Lake, Sea, Ocean, River

An in-flight collision with water for undetermined reasons, due to the wreckage never being recovered from the water.

It is believed that the pilot may have lost control of the airplane after suffering a loss of situational awareness after he lost visual contact with the airport lights.

An undetermined system malfunction in the right engine, which led to an increase in fuel usage beyond the pilot's planned fuel consumption rate and eventual fuel supply exhaustion.

Undetermined as the aircraft was not recovered.

Fuel exhaustion due to the pilot's failure to ensure that an adequate fuel supply was onboard. A contributing factor was the lack of suitable terrain for the forced landing.

The following findings were identified:
- The pilot initiated a go-around from final approach because of a vehicle on the airstrip.
- The left propeller showed little evidence of rotation damage. The reason for a possible loss of left engine power could not be determined.
- For reasons that could not be established, the pilot lost control of the aircraft at a low height.

Findings as to Causes and Contributing Factors:
1. The crew did not follow the company's SOPs for the briefing preceding the approach and for a missed approach.
2. In the approach briefing, the captain did not specify the MDA or the MAP, and the first officer did not notice these oversights, which shows a lack of coordination within the crew.
3. The captain continued descent below the MDA without establishing visual contact with the required references.
4. The first officer probably had difficulty perceiving depth because of the whiteout.
5. The captain did not effectively monitor the flight parameters because he was trying to establish visual contact with the runway.
6. The chief pilot (the captain of C-FGOI) set a bad example to the pilots under him by using a dangerous method, that is, descending below the MDA without establishing visual contact with the required references and using the GPWS to approach the ground.
Findings as to Risks:
1. The operations manager did not effectively supervise air operations.
2. Transport Canada did not detect the irregularities that compromised the safety of the flight before the occurrence.
3. Régionnair had not developed GPWS SOPs for non-precision approaches.
Other Findings:
1. The GPWS 'MINIMUMS' alarm sounded at a height that did not leave the captain time to initiate pull-up and avoid striking the ground because of the aircraft=s rate of descent and other flight
parameters.
2. Neither the captain nor the first officer had received PDM training or CRM training.
3. At the time of the approach, the ceiling and visibility unofficially reported by the AAU were below the minima published on the approach chart.
4. The decision to make the approach was consistent with existing regulations because runway 02/20 was not under an approach ban.
5. Some Régionnair pilots would descend below the MDA and use the GPWS to approach the ground if conditions made it impossible to establish visual contact with the required references.

The pilot's failure to maintain adequate altitude during the approach.

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.