Airport (less than 10 km from airport)

Failure of the n°4 engine during takeoff following the failure of the high pressure compressor.

Wrong approach configuration on part of the crew who landed too far down the runway, reducing the landing distance available. The following contributing factors were identified:
- Excessive speed on approach (the IAS was 143 knots upon touchdown),
- The crew completed the approach in a too steep descent,
- Incorrect flare which caused the aircraft to land too dar down the runway,
- Insufficient landing distance available,
- The crew failed to initiate a go-around procedure.

The pilot’s inadequate preflight fuel planning and management in-flight, which resulted in total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s use of performance-impairing medications.

The degraded performance of the airplane due to the pilot not properly setting the flaps and retracting the landing gear after takeoff. Contributing to the accident was the pilot’s fatigue.

Loss of control following an unstabilized approach. The failure of the crew to initiate a go-around procedure was considered as a contributing factor.

Findings as to Causes and Contributing Factors:
1. After the take-off at reduced power, the aircraft performance during the initial climb was lower than that established at certification.
2. The right engine experienced a problem in flight that led to a substantial loss of thrust.
3. The right propeller was not feathered; therefore, the rate of climb was compromised by excessive drag.
4. The absence of written directives specifying which pilot was to perform which tasks may have led to errors in execution, omissions, and confusion in the cockpit.
5. Although the crew had the training required by regulation, they were not prepared to manage the emergency in a coordinated, effective manner.
6. The priority given to ATC communications indicates that the crew did not fully understand the situation and were not coordinating their tasks effectively.
7. The impact with the berm caused worse damage to the aircraft.
8. The aircraft’s upside-down position and the damage it sustained prevented the occupants from evacuating, causing them to succumb to the smoke and the rapid, intense fire.
9. The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.
10. The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Findings as to Risk:
1. Deactivating the flight low pitch stop system warning light or any other warning system contravenes the regulations and poses significant risks to flight safety.
2. The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.
3. Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.
4. The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.
5. The lack of an in-depth review by TC of SOPs and checklists of 703 operators poses a safety risk because deviations from aircraft manuals are not detected.
6. Conditions of employment, such as flight hours–based remuneration, can influence pilots’ decisions, creating a safety risk.
7. The absence of an effective non-punitive and confidential voluntary reporting system means that hazards in the transportation system may not be identified.
8. The lack of recorded information significantly impedes the TSB’s ability to investigate accidents in a timely manner, which may prevent or delay the identification and communication of safety deficiencies intended to advance transportation safety.

A tyre burst on the left main gear during the takeoff procedure. Debris damaged hydraulic lines and were ingested in the left engine that should be shut down.