Landing (descent or approach)

Loss of engine power due to fuel contamination.

Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.

The cause of the occurrence could not be determined; however, it is probable that the pilots did not monitor the altimeter properly and allowed the aircraft to descend until it struck the surface of the ice.

Further the analysis of the flight recordings between the aircraft and the Romanian Air Traffic Services, statements and all other data contained by the investigation file the following conclusions have been reached:
- The meteorological conditions at Iași Airport were difficult and have not permitted the landing of the aircraft,
- The decision for landing on Bacău Airport was made by the crew,
- At the moment the meteorological conditions at Bacău Airport assured the minimum conditions for landing the aircraft,
- The air traffic control was performed by Bacău TWR and PAR, according to international regulations, providing permanent information regarding the aircraft during the final approach for landing.
We mention that after the first missed landing the crew maintained its decision to perform a second approach for landing, knowing the meteorological conditions on Bacău Airport.

The accident was the consequence of the following factors:
(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence
of procedural discipline;
(2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps;
(3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots;
(4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training;
(5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and
(6) The unavailability of suitable training simulators that precluded fully effective flightcrew training.
Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory.

The pilot's improper remedial action concerning a right engine power anomaly, and his failure to maintain adequate airspeed during go-around from an aborted precautionary landing, which resulted in a loss of aircraft control and an uncontrolled descent. Factors related to the accident were: failure of the owner/operator/pilot to assure proper maintenance inspection of the aircraft, failure to comply with a service bulletin concerning the engine fuel controls, subsequent bearing failure in the right engine fuel control, and the pilot's lack of familiarity with this make and model of aircraft.

The crew of Empress 204 allowed the aircraft to descend below the minimum descent altitude for the approach.

Airspeed not maintained, inadvertent stall/mush, and altitude inadequate for recovery from the inflight loss of control by the pilot-in-command while circling for landing.