Positioning

A partial loss of engine power for an undetermined reason. Contributing to the accident were the pilot's inadvertent encounter with IMC conditions, and a whiteout during his attempted go around from an emergency landing approach.

Findings as to Causes and Contributing Factors:
1. The aircraft was configured late for the approach, resulting in an unstable approach condition.
2. The pilot flying carried out a steep turn at a low altitude, thereby increasing the load factor. Consequently, the aircraft stalled at an altitude that was too low to allow the pilot to carry out a stall recovery procedure.
Findings as to Risk:
1. The time spent programming the global positioning system reduced the time available to manage the flight. Consequently, the crew did not make the required radio communications on the mandatory frequency, did not activate the aircraft radio control of aerodrome lighting (ARCAL), did not make the verbal calls specified in the standard operating procedures (SOPs), and configured the aircraft for the approach and landing too late.
2. During the second approach, the aircraft did a race-track pattern and descended below the safe obstacle clearance altitude, thereby increasing the risk of a controlled flight into terrain. The crew’s limited instrument flight rules (IFR) experience could have contributed to poor interpretation of the IFR procedures.
3. Non-compliance with communications procedures in a mandatory frequency area created a situation in which the pilots of both aircraft had poor knowledge of their respective positions, thereby increasing the risk of collision.
4. The pilot-in-command monitored approach (PICMA) procedure requires calls by the pilot not flying when the aircraft deviates from pre-established acceptable tolerances. However, no call is required to warn the pilot flying of an approaching steep bank.
5. The transfer of controls was not carried out as required by the PICMA procedure described in the SOPs. The transfer of controls at the co-pilot’s request could have taken the pilot-in-command by surprise, leaving little time to choose the best option.
6. Despite their limited amount of IFR experience in a multiple crew working environment, the two pilots were paired. Nothing prohibited this. Although the crew had received crew resource management (CRM) training, it still had little multiple crew experience and consequently little experience in applying the basic principles of CRM.
Other Findings:
1. The emergency locator transmitter (ELT) had activated after the impact but due to circuit board damage its transmission power was severely limited. This situation could have had serious consequences had there been any survivors.
2. The Chibougamau/Chapais airport does not have an aircraft rescue and firefighting service. Because the fire station is 23 kilometres from the airport, the firefighters arrived at the scene 26 minutes after the accident.
3. Although this accident does not meet the criteria of a controlled flight into terrain (CFIT), it nonetheless remains that a stabilized constant descent angle (SCDA) non-precision approach (NPA) would have provided an added defence tool to supplement the SOPs.
4. After the late call within the mandatory frequency (MF) area, the specialist at the Québec flight information centre asked the crew about its familiarity with the MF area while the aircraft was in a critical phase of the first approach, which was approaching the minimum descent altitude (MDA). This situation could have distracted the flight crew while they completed important tasks.
5. The standard checklist used by the flight crew made no reference to the enhanced ground proximity warning system (EGPWS). Therefore, the crew was not prompted to check it to ensure that it was properly activated before departure.

Loss of control during initial climb in IMC conditions after the crew suffered a spatial disorientation. The following factors were identified:
- Weather conditions were not suitable for the completion of the flight,
- The crew failed to prepare the flight according to published procedures,
- The crew failed to follow the pre-takeoff checklist,
- The copilot did not have adequate training for this type of operation,
- The captain had emotional conditions that compromised flight operations,
- The relationship between both pilots was incompatible,
- The main attitude indicator was out of service since a week and the crew referred to the emergency attitude indicator,
- Because of poor flight preparation and non observation of the pre-takeoff checklist, the captain forgot to switch on the emergency attitude indicator prior to takeoff,
- At the time of the accident, the captain had accumulated 15 hours and 22 minutes of work without rest, which is against the law,
- The captain showed overconfidence and inflexibility which weakened his performances,
- Both pilots disagreed on operations,
- The visibility was poor due to the night and the ceiling at 300 feet above ground,
- The state of complacency of the organization was characterized by a culture adaptable to internal processes, without the adoption of formal rules for the operations division and the acceptance of operating conditions incompatible with security rules and protocols, which allowed the newly hired crew to feel free to act in disagreement with the standards and regulations in force at the time of the accident,
- Performing a sharp turn to the right in IMC conditions associated with a long working day and a lack of rest,
- The level of stress of the captain due to intense fatigue generated by a high workload and an insufficient rest period,
- Poor crew discipline,
- Poor judgment of the situation,
- Poor flight planning,
- Failures in the operator's organizational processes and lack of supervision of flight operations.

Engine failure for unknown reasons.

A loss of power on both engines for an undetermined reason.

The mechanic's failure to secure the right engine cowling fasteners. Contributing to the incident was the pilot's inadequate preflight inspection.

The Flight Standards Inspectorate determined that the probable cause of this accident was Propulsion System Malfunction due to fuel exhaustion of the left engine, followed by inappropriate crew response (fuel mismanagement).
Contributing Factors:
- Pilot’s unfamiliarity with aircraft fuel system.
- Pilot’s limited command experience. (He was a new hire, low time pilot)
- Pilot’s failure to conduct a proper preflight inspection of his aircraft. (did not visually check fuel tanks despite knowing that the gauges were faulty)
- Pilot’s complacency with documentation of defects. (Pilot never advised maintenance or management that the gauges were faulty)
- Pilot’s reliance on indications that he admitted were erroneous.
- Pilot’s lack of situational awareness.
- Pilot’s failure to recognize that his problem was fuel exhaustion and not engine failure and neglected to use cross-feed procedure.