Alberta

Findings as to causes and contributing factors:
1. The aircraft joined the final approach well above the optimal 3° descent path and, during the steep approach that followed, the aircraft’s airspeed continually decelerated and resulted in an unstabilized approach.
2. On short final, the pilot reduced the rate of descent by increasing pitch rather than by adding power. As a result, the airspeed continued to decrease and the aircraft entered a stall, resulting in a hard landing and a subsequent bounce.
3. During the attempted rejected landing, the aircraft entered a 25° nose-high attitude and approached a stall condition. This low-speed condition combined with the high power setting resulted in the aircraft entering a rapid roll to the left and striking the runway in an inverted attitude.
4. The passengers did not receive a safety briefing before departure or before landing, and multiple items in the cabin were not secured. As a result, 1 passenger sustained serious injuries due to the deceleration forces and the loose items that were thrown around in the cabin during the accident.
5. The pilot was not wearing the available shoulder harness, and his torso was unrestrained during the impact. As a result, he sustained serious injuries.

Findings as to risk:
1. If pilots do not declare all health issues to Transport Canada Civil Aviation Medical Examiners and pilots’ family physicians do not declare issues assessed to be a risk to aviation safety to Transport Canada, there is an increased risk that pilots will operate with diagnosed medical conditions or medical side effects that could affect flight safety.
2. If an aircraft propeller is rotating and passengers are not supervised during boarding operations, there is a risk that passengers may inadvertently contact the propeller, potentially causing fatal injuries.

Other findings:
1. Following a review of the pilot’s medical history and prescription medication use, the investigation determined that the medication did not contribute to the accident.

Findings as to causes and contributing factors:
1. The pilot did not continuously use oxygen above 13 000 feet and likely became hypoxic as the aircraft climbed to 15 000 feet. The pilot did not recognize his symptoms or take action to restore his supply of oxygen.
2. As a result of hypoxia-related cognitive and perceptual degradations, the pilot was unable to maintain effective control of the aircraft or to respond appropriately to the asymmetric power condition.
3. The aircraft departed controlled flight and entered a spin to the right because the airspeed was below both the published minimum control speed in the air and the stall speed, and because there was a significant power asymmetry, a high angle of attack, and significant asymmetric drag from the windmilling propeller of the right engine.
4. When the aircraft exited cloud, the pilot completed only 1 of the 7 spin-recovery steps: reducing the power to idle. As the aircraft continued to descend, the pilot took no further recovery action, except to respond to air traffic control and inform the controller that there was an emergency.

Findings as to risk:
1. If flight crews do not undergo practical hypoxia training, there is a risk that they will not recognize the onset of hypoxia when flying above 13 000 feet without continuous use of supplemental oxygen.

Other findings:
1. The weather information collected during the investigation identified that the loss of control was not due to in-flight icing, thunderstorms, or turbulence.
2. Because the Appareo camera had been bumped and its position changed, the pilot’s actions on the power controls could not be determined. Therefore, the investigation was unable to determine whether the power asymmetry was the result of power-quadrant manipulation by the pilot or of an aircraft system malfunction.
3. The flight path data, audio files, and image files retrieved from the Appareo system enabled the investigators to better understand the underlying factors that contributed to the accident.

It was determined that the pilot continued the descent under VFR mode in IMC conditions, resulting in a controlled flight into terrain.

Findings as to Causes and Contributing Factors:
1. The conduct of the flight crew members during the instrument approach prevented them from effectively monitoring the performance of the aircraft.
2. During the descent below the minimum descent altitude, the airspeed reduced to a point where the aircraft experienced an aerodynamic stall and loss of control. There was insufficient altitude to effect recovery prior to ground impact.
3. For unknown reasons, the stall warning horn did not activate; this may have provided the crew with an opportunity to avoid the impending stall.
Findings as to Risk:
1. The use of company standard weights and a non-current aircraft weight and balance report resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.
2. Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.
3. Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.
4. Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance parameters of an instrument approach.

Findings as to Causes and Contributing Factors:
1. The gyro/horizon failed due to excessive wear on bearings and other components, resulting from a lack of maintenance and due to a vacuum system that was possibly not at minimum operating requirements for the instrument.
2. The gyro/horizon was reinstalled into the aircraft to complete the occurrence flight without the benefit of the recommended overhaul.
3. The autopilot became unusable when the attitude information from the gyro/horizon was disrupted.
4. The pilot had not practised partial panel instrument flying for a number of years, was not able to transition to a partial panel situation, and lost control of the aircraft while flying in instrument meteorological conditions.
5. The aircraft was loaded in excess of its certified gross weight and had a centre of gravity (C of G) that exceeded its aft limit. These two factors made the aircraft more difficult to handle due to an increase of the aircraft’s pitch control sensitivity and a reduction of longitudinal stability.
6. The structural limitations of the aircraft were exceeded during the uncontrolled descent; this resulted in the in-flight breakup.
7. There were a number of deficiencies with the company’s safety management system (SMS), in which the hazards should have been identified and the associated risks mitigated.
8. The company did not conduct an annual risk assessment as required by its SMS; this increased the risk that a hazard could go undetected.
9. The Canadian Business Aviation Association (CBAA) audit did not identify the risks in the company’s operations.
Findings as to Risk:
1. Lack of adequate instrument redundancy increases the risk of loss of control in single-pilot instrument flight rules (IFR) aircraft operations.
2. The pilot did not reduce his airspeed while attempting to maintain control of the aircraft; a lower speed would have allowed a greater margin to maximum operating speed (Vmo) while manoeuvring.
3. There were no quick-donning oxygen masks on board and the pilot was not wearing an oxygen mask at the time of the occurrence, as required by regulation.
4. If effective oversight of private operator certificate (POC) holders is not exercised by the regulator or its delegated organization, there is an increased risk that safety deficiencies will not be identified and properly addressed.
Other Finding:
1. The approved maintenance organization (AMO) that was maintaining the aircraft did not have the approval to maintain PA-46 turbine aircraft.