The Transportation Safety Board of Canada has concluded its lengthy and detailed investigation of a fatal airplane crash in Terrace in the fall of 1989, issuing a final report last week containing seven recommendations intended to pre- vent the same sort of occurrence in the future. The board concluded, as did a coroner’s inquest at Terrace last July, that the captain of the Metro Il commuter aircraft became disoriented in smoke and fog and flew the airplane into the ground, under the illusion that it was climbing when it was actually descending. The report, based on much of the same testimony of eye witnesses and experts as the coro- ner’s inquest, reached many of the same conclusions. Base on information from the airplane’s Flight Data Recorder and Cockpit Voice Recorder recovered from the wreckage, the report is minutely critical of the approach procedure used by the captain and co-pilot, noting lack of communication in the cockpit, lack of anticipation that the landing might have to aborted due to deteriorating weather, and lack of adherence to accepted procedure in the approach. In the 65-page report the board expresses the opinion, based on available information, that the captain in fact never had visual contact with the runway he was intending to land on. The initial approach altitude was too high, the captain selected the wrong circling altitude for the approach, and he did not brief the co-pilot on a missed approach procedure in case they had to pull out of the landing. The co-pilot, the report says, apparently saw some of these problems but was not assertive enough in expressing his concerns to the captain; from the Cockpit Voice Recorder tape, in fact, it is revealed that the co- pilot twice called out that the airplane was descending just seconds before it struck the trees near Beam Station Rd. west of the airport, The Flight Data Recorder shows the captain reacted to the second call, but it was too late. The beard blames the operator, Skylink Airlines, for some of the flawed judgment exhibited by the flight crew. "The deficiencies... can each be attributed, at least partly, to an inadequate availability of resources in the operation and monitoring of the company," the report says. Examination of the pilots’ background revealed con- scientious and capable flyers, it says, adding, "... had this crew been better trained, monitored and informed, the deficiencies noted would have been reduced or elimi- nated.” The board was hampered in its investigation by lack of available information in two areas: the Flight Data Recorder was not of a type approved for installation in the Metro III and no calibration data were available for the FDR; and there was no copy of the flight’s weight and balance cal- culation left at the company’s operations centre at the Vancouver airport — the only existing copy was destroyed in the crash. The report recommends to Transport Canada that its current procedures for checking FDR requirements be brought into line with the require- ments of the Air Navigation Orders and the Engineering and Inspection Manual. It also recom- mends that airline companies be required to retain a copy on the ground of every commercial flight’s weight and balance cal-. culations. The report also notes flaws“in Transport Canada’s current Ie- quirements for instrument flight ratings for pilots. There have been 415 crashes in Canada since 1977 that involved multi-engine com- mercial passenger-carrying aircraft being flown into the ground, re- sulting in 77 deaths. The crashes all occurred in instrument flight conditions, and in each case the aircraft were found capable of sustaining flight — the crashes were due to. misjudgment by the flight crew. According to the board’s find- ings, pilots on check flights for instrument rating renewals are not required to fly in actual or simu- lated instrument conditions because inspectors are concemed about the tisk of collision during the check flight. The report recommends that all pilots seeking an instrument rating for commercial passenger operations be required to demon- strate their abilities in actual or simulated instrument flight condi- tions, The board was also concermmed about the apparent lack of standard procedure used by the pilots of Skylink 070 as revealed by the Cockpit Voice Recorder. They recommend that Transport Canada establish guidelines for the creation of Standard Operating Procedures, and that all air carriers regardless of size be required to publish SOP’s to cover the conduct of all their flight operations. The board’s final point is the apparent vagueness of what is required by a pilot to establish visual reference to a landing area during a circling approach. The report urges Transport Canada to establish a clear definition of the visual requirements to minimize the chance that a pilot could mis- interpret its meaning. During the time between the crash on Sept. 26, 1989, and publi- cation of the board’s report, Trans- port Canada addressed one other concern that arose out of the acci- dent. Skylink had been granted a waiver to operate its Metro III's under a type of certification called the Small Aircraft Order, even though its all-up weight of 14,000 placed in the Large Aircraft cate- gory. The company was granted a waiver because it also operated Meiro II aircraft, similar in con- figuration to the larger airplanes. The waiver saved Skylink from the expense and time of having to meet much more stringent require- ments on an aircraft that was vir- tually identical to airplanes the company owned and already operated under less strict rules, As a consequence, however, not only were the maintenance requirements less stringent but also crew train- ing and a host of other operational matters. Transport Canada officially re- cognized the problem and rescinded its waiver policy on Jan. 12, 1990, Commuter-class aircraft can no longer be operated under the Small Aircraft Order. Terrace Review — Wednesday, January 16, 1991 A5 _ Crash analysis prompts recommendations people. At least two families of passengers who died in the acci- dent are pursuing legal action against Skylink. Roger Ayotte, chief investigator in the Skylink study, said Monday that the board’s recommendations who are required to respond within a fixed period of time. Ayotte says he expects that reponse no later than the end of March. Transport Canada is compelled to either adopt the recommendations or provide an explanation to the board if they do not adopt them, Ayotte said. The Skylink crash killed seven have gone to Transport Canada, It took well over a year for the Transportation Safety Board of Canada to aa eae ee complete its study of the crash Sept. 26, 1989 of Skylink flight 070 at the Terrace-itmat airport. The board’s findings | were issued in a final report fast week that urges changes to transportation practices that could make flying safer for everyone if they are followed by Transport Canada. | Skylink report notes emergency response confusion It took ambulances 45 minutes to reach the scene after Skylink flight 070 crashed near the Terrace-Kitimat airport Sept. 26, 1989. Although none of the people on board the aircraft survived the crash — and the Trans- portation Safety Board of Canada has deter- mined that the crash was not survivable — the board took note of the problem in its final report on the accident, issued last week. The lengthy response time of the ambulances was caused by several factors, the board determined. Under the Terrace Airport Emer- gency Plan, the airport fire department takes responsibility for coordinating crash, fire- fighting and rescue services for any accident within a five-mile radius of the airport. Under plan, however, the RCMP are responsible for notifying the ambulance service, and in this instance the Terrace detachment failed to do that. According to the board’s Findings, the central ambulance dispatch centre in Kam- loops — which fields all ambulance calls in B.C. outside the lower mainland and Vancouver Island — learned about the crash at 8:42 a.m., 13 minutes after the crash alarm sounded at the airport, through an informal call from the Terrace stand-by ambulance driver. Official notification came two minutes later from the B.C. Ambulance Service pro- vincial headquarters, who were notified by the Rescue Coordination Centre in Victoria. ‘The report indicates the Kamloops dispatch centre sent one ambulance to the airport and a second one down Beam Station Rd. in case the crash site was west of the airport. At that time due to fog and smoke the exact location of the downed airplane was unknown. Airport fire chief George Wright discovered a.m. Shortly afterward, while driving up Beam Station Rd., the second ambulance driver heard the crash site location being confirmed on his radio scanver. But when Kamloops, under the impression that ambu- lance crews would have to be flown to the site by helicopter, directed him to return to the airport, he did so without telling the dispatch centre that the site was accessible from the road on which-he was already travelling. As a result, the report states, ambulance services were not available at the crash site until 45 minutes after the alarm. Although in this case the ambulance crews could have done nothing, the problem could have been serious if anyone had survived and required immediate medical treatment. "Since this accident, the B.C. Ambulance Service has instructed their ambulance crews to report any dispatch-related information of which they become aware during an ambu- lance,” the report states. Matters could have been worse on the morn- ing of the crash, however, if it hadn’t been for the foresight of Terrace airport manager Darryl Laurent, Transport Canada provides crash, firefighting and rescue services for specified hours during the day at the airport. Prior to the Skylink crash the CFR hours had been from 9:30 a.m. to 8:30 p.m., with person- nel starting duty half and hour before the official time in the morning and staying on half an hour after the official time in the evening, Laurent on his own initiative decided the airport fire chief should start his shift at 8 a.m. to provide partial CFR coverage for early morning flights. Without that Initiative, there would have been no CFR services immediately available the wreckage near Beam Station Rd. at 8:53 when flight 070 went Into the trees.