Aviation Investigation

References

What can we learn from this?

Aviation Investigation Report A95H0012. (n.d.). Retrieved March 7, 2015, from http://www.tsb.gc.ca/eng/rapports-reports/aviation/1995/a95h0012/a95h0012.asp

Thank you

(n.d.). Retrieved March 9, 2015, from http://laws-lois.justice.gc.ca/eng/regulations/SOR-96-433/FullText.html#s-703.28

• There are many things that can influence the decisions we make

• industry norms
• succeeding once before
• reluctance to fail at completing a task

Western Straits Air. (n.d.). Retrieved March 12, 2015, from http://gent-family.com/Aircraft/westernstraits.html

• We choose what influences us

Wanderin' Weeta (With Waterfowl and Weeds). (n.d.). Retrieved March 12, 2015, from http://wanderinweeta.blogspot.ca/2012/09/tyee-spit-campbell-river.html

Campbell River Airport. (n.d.). Retrieved March 12, 2015, from http://www.panoramio.com/photo/2302606

Findings - TSB

What Happened?

• They had 14 findings, first 10 were mostly non-contributing factors

H

Hardware

None identified

• The overdue hot section inspection and flight instruments inspection were not a factor in this accident

• The pilot crossed Tyee Spit, a frequently used alternate landing site

11. The continued flight into marginal weather conditions resulted in the progressive loss of the pilot's situational awareness and the collision with the terrain.

Software

Environment

Regulations

• be in compliance with VFR in uncontrolled airspace

• flown with reference to the ground or water
• clear of cloud
• stay within sight of the surface of the earth at all times
• flight visibility of two miles

• SVFR weather minima

Weather

• " "
• flight visibility of at least one mile

• prior to June 1990, an SVFR clearance would not have been approved for the accident flight

Ceilings and visibility that required SVFR

L

S

E

Liveware (others)

Western Straits Air

• The most recent operational audits, conducted in July 1993 and January 1995, were deemed to be satisfactory.

• The pilot was aware of the weather at Campbell River but decided to continue regardless

• Aviation industry norms to push weather to get into Campbell River

Software Cont.

Aviation Culture

• use of SVFR in such weather conditions had become an accepted norm

in the Campbell River control zone

• pilot decided to continue despite marginal weather conditions due to:

1. past practice

2. industry-accepted norms

12. The pilot's decision to continue the flight into marginal weather conditions was probably influenced by the prevailing industry attitudes and practices regarding VFR and SVFR operations.

• He had been successful before with similar weather conditions

L

13. In the marginal weather of this occurrence, the pilot's use of visual flight procedures supplemented by IFR navigational methods did not provide the level of safety normally associated with either regime.

Liveware ( pilot)

• Decision to continue towards Campbell River despite the alternative to land at Tyee Spit

• Once he obtained SVFR, he could attempt the airport landing without violating any weather limits.

• Decision to fly VFR and use IFR navigational systems

• Collided with the mountain in straight and level flight suggests he lost situational awareness

• Simultaneously flying VFR and using IFR navigation methods

14. The regulations governing VFR and SVFR commercial operations at the time of this accident were the same as the regulations assessed in the 1990 TSB safety study as providing inadequate safety margins.

Factors cont.

• Lack of situational awareness

• Pilots decision to land at Campbell River despite deteriorating weather

• Norms and practices by both the pilot and aviation industry

Factors

Pilot

• VFR into marginal weather

• Aircraft engine was 92.5 hours over the 1,250 hours of operating time allowed between hot section inspections.

• 37 years old

• ATPL

• 9,002 total flying hours

• 1,251 hours on type

• Pilot was certified and qualified for the flight in accordance to existing regulations

• Aircraft was over-loaded by 900 pounds and exceeded the aft C of G limit

Weather

• The pilot received several weather reports from Triumph Bay to Campbell River

• At 1902 PDT he received the 1900 PDT actual weather: measured 300 feet overcast, visibility 2 miles in light rain and fog.

• At 1904 PDT, he overheard and acknowledged the crew of another aircraft, who reported breaking clouds at 550 feet agl, on approach to runway 11

• 30 minutes after the accident, the pilot of a fixed-wing, search and rescue (SAR) aircraft reported that, on approach to Campbell River, the aircraft broke out of clouds at 200 to 300 feet agl, and that the visibility was 1/2 mile or less

Summary of the Accident

• de Havilland DHC-3 (turbine) Otter, C-FEBX

• en route from Triumph Bay to Campbell River with 10 passengers on September 27, 1995

• approaching Campbell River, pilot requested SVFR

• at an intercept heading for final approach; pilot crashed into a nearby mountain, killing 7 passengers and pilot

Aviation Investigation

Victoria Vargas