The Transportation Safety Board found that a workplace subculture that encouraged unnecessary risk-taking at a northern Ontario airline was a key factor in a 2019 crash landing in Sachigo First Nation Lake.
The Transportation Safety Board (TSB) released its report on the accident on Thursday, which found that the risky decisions made by the pilot that day stemmed from a “distorted perception of risk resulting from past experience successful in similar situations” and “the results-oriented subculture of some of North Star Air’s DC3-TP67 pilots.”
In December 2019, the North Star Air Ltd. DC3 aircraft. was on a cargo flight from Red Lake, Ontario to Sachigo Lake First Nation in northwestern Ontario. Despite the conditions and his instrument guided flight training, the pilot attempted to land using what is known as visual flight rules for clear conditions, when he should have relied on his instruments.
As the pilot attempted to land, the aircraft struck the ground approximately 200 meters from the runway, destroying the aircraft. No one was injured in the accident.
“The captain likely experienced attentional narrowing during a high workload visual approach at very low altitude,” the report said.
“This most likely resulted in an involuntary but controlled descent which was not detected until the aircraft collided with terrain.”
North Star Air is an airline based in Thunder Bay, Ontario that largely serves First Nations in northern Ontario.
The survey found that parts of the company’s work culture emphasized getting the job done rather than following regulations and pilots taking unnecessary risks, such as not relying on their instruments in bad weather. The pilot and co-pilot also did not file a flight plan and were not wearing their suspenders, the report said.
Meanwhile, the report also found that the company lacked oversight over its pilots who engaged in risky behavior, with no member of management overseeing the day-to-day operations of DC3 pilots.
“The lack of direct supervision meant that company pilots had considerable latitude when it came to making weather-related operational decisions,” the report said. “Over time, a subculture … developed among some DC3-TP67 pilots that went undetected by the company’s management team.”
Changes made
Following the accident, the company implemented a quality control program, and a Transport Canada follow-up inspection in 2020 found that the airline had indeed resolved its issues, the TSB report said.
North Star Air’s president and chief operating officer responded to the report after it was released on Thursday, saying changes made by the company in the wake of the crash have continued.
“We took immediate action, including procedural and personnel changes within our DC3 operation, it was just a small group of individuals with this operation that we needed to address,” said Jeff Stout, president and chief operating officer of the company.
These procedural changes included the proper filing of documents, such as flight plans, and better adherence to safety procedures.
“The changes we have made have, we believe, had an immediate and profound effect, not only within our DC3 operation, but within our entire company by strengthening our safety culture,” he said. he declares.
In the past two years, Transport Canada audited the company twice, and both came back without finding any issues, Stout said.
“The team has much to be proud of with the changes we’ve made,” he said.
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