Accident Report

[lostinthebattle]

http://www.cbc.ca/canada/north/story/20 ... crash.html

[Widow]

According to the safety board's report into the crash, the pilot took off despite knowing ice and poor visibility were being forecast for the route between Yellowknife and the lodge.

"The pilot self-dispatched on a flight that was not in accordance with the requirements outlined in the company operations manual," the report stated in part.

"He continued the flight after encountering conditions beyond his capabilities in regards to training, equipment, and operating conditions."

Ah yes, the old "self-dispatched" pilot-error.

[The Hammer]

Sometimes it is, what it is Widow

As much as we like to blame the system, sometimes it may come down to poor decision making.

You can lead a horse to water but you can't make him drink (not specific to this case)

[Widow]

I understand that Hammer. It would seem clear they shouldn't have taken the trip. But as a pax, or as the survivor of someone who died because the "system" didn't work ... I can't help but wonder why the CP, or OP, or another pilot ... someone wouldn't have said "don't do it". I find it so hard to understand why a pilot would, with foreknowledge, willingly take off into unacceptable weather without SOME kind of pressure to do so. You would have to be an idiot ... and why the heck would anyone hire an idiot to fly a plane?

[Chuck Ellsworth]

and why the heck would anyone hire an idiot to fly a plane?

Good question widow, but there are a lot of operators out there where it is a bonus to be an idiot so you can be intimidated into flying wrecklessly.

I can't help but wonder why the CP, or OP, or another pilot ... someone wouldn't have said "don't do it".

You need only research the accident in Winnipeg widow to see that there is no need for a CP or a OP's manager to give a sh.t because as long as they are part of the good old boys club with TC they are safe from and accountability....and if the company is paying money under the table to some of TC's finest they are have even less to worry about....

......in other words widow the regulator is not only useless it is corrupt at the top....


N O T E:::

I said "" and if "" the company is paying money under the table to some of TC's finest......personally it is my opinion that this has to be the case in some instances...how else do you explain why any government official who has the mandate to enforce the law goes blind?

[godsrcrazy]

. are you suggesting that this company has someobne on the payroll.


Widow i feel for your loss but is there any incident you will not blame on TC.

Before everyone gets smart ass i do mean someone from Transport Canada.

[Widow]

Did I mention TC somewhere?

[Chuck Ellsworth]

. are you suggesting that this company has someobne on the payroll.

Go read my " Note " .

What I said is I personally think that it is quite possible that there are some TC top officials on the take....having spent several years in a legal battle with them and having seen just how dishonest several of their top managers are it is not unreasonable to suspect they can be bought.....

As to that company I have no idea if they are or are not paying someone in TC off...what actions were taken by TC against the CP and OP's manager in that accident investigation?

...lets put it this way, I have more respect for the corrupt officials in Africa that the ones we have in TCCA.

[Widow]

It's odd that the CADORs for this incident does not indicate the class of investigation. I don't see anything published on the TSB site, so I wonder if what these folks got was a letter to the coroner (non-report), similar to what was done in our case ... a class 5 investigation. I was going to say, now that we see the "cause" of this accident, the lawsuits will start ... but then I noticed the pax were all working at the lodge, so presumably covered by worker's comp ... there will be no lawsuits.

[EPR]

How can this be "self dispatched" when the company in question has a 24 hour dispatcher?
People I know in this company (many have since left) tell me that the CP "Lima Bravo" was seen doing his usual "ranting and raving" to this new pilot shortly prior to the fatal flight.
This is a farce in the fact that this tragedy just seems to be swept under the carpet.

[trey kule]

widow wrote:

why a pilot would, with foreknowledge, willingly take off into unacceptable weather without SOME kind of pressure to do so. You would have to be an idiot ... and why the heck would anyone hire an idiot to fly a plane?

Well, let me tell you. In smaller operations, one of the CP's real duties during bad Wx is to keep some of these pilots from killing themselves. Ego plus inexperience is a dangerous combination.

One poster posted...it is what it is....not bad words to think about Widow. Because of your tragic loss few people here want to disgree with you ...sometimes you have to put the responsibility where it belongs, not where you wish it to belong..
The "system" can only do so much. To assume that there was "pressure" somewhere on the pilot is not a correct assumption on your part, and can lead you, using perfect logic to the totally wrong conclusion. As to why someone would hire someone like that, my thoughts are that the hiring practices at many small operators are far from perfect. It is not a conscienscous decision . I can speak from experience when I tell you as a CP in Canada I went to great lengths to hire the best I could, and I made some mistakes in character assessment. Fortunately, the companies never had a problem, but I am sure there was some luck over time that made it that way.

If you are going to jump on every accident and analysize it, please try and do so without a preconceived bias. It is simply not fair.

[Liquid Charlie]

What happened here is not new -- been going on since the days of Wop May and will continue. I doubt if there are many of us in the industry(especially anyone who started in the "Bush") that have not jammed ourselves up where the outcome could have gone either way. Widow has experienced the heartache first hand and there are a lot of us who have lost close friends. Sadly it will continue.

The problem is that there is no system once you get to a certain point and more so in a small vfr airplane. The buck stops with the pilot and his ability to get himself out of the hole that circumstances -- some beyond his control -- have put him into.

What is a dispatcher going to tell you here (remember most dispatchers for these small companies are very inexperienced) - he will read you the forecast, tell you the notams and that's all -- and most of us walk away thinking - I could have done that without his help.

This guy was not an idiot -- just a poor inexperienced SOB who will never have the chance to learn from his experiences and mistakes -

[Doc]

As Liquid says...."(he) will never have the chance to learn from his mistake.....". So "we" must learn form his mistake. That's why we have these little "chats"....to exercise our gray matter. Because, once the cockpit door closes, and the engine is lit, there really is no "system". At least, not one that can "save you from yourself". The buck really stops with the PIC, in a case like this. When you get "that" feeling, that you've bitten off more than you can chew, it's time to "chicken out" and preform that most life saving of all aviation maneuvers....the one hundred and eighty degree turn.

[BTD]

I could be mistaken on this, but I believe that if your company does not employ a licensed dispatcher, it is considered self dispatching. Someone who answers phones and tells you schedules and is titled "dispatcher" doesn't necessarily qualify them as a dispatcher under the regulations, and therefore the flight operates as self dispatched.

I'm not arguing how well the system operates, just that it does.

BTD

[Liquid Charlie]

there are a lot of "self dispatch" companies out there -- another is Wasaya -- which surprised me --

[BeaconInbound]

This is exactly the kind of thing I went through last winter. Icing in the forecast, aircraft not certified for icing, and my chief pilot argued that the CARS only excluded uncertified aircraft from flight into "known icing". I consequently showed him where the CARS stated forecast and known icing, and thus a conference call was then required with my boss, the 705 chief pilot, and Flight Ops Director...and was told the whole time that there was no pressure to do the flight (then why the conference call?). In the end the boss told me that he would be happy if i just took off to "have a look". He also told me he "had my back" if any issue came up. I refused the flight and although no real retaliation for my decision came forward, I later learned that the company feels I'm a substandard pilot and I'm difficult to deal with. I find it frustrating that an FOM is written to appease TC, but then we are verbally told we can interpret the rules to fit the circumstances.

[square]

This is exactly the kind of thing I went through last winter. Icing in the forecast, aircraft not certified for icing, and my chief pilot argued that the CARS only excluded uncertified aircraft from flight into "known icing". I consequently showed him where the CARS stated forecast and known icing, and thus a conference call was then required with my boss, the 705 chief pilot, and Flight Ops Director...and was told the whole time that there was no pressure to do the flight (then why the conference call?). In the end the boss told me that he would be happy if i just took off to "have a look". He also told me he "had my back" if any issue came up. I refused the flight and although no real retaliation for my decision came forward, I later learned that the company feels I'm a substandard pilot and I'm difficult to deal with. I find it frustrating that an FOM is written to appease TC, but then we are verbally told we can interpret the rules to fit the circumstances.

This makes me very angry.

[Donald]

This is exactly the kind of thing I went through last winter. Icing in the forecast, aircraft not certified for icing,

Could not every Navajo in Canada be restricted to VFR only from November until March on this basis alone?

[Doc]

Any time you enter cloud during the winter months you will most likely encounter our old friend, "ice" which may, or may not have been in the forecast. This can range from just a light "frosting" easily handled by pretty much any light twin, to "terror" in the skies! But, we all know that. I've ventured into an area of "forecast" ice, often as not, to find no ice whatsoever. I've also found it when not forecast. A little common sense comes into play here. We stay well clear of any kind of freezing precipitation at all costs, however, when some "light" ice is in the forecast, we may be called upon to "go have a wee look". This is when, we as the PIC must call upon this common sense to know when to say "when". If your Navajo is equipped with serviceable boots and hot props, a little surface ice is easily handled. With no boots or hot props, a "U-turn" is in order immediately upon encountering ANY ice formation, of any kind! When in doubt, chicken out! No doubt about it

[Coast-dog]

This is exactly the kind of thing I went through last winter. Icing in the forecast, aircraft not certified for icing,

Could not every Navajo in Canada be restricted to VFR only from November until March on this basis alone?

De-ice equipped aircraft are never intended to be operated in icing conditions for an indefinite period of time - I'm confident you're aware of this.

De-ice gear is supposed to give you a chance to get out of the icing conditions.

Though, people get away with is all the time; you can operate a PA31 in trace-light ice for what seems like an eternity. Also, trace->light ice in a PA31 might be light->moderate in an aircraft with a critical airfoil shape.

Restricting PA31 operations to VFR-only would only indicate to me a total and utter failure of pilot training; where has all the good airmanship gone? What happened to thinking about the flight conditions in which you could encounter along your route of flight?

Don't institute rules as a band-aid for bad airmanship.

[BeaconInbound]

De-ice equipped aircraft are never intended to be operated in icing conditions for an indefinite period of time - I'm confident you're aware of this.

De-ice gear is supposed to give you a chance to get out of the icing conditions.

Though, people get away with is all the time; you can operate a PA31 in trace-light ice for what seems like an eternity. Also, trace->light ice in a PA31 might be light->moderate in an aircraft with a critical airfoil shape.

Restricting PA31 operations to VFR-only would only indicate to me a total and utter failure of pilot training; where has all the good airmanship gone? What happened to thinking about the flight conditions in which you could encounter along your route of flight?

Don't institute rules as a band-aid for bad airmanship.

Aviation is inherently a risky business, and it's our job as pilots to minimize the risk through training, regs, and equipment. After all, many a good pilot died figuring all this out so that we could fly safer. As I originally stated, the aircraft was NOT certified for flight into icing, known or forecast, and the forecast called for severe clear...which, as we all know, is a no-go no matter what aircraft you are flying. Contrary to what you may believe, Coast-Dog, I'm not using the rules to cop out of the flight. I'm using them to ensure the success of the flight...a service I'm sure any passenger would value. I believe I was using good airmanship in thinking about the conditions I may encounter along the route of flight (I should mention it was night as well). What if the icing is so severe that I can't complete that 180 degree turn to get out of it. Does the company have my back...of course not. Pilot error in the form of bad decision-making is how the TSB report will read..they may mention company pressure in the report, but it won't matter. The rules are clear: No aircraft is permitted to fly in forecast or known icing if it's uncertified.

[Doc]

"Aviation is inherently a risky business...."
Sorry mate, got to disagree with you on that one. We can MAKE it risky, but we can also make getting out of bed risky. No need for it to be.
Now, on the other hand, nobody should be "pushing" you out the door if you're not comfortable with the forecast. I'd sure rather you were "down here" wishing you should be "up there", than the other way around.

[Highflyinpilot]

I agree with doc, aviation isnt inherently risky, just unforgiving.

[Coast-dog]

Sorry B.I., I must have missed that part.

I still take the stand that you can't legislate safety - if we want to be safe, we'd never get in an airplane in the first place!

For any and every rule in place, I'm confident any one of use can think of at least one person we know (maybe even ourselves?) that have either bent or ignored any particular rule you care to mention.

Fortunately for us, we're here to bicker about it.

I'll second H.F.P. & Doc's comments.

We can do our best to make the decisions that minimize the risks inherent in our daily work.

[BeaconInbound]

Perhaps, I overstated the risk thing. We've only been doing this for a little over 100 years...not a long time relative to human existence. How many people got hurt figuring out that they shouldn't fly into thunderstorms, or took off from a dark runway and experienced black-hole effect. Every time someone took a plane to the sky they were risking their lives...all for the advancement of the science of flight. There are reasons why we have attitude indicators and stall warning systems. There are reasons why TCAS and GPWS exist. But there had to be those risk-takers in the beginning to get it all figured out. Today, we may not be taking the same risk those pioneers took, but we'd be pretty vane to think we have it all figured out. There are too many variables and too many hands in the pot to say that there is no risk involved in propelling thousands of pounds of metal thousands of feet into the atmosphere. This is why I say that our job is to minimize risk even if it is small, but flying has become so commonplace and the procedures and rules we follow are so ingrained in us that we feel perfectly safe...doesn't mean there isn't any risk associated with it...even if it is minuscule. Doc, I don't know of anyone who killed themselves getting out of bed, but I'm familiar with a woman who will hurt me if I don't get up and mow the lawn