Author: Jeevan A. Robinson | Date: 06 May 2015
In our first installment of this series back in February, 2015, we revealed the recent sanctions imposed against Fly Montserrat - the removal of Nigel Harris from operational roles of the airline. See that article here.
We have spent the period since then, looking further into this story, and now the public gets an opportunity to learn of the events leading up to the airline's fatal crash of 2012, the numerous opportunities the airline and British Government representative on Montserrat ignored that could have prevented the accident, and the Montserrat Governor's ability and seemingly repeated willingness to alter and suppress information regarding any air safety concern in the British Territory.
Fly Montserrat uses Britten-Norman BN-2 Islander aircraft, and problems with the aircraft's design were first highlighted in 1968 when Australia's Civil Aviation Authority ordered all BN-2 to be modified in order to prevent water being sucked into the engine, causing catastrophic engine failure. This design flaw contributed to the deaths of 9 people on August 2nd 1984 in Puerto Rico.
For that crash, the US Transportation Safety Board (TSB) determined the cause of the crash was pilot inexperience after water had been sucked into one of the engines during take-off, stating "the pilot's improper performance of the emergency procedures indicates a lack of proficiency due to inadequate training and insufficient experience."
The TSB recommended all BN-2 world-wide be modified to the Australian standard.
Responding to the report, the UK Civil Aviation Authority (CAA) did not dispute the findings or the need for experienced pilots in order to recover from engine failure. The CAA did state that engine failure due to water contamination could be minimized "if" the conditions for an accurate fuel check were present and fuel tanks were checked before each flight.
The airline's first catastrophic mid-air engine failure occurred on November 17th 2010, only one year after the airline started scheduled flights. As the charter flight began its ascent from Antigua and banked to the right towards its flight path to Montserrat, the right engine failed and the pilot declared a "Mayday". The experienced pilot was able to regain control of the aircraft, circle the airport and land back at Antigua.
In a recent interview, the 2 passengers who were on this flight said they were grateful the pilot was experienced and relayed the pilot's comments about how training for such an event could not capture the terror when it actually happened. With more than 3,000 hours flying experience, this was the first time the pilot was forced to deal with such an event.
In an interview with MNI Alive on October 19th 2012, the Governor of Montserrat, Adrian Davis, stated he was aware of these incidents and that they had been "fully investigated." However, no report of this near-fatal incident seems to exist.
Only 3 years into operations and less than 2 years after the airline's first mid-air engine failure, the second failure occurred and resulted in the fatal crash of October 7th 2012, taking the lives of Jason Forbes, Annya Duncan and Sandrama Poligadu, while seriously injuring a 4th passenger, Michael Hudson.
As the much less experienced pilot began his ascent from Antigua and banked to the right on a flight path to Montserrat, a catastrophic failure occurred with the right engine.
In its preliminary report, the Eastern Caribbean Civil Aviation Authority (ECCAA) determined the pilot had just 710 hours of flying experience. The report stated "the fuel system feeding that engine found significant quantities of water" and there was no evidence the pilot attempted to execute the emergency engine-out procedure. The preliminary report issued by the UK's CAA Air Accidents Investigation Branch (AAIB) repeated these findings and found "similar causal factors" with the 1984 accident, recommending all BN-2 aircraft be modified to the standard first ordered in 1968.
In response to a question regarding the airline's unsafe operations in our interview following the crash, Governor Davis stated "if..there is evidence of inappropriate behaviour then this will be acted upon. But we must wait for the investigation to be completed." Similar to the 2010 catastrophic engine failure however, no ECCAA or AAIB accident report seems to exist, or does it?
On October 7th 2013, the Antigua Observer reported Director General of the Eastern Caribbean Civil Aviation Authority (ECCAA), Donald McPhail, confirmed the [final crash] report was complete but did not indicate the timeline in which it was submitted. The director added he would have to contact his team before any information could be released. McPhail said this was in keeping with protocol. It is important to note that ECCAA's preliminary crash report stated "further investigation [and the final report] will encompass all operational and engineering matters relevant to the accident."
The absence of a publicly available crash report is no coincidence. The Civil Aviation (Investigation of Air Accidents And Incidents) Regulations (S.R.O. 72/2007) of Montserrat gives the Governor the power to alter any reports and recommendations "if, in the Governor’s opinion, it is likely to adversely affect the reputation of any person, until the Governor has...made such changes to the report as he thinks fit."
In fact, the Governor may not have any obligation to inform the public of safety issues at all "on the ground[s] that the disclosure of it would be injurious to the public interest."
It stands to reason that having the power to alter or suppress reports of incidents, accidents and the recent sanctions would also necessitate the ability to deny such behaviour.
However, the Governor's powers extend far beyond those outlined above. In 2007, the UK Parliament passed "The Air Navigation (Overseas Territories) Order 2007" which removed the professional Civil Aviation Authority and its wholly owned subsidiary, Air Safety Support International (ASSI) as the "competent authority" and vested all powers in the appointed DFID Governor-of-the-day.
Most shocking is "the Governor may exempt from any of the provisions of this Order...or any regulations made thereunder, any aircraft or persons or classes of aircraft or persons, either absolutely or subject to such conditions as he thinks fit."
The CAA and ASSI, the professional regulatory bodies, have been reduced to advising the Governor who is free to act "as he thinks fit".
So it begs the question; If the British Governor is protecting the airline management's reputation, who is protecting the public? If a British Governor can alter or silence the industry's leading experts and authorities, or simply take their findings and recommended penalties "under advisement", can passengers have any confidence that experts have ultimate and unfettered responsibility for their safety?
Both instances of engine failure detailed in this article - the near-fatal 2010 incident and the fatal crash less than 2 years later - involved the same aircraft, VP-MON, the airline's unmodified BN-2. Even after the availability of the 1968 modification, the 1984 crash and the company's own 2010 catastrophic engine failure, the airline continued to allow inexperienced pilots to fly the unmodified VP-MON.
In the wake of the 2010 failure, did the airline's management use the incident to ensure more training and stricter oversight of procedures were put in place?
Did the airline ensure only its most experienced pilots were allowed to fly the unmodified aircraft as it was more prone to catastrophic engine failure?
While the first engine failure was obviously reported to the Governor and in his words, "fully investigated", the absence of a report ensured there were no lessons or recommendations that would prevent the subsequent crash.
Perhaps most shocking is the fact that there were dozens of Mandatory Occurrence Reports (MOR) filed by Air Traffic Controllers and sent directly to ASSI for months prior to the crash. The vast majority of these MOR detailed VP-MON and multiple engine failures while starting, while on the apron and while taxiing. Air Traffic Controllers have expressed their frustration at the repeated failure of ASSI and the Governor to act on these reports. There was never any follow-up with the control tower staff after any of these reports were filed. No findings or recommendations were ever published, and controllers have expressed they were not surprised by the fatal crash of VP-MON.
The Montserrat public deserves answers to the following questions:
Why does the British Governor have the power to alter or suppress vital safety information the public needs in order to make informed decisions before using the airline?
Does the British Government value a corporate individual's reputation over the safety of citizens and foreign passengers?
If the British Government can alter and suppress information, should it have ordered the airline to invest in the modification needed to avoid the likelihood of fatalities, particularly in light of the multiple MOR regarding repeated engine failures of VP_MON?
Would the publication of the 2010 engine failure have forced the CAA to issue a mandatory order for the modification?
Why does the flying public not enjoy the same level of air safety as passengers traveling within the UK?
An accident is defined as "an unfortunate incident that happens unexpectedly". Could the crash of VP-MON been avoided? You decide.