Charter/Taxi (Non Scheduled Revenue Flight)

Rupture of a crank and subsequent total loss of power and fire in the right engine during rotation of the plane, which reduced the performance of the aircraft, causing the pilot to lose control of the aircraft, resulting in the immediate collision with the ground.

Stall and loss of control after the cargo shifted during initial climb. It was determined that the cargo was not properly secured in the cabin and moved to the rear during initial climb. The distance between the aircraft and the ground was insufficient to expect recovery. It was also reported that the aircraft has been refueled with AI-96 motor gasoline instead of aviation fuel.

Findings as to Causes and Contributing Factors:
1. The pilot flew a high-drag approach configuration for which his proficiency was not established.
2. The pilot most likely allowed the airspeed to decrease to the point that the aircraft stalled on approach at an altitude at which recovery was unlikely.
3. The impact was non-survivable because of the high impact forces.
Findings as to Risk:
1. The emergency locator transmitter (ELT) airframe antenna was broken off above the fuselage; however, the flight was within the 30-day period allowed by regulation for flight with an unserviceable ELT.
2. The pilot did not secure the cargo prior to flight, which allowed the cargo to shift forward on impact.
3. The weight and centre of gravity (C of G) were not indicated in the operational flight plan and load record, and the aircraft’s weight and C of G could only be estimated.

Findings as to Causes and Contributing Factors:
1. The aircraft was positioned over the runway threshold at an altitude that did not allow a landing at the beginning of the runway, and this, combined with a tailwind component and the wet runway surface, resulted in a runway excursion.
2. Failure to follow standard operating procedures and a lack of crew coordination contributed to confusion on landing, which prevented the crew from aborting the landing and executing a missed approach.
3. The pilot-in-command held several management positions within the company and controlled the pilot hiring and dismissal policies. This situation, combined with the level of experience of the co-pilot compared with that of the pilot-in-command, had an impact on crew cohesiveness.
Findings as to Risk:
1. The pilot-in-command of C-FMAI decided to execute an approach for Runway 05 without first ensuring that there would be no possible risk of collision with the other aircraft.
2. The regulatory requirement to conform to or avoid the traffic pattern formed by other aircraft is not explicit as to how the traffic pattern should be avoided, in terms of either altitude or distance, which can result in risks of collision.
3. The regulations do not indicate whether the missed approach segment should be considered part of the traffic pattern; this situation can lead pilots operating in uncontrolled airspace to believe that they are avoiding another aircraft executing an instrument approach when in reality a risk of collision exists.

The loss of control immediately after liftoff was the consequence of an aircraft contaminated with ice, resulting in an excessive weight, a loss of lift and a consequent stall. The following factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP procedures prior to takeoff,
- The aircraft has not been deiced prior to takeoff, increasing the total weight of the aircraft by 231 kilos, 8% above the MTOW,
- This situation caused the CofG to be out of the permissible limits,
- Poor judgment on part of the crew when the undercarriage were lowered.

The Commission believes that the accident can be explained by a series of several causes which, taken separately, would not lead to an accident.
The causes are related to:
1 - the lack of rigor in the approach and landing phase evidenced by a failure to follow standard operating procedures, including the arrival checklist.
2 - the failure to strictly comply with the holding, approach and landing procedures in force for the aerodrome of Ghardaïa.
3 - the fact that the captain seemed occupied by the visual search maneuvers that put him temporarily out of the control loop. He was so focused on the visual search for the runway and abandoned the monitoring of parameters that are critical for the safety of the flight. This concentration completely disoriented him.
4 - the fact that the crew did not respond appropriately to different alarms that occurred, indicating a lack of control in the operation of the aircraft in that kind of situation. Lack of control was apparently due to his lack of training on this aircraft type.
5 - The activities in the southern part of Algeria may cause a certain routine that can promote the tendency to conduct visual approaches. It seems, indeed, that the crew is more experienced in visual flights.
6 - A lack of coordination and communication between the crew members flying together for the first time.

No conclusive evidence could be found from the findings gathered through this investigation to determine the probable cause. However, based on the work done, it could be concluded that any combination of these findings could have caused or contributed to the accident. Although the crew at the last stage of this accident attempted to correctly recover, the gravity upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Possible causes:
- Trim/Feel Unit Fault (Aileron Trim Runaway),
- Temporarily, Spoiler wing cable jam (Spoiler offset of the neutral position),
- Temporarily, F/O wheel jam (Spoilers offset of the neutral position),
- Autopilot Actuator Hardover Fault.
Possible contributing factors:
- A distraction developing to Spatial Disorientation (SD) until the time the F/O announced 'A/C turning right' with acknowledgment of the captain,
- Technical log copies were kept on board with no copy left at departure station,
- Operator write up of defects was not accurately performed and resulting in unclear knowledge of actual technical status,
- There are conflicting signals which make unclear whether the captain remained in SD or was the crew unable to perceive the cause that was creating an upset condition until the time when the F/O announced that there was no A/P in action,
- After the time then the F/O announced 'no A/P commander' the crew behavior suggests the recovery attempt was consistent with expected crew reaction, evidences show that the corrective action was initiated in full, however the gravity of the upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Additional findings:
- The ECAA authorization for RAM B737 simulator was issued at a date later than the date of training for the accident crew although the inspection and acceptance test were carried out at an earlier date.
- Several recorded FDR parameters were unreliable and could not be used for the investigation.

Findings as to Causes and Contributing Factors:
1. The pilot attempted to take off from an airstrip that was covered with approximately 18 inches of snow, and the aircraft did not accelerate to take-off speed because of the drag; the aircraft was forced into the air and was unable to climb out of ground effect and clear the obstacles.
2. The pilot did not abort the take-off when it became apparent that the aircraft was not accelerating normally and before the aircraft became airborne.
Findings as to Risk:
1. Unidirectional G switches, which are found on many types of ELTs, do not always activate the unit when impact forces are not aligned with the usual direction of flight.
Other Findings:
1. The validity of the aircraft’s certificate of airworthiness was affected while it flew more flights than allowed by the ferry permit issued by Transport Canada.
2. The rear passenger seat was found to be installed incorrectly, contrary to de Havilland Alert Service Bulletin A3/49, dated 19 July 1991.

The pilot's inadequate evaluation of the weather conditions, and his failure to maintain adequate altitude/clearance, which resulted in a collision with terrain during the final landing approach. A factor contributing to the accident was the presence of a downdraft.