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Josh Lynn, Digital News Editor CTV News Saskatoon | October 28, 2021
A newly released report provides a glimpse into the terrifying moments experienced by passengers during a 2017 plane crash in northern Saskatchewan.
Twenty-five people were injured when an ATR 42-320 turboprop plane crashed shortly after taking off from the Fond du Lac airstrip on Dec. 13, 2017.
Nineteen-year-old Arson Fern Jr. later died in hospital from his injuries.
After a nearly four-year wait, the Transportation Safety Board released the results of its investigation into the crash on Thursday.
The TSB report outlines how a combination of lapses in safety procedures, poor weather and underlying issues facing many northern airports in Canada contributed to the crash.
While the plane, operated by West Wind Aviation initially climbed after takeoff, the aircraft began to roll due to ice build-up.
The pilot was unable to regain control and the plane crashed just 17 seconds after takeoff, according to the report.
CHAOS AFTER CRASH
The plane’s rapid descent gave passengers little time to brace and damage to the plane at the moment of impact “compromised the restraint systems limiting the protection afforded to the aircraft occupants,” the report says.
In the chaotic moments following impact, due to their injuries, the people on board struggled to take “post-crash survival actions in a timely manner.”
Because of “unapproved repairs” the flight attendant seat “failed” on impact, making it difficult for her to initiate evacuation and survival procedures, the report says.
Everyone on the plane was injured in the crash and many passengers started calling for help using their cell phones.
A baby that wasn’t restrained “received flailing and crashing injuries” during the crash, according to the report.
Current TSB rules surrounding the use of child restraints had not yet come into effect at the time of the crash, the report says.
It took 20 minutes for the first 17 passengers to evacuate the downed plane. Getting those who remained out took “much longer,” the report says.
One passenger was trapped in the wreckage for three hours before being freed by rescuers.
In total, in addition to Fern’s death, nine passengers and one crew member were seriously injured. Thirteen passengers and two crew members came away with minor injuries, according to the report.
Three people were located in an area of the plane where damage was particularly severe.
Two of them experienced “serious life-changing injuries.”
Fern was the other passenger; he died 12 days later.
While the TSB highlighted aspects inherent in the design of the ATR 42-320 that made it less “crashworthy,” the sprawling 240-page report is mainly focused on how the tragedy could have been avoided in the first place.
In April 2018, the TSB previously shared its preliminary findings, saying the aircraft was not de-iced before take-off and that ice had built up on the plane.
In their final report into the crash, TSB investigators lay out a series of questionable decisions going back to when the flight crew began their day in Saskatoon.
While the crew and dispatcher “were aware of the forecast ground icing” the decision was made to go ahead with the day’s planned route which included remote airports “that had insufficient de-icing facilities.”
The crew first flew from Saskatoon to Prince Albert “without difficulty.”
While approaching Fond du Lac on the second leg of the crew’s journey, the plane encountered in-flight icing and the crew activated the aircraft’s anti-icing and de-icing systems.
Due to the limitations of the two systems, some residual ice started to collect on the plane.
The ice didn’t noticeably change how the plane handled and the crew likely didn’t feel “the residual ice was severe enough to have a significant effect on aircraft performance.”
However, the flight data recorder showed the plane’s drag and lift performance was degraded by 28 per cent and 10 per cent respectively, the report says.
The plane was on the ground in Fond du Lac for 48 minutes with more ice or frost forming on the plane’s “critical surfaces.”
Once the 22 passengers were on board, the first officer inspected the plane.
“Because the available inspection equipment was inadequate, the first officer’s ice inspection consisted only of walking around the aircraft and looking at the left wing from the top of the stairs at the left rear door, without the use of a flashlight on the dimly lit apron,” the report says.
The first officer who was “unaware of the full extent of the ice” told the captain there was some ice on the plane.
“The captain did not inspect the aircraft himself, nor did he attempt to have it de-iced; rather, he and the first officer continued with departure preparations,” the report says.
The TSB report says the crew was unconcerned because departures “with some amount of surface contamination” had become common practice due to the “inadequacy of de-icing” equipment at remote airports.
“The past success of these adaptations resulted in this unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart,” the report says.
By the time the aircraft took to the air again en route to Stony Rapids, the ice on the plane had increased its drag by 58 per cent and its lift had decreased by 25 per cent.
It soon hit the ground near the runway.
As part of its investigation, the TSB surveyed pilots work regularly fly in and out of remote airports across Canada.
“The responses received to several questions showed that operations at these remote airports were routinely affected by the unavailability and inadequacy of equipment to inspect, de-ice, or anti-ice aircraft,” the TSB report says.
Based on its findings, which were first shared in December 2018, the TSB recommended that the Department of Transport identify locations where there is inadequate de-icing and anti-icing equipment and “take urgent action” to make sure it is available.
During a virtual media availability, TSB Chair Kathy Fox said while responsibility primarily rests with operators, passengers shouldn’t be shy about advocating for their safety.
“There’s nothing that stops a passenger from asking the operator what, you know, what actions do they take, especially if there’s more than one operator operating out there,” Fox said.
“They can question, you know, the airport authority, they can see themselves. I’m sure we’ve all been on an airplane at some point where it’s snowing or there’s icing conditions and we’re told ‘well we have to go to the de-icing bay to de-ice the aircraft and so there are ways that passengers can find that out,” Fox said.
She also emphasized that while the TSB report identified specific safety issues related to the Fond du Lac crash, thousands of flights safely land and take off from Canada’s remote airports every year.
HISTORY OF ‘NON-COMPLIANCE’
The investigators also found Transport Canada’s “surveillance policies and procedures were inconsistently applied to the oversight” of West Wind, which began operating under the name Rise Air earlier this year.
“We believe the TSB’s final report is fair in its findings. We acknowledge the issues it identifies and accept responsibility for them.,” Rise Air CEO Derek Nice said in a statement
.”We are sorry for the harm caused to the passengers and crew on that flight, their relatives and loved ones, and their communities, and we’re determined that something like this can never happen again.”
“As detailed in the findings of several TSB investigations, there have been a number of past examples where Transport Canada has been slow to either identify or to rectify unsafe conditions at an operator,” the report says.
As an airline that “had a history of system-level and systemic non-compliance issues, the agency should have been more consistent in its approach to West Wind, the report argues.
West Wind was temporarily grounded following the crash. It was allowed to resume operations in May 2018.
As part of its December 2018 recommendations, the TSB said the Department of Transportation and air operators take action to “likelihood of aircraft taking off with contaminated critical surfaces.”