Report released into fatal near Fort St. John

[rocks25]

The report has been released by the TSB into the fatal Cessna 185E C–FXJN crash last winter near Fort St.John YXJ... officially it is a CFIT crash, with a cell phone connection...

The TSB mentions:

"The aircraft had experienced several large altitude deviations while the pilot was using his cellphone. While it did not appear that the pilot was actively engaged in cell phone communications during the last 11 minutes of the flight, this distraction was prevalent throughout the flight and in conjunction with the night conditions encountered, may have contributed to the CFIT event."

Any lessons here for pilots? Time to officially ban cell phone use by pilots during flight?


http://www.tsb.gc.ca/eng/rapports-repor ... 0.asp#fn_2

[gustind]

Any time he replies to a text message, the altitude dropped at which point he picked it up again. Quite an interesting report unfortunately.

[Rowdy]

Why does it seem like there is something blatantly amiss with this report?

11 minutes from the time of the last cell contact and THATS what they're attributing the loss of situational awareness to? Thats a joke right?

I hate to be 'that guy' but Im not so trusting at the TSB and their 'findings' in terms to the wing that separated from the aircraft and was found some distance from the rest of the wreckage.

[rocks25]

Interesting. I've requested copies of their lab reports and i'll post them here when I get them. Something doesn't quite add up on this one for me.

[DanWEC]

I thought the chronology was odd too, but it's only a fraction of the report, so who knows.
Also said he spent 28 minutes on his phone between 3500 and 4600 feet? In northern AB? I can never get that kind of reception in SWO.

[GyvAir]

No need to be in cell contact to be head down, mind elsewhere, thinking about and thumbing out your next text reply.

[gustind]

I thought the chronology was odd too, but it's only a fraction of the report, so who knows.
Also said he spent 28 minutes on his phone between 3500 and 4600 feet? In northern AB? I can never get that kind of reception in SWO.

I've personally made a phone call at 7000ft over Petawawa area inbnd to CYOW to a guy in the GTA. You gotta take your phone out of your pocket for a while and leave it up on the dash (away from the compass) to catch some signals, then make the call.

[V1 Rotate]

Talking on the phone as a contributing factor? How is it any different than talking on the radio?
Especially with the length of time from last phone use to time of impact.

Black hole I definitely buy, especially for someone with little night time experience and hardly any in sparsely populated areas.

[sueonkent]

Whats wrong with wiring the cell phone to the avionics system and talk into the headset mike as if talking to another a/c?

[Wilbur]

The pattern looks like he might have been typing out a response to the last test message recieved. Combine that with being tired at the end of long day and black hole affect...

I feel sorry for the people he was talking and texting with. They will almost certainly feel a sense of guilt or resonsibility however unwarranted.

[patter]

That pilot had a long work day. I wonder if fatigue factored into it.
Who gave the tsb his phone records? I am Pretty sure that wouldn't have happened if they had known such a damning report was to have been written.
I wonder what that chart would look like if we spread it out more and maybe put time instead of distance on the bottom.
Did the cruising altitude actually apply on this flight?

[Wilbur]

Nobody needed to give TSB the phone records. They would either recover the information directly from the device itself or obtain a production order for the service provider to supply the records.

[CFR]

Whats wrong with wiring the cell phone to the avionics system and talk into the headset mike as if talking to another a/c?

My Iphone links via bluetooth to my ZULU headset. I can listen to music or make and receive phone calls. Radio transmissions override anything else (phone or music) and shuts down the external input for a second or so after the radio transmission ceases (it actually ramps down and then back up). The only problem is that I made a mistake and told my wife she could call me in flight!

[patter]

R u saying anyone can get a production order for ur phone records? I googled production order, and it was linked to criminal, justice....didn't see TSB.
Didn't that phone become property of the estate when the pilot died.

There are a few of these tsb reports of late that are worrisome.

[grimey]

I know it's shocking patter, but TSB investigators are actually given powers to, you know, investigate things. Which includes getting warrants, seizing relevant items, and demanding the production of documents. They can also autopsy you if you @#$! up badly enough. The horror.

Canadian Transportation Accident Investigation and Safety Board Act (S.C. 1989, c. 3)

Powers of investigators

19.
(3) Where a justice of the peace is satisfied by information on oath that an investigator believes on reasonable grounds that there is, or may be, at or in any place, any thing relevant to the conduct of an investigation of a transportation occurrence, the justice may, on ex parte application, issue a warrant signed by the justice authorizing the investigator to enter and search that place for any such thing and to seize any such thing found in the course of that search.
Marginal note:Warrants may be obtained by telephone, etc.

(4) The procedure set out in section 487.1 of the Criminal Code applies in relation to the obtaining of warrants under this section, subject to regulations made under paragraph 34(1)(h).

(5) Where any thing is seized by an investigator under subsection (1), the investigator
(a) may, subject to paragraph (b), cause such tests, including tests to destruction, to be conducted on the thing as are necessary for the purposes of the investigation in respect of which the thing was seized;
(b) shall, to the extent that it is practical and safe to do so and does not unreasonably impede the progress of the investigation,
(i) take all reasonable measures to invite the owner of the thing, and any person who appears on reasonable grounds to be entitled to it, to be present at any tests referred to in paragraph (a), and
(ii) allow persons referred to in subparagraph (i) to be present at those tests; and
(c) subject to the need to conduct such tests, shall cause the thing to be preserved pending its return in accordance with section 20.


(9) An investigator who is investigating a transportation occurrence may
(a) where the investigator believes on reasonable grounds that a person is in possession of information relevant to that investigation,
(i) by notice in writing signed by the investigator, require the person to produce the information to the investigator or to attend before the investigator and give a statement referred to in section 30, under oath or solemn affirmation if required by the investigator, and
(ii) make such copies of or take such extracts from the information as the investigator deems necessary for the purposes of the investigation;[/b]
(b) where the investigator believes on reasonable grounds that the medical examination of a person who is directly or indirectly involved in the operation of an aircraft, ship, rolling stock or pipeline is, or may be, relevant to the investigation, by notice in writing signed by the investigator, require the person to submit to a medical examination;
(c) where the investigator believes on reasonable grounds that a physician or other health practitioner has information concerning a patient that is relevant to that investigation, by notice in writing signed by the investigator, require the physician or practitioner to provide that information to the investigator; or
(d) where the investigator believes on reasonable grounds that the performance of an autopsy on the body of a deceased person, or the carrying out of other medical examinations of human remains, is, or may be, relevant to the conduct of the investigation, cause such an autopsy or medical examination to be performed and, for that purpose, by notice in writing signed by the investigator, require the person having custody of the body of the deceased person or other human remains to permit the performance of that autopsy or that medical examination.
Marginal note:Persons to comply with requirements imposed under paragraph (9)(a), (c) or (d)

(10) No person shall refuse or fail to produce information to an investigator, or to attend before an investigator and give a statement, in accordance with a requirement imposed under paragraph (9)(a), or to provide information in accordance with a requirement imposed under paragraph (9)(c) or to make the body of a deceased person or other human remains available for the performance of an autopsy or medical examination in accordance with a requirement imposed under paragraph (9)(d).

[5x5]

Regardless of the cause, it is a shame he died and my condolences to family and friends.

As far as phone calls being the same as radio calls - not likely. Radio calls are directed to an issue involved in flight, usually at the moment, and aid in the proper/safe conduct of the flight. There are prescribed processes and more or less specific phraseology to be used in making such calls. They tend to be short and concise. Not much effort is required to interpret and understand correctly made calls. Why are there so may threads about rambling calls using poor and unnecessary phrases?

Phone calls on the other hand have no form or flight specific purpose. They require focus and interpretation. And lacking prescribed form and phrasing, replies require much more thought to maintain flow of the conversation. They tend to be rambling and last relatively long times. Since they are not related to the flight, or at least not to that particular phase of flight, they distract the pilot from actually flying the plane.

[patter]

I am sorry he died as well.
And I am sorry this report is making an example about texting and calling. It is not illegal. Pilots text and call on company time all the time. For company bizness.
If u were to use a west bound altitude of 3900 or 4000 in the chart the pilot is flying within ppl standard.

[grimey]

I am sorry he died as well.
And I am sorry this report is making an example about texting and calling. It is not illegal. Pilots text and call on company time all the time. For company bizness.
If u were to use a west bound altitude of 3900 or 4000 in the chart the pilot is flying within ppl standard.

Nobody said it was illegal. It may have served as a contributing factor to the accident, which is why it was included in the report.

[Trematode]

I am sorry he died as well.
And I am sorry this report is making an example about texting and calling. It is not illegal. Pilots text and call on company time all the time. For company bizness.
If u were to use a west bound altitude of 3900 or 4000 in the chart the pilot is flying within ppl standard.

What PPL standard are you using?

Last I checked +/- 200' was the PPL standard for the cruise phase. At best the chart shows +/- 500' -- at worst it shows -1000'. What's more is that 2 of the big altitude losses seem correlated with call #1 and #3.

You can argue about how closely correlated the cell phone use was, and there may well have been some other reason for the varriations in altitudes, but it looks like he probably should have been paying more attention to controlling the aircraft, whatever the cause of the deviations.

I see nothing wrong with the report mentioning that use of the cell phone may have been a contributing factor. The findings explicitly state that the loss of altitude was due to "undetermined reasons". If the mere mention of cell phone use being distracting in this report touches any nerves, you may have cause to re-examine how you've been using your phone in the plane.

Personally, I think cell phones are an awesome tool to have in the aircraft in certain situations -- I've got local ATC and FSS numbers stored in my cell's contacts -- but just like any other piece of kit there's potentional for misuse.

[Kratos_vis]

What PPL standard are you using?

Last I checked +/- 200' was the PPL standard for the cruise phase. At best the chart shows +/- 500' -- at worst it shows -1000'. What's more is that 2 of the big altitude losses seem correlated with call #1 and #3.

You can argue about how closely correlated the cell phone use was, and there may well have been some other reason for the varriations in altitudes, but it looks like he probably should have been paying more attention to controlling the aircraft, whatever the cause of the deviations.

I see nothing wrong with the report mentioning that use of the cell phone may have been a contributing factor. The findings explicitly state that the loss of altitude was due to "undetermined reasons". If the mere mention of cell phone use being distracting in this report touches any nerves, you may have cause to re-examine how you've been using your phone in the plane.

Personally, I think cell phones are an awesome tool to have in the aircraft in certain situations -- I've got local ATC and FSS numbers stored in my cell's contacts -- but just like any other piece of kit there's potentional for misuse.

I will have to agree with this guy. I think when flying one should concentrate on all aspect of the flight. Its is no time to be on the phone with the friend or the wife. The cell phone may not be the reason why this airplane went down, but i am sure we all can say from reading the repot and seeing the map above, it contributed to it. My condolences to his friends and family.

[patter]

Those standards are smooth air, daytime.
I don't see plus or minus 500 hundred on that chart.
I don't see correlation to texting or phone calls making a major excursion at the end of the flight.
I see speculation, and and a report that published fairly quickly. As if there was no resistance to the first copy that was sent out.
I see the TSB trying to push an envelop. Pilots are very good at multi tasking and setting priority of tasks.

[patter]

And plus or minus 200 gets u a 3
U double it to get a 1
In smooth air
There are a few small other details.

[grimey]

Those standards are smooth air, daytime.
I don't see plus or minus 500 hundred on that chart.

Did you look at the chart?



Maximum enroute altitude: 4600. Minimum enroute altitude: 3500. that's +100, -1000.

I don't see correlation to texting or phone calls making a major excursion at the end of the flight.
I see speculation, and and a report that published fairly quickly. As if there was no resistance to the first copy that was sent out.
I see the TSB trying to push an envelop. Pilots are very good at multi tasking and setting priority of tasks.

With all due respect, you're delusional. You're objecting to TSB noting that using a cell phone and texting in flight may be a distraction, which has been proven to be the case. They didn't say it caused the accident, they said the use of phones is a risk.

http://en.wikipedia.org/wiki/Texting_wh ... tute_Study