A combination of crew error and lack of training led to the crash of a government water bomber into a Labrador lake last summer.
The Transportation Safety Board released its report into the incident Thursday.
Neither the pilot nor co-pilot was injured in the July 3 incident on Moosehead Lake, but the aircraft was destroyed and sank to the bottom.
According to investigators, the water bomber crashed because it had scooped up too much water from the lake and was too heavy to take off again.
The three-year-old plane was helping fight last summer's forest fires in the area, which had destroyed cabins and was threatening the towns of Wabush and Labrador City.
The report focused on switches that open and close doors on the belly of the water bomber, where the water is sucked in and later dumped on fires.
Investigators found that a switch was inadvertently moved to the "manual" position before the flight, meaning the crew would have to close the doors themselves once they had a safe amount of water on board. If it had been in the "auto" position, the doors would've closed on their own.
But by the time the crew noticed the problem, they had too much water and it was too late.
Doug McEwen, who investigated the crash for the TSB, said trying to take off anyway was a mistake.
"The manufacturer recommends that the aircraft be stopped on the water,`` he said. `The process to do that is to stop on the water and allow the aircraft to open the tank doors. The water is lowered to a level that the aircraft then can become safe to operate."
Instead, the pilot tried to turn left for more distance to take off, but a wing hit the water causing the nose of the plane to go under. The aircraft was about seven feet off the surface at the time, and came to rest upright, but slowly sinking.
The co-pilot was able to grab a life-jacket and climb out through an overhead escape hatch. But the pilot's life-jacket had floated away, and he got out through a side window, joining his co-pilot on the roof as the plane continued to sink. They were able to call for help with a cellphone, and were picked up by a boat about a half hour later, with the plane going to the bottom shortly thereafter in about 15 feet of water.
Satellite phones have since been installed on water bombers.
The TSB report noted neither pilot tried to activate the emergency locator transmitter (ELT), shut down the engines, or turn off electric power.
Investigators also found there might have been other factors at play, including stress on the pilot who was going through a personal crisis at the time. They said he may have been distracted by that, since he had received a phone call the day of the crash that was "particularly distressing."
Considered taking time off
"(The pilot) had considered taking a leave of absence, but in light of the (threat posed by the forest fires), had continued working," the report states. "The pilot's level of distraction due to the effects of chronic stress created a situation in which errors were more likely to occur."
But investigators didn't just focus on the crew.
They also found the provincial government was lax in training for fighting forest fires from the sky. And that real life-jackets and life-rafts were never used as training aids.
"If individuals are not trained on safety equipment installed on the aircraft, then there is an increased risk that the individuals may not be aware of how to effectively use the equipment to ensure their survival."
What's more, the report said life-jackets and the life-raft on the plane were hard to get at, and not secured.
It also noted that the established pre-flight checklist didn't include the switch that had been inadvertently moved from auto to manual.
The report does note the province has since rectified some of the problems that may have contributed to the crash.
The pilots' bosses have been waiting for the TSB report before deciding if they will be disciplined.