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Air transportation safety investigation report A19C0145

Press Release

Controlled flight into terrain
North Star Air Ltd.
Douglas DC3C Basler Turbo Conversions TP67, C-FKAL
Sachigo Lake Airport, Ontario
03 December 2019

The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. This report is not created for use in the context of legal, disciplinary or other proceedings. See Ownership and use of content.

Executive summary

On 03 December 2019, a captain and first officer from North Star Air Ltd. (North Star Air) were scheduled to conduct a daytime cargo flight on board the Douglas DC3C Basler Turbo Conversions TP67 (DC3-TP67) aircraft (registration C-FKAL, serial number 25285) from Red Lake Airport (CYRL), Ontario, to Sachigo Lake Airport (CZPB), Ontario. During flight planning, the captain checked the weather: at 0700 Central Standard Time (CST), CYRL reported an overcast ceiling at 700 feet above ground level (AGL). Muskrat Dam Airport (CZMD), Ontario, located 30 NM southeast of CZPB, reported instrument meteorological conditions (IMC) with an overcast ceiling at 500 feet AGL. The forecast at CZMD was to improve to 1500 feet AGL with a possible fluctuation to 700 feet AGL and decreased visibility by 0900 CST, i.e., the aircraft’s estimated time of arrival into CZPB. The flight departed CYRL under visual flight rules (VFR) at 0800 CST. The reported weather at the time was broken ceiling at 1200 feet AGL and an overcast layer based at 2000 feet AGL.

Shortly after takeoff, the aircraft entered, and climbed above, the cloud layers before reaching the planned cruising altitude, which was not in accordance with the applicable regulations for VFR flights. Before commencing the descent to CZPB, the pilots obtained the 0800 CST hourly weather report at CZMD, which had remained generally unchanged from the 0700 CST report, and elected to carry out a visual approach to Runway 10. The captain initiated a descent through the cloud layers by reference to the flight instruments.

Once the aircraft broke out of cloud at very low level, the aircraft was not in a position to continue with the planned visual approach. The captain made low-level manoeuvres in an attempt to land, flying a large 360° turn, as low as 100 feet AGL (i.e. about 400 feet below the required minimum altitude), and then flew a manoeuvre similar to a left-hand circuit, which brought the aircraft within close proximity to a significant obstacle (a 150-foot tall tower), in meteorological conditions below the VFR minimum requirements. Given that the captain had not briefed the first officer, the latter was unaware of the captain’s intentions and began calling out airspeed and altitudes. On the last attempt, during the low-level downwind leg, when the aircraft passed abeam the threshold of Runway 10, the captain initiated a left-hand turn and began descending. About 10 seconds later, the aircraft collided with terrain, in a near wings-level attitude, approximately 650 feet southwest of the threshold of Runway 10. The aircraft slid 350 feet southward along the ground before it came to a rest on a southwesterly heading.

The captain likely experienced attentional narrowing while carrying out a high-workload visual approach at very low altitude in IMC. This most likely resulted in an inadvertent but controlled descent that was not detected until the aircraft collided with terrain.

The uninjured pilots evacuated the aircraft via the right-hand cockpit window. The aircraft sustained substantial damage; however, there was no post-impact fire.

The 406-MHz emergency locator transmitter (ELT) activated; however, the whip antenna had been ripped off during the impact sequence and no signal was detected by the search and rescue satellite system. The TSB had previously recommended that Transport Canada (TC) establish more rigorous ELT system crash survivability requirements, and TC has since implemented updated regulations for new ELT design approvals; however, those requirements do not apply to legacy ELTs like the one the occurrence aircraft was equipped with. If aircraft operate with ELTs approved under legacy design standards, there remains a risk that potentially life-saving distress signals will not be detected because of damage caused to the ELT system during an accident.

Although the regulations did not require the occurrence aircraft to be equipped with a flight data recorder or a cockpit voice recorder (CVR), North Star Air had installed a CVR. However, following repairs, a paperwork error resulted in the CVR being placed in inventory instead of being re-installed in the occurrence aircraft. At the time of occurrence, it had been 329 days since the CVR had been removed, i.e., over 200 days beyond the maximum permissible time defined in the minimum equipment list. Without the CVR, valuable information was not available to assist the investigation. If cockpit voice and flight data recordings are not available, it is more difficult to accurately assess crew resource management, standard operating procedure execution and effectiveness, and workload management. As a result, the absence of on-board flight recordings can limit the identification of safety deficiencies and the advancement of safety.

The investigation revealed that the result-oriented subculture of some North Star Air’s DC3-TP67 pilots, which emphasized mission completion over regulatory compliance, resulted in VFR flights, such as the occurrence flight, being conducted in IMC. The investigation also determined the captain had a history of conducting VFR flights in IMC. The decision to depart on, and continue, a VFR flight in IMC was influenced by a distorted perception of risk resulting from successful past experience in similar situations. In addition, the company structure was such that there was no operational management presence and no day-to-day direct pilot supervision of DC3-TP67 flight operations and flights crews at the company’s remote bases, nor is it required by regulation. The absence of direct supervision meant that company pilots had considerable latitude when it came to making operational weather-related decisions. Over time, a culture of non-compliance developed that went undetected by the company management team. If minimal supervision of flight crews occurs within a company’s flight operation, there is a risk that previously identified unsafe or non-compliant practices will persist.

In December 2017, TC informed North Star Air that it had received allegations related to company DC3-TP67 aircraft operated on multiple occasions under VFR in IMC. TC provided the information about the allegations to the company for its internal investigation. In response, the operations manager contacted all the DC3-TP67 captains verbally and via email reminding them of the requirement to abide by the regulations, but the company did not outline any additional measures to monitor North Star Air’s DC3-TP67 operation for reoccurrence. Additionally, in February 2018, TC initiated a reactive process inspection (PI) that included 3 flight inspections, which were deemed uneventful.

North Star Air had a safety management system (SMS), even though at the time of the allegations it was not required by regulations. An SMS hazard report was created and entered into North Star Air’s SMS database. However, the SMS did not identify the underlying factors that led to the reported instances of company aircraft operating VFR flights into IMC and the company did not take any additional measures to monitor its DC3-TP67 operation to ensure flights were being conducted in accordance with regulations. Additionally, TC’s November 2018 PI did not include a review of the 2017 allegations. As a result, previously identified unsafe practices persisted, and played a direct role in this occurrence. If TC relies on operators to investigate allegations of regulatory non-compliance without monitoring them, there is an increased risk that the unsafe practices that are being investigated will persist.

Safety management is on the TSB Watchlist and will remain on it until transportation operators that do have an SMS demonstrate to TC that it is working—that hazards are being identified and effective risk-mitigation measures are being implemented.

The investigation revealed that TC’s approach to surveillance resulted in North Star Air’s SMS being approved even though several elements were not fully implemented. If TC approves a company’s SMS without first conducting an in-depth review to ensure that all required elements are present and effective, SMS enterprises may not have the ability to effectively manage safety.

The TSB previously recommended that TC conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety. In its latest response, in September 2021, TC indicated that it was taking measures to update and improve its surveillance methodology.

Regulatory surveillance is also on the TSB Watchlist and will remain on it until TC demonstrates through surveillance activity assessments that the new surveillance methodology is identifying non-compliances, and that TC is ensuring that a company returns to compliance in a timely fashion and is able to manage the safety of its operations.

Following the occurrence, North Star Air implemented a flight operations quality assurance program. Additionally, in December 2020, TC conducted a PI focused on the evaluation and effectiveness of the long-term corrective action plan related to the flight operations findings from the December 2019 PI. TC concluded that the long-term corrective actions taken by North Star Air were effective.

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