Landing (descent or approach)

The inability to stop the airplane on the remaining runway because of icy runway conditions. A factor was the failure of the drag chute to properly deploy.

The pilot’s improper fuel management, which resulted in a loss of engine power during an instrument landing due to fuel exhaustion.

Findings as to Causes and Contributing Factors:
1. An abbreviated visual approach was conducted at night in instrument meteorological conditions, which resulted in the flight crew’s inability to obtain sufficient visual reference to judge their height above the ground.
2. The flight crew did not monitor pressure altimeter readings or reference the minimum altitude requirements in relation to aircraft position on the approach, resulting in controlled flight into terrain.
3. The pilots had not received training and performance checks for the installed global positioning system (GPS) equipment, and were not fully competent in its use. The attempts at adjusting the settings likely distracted the pilots from maintaining the required track and ground clearance during the final approach.
Findings as to Risk:
1. The precision approach path indicator systems (PAPI) at Cambridge Bay had not been inspected in accordance with the Airport Safety Program Manual. Although calibration of the equipment did not have a bearing on this occurrence, there was an increased risk of aircraft misalignment from the proper glide path, especially during night and reduced visibility conditions.
2. The flight crew’s cross-check of barometric altimeter performance was not sufficient to detect which instrument was inaccurate. As a result, reference was made to a defective altimeter, which increased the risk of controlled flight into terrain.
3. Operators’ maintenance organizations normally do not have access to the troubleshooting information contained in Component Maintenance Instruction Manuals for the Intercontinental Dynamics Corporation altimeters. Therefore, aircraft could be dispatched with damaged instruments with the potential for developing a loss of calibration during flight.
4. The flight was conducted during a period in which the crew’s circadian rhythm cycle could result in cognitive and physical performance degradation unless recognized and managed.

The pilot’s improper configuration of the airplane following an engine shutdown, which resulted in a low-altitude, unstabilized approach. Contributing to the accident was a loss of engine power for undetermined reasons.

Controlled flight into terrain after the crew descended too low on final approach.
The following contributing factors were identified:
- Limited visibility due to the night and low clouds,
- The approach was completed with a tailwind component,
- The approach was started about an hour after sunset,
- The copilote was inexperienced.

The accident was caused by the loss of control of the airplane by the crew following the improvised demonstration of the functioning of the angle of attack protections, while the blockage of the angle of attack sensors made it impossible for these protections to trigger. The crew was not aware of the blockage of the angle of attack sensors. They did not take into account the speeds mentioned in the program of checks available to them and consequently did not stop the demonstration before the stall.
The following factors contributed to the accident:
• The decision to carry out the demonstration at a low height
• The crew’s management, during the thrust increase, of the strong increase in the longitudinal pitch, the crew not having identified the pitch-up stop position of the horizontal stabilizer nor acted on the trim wheel to correct it, nor reduced engine thrust
• The crew having to manage the conduct of the flight, follow the program of in-flight checks, adapted during the flight, and the preparation of the following stage, which greatly increased the workload and led the crew to improvise according to the constraints encountered
• The decision to use a flight program developed for crews trained for test flights, which led the crew to undertake checks without knowing their aim
• The absence of a regulatory framework in relation to non-revenue flights in the areas of air traffic management, of operations and of operational aspects
• The absence of consistency in the rinsing task in the airplane cleaning procedure, and in particular the absence of protection of the AOA sensors, during rinsing with water of the airplane three days before the flight. This led to the blockage of the AOA sensors through freezing of the water that was able to penetrate inside the sensor bodies.
The following factors also probably contributed to the accident:
• Inadequate coordination between an atypical team composed of three airline pilots in the cockpit
• The fatigue that may have reduced the crew’s awareness of the various items of information relating to the state of the systems.

Findings as to Causes and Contributing Factors:
1. Though icing conditions were encountered, the airframe de-icing boots were not cycled nor was the Vref speed increased to offset the effects of aircraft icing.
2. An abrupt change in aircraft configuration, which included a reduction in power to flight idle and the addition of 35° flap, caused the aircraft’s speed to rapidly decrease.
3. The aircraft entered an aerodynamic stall due to the decreased performance caused by the icing. There was insufficient altitude to recover the aircraft prior to impact with the runway.
Finding as to Risk:
1. The company had not incorporated the British Aerospace Notice to Aircrew into its standard operating procedures (SOP) at the time of the occurrence. Therefore, crews were still required to make configuration changes late in the approach sequence, increasing the risk of an unstabilised approach.