Something about not using superior skills?

Theres’s an old saying that truly superior pilots are those who use their superior judgment to avoid those situations where they might have to use their superior skills. It’s a good saying.

On 19 August 2013 a Buffalo Airways DC-3 with 21 passengers on board took off from the Yellowknife airport in Canada. Almost immediately the right engine burst into flames. The propellor didn’t fully feather, dragging the plane down. The pilot used great stick and rudder skills to circle the big tailwheel airliner around the pattern (circuit) and land. Landing was hard, the gear was still up, and they were 100 yards short of the runway; but everybody walked away uninjured. The passengers and press reports praised the pilot:

“Damn good pilot.”

“I think the crew did a marvelous job under the circumstances. Mechanical problems do happen and it’s how you react to it. I think they reacted very well to it.”

DC3 gear up on ground
photo credit: TSB

Much later, the detailed accident report was issued by TSB. It shows serious failings of the airline and the regulator that resulted in a pilot having to use some superior skills. Buffalo Airways is portrayed in the reality TV show Ice Pilots NWT as a “renegade Arctic airline”. Turns out the TV PR contained some truth.

The airplane had not been weighed in years. Passenger and cargo weights were ‘estimated’ and seemingly massaged to fit into the legal weight and balance forms. This work was routinely in flight, after the plane had taken off! The accident investigation determined the DC-3 took off overweight.

They also found more than just terrible weight and balance practices. The airline didn’t do a full airfield analysis to ensure a safe climb path in the event of an engine failure. TSB reported:

 The organizational culture at Buffalo Airways was not supportive of a system that required the organization to take a proactive role in identifying hazards and reducing risks.

This culture, and the practices it encouraged, were not spotted or corrected by its regulator, Transport Canada. Instead, the airline was recognized as an SMS-compliant operator (SMS stands for Safety Management System, the latest and greatest safety regulatory framework). The TSB report concluded that:

The current approach to regulatory oversight, which focuses on an operator’s SMS processes almost to the exclusion of verifying compliance with the regulations, is at risk of failing to address unsafe practices and conditions. If TC does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.

Ouch.

So here we have a modern forward-thinking SMS-promoting regulator not noticing that a self-proclaimed renagade airline is not following basic rules of the air. In the end, it came down to a pilot’s superior airmanship skills to save lives. But as the saying goes, the truly superior pilot uses judgement well before we get to that point.

That’s easy to say, but real hard to do as a pilot when you’re being pushed by management, peer pressure, a history of flights successfully completed, and a regulator that says: Congratulations – you’re SMS compliant.

 

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