Scheduled Revenue Flight

A self-locking nut, other than castle nut with cotter pin as specified, had been installed at the bolt for connection between pull rod and bellcranck in the elevator control system. The nut screwed off, resulting in bolt loss, which led to the loss of pitch control.

It is believed that the aircraft suffered a structural failure due to severe turbulences while flying in bad weather conditions.

It is believed that the crew encountered windshear during the last portion of the flight.

The following findings were identified:
- The crew failed to follow the pre-takeoff checklist,
- The takeoff procedure was initiated with the flaps retracted in the full up position,
- The pilot-in-command started the rotation at an insufficient speed,
- The aircraft stalled during initial climb and the distance between the aircraft and the ground was insufficient to expect recovery,
- Winds from 25-35 knots were gusting at the time of the accident.

Findings as to Causes and Contributing Factors:
1. The crew did not follow the company's SOPs for the briefing preceding the approach and for a missed approach.
2. In the approach briefing, the captain did not specify the MDA or the MAP, and the first officer did not notice these oversights, which shows a lack of coordination within the crew.
3. The captain continued descent below the MDA without establishing visual contact with the required references.
4. The first officer probably had difficulty perceiving depth because of the whiteout.
5. The captain did not effectively monitor the flight parameters because he was trying to establish visual contact with the runway.
6. The chief pilot (the captain of C-FGOI) set a bad example to the pilots under him by using a dangerous method, that is, descending below the MDA without establishing visual contact with the required references and using the GPWS to approach the ground.
Findings as to Risks:
1. The operations manager did not effectively supervise air operations.
2. Transport Canada did not detect the irregularities that compromised the safety of the flight before the occurrence.
3. Régionnair had not developed GPWS SOPs for non-precision approaches.
Other Findings:
1. The GPWS 'MINIMUMS' alarm sounded at a height that did not leave the captain time to initiate pull-up and avoid striking the ground because of the aircraft=s rate of descent and other flight
parameters.
2. Neither the captain nor the first officer had received PDM training or CRM training.
3. At the time of the approach, the ceiling and visibility unofficially reported by the AAU were below the minima published on the approach chart.
4. The decision to make the approach was consistent with existing regulations because runway 02/20 was not under an approach ban.
5. Some Régionnair pilots would descend below the MDA and use the GPWS to approach the ground if conditions made it impossible to establish visual contact with the required references.

The following findings were identified:
- There was the participation of factors, with their own characteristics, that caused failures of attention, judgment and perceptual evaluation of distances and temporality. The qualitative training deficiency, the lack of cabin resource management and the low situational alert were significant contributing factors to the accident.
- PF has performed poorly in the use of the correct piloting technique in the combination of Speed x Ratio of Descent parameters.
- The instructor assigned by the company to supervise the acquisition of operational experience on route had not received specific instruction for the performance of this task. Technical and operational supervision was lacking.
- PF had good flight experience, but not in this type of aircraft. It was in the phase of acquiring operational experience in route. The inadequate action was also due to the little experience in the aircraft and in the circumstance of the operation, which required a quick correction close to the ground.
- The pilots did not adequately utilize the resources available in the cockpit for the proper operation of the aircraft. PF did not make the necessary corrections to modify the aircraft's trajectory, which was its assignment. The instructor (PNF), in turn, did not effectively correct or interfere with the PF flight, which would have been his responsibility since he was the supervisor of the operation. The pilots did not observe, yet, the technical-operational procedure foreseen in the Flight Operations Manual (MOV), regarding the GPWS warning. The crew did not observe that the warning determined an unsafe condition close to the touch. It was characterized an ineffective fulfillment of the tasks assigned to each crew member, besides the non-observance of the operational rules.
- On the IMC approach made, the PF varied the parameters, remaining high on the ramp. Upon reaching visual conditions, the PF increased the descent rate of the aircraft. The PNF, concerned with locating the runway, did not consider an inadequate PF correction.
- The PF, with the intention of reducing the drop ratio, did not apply correctly, in amplitude and in time, the power available in the engines. Near the touch, the PF increased the pitch angle, trying to reduce the drop ratio. Considering the low height (approximately 80 ft) and engine power (IDLE), the aircraft continued with a high rate of descent (approximately 1,800 ft/min), without the action taken by the PF altering its path. The PNF did not interfere in the application of the commands. Therefore, there was inadequate use of the aircraft commands by the crew members, in conditions for which they were qualified.
- The PF, even being alerted by the PNF about the low speed and high rate of descent, thought it was applying an adequate correction, however it kept the aircraft in an incompatible performance for landing. The PNF, despite having experience in flight and in the aircraft, showed a lack of knowledge of its limits regarding the point of irreversibility of an unsafe situation. The PNF was limited to alerting the PF about the situation, not guiding it on the correct way to make the corrections.
The PNF overestimated PF's capacity and did not take or try to take over the controls.
- The pilots were not aware of the maximum rate of descent during the touch for which the aircraft was certified, nor were they aware of the variation of that rate with respect to weight. The availability of the autopilot to the MDA could have minimized the ramp deviation observed.

Poor flight preparation on part of the crew who neglected several published procedures. It was determined that the pilot was intoxicated at the time of the accident.

The pilot's continued VFR flight into instrument meteorological conditions. Factors in the accident were dark night conditions, snow covered terrain, and low ceilings.