Quebec

Findings as to Causes and Contributing Factors:
1. After the take-off at reduced power, the aircraft performance during the initial climb was lower than that established at certification.
2. The right engine experienced a problem in flight that led to a substantial loss of thrust.
3. The right propeller was not feathered; therefore, the rate of climb was compromised by excessive drag.
4. The absence of written directives specifying which pilot was to perform which tasks may have led to errors in execution, omissions, and confusion in the cockpit.
5. Although the crew had the training required by regulation, they were not prepared to manage the emergency in a coordinated, effective manner.
6. The priority given to ATC communications indicates that the crew did not fully understand the situation and were not coordinating their tasks effectively.
7. The impact with the berm caused worse damage to the aircraft.
8. The aircraft’s upside-down position and the damage it sustained prevented the occupants from evacuating, causing them to succumb to the smoke and the rapid, intense fire.
9. The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.
10. The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Findings as to Risk:
1. Deactivating the flight low pitch stop system warning light or any other warning system contravenes the regulations and poses significant risks to flight safety.
2. The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.
3. Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.
4. The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.
5. The lack of an in-depth review by TC of SOPs and checklists of 703 operators poses a safety risk because deviations from aircraft manuals are not detected.
6. Conditions of employment, such as flight hours–based remuneration, can influence pilots’ decisions, creating a safety risk.
7. The absence of an effective non-punitive and confidential voluntary reporting system means that hazards in the transportation system may not be identified.
8. The lack of recorded information significantly impedes the TSB’s ability to investigate accidents in a timely manner, which may prevent or delay the identification and communication of safety deficiencies intended to advance transportation safety.

Findings as to Causes and Contributing Factors:
For undetermined reasons, the crew continued its descent prematurely below the published approach minima, leading to a controlled flight into terrain (CFIT).
Findings as to Risk:
1. The use of the step-down descent technique rather than the stabilized constant descent angle (SCDA) technique for non-precision instrument approaches increases the risk of an approach and landing accident (ALA).
2. The depiction of the RNAV (GNSS) Runway 12 approach published in the Canada Air Pilot (CAP) does not incorporate recognized visual elements for reducing ALAs, as recommended in Annex 4 to the Convention, thereby reducing awareness of the terrain.
3. The installation of a terrain awareness warning system (TAWS) is not yet a requirement under the Canadian Aviation Regulations (CARs) for air taxi operators. Until the changes to regulations are put into effect, an important defense against ALAs is not available.
4. Most air taxi operators are unaware of and have not implemented the FSF ALAR task force recommendations, which increases the risk of a CFIT accident.
5. Approach design based primarily on obstacle clearance instead of the 3° optimum angle increases the risk of ALAs.
6. The lack of information on the SCDA technique in Transport Canada reference manuals means that crews are unfamiliar with this technique, thereby increasing the risk of ALAs.
7. Use of the step-down descent technique prolongs the time spent at minimum altitude, thereby increasing the risk of ALAs.
8. Pilots are not sufficiently educated on instrument approach procedure design criteria. Consequently, they tend to use the CAP published altitudes as targets, and place the aircraft at low altitude prematurely, thereby increasing the risk of an ALA.
9. Where pilots do not have up-to-date information on runway conditions needed to check runway contamination and landing distance performance, there is an increased risk of landing accidents.
10. Non-compliance with instrument flight rules (IFR) reporting procedures at uncontrolled airports increases the risk of collision with other aircraft or vehicles.
11. If altimeter corrections for low temperature and remote altimeter settings are not accurately applied, obstacle clearance will be reduced, thereby increasing the CFIT risk.
12. When cockpit recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
13. Task-induced fatigue has a negative effect on visual and cognitive performance which can diminish the ability to concentrate, operational memory, perception and visual acuity.
14. Where an emergency locator transmitter (ELT) is not registered with the Canadian Beacon Registry, the time needed to contact the owner or operator is increased which could affect occupant rescue and survival.
15. If the tracking of a call to 911 emergency services from a cell phone is not accurate, search and rescue efforts may be misdirected or delayed which could affect occupant rescue and survival.
Other Findings:
1. Weather conditions at the alternate airport did not meet CARs requirements, thereby reducing the probability of a successful approach and landing at the alternate airport if a diversion became necessary.
2. Following the accident, none of the aircraft exits were usable.

Findings as to Causes and Contributing Factors:
1. The aircraft was configured late for the approach, resulting in an unstable approach condition.
2. The pilot flying carried out a steep turn at a low altitude, thereby increasing the load factor. Consequently, the aircraft stalled at an altitude that was too low to allow the pilot to carry out a stall recovery procedure.
Findings as to Risk:
1. The time spent programming the global positioning system reduced the time available to manage the flight. Consequently, the crew did not make the required radio communications on the mandatory frequency, did not activate the aircraft radio control of aerodrome lighting (ARCAL), did not make the verbal calls specified in the standard operating procedures (SOPs), and configured the aircraft for the approach and landing too late.
2. During the second approach, the aircraft did a race-track pattern and descended below the safe obstacle clearance altitude, thereby increasing the risk of a controlled flight into terrain. The crew’s limited instrument flight rules (IFR) experience could have contributed to poor interpretation of the IFR procedures.
3. Non-compliance with communications procedures in a mandatory frequency area created a situation in which the pilots of both aircraft had poor knowledge of their respective positions, thereby increasing the risk of collision.
4. The pilot-in-command monitored approach (PICMA) procedure requires calls by the pilot not flying when the aircraft deviates from pre-established acceptable tolerances. However, no call is required to warn the pilot flying of an approaching steep bank.
5. The transfer of controls was not carried out as required by the PICMA procedure described in the SOPs. The transfer of controls at the co-pilot’s request could have taken the pilot-in-command by surprise, leaving little time to choose the best option.
6. Despite their limited amount of IFR experience in a multiple crew working environment, the two pilots were paired. Nothing prohibited this. Although the crew had received crew resource management (CRM) training, it still had little multiple crew experience and consequently little experience in applying the basic principles of CRM.
Other Findings:
1. The emergency locator transmitter (ELT) had activated after the impact but due to circuit board damage its transmission power was severely limited. This situation could have had serious consequences had there been any survivors.
2. The Chibougamau/Chapais airport does not have an aircraft rescue and firefighting service. Because the fire station is 23 kilometres from the airport, the firefighters arrived at the scene 26 minutes after the accident.
3. Although this accident does not meet the criteria of a controlled flight into terrain (CFIT), it nonetheless remains that a stabilized constant descent angle (SCDA) non-precision approach (NPA) would have provided an added defence tool to supplement the SOPs.
4. After the late call within the mandatory frequency (MF) area, the specialist at the Québec flight information centre asked the crew about its familiarity with the MF area while the aircraft was in a critical phase of the first approach, which was approaching the minimum descent altitude (MDA). This situation could have distracted the flight crew while they completed important tasks.
5. The standard checklist used by the flight crew made no reference to the enhanced ground proximity warning system (EGPWS). Therefore, the crew was not prompted to check it to ensure that it was properly activated before departure.

Finding as to Causes and Contributing Factors:
1. The aircraft stalled at an altitude that was too low for the pilot to recover.
Findings as to Risk:
1. The aircraft was flying at an altitude that could lead to a collision with an obstacle and that did not allow time for recovery.
2. The steep right bank of the aircraft considerably increased the aircraft’s stall speed.
3. The form used to record the pilot’s flight time, flight duty time, and rest periods had not been updated for over a month; this did not allow the company manager to monitor the pilot’s hours.
4. At the time of the occurrence, the Aéropro company operations manual did not make provision for the restrictions on daytime VFR flights prescribed in Section 703.27 of the Canadian Aviation Regulations.
Other Findings:
1. The fact that the aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice recorder (CVR) limited the information available for the investigation and limited the scope of the investigation.
2. Since the aircraft was on a medical evacuation (MEDEVAC) flight, the company mistakenly advised the search and rescue centre that there were two pilots on board the aircraft when it was reported missing.

Findings as to Causes and Contributing Factors:
1. The engine stopped as a result of fuel starvation; the amount of fuel in the wings was less than the amount estimated by the pilot, the fuel senders gave an incorrect reading, and the low fuel pressure warning light could illuminate randomly.
2. The engine stopped at low altitude, which reduced the time needed to complete the emergency procedure. The pilot was unable to glide to the lake and made a forced landing on an unsuitable terrain, causing significant damage to the aircraft and injuries to the occupants.
Findings as to Risk:
1. The wing tank selection system was subject to icing in cold weather, and the pilots adopted the practice to place the wing tank selector in the middle position, which is contrary to the aircraft flight manual supplement instructions and a placard posted on the instrument panel.
2. When the change to the type design was approved through issuance of the Supplementary Type Certificate (STC), Transport Canada did not notice the fact that the fuel senders and triple fuel level gauge did not meet airworthiness standards; Transport Canada issued an STC that contained several deficiencies. 3. Storage of the shoulder harnesses underneath the aircraft interior covering made them inaccessible; since the pilot and the front seat passenger did not wear their shoulder harness, their protection was reduced.

Finding as to Causes and Contributing Factors:
1. The pilot attempted to cross the mountain ridge in adverse weather, and the aircraft stalled at an altitude from which recovery was not possible. Loss of visual references, strong updrafts, moderate to severe turbulence and possible wind shear likely contributed to the onset of the aerodynamic stall.
Other Finding:
1. Had this been a survivable accident, rescue efforts may have been compromised by a lack of communication. A satellite phone provides a more effective means of communication when in remote areas.

Findings as to Causes and Contributing Factors:
1. The flight crew attempted a night landing in the absence of runway edge lights. The aircraft touched down 300 feet to the left of Runway 05L and 1800 feet beyond the threshold.
2. The runway was not closed for night use despite the absence of runway edge lights. Nothing required it to be closed.
3. Poor flight planning, non-compliance with regulations and standard operating procedures (SOPs), and the lack of communications between the two pilots reveal a lack of airmanship on the part of the crew, which contributed to the accident.
Findings as to Risk:
1. Because they had not been given a safety briefing, the passengers were not familiar with the use of the main door or the emergency exit, which could have delayed the evacuation, with serious consequences.
2. The armrest of the side seat had not been removed as required and was blocking access to the emergency exit, which could have delayed the evacuation, with serious consequences.
3. Because they had not been given a safety briefing, the passengers seated in the side seats did not know that they should have worn shoulder straps and did not wear them, so they were not properly protected.
4. The possibility of flying to an airport that does not meet the standards for night use gives pilots the opportunity to attempt to land there, which in itself increases the risk of an accident.
5. The landing performance diagrams and the chart used to determine the landing distance did not enable the flight crew to ensure that the runway was long enough for a safe landing on a snow-covered surface.

Finding as to Causes and Contributing Factors:
1. The aircraft struck the water for undetermined reasons.
Findings as to Risk:
1. The certificate of airworthiness was not in effect at the time of the accident because of the airworthiness directives that had not been completed.
2. The distress signal emitted by the fixed, automatic emergency locator transmitter (ELT) was not received because of the reduced range of the signal once the ELT was submerged, which could have increased the response time of search and rescue units if there had been no witnesses to the accident.
3. The pilot had not made a training flight with an instructor for more than 19 months, which could have resulted in a degradation of his skills and decision-making process.

Findings as to Causes and Contributing Factors:
1. The aircraft was positioned over the runway threshold at an altitude that did not allow a landing at the beginning of the runway, and this, combined with a tailwind component and the wet runway surface, resulted in a runway excursion.
2. Failure to follow standard operating procedures and a lack of crew coordination contributed to confusion on landing, which prevented the crew from aborting the landing and executing a missed approach.
3. The pilot-in-command held several management positions within the company and controlled the pilot hiring and dismissal policies. This situation, combined with the level of experience of the co-pilot compared with that of the pilot-in-command, had an impact on crew cohesiveness.
Findings as to Risk:
1. The pilot-in-command of C-FMAI decided to execute an approach for Runway 05 without first ensuring that there would be no possible risk of collision with the other aircraft.
2. The regulatory requirement to conform to or avoid the traffic pattern formed by other aircraft is not explicit as to how the traffic pattern should be avoided, in terms of either altitude or distance, which can result in risks of collision.
3. The regulations do not indicate whether the missed approach segment should be considered part of the traffic pattern; this situation can lead pilots operating in uncontrolled airspace to believe that they are avoiding another aircraft executing an instrument approach when in reality a risk of collision exists.