Charter/Taxi (Non Scheduled Revenue Flight)

Findings as to Causes and Contributing Factors
1. The pilot likely departed and continued flight in conditions that were below visual
flight rules (VFR) weather minima.
2. The pilot continued his VFR flight into instrument meteorological conditions (IMC),
and did not recognize his proximity to terrain until seconds before colliding with
Thormanby Island, British Columbia.
3. The indication of a marginal weather improvement at Powell River, British Columbia,
and incorrect information from Merry Island, British Columbia, may have
contributed to the pilot’s conclusion that weather along the route would be sufficient
for a low-level flight.
Findings as to Risk:
1. The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received.
2. Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety.
3. The lack of pilot decision making (PDM) training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions.
4. Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions.
5. Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions.
6. Incremental growth in Pacific Coastal’s support to Kiewit did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected.
7. Transport Canada’s guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows.
8. Previous discussions between Pacific Coastal and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk.
9. There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart.
10. Because the aircraft’s emergency locator transmitter (ELT) failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed.
11. On a number of flights, pilots on the Vancouver–Toba Inlet route, British Columbia, departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits.
12. The over-reliance on global positioning system (GPS) in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers.
Other Finding:
1. The SPOT Satellite Messenger data transmitted before the crash helped to narrow the search area and reduce the search time to find the aircraft. The fact that the wrong data were consulted caused an initial delay in reporting the missing aircraft.

The pilot failed to carry out a proper assessment of the wind conditions. The aircraft failed to gain height as a result of a possible down draft and collided with obstacles on the ground after landing. The pilot failed to maintain directional control after take-off, resulting in a landing on the left side of the runway after aborting the take-off.

The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures.
Contributing to the accident were:
- Deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of critical systems in the wheel well area to result in uncommanded forward thrust that increased the severity of the accident,
- The inadequacy of Learjet’s safety analysis and the FAA’s review of it, which failed to detect and correct the thrust reverser and wheel well design deficiencies after a 2001 uncommanded forward thrust accident,
- Inadequate industry training standards for flight crews in tire failure scenarios,
- The flight crew’s poor crew resource management (CRM).

It is believed that the accident was the consequence of an engine failure for unknown reasons.

Findings as to Causes and Contributing Factors:
1. While likely climbing to fly above a cloud-covered ridge and below the overcast ceiling, the aircraft stalled aerodynamically at a height from which full recovery could not be made before striking the trees.
2. The aircraft broke apart upon impact, and electrical arcing from exposed wires in the presence of spilled fuel caused a fire that consumed most of the aircraft.
Findings as to Risk:
1. While the company’s established communications procedures and infrastructure met the regulatory requirements, they were not effective in ascertaining an aircraft’s position and flight progress, which delayed critical search and rescue (SAR) action.
2. The emergency locator transmitter was destroyed in the crash and failed to operate, making it difficult for SAR to find the aircraft. This prolonged the time the injured survivors had to wait for rescue and medical attention.

The captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were:
- The pilots’ poor crew coordination and lack of cockpit discipline,
- Fatigue, which likely impaired both pilots’ performance, and
- The failure of the Federal Aviation Administration to require crew resource management training and standard operating procedures for Part 135 operators.

Findings as to Causes and Contributing Factors:
1. The linkpin plugs had not been installed in the recently overhauled engine, causing inadequate lubrication to the linkpin bushings, increased heat, and eventually an abrupt engine failure.
2. Immediately following the engine failure, while the pilot manoeuvred the aircraft for a forced landing, the aircraft entered an aerodynamic stall at a height from which recovery was not possible.
Finding as to Risk:
1. The failure to utilize available shoulder harnesses increases the risk and severity of injury.

Operational error of the pilot in command by not applying normal approach procedures recommended by the manufacturer and loss control of the aircraft (stall) while returning to land with the left engine cowling open.
The following contributing factors were identified:
- During the preflight inspection, the pilot failed to detect that the left engine cowling was unlatched,
- Return with the intention of landing with a speed very close to the stall speed, possibly to avoid the detachment of the engine cowling due to the wind force,
- Probable increased stall speed by altering the left wing aerodynamics due to the engine open cowl,
- Not having high enough altitude to recover from a stall condition,
- Possible decreased physiological capabilities of the commander of the aircraft, due to the presence of alcohol in his system,
- Possible pilot distraction due to weather conditions and the opening of the engine cowling.