Criminal negligence overturned in 2002 Winnipeg crash . . .

[AEROBAT]

Auxbaton,
We can beat this to death and you know I cannot convince you of anything or conversely you probably will not change my mind. However I still believe the ULTIMATE responsability rests with the pilot. Of course there may be pressure from his company, everyone in every occupation gets pressure.

I am sure a civil lawsuit will find the company jointly responsable.

[Brewguy]

Let's examine an analogy:
Say a professional engineer designs something ... oh, lets go with a bridge.

Everything is expensive these days (steel, concrete, etc) and the company puts pressure on the guy to get the job done on the cheap. The engineer knows how the bridge should be built, but gives into the pressure and skimps a little on the materials (designs it with a little less steel, and slightly thinner concrete, etc.). Just shaving a tiny bit here & there.

Now, generally speaking things are 'over engineered' on purpose ... built stronger than they need to be. So this engineer thinks to himself, okay, this should still be strong enough.

This isn't the first project he's done it on. So far, all of the other projects he's narrowed the margins on have held up just fine. So he feels okay about doing it this time.

The bridge collapses and kills someone, and injures others.

Guess who is responsible?
The guy whose (professional engineers) stamp is on the drawings. That's who.

Should the company (either his employer and/or the client) share some blame? Possibly. It's them who pushed for getting something done cheaper. But ultimately, it's the so called professional who should have known better, who will be held legally liable, and who will be damn lucky if they are ever allowed to work as an engineer again.

When it comes to building a structure, its the engineer who has ultimate authority (by putting his stamp on a design/drawing). In aviation, it's the PIC.

Just because you've done something you know is wrong (or should have known is wrong) and gotten away with it before, doesn't let you off the hook.

You know those gold bars many commercial pilots wear on their shoulders ... they are there to remind you of the weight of responsibility you carry, not just to make you look cool.

[AuxBatOn]

Let's examine an analogy:
Say a professional engineer designs something ... oh, lets go with a bridge.

Everything is expensive these days (steel, concrete, etc) and the company puts pressure on the guy to get the job done on the cheap. The engineer knows how the bridge should be built, but gives into the pressure and skimps a little on the materials (designs it with a little less steel, and slightly thinner concrete, etc.). Just shaving a tiny bit here & there.

Now, generally speaking things are 'over engineered' on purpose ... built stronger than they need to be. So this engineer thinks to himself, okay, this should still be strong enough.

This isn't the first project he's done it on. So far, all of the other projects he's narrowed the margins on have held up just fine. So he feels okay about doing it this time.

The bridge collapses and kills someone, and injures others.

Guess who is responsible?
The guy whose (professional engineers) stamp is on the drawings. That's who.

Should the company (either his employer and/or the client) share some blame? Possibly. It's them who pushed for getting something done cheaper. But ultimately, it's the so called professional who should have known better, who will be held legally liable, and who will be damn lucky if they are ever allowed to work as an engineer again.

When it comes to building a structure, its the engineer who has ultimate authority (by putting his stamp on a design/drawing). In aviation, it's the PIC.

Just because you've done something you know is wrong (or should have known is wrong) and gotten away with it before, doesn't let you off the hook.

You know those gold bars many commercial pilots wear on their shoulders ... they are there to remind you of the weight of responsibility you carry, not just to make you look cool.

No doubt, the guy screwed up, but it is not criminal negligence. The company that puts pressure on the pilot and treatens him with his job should be.

As far as your analogy, I don't think you can compare both and you are quite wrong with how things work in engineering. In your example, it would be criminal negligence only if the engineer knew his design would not measure up to the required specifications and still stamped it. There is quite a code that your are responsible to in the engineering buisness. Similar to what Doctors and Lawyers have.

Plus, there are often more than 1 engineer working on a project. There is 1 lead engineer that will track the progress of several sub-projects. The lead engineer is usually the one that will sign the blue prints. There are many levels of oversight. This is definately not the case within a normal aviation company in Canada.

[AEROBAT]

Auxbaton,

For arguments sake grab a map and do a flight plan using the data in the TC report. See if you still have as much sympathy toward the pilot. It only takes a few minutes.

[stratcat]

I wonder if the flight planning works using the numbers Keystone tells the pilots to use for flight planning, weather that was forcast to be I believe VFR returning to YWG. Take into account that if I remember reading details correctly in the papers, he told the chief pilot that morning he couldnt take the load and all the chief pilot did was turn around and walk away. If Keystone teaches to use the fuel gauges as gospel truth, as any of us know they are not accurate and usually go down slow on the top half then really quickly on the last half. What if they showed good fuel leaving the lodge and good fuel going by Gimli and fell quickly, he would have had no choice but continue to YWG. Throw in the autopilot not just not working but actually removed. Throw in company culture where if he declared an emergency his life at the company would be hell. Thats 6 links in the accident chain already. He did screw up,thats not the question. To say he knowingly took off knowing he didnt have enough fuel,I dont think thats true. I dont think he got up that morning wanting to crash. Maybe we should learn from him to spot our own links in the chain which we have all had.

[AEROBAT]

I guess you didn't read the TSB report.
He estimated the fuel tanks to be 3/4 full. The company manual said dry tanks in 4 hours and 45 minutes. That is 3 hours and 33 minutes time.

Swan River to Winipeg= 1 hour and 38 min

Winipeg to Bud's= 1 hour and 31 min

Bud's to time of crash= 1 hour and 30 min

Or try it this way company manual 250 PPH for the first hour and 210 PPH for remaining time in flight.

That's 750 pounds at 250PPH for the first hour of each flight and 336 pounds for the remaining time of flight according to the company manual. 1086 pounds. The plane had 1092 usable.

Where was the alt. +45 minutes? Or even VFR reserve?

[somepilot]

Playing devil's advocate here:

Maybe pilot thought he had 850 lbs fuel on board (Pilot reported just over 3/4 fuel)
850lbs at 240 lbs /hr burn = 3:30 fuel for the trip YWG to Fishing Lodge & return to YWG.
This not even taking in to account the lower burn of 210 lbs/hr

If he planned 1:20 min each leg / 2:40 round trip plus 15-20 min for circuit etc
he would have thought he had 30 minutes of fuel to spare (VFR reserves)

Maybe VFR or SVFR was in the forecast for the return trip so he did not take IFR fuel. This would also accomodate a large payload.

Maybe the fuel guage indicated he still had VFR fuel reserves going past Pine Dock on the return so he did not stop to refuel.

Maybe the fuel guage dropped like crazy over Gimli where the only option was to continue to Winnipeg.

Perhaps the stress of the situation there was some disbelief / denial of the imminent danger of the situation so a Mayday was not declared.

The same stress caused the pilot to fly a poor ILS approch causing a missed approach.

The rest is history.

[spartacus]

Maybe...just maybe if someone else that had done the same thing and killed someone had been charged and convicted...well maybe this guy would have had some balls to say no, and not been a big pussy and did what he did.

sorry, NO sympathy for that guy at all.

As a captain, your job is to keep your pax alive. You need the balls to say NO, job or no job.

The wrong message (the right one could have been sent years ago) has been sent, yet again.

[Sidebar]

Here's a link to the trial judge's decision to convict. http://www.canlii.org/en/mb/mbqb/doc/20 ... bqb265.pdf

Once I find the appeal decision, I'll post a link to that as well.

[stratcat]

Maybe Keystone teaches that a ho holds 5 hours.If he got in and 3/4 tanks. 3/4 of 5 hours is 3 hours and 45 minutes. 1.5 hours up and 1.5 hours back.That leaves 45 minutes vfr reserve or 15 minutes to St Andrews with 30 min IFR. If he planned 230 first hour and 210 every hour after it would be 828 pounds to do it with 45 min vfr or St Andrews with IFR. Fuel is expensive in the north and I see them pushing 5 hours. I know people who have worked there and stopped for fuel and got shit for it.I would like to see the log books of other airplanes,I bet a lot of trips there and back had similar fuel loads, on paper anyway. If they are training and pushing 5 hours they should be in front of a judge too.

[AEROBAT]

Sidebar,

Thanks for posting that link. I knew Bob Lamoureux well, he did my multi. Oddly enough my "career" was similar to Tayfel's but I started flying for hire around '91 and never did the instructor thing, which I regret.

You can imagine what he must have felt like after the accident. This topic should be required reading in commercial ground school.

I also noticed how one of the witnesses quit Keystone over safety issues.

[AEROBAT]

Stratcat,

Their manual says 4:45 according to the TSB. He didn't file St. Andrews, he filed Island Lake and he admitted that was impossible in court. He used 1.2 hours estimate for his legs and admitted they were usually longer.

There were lots of mitigating factors I am sure, but in the end it is the pilot who gets ripped a new ###hole regardless. Hindsight is 20/20 but if you layed this scenario out on a private pilot ground school course how many will fail?

[Doc]

The manual could be a copy of Moby Dick for all the good it did. He knew he didn't have enough gas.....and he ran out of gas.

"but in the end it is the pilot who gets ripped a new ###hole regardless."

Sometimes a pilot could really use a new one!

[snoopy]

Well, there are lots of ways a company can "help" or "encourage" a pilot to fudge flight planning information - unrealistic block airspeeds; optimistic fuel burns based on unattainable high altitudes; reduced power settings (which then negates the block speed further) or unrealistic (paper) leaning; block leg times; unrealistic upper winds; fuel weights based on incorrect temperatures, or simply wrong fuel weights. I know of one company that was using the fuel weights for Jet B even though they had actually been using Jet A, for many months. Not one pilot questioned the weights, and when this one did, the chief pilot got quite upset because using the correct fuel numbers would mean leaving at least one male passenger behind.

I find it amazing that many pilots don't question the numbers they receive during initial training, and compare them with actual/forecast weather, flight manual and realized performance gleaned with experience. Plus one must consider that not all aircraft perform to flight manual numbers, which were generally determined under controlled conditions with a new aircraft and a professional test pilot. Flight manual numbers are designed to sell aircraft, and do not always reflect reality.

If a pilot does choose to question company information and decides to use more realistic numbers when no other pilots within the company do this, the pilot is usually punished for going against company "rules". Contingency fuel? Just try and incorporate that and see where it gets you!

This is where pilots need to support and encourage themselves and others to make good decisions. That way, it won't be such a shock to a company - all pilots would be operating with the same mindset, as opposed to one "renegade" pilot flying safely, and differently from the rest.

Cheers,
Kirsten B.

[shitdisturber]

Here's an interesting question that occurs to me, probably because I have too much time on my hands but that's irrelevant. The Manitoba Court of Appeal has ruled that the trial judge was in error for convicting Tayfel of criminal negligence. If you read up on the Court, that means that a minimum of three higher court justices heard the appeal and ruled that there was no basis for making that determination. Since that is the case, would that mean that the judge who heard the case and erroneously convicted Tayfel was negligent in the performance of his or her duties?

[somepilot]

From the Canadian Criminal Code:

The maximum sentences to which the accused in this case can be sentenced are:

- life imprisonment regarding the conviction for criminal negligence causing death;

- ten years imprisonment for each conviction for criminal negligence causing bodily harm;

- five years imprisonment regarding the conviction for dangerous operation of an aircraft.


I would hate to be the Captain of an airliner with a couple hundred people on board.

[Brewguy]

somepilot: in Canada, sentences are typically (if not always?) served concurrently, not consecutively. Meaning if you're found guilty of three offences, two that carry 10 year sentences and one that carries a 5 year sentence; you end up serving a total of 10 years ... not 25. We're not like the US where they sentence people to ridiculous things, like 230 year sentences. Besides, don't we still have some form of 'mandatory' parole (except for 'dangerous offenders") once you've served 2/3 of the sentence ? So the above is closer to 6 1/2 years.

[Doc]

If a pilot does choose to question company information and decides to use more realistic numbers when no other pilots within the company do this, the pilot is usually punished for going against company "rules". Contingency fuel? Just try and incorporate that and see where it gets you!

This comment is an absolute, and total crock of shit!

Snoopy, if this is the reaction you have received from companies when you want to take "extra" fuel, you've been working for the wrong companies.

I have NEVER EVER had ANY problems with ANY company over the question of fuel load. EVER! Even a company I have said less than favorable things about on a regular basis, NEVER gave me any grief on the subject of fuel load. EVER. On some matters, they were a total PITA, but not on fuel.

Bottom line. The company doesn't really want you to glide it onto Portage and Main, any more than you do.

I guess the approach a pilot should take is very simple. "Top up the tanks if your will, my good man...."

Forget the warm and fuzzy excuses, like "company culture", be a "man" and fill 'er up!

It's YOUR ass on the line kids, not the company's.

[snoopy]

A crock of shit? REALLY?! What was I thinking? THANK YOU for bringing me to my senses. You're absolutely right, what I described NEVER happens. The industry is wonderful, every company is great and nobody ever dies. This was just one fluke instance - how could this have happened? It's never happened before...

[Doc]

A crock of shit? REALLY?! What was I thinking? THANK YOU for bringing me to my senses. You're absolutely right, what I described NEVER happens. The industry is wonderful, every company is great and nobody ever dies. This was just one fluke instance - how could this have happened? It's never happened before...

Ah, so you have seen the light.
Accidents will continue to happen if we continue to look for excuses, and refuse to accept the fact, that sometimes we do it to ourselves. The buck really does stop in the cockpit. I'm in no way "sticking up" for Keystone. TC should have shut them down, and tossed away the key. This didn't happen. TC is a spineless, toothless drain on our tax dollar. They will never back up a pilot against a company. So, piss poor company culture is here to stay. As is global warming. But continuing a flight with less than the required fuel load, is the pilot's fault, not the fault of company "culture". But, folks like Snoopy continue to beat the "it's not our fault, it's the company culture" drum. It's falling on deaf ears here.
If you can name one company that refuses to allow you to carry enough fuel to get the job don, then by all means please do. I've been doing this since the early '70's. I've never had this occur....and I've worked for some very "fly by night" operations. So, name one.....because, I just don't buy the fact there are companies out there who would willingly allow their airplanes to run out of gas. Apparently you do? Again, name one....

[snoopy]

Doc,
Respectfully, please don't put words in my mouth. "But, folks like Snoopy continue to beat the "it's not our fault, it's the company culture" drum." Regretfully, my message seems to have escaped you completely, but based on your persona here I am not surprised.
Hopefully somebody will listen.
Cheers,
Kirsten B.

[xsbank]

Hedley (sniff) said "Skin, Tin, Ticket," which I think is more accurate.

Doc, once you bring in "Global warming" you shoot yourself in the foot.

Let's look at this another way. Next time you are sitting around with the pilots you work with, choose which one of you is most likely to be the next to: land gear up; go off the end of the runway; run out of gas; damage an A/C etc. Then ask yourself why that will happen? Is there is anything in your choice's character, culture, background or maybe the attitude of the CP? Has anyone had a huge family stressor, like a break-up, sickness, death? Do any of your crew drink too much? Do any drive too fast, have speeding tickets? Like to hang-glide or do other high-risk activities? Do not have partners? Doesn't sleep well? Has a medical issue?

Don't always do a run-up? Taxi a bit too fast? Are frequently late for work? Hit the barber pole often? Don't know their QRH? Fly the plane with the most-chewed props? The one that has the most hot-sections? Most log-book corrections?

Do any of the crew seem to be loony or irrational or have a hate-on for something? Bummed out or depressed?

What will the reason be if one of the above has an accident? Just a moron, a doofus, somebody who should have been a plumber? "I always thought he was an idiot?"

Does someone who has an 'accident' have to have a character flaw? An intention to hurt someone? An inability to care for others?

Statistically, the accidents continue to happen. Your chance of having an accident is significantly more likely than your chance of winning the lottery.

I think we should let this guy go because those who have been appalled at his accident have either modified their behaviour to avoid the same fate, or they have just been appalled at his behaviour and just think it could never happen to them. Either way, Tayfel has paid for his accident and should just be left alone.

I'll probably delete this.......

[xsbank]

I'm trying not to get personal, so I guess that means no good stuff either....

[Doc]

Again, I do not in any way agree with the decisions Mark made, but The fact is, many companies reward poor decisions and punish good decisions.

Not intended to be personal, but comments like this one would certainly lead one to believe the blame is with the company, and not the pilot.

[snoopy]

"disengage"...."check"

Cheers,
Kirsten B.