Kenn Borek Air Flight KBA 103 — a Beechcraft King Air 100 with 10 souls on board — crashed on Oct. 25, 2010, during an RNAV (GNSS) approach to Runway 08 at Kirby Lake Airport (CRL4), Alberta, Canada. The airplane struck the ground some 174 ft. short of the threshold, then bounced and came to rest off the edge of the runway. The captain was fatally injured. The first officer and three passengers suffered serious injures, and the five additional passengers suffered minor injuries.

Canada's Transportation Safety Board (TSB) investigated this accident. While the TBS does not issue a “probable cause,” it does issue “findings” as to causes and risks and it reports on safety actions taken. In this incident, the TSB concluded that the crew stalled the airplane after descending below MDA and that the pilots' “conduct . . . during the instrument approach prevented them from effectively monitoring the performance of the aircraft.” The investigators also determined that the stall warning horn did not activate, thus depriving the crew of at least one opportunity to avoid the stall.

The TSB's “findings of risk” — actions that were seen in the review of this flight that could set the stage for an accident sequence — included:

The use of company standard weights and a non-current aircraft weight and balance report that resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.

Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.

Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.

Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance para–meters of an instrument approach.