Dear TSB...Please do your job

[pelmet]

Occurrence No.: A17C0028 Occurrence Type: ACCIDENT
Class: CLASS 5 Reportable Type:
Date: 2017-03-17 Time: 12:20:00 CDT
Region of Responsibility: CENTRAL
Location: 0.70 Nautical miles W From CYPL - PICKLE LAKE
Country: CANADA Province: ONTARIO
Ground Injuries: Fatal: 0 Minor: 0
Serious: 0 Unknown: 0
---------- Aircraft 1 ----------
Registration: C-FKGL Operator: NORTH STAR AIR LTD.
Manufacturer: DOUGLAS Operator Type: COMMERCIAL
Model: DC-3C CARS Sub Part: 704 - COMMUTER
Injuries: Fatal: 0 Minor: 0
Serious: 0 None: 3
Unknown: 0

Dear TSB(and Kathy Fox),

A DC-3 crashed on takeoff recently from Pickle Lake. This is a significant event for a very large aircraft. I see that this accident has been classed as a Class 5 investigation meaning that there will never be a final report(as compared to a class 3 investigation).

Could you please do an investigation into this so that pilots in Canada and around the world can find out what the likely cause was for this accident. Instead, we will never find out what the likely cause is. This reminds me of the two DC-4's that crashed several years back in the NWT where the TSB could not be bothered to do an investigation.

In the US where there seems to be a much more robust accident investigation process where most significant small accidents have a report with a probable cause instead of a brief statement that we see in this case that leaves readers with no way to learn about what happened.

On this very forum there has been a thread about this accident which has discussed the flight characteristics of the DC-3 and its sensitivity to contaminated wings which some pilots may not be aware of. While this may have nothing to do with this particular accident, it is an issue that is worth pursuing as this type of aircraft is still flying in several locations in Canada.

In an era of big government spending where like-minded governments of Canada and Ontario have increased spending significantly for programs such as Ontario's recent announcement to spend 100 million dollars to give money to people for no reason other than to give them money regardless of whether they are working or not, I ask you to please stop this policy of not investigating accidents in order to save money and demand the appropriate funding to properly investigate accidents.

Otherwise, you risk deaths and damage by continuing this pursuit of non-investigation due under the guise of nothing to be learned.

A Canadian taxpayer.

[AirFrame]

I suspect the issue is much less that the TSB "decided" not to investigate, than the TSB didn't have the resources to investigate.

Talk Ottawa into giving the TSB more money, and they'll be able to afford more staff to do more investigations. Without more money, they have to investigate accidents with the greatest ROI... Where they can learn the most they can about problems with aircraft used in large numbers in the commercial passenger-carrying fleet. Antique aircraft used in small numbers to carry cargo aren't going to give the same return.

[flyboyf28]

Dear Pelmet;

This is my first time on Av Canada!. I avoid this site because of the incalculable amount if un verified information that is posted here.

I will give you some facts about this occurrence that you may not be aware of.

1. The TSB deployed to and did in fact investigate this occurrence.

2. Part of the TSB investigation process is to assess and "classify " information

3. Wind and weather information was scrutinized to a great degree. as were company operational procedures and policies.

4. Analysis of all available and potential information precluded the TSB from making a compelling and conclusive argument as to the cause of this accident.

5. It was for these reasons that TSB personnel did not produce a public report into this investigation.

[Jimmy2]

They probably know what caused it. But the evidence was removed before they got to the aircraft. With no way to prove it there is no point in doing an investigation. Certainly not when they know they are not going to find some other cause. I'd rather they not spend a lot of money to show the aircraft was perfectly serviceable.

[CpnCrunch]

Apparently it was flown off the ice, according to a comment here:

http://avherald.com/h?article=4a679ae2

How you do legally take off VFR in 3/4SM visibility anyway?

[Cat Driver]

Don't be to quick to opine on why it crashed because it may not have been caused by contaminated wings and tail plane not cleaned properly before take off.

They may have been working very long hours and both fell asleep as soon as it was airborne.

The TSB in all their vast knowledge knows this and just assumes we do also.

[phillyfan]

If you have the answers why not apply? The TSB is always looking.

[Illya Kuryakin]

I'm confused (not unusual). Are they now saying it did not come down due to wing contamination? Seemed pretty plausible to me?
Illya

[Axial Flow]

Why worry about what the TSB does. They have no teeth to do anything...Transport who does also doesn't get anything done either...

Essentially do the best you can do, because the government is not here to help you.

tsb.JPG (39.03 KiB) Viewed 5847 times

[pelmet]

The problem is....

Sometimes the recommendations that are made by the TSB are not realistic or are cost-prohibitive.

I give you an example. In Sep 2013, a city bus in Ottawa collided with a train killing several people on the bus which did not stop for the train. This despite the fact that there were not only the standard blinking lights but gates that lower at this crossing when a train is approaching. The bottom line was that the driver of the bus was not paying attention due to talk with a passenger and maybe looking at a video monitor.

http://www.bst-tsb.gc.ca/eng/rapports-r ... 3t0192.asp

To quote from a news article..."“It’s time to take action,” TSB chair Kathy Fox said. “With so many buses, cars and trains along these roads every day, and a population that continues to increase, Transport Canada needs to provide specific, detailed guidance of when roads and railways need to be separated.“Moreover, we want the City of Ottawa to reconsider the need for grade separation of the Woodroffe Avenue, Transitway and Fallowfield Road crossings.” The city considered an underpass when the Transitway extension was built in the early 2000s, but decided against it when the estimated costs came in at more than $100 million."

http://www.bst-tsb.gc.ca/eng/rapports-r ... 3t0192.asp

So the TSB basically made a 100 million dollar recommendation which is probably more like 125 million in today's dollars. Expanded to include the likely case of many more similar situations, this recommendation could cost tens of billions of dollars. All because a driver wasn't paying attention. Lots of accidents happen because people are not paying attention. We could eliminate head-on collisions, which have probably killed thousands of people over the years, by splitting up all highways. But there is a huge cost.

It is easy to make a recommendation without considering the cost or worrying about it, which is what a lot of safety boards do. That is why a lot of recommendations are ignored. For years, the FAA and the NTSB fought over the requirement for seat belts for children under two with the NTSB recommending again and again to require seat belts. To quote from an article linked below....

http://blogs.gonzaga.edu/gulawreview/fi ... ompson.pdf

"the FAA released a study concluding that mandating child restraint systems would force many parents with small children to travel by other means due to the increased cost of an extra plane ticket. Furthermore, the FAA believed that as a result of the increase in nonairline transportation, the death rate in travel would increase by about eighty two additional adult and child deaths a year.Finally, the FAA stated that child safety seats, if mandated, would "only" save the lives of five infants in aviation accidents over the next ten years."

So there can be consequences to making recommendations without looking at the overall result(which I suspect happens at some safety boards).

[Axial Flow]

I agree, except the last recommendation you posted. In regards to car seats for infants, I am sure the Captain of the Metro in Sanni crash would have rather had the baby in a car seat instead of the rudder peddles. It should be mandatory, but also a lot of smaller aircraft would not have the ability to strap a car seat safely in the seats.

Even with action from TC only in the case of IMC while VFR only 25% received consequences...

"Between November 1999 and January 2009, TC's Aviation Enforcement Section initiated 20 actions in the Pacific Region pertaining to contraventions of regulations concerning VFR Minimum Visual Meteorological Conditions.15 Of these, no punitive actions resulted."

[pelmet]

I agree, except the last recommendation you posted. In regards to car seats for infants, I am sure the Captain of the Metro in Sanni crash would have rather had the baby in a car seat instead of the rudder peddles. It should be mandatory, but also a lot of smaller aircraft would not have the ability to strap a car seat safely in the seats.

What the captain of a crash in Saniqiluaq may want does not change the results of the FAA study.

Little picture versus big picture.

[swordfish]

Apparently it was flown off the ice, according to a comment here:

http://avherald.com/h?article=4a679ae2

How you do legally take off VFR in 3/4SM visibility anyway?

They must have been "clear of cloud, and had 1 mile visibility" from where they were...

[swordfish]

Don't be to quick to opine on why it crashed because it may not have been caused by contaminated wings and tail plane not cleaned properly before take off.

They may have been working very long hours and both fell asleep as soon as it was airborne.

The TSB in all their vast knowledge knows this and just assumes we do also.

They've obviously missed this subtlety in the new NPA on flight and duty time regulations:

"No sleeping during take-off".

They've prescribed just about everything else you could possibly think of, don't know how they missed that one.

[swordfish]

Why worry about what the TSB does. They have no teeth to do anything...Transport who does also doesn't get anything done either...

Don't you believe it. They're introducing a new rule in the Seaplane Regulations that requires everyone (yes, crew included) to wear life jackets (PFDs) so that when some idiot driving a standard Beaver lands downwind/crosswind with the wind gusting to 18 kts and whitecaps, and then inexplicably flips over, everyone on board will be able to survive the 6° water and float to the surface, where they can be rescued.

Oh yes...TC is definitely getting proactive in saving lives.

[confusedalot]

so maybe everyone in any aircraft should be constantly wearing life vests when over water in case something happens?

looks good in a meeting room, far away from reality. tc considers this as standard procedure. then they go to lunch. case closed.

[Heliian]

so maybe everyone in any aircraft should be constantly wearing life vests when over water in case something happens?

No, only people on seaplanes that are landing and taking off from water. It's really a no-brainer, life-jackets save lives. Question it if you will, but the studies have shown them to be beneficial. Just another part of the job now really, so stop your whining.

[Redneck_pilot86]

Where does it say they were VFR?

Apparently it was flown off the ice, according to a comment here:

http://avherald.com/h?article=4a679ae2

How you do legally take off VFR in 3/4SM visibility anyway?

They must have been "clear of cloud, and had 1 mile visibility" from where they were...

[confusedalot]

so maybe everyone in any aircraft should be constantly wearing life vests when over water in case something happens?

No, only people on seaplanes that are landing and taking off from water. It's really a no-brainer, life-jackets save lives. Question it if you will, but the studies have shown them to be beneficial. Just another part of the job now really, so stop your whining.

Are you british? tc?

[CpnCrunch]

Where does it say they were VFR?

It says VFR the CADORS, and I don't see any flight plan in flightaware either. Of course that's not definitive.

[goingnowherefast]

Pickle Lake is uncontrolled airspace and so is most of NW Ontario. There is no practical difference between IFR and VFR. I suspect when they wrote VFR in that box just because they had to write something.

[pdw]

Dear TSB(and Kathy Fox),

A DC-3 crashed on takeoff recently from Pickle Lake. This is a significant event for a very large aircraft. I see that this accident has been classed as a Class 5 investigation meaning that there will never be a final report(as compared to a class 3 investigation).

Could you please do an investigation into this so that pilots in Canada and around the world can find out what the likely cause was for this accident. Instead, we will never find out what the likely cause is. This reminds me of the two DC-4's that crashed several years back in the NWT where the TSB could not be bothered to do an investigation.

In the US where there seems to be a much more robust accident investigation process where most significant small accidents have a report with a probable cause instead of a brief statement that we see in this case that leaves readers with no way to learn about what happened.

On this very forum there has been a thread about this accident which has discussed the flight characteristics of the DC-3 and its sensitivity to contaminated wings which some pilots may not be aware of. While this may have nothing to do with this particular accident, it is an issue that is worth pursuing as this type of aircraft is still flying in several locations in Canada.

In an era of big government spending where like-minded governments of Canada and Ontario have increased spending significantly for programs such as Ontario's recent announcement to spend 100 million dollars to give money to people for no reason other than to give them money regardless of whether they are working or not, I ask you to please stop this policy of not investigating accidents in order to save money and demand the appropriate funding to properly investigate accidents.

Otherwise, you risk deaths and damage by continuing this pursuit of non-investigation due under the guise of nothing to be learned.

A Canadian taxpayer.

Did you s e n d them a/this letter as well or just post it here ?

I found that it's often true, that accidents sometimes get more attention to get investigated when a lot of people demand it due to the losses of life, .... ie so maybe just the way it is ? And if the reason for why it crashed is known by those in the know, maybe no reason left to produce big expenditures on the topic for the Canadian Taxpayer.

[black hole]

Its Because its being looked after through an internal SMS investigation

BH

[Jean-Pierre]

HAHAHAHA​

[Black_Tusk]

Where does it say they were VFR?

It says VFR the CADORS, and I don't see any flight plan in flightaware either. Of course that's not definitive.

Isn't YPL uncontrolled? Flight plan not necessary to fly IFR. Been a while since I've been up there and can't remember.