Landing (descent or approach)

It was determined that the aircraft impacted ground after the pilot continued the approach in below minima weather conditions.
The following findings were identified:
- The pilot continued the descent below MDA until the aircraft impacted ground,
- Few seconds prior to the accident, ATC instructed twice the pilot to initiate a go-around procedure, but this was too late,
- The pilot was approaching the airport at an excessive speed and below the glide,
- Poor visibility due to low clouds (below minimums).

The following findings were identified:
- The crew failed to follow the published procedures,
- The crew failed to adhere to SOP's,
- The EGPWS system failed to activate and to warn the crew about the insufficient altitude,
- The EGPWS failed 86 times during the last 235 flights and was removed from another aircraft to be installed on TC-AKM 10 days prior to the accident,
- Lack of visibility due to the night,
- The CVR system was unserviceable,
- The DFDR system was partially unserviceable and recorded the last 15 minutes of flight only,
- Lack of crew training,
- The captain followed only 20 of the requested 32 hours training,
- The copilot followed a 32-hours training program in Sofia but this was not documented,
- A probable lack of situational awareness on part of the crew.

Findings as to Risk:
1. Because aircraft EWH information is not readily available to pilots, crews may continue to conduct approaches with an aircraft mismatched to the visual glide slope indicator (VGSI) system, increasing the risk of a reduced TCH safety margin.
2. Due to limited knowledge of the various VGSI systems in operation and their limitations, flight crews will continue to follow visual guidance that might not provide for safe TCH.
3. Jetport did not develop an accurate company risk profile. This precluded identification of systemic safety deficiencies and development of appropriate mitigation strategies.
4. If adequate safety oversight of POC operators is not maintained by the regulator, or the delegated organization, especially during SMS implementation, there is an increased risk that safety deficiencies will not be identified.
5. The fact that the Canadian Business Aviation Association (CBAA) did not insist that milestones for SMS implementation and development be followed may result in some POC operators never reaching full SMS compliance.
6. If Transport Canada does not ensure that the CBAA fulfills its responsibilities for adequate oversight of the Canadian Aviation Regulations (CARs) subpart 604 community, safety deficiencies will not be identified and addressed.
7. The audit of Jetport’s SMS, conducted by the CBAA–accredited auditor, did not identify the deficiencies in the program or make any suggestions for improvement. Without a comprehensive audit of an operator’s SMS, deficiencies could exist resulting in the operator’s inability to implement an effective mitigation strategy.
8. Contrary to the recommendations made in the Transport Canada/CBAA feasibility studies, the CBAA did not have a quality assurance program for its audit process. As a result, there is a risk that the CBAA will fail to identify weaknesses in the POC audit program.
9. At the time of the accident, no one at Fox Harbour (CFH4) had been assigned responsibility for regular maintenance of the APAPI, therefore preventing timely identification of APAPI equipment misalignment.
10. Jetport’s risk analysis before the introduction of the Global 5000 did not identify the incompatibility between the EWH of the aircraft and the APAPI at CFH4.
11. Not wearing shoulder harnesses during landings and take-offs increases the potential risk of passenger injuries.
12. Passengers not wearing footwear could impede evacuation, increase the risk of injury, and reduce post-crash mobility and (potentially) survival.
Other Findings:
1. A SMS integrates sound risk management policies, practices, and procedures into day-to-day operations and, properly implemented, offers great potential to reduce accidents.
2. Contrary to its own assessment protocol, Transport Canada did not document its decision to close off the CBAA assessment even though the CBAA had not submitted an acceptable corrective action plan.
3. Depiction of the different types of VGSIs differs, depending on the publication.

Wrong approach configuration on part of the crew who decided to continue the approach to Quito Airport, knowing the poor runway conditions, poor weather conditions and the aircraft weight, and his failure to initiate a go-around procedure while forcing the aircraft to intercept the PAPI, causing the aircraft to be unstabilized.
Contributing factors:
- On the date of the incident, the crew did not have specific regulations and operating procedures (the briefing of the operator for the airport in Quito was inappropriate to the existent conditions).
- The fact that the crew still being experienced similar airports in Quito and had not experienced similar weather situations, circumstances that would have allowed a strategy of approximation consistent with the terms of this operation, in particular as regards:
- Calculations in flight for landing runway length,
- Minimum altitude to start the maneuver of changing the path of ILS to PAPI,
- Carrying out a very detailed briefing that allowed unwanted deviations on approach,
- The weather conditions existing at the time of landing (visibility, tail wind and moderate rain).

Failure of the engine n°3 during initial climb following a bird strike.

The pilot's intentional visual flight rules (VFR) flight into instrument meteorological conditions (IMC), and his failure to maintain clearance from the trees and terrain during climb. Contributing to the accident were the weather conditions of fog and a low ceiling, and the mountainous/hilly terrain.

The flight crew did not appear to have an awareness that the aircraft was above the desired approach path to runway 35 at Malang until they sighted the visual approach slope indication lighting system. The pilot in command continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions. Non-adherence by the flight crew to stabilized approach procedures, which resulted in the initial severe hard landing at Malang, together with the omission of a high bounced landing recovery, resulted in substantial damage to the aircraft. The following findings were identified:
- The PIC allowed the approach at Malang to become unstabilized and did not correct that condition.
- The PIC continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions.
- Neither pilot responded appropriately to the ground proximity warning system voice aural ‘SINK RATE’ or ‘PULL UP’ warnings that sounded during the final approach to Malang.
- The PIC did not initiate action to recover from the high bounced landing following the initial severe hard landing impact.
- The PIC did not ensure that effective crew coordination was maintained during the landing approach.

The first officer's failure to maintain airspeed during approach, and the captain's inadequate remedial action. Contributing to the accident was the first officer's failure to comply with procedures, windshear, and the lack of windshear warning from air traffic control.