COPA Safety Program
COPA offers seminars to help pilots stay current, including sessions to maintain the 24-month recurrency.
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Good safety information is key to the continuous improvement of aviation safety. As the main source of aviation occurrence information in Canada, the Civil Aviation Daily Occurrence Reporting System (CADORS) is an invaluable aviation safety tool.
Click here for an informative article from BCGA that explains what it means to pilots if they are involved in an occurrence that is recorded in the system.
Warren Le Grice
The long road from “The Captain is always right” to Safety Management Systems
The concept in the transportation industry, that the captain is always right, very likely dates back to the 17th century when sailing ships provided the fastest mode of world travel. Sailors would question the wisdom of the Commanders decision making, at their own peril. Changes to safety standards were introduced very slowly, and over an extended period time. More often than not, major tragic events were the catalyst for change, and in that respect, not a whole lot has changed over the centuries.
The Scilly Naval disaster in 1707 involving the loss of four ships, onto the rocks west of Scilly, on the night of Oct 22, and the loss of over 1300 mariners in stormy weather, would eventually lead to a major change in navigation. At that point in history, mariners were able to calculate their latitude but not longitude. In 1714 the British government passed the Longitude Act, which offered up a prize of 20,000 British pounds ( about 1.5 million pounds today) for a practical and useful method to determine longitude to an accuracy of one half a degree.
Longitude at that time was calculated by “dead reckoning”. John Harrison’s marine chronometer in 1735 would finally solve the problem of calculating longitude while at sea. His solution would revolutionize navigation and increase the safety of sea travel.
The sinking of RMS Titanic in the early hours of April 15, 1912 resulted in major changes to maritime regulations, and leading to the establishment of the International Convention for the Safety of Life at Sea in 1914. In spite of six warnings of icebergs in the area, the Captain was travelling at a speed that was only 3 knots below the maximum design speed, attempting it is believed, to set a speed record on the trip to New York. The glancing blow to an iceberg sliced open six of the sixteen compartments. The ship had been designed to withstand being able to stay afloat after four compartments being breached. As the ship only carried 20 lifeboats, over one thousand passengers perished. Captain Edward Smith went down with his ship.
On June 18, 1972 BEA Flight 548 a VC10 Trident, crashed 3 mins after taking off from runway 28R at Heathrow on a flight to Brussels. There were 118 persons on board and there were no survivors. Investigation revealed that the flaps and leading edge devices were retracted prematurely and the aircraft entered a deep stall from which there was no recovery. The pilot in command was a senior captain with the airline, the first and second officers were junior pilots.
There had been a strong argument between Captain Key and another pilot in the crew briefing room, immediately prior to the flight involving another pilot regarding impending strike action at the airline. There was some evidence in the autopsy that the captain had previous heart damage. Investigators determined what had happened to the VC10, but not why it had happened.
This accident would result in the installation of CVRs, (cockpit voice recorders), which are now standard equipment on airliners around the world.
Tenerife / Portland Oregon
On March 27, 1977 two Boeing 747s were both heading for Las Palmas. On Gran Canary Island in the Canary Islands to take their passengers to meet cruise ships. A terrorist bomb being set off in the Las Palmas terminal building, resulted in both aircraft being re-routed to Tenerife airport. Tenerife airport is located on another island about 30 miles west of Las Palmas.
Tenerife is a secondary airport and it would soon become over whelmed by the number of aircraft that were diverted there from Las Palmas. The airport had no surface detection radar and had but a single runway, 12/30. Both 747s, KLM4805 and PAA1736 were both delayed several hours on the ground at Tenerife, and when Las Palmas airport did finally open, there was a rush to depart, as the crew duty times were almost up, which meant the aircraft and several hundred passengers would have to wait until the next day to depart.
As the parallel taxiway was blocked by parked aircraft, the two 747s would have to back track on runway 12 for their departures on runway 30. As the two aircraft began their taxi with KLM4805 in the lead followed by PAA1736 low cloud moved down and covered the airport to the point that the airport went IMC. KLM was piloted by Capt. Jacob van Zanten a very senior captain and training captain with the airline. Two first and second officers were former students of van Zanten who was very anxious to get on his way.
The KLM aircraft went to the far end and turned around and was waiting for Clipper 1736 to back track and take the last taxi way, in order to clear the runway and be number two for departure. The thick cloud prevented either aircraft from seeing the other, and the visibility was likely below take-off limits.
van Zanten who was the pilot flying, was very anxious to be on his way and started to advance the power levers. The co-pilot stopped him by reminding him that they did not yet have their IFR clearance. After obtaining their IFR clearance they still needed a take-off clearance from the tower, which they would not receive until Pan American had reported clear of the runway.
Radio communications were disrupted, but PAA did state they were still on the runway but that message was distorted by another radio transmission. The Captain again advanced the power levers and then the second officer questioned “is he not clear then” van Zanten replied yes he was clear, and commenced the take off run, with out a take-off clearance. The first officer had the nerve to intervene once, but probably didn’t think he could get away with it a second time.
PAA saw the lights of KLM shaking and the Bob Bragg the first officer said to Captain Grubb, I think he is taking off, get off, get off. KLM saw the Clipper as they came out of the low cloud and struck the PAA1736 well behind the cockpit. Of the KLM crew of 14 and 234 passengers, there were no survivors.
Of the PAA crew of 16, 9 were fatally injured and of the 380 passengers, 326 were fatally injured. Because a pilot was in a hurry, and would not listen to his crew, there were 583 fatalities, and Tenerife remains the world’s worst aviation accident. KLM airlines after initially blaming the accident on ATC, did finally admit that their crew was responsible for the accident, and provided financial compensation to the families of all the victims.
UAL173 Portland Oregon- Dec 28- 1978
The DC8 was inbound from Denver and when the landing gear was lowered for landing, there was an unusual noise when the gear was extended. The aircraft was put into a hold at low altitude while the crew went through check lists, and prepared for a possible gear failure on landing. The first and second officers were aware that they were rapidly burning through their fuel at low altitude, with gear and flaps extended.
The captain did not grasp their situation until engines started to fail and the crew members failed to effectively communicate their concerns about the fuel situation. Captain McBroom was able to perform an engine out landing in a wooded area east of the airport. There were 10 fatalities. Family members and passenger who spoke to McBroom at reunion of crash survivors in 1998, reported that he was a broken man who was plagued by guilt over his role in the accident.
The above two accidents lead to CRM -Cockpit Resource Management being introduced by United Airlines and that training has now world wide acceptance, now called Crew Resource Management.
A reactive approach to safety has been the norm for the last 400 years.
It has been the practice to wait for an accident to happen, investigate it and then implement changes to prevent it from reoccurring.
Lytton B.C – June 2021
The latest example of waiting until an accident occurs is demonstrated in the Lytton fire on June 30, after days of record braking heat. Transport Canada has ordered new safety measures for rail operators across Canada aimed at reducing the risk of wildfires after speculation that a passing train sparked the blaze that destroyed the village of Lytton and killed two people.
A pro-active approach works to identify possible safety failures before they lead to an accident and that approach is applied in a Safety Management System. SMS is achieving world wide acceptance in the aviation community.
The block diagram below represents a concept that would work for the Abbotsford Flying Club. SMS entails a “cultural change” where safety is the focus and a culture of continuous learning is encouraged and supported.
A Safety Management System includes several components, which work towards the simple goal of having everyone go home safely, at the end of the day.
A very interesting article about flight into cloud.
The “Safety Culture” of any aviation organization, can either make or break that organization. That proved to be the case with JU-Air of Switzerland. The Final Report, No. 2370 compiled by the Swiss Transportation, Safety Investigation Board, STSB, describes the accident of JU-Air, August 2, 2018 which occurred 1.2 nm SW of Piz Segnas, Flims, Switzerland. This 78-page accident report, with added appendixes, makes for a very interesting reading. The report is one of the most comprehensive reports I have seen in recent years. It provides a very detailed look at all the negative aspects of human behaviour that lead to the loss of 17 tourists, and the three-person crew, which was on a scenic flight through the Swiss Alps. The LOC or loss of control accident was, as are most accidents, completely preventable.
I have found the SHELL model of accident causal factors, very useful over the many years that I have been promoting aviation safety. I will utilize that jigsaw puzzle model, which was introduced by Edwards and Hawkins back in the 1970s, as we examine a number of the factors that when combined together, lead to the fatal accident. Do all the pieces of the puzzle fit together with the L or liveware (pilot) in the center or not?
Examples: written instructions, flight operation manual, SOPs -standard operating procedures, SMS – Safety Management System.
Swiss investigators identified numerous issues with regard to maintenance:
JU-Air’s maintenance program “lacked essential information on topics such as partial and major overhauls of the airframe, surface protection, and supplementary inspection documentation. In general, it was difficult to trace the maintenance work performed as well as the modifications and repairs made, because the maintenance documentation was flawed, incomplete or kept in an unsystematic manner.”
The empty weight of the aircraft, and the center of gravity values, were incorrect in the operations manual, therefore pilots had been systematically miscalculating these figures, including on the day of the accident flight. The aircraft was loaded, slightly aft of its rearward limit, making it more difficult to control in the event of a stall.
Mountain Flying Techniques
The risks of VFR flight or mountain flying were never assessed, despite the existence of an approved SMS ( Safety Management System). The fact that mountain flying was completely ignored was a major indicator of a dysfunctional system of risk assessment, as almost all the flying was over mountainous terrain. Investigation of the JU-Air revealed that the routes and altitudes selected by JU-Air left no margin for error. Aircraft were routinely flown down the center of valleys, it was common to cross mountain ridges at more than 45 degrees and at altitudes that did not provide any escape route, should the aircraft encounter wind shear or down flowing air.
The routes and altitudes flown by JU-Air were not only unsafe but also illegal. The JU-52 was required to remain at least 2,000 feet above any terrain within 9.3 km of its route of flight, because the aircraft could not maintain level flight above 8,200 feet, in the event of an engine failure. Pilots flying the route would not be able to follow the 2,000 feet above terrain, as that would involve flight at 12,500 feet. There was another air regulation stating the aircraft could not fly over 12,500 feet, as the airplane was non-pressurized. Basically the JU-52 was not the right aircraft for the mission. The terrain clearance distances were not mentioned in the JU-Air operations manual. One wonders how the Swiss authority would ever approve a document with those major shortcomings.
Investigators discovered that there were 150 safety-related incidents that had occurred prior to the accident, and there was no in-depth analysis performed of any of them. Risky behaviour was commonplace at JU-Air and the operation was being managed without any regard to operational risk. Safety regulatory over-sight had been systematically deficient.
The risks of VFR flight or mountain flying had never been assessed, despite the existence of an approved SMS.
The Junkers Ju52 a low wing trimotor was designed in 1931 and entered service with Lufthansa, the German civil airline, in 1932. The BMW-powered aircraft could carry up to 18 passengers. Approximately 6,000 units were ordered by the Luftwaffe and saw service in WW2 as bombers and military air transports.
At the time of the accident in 2018, the aircraft was then an antique, having been built in 1939. It was powered by three nine-cylinder radial engines, turning fixed pitch propellers.
The Swiss Transportation Safety Investigation Board identified the following issues with the aircraft:
“Numerous engine faults on JU-Air aircraft were recorded between 2008 and the accident. The investigation revealed that 17 safety-related engine malfunctions or system faults in relation to an engine took place during flight. On each of these occasions, it was necessary to shut down an engine or run it on reduced power. In 14 out of 17 instances the flight was aborted. On one occasion, an engine failed completely. Several cases of pronounced vibrations caused by loose propeller blades occurred on flights between 2012 and 2018.
The Junkers Company had long since disappeared years before the accident, and as result, no one held a type certificate. JU-Air had been making the required spare parts through subcontractors, and not all were qualified to produce parts. None of the spare parts received approval from the Swiss FAA.
This accident demonstrates how pilots with any one of the five hazardous attitudes …
… can be accidents waiting to happen, and far too often take trusting and unwitting passengers on their final flight. The accident pilots would appear to have demonstrated 4 out of the 5 hazardous attitudes.
Any aviation organization must have effective oversight into how their personnel are performing, or they will discover their weak areas by “accident”.
Government agencies tasked with monitoring aviation safety have to do their job, they need to “trust and verify”
There are no new accidents, just new victims.
The number of flying hours a pilot has logged may well be a good indicator of future performance, but it is the next hour of flying that is really important.
We used to have a saying at Systems Safety, Transport Canada, and it is still valid today,
“ If you think flight safety is expensive, try having an accident”
As Captain A.G. Lamplugh, a British pilot from the early days of aviation said “Aviation itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity, or neglect.”
Warren Le Grice
A mid-air collision is probably a pilot’s worst nightmare, and is the main reason that air traffic
control exists. Mid-airs are the result of a loss of situational awareness on the part of one, or both of the pilots involved. These accidents are often preceded by either a breakdown in
communication or a total absence of it.
I will relate two of my own near-miss experiences, in this article, and discuss two fatal
accidents in which I knew the pilots involved.
The first close call that I experienced, was at Penticton in the spring of 1969. I was flying a Champion Tri-Traveller with my younger brother as my back seat passenger. We had just landed CF-XNE on runway 34. I needed to taxi back to the Penticton Flying Club hangar where the airplane was tied down, so we moved over to the left side of the runway and I did a 180 degree turn to taxi back towards the runway threshold.
Now in 1969 there was no such thing as a MF (Mandatory Frequency). That would come as a result of the PWA crash at Cranbrook 1989. Pentiction Aeradio, where I worked at the time, provided an airport advisory service on 122.2 mhz. I had called in and announced my intentions and received the airport advisory, I did not hear any other aircraft on the frequency. We at the Aeradio Station, were well aware of a mid-air collision that had occurred in April of 1963, when eight people were killed in a mid-air between an Aero Commander Twin, and a Cessna 140 over Skaha Lake, while both aircraft were on approach to runway 34.
As I taxied towards the threshold of runway 34, I noticed a Stinson Voyager about a mile final, and above him and slightly behind, was a Cherokee, which was owned by the same flying school as the airplane I was flying. I said to my brother “look at those guys on final”. As the Stinson was starting to round out for its landing, the Cherokee’s right gear leg contacted the Stinson’s starboard wing, and I noticed bits of fabric being torn off and the Stinson contacted the pavement quite firmly. The Stinson pilot was able to maintain control of his machine and continued to taxi straight ahead. The Cherokee pilot, who as it turned out, was a student pilot on his first solo, then turned to the left and added power in order to do a go around. This action took him on a heading towards our airplane. I turned right towards the VASIS lights located on the grass, left of the runway, to avoid being hit.
The student pilot then banked right and climbed away and did another successful circuit and landed with a bent right undercarriage. The Stinson had major damage to the right wing and the pilot luckily was not injured. It was a classic high-wing, low-wing situation, compounded by the fact that nether pilot was aware of the other aircraft, as there was no radio communication. I believe the student pilot never came back for any more lessons, both aircraft would be written off in later years and the flying school crashed themselves out of business within two years.
Approximately ten years later, I was now a Terminal Controller at the VR ACC. I was flying my Arrow CF-UKE, the aircraft I mentioned in a previous article. I was giving instrument dual to my friend Rick Quiring, who had been my OJI ( On Job Instructor) in Terminal. We had filed IFR and were going to Victoria to do and ILS on runway 26 ( the movement of the magnetic north pole, would necessitate renumbering the runway several years later), then a missed approach back to Vancouver, where we kept the machine. It was a summer evening and the weather at Victoria was about 1800 feet broken and 20 miles visibility, very stable air and no precipitation.
We had flown the transition from the Victoria VOR over to the Victoria NDB which was at that time located on Sidney Island, about 4 miles on final for RWY 26. We received our approach clearance from Vancouver Terminal. Just prior to procedure turn, we were changed over to YJ tower, and on initial contact with the Tower there was no mention made of any other aircraft. As we were intercepting the localizer inbound, we broke out at the bottom of cloud base. The next thing I saw were three bright lights climbing up towards us.
I took the controls from Rick said “ I have control” and we did a right descending turn. Once we got sorted out again and back the ILS, I told the Tower we had just passed a jet going the opposite direction. The tower had departed the aircraft on runway 08, unbelievable! The reply I got was “ Oh, he is VFR going for an approach”. I replied that the aircraft which turned out to be a British Midlands 737 couldn’t have been VFR as we were IMC during procedure turn. Very dangerous behaviour on the part of the tower controller and of the pilot of the 737. You cannot make this kind of stuff up!
Had we not broken clear of cloud when we did, we would have collided for sure. Now days that type of incident would have resulted in a TSB investigation and action by Transport Canada. There were three of us on board that evening, as we also had another VR Terminal controller with us, so had the 737 got us, it would have taken out about 15% of the VR Terminal staff in one fell swoop.
The mid-air collision which occurred on November 20, 1999, in CYA125(T) is well documented as report # A99P0168 by the TSB. The mid-air involved a C152 operated by Pacific Flying Club and a privately owned Aircoupe owned and flown by one of my two friends Alvin and Stan out of Langley. Alvin was an instructor at BCIT in Burnaby, and Stan was a retired CP Air engineer. The C152 had a young instructor on board and a 15 year student pilot who was working on his recreational license.
CYA125(T) was a Class F special use airspace, located over Surrey, and the north portion of that airspace infringed on the localizer for runway 26 at Vancouver. It was capped at 2000 feet, which meant as terminal controllers we couldn’t come below 2500 feet with light and medium weight IFR aircraft, and 3000 feet for heavy jets. This certainly affected operations when Rwy 26 was active at Vancouver. The airspace was a bit of a nuisance from an IFR perspective, and we used to comment on the number of aircraft, that we observed, jammed into that airspace on a good VFR day. It really was an accident waiting to happen.
I remember the day of the accident well. It occurred late in afternoon on a November weekend. It was the first day of reasonable weather, following a dismal week, of almost constant rain. The weather improvement created an opportunity for many pilots to finally go flying. Transport Canada was aware of the elevated risk, that CYA125 posed to VFR aircraft. Numerous flying training aircraft, were squeezed into only really 1500 feet of vertical airspace. Following the accident, in which all four persons were killed, Transport Canada eliminated the special use airspace, and PFC installed flashing landing lights on all their aircraft.
The last accident occurred over Nairn Falls Provincial Park, four miles SW of the Pemberton Airport on June 29, 2013. The aircraft involved were a Stemme S10 motor glider and a C150. The motor glider was being flown by a friend of mine Rudy, who was my one of my instructors, when I was flying gliders at Pemberton, a number of years ago. Rudy was operating his motor glider operating scenic flights on the day of the accident. Rudy was an experienced glider and powered aircraft pilot, with over 3,000 hrs of flight time.
Weather permitting, the scenic flights involved taking passengers, one at a time, out west of the airport and over the Ipsoot Glacier, to an altitude of 8400 feet, a really spectacular flight. The engine would be shut down at altitude and the propeller stowed and the aircraft would become a sailplane for the descent and landing.
Rudy’s business, Pemberton Soaring, was a real grass roots operation, he slowly built up his glider fleet from one Blanik L33 and a Bellanca Scout towplane, into several sailplanes. Over the few years, rental pilots and one of his own tow pilots wrote-off most of his aircraft, to the point where he was only operating the Stemme motor glider.
A sailplane requires rising air, in order that the flight become anything other than a sled ride. In the Pemberton area, that would require flying relatively close to terrain, in search of rising boundary layer air. Rudy would likely have been using that method on his descent to the airport. As he rounded the mountain side above the Nairn Falls Park, he encountered opposite direction traffic.
The Cessna 150 which was on a VFR flight plan, from Lillooet to Nanaimo had on board a man, his wife and their dog. The pilot had a Private License and 127 hours of flight time. There is an ATF frequency at Pemberton on 123.2 mhz. Rudy had made a radio call inbound to the field, which was heard by witness, but the witness did not recall hearing the Cessna pilot make any transmissions.
The sailplane when viewed head on, would have presented a very small profile to the C150 pilot. The long nose of the sailplane, combined with the view from the semi reclining seats in the sailplane, would have made it difficult to see the Cessna below. Both pilots likely thought they had the sky to themselves. The collision resulted in both aircraft shedding a wing each and the wreckage spiralling down amongst people in the campsite below. None of the four people in the two aircraft, survived the accident.
Back at the airport, the other two members of the family of the young boy, who was the passenger in the motor glider, were waiting for their turn at a scenic flight.
Rudy left a wife and two teenage sons. There is plaque located in the picnic grounds on the Pemberton Airport, which was placed in honour of Rudy.
Mid-air collisions remain a very threat, however we can mitigate risk by a number of means.
Fly professionally and make good decisions.
“ Plan continuation bias”, by Warren Le Grice
Welcome to the “ Safety Corner”. I used to write a similar column, when I was a member of the Boundary Bay Flying Club. I have been involved in the promotion of flight safety for many years and will continue to do so with the AFC.
In the early 1990s, when the ATC system was still operated by Transport Canada, I had an opportunity to participate in a 20 month secondment with System Safety Branch, as a Regional Safety Officer . At the time I was working as a Course Director in our Regional Training School at the VR ACC.
I was fortunate enough to work with an excellent mentor, during my time with System Safety, Vince Edwards, an experienced fixed wing and helicopter pilot. During my time with the Safety Branch, I developed a keen interest in human factors and why pilots make the decisions they make. I was tasked with delivering the PDM ( Pilot Decision Making) course to Flying Schools and Flying Clubs around B.C. A side benefit to the secondment was the opportunity to receive dual on both Transport’s amphibious Beaver C-FDTI and the Jet Ranger C-GCGQ.
With the preceding narrative as some background, I can now relate the story of my first aircraft partnership, what happened to the aircraft and one of my partners.
I controlled at Vancouver Tower from 1971 to 1979, a very interesting airport to control during that time period. My first aircraft partnership was in a 1968 Piper Arrow, CF-UKE. My four other partners and I purchased the airplane in 1979. I was able to build up my IFR experience in the airplane over the next couple of years and was able to give one of my partners, Dave, most of the dual he needed to get his instrument rating.
We had one good cross country from Carson City, Nevada, back to Vancouver, in the Arrow, as one of the partners got weathered in, and wisely decided to return to VR by airlines. Dave and I were able to practice all the IFR approaches in the lower mainland and southern Vancouver Island, including Nanaimo. Now in the early 1980s Nanaimo had only one NDB approach which terminated at the YCD NDB, if you didn’t see the airport from the beacon inbound, you carried out the missed approach, so obviously the limits were quite high, probably about 1000 feet and 3 miles.
I do remember advising Dave to take it easy, and be careful as he built up his experience, after he achieved his instrument rating. The Arrow had only 2 VOR/ILs receivers, no DME and no de-icing capability was really just a fair weather IFR airplane. Unfortunately as he got more experience in the airplane, he would take on IFR flights that I wouldn’t attempt, and once told me about an icing experience he had going into Port Hardy.
In 1981 when the mortgage rate went to 19 ¼ on our home in Burnaby, I decided it was time to sell my share in the airplane. It would be approximately a year later when I heard on the news, that UKE had crashed into a mountain, south west of the Nanaimo airport. My first thought was, what was the airplane doing going into Nanaimo at night? We kept the airplane on the south ramp at Vancouver, so I couldn’t figure out what reason there would be for flying into Nanaimo at night, on that fall evening. I concluded the pilot must have been Dave, as he was the only IFR rated partner at the time.
I got the full story a couple of weeks later, from one of my ex partners who was an electronics tech with Transport Canada. Dave was a keen bird hunter and had flown over to Alberta with his youngest daughter, to shoot geese and ducks around Brooks, Alberta. He had asked permission of a farmer to shoot on his property, and after the hunt was invited in for coffee. The farmer’s sister –in –law, was visiting from Port Alberni, having travelled out by Greyhound. When Dave was told she would be returning soon, he volunteered to fly the lady back as far as Nanaimo as he had a spare seat.
The aircraft was on an IFR flight plan to CD, and as is often the case, the weather was deteriorating in the lower mainland, as the flight progressed from Alberta. Dave was likely anticipating doing an approach in VFR conditions upon his arrival. Now we had never done a night landing at Nanaimo as part of training, and I don’t know if Dave had ever done one once he was on his own. As the flight progressed through the Vancouver Terminal airspace, and was approaching Nanaimo, UKE was cleared to the Nanaimo airport for an approach, radar service was terminated and a the frequency change to Nanaimo radio was given. During the early 1980s VR Terminal controlled both CD and YJ airports as well as VR as there wasn’t anywhere near the IFR traffic there is today.
The last communication from the aircraft to Nanaimo Radio was, “are the runway lights on? ” The aircraft failed to arrive and was located a day or so later, having flown into the side of a mountain located a few miles south west of the airport. The aircraft was in level flight, likely in cloud and hit a large tree almost head on, killing all three occupants instantly.
The accident was a classic CFIT ( Controlled Flight Into Terrain) situation, likely brought on by pilot fatigue, stress and not being prepared to do a non precision approach, following a long day.
There is an interesting side note to this story. A couple of years later at the Area Control Center, I was facilitating a series of human factor workshops for all Transport Canada control and FSS staff in the province. The subject was “ Situational Awareness”, and the first question I asked each class was, had they ever had an experience where loss of situational awareness had lead to an accident or incident? On different workshops, the Terminal controller who cleared UKE for the approach that night, and the Nanaimo FSS who last spoke to the aircraft, related their stories. The FSS member had the family of the passenger who was headed for Port Alberni, waiting at the counter in the FSS, for word of their family member. It was a tragic experience for all involved.
So what can we take away from this accident?
NASA has recently come up with a new term “ Plan Continuation Bias”. The premise is when the pilot has somewhere to get to, he or she ignores the environment. The more the person has invested in the plan, the less likely they are to change that plan. Another way of putting it would be to say when a journey is almost over, people tend to go into auto-pilot, ignore changing and potentially dangerous environmental factors.
Had my ex-partner decided as they approached his home base in Vancouver, “gosh I am tired, let’s just do the ILS onto runway 08 and we’ll put the lady in the back seat ,on a ferry tomorrow”, I have already saved her a very long bus ride”. Had that been the case, his wife would have grown old with her husband and younger daughter and the older daughter would have had a Dad and a younger sister.
Know your aircraft’s limitations and more importantly know your own.
Fly professionally and make good decisions.