I note that no one had mentioned that the TSB stated fatigue and stress were a factor, the fatigue seems to be from lack of sleep, but what were the stress facors involved?
Cat
I think this report is very well done. This pilot made some poor decisions that he would not normally do. The TSB highlighted some of the stress factors involved. Were they overwhelming to this pilot....it appears so in this case. I think we all have gotten “tunnel vision” at times and the key is to recognize that, take a step back and look at the big picture. Of course fatigue makes it harder to recognize poor judgment.
From the information available, there is no indication that the accident pilot was a risk taker or that his decision making was negatively influenced by routine job stresses. A review of the records of his previous flights into Pelee Island show that it was not his practice to fly the aircraft in an overweight condition.
The pilot made a number of decisions that increased the risk to the safe operation of flight. He uploaded 1000 pounds of fuel before leaving Windsor when there was already ample fuel on board to complete the flights to and from Pelee Island, including alternate fuel. Although he normally uploaded more fuel than required as a precautionary measure after considering the passenger load for the return trip, in this instance, it exacerbated the eventual overweight condition of the accident flight. For the flight from Pelee Island to Windsor, he chose an alternate airport that did not satisfy the POH warning not to fly into an airport where freezing rain or drizzle conditions exist. There is no indication that he informed ATC of his change of alternate from Sarnia to Detroit. The pilot attempted the flight although he was aware of the ice contamination on the aircraft. All of the above decisions were inconsistent with the pilot's normal approach to flight safety.
While it could not be established with certainty that the pilot was fatigued, given his past performance, it is likely that a combination of fatigue and stress reduced his working memory and narrowed his attention. Specifically, the scheduled short turnaround time, the large passenger load, the adverse weather conditions, the lack of de-icing equipment, and the need to complete the flight may have acted as stressors.
For the accident flight, there are indications that the pilot's assessment of risk was likely degraded by some combination of stress and fatigue. The known effects of fatigue on risk assessment could account for his assessment that the flight risk was low or for his tolerance of increased risk to complete the short flight.
The pilot's decision to fly overweight and without addressing the wing contamination pointed out by two individuals are other indications of his degraded assessment of risk. Retracting the flaps after take-off, contrary to the POH cautions not to raise the flaps when encountering icing conditions, is a further indication of his degraded performance.
Consistent with the known effects of fatigue-related perseveration, there is no indication that the pilot considered changing his original plan to complete the flight in spite of a heavier-than-normal passenger load and a direct report of contamination on the wing. He appeared to have narrowed his attention solely to completing the planned flight, regardless of several factors that indicated that the flight should not be completed.
Just so we're clear, I was not defending the system. I was just offering my opinion on how it works.
Regarding insurance, every insurance policy has liability limits. If you are insured for $10 million and are levied with a $20 million judgment, you are on the hook for the balance. And yes your premiums will go up, if you can get coverage at all.
Did the pilot in this case f$%k up? Yes, and he should shoulder the majority of the blame for this very avoidable accident. I do believe that the company needs to accept some responsibility for this as well though. There had to be a reason why he didn't cancel this flight. Was this pilot getting pressure from some 200 hour wannabe working in dispatch? Is it possible that company culture promoted a cavalier attitude toward weather and the limitations of the aircraft? Is it reasonable to say that the pilot should never have been placed in this position to begin with? What would the response have been from the company if he had successfully completed this flight?
I personally think that we shouldn't pass judgement based on elements we'll never know about. What I mean by that is the pilot sounded like a inteligent person and we don't know exactly what his thinking process was at the time and had it of been any one of us in the same conditions thinking the same thoughts would we have handled it any differently than he did?
Were mistakes made..most certainly, have we learned anything from this..I hope so.....
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Putting money into aviation is like wiping before you poop....it just don't make sense!
I don't get it. The point you seem to be upset about is responsibility. We must all take responsibility for our actions. That doesn't mean that we need to be prepared to say "sorry" whenever our actions cause harm.
This isn't some grand decay of society. It's been the case for eons. If you steal something, you must make reparations. If you injure or kill someone, same.
Of course there are extremes like the litigation-fest we see in the US but they recognize the problem and the introduction of tort reform is slowly but surely addressing that. But I don't think we're talking about a frivolous lawsuit here.
I'm having a hard time believing that if it was your family member on that airplane you would walk away from litigation.
We have to get away from using TSB's catch-all terms, like fatigue and stress being factors! This guy got into an ice covered airplane, in freezing rain, more than half a TON overweight, after having some of these facts brought to his attention, actually tried to fly the bloody thing!! Is anybody listening? There are NO factors...it is totally his fault! He was tired? Boohoo! He was under stress? Boohoo! Keep tossing out the excuses...they're all total bull shit!!!!
I don't think anyone is disputing that the pilot was at fault, Doc. It's blatantly obvious that he made several mistakes. Contributing factors are looked at in every accident and incident in order to see why mistakes are made, not to excuse mistakes. Or do you think that he would have made the same decision regardless of whether he was tired or under stress? The records of his previous flights would seem to say he wouldn't.
I'd like to know how the pax could see ice on top of the wing? They must have been giants.
I also believe I read that the aircraft was overweight for "icing" conditions. Does the Caravan have a lower takeoff weight for flight into ice? If it does have a weight restriction was it still overweight for normal conditions?
grimey....My point was (at least my meaning was) there are mistakes made due to fatigue, stress, whatever. But are you going to look down the barrel of a loaded gun because you are tired? My point is, there are little mistakes.....but this? In a case like this, pointing to contributing factors, to me at least, makes no sence...unles somebody is pissed drunk, or has just suffered a severe brain injury etc.
whipline.....there would have been ice all over the plane....not just the wings..Oh, and there is a reduced wieght fo a Caravan to depart in frezzing rain....it's called go to the bar and have a beer!
Most accidents have more than one cause...ie. break one link in the chain, and you'll bend the bird. The Keystone accident was caused by a chain of events....several chances to buy fuel.....high approach, etc. But this Caravan crash had no "chain". He just threw the saddle on a horse with no legs...and the rest is history.
Wayne was without a doubt one of the most cautious pilots I have every worked with. I have on numerous occasions watched him turn down flights due to weight, weather or any other condition he felt was unsafe.
I find it hard to believe that he could be forced to fly by any company. He never was before, and believe me the pressure was on with our previous employer!
Regardless. It would appear he made some very poor decisions that cost him, his passengers and his fiance their lives. Hopefully someone learns from the accident and can make better decisions.
R.I.P. Wayne. I too hope you are in a better place!
Oh, and as a passenger. If I felt the flight was unsafe I would walk away in a heartbeat!
It looks like it is related to this TATC decision (although it appears that the text of the final decision made on July 5th, 2007 is not on the site yet due to translation delays...)
The right of applicant to be tried within a reasonable amount of time
The delay period in this case can be broken down as follows:
The accident of January 17, 2004;
The investigation starting in January 2004, including the visit of Mr. McEvoy to the premises of Georgian Express of February 2004;
The issuance of the letter of allegation of September 14, 2004;
The continuation of the investigation;
The Notice of Assessment of Monetary Penalty of January 11, 2005;
The scheduling of the Hearing including the motions dealing with preliminary matters in August and September, 2005; and
The present Hearing of October 24, 2005.
This amounts to a total period of 21 months.
I agree with counsel for applicant that none of the delays can be attributed in any way to the fault of the applicant. For example, applicant’s counsel from the very start indicated to the Registrar of the Tribunal that he wished for an expeditious hearing in this matter.
But after the hearings ...
Heard: October 24-27, 2005, February 7-10 and March 13-14, 2006, Toronto, Ontario
Decision: July 5, 2007
It took another year and a half to decide?
I also noticed the fine was considerably reduced ...
Total Monetary Penalty Assessed: Total: $ 53,750.00 (Canadian Funds)”
Just throwing this out there, and if it has already been mentioned I apologize, I didnt read the entire thread.
These guys and there dogs were flying home from a hunting trip, right? To me, this would mean that they flew in as well. They obviously made it in, despite being so overweight...maybe this was also a factor in the pilots descision to make the pick-up? I don't know the pilot or what pressures he was under...but isn't it possible he had seen that the plane could do it...and then the ice was the little extra that put it over the edge? Don't get me wrong, I am not saying it was ok, just speculating.
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The only three things a wingman should ever say: 1. "Two's up" 2. "You're on fire" 3. "I'll take the fat one"
