TSB Recommendation A93-03

The lack of a company crew pairing policy was identified as contributing to the accident. The captain and co-pilot had been in their respective crew positions for less than one month, and the accident flight was the co-pilot's first night flight in the C99, his first trip into Moosonee, and his first flight with the captain.

Crew pairing has been identified as a contributing factor in other occurrences. In July 1987, a Lockheed 1011 was involved in a near collision with a Boeing 747 as a result of a navigational error over the Atlantic Ocean. The Lockheed 1011 flight crew, who did not perform adequate navigational cross-checks, had limited experience in North Atlantic flying, with no crew member having more than six return trips (Report 87-A74947 refers). Furthermore, in 1987, the crew of a Boeing 737 Combi flew off track while on approach to Prince George, British Columbia, because of an improper navigation switch selection. Neither pilot had been in the cockpit of a Combi before (Report 87-P74128 refers). In August 1989, the flight crew of a Boeing 727 apparently failed to notice a navigation error, resulting in a loss of separation with another aircraft. The captain was not accustomed to the type of approach being flown, the co-pilot was new to the aircraft, and neither pilot was familiar with the destination (Report A89A0209 refers).

The U.S. National Transportation Safety Board (NTSB) has recognized the importance of proper crew pairing. In October 1986, following the investigation of three commuter air carrier accidents in which crew pairing was identified as a contributing factor, the NTSB recommended that the U.S. Federal Aviation Administration (FAA) caution commuter air carrier operators not to schedule on the same flight crew members with limited experience in their respective positions. Furthermore, following the crash of a McDonnell Douglas DC -9-14 on 15 November 1987, in which crew pairing was again identified as a contributing factor, the NTSB recommended that the FAA establish minimum experience levels for each pilot-in-command and second-in-command pilot, and that such criteria be used to prohibit the pairing of pilots who have less than the minimum experience in their respective positions. The FAA responded to these recommendations by bringing the crew pairing issue to the attention of air carriers and requesting that they develop, to the extent possible, appropriate crew pairing policies and procedures.

Crew pairing was also recently addressed by the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario. It was recommended that Transport Canada (TC) encourage air carriers which lack pilots with sufficient experience on a new aircraft type to provide highly experienced pilots from outside the air carrier to assist in training the air carrier's pilots and to fly with them until an adequate level of flight experience is gained on the new aircraft type. Additionally, it was recommended that TC proffer for enactment legislation with respect to flight crew pairing. That legislation would require that one of the flight crew members, either the pilot-in-command or the first officer, have substantial flight experience on the aircraft type.

Many factors must be considered when flight crews are made up. Not only must the crew be familiar with the aircraft type, but it should also be familiar with the aspects of the operating environment specific to a particular aircraft, an operating area, the type of operation, the time of day, and, if possible, the crew members should be familiar with each other.

In view of the importance of crew pairing to effective cockpit performance and in view of the many factors which can contribute to poor crew pairing, the Board recommended that: