Good morning ladies and gentlemen,
My name is Daniel Verreault, and I am Director of Air Investigations at the Transportation Safety Board of Canada. With me today is my colleague Marc Fernandez, the investigator-in-charge for the investigation into the aviation occurrence at Sept-Îles on 12 August 1999.
I will first present a brief overview of the circumstances that led to the accident and some of the investigation findings, before Marc goes on to provide more technical details. I will then discuss the Board's recommendations.
After that, we will both be available for questions.
The Beech 1900D, operated by Régionnair, was on a scheduled flight from Port-Menier, on Anticosti Island, to Sept-Îles when the accident occurred. The Beech 1900D can carry 19 passengers. This was the return leg of the regular service from Sept-Îles to Port-Menier to Mont-Joli and back. The aircraft took off at 2334 eastern daylight time with two pilots and two passengers on board. It crashed at 2357 after striking trees. The wreckage was found on sloping terrain one nautical mile from the runway at Sept-Îles. The post-impact fire destroyed the wings, the right engine, and the right central portion of the fuselage. Since the cabin remained relatively intact, the passengers were able to exit the aircraft, but the cockpit separated from the fuselage and was crushed. The captain was killed, and the first officer was seriously injured. The passengers sustained minor injuries.
The crew took off under instrument flight rules in controlled airspace. The take-off and en route portions of the flight were uneventful. The first officer (in the right-hand seat) was flying the aircraft.
After taking off from Port-Menier, the crew received a weather report from the Sept-Îles Flight Service Station indicating a ceiling of 200 feet and visibility of 1/4 statute mile in fog. On the day of the occurrence, the reported ceiling and visibility remained below the minimum descent altitude for all approaches to Sept-Îles Airport.
The TSB examined the aircraft and its maintenance records.
The records indicate that the aircraft was maintained in accordance with existing regulations and the manufacturer's requirements. The landing gear was down prior to the accident, and the flight data recorder showed that the engines were operating normally at the time of impact.
There were no reported problems with navigation aids or communication systems in the area or at Sept-Îles Airport at the time of the accident.
In short, flight safety was not compromised by any system failure or technical or structural problems.
As mentioned in the report, both crew members were experienced pilots and were very familiar with the area.
Both pilots, however, were working for two air carriers, and their time on duty over the previous 30 days and 90 days exceeded the maxima set by Transport Canada. The first officer in particular was probably suffering from chronic fatigue, since he had worked an average of 14 hours a day and had had only one day off in the 30 days preceding the accident. The manager of operations for the air carrier was not adequately supervising the flying hours and the hours on duty of the company pilots, and Régionnair was not keeping track of the pilots' daily flying hours with the other air carrier.
I will now turn the microphone over to Marc Fernandez.
Before I go over the two recommendations in the TSB report and answer your questions, I would like to remind everyone that it is not the function of the Transportation Safety Board to assign fault or determine civil or criminal liability for an accident. Our job is to investigate and find out what happened, why it happened, and to identify safety deficiencies. The TSB's mandate is to advance transportation safety.
When we identify a problem, we bring it to the attention of the relevant authorities in the form of a recommendation. It is up to those authorities to take corrective measures to address the problem. In this particular instance, the Board has issued two recommendations.
Forty-five per cent of air accidents reported to the TSB between 1992 and 2001 occurred during the approach or landing phase. The Board also reviewed occurrence data and found that several accidents had occurred in Canada similar to the one in Sept-Îles. Between January 1994 and December 2001, poor visibility and/or low ceilings were a factor in 24 accidents in Canada. All these accidents involved qualified pilots who were flying airworthy aircraft registered in Canada and who were either conducting an instrument approach, making a missed approach, or landing after an instrument approach. These accidents resulted in 34 fatalities and 28 serious injuries, not to mention damage to property and the environment.
We have determined that some pilots regularly conduct user-defined GPS approaches in conditions below the minima published in Canada Air Pilot. Some pilots do not recognize the safety value in the criteria used to design approaches; this might explain why they sometimes do not follow established approach procedures and instead conduct user-defined GPS approaches. Pilots and air carriers also have to contend with a variety of market pressures and environmental constraints.
The Canadian aviation community has discussed the need for additional regulatory restrictions for instrument approaches in poor weather for several years. Transport Canada has already taken steps to implement new approach ban regulations based on visibility. These new regulations should reduce the likelihood of accidents during instrument approaches in low visibility conditions. The TSB commends Transport Canada for taking this initiative but notes that it has been ongoing for two years now.
Until the new regulations are in effect, the existing safeguards will be inadequate to reduce the risks associated with pilots descending below the decision height or the minimum descent altitude.
Therefore, the Board recommends that:
The Department of Transport expedite the approach ban regulations prohibiting pilots from conducting approaches in visibility conditions that are not adequate for the approach to be conducted safely.
Although this by no means applies to the majority of pilots, it is obvious that some them, for whatever reason, are still conducting approaches in poor weather--even when the chances of landing safely are slim. These accidents are a direct result of poor weather and the crew's decisions. Such accidents will continue to happen unless new measures are taken. The Board believes that an enforceable, regulatory barrier is required.
The Board feels that the proposed ban on approaches--based solely on visibility conditions--is inadequate because it does not address the ceiling issue. In recent years, the TSB has investigated a number of accidents that happened when visibility was good but the ceiling was below the limits stated in Canada Air Pilot for the particular approach flown.
Therefore, the Board recommends that:
The Department of Transport take immediate action to implement regulations restricting pilots from conducting approaches where the ceiling does not provide an adequate safety margin for the approach or landing.
The number of accidents, fatalities, and injuries provides ample evidence that the existing safety provisions are not effective in preventing this type of accident. We clearly need additional protective measures to minimize the risk of accidents in poor visibility or very low ceilings. In conclusion, the Board considers that these recommendations are necessary and must be acted upon to reduce the risk of accidents and to improve the safety of passengers and crews.
If you have any questions, we will be pleased to answer them.
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