News conference for Carson Air (A15P0081)
Kathy Fox, TSB Chair
Jason Kobi, TSB Investigator-in-Charge
Richmond, British Columbia
2 November 2017
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On Monday morning April 13, 2015, a Metro II turboprop departed Vancouver International airport on a cargo flight to Prince George, BC, only to disappear from air traffic control radar about 6 minutes after takeoff.
The crew provided no warning that something had gone wrong and, when the wreckage was discovered later that afternoon, TSB investigators had few initial clues about the cause of the accident. Both pilots died in the crash, and there were no voice or data recorders on board.
However, only a few weeks into the investigation, toxicology results received from the coroner showed that the captain had a blood alcohol content of 0.24, meaning he had consumed a significant amount of alcohol on the day of the occurrence.
I recognize that this is … sensitive personal information, especially for the families of those involved. But once this fact was known, it became part of our investigation. What we learned has nationwide implications, ultimately leading to the recommendation we are issuing today:
That is, for Transport Canada to work with the aviation industry and employee representatives to develop requirements for a comprehensive substance-abuse program—including drug and alcohol testing—to reduce the risk of on-the-job impairment for those in safety-sensitive positions.
I'll talk more about that recommendation in a few minutes, but first, I'll turn things over to Jason Kobi, the investigator in charge. He will walk you through the events of that day, explaining what we know, what we may never know, and why we think the flight may have ended the way it did.
Thank you, Kathy.
On the morning in question, the pilot and co-pilot arrived at work, attended to pre-flight duties such as preparing the flight plan and loading the cargo, and chatted with other company pilots. It seemed like a typical start to a typical day. No one reported any unusual behavior, from either pilot.
Shortly after takeoff, just a few minutes after 7 a.m., the aircraft climbed through 7500 feet, and at 7:08 the crew acknowledged clearance to climb to their cruising altitude of 20 000 feet.
And then: nothing. 80 seconds after that final conversation with air traffic control, the aircraft disappeared from radar.
There was no cockpit voice recorder or flight data recorder on board. The TSB has previously stated on numerous occasions that the lack of hard data significantly undermines our ability to determine what happened in an accident, and this case was no different. As a result, we spent months scouring wreckage, weather reports, air-traffic control logs and maintenance and company personnel records—all to rule out as many possibilities as we could.
In the end, we were able to determine that the aircraft entered a steep dive, and the subsequent extreme speed exceeded the aircraft's structural limits, resulting in an in-flight breakup. The first component to fail was the horizontal stabilizer in the tail, then the wings folded up, and the main fuselage was destroyed by the propellers. The wreckage continued toward the ground, with debris scattered over a wide area.
But the question remained: why?
Unfortunately, we were never able to determine this with certainty. We identified three possible scenarios, but all of them leave us with unanswered questions.
The first is the possibility of a problem in the aircraft's pitot system, which provides the flight crew with airspeed information. If, for instance, the heaters for the pitot tubes malfunctioned—or if the pilot did not turn them on—they may have become blocked with ice. And if this happened while the aircraft was in cloud, the crew may have inadvertently initiated a descent while trying to find out what was happening with their flight instruments. The initiation of that kind of a descent, however, would have been unlike the rapid, almost vertical flight path followed by this aircraft—which should have been immediately, physically apparent to the pilots.
The second possible scenario is pilot incapacitation. Based on the captain's high blood alcohol content, his physical and mental performance would have been significantly impaired. He might even have slipped into unconsciousness during the flight. However even if the captain had been, for example, slumped forward toward the controls, we found no indication that the first officer was incapacitated, and he should still have been able to regain control of the aircraft.
The third scenario that we could neither confirm nor rule out was the possibility that the aircraft was intentionally placed into the steep dive. The investigation identified a number of flight-specific factors consistent with an intentional act. These include the aircraft's descent in the direction of flight, its full nose-down trim setting, the duration of the dive, the absence of any type of emergency communication, and the absence of any apparent recovery action during the descent.
The investigation also identified other, possibly coincidental, factors to corroborate this including: the presence of physical-health indicators of long-term heavy alcohol use; the fact that there is a significant relationship between alcohol use and suicidal behaviour; and the deliberate Germanwings flight-into-terrain occurrence only 20 days prior. But again, though several coincidental factors were present, the investigation could not conclude anything about the captain's predisposition to commit an intentional act.
Thank you, Jason.
To re-iterate, the TSB is unable to confirm why the aircraft entered a steep dive leading to its subsequent in-flight breakup. This is not satisfying for the TSB, nor for the families of those involved, and not for the Canadian public, which continues to rely on one of the safest transportation systems in the world.
We do believe that alcohol impairment almost certainly played a role, and so there are lessons that can be learned from this, and improvements that can be made.
Although Transport Canada regulations and companies all over the country, including this operator, prohibit flying while impaired, these rely heavily on self-policing. And previous TSB investigations, along with several recent high-profile events reported in the media, have shown that rules and self-policing are not always enough. What's needed is something more, especially for safety-sensitive positions, where, to be plain, people's lives could be at stake.
Other countries, including the United States and Australia, have found that mandatory drug and alcohol testing is most effective—when complemented by other initiatives such as education, employee assistance programs, rehabilitation- and return-to-duty programs, and peer support. There is, however, no similar requirement for such programs within the Canadian aviation industry, at least not at present. As such, the risk continues to exist that impairment among those in safety-sensitive positions will go unrecognized or unreported.
Yes, we realize that employees within Canada's aviation industry will have concerns under any possible testing regime, and those concerns are understandable and must be addressed. At the same time, the regulator and the operators must also consider public safety.
That is why the TSB is recommending a comprehensive approach, not "just testing." We are calling for Transport Canada, in collaboration with the Canadian aviation industry and employee representatives, to develop and implement requirements for a comprehensive substance-abuse program—including drug and alcohol testing—to reduce the risk of impairment of persons while engaged in safety-sensitive functions. These requirements should consider and balance the need to incorporate human rights principles enshrined in the Canadian Human Rights Act with the responsibility to protect public safety.
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