety requirements for the operation. In addition, the emergency nature of the flight request possibly added to the motivation of the pilot and the coordinator.
- It is possible that, due to having little total experience either both of flight and in the aircraft, the pilot lost control of the aircraft when faced with the situation of in-flight engine failure after the takeoff.
- It is possible that the pilot and the coordinator prioritized the emergency requirement of the situation, failing to evaluate other aspects relevant for the safety of the flight, such as planning, for example.
- The lack of control on the part of the company’s management in relation to the flights operating outside of the main base allowed the pilot and the base manager to conduct a flight without the operating sector authorization. The lack of supervision of the air transport service provision by the contracting organizations allowed the company to provide services without the minimum conditions required by the legislation. Such conditions exposed the passengers to the risks of an irregular operation.

On the second landing attempt at a high altitude airfield (6,809 ft MSL), poor CRM coupled with a late power reduction by MP1 caused the MA to touchdown 27 KIAS faster than computed touchdown landing speed leading to the aircraft going off the end of the runway at approximately 49 KIAS. Because of unique aircraft performance characteristics when operating into and out of high altitude airfields, there was no way that the MA could perform a 50% flap landing (in accordance with T.O. 1C-130(C)J-1-1 landing assumptions, nose wheel landing gear speed restrictions and power level transition speed restrictions) at FOB Shank and land 27 KIAS fast. The MA’s actual landing speed simply overtasked the aircrafts capability to stop within the runway available.
Several factors substantially contributed to this mishap, including:
- Channelized attention,
- Risk assessment during operation,
- Delayed necessary action,
- Response set,
- Procedural error.

Breakdown in communication during the planning and execution of an unapproved procedure has been determined to be the probable cause of this accident.
Other contributing factors:
- Use of an unapproved procedure to aid in a maneuver that was critical,
- Too many persons were planning the maneuver and not coordinating their actions,
- Failure of planners of the maneuver to verify whether participants were in the right position,
- Inexperienced persons used in the execution of a maneuver that was not approved,
- Vehicle parked to close to the side of the runway,
- Vehicle left with engine running while parked near the runway.