Mountains

Findings as to Causes and Contributing Factors:
1. As the aircraft approached high terrain in a climb, the pilot, for undetermined reasons, did not turn away from the terrain; the aircraft struck tree tops and crashed.
2. The aircraft’s climb performance was adversely affected by density altitude and the relatively high aircraft weight, so that the aircraft was unable to clear the high terrain ahead.
Findings as to Risk:
1. The licensed passenger had not informed the TC medical examiner who conducted her last medical that she had been diagnosed with coronary artery disease, posing the risk that she could pilot an aircraft while not medically fit to do so.
2. The aircraft was being operated at a higher weight than was justified by the STC, under which it was converted to an amphibian. Some of the structural modifications called for by the STC for the higher weight had not been carried out.
Other Findings:
1. It could not be determined who was piloting the aircraft on the occurrence flight.

The cause of the accident is attributable to the human factor and can be identified in the impact of the aircraft against certain trees following the setting of an inadequate escape manoeuvre.
The following causal factors may have contributed to the dynamics of the accident:
- The crew's failure to strictly comply with the Operator's Manual of Operations, which provided that the route of attack and escape should not be made uphill, unless there were very limited differences in level that could be overcome without power fluctuations,
- The failure to carry out, as a precautionary measure, since the trajectory of the attack route has changed (from descending to ascending), a new reconnaissance with subsequent briefing by the crew, in order to properly assess the different perspective of all the elements of interest (orography, escape route, etc..), even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in unstabilized conditions, therefore not in line with what is previewed from the operating manual, even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in not stabilized conditions, therefore not in line with what is previewed from the operating manual;
- The existence of communication problems within the cockpit, deriving from the fact that there was no information flow between the co-pilot (depositary of the information necessary for the assumption of the most appropriate operational decisions) and the commander, responsible for the final decisions; in this regard, it should be noted that radio communications with the DOCFS were made by the co-pilot in Italian, as the latter was not known by the commander, of Canadian nationality,
- The significant difference in experience and age between the two crew members, with possible negative effects in terms of crew coordination,
- The presence of critical points in the operating manuals, partly eliminated after the accident,
- The presence of locally significant turbulence.

Controlled flight into terrain after the crew failed to maintain horizontal and vertical situational awareness of the aircraft’s proximity to the surrounding terrain.
The following contributing factors were identified:
- Unfamiliarity with the airspace and the route in particular and the existence of high ground on the planned flight route,
- Inadequate flight planning by the pilots and distraction of their attention when they were instructed to contact Nanyuki,
- Poor pilot briefing by the Wilson ATC briefing office,
- Poor communication between the air traffic control units,
- Failure of the radar controller to advise the pilot of termination of radar service,
- Lack of a radar system minimum safe altitude warning to the radar controller,
- Poor civil military coordination during transit through the military airspace.

Findings as to Causes and Contributing Factors:
1. For undetermined reasons, the Electra did not climb sufficiently to avoid striking the rising terrain.
2. Given the flight path and the rate of climb chosen, a collision with the terrain was unavoidable.
3. The characteristics of the terrain were deceptive, making it difficult for the pilots to perceive their proximity and rate of closure to the rising ground in sufficient time to avoid it.
Other Findings:
1. Performance calculations show that the Electra—in the absence of limiting mechanical malfunction—could have climbed at a rate that would have allowed the aircraft to avoid the terrain.
2. Although a functional cockpit voice recorder was installed in the aircraft, it was not required by regulation and it was not used; as a result, vital clues that could have shed light on the circumstances of this accident were not available.
3. The emergency locator transmitter could not transmit a signal as a result of severe impact forces that exceeded the design criteria.

Controlled flight into terrain after the crew initiated the descent prematurely in poor visibility.

The pilot's failure to follow IFR procedures by not following the published approach procedures, which resulted in an in-flight collision with terrain. Factors contributing to the accident were a low ceiling, and the pressure induced by conditions/events (the open baggage door).

Controlled flight into terrain caused by the combination of the following factors:
- The decision of the pilot to take off from an airfield that was not suitable for night operations,
- The absence of a copilot considerably increased the workload of the captain, assuming that the copilot could have assisted him in the reconnaissance of the terrain, the preparation of the flight, the assistance to the patient and the medical team,
- Lack of visibility due to the night and lack of visual reference points on the ground, especially since the pilot had to wear corrective glasses,
- The pilot could not clearly distinguish the various parameters displayed on his instrument's panel because he forgot his glasses.

The accident was the consequence of a controlled flight into terrain due to the combination of the following factors:
- Loss of situational awareness on part of the flying crew,
- The crew failed to comply with the Standard Operational Procedures published by the operator,
- The crew failed to follow the published approach charts,
- Implementation of a non-precision approach,
- Incorrect use of the automated flight systems,
- Inadequate training (LOFT),
- The crew descended below the MDA in limited visibility.

The pilot's failure to maintain clearance from terrain.