Weather, pilot inexperience cause of North Spirit Lake crash
The Transportation Safety Board of Canada (TSB) says poor weather conditions and pilot inexperience caused the fatal plane crash near North Spirit Lake First Nation last year.
In its investigation report released on Nov. 21, TSB says the crash was caused by weather that led to ice buildups, and the pilot’s relative inexperience with flying the type of aircraft, flying commercial flights to remote airports, and flying in winter operations with icing conditions.
On Jan. 10, 2012, a Piper PA31 Navajo aircraft operated by Keystone Air Service departed Winnipeg and crashed about two hours later more than a kilometre from the North Spirit Lake airport.
The plane struck the frozen lake before being engulfed in flames.
The crash killed three passengers – including a North Spirit Lake member – and the lone pilot. A fourth passenger survived with injuries.
According to the report, the plane had been flying above the clouds until it reached the community. However, it could not land until the runway was cleared of snow.
The plane circled the community for about 25 minutes while waiting for ground crews to plow the runway. As it circled, the exposure to light snow and drizzle conditions led to ice buildups on the windshield and wings.
Once the ground confirmed snow removal was complete, the aircraft began to make its approach.
“During the approach, the aircraft banked to the left and then steeply to the right, and then struck the ice at about (9:57 a.m.),” the report states.
The TSB said it reached three findings on the cause of the crash.
It said the decision to approach to an airport not serviced by an instrument approach in adverse weather conditions was “likely the result of inexperience, and a desire to successfully complete the flight.”
The decision to descend into cloud and continuing into ice conditions was “likely the result of inadequate awareness of the aircraft’s performance in icing conditions and de-icing capabilities.”
The third factor was the ice buildup on the wings, which would have led it to stall during final approach “at an altitude from which recovery was not possible.”
The aircraft did not have a flight recorder, and the community did not have a flight control station.
Recently, the TSB issued a recommendation calling for the installation of lightweight flight recording systems on board small commercial aircraft.
The pilot of the fatal flight had 2,400 hours of flight experience, about 150 of which were with the type of aircraft that crashed.
The investigation also stated wordings in the flight manuals related to “known icing conditions” and similar terms were inconsistent, and may have led to confusion of the aircraft’s capability in icing conditions.
Since the crash, Keystone Air Service revised its operations manual to better reflect operational requirements in icing conditions. It also implemented a multi-crew policy, which applies to all instrument flights, and it amended its flight training record-keeping procedures to make it easier and more efficient to prove that all required training has been completed. It also revised its operational flight plan form to include the calculated landing weight and centre of gravity.
Three months after the accident, NAV Canada – a private company that owns and operates Canada’s civil air navigation service – published an approved instrument approach procedure for the North Spirit Lake airport.
The chartered plane was carrying three employees of a Winnipeg-based company that provides financial management services to First Nations communities. The plane was scheduled to proceed onto Deer Lake First Nation after dropping off a passenger in North Spirit Lake.
One of the deceased, Martha Campbell, grew up in North Spirit Lake and was living in Winnipeg at the time.
Email to a Friend
add to del.icio.us