Landing (descent or approach)

The accident was caused by the combination of the following factors:
- The erroneous actions of the flight engineer when trying to lower the landing gear,
- Failure of the flight crew to conduct the necessary (final approach) checks,
- The failure by the crew to check and respond to landing gear warning indications,
- The execution of a flight with an incomplete composition of crew, causing additional workload on the flight engineer during the approach (height and speed call outs),
- Late commands to go around by the air traffic controller,
- On the Yak-40 the landing gear handle moves to the opposite direction for retraction and lowering compared to the Antonov 24 (the flight mechanic had more, and recent, flight experience on the Yakovlev 40 jet),
- The large workload and fatigue of the crew during the recent six days before the incident.

The following findings were identified:
- Dimension and intensity of the storm front and dynamics of the weather conditions,
- Inadequate use of resources in decision-making during the flight (proactive),
- Loss of alternative landing facilities at increasing time pressure (reactive),
- Landing of the aircraft outside the operating area of an aerodrome,
- Collision with the embankment due to the non-detection of an obstacle.
Systemic causes:
- Inadequate information on weather conditions and development before and during the flight,
- Inadequate information on the Werneuchen Special Airfield due to an ambiguous map display as well as misleading or lack of communication,
- Inadequate labeling/marking of the operational and non-operational areas of the airport.

The crew reported that the undercarriage could not be raised. Loss of control on final approach after all four engines stopped due to a fuel exhaustion.

It is estimated that the accident was caused as follows:
The aircraft was being operated on a training flight at Shimoji-Shima Airport, and was making a one-engine-out touch-and-go landing with the right engine simulated inoperative. The touchdown was late and beyond the normal aim point, and on the direction of the instructor, the trainee pilot attempted to go around on only the left engine. However, the trainee mishandled the aircraft, and then, seeing the instructor advance the right engine’s thrust lever, he applied right rudder pedal mechanically. This coincided with an increase in the rotation speed of the left engine, and the aircraft’s attitude suddenly changed towards the right. Because the trainee pilot could not fully correct this and the instructor was late in taking over control, the aircraft veered off the east side of the runway into a grass area and was damaged. Moreover, it is estimated that the following causal factors contributed to the accident:
1) The instructor did not take over when he directed the trainee to go around, or at an earlier stage, because he thought to allow the trainee pilot to handle the aircraft as much as possible, and because he did not sufficiently recognize that a go-around with one-engine simulated inoperative is a difficult maneuver for an inexperienced pilot.
2) Regarding the instructor’s intent to allow the trainee pilot to handle the aircraft as much as possible, the company’s instructional guidelines contained statements meaning that a judgment to go around should be made by the trainee pilot, and that during simulated one-engine-out touch-and-go training landings, the go-around after landing should continue with one engine simulated inoperative.
3) Regarding the instructor’s insufficient recognition of the difficulty of a go-around with one engine simulated inoperative for an inexperienced pilot, the instructor had not been trained to deal with the situation encountered in the accident, and the company’s regulations and manuals did not describe considerations on the difficulty of executing a go-around with one-engine simulated inoperative for an inexperienced pilot or on the effects of the wind on such maneuvers.
4) Regarding the delay in the instructor taking over control of the aircraft, the instructor was not following with his hands on the control wheel and was not in a position to take over immediately if necessary, and when the instructor had changed from being a simulator instructor to a flight instructor, he had not received sufficient training on cautionary matters regarding training in actual aircraft.

The energy accumulated in the set of tires deflated the tire n°2, reducing the braking effectiveness by 50% due to the loss of the antiskid of that set in the same proportion, and subsequently the loss of 100% of the effectiveness of braking when tires n°3 and 4 burst successively, causing the aircraft to exceed the remaining runway length leading to the accident situation.
The following contributing factors were identified:
- The increase in speed of the VRF by the crew that increased the landing length,
- An unstabilized approach completed by the the crew,
- The pressure exerted on the crew due to the public order situation in the city of Florence for the purpose of a possible overnight stay of the aircraft and consequently the crew.

Findings as to Causes and Contributing Factors:
1. The pilot did not correctly calculate the amount of fuel required to accomplish the flight from Winnipeg to Gunisao Lake and return, and did not ensure that the aircraft carried sufficient fuel for the flight.
2. The ILS approach was flown above the glideslope and beyond the missed approach point, which reduced the possibility of a safe landing at Winnipeg, and increased the risk of collision with terrain.
3. During the missed approach, the aircraft's engines lost power as a result of fuel exhaustion, and the pilot conducted a forced landing at a major city intersection.
4. The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.
Findings as to Risk:
1. The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
2. The company operations manual did not reflect current company procedures.
3. The company did not provide an adequate level of supervision and allowed the flight to depart without adequate fuel reserves. The company did not have a safety system in place to prevent a fuel exhaustion situation developing.
Other Findings:
1. The pilot did not advise air traffic control of his critical situation in a timely fashion.

The crew deviated from the prescribed missed approach procedure during an attempted Instrument Landing System landing on Runway 29 at George in Instrument Meteorological Conditions and lost situational awareness aggravated by the presence of strong upper SouthWesterly winds. They allowed the aircraft to drift off course resulting in a controlled impact with terrain 6.7 nm North-East of the aerodrome. Contributing factors to the probable cause were the weather conditions, the intermittent unreliability of the Instrument Landing System, the serviceability of the directional gyro and the uncleared defects.