Manitoba

Findings as to Causes and Contributing Factors:
1. The left engine fuel control support assembly failed in fatigue and released one of three attachment bolts, which resulted in a slight displacement of the fuel control and changed the propeller control dimension. As a result, Beta pressure was achieved and propeller reverse was available for the left engine before it was available for the right engine.
2. The pilot selected thrust reverse without confirmation that the Beta lights were on for both engines, and the aircraft veered from the runway, most likely as a result of temporary asymmetric thrust.
Finding as to Risk:
1. There is no requirement to include the Beta light call as part of the pre-landing briefing. Briefing this item would remind the pilots of the need to confirm Beta light activation for both engines before application of thrust reverse.

Findings as to Causes and Contributing Factors:
1. The aircraft departed at a weight exceeding the maximum take-off weight and the maximum weight for operation in icing conditions.
2. After departure from Winnipeg, the aircraft encountered in-flight icing conditions in which the aircraftís performance deteriorated until the aircraft was unable to maintain altitude.
3. During the attempt to return to the Winnipeg International Airport, the pilot lost control of the aircraft, likely with little or no warning, at an altitude from which recovery was not possible.
Findings as to Risk:
1. Aviation weather forecasts incorporate generic icing forecasts that may not accurately predict the effects of icing conditions on particular aircraft. As a result, specific aircraft types may experience more significant detrimental effects from icing than forecasts indicate.
2. Bulk loading prevented determining the cargo weight in each zone, resulting in a risk that the individual zone weight limits could have been exceeded.
3. The aircraftís centre of gravity (CG) could not be accurately determined, and may have been in the extrapolated shaded warning area on the CG limit chart. Although it was determined that the CG was likely forward of the maximum allowable aft CG, bulk loading increased the risk that the CG could have exceeded the maximum allowable aft CG.
4. The incorrect tare weight on the Toronto cargo container presented a risk that other aircraft carrying cargo from that container could have been inadvertently overloaded.
Other Findings:
1. The pilotís weather information package was incomplete and had to be updated by a telephone briefing.
2. The operatorís pilots were not pressured to avoid using aircraft de-icing facilities or to depart with aircraft unserviceabilities.
3. The aircraft departed Winnipeg without significant contamination of its critical surfaces.
4. The biological material on board the aircraft was disposed of after the accident, with no indication that any of the material had been released into the ground or the atmosphere.
5. The fact that the aircraft was not equipped with flight data recorder or cockpit voice recorder equipment limited the information available for the occurrence investigation and the scope of the investigation.

Findings as to Causes and Contributing Factors:
1. The pilot did not correctly calculate the amount of fuel required to accomplish the flight from Winnipeg to Gunisao Lake and return, and did not ensure that the aircraft carried sufficient fuel for the flight.
2. The ILS approach was flown above the glideslope and beyond the missed approach point, which reduced the possibility of a safe landing at Winnipeg, and increased the risk of collision with terrain.
3. During the missed approach, the aircraft's engines lost power as a result of fuel exhaustion, and the pilot conducted a forced landing at a major city intersection.
4. The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.
Findings as to Risk:
1. The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
2. The company operations manual did not reflect current company procedures.
3. The company did not provide an adequate level of supervision and allowed the flight to depart without adequate fuel reserves. The company did not have a safety system in place to prevent a fuel exhaustion situation developing.
Other Findings:
1. The pilot did not advise air traffic control of his critical situation in a timely fashion.

Findings as to Causes and Contributing Factors:
1. The aircraft was flown into terrain during an overshoot because the required climb angle was not set and maintained to ensure a positive rate of climb.
2. During the go-around, conditions were present for somatogravic illusion, which most likely led to the captain losing situational awareness.
3. The first officer did not monitor the aircraft instruments during a critical stage of flight; it is possible that he was affected by somatogravic illusion and/or distracted by the non-directional
beacon to the extent that he lost situational awareness.
Other Findings:
1. The absence of approach aids likely decreased the crew=s ability to fly an approach from which a landing could be executed safely.
2. The company standard operating procedures (SOPs) did not define how positive rate is to be determined.

Findings as to Causes and Contributing Factors:
1. The number three cylinder lower forward through stud was missing its base nut, which allowed the lower rear base nut of the number two cylinder to loosen.
2. The missing base nut of the through stud indicates that the base nut did not have sufficient clamping force; however, it could not be determined if the base nut did not receive the required torque during installation or if the base nut lost its clamping force during engine operation.
3. The d-inch studs and the 2-inch through studs of the number two cylinder failed in fatigue, and the number two cylinder of the left engine separated from the crankcase.
4. The left propeller could not be feathered because of interference between the propeller governor control and the separated number two cylinder.
5. The drag from the unfeathered left propeller and the deformed left engine cowling resulted in the aircraft being incapable of maintaining its altitude.
Other Findings:
1. The pilot was certified and qualified for the accident flight.
2. The aircraft's weight and balance were within the specified limits at the time of the accident.
3. The ELT was not readily accessible without tools.

Findings as to Causes and Contributing Factors:
1. The most likely accident scenario during the second take-off is that water contamination migrated from the centre fuel tank to the engine, resulting in a loss of engine power.
2. The engine stopped at a point from which there was insufficient time for the engine to restart, nor from which a safe landing could be made.
3. Indications of water contamination were found in the fuel system after the occurrence; however, the source(s) of the water contamination could not be identified.
Other Findings:
1. Examination of the aircraft and testing of the engine and components did not identify any pre-occurrence structural, mechanical, or electrical defects or malfunctions that would have
contributed to this occurrence.
2. The post-crash fire in the carburettor most likely resulted from uncontaminated fuel brought forward by the windmilling engine and the pilot's efforts to clear contamination from the fuel
system.
3. The pilot's use of his shoulder harness likely prevented more serious injuries during the impact sequence.
4. The engineer's injuries likely would have been less severe had he been using both his seat belt and shoulder harness.
5. The pilot was certified and qualified for the flight.
6. The aircraft's weight and centre of gravity were within approved limits.
7. The aircraft's records indicated that the aircraft had been certified and maintained in accordance with existing regulations.
8. The aircraft's engine power loss during the first attempted take-off was likely due to water contamination in the fuel.

Findings as to Causes and Contributing Factors:
1. At the time of the occurrence, the base of the cloud at Little Grand Rapids was between 100 and 300 feet agl, with fog to the east of the airport, and the visibility was one to two miles.
2. The aircraft was flown in marginal weather at low level, below the minimum en route altitude for commuter operations and below the MDA for the NDB A approach at Little Grand Rapids. The MDA for the approach was 1 560 feet asl, 555 feet above the airport elevation.
3. While the aircraft was being manoeuvred at very low level in marginal weather, it descended after an abrupt turn, and flew, in controlled flight, into the terrain.
Other Findings:
1. At both take-off and landing, the aircraft was about 1 000 pounds heavier than the relevant maximum allowable weight.
2. The GPS installed in C-GVRO was not approved as a primary navigational aid. The available information indicates that the flight crew used the GPS as a primary navigational aid during the last approach to Little Grand Rapids.
3. The aircraft was not equipped with a GPWS, nor was it required to be by regulation.
4. The weight and balance report that was submitted to Transport Canada, required for the importation of C-GVRO, contained numerous discrepancies; the report was not reviewed for accuracy by Transport Canada.
5. The emergency locator transmitter (ELT) produced a very weak signal because the antenna cable had been installed with little slack, and it pulled out of the antenna fitting during impact.
6. It could not be determined whether the presence of carbon monoxide and diphenhydramine in the captain's body affected his decision making and level of alertness.
7. The company, which had been an air taxi operator, did not effectively manage either the addition of the more complex commuter operations or the introduction of the larger Bandeirante aircraft.
8. The difficulty that the company had in the transition to commuter operations and in the introduction of the Bandeirante aircraft was underestimated by Transport Canada.
9. There were inadequacies in TC=s oversight, whereby the post-certification audit of the company was not conducted, thus eliminating an important mechanism by which TC could have found, and addressed, the inadequate safety management practices, non-conformance with pilot training requirements, and related operating irregularities.
10. The pilots had passed their flying proficiency and medical tests, but they had not completed elements of pilot training requirements with respect to servicing and operational control and right seat conversion as prescribed by TC. Also, no company pilot had received required training in the use of onboard survival or emergency equipment.
11. There was no indication found of any pre-impact failure or malfunction of the airframe, flight controls, or engines.
12. The aircraft was not equipped with either a CVR or an FDR; TC had given the company an exemption to operate without a CVR until 01 August 1998, and the aircraft was not required to be equipped with an FDR.
13. The absence of recorders on this aircraft, which was configured to carry 20 people, left many of the otherwise ascertainable facts associated with the accident unknown and reduced the opportunity of uncovering risks to safety associated with the flight.
14. Conditions were conducive to the pilot experiencing a false sensation that the aircraft was climbing (somatogravic illusion) after increasing the engine power, and he may have been manoeuvring to avoid an abandoned fire tower.

The left main gear drag links may have failed in overload.