TSB report of August 2013 Air Nootka Accident

[ragbagflyer]

The previous thread is locked up due to the usual reasons. http://www.avcanada.ca/forums2/viewtopi ... 18&t=91083

The report is found here. http://www.tsb.gc.ca/eng/rapports-repor ... 3P0166.asp

I'm not sure I buy the "VFR flight into IMC conclusion though". My understanding was that the aircraft contacted the tree rising above the others because it was missed by the pilot but not because they were IMC. Low above the tree tops sure, but IMC? I doubt it.

One thing that stands out to me is that despite comments in the initial speculation that it didn't make sense that a mayday call was made after the impact, that was in fact what had happened.

Rest in Peace Grant.

[shimmydampner]

Cloud bases at 400 AGL, crash site at 800 AGL...what's not to buy?
When will people learn that even highly experienced guys can get killed by clowning around in poor weather?

[pelmet]

Cloud bases at 400 AGL, crash site at 800 AGL...what's not to buy?
When will people learn that even highly experienced guys can get killed by clowning around in poor weather?

You mean ASL. Looks like I was right about this one. I would be pretty pissed off with the pilot if I were a relative of the pax.

To clear any doubt there may be for the OP....

"Findings as to causes and contributing factors
1.The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others."

[Meddler]

Wow. Some folks would ease up a bit when it's clear the deceased is a friend of the poster. But I guess making your point is more important eh.

Grant was a fine guy.

I agree with the op. The TSB can't stand to not stick a label on a crash. "Hit a tree in low VMC" doesn't fit any of their slots so they stick the VFR into IMC label on it regardless.

[pelmet]

Wow. Some folks would ease up a bit when it's clear the deceased is a friend of the poster. But I guess making your point is more important eh.

Grant was a fine guy.

I agree with the op. The TSB can't stand to not stick a label on a crash. "Hit a tree in low VMC" doesn't fit any of their slots so they stick the VFR into IMC label on it regardless.

I obviously was not part of the investigation. But, if you have some sort of evidence that the investigators intentionally misled in this report, please present it to us. Being a friend of the pilot is usually one of the most likely reasons to have a bias as compared to investigating an accident where you have no personal link. That is why if an investigator has a personal link with the company or crew in the accident, they will typically be barred from the investigation.

As I know neither of the parties with an opinion (TSB and friend of the pilot) on the cause of this accident, I think I will stick with the official investigation view. While there is no 1000% guarantee that it is correct, it falls in line with the circumstances surrounding the accident and what has happened over and over again in the history of aviation. Flying in crap weather in hilly terrain is high risk. I know it gets done and can be done but it can be unforgiving of the smallest of errors.

Perhaps there was some vis and it was not in technical IMC. But sometimes the windshield that was not the clearest to begin with and is now rain splattered makes in damn hard to see forward even if it is still somewhat reasonable vis out the side window. And an unusually tall tree camouflaged by the surrounding trees can easily be missed as you skim along the top of the forest.

I would think that the relatives of the pax would consider this an important point to make and their concerns of a bit more importance. Who cares if the PIC was a great guy. As a pax, I would rather have a jerk that knows what he is doing than a nice guy kill me. Being a nice guy has nothing to do with the cause of the accident.

[Sidebar]

The TSB can't stand to not stick a label on a crash. "Hit a tree in low VMC" doesn't fit any of their slots so they stick the VFR into IMC label on it regardless.

First, I offer my condolences on the loss of your friend.

Just what is "low VMC" anyhow? Where is that defined? The most recent TC ASL (http://www.tc.gc.ca/media/documents/ca- ... 3_2014.pdf) provided definitions for both VMC and IMC, but did not mention "low VMC."

VMC: When operating in uncontrolled airspace below 1 000 ft AGL, meteorological conditions must permit pilots operating under VFR to operate their aircraft with visual reference to the surface, clear of cloud, and in no less than 2 mi. flight visibility during the day (Canadian Aviation Regulation 602.115).

IMC: In IMC, visual reference is not possible and pilots must maintain aircraft control using only the instruments.

Here's what the TSB report said about Air Nootka operations policies and the CARs regarding VFR operations.

The Air Nootka COM also states that, for VFR flights conducted below 1000 feet above ground level (agl) in uncontrolled airspace, the flight visibility must not be less than 2 nm and the aircraft must be operated clear of cloud and with visual reference to the surface. The COM states that IFR, night VFR, and VFR over-the-top are all prohibited. The applicable CARs for this type of operation further state that, other than for take-off or landing, the aircraft must be operated at least 300 feet agl.

Here's the weather information from the TSB report:

Weather
The nearest official weather was recorded at the Estevan Lighthouse, British Columbia, about 6 nm south-southwest of the accident site, and 8 nm southwest of Hesquiat Lake. At 0940 the lighthouse keeper observed
•overcast with 300 to 400-foot ceiling;
•moderate rain and fog;
•visibility 3 statute miles (sm);
•wind out of the east at 15 knots, gusting to 26 knots;
•sea state 4 feet with moderate low swell;
•barometer 1013.6 hPa and rising (29.94 inches of mercury).

The lighthouse weather at 1240 was nearly identical.

Air Nootka pilots occasionally call Estevan Lighthouse for weather conditions in that area, but C-GPVB's pilot did not speak to the lighthouse keeper on the day of the accident.

It was reported that the weather at Hesquiat Lake when C-GPVB arrived included low cloud ceiling and reduced visibility in drizzle. When the other 2 Air Nootka aircraft arrived at Hesquiat Lake, about 20 minutes after C-GPVB departed, the ceiling was about 400 feet and visibility was about 2 ½ nm in rain with a gusty southeast wind. Weather conditions on the opposite (west) side of Hesquiat Peninsula were marginally better, with ceilings varying from 400 to 600 feet asl and visibility varying from 2 ½ to 4 nm in rain.

In order to fly under VFR, the pilot needed be clear of cloud, be at least 300 AGL, and have visual reference with the surface. Given the weather conditions, he almost certainly was not clear of cloud. Since the aircraft hit a 160 foot tree, it was definitely not operating at 300 AGL. The pilot may have had some visual reference, but whatever he saw, it was insufficient to allow him to avoid the tree. My conclusion is that he was not in VMC and he was not in compliance with VFR.

[ragbagflyer]

I'm not trying to start an argument here nor am I suggesting that weather and pilot judgement weren't factors in this accident.

I was told shortly after the accident that a passenger had reported Grant had turned his head back to talk to pax in the back of the aircraft just as the tall tree (seen by the passenger) contacted the aircraft. Tree top level in loaded beaver in rising terrain isn't the place to be with visual reference or not. My comment was based on my musings that there are certain details from the investigation that won't always make the final report, for a variety of reasons. To read the report I think most people, including myself would read it to mean the aircraft climbed into cloud in a way that would mean that flight with reference to the instruments only was intended. What I was saying was that scenario seems unlikely to me.

[pdw]

A significant distraction is part of the reporting if it's in the accident sequence, provided the passenger account is available. The visual distraction when "turned his head back just as the tall tree contacted the aircraft" (not even looking towards the obstacle to avoid it) isn't trivial, and also the chance there for a 'lowering elevator / yoke movement contribution' in the process. What level of distraction would a 'verbal exchange' be from "the back of the plane" over the noise of the engine ?

[RatherBeFlying]

Witness accounts by surviving passengers are likely behind the TSB's statement the a/c was in cloud. But we do not know for sure what the pilot was seeing. Given that the pilot turned to talk to a passenger in the back, he must have been comfortable with what he was seeing.

Cloud in hilly terrain is usually mixed.

Bottom line is that his margins were so tight a taller tree took him down.

If a taller tree is backgrounded with a treed upslope, you likely won't see it in time.

[Cat Driver]

If a taller tree is backgrounded with a treed upslope, you likely won't see it in time.

In the water bombing business we called them " Widow makers "

[ragbagflyer]

A good case can be made the the fuel tank bladder retrofit. Sitting on top of a pile of avgas contained in a paper thin aluminum tank terrifies me when I'm over anything but water. It's a cheap mod in the grand scheme of things too.

[xsbank]

Hi Cat, also used to call them "Grey Ghosts." One of our guys came home one day with bits of old silver cedar embedded in his flaps from a particularly gnarly one. That was in the Elaho River; we thought there must be an old Indian burial ground in there as there was also a 212 on its side in the river and I seized an engine on a run in there.

I also think this accident is a good reminder for all of us to conduct a rigorous self-appraisal, examine your skills and know when it's time to hang up your spurs. To a large degree, and with my own 3500 hours floats, I feel that driving a Beaver on the coast (mine is all coast) is a younger man's job. I don't mean to cast aspersions on anyone here, nor this late pilot (I flew out of Tahsis in the mid-70s) but our reflexes get slower, we hurt more and for longer and maybe we are just a little too good?

I remember another Beaver pilot, wore a suit mostly, flew the coast for years, had a solid head of grey hair, great guy, well liked, stayed on the coast after I moved on to IFR, vanished ione day in his airplane. Vanished. They still haven't found him and I have forgotten his name, which I find both scary and apropos.

I think there is too much randomness and risk to committing the float thing for too many years, another reason why I have gone boating. A very personal decision!

[pelmet]

Hi Cat, also used to call them "Grey Ghosts." One of our guys came home one day with bits of old silver cedar embedded in his flaps from a particularly gnarly one. That was in the Elaho River; we thought there must be an old Indian burial ground in there as there was also a 212 on its side in the river and I seized an engine on a run in there.

I also think this accident is a good reminder for all of us to conduct a rigorous self-appraisal, examine your skills and know when it's time to hang up your spurs. To a large degree, and with my own 3500 hours floats, I feel that driving a Beaver on the coast (mine is all coast) is a younger man's job. I don't mean to cast aspersions on anyone here, nor this late pilot (I flew out of Tahsis in the mid-70s) but our reflexes get slower, we hurt more and for longer and maybe we are just a little too good?

I remember another Beaver pilot, wore a suit mostly, flew the coast for years, had a solid head of grey hair, great guy, well liked, stayed on the coast after I moved on to IFR, vanished ione day in his airplane. Vanished. They still haven't found him and I have forgotten his name, which I find both scary and apropos.

I think there is too much randomness and risk to committing the float thing for too many years, another reason why I have gone boating. A very personal decision!

I understand that there are some limits pushed in the operations in this area. I suppose that is the reality of the job and I have operated in some similar circumstances of legality. But if you are pushing the limits so far, that the somewhat slower reflexes of age are all that makes the difference between an accident or not, perhaps the problem is decision-making.

Water bombing, ag-flying, or low level aerobatics perhaps but float ops especially with passengers.....I don't think so.

[xsbank]

Pelmet, operating on the coast, you are constantly encountering adverse conditions such as drizzle, swells, tides, logs, winds, boat swells etc even when operating entirely legally. I am only suggesting that each individual assess his own ability to continue operating in adverse, difficult conditions, as I have observed over a long observation period (my career) that even high-time, vastly experienced float drivers are not immune to the dangers inherent to this niche of aviation.

Maybe go gently into retirement? Is that a better way to put it?

Remember Widow?

Kinda why you don't see elderly fighter pilots, although they rarely get to assess themselves, someone else usually promotes them.

[shimmydampner]

I can't believe that fuel bladders and retiring from float flying is the take away from this. What a crock. How about not endangering your life and the lives of your passengers by stooging around the tree tops in crap weather? Maybe that's the real big glaring lesson here.

[xsbank]

I have been in this business long enough that I have reached my limit for outrage. Usually the fact that somebody screwed up and killed a bunch of people doesn't sit well with me either, but my comment was meant as a positive comment. I'm not going to mention the Taiwanese airplane with the engine failure and the patently unfeathered prop.

Myself and two friends have recently retired from our "real" jobs (no insult intended) and we all thought about going back to our roots, flying floats. We all cut our teeth here on the coast and we were all pretty good at it. None of us ever hurt anyone. After some really serious beakers of beer, we all decided that as we had 'survived' aviation, it should be allowed to carry on without us, so we all have boats and only one of us still has a license, degraded to private. You need to know when to quit, when to just quietly go into the sunset.

That's all.

[shimmydampner]

l think l see your point XS, and I admire your decision not to attempt a return to bush flying. Some pilots aren't as self aware. It's important to recognize the hard work and unique skill set required for that type of work as well as the inherent risk.
All that being said, if a person wanted to make a career in the bush, and was smart about managing those inherent risks, it's easily doable. I think the problem is that most of the accidents in this type of flying are a result of completely disregarding one or more of those risks, and this accident is no exception. Innocent people got maimed and killed because some guy took unnecessary risk.