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Matt Bromley |
EDMONTON - The investigation into a deadly northern plane crash has found it was caused by a combination of marginal weather and the pilot's marijuana use.
The pilot and one passenger were killed when the Air Tindi plane went down near a community on the east arm of Great Slave Lake in October 2011.
A Transportation Safety Board investigation found the weather that day was rainy and overcast with poor visibility.
"The aircraft was flown at low altitude into an area of low forward visibility, which prevented the pilot from seeing and avoiding terrain," the investigation concludes. "Weather during the accident flight was marginal for (visual flight rules) flight."
The Cessna 208B Caravan did not have electronic aids such as a terrain awareness and warning system or terrain-warning GPS. But it was fully equipped for instrument flying and the pilot and the company were qualified in such navigation.
"Flying under (instrument flight rules) would have provided a margin of safety given the weather conditions," the board wrote. "It could not be determined why the pilot chose to fly under (visual flight rules)."
The report also found the pilot was flying over Great Slave Lake beyond the gliding distance of his airplane.
There was another issue as well.
"Toxicology testing revealed that concentrations of cannabinoids found in the pilot's bloodstream were sufficient to have impaired pilot performance and decision-making during the flight."
Those concentrations were "considerably greater" than levels that impaired pilot performance in flight simulator tests, the report says.
"The quantity of psychoactive components in the pilot's system is considered to have been sufficient to have resulted in impairment of cognitive processes."
The flight did not have a co-pilot.
The board says Air Tindi has since instituted random drug tests for all employees in safety-sensitive jobs.
In a prepared statement, Air Tindi said: "The (board) report indicates that this accident was a function of various factors, including poor weather conditions and some of the decisions made by the pilot. The accident was a tragedy by any measure and we remain deeply saddened by the tragic consequences of that accident."
The statement also says that Air Tindi has "always had ... stringent monitoring for all team members who work in safety-sensitive positions."
"We would like to again express our condolences to the friends and family affected," said Air Tindi president Sean Loutitt.
The company did not answer questions about the board's report.
Since 1991, the Transportation Safety Board has found four air, marine or rail accidents in which operators either tested positive for marijuana or were known to have used it while responsible for their vehicles.
Mandatory drug testing for employees in federally regulated transportation industries does not exist in Canada, although it does in the U.S.
The regularly scheduled flight went down about 25 kilometres from the community of Lutsel K'e, narrowly missing a massive cliff but crashing onto a narrow peninsula. Rescuers responded immediately.
A privately owned Twin Otter landed on Great Slave Lake near the crash site and rescuers beat their way through the bush to the site.
A helicopter owned by Great Slave Helicopters also flew in, as did a Royal Canadian Air Force Hercules search-and-rescue aircraft. RCMP also choppered to the site.
Two of the four passengers, both from Lutsel K'e, were injured. Rescuers were unable to save the pilot, Matthew Bromely, 28, and passenger Timothy Harris, 54.
Since the accident, the board has required all planes with more than six passenger seats to have terrain awareness and warning systems installed by July 2014.
http://www.globalnews.ca
http://tsb.gc.ca
EDMONTON, AB, March 20, 2013 /CNW/ - The Transportation Safety Board of Canada (TSB) today released its investigation report (A11W0151) into the controlled flight into terrain (CFIT) accident on 4 October 2011 that involved a Cessna 208B Caravan operated by Air Tindi Ltd. near Lutsel K'e, Northwest Territories.
The Cessna Caravan was operating under visual flight rules (VFR), under which the pilot must maintain constant visual reference to the ground. The flight departed during daylight hours from Yellowknife to Lutsel K'e, Northwest Territories, with one pilot and three passengers aboard. When it did not arrive on time, a search was launched, and the aircraft was found 26 nautical miles west of Lutsel K'e on high terrain near the crest of Pehtei Peninsula. The pilot and one passenger were fatally injured, and the two other passengers were seriously injured. Although no emergency locator transmitter (ELT) signal had been received, it was found to be operational when the search team found the aircraft.
The flight and the nature of the crash were characteristic of a CFIT accident, identified on the TSB's Watchlist as one of the safety issues posing the greatest risk to Canadians.
The aircraft was flown at low altitude into an area of low forward visibility, which prevented the pilot from seeing and avoiding terrain. Weather during the accident flight was marginal for VFR flight, and the aircraft did not have a terrain awareness and warning system (TAWS) or terrain-warning features on its GPS. The pilot, aircraft and company were all qualified to operate under instrument flight rules (IFR), under which pilots fly using cockpit instruments rather than visual references. Flying under IFR would have provided a margin of safety given the weather conditions. It could not be determined why the pilot chose to fly under VFR.
Toxicology testing revealed that concentrations of cannabinoids found in the pilot's bloodstream were sufficient to have impaired pilot performance and decision-making during the flight.
Since the accident, Air Tindi has taken measures to improve safety, such as dispatching all scheduled flights under IFR; installing cockpit imaging and flight data monitoring devices in its Cessna 208B fleet; and introducing random drug and alcohol tests for employees in safety-sensitive positions.
The ELT manufacturer made changes to its ELT designs to improve signal detection, and it also revised the instructions on how to secure ELT installations properly in aircraft. Canadian, U.S., and European regulators have taken steps to raise awareness of the need for adequate instructions to ensure that hook and loop (Velcro) fasteners securing ELTs are sufficiently tightened, and the FAA for its part has changed the design criteria for all new ELTs to exclude hook and loop fastener mounting systems.
Transport Canada enacted regulations requiring TAWS to be installed in all turbine-powered aircraft with 6 or more passenger seats by July 2014.
Collisions with land and water are a TSB Watchlist issue.
http://www.newswire.ca
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