Lack of de-icing led to Fond-du-Lac, Sask. plane crash: TSB report | Globalnews.ca

The Transportation Safety Board of Canada (TSB) determined a lack of adequate de-icing equipment and the practice of taking off without de-icing led to the 2017 plane crash in Fond-du-Lac, Sask.

There were 22 passengers and three crew members on board the West Wind Aviation ATR-42 aircraft. All were injured in the crash, ten seriously. One passenger died days later.

The findings were released on Thursday in an investigation report by TSB.

On Dec. 13, 2017, the aircraft departed Fond-du-Lac Airport for Stony Rapids, Sask.

The aircraft collided with trees and terrain about 450 metres west of the departure end of Runway 28.

“Early in the investigation, it was determined that the aircraft took off from Fond-du-Lac Airport with ice contamination on the aircraft’s critical surfaces,” TSB said in a release.

The operator had “some de-icing equipment” in the terminal building, but TSB says it was “not adequate” for de-icing an ATR-42 aircraft.

In 2018 the TSB recommended making sure there was adequate de-icing and anti-icing equipment available for operators who need it. TSB also recommended Transport Canada “take action to improve compliance with the regulations to reduce the likelihood that crews take off with snow or ice contamination.”

The investigation also found that “well before the accident” the aircraft encountered icing conditions during the descent toward Fond-du-Lac.

“The flight crew activated both the anti-icing and de-icing systems, but some ice remained on the aircraft. However, the crew did not notice any handling abnormalities and landed without incident.”

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TSB said 45 minutes before the flight took off, icing conditions were still present and more ice had formed on the aircraft.

“After carrying out a pre-flight inspection, the first officer notified the captain of the presence of some ice on critical surfaces, but there was no further discussion or action taken.”

“Because the available inspection equipment was inadequate, the first officer’s ice inspection consisted of walking around the aircraft, at night, on a dimly lit apron, without a flashlight, and looking at the left wing from the top of the stairs at the left rear entry door. As a result, the full extent of the residual ice and ongoing accretion was unknown to the flight crew.”

TSB said departing from remote airports like Fond-du-Lac with “some amount of surface contamination” on the plane’s critical surfaces had become a common practice.

This was in part due to the “inadequacy of de-icing equipment or services at these locations.”

“The past success of these adaptations resulted in the unsafe practice becoming normalized and this normalization influenced the flight crew’s decision to depart,” TSB said.

“During takeoff, the aircraft initially climbed; however, immediately after liftoff, the aircraft began to roll to the left without any pilot input. This roll was as a result of asymmetric lift distribution due to uneven ice contamination on the aircraft.”

“This loss of control in the roll axis, which corresponds with the known risks associated with taking off with ice contamination, ultimately led to the aircraft colliding with terrain.”

TSB added following the plane hitting the ground, “the survivable space between the floor above the main landing gear and the collapsed upper fuselage and the structure was reduced.”

TSB said this led to severe injuries suffered by passengers seated in this area, included the subsequent death of one passenger.

“The design standards in effect at the time the ATR 42 was certified did not specify minimum loads the structure must be able to tolerate to allow a survivable space or minimum loads for fuselage impact energy absorption. As a result, the ATR 42 was not designed with these crashworthiness principles in mind.”

TSB said following the incident, West Wind, now known as Rise Air Aviation, has taken steps to improve internal risk assessments and now provides additional training, guidance, and better de-icing equipment to crews.

The full 240-page investigation report can be found on TSB’s website.