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Latest Update On The Carson Air Crash In April 2015


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  • 2 years later...

And here is the final report.

TSB recommends substance abuse program following fatal 2015 in-flight breakup north of Vancouver, British Columbia Français


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Transportation Safety Board of Canada

13:00 ET

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RICHMOND, BC, Nov. 2, 2017 /CNW/ - The Transportation Safety Board of Canada (TSB) is recommending that Transport Canada work with the aviation industry and employee representatives to develop and implement requirements for a comprehensive substance abuse program to reduce the risk of impairment of persons while engaged in safety-sensitive functions. The details are in the investigation report (A15P0081) released today into the fatal 2015 in-flight breakup of a cargo aircraft operated by Carson Air Ltd.

 

On 13 April 2015, the Carson Air Swearingen SA-226-TC Metro II was carrying freight from Vancouver International Airport to Prince George Airport, British Columbia, with a crew of two pilots on board. About six minutes after departure, the aircraft disappeared from radar. Its last known position was approximately 15 nautical miles north of the airport at an altitude of about 7500 feet. Ground searchers found aircraft wreckage on steep, mountainous, snow-covered terrain later in the day. The aircraft had experienced a catastrophic in-flight breakup. Both the captain and first officer were fatally injured, and the aircraft was destroyed.

The investigation determined that the aircraft entered a steep dive, then accelerated to a high speed which exceeded the aircraft's structural limits and led to an in-flight breakup. Subsequent toxicology testing indicated that the captain had consumed a significant amount of alcohol on the day of the occurrence. As a result, alcohol intoxication almost certainly played a role in the events leading up to the accident.

"In Canada, regulations and company rules prohibit flying while impaired, but they rely heavily on self-policing," said Kathy Fox, Chair of the TSB. "What is needed is a comprehensive substance abuse program that would include mandatory testing as well as complementary initiatives such as education, employee assistance, rehabilitation and peer support."

"We realize that employees within Canada's aviation industry will have concerns under any possible testing regime," added Chair Fox. "This is why we recommend that the substance abuse program consider and balance the need to incorporate human rights principles enshrined in the Canadian Human Rights Act with the responsibility to protect public safety."

Pilot incapacitation is one of three scenarios which the TSB has not ruled out to explain the possible events that led to the accident. It is also possible that the heaters of the pitot system, which provides airspeed information, were off or malfunctioned. The third scenario involves a number of flight-specific factors that are consistent with an intentional act.

However, without objective data from a cockpit voice recorder or flight data recorder, it is impossible to determine with certainty which scenario played out during the occurrence flight. The TSB has previously recommended (A13-01) the installation of lightweight flight recording systems aboard smaller commercial aircraft and flight data monitoring by smaller commercial operators, both to advance transportation safety and to provide data to investigators following an occurrence.

Link to the Full Final Report: http://www.tsb.gc.ca/eng/rapports-reports/aviation/2015/a15p0081/a15p0081.asp

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BAC of 0.24?  I find that hard to believe.  Assuming he wasn't actually drinking during the flight he would have had a higher BAC in the preflight timeframe.  IDK, maybe he was drinking during the flight.

Effects At Specific B.A.C. Levels

The effects of alcohol intoxication are greatly influenced by individual variations among users. Some users may become intoxicated at a much lower Blood Alcohol Concentration (BAC) level than is shown.

0.02-0.03 BAC: No loss of coordination, slight euphoria and loss of shyness. Depressant effects are not apparent. Mildly relaxed and maybe a little lightheaded.

0.04-0.06 BAC: Feeling of well-being, relaxation, lower inhibitions, sensation of warmth. Euphoria. Some minor impairment of reasoning and memory, lowering of caution. Your behavior may become exaggerated and emotions intensified (Good emotions are better, bad emotions are worse)

0.07-0.09 BAC: Slight impairment of balance, speech, vision, reaction time, and hearing. Euphoria. Judgment and self-control are reduced, and caution, reason and memory are impaired, .08 is legally impaired and it is illegal to drive at this level. You will probably believe that you are functioning better than you really are.

0.10-0.125 BAC: Significant impairment of motor coordination and loss of good judgment. Speech may be slurred; balance, vision, reaction time and hearing will be impaired. Euphoria.

0.13-0.15 BAC: Gross motor impairment and lack of physical control. Blurred vision and major loss of balance. Euphoria is reduced and dysphoria (anxiety, restlessness) is beginning to appear. Judgment and perception are severely impaired.

0.16-0.19 BAC: Dysphoria predominates, nausea may appear. The drinker has the appearance of a "sloppy drunk."

0.20 BAC: Felling dazed, confused or otherwise disoriented. May need help to stand or walk. If you injure yourself you may not feel the pain. Some people experience nausea and vomiting at this level. The gag reflex is impaired and you can choke if you do vomit. Blackouts are likely at this level so you may not remember what has happened.

0.25 BAC: All mental, physical and sensory functions are severely impaired. Increased risk of asphyxiation from choking on vomit and of seriously injuring yourself by falls or other accidents.

0.30 BAC: STUPOR. You have little comprehension of where you are. You may pass out suddenly and be difficult to awaken.

0.35 BAC: Coma is possible. This is the level of surgical anesthesia. 

0.40 BAC and up: Onset of coma, and possible death due to
respiratory arrest.

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Seeker, the following is from the final report

1.16.5 Tolerance to the effects of alcohol

Physical dependence on alcohol involves tolerance to alcohol's effects, and withdrawal symptoms when drinking is stopped.Footnote24 Three types of tolerance to alcohol can develop: functional, acute, and metabolic tolerance. Functional tolerance to alcohol's effects on brain function, behaviour, and performance leads to consumption of increasing amounts of alcohol on future occasions. Chronic heavy drinkers often display functional tolerance, showing few obvious signs of intoxication, even at a very high BAC that, in others, would be incapacitating or even fatal (e.g., more than 0.35% BAC).Footnote25 For example, research on people with alcohol dependence who voluntarily entered a detoxification centre for treatment showed that many had normal speech and gait, as well as an unimpaired ability to undress, even with BACs of 0.35% and greater.Footnote26

Acute tolerance to some of alcohol's effects can develop within a single drinking session. This effect is related to the pharmacokineticsFootnote27 of alcohol in the body and what is called the "BAC curve." Alcohol-induced impairment is greater when BAC is measured soon after beginning alcohol consumption than when it is measured later in the drinking session, even if the BAC is the same at both timesFootnote28 (Figure 4). The intoxicating effect of the same BAC is considerably less when it lies on the descending slope of the curve (point B) than on the ascending slope (point A).

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