The final report into an Air Tindi crash that killed both crew members in January 2019 focuses on how decisions were made about faulty equipment on the aircraft.
The plane, a King Air 200, was equipped with two attitude indicators. One was already out of action when the flight began. Pilots Will Hayworth and Zach McKillop lost use of the other before the crash outside Whatì.
Attitude indicators tell a flight crew how the plane is oriented relative to the horizon. They are vital when weather conditions or darkness obscure the land below the aircraft. (Altitude, also important in flight, is a different concept.)
A report from the Transportation Safety Board of Canada (TSB), issued on Monday, states the crew knew the first attitude indicator – on the right-hand side of the aircraft – had a problem before the journey began.
The TSB states the pilots believed the problem would rectify itself once the plane took off, so they departed into snowy conditions.
“Before starting their descent to Whatì Airport, the crew attempted to troubleshoot the still faulty right-side attitude indicator, but was not successful,” a summary of the TSB’s report reads.
As the plane was descending toward the Whatì airstrip, the other attitude indicator, on the left-hand side, also failed.
The TSB said the pilots tried to use partial-panel flying techniques to keep control. Partial-panel flight means using whichever cockpit instruments are still working to try to navigate safely.
“The captain did not have recent experience in flying partial panel and, as a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive,” the TSB concluded.
“The flight crew was unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.”
The TSB said Air Tindi had since taken “a number of safety actions” including an internal investigation and the installation of a third, backup attitude indicator in all of its aircraft that had lacked one. Attitude indicators on each aircraft now have “life limits” after which they must be replaced, and training has been amended.
Chris Reynolds, who became Air Tindi’s president in September last year, told Cabin Radio the report was “tough to read through.”
“Wounds are reopened for reliving that day and the weeks following and, of course, the memories of Will and Zach. My thoughts are with their families and friends,” Reynolds said.
Minimum equipment list
The cockpit voice recorder, recovered after search and rescue teams waded through hip-deep snow to reach the crash site, was vital to the TSB’s investigation.
Data from the flight shows less than a minute and a half elapsed between the second attitude indicator failing and the crash.
Once use of the indicators had been lost, the plane ended up in a steep descent and hit the ground at high speed.
It took hours to locate the plane’s debris field in the NWT wilderness, despite ground searches being scrambled by the communities of Whatì and Behchokǫ̀ as Air Tindi and other Yellowknife-based aviation companies began efforts of their own.
Search and rescue technicians dropped by a Canadian Armed Forces Hercules aircraft eventually located and reached the site seven hours later.
A Transportation Safety Board of Canada image shows the trajectory of the Air Tindi flight.
The report examines the decision to begin the journey despite one of the two attitude indicators refusing to work.
According to the TSB, the airline’s minimum equipment list – which helps pilots decide whether an aircraft is airworthy before take-off – specifies that the plane should not have taken off without that indicator working.
However, the flight crew decided the attitude indicator “had delayed initiation rather than that it was unserviceable,” the TSB stated. As the crew thought the indicator would eventually start to work, they continued.
Why the second indicator then failed in mid-air is still unknown, the TSB said.
When the second indicator failed, it unexpectedly disconnected the plane’s autopilot. The captain went into a “cognitive overload” trying to keep the plane flying. Neither of the crew fully recognized what was happening in time to correct it and keep the aircraft aloft.
The investigation found Air Tindi’s pilot training at the time “met or exceeded” all regulatory requirements.
However, the final report backs up a broader concern expressed by Jonathon Lee, a Transportation Safery Board official, at a conference in Yellowknife last year.
The report found that the pilots had no recent training in partial-panel flying, where they must use an incomplete set of cockpit instruments.
Lee told Cabin Radio last year this was a problem throughout the aviation industry: many pilots’ partial-panel flying ability is not routinely tested after they receive their commercial pilot’s licence, and nor does it have to be.
“The last time [partial-panel flying] showed up in Transport Canada documentation for instrument flight tests was 1992,” said Lee at the time. (Transport Canada, the federal department governing transportation, is a separate entity to the Transportation Safety Board, which investigates accidents and makes safety recommendations.)
“Currently, the only time a pilot is tested on partial-panel flying skills is when they do their commercial flight test,” said Lee. “After that, there are no more assessments, officially.”
Monday’s report ultimately focuses on two issues: crew resource management and threat and error management.
Crew resource management means how the crew uses everything at its disposal – communication between themselves, instruments, and any other technology to hand – to fly the plane.
Threat and error management is how the crew handles a problem that might affect a flight.
The TSB’s conclusion states that in this incident, both of the above were “not effective.”
Incident will form part of training
“Air Tindi agrees with both the process and the findings within it,” said Reynolds by phone on Monday morning.
Reynolds made a point of thanking the NWT’s aviation community and the many other community members who had come to the airline’s assistance on that day and since.
He said Air Tindi’s crew training would now include specific reference to this incident in sections related to crew resource management.
“We have put this incident right in there,” Reynolds said. “This accident was one that we didn’t see coming and wouldn’t have predicted coming.
“The flight crews going through the training will relive it, unfortunately, but we owe that to Will and Zach.”
Zach McKillop passed away on his 28th birthday. A fund of more than $30,000 raised online in his memory was to be put toward a bursary for future students at Sault College’s School of Aviation.
He was remembered by his family as a “charismatic, adventurous man” who loved the North and the outdoors.
Will Hayworth had been a part of Air Tindi since 2011. Flying had been in his DNA, family members said, with a grandfather and two great uncles who flew for Canada and England during World War II.
“We just hope he’s up there now, finally flying with all those who inspired his dream,” Will’s family told Cabin Radio last year.