Pilot decision-making and poor weather conditions contributed to the fatal plane crash killing Shawn Thomas Kitchen and Julia Lane last summer, according to a Transportation Safety Board (TSB) investigation.

The TSB released its investigation report this morning.

The accident occurred on Aug. 6, 2019. The Alkan Air 208B Grand Caravan Cessna was travelling from Rackla, a mining airstrip northeast of Mayo, to the Mayo airport.

The plane crashed on the side of a mountain near Mayo Lake.

Both Kitchen, the 24-year-old Whitehorse pilot, and Lane, 33, of Vancouver, were confirmed dead at the scene.

Lane had been working in the Rackla area for a geological consulting firm.

The TSB investigation found that low visibility due to poor weather contributed to the accident.

The aircraft diverted from the intended route, turning south into a box canyon, where clouds would likely have obscured the mountain tops.

“Within the box canyon, the canyon floor elevation increased abruptly,” the report says.

“...The low visibility prevented the pilot from detecting this and taking sufficient actions to prevent collision with terrain.”

The aircraft struck the rising terrain, fatally injuring the pilot and passenger and destroying the aircraft. The investigation found that a brief post-impact fire followed the crash.

The TSB resolved that the accident was not survivable, due to the force of impact.

The investigation found that the pilot continued a low-altitude, high-speed flight in poor weather conditions, reducing his opportunities to avoid the terrain.

The poor conditions, combined with pilot decision-making, contributed to the accident.

Kitchen was certified and qualified for the flight, the report determined.

The pilot had worked for Alkan Air since 2016 and had completed his training as a captain on the Cessna Caravan in May 2019. 

Kitchen’s training assessments describe the pilot as “exceptional, well organized, flew above standard, and adapted well.”

The Aug. 6 flight was Kitchen’s first assignment as a captain at Alkan Air in a challenging operational environment: remote, with mountainous terrain, the report notes.

“The pilot’s above-average performance during training and the company’s confidence in the pilot to perform this type of flying suggests that he had a significant level of confidence and optimism,” the report’s analysis says.

Alkan Air had provided Kitchen with training that exceeded what was required of the company by regulations. Weather restrictions were also placed on the pilot.

The pilot was not allowed to fly if cloud height was below 2,000 feet above ground level.

The hourly weather and forecast weather in Mayo never went below those restrictions; however, weather encountered along the route was less than those restrictions, the report says.

The TSB resolved that several factors influenced the pilot’s decision to continue the low-altitude flight into poor weather conditions.

The pilot had recently completed a similar flight under similar conditions, the TSB found.

“The pilot’s decision-making would have been affected by his familiarity with the route and, consequently, he likely did not consider an alternate route to avoid the poor weather conditions,” the report says.

Shortly after departure, Kitchen encountered low cloud ceilings requiring him to fly as low as 30 metres (100 feet) above terrain. 

“When flying at low altitude, pilots direct a significant portion of their attention outside the aircraft to avoid striking trees,” the report says.

The pilot was likely focused outside the aircraft when it turned into the box canyon, the report suggests.

The increased “cognitive workload” of flying at low altitudes reduces a pilot’s ability to refer to map displays and maintain awareness of the aircraft’s location.

“The pilot turned into the box canyon likely believing that it was the continuation of Granite Creek as it turned to the south, toward the west end of Mayo Lake,” the report says.

“The GPS did not record a change of altitude that would suggest the pilot was trying to perform a best angle ... to clear the ridge of the box canyon.”

A possible alternative for the pilot was to fly primarily by reference to instruments, rather than visuals. This would have allowed the pilot to fly into the clouds, at a safe altitude.

Transitioning to instrument-primary flying mid-flight can be considered in an emergency, the report says.

It adds, however, that the pilot had no history of transitioning from visual flying rules to instrument flying rules in an emergency.

The aircraft’s low-terrain warning systems were ineffective in alerting the pilot of the sudden steep terrain, the report found.

The aircraft does have terrain awareness and warning systems, but they are designed for flights where most of the route is well above terrain. 

When flying in mountainous terrain, the cautions and alerts would be “near-continuous,” and the pilot may have silenced them to avoid distraction.

When the pilot turned into the box canyon, the warning systems were ineffective either because they had been silenced or because multiple alerts had sounded in the preceding minutes.

The aircraft impacted terrain at approximately 11:15 in the morning.

Eyewitnesses at a nearby exploration camp had seen and heard the aircraft flying at “near tree-top level” close to the site of the crash.

They were the first to arrive on the scene, approximately 60 minutes after impact.

The force of the crash saw both wings partially detached, the left elevator separated and all four propeller blades broken free from the hub.

Alkan Air has taken a number of safety actions since the accident.

Cessna captains with fewer than 2,000 flight hours will now be required to fly with a second flight crew member on the craft. Captain trainees must work as a second crew member for one season.

The training program for Cessna Caravan pilots now includes low-level route training.

Alkan Air has also modified its emergency response plan.

“The entire Alkan Air team extends our sincere condolences to Shawn’s and Julia’s family, friends and colleagues,” Alkan president Wendy Tayler said today.

“We appreciate the effort of the Transportation Safety Board in preparing this report as we continually work with the agency as a company and as an industry to ensure the health and safety of our employees and passengers.”

As a legal action was filed against Alkan Air on July 10 in Yukon Supreme Court, it is not appropriate for the company to comment on the accident, the TSB report nor any related issues, Tayler added.

“Alkan Air thanks Yukoners for the support they continue to demonstrate and for their understanding during this time,” Tayler said.