AVIATION Reports - 2004 - A04H0001

Appendices

Appendix A - Map of the Crash Region
Appendix B - Map of Pelee Island
Appendix C - Graphic Area Forecast Chart
Appendix D - Wreckage Recovery
Appendix E - Crash Site Debris Field
Appendix F - Passenger Door Placards
Appendix G - List of Supporting Reports
Appendix H - Glossary

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Appendix A - Map of the Crash Region

Appendix B - Map of Pelee Island

Appendix C - Graphic Area Forecast Chart

Appendix D - Wreckage Recovery

General

At the time of the accident, the lake was covered with ice from 2 to 12 inches thick. The water depth around Pelee Island was approximately 20 to 26 feet. When the first responder, a United States Coast Guard (USCG) helicopter, arrived at the crash site, the entire empennage was visible above the water. The empennage was observed to sink beneath the surface of the lake approximately four hours after the occurrence. The sinking coincided with the arrival on scene of the USCG ship Neah Bay (see Photo 1). Some pieces of debris from the aircraft, such as the cargo pod and engine cowling, were recovered from the surface of the ice.

At approximately 0830 eastern standard time on 19 January 2004, the Canadian Coast Guard Ship (CCGS) Samuel Risley arrived on scene. Its initial search included the area where surface debris was spotted. Surface debris that was not recovered by the USCG ship Neah Bay was retrieved and brought aboard the CCGS Samuel Risley.

In addition to the CCGS Samuel Risley's crew, the following personnel were on board: a TSB regional investigator, the southwest regional chief coroner, an Ontario Provincial Police (OPP) detective to assist the coroner, an OPP investigating officer, six members from the OPP Underwater Search and Recovery Unit with a remotely operated vehicle (ROV) and surface supply diving equipment, and two OPP forensic identification officers.

The next several days were spent searching an area of approximately six million square feet using sonar, a magnetometer, and a video imaging camera. One of the limiting factors in locating the aircraft was that the crash coordinates were reported differently by the responding agencies. The aircraft was located on January 26. On the morning of January 27, divers entered the water and completed a video survey of the aircraft. It was decided to first drag the aircraft closer to the ship, then dive and resurvey the wreckage with a video camera.

The aircraft was rigged with one strap through the back doors and pulled closer to the CCGS Samuel Risley. A spreader bar was also used to spread the load evenly across the length of the fuselage by placing the straps at several fixed locations instead of a single lifting point. Using a chain saw, slabs measuring 10 feet by 10 feet were cut in the ice surface. These slabs were removed by the ship's crane, creating a hole approximately 30 feet by 40 feet. The ship's crane was used to lift the aircraft through the hole. The aircraft was recovered completely in one lift. It then took approximately two hours to lift the aircraft clear of the water and position it on stable ice. The aircraft was then loaded onto the ship.

On January 30, two more dives were completed to recover small debris from the bottom of the lake. At approximately 1800, the ship set sail for a docking facility in Windsor. The wreckage was first transported to a hangar facility for a preliminary inspection and then taken to the TSB Engineering Laboratory in Ottawa for detailed examination.

Operational Obstacles

The non-availability of accurate coordinates for the crash site proved to be a major challenge. There was confusion as to whether relayed position coordinates were in degrees, minutes and seconds or degrees and decimal minutes. There were also problems with the accuracy of the coordinates. Some of the coordinates received were accurate to three decimal places while others were accurate to one decimal place. This meant that the coordinates were accurate anywhere from one hundred feet to one mile. It took eight days to finally confirm the positions and get more accurate information about the initial response to the occurrence. Once the new information was received and the decision was made to resume the search at the new coordinates, it took little time to locate the aircraft.

Environmental Obstacles

The harsh operating environment proved to be the most challenging obstacle during both the search and recovery. The ice prevented the use of a boat-drawn, side-scan sonar, and the ice hindered access by non-ice-breaking vessels. Additionally, once the aircraft was found, there was the problem of how to clear a hole in the ice large enough to pass the aircraft through. There were many areas where the ice was thick and safe to work on, but there were also areas of open water or ice leads created by shifting ice that had recently frozen over. This was often complicated by drifting snow that would cover the ice, hiding the thin areas.

Foul weather and extreme changes in temperature also hampered the search. During the 13-day search and recovery, the team dealt with temperatures that ranged from 0ºC to -20ºC, in both calm and gale force winds, and in both rain and snow. All these factors affected the ability of teams to work safely on the ice (see Photo 2).

The shallow water around Pelee Island presented further unique challenges. With only a few feet of water under the keel of the ship at any given time, the ship could only move if the sonar confirmed that an area was clear of obstacles.

Appendix E - Crash Site Debris Field

Appendix F - Passenger Door Placards

Appendix G - List of Supporting Reports

The following TSB Engineering Laboratory reports were completed:

• LP 018/04 - Structures Group Report
• LP 022/04 - Instruments Examination Report
• LP 023/04 - Powerplants and Propeller Systems Report
• LP 036/04 - Aircraft Performance Analysis Report
• LP 046/04 - Position Coordinates Report

These reports are available from the Transportation Safety Board of Canada upon request.

Appendix H - Glossary

ACIM	Air Carrier Inspector Manual
AD	Airworthiness Directive
agl	above ground level
AIAA	American Institute of Aeronautics and Astronautics
A.I.P. Canada	Aeronautical Information Publication
AOA	angle of attack
AOC	Air Operator Certificate
asl	above sea level
ATC	air traffic control
ATPL	airline transport pilot licence
ATS	air traffic services
CARs	Canadian Aviation Regulations
CASS	Commercial Air Service Standards
CBA	Commercial and Business Aviation
CCGS	Canadian Coast Guard Ship
CLmax	maximum lift coefficient
ELT	emergency locator transmitter
FAA	Federal Aviation Administration
FAR	Federal Aviation Regulations
FIC	Flight Information Centre
g	load factor
GFA	graphic area forecast
IFR	instrument flight rules
IMC	instrument meteorological conditions
KCAS	knots calibrated airspeed
kg	kilograms
KIAS	knots indicated airspeed
km	kilometres
lbs	pounds
METAR	aviation routine weather report
N	north
NASA	National Aeronautics and Space Administration
NDB	non-directional beacon
nm	nautical miles
NOTAM	Notice to Airmen
NTSB	National Transportation Safety Board
OAT	outside air temperature
OPP	Ontario Provincial Police
OSTC	Owen Sound Transportation Company
POH	pilot operating handbook
POI	principal operations inspector
PPC	pilot proficiency check
ROV	remotely operated vehicle
RWY	Runway
SAR	search and rescue
sm	statute miles
SOPs	standard operating procedures
TAF	terminal aerodrome forecast
TC	Transport Canada
TP	Transport Publication
TSB	Transportation Safety Board of Canada
UNICOM	private advisory station located at an uncontrolled aerodrome
USCG	United States Coast Guard
VFR	visual flight rules
VOR	very high frequency omni-directional range
W	west
º	degrees
ºC	degrees Celsius
ºF	degrees Fahrenheit
ºM	degrees magnetic
ºT	degrees true
'	minutes

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1. All times are eastern standard time (Coordinated Universal Time minus five hours).

2. See Glossary at Appendix H for all abbreviations and acronyms.

3. The OSTC operates the ferry service between Pelee Island and the mainland. It contracts for an air service when Lake Erie is frozen.

4. Much of the information in this section was extracted from TSB Engineering Laboratory report LP 036/04, Aircraft Performance Analysis Report, which is available upon request.

5.

• American Institute of Aeronautics and Astronautics (AIAA) 2003-0728, Effect of Airfoil Geometry on Performance with Simulated Intercycle Ice Accretions, M.B. Bragg and A.P. Broeren;
• AIAA 2002-0240, Effects of Intercycle Ice Accretions on Airfoil Performance, M.B. Bragg et al;
• AIAA 99-0092, Effects of Simulated - Spanwise Ice Steps on Airfoils, Experimental Investigation, S. Lee and M.B. Bragg;
• DOT/FAA/AR-02/68, dated May 2002, Effects of Residual and Intercycle Ice Accretions on Airfoil Performance.

6. Poor sleep quality, cognitive and psychomotor performance impairments, gastrointestinal distress, insomnia, and anxiety are also outcomes of circadian disruption. J.R. Belgan, C.M. Winget, and L.S. Rosenblatt, The Desynchronisis Syndrome, Annual scientific meeting: Aerospace Medical Association, Washington, D.C.: Pre-prints of scientific program, 1973.

7. D.I. Tepas and T.H. Monk, "Work Schedules," in G. Salvendy (Ed.), Handbook of Human Factors, New York: John Wiley & Sons, 1987, pp. 819-843.

8. K.E. Klein and H.M. Wegmann, Significance of Circadian Rhythms in Aerospace Operations (NATO AGARDograph, 247), Neuilly sur Seine, France: NATO AGARD, 1980.

9. S. Campbell, "The Basics of Biological Rhythms," in M.R. Pressman and W.C. Orr (Eds.), Understanding Sleep: The Evaluation and Treatment of Sleep Disorders, Washington, D.C.: American Psychological Association, 1997, pp. 35-56.

10. J.A. Horne, Why We Sleep-The Functions of Sleep in Humans and Other Mammals, Oxford, England: Oxford University Press, 1988, cited in Y. Harrison and J.A. Horne, "The Impact of Sleep Deprivation on Decision Making: A Review," Journal of Experimental Psychology Applied, 6, 2000, pp. 236-249.

11. F. Wimmer, R.F. Hoffman, R.A. Bonato and A.R. Moffit, "The Effects of Sleep Deprivation on Divergent Thinking and Attention Processes," Journal of Sleep Research, 1, 1992, pp. 223-230.

12. J.A. Horne, "Sleep Deprivation and Divergent Thinking Ability," Sleep, 11, 1988, pp. 528-536.

13. S. Sonnentag and M. Frese, "Stress in Organizations," in W.C. Borman, D.R. Ilgen, and R.J. Klimoski (Eds.), Handbook of Psychology, volume 12: Industrial and Organizational Psychology, Hoboken, New Jersey: John Wiley & Sons, 2003, pp. 453-491.

14. G.R. Hockey, A.J. Maule, P.J. Vlough, and L. Bdzola, "Effects of Negative Mood States on Risk in Everyday Decision Making," Cognition and Emotion, 14, 2000, pp. 823-856.

15. M.M. Lorist, M. Klein, S. Nieuwenhuis, R. de Jong, G. Mulder, and T.F. Meijman, "Mental Fatigue and Task Control: Planning and Preparation," Psychophysiology, 37, 2000, pp. 614-625.