Remembering Damien Hancock
The resulting TSB recommendation A01-01,
The Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those operators who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations.
was arguably the most important in the history of air taxi accident investigations in Canada. Although the TSB has assessed the Transport Canada response as "Fully Satisfactory", there is no evidence that such a review was actually conducted.
Investigators finish work at crash site
Last Updated: Wednesday, March 31, 1999 | 6:50 AM ET
CBC News
Investigators with the Transportation Safety Board have finished studying the wreckage of an airplane that crashed on Davis Inlet's frozen harbour almost two weeks ago.
The crash of the Inter-Provincial Airways Twin Otter killed the co-pilot. The pilot is still in hospital.
Witnesses told investigators visibility at the time of the crash was limited by blowing snow. But Al Coomber of the Transportation Safety Board says it's not clear what role the weather played in the accident.
He has confirmed that the emergency locator transmitter didn't work when the plane crashed. The impact broke the transmitter case and separated it from the batteries. Coomber says that's likely the reason the equipment failed.
A preliminary report on the crash is due in three months.
TSB Report A99A0036
3.0 Conclusions
3.1 Findings as to Causes and Contributing Factors
- The captain decided to descend below the minimum descent altitude (MDA) without the required visual references.
- After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice.
3.2 Findings as to Risk
- The flight crew did not follow company standard operating procedures.
- Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present.
- Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight.
- The cargo was not adequately secured before departure, which increased the risk of injury to the crew.
- The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight.
- There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities.
- The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation.
- Records establish that the aircraft departed approximately 500 pounds overweight.
3.3 Other Findings
- The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training.
- During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions.
- There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches.
- It was determined that an ice-contaminated tailplane stall did not occur.
- The fuel weight was not properly recorded in the journey logbook.
- The wreckage pattern was consistent with a controlled, shallow descent.
- The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable.
4.0 Safety Action
4.1 Action Taken
After the accident, Transport Canada (TC) conducted a regulatory audit of the operator and increased the frequency of in-flight checks and general inspection of the Goose Bay operation.
4.2 Action Required
Regulatory Safety Oversight
This occurrence investigation uncovered several serious deficiencies in the conduct of the mission. These deficiencies could be symptomatic of a broader and ongoing disregard for regulations and company standard operating procedures (SOPs). Indicators of the deficiencies are as follows: the presence of poor company loading practices at Goose Bay; inadequate company supervision of the Goose Bay operation; non-adherence to aircraft SOPs; and deliberate operation of the aircraft below the minimum descent altitude (MDA) when adequate visual references for landing were not present. These deviations from normal practices were present in day-to-day operations.
The TSB has observed similar deficiencies in the conduct of business in other organizations, as demonstrated by the occurrences referenced in Appendix A--Supporting Documentation to Section 4.2. Common findings relating to regulatory oversight in these accidents, in general terms, were as follows:
- descent below MDA without adequate visual references;
- non-adherence to SOPs;
- operating under visual flight rules when in instrument meteorological conditions;
- operating the aircraft in an overweight condition; and
- inadequate company supervision of operations or maintenance.
Generally, these accidents have been with smaller commercial operators or during operations in remote areas where oversight is difficult. In these operations, there were clear indications that a culture was allowed to exist in which crews and operators operated outside the safety regulations, with catastrophic consequences.
It is recognized that effective safety oversight of smaller or remote operations is a challenging task. Notwithstanding this challenge, the level of acceptable risk should not be greater for passengers and crews who fly on aircraft operated by smaller operators or who operate in or into remote areas, simply because oversight is difficult. It is also recognized that there have been initiatives undertaken by TC to reduce the level of risk in these operations. However, these and other accidents indicate that more needs to be done. It appears that the traditional methods of inspection, audit, general oversight, and regulatory penalties have had limited success in fostering appropriate safety cultures in some companies and individuals; consequently, unsafe conditions continue to exist and unsafe acts are still being committed.
These serious accidents indicate that some operators and crews have disregarded safety regulations and, consequently, put passengers and themselves at an unnecessary and unacceptably high level of risk. In these accidents, findings indicate that, in certain areas of commercial operations, the safety oversight efforts of TC have been somewhat ineffective. Therefore, the Board recommends that:
A01-01 The Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those operators who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations.
Appendix A - Supporting Documentation to Section 4.2
Remembering Damien
June 23, 1976 - March 19, 1999
June 23, 1976 shall always remain one of the fondest memories Howard and I treasure in our married lives. It is the birth date of our first born, a baby boy whom we named Damien. Damien enriched our young lives beyond measure.
As a young child he loved the outdoors, played with his Tonka trucks and loaders; he loved to build roads. His love of toys and outdoors was eclipsed only by his love for hockey. By the time he was four years old, he was playing with the bigger boys' hockey team earning awards such as most valuable player and most goals scored. As he grew older, Damien also loved to ski, snowboard and snowmobile.
When Damien finished high school, he went on to study as a Geological Field Technician. It was during his work as a GFT, being transported to and from the field by helicopter, that Damien took an interest in flying and decided to become a pilot. He did his training in Moncton, NB, and in ten months he completed the program. He made may visits home during those ten months as his family, and the love of his life, Wavey, were waiting for him back in Labrador. They were married on June 26th, 1998.
10th Year Memorial, Davis Inlet, NL
Damien received his first job as a pilot in November 1998 and with his wife Wavey, moved to Goose Bay, NL. He enjoyed his job very much. We were very proud of him. A friend of mine once asked Damien, "Why did you become a pilot?" He replied, "When I am up there above those clouds I know I am heavenward bound." That statement has comforted me over the years. His statement to my friend has now been realized.
March 19, 1999 is a date that shall be forever etched in the hearts and minds of my husband Howard and I as the saddest day of our lives. On that dreadful day, our first born and eldest son Damien, at the tender age of 22, took his final flight.
- Freda Hancock, mother of Damien
In loving memory of Damien Hancock
June 23, 1976 - March 19, 1999
"You make known to me the path of life;
in your presence there is fullness of joy;
at your right hand are pleasures forevermore."
(Psalm 16:11)
More Information
More information about this crash, recommendation A01-01 and Transport Canada's response can be found at WapitiWatch.ca, a website dedicated to Damien.
