Landing (descent or approach)

A leaking parking brake valve, which allowed air to enter the left brake line and resulted in the eventual failure of the left wheel brake during the landing roll.

The accident was probably as a result of the pilot’s attempt to recover to normal flight following a stall or significant loss of airspeed at a low height, after a rapid climb manoeuvre having become disoriented during the approach in fog.

It is believed that, following a wrong approach configuration, the aircraft landed too far down the runway, reducing the landing distance available. In such situation, the aircraft could not be brought to a safe halt. As the landing maneuver was obviously missed, the crew should initiate a go-around procedure. It was also reported that the aircraft CofA expired 31 May 2012 and that the aircraft was removed from the Armenian registered on 26 Oct 2012.

Loss of control after landing due to the failure of the nosewheel steering system.

Findings as to causes and contributing factors:
1. An accurate take-off weight and balance calculation was not completed prior to departure, resulting in an aircraft weight that exceeded its maximum certified takeoff weight.
2. The right engine number 1 cylinder failed during the take-off sequence due to a preexisting fatigue crack, resulting in an engine fire.
3. After the right propeller’s feathering mechanism was activated, the propeller never achieved a fully feathered condition likely due to a seized bearing in the feathering pump.
4. The windmilling right propeller caused an increase in drag which, combined with the overweight condition, contributed to the aircraft’s inability to maintain altitude, and the aircraft collided with terrain short of the runway.
5. The operator’s safety management system was ineffective at identifying and correcting unsafe operating practices.
6. Transport Canada’s surveillance activities did not identify the operator’s unsafe operating practices related to weight and balance and net take-off flight path calculations. Consequently, these unsafe practices persisted.
Findings as to risk:
1. If companies do not adhere to operational procedures in their operations manual, there is a risk that the safety of flight cannot be assured.
2. If Transport Canada does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.
3. If cockpit or data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
Other findings:
1. Current Canadian Aviation Regulations permit a transport category piston-powered aircraft to carry passengers without a flight data recorder or cockpit voice recorder.
2. The crew resource management component of the flight attendant’s training had not been completed.

The NTSB determined that the probable causes of the crash were:
- The crew continued an unstabilized approach into Birmingham Airport,
- The crew failed to monitor the altitude and inadvertently descended below the minimum descent altitude when the runway was not yet in sight.
Contributing factors were:
- The flight crew's failure to properly configure the on-board flight management computer,
- The first officer's failure to make required call-outs,
- The captain's decision to change the approach strategy without communicating his change to the first officer,
- Flight crew fatigue.

The pilot's failure to maintain airspeed while banking aggressively in and out of clouds for landing in gusty tailwind conditions, which resulted in an aerodynamic stall and uncontrolled descent.

It is believed that the control was lost after landing following a possible multiple tyre burst.

The trace from the radar data shows that the aircraft followed the ILS Z 26 procedure track in the horizontal plane to about 6.4 NM from the runway threshold. This observation is consistent with the autopilot tracking of the ILS Z 26 procedure entered into the FMS in GPS mode. The transition from GPS to LOC occurred after the FAP. Although the APP mode was engaged, the aircraft did not descend as expected by the pilot. It continued in line with the localizer but in level flight at 4000 feet for more than 1 nm. The pilot attempted to catch up with the glide path from above. Unable to stabilize his course, he aborted the approach without following the prescribed go-around path or the heading and altitude instructions provided by the controller. He made a succession of left and right turns and climbs and descents. The track and readbacks show that he lost situational awareness. The airspeed regression following the last climb caused the pilot to lose control of the aircraft, which collided with the ground. The entire approach was flown with no outside visibility.
Contributing factors (may have contributed to the loss of control):
- A coding error in the Garmin 1000 avionics suite database that prevented the automatic transition from GPS mode to LOC mode. Thus the automatic interception of the descent plan did not occur, which probably surprised the pilot and led him to resume manual piloting with excessive corrections.
- The pilot's overconfidence in the aircraft's autopilot system.
- Lack of knowledge of the conditions required for the aircraft autopilot system to capture and track the glide path.
- Lack of consistency verification by the pilot between the coded procedure in the avionics suite and his breakthrough sheet.
- The pilot's lack of total and recent instrument flight experience without external visual reference, which may have contributed to his increased stress, lack of availability, and spatial disorientation.
- Sensory illusions that the pilot may have been confronted with, given the numerous changes in aircraft attitude, without external visual reference.
- The acquisition of additional experience and skills with safety pilots after obtaining the SET class rating, which is ineffective and outside the regulatory training framework, which can lead pilots to free themselves from this support when it is considered to be restrictive.