Aviation Investigation Report A16A0032 - Transportation Safety Board of Canada
2.2 Approach planning
While in cruise flight, the pilot recognized there would be a strong tailwind during the descent. The pilot developed his approach plan, which included starting a 1500-feet-per-minute (fpm) descent when prompted to do so by the aircraft's global positioning system (GPS) in order to cross the initial approach waypoint (DAVAK) at 3000 feet above sea level (ASL). The minimum descent altitude (MDA) of 620 feet ASL was set on the radio altimeter, and the missed-approach altitude of 1900 feet ASL was noted. Other than the briefing on the minimum descent and missed approach altitudes, there was no briefing of when or under what conditions a go-around would be performed.
The pilot subsequently decided to delay the descent to reduce fuel consumption and to minimize the time spent in cloud by adopting a higher airspeed and rate of descent. This led the pilot to further revise the plan to carry out the descent at 250 knots indicated airspeed and at a rate of 2000 fpm. This new plan would still have enabled the aircraft to reach DAVAK at or near 3000 feet. However, the faster and steeper descent would cause the aircraft to be in a high-energy condition, which would require more vigilant monitoring by the pilot.
The broken ceiling at 200 feet was approximately 400 feet lower than the MDA; however, there was no discussion of the potential risks associated with continuing the approach. No contingency plan, such as performing a go-around if circumstances dictated, was discussed. The pilot continued with his original plan to land at CYGR.
If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.
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.