Wings Magazine

Making someone accountable

And that's the way it always goes ... another real life example of the "swiss cheese model" of accident causation.

November 5, 2007  By Drew McCarthy

At the beginning of November 2007, a Calgary-based pilot was found guilty of criminal negligence
causing death, four counts of criminal negligence causing bodily
harm, and dangerous operation of an aircraft.  Read the news report here.

The pilot, 42-tear old Mark Tayfel, was flying a Piper
Navajo owned by Keystone Air when it
crashed on a Winnipeg street in June 2002.  The pilot and six passengers were injured ( one, Chester Jones, died a few weeks later) when both engines cut out due to lack of fuel shortly after missing an attempted landing at YWG.

In a 69-page ruling, Justice Holly Beard concluded that Tayfel had no reasonable excuse for
running out of fuel.

An aviation expert called by the defence said that Tayfel should be
commended, not criminalized, for the crash-landing. The expert told the court that the real blame should rest
with Tayfel's employer, Keystone Air.


The  defence maintained that Tayfel was pressured into flying despite the fact that he'd raised concerns with the chief pilot that the aircraft wasn't equipped with a mandatory auto-pilot. The device likely would have helped Tayfel make a safe landing in
Winnipeg. During cross-examination, Tayfel admitted he didn't push the

The auto-pilot could perhaps have changed the situation, but, had the pilot been diligent about checking the fuel, the accident would almost certainly have been avoided.

Tayfel most obviously made a mistake in judgment that day, but unless he was trying to kill himself, he must have believed that he had enough fuel. Someone else probably believed that flying without the auto pilot would likely be okay (at least this time).

And that's the way it always goes … another real life example of the "swiss cheese model" of accident causation. So many responsible, but in this case, only one made accountable.

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