Aviation Safety Letter 4-2003

Pilot Error or Poor Management?


On October 15, 2001, a Piper PA-31 departed Yellowknife, Northwest Territories, at 20:43 on a night IFR charter flight to Fort Liard. One pilot and five passengers were on board. On arrival at Fort Liard, in conditions of moderate to heavy snow, the pilot initiated an non-directional beacon (NDB) approach with a circling procedure for Runway 02. At about 22:33, the aircraft struck a gravel bar on the west shoreline of the Liard River, 1.3 NM short of the threshold of Runway 02, and 0.3 NM to the left of the runway centreline. The aircraft sustained substantial damage, but no fire ensued. Three passengers were fatally injured, and the pilot and two passengers were seriously injured. This synopsis is based on the Transportation Safety Board of Canada (TSB) Final Report A01W0261.

The pilot called the Yellowknife FSS at 18:22 for weather and to file a flight plan. He was informed of an advancing warm front and associated snow. Significant snow was to be expected with the advancing warm front with 5 to 10 cm forecast for the Fort Nelson/Fort Liard area. An analysis of the aviation routine weather reports (METAR) show that the advancing warm front was close to Fort Nelson at 20:28, where the clouds had lowered to 1100 ft overcast with visibilities of 1.5 SM in snow.

The pilot filed an IFR flight plan from Yellowknife direct to Fort Liard, with Fort Nelson as the alternate, and an expected departure time of 19:00. Passenger delays made him revise his departure twice, first to 19:50, and later to 20:25. On that third call, at 20:08, the pilot queried about the en-route weather. At 20:00 at Fort Nelson, the overcast cloud had rapidly gone from 8 000 ft AGL to 3 000 ft AGL, and the leading edge of the cloud associated with the advancing warm front was somewhere between Fort Nelson and Fort Simpson. It was not known whether the leading edge of the cloud had reached the Fort Liard area at that time. The FSS briefer advised that if the flight arrived in Fort Liard soon, the weather shouldn't be too bad. The pilot and passengers discussed delaying the flight until the following day; the pilot informed the passengers that he was certified for night flying and that he felt the weather around Fort Liard would be suitable for the flight, so they decided to leave that night.

The Fort Liard weather began to deteriorate significantly at approximately 21:50. A thick cloud band moved over Fort Liard at about 22:00, producing heavy snow showers, and the visibility at the airport should have dropped to ½ to 3 SM in snow with obscured/precipitation ceilings of 500 to 1 200 ft AGL. During the overnight period, 14 cm of wet snow fell at Fort Liard. Witnesses at Fort Liard estimated the ground visibility to be ½ to 1½ mi. in snow at the time of the accident. Deteriorating weather conditions at Fort Nelson were reported to the pilot at 21:52, with a ceiling of 1 100 ft overcast, 1½ mi. visibility in snow and an altimeter setting of 29.86. The pilot's last transmission was at 21:59, when he advised he was crossing the 150° radial of the Fort Simpson VHF omnidirectional range (VOR) at 51 distance measuring equipment (DME).

The pilot did not express any concerns and there was no warning of the impending impact. The aircraft contacted the ground in approximately a 5° nose-low and 5° to 10° left-wing low attitude, and remained upright. The impact forces did not significantly compromise the survival space in the cabin or cockpit areas. The pilot sustained severe head injuries and the right seat passenger sustained fatal head injuries due to impact forces. These injuries may have been prevented or reduced in severity had the upper torsos of these occupants been restrained by the available shoulder harnesses.

Aerial view shows wreckage at arrow A, and intended landing runway at arrow B.
Aerial view shows wreckage at arrow A, and intended landing runway at arrow B.

The Fort Liard Airport is served by a Community Aerodrome Radio Station (CARS), which was closed at the time of the occurrence. A call-out to have an observer could have been made for a fee of $149.80, but the operator had never requested such a call-out and it is not known if the pilot even knew if the call-out was available to him. As there was no observer on duty, no official weather observation was taken near the time of the accident. As a result, the pilot did not have the Fort Liard altimeter setting, which was later estimated to be at 29.92 or 29.93 at the time of the accident. Both aircraft altimeters were found set at 30.12, which was the setting for Fort Simpson at 20:00. The company approach to Fort Liard did not provide for the use of a remote altimeter setting, and the unauthorized use of the Fort Simpson altimeter setting would have resulted in the altimeter reading being 200 ft too high.

The pilot was properly licensed for the flight but had not completed the required night takeoffs and landings to meet the night recency requirements necessary to carry passengers. While the operator tracked flight duty times, it did not have an adequate system in place to monitor qualifications for specific operations. The pilot was also a young new hire with little experience, and had flown single pilot on a PA-31 passenger-carrying charter only once previously, on a visual flight rules (VFR) flight.

He had logged a total of 1 157 flying hours, with 77 hr on PA-31 aircraft. While his log had 20.3 hr of PA-31 dual, his company's training record indicated he had received only 6.5 hr. Much of the dual time he had logged involved revenue flights that he had flown for familiarization. He had also logged 14 hr of similar "dual" hours with a previous employer. While this experience is valuable for familiarization and the building of local knowledge, it does not qualify as dual time, since revenue flights are not considered training. Therefore, out of a logged total of 127 hr of multi-engine experience, 28 of those hours were acquired as a non-revenue passenger with no crew status.

Several weeks before the occurrence, the pilot, flying as SIC from the left seat, had lost situational awareness during an NDB approach. He flew through the intercept for the inbound course, initiated the final descent late, and overflew the missed approach point prior to reaching the minimum descent altitude (MDA). He continued to descend for some distance past the missed approach point, and possibly past the runway, without the runway in view. He commenced the missed approach procedure on command by the pilot-in-command (PIC). The PIC assumed control and completed another approach and the landing from the right seat. The circumstances of the incident had been related to the training pilot and the operations manager verbally, but may not have been reported at all to the chief pilot. The company took no action following the incident.

The pilot may also have suffered from fatigue after a long duty day. His period, the flight duty time can be extended by one-half the length of the rest period, up to a maximum of 3 hr. The pilot was provided with a day room in Yellowknife to rest from 14:00 to 19:00. During this 5-hr rest period, the pilot was observed eating in the hotel restaurant between 14:10 and 14:40, and he made at least two phone calls, one at 16:00 and one at 18:22. The performance of a night, non-precision, circling approach in instrument meteorological conditions (IMC) at the end of a long and extended duty day would have commanded a high degree of skill, attention, and task loading. Whether his "rest" was sufficient to offset the effects of acute fatigue remains questionable.

The company management team comprised an operations manager and a chief pilot, both of whom were on leave at the time of the occurrence. The company operations manual required that, when either the operations manager or the chief pilot was absent, another qualified person was to be appointed to the position. According to the TSB report, no other qualified person was appointed to manage the operation, and with both managers absent, this very inexperienced pilot was left in a self-dispatch mode.

A circling procedure is a visual manoeuvre, after completing an instrument approach, to position the aircraft for landing on a runway not suitably located for a straight-in landing. The A.I.P. Canada identifies four typical circling manoeuvres that will ensure the aircraft remains within the protected area while conducting a circling approach. The pilot is required to keep the runway in sight after initial visual contact, and to remain at the circling MDA until a normal landing is assured. However, the TSB determined that the operations manager favoured a non-typical teardrop circling procedure to Runway 02, which required the pilot to fly over the airport on a heading reciprocal to the runway heading, and then carry out a teardrop procedure and return to the airport. This effectively ensured the pilot would be unable to maintain visual reference of the runway, as required during a circling approach.

Conclusion — Although the operator's management structure appeared to have all the resources in place to provide operational guidance and support, there were deficiencies in its application and as a result did not adequately manage the operational risks. This was indicated by the absence of those responsible for operational control, who could not monitor the developing weather, and the flight being dispatched as single-pilot despite the pilot's limited experience and his demonstrated weakness in non-precision IFR skills in the recent past. The chief pilot was responsible for ensuring the pilot was qualified before being assigned to an aircraft, but the pilot was not qualified. The operator did not track qualifications for specific operations, and recommended the use of a non-typical circling procedure. The pilot was either unaware that the CARS operator could be recalled, or had learned that it was company practice not to recall the CARS operator after hours. Regulations required the pilot to obtain a current altimeter setting; on the accident night this failure resulted in a 200 ft altimeter error. He should have witnessed and been trained on how to recall the CARS operator. These deficiencies in the safety management of the company could have been identified through a more effective safety management system. This is a systemic accident that resulted in controlled flight into terrain (CFIT). This young pilot should not have been placed in a situation where he had to self-dispatch on a single-pilot IFR flight. For this reason, the operator failed him, and failed the passengers.

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