Accident Overview
On the day of the accident, at 0557 Eastern Daylight Time, an aircraft departed from Runway 30 at Québec/Jean Lesage International Airport on an instrument flight rules flight to Sept-Îles, Quebec. The takeoff run began at 0557. Sixty-eight seconds later, the co-pilot informed the airport controller of a problem with the right engine and stated the intention to return to land on Runway 30. The co-pilot then requested aircraft rescue and fire-fighting (ARFF) services and reported that the aircraft could no longer climb. A few seconds later, the aircraft struck the ground 1.5 nautical miles from the end of Runway 30. It traveled 115 feet before striking a berm, then broke up and caught fire, coming to rest inverted 58 feet further. The two crew members and five passengers died in the accident. The emergency locator transmitter (ELT) did not transmit a signal.
Probable Cause Findings
The investigation identified the following causes and contributing factors:
1. After take-off at reduced power, aircraft performance during initial climb was lower than certified. 2. The right engine experienced a problem in flight leading to substantial loss of thrust. 3. The right propeller was not feathered, causing excess drag that compromised climb rate. 4. Absence of written directives specifying task allocation between pilots may have led to errors, omissions, and confusion. 5. The crew had required training but were not prepared to manage the emergency in a coordinated, effective manner. 6. Priority given to ATC communications indicated the crew did not fully understand the situation and were not coordinating tasks effectively. 7. Impact with the berm caused worse damage. 8. The aircraft’s inverted position and damage prevented evacuation, causing occupants to succumb to smoke and fire. 9. Poor safety culture at Aéropro contributed to acceptance of unsafe practices. 10. Transport Canada's significant measures did not ensure regulatory compliance, allowing unsafe practices to persist.
Additionally, the investigation listed several findings as to risk, including deactivation of warning systems contravening regulations, inadequate maintenance procedures and practices preventing determination of engine power capability, lack of rigor in maintenance documentation, non-compliant recording of defects in aircraft journey log, lack of in-depth review of standard operating procedures and checklists by Transport Canada, flight hours-based remuneration influencing pilot decisions, absence of an effective non-punitive and confidential voluntary reporting system, and lack of recorded information impeding the Transportation Safety Board's ability to investigate.