A Pilot's Perspective.

By Barry Meek.

May 2014 

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 no survivors.

             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 attention decrements.

            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.             

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