Associated links (A17C0146)
Kathy Fox, TSB Chair
and
David Ross, Investigator-in-charge, TSB
Saskatoon, Saskatchewan
14 December 2018
Check against delivery.
Kathy Fox
Good morning.
On 13 December 2017, an ATR 42 aircraft operated by West Wind Aviation departed Fond-du-Lac Airport, Saskatchewan, with 3 crew members and 22 passengers on board. Seventeen seconds after takeoff the aircraft collided with trees and terrain. All 25 occupants were injured, 10 of whom sustained serious injuries. One of the seriously injured passengers subsequently died.
The TSB's investigation into the occurrence is ongoing. Today, based on what we've learned thus far, we are releasing two recommendations regarding flight crews that take off with frost, ice or snow contamination on aircraft, particularly at remote northern airports. First, we want Transport Canada, air operators, and airport authorities to make sure that adequate de-icing and anti-icing equipment is available for those who need to use it; and second, there must be greater compliance with regulations to reduce the likelihood that crews take off with contamination on “critical” aircraft surfaces—such as wings, propellers, stabilizers, or even some parts of the fuselage.
I'll talk more about both recommendations in a few minutes, but first I'll turn things over to the Investigator-in-charge, Mr. David Ross. He'll explain how the TSB came to learn just how widespread this problem is.
David Ross
Whenever the TSB begins an investigation, we look at a broad range of factors—mechanical issues, but also things like weather, operational policies and procedures, training, and human performance. The goal is to gather as much information as possible when establishing a sequence of events, and also because as an investigation evolves you never know what may turn out to be important later.
In this occurrence, we learned early on that the aircraft was not de-iced before takeoff, despite a pre-flight inspection by one of the pilots that revealed the presence of ice on critical aircraft surfaces. We also learned that there was some de-icing equipment in the terminal building at Fond-du-Lac, but that it was insufficient; for instance, neither of the two available ladders was tall enough to permit de-icing of the wings or horizontal stabilizer, nor did the hand-held spray systems have the capacity to clean the entire aircraft.
According to the Canadian Aviation Regulations, “No person shall conduct or attempt to conduct a take-off in an aircraft that has frost, ice or snow adhering to any of its critical surfaces.” The reason is straightforward: snow or ice on critical surfaces will result in aerodynamic degradation, which can lead to difficulty controlling an aircraft.
But when the equipment necessary to enable crews to follow this rule is not available … well, not only does that needlessly increase the risk, it effectively removes a defence that was put in place to operate safely and save lives. So, last summer, the TSB sent out a questionnaire to pilots at 83 Canadian operators that fly out of many of Canada's remote northern airports. We wanted to know whether the circumstances of the Fond-du-Lac occurrence existed in the wider Canadian industry.
The results of this questionnaire, which was both voluntary and anonymous, were revealing.
We received over 650 completed responses from pilots flying many types of aircraft across a wide spectrum of commercial operations.
Our preliminary analysis of the data indicates that at remote northern airports, aircraft frequently take off with contaminated critical surfaces. When I say aircraft, I mean the full range: transport jets and turboprops, commuter turboprops, and all types of air taxi aircraft.
How often does this happen?
The short answer is: far too often. In fact almost 40% of participating pilots reported they are “rarely” or “never” able to have their aircraft effectively de-iced at remote airports.
This is not a small problem. Respondents indicated a wide geographic distribution. And since many remote airports can have an icing season of 10 months or more, the risk, frankly, is substantial.
That's why we're here today, instead of waiting for the investigation to be completed. Because it's already winter at these airports, and these recommendations need to be addressed now.
Kathy Fox
When the TSB issues a recommendation, it's because we've identified a significant and systemic safety deficiency for which action must be taken. Thousands of flights take off every year from remote northern airports, and the data from the questionnaire are clear. This issue is widespread, it is recurrent, and it leaves passengers and crews exposed to unnecessary risk.
Here, then, is what's needed. The first step is to make the necessary equipment available. Transport Canada, air operators, and airport authorities need to collaborate, urgently, to identify high-risk locations, analyze the risks, and take mitigating action. In other words, give people the tools they need to do their job. Better sprayers and equipment to get to high surfaces—lifts and booms, for example. For de-icing, and for anti-icing. As pilots across the country have told us: you can't use what you don't have.
The second step is to improve compliance. Why do so many pilots continue to conduct takeoffs with frost, ice or snow on critical surfaces—despite an explicit rule saying they're not supposed to? Beyond the issue of inadequate equipment and operational pressures, it's partly human nature. Do something slightly risky once—without anything bad happening—and you're more likely to do it a second time. Not because you're unaware of the risks, but because you personally have yet to experience any negative consequences. Do it repeatedly, even if only a little bit each time, and the resulting deviation from the rule—deviation from safe operating procedures—becomes normalized.
Reversing this will require urgent action from Transport Canada and air operators. They could, for instance, change company policies, training, or operational standards. Another option would be to modify pre-flight checklists, requiring, say, a clean aircraft or else some other mitigation response from the pilot-in-command. But regardless of what action is taken, the result must increase compliance with the Canadian Aviation Regulations, and reduce the likelihood that flight crews take off with contaminated critical surfaces … and all this needs to happen soon.
If it doesn't, the people travelling to and from many northern remote communities across Canada, will remain at unnecessary risk.
Thank you.