Background
On 22 December 2012, Perimeter Aviation LP operated a charter flight (PAG993) from Winnipeg/James Armstrong Richardson International Airport, Manitoba, to Sanikiluaq, Nunavut, using a Fairchild SA227-AC Metro III aircraft (registration C-GFWX, serial number AC650B). The flight departed at 1939 Coordinated Universal Time (1339 Central Standard Time).
Flight and Approach Sequence
An attempted visual approach to Runway 09 was discontinued, and a non-precision non-directional beacon (NDB) approach to Runway 27 was conducted. The crew established visual contact with the runway environment and initiated a circling approach to Runway 09, but lost visual contact and returned to the Sanikiluaq NDB. A second NDB Runway 27 approach was performed with the intention to land on Runway 27. Visual contact with the runway environment was regained after passing the missed approach point. The aircraft executed a steep descent, followed by a rejected landing initiated at 20 to 50 feet above the runway. The aircraft struck the ground approximately 525 feet beyond the departure end of Runway 27. The occurrence took place at 2306 Coordinated Universal Time (1806 Eastern Standard Time) during hours of darkness. The 406 MHz emergency locator transmitter activated upon impact.
Injuries and Damage
The flight crew (2 members) and 1 passenger sustained serious injuries; 5 passengers received minor injuries; and 1 infant was fatally injured. Occupants evacuated through the forward right overwing exit and were immediately taken to the local health centre. The aircraft was destroyed.
Official Findings
The investigation identified the following causes and contributing factors: 1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain during flight planning, and negatively affected crew situational awareness during approaches. 2. Weather conditions below published landing minima at the alternate airport and insufficient fuel eliminated favorable diversion options, putting pressure on the crew to land at Sanikiluaq. 3. Frustration, fatigue, and increased workload and stress during instrument approaches led to attentional narrowing and a shift from well-learned procedures. 4. The lack of an instrument approach for the into-wind runway and unsuccessful circling attempts led the crew to choose a tailwind landing, resulting in a steep, unstable approach. 5. The final descent was initiated beyond the missed approach point, and with a 14-knot tailwind, the aircraft remained above the desired 3-degree descent path. 6. Neither pilot heard ground proximity warning system warnings; both were focused on landing. 7. During final approach, the aircraft was unstable in several parameters, contributing to excessive speed and altitude halfway down the runway. 8. The aircraft was not positioned to land and stop within the runway confines, and a go-around was initiated from a low-energy landing regime. 9. The captain possibly eased off on the control column due to low airspeed, which, combined with a configuration change, may have contributed to poor climb performance. 10. A sufficient rate of climb to ensure obstacle clearance was not established, and the aircraft collided with terrain. 11. The infant passenger was not restrained in a child restraint system; the infant was ejected from the mother's arms during impact, and contact with interior surfaces contributed to the fatal injuries.
Additional risk findings and other observations were also documented in the investigation report.