Airport (less than 10 km from airport)

NTSB did not conduct any investigation on this event.

Findings as to Causes and Contributing Factors:
1. The flight crew attempted a low-energy go-around after briefly touching down on the runway. The aircraft’s low-energy state contributed to its inability to accelerate to the airspeed required to accomplish a successful go-around procedure.
2. The rapid power lever advancement caused an inadvertent shutdown of the left engine, which exacerbated the aircraft’s low-energy status and contributed to the eventual loss of control.
3. The inadvertent activation of the autofeather system contributed to the crew’s loss of situational awareness, which adversely influenced the decision to go around, at a time when it may have been possible for the aircraft to safely stop and remain on the runway.
4. The shortage and ambiguity of information available on rejected landings contributed to confusion between the pilots, which resulted in a delayed retraction of the flaps. This departure from procedure prevented the aircraft from accelerating adequately.
5. Retarding the power levers after the first officer had exceeded maximum power setting resulted in an inadequate power setting on the right engine and contributed to a breakdown of crew coordination. This prevented the crew from effectively identifying and responding to the emergencies they encountered.
Findings as to Risk:
1. The design of the autofeather system is such that, when armed, the risk of an inadvertent engine shutdown is increased.
2. Rapid power movement may increase the risk of inadvertent activation of the negative torque sensing system during critical flight regimes.
Other Findings:
1. There were inconsistencies between sections of the Conair aircraft operating manual (AOM), the standard operating procedures (SOPs), and the copied AOM that the operator possessed. These inconsistencies likely created confusion between the training captain and the operator’s pilots.
2. The operator’s CV-580A checklists do not contain a specified section for circuit training. The lack of such checklist information likely increased pilot workload.

The pilot's failure to extend the landing gear prior to landing, which resulted in the propellers striking the runway, an aborted landing, and an in-flight collision with terrain.

Double engine failure on approach caused by a fuel exhaustion. The following findings were identified:
- Poor flight preparation on part of the pilot,
- Miscalculation of fuel consumption for the flying distance (about an hour),
- The day prior to the accident, tanks were filled with a quantity of 130 liters of fuel, barely 13 liters more than the quantity theoretically necessary for the flight in the conditions existing at the time of the accident,
- No technical anomalies were found on the airplane and its equipment,
- Poor organizational culture within the operator regarding fuel policy,
- Qualitative deficiency in the instruction given to the pilot who had not acquired the basic knowledge for fuel management,
- Failure to observe the actual quantity of fuel in the tanks prior to departure,
- Shortcomings in the operator's organizational processes,
- Inadequate supervision of flight planning activities by the operator who failed to identify any flaws in the fuel management procedures by the pilots.

The pilot's failure to attain a proper climb rate and to maintain adequate clearance from the terrain during the initial climb in dark night conditions, which resulted in an in-flight collision with terrain.

The investigation determines that the probable causes of this accident to be the following;
• Substandard maintenance that was performed. (Due to the improper flange on the hydraulic line, the hydraulic line came loose from its housing and depleted the fluid from the hydraulic
reservoir).
• Failure of the back up emergency blow down bottle system. It has been determined from inspection that the cable that connects the emergency blow down bottle system in the nose well of the aircraft to the T-handle in the cockpit, exhibited excessive play. Therefore even though the cable was pulled all the way to its fullest extent, it did not allow movement of the pin that would have provided activation of the system. Annual inspection report completed in December 2005 revealed that the portion of the Annual Inspection that required inspection of the emergency blow down bottle was not signed off by the mechanic as having been accomplished. However, the aircraft was returned to service with this discrepancy outstanding.
• Pilot’s lack of qualification and unfamiliarity with this aircraft, its systems and emergency procedures. ( Evidence of falsification of qualification and time requirement exists in pilot’s logbook).
• Pilot’s poor decision making and impaired judgement. (Possibility of impaired judgement due to pilot fatigue).
• Pilot’s failure in assessing the severity of his situation.
• Pilot’s failure to notify ATC of his problem. (Problem was discovered 20 miles prior to the accident).
• Pilot’s failure to properly assess the conditions for landing and maintain vigilant situational awareness while manoeuvring the aircraft after landing. (From post accident inspection, it was noted that the flaps were not extended for the landing. Had it been extended the aircraft glide path as well as the distance required for roll out after landing may have been greatly decreased).
• Pilot’s failure to take immediate action once he realized his predicament. (Pilot stated that after the propeller made contact with the ground, he decided to apply power and go around, but it was too late. Failure to act also can be attributed to possible pilot fatigue as (pilot was out all day shopping and then decided to leave at such a late hour) well as pilot’s unfamiliarity with aircraft systems and performance capabilities).
• Pilot’s failure to request Emergency Service Assistance. Had this service been requested in a timely manner, preparations could have been made to prevent the fire from spreading to the degree in which it did.

Wrong approach configuration on part of the captain who decided to landed while the aircraft was too high on the glide. Failure of the captain to initiate a go-around procedure after the copilot warned him three times about that.