News conference for the release of Aviation Investigation Report A12Q0216 (Sanikiluaq): Opening remarks

Kathy Fox
Chair, Transportation Safety Board of Canada
Gayle Conners
Investigator-in-Charge, Transportation Safety Board of Canada
Winnipeg, Manitoba, June 29, 2015

Check against delivery.

Kathy Fox

Good afternoon. Thank you for coming today.

On the afternoon of December 22, 2012, Perimeter Aviation Flight 993 left Winnipeg, Manitoba, bound for Sanikiluaq, Nunavut, a remote community in eastern Hudson’s Bay. As the flight approached its destination, it had already been a long day for the 2 crew and 7 passengers, and marginal weather was just one element in a list of things that hadn’t gone as planned. The crew made one approach without success and then tried again.

“Too high, too steep, and too fast.” You’ll hear that phrase more than once today. In just a moment, I’m going to turn things over to Gayle Conners, the investigator-in-charge. She will briefly explain the details of the flight, how a complex series of events lined up to create a tragedy, and how actions made over the course of the entire day resulted in an ever-narrowing list of options at the end—options that resulted in the death of a six-month-old baby, as well as injuries to everyone onboard.

First, I’ll highlight the two recommendations we are issuing today, aimed at making air travel safer for infants and children.

  • One - That commercial air carriers start routinely tracking and reporting data on the number of infants and children travelling; and
  • Two - For the development and mandatory use of child restraint systems so that infants and young children travelling on commercial aircraft will receive the same level of safety as adults.

Gayle Conners will now walk you through the sequence of events, and how things unfolded that day. Gayle?

Gayle Conners

Thank you.

Flight 993’s departure for Sanikiluaq was originally scheduled for mid-morning, but issues arose beforehand to delay the departure time by four hours. This included the lack of an Arctic survival kit and instrument-approach charts, as well as a repair made to a faulty switch on the cargo door. The aircraft also took on additional freight, which in turn, meant changes to the fuel load and still further changes to the flight plan.

Eventually, after checking the weather reports for Sanikiluaq, as well as for the alternate airport in Kuujjuarapik, the flight took off, only for the flight crew to realize they had forgotten the instrument procedures charts for approach and landing. Rather than return to the airport and extend the flight time even more, the captain instead radioed the company to obtain most of the required information.

The en route portion of the flight itself was uneventful and, prior to descent, the crew obtained weather updates. Although conditions at Sanikiluaq were considered marginal but acceptable for landing, weather for the alternate airport of Kuujjuarapik—and in fact, all along the east coast of Hudson’s Bay—had worsened, meaning there were no backup options within range.

Given that they were already approaching from the southwest, the initial plan was to come in on a straight-in visual approach to land eastbound, into the wind, on Runway 09. Weather conditions, however, did not permit this, and although the crew could see the lights of the town, they could not see the runway environment.

When flying in cloud, crews use what’s known as an “instrument approach procedure” to descend and line up with the runway. These are detailed instructions on altitudes and courses to be flown, as well as obstacles and terrain. In this occurrence, there was no published instrument approach procedure for Runway 09. The crew therefore used the published procedure information for Runway 27, then circled to try and land in the opposite direction, on Runway 09, as the wind direction favoured landing that way. But visibility was insufficient. So they circled a second time, briefly sighting the runway environment only to lose it again in the marginal weather.

At this point, the crew began feeling a growing pressure to land. Crew communication started to break down. Stress, workload, frustration, and fatigue combined to narrow their attention, and they shifted away from well-practiced procedures.

The captain decided to make a last attempt at landing on Runway 27, after which the plan was to proceed to the alternate airport, 90 miles southeast. But landing on Runway 27 also meant accepting a significant tailwind, which would increase the aircraft’s groundspeed. In part because of this, they came in too high, too steep and too fast, sighting the runway later than expected. By the time the captain decided to reject the landing, it was too late: the aircraft impacted the ground 525 feet past the runway, bouncing and scraping along the rocky terrain for approximately another 1100 feet.

The crew and the adult passengers, secured by their seat belts, suffered injuries ranging from minor to serious. A lap-held infant, not restrained by any device or seatbelt, was fatally injured.

Although this investigation identified issues associated with pre-flight planning, crew communication, and unstable approaches, these issues have been addressed by the TSB before and recommendations have been put forward. As such, the safety issues that stand out most are those regarding infants and children. And so today, we are making two recommendations aimed at addressing the risks when infants and children travel by air. To talk more about these, I return you to the Chair.

Kathy Fox

Thank you, Gayle.

Worldwide, approximately 3 billion people get on an aircraft each year. North America is still the largest domestic market, and, according to figures from Transport Canada, traffic at Canadian airports is on the rise—with over 85 million passengers in 2013.

Commercial air carriers collect a lot of data. They know how many seats have been sold, how much fuel is on board, and how much cargo is transported—they have to, in order to stay in business. But how many children fly each year? How many infants are held in the arms of a parent or guardian? We have no idea. And statistics are not available.

What’s needed is better data—to conduct research, to assess risks, and to outline emerging trends related to the carriage of infants and children. This is not a difficult task. And that’s why today, we are recommending that Transport Canada require commercial air carriers to collect and report, on a routine basis, the number of infants and young children travelling.

I’ll now turn to the second recommendation we are issuing today: the need for the development and mandatory use of child-restraint systems for commercial aircraft.

Every day, Canadian families board commercial aircraft with infants and young children. And every day, the majority of them trust that, if something goes wrong, a parent’s arms can restrain a child safely.

But that’s not possible. In the case of severe turbulence, a sudden deceleration, or a crash such as this one, adults are not strong enough to adequately restrain an infant just by holding on. Research has proven it. Research has also proven that, just like in an automobile, the standard adult seatbelt isn’t suitable for a young child. Transport Canada and the airlines are aware of the risk. In fact, they already encourage infants and young children to travel in an approved child-restraint system during flights, one appropriate to their age and size. The problem is, these systems are not mandatory. And while there has been, and continues to be, research on the development of standards, there has been no progress with respect to requiring their use aboard commercial aircraft.

This accident saw an infant ripped from his mother’s arms and killed in the subsequent impact, even though everyone else survived. Other occurrences in Canada and elsewhere show that crew, adult passengers and children have sustained injury during unexpected moderate to severe turbulence. They also show how lap-held infants and children would have likely survived or suffered less severe injury had they been properly restrained.

I am aware that mandatory child-restraint systems on aircraft may be considered a controversial idea. There are certainly many issues involved. But infants are not restrained at all, and a standard adult seatbelt is ill-suited for a young child. It’s time to do right by our children. They deserve the same level of safety. What’s needed is a proper child-restraint system, one that stops the youngest on board from becoming projectiles, causing injury and possibly death to themselves or other passengers.