Dangerous decisions by an airplane Captain in December of 2019 were the primary cause behind a major plane crash near Sachigo Lake First Nation almost three years ago.
On December 3, 2019, North Star Air’s Basler BT-67 Cargo Plane left the Red Lake Airport before crashing into trees and terrain about 500 metres southwest of the Sachigo Lake Airport’s gravel runway, sustaining substantial damage.
Only two crew members were aboard the flight at the time, and no one was injured in the incident.
The Transportation Safety Board of Canada wrapped up their investigation and published a report on the incident last week.
Their report states that a ‘distorted perception of risk and a results-oriented subculture within the company contributed to the accident’, and the report goes on to outline a variety of risk factors within the company, including safety management, regulatory surveillance and disregarding rules for efficiencies.
The TSB’s report says under Visual Flight Rules, pilots must fly at certain altitudes based on the weather and the cloud level. They say despite the captain checking weather reports before take-off, he was flying lower than applicable regulations for VFR flights.
Then, when the captain initiated a descent through the cloud layers into the Sachigo lake area, the aircraft broke out of the clouds at a very low level and was not in a safe position to land with the captain’s planned approach.
The captain then made low-level maneuvers in an attempt to land, flying in a large 360 degree turn and as low as 400 feet below the required minimum altitude, before flying in a circuit pattern. During this, the aircraft nearly struck a 150-foot tall tower.
Shortly afterwards, the aircraft collided with terrain near its wing-level, about 650 feet southwest of the runway. The aircraft slid another 350 feet before it came to a stop. There was no fire, but was substantial damage to the aircraft and area.
“The captain likely experienced attentional narrowing while carrying out a high-workload visual approach at a very low altitude. This most likely resulted in an inadvertent but controlled descent that was not detected until the aircraft collided with terrain,” states the report.
The TSB adds the captain had a history of similar flights, and his decision to depart and continue the flight was likely influenced by the ‘distorted perception of risk’ from past successful experiences.
They add there was no operational management presence and no day-to-day supervision of the pilot, their flights or the flight crews, leading to a subculture of non-compliance that they say went undetected by the management team.
Of note, the TSB had conducted investigations into North Star Air’s conduct in December of 2017 for similar VFR flights. The company had reminded pilots to follow the rules, but did not outline any additional measures. A re-investigation in 2018 found no issues.
But now, the TSB says following their most-recent investigation, North Star Air has implemented a flight operations quality assurance program, and they have implemented a long-term corrective action plan, which Transport Canada has deemed effective.
Sachigo Lake First Nation is located roughly 425 km north of Sioux Lookout in the Kenora District.