TSB report reveals causes behind airline crew deaths

QUEBEC CITY (Canadian OH&S News)

Failures in training, operating procedures and a lagging company safety culture were pinned as the cause of a plane crash that killed two crew members and five passengers two years ago.

On June 23, 2010, a Beechcraft A100 King Air operated by air taxi operator Aéropro had taken off from a Quebec City airport shortly before 6 a.m.

When engine troubles forced it to turn around, the co-pilot radioed to inform flight controllers of their intention to turn back, and that the plane could no longer gain altitude.

Seconds later, the plane crashed into a berm. Everyone on board was killed in the impact and resulting fire.

An investigation from the Transportation Safety Board of Canada (TSB) found the aircraft had taken off under decreased power — against manufacturer recommendations, but also a common procedure at Aéropro. And when the right engine failed, the propeller’s blades were not parallel to the airflow, creating excessive drag.

Though Aéropro’s training met regulatory requirements, the TSB found it did not prepare pilots for an emergency situation. Additionally, the company’s emergency checklist was outlined for only one pilot, not giving directions as to who was to perform what task during two-pilot operations, possibly causing confusion during the incident.

“We found numerous safety deficiencies in the areas of pilot training, company operating procedures, maintenance documentation and the company’s safety culture,” said André Turenne, the TSB’s lead investigator in the incident, noting that while unsafe practices were uncovered by Transport Canada dating back to April of 2007, the steps taken to ensure compliance with regulations were not effective and the unsafe practices continued.

Company’s air operator certificate revoked

“I am deeply concerned that, as the report states, the significant measures taken by Transport Canada did not have the expected results,” said transport minister Denis Lebel in a statement, noting that Aéropro’s Air Operator Certificate was revoked in July of 2010 and the company no longer provides air transportation services.

Since the incident, Transport Canada has made significant changes to its surveillance program, the TSB report notes, including updates to surveillance planning methods and introducing tools that provide an improved capacity for monitoring and analyzing risk indicators in the aviation system.

In April of 2007 Transport Canada reported that unless there was a “radical change” in management culture, close monitoring of the company’s operations would be necessary to improve its safety performance. The company disputed the findings, and Transport Canada did not take further action until almost a year later, when it performed its most recent regulatory audit inspection in March.

The audit found, among other things, numerous deficiencies in training records as well as failures of the operations manager with regards to training programs and operations manuals that were no longer compliant with existing regulations.

Following a Program Validation Inspection in October of 2009, Transport Canada revoked its approval of the company’s operations manager after finding he had not carried out his duties in ensuring regulatory requirements were followed.

“Air taxi companies operate in a challenging environment: serving smaller airports with less infrastructure and flying smaller aircraft equipped with less sophisticated navigation and warning systems, among other factors,” added Turenne. “The risks posed by these challenges can be mitigated with a proactive and robust company safety culture.”

The report comes on the heels of two separate incidents at Canadian airports. On August 10, an OK Tire employee was crushed and killed while replacing the tire of a tow vehicle at Montreal-Trudeau Airport.

Two days later in Yellowknife, a Canadian North ramp worker was injured and taken to hospital after being hit by an Air Canada Jazz plane taxiing down the runway.

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