At a news conference in Winnipeg on Monday, the investigators said inclement weather, poor visibility, fatigue and a departure from established protocols all played a part in the Perimeter Aviation crash 2½ years ago that claimed Isaac Appaqaq's life.
Transportation Safety Board chair Kathy Fox said that the twin-engine turbo prop "came in too high, too steep, too fast" in its flight from Winnipeg to Sanikiluaq, Nunavut, three days before Christmas in 2012.
Appaqaq was thrown from his mother's lap and died of multiple injuries, Nunavut's chief coroner Padma Suramala stated a few days after the crash.
"What stands out most was the tragic fate of the baby on this aircraft," said Fox.
"We think infants and children deserve an equivalent level of safety as adults on board aircraft, and that is why we are calling on Transport Canada and the aviation industry to take action. It's time to do right by our children."
The flight was carrying seven passengers — plus a pilot and co-pilot — when it overran the runway in Sanikiluaq on its second landing attempt.
"The flight took off only for the flight crew to realize that they had forgotten the instrument procedure charts for approach and landing. Rather than return to the airport and extend the flight time even more, the captain instead radioed the company to obtain most of the required information," said Gayle Conners, who was in charge of the investigation.
"By the time the captain tried to reject the landing, it was too late."
The plane came down hard, touching down 200 metres past the end of the runway and scraping over the rocky terrain for another 335 metres before coming to a stop.
The eight other people on board suffered various non-life-threatening injuries.
Conners said that the investigation revealed stress and other issues affected decisions involved in making the landing.
"The crew began feeling a growing pressure to land. Crew communications started to break down. Stress, workload, frustration and fatigue combined to narrow their attention, and they shifted away from well-practised procedures," Conners said.
Beyond what led to the crash, Fox said the findings show that adults are not strong enough to adequately restrain infants during turbulence or a crash-landing just by holding them in their arms.
Transport Canada and airlines are already aware of the risks, Fox said, adding they encourage families with children or infants to travel using "an approved child-restraint system during flights."
"The problem is these systems are not mandatory," said Fox.
The Transportation Safety Board released two recommendations aimed at ensuring the safety of children and infants flying on commercial airliners.
"One, that commercial air carriers start routinely tracking and reporting data on the number of infants and children travelling," said Fox.
"And two, for the development and mandatory use of child-restraint systems so that infants and young children travelling on commercial aircraft will receive the same level of safety as adults."
Parents against recommendation
CBC News spoke with travellers in Winnipeg's James Armstrong Richardson International Airport Monday about the suggested development of a mandatory child-restraint system for young kids.
If the safety board's recommendations are put in place, parents travelling with babies or infants would likely have to pay for an extra seat. Arne Thomassen said that doesn't sit well with him.
"I think Transport Canada and our governments are just interfering with too many things in our lives and adding these costs is ridiculous," said Thomassen.
"There's lots of young families that would not be able to afford to travel by adding another $4,500 to their flight."
Shaun Kehler said even if he is mandated to purchase another ticket, his son will not be taking up an extra seat.
"He's sitting on me the whole time, so I don't think it's fair he has to have his own seat when I'm going to be holding him the whole time anyway," said Kehler.
"In an airplane I think if we crash it would be better [he was] in my arms than actually on a seat that they don't have a seatbelt to fit him."
More info needed
Fox said having more reliable information about the frequency and number of children aboard flights will help inform efforts to make flying safer.
"What's needed is better data to conduct research to assess risks and to outline emerging trends related to the carriage of infants and children," said Fox.
Following the release of the report, Canada's Transport Minister Lisa Raitt responded by saying she expects the federal government will take a close look at the safety board's recommendations.
"Our thoughts and prayers continue to be with the victim's family," said Raitt. "We expect Transport Canada [will] review these recommendations on an expedited basis.
Sanikiluaq, where the Perimeter Aviation flight crash-landed, is an Inuit community of 850 residents, situated on the Belcher Islands in southeastern Hudson Bay.Suggest a correction