Plane crashes after takeoff in northern Saskatchewan 25 people on board
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However, the aircraft was not de-iced before takeoff, and the takeoff was commenced with ice contamination on the aircraft.
As reported by the CTSB.
Almost unbelievable that a Canadian operator would have allowed that to happen. Of all countries, especially after the well documented Air Ontario Flight 1363 crash at Dryden that is used as a training video about what can go wrong in winter ops, I would not have expected this to happen there.
As reported by the CTSB.
Almost unbelievable that a Canadian operator would have allowed that to happen. Of all countries, especially after the well documented Air Ontario Flight 1363 crash at Dryden that is used as a training video about what can go wrong in winter ops, I would not have expected this to happen there.
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@RAT 5
Much as Capt Smith was far too good a seaman for the Titanic to be lost under his command. Over-confidence, complacency, whatever you might call it ...
I would not have expected this to happen there.
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Most likely a lethal combination of time pressure and complacency. Couple this with a regulatory environment whereby most of these northern operators are not likely to have the deice infrastructure available due to cost pressures. Yes , COST. Whether or not Transport Canada has factored the likelihood of such an occurrence into it`s risk management models remains to be seen. SMS has failed here. Why accept one type of deice infrastructure at Fond du Lac and another type at say , Regina ? Need to rethink the minimum deice systems available at most northern destinations. Without this , a recurrence is likely.
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Yes, this. I'm not at all surprised that a remote northern community of 700 persons doesn't have adequate de-ice equipment. Or if there was better equipment, when the need arose, it was covered in snow with a flat battery. But what culpability does the regulator have in this case? Sure the decision to depart without de-icing is ultimately on the crew, but the lack of meaningful equipment likely contributed to that decision, and TC must have approved of their inadequate de-ice facilities. Of course, daily air service to a remote aboriginal community is almost certainly heavily subsided. And having a de-ice truck stored in a heated garage is going to mean that the Government will have to pay greater subsidies for air service.
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Impressive piece of equipment they have. Can it be realistically used to de-ice ATR42 in anything else than clear frosty day? Your holdover time will run out before you finish one wing...
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[
If there's no active precip or active frost then HOT isn't an issue. It's deicing equipment, not anti-icing - you can take as long as you like to remove ice if there's nothing new forming. (At least in terms of ending up with a clean airframe - obviously there are commercial/operational time constraints)
If there's no active precip or active frost then HOT isn't an issue. It's deicing equipment, not anti-icing - you can take as long as you like to remove ice if there's nothing new forming. (At least in terms of ending up with a clean airframe - obviously there are commercial/operational time constraints)
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For anyone interested - and there are some interesting aspects - TSB published the report this week:
https://www.tsb.gc.ca/eng/rapports-r...6/a17c0146.pdf
https://www.tsb.gc.ca/eng/rapports-r...6/a17c0146.pdf
Back when Transport Canada decided that passenger safety would be the responsibility of SMS paperwork rather than Transport Canada inspectors, the biggest justification was that there was now a "Responsible Executive" with the operational and financial authority to make safety decisions.
Here we have a passenger fatality under the following circumstances:
1. When West Wind commenced operations into Fond-du-Lac Airport (CZFD) in 2014, no effective risk controls were in place to mitigate the potential hazard of ground icing at CZFD
6. Because the available inspection equipment was inadequate ... the full extent of the residual ice and ongoing accretion was unknown to the flight crew
7. Departing from remote airports, such as CZFD, with some amount of surface contamination on the aircraft’s critical surfaces, had become common practice, in part due to the inadequacy of de-icing equipment or services at these locations.
19. If a company’s safety culture tolerates unsafe practices, there is a risk that these practices will continue and become a company norm.
20. If organizations do not adequately identify hazards and analyze risks, potential mitigation methods can be overlooked, increasing the risk of an adverse consequence.
What action was taken against the "Responsible Executive"? Are there any consequences to profit maximizing corner cutting that leads to a passenger fatality? Or is this acceptable behaviour for a "Responsible Executive"?
Here we have a passenger fatality under the following circumstances:
1. When West Wind commenced operations into Fond-du-Lac Airport (CZFD) in 2014, no effective risk controls were in place to mitigate the potential hazard of ground icing at CZFD
6. Because the available inspection equipment was inadequate ... the full extent of the residual ice and ongoing accretion was unknown to the flight crew
7. Departing from remote airports, such as CZFD, with some amount of surface contamination on the aircraft’s critical surfaces, had become common practice, in part due to the inadequacy of de-icing equipment or services at these locations.
19. If a company’s safety culture tolerates unsafe practices, there is a risk that these practices will continue and become a company norm.
20. If organizations do not adequately identify hazards and analyze risks, potential mitigation methods can be overlooked, increasing the risk of an adverse consequence.
What action was taken against the "Responsible Executive"? Are there any consequences to profit maximizing corner cutting that leads to a passenger fatality? Or is this acceptable behaviour for a "Responsible Executive"?
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Couple of points:
Semantics perhaps but the correct title is Accountable Executive.
The F/O - Captain rated and considerably more experienced than the Captain flying the departure - during his walkaround saw critical surface ice contamination, most visibly on the rear empennage while boarding from R1.
When taking his seat in the cockpit he relayed that information to the Captain.
Prior to takeoff they were both heard on the CVR as seeing ice on the spoilers, which was part of the final surface contamination checks.
Semantics perhaps but the correct title is Accountable Executive.
The F/O - Captain rated and considerably more experienced than the Captain flying the departure - during his walkaround saw critical surface ice contamination, most visibly on the rear empennage while boarding from R1.
When taking his seat in the cockpit he relayed that information to the Captain.
Prior to takeoff they were both heard on the CVR as seeing ice on the spoilers, which was part of the final surface contamination checks.
