Human factor

The following factors were identified:
- Application of the commands - contributed
There was no effective action on the aircraft controls during the final approach to avoid a brutal impact with the ground prior to the runway threshold.
- Adverse weather conditions - undetermined
It is possible that the aircraft was under the effect of the phenomenon known as windshear, which affected the approach profil and the subsequent impact with the ground short of runway.
- Pilot judgement - contributed
The risks of a possible windshear during the final approach were not adequately considered by the pilot. The decision to proceed for the landing, to the detriment of the alternative recommended by experts to perform a missed approach, proved decisive for the development of the accident.

Findings as to causes and contributing factors:
1. Neither pilot had considered that the combination of landing at night, in reduced visibility, with a crosswind and blowing snow, on a runway with no centreline lighting, was a hazard that may create additional risks.
2. The blowing snow made it difficult to identify the runway centreline markings, thereby reducing visual cues available to the captain. This situation was exacerbated by the absence of centreline lighting and a possible visual illusion caused by blowing snow.
3. Due to the gusty crosswind conditions, the aircraft drifted to the right during the landing flare, which was not recognized by the crew.
4. It is likely that the captain had difficulty determining aircraft position during the landing flare.
5. The flight crew’s decision to continue with the landing was consistent with plan continuation bias.
6. During landing, the nosewheel struck the compacted snow windrow on the runway, causing the nose landing gear to collapse.

Findings as to risk:
1. If aircraft are not equipped with a 406 MHz-capable emergency locator transmitter, flight crews and passengers are at increased risk of injury or death following an accident because search-and-rescue assistance may be delayed.
2. If operators do not have defined crosswind limits, there is a risk that pilots may land in crosswinds that exceed their abilities, which could jeopardize the safety of flight.
3. If composite propeller blades contact objects and separate, and then strike or penetrate the cabin, there is a risk of injury or death to occupants seated in the propeller’s plane of rotation.
4. If modern crew resource management training is not a regulatory requirement, then it is less likely to be introduced by operators and, as a result, pilots may not be fully prepared to recognize and mitigate hazards encountered during flight.
5. If organizations do not use modern safety management practices and do not have a robust safety culture, then there is an increased risk that hazards will not be identified and mitigated.
6. When testing an emergency locator transmitter’s (ELT) automatic activation system, a sticking g-switch may go undetected if more than 1 football throw is necessary to activate the ELT. As a result, the ELT might not activate during an accident, and search-and-rescue assistance may be delayed, placing flight crews and passenger at an increased risk for injury or death.

The unstable approach in black-hole conditions, resulting in the airplane overshooting the runway extended centerline and descending well below a safe glidepath for the runway. Contributing to the accident was the lack of monitoring by the copilot allowing the pilot to fly well below a normal glidepath.

The aircraft’s centre of gravity was significantly aft of the aft limit. When landing flap was set, full nose-down elevator and elevator trim was likely to have had no effect in lowering the nose of the aircraft. Unless the flaps had been retracted immediately, the nose-up pitch may also have resulted in tail plane stall, exacerbating the pitch up. The wings stalled, followed immediately by the right wing dropping. Recovery from the stall at such a low height was not considered possible.
Other factors:
Other factors is used for safety deficiencies or concerns that are identified during the course of the investigation, that while not causal to the accident, nevertheless should be addressed with the
aim of accident and serious incident prevention, and the safety of the travelling public.
a) Following the reweighing of SBC, the operator did not make adjustments to account for the shift of the moment arm as a result of the reweighing. Specifically, a reduction of allowable maximum weight in the baggage compartment.
b) The pilot, although signing the flight manifest on previous flights attesting that the aircraft was loaded within c of g limits, had not computed the c of g. No documentation was available to confirm that the pilot had computed the c of g for the accident flight, or any recent flights.
c) All of the High Frequency radio transmissions between Air Traffic Services and SBC were significantly affected by static interference and a lot of hash, making reception difficult, and many transmissions unclear and unreadable. This is a safety concern to be addressed to ensure that vital operational radio transmissions are not missed for the safety of aircraft operations, and the travelling public.

The pilot's failure to maintain directional control during the aborted landing in gusty crosswind conditions, which resulted in a runway excursion and a collision with a tree.

Controlled flight into terrain after the crew continued the approach in poor visibility without visual contact with the environment. Misidentification of the environment on part of the crew was a contributing factor, as well as the fact that the crew deactivated the GPWS alarm and failed to initiate corrective maneuver.

The collision was the result of a poor coordination by ATC staff at Jakarta Airport. The following factors were reported:
- Handling of two movements in the same area with different controllers on separate frequencies without proper coordination resulted in the lack of awareness to the controllers, pilots and towing car driver,
- The communication misunderstanding of the instruction to follow ID 7703 most likely contributed the towed aircraft enter the runway,
- The lighting environments in the tower cab and turning pad area of runway 24 might have diminished the capability to the controllers and pilots to recognize the towed aircraft that was installed with insufficient lightings.

Most probably the accident with An-2 RA-54828 aircraft after its takeoff in order to perform crop dusting was caused by inadvertent engine cut-off due to water ingestion into fuel flow system. Most probably water ingestion into engine fuel flow system was due to violation of refueling procedure by the crew. The aircraft sustained significant damage during the emergency landing on slush soft surface.

Findings as to causes and contributing factors:
1. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach.
2. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.
4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.
5. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.
6. It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.

Findings as to risk:
1. If the weight of an aircraft exceeds the certified maximum take-off weight, there is a risk of aircraft performance being degraded, which may jeopardize the safety of the flight.
2. If pilots engage in non-essential communication during critical phases of flight, there is an increased risk that they will be distracted, which reduces the time available to complete cockpit activities and increases their workload.
3. If flight, cockpit, or image/video data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
4. If pilots do not recognize that changing circumstances require a new plan, then plan continuation bias may lead them to continue with their original plan even though it may not be safe to do so.
5. If pilots do not apply stable-approach criteria, there is a risk that they will continue an unstable approach to a landing, which can lead to an approach-and-landing accident.
6. If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.
7. If a flight plan does not contain search-and-rescue supplementary information, and if that information is not transmitted or readily available, there is a risk that first responders will not have the information they need to respond adequately.

Other findings:
1. Transport Canada does not monitor or track the number of days foreign-registered aircraft are in Canada during a given 12-month period.
2. Turbulence and icing were not considered factors in this occurrence.
3. Transport Canada considers that the discretionary installation of an angle-of-attack system on normal-category, type-certificated, Canadian-registered aircraft is a major modification that requires a supplemental type certificate approval.
4. Although the aircraft was not in compliance with Airworthiness Directive 2006-17-05 at the time of the occurrence, there was no indication that it was operating outside of the directive’s specifications.
5. Although not required by regulation, the installation and use of a lightweight flight recording system during the occurrence flight, as well as the successful retrieval of its data during the investigation, permitted a greater understanding of this accident.

The fatal air accident to the Boeing 737-8KN A6-FDN aircraft occurred during the second go around, due to an incorrect aircraft configuration and crew piloting, the subsequent loss of PIC’s situational awareness in nighttime in IMC. This resulted in a loss of control of the aircraft and its impact with the ground. The accident is classified as Loss of Control In-Flight (LOC-I) occurrence.
Most probably, the contributing factors to the accident were:
- The presence of turbulence and gusty wind with the parameters, classified as a moderate to-strong "windshear" that resulted in the need to perform two go-arounds;
- The lack of psychological readiness (not go-around minded) of the PIC to perform the second go-around as he had the dominant mindset on the landing performance exactly at the destination aerodrome, having formed out of the "emotional distress" after the first unsuccessful approach (despite the RWY had been in sight and the aircraft stabilized on the glide path, the PIC had been forced to initiate go-around due to the windshear warning activation), concern on the potential exceedance of the duty time to perform the return flight and the recommendation of the airline on the priority of landing at the destination aerodrome;
- The loss of the PIC’s leadership in the crew after the initiation of go-around and his "confusion" that led to the impossibility of the on-time transition of the flight mental mode from "approach with landing" into "go-around";
- The absence of the instructions of the maneuver type specification at the go-around callout in the aircraft manufacturer documentation and the airline OM;
- The crew’s uncoordinated actions during the second go-around: on the low weight aircraft the crew was performing the standard go-around procedure (with the retraction of landing gear and flaps), but with the maximum available thrust, consistent with the Windshear Escape Maneuver procedure that led to the generation of the substantial excessive nose-up moment and significant (up to 50 lb/23 kg) "pushing" forces on the control column to counteract it;
- The failure of the PIC within a long time to create the pitch, required to perform go around and maintain the required climb profile while piloting aircraft unbalanced in forces;
- The PIC’s insufficient knowledge and skills on the stabilizer manual trim operation, which led to the long-time (for 12 sec) continuous stabilizer nose-down trim with the subsequent substantial imbalance of the aircraft and its upset encounter with the generation of the negative G, which the crew had not been prepared to. The potential impact of the somatogravic "pitch-up illusion" on the PIC might have contributed to the long keeping the stabilizer trim switches pressed;
- The psychological incapacitation of the PIC that resulted in his total spatial disorientation, did not allow him to respond to the correct prompts of the F/O;
- The absence of the criteria of the psychological incapacitation in the airline OM, which prevented the F/O from the in-time recognition of the situation and undertaking more decisive actions;
- The possible operational tiredness of the crew: by the time of the accident the crew had been proceeding the flight for 6 hours, of which 2 hours under intense workload that implied the need to make non-standard decisions; in this context the fatal accident occurred at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors.
The lack of the objective information on the HUD operation (there were no flight tests of the unit carried out into the entire range of the operational G, including the negative ones; the impossibility to reproduce the real HUD readings in the progress of the accident flight, that is the image the pilot was watching with the consideration of his posture in the seat trough the stream video or at the FFS) did not allow making conclusion on its possible impact on the flight outcome. At the same time the investigation team is of the opinion that the specific features of the HUD indication and display in conditions existed during final phase of the accident flight (severe turbulence, the aircraft upset encounter with the resulting negative G, the significant difference between the actual and the target flight path) that generally do not occur under conditions of the standard simulator sessions, could have affected the situational awareness of the PIC, having been in the highly stressed state.