3.0 Findings
3.1 Findings as to causes and contributing factors
3.2 Findings as to risk
3.3 Other findings
3.1 Findings as to causes and contributing factors
- The pilot's inability to effectively manage the aircraft's energy condition led to an unstable approach.
- The pilot "got behind" the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
- 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.
- 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.
- 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.
- 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 MU-2B for the conditions experienced during the occurrence flight.
3.2 Findings as to risk
- 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.
- 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.
- 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.
- 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.
- 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.
- If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.
- 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.
3.3 Other findings
- Transport Canada does not monitor or track the number of days foreign-registered aircraft are in Canada during a given 12-month period.
- Turbulence and icing were not considered factors in this occurrence.
- 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.
- 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.
- 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.
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