Nunavut

The exact cause of the accident remains unknown.

Findings as to causes and contributing factors:
1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a workaround solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq).
2. Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).
3. Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing and a shift away from welllearned, highly practised procedures.
4. Due to the lack of an instrument approach for the into-wind runway and the unsuccessful attempts at circling, the crew chose the option of landing with a tailwind, resulting in a steep, unstable approach.
5. The final descent was initiated beyond the missed approach point and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3- degree descent path.
6. Neither pilot heard the ground proximity warning system warnings; both were focused on landing the aircraft to the exclusion of other indicators that warranted alternative action.
7. During the final approach, the aircraft was unstable in several parameters. This instability contributed to the aircraft being half-way down the runway with excessive speed and altitude.
8. The aircraft was not in a position to land and stop within the confines of the runway, and a go-around was initiated from a low-energy landing regime.
9. The captain possibly eased off on the control column in the climb due to the low airspeed. This, in combination with the configuration change at a critical phase of flight, as called for in the company procedures, may have contributed to the aircraft’s poor climb performance.
10. A rate of climb sufficient to ensure clearance from obstacles was not established, and the aircraft collided with terrain.
11. The infant passenger was not restrained in a child restraint system, nor was one required by regulations. The infant was ejected from the mother’s arms during the impact sequence, and contact with the interior surfaces of the aircraft contributed to the fatal injuries.
Findings as to risk:
1. If instrument approaches are conducted without reference to an approach chart, there is a risk of weakened situational awareness and of error in following required procedures, possibly resulting in the loss of obstacle clearance and an accident.
2. If additional contingency fuel is not accounted for in the aircraft weight, there is a risk that the aircraft may not be operated in accordance with its certificate of airworthiness or may not meet the certified performance criteria.
3. If Transport Canada crew resource management (CRM) training requirements do not reflect advances in CRM training, such as threat and error management and assertiveness training, there is an increased risk that crews will not effectively employ CRM to assess conditions and make appropriate decisions in critical situations.
4. If a person assisting another is seated next to an emergency exit, there is an increased risk that the use of the exit will be hindered during an evacuation.
5. If a person holding an infant is seated in a row with no seatback in front of them, there is an increased risk of injury to the infant as no recommended brace position is available.
6. If young children are not adequately restrained, there is a risk that injuries sustained will be more severe.
7. If a lap-held infant is ejected from its guardian’s arms, there is an increased risk the infant may be injured, or cause injury or death to other occupants.
8. If more complete data on the number of infants and children travelling by air are not available, there is a risk that their exposure to injury or death in the event of turbulence or a survivable accident will not be adequately assessed and mitigated.
9. If temperature corrections are not applied to all altitudes on the approach chart, there is an increased risk of controlled flight into terrain due to a reduction of obstacle clearance.
10. If the missed approach point on non-precision instrument approaches is located beyond the 3-degree descent path, there is an increased risk that a landing attempt will result in a steep, unstable descent, and possible approach-and-landing accident.
11. If there is not sufficient guidance in the standard operating procedures, there is a risk that crews will not react and perform the required actions in the event that ground proximity warning system warnings are generated.
12. If standard operating procedures, the Airplane Flight Manual and training are not aligned with respect to low-energy go-arounds, there is a risk that crews may perform inappropriate actions at a critical phase of flight.
13. If non-compliant practices are not identified, reported, and dealt with by a company’s safety management system, there is a risk that they will not be addressed in a timely manner.
14. If Transport Canada’s oversight is dependent on the effectiveness of a company’s safety management system’s reporting of safety issues, there is a risk that important issues will be missed.
Other findings:
1. The quick response of the people on the ground reduced the exposure of passengers and crew to the elements.

Findings as to causes and contributing factors:
1. The late initiation and subsequent management of the descent resulted in the aircraft turning onto final approach 600 feet above the glideslope, increasing the crew’s workload and reducing their capacity to assess and resolve the navigational issues during the remainder of the approach.
2. When the heading reference from the compass systems was set during initial descent, there was an error of −8°. For undetermined reasons, further compass drift during the arrival and approach resulted in compass errors of at least −17° on final approach.
3. As the aircraft rolled out of the turn onto final approach to the right of the localizer, the captain likely made a control wheel roll input that caused the autopilot to revert from VOR/LOC capture to MAN and HDG HOLD mode. The mode change was not detected by the crew.
4. On rolling out of the turn, the captain’s horizontal situation indicator displayed a heading of 330°, providing a perceived initial intercept angle of 17° to the inbound localizer track of 347°. However, due to the compass error, the aircraft’s true heading was 346°. With 3° of wind drift to the right, the aircraft diverged further right of the localizer.
5. The crew’s workload increased as they attempted to understand and resolve the ambiguity of the track divergence, which was incongruent with the perceived intercept angle and expected results.
6. Undetected by the pilots, the flight directors likely reverted to AUTO APP intercept mode as the aircraft passed through 2.5° right of the localizer, providing roll guidance to the selected heading (wings-level command) rather than to the localizer (left-turn command).
7. A divergence in mental models degraded the crew’s ability to resolve the navigational issues. The wings-level command on the flight director likely assured the captain that the intercept angle was sufficient to return the aircraft to the selected course; however, the first officer likely put more weight on the positional information of the track bar and GPS.
8. The crew’s attention was devoted to solving the navigational problem, which delayed the configuration of the aircraft for landing. This problem solving was an additional task, not normally associated with this critical phase of flight, which escalated the workload.
9. The first officer indicated to the captain that they had full localizer deflection. In the absence of standard phraseology applicable to his current situation, he had to improvise the go-around suggestion. Although full deflection is an undesired aircraft state requiring a go-around, the captain continued the approach.
10. The crew did not maintain a shared situational awareness. As the approach continued, the pilots did not effectively communicate their respective perception, understanding, and future projection of the aircraft state.
11. Although the company had a policy that required an immediate go-around in the event that an approach was unstable below 1000 feet above field elevation, no go-around was initiated. This policy had not been operationalized with any procedural guidance in the standard operating procedures.
12. The captain did not interpret the first officer’s statement of “3 mile and not configured” as guidance to initiate a go-around. The captain continued the approach and called for additional steps to configure the aircraft.
13. The first officer was task-saturated, and he thus had less time and cognitive capacity to develop and execute a communication strategy that would result in the captain changing his course of action.
14. Due to attentional narrowing and task saturation, the captain likely did not have a high- level overview of the situation. This lack of overview compromised his ability to identify and manage risk.
15. The crew initiated a go-around after the ground proximity warning system “sink rate” alert occurred, but there was insufficient altitude and time to execute the manoeuvre and avoid collision with terrain.
16. The first officer made many attempts to communicate his concerns and suggest a go-around. Outside of the two-communication rule, there was no guidance provided to address a situation in which the pilot flying is responsive but is not changing an unsafe course of action. In the absence of clear policies or procedures allowing a first officer to escalate from an advisory role to taking control, this first officer likely felt inhibited from doing so.
17. The crew’s crew resource management was ineffective. First Air’s initial and recurrent crew resource management training did not provide the crew with sufficient practical strategies to assist with decision making and problem solving, communication, and workload management.
18. Standard operating procedure adaptations on FAB6560 resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness. First Air’s supervisory activities did not detect the standard operating procedure adaptations within the Yellowknife B737 crew base.

Findings as to risk:
1. If standard operating procedures do not include specific guidance regarding where and how the transition from en route to final approach navigation occurs, pilots will adopt non-standard practices, which may introduce a hazard to safe completion of the approach.
2. Adaptations of standard operating procedures can impair shared situational awareness and crew resource management effectiveness.
3. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some first officers may feel inhibited from doing so.
4. If hazardous situations are not reported, they are unlikely to be identified or investigated by a company’s safety management system; consequently, corrective action may not be taken.
5. Current Transport Canada crew resource management training standards and guidance material have not been updated to reflect advances in crew resource management training, and there is no requirement for accreditation of crew resource management facilitators/instructors in Canada. This situation increases the risk that flight crews will not receive effective crew resource management training.
6. If initial crew resource management training does not develop effective crew resource management skills, and if there is inadequate reinforcement of these skills during recurrent training, flight crews may not adequately manage risk on the flight deck.
7. If operators do not take steps to ensure that flight crews routinely apply effective crew resource management practices during flight operations, risk to aviation safety will persist.
8. Transport Canada’s flight data recorder maintenance guidance (CAR Standard 625, Appendix C) does not refer to the current flight recorder maintenance specification, and therefore provides insufficient guidance to ensure the serviceability of flight data recorders. This insufficiency increases the risk that information needed to identify and communicate safety deficiencies will not be available.
9. If aircraft are not equipped with newer-generation terrain awareness and warning systems, there is a risk that a warning will not alert crews in time to avoid terrain.
10. If air carriers do not monitor flight data to identify and correct problems, there is a risk that adaptations of standard operating procedures will not be detected.
11. Unless further action is taken to reduce the incidence of unstable approaches that continue to a landing, the risk of controlled flight into terrain and of approach and landing accidents will persist.

Other findings:
1. It is likely that both pilots switched from GPS to VHF NAV during the final portion of the in-range check before the turn at MUSAT.
2. The flight crew of FAB6560 were not navigating using the YRB VOR or intentionally tracking toward the VOR.
3. There was no interference with the normal functionality of the instrument landing system for Runway 35T at CYRB.
4. Neither the military tower nor the military terminal controller at CYRB had sufficient valid information available to cause them to issue a position advisory to FAB6560.
5. The temporary Class D control zone established by the military at CYRB was operating without any capability to provide instrument flight rules separation.
6. The delay in notification of the joint rescue coordination centre did not delay the emergency response to the crash site.
7. The NOTAMs issued concerning the establishment of the military terminal control area did not succeed in communicating the information needed by the airspace users.
8. The ceiling at the airport at the time of the accident could not be determined. The visibility at the airport at the time of the accident likely did not decrease below approach minimums at any time during the arrival of FAB6560. The cloud layer at the crash site was surface-based less than 200 feet above the airport elevation.

Findings as to Causes and Contributing Factors:
1. At the fuel compound, the 45-gallon drum containing slops was located near the stock of sealed 45-gallon drums of 100LL AVGAS, contributing to the fuel handler selecting the drum of slops in error.
2. The 45-gallon drum of slops had similar markings to the stock of sealed 45-gallon drums of 100LL AVGAS, preventing ready identification of the contaminated drum.
3. The fuel handler did not notice that the large bung plug was not sealed on the second 45-gallon drum and, as a result, delivered the drum of slops to the aircraft.
4. The pilots did not notice that the large bung plug was not sealed on the second 45-gallon drum and, as a result, fuelled the aircraft with contaminated fuel.
5. The pilots were inexperienced with refuelling from 45-gallon drums and did not take steps to ascertain the proper fuel grade in the second 45-gallon drum. As a result, slops, rather than 100LL AVGAS, was pumped into the aircraft’s fuel system.
6. The fuel system design was such that the fuel from both wing fuel cells combined in the centre fuel cell and, as a result, contaminated fuel was fed to both engines.
7. The contaminated fuel resulted in engine power loss in both engines and the aircraft was unable to maintain altitude after takeoff.
Finding as to Risk:
1. The impact force angles were substantially different from that of the ELT’s G-switch orientation. As a result, the ELT did not activate during the impact. This could have delayed search and rescue (SAR) notification.

Landing gear went through the ice after landing on ice/snow terrain.

Findings as to Causes and Contributing Factors:
1. An abbreviated visual approach was conducted at night in instrument meteorological conditions, which resulted in the flight crew’s inability to obtain sufficient visual reference to judge their height above the ground.
2. The flight crew did not monitor pressure altimeter readings or reference the minimum altitude requirements in relation to aircraft position on the approach, resulting in controlled flight into terrain.
3. The pilots had not received training and performance checks for the installed global positioning system (GPS) equipment, and were not fully competent in its use. The attempts at adjusting the settings likely distracted the pilots from maintaining the required track and ground clearance during the final approach.
Findings as to Risk:
1. The precision approach path indicator systems (PAPI) at Cambridge Bay had not been inspected in accordance with the Airport Safety Program Manual. Although calibration of the equipment did not have a bearing on this occurrence, there was an increased risk of aircraft misalignment from the proper glide path, especially during night and reduced visibility conditions.
2. The flight crew’s cross-check of barometric altimeter performance was not sufficient to detect which instrument was inaccurate. As a result, reference was made to a defective altimeter, which increased the risk of controlled flight into terrain.
3. Operators’ maintenance organizations normally do not have access to the troubleshooting information contained in Component Maintenance Instruction Manuals for the Intercontinental Dynamics Corporation altimeters. Therefore, aircraft could be dispatched with damaged instruments with the potential for developing a loss of calibration during flight.
4. The flight was conducted during a period in which the crew’s circadian rhythm cycle could result in cognitive and physical performance degradation unless recognized and managed.

Findings as to Causes and Contributing Factors:
1. The pilot lost control of the aircraft while conducting a go-around from a balked landing on an ice strip.
2. The aircraft's centre of gravity (C of G) on the accident flight was beyond the aft C of G limit.
3. The actual C of G of the aircraft at basic operating weight was 16.7 inches aft of the C of G provided in the weight and balance report.
4. The load sheet index number used by the crew was inaccurate.
5. The stack of 2x4 lumber was inadequately secured and may have shifted rearward during the go-around.
6. The crew did not recalculate the aircraft's weight and balance for the second flight.
7. Leaks in the heater shroud allowed carbon monoxide gas to contaminate cockpit and cabin air.
8. The captain's carboxyhaemoglobin level was 17.9%, which may have adversely affected his performance, especially his decision making and his visual acuity.
Other Findings:
1. The carbon monoxide detector had no active warning system. The user directions for the detector, which are printed on the back of the detector, are obscured when the detector is installed.
2. The company maintenance facility overhauled the heater as required by the Transport Canada-approved inspection program.
3. Although the manufacturer's maintenance instruction manual for the S200 heater, part number 27C56, lists inspection and overhaul procedures, it does not specify their intervals.
4. No maintenance instructions are available for the heater, part number 27C56. The company maintenance facility did not conduct inspections, overhauls, or pressure decay tests as specified for later manufactured heaters.

Findings as to Causes and Contributing Factors:
1. The captain rejected the take-off at a speed well above the engine-failure recognition speed (V1) with insufficient runway remaining to stop before the end of the runway.
2. The far-forward position of the centre of gravity contributed to the pilot not rotating the aircraft to the normal take-off attitude.
3. The aircraft never achieved the required pitch for take-off. The captain=s inability to accurately assess the pitch attitude was probably influenced by the heavier than normal elevator control forces and the limited nighttime visual references.
4. The loadmaster did not follow the company- and Transport Canada-approved procedures to evaluate the excess baggage added to the aircraft, which led to a discrepancy of 450 pounds and a C of G position further forward than expected.
5. The performance analysis suggested that the aircraft was under-rotated as a result of a forward C of G loading and the generated lift never exceeded the aircraft=s weight during the take-off attempt.
Findings as to Risk:
1. The aircraft was approximately 200 pounds over maximum gross take-off weight.
2. The aircraft accelerated more slowly than normal, probably because of the snow on the runway.
3. Although atmospheric conditions were conducive to contamination and the aircraft was not de-iced, it could not be determined if contamination was present or if it degraded the aircraft performance during the attempted take-off.
4. Water methanol was not used for the occurrence take-off. Use of water methanol may have reduced the consequences of the rejected take-off.
5. The captain did not call for the overrun drill, and none of the items on the checklist were covered by the crew.
6. The co-pilot did not follow the emergency checklist and call air traffic control to advise of the rejected take-off or call over the public address system to advise the passengers to brace.
7. The aircraft lost all its electrical systems during the impact with the large rocks, rendering the radios unserviceable.
8. No HS-748 simulator exists that could be used to train pilots on the various take-off and rejected take-off scenarios.
9. There was confusion regarding the aircraft=s location. The flight service station, fire trucks, and intervening teams were not using an available grid map for orientation.
10. There is a risk associated with not de-icing aircraft before take-off in weather conditions such as those on the day of the accident.
11. There is a risk associated with not calculating the WAT limit and performance of an aircraft during an engine-out procedure in an environment with obstacles.
Other Findings
1. The aircraft=s brakes, anti-skid system, and tires functioned properly throughout the rejected take-off.