Manitoba

Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. A fatigue fracture originated in the bolt hole bore of the right-hand wing lift strut’s upper outboard lug plate, and eventually led to an overstress fracture of the right-hand wing lift strut’s upper outboard and inboard lug plates during the left turn prior to the final approach.
2. The failure of the outboard and inboard lug plates led to the separation of the righthand wing lift strut from the wing and, subsequently, the separation of the right wing from the aircraft.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If operational flight plans data and load calculations are not available, there is a risk that, in the event of a missing aircraft or accident, aircraft information, including its number of occupants, route, cargo, and weight and balance information, will not be available for search and rescue operations or accident investigation.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The detailed visual inspection prescribed in the Viking Air Ltd. Supplementary Inspection and Corrosion Control Manual, and required by Airworthiness DirectiveCF2018-4, did not identify cracks that could form in the right-hand wing strut’s upper outboard lug plate.

Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.

Findings as to causes and contributing factors:
1. The left engine low oil pressure indications during the previous and the occurrence flights were likely the result of a steady oil leak past the rear turbine air-oil seal assembly.
2. The loss of engine oil pressure resulted in a loss of propeller control authority on landing and the upset of the aircraft.
3. After consultation with maintenance, the crew considered the risks associated with landing single engine and without hydraulic pressure for the nose-wheel steering, and decided to continue the flight with both engines running, even though this was not consistent with the QRH procedures for low oil pressure indications.
4. Carbon deposits that accumulated within the inside diameter of the bellows convolutions interfered with the bellows’ ability to expand and to provide a positive seal against the rotor seal.

Findings as to risk:
1. If Canadian Aviation Regulations (CARs) subparts 703 and 704 operators do not provide initial or recurrent crew resource management training to pilots, these pilots may not be prepared to avoid, trap, or mitigate crew errors encountered during flight.
2. If operators of the SA227-AC Metro III aircraft rely solely on the emergency procedures listed in the aircraft flight manual, continued engine operation with low oil pressure may result in loss of control of the aircraft.
3. If an engine is not allowed to sufficiently cool down prior to shutdown, oil that remains trapped within hot areas of the engine may heat up to a point where the oil decomposes, creating a carbon deposit.
4. If flight data, voice, and video recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Other findings:
1. The investigation was unable to determine the length of cooldown periods for the occurrence aircraft. However, a random sampling of engine shutdowns for similar company aircraft showed that 50% had not completed the full 3-minute cooldown period.
2. Despite having received limited crew resource management (CRM).

Findings as to causes and contributing factors:
1. Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
2. The fueling operation was not adequately supervised by the flight crew.
3. A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
4. The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.

Findings as to risk:
1. If administrative and physical defences against errors in aviation fuel operations are circumvented or disabled, there is a risk that the incorrect type of fuel will be delivered.
2. If a reduced-diameter spout is available to accommodate non-standard fuel filler openings, there is an increased risk that Jet-A1 fuel can be dispensed into an aircraft that requires AVGAS.

Other findings:
1. Aircraft that were manufactured prior to the current airworthiness standards, or that have been modified by the installation of turbine engines, may have fuel filler openings that do not meet the dimension requirements.
2. The airworthiness standards for rotorcraft do not specify the size of fuel filler openings.
3. The use of all of the available restraint systems in the aircraft contributed to the survival of the occupants.
4. There was no post-crash fire, likely due to the separation of the battery from the aircraft and to the rain-saturated crash site.
5. The absence of a post-impact fire contributed to the survival of all of the aircraft's occupants.

Failure of the right main gear for unknown reasons.

Findings as to causes and contributing factors:
1. The aircraft departed Snow Lake overweight and with an accumulation of ice on the leading edges of its wings and tail from the previous flight. As a result, the aircraft had reduced take-off and climb performance and increased stall speed, and the protection afforded by its stall warning system was impaired.
2. A breakdown in the company’s operational control resulted in the flight not operating in accordance with the Canadian Aviation Regulations and the company operations manual.
3. As a result, shortly after departure, the aircraft stalled at an altitude from which recovery was not possible.
Findings as to risk:
1. If companies operate in instrument meteorological conditions for which they are not authorized, there is an increased risk that accidents may occur.
2. If Transport Canada does not provide the same degree of oversight for repetitive charter operations as it does for a scheduled operator, the risks in the operator’s activities may not be fully evaluated.
3. If passenger briefings are not provided and passengers are not properly seated and restrained, there is an increased risk of injuries to those passengers and the other occupants in the event of an accident.
4. If flights are conducted without ensuring an ice-free airframe, there is a risk of decreased aircraft performance and of loss of control and collision with terrain.
Other findings:
1. On impact, the aircraft’s seats and cabin deformed as designed, and this deformation partially attenuated the impact forces.

Findings as to Causes and Contributing Factors:
Runway conditions, the pilot's takeoff technique, and possible shifting wind conditions combined to reduce the rate of the aircraft's acceleration during the takeoff roll and prevented it from attaining takeoff airspeed. The pilot rejected the takeoff past the point from which a successful rejected takeoff could be completed within the available stopping distance. The steep drop-off and sharp slope reversal at the end of Runway 33 contributed to the occupant injuries and fuel system damage that in turn caused the fire. This complicated passenger evacuation and prevented the rescue of the injured passenger. The deceased passenger was not wearing the available shoulder harness. This contributed to the serious injuries received as a result of the impact when the aircraft reached the bottom of the ravine and ultimately to his death in the post-impact fire.
Findings as to Risk:
If pilots are not aware of the increased aerodynamic drag during takeoff while using soft-field takeoff techniques they may experience an unexpected reduction in takeoff performance. Incomplete passenger briefings or inattentive passengers increase the risk that they will be unable to carry out critical egress procedures during an aircraft evacuation. When data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety. Although the runway at Pukatawagan and many other aerodromes are compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond the runway ends may increase the likelihood of damage to aircraft and injuries to crew and passengers in the event of an aircraft overrunning or landing short. TC's responses to TSB recommendations for action to reduce the risk of post-impact fires have been rated as Unsatisfactory. As a result, there is a continuing risk of post-impact fires in impact-survivable accidents involving these aircraft. The lack of accelerate stop distance information for aircraft impedes the crew's ability to plan the takeoff-reject point accurately.
Other finding:
Several anomalies were found in the engine's power control hardware. There was no indication that these anomalies contributed to the occurrence.

Findings as to Causes and Contributing Factors:
1. The crew conducted an Area Navigation (RNAV) approach for which they were not trained, with an aircraft that was not properly equipped nor approved for such purpose.
2. The aircraft descended 300 feet below the minimum descent altitude (MDA) as a result of a number of lapses, errors and adaptations which, when combined, resulted in the mismanaged approach.
3. The aural warning on the aircraft’s altitude alerter had been silenced prior to the approach, which precluded it from alerting the crew when the aircraft descended below minimum descent altitude.
4. The SkyNorth standard operating procedures for conducting a non-precision approach were not followed, which resulted in the aircraft descending below the minimum descent altitude. During the ensuing missed approach, the aircraft struck trees.
Findings as to Risk:
1. The lack of a more-structured training environment and the type of supervisory flying provided increased the risk that deviations from standard operating procedures (SOPs) would not be identified.
2. There are several instrument approach procedures in Canada that contain step-down fixes that are not displayed on global positioning system (GPS) units. This may increase the risk of collision with obstacles during step-downs on approaches.

Findings as to Causes and Contributing Factors:
1. An electrical short circuit in the cockpit pedestal area produced flames and smoke, which induced the crew to take emergency action.
2. The detrimental effects of aging on the wires involved may have been a factor in this electrical arc event.
3. The crew elected to return to the airport at low level in an environment with inadequate visual references. As a result, control of the aircraft was lost at an altitude from which a recovery was not possible.
Findings as to Risk:
1. The actions specified in the standard operating procedures (SOP) do not include procedures for an electrical fire encountered at low altitude at night, which could lead to a loss of control.
2. Visual inspection procedures in accordance with normal phase inspection requirements may be inadequate to detect defects progressing within wiring bundles, increasing the risk of electrical fires.
3. In the event of an in-flight cockpit pedestal fire, the first officer does not have ready access to available fire extinguishers, reducing the likelihood of successfully fighting a fire of this nature.
4. Sealed in plastic containers and stored behind each pilot seat, the oxygen masks and goggles are time consuming to access and cumbersome to apply and activate. This could increase the probability of injury or incapacitation through extended exposure to smoke or fumes, or could deter crews from using them, especially during periods of high cockpit workload.
Other Finding:
1. A failure of the hot-mic recording function of the cockpit voice recorder (CVR) had gone undetected and information that would have been helpful to the investigation was not available.