In its investigation report (A15C0163) released today, the Transportation Safety Board of Canada (TSB) found that ice accumulation and the company practice to operate in icing conditions led to the December 2015 crash of a cargo plane near Pickle Lake, Ontario.
At 0900 on 11 December 2015, a Cessna 208B Caravan, operating as Wasaya Airways Limited flight 127, left Pickle Lake Airport, Ontario, for Angling Lake / Wapekeka Airport, Ontario, with the pilot and a load of cargo on board. Less than 10 minutes into the flight, the aircraft began descending, made a sharp right turn, climbed again before starting another descent, then collided with trees and terrain at an elevation of 1460 feet above sea level. The pilot was fatally injured, and the aircraft was destroyed. No signal was received from the emergency locator transmitter (ELT), which was damaged during the crash, and there were no flight recording devices aboard.
The investigation established that the aircraft performance was consistent with operation in icing conditions that exceeded the capabilities of the aircraft. The high takeoff weight also exacerbated the problem. As the aircraft continued its flight in icing conditions, rather than returning to base, it experienced substantially degraded aircraft performance as a result of ice accumulation, which led to an aerodynamic stall, loss of control, and collision with terrain.
The investigation also determined that company practices did not ensure that operational risks were assessed and managed appropriately. Flying into forecast icing conditions was a company norm although four of the five Cessna 208B aircraft were prohibited from operating in these conditions. At the time of the accident, the operator had not implemented all of the mitigation strategies from its January 2015 risk assessment of Cessna 208B operations in known or forecast icing and remained exposed to some unmitigated hazards that had been identified in the risk assessment. Consequently, pilots lacked important information and tools for sound decision-making and for safe, efficient operations.
The presence of flight recording devices can help identify safety deficiencies, which is why the Board previously recommended (Recommendation A13-01) that Transport Canada work with industry to remove obstacles to the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry them. The Board also issued four other recommendations in 2016 (Recommendations A16-02, A16-03, A16-04 and A16-05) to address deficiencies in ELT design standards which may delay search and rescue operations after an accident. International collaboration is now underway to improve ELT specifications.
Following the accident, Wasaya conducted two safety management system investigations. As a result, the company increased minimum weather requirements for visual flight rules flights and improved operational flight plan procedures. It also increased the time allocated for technical training on the Cessna, tested a reporting system for icing encounters, and revised the maintenance schedule for the application of anti-icing treatments.
Wasaya Airways received and acknowledged the findings of the Canadian Transportation Safety Board (TSB) related to the loss of Wasaya flight 127 on December 15, 2015.
“First and most importantly, we recognize and respect the privacy of the family of Captain Nick Little. Our thoughts and prayers continue to be with the family as they grieve their loss,” said Michael Rodyniuk, President and Chief Executive Officer of Wasaya Airways.
“Aviation is inherently dangerous and in Wasaya’s operating environment, safety must be the priority, always. At Wasaya Airways, Safety is the company’s priority. The loss of Captain Little and flight 127 on December 15th, 2015 cannot be undone; however, we can learn from the event and take every precaution to make certain it never happens again”, the airline said in a statement.
“Toward that end, Wasaya has enhanced and implemented safety procedures based on the TSB findings. Changes to Wasaya’s flight operations department, aircraft loading and maintenance procedures have been made. Minimum conditions for Wasaya flights operating in Visual Flight Rules (VFR) conditions have been increased well beyond the minimum required under Canadian Aviation Regulations (CARs). Enhanced cold weather and icing training for Wasaya Flight Crews has been implemented. Wasaya continues to advocate for safer operating conditions in the north and is working with Transport Canada to bring about positive improvements to navigation aids and infrastructure”.
“The steps we are and have taken will enhance the safety of our operation and throughout our region,” Rodyniuk said. “We thank the TSB for their diligent work. We cannot bring Captain Little back; however, the learnings from the loss of Wasaya 127 will enhance aviation safety.”