Lack of visual references attributed to Grand Manan accident: TSB

February 16, 2016 | Dartmouth, N.S.
Written by Transporation Safety Board of Canada
In its investigation report (A14A0067) released on Friday, the Transportation Safety Board of Canada (TSB) found that a lack of visual references and low visibility due to weather led to a collision with terrain involving a Piper PA-31 in Grand Manan, New Brunswick. The captain and a paramedic, who was not wearing a seatbelt, sustained fatal injuries. The other pilot and second passenger sustained serious injuries.
On the early morning of 16 August 2014, during the hours of darkness, a Piper PA-31 aircraft operated by Atlantic Charters was returning to Grand Manan from Saint John New Brunswick following a medevac flight. There were two pilots, a paramedic and a nurse on board. While attempting to land a second time on Runway 24, the aircraft contacted a road approximately 1500 feet from the runway, continued through 100 feet of brush, became briefly airborne and struck the ground approximately 1000 feet from the runway threshold. The aircraft was destroyed.

The investigation determined that the weather at the time of both approaches was likely such that the captain could not see the required visual references to ensure a safe landing. For undetermined reasons, the captain started a steep descent 0.56 nautical miles from the threshold, which went uncorrected until it was too late to recover, and the aircraft struck terrain short of the runway. Approach-and-landing accidents are on the TSB's Watchlist.

The investigation also determined that having only one headset on board prevented a shared situational awareness among the crew. The company did not provide any formal crew resource management (CRM) training, and such training was not required by regulation. However, there is a risk that pilots will be unprepared to avoid or mitigate abnormal situations in flight if CRM training is not provided, as called for in a TSB recommendation A09-02.

Additionally, the investigation found that Transport Canada's (TC) surveillance activities of Atlantic Charters had not identified the discrepancies in the company's operating practices related to  continuing airworthiness. If TC does not adopt a balanced approach that combines thorough inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified. This highlights another issue on the TSB's Watchlist: Safety management and oversight.

The aircraft was not equipped with a flight data recorder or a cockpit voice recorder, nor was it required. However, data recordings from lightweight flight recorder systems, as called for in TSB recommendation A13-01, could have provided useful information to investigators and enhance TSB's ability to identify safety deficiencies.

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