Narrative
On the evening of the accident, TW350, a twin-engine turboprop aircraft, departed La Ronge, Saskatchewan, at 1930 central standard time under instrument flight rules. The flight, operating under Canadian Aviation Regulations Part VII, Subpart 3 (Air Taxi Operations), was bound for Sandy Bay with two flight crew and two emergency medical technicians on board. At 1948, air traffic control cleared the flight out of controlled airspace via the Sandy Bay Runway 05 non-directional beacon approach. The crew flew the approach straight-in and initiated a go-around from the landing flare. During the go-around, the aircraft failed to maintain a positive rate of climb and collided with trees just beyond the departure end of the runway.
All four occupants survived the impact and evacuated the aircraft. The captain subsequently died of his injuries before rescuers arrived. Both emergency medical technicians sustained serious injuries, while the first officer received minor injuries. The aircraft was substantially damaged by impact forces and was destroyed by a post-impact fire. The accident occurred at 2002 during the hours of darkness.
Findings
The investigation documented numerous findings related to operational and regulatory factors. Among the findings, it was noted that some air taxi and commuter operators may not provide crew resource management (CRM) training without a regulatory requirement. Transport Canada's Prairie and Northern Region management practices regarding audit program replacements were found to not conform to risk management policies. The oversight system in place at the time had limitations that prevented full appreciation of supervisory deficiencies within the operator.
Additional findings addressed the use of self-dispatch systems, cold temperature altitude corrections, wind and runway condition verification, altimeter settings, and unauthorized use of GPS during IFR approaches. Crew deviations from standard operating procedures were identified, along with the impact of punitive actions on hazard reporting in a safety management system. The challenges of night approaches with limited visual cues and navigational aids were highlighted, as well as the need for objective pilot performance data in hiring.
The operator's safety management system was not yet capable of detecting and mitigating the risks underlying the occurrence. It was very likely that the captain became the pilot flying for the last 20 seconds of the flight, and the scenario that neither pilot was controlling the aircraft was considered very unlikely.