Addressing substance abuse in the aftermath of tragedy

By Kathy Fox,
Chair, Transportation Safety Board

This article was originally published in the February-March 2018 issue of Skies magazine.

On the morning of April 13, 2015, a Metro II turboprop departed Vancouver International Airport on a cargo flight to Prince George, British Columbia, only to disappear from air traffic control radar about six minutes after takeoff. When the wreckage was discovered later that afternoon, TSB investigators had few clues about the accident's cause: both pilots died in the crash, and there were no voice or data recorders on board.

Eventually, using data from ground radar and air traffic control logs, TSB investigators were able to piece together the flight path: shortly after acknowledging a clearance to climb to flight level 200, the aircraft entered a steep dive, and the subsequent extreme speed exceeded the aircraft's structural limits, resulting in an in-flight breakup.Footnote 1

But knowing what happened in an accident is only the first step; just as important is finding out why. That's where another piece of information proved critical: a toxicology report from the coroner showing that the captain had a blood alcohol content of 0.24—meaning he had consumed a significant amount of alcohol on the day of the occurrence.

Taking this into account, investigators narrowed down the list of possible scenarios to just three. Although each one still leaves unanswered questions, each also has a common element: alcohol.

The first scenario is pilot incapacitation. Based on the captain's high blood alcohol content, his physical and mental performance would have been significantly impaired. He might even have slipped into unconsciousness during the flight. Yet the TSB's investigation found no indication that the first officer was incapacitated, and he should still have been able to regain control of the aircraft.

The second scenario involves the aircraft's pitot system. If, for instance, the heaters for the pitot tubes malfunctioned—or if the pilot's level of impairment was such that he did not turn them on—they may have become blocked with ice. And if this happened while the aircraft was in cloud, the crew may have inadvertently initiated a descent while trying to find out what was happening with their flight instruments. The initiation of that kind of a descent, however, would have been unlike the rapid, almost vertical flight path followed by this aircraft—which should have been immediately, physically apparent to the pilots.

The third scenario involves the possibility that the aircraft was intentionally placed into the steep dive. The investigation identified several flight-specific factors consistent with this, including: the aircraft's descent in the direction of flight, its full nose-down trim setting, the duration of the dive, the absence of any type of emergency communication, and the absence of any apparent recovery action during the descent. Moreover, post-mortem examination revealed that the captain exhibited physical-health indicators of long‑term heavy alcohol consumption, which is associated with increased risk of suicide. The investigation, however, was unable to establish whether the captain had any disposition toward such an act.

Ultimately, it could never be determined exactly why the aircraft entered such a steep dive that day. Nonetheless, there is a clear need to address the risks of impairment among employees in safety-sensitive positions.

One option, favored by countries such as the United States and Australia, is mandatory drug and alcohol testing. This has been shown to be most effective when complemented by other initiatives such as education, employee assistance programs, rehabilitation- and return-to-duty programs, and peer support.

Currently, there is no similar requirement for such programs within the Canadian aviation industry. And although Transport Canada regulations prohibit flying while impaired, these rely heavily on self-policing. Yet previous TSB investigations have shown that self-policing is not enough; drugs and alcohol are simply not conducive to making sound decisions, especially about whether one is fit to fly.

The TSB acknowledges that employees within Canada's aviation industry will have concerns under any possible testing regime here, and those concerns are understandable and must be addressed. At the same time, the regulator and the operators must also consider public safety.

That is why the TSB recommends a comprehensive approach, not "just testing." We are calling for Transport Canada, in collaboration with the Canadian aviation industry and employee representatives, to develop and implement requirements for a comprehensive substance-abuse program—including drug and alcohol testing—to reduce the risk of impairment of persons while engaged in safety-sensitive functions. These requirements should consider and balance the need to incorporate human rights principles enshrined in the Canadian Human Rights Act with the responsibility to protect public safety.

Such a program would contribute to reducing the risk of impairment on the job while also providing help to those employees with substance-abuse problems. That's a win for all concerned, and hopefully, one that happens before more lives are lost in needless tragedy.

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