Airport (less than 10 km from airport)

The flight crew did not appear to have an awareness that the aircraft was above the desired approach path to runway 35 at Malang until they sighted the visual approach slope indication lighting system. The pilot in command continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions. Non-adherence by the flight crew to stabilized approach procedures, which resulted in the initial severe hard landing at Malang, together with the omission of a high bounced landing recovery, resulted in substantial damage to the aircraft. The following findings were identified:
- The PIC allowed the approach at Malang to become unstabilized and did not correct that condition.
- The PIC continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions.
- Neither pilot responded appropriately to the ground proximity warning system voice aural ‘SINK RATE’ or ‘PULL UP’ warnings that sounded during the final approach to Malang.
- The PIC did not initiate action to recover from the high bounced landing following the initial severe hard landing impact.
- The PIC did not ensure that effective crew coordination was maintained during the landing approach.

The stall that occurred during the initial climb was the result of the copilot's confusion in interpreting the information transmitted by the captain which led him to initiate the rotation before reaching the speed of 95 knots (V1). The crew could not obtain sufficient power from both engines because they had not activated the methanol water system in view of the existing meteorological conditions, the wet runway and the takeoff weight, which remains a contributing factor.

The first officer's failure to maintain airspeed during approach, and the captain's inadequate remedial action. Contributing to the accident was the first officer's failure to comply with procedures, windshear, and the lack of windshear warning from air traffic control.

It is believed that the aircraft landed too far down the runway, reducing the landing distance available.

Findings as to Causes and Contributing Factors:
1. The aircraft was configured late for the approach, resulting in an unstable approach condition.
2. The pilot flying carried out a steep turn at a low altitude, thereby increasing the load factor. Consequently, the aircraft stalled at an altitude that was too low to allow the pilot to carry out a stall recovery procedure.
Findings as to Risk:
1. The time spent programming the global positioning system reduced the time available to manage the flight. Consequently, the crew did not make the required radio communications on the mandatory frequency, did not activate the aircraft radio control of aerodrome lighting (ARCAL), did not make the verbal calls specified in the standard operating procedures (SOPs), and configured the aircraft for the approach and landing too late.
2. During the second approach, the aircraft did a race-track pattern and descended below the safe obstacle clearance altitude, thereby increasing the risk of a controlled flight into terrain. The crew’s limited instrument flight rules (IFR) experience could have contributed to poor interpretation of the IFR procedures.
3. Non-compliance with communications procedures in a mandatory frequency area created a situation in which the pilots of both aircraft had poor knowledge of their respective positions, thereby increasing the risk of collision.
4. The pilot-in-command monitored approach (PICMA) procedure requires calls by the pilot not flying when the aircraft deviates from pre-established acceptable tolerances. However, no call is required to warn the pilot flying of an approaching steep bank.
5. The transfer of controls was not carried out as required by the PICMA procedure described in the SOPs. The transfer of controls at the co-pilot’s request could have taken the pilot-in-command by surprise, leaving little time to choose the best option.
6. Despite their limited amount of IFR experience in a multiple crew working environment, the two pilots were paired. Nothing prohibited this. Although the crew had received crew resource management (CRM) training, it still had little multiple crew experience and consequently little experience in applying the basic principles of CRM.
Other Findings:
1. The emergency locator transmitter (ELT) had activated after the impact but due to circuit board damage its transmission power was severely limited. This situation could have had serious consequences had there been any survivors.
2. The Chibougamau/Chapais airport does not have an aircraft rescue and firefighting service. Because the fire station is 23 kilometres from the airport, the firefighters arrived at the scene 26 minutes after the accident.
3. Although this accident does not meet the criteria of a controlled flight into terrain (CFIT), it nonetheless remains that a stabilized constant descent angle (SCDA) non-precision approach (NPA) would have provided an added defence tool to supplement the SOPs.
4. After the late call within the mandatory frequency (MF) area, the specialist at the Québec flight information centre asked the crew about its familiarity with the MF area while the aircraft was in a critical phase of the first approach, which was approaching the minimum descent altitude (MDA). This situation could have distracted the flight crew while they completed important tasks.
5. The standard checklist used by the flight crew made no reference to the enhanced ground proximity warning system (EGPWS). Therefore, the crew was not prompted to check it to ensure that it was properly activated before departure.

The pilot's failure to maintain aircraft control during the landing.

A partial power loss in the right engine due to the failure of the number one exhaust valve, and the airplane's inability to maintain a climb on one engine for unknown reasons. Contributing to the accident were fog and rising terrain.