Air Tindi Fatal TSB Report To Be Released March 20, 2013

[single_swine_herder]

Watch this one.

Highly damning of the pilot's off-hours "habits" mixed with flying.

This isn't the way anyone should want to end their career and life in the news media. Five ng/ml is considered threshold of impairment, these results are over 10 times that value.

AVIATION INVESTIGATION REPORT A11W0151

Excerpt in part:

Toxicology

Post-mortem toxicological screening revealed the presence of cannabinoids in the pilot’s system. Femoral blood contained 50.1 nanograms per millilitre (ng/ml) of delta9-tetrahydrocannabinol (delta9-THC), and 21.6 ng/ml of carboxy-THC. Pleural fluid contained 11.9 ng/ml of delta9-THC, as well as 41.8 ng/ml of carboxy-THC. Urine contained 272 ng/ml of carboxy-THC.

Considering the significant amount of THC in the pilot’s blood, the TSB considered confirmation by retesting. The small quantity of remaining femoral blood sample precluded retesting.

Cannabinoids

Cannabinoid Physiology

Delta9-THC is the principal psychoactive cannabinoid found in marijuana, hashish, hash oil, and certain hemp products. Delta9-THC is metabolized in the liver, with the formation of psychoactive and inactive compounds. Carboxy-THC is an inactive metabolite. THC compounds are stored in fatty tissue, reaching peak concentrations in 4 to 5 days.

Metabolic products are eventually excreted and total elimination of a single dose may take up to 30 days.

Recency

A number of factors complicate accurate determination of the recency of cannabinoid use. These include the mode of intake (smoking versus eating), concentration of cannabinoids, and individual variations.

9 Delta9-THC blood plasma concentrations in live subjects over 2 to 3 ng/ml have been shown to indicate marijuana smoking within 6 hours.

10 Dispersal and redistribution of cannabinoids occurring in the post-mortem interval before sampling for toxicological analysis can alter the presence of cannabinoids in tissues and fluids. This increases the difficulty in the application of formulae to establish accurate usage time-frames.

Effects of THC

Flight simulator experiments have demonstrated that THC has wide ranging effects on human performance, including impairment of working memory, coordination, tracking, perceptual-motor performance, temporal perception, and vigilance. The effects of impairment increase with the complexity of the task.

13 A blood delta9-THC concentration over 5 ng/ml is the threshold considered to be necessary for possible impairment. Even allowing for a reasonable margin of error in the toxicology results, the amount of THC present in this occurrence is considerably greater than the threshold that resulted in degraded pilot performance in studies on the impairing effects of THC.


Studies have established the relative risk of road accidents involving cannabis-impaired versus sober drivers as “odds ratios”. A blood delta9-THC concentration of 6 to 8 ng/ml correlated with a blood alcohol level of .05%, and an odds ratio of 1.5 to 2 times the risk of accident for a sober person. Drivers who were under the influence of cannabis tended to compensate consciously by operating more cautiously.

The duration of THC effects is variable, subject to a number of conditions. Generally, after a single dose of marijuana, there will be some impairment for up to 6 hours. Experiments have suggested significant carry-over impairment in complex human/machine performance such as flying, up to 24 hours after a moderate dose of THC via inhalation. This influence can occur after an individual ceases to be aware of any influence of the drug.

VFR Flight in Marginal Weather

It could not be determined why the pilot chose to fly the trip under VFR. Conditions were suitable to enable operation under IFR at altitudes providing safe terrain clearance. The pilot, the aircraft and the company were qualified to operate the trip under IFR. The en route weather was suitable, and with the freezing level well above the minimum IFR route altitude, icing was not a factor to preclude IFR flight. The cloud base was above the minimums required for successful completion of an approach and landing at Lutsel K’e. Before departure, the forecast weather was such that Yellowknife could be filed as an IFR alternate.

The fuel load was not considered to be a factor in the pilot’s decision to fly the trip under VFR rather than IFR. Fuel was readily available at Yellowknife, and there was adequate time between the arrival from Fort Simpson and the departure for Lutsel K’e to bring the fuel quantity to IFR requirements under the supervision of dispatch personnel.

Although the pilot had gained experience in an IFR environment during his flying as a co-pilot in multi-engine aircraft, he had limited experience in single-pilot IFR operations. This may have led to reluctance to file an IFR flight plan on the accident flight, and the decision to remain visual in marginal VFR weather conditions. The route lay mostly in uncontrolled airspace, and when flight visibility deteriorated, the pilot had the option of climbing without ATC clearance to a safe altitude, and conducting an instrument approach at Lutsel K’e. The pilot apparently was willing to fly in cloud as indicated by the earlier flight from Fort Simpson to Yellowknife, albeit on a VFR flight plan in controlled airspace.

Pilot Decision-Making and THC Effects

On the day of the accident, aspects of the pilot’s planning, flying technique and decision-making were inconsistent with regulatory and administrative requirements, the company operations manual policy, and safe flying practices. These included VFR flight in marginal visual weather conditions, flight in IMC on a VFR flight plan, and overwater flight beyond gliding distance of land. The quantity of psychoactive components in the pilot’s system is considered to have been sufficient to have resulted in impairment of cognitive processes. This would likely have had an effect on planning and conduct of the accident flight.

It is possible that the pilot, under the influence of cannabis, avoided the higher workload of IFR flight in IMC, choosing to remain visual for the trip to Lutsel K’e.

Random testing of employees in safety sensitive positions may mitigate this risk.

[toelessjoe]

Well now.

This explains a lot.


- Toeless.

[single_swine_herder]

I think you'll find the company's response interesting .....

Air Tindi Ltd.

The company issued a company directive, dated 07 October 2011, which initiated the following policies for scheduled services operations:


Dispatch limitations:
• All scheduled flights will be dispatched under IFR. VFR flight may only be conducted if authorized by operations management personnel.
• No company aircraft may be operated on any scheduled passenger flight when the observed weather is at, or forecast to be lower than, the alternate minima for the destination airport.

Air Tindi instituted changes to the operational control system of scheduled passenger flights to ensure adequate flight following and timely reporting of departure and arrival times to the company System Operations Control Centre (SOCC).
In order to facilitate incident and accident investigations, Air Tindi has commenced installation of Appareo Vision 1000 Systems cockpit imaging and flight data monitoring devices in the Cessna 208B fleet.
In order to improve operational oversight, the company has consolidated most management personnel at the airport base.
The company has revised the existing drug and alcohol policy to include random testing of employees in safety-sensitive positions. These positions include pilots, maintenance engineers and dispatch personnel.

http://www.appareo.com/primarymenu/prod ... sion-1000/

[toelessjoe]

The new D & A policy affects every one at Discovery Air, not just Tindi. You should pm Doc about his thoughts on the subject.

- Toeless.

[2.5milefinal]

I'm thinking random testing for all Canadian commercial pilots is coming...sooner than later.

[xsbank]

I would be very surprised if the insurance will pay off on this one - this "accident" might finish off Tindi with all the claims that will arise...

Anybody still in favour of smoking up on their days off?

[ymxnewbie]

I'd feel better about this if there was a second sample... or anything. Tough one to swallow.

[ODA]

How come I can't find the report on the TSB website?? Link anyone??

[jpilot77]

http://www.tsb.gc.ca/eng/rapports-repor ... 1w0151.asp

[2.5milefinal]

"I'd feel better about this if there was a second sample"
Really?
Some of you guys just do not get it do you(?)

[buck82]

I'm surprised they didn't have two samples as well. Normal protocol with WADA testing (World anti doping association) requires two samples. If the first one is a positive test, then the second sample is tested also. If the second is positive you declare a positive test result. Perhaps coroners are only required to run one test.
I'm not against drug testing, but if not done correctly and to the right standards the results can be misleading. In this case it looks pretty clear cut, however a second test would prove the first test was correct.

[Diadem]

One test? They took samples from his lungs, femur and urine. Not only are those three different tests, but they're tests using three different fluids.

[SurfViper]

I, unfortunately, know for a fact that Tindi isn't the only YZF 703/704 operator faced with this problem. I wonder if it won't take a similar incident/accident before other parent companies institute ongoing random testing (and actually follow through on it) rather than just a simple pre-hire screening test.

[OMGWTFBBQ]

I'm curious as to how you got ahold of this and posted some of its contents, word for word, before it was offically released? This report really throws the pilot under the bus. So the guy burned one down at some point in time, and it cost him his life.. unfortunately its difficult to tell if he was under the influence at the time of the accident, all it determines is that he had it in his system.. An execution of an amended D&A policy of course will help mitigate the risk indeed, and I believe it is the correct route, its unfortunate that an accident had to occur before such a course of action was taken. Also regarding testing I have heard that Tindi does random testing to employees beyond the inital hire test. Sad and unfortunate occurance that could have been easily avoided had SOPs been followed.. there is a reason they are there.

[ReserveTank]

This report really throws the pilot under the bus.

I have a feeling that this accident would have happened even without the alleged marijuana use. Northern operators like for you to push fuel and VFR weather. If you don't do it, they'll find some other guy to do it. Your SOPs always say what TC wants to hear, but the verbal contract with your boss in the pilot room is quite a different matter. You see, loading fuel adds weight which costs him potential revenue-That's why you should take min fuel and .. run "VFR". It's not as if the accident pilot invented this concept when he was stoned. It's been this way for years, and as long as companies have the ability to keep suing TC enforcement, TC will not touch these places.

[esp803]

Northern operators like for you to push fuel and VFR weather. If you don't do it, they'll find some other guy to do it.

In my time north of 60 I have NEVER been pressured to push fuel and especially weather. They pay me the big bucks to say no when it needs to be said.

E

[2.5milefinal]

Ah yes but because there was dope in this guys blood the public will not care what the companies(bosses) do up north. They just know the pilot was high. The dope smokers out there may not like it that this accident is blamed on marijuana use, but that's just the way it is going to be.
Don't crash airplanes when you are doing drugs I always say.

OMGWTFBBQ please change your Avatar, that's Cat Drivers. It has been for years.

[esp803]

Whoa... I thought the writing was off for Cat Driver... Just looked at the avatar and assumed....

[OMGWTFBBQ]

OMGWTFBBQ please change your Avatar, that's Cat Drivers. It has been for years.

Its been mine for the last 7 years, and its also in the default selection of avatars for avcanada forums. I dont see why I need to change it because some other guy uses it as well.. Lets stay on topic here... K thanks.

[2.5milefinal]

ok whatever I'm done here anyway.

[Chuck Ellsworth]

It's not as if the accident pilot invented this concept when he was stoned.

Maybe pilots could use the defense that they have to be stoned to accept the working conditions and the lack of government oversight in aviation?

[Flybabe]

One test? They took samples from his lungs, femur and urine. Not only are those three different tests, but they're tests using three different fluids.

Glad I wasn't the only one that noticed that.

[ReserveTank]

In my time north of 60 I have NEVER been pressured to push fuel and especially weather. They pay me the big bucks to say no when it needs to be said.

E

I'm glad to get some feedback to the contrary. Your conditions are the way it should be as a general standard. There's a few good operators out there, but for many, pushing is still a big problem. Many pilots feel they cannot say no or at least delay the flight. They fear reprisal from their employer. They feel that they will be perceived as a "troublemaker" by fellow pilots. They feel that they won't get a good reference when it's time to move on.

Not that it exonerates the pilot. He should not have been using. But there is a deeper reality. Simple people are just going to see the drug use part and run with it, leading us to random testing nationwide.

[Independence]

While the drug thing is obviously an issue, what jumps out at me from the report is that the pilot may have lacked confidence in his IFR skills and experience and was more comfortable .. running than filing IFR (for which he was qualified and conditions suitable).
Perhaps the questions should be along the lines of did the company release the pilot for single pilot IFR before he was actually ready even though he was legal (which are two different things).

[SeptRepair]

Reading the report was quite enlightening. Learned some new things today. What really stands out to me is the amount of THC in his system. Dissecting the report leads me to believe he burned one back between flights. Anybody else read that into it?