New Brunswick

Findings as to causes and contributing factors:
1. The captain commenced the flight with only a single headset on board, thereby preventing a shared situational awareness among the crew.
2. It is likely that the weather at the time of both approaches was such that the captain could not see the required visual references to ensure a safe landing.
3. The first officer was focused on locating the runway and was unaware of the captain’s actions during the descent.
4. For undetermined reasons, the captain initiated a steep descent 0.56 nautical mile from the threshold, which went uncorrected until a point from which it was too late to recover.
5. The aircraft contacted a road 0.25 nautical mile short of the runway and struck terrain.
6. The paramedic was not wearing a seatbelt and was not restrained during the impact sequence.
Findings as to risk:
1. If cockpit data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If crew members are unable to communicate effectively, then they are less likely to anticipate and coordinate their actions, which could jeopardize the safety of flight.
3. If crew resource management training is not provided, used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight.
4. If an actual weight and balance cannot be determined, then the aircraft may be operating outside of its approved limits, which could affect the aircraft’s performance characteristics.
5. If pre-computed weight and balance forms do not include standard items, then it increases the likelihood of omissions in weight and balance calculations, which increases the risk of inadvertently overloading or incorrectly loading the aircraft.
6. If organizations carry out a maintenance task that they consider to be elementary work and the task is not approved as an elementary work task, then there is a risk that the aircraft will not conform to its type design, which could jeopardize the safety of flight.
7. If individuals are performing maintenance tasks for which they have not received approved training, then there is a risk that the task will not be performed in accordance with the manufacturer’s instructions.
8. If components are not installed in accordance with the manufacturer’s instructions, then occupants are at a greater risk of injury or death during an incident or accident if these components are not properly secured.
9. If organizations do not record when maintenance is carried out, then the proper completion of tasks cannot be confirmed, and there is a risk that the aircraft will not conform to its type design, which could jeopardize the safety of flight.
10. If an aircraft is modified without regulatory approval and without supporting documentation, then the aircraft is not in compliance with all applicable standards of airworthiness, which could jeopardize the safety of flight.
11. If an operator undertakes unapproved changes to a supplemental type certificate, then there is a risk that the aircraft will not be airworthy, which could jeopardize the safety of flight.
12. If organizations do not use modern safety management practices, then there is an increased risk that hazards will not be identified and risks mitigated.
13. If Transport Canada does not adopt a balanced approach that combines thorough inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.
14. If organizations contract aviation companies to provide a service with which the organizations are not familiar, then there is an increased risk that safety deficiencies will go unnoticed, which could jeopardize the safety of the organizations’ employees.
15. If passengers are not provided with a regular safety briefing, then there is an increased risk that they will not use the available safety equipment or be able to perform necessary emergency functions in a timely manner to avoid injury or death.
16. If passengers are not properly restrained, then there is an increased risk of injuries and death to those passengers and the other occupants in the event of an accident.
17. If carry-on baggage, equipment or cargo is not restrained, then occupants are at a greater risk of injury or death if these items become projectiles in a crash.
18. If carry-on baggage, equipment or cargo is not restrained, then there is an increased risk that the occupants’ access to normal and emergency exits, and to safety equipment, will be completely or partially blocked.
19. If pilots continue an approach below published minimum descent altitudes without seeing the required visual references, then there is a risk of collision with terrain and/or obstacles.
20. If current charts and databases are not used, then navigational accuracy and obstacle avoidance cannot be assured.
21. If GPS (global positioning system) approaches are conducted without the approved Operations Specification, then there is a risk that the pilot’s training and knowledge will be inadequate to safely conduct the approach.
22. If medical symptoms/conditions are not reported to Transport Canada, then it negates some of the safety benefit of examinations and increases the risk that pilots will continue to fly with a medical condition that poses a risk to safety.
Other findings:
1. The pilot who installed the air ambulance system did not have approved training, nor was the pilot approved to carry out elementary work.
2. Atlantic Charters was not approved to install the air ambulance system as an elementary work task.
3. Atlantic Charters’ pre-computed weight and balance form did not include a line item to indicate nacelle fuel.
4. The semi-annual safety training offered to paramedics in lieu of safety briefings prior to flights did not meet regulatory requirements.

Findings as to Causes and Contributing Factors:
1. Although for the time of the approach the weather reported for Fredericton—ceiling 100 feet and visibility c mile—was below the 200-foot decision height and the charted ½ -mile (RVR 2600) visibility for the landing, the approach was permitted because the reported RVR of 1200 feet was at the minimum RVR specified in CAR 602.129.
2. Based on the weather and visibility, runway length, approach and runway lighting, runway condition, and the first officer’s flying experience, allowing the first officer to fly the approach is questionable.
3. The first officer allowed the aircraft to deviate from the flight path to the extent that a go-around was required, which is an indication of his ability to transition to landing in the existing environmental conditions.
4. Disengagement of the autopilot at 165 feet rather than at the 80-foot minimum autopilot altitude resulted in an increased workload for the PF, allowed deviations
from the glide path, and deprived the pilots of better visual cues for landing.
5. In the occurrence environmental conditions, the lack of runway centre line and touchdown-zone lighting probably contributed to the first officer not being able to see the runway environment clearly enough to enable him to maintain the aircraft on the visual glide path and runway centre line.
6. The first officer’s inexperience and lack of training in flying the CL-65 in low-visibility conditions contributed to his inability to successfully complete the landing.
7. The situation of a captain being the PNF when ordering a go-around probably played a part in the uncertainty regarding the thrust lever advance and the raising of the flaps because there was no documented procedure covering their duties.
8. The go-around was attempted from a low-energy situation outside of the flight boundaries certified for the published go-around procedures; the aircraft’s low energy was primarily the result of the power being at idle.
9. The sequential nature of steps within the go-around procedures, in particular, in directing the pitch adjustment prior to noting the airspeed, the compelling nature of the command bars, and the high level of concentration required when initiating the go-around contributed to the first officer’s inadequate monitoring of the airspeed during the go-around attempt.
10. Following the command bars in go-around mode does not ensure that a safe flying speed is maintained, because the positioning of the command bars does not take into consideration the airspeed, flap configuration, and the rate of change of the angle of attack, considerations required to compute stall margin.
11. The conditions under which the go-arounds are demonstrated for aircraft certification do not form part of the documentation that leads to aircraft limitations or boundaries for the go-around procedure; this contributed to these factors not being taken into account when the go-around procedures were incorporated in aircraft and training manuals.
12. The published go-around procedure does not adequately reflect that once power is reduced to idle for landing, a go-around will probably not be completed without the aircraft contacting the runway (primarily because of the time required for the engines to spool up to go-around thrust).
13. The Air Canada stall recovery training, as approved by Transport Canada, did not prepare the crew for the conditions in which the occurrence aircraft stick shaker activated and the aircraft stalled.
14. The limitations of the ice-detection and annunciation systems and the procedures on the use of wing anti-ice did not ensure that the wing would remain ice-free during flight.
15. Ice accretion studies indicate that the aircraft was in an icing environment for at least 60 seconds prior to the stall, and that during this period a thin layer of mixed ice with some degree of roughness probably accumulated on the leading edges of the wings. Any ice on the wings would have reduced the safety margins of the stall protection system.
16. The implications of ice build-up below the threshold of detection, and the inhibiting of the ice advisory below 400 feet, were not adequately considered when the stall margin was being determined during the 1996 certification of the ice-detection system and associated procedures.
17. The stall protection system operated as designed: that it did not prevent the stall is related to the degraded performance of the wings.
18. The Category I approach was without the extra aids and defences required for Category II approaches.
19. Canadian regulations with respect to Category I approaches are more liberal than those of most countries and are not consistent with the ICAO International Standards and Recommended Practices (Annex 14), which defines visibility limits; in Canada, the visibility values, other than RVR, are advisory only.
20. Even though a Category I approach may be conducted in weather conditions reported to be lower than the landing minima specified for the approach, there is no special training required for any flight crew member, and there is no requirement that flight crew be tested on their ability to fly in such conditions.
21. Air Canada’s procedures required that the captain fly the aircraft when conducting a Category II approach, in all weather conditions; however, the decision as to who will fly low-visibility Category I approaches was left to the captain, who may not be in a position to adequately assess the first officer’s ability to conduct the approach.
22. The aircraft stalled at an angle of attack approximately 4.5 degrees lower, and at a CLmax 0.26 lower, than would be expected for the natural stall.
23. On final approach below 1000 feet agl, the wing performance on the accident flight was degraded over the wing performance at the same phase on the previous flight.
24. The engineering simulator comparison indicated two step reductions in aircraft performance, at 400 feet and 150 feet agl, as a result of local flow separation in the vicinity of wing station (WS) 247 and WS 253.
25. Pitting on the leading edges of the wings had a negligible effect on the performance of the aircraft.
26. The sealant on the leading edges of both wings was missing in some places and protruding from the surface 2 to 3 mm in others. Test flights indicate that the effect of the protruding chordwise sealant on the aircraft performance could have accounted for a reduction of 1.7 to 2.0 degrees in maximum fuselage angle of attack and of 0.03 to 0.05 in CLmax.
27. The maximum reduction in angle of attack resulting from ground effect is considered to be in the order of 0.75±0.5 degree: the aircraft angle of attack was influenced by ground effect during the go-around manoeuvre.
28. The performance loss caused by the protruding sealant and by ground effect was not great enough to account for the performance loss experienced; there is no apparent phenomenon other than ice accretion that could account for the remainder of the performance loss.
29. Neither Bombardier Inc., nor Transport Canada, nor Air Canada ensured that the regulations, manuals, and training programs prepared flight crews to successfully and consistently transition to visual flight for a landing or to go-around in the conditions that existed during this flight, especially considering the energy state of the aircraft when the go-around was commenced.
Other Findings:
1. Both the captain and the first officer were licensed and qualified for the duties performed during the flight in accordance with regulations and Air Canada training
and standards, except for minor training deficiencies with regard to emergency equipment.
2. The occurrence flight attendant was trained and qualified for the flight in accordance with existing requirements.
3. The aircraft was within its weight and centre-of-gravity limits for the entire flight.
4. Records indicate that the aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures.
5. There was no indication found of a failure or malfunction of any aircraft component prior to or during the flight.
6. When the stick shaker activated, it is unlikely that the crew could have landed the aircraft safely or completed a go-around without ground contact.
7. When power was selected for the go-around, the engines accelerated at a rate that would have been expected had the thrust levers been slammed to the go-around power setting.
8. The aircraft was not equipped with an emergency locator transmitter, nor was one required by regulation.
9. The lack of an emergency locator transmitter probably delayed locating the aircraft and its occupants.
10. Passengers and crew had no effective means of signaling emergency rescue services personnel.
11. The flight crew did not receive practical training on the operation of any emergency exits during their initial training program, even though this was required by
regulation.
12. Air Canada’s initial training program for flight crew did not include practical training in the operation of over-wing exits or the flight deck escape hatch.
13. Air Canada’s annual emergency procedures training for flight crew regarding the operation and use of emergency exits did not include practical training every third year, as required. Annual emergency exit training was done by demonstration only.
14. The flight crew were unaware that a pry bar was standard emergency equipment on the aircraft.
15. The four emergency flashlights carried on board were located in the same general area of the aircraft, increasing the possibility that all could be rendered inaccessible or unserviceable in an accident. (See section 4.1.6)
16. That there was a Flight Service Station specialist, as opposed to a tower controller, at the Fredericton airport at the time of the arrival of ACA 646 was not material to this occurrence.

The aircraft lost power on the left engine during the approach for undetermined reasons and descended into the ground. The cause of the engine power loss was not determined. The low airspeed, at the time of the engine power loss, decreased the time available to the pilot to secure the emergency in accordance with the POH, and contributed to the poor single-engine performance of the aircraft.

There was a loss of power from the right engine, and the pilot did not conserve altitude or configure the aircraft for maximum performance following the loss of power. Control of the aircraft was lost, probably as the pilot was attempting to intercept the ILS for runway 13 during a low-level turn. Contributing factors were the overweight condition of the aircraft and the lack of in-flight emergency procedures training received by the pilot.

The crew of Empress 204 allowed the aircraft to descend below the minimum descent altitude for the approach.

A fuel pump go dry and ignited fuel vapor after becoming overheated. Fifth KC-135 accident due to similar causes. At least 1,500 liters of fuel must remain in all tanks to avoid fuel pump overheating.

It was determined that the crew landed on a runway that was closed to trafic due to a snow removal procedure.