Landing (descent or approach)

Findings as to causes and contributing factors:
- The pilot relied exclusively on the gauge readings to determine the quantity of fuel on board, without cross-checking the fuel consumption since the last fueling to validate those gauge readings.
- The pilot misread the fuel gauges and assumed that the aircraft had enough fuel on board to meet the minimum fuel requirements of the Canadian Aviation Regulations for this visual flight rules flight, rather than adding more fuel to meet the greater reserves required by the company operations manual.
- The pilot did not monitor the fuel gauges while in flight and decided to extend the flight to carry out a practice instrument approach with insufficient fuel to complete the approach.
- The right engine stopped due to fuel exhaustion.
- The pilot did not carry out the approved engine failure procedure when the first engine stopped, and the propeller was not feathered, resulting in significant drag which reduced the aircraft's gliding range after the second engine stopped.
- The pilot continued flying toward Montréal/St-Hubert Airport (CYHU), Quebec, despite having advised air traffic control of the intention to divert to the St-Mathieu-de-Beloeil Airport (CSB3), Quebec, and without communicating the emergency. The priority given to communications resulted in the aircraft moving farther away from the intended diversion airport.
- The left engine stopped due to fuel exhaustion 36 seconds after the right engine stopped, when the aircraft was 7.4 nautical miles from Runway 24R at Montréal/St-Hubert Airport (CYHU), Quebec, and 2400 feet above sea level.
- The pilot's decision to lower the landing gear while the aircraft was still at 1600 feet above sea level further increased the drag, reducing the aircraft's gliding range. As a result, the aircraft was not able to reach the runway at St-Mathieu-de-Beloeil Airport (CSB3), Quebec.
- The operations manager was unable to perform the duties and responsibilities of the position related to monitoring and supervision of flight operations. As a result, the safety of more than half of the flights was compromised.
Findings as to risk:
- If the total fuel quantity required for a flight is not calculated and clearly displayed on the operational flight plan, there is an increased risk that aircraft will depart without the fuel reserves required by the Canadian Aviation Regulations.
- If flights are planned and carried out without the fuel reserves required by the Canadian Aviation Regulations, there is an increased risk of fuel exhaustion resulting from unanticipated situations that extend the duration of the flight.
- If pilots elect to extend flight without first determining whether sufficient fuel reserves are available to do so, there is an increased risk of fuel exhaustion.
- If pilots do not regularly check the quantity of fuel on board, there is an increased risk of fuel exhaustion.
- If pilots do not rule out a fuel leak before opening the crossfeed valve, they risk losing all of the remaining fuel on board.
- If a pilot does not maintain control of an aircraft until landing, the force of an impact following an aerodynamic stall is likely to be far greater, increasing the risk of injury or death during a forced landing.
- If a pilot does not declare an emergency to air traffic control in a timely manner, the pilot may be deprived of assistance and resources that could help deal with the emergency, increasing the risk of an accident.
- If pilots do not receive training in dealing with complex emergencies that require prioritizing tasks, there is a risk that they will not react effectively to emergencies, increasing the risk of an accident.
- If companies do not establish a process to monitor the performance of their pilots during training and testing, there is a risk that those companies will inadvertently assign pilots to carry out flights for which they are not proficient.
- If a flight is planned and authorized solely by the pilot, with no cross-check for compliance with existing regulations, there is a risk that deviations will continue undetected, reducing the safety of the flight.
- If pilots operate without regular supervision to ensure compliance with regulations and company procedures, coupled with effective training, there is a risk of procedural adaptations that result in reduced safety margins.
- If companies assign inexperienced personnel to key flight operations management positions, there is a risk that deviations in performance or from regulations will not be detected, reducing the safety of flight operations.
- If the pilot proficiency check requirements for a chief pilot are not more stringent than those for other pilots, there is a risk that the chief pilot will be unable to perform the duties required to ensure the safety of company training and operations.
- If the approval process for appointment of operations management personnel by companies is reduced to a compliance checklist based on the minimum standards in the Commercial Air Service Standards and on pilot proficiency checks that may be repeated an unlimited number of times, there is a risk that candidates who are unfit to perform the duties and responsibilities of their positions will be appointed.
- If Transport Canada does not take into consideration the combined knowledge and experience of a new operator's management team, there is a risk that the operator will lack the skills necessary to ensure the safety of flight operations.
- If process inspections carried out by Transport Canada do not examine factors related to a recent occurrence, there is a risk that those hazardous conditions will go undetected and will persist.
If process inspections carried by TC on newly certificated operators do not closely examine the outcomes of company processes, there is a risk that hazardous conditions will not be identified and will persist.
- If the inability of appointed individuals to perform their duties and responsibilities does not constitute grounds for suspending or revoking the ministerial approval of such appointments, there is a risk that operations management personnel who are not competent will remain in their positions, increasing the risk to flight safety.
Other findings:
- The chief pilot did not meet the requirements of the Canadian Aviation Regulations at the time of appointment.
- There was no indication that the aircraft's fuel gauges were not functioning properly at the time of the occurrence flight, and it is unlikely that a deviation of the fuel gauge indicator was a factor in the pilot's decision to take off.
- C-GJSU had approximately 260 pounds of fuel on board when it took off from Montréal/St-Hubert Airport (CYHU), Quebec, and did not experience a fuel leak during the occurrence flight.

Primary cause:
- During landing roll, due to hydraulic system pressure low, nose wheel steering mechanism and braking action are not effectively operated and aircraft veer off runway left side.
- PIC did not operated the emergency hydraulic pump while hydraulic low pressure warning come on.
Secondary cause:
- Hydraulic system pressure low due to hydraulic tank fluid level more than normal and tank pressurize compress air line filter blockage.

Engine trouble for unknown reasons.

The following contributing factors were identified:
- The procedure of selecting Power Lever Lock to “OPEN” during approach was made without comprehensive risk assessment.
- Both power levers entered BETA MODE at 90 feet due to the safety device namely Power Lever Lock has been opened during approach, which was in accordance to the operator procedure and lifting of Mechanical Power Lever Stop Slot which was not realized by the pilots.
- The movement of power levers to BETA MODE resulted the pitch angle changed to low pitch angle which produced significant drag and made the aircraft loss of significant lift.

The cause of the runway excursion was foreign object debris inside the electrohydraulic servo valve (EHSV) that blocked a hydraulic port and caused an uncommanded nose wheel deflection to the left. Prior to the disassembly of the EHSV and discovery of the debris the unit had passed an acceptance test as performed on any newly manufactured unit. The NTSB reported that a number of pilots use binder brackets instead of the chart holders installed by Embraer to hold their binders (containing charts) etc., these binder brackets not having been approved by Embraer. The binder is directly above the nosewheel steering tiller, the NTSB wrote: "The NTSB is concerned that a binder being held by an unapproved bracket may become dislodged, fall, and strike the tiller, engaging the nosewheel steering system and possibly providing a nosewheel steering input. If this happens during the landing roll, the nosewheel steering input could cause a runway excursion." The NTSB therefore recommended to study and revise the acceptance tests and to issue an operational bulletin to inform flight crew that the use of binder brackets is not approved and could create a hazardous situation if the binder becomes dislodged.

The following contributing factors were identified:
- The flight did not meet the criteria according to the recommended elements of stabilized approach which required go around.
- The aircraft touched down with 2° misalignment with the runway direction then the aircraft veered off to the left.
- The recovery action was not in accordance to the correct technique according to the ALAR Tool Kit.

On the second landing attempt at a high altitude airfield (6,809 ft MSL), poor CRM coupled with a late power reduction by MP1 caused the MA to touchdown 27 KIAS faster than computed touchdown landing speed leading to the aircraft going off the end of the runway at approximately 49 KIAS. Because of unique aircraft performance characteristics when operating into and out of high altitude airfields, there was no way that the MA could perform a 50% flap landing (in accordance with T.O. 1C-130(C)J-1-1 landing assumptions, nose wheel landing gear speed restrictions and power level transition speed restrictions) at FOB Shank and land 27 KIAS fast. The MA’s actual landing speed simply overtasked the aircrafts capability to stop within the runway available.
Several factors substantially contributed to this mishap, including:
- Channelized attention,
- Risk assessment during operation,
- Delayed necessary action,
- Response set,
- Procedural error.

Primary Cause:
- During landing roll FO retracted PIA to GI position, its remain above Ground Idle position (36.8/ 36.6) degree. After (18) seconds flap position changed to retract and both engines torque start to increase.
- Aircraft IAS unable to rapid decelerate during crews applied braking.
Secondary Cause:
- Both crews are not initiated power lever reversing position.
- Crews need multi-crew operation.