Multiple Errors Caused Northern Plane Crash: TSB

Wednesday, October 14, 2009 at 12:21



The Transportation Safety Board has released its findings into a plane crash in Sandy Bay that claimed the life of the pilot.


The TSB says the incident, which occurred on Jan. 7, 2007, was fraught with errors.


The accident occurred after the King Air craft slammed into the ground during an aborted landing attempt.


Lead investigator David Ross says the crew did not perform an assessment of the aircraft before they departed which meant they were forced to make some decisions on the fly.


Another problem, he says, is that the pilot decided to let a less-experienced crew member fly the plane, which went against the policy of owner Transwest Air.


“For example, the company provided guidance that the captain was required to fly the aircraft on the first flight of the day, and also to perform landings on runways less than 3,500 ft. long. In this particular instance, the captain decided that the first officer would be the pilot flying for the flight from La Ronge to Sandy Bay,” Ross says.


Ross also says the crew should have flown past the runway first or circled around it, so they could perform a visual inspection first.


“The company provided specific information that in places, such as Sandy Bay, that did not have precision approach path indicators or instrument guidance systems to provide information to the crew, ‘straight-in’ approaches were prohibited,” he says.


Ross says this “straight-in” approach left little room for error, and when things started to go wrong, the crew didn’t have sufficient time or preparation to react.


He also says the crew’s lack of co-ordination was partially due to the fact they had not received recent crew resource management training.


Meantime, Ross says the board also found fault with Transwest Air in a couple of areas.


He says the company’s standard operating procedures, with the selection of flaps during go-around, likely left both pilots controlling flap gears.


And, he says, the company’s supervisory activity had deficiencies in it that permitted the undetected development of deviations.


In conclusion, he says, the TSB is calling for flight crews to be trained to work together better and use all available tools to make the right decisions under pressure.