Human factor

The pilot’s improper configuration of the airplane following an engine shutdown, which resulted in a low-altitude, unstabilized approach. Contributing to the accident was a loss of engine power for undetermined reasons.

Controlled flight into terrain after the crew descended too low on final approach.
The following contributing factors were identified:
- Limited visibility due to the night and low clouds,
- The approach was completed with a tailwind component,
- The approach was started about an hour after sunset,
- The copilote was inexperienced.

Loss of control in altitude for undetermined reasons.

The pilot's continued visual flight into instrument meteorological conditions, which resulted in an in-flight collision with terrain.

The accident was caused by the loss of control of the airplane by the crew following the improvised demonstration of the functioning of the angle of attack protections, while the blockage of the angle of attack sensors made it impossible for these protections to trigger. The crew was not aware of the blockage of the angle of attack sensors. They did not take into account the speeds mentioned in the program of checks available to them and consequently did not stop the demonstration before the stall.
The following factors contributed to the accident:
• The decision to carry out the demonstration at a low height
• The crew’s management, during the thrust increase, of the strong increase in the longitudinal pitch, the crew not having identified the pitch-up stop position of the horizontal stabilizer nor acted on the trim wheel to correct it, nor reduced engine thrust
• The crew having to manage the conduct of the flight, follow the program of in-flight checks, adapted during the flight, and the preparation of the following stage, which greatly increased the workload and led the crew to improvise according to the constraints encountered
• The decision to use a flight program developed for crews trained for test flights, which led the crew to undertake checks without knowing their aim
• The absence of a regulatory framework in relation to non-revenue flights in the areas of air traffic management, of operations and of operational aspects
• The absence of consistency in the rinsing task in the airplane cleaning procedure, and in particular the absence of protection of the AOA sensors, during rinsing with water of the airplane three days before the flight. This led to the blockage of the AOA sensors through freezing of the water that was able to penetrate inside the sensor bodies.
The following factors also probably contributed to the accident:
• Inadequate coordination between an atypical team composed of three airline pilots in the cockpit
• The fatigue that may have reduced the crew’s awareness of the various items of information relating to the state of the systems.

Findings as to Causes and Contributing Factors:
1. Though icing conditions were encountered, the airframe de-icing boots were not cycled nor was the Vref speed increased to offset the effects of aircraft icing.
2. An abrupt change in aircraft configuration, which included a reduction in power to flight idle and the addition of 35° flap, caused the aircraft’s speed to rapidly decrease.
3. The aircraft entered an aerodynamic stall due to the decreased performance caused by the icing. There was insufficient altitude to recover the aircraft prior to impact with the runway.
Finding as to Risk:
1. The company had not incorporated the British Aerospace Notice to Aircrew into its standard operating procedures (SOP) at the time of the occurrence. Therefore, crews were still required to make configuration changes late in the approach sequence, increasing the risk of an unstabilised approach.

Double engine failure caused by a fuel exhaustion. The following contributing factors were identified:
- Poor flight planning,
- The crew failed to add sufficient fuel prior to departure from Teresina Airport,
- The fuel quantity was insufficient for the required distance,
- The crew failed to follow the published procedures,
- Overconfidence from the crew,
- Poor organisational culture on part of the operator,
- Lack of discipline and poor judgment on part of the crew,
- Lack of supervision.

The pilot's failure to maintain control of the airplane during final approach for landing in night, visual meteorological conditions for undetermined reasons.

Findings as to Causes and Contributing Factors
1. The pilot likely departed and continued flight in conditions that were below visual
flight rules (VFR) weather minima.
2. The pilot continued his VFR flight into instrument meteorological conditions (IMC),
and did not recognize his proximity to terrain until seconds before colliding with
Thormanby Island, British Columbia.
3. The indication of a marginal weather improvement at Powell River, British Columbia,
and incorrect information from Merry Island, British Columbia, may have
contributed to the pilot’s conclusion that weather along the route would be sufficient
for a low-level flight.
Findings as to Risk:
1. The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received.
2. Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety.
3. The lack of pilot decision making (PDM) training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions.
4. Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions.
5. Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions.
6. Incremental growth in Pacific Coastal’s support to Kiewit did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected.
7. Transport Canada’s guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows.
8. Previous discussions between Pacific Coastal and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk.
9. There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart.
10. Because the aircraft’s emergency locator transmitter (ELT) failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed.
11. On a number of flights, pilots on the Vancouver–Toba Inlet route, British Columbia, departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits.
12. The over-reliance on global positioning system (GPS) in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers.
Other Finding:
1. The SPOT Satellite Messenger data transmitted before the crash helped to narrow the search area and reduce the search time to find the aircraft. The fact that the wrong data were consulted caused an initial delay in reporting the missing aircraft.