At the time the crew of Regionnaire Flight 347 were beginning their approach into Sept-Îles, the weather was being reported as a 200 foot overcast ceiling and 1/4 mile visibility in fog. With only Runway 13/31 available for use that day, the crew planned for an approach onto runway 31, for which there exists only an NDB approach. In the hierarchy of instrument approaches, NDB approaches fall into the bottom of the list, at least with regards to precision. Generally speaking, the greater the precision of the approach aid you are using in order to align yourself with the approach path, the lower you can descend. ILS approaches, which give precise lateral and vertical guidance, can guide most aircraft down to 200 feet above the ground. NDB approaches on the other hand, have higher minimums owing to the fact that they are not as precise. The minimums for the NDB Runway 31 approach into Sept-Îles is 506 feet above ground or 680 feet above sea level. What the crew of flight 347 should have done after they crossed the NDB beacon heading towards the airport was descend to 680 feet on their altimeters, and fly at that altitude until one of two things happened; either they would gain sight of the runway before the specified missed approach point, and with the runway in sight, continue the descent to land, or if the low ceiling and visibility prevented them from seeing the runway environment before the missed approach point, initiate a climb at the missed approach point and set up for another approach, or proceed to their alternate airport. Instead of stopping their descent at 680 feet until they had the runway in sight, intentionally or otherwise, the crew continued the descent below that altitude. Their radar altimeters, which are usually set to the MDA, or the height you are permitted to descend to without the runway in sight which in this case was 506 feet above ground, was instead set to 100 feet. This could have indicated that the decision to continue below minimums was a conscious decision, and not a fatigue induced error. At 100 feet the radar altimeter sounded, alerting the crew to their proximity to the ground, as did the ground proximity warning system (GPWS). The aircraft came to rest just under a mile from the airport, the cockpit having completely separated from the remainder of the fuselage, leaving the captain fatally injured while the copilot and two passengers sustained major and minor injuries respectively.
While the errors and violations of regulation that the crew of Flight 347 made on their series of flights that evening were many, it is not my place to make comments on the actions of the crew that evening, nor do I believe there is any benefit to be gained from writing about what the rest of us "could have done" if placed in their shoes that night. Notwithstanding the death of Captain Yvan Tremblay, I believe the real tragedy is the lack of ownership Gagné takes for his actions that evening.
When talking about his working for two companies in order to build time and experience Gagné states "obviously you make arrangements, and quickly you're logbook entries go past legal limits".
In the next bit, Gagné talks about the legal requirement for operators to remove flight crew from duty who are or will go over the legally allowed limit; "thats what should have happened, but it is not always followed very rigorously. You have to submit your flying hours once a month, so by the end of the 30 days, you may very well have exceeded those limits without even realizing it yourself" This I don't buy. As pilots we are required to track our flight and duty times to ensure that we do not exceed those limits set by the regulations. While operators are legally required to remove the flight crew from duty if there is a threat that they will exceed flight duty limitations, the onus rests on the pilot's shoulders to advise the operator that you are approaching those limitations.
In the closing minutes of the first segment, Gagné finishes off by saying "no one wants to be exhausted, no one wants to get hurt, no wants to have an accident, but it's the culture of the industry that brings us there."
I agree that no pilot worthy of a license wants to be exhausted, or get hurt or have an accident, however I do not buy into the idea that it is pilot culture that is to blame. While there are undoubtly pilots in the industry who are willing to bend or break the rules in order to complete a flight, the majority of pilots show up to work quite willing and able to make the tough, and sometimes unpopular decisions that need to be made in order to maintain the legality and more importantly, the safety of the flight. We may lay blame to culture, or pressure from management, or lack of regulatory oversight, or any of the other hosts of excuses that exist, but the reality is that it is the pilot in command who bears the responsibility for the flight. While pressure from management or passengers can be uncomfortable at best and the temptation to cut corners sometimes almost overpowering, ultimately it's the name and license number on the flight plan that will be held accountable when and if things come off the rails.
As it has been demonstrated many times in the past, even the best pilots are not immune from making mistakes, but as Henry S. Haskins once said "Mistakes fail in their mission of helping the person who blames them on the other fellow. "
CBC The National "Dead Tired"-http://www.cbc.ca/thenational/indepthanalysis/story/2010/03/24/national-deadtired.html
Regionnaire Flight 347 TSB Accident Report- http://www.tsb.gc.ca/eng/rapports-reports/aviation/1999/a99q0151/a99q0151.asp
