a ee ae

Ta i a Rone oe ne

FER EE EAR ee

Jury recommends, but
crash cause still unknown

by Michael Kelly —

TERRACE— A _ five-member

coroner’s jury for the inquest into.
the Skylink airplane crash that
killed seven people at the Terrace-
Kitimat. airport Sept. 26, 1989

issued its recommendations June
20.

After hearing testimony from 13
witnesses, most of whom. were
cross-examined by lawyers repre-
senting the families of crash vict-
ims, Skylink and - Transport
Canada, the jury recommended that
all commercial pilots be given a
compulsory training course called
Cockpit Resource Management.
The course is available through
Transport Canada at a cost of
about $1,500. .

The jury’s other recommendation
called for additional radio naviga-
tion aids at the Terrace-Kitimat
airport: installation of a microwave
landing system (MLS), installation
of a localizer (a radio transmitting
device that forms part of an instru-
ment landing system) on runway
33 (the runway that would have
given ‘flight 070 a more direct
approach), or the installation of
another non-directional -beacon.
When questioned about the last
recommendation, one of the pilots
who testified at the inquest sald he
believed * the additional beacon
would. allow a straight-in. instru-
ment approach on runway 15, the
runway on which 070 was intend-
ing to Jand before it crashed.

The first day of the three-day
inquest was taken up entirely by
questioning and cross-examination
of Roger Ayotte, the chief investi-
gator for the Canadian Aviation
Safety Board. Ayotte spent nine
hours on the stand backing up

‘conclusions the investigating team

had drawn from examining the
wreckage, interviewing witnesses
and analyzing material from the
flight data recorder and cockpit
voice recorder. He cited several
examples of sloppy airmanship on
the part of the crew, but noted that
none of their procedural errors in
isolation could be called a contrib-
uling cause to the accident.
Ayotte said he had concluded

_ that captain Craig Ashe had

become disoriented while descend-

_ing through fog on the last por-

tions of the approach. Ashe
attempted to fly a missed approach
but unknowingly flew the aircraft
into the ground, Ayotte said, think-
ing he was climbing instead of
descending.

Ayotte noted numerous flaws in
the crew’s procedure during the
approach: there was no discussion
of what they would do if unable to

-. land and the requirement a a

missed approach came up; the

aircraft came in below the required

minimum altitude for the speed at
which it was flying, going within

200 feet of the ground at one point.

during the circuit when both pilots
were aware the airport is ringed
with obstructions and trees taller
than 60 feet; an altiiude alert sys-
tem in the Metro III aircraft was

not engaged; the fact that an air-

craft attempting to land 15 minutes
ahead of them had to use a missed
approach should have alerted both
1o deteriorating weather and vis-.

ibility over the airport; and the ©

crew failed to call in to the Flight
Services Station-on any portion of
the approach. Ayotte qualified his

criticism by adding that not all of
these procedures are required by. -

tegulation, but all of them are
considered part. of “good
airmanship.

Yet during the second day of the
inquést the jury heard from two
pilots who had flown with Craig
Ashe, and both considered him a
top-notch professional pilot. Under
cross-examination by N.A. Smith,
a Vancouver lawyer representing
crash victim widow Monica Case,
one pilot testified that Ashe was
“very. good" at shooting the Ter-
face approach, Bryan McCook said
he had flown as co-pilot with Ashe
on the Terrace run many times
over a period of months.

"He followed ‘the approach as
published, never deviated. He
didn’t care: if you got in, you got
in. If you didn’t, you go back to
Vancouver," he said.

When asked if the pilots were .

subjected to pressure from the
company to get into Terrace, Mc-
Cook replied, "None whatsoever."

He admitted later under question-

ing by Transport Canada lawyer —

Paul Partridge, however, that he
had told investigators he was under
pressure sometimes from Skylink
management when his flights’

returned late to Vancouver from -

Terrace. "You just lake the heat,"
he said. "He signs my pay cheque,
he doesn’t run my life. To tell you
the iruth, nobody took the presi-
dent (Rafael Zur) too seriously.”
McCook then commented, after
being asked by Partridge about a

remark he made to investigators

implying that no one in the com-
pany wanted Zur to fly the Metro
aircraft,
license, he’s an unsafe pilot."
Coroner John Wolsey cut off
Partridge and McCook at that point
because Zur’s abilities as a pilot
weren't relevant to the inquest.
McCook stated while being ques-
tioned by coroner’s counsel Mitch
Houg, "Craig Ashe was a very safe
pilot. He was very professional and
I always felt very confident with
him. He always. flew by the book."
Bill Ashe, Craig Ashe’s brother,
was chief pilot for Skylink until
shortly before the date of the
crash. He added to McCook’s
earlier statement. that Terrace is
one of the most challenging air-

‘ports in Canada by saying that.

Skylink used only its most experi-
enced pilots on the Terrace run.
When asked if he had any explana-

‘don for what happened to the

airplane after Ashe started the

missed aproach, ‘he sald, "I have

no idea, I have no theoties." :

Under cross-examination. Ashe,
who has extensive experience with -

small regional airlines like Skylink,
said their training program was as

good as any other he'd seen in his .
career. At the time he left .the

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company he was in the process of
setting up a Standard Operating
Procedure — specific coordination
rules for flight crews — in con-
junction with advisors from Trans-
port Canada.

"He shouldn’t have a —

The coroner’s final witness was
Donald Royal, an air carrier ins-
pector for Transport Canada.
Royal, whose job involves testing
pilots and reviewing training and
operations procedures with airlines,
said SOP’s are beneficial in gen-
eral but probably wouldn’t have
helped in this particular accident.

"It won’t help to add more re-
quirements if what was already
required wasn’t being done," he
said, referting to the approach
procedure apparently used by Ashe
and Aikenhead, Under cross-exam-
ination, Royal said that if the flight
070 approach had been part of a
flight test the crew would have
failed on a number of points: lack
of briefing, flying past the pub-
lished missed approach point if the
runway was obscured in fog,
dropping below. the minimum
descent altitude before the landing
was guaranteed, =

"There is no. reason to believe
SOP’s would have. made a differe-
nce; they won't matter unless the
pilots choose to follow them."

Royal went on to note that there
is a training program available

through Transport Canada —
cockpit resources management —
that could help pilots avoid getting
into circumstances like those that
resulted in the crash of Skylink
070. The course encourages,
among other things, clear com-
munication between crew memb-
ers: "If the co-pilot had questioned
ihe captain about the approach, it
might have provoked the captain to
lake a closer look at what was
happening.

"Pilots should question each
other. Anything abnormal must be
rectified. My personal recommen-
dation is that carriers should look
into providing this course for their
air crews."

The jury adopted Royal’s reco-
mmendation.

Royal’s final contribution to the
inquest was a theory of what
occurred in the cockpit just before
the crash, a theory somewhat dif-
ferent from that presented by Rog-
er Ayolte. Royal began by noting
that the Metro III has a long fusel-
age in proportion to its wingspan,
with an exaggerated tendency for
the nose to go upward under accel-
eration. When power is applied the
pilot has to apply forward force to
the control column to counteract
that tendency. Applying. trim’ to

cep’ the nose down is part of

controlling the airplane in power-

_on, climbing maneuvers like: the

Start of a missed approach.
Royal described the frenzied
activity that occurs in the cockpit
during a missed approach. The
captain has to switch attention
from visual to instrument refere-
nces, focus on the engine instru-
ments as he applies full power to
the engines, listen to the co-pilot,
who is yelling at him as the land-
ing gear and flaps are retracted,
and attend to numerous other criti-.
cal matters. As all this occurs,
Royal said, the pilot tends to
ignore the fact that he is pressing
forward on the control column as
long as it feels like the aircraft is
climbing out and under control.
"I've seen it happen many times
on check rides (on Metro III aircr-
aft). Inadvertently, the pilot slowly
levels and then pitches over the
aircraft without realizing it,”
He believes that is exactly what
happened to Craig Ashe.
In addition to their reconnmenda-
tions the jury also issued a verdict:
the passenger and crew of Skylink
070 died of multiple deceleration
and impact injuries (as specified in
the pathology report); the deaths of
pilots Craig Ashe and Paul Alken-
head were accidental, and the a
deaths of the five passengers were
homicide, meaning they were the . *
consequence of actions by another =”
person or persons with no blame oe
attached. _