On January 17, 2004, a Cessna 208B Caravan was on a flight from Pelee Island, Ont., to Windsor, Ont., with one pilot and nine passengers on board. The aircraft took off from Runway 27 at approximately 16:38 Eastern Standard Time and used most of the 3 300-ft runway for the take-off run. It then climbed out at a very shallow angle while turning north over the frozen surface of Lake Erie, toward Windsor. The aircraft struck the surface of the lake approximately 1.6 NM from the departure end of the runway. All 10 persons on board were fatally injured.

Findings as to causes and contributing factors

1.        At takeoff, the weight of the aircraft exceeded the maximum allowable gross take-off weight by at least 15 percent, and the aircraft was contaminated with ice. Therefore, the aircraft was being flown significantly outside the limitations under which it was certified for safe flight.

2.        The aircraft stalled, most likely when the flaps were retracted, at an altitude or under flight conditions that precluded recovery before it struck the ice surface of the lake.

3.        On this flight, the pilot’s lack of appreciation for the known hazards associated with the overweight condition of the aircraft, ice contamination, and the weather conditions was inconsistent with his previous practices. His decision to take off was likely adversely affected by some combination of stress and fatigue.

Findings as to risk

1.        Despite the abbreviated nature of a September 2001 audit, the next audit of the operator was not scheduled until September 2004, at the end of the 36-month window.

2.        The internal communications at Transport Canada did not ensure that the principal operations inspector responsible for the air operator was aware of the Pelee Island operation.

3.        The standard passenger weights available in the Aeronautical Information Publication (A.I.P.) at the time of the accident did not reflect the increased average weight of passengers and carry-on baggage resulting from changes in societal-wide lifestyles and in travelling trends.

4.        The use of standard passenger weights presents greater risks for aircraft under 12 500 lbs than for larger aircraft due to the smaller sample size (nine passengers or less) and the greater percentage of overall aircraft weight represented by the passengers. The use of standard passenger weights could result in an overweight condition that adversely affects the safety of flight.

5.        The Cessna Caravan de-icing boot covers up to a maximum of 5 percent of the wing chord. Research on this wing has shown that ice accumulation beyond 5 percent of the chord can result in degradation of aircraft performance.

6.        At the Pelee Island Airport, the air operator did not provide the equipment that would allow an adequate inspection of the aircraft for ice during the pre-flight inspection and did not provide adequate equipment for aircraft de-icing.

7.        Repetitive charter operators are not considered to be scheduled air operators under current Transport Canada regulations, and, therefore, even though the charter air operator may provide a service with many of the same features as a scheduled service, Transport Canada does not provide the same degree of oversight as it does for a scheduled air operator.

8.        A review of the Canadian Aviation Regulations (CARs) regarding simulator training requirements indicates that there is no requirement to conduct recurrent simulator training if currency and/or pilot proficiency checks (PPC) do not lapse.

9.        Commercial Air Service Standard 723.91(2) does not clearly indicate whether there is a requirement for simulator training following expiration of a PPC.

10.     Incorrect information on the passenger door placards, an incomplete safety features card, and the fact that the operating mechanisms and operating instructions for the emergency exits were not visible in darkness could have compromised passenger egress in the event of a survivable accident.

11.     The dogs being carried on the aircraft were not restrained, creating a hazard for the flight and its occupants.

Safety actions taken
(The following are only a selection of the major safety actions taken)

Operator

• The operator installed an aircraft de-icing machine on Pelee Island immediately following the accident.
• The company now employs a second crew member on all passenger flights.
• In an effort to reduce perceived mission pressure on aircraft captains, the chief pilot now reviews the weather each day to forecast delays or cancellations.
• The chief pilot is reviewing every flight plan to verify that the weight and balance program is being followed.

Transportation Safety Board of Canada (TSB)

The TSB identified risks associated with using standard weights, and issued two aviation safety recommendations:

The Department of Transport require that actual passenger weights be used for aircraft involved in commercial or air taxi operations with a capacity of nine or fewer passengers. (A04-01)

and

The Department of Transport re-evaluate the standard weights for passengers and carry-on baggage and adjust them for all aircraft to reflect the current realities. (A04-02)

Transport Canada

In response to A04-01, Transport Canada indicated that it continues to review the standards, and that one of the options under consideration is to require the use of actual passenger weights. The TSB feels the present risks associated with using standard weights will remain until a new standard is put in place to ensure that actual weights are used for aircraft carrying nine passengers or less. In response to A04-02, Transport Canada re-evaluated the standard weights for passengers and carry-on baggage and, effective January 20, 2005, adjusted them for all aircraft to reflect current realities, and amended the guidance material.

The Federal Aviation Administration (FAA)

The FAA released a comprehensive guide that provides air operators of large, medium, and small cabin aircraft with options for calculating passenger weights, to reflect current realities.

The FAA issued Airworthiness Directive (AD) 2005-07-01, effective March 29, 2005, and subsequently issued AD 2006-06-06, effective March 24, 2006, which supersedes AD 2005-07-01. The AD was the result of several accidents and incidents involving the Cessna 208 and 208B operating in icing conditions. The purpose of the AD is to ensure that pilots have enough information to prevent loss of control of the aircraft while in flight during icing conditions. The AD is applicable to Cessna 208 aircraft in Canada. For the most accurate and current information, consult: www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/MainFrame?OpenFrameSet.

On March 24, 2006, TC issued Service Difficulty Alert 2006-01R2,—Cessna 208 (Caravan) Series-Operation Into Known or Forecast Icing Conditions—which addresses the FAA AD and which makes further recommendations to Canadian Cessna Caravan C208 operators. For details consult: www.tc.gc.ca/CivilAviation/certification/continuing/Alert/2006-01.htm. Readers are encouraged to read the full report of this major investigation on the TSB Web site. —Ed.