Flying with partial instruments led to a 2019 loss of control and collision with ground near Whatì Airport, Northwest Territories
Edmonton, Alberta, 27 April 2020 —The Transportation Safety Board of Canada (TSB) today released its investigation report (A19W0015) into a fatal aircraft accident involving a loss of control and collision with terrain that took place in 2019 near the Whatì Airport, Northwest Territories.
On 30 January 2019, an Air Tindi Ltd. Beechcraft King Air 200 aircraft departed Yellowknife Airport, Northwest Territories, on an instrument flight rules flight itinerary to Whatì Airport, Northwest Territories, with two flight crew members on board. As the aircraft began the approach to Whatì Airport, it departed controlled flight and impacted terrain. The two flight crew members received fatal injuries. The aircraft was destroyed.
Prior to departure, the flight crew acknowledged that the right-side attitude indicator was not operative. An attitude indicator is critical to help pilots assess the position of the aircraft when they can’t see the ground or horizon. As they expected it to become operative at some point in the flight, a decision was made to depart into instrument meteorological conditions with only the left-side attitude indicator operating. Before starting their descent to Whatì Airport, the crew attempted to troubleshoot the still faulty right-side attitude indicator, but was not successful. During the descent, for undetermined reasons, the left-side attitude indicator also failed. The captain then attempted to use partial panel flying techniques to maintain control of the aircraft. Partial panel is a term used when any one, or more, of the principal flight instruments are unserviceable. The captain did not have recent experience in flying partial panel and, as a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive. The flight crew was unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.
The investigation determined that the crew did not effectively manage and mitigate the risk associated with the unserviceable right-side attitude indicator. Crew resource management was also not effective and resulted in a breakdown in verbal communication, loss of situation awareness, and the aircraft entering an unsafe condition.
The investigation also determined that if flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft may be operated without systems that are critical to safe operation. Additionally, if flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.
Following the occurrence, Air Tindi Ltd. took a number of safety actions, which included the conduct of an internal safety investigation and the implementation of changes to the minimum equipment list. Air Tindi Ltd. also installed a third attitude indicator in all company aircraft that had not already been so equipped; standardized and labelled power supplies for all attitude indicators in the company’s King Air fleet; established life limits on all attitude indicators in company aircraft; and amended its training programs.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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