British Columbia

Findings as to causes and contributing factors:
1. The crew did not complete the before-landing checks, ignored aural warnings, and did not lower the landing gear, which resulted in a gear-up landing.
Findings as to risk:
1. The aircraft was not equipped with a GPWS, which could have prevented this accident.
2. The before-landing checklist in use did not reflect the AFM requirement that the speed brakes should be retracted prior to 50 feet.

Findings as to Causes and Contributing Factors:
1. The pilot abandoned his attempt to fly through the pass because of unsuitable weather conditions. He flew into a confined area that required him to manoeuvre the aircraft aggressively to avoid the rising terrain, causing the aircraft to stall.
2. The aircraft weight exceeded the certificated MAUW, and the CG was outside the floatplane aft limit. The out-of-limit weight and balance aggravated aerodynamic stall and produced rapid and
uncontrolled aircraft attitudes from which the pilot could not recover before striking the trees.
3. Basic weight and balance of the aircraft was incorrectly recorded in several aircraft documents, leading to remarkable discrepancies in take-off weight and CG calculations. As a result, a pilot could not calculate an accurate weight and balance. In certain conditions, calculations erroneously showed that the aircraft was below maximum allowable gross weight.
Findings as to Risk:
1. The practice of using a non-standard passenger weight led to inaccurate take-off weight calculations and provided an estimated total passenger weight that was 185 pounds less than actual.
2. Weight and balance calculations performed using inaccurate figures would not have revealed that the aircraft was overloaded until it was approximately 450 pounds beyond the maximum limit.
3. Aircraft weight exceeded the maximum allowable gross weight, and the CG was outside the aft CG limit. This weight and balance combination placed the aircraft outside the manufacturer’s
original design envelope, to where slow speed and stall handling characteristics are neither proven nor certificated.
4. Cargo was not secured by the available cargo restraint and might have shifted during aircraft manoeuvring. Such cargo movement would have exacerbated the effects of the existing aft CG and likely increased the level of injury to the occupants.
Other Findings:
1. The pilot chose to fly above cloud in accordance with the visual flight rules and could not descend through the cloud at his intended landing site.
2. The Alaska cargo door installation increases the volume of the cargo compartment. The installation is thereby conducive to larger loads being stowed farther aft and possible overloading of the cargo compartment.
3. The DHC-2 Beaver is not equipped with an aural or visual stall warning system, nor is it required by regulation. Warning of an impending stall is dependent on juddering or some other aerodynamic indication.

Findings as to Causes and Contributing Factors:
1. For reasons not determined, the pilot did not adhere to the procedures depicted for the LOC DME-B approach to runway 16 at Penticton. As a result, the aircraft did not remain within the confines of protected airspace, was below the minimum safe altitude for the procedure turn, and struck the tower.
Findings as to Risk:
1. The approach was flown in weather conditions that virtually precluded the pilot from completing a landing.
Other Findings:
1. The pilot's flight medical certificate had expired one month prior to the accident, and no information could be found that he had submitted to an FAA medical during that time.

Findings as to Causes and Contributing Factors:
1. A planetary gear disintegrated in the propeller reduction gearbox of the No. 2 engine and caused the engine drive shaft to disconnect from the propeller, resulting in a loss of propulsion from this engine.
2. The planetary gear oil strainer screen wires fractured by fatigue as a consequence of the installation at the last overhaul. This created an unsafe condition and it is most probable that the release of wire fragments and debris from this strainer screen subsequently initiated or contributed to distress of the planetary gear bearing sleeve and resulted in the disintegration of the planetary gear.
3. Although airspeed was above Vmc at the time of the power loss, the aircraft became progressively uncontrollable due to power on the remaining engine not being reduced to relieve the asymmetric thrust condition until impact was imminent.
Findings as to Risk:
1. The propeller reduction gearboxes were inspected in accordance with the West Coast Air maintenance control manual. These inspections exceeded requirements of the de Havilland Equalized Maintenance Maximum Availability program. Since the last inspection, 46 hours of flight time before the accident, did not reveal any anomaly, a risk remains of adverse developments with
resulting consequences occurring during the unmonitored period between inspections.
2. Regulations require the installation of engine oil chip detectors, but not the associated annunciator system on the DHC-6. Without an annunciator system, monitoring of engine oil contamination is limited to the frequency and thoroughness of maintenance inspections. An annunciator system would have provided a method of continuous monitoring and may have warned the crew of the impending problem.
3. Although regulations do not require the aircraft to be equipped with an auto-feather system, its presence may have assisted the flight crew in handling the sudden loss of power by reducing the drag created by a windmilling propeller.
4. Since most air taxi and commuter operators use their own aircraft rather than a simulator for pilot proficiency training, higher-risk emergency scenarios can only be practiced at altitude and discussed in the classroom. As a result, pilots do not gain the benefit of a realistic experience during training.
Other Findings:
1. The fact that the aircraft remained upright and floating in daylight conditions contributed to the successful evacuation of the cabin without injury and enabled about half of the passengers to locate and don their life vests.
2. The aircraft was at low altitude and low airspeed at the time of power loss. The selection of full flaps may have contributed to a single-engine, high-drag situation, making a successful landing difficult.

Findings as to Causes and Contributing Factors:
1. The pilot did not avoid the trees that obstructed his immediate flight path on descent to the lake.
2. The damage to the aircraft from the tree-strike seriously compromised the pilot's ability to control the aircraft, to the point where continued flight was impossible.
3. The pilot and the passenger suffered serious injuries. It is highly likely that proper use of a passenger restraint system would have lessened the injuries to both persons.
Findings as to Risk:
1. Canadian regulations regarding the use of seats and seat restraint systems are not sufficiently clear about high-risk, aerial work operations, such as aerial application.
2. Transport Canada was not advised of the fish-dropping operations and was unaware that the passenger in the cabin was unrestrained during high-risk operations.
3. Canadian regulations do not require specific training in aerial application techniques, such as fish-dropping.
4. The installation of the fish-hopper equipment constituted an aircraft modification, which had not been approved by Transport Canada.
Other Findings:
1. The operator did not maintain a proper logbook.

Findings as to Causes and Contributing Factors:
1. The pilot's decision to depart from the unlit location was likely the result of the many psychological and physiological stressors encountered during the day.
2. The pilot most likely experienced spatial disorientation-precipitated by local geographic and environmental conditions-and lost control of the aircraft.
Findings as to Risk:
1. Without a safety management program that routinely disseminates safety information, RCMP pilots may be inadequately sensitized to the limitations of decision making and judgement.
2. The RCMP had no current, concise standard operating procedures (SOPs) for its non-604 operations. Without useable SOPs, the pilots in some instances operate without clearly established limits and outside of acceptable tolerances.

Findings as to Causes and Contributing Factors:
1. When the pilot entered a turn, the combined effects of the increased g-forces, power reduction, the aircraft=s heavy weight, the aft CofG, retraction of the flaps, and the wind conditions resulted in
the aircraft stalling. The aircraft struck the lake surface before the pilot was able to re-establish a level-flight attitude.
2. The aircraft was operating in excess of 385 pounds above the maximum gross takeoff weight, and the CofG was about 2.7 inches aft of the aft limit. This loading configuration aggravated the stall characteristics of the aircraft.
3. The pilot reduced power and raised the flaps before the climb was complete, contrary to the Pilot Operating Handbook, thereby increasing the aircraft's stall speed.
Other Findings:
1. The shoulder harnesses worn by the pilot and the front passenger likely prevented serious head injuries.
2. The centre seat broke from its footings. This may have incapacitated the two passengers inside the aircraft or impeded their escape.

Findings as to Causes and Contributing Factors:
1. Weather conditions at the time and location of the occurrence were not suitable for visual flight.
2. While the pilot was attempting to regain visual flight, he allowed the aircraft to descend and it struck the ice surface. The weather and surface conditions were such that it would have been virtually impossible to visually detect the ice surface.
Other Finding:
1. In the absence of en route weather reporting facilities, the pilot could only estimate weather conditions based on the area forecast and informal reports received from lay personnel.

Findings as to Causes and Contributing Factors:
1. The pilot took off with frost adhering to the aircraft's lifting surfaces, which increased drag and reduced the ability of the wings to produce lift.
2. At take-off, the aircraft was about 510 pounds in excess of its maximum take-off weight, adversely affecting aircraft performance.
3. The aircraft experienced an aerodynamic stall and loss of control when the flaps were retracted from 10 degrees to zero. Retracting the flaps reduced the amount of lift being produced by the wing, already performing poorly because of contamination.
Other Findings:
1. Appropriate entries were not recorded in the aircraft=s journey and maintenance logs, and the weight and balance documentation was not amended.
2. The floats absorbed much of the impact energy and likely enhanced survivability of the accident.