Air Tindi safety culture criticized in TSB’s 2023 crash report

Air Tindi pilots accepted unsafe practices as the norm, an investigation into a Twin Otter crash near the Diavik mine in December 2023 has concluded.

The plane, with two crew and eight passengers on board, hit a hill while trying to land at a work camp on the tundra in poor visibility. While nobody was killed, two people were seriously hurt.

The Transportation Safety Board’s final report, published on Thursday, found that while Air Tindi had the right procedures on paper, the airline’s safety culture had gradually drifted toward riskier flying.

Unsafe practices were informally reinforced over time without management appearing to notice or bridge the gap between theory and day-to-day experience, the TSB concluded.

Chris Reynolds, Air Tindi’s president, said he accepted the investigation’s findings and his airline had taken corrective steps.

“There’s a pride in being able to get the job done in pretty extreme or hostile environments. But unfortunately, there’s a tendency to use past experiences and how you got it done before to keep pushing forward, and to see if you can get it done again,” Reynolds told Cabin Radio.

“That’s what we need to curb, and not only curb but provide more support and more oversight – stop that and change the focus from goal-based decision-making to risk-based decision-making.”

Improvements in the two years since the crash have ranged from an $8-million aircraft instrumentation upgrade to “pretty extensive changes” in Air Tindi’s dispatch system, giving ground dispatchers more authority, Reynolds said.

Asked if he was happy that the airline’s culture has since changed, he said: “I’m very happy with how things are going. And that was as simple as personally talking to every single one of our pilots and discussing what we’re going to change going forward and how we’re going to change it.”

What happened to the plane

On December 27, 2023, an Air Tindi Twin Otter carrying winter road construction workers was trying to land at a camp on the frozen Lac de Gras when it came to grief.

Read our coverage from the time:
Dec 27, 2023: Herc rescue crew reaches stricken Air Tindi flight
Dec 28, 2023: Helicopters bring crew and passengers to safety
Jan 5, 2024: Air Tindi plane hit hill in ‘basically a whiteout’
Jan 7, 2024: Hercules crew describes Air Tindi rescue jump

While conditions had been fine for visual flight rules in Yellowknife, the weather in the vicinity of Lac de Gras required much more reliance on instruments.

The flight crew made multiple passes of the landing site and had trouble differentiating the shoreline from the lake ice.

Eventually, having performed an arc to the east of the site before returning in a final attempt to land, the crew “saw a hill in the windscreen” too late to avoid it, the TSB report stated.

The aircraft became wedged on the hilltop with half of it overhanging the edge. A Hercules rescue team and rescuers from Diavik arrived at the scene about eight hours later. Those involved were airlifted to safety the next morning.

The captain of the flight had 14,300 hours’ flying time, of which 8,000 were on this type of aircraft. The first officer was much newer to the role, having been promoted to a full-time flying position a month earlier.

“There was no indication that the performance of the flight crew members was negatively affected by medical or physiological factors, including fatigue,” the TSB stated, and there were no relevant existing concerns with the aircraft.

Why did the crash occur?

Various factors contributed to the crash.

For example, the crew had disabled a system that warns them when the plane is too close to the ground, which the TSB said eliminated “a critical safeguard.”

However, that action was also defensible and commonplace as the system, in Reynolds’ words, is “not made for landing on a frozen lake on skis.” The TSB said pilots often turned it off to avoid the distraction if it sounded in error.

“It had to be disabled at some point,” Reynolds said of the system, “but it could have been disabled better.”

The pilots relied heavily on electronic aids that wouldn’t ordinarily be leaned on to the extent they were on the day, and they didn’t adequately assess the risk posed by the conditions, the TSB found.

As an example, the crew decided to take off from Yellowknife by relying more on the weather above the city than the weather at their destination.

As long as the weather in Yellowknife was appropriate for so-called “visual flight rules” or VFR operations, the report stated, it was standard practice for Air Tindi flights to depart “regardless of the weather at the destination.”

“As the aircraft continued closer to destination, it became increasingly unlikely that the flight crew would discontinue the flight and return to [Yellowknife] owing to a downplaying of the risk in favour of goal completion,” the TSB stated.

What went wrong at the airline?

This formed part of a broader concern the TSB outlined regarding the airline’s safety culture.

“Although Air Tindi’s philosophy, policies, and procedures were thorough and in alignment with each other, at the time of the occurrence, the practices were not,” the TSB wrote.

For example, the TSB suggested the captain’s extensive experience may have led him to adopt a “higher-risk threshold for weather limits” than was necessarily wise – but the airline had also fostered a culture in which junior pilots showed significant deference to more senior colleagues.

“The first officers at Air Tindi revere the experienced off-strip captains and hold them in high regard, and may sometimes succumb to the halo effect during VFR flights in inclement weather,” the report stated,

“The first officers would not voice concerns about unsafe practices … because there was a perceived notion that ‘this is how it’s done’ when flying in the North.

“Pilots felt that management accepted that these practices were taking place.”

This concern had been raised previously, the TSB stated, and Transport Canada – a separate government entity that oversees nationwide transportation policy – had investigated a “pattern of accidents” at Air Tindi that appeared to involve similar issues.

“Seasoned Twin Otter captains have had influence on some captains to emulate their style of flying,” Transport Canada’s inspectors concluded. “There is a perceived pressure by crews to be on time, causing some to rush, even if this pressure is acknowledged as not coming directly from management.”

Even so, the TSB – which exists to scrutinize accidents and make recommendations but which does not set policy – said Transport Canada needed to improve its oversight.

The TSB concluded that “Air Tindi pilots have accepted unsafe practices as being normal work and therefore no longer perceive the risks in these practices.”

“Company oversight had also become desensitized to the risk posed by these practices because the practices were only used operationally (during flight) and were not directly observed by company management,” the report continued.

“The result was a gradual but undetected increase in risk over time.”

Air Tindi ‘put in better boundaries’

Reynolds said the TSB’s report aligned with the airline’s own internal findings and Air Tindi had embarked on a “big cultural shift” in the two years since the incident.

He said the airline had moved “from a mindset where pride was primarily on experience and skill – ‘we’ve done this before, we know how to get the job done’ – to a culture where that experience is now used to identify and manage the risk first.”

“We still value the skill and the knowledge, but we’re channeling it into risk-based decisions over focusing on getting the job done,” he said.

The TSB noted Air Tindi had taken nine corrective actions since the crash. (It isn’t the safety board’s job to assess those actions, they were simply listed.)

In commenting on the steps Air Tindi had taken, Reynolds sought to emphasize the nuance of flying in remote areas of the North and the difficulty of those trips.

“There are no road signs flying along in the air indicating the amount of visibility you have at any given time. When you’re dealing with a featureless terrain, there’s no trees, there’s no hills, there’s no anything,” he said.

“There’s not an obvious cut-off point where it’s OK all of a sudden, you know?

“What we needed to do is put in better boundaries and better restrictions to say, ‘Stop. This risk is not worth it. We’re going to take a step back and we’re not going to continue.’”

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