Missing north of Peterborough

[photofly]

Are there any company procedures for doing so when the communications are about or with another aircraft in difficulty? In this case the AC flight crew(s) in question would have to have decided of their own volition that the radio comms might be useful in any future investigation about the non company aircraft. Does this every happen?

[TSB Tasker]

An update on some facts so far:

- The aircraft departed CYRO at 1803EST and the last radio transmission was recorded at 2127EST.
- The aircraft was recovered with a total of 6.2 USG in the tanks.
- There was a significant propeller strike on a tree ~30 feet from the wreckage, ~20 ft from the ground.
- The aircraft was equipped with a single VOR receiver and CDI.
- No Aviation GPS was recovered.
- Two cellphones were recovered, an HTC One, and a Blackberry Curve.

If you have any information or opinion you think is important to the investigation, please contact me at ewan.tasker@bst-tsb.gc.ca

Ewan Tasker.

[cgzro]

I dont know any pilots with smart phones that have not mucked with different GPS applications to see how well they work... In general they work superbly and can easily be used to navigate you to within a few 10s of feet of a runway .. Assuming the database of aviation waypoints is accurate, which is not always the case.

Perhaps they were using a cell phone GPS and were somehow misled by it? Often the cell phones use lat long of cellular towers to augment the positioning when gps is weak. Perhaps one of those was incorrect in the db on the phone. Or perhaps the gps app was crap and had a bad magnetic deviation model for that area...

[CpnCrunch]

Thanks for posting the update, Ewan.

The HTC One has a GPS with Glonass, so they could have just clicked on Google Maps to get a pretty good idea of their position even without having an aviation navigation app.

Regarding cgzro's comment: I guess TSB can check to see if Air Nav Pro or any other aviation GPS apps were installed on the phone.

Sounds like a combination of flying around lost for a few hours, followed by disorientation and crash into the trees.

[cgzro]

Google maps wont work without cell coverage for data to download the map.. But dozens of other GpS apps would have worked fine assuming they had battery left in the phone. Most of those phones wont go 3 hrs GPS without a charge though.

I worry about kids however blindly trusting these ithings.. None are certified and can do,wierd things occasionally.

The cell phone GPS app angle seems worthy of more digging.

[CpnCrunch]

Yes, you're correct. However google maps caches the maps so they probably would have at least been able to see their position relative to their home.

And yes, you should never rely on a phone for navigation. Although a single VOR with no DME isn't much use either if you get lost.

[cap41]

Google maps wont work without cell coverage for data to download the map.. But dozens of other GpS apps would have worked fine assuming they had battery left in the phone. Most of those phones wont go 3 hrs GPS without a charge though.

I worry about kids however blindly trusting these ithings.. None are certified and can do,wierd things occasionally.

The cell phone GPS app angle seems worthy of more digging.

POOR decision making!!

NO GPS is bad enough. But, if you are relying on your phone. Would you not bring a charger?? Every 150 I have been in has a 12V connection. I've use Air Nav std all the time. If I'm going country I bring a charger.

Im a low time pilot, I would not rely on iPad, iPhone GPS. But, I would never leave on a country without 2 GPS, and using flight following etc.

[airway]

And yes, you should never rely on a phone for navigation. Although a single VOR with no DME isn't much use either if you get lost.

True, if there is no VOR reception

If there is 1 VOR, you can time how long it takes to cross 5 or 10 degrees of radials, and use a formula to determine how far away from the VOR you are.

Or, if you are receiving 2 VOR's, you can get your position within a few miles, by triangulation.

[pelmet]

Sounds like a combination of flying around lost for a few hours, followed by disorientation and crash into the trees.

I'm sure the investigators will analyze the crash pattern to determine if it was a stall/spin scenario or high speed dive or just a regular CFIT. After checking other things such as the usual control continuity and other standard items and assuming no other so-called "golden nuggets" of evidence are found, the TSB will make an unsurprising conclusion about this accident with nothing new to learn that was not already learned long ago.

Until poor judgement can somehow be regulated we will continue to have these sort of accidents. They are inevitable just like judgement related car, boat, scuba, skydiving, and ski accidents are inevitable. I have participated in all of them and made errors in all but if you can improve judgement you can eliminate much of the carnage. All these activities seem to settle at what seems to become an acceptable rate of "loss". A slight bit of paranoia is a good thing for key items.

The only thing I can suggest is a mandatory requirement for initial discussion at the entry level on how poor judgement/personal characteristics significantly affect the accident rate and a generic test to identify to individuals their accident potential due to their own personality and what can be done to mitigate that potential. A lot of accident report reading in my opinion would go a long way along with straight, in your face talk(maybe on video) about all the realities of the dangers of aviation. For example, all the very smart doctors and lawyers who have killed themselves in aircraft accidents because of their personality traits.

For example, theory of flight is nice but the chart showing that your C-150 can land on a certain short grass strip is not much use when it is covered in dew. It should be obvious, but I first realized that from an accident report many years ago, not groundschool. Have applied this in practice in the case of landing a twin Cessna for a regular maintenance check on a very short grass strip where braking was always required. Always arrived mid-day to late afternoon on dry grass and was always successful(with one go-around due to floating), all courtesy of one of several thick volumes of TSB/CASB summary reports read a long time ago. They still sit on my shelf and I have been collecting reports ever since. I am not smart enough to figure out all this stuff by myself.

[MIQ]

Pelmet, what you are saying is all correct. It's basically the process of learning through experience which sounds very obvious. Naturally in our industry experience is what matters the most and I would say even more so than in other industries. I don't know a lot of industries where the employee's experience is measured with such high accuracy as it is in aviation. If you think about it, especially in the first 10 years of your career experience is measured down to 6 minutes exactly on all sorts of different levels. And that's what I find a bit critical at times. We have just discussed how dangerous we believe it is to fly VFR night cross countries in single engine airplane. Why do we think then that it is such a great idea to request 25 hours night cross country PIC from mostly inexperienced pilots (I'm including myself here)? As always stated night cross country PIC time is the hardest time to get for your ATPL so I often see suggestions to get it done early on. When you are actually flying for a commercial business in a multi crew environment you most likely won't be logging PIC time at that point. So essiemtially, most people get it done while they're at under 500 hours on single VFR airplanes. I feel, if we wouldn't have the 25 night XC PIC requirement, the two guys could still be alive because they could have been less inclined to operate the aircraft at night time. I can see why TC imposed that regulation in the first place, which brings us back to the 'learning through experience'. However I feel sometimes it might be better to get this experience not when you're by yourself. How about PIC under supervision, or counting 50 co pilot night XC as much as 25 PIC or something along those lines? Especially if you consider how easy it is to get the night rating in the first place...

[Rookie50]

Pelmet, what you are saying is all correct. It's basically the process of learning through experience which sounds very obvious. Naturally in our industry experience is what matters the most and I would say even more so than in other industries. I don't know a lot of industries where the employee's experience is measured with such high accuracy as it is in aviation. If you think about it, especially in the first 10 years of your career experience is measured down to 6 minutes exactly on all sorts of different levels. And that's what I find a bit critical at times. We have just discussed how dangerous we believe it is to fly VFR night cross countries in single engine airplane. Why do we think then that it is such a great idea to request 25 hours night cross country PIC from mostly inexperienced pilots (I'm including myself here)? As always stated night cross country PIC time is the hardest time to get for your ATPL so I often see suggestions to get it done early on. When you are actually flying for a commercial business in a multi crew environment you most likely won't be logging PIC time at that point. So essiemtially, most people get it done while they're at under 500 hours on single VFR airplanes. I feel, if we wouldn't have the 25 night XC PIC requirement, the two guys could still be alive because they could have been less inclined to operate the aircraft at night time. I can see why TC imposed that regulation in the first place, which brings us back to the 'learning through experience'. However I feel sometimes it might be better to get this experience not when you're by yourself. How about PIC under supervision, or counting 50 co pilot night XC as much as 25 PIC or something along those lines? Especially if you consider how easy it is to get the night rating in the first place...

Interesting comments, MIQ. Would support that as an area to study by TC. At 700 hrs TT I am certainly more cautious at night than I was at 200. Not that I was reckless then, just I'm less willing to do long cc at night, now. I just did a small batch after a hiatus, in case its needed, and while I'm comfortable, certainly the risk factors are far higher in any phase of flight, and I can't say I love the black hole effect descending to a small runway with blackness in front of it. Must be creeping age, perhaps.

On another note, contrary to the assumption, it's looking rather like "getting lost and running out of fuel" is not the proximate cause here, and and a loss of control, likely, looking at the weather in the area, an encounter with pitch black IMC.

At low time myself, but far more than these pilots and an IR rating, I wouldn't enjoy that very much.

[PilotDAR]

The longer I fly, the less I feel immune to those simple, and often fatal events. Yes, My experience is helping me avoid those conditions, but I think I have long ago used up all of my newbie luck. I have no idea, how early on I somehow felt that these bad things could happen to me, other than a couple of real eye openers in the right seat of my buddy's 150 in my early teens. I have seen so many things, and cleaned up so many wrecked airplanes, I'm always trying to figure out what they did wrong, and how big the gap is from that, and what I often do. Some of those gaps are alarmingly small.

Add to that, simulators and games. It crashes, and you go again. No consequences. I used to fly (and actually maintain) one of those old ATC 810 simulators - zero visual. Occasionally, you'd "crash" it - no consequences. I remember vividly my first "crash" in Flight Safety's Twin Otter simulator. A botched single engined go around, slower than Vmc, and I could not hold it. I saw the ground coming at me, and that got my attention. After I hit, I reminded myself it was only a sim, but it's so realistic, I'd forgotten for while, and thought I was done. Memorable.

And, a few times since, I've seen the ground coming, or worse, did not see it, but knew it was there somewhere. I've avoided hitting it. But, I HAVE the memories, which cause me fear. I have helped lift two dead friends from their crashed planes, so I have those memories too. If the newbie pilots had the memories of these terrible events, or the very near approach to them, we would have many fewer of these accidents, 'cause they would simply be [wisely] afraid to get near those situations at all.

Yes, I still fly night VFR cross country, but I make sure that a whole bunch of other factors are going my way first, and have lo tolerance for degradation of those conditions before I turn around....

[TSB Tasker]

The Investigation Report into this accident has been released.

You can find it at the following links,

http://www.tsb.gc.ca/eng/rapports-repor ... 4O0217.asp

or

http://www.tsb.gc.ca/eng/rapports-repor ... 4O0217.pdf


The news release reads as follows:

News release

Faulty navigation equipment and limited visual reference led to a November 2014 aircraft accident near Whitney, Ontario

Richmond Hill, Ontario, 15 March 2016 – In its investigation report (A14O0217) released today, the Transportation Safety Board of Canada (TSB) determined that a faulty navigation receiver and difficulty holding aircraft heading while flying in conditions of limited visual reference, led the pilot of an aircraft to become lost, and eventually collide with terrain near Whitney, Ontario. Both occupants were fatally injured.

On 11 November 2014, at 1803 Eastern Standard Time, a Cessna 150M with two people on board departed from the Ottawa/Rockcliffe Airport under night visual flight rules for a flight to the Toronto Buttonville Municipal Airport. At 2025, the pilot transmitted a mayday indicating that he was lost and that the aircraft was low on fuel. The aircraft was below radar coverage, and air traffic control (ATC) attempted to assist the aircraft in locating a suitable aerodrome. At 2127, the pilot made a final radio transmission, and the aircraft crashed shortly thereafter.

The investigation determined that the aircraft was being operated in darkness, below a layer of clouds with limited visual reference, and over an area with few ground lights. The pilot was navigating by relying solely on aircraft heading and the information provided by an onboard navigation instrument (VHF omnidirectional range (VOR) receiver). A component within the receiver had deteriorated and was overheating, causing it to periodically display incorrect information. The pilot relayed this incorrect location information to ATC, rendering ATC assistance ineffective. Further, because the pilot was uncertain of the amount of fuel remaining in the aircraft, ATC attempted to route the aircraft to the perceived nearest airport with runway lighting rather than to one slightly more distant in a better lit, more populated area.

Shortly before the accident, the pilot entered a shallow descent, possibly in an effort to maintain visual flight in deteriorating weather, and as a result, the aircraft struck a heavily treed area.


The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca

[PilotDAR]

Thanks TSB Tasker, your active participation here is really appreciated!

[Rookie50]

Thanks TSB Tasker, your active participation here is really appreciated!

+ 1. As a GA pilot, I can add I read many many accident reports, especially from my home area. I attempt to learn from them.

[pelmet]

There is no doubt that based on the limited experience of the pilot, this was a challenging situation that could have misled many a pilot. The decision to take full fuel was a good one. The plan to use a VOR was also a good one. Whether or not he was using a VFR chart properly is unknown but that could have saved the day. I always bring a VFR chart with me and draw a line for the planned cross country route along with a quick writedown of planned heading. By comparing the VOR radial(or GPS track if that is what you are using) with the visual picture, you can confirm that you are actually on course. There are towns to use as a reference on the initial portion of the route for the accident flight.

Based on the approximately 30 degree track divergence from the planned route, a close comparison to the VFR chart may have saved the day and made the pilot aware that something was amiss. If the heading indicator was properly set, it would have indicated a heading significantly different than planned, if they had a planned heading. There was certainly a planned track based on VOR radial to be used. Flight following would only have been available for the initial portion of the route but aside from providing traffic information, a controller may have questioned the pilots actual route of flight.

It would have been helpful if the report had discussed what pre-flight or in-flight planning material was found in the wreckage as it would help us determine if the pilot decided to rely 100% on VOR navigation. The report doesn't mention anything about pre-flight planning and in-flight chart usage the traditional way we were taught in flight school but this accident is an example of how such a thing can provide a backup to identify a faulty instrument, along with noting that the heading doesn't seem to be close to the desired track.

In reality, it probably wouldn't have taken too much longer to take the more southerly route and have airports and well lit areas nearby to the south as the published radar pictures show a line of precip and a cold front approaching at 25 knots which is what they ended up encountering over more northerly dark terrain area. If it were a high time pilot flying with appropriate experience, I could see going the direct route based on calculated risk but for a low timer, he was in over his head very quickly.

That is where judgement becomes crucial for all pilots. Understanding our inexperience and acting accordingly. And even though we may become high timers, upon trying a new challenge, for example, deciding to get into float flying, you suddenly become a low-timer again and need to consider yourself, at least in some aspects of the operation, as a newbie again.

[raff]

One aspect of the TSB report has me wondering a little. It says that Island Air has never had its program approved under certain ontario legislation. I did my ppl training there at the turn of the century and I recall all sorts of commercial training going on. What gives? Is this some grey area tug of war between fed and prov jurisdiction.

Also, does the 3 attempts at commercial written and 2 attempts at flight exam suggest anything. I am not trying to be a jerk or to denigrate anyone, but I am interested in the extent to which a pilot might find themselves having that much difficulty on the commercial with a letter of recommendation in their hands.

For the record I was pretty happy with my training at Island Air.

On a more personal note, i don't hold a night rating but flown at night lots with PIC's who hold the rating. In southern ontario on a clear and well lit night, night flying does not look to difficult. Its not hard to imagine getting overconfident.

One lesson from all of this is to have a second navigational source (other than your eyes and a map) so you have a backup and so you can detect a problem. There is no reason to be flying anymore without a handheld gps as a backup in an emergency.

[Rookie50]

One aspect of the TSB report has me wondering a little. It says that Island Air has never had its program approved under certain ontario legislation. I did my ppl training there at the turn of the century and I recall all sorts of commercial training going on. What gives? Is this some grey area tug of war between fed and prov jurisdiction.

Also, does the 3 attempts at commercial written and 2 attempts at flight exam suggest anything. I am not trying to be a jerk or to denigrate anyone, but I am interested in the extent to which a pilot might find themselves having that much difficulty on the commercial with a letter of recommendation in their hands.

.

I'm curious about something. What is Island Airs responsibility is all of this -- if I may ask. I'm confused from the report, for starters, if the CPL training they were giving this pilot was actually legal in Ontario.

Second point, of course, is this flight being the CPL X - country, where does instructor supervision of this flight come into play --- with a extremely low time and inexperienced at night pilot, a route he had never flown, who had struggled with VOR navigation, with a plane equipped with a single VOR and weather moving in? No flight plan even filed?

He "had a chat about the flight with a flight instructor friend". What about the person who did his CPL recommend?

Seems like supervison really broke down here.

FWIW,
if I was flying that plane as equipped, at night, at my current experience today, I'd be following the 401. Not even sure I'd want to fly it at night at all.

[photofly]

This wasn't a training flight and he wasn't under the supervision of a flight instructor. He hired an aircraft not from Island Air but from an aircraft rental company called Flyblocktime. Presumably he could have hired from Island Air, but he chose not to - I'm going to guess because Flyblocktime is significantly cheaper: their PA28 is only $78/hr dry, in blocks of 10 hours. Island Air charges $150/hr wet, for the smaller C150.

The pilot had passed his CPL flight test on 26 March 2014. We don't know if he had any further flight training after that date but I'm going to guess not. I don't know for sure, but if the "flight instructor friend" had any connection to Island Air I suspect the report would have mentioned it. And I don't believe Island Air offers training (or supervision) for flights in aircraft rented from third parties. Again, the report would have mentioned it.

The accident occurred on 11 November 2014. It's hard to make a case that 'supervision really broke down here" more than seven months after a pilot leaves a flight school.

[Rookie50]

This wasn't a training flight and he wasn't under the supervision of a flight instructor. He hired an aircraft not from Island Air but from an aircraft rental company called Flyblocktime. Presumably he could have hired from Island Air, but he chose not to - I'm going to guess because Flyblocktime is significantly cheaper: their PA28 is only $78/hr dry, in blocks of 10 hours. Island Air charges $150/hr wet, for the smaller C150.

The pilot had passed his CPL flight test on 26 March 2014. We don't know if he had any further flight training after that date but I'm going to guess not. If the "flight instructor friend" had any connection to Island Air I suspect the report would have mentioned it. And I don't believe Island Air offers training (or supervision) for flights in aircraft rented from third parties. Again, the report would have mentioned it.

The accident occurred on 11 November 2014. It's hard to make a case that 'supervision really broke down here" more than seven months after a pilot leaves a flight school.

Fair points -- I missed the 7 month lapse. I suppose pilots cannot be forced to seek guidance, either, FWIW. While no one in particular may be "at fault" it's hard not to conclude needed supervision was missing.

I have 2 questions in response.

A) the 300 NM XC is a required element to complete the CPL. Therefore what does the Cars say, if anything, about the requirement for supervision until all requirements are met? (Perhaps not necessarily by Island air as that relationship was discontinued by the pilot) Is not the XC a required "training flight?"

Beyond that -- what is common practice for supervision of the CC? (If after the flight test was passed)

B) If Island Air was not authorized to offer CPL flight training in Ontario, does that invalidate the progress the pilot has made so far (including the flight test). Moreover, if the training was not legal, why would a flight test even be administered? (Unrelated to the accident per SE)

[photofly]

A) the 300 NM XC is a required element to complete the CPL. Therefore what does the Cars say, if anything, about the requirement for supervision until all requirements are met?[

No supervision is required "until requirements are met". The pilot has a PPL and can use the privileges of a PPL until he gains a higher licence.

CAR421.30 lists the requirements for a 300nm XC under (a)(ii)(B)(I) which is part of the "commercial pilot flight training in aeroplanes ... solo flight time" so yes, it's still training, and strictly should be under supervision. However this is not strictly enforced. For my CPL I simply picked one of a selection of many trips >300nm that I'd flown. Moreover, if a pilot wants to fly a 300nm cross-country without the supervision of an instructor - even if they were later to find it won't be counted by TC towards the licensing requirements - there's still nothing to stop him or her making that flight of their own accord. And it would still count towards the 20 hours cross-country PIC time requirement, that isn't listed under "instruction flight time."

Beyond that -- what is common practice for supervision of the CC? (If after the flight test was passed)

I don't know what common practice is. I would guess that if a student is doing the CC in a flight school aircraft and announces his or her intention to make the qualifying flight, their instructor would supervise the planning, to a greater or lesser extent. this kind of cross country should be within the capabilities of a PPL with a night rating.

B) If Island Air was not authorized to offer CPL flight training in Ontario, does that invalidate the progress the pilot has made so far (including the flight test).

No.

Moreover, if the training was not legal, why would a flight test even be administered? (Unrelated to the accident per SE)

In 2007 (I think) the Ontario Government did a land-grab over vocational training and imposed a registration regime for anyone offering vocational training for money (the Private Career Colleges Act.) However flight training standards are federally regulated so the provincial government can't dictate anything to TC and they don't have the authority to declare any training which meets the federal standards (as set by TC) as invalid. They can issue fines to the flight school for not jumping through the right provincial hoops and paying the stiff levy they require, but the trainee pilot isn't at fault - the provincial legislation is intended to protect the student and not penalize them.

As far as the flight test goes: as a designate of the Minister (and therefore a federal representative) it's not the Pilot Examiner's job to check the circumstances of the training in respect of provincial legislation.

I was actually surprised to see this element included in the report. It's hard to see how it's relevant to the accident.

I think if you're going to try to shine a light on the training in this particular instance I'd be looking at the night flying and night training the pilot had done rather than the CPL training. But that would have been some time even earlier.

[Rookie50]

Yep, night...is different for sure. Haze and no ground lights = can be practically IMC.

West of Ottawa navigating by DR / map reading would be a challenge.

No flight plan, no Flight following....sad outcome.

[pelmet]

Yep, night...is different for sure. Haze and no ground lights = can be practically IMC.

West of Ottawa navigating by DR / map reading would be a challenge.

No flight plan, no Flight following....sad outcome.

It can be done. I have flown the same route(in the opposite direction) using only the map at night. The gear warning horn would not stop when it was selected up and I didn't feel like leaving it down, so I just shut off all electrics. Fortunately, I was able to jam a flashlight between the sun visors so I could read the map and fly. I was surprised to discover(on a nice night at 3,500') that the antennas as shown on the map and the north/south roads and the occasional town made for an easier than expected experience.

The flight conditions and the VOR issue among other things made the accident flight more challenging for sure, but it can be done. Assuming I had confidence in the aircraft, I may have done the direct thing that night as well but you need back up plans.

[cncpc]

Yep, night...is different for sure. Haze and no ground lights = can be practically IMC.

West of Ottawa navigating by DR / map reading would be a challenge.

No flight plan, no Flight following....sad outcome.

It can be done. I have flown the same route(in the opposite direction) using only the map at night. The gear warning horn would not stop when it was selected up and I didn't feel like leaving it down, so I just shut off all electrics. Fortunately, I was able to jam a flashlight between the sun visors so I could read the map and fly. I was surprised to discover(on a nice night at 3,500') that the antennas as shown on the map and the north/south roads and the occasional town made for an easier than expected experience.

The flight conditions and the VOR issue among other things made the accident flight more challenging for sure, but it can be done. Assuming I had confidence in the aircraft, I may have done the direct thing that night as well but you need back up plans.

Really? Is this loosely based on a partially true story?