The Transportation Safety Board of Canada (TSB) has issued a report on its investigation into the August 16, 2014, air ambulance crash on Grand Manan.
     Atlantic Charters' Piper PA‑31 Navajo was returning from a medevac flight to Saint John with two pilots and two passengers, arriving at Grand Manan at 5 a.m. The airport approach is over a sparsely populated and dimly lit area, and it was foggy at the time. On the first attempt to land, pilot Klaus Sonnenberg decided to carry out a go‑around and circled for a second approach. The plane landed on Bancroft Road, about a quarter‑mile from the runway threshold, travelled through 100 feet of brush and was briefly airborne as the terrain dropped away, then banked steeply into the ground. Sonnenberg and paramedic William Mallock were killed. The first officer and a nurse were seriously injured. When first responders arrived about 15 minutes later, they were unable to see the plane through the fog.
     Investigators found no indication of mechanical or flight control systems failure. Nor did they think that Sonnenberg's 2012 diagnosis of vestibular neuritis, which can cause dizziness and imbalance, was a factor. However, they did note that the condition was not reported to Transport Canada by either Sonnenberg or his doctor, who was the area aviation medical examiner.
     They were unable to determine whether the aircraft was within its weight and balance limitations. The report cites a number of discrepancies in these forms and in maintenance records, acknowledging that some records had been lost in a fire. It also questions the training and authorization of company pilots who swapped the interior equipment between passenger and medevac configurations, noting that the required documentation in journey logs and weight and balance forms was lacking.
     The report states that situational awareness and communication between the two pilots was reduced because there was only one headset aboard, thus "the first officer was focused on locating the runway and was unaware of the captain's actions during the descent." Investigators believe that a GPS unit was being used on the approach and state that when operating under the Canadian Aviation Regulations subpart pertaining to this flight, "the company was not authorized to conduct GPS approaches." Other stated risks included loose medical equipment bags in the cabin and the fact that Mallock was not wearing a seatbelt. Ambulance New Brunswick (ANB) required Atlantic Charters to provide semiannual safety training to flight paramedics in lieu of a safety briefing prior to each flight; the report states "this practice does not meet the regulatory requirements" and may increase risk.
      A steep descent preceded the crash. Two possible scenarios are presented in the report: either an attempt to "get under the weather" in order to see the runway lights early or a visual illusion caused by fog and darkness, which can create the impression of being too high. The latter was a factor in 21% of approach/landing accidents in a 1998 Flight Safety Foundation study. Investigators could not determine which might have been the case; however, lack of visual references is the significant factor in both, with the road likely indistinguishable from surrounding terrain.
      The report notes that approach‑and‑landing accidents are on its watchlist as one of the problems posing greatest risk to aviation safety. The TSB urges Transport Canada to implement regulations and oversight of formal safety processes, and says the current procedures are "at risk of failing to identify and address unsafe practices and conditions." The report also comments on ANB's "limited aviation knowledge" and unfamiliarity with some standard industry terms and the importance of regulated safety procedures, which means the organization relies on its service providers to ensure compliance. However, the TSB's goal is "advancing transportation safety. It is not the function of the board to assign fault or determine civil or criminal liability."
     In response to an inquiry to ANB, director of operations Yvon Bourque wrote, "Our top priority is, and always has been, the safety of our patients, paramedics and the general public.
     "We continue to review this report to understand as fully as possible what factors contributed to the fatal crash on August 16, 2014. Our thoughts remain with the families of those affected."
     In response to the report, Atlantic Charters issued the following statement: "The company believes the Transportation Safety Board investigation and the ensuing report have failed the affected families, public and aviation industry. We will continue to challenge this report until the actual incident and public safety are served."
      Sonnenberg had over 17,000 flying hours, 20 years of experience with PA‑31s and had been flying medevacs and charters on Grand Manan for over 30 years. Islanders fought long and hard to retain Atlantic Charters as their primary medevac provider, citing round‑the‑clock availability and reliable service, following changes to the provincial air ambulance service in recent years. As news of the report spread, many expressed their continued support for the company on social media, reminding readers of loved ones whose survival they attribute to a timely medevac. The 42‑page report is available online at <www.tsb.gc.ca/eng/rapports‑reports/aviation/2014/a14a0067/a14a0067.pdf>.