Bad Decisions by Pilot
/ Tragic Result
(2014 is the 10-year anniversary of this crash.)
Freezing rain mixed with light snow was falling over a large
area around the Great Lakes on January 17 in 2004. It was the
type of weather that most pilots prefer to avoid. But sometimes
there are pressures that promote bad decision making. A
combination of unforgiving weather and a stressed, fatigued
pilot who chose to take off into it, ended in a crash that is
still vividly remembered by residents of a tiny Canadian Island
in Lake Erie.
In Lake Erie, thirty five miles south of the Windsor,
Ontario, sits Pelee Island. It has a population of only about
180 full-time residents, and like many isolated places, it
struggles to survive as a viable community. Tourism has evolved
as the main economic driver of the island. But even though it’s
surrounded by 35 million people, Canadians and Americans, the
little island township is one of Ontario’s most remote
communities. 'Sometimes it’s as hard to get here as it is to
get to Hudson Bay,' says township Mayor Rick Masse.
Access to Pelee Island is by ferry in summer, and by
commuter planes during winter months when the lake is frozen.
Like communities in the far north, all provisions arrive by air
in the winter. The elementary school has less than ten pupils,
while high school students must live on the mainland and attend
classes, often returning home on weekends via the air service.
There are many challenges to individuals living in
such remote, practically inaccessible locations. Isolation and
loneliness notwithstanding, there is not much in the way of
income sources for the locals. Tourism is seasonal, so in the
late fall and early spring months when things are quiet, the
island actively promotes pheasant hunting. The annual events
are important to the economy. They allow accommodations owners
and restaurants to make some additional money before and just
after the long winters. The hunts that started in the 1920s
used to draw over twenty two hundred hunters over a three-week
period. They now attract only about fifteen hundred.
On that dark, freezing, wet January night in 2004,
a group of eight Canadian hunters was returning to the mainland
following their contribution to the economy of Pelee Island.
Unfortunately, their aircraft carried more than just the
passengers. With a heavy load of ice, it would not get more
than two miles from the Pelee airport before crashing, leaving
Excerpts from the Transportation Safety Board tell
the story: “Georgian Express Flight 126, a Cessna Caravan
208B, departed Pelee Island en route to Windsor, Ontario, at
4:38 p.m. eastern standard time. Shortly after take-off, the
aircraft struck the ice-covered surface of Lake Erie, killing
all 10 occupants.”
Cessna Caravan like the one in the story:
Eight hunters, one other passenger, the pilot and
two hunting dogs perished.
That statement tells what happened. But why did it
happen? This was an easy one for the TSB to figure out.
First, the aircraft was overweight when it took off. Seriously
overweight, by almost 1,300 pounds, at least 15% above MGTW.
The aircraft was also contaminated with ice on departure.
Freezing rain was falling during the descent into Pelee Island
and on the ground during the turnaround. The pilot did a visual
check of the plane and proceeded to load the passengers and
cargo without de-icing the aircraft.
Witnesses heard the crash, but no one actually
saw it. At 19:08, the aircraft empennage and debris were
spotted by a United States Coast Guard helicopter on the frozen
surface of the lake, about 1.6 nautical miles from the departure
end of the runway. There were no survivors. The empennage sank
beneath the surface some four hours later. The wreckage recovery
was not fully completed until 13 days later.
The 32 year old pilot held a valid airline
transport pilot license (ATPL) and had been employed by Georgian
Express Ltd. since November 2000. His total time was about
3,500 hours with 957 hours on the Caravan. No one knows why
such an experienced, careful pilot would make the decision to
depart into freezing rain with an overweight, iced-up airplane
carrying ten people.
The following is what’s known to have occurred in
the few days preceding the crash. On January 13, the pilot flew
as a passenger to Los Angeles, then returned to Toronto on
January 16, the day before the accident flight. From L.A. he
arrived at Toronto about 9 pm. Using conservative estimates for
the time it would take to process through the airport and drive
home, it is unlikely that he could have been in bed much before
midnight. He arrived at work the following morning at 0445. This
allowed for approximately four hours of potential sleep time the
night before the accident flight.
At 0600 in the morning the pilot flew the
Caravan from Toronto to Windsor, Windsor to Pelee Island and
return, landing back in Windsor at 0916. Then after a rest
period, he returned to the airport at 1445 to prepare for the
afternoon Pelee Island flight to pick up the hunters.
With the information known, we can surmise that
this fellow was indeed tired. More like fatigued! Jet lag was
likely a player (he had been through 3-hour time zone changes
twice in the preceding four days), and the night before this
flight, his sleep time was only about four hours. But there
were some serious lapses in judgment displayed as well. For
instance, although there was plenty of fuel on board the
aircraft for the afternoon flight to Pelee Island and back to
Windsor, with reserves and alternates, he chose to take on
another 1,000 pounds before departing. He knew what he was
picking up over there; eight big men, a small woman, 590 pounds
of baggage, and two 70-pound hunting dogs. The question, “why
add more fuel?” begs an answer.
If that wasn’t serious enough, the observed
weather should have been probable cause to cancel the flight.
Visibility was 2 miles in light snow, freezing rain and mist,
overcast at 500’ AGL. Another aircraft had reported putting in
at an island 10 miles away with over a quarter inch of ice
accumulated on the airframe. The fact that there was no
de-icing facility on Pelee would be a consideration as well,
given there would be a stopover lasting at least 10 minutes to
pick up the passengers and load the cargo.
It is common sense to most pilots that take-off
should not be attempted with ice or frost contamination on the
surface of an airplane. Cessna puts it in writing: The Cessna
Caravan POH states in Supplement 1 that “the in-flight ice
protection equipment is not designed to remove ice, snow, or
frost accumulations on a parked aircraft sufficiently to ensure
a safe take-off or subsequent flight. Other means (such as a
heated hangar or approved de-icing fluids) must be used to
ensure that all wing, wing strut, landing gear, cargo pod, tail
,control, propeller and windshield surfaces, and the fuel vents
are free of ice, snow, and frost accumulations before take-off.
If these requirements are not accomplished, aircraft performance
will be degraded to a point where a safe take-off and climb out
may not be possible.”
It seems pretty clear that the pilot made some poor
choices, possibly because of the fatigue. Add to that fatigue,
the stress he would be feeling as well. Picking up ice en route
to Pelee in the first place, would be cause to consider
canceling and returning to Windsor. But knowing there were
eight big, tired, wet, and cranky hunters waiting to get the
hell out of there might have been probable cause for him to
think, “let’s get this over and done”.
Many studies have been done on stress and the ways
in which it can affect those subjected to it. While not getting
into too much detail (that’s another whole article) we know that
while stress may not decrease overall job performance, it can
impair basic cognitive processes such as working memory and
attention. Individuals under stress do not retain as much
information in memory while making decisions, nor are they able
to attend to as many simultaneously presented pieces of
information as unstressed individuals. Stress and fatigue
combined can further exacerbate these working memory and
Cause of this accident was chalked up to pilot error
and bad decision making for reasons not exactly understood.
Many sources declared this fellow to be a safe, conscientious
pilot who had often canceled flights in the past due to weather
or mechanical issues. So why did he choose to fly on that
particular flight with an obviously overweight, ice-contaminated
airplane? We will never know the answer to that.
When mechanical malfunctions or weather conditions
cause a crash, we can understand. But humans are not machines.
We’re not always predictable. We can think and control our
thoughts. We have feelings like love and compassion and
regret. We also have emotions called fear, anger, happiness and
sadness. Humans can learn and be trained, but we cannot be
programmed never to make a mistake. Transport Canada and the
FAA would like to think it’s possible, but human error will
always figure into accidents in a significant way.