Pilots are often expected to perform a number of concurrent activities. In this case, this involved flying and monitoring the aircraft as well as visually acquiring the runway. During these multitasking situations, the crew may prioritize activities based on their perceived level of importance. In this case, the act of visually finding the runway was categorized as being of primary importance. As such, the crew's cognitive efforts were directed to this activity at the expense of monitoring the flight profile.
The aircraft was equipped with a stall warning system, which did not activate prior to the aircraft entering a low energy state. The aircraft's wing deicing system appeared to be functional throughout the approach and the post-impact inspection of the aircraft did not indicate an accumulation of ice on the critical flight surfaces. The investigation was unable to determine why the stall warning system did not activate.
Kenn Borek Air Ltd. has taken the following safety actions:
Amended the weight and balance calculation procedure to require flight crews to confirm the correct aircraft configuration and passenger weights.
Implemented a company line check program to ensure adherence to SOPs including sterile cockpit procedures.
Developed and implemented a procedures review exam for flight crew, emphasizing SOP and company procedures for stabilized approaches, sterile cockpit, and crew roles and duties during non-precision approaches at remote airports with limited services.
Amended company SOP and placarded aircraft equipped with a Garmin 155XL regarding conducting GPS approaches. These approaches will be flown from the left seat only.
When all is said and done, this accident reflects the old maxim that a pilot's responsibilities are to aviate, navigate and communicate — in that order. Somebody has to be flying the airplane at all times and that includes monitoring airspeed, altitude, configuration and performance. It doesn't matter where the runway is if you don't have enough airspeed to remain aloft until you reach it.