It was chaos in the cockpit of Transwest Air Flight 350 on the snowy night it overshot the runway at remote Sandy Bay, Sask., roared like a weed-whipper through evergreen trees and burst into flames, killing the pilot.
Canada's air safety investigators said Wednesday the pilots on the January 2007 medevac turboprop didn't get along, barely communicated, broke major pre-flight and in-flight rules and effectively worked against each other as the plane hurtled toward the ground.
"The crew was unable to work effectively as a team to avoid, trap or mitigate errors and safely manage the risks associated with the flight," David Ross, a senior investigator with the Transportation Safety Board of Canada, said in an interview from Winnipeg.
It's a problem, the board reports, that is more widespread than the Sandy Bay crash, adding that Transport Canada needs to invoke mandatory training for crews of commuter and taxi aircraft to ensure they work together when crisis strikes.
Rick Wolsey, 52, of Ontario, has been identified as the victim of the crash of the Beech A100 King Air craft, operated by Prince Albert-based Transwest Air, though he is not named in the report.
His first officer, a woman, 24 at the time, had minor injuries while two emergency medical technicians on board were injured severely but survived.
The report paints a damning picture of two flyers who didn't get along. He was the grizzled veteran, she the eager newbie. He didn't trust her flying and told this to his supervisor a few months before the crash. Work with her, he was told. Be more assertive. Give her tips.
Less than two months before the crash they were flying in to Meadow Lake, Sask. She told him he was banking excessively and coming in too low. He ignored her, and ended up having to land on the wrong runway, with the flaps not fully extended. The company investigated, told Wolsey to smarten up but didn't take further action. She was told to be more assertive.
Two weeks later, both were suspended when they failed to notify the airport at Fort McMurray, Alta., that they were coming in for a landing until they were just two minutes out.
They were oil and water, said the report: "One pilot had advised (a Transwest supervisor) verbally of his concern about pairing the captain and first officer, and also verbally advised the La Ronge base manager not to pair the captain and the first officer."
Nevertheless they were paired again on Jan. 7, 2007, when a call came in from the Sandy Bay Medical Centre. A patient needed to be transferred from Sandy Bay to Flin Flon, Man.
There were clouds and scattered flurries in the region when the plane took off at 7:30 p.m. from La Ronge for the 190-kilometre flight east to Sandy Bay.
The runway at Sandy Bay was gravel and snow and shorter than most. Cold temperatures can nobble altitude readings. The landing approach could be tricky. They never discussed it.
There were no pre-flight aircraft performance calculations. They didn't leave behind a copy of the passenger manifest as required. The two EMTs in the back were not told a thing, either on takeoff or on the aborted approach.
You fly, Wolsey told the first officer as she sat down to his right in the plane for the half-hour trip at 11,000 feet. At one point he took control of the steering, then handed it back.
"I have control," she said. "You have control," he said, following standard procedure.
As they started their descent into the Sandy Bay aerodrome, they could see the distant lights of the town and hydroelectric dam set in the inky blackness. She had plotted a straight-on approach and he coached her in.
Flaps were in landing position. Wheels down. Landing lights on. All set.
You're too high, he told her, as he cut back the engine power. Steepen the descent.
She realized they'd miscalculated and were fast running out of runway. Perhaps we should do a go-around, she suggested, failing to flag the impending danger.
No. Cut power and land.
They were just metres above the runway and the end fast approaching. Now Wolsey realized they couldn't make it. They had to bail out.
He grabbed the controls, not saying a word, slamming the levers to full power, adjusting the flaps almost at the same time she was trying to adjust the flaps.
He was disoriented in the darkness. He thought they were pulling up. Instead they were heading down into the tall poplar and evergreen trees that suddenly loomed up and filled the cockpit windshield.
The plane hit the forest at full force, carving and bending trees as the plane travelled the length of a hockey rink, slicing off the tips of the wings and ripping open the underslug fuel tanks in their rubber bladders.
Whumpa, whumpa, whumpa. They came to a rest with the nose pushed in.
Everyone survived but Wolsey was hurt badly. Fallen trunks covered the plane and blocked the door. The first officer and an EMT managed to kick it open and scramble through the waist-deep snow to look for help. The leaking fuel caught fire and the plane erupted in a hot whoosh of yellow and orange.
Help was already on the way but took time in the dense bush. Police and rescuers arrived on snowmobiles two hours later. By then Wolsey was dead.
Ross said crew management training, or CRM, is a widely accepted practice that builds trust and reduces friction in flight crews. The training gives flight crews tips and guidelines to reduce errors, communicate better and mitigate disaster when it occurs.
The board said the training needs to be mandatory for commuter and air taxi aircraft. Wolsey and his first officer had some training, but not with Transwest, and none was required by the company.
In the last 15 years, the board said, it has investigated eight such incidents across Canada, where lack of CRM training had contributed to a crash.
The incidents led to seven deaths and one minor injury.
"The potential for more serious consequences was high."
Transport Canada spokesman Brad McNulty said they are examining the recommendation.
"We have 90 days to review and develop a formal response," he said from Ottawa.