Pilot error on weather, weight led to Air Tindi forced landing: report
Transportation Safety Board of Canada looks at incident credits skills of pilot, passengers for survival
Shane Magee
Northern News Services
Thursday, March 24, 2016
LIIDLII KUE/FORT SIMPSON
The pilot of an Air Tindi flight who made an emergency landing on Great Slave Lake in November 2014 had underestimated the severity of icing conditions and overloaded the Cessna Caravan for the type of weather it encountered, states a report released March 24 examining the factors leading to the incident.
This Air Tindi Cessna Caravan 208B, with one pilot and five passengers on board, made an emergency landing Nov. 20, 2014, on the ice of the North Arm of Great Slave Lake. No one was injured even though the plane slammed into a rocky outcrop before coming to a stop. - photo courtesy of Transportation Safety Board of Canada
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The factors combined to force a landing in the dark on the ice of the lake's North Arm on Nov. 20, roughly 33 kilometres northwest of the city.
The Transportation Safety Board of Canada report reveals the aircraft touched down at a high rate of speed about 1,600 feet from open water, then continued on the ice for about 2,300 feet before slamming into a rock outcropping, causing severe damage to the plane.
The pilot and all five passengers on the flight from Yellowknife to Fort Simpson were uninjured. They were rescued from the ice about four hours after the landing.
The board's report credits the pilot for keeping the Caravan 208B in the air and under control as it landed despite challenges.
"This minimized structural damage and increased survivability for the aircraft's occupants," the report states.
Alasdair Martin, president of Air Tindi, in an interview after the report was released, also gave credit to the pilot for his actions to save lives.
The report outlines numerous changes the company has made to policies and other factors that contributed to the accident. Martin said the company has largely addressed issues raised in the report which he called factually accurate.
"We take this very seriously and I am comfortable we've done everything we can," he said.
Now the company has a support system providing help to pilots, including weather information and assistance with weight and balance issues - which the report highlighted as an issue.
"The key is, if there's a potential for icing, it needs to be taken very seriously," Martin said.
Pilot misinterpreted weather
The flight had been scheduled to leave Yellowknife the evening of Nov. 19 but didn't because of icy weather conditions in Fort Simpson.
The flight was then set to take off early the next morning to get the company's schedule back on track, the report states.
The pilot had requested weather information about icing conditions but because there hadn't been a previous flight through the same area, there was limited information about conditions in the air.
As well, a weather report was misread and pilots have a tendency, according to the report, to believe some weather information is unreliable, leading to a lack of vigilance in its use.
"This lack of vigilance resulted in an abbreviated weather analysis, which led to an incomplete picture concerning where the icing conditions were," the report states.
The pilot flew into a more severe ice storm than expected, resulting in loss of aerodynamic performance that made it impossible to prevent the landing. The pilot also did not extend the plane's flaps as he was supposed to in the situation.
The plane was also 342 pounds too heavy for the conditions it was about to fly into because "he did not have an appreciation for the limitations of flight into known icing conditions," the report states.
He had used his previous experience for the work, the report states, and failed to accurately reflect the actual weights of the fuel, passengers and cargo. That ran against company procedures but was not noticed because of a lack of supervision.
Martin said the company has increased support to pilots for pre-flight operations.
The company grounded its Caravan planes after the incident but returned them to service after policy changes.
The report also examined how emergency equipment was placed on the plane and the pre-flight briefings given to passengers. The equipment was in the belly of the plane and couldn't be easily removed because it was trapped between the plane and the ice after the nose and left wing landing gear were torn out upon impact with the outcrop.
The briefing of passengers before the flight about emergency exit procedures has changed and the emergency kit has been moved to make it easier to access, Martin said in a previous interview.
Last year, the company said the pilot involved in the emergency landing had returned to service within about a week of the incident.
The report also makes note of the lack of 9-1-1 emergency phone service in the territory.
After the landing passengers tried to use cellphones. One phone had service but when the passenger tried calling, he or she got a message that their usage agreement had expired.
"In areas with 9-1-1 availability, the service would have been usable without a valid cellular service agreement," the report states.
