Transportation Safety Board Releases Investigation Findings Almost Four Years After Fond-du-Lac Crash

The Transportation Safety Board has released its investigation report of a West Wind Aviation plane that crashed almost four years ago.

It was December 13th, 2017 that the aircraft crashed shortly after take off at the Fond-du-Lac Airport in northern Saskatchewan where 22 passengers and three crew members on board were injured, ten of them seriously and one 19-year old man, Arson Fern Jr., later died in hospital from his injuries.

In its report, the TSB determined that the lack of adequate de-icing equipment and the practice of taking off without de-icing led to the fatal accident.

The plane was flying to Stony Rapids when shortly after takeoff the aircraft collided with trees and terrain about 450 metres west of the runway. The aircraft was destroyed.

The TSB had issued two recommendations after the crash and now says that while Transport Canada agrees with the recommendations and some steps have been taken, more action is needed. Chair of the Transportation Safety Board, Kathy Fox, says, “Companies need to make more and better de-icing and anti-icing equipment available. TC must also increase the frequency of its targeted inspections. Until the TSB’s recommendations are fully implemented, what happened to this flight could still happen to other flights operating in Canada’s remote and northern airports.”

The TSB also indicated that adapting to ice contamination on the aircraft had become normalized. The past success of departing from remote airports like Fond-du-Lace with ice had become common practice due, partly, to the inadequacy of de-icing equipment or services at these locations. This, the TSB says, influenced the flight crew’s decision to take off.

As well, the crash highlighted lack of survivable space between the floor above the main landing gear and the collapsed upper fuselage which led to severe injuries to passengers seated in that area. The design standards in effect at the time the plane was certified was not designed with certain crashworthiness principles in mind like: minimum loads the structure must be able to tolerate to allow a survivable space; or minimum loads for fuselage impact energy absorption.

The TSB investigation also says that if the application of Transport Canada’s surveillance policies and procedures is inconsistent, and the report says it was in relation to West Wind Aviation, there is a risk that resulting oversight will not ensure that operators are able to effectively manage the safety of their operations.

TSB says West Wind has taken steps to improve its internal risk assessments, and now provides additional training, guidance, and better de-icing equipment to its crews.

From the report:

The investigation found that, well before the accident, during the descent toward Fond-du-Lac, the aircraft encountered icing conditions. The flight crew activated both the anti-icing and de-icing systems, but some ice remained on the aircraft. However, the crew did not notice any handling abnormalities and landed without incident. During the 45 minutes on the ground prior to the accident icing additional ice formed on the aircraft. After carrying out a pre-flight inspection, the first officer notified the captain of the presence of some ice on critical surfaces, but there was no further discussion or action taken. Because the available inspection equipment was inadequate, the first officer’s ice inspection consisted of walking around the aircraft, at night, on a dimly lit apron, without a flashlight, and looking at the left wing from the top of the stairs at the left rear entry door. As a result, the full extent of the icing situation was unknown to the flight crew

The Transportation Safety Board’s two initial recommendations included making sure adequate de-icing and anti-icing equipment is available for those operators who need it (A18-02). The second urged Transport Canada (TC) to take action to improve compliance with the regulations to reduce the likelihood that crews take off with snow or ice contamination (A18-03).

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