One of half a dozen or so contributing factors in the report was:
• A 27 minute taxi before the passengers boarded, with the pilot’s door ajar likely exacerbated the pilot’s elevated carboxyhaemoglobin level.
Not in previous reports, it is a new factor. Does its inclusion indicate an acceptance that the CO in cabin via 3×3/16 holes factor will not stand alone?
Is it credible?
The report states it is not a Beaver cabin cooling technique to taxi with door ajar and there are no witness (operator, fellow pilots, pax on earlier flts) statements to verify it was peculiar to NOO’s pilot.
When the pilot opened his door and smelt exhaust fumes, would he not have shut the door? He’d be thinking CO, maybe a cracked cylinder head, do I go ahead with take off at near max weight?
From the report:
Operator observations of pilot’s approach to safety
The operator’s Chief Pilot stated that the pilot had good aircraft handling skills and was conservative with his decision-making. A previous Chief Pilot for the operator also indicated that, while he had not flown with the pilot, he was a reliable, steady operator who did not take risks, and had a very strong attitude to safety. The pilot was described by his work colleagues as being:
- very diligent and methodical
- very meticulous, always correcting small things
- a safe pilot who had all the experience behind him; he had no issues with grounding an aircraft and was safety ‘conscientious’.
It would have been uncharacteristic for him to risk it, flown, and not contact the company to let them know there was a problem as he did earlier in the day re a 150 mag drop. (limit 100)
There are no eyewitnesses to confirm door ajar but there are three pics that claim to show the door open as such. (Figure 16)
The top and bottom pics are from a distance, unclear, and at best are inconclusive. The middle pic is taken from inside showing a top edge gap between door and frame. The gap is even along its whole length, not at a widening angle from hinge line aft as you would expect. The gap is parallel as in another internal pic (Fig 6) where door is closed.
An open and shut case.