Low visibility, lack of visual references caused fatal crash, says TSB

(Canadian OH&S News) — A new investigation report from the Transportation Safety Board of Canada (TSB) has concluded that visual difficulties, likely caused by the weather, led to a collision between an aircraft and terrain that killed two people, including a paramedic, and seriously injured two others in Grand Manan, N.B. on Aug. 16, 2014.

Early that morning, an Atlantic Charters (AC) Piper PA-31 aircraft left St. John for Grand Manan, carrying a captain, a second pilot, a paramedic and a nurse, returning from a medevac flight. During a second attempt to land at Grand Manan Airport, the aircraft struck a road about 450 metres from the runway, continued through about 30 metres of brush, became airborne again and then struck the ground a second time. The captain and paramedic sustained fatal injuries, while the other pilot and the nurse survived.

The report, published on Feb. 12, speculated that dense fog with extremely limited visibility had likely interfered with the landing, making the required visual references hard for the pilots to detect. The aircraft’s unexplained steep descent at about 0.56 nautical miles from the threshold suggested that the captain could not see the references clearly.

The TSB’s investigation also found that the flight had had only one headset onboard, which had prevented communication among everyone in the craft about the flight situation. In addition, the paramedic who perished in the collision had not been wearing a seatbelt properly, and AC had not provided any formal crew resource-management training. The aircraft did not contain a flight data recorder or cockpit voice recorder, which are not required for this kind of flight.

“If crew resource-management training is not provided, used and continuously fostered, then there is a risk that pilots will be unprepared to avoid or mitigate crew errors encountered during flight,” the report warned. “If cockpit data recordings are not available to an investigation, then the identification and communication of safety deficiencies to advance transportation safety may be precluded.”

Another TSB finding was that Transport Canada had not identified the discrepancies in AC’s operating practices regarding air safety in its surveillance of the airline.

“If Transport Canada does not adopt a balanced approach that combines thorough inspections for compliance with audits of safety-management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents,” the TSB noted. “If organizations do not use modern safety-management practices, then there is an increased risk that hazards will not be identified and risks mitigated.”

Based in Saint John, AC provides charter services throughout eastern North America.