“Sensation Seeking” Survey Fatal Accident

Posted by on Aug 3, 2024 in Accidents & Incidents, Fixed Wing, Human Factors / Performance, Mining / Resource Sector, Safety Culture, Safety Management, Special Mission Aircraft | 0 comments

“Sensation Seeking” Survey Fatal Accident (Exact Air Piper PA-31 C-FQQB)

On 30 April 2017 Piper PA-31 Navajo C-FQQB operated by Exact Air crashed 3.5 NM from Schefferville Airport, Quebec while returning there from its second magnetometric geophysical survey flight of the day.  Both pilots onboard died during the Controlled flight Into Terrain (CFIT) accident.

Wreckage of Exact Air Piper PA-31 C-FQQB (Credit: TSB)

The Accident

According to the Transportation Safety Board of Canada (TSB) safety investigation report the survey area was 90 NM from Schefferville Airport.  The surveys were conducted at 300 feet above ground level with a crew of two.

Although the regulations do not require it, the company decided to add a 2nd pilot on board the magnetometric survey flights and gave the pilots additional training in the right-hand seat on standard operating procedures (SOPs), including instrument approaches using the global positioning system (GPS).

The occurrence pilots were 24 and 25 years old. [They] alternated the roles of pilot-in-command and co-pilot on each flight.

Because survey flights are conducted at low altitude, the crew had conducted a reconnaissance flight over the survey area to identify potential hazards.

TSB note that:

The pilot-in-command had been employed by the company since March 2016.

He had 462 hours total time, 112 on type.

This was his first magnetometric survey contract, and he had conducted about 16 flights as co-pilot to familiarize himself with this type of aerial work before being assigned to the role of pilot-in-command the week before the accident.

The pilot-in-command was the pilot flying for the accident flight.

The co-pilot had been employed by the company since September 2014.

He had 1693 hours total time, c650 on type.

This was his 4th magnetometric survey contract, and he had trained the occurrence pilot-in-command during the first flights of the contract.

The co-pilot was the pilot monitoring.

C-FVTL, another Piper PA-31 of Exact Air was simultaneously taking part in the survey. The TSB investigation revealed that during the daytime return flight C-FQQB…

…descended to a height of less than 100 feet AGL and maintained this altitude until colliding with the wires at 1756.

Exact Air Piper PA-31 C-FQQB: Tracks of the Two Very Low Level Flight Segments That Day (Credit: TSB)

Its ground speed during the last minute before the impact was 169 knots, or 286 feet per second.  At 1756, while the aircraft was flying over railway tracks, it struck power transmission line conductor cables and crashed on top of a mine tailings deposit about 3.5 nautical miles northwest of Schefferville Airport.

Accident Site: Exact Air Piper PA-31 C-FQQB (Credit: TSB)

Shortly after C-FVTL arrived at Schefferville its crew realised that C‑FQQB had not landed.

After unsuccessful attempts to make radio contact, a search was initiated. Less than an hour later, the wreckage of the missing aircraft was located.

The Safety Investigation

[No] emergency locator transmitter (ELT) signal was captured. Damage to the antenna coaxial cable likely led to the rapid discharge of the battery. However, the broken antenna and the fact that the wreckage was upside down would have made it impossible to detect the signal.

This is a common phenomenon.  TSB note that:

The current emergency locator transmitter system design standards do not include a requirement for a crashworthy antenna system. As a result, there is a risk that potentially life-saving search‑and‑rescue services will be delayed if an emergency locator transmitter antenna is damaged during an occurrence.

The left engine was separated from the main wreckage.  Electrical transmission cables were found  wrapped around its propeller drive shaft.

Left engine of C-FQQB: the circle shows the severed pieces of cable wrapped around the propeller drive shaft: Exact Air Piper PA-31 C-FQQB (Credit: TSB)

TSB comment that:

There is nothing to indicate airframe or engine failure or system malfunction prior to the collision. All damage to the aircraft was consistent with overload forces from the impacts with the wires and the ground.  There is [also] nothing to indicate that weather conditions may have contributed to this occurrence.

On mapping:

The VFR Navigation Chart (VNC) is used by VFR pilots on short to extended cross-country flights at low to medium altitudes and at low to medium airspeeds.  According to ICAO, all structures over 300 feet (about 90 m) high are considered obstacles and must be shown on a VNC. The power transmission line severed by the occurrence aircraft [which was 70 ft AGL] was not depicted…and there was no regulatory requirement for it to be shown. In general, power transmission lines are depicted on a VNC because they are useful cultural landmarks that can assist in visual navigation. They are portrayed based on the availability of source data and the application of the product specification. Segments of power transmission lines may be suppressed and/or masked in order to ensure readability at chart scale (1:500 000). Based on specification rules, other linear cultural landmarks, such as roads and railways, take priority over power-line depiction, if their proximity to one another poses readability concerns (e.g., if text and features overlap).

TSB note that:

Wires can be difficult to see during flight. According to an article published in Aviation Week, “Wires aren’t consistently visible all of the time. Changing sunlight patterns can obscure them. […] A wire that is perfectly visible from one direction may be completely invisible from the opposite.”  For this reason, Transport Canada advises pilots to always cross power transmission lines at their towers, and to follow ridgelines and avoid flying in the centre of valleys.

For the very-low-altitude flight at the time of impact, the reaction time to avoid the wires was estimated at just 3.5 seconds.

The TSB analysis concentrated on pilot behaviour, commenting:

The…co-pilot had previously expressed his enjoyment of low flying, but there was nothing to indicate that this was the case for the pilot-in-command.

TSB say:

Sensation seeking is the tendency to seek novel, varied, complex, and intense sensations and experiences.

Low flying produces intense sensations in pilots by requiring high levels of cognitive and attentional resources in an unforgiving environment. Men and younger persons typically score higher on sensation-seeking scales than do women and older persons, with peak levels occurring in late adolescence (18 to 20 years of age).

All activities carry a degree of associated risk. It is up to the individual to assess the level of risk associated with an activity when deciding whether or not to engage in it.

An analysis of GPS data by TSB showed that the pilots had recently conducted 27 flight segments at ‘very low altitude’ (i.e. 100 feet AGL and below the already low survey height).  TSB note that:

Individuals who repeatedly perform a dangerous activity with no, or few, negative repercussions may become desensitized or habituated to the high level of risk.

In this case the prior task of…

…maintaining an altitude of precisely 300 feet AGL required a significant degree of sustained attention.  On the day of the accident, the crew was conducting their 2nd magnetometric survey flight of nearly 5 hours. Thus, at the time of the accident, the crew were probably subject to the effects of mental fatigue, which may have increased their tendency to take risks…

…as well one would assume their ability to maintain vigilance.  TSB therefore determined that:

….sensation seeking, mental fatigue, and an altered risk perception very likely contributed to the fact that, immediately after completing the magnetometric survey work, the pilot flying descended to an altitude varying between 100 and 40 feet AGL and maintained this altitude until the aircraft collided with the wires.

In relation to safety management:

Exact Air was not required to incorporate a formal SMS. However, the company voluntarily developed an SMS and published its SMS manual in February 2006.

Transport Canada does not evaluate voluntary SMS and at the time of the TSB report…

…approximately 90% of all Canadian aviation certificate holders are still not required by regulation to have an SMS.

The TSB however do not describe the SMS further, nor evaluate the effectiveness, or otherwise, of this voluntary SMS.

Although the company had access an unspecified flight-monitoring system used by the survey customer that…

….recorded the aircraft’s position every 2 minutes [but] the system did not allow flights to be followed in real time, and there was no process for evaluating the way in which a flight had been conducted.

TSB note that:

If Transport Canada does not take concrete measures to facilitate the use of lightweight flight data recording systems and flight data monitoring [FDM], there is a risk that operators will be unable to proactively identify safety deficiencies before they cause an accident.

Safety Actions

After the accident, Exact Air simply…

…conducted an awareness campaign and held meetings with all company staff regarding the causes of the accident and the risks associated with low-altitude flying.

And vaguely:

They also held a meeting with the management of GDS (the client) to explain the situation and to emphasize the necessity of teamwork to prevent other dangerous behaviours.

No TSB recommendations were raised.

Safety Resources

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