Takeoff (climb)

Findings as to Causes and Contributing Factors:
1. The aircraft took off with contaminated surfaces, without an inspection by the pilot-in-command. This contamination contributed to reducing the aircraft' performance and to the subsequent stall.
2. At take-off, the aircraft was more than 200 pounds over the maximum allowable take-off weight. This added weight contributed to reducing the aircraft's performance.
3. During the initial climbout, the pilot-in-command did not follow the recommended procedure when he entered an area of wind shear. Consequently, the aircraft lost more speed, contributing to the stall.
4. Insufficient altitude was available for the pilot to recover from the stall and avoid striking the water.
5. The co-pilot's shoulder harness was not installed properly. The co-pilot received serious head injuries because she was not restrained.
Findings as to Risk
1. The crew's lack of experience in the existing conditions was not conducive to effective decision making during the pre-flight planning and the flight.
2. The stall warning system was defective and, in other circumstances, could not have alerted the crew of an impending stall.
3. The crew did not transmit an emergency message after the pilot-in-command decided to return to Baie-Comeau for landing. This lack of a message delayed the rescue operation.
4. The emergency signal was not received by the Mont-Joli Flight Service Station because the Baie-Comeau remote communications outlet (RCO) was not equipped with the 121.5 MHz emergency frequency. The RCO was not required to be equipped with the emergency frequency.
5. The emergency locator transmitter (ELT) was not installed in accordance with Britten-Norman's instructions. The ELT's installation on the floor of the aircraft increased the risk of damage.
6. Transport Canada did not comply with its established audit standards for regulatory audits of the operator, thus increasing the risk that training and operational deficiencies would not be identified.
7. The emergency signal probably ceased after the ELT was ejected from its mounting plate and the antenna connection contacted the water. The ejection contributed to reducing the signal and
prevented the SARSAT (search and rescue satellite-aided tracking) system from validating the
8. One of the occupants might have had a greater chance of survival had lifejackets been on-board the aircraft. Existing regulations did not require life jackets to be carried on board.
9. The aircraft had numerous mechanical deficiencies that should have been detected by Air Satellite's staff.
10. According to the Baie-Comeau airport emergency plan, a helicopter could be used only after confirmation of a crash in water. The emergency response time was therefore longer than it could
have been.
11. The configuration of the instrument panel made it difficult to read and interpret the flight instruments from the co-pilot's seat.
12. Air Satellite's manual of standard operating procedures did not promote effective crew coordination.
13. The pilot-in-command and the co-pilot had not taken courses in crew resource management or pilot decision making. These courses would have promoted effective crew coordination but were not required under existing regulations.
14. The high turnover of flight personnel and the repeated changes in the position of company chief pilot did not allow adequate supervision of operations.

Findings as to Causes and Contributing Factors:
1. The captain rejected the take-off at a speed well above the engine-failure recognition speed (V1) with insufficient runway remaining to stop before the end of the runway.
2. The far-forward position of the centre of gravity contributed to the pilot not rotating the aircraft to the normal take-off attitude.
3. The aircraft never achieved the required pitch for take-off. The captain=s inability to accurately assess the pitch attitude was probably influenced by the heavier than normal elevator control forces and the limited nighttime visual references.
4. The loadmaster did not follow the company- and Transport Canada-approved procedures to evaluate the excess baggage added to the aircraft, which led to a discrepancy of 450 pounds and a C of G position further forward than expected.
5. The performance analysis suggested that the aircraft was under-rotated as a result of a forward C of G loading and the generated lift never exceeded the aircraft=s weight during the take-off attempt.
Findings as to Risk:
1. The aircraft was approximately 200 pounds over maximum gross take-off weight.
2. The aircraft accelerated more slowly than normal, probably because of the snow on the runway.
3. Although atmospheric conditions were conducive to contamination and the aircraft was not de-iced, it could not be determined if contamination was present or if it degraded the aircraft performance during the attempted take-off.
4. Water methanol was not used for the occurrence take-off. Use of water methanol may have reduced the consequences of the rejected take-off.
5. The captain did not call for the overrun drill, and none of the items on the checklist were covered by the crew.
6. The co-pilot did not follow the emergency checklist and call air traffic control to advise of the rejected take-off or call over the public address system to advise the passengers to brace.
7. The aircraft lost all its electrical systems during the impact with the large rocks, rendering the radios unserviceable.
8. No HS-748 simulator exists that could be used to train pilots on the various take-off and rejected take-off scenarios.
9. There was confusion regarding the aircraft=s location. The flight service station, fire trucks, and intervening teams were not using an available grid map for orientation.
10. There is a risk associated with not de-icing aircraft before take-off in weather conditions such as those on the day of the accident.
11. There is a risk associated with not calculating the WAT limit and performance of an aircraft during an engine-out procedure in an environment with obstacles.
Other Findings
1. The aircraft=s brakes, anti-skid system, and tires functioned properly throughout the rejected take-off.

The pilot's spatial disorientation which resulted in a loss of aircraft control. Factors were fog, low ceilings, and dark night conditions.

Loss of control during initial climb after the crew raised the flaps due to the presence of severe icing conditions which impaired the controllability of the aircraft and its aerodynamic characteristics. The short distance between the aircraft and the ground did not allow the crew to expect recovery.

It was determined that the crew was cleared for takeoff while the bus driver did to establish any contact with the tower and elected to cross the runway without prior permission or traffic check. It was reported that ATC was not aware of the presence of the minibus at this time.

During the investigation it was found that the aircraft was overloaded.

A downdraft, which exceeded the aircraft's climb performance. A factor was the thunderstorms in the vicinity of the airport.

The takeoff was initiated at an insufficient speed of 65 knots. It was determined that the friction locks of the throttles were not or not properly set prior to takeoff. Due to the vibration of the airplane, the throttles slowly retarded during the takeoff roll.

It was determined that the aircraft had been shot down by a SAM-7 surface-to-air missile.