Despite errors, agency refuses to re-open plane crash probe
Former pilot finds errors in analysis of nearly 25-year-old air ambulance crash that killed four
A former pilot is pressing federal investigators to take another look at a plane crash that killed four people in Northern Ontario almost 25 years ago to resolve unanswered questions over the fatal air ambulance flight.
Mark Norrish says he wants the Transportation Safety Board to go back to its report on a Nov. 29, 1988 air ambulance crash in Chapleau, Ont., and re-do the analysis based on errors he says he has found in the final report.
But the board is refusing, arguing the errors in the report don't change the fact that there isn't enough information available to determine why the plane crashed. And, last month, a lawyer for the agency wrote Norrish and told him he had to destroy records about the crash that he obtained under federal Access to Information laws.
Norrish flew for Voyageur Airways, the airline whose plane crashed, at the time of the accident. But he says he didn't follow the investigation and never saw the final report until he looked it up in 2011.
The mysterious crash of the Beechcraft King Air killed all four on board: the pilot, co-pilot and two paramedics on their way to pick up a woman in Chapleau who had shot herself. The woman was taken to hospital by land instead and survived.
"I read the report and I was astounded to find that the investigation had never been solved," Norrish said.
"I got a bit of a sick feeling in the pit of my stomach because the circumstances of the accident sounded quite a bit like an incident that happened to me while I was at Voyageur."
The crash report, released in 1991, didn't find a reason for the accident. It did suggest the pilot and co-pilot were flying too low, saying they "may, for unknown reasons, have become distracted during the descent ... and unknowingly descended below the appropriate minimum altitude."
The report reminded Norrish of his own close call a few months after the Voyageur 796 crash, in which he recalls a one-inch altimeter setting error that put him and his first officer 1,000 feet closer to the ground than they thought they were. And he believes that could be what happened to the pilots trying to land in Chapleau in 1988.
Unsatisfied with what he learned from the report, Norrish requested the case file under federal Access to Information laws. Comparing the report to the investigation notes and technical report, he said he's found two errors in the analysis.
Norrish wants to see the TSB take another look at the crash of Voyageur 796. And at least one of the families affected supports his call.
Different weather reported
The Voyageur flight was the first for the company under a contentious new contract to provide air ambulance services for Ontario. A union for the paramedics protested the contract over concerns the pilots were less experienced than the pilots with the airline that had the contract previously.
The crash report found pilot David Townsend was a cautious, experienced pilot "not known to push the weather" or otherwise compromise safety standards, though there was no sign he'd ever flown into Chapleau.
One of the medics who was killed, Ian Harris, had been at a protest at Queen's Park just weeks before the crash, and, investigators said, took out extra life insurance a few days before the accident, according to interview transcripts released under federal Access to Information laws. The transcripts also show a journalist in Timmins told investigators that he'd gotten a call hours before the crash from a medic, later determined to be Harris, who complained about how the Voyageur pilots were overly aggressive on takeoffs and landings.
In December, 2011, Norrish petitioned the board to re-open its investigation based on a theory he has about the altimeter setting, a common cause of crashes where everything seems normal until the crash itself. Pilots set their altimeters based on information provided by the airport and the instrument tells them how far above ground they are.
The board denied the petition based on a lack of new information — while problems with altimeter settings were discovered in the 1990s to be more widespread than previously thought, there was no flight recorder in Voyageur 796, so it's impossible to prove it was a problem in this case, the board said.
The board also said it is "of the opinion that a full re-examination of the investigation would not result in a conclusive determination as to whether there was an altimeter setting error."
Unsatisfied, Norrish requested the file from Library and Archives Canada, and got thousands of pages.
Conditions at time of crash unclear
The last observation from the ground at Chapleau the night of the crash was taken two hours before the plane was to land and noted an overcast sky with a ceiling of 2,000 feet (610 metres) with four miles (6.4 kilometres) visibility. The ceiling is the height at which cloud cover ends.
But the report into the crash instead lists the conditions two hours before as a 1,000-foot (305-metre) ceiling, broken clouds and eight miles (12.8 kilometres) visibility. Those observations, along with temperature readings, appear to match the conditions logged 24 hours later, albeit with a different ceiling.
A worker for another airline who was called into the airport at 1 a.m. — about two hours after the crash — said she measured the ceiling at 700 to 800 feet (213 to 244 metres) with scattered or broken clouds and two miles (3.2 kilometres) visibility. Those are also the conditions that the TSB sent in an email to CBC News in response to questions about the erroneous weather in the report. The airline worker told investigators that the search and rescue crew who landed just before 2 a.m. found a much higher ceiling of 6,000 feet (1,829 metres) with visibility between two and three miles (3.2 to 4.8 kilometres).
"They should at least correct the errors in the investigation," Norrish said. "I think we owe it to the four people who died in that crash."
It took him a day to conclude the investigators had used the wrong weather in their accident analysis. Instead, he believes they used weather reported 24 hours later.
The actual weather would have put the cloud ceiling higher than the ceiling investigators cited in writing the report. Norrish believes that makes it possible Townsend and first officer Byron Ewart were trying a different approach route, one based on visual cues rather than the instrument-based approach assumed by the TSB.
"And I checked it 10 times myself, and I still didn't quite believe what I was looking at," Norrish said.
"When you do the technical analysis, it makes a difference in the analysis of the accident."
Norrish went back to the agency in an email asking for confirmation of his finding — a finding CBC News has confirmed with a former air force pilot — and got a letter back from Wendy Tadros, chair of the TSB.
"She told me that they had no resources and no mandate to look into the matter any further, so they considered the case closed," Norrish said.
Jacqueline Roy, a spokeswoman for the board, told CBC News that TSB has just under 100 investigations underway and the focus of the board is is on improving current safety practices.
'No new evidence'
The debate over visual versus instrument flight rules is a key point of dispute between Norrish and the board. If the plane was flying "visual flight rules," then it wasn't too low, Norrish says.
TSB's response to CBC News' questions about the plane's approach treats it as a separate theory from Norrish's altimeter theory. Yet Norrish says pilots performing a visual approach, especially in a small town with few lights, would still rely on the altimeter to tell them how high above the ground the plane is.
"The latest theory being advanced, that the crew was flying VFR, is speculation," TSB spokesman Chris Krepski wrote in an emailed statement. "It is impossible to determine this without a Cockpit Voice Recorder."
"We reiterate, there is no new evidence, including the weather information, that would likely change the outcome of the investigation, which is that the aircraft descended below the applicable minimum Instrument Flight Rules (IFR) altitude while approaching ... Chapleau."
Norrish has also found that while a technical report shortly after the crash said the debris trail started 1.4 kilometres from the airport, the full report released in 1991 said the distance was 1.5 nautical miles, which would have put it almost twice as far away.
Roy admits there may be factual inaccuracies in the report, but says neither error would lead to a different result.
"It is our view that they [different weather or wreckage trail distance] would not change the fact that this aircraft descended below applicable minimum IFR altitude and struck the ground. They may well generate additional theories as to why the crew did so—but these are theories that will never be capable of being proven on the basis of the available evidence... If further investigative work would only result in theories that will never be capable of proof, how will the public interest be served by re-opening this investigation?" she said in an email to CBC News.
"The Board spent considerable time reviewing the petition and found the theory set forth could not be proven one way or the other. On the face of it, the latest arguments seem to amount to more of the same."
Medic's son wants another look
Norrish isn't the only one who'd like to see the mystery of the crash solved.
Dan Contant, whose father, Donald, was killed in the crash, says he would like to see some closure for the families of the men who died. He's looked at Norrish's website and says it appears there are inconsistencies.
"It definitely warrants a re-look at all of these investigations that happened over all this time," he said, acknowledging that it doesn't change the outcome for his family.
"[To] find out even if it was pilot error or wasn't pilot error. It would be nice to find out for sure and it would give closure to a lot of the families, as well, that were involved in that."
Like his father, Dan Contant became a paramedic after his mother suggested he might like the career as much as his father had. He now works for Ornge, Ontario's air ambulance service, where they have awards given to the Voyageur 796 flight crew posted on the wall of the hangar.
Max Shapiro, president of Voyageur, says there isn't enough information on Norrish's website "to have a meaningful comment" on his theory.
"Suffice it to say that we could not find much fault with the final TSB report," Shapiro said in an email to CBC News.
'Will always remain theories'
Roy says the board decided re-opening the investigation wouldn't advance transportation safety, pointing out that the accident was 25 years ago and the evidence is limited because there was no flight recorder on board.
"In the future, there may be yet another theory advanced and another and another. So the question becomes, will re-opening this investigation to examine theories, theories which in our opinion cannot be proven and will always remain theories, a responsible use of investigators time and taxpayers monies?"
Norrish says it looks like the board didn't do a good job of investigating the case or looking at his petition.
"I'm not an expert on these matters. I'm not a politician, I'm not a lawyer. But to me, the board is an independent agency but it doesn't seem that they're being accountable and it also doesn't seem like there's much oversight involved," he said.
Norrish believes the board was overworked at the time of the crash, with at least one major investigation under way. But he'd still like to see the crash analysis re-done, arguing it wouldn't take long.
Norrish also raised the issue that Voyageur's former director of operations, Mark Clitsome, is now the safety board's director of air investigations.
Krepski says it isn't an issue.
"For the record, Mr. Clitsome was not involved in the original investigation, in the production of the report or in the review of the petition," he said.