TSB # A 07/97
Shortly after take-off, on November 25, 1995 a Piper Navajo PA-31-325, C-GLOM, operated by Eagle Air Services crashed at Wollaston Lake, Saskatchewan
Report No. A95C0250
(For release 18 June 1997)
(Hull, Quebec) - The Transportation Safety Board (TSB) has concluded its investigation into the crash of a Piper Navajo onto the frozen surface of Wollaston Lake, Saskatchewan, on the night of 25 November 1995. The aircraft, operated by Eagle Air Services, had just taken off on a medical evacuation (MEDEVAC) flight en route to La Ronge when it levelled off, turned to the left, descended and struck the frozen surface of the lake.
The pilot and the patient, who was on a stretcher, suffered serious injuries; the other two occupants sustained minor injuries, and the aircraft was destroyed.
In its report, the Board determined that the left propeller was likely on its start locks after take-off, which, as the airspeed increased, allowed the propeller to overspeed. The pilot was unable to resolve the situation in time to prevent the aircraft from striking the frozen surface of the lake.
Inadequate restraint provided by the stretcher and its restraining strap contributed to the severity of the patient's injuries. The Board also noted a lack of standards regarding stretchers and restraining devices used in MEDEVAC aircraft, and a lack of standards as to the operation of MEDEVAC flights.
Aircraft operators are required to obtain Transport Canada (TC) approval for aircraft modifications to accommodate air ambulance equipment. However, TC does not set standards for stretchers or for other equipment which is temporarily installed in a MEDEVAC aircraft to accommodate patients. In addition, TC relies on operators to voluntarily make the necessary changes to aircrew training and operational procedures before offering air ambulance services to the public. In this occurrence the operator was conducting an air ambulance service without a TC-approved stretcher installation, additional crew training, or the amended manuals to reflect specific air ambulance procedures.
Several provinces have set standards for operation of air ambulance services under their jurisdiction, but these standards are difficult for the provinces to enforce when the service is paid for by non-provincial organizations.
Without minimum standards, crews and patients involved in air ambulance services will remain at risk because of inappropriate equipment or crews that have not been adequately trained in meeting the special needs of non- ambulatory medical patients. The Board believes that a consistent level of safety across Canada cannot be attained through voluntary measures and has recommended that:
The Department of Transport require all air carriers operating air ambulance services in the course of their business to provide the equipment, procedures, and crew training necessary to ensure a level of safety for patients consistent with that provided by commercial air services to fare-paying passengers. [A97-01]
The Board is concerned that the continuing involvement of MEDEVAC flights in accidents is disproportionate to the activity rate. Too often, patients have become victims of air accidents, which raises questions as to the adequacy of the regulatory oversight for the maintenance of safety standards for air ambulance operations. This accident highlights the need for a consistent and realistic regulatory framework for all MEDEVAC operations undertaken in Canada.
The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil.
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The TSB is an independent agency that investigates marine, pipeline, railway and aviation 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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