Charter/Taxi (Non Scheduled Revenue Flight)

Detailed investigation and analyses of the examinable evidence confirmed that the aircraft had developed some problem with its Engine No.2 (Right) immediately after takeoff which was observed by the cockpit crew as propeller feathering on its own. No concrete evidence could be found which would have led to the engine’s propeller malfunction as observed. The only probable cause of propeller feathering on its own could be the wear & tear of the beta valve leading to beta system malfunction. However, this anomaly at the most could have led to the non availability of one engine and making a safe landing with a single engine since the aircraft was capable of landing with a single engine operation. Some of the actions by the cockpit crew before takeoff and subsequent to the observed anomaly in the Engine No.2 were not according to the QRH / FCOM which aggravated the situation and resulted into the catastrophic accident.
The following factors contributed to the accident:
The aircraft accident took place as a result of combination of various factors which directly and indirectly contributed towards the causation of accident.
The primary cause of accident includes, inappropriate skill level of Captain to handle abnormal operation of engine No 2 just after takeoff, failure of cockpit crew to raise the landing gears after experiencing the engine anomaly, execution of remedial actions by FO before the attainment of minimum safe altitude of 400 ft AGL resulted in non conformance and non compliance of cockpit crew to OEM recommended procedures to handle such situations.
The lack of situational awareness and CRM failure directly contributed towards ineffective management of the flight deck by the cockpit crew.
The contributory factors include inadequate cockpit crew simulator training monitoring mechanism both at operator and CAA Pakistan levels in respect of correlation of previous / current performance and skill level of cockpit crew during the simulator training sessions along with absence of conduct of recurrent / refresher simulator training between two annual simulator checks in accordance with ICAO Annex-6 guidelines and CAA Pakistan (applicable ANOs) requirements for specific type of aircraft in a year.

Findings as to Causes and Contributing Factors:
1. The conduct of the flight crew members during the instrument approach prevented them from effectively monitoring the performance of the aircraft.
2. During the descent below the minimum descent altitude, the airspeed reduced to a point where the aircraft experienced an aerodynamic stall and loss of control. There was insufficient altitude to effect recovery prior to ground impact.
3. For unknown reasons, the stall warning horn did not activate; this may have provided the crew with an opportunity to avoid the impending stall.
Findings as to Risk:
1. The use of company standard weights and a non-current aircraft weight and balance report resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.
2. Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.
3. Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.
4. Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance parameters of an instrument approach.

Contributing safety factors:
• The weather was marginal for flight under the visual flight rules, with broken cloud forecast down to 500 ft above mean sea level in the area.
• The pilot, who did not hold a command instrument rating, entered instrument meteorological conditions because he was adhering to an un-written operator rule not to fly below 1,000 ft above ground level.
• The pilot became lost in cloud and flew the aircraft towards the Mt Strzelecki Range, exiting the cloud in very close proximity to the terrain.
• The aircraft exited the cloud in a small valley, within which the pilot could neither turn round nor out-climb the terrain.
Other key findings:
• The aircraft exited cloud before impacting terrain and with sufficient time for the pilot to execute a forced landing.
• The design of the aircraft’s seats, and the provision to passengers in the GA-8 Airvan of three-point automotive-type restraint harnesses with inertia reel shoulder straps contributed to the passengers’ survival, almost without injury.

The following findings were identified:
1. Acklins Blue Air Charter was advertising and operating as a Bahamas air taxi operator without having undergone the certification process in contravention of Bahamas Civil Aviation (Safety) Regulations Schedule 12.
2. The airplane was issued a Certificate of Airworthiness on May 19, 2010, by the Bahamas Flight Standards Inspectorate, and was being operated by Acklins Blue Air Charter.
3. The Cessna 402C aircraft is classified in the performance Group C. This requires rapid feathering of the propeller of a failed engine and the raising of flap and the landing gear in order to achieve maximum climb performance.
4. The airplane maintenance records were not located; therefore, no determination could be made whether the airplane was being maintained in accordance with Bahamas Civil Aviation Regulations.
5. The 12,000 hour pilot and second pilot were not qualified to operate in Bahamas commercial air taxi operations.
6. No determination could be made whether the pilot or second pilot had completed required training and had accomplished a satisfactory recurrent flight check of their flying ability as required by CASR Schedule 12 and 14 for aircraft operating in commercial air transportation as well as the stipulation by the insurance policy.
7. Post-accident weight and balance calculations indicate the airplane was being operated approximately 523 pounds over maximum certificated takeoff weight (6,850 lb)
8. The pilot was advised by an air traffic controller that white smoke was trailing the left engine during takeoff; the pilot did not declare an emergency or advise the controller of any engine failure or mechanical abnormality.
9. The airplane's left engine could not produce rated shaft horsepower during takeoff.
10. Several factors contributing to the degradation of the airplane's performance and its inability to maintain flight include the wind-milling propeller, the pilot's intentional initiation of a steep turn to return to the departure airport, and his intentional lowering of the landing gear during the turn to return.
11. While turning to return, the airplane stalled, pitched nose down, and impacted in a lake.
12. The search and rescue efforts were timely and appropriate; however, the lack of accurate information on the pilot submitted flight plan delayed recovery of all victims.
13. The left propeller was not feathered.
14. The No. 2 cylinder of the left engine failed due to fatigue that originated in the root of the cylinder head thread that was engaged with the first thread on the barrel.
15. Post-accident inspection of the cockpit revealed several switches for the right engine were secured; however, no determination could be made when the switches were placed / moved in those positions.
16. No evidence of failure of the airplane's structures or flight control system contributed to the accident.
17. Existing regulations did not require the aircraft to be fitted with flight recorders. The lack of any recorded data about the aircraft's performance or the flight crew conversations deprived the investigation team of essential factual information.
18. Current Civil Aviation Department personnel and budget resources may not be sufficient to ensure that the quality of surveillance for certified as well as uncertified air carrier operations will improve.
19. Airside access procedures are inadequate at Fixed Base Operators. Access to the secure airside occurring without any check of individuals to challenge whether they have a legitimate reason for accessing the secure airside. FBO door to access airside is not secured or locked continuously; persons observed walking in and out without being challenged.
20. Flight Plan Forms are being accepted and transmitted to ATC with incomplete information. This information is vital for search and rescue purposes.
21. Weather was not a factor in the accident.
22. ATC was not a factor in the accident.
23. Currently flight plans for private flights are only required for international operations.
24. The pilot was aware of discrepancy associated with the manifold pressure reading of the left engine prior to takeoff. This discrepancy was brought to his attention by a client from the flight immediately preceding the accident flight.
25. The exact center of gravity of the accident airplane could not be calculated accurately as no indication of what seat each passenger occupied in the airplane and no indication of where luggage or equipment were placed on the aircraft could be determined. However, due to the exceedance of weight limits the aircraft was already outside the allowable center of gravity envelope developed by the manufacturer.
26. The pilot had insufficient time to prepare for the approach to runway 27 before beginning the approach. The airplane pitched up quickly into a stall, after extension of gear, recovery before ground impact was unlikely once the stall began.
27. Post accident inspection did not reveal any mechanical evidence or problems with the right hand engine.
28. The pilot's decision to return to the airfield was reasonable. Once the aircraft began to lose height a return to the airfield became impractical and a forced landing in the direction of flight should have been attempted.
29. The right propeller was never recovered from the lake.
The following causal factors were identified:
1. The left engine suffered a mechanical failure of the #2 cylinder, and therefore could not produce rated shaft horsepower. No indication of total loss of power with the left engine reported.
2. Right Engine electrical and engine control switches were found in the “OFF” position, therefore the aircraft was incapable of climbing on the power of one engine alone.
3. The excess weight above the maximum weight allowed for takeoff may have been an important factor in the aircraft's inability to gain adequate altitude after takeoff.
4. The pilot secured the right engine which was mechanically capable of producing power resulting in a total loss of thrust. He then sometime thereafter initiated a steep turn with gear down and the left engine already not developing sufficient shaft horsepower to sustain lift.
5. The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the left.

Findings As To Causes and Contributing Factors:
The bird strike occurred on take-off at an altitude of less than 50 feet. Gulls were ingested in the left engine, which then lost power.
After the loss of engine power, the flight crew had difficulty controlling the aircraft. The aircraft touched the ground, forcing the pilot flying to abort the take-off when the runway remaining was insufficient to stop the aircraft, resulting in the runway overrun.
Findings As To Risks:
Although a cannon was in place, it was not working on the day of the accident, which increased the risk of a bird strike.
The presence of a goose and duck farm outside the airport perimeter but near a runway increases the risk of attracting gulls.
Operators subject to Canadian Aviation Regulations Subpart 703 are not prohibited from having an aircraft take off from a runway that is shorter than the accelerate-stop distance of that aircraft as determined from the performance diagrams. Consequently, travellers carried by these operators are exposed to the risks associated with a runway overrun when a take-off is aborted.
The absence of a CVR makes it harder to ascertain material facts. Consequently, investigations can take more time, resulting in delays which compromise public safety.

The pilot's delayed application of full power during a soft/wet field takeoff, resulting in a collision with trees during takeoff.

Contributing safety factors:
• The operator’s processes for determining the aircraft’s required landing distance did not appropriately consider all of the relevant performance factors.
• The operator’s processes for learning and implementing change from the previous runway overrun incident were ineffective.
• The flight crew did not use effective crew resource management techniques to manage the approach and landing.
• The crew landed long on a runway that was too short, affected by a tailwind, had a degraded surface and was water contaminated.
• The crew did not carry out a go-around during the approach when the visibility was less than the minimum requirements for a visual approach.
• The baulked landing that was initiated too late to assure a safe takeoff.
Other safety factors:
• The aircraft aquaplaned during the landing roll, limiting its deceleration.
• The runway surface was described as gravel, but had degraded over time.
• The weather station anemometer was giving an incorrect wind indication.

Undetermined.