Airport (less than 10 km from airport)

The accident was the consequence of a controlled flight into terrain.
The following contributing factors were identified:
• While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain.
In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
• After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
• Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
• When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for
an extended period. In accordance with the operator’s stabilized approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
• The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
• The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
• Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile. Although the operator had specified a flight profile for a straight-in approaches and stabilized approach criteria in its operations manual, and encouraged the use of stabilized approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimizing the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations.

Other factors that increased risk:
• Although an applicable height of 1,000 ft for stabilized approach criteria in instrument meteorological conditions has been widely recommended by organizations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilized approach criteria. (Safety issue)
• The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:
- There was no requirement for piston-engine aeroplanes to be fitted with a TAWS, even though this was an ICAO standard for such aeroplanes authorized to carry 10 or more passengers, and this standard had been adopted as a requirement in many comparable countries.
- There was no requirement for turbine-engine aeroplanes authorized to carry 6–9 passengers to be fitted with a TAWS, even though this had been an ICAO recommended practice since 2007, and this recommended practice had been adopted as a requirement in many comparable countries. (Safety Issue)

Other findings:
• The forecast weather at Lockhart River for the time of the aircraft’s arrival required the pilot to plan for 60 minutes holding or diversion to an alternate aerodrome. The aircraft had sufficient fuel for that purpose; and the aircraft had sufficient fuel to conduct the flight from Cairns to Lockhart River and return, with additional fuel for holding on both sectors if required.
• There was no evidence of any organizational or commercial pressure to conduct the flight to Lockhart River or to complete the flight once to commenced.
• Based on the available evidence, it is very unlikely that the pilot was incapacitated or impaired during the flight.
• There was no evidence of any aircraft system or mechanical anomalies that would have directly influenced the accident. However, as a consequence of extensive aircraft damage, it was not possible to be conclusive about the aircraft’s serviceability.
• The aircraft was fitted with Garmin GNS 430W GPS/navigational units that could be configured to provide visual (but not aural) terrain alerts. However, it could not be determined whether the
terrain awareness function was selected on during the accident flight.

The pilot's improper decision to continue an instrument approach to landing following a loss of visual reference with the runway, which resulted in the airplane touching down left of the runway in snow and flipping over.

The flight crew's failure to stop the airplane on the available runway, which was wet and resulted in the airplane impacting a ditch.

The investigation concluded the probable cause of the accident was that the aircraft lost control on final approach to runway 33 as a result of flying with asymmetrical power.

The pilot's failure to lower the landing gear before landing. Contributing to the accident was the examiner's failure to check that the landing gear was extended.

The aircraft stalled during initial climb because its total weight was above the MTOW and the CofG was well beyond the aft limit. The crew failed to prepare the flight according to procedure and, failed to proceed with a mass and balance calculation and the passengers and lugages were incorrectly placed in the cabin according to the CofG.

The investigation determined that the accident was caused by the following probable cause(s):
- Loss of in-flight control as a result of slowing below Minimum Control Speed and drag, generated by the failure of the right engine (No. 2).
- Failure of engine No. 2, due to lack of lubrication, possibly caused by oil leakage through an 11.5 mm fracture, found in one of the sides of cylinder No. 2 at the height of the intake valves.
- Inappropriate application by the crew of the emergency procedure for landing with an inoperative engine, by not declaring the emergency, not feathering the propeller of the inoperative engine and configuring the aircraft early for landing (with landing gear and flaps) without having a safe runway, making it difficult to control the aircraft and placing it in a condition of loss of lift and control.

Contributing Factors:
- Failure of the operator to emphasize in the crew training program the techniques and procedures to be followed in the event of engine failure, among others, the declaration of emergency to ATC, the flagging of the propeller of the inoperative engine, the care in the application of power to the good engine so as not to increase yaw and not to configure the aircraft until landing has been assured.
- Lack of emergency calls by the crew, which denotes deficiencies in the Operator's Safety Management System, and which prevented the early warning of the aerodrome support services and deprived the crew of possible assistance from other aircraft or from the same operator.

The accident with the Boeing 737-500 VQ-BPS aircraft occurred during the landing as a result of a collision of the aircraft with a snow parapet 1.1 m high at a distance of 32 m to the runway threshold (within the paved section of the runway), which resulted in damage to the main landing gear and their subsequent "folding" in the process of moving along the runway.
The accident was caused by a combination of the following factors:
- the presence of contradictions in the Federal Aviation Rules for flights in the airspace of the Russian Federation, the airline's radio control system and the aircraft operational documentation regarding the need and procedure for introducing temperature corrections to the readings of barometric altimeters at low ambient temperatures;
- Failure by the operator of the Usinsk aerodrome to comply with the FAP-262 requirements for the maintenance of the aerodrome, which resulted in the presence of snow parapets on the paved section of the landing strip;
- the operator of the Usinsk aerodrome did not eliminate the shortcomings in the winter maintenance of the aerodrome, noted based on the results of the inspection by the Rosaviatsia commission on January 22, 2020;
- lack of risk assessment in the airline associated with the execution of approaches in the baro-VNAV mode in the presence of factors that impede such approaches (low ambient temperatures, snow-covered underlying surface, drifting snow (snowstorm), significant changes in the relief in front of the runway end, lack of PAPI-type lights), as well as appropriate recommendations to the crews on the specifics of such approaches, including after the transition to visual flight, and crew training;
- insufficient assessment by the crew during the preparation of the existing threats (hazard factors) and making an insufficiently substantiated decision to perform an RNAV (GNSS) approach (under the control of the autopilot in LNAV/VNAV mode) without introducing a correction for low outside air temperature in altitude overflying waypoints, which led to a flight below the established glide path;
- performing a flight along the "extended glide path" after turning off the autopilot and switching to manual piloting without attempting to enter the set glide path;
- the PIC may have had a visual illusion of a "high glide path" due to a snow-covered underlying surface, a snowstorm and the presence of a ravine directly in front of the runway end in the absence of PAPI type lights, which led to an incorrect assessment of the aircraft's flight altitude after switching to manual piloting, lack of reaction to timely and correct warnings of the co-pilot and exit to the runway end at a height significantly less than the established one.