Ambulance

The pilot's failure to maintain clearance from mountainous terrain. Contributing to the accident was the pilot's inadequate preflight planning, improper in-flight planning and decision making, the dark night, and the controller's failure to issue a safety alert to the pilot.

Failure to maintain clearance from terrain due to spatial disorientation.

The pilots’ mismanagement of an abnormal flight control situation through improper actions, including failing to control airspeed and to prioritize control of the airplane, and lack of crew coordination. Contributing to the accident were Marlin Air’s operational safety deficiencies, including the inadequate checkrides administered by Marlin Air’s chief pilot/check airman, and the Federal Aviation Administration’s failure to detect and correct those deficiencies, which placed a pilot who inadequately emphasized safety in the position of company chief pilot and designated check airman and placed an ill-prepared pilot in the first officer’s seat.

Finding as to Causes and Contributing Factors:
1. The aircraft stalled at an altitude that was too low for the pilot to recover.
Findings as to Risk:
1. The aircraft was flying at an altitude that could lead to a collision with an obstacle and that did not allow time for recovery.
2. The steep right bank of the aircraft considerably increased the aircraft’s stall speed.
3. The form used to record the pilot’s flight time, flight duty time, and rest periods had not been updated for over a month; this did not allow the company manager to monitor the pilot’s hours.
4. At the time of the occurrence, the Aéropro company operations manual did not make provision for the restrictions on daytime VFR flights prescribed in Section 703.27 of the Canadian Aviation Regulations.
Other Findings:
1. The fact that the aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice recorder (CVR) limited the information available for the investigation and limited the scope of the investigation.
2. Since the aircraft was on a medical evacuation (MEDEVAC) flight, the company mistakenly advised the search and rescue centre that there were two pilots on board the aircraft when it was reported missing.

The pilot's failure to maintain an adequate altitude and descent rate during a night visual approach. Dark night conditions and mountainous terrain are factors in the accident.

The copilot's failure to maintain the proper airspeed, and failure to obtain the proper touchdown point, and the pilot-in-command's inadequate supervision, which resulted in an overrun. Contributing to the accident was the PIC's failure to activate the speed brake upon touchdown and the snow contaminated runway.

Findings as to Risk:
1. Some Canadian Air Regulations (CARs) subpart 703 air taxi and subpart 704 commuter operators are unlikely to provide initial or recurrent CRM training to pilots in the absence of a regulatory requirement to do so. Consequently, these commercial pilots may be unprepared to avoid, trap, or mitigate crew errors encountered during flight.
2. Transport Canada (TC) Prairie and Northern Region (PNR) management practices regarding the June 2006 replacement of the regional combined audit program, in order to manage safety management system (SMS) workload, did not conform to TC’s risk management decision-making policies. Reallocation of resources without assessment of risk could result in undetected regulatory non-compliance.
3. Although TC safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated by the PNR managers because of the limitations of the oversight system in place at that time.
4. It is likely that the National Aviation Company Information System (NACIS) records for other audits include inaccurate information resulting from data entry errors and wide use of the problematic audit tracking form, reducing the effectiveness of the NACIS as a management tracking system.
5. Self-dispatch systems rely on correct assessment of operational hazards by pilots, particularly in the case of unscheduled commercial service into uncertified aerodromes. Unless pilots are provided with adequate decision support tools, flights may be dispatched with defences that are less than adequate.
6. TWA King Air crews did not use any standard practice in applying cold temperature altitude corrections. Inconsistent application of temperature corrections by flight crews can result in reduction of obstacle clearance to less than the minimum required and reduced safety margins.
7. The practice of not visually verifying wind/runway conditions at aerodromes where this information is otherwise unavailable increases the risk of post-touchdown problems.
8. The company dispatched flights to Sandy Bay without a standard means for crews to deal with non-current altimeter settings. Use of non-current or inappropriate altimeter settings can reduce minimum obstacle clearance and safety margins.
9. The crew was likely unaware of their ¼ nautical mile (nm) error in the aircraft position in relation to the runway threshold resulting from use of the global positioning system (GPS). Unauthorized and informal use of the GPS by untrained crews during instrument flight rules (IFR) approaches can introduce rather than mitigate risk.
10. Widespread adaptations by the King Air pilots resulted in significant deviations from the company’s SOPs, notwithstanding the company’s disciplinary policy.
11. In a SMS environment, inappropriate use of punitive actions can result in a decrease in the number of hazards and occurrences reported, thereby reducing effectiveness of the SMS.
12. Pilot workload is increased and decision making becomes more complicated where limited visual cues are available for assessing aircraft orientation relative to runway and surrounding terrain.
13. Aerodromes with limited visual cues and navigational aids are not explicitly identified in flight information publications as hazardous for night/IFR approaches. Passengers and crews will continue to be exposed to this hazard unless aircraft and aerodrome operators carry out risk assessments to identify them and take mitigating action.
14. To properly assess applicants for pilot positions, operators need access to information on experience and performance that is factual, objective, and (preferably) standardized. Because some employers are unprepared to provide this information—fearing legal action—this may lead to the appointment of pilots to positions for which they are unsuited, thereby compromising safety.
Other Findings:
1. TWA’s safety management system was not yet capable or expected to be capable of detecting, analyzing, and mitigating the risks presented by the hazards underlying this occurrence.
2. The first officer and captain met competency standards on the completion of their initial flight training before they began employment as line pilots.
3. It is very likely that the captain became the pilot flying for the remaining 20 seconds of the flight. The scenario that neither pilot was controlling the aircraft at that time is considered very unlikely.

The lack of flight recorders made it impossible to trace the chain of events on board the aircraft. As a result, the causes of the accident could not be determined with precision. However, at least two scenarios could simultaneously explain the length of the takeoff roll and the low height after rotation: a lack of control of the airplane by the pilot, either by poor adjustment of the elevator trim or because his attention would have been focused inside the cockpit by any event, without reaction from the pilot passenger seated on the right. This scenario is consistent with his relative inexperience with the type of aircraft. The second scenario could be based on an inappropriate decision to seek significant speed after take-off or improvised instruction, neither pilot being aware of the obstacle constraints of the airfield. The significant obscurity, the operating specificities in medical transport and the presence of a second pilot with a status and role not provided for in the operations manual, without there being therefore any crew or distribution of tasks within the company's crew, are likely contributing factors. The 48-year-old pilot had a total of 3,500 flight hours, including 450 on type. The company agent who was seating on the right was a professional pilot who did not have a license on this type of aircraft and took advantage of the flight, in agreement with the corporate management, to acquire experience in a view to his future qualification on this type of airplane. He had a total of more than 4,000 flight hours.

Findings and Probable Cause could not be determined as the aircraft was stripped of its components, instrumentations, manuals and CVR by the owners of the aircraft, without permission or authorization from the Accident Investigation Personnel (Department of Civil Aviation). Documents and manuals requested of the owners were never obtained. The help of the NTSB as well as the FAA were enlisted in an effort to retrieve documents from the owners. All attempts were fruitless.

The failure of the pilot to execute the published emergency procedures pertaining to configuring the airplane for single engine flight, which would have allowed him to maintain minimum controllable airspeed (VMC) and level flight. The pilot's failure to maintain minimum controllable airspeed (VMC) led to a stall and subsequent VMC roll at a low altitude. Contributing to the accident was the operator's inadequate pilot training in the single engine flight regime, and the loss of power from the left engine for undetermined reasons.