Winnipeg, Manitoba, 4 August 2022 — The Transportation Safety Board of Canada (TSB) released its investigation report (A19C0145) into the December 2019 collision with terrain of a North Star Air Douglas DC3C Basler Turbo Conversions TP67 (DC3-TP67) aircraft near Sachigo Lake Airport, Ontario. The investigation found that a distorted perception of risk and a results-oriented subculture among some DC3-TP67 pilots within the company contributed to the accident. The report also mentions risk factors related to safety management and regulatory surveillance.
On 3 December 2019, the aircraft was scheduled to conduct a daytime visual flight rules (VFR) cargo flight from Red Lake Airport, Ontario, to Sachigo Lake Airport, Ontario. Weather reports obtained by the captain for the flight route were marginal for VFR, with reports of instrument meteorological conditions (IMC). Shortly after takeoff, the aircraft entered, and climbed above, the cloud layers before reaching the planned cruising altitude.
Before commencing the descent to Sachigo Lake Airport, the pilots obtained the latest weather report, and carried out a visual approach to the runway. A descent was initiated through the cloud layers by reference to the flight instruments. Once the aircraft broke out of cloud at very low level, the aircraft was not in a position to continue with the planned visual approach, yet several attempts were made to land. During the last attempt, the aircraft collided with terrain southwest of the runway and slid along the ground before coming to rest. The two crew members were uninjured, though the aircraft was substantially damaged.
The investigation found that the decision to depart on, and continue, a VFR flight in IMC was influenced by a distorted perception of risk resulting from successful past experience in similar situations. The results-oriented subculture of some of North Star Air’s DC3-TP67 pilots, which emphasize mission completion over regulatory compliance, resulted in VFR flights, such as the occurrence flight, being conducted in IMC.
The report includes findings related to safety management and regulatory surveillance, two issues on the TSB Watchlist 2020. North Star Air’s safety management system did not identify the underlying factors that led to the reported instances of company aircraft operating VFR flights into IMC, nor were any additional measures taken to monitor its DC3-TP67 operation to ensure flights were being conducted in accordance with regulations. As a result, previously identified unsafe practices persisted, and played a direct role in this occurrence.
In 2017, Transport Canada (TC) had provided information to the company of allegations regarding VFR flights in IMC for its internal investigation. A 2018 TC inspection of company operations did not include information about these allegations, about corrective action, or that the company investigation into these allegations was still open after almost two years. As seen in this occurrence, the unsafe practice of operating under VFR in IMC persisted unbeknownst to the regulator. If TC relies on operators to investigate allegations of regulatory non-compliance without monitoring them, there is an increased risk that the unsafe practices that are being investigated will persist.
Following the occurrence, North Star Air implemented a flight operations quality assurance program.
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.