Air Tindi Flight Missing

[Illya Kuryakin]

Doesn’t matter. Air Tindi does not operate their 200s single pilot. The capts don’t do single pilot PPCs. If it left the ground with the right side ADI u/s then it wasn’t airworthy.

And there you have it.
Illya

[Donald]

Air Tindi's president seems to agree with you.
https://nnsl.com/yellowknifer/key-fligh ... ndi-crash/

Do you have the whole article?

[lownslow]

That then would add recognition time to the mix and eaten into the 84 seconds they had.

Has the TSB said where they got the 84 seconds figure from? If it was internally recorded by the instrument then you can consider however long it took to notice but if it came from the CVR then that would be the actual time of recognition.

[Donald]

So were the pilots "give'ers" for flying a broken plane, or was the company "pushers" for not fixing known defects and asking crews to go?

In a perfect world, we know the correct answer (hardest thing about flying...).

But this is 703 northern flying with low-timers, and instances where companies take advantage.

[seven-oh-nooo]

So were the pilots "give'ers" for flying a broken plane,

I can't be everywhere at once. The thought of this keeps me up at night.

[leftoftrack]

.

[JL]

TSB final report

https://www.tsb.gc.ca/eng/rapports-repo ... w0015.html

[porcsord]

Condolences to all those affected.

This is one of the more harrowing reports I've read recently. It seems they broke out at about 2000agl and attempted a recovery, but with a descent rate of 34,000'/min were unable to recover at that point (about 4 seconds to act).

Reading this has got me thinking about the last time I genuinely flew partial panel. It's been longer than I care to admit, and will be going into the sim this week to get some practice.

PS

[flyingnorm]

This accident sequence has me asking some questions.

1. What are real world failure rates for G1000 or similar flight decks? Not talking about a bug or incorrect setting but rather loss of adhrs.

2. Do you find the company culture shifting when a certain piece of equipment is so unreliable that its always broke?

[airway]

I just skimmed the accident report, and did not see anything about what attitude instruments were installed in that aircraft that were available for use when both of their primary Attitude Indicators failed.

Did they have any of these?

Standby Attitude Indicator
Turn and Bank Indicator
Turn Coordinator

[porcsord]

I didn't see mention of other instruments other than there wasn't a third attitude indicator. They did have foreflight, with synthetic vision and adhrs through the garmin unit....

[digits_]

So were the pilots "give'ers" for flying a broken plane, or was the company "pushers" for not fixing known defects and asking crews to go?

In a perfect world, we know the correct answer (hardest thing about flying...).

But this is 703 northern flying with low-timers, and instances where companies take advantage.

I only see this getting worse. 2 months ago, nobody was afraid for their job, and people still did stuff like this.
Now you have the same low time pilots, but afraid for their jobs -if they still have them-, making it harder to say no again.

Things will get nasty. Hopefully all creative operators have read the accident report.

[YYZSaabGuy]

I only see this getting worse. 2 months ago, nobody was afraid for their job, and people still did stuff like this.
Now you have the same low time pilots, but afraid for their jobs -if they still have them-, making it harder to say no again.
Things will get nasty. Hopefully all creative operators have read the accident report.

"Creative operators" aren't going to learn anything from this report - none of the TSB's findings related to any kind of pressure from Air Tindi to undertake flights, or pointed so much as a finger at the operator's maintenance practices or operational controls. Sadly, this accident appears to be attributable 100% to pilots not dealing appropriately with a dual AI failure:

3.0 Findings
3.1 Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
For undetermined reasons, the left-side attitude indicator failed in flight.
Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
The captain and first officer likely experienced spatial disorientation.
Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.

3.2 Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
If flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.

3.3 Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.

[digits_]

I only see this getting worse. 2 months ago, nobody was afraid for their job, and people still did stuff like this.
Now you have the same low time pilots, but afraid for their jobs -if they still have them-, making it harder to say no again.
Things will get nasty. Hopefully all creative operators have read the accident report.

"Creative operators" aren't going to learn anything from this report - none of the TSB's findings related to any kind of pressure from Air Tindi to undertake flights, or pointed so much as a finger at the operator's maintenance practices or operational controls. Sadly, this accident appears to be attributable 100% to pilots not dealing appropriately with a dual AI failure:

In an accident like this, where there are no passengers hurt, would the TSB interview other employees? If they only focus on company produced paperwork, chances are they wouldn't find company faults.

[YYZSaabGuy]

I only see this getting worse. 2 months ago, nobody was afraid for their job, and people still did stuff like this.
Now you have the same low time pilots, but afraid for their jobs -if they still have them-, making it harder to say no again.
Things will get nasty. Hopefully all creative operators have read the accident report.

"Creative operators" aren't going to learn anything from this report - none of the TSB's findings related to any kind of pressure from Air Tindi to undertake flights, or pointed so much as a finger at the operator's maintenance practices or operational controls. Sadly, this accident appears to be attributable 100% to pilots not dealing appropriately with a dual AI failure:

In an accident like this, where there are no passengers hurt, would the TSB interview other employees? If they only focus on company produced paperwork, chances are they wouldn't find company faults.

Fair point. I have no idea about the level of interviews the TSB undertook. I do question, though, whether there would've been pressure of any kind to dispatch an empty aircraft.

[digits_]

From what I've seen (not necessarily at Air Tindi), is that pressure is seldom linked to one flight. It's a culture thing. A company wants you to go when you can, a company questions you when you snag a plane, things like that. Also, if a flight was unimportant, it wouldn't have been dispatched to begin with.

*speculation*
Not snagging the broken attitude indicator could imply they were expecting a "ground tested serviceable" reply. There might not have been pressure from the operations team, it could have been a lack of faith in the maintenance department.

If someting has intermittent snags, and they never get fixed but always signed out with a "no faults found"- variety, in the end one will stop snaging things like that.

[YYZSaabGuy]

From what I've seen (not necessarily at Air Tindi), is that pressure is seldom linked to one flight. It's a culture thing. A company wants you to go when you can, a company questions you when you snag a plane, things like that. Also, if a flight was unimportant, it wouldn't have been dispatched to begin with.

*speculation*
Not snagging the broken attitude indicator could imply they were expecting a "ground tested serviceable" reply. There might not have been pressure from the operations team, it could have been a lack of faith in the maintenance department.

If someting has intermittent snags, and they never get fixed but always signed out with a "no faults found"- variety, in the end one will stop snaging things like that.

Your call, but I think there is more than enough in this particular TSB report to chew over and consider without adding unfounded speculation about other factors (or other operators, for that matter) that the TSB neither identified nor attributed as being relevant to this accident. But hey, if speculation is your thing, fill your boots.

[GoinVertical]

Did they have any of these?

Standby Attitude Indicator
Turn and Bank Indicator
Turn Coordinator

This is a big question that isn't answered - was the aircraft equipped with a turn coordinator or turn and bank indicator?

Anyone at Tindi or have access to someone who is or their KA MEL?

I don't think it's reasonable to expect anyone to be able to fly IMC with just heading, airspeed, and altitude.

I don't know what the culture is like at Tindi's 703 op, but from the report it really sounds like the captain expected the FO's attitude indicator to come to life eventually. Anyone who has experience with vacuum driven gyros in the cold has seen this.

The decision to not wait for the aircraft to warm up and the gyro to come to life before departure is where it all went wrong. The question is why that decision was made.

[Ki-ll]

Captain’s attitude indicator was a combined instrument.
It had both rate of turn indicator and a ball. Now I don’t recall reading anywhere that rate of turn indicator would or wouldn’t work with the GYRO flag.
Regardless of that, there were two iPads with ForeFlight AHRS. How well do they work?

[airway]

Did they have any of these?

Standby Attitude Indicator
Turn and Bank Indicator
Turn Coordinator

This is a big question that isn't answered - was the aircraft equipped with a turn coordinator or turn and bank indicator?

Anyone at Tindi or have access to someone who is or their KA MEL?

I don't think it's reasonable to expect anyone to be able to fly IMC with just heading, airspeed, and altitude.

I don't know what the culture is like at Tindi's 703 op, but from the report it really sounds like the captain expected the FO's attitude indicator to come to life eventually. Anyone who has experience with vacuum driven gyros in the cold has seen this.

The decision to not wait for the aircraft to warm up and the gyro to come to life before departure is where it all went wrong. The question is why that decision was made.

I'm pretty sure that if a IFR aircraft is equipped with 2 Attitude Indicators with separate power supplies, there is no requirement for a standby AI, T&B indicator, Turn Coordinator, or even a ball.

[Cliff Jumper]

I'm pretty sure that if a IFR aircraft is equipped with 2 Attitude Indicators with separate power supplies, there is no requirement for a standby AI, T&B indicator, Turn Coordinator, or even a ball.

You're pretty sure?

I'm pretty sure that you're wrong.

[Axial Flow]

With a third attitude indicator installed, you may use a slip-skid indicator in lieu of a turn and slip indicator or turn coordinator.


Power-driven Aircraft — IFR

605.18 No person shall conduct a take-off in a power-driven aircraft for the purpose of IFR flight unless it is equipped with

(a) when it is operated by day, the equipment required pursuant to paragraphs 605.16(1)(a) to (h)



605.16 (1) No person shall conduct a take-off in a power-driven aircraft for the purpose of night VFR flight, unless it is equipped with

(a) the equipment referred to in paragraphs 605.14(c) to (n);

(b) a sensitive altimeter adjustable for barometric pressure;

(c) subject to subsection (2), a turn and slip indicator or turn coordinator;

(2) Where the aircraft is equipped with a third attitude indicator that is usable through flight attitudes of 360° of pitch and roll for an aeroplane, or ± 80° of pitch and ± 120° of roll for a helicopter, the aircraft may be equipped with a slip-skid indicator in lieu of a turn and slip indicator or a turn coordinator.

Would nice for CARS to require a third attitude indicator for all Part 7 operations. I have flown 7-8 leg days with Stratus 3 connected to Foreflight and only had to calibrate it on the ground for initial flight, and by end of day it was only a few degrees out for pitch and roll. So systems available like the Lynx or Garmin Connext or Flight Stream coming directly from AC AHRS you would be set.

[flyingnorm]

Since the CP AI failed and was not snagged on the ground it could raise a company culture question. Alternatively, it could raise a question around a specific piece of equipment thats always broke, or is at least experiencing a series of failures in a short time. I had five flight director failures in a short lengths of time in the same aircraft. Got to the point where I limited myself to marginal vfr flights because it was going to tank sometime on the next flight. You get the instrument overhauled, install it and it works, 10 hours later or sometimes sooner its broke again. Certain models of the electomechanical instuments are getting long on the tooth, and overhaul shops don't have access to either the knowledge or components to properly rebuild the instruments. In such cases, its a big step to look at an efis upgrade on an older airplane, and its just the CP side after all. Yes culture, but a culture created by certain specific models of junk equipment rather than some other unhealthy company cultures created by other circumstances or individuals. The failure rate of the model of AI in the accident report is quite telling.

[goingnowherefast]

If maintenance gives me a signout of "ground test serviceable" or "no faults found", I'm pretty quick to write a more detailed snag the next time it fails. Might take some pictures with my phone. This little back and forth can only go on for so long before it's a reoccuring defect, and requires more attention. SMS reports have a fantastic way of causing reoccurring and frustrating problems to get fixed.
Pilots can have an influence on company culture as well, just make sure you're a positive influence on company culture.

[2R]

Sadly, lots to learn in the reading of safety reports .
What did you learn from reading this particular report ?