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The Pelee Island Crash

On 17 January 2004, a Cessna 208 Caravan was destroyed when it crashed after take-off from Pelee Island Airport, Ontario, Canada (TSB, 2005b). On board were the pilot, his girlfriend, eight men and two dogs. All were killed. The aircraft had landed after a short 15-minute flight from Windsor, Ontario. It had picked up some icing in flight, and people on the ground commented on this to the pilot. After a short turnaround, the aircraft made ready to depart. By now, freezing rain was falling. The girlfriend was not ticketed, and no passenger manifest was produced. Contrary to regulations, the dogs were not carried in cages but roamed freely on the floor of the aircraft. The passengers, a hunting party, were not weighed before boarding. The aircraft was considerably overweight as well as carrying a burden of ice from the in-bound flight. The icing conditions prevailing when the pilot took off simply aggravated the problem. Observers noticed that the aircraft took most of the runway to get airborne. Shortly after take-off, the noise of a crash was heard.

This accident is of interest, in the context of this chapter, as much because of the circumstances surrounding the flight as of the actions of the pilot. Therefore, I need to explain the context of the flight that day. Pelee Island is the southernmost community in Ontario, Canada. Located at the western end of Lake Erie, the island is connected by ferry services to both Canada and the United States. The Owen Sound Transportation Company (OSTC) provided the main ferry service to the island. Once privately owned, OSTC was now a subsidiary of the Province of Ontario government. In winter, once Lake Erie freezes, communication links were maintained by a charter air service provided by Georgian Express.

Transport Canada’s (TC) Commercial and Business Aviation Division (CBAD) is responsible for the oversight of commercial air operations that fall within its remit. When an operator applies for an approval to conduct a service, the CBAD is required to assess the safety and viability of the application. The functions of the CBAD are divided between certification - which deals with new applications and changes to existing operations - and operations, which deal with the ongoing oversight of air operator certificate (AOC) holders, of which Georgian Express was one. In order to fulfil this obligation, the operations subdivision appointed a principal operations inspector (POI) to work with Georgian Express.

The OSTC notified the CBAD of its intention to start the winter air service and was told, in a letter dated 11 December 2003, copied to the certification subdivision, that the request must come from the AOC holder, Georgian Express. As the OSTC did not hold an AOC in its owrn right, the operations subdivision of the CBAD was not copied in on the correspondence. The air link was conducted as though it were a scheduled service but under a subsidy arrangement and, as such, constituted a charter operation. Therefore, it did not require Georgian Express to apply for an amendment to its AOC. The department that had daily oversight of the company, then, was unaware of the plan.

The TC POI had a responsibility to conduct regular inspections and audits of air operators. A scheduled audit of Georgian Express had been started on 11 September 2001 and immediately suspended given the tragic events of that day. The audit was rescheduled for September 2004, based on the POI’s ongoing assessment of the nature of Georgian Express’ operations. However, special purpose inspections can be triggered by significant changes to a company’s operations. The commencement of the Pelee flights would be just such a significant change but, as we have just seen, the operations subdivision had not been included in any communications, and the POI did not know about the new Pelee Island route.

Georgian Express flights were operated as pilot self-dispatch, meaning that operational control was delegated to the pilot in command. It was the company’s responsibility to co-ordinate the services required for the operation, such as fuel, de-icing and passenger handling, and to make appropriate arrangements. The company’s operations manager travelled on the first flight of the new service, on 13 December 2003, to check arrangements. As no de-icing was available at Pelee Island Airport, the company provided small, two-gallon containers of de-icing fluid, with an attached spray, to be carried on the aircraft for use at remote locations. According to procedures, a company flight plan was supposed to be prepared for each flight. The flight plan was used to record details of load, fuel, passengers and aircraft weight and balance. Passenger weights were calculated using a set of industry-standard figures. A copy of the completed flight plan was supposed to be left with the passenger agent before departure. No flight plan was found for the accident flight, nor were any deicing fluid containers found in the wreckage.

The 208 Caravan is manufactured by the Cessna Aircraft Company. The design of an aircraft must satisfy international standards of airworthiness before it can be awarded a certificate of Release to Service. The characteristics of the aircraft under different conditions of flight are tested, and engineers are required to provide solutions to a variety of safety contingencies. The aircraft cannot be used until it receives a certificate from the airworthiness division of the appropriate authority, in this case, the US Federal Aviation Authority (FAA) as the state of manufacture. The effect of ice on aircraft performance is well known, as we saw in Chapter 1, and the regulatory authorities and manufacturers publish specific regulations, general guidance and seasonal reminders about flying in icing conditions. There are specific regulations that cover the removal of ice, particularly on the wings of aircraft, before take-off and take-off in conditions of freezing precipitation. The Cessna 208 Caravan is also fitted with devices to prevent the formation of ice on exposed surfaces critical to flight and to remove ice once it has started to form.

The weather conditions prevailing en route to and at Pelee Island were conducive to the formation of ice. The accretion of ice on an aircraft is an unfortunate application of the laws of physics. Therefore, under certain conditions, there is a known risk of ice formation. Ice is a hazard in that it adds to the weight of an aircraft and can affect performance. It can also disrupt the aerodynamic properties of the aircraft. Exposure to icing is a hazardous condition, but the risk is mitigated unless the rate and extent of ice formation exceed the capability of the aircraft’s protection systems. The pilot of the Caravan at Pelee Island was aware of the icing conditions on that day, and he had needed to de-ice the aircraft on an earlier flight. On the outbound trip, the formation of ice did not seem to have impaired the aircraft’s performance. Possibly, the pilot thought that the absence of any adverse effects would similarly apply to the return trip. His immediate experience may have shaped his construction of risk. But that is all conjecture. What we do know is that the combination of an overweight aircraft and the degraded aerodynamic properties of the ice-covered wing reduced the performance margins available to the pilot, thus rendering the aircraft unsafe. The crash of the aircraft in January 2004 resulted in the tragic loss of all on board. This brief synopsis of events, though, points towards a complex scenario being played out on that day.

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