AVIATION INVESTIGATION REPORT A12Q0216 LOW-ENERGY REJECTED LANDING AND COLLISION WITH TERRAIN

AVIATION INVESTIGATION REPORT A12Q0216 LOW-ENERGY REJECTED LANDING AND COLLISION WITH TERRAIN
AVIATION INVESTIGATION REPORT
A12Q0216
LOW-ENERGY REJECTED LANDING AND
COLLISION WITH TERRAIN
PERIMETER AVIATION LP
FAIRCHILD SA227-AC METRO III, C-GFWX
SANIKILUAQ, NUNAVUT
22 DECEMBER 2012
The Transportation Safety Board of Canada (TSB) investigated this occurrence for the
purpose of advancing transportation safety. It is not the function of the Board to assign fault
or determine civil or criminal liability.
Aviation Investigation Report A12Q0216
Low-energy rejected landing and
collision with terrain
Perimeter Aviation LP
Fairchild SA227-AC Metro III, C-GFWX
Sanikiluaq, Nunavut
22 December 2012
Summary
On 22 December 2012, the Perimeter Aviation LP, Fairchild SA227-AC Metro III (registration
C-GFWX, serial number AC650B), operating as Perimeter flight PAG993, departed
Winnipeg/James Armstrong Richardson International Airport, Manitoba, at
1939 Coordinated Universal Time (1339 Central Standard Time) as a charter flight to
Sanikiluaq, Nunavut. Following an attempted visual approach to Runway 09, a nonprecision non-directional beacon (NDB) Runway 27 approach was conducted. Visual contact
with the runway environment was made and a circling for Runway 09 initiated. Visual
contact with the Runway 09 environment was lost and a return to the Sanikiluaq NDB was
executed. A second NDB Runway 27 approach was conducted with the intent to land on
Runway 27. Visual contact with the runway environment was made after passing the missed
approach point. Following a steep descent, a rejected landing was initiated at 20 to 50 feet
above the runway; the aircraft struck the ground approximately 525 feet beyond the
departure end of Runway 27. The 406 MHz emergency locator transmitter activated on
impact. The 2 flight crew and 1 passenger sustained serious injuries, 5 passengers sustained
minor injuries, and 1 infant was fatally injured. Occupants exited the aircraft via the forward
right overwing exit and were immediately transported to the local health centre. The aircraft
was destroyed. The occurrence took place during the hours of darkness at 2306 Coordinated
Universal Time (1806 Eastern Standard Time).
Le présent rapport est également disponible en français.
Table of contents
Summary ...................................................................................................................i
1.0 Factual information ......................................................................................... 1
1.1
History of the flight ............................................................................................................... 1
1.2
Injuries to persons .................................................................................................................. 9
1.3
Damage to aircraft.................................................................................................................. 9
1.4
Other damage ....................................................................................................................... 10
1.5
Personnel information ......................................................................................................... 10
1.6
1.7
1.5.1
Flight crew ..............................................................................................................................10
1.5.2
Community aerodrome radio station observer/communicator .....................................11
Aircraft information............................................................................................................. 12
1.6.1
General ....................................................................................................................................12
1.6.2
Minimum equipment list item.............................................................................................12
1.6.3
Altimeters ...............................................................................................................................13
1.6.4
Terrain awareness devices ...................................................................................................14
1.6.5
Global positioning system ....................................................................................................15
1.6.6
Guardian Mobility SkyTrax .................................................................................................16
Meteorological information ................................................................................................ 16
1.7.1
Pre-flight weather information ............................................................................................16
1.7.2
Weather obtained prior to descent for landing at Sanikiluaq .........................................17
1.7.3
Environment Canada weather study ..................................................................................18
1.8
Aids to navigation................................................................................................................ 19
1.9
Communications .................................................................................................................. 19
1.10 Aerodrome information ...................................................................................................... 19
1.10.1
General ....................................................................................................................................19
1.10.2
Runway and taxiway lighting .............................................................................................20
1.10.3
Approach slope indicator system........................................................................................21
1.10.4
Sanikiluaq community aerodrome radio station ..............................................................22
1.10.5
Sanikiluaq aircraft rescue and fire fighting .......................................................................22
1.11 Flight recorders .................................................................................................................... 22
1.12 Wreckage and impact information .................................................................................... 23
1.13 Medical and pathological information.............................................................................. 23
1.14 Fire.......................................................................................................................................... 23
1.15 Survival aspects .................................................................................................................... 24
1.15.1
Perimeter emergency response ...........................................................................................24
1.15.2
Cabin safety/aircraft occupant seats ..................................................................................25
1.16 Tests and research ................................................................................................................ 37
1.16.1
Stabilized constant descent angle instrument approach techniques ..............................37
1.16.2
TSB laboratory reports ..........................................................................................................39
1.17 Organizational and management information ................................................................ 39
1.17.1
General ....................................................................................................................................39
1.17.2
Perimeter Aviation LP ..........................................................................................................39
1.17.3
Route and charter packages .................................................................................................41
1.17.4
Flight planning ......................................................................................................................41
1.17.5
Perimeter Aviation LP operational manuals .....................................................................42
1.17.6
Standard operating procedures ...........................................................................................43
1.17.7
Approaches ............................................................................................................................45
1.17.8
Stable approach criteria ........................................................................................................47
1.17.9
Discontinued approach and landings ................................................................................48
1.17.10 Ground proximity warning system training .....................................................................52
1.17.11 Safety management systems ................................................................................................53
1.17.12 Safety case ..............................................................................................................................54
1.17.13 Transport Canada oversight ................................................................................................55
1.18 Additional information ....................................................................................................... 59
1.18.1
Human performance issues .................................................................................................59
1.18.2
Crew resource management ................................................................................................61
1.18.3
Instrument approach design ................................................................................................67
1.18.4
Approach and landing accidents ........................................................................................69
1.18.5
TSB Watchlist .........................................................................................................................71
1.18.6
Flight Safety Foundation Approach and Landing Accident Reduction Tool
Kit ............................................................................................................................................71
1.18.7
Go-around – Flight Safety Foundation European Advisory Committee.......................71
1.18.8
Aircraft performance ............................................................................................................74
1.19 Useful or effective investigation techniques .................................................................... 74
2.0 Analysis .......................................................................................................... 75
2.1
General .................................................................................................................................. 75
2.2
Weather ................................................................................................................................. 75
2.3
Human performance issues ................................................................................................ 76
2.3.1
2.4
Cumulative effects of frustration, fatigue and stress........................................................76
Crew resource management ............................................................................................... 78
2.4.1
Crew resource management training standards ...............................................................78
2.4.2
Training received by the crew .............................................................................................78
2.4.3
Crew resource management during the approaches .......................................................78
2.5
Stable approach criteria ....................................................................................................... 82
2.6
Descent technique for non-precision approaches............................................................ 83
2.7
Rejected landing ................................................................................................................... 83
2.7.1
General ....................................................................................................................................83
2.8
2.9
Cabin safety .......................................................................................................................... 84
2.8.1
In-cabin seating ......................................................................................................................84
2.8.2
Passenger briefings ...............................................................................................................85
2.8.3
Restraint systems ...................................................................................................................85
2.8.4
Lack of data regarding infant and child passengers ........................................................86
Organizational issues .......................................................................................................... 87
2.9.1
Company ground proximity warning system training....................................................87
2.9.2
Airplane flight manual procedure for balked landing versus standard
operating procedures for go-around ..................................................................................87
2.9.3
Safety case ..............................................................................................................................87
2.9.4
Extra fuel ................................................................................................................................88
2.10 Transport Canada oversight ............................................................................................... 88
3.0 Findings .......................................................................................................... 90
3.1
Findings as to causes and contributing factors ................................................................ 90
3.2
Findings as to risk ................................................................................................................ 91
3.3
Other findings....................................................................................................................... 92
4.0 Safety action ................................................................................................... 93
4.1
Safety action taken ............................................................................................................... 93
4.1.1
4.2
Perimeter Aviation LP ..........................................................................................................93
Safety action required.......................................................................................................... 95
4.2.1
Reporting of number of infant and child passengers travelling by air ..........................95
4.2.2
Required use of child restraint systems .............................................................................96
Appendices ............................................................................................................ 98
Appendix A – Sanikiluaq, NU, NDB RWY 27 (GNSS) ............................................................. 98
Appendix B – Flight path .............................................................................................................. 99
Appendix C – Sanikiluaq, NU (CYSK) aerodrome chart ....................................................... 100
Appendix D – Flight path profile .............................................................................................. 101
Appendix E – Graphic area forecast (GFA).............................................................................. 102
Appendix F – International policy and efforts regarding child restraint systems and inflight safety ......................................................................................................................... 103
Appendix G – Perimeter Metro III go-around procedure ...................................................... 108
Appendix H – Approach-and-Landing Accident Reduction Task Force
recommendations............................................................................................................... 109
Appendix I – List of acronyms and abbreviations .................................................................. 111
Aviation Investigation Report A12Q0216 | 1
1.0
Factual information
1.1
History of the flight
On 22 December 2012, the Fairchild SA227-AC Metro III, 1 operated under instrument flight
rules (IFR) 2 as Perimeter flight PAG993, was chartered for a flight from Winnipeg/James
Armstrong Richardson International Airport (CYWG), Manitoba, to Sanikiluaq (CYSK),
Nunavut. The charter flight was operated under Subpart 704 of the Canadian Aviation
Regulations (CARs). 3 This route is normally operated by Keewatin Air, a Perimeter Aviation
LP (Perimeter) sister company, 4 every Monday, Wednesday and Friday. The normally
scheduled flight on the previous day (Friday, 21 December 2012) had been cancelled due to
poor weather in CYSK. With extra cargo and passengers needing to travel to CYSK before
Christmas, Keewatin Air completed a flight on the morning of 22 December 2012 and had
chartered Perimeter to complete an additional flight. The Perimeter flight crew had been
notified in the early evening of 21 December 2012 that they would be operating flight
PAG993 the next morning.
Upon arriving at the airport at approximately 1330 Coordinated Universal Time (UTC), 5 the
captain checked the weather on the NAV CANADA aviation website and filed the flight
plan with Winnipeg flight information centre (FIC). The 3-hour IFR flight was initially flight
planned to depart at 1530 UTC. The chosen alternate aerodrome 6 was Moosonee (CYMO),
Ontario. Perimeter does not operate scheduled flights to CYSK. As there were several
MEDEVAC and charter flights to areas in Nunavut that day, there was an insufficient
number of available instrument approach charts for Nunavut at the flight planning/flight
following office during pre-flight planning. It was arranged that a set of charts would be
picked up at Keewatin Air prior to departure.
The first officer (FO) reported to work at 1345 UTC and inspected the aircraft. As no survival
kit was on board and was necessary as per company procedure, 7 the captain was advised
1
The SA227-AC is also known as the Metro III or the SW4.
2
Please refer to Appendix I – List of acronyms and abbreviations.
3
Commuter air transport service (i.e. a multi-engine aeroplane) that has a maximum certificated
take-off weight (MCTOW) of 8618 kg (19 000 pounds) or less and a seating configuration,
excluding pilot seats, of 10 to 19 seats.
4
Perimeter Aviation LP falls under the umbrella of Exchange Income Corporation (EIC). Other
related companies that fall under EIC are Calm Air, Bearskin Airlines, Keewatin Air, Custom
Helicopters, and Regional One.
5
All times Coordinated Universal Time (UTC) (Central Standard Time plus 6 hours; Eastern
Standard Time plus 5 hours). UTC is used in this report due to multiple time zones.
6
Alternate aerodrome means an aerodrome to which a flight may proceed when landing at the
intended aerodrome of destination becomes inadvisable.
7
Perimeter Aviation LP, Company Operations Manual (COM), Section 17.3.11 requires that a survival
kit be on board when the flight takes place above 66° latitude in uncontrolled airspace or off
2 | Transportation Safety Board of Canada
and one was requested. There were several flights to the North taking place that day, and
Perimeter did not have a survival kit available for the CYSK flight. It was arranged to have
one supplied by Keewatin Air and it was obtained prior to departure. During inspection of
the aircraft, it was noticed that the cargo door unsecure warning light remained illuminated;
maintenance was advised, the cargo door handle position switch was replaced, and the
aircraft returned to service approximately 3 hours later.
Following completion of the maintenance work, the captain checked the actual weather,
aerodrome and area forecasts for the takeoff, en-route, destination, alternate and return trip
segments again (see Section 1.7 Meteorological information), and filed a new flight plan, with
a planned departure time of 1930 UTC. After taxiing from the Perimeter ramp to the
Keewatin Air ramp, freight and fuel were loaded, and passengers embarked. Due to
additional freight added, less fuel could be carried. Therefore, the planned alternate airport
was changed to Kuujjuarapik (CYGW), Quebec, situated 90 nautical miles (nm) southeast of
CYSK.
The weight and balance/loadsheet indicated that the take-off weight from CYWG to CYSK
was 15 993 pounds, which is just below the aircraft maximum allowable take-off weight of
16 000 pounds. However, an additional 200 pounds of fuel had been loaded which did not
appear on the loadsheet. At normal consumption rates, the fuel load declared would provide
5 hours of fuel on board. The extra 200 pounds of fuel would allow for an additional
20 minutes of flight.
The FO briefed the passengers on the use of seatbelts and location of emergency exits.
Although required by regulations, no individual safety briefing was given to a mother
holding her infant; 8 she was seated in the first seat on the left, seat 1L, next to the main door.
There was no assigned seating; passengers chose their own seat. The mother of the infant
was not directed to sit elsewhere.
PAG993 departed at 1939 UTC, 4 hours later than originally planned. The captain was seated
in the left seat and was the pilot not flying (PNF). The FO was seated in the right seat and
was the pilot flying (PF) out of CYWG. Shortly after departure, the captain realized that the
instrument approach charts for CYSK had been forgotten.
The captain chose not to return to CYWG to obtain the instrument approach charts as this
would delay the flight even more and add to the crew duty day. Instead, he obtained chart
information pertaining to the non-directional beacon (NDB) Runway 27 instrument approach
for CYSK via radio from a company pilot (Appendix A). Information obtained did not
include the direction for the procedure turn or the minimum descent altitude (MDA)(620 feet
above sea level [asl]) for the circling approach to Runway 09.
designated routes. However, due to its remote location and environment, Sanikiluaq is an
exception (survival kit required) despite being located south of 66° latitude.
8
Perimeter Aviation LP, Company Operations Manual (COM), Section 10.8.9, Individual Safety
Briefing, and Canadian Aviation Regulations (CAR) 724.34 (2).
Aviation Investigation Report A12Q0216 | 3
The take-off, climb and cruise segments of the flight were uneventful, with the exception of
light turbulence for which the crew requested a climb to FL230. 9 Flying duties were shared
for the cruise portion of the 3-hour flight. Weather condition updates and forecasts for
destination and alternate airports were not verified until just prior to descent.
When the aircraft was 82 nm to the west of CYSK, just before starting descent, the crew
contacted the community aerodrome radio station (CARS) observer/communicator for the
latest weather and runway surface condition (RSC) for CYSK. The crew also requested
weather for CYSK and CYGW with Quebec Radio. CYGW, the flight-planned alternate
airport, showed weather to be worse than what was obtained prior to departure. Due to the
poor weather conditions at CYGW, weather for La Grande Rivière airport (CYGL), Quebec,
located 260 nm south-southeast of CYSK, was also obtained.
The crew discussed the
Figure 1. Approximate trajectory arriving at CYSK from the west
(Source: Google Earth, with TSB annotations)
remaining fuel on board
and determined they
would not have enough
fuel for CYGL plus the
required reserve; 10 CYGL
was therefore discarded
as an alternate airport
option. There was
sufficient fuel on board to
conduct several
approaches at CYSK
before needing to
consider diverting to
CYGW. Given the
weather, there was doubt
as to whether a diversion
to the alternate airport
was practical. CYSK has a
gravel runway, and
company procedures require that landing on gravel runways be conducted by the captain; 11
therefore, the captain assumed PF duties. The FO was designated as PNF.
Appendix B shows a compilation of all flight trajectories during the attempted landings at
CYSK. The aircraft arrived from the west, and the wind direction was slightly left of the
9
Flight Level 230, 23 000 feet above mean sea level.
10
Canadian Aviation Regulations (CAR) 602.88 (4) (a) and 704.20 (a) Fuel requirements for a flight
conducted under IFR [instrument flight rules].
11
Perimeter Aviation LP, Company Operations Manual (COM), Chapter 9, Section 9.15.2.5 Gravel
Runway Operations (704), (OpSpec 029).
4 | Transportation Safety Board of Canada
arrival track. There is no published instrument approach for Runway 09 at CYSK. The crew’s
plan was to descend to the minimum safe altitude (MSA) of 1600 feet asl and, if the runway
environment for landing Runway 09 could be seen, then a straight-in visual approach
Runway 09 would be executed (Figure 1).
If not, then the NDB Runway 27 instrument approach with a circling for Runway 09 would
be completed. This approach was briefed, and appropriate instruments, navigation aids,
GPS (global positioning satellite navigation system) and radios were set up for the NDB
approach. The missed approach procedure was briefed as runway heading to MSA. The
estimated time of arrival at CYSK was 2243 UTC. The crew intended to conduct 2 approaches
before diverting to the alternate airport. The crew is not required by regulations or company
procedures to conduct a passenger briefing prior to descent or landing. However, passengers
had been told during the take-off briefing to keep their seatbelts on at all times during the
flight.
The reference speed (VREF) 12 for the approach and landing was 113 knots 13 plus consideration
for wind gusts, resulting in a target speed of 118 knots to cross the threshold. The crew
rounded this off to 120 knots. At 2240 UTC, the weather at CYSK was reported as: wind 040°
magnetic (M) at 15 knots gusting to 20 knots, altimeter setting 29.24 inches of
mercury (in. Hg).
The runway environment
for landing straight-in
Runway 09 was not visible
while flying inbound to
the YSK NDB at
1600 feet asl. After passing
the YSK NDB at
2244 UTC, the aircraft
proceeded outbound to
complete the full
procedure turn for the
NDB Runway 27 approach
(Figure 2). The procedure
turn is published to be
executed on the north side
of the approach track at
1400 feet asl.
Figure 2. Approximate trajectory of the first approach (Source: Google
Earth, with TSB annotations)
The published MSA is
1600 feet asl. The
12
VREF (reference speed) is 1.3 times the stall speed with full landing flaps or with selected landing
flaps. Speed calculated to cross threshold.
13
All speeds are indicated airspeed (IAS) unless otherwise specified.
Aviation Investigation Report A12Q0216 | 5
procedure turn was executed at 1600 feet indicated; however, on the south side of the
approach track. According to CAR 602.127(1), “…the pilot-in-command of an IFR aircraft
shall, when conducting an approach to an aerodrome or a runway, ensure that the approach
is made in accordance with the instrument approach procedure.”
The lights of the town, situated just over 0.6 nm east of the airport, were observed while the
aircraft was on final approach; the crew could not see the runway environment. Visual
contact with the runway environment was made approximately 0.6 nm from the threshold of
Runway 27 at an indicated altitude 14 of 600 feet. The published MDA 15 is 560 feet asl; the
published minimum circling altitude of 620 feet asl had not been obtained and therefore not
used. A left-hand circling for Runway 09 was initiated. The aircraft descended to an
indicated altitude of approximately 500 feet. Thirty seconds later, at 2251 UTC, visual contact
with the ground was lost, and the circling manoeuvre 16 was continued in instrument
meterological conditions (IMC). A go-around17 was not called or initiated, and the published
missed approach procedure was not followed.
14
Indicated altitude shows altitude above sea level (asl) and is read directly from the altimeter when
set to the current barometric pressure.
15
The minimum descent altitude (MDA) is a specified altitude referenced to sea level for a nonprecision approach below which descent must not be made unless the visual reference required to
continue the approach to land has been established.
16
Circling is an instrument flight rules (IFR) procedure that is conducted by visually manoeuvring
an aircraft, after completing an instrument approach to one runway, into position for landing on
another runway. Visual contact with the runway environment must be maintained during the
circling manoeuvre. The minimum descent altitude (MDA) provides 300 feet above all obstacles
within the visual manoeuvring area.
17
Go-around: a transition from an approach to a stabilized climb.
6 | Transportation Safety Board of Canada
At 2253 UTC while
continuing to circle in
IMC, the aircraft
descended to an indicated
altitude of 400 feet, at a
speed of 140 knots. The
wind was pushing the
aircraft south of the
Runway 09 centreline in
an area southwest of the
runway where the terrain
elevation is 223 feet asl,
resulting in a height of
155 feet above ground
level (agl) when applying
cold temperature
corrections (Figure 3). 18
As the aircraft came
abeam and south of the
runway, the crew sighted
the runway again but were
not in a position to land on
Runway 09. Initially, a
second circling manoeuvre
for Runway 09 was
commenced (Appendix B).
While in the left turn,
visual contact with the
runway was lost again. At
2255 UTC, a missed
approach was initiated
north of the runway.
However, the missed
approach procedure as
published was not
followed (Appendix A). 19
Twice in quick succession
Figure 3. Approximate trajectory of the first circling (Source: Google Earth,
with TSB annotations)
Figure 4. Approximate trajectory of the second circling (Source: Google
Earth, with TSB annotations)
18
400 feet above sea level (asl) – 223 feet terrain height = 177 feet above ground level (agl).
Application of cold temperature corrections, the true altitude above ground was 155 feet agl.
Terrain information is also available in the Canada Flight Supplement.
19
The published missed approach procedure for the CYSK NDB Runway 27 dictates a climb to
1600 feet on a track of 278°, then return to the YSK NDB.
Aviation Investigation Report A12Q0216 | 7
during this procedure, the FO reminded the captain that the MSA was 1600 feet. The captain
responded 1500 feet, and no correction was applied; this error was not corrected by the FO.
The aircraft continued to circle left and climb back towards the NDB (Figure 4).
This time, the objective was to execute a second NDB Runway 27 approach with the intent to
land on Runway 27.
The captain indicated this would be the last attempt at landing at CYSK. They would then
proceed to the flight-planned alternate, CYGW, approximately 30 minutes away. Fuel at this
time was 1000 pounds, giving approximately 1.6 hours of flight. The full procedure turn was
once again flown on the opposite side of the published procedure, this time at an indicated
altitude of 1500 feet (1389 feet asl when applying cold temperature corrections), 211 feet
below the published MSA of 1600 feet asl (Figure 5).
At 2259 UTC, the FO
radioed CYSK CARS to
obtain an update on wind
conditions; wind was
050°M at 15 gusting
20 knots, altimeter setting
29.23 in. Hg. In these
conditions, landing
Runway 27 resulted in an
11-knot crosswind and a
14-knot tailwind
component. The landing
performance calculations
for the aircraft are based
on a maximum tailwind
component of 10 knots. 20
Figure 5. Approximate trajectory of the second approach (Source: Google
Earth, with TSB annotations)
For this approach, the GPS
was used to carry out the
NDB RWY 27 (GNSS) 21
overlay approach, to navigate towards the airport. The GPS was set up to navigate to the
airport reference point, located at the centre point of the runway, to provide the crew with
the approximate distance of the aircraft from the threshold of Runway 27 and more precise
tracking to the airport (Appendix C).
20
Fairchild, SA227-AC Airplane Flight Manual, Section 4B-17 8AC.
21
GNSS: stands for global navigation satellite system, and is the standard generic term for satellite
navigation systems that provide autonomous geo-spatial positioning with global coverage,
e.g. GPS navigation.
8 | Transportation Safety Board of Canada
The before landing checklist was completed prior to interception of the final approach path
for Runway 27. At 2302:36 UTC, the FO reported the aircraft position as procedure turn
inbound. The CARS observer/communicator acknowledged the position report, and
provided the wind and visibility (1½ statute miles [sm]). The aircraft was established at an
indicated altitude of 400 feet, 3 nm from the airport, 197 feet below the published MDA,
without having established the required visual references. 22
At 2305:57 UTC, the crew acquired visual contact with the runway at 400 feet indicated, just
beyond the missed approach point (MAP), at approximately 0.7 nm from the threshold of
Runway 27. Full flaps were selected for landing, power decreased to idle, and the descent
was initiated at 2306:07 UTC. The speed was 140 knots (Appendix D).
The ground proximity warning system (GPWS) generated a SINK RATE warning at
2306:11 UTC as the rate of descent exceeded 1500 feet per minute (ft/min), followed by a
PULL UP warning at 2306:13 UTC as the rate of descent exceeded 1800 ft/min. The
PULL UP-PULL UP warning sounded 3 times over a 4-second period. The first PULL UP
warning occurred as the aircraft was approximately 200 feet from the threshold of the
runway, at a height of approximately 180 feet agl and a speed of 145 knots (estimated
159 knots ground speed). The last warning at 2306:17 UTC, occurred approximately 900 feet
past the threshold, at approximately 60 feet agl. The high rate of descent was reduced over
the runway. At 2306:21 UTC, the aircraft passed the runway midpoint in a nose-up attitude
at a height of approximately 20 to 50 feet agl with a speed of 125 knots resulting in a ground
speed of approximately 135 knots. Two seconds later, the captain called for a go-around,
engine power was increased, gear retracted and flaps set to the ¼ position setting. At that
time, the aircraft was approximately 2300 feet beyond the Runway 27 threshold.
At 2306:29 UTC, the FO called the speed at 105 knots. 23 At 2306:33 UTC, the aircraft collided
with terrain beyond the departure end of Runway 27 and south of the runway centreline.
The aircraft continued to slide and rotate right, before coming to rest on an easterly heading.
The FO initiated the evacuation. The forward right overwing window emergency exit was
used to exit the aircraft. The captain made a mayday call on the CYSK radio frequency.
Airport employees, family members and other villagers awaiting the aircraft’s arrival
immediately responded to the occurrence. All occupants were transported to the community
health centre. The quick response of the people on the ground reduced the exposure of
passengers and crew to the elements. The flight crew were flown to Winnipeg for medical
care the following day.
22
Canadian Aviation Regulations (CAR) 602.128 (2) (b) “…no pilot-in-command of an IFR aircraft
shall, in the case of a non-precision approach, descend below the minimum descent altitude,
unless the required visual reference necessary to continue the approach to land has been
established.”
23
The SA227 Perimeter Standard Operating Procedures target climb speed is 140 knots. However, the
average target climb speed for the Metro III, depending on the weight of the aircraft but for most
weights, is approximately 110 knots.
Aviation Investigation Report A12Q0216 | 9
1.2
Injuries to persons
Table 1. Injuries to persons
Crew
Passengers
Others
Total
Fatal
-
1
–
1
Serious
2
1
–
3
Minor/None
–
5
–
5
Total
2
7
–
9
1.3
Damage to aircraft
The doors of all 3 landing gear bays were open on impact and were torn away, indicating
that the gear was in transition when the aircraft struck the ground, but not yet fully up and
locked. The right main gear and the nose landing gear were torn away on impact with the
ground. The left main gear was found retracted into the gear well; however, the tires were
cut and bruised; the left main gear retracts slightly ahead of the right gear in normal
operation. The landing gear selector in the cockpit was found in the UP position.
Both propellers had broken away from the engine propeller shafts close to the initial impact
point. The propeller blades were severely distorted and several had separated from the
propeller hubs. The damage sustained by the propellers indicated that both engines were
producing significant power at the time of impact.
The fuselage belly skin and
Photo 1. Aircraft wreckage (Source: Royal Canadian Mounted Police)
underside of the engines
were cut and ripped open
while sliding across the
sharp, rocky terrain,
exposing wire bundles,
hoses, insulation, lines, and
buckling the floor. The
fuselage fractured at the
forward pressure bulkhead
and in the rear baggage
compartment area below
the dorsal fin. Snow and
gravel entered the cockpit
floor areas via the openings
in the floor and fuselage. Both wings remained attached to the fuselage, but were
substantially damaged. There was no post-impact fire (Photo 1).
10 | Transportation Safety Board of Canada
There was no indication of any pre-impact damage to any of the flight controls. The flaps
were at approximately the ¼ setting corresponding with the flap lever position in the
cockpit. The flaps did not appear to be damaged.
1.4
Other damage
With the exception of minor oil spillage from the engines, there was no damage to property
or the environment.
1.5
Personnel information
1.5.1
Flight crew
1.5.1.1
General
Based on available records, the pilots were certified and qualified for the flight in accordance
with existing regulations.
Table 2. Flight crew information
Captain
First officer
Pilot licence
ATPL (airline
transport pilot
licence)
CPL
(commercial
pilot licence)
Medical expiry date
01 April 2013
01 May 2013
Total flying hours
5700
1250
Hours on type
2330
950
Hours in the last 7 days
18
14
Hours in the last 30 days
63
45
Hours in the last 90 days
144
153
Hours on type in the last 90 days
144
153
Hours on duty prior to the occurrence
9.5
9.5
Hours off duty prior to the work period
48
9.5
1.5.1.2
Captain
The captain was hired by Perimeter in May 2006 as FO on the Fairchild SA226-AC Metro II
and the Fairchild SA227-AC Metro III. In April 2007, he was awarded a captain position on
the Metro II, and on the Metro III in January 2008. In August 2008, he went on to work with a
large air carrier overseas as FO on heavy jet aircraft. In March 2009, the captain flew large
turboprop aircraft for a Canadian Subpart 705 operator initially as FO, then as captain. In
June 2011, he flew as FO on heavy jet aircraft with a different Canadian air carrier. His
departure from that company was precipitated by a layoff of flight crew. In October 2012, the
captain returned to Perimeter to fly as captain on the Metro III.
During his previous years of employment with Perimeter, the captain had gained experience
flying in the North. Since being rehired, he had been to CYSK twice before the day of the
Aviation Investigation Report A12Q0216 | 11
occurrence, once by day and once by night. Visual meteorological conditions (VMC) had
prevailed on both occasions. As captain, he was authorized to land on gravel surface
runways.
For the 7-day period prior to the occurrence, the captain had flown a total of 18 hours with a
total duty time of 34.4 hours for that period. The captain was off duty the 2 days preceding
22 December. He had a fairly good sleep the night before reporting for duty; he woke once
and had taken 1.5 hours before falling back to sleep but eventually managed to do so. He felt
rested prior to beginning the work shift. He had been on duty for approximately 9.5 hours
when the occurrence took place.
The originally planned total duty day, including the return trip, would normally have taken
approximately 9.5 hours. Because of the delays incurred, the flight crew’s duty day was
extended. Had the delayed flight landed without incident at CYSK and the aircraft flown
back to Winnipeg as planned, the duty day for both crew members would have been
approximately 14 hours. 24
1.5.1.3
First officer
The FO began employment with Perimeter as a ramp worker while he completed his multiengine and instrument ratings. He commenced duty as FO on the Metro III in July 2011. The
FO had flown to CYSK once before, the previous summer, by day in VMC. As FO, he was
not authorized to land on gravel surface runways. In the 72 hours prior to the occurrence, the
FO was off duty for 48 hours, followed by a 12.3-hour flight duty day on the day before the
occurrence, which included 7 hours of flight time. He was off duty approximately 9.5 hours
before reporting for work on the morning of 22 December. He had slept well and felt rested
for the flight. He had been on duty for approximately 9.5 hours when the occurrence took
place.
It was the first time the FO and captain had flown together.
1.5.2
Community aerodrome radio station observer/communicator
The CARS observer/communicator on duty at CYSK was hired in December 1999.
Revalidation training is completed every 3 years; his last revalidation training was
completed in February 2010. His next revalidation training was due in February 2013. At the
24
Canadian Aviation Regulations (CAR) 700.16 and Perimeter Aviation LP, Company Operations
Manual, Chapter 8, Section 8.6.7: The maximum flight duty time allowed for the flight crew
member, operating under Subpart 704 operations, is normally 14 consecutive hours in any
24 consecutive hours. The maximum flight time and flight duty time may be exceeded by
3 consecutive hours if the flight is extended as a result of “unforeseen operational circumstances”. If
less than 9 seats had been made available, the return flight could have been conducted under
Subpart 703 operations, in which case maximum flight duty time is 15 hours in any 24 consecutive
hours.
12 | Transportation Safety Board of Canada
time of the occurrence, the CYSK CARS was staffed as required with
1 observer/communicator.
1.6
Aircraft information
1.6.1
General
The aircraft was equipped with 2 Garrett engines and 2 McCauley 4-bladed propellers. It is a
pressurized aircraft first produced by Swearingen Aircraft and later by Fairchild.
M7 Aerospace, a part of Elbit Systems of America, currently holds the type certificate for the
SA227-AC Metro III. C-GFWX was imported to Canada in 1998; Perimeter purchased the
aircraft in 2005.
Table 3. Aircraft information
Manufacturer
Fairchild Aircraft Corporation
Type and model
SA227-AC Metro III
Year of manufacture
1985
Serial number
AC 650 B
Certificate of airworthiness
07 April 2003
Certificate of registration
19 August 2009
Total airframe time
32 982 hours
Engine type (number of engines)
Garrett TPE 331-11U-612G (2)
Maximum allowable take-off weight
16 000 pounds
Records indicate that the occurrence aircraft was certified, equipped, and maintained in
accordance with existing regulations and approved procedures. The aircraft weight and
centre of gravity were within the prescribed limits at the time of the occurrence. C-GFWX
was not equipped with an autopilot nor was it required by regulations. 25
There were no reported technical difficulties with the aircraft throughout the flight, nor any
alerts or warning lights relevant to any aircraft system anomaly or failure.
1.6.2
Minimum equipment list item
The right engine single redline limit (SRL) computer was not functioning normally and had
been deferred in the journey log in accordance with the minimum equipment list (MEL). 26 A
placard had been installed on the instrument panel adjacent to the right exhaust gas
temperature (EGT) and torque indicators. This inoperative SRL had no bearing on normal
engine operation given the cold temperatures on the day of the occurrence. As per the MEL
25
Subpart 704 (Commercial Air Service) flight operations do not require that autopilot be installed
and used when operated with 2 pilots.
26
Perimeter SA-227 Minimum Equipment List, Amendment 2, 31 December 2011, ATA 77-02-1.
Aviation Investigation Report A12Q0216 | 13
policy, the SRL item could be deferred until midnight local time on 22 December 2012 (0600
UTC on 23 December), at which time maintenance was expected to rectify the issue.
The other MEL item was the left-hand essential bus lighting. The associated placard had
been placed by the light switch and the appropriate logbook entries were completed. This
inoperative system did not affect aircraft performance during the flight.
1.6.3
Altimeters
CARs, Standard 625, Appendix C, requires calibration of altimetry devices and air traffic
control (ATC) transponders every 24 months. The captain’s altimeter was last calibrated on
25 February 2011 and was installed 28 February 2011. The FO’s altimeter was last calibrated
on 16 August 2011 and was installed on 07 August 2012. The ATC transponder systems were
calibrated on 16 December 2012.
As found at the site, both altimeter barometric scales were set to 29.24 in. Hg. The left
altimeter read 90 feet asl. The right altimeter indication mechanism was broken due to
impact forces.
Pressure altimeters are calibrated to indicate true altitude under international standard
atmosphere (ISA) conditions. Any deviation from ISA will result in an erroneous reading on
the altimeter. In a case where the temperature is lower than ISA, the true altitude will be
lower than the indicated altitude. The altimeter error may be significant and becomes
extremely important when considering obstacle clearance in very cold temperatures.
Therefore, temperature corrections for cold weather should be added to the published
altitudes on instrument approach charts, but there is no regulatory requirement to do so. The
Aeronautical Information Manual (AIM) states that for practical operational use, it is
appropriate to apply a temperature correction when the value exceeds 20% of the associated
minimum obstacle clearance. 27
The Canada Air Pilot General Pages (CAP GEN) Altitude Correction Chart shows that
altimeter errors due to cold temperatures can occur at temperatures of 0°C and below. As the
surface temperature was -5°C, a correction should have been made to the published
procedure altitudes. A correction of 119 feet should have been added to the published sector
altitude, a correction of 103 feet to the minimum published altitude for the procedure turn,
and a correction of 37 feet to the MDA for the NDB Runway 27 approach, since that was the
MDA used.
Since the procedure turn was executed on the opposite side of that published, and outside of
the airspace to be protected, the MSA of 1600 feet asl should have been used and corrected.
With the applicable cold temperature correction, the procedure turn should have been
executed at 1719 feet. The MDA of 560 feet asl, when corrected, results in an indicated
altitude of 597 feet. The crew had applied the required cold temperature correction only to
27
Transport Canada, Aeronautical Information Manual, Section RAC 9.17.1, p. 283.
14 | Transportation Safety Board of Canada
the published MDA for the NDB Runway 27 approach and rounded it off to 600 feet asl; the
circling MDA of 620 feet, which had not been obtained, was not used.
The aircraft was also equipped with a radio altimeter which indicates the height of the
aircraft above ground level (agl). It is positionned on the lower left-hand corner of the
instrument panel, by the captain’s left knee, and is not visible to the FO. Training on the
radio altimeter is included in the GPWS training and in flight training. Crews are told to set
it for the “level-off” height on takeoff and then to the MDA/DH (minimum descent
altitude / decision height) 28 approach minima when flying an instrument approach. Postoccurrence examination of the radio altimeter showed the setting marker (bug), set to
490 feet agl, which corresponds to 600 feet asl.
1.6.4
Terrain awareness devices
As of 04 July 2012, the CARs 29 require that aircraft manufactured on or after that date be
equipped with a terrain awareness and warning system (TAWS). Aircraft manufactured
before 04 July 2012 are required to be in compliance with these regulations by 04 July 2014.
The occurrence aircraft had been equipped with the Sunstrand Mark VI 30 GPWS before it
was purchased by Perimeter in 2005. This GPWS provides alerts and warnings for
inadvertent flight into terrain. It also monitors aircraft configuration and provides warnings
when the aircraft is in a non-standard landing configuration; however, it does not meet the
new TAWS requirements. Perimeter was upgrading its aircraft fleet to meet the new
regulations for TAWS.
One of the modes of the Mark VI GPWS is to provide advisory callouts. One of these
advisory callouts is the MINIMUMS-MINIMUMS callout. As the aircraft descends through
the selected height set on the radio altimeter, the MINIMUMS-MINIMUMS callout is
generated. These callouts were generated during both approaches and during both circling
procedures.
Another mode of this GPWS provides alerts and warnings for excessive rates of descent with
respect to above ground level (agl) altitudes. This mode becomes active as the aircraft
descends below 2450 feet agl. The system monitors radio altitude and rate of descent. An
alert, such as SINK RATE, requires a corrective measure, while a PULL UP warning requires
that the crew execute the Pull-Up In-flight Warning procedures. The chart in Figure 6
identifies the 2 envelopes of protection.
28
Decision height is the height of the decision altitude above the touchdown zone elevation or
runway threshold. The decision altitude is an altitude specified on a precision approach procedure
or an approach procedure with vertical guidance at which the missed approach procedure shall be
initiated if the visual reference required to continue the approach to land has not been established.
NAV CANADA CAP GEN, Canada Air Pilot, Instrument Procedures, p. 9.
29
Transport Canada, Advisory Circular (AC) 600-003, Regulations for Terrain Awareness Warning
Systems.
30
Honeywell Aerospace, part number 965-0686-001.
Aviation Investigation Report A12Q0216 | 15
Figure 6. Ground proximity warning system warning chart (Source: Honeywell MK VI Warning System
GPWS Pilot Guide, p. 6)
If penetrated, the outer envelope, indicated in yellow on the chart, activates the SINK RATE
alert every 3 seconds and the red GPWS warning light illuminates. When the aircraft exits
the alert envelope, the voice message ceases and the red warning light extinguishes. As the
altitude above ground decreases, the rate of descent necessary to cause an alert or warning
decreases.
If penetrated, the inner envelope, indicated in red on the chart, activates an urgent
continuous PULL UP voice message and the red GPWS warning light illuminates. When the
aircraft exits the alert envelope, the voice message ceases and the red warning light
extinguishes. The system may revert to the SINK RATE alert if the aircraft does not also exit
that envelope during recovery.
As in the chart example, if the aircraft is descending through 2000 feet agl, a rate of descent
of approximately 4400 ft/min would produce a SINK RATE alert. The same alert would only
require a 1800 ft/min rate of descent to activate at 500 feet agl.
1.6.5
Global positioning system
The aircraft was equipped with a Bendix/King KLN 90B GPS. This type of GPS does not
store any track data. As a consequence, no further examination of this device was performed.
The KLN 90B meets the Federal Aviation Administration (FAA) TSO C129 standard 31 and is
certified for en-route, terminal and non-precision instrument approach navigation. The
operator had the necessary operations specification (OpSpec) 32 for the crew to conduct GPS
approaches with this type of GPS unit.
31
Federal Aviation Administration (FAA), TSO-C129, dated 12/10/92-Airborne Supplemental
Navigation Equipment Using the Global Positioning System (GPS).
32
Operations Specification, Part IV, No. 100, IFR Instrument Approaches – Global Positioning
System (GPS).
16 | Transportation Safety Board of Canada
1.6.6
Guardian Mobility SkyTrax
The aircraft was equipped with a Guardian Mobility, Guardian 3 Globalstar flight tracking
system. The on-board system sends the aircraft’s GPS position to the server every 6 minutes.
Information for the occurrence flight was retrieved and indicated that the unit began
transmitting position reports at 1933 UTC at the start of the flight. The last position report
was at 2301 UTC, approximately 5 minutes before the occurrence.
1.7
Meteorological information
1.7.1
Pre-flight weather information
For pre-flight planning purposes, pilots refer to aviation routine weather reports (METAR),
aerodrome forecasts (TAF), and graphic area forecasts (GFA) information. For airports where
there are no TAFs, only METARs and GFAs are used. TAFs are intended to relate to weather
conditions for flight operations within 5 nm of the centre of the runway. They are prepared
4 times daily with periods of coverage from 12 to 24 hours. GFAs consist of a series (6 charts)
of temporally adjusted weather charts, each depicting the most probable meteorological
conditions expected to occur below 24 000 feet over a given area at a specified time.
For flight planning purposes, the captain had checked weather upon reporting for duty in
the morning, and again at 1750 UTC.
1.7.1.1
Sanikiluaq weather prior to departure
The 1700 UTC METAR at CYSK was as follows: winds 020° True (T) at 15 knots, visibility
8 sm in light snow and drifting snow, cloud ceiling overcast at 1400 feet agl, temperature 5°C, dew point -6°C, altimeter setting 29.56 in. Hg. TAFs are not issued for CYSK.
1.7.1.2
Kuujjuarapik weather prior to departure
The alternate airport for the flight was CYGW, 90 nm southeast of CYSK. The 1700 UTC
METAR for CYGW was as follows: winds 010°T at 16 knots, visibility 3 sm in light snow,
cloud ceiling overcast at 600 feet agl, temperature -5°C, dew point -6°C, altimeter setting
29.38 in. Hg. The TAF at CYGW, issued at 1740 UTC on 22 December 2012, valid from
1800 UTC on 22 December 2012 to 0600 UTC on 23 December 2012, indicated:
Winds 010°T at 15 knots, visibility 1½ sm in light snow, cloud ceiling overcast
at 800 feet agl. Temporarily from 1800 [UTC] to 2200 [UTC] visibility 3 sm in
light snow, cloud ceiling overcast 1000 feet agl, 40% probability from
1800 [UTC] to 2200 [UTC] of visibility ¾ sm in light snow and blowing
snow. 33 From 2200 [UTC], variable wind at 3 knots, visibility 2 sm in light
33
According to the Manual of Standards and Procedures for Aviation Weather Forecasts (MANAIR),
Section 2.9.5, the PROB40 of ¾ of a statute mile (sm) would cover visibilities from zero (0) to
1¼ sm.
Aviation Investigation Report A12Q0216 | 17
snow, cloud ceiling overcast 1500 feet agl. Temporarily from 2200 [UTC] on
22 December to 0600 [UTC] on 23 December, visibility 4 sm in light snow.
Remarks, next forecast at 0000 [UTC] on 23 December.
METARs issued for 1700 UTC for CYSK and CYGW did not raise concerns about weather
conditions for arrival after 2200 UTC. The TAF for CYGW issued at 1740 UTC allowed for
CYGW to be used as an alternate.
1.7.1.3
Other weather information reviewed prior to departure
METARs and TAFs for other airports relevant to the flight were also consulted by the
captain. They included Winnipeg/James Armstrong Richardson International
Airport (CYWG), Manitoba; Moosonee (CYMO), Ontario; Brandon (CYBR), Manitoba; 34
Dauphin (CYDN), Manitoba; Kenora (CYQK), Ontario; La Grande Rivière (CYGL), Quebec;
and Pickle Lake (CYPL), Ontario.
The GFA (GFACN32) for the Prairies region, issued at 1732 UTC, valid on 23 December 2012
at 0000 UTC, was consulted for the departure and a portion of the en-route phase of the
flight. The GFA (GFACN33) for the Ontario-Quebec region was consulted for the en-route
and destination phases of the flight. The GFACN33, issued at 1732 UTC, valid on
23 December 2012 at 0000 UTC (Appendix E) indicated a cloud base at 3000 feet asl with tops
to 22 000 feet asl, and visibility 2 to 4 sm in light snow. Scattered towering cumulus (TCU)
10 000 feet asl, bringing visibility to ¾ sm in light snow showers and blowing snow, ceilings
300 feet agl.
1.7.2
Weather obtained prior to descent for landing at Sanikiluaq
Prior to descent at 2225 UTC, the crew requested weather for CYSK from the CARS
observer/communicator on the airport frequency. The following information was obtained:
Observed at that time, wind 040°M at 20 gusting 25 knots, altimeter 29.25 in. Hg. The runway
surface condition (RSC) was also provided. Runways 09/27, 70% loose snow, 20% trace, 10%
compacted snow and ice patches. Report issued 21 December 2012 at 2133 UTC.
Later, at 2229 UTC, the crew requested weather on the Quebec FIC radio frequency. The
following information was obtained:
CYSK 2200 UTC METAR: wind 010°T at 17 knots gusting 25 knots, visibility 2 sm in light
snow and blowing snow, cloud ceiling overcast 1200 feet agl, temperature -5°C,
dewpoint -6°C, altimeter setting 29.28 in. Hg.
CYGW 2200 UTC METAR: wind 030°T at 8 knots, visibility ½ sm in moderate snow, vertical
visibility 400 feet, temperature -4°C, dewpoint -5°C, altimeter setting 29.18 in. Hg.
34
Brandon (CYBR) in Manitoba was the chosen alternate airport for the return segment of the
charter flight.
18 | Transportation Safety Board of Canada
CYGL 2200 UTC METAR: wind 290°T at 10 knots gusting 17 knots, visibility 1½ sm in light
snow and drifting snow, vertical visibility 1300 feet, temperature -7°C, dew point -9°C,
altimeter setting 29.17 in. Hg. In remarks, visibility was noted as variable from 1 to 2 sm.
1.7.3
Environment Canada weather study
1.7.3.1
General
To assist in this investigation, the TSB requested that Environment Canada conduct a
weather study for the flight from CYWG to CYSK with the alternate airport as CYGW. The
weather information that follows was taken from the study provided.
1.7.3.2
Area weather
The GFA for southern Hudson Bay, issued at 1732 UTC on 22 December 2012, valid at
0000 UTC on 23 December 2012, showed a strong low pressure system located over central
Quebec. CYSK was located in the areas of cloud and snow covering all of southeastern
Hudson Bay. Most areas west and north of the system experienced strong winds, low clouds,
and low visibilities in snow and blowing snow. The snow began falling at CYGW and CYSK
during the morning on the day of the occurrence, and conditions in snow and blowing snow
deteriorated steadily throughout the afternoon with the approach of the low pressure
system.
This forecast called for prevailing visibilities between 2 and 4 sm in snow, with the exception
that 25 to 50% of the area would have scattered towering cumulus cloud (TCU) giving
visibilities of ¾ sm in snow showers. The cloud bases would be 3000 feet asl except in the
vicinity of the TCUs, where ceilings would be as low as 300 feet agl.
There was a low-level jet stream with a wind speed peak of 40 knots from the east at 100°T
between 1800 feet and 2300 feet asl. The low-level jet stream in the area of CYSK on the day
of the occurrence did not reach the ground. The fact that the wind direction was constant
with height indicates that directional wind shear would have been unlikely. Wind shear due
to speed was possible given that the winds were so high, but the lower levels of the
atmosphere were homogeneous, and the change in wind speed was mostly gradual with
height, so turbulence as a result of shear would have been minimal. Mechanical turbulence
between the surface and 1000 feet agl due to the high winds interacting with the ground
topography would be the most likely turbulence phenomenon expected to occur with this
type of atmosphere. With wind speeds less than 20 knots, the turbulence intensity would
have been less than what is categorized as moderate. Moderate turbulence may have
occurred with wind speeds between 20 and 30 knots.
1.7.3.3
Aerodrome forecast amendments for Kuujjuarapik
The TAF for CYGW, consulted for flight planning prior to departure from CYWG, was
issued at 1740 UTC. This TAF was amended at 1936 UTC to indicate a change in the wind.
The weather conditions prior to 2200 UTC were significantly changed, with a forecast ceiling
of 500 to 1000 feet agl and the visibility ranging from ½ sm in moderate intensity snow to
3 sm in light snow. Wind gusts to 25 knots were also added to the forecast during this time
Aviation Investigation Report A12Q0216 | 19
period. From 2200 UTC, the wind was forecast to be northerly at 12 gusting to 22 knots and
then become light and variable by 0000 UTC on 23 December. The forecast ceilings and
visibility range from 2200 UTC to 0600 UTC remained the same as previously issued.
The TAF for CYGW was amended a second time at 2211 UTC adjusting the forecast between
2200 UTC and 0000 UTC to an obscured or overcast ceiling ranging from 400 to 1000 feet agl
and visibility ranging from ½ sm in moderate snow to 2 sm in light snow, with northerly
winds to 8 knots. The forecast remained unchanged for the period after 0000 UTC on
23 December 2012.
The crew were not aware of these 2 TAF amendments, as the first was issued as the aircraft
was taking off from CYWG and the other while the aircraft was en route. No weather
forecast updates were obtained after departure from CYWG.
1.8
Aids to navigation
The navigation aid serving CYSK is the YSK NDB used for the NDB Runway 27 approach.
The YSK NDB was serviceable on the day of the occurrence. GPS was also used for
navigation and distance information. The crew did not report any navigation aids difficulties
during the flight.
1.9
Communications
There were no issues with the effectiveness of communication service with any of the air
traffic services units or the CYSK CARS services involved with PAG993. The flight was on
radar for departure and climb out of CYWG. It remained on radar during the cruise portion
of the flight at FL230. Radar contact with PAG993 was lost as it descended below FL195 into
uncontrolled airspace, approximately 54 nm from CYSK. 35
1.10
Aerodrome information
1.10.1
General
Sanikiluaq is a small isolated community in the Belcher Islands, Nunavut, located in Hudson
Bay, approximately 780 nm east-northeast of Winnipeg. The community is served by a
certified airport which is owned and operated by the Government of Nunavut, Department
of Economic Development and Transportation, Nunavut Airports Division.
There is 1 operational runway, 09/27, aligned 088°/268°M. The runway is 3807 feet long by
100 feet wide with a gravel surface. The Runway 27 touchdown zone elevation is 110 feet asl.
The longitudinal slope from Runway 27 is down by 1.1% for the first 2300 feet, and then up
35
Sanikiluaq (CYSK) is situated in Class G uncontrolled airspace. Air traffic control has neither the
authority nor the responsibility for exercising control over air traffic. Air Traffic Services units do
provide flight information and alerting services.
20 | Transportation Safety Board of Canada
1.3% for the last 1500 feet of the runway. Crosswind conditions are expected at CYSK as
runway orientation does not usually favour prevailing winds. At the time of the occurrence,
CYSK was serviced by only 1 instrument approach, the NDB Runway 27 approach.
1.10.2
Runway and taxiway lighting
The runway identification lights are unidirectional flashing strobe lights situated at each end
of the runway. These lights are provided at aerodromes where terrain prevents the
installation of approach lights, or where unrelated non-aeronautical lights or the lack of
daytime contrast reduces the effects of approach lights. At night, these lights are operated in
conjunction with the runway lights. CYSK is not equipped with approach lights. To help
identify the runway and align with it, the take-off and landing area boundaries of the CYSK
airport are indicated by unlighted solid international orange coloured type boundary
markers; these are not visible at night.
The threshold and runway end lights are variable intensity red and green light units in the
form of wing bars along the threshold on each side of the runway centreline. Red shows in
the direction of takeoff and green shows in the direction of landing.
CYSK runway edge lights are variable-intensity white lights at the runway edges along the
full length of the runway, spaced at 200-foot intervals. The runway lights are operated by the
aircraft radio control of aerodrome lighting (ARCAL) type K system. During the approach of
flight PAG993, the runway lights were ON and set to the maximum intensity setting (B3
setting).
Aviation Investigation Report A12Q0216 | 21
1.10.3
Approach slope indicator system
An approach slope indicator system is installed
at an aerodrome to provide flight crews with
visual (vertical) guidance to help in establishing a
stabilized descent during an approach to landing.
Figure 7. Abbreviated precision approach path
indicator (APAPI) (Source: Transport Canada,
Aeronautical Information Manual, AGA, p. 67)
Both Runway 27 and Runway 09 are equipped
with an abbreviated precision approach path
indicator (APAPI) 36 approach slope indicator
system. The APAPIs are situated on the left side
of the runway, 856 feet from the threshold and
consist of 2 light units in the form of a wing bar
(Figure 7).
Two white lights will be seen if the aircraft is too
high on the approach slope, 1 white light and
1 red light when on the correct approach slope,
and 2 red lights if the aircraft is below the
approach slope. CYSK APAPI, as adjusted,
allows for a wheel clearance height of
approximately 20 feet over the threshold.
The CYSK APAPIs were verified every other day just prior to the occurrence. The APAPI
units are checked for general condition, snow and ice contamination, and calibration values.
The initial values found before re-leveling 37 are recorded and then the nuts on the threaded
rods are adjusted until the inclinometer indicates the desired values.
There is no range of tolerance acceptable for service. A Notice to Airmen (NOTAM) is issued
if the values cannot be readjusted to the specified values. The APAPI Findings/Adjustments
forms for 17, 19 and 21 December 2012 showed that none of the values were out of tolerance,
and therefore did not require readjustment. The last verification done on 21 December 2012
showed the system to be serviceable.
The CYSK APAPI is set for a 3-degree approach slope. The instrument approach chart
depiction for the CYSK NDB Runway 27 approach, however, shows that if starting the
descent at the MAP from the MDA of 560 feet asl, there is a 4.7-degree descent angle to a
point approximately 20 feet above the threshold. Therefore, the initial APAPI indication seen
by the crew at MDA, at the MAP would show 2 white lights indicating that the aircraft was
too high. Any attempt to regain the desired 3-degree descent slope from the MAP, at 0.9 nm
36
APAPI is an abbreviated precision approach path indicator system used for aerodromes serving
aircraft with eye-to-wheel height of up to 10 feet.
37
Leveling of the unit is executed with an inclinometer; at level 0.0, the angle for Box 2 should be
2 degrees 45 minutes, and at level 0.0, the angle for Box 1 should be 3 degrees 15 minutes.
22 | Transportation Safety Board of Canada
from the threshold of Runway 27, would initially require a greater rate of descent and likely
result in a GPWS alert or warning.
1.10.4
Sanikiluaq community aerodrome radio station
At CYSK, a CARS observer/communicator completes the hourly surface weather
observations and reporting. Communication equipment is used to provide operational
information to flight crews. The CARS unit is housed in the airport terminal building.
Normal operating hours are published in the Canada Flight Supplement (CFS), and are usually
from Monday to Friday. Since the normally scheduled Keewatin Air flight on Friday,
21 December, had been rescheduled for Saturday, 22 December, and there was the additional
Perimeter charter flight arriving, the CARS observer/communicator was called to work on
Saturday. The METARs were available to the Perimeter crew for flight planning and arrival.
The CARS observer/communicator was in communication with the flight crew and relayed
runway surface conditions, wind, and altimeter setting.
The visibility reported in the METAR is the prevailing visibility 38 at the time of the weather
observation. A visibility chart, depicting the distance of known objects from the airport, is
used by the CARS observer/communicator to estimate the observed visibility 39 for different
horizon sectors. Flight visibility is the visibility observed by the flight crew while in flight.
These visibilities may differ as they are taken from different locations and heights, and at
different times. Although the CARS observer/communicator reported the visibility as 1½ sm
(1.3 nm) while the aircraft was on the second approach, the crew did not acquire visual
reference to the runway environment until approximately 0.7 nm from the airport, past the
MAP.
1.10.5
Sanikiluaq aircraft rescue and fire fighting
The CARS observer/communicator initiated the CYSK airport emergency response plan
procedures immediately after the occurrence. Prompt assistance was available by local
residents, airport employees, and medical personnel who happened to be at the airport
awaiting the arrival of the aircraft. There is no aircraft rescue and fire fighting (ARFF)
capability located at CYSK nor was there a need for local fire fighting intervention. The
Royal Canadian Mounted Police (RCMP), the law enforcement agency in place at Sanikiluaq,
was notified of the occurrence and took control of the site.
1.11
Flight recorders
The cockpit voice recorder (CVR) was a solid-state L3 model FA2100 with a nominal
recording capacity of 2 hours. The recording included the captain and FO radio channels,
cockpit area microphone (CAM) channel, an extra channel, and also 2 tracks of the last
38
Prevailing visibility is the maximum visibility value common to sectors comprising one-half or
more of the horizon circle.
39
Observed visibility is the visibility on the ground, taken at eye level.
Aviation Investigation Report A12Q0216 | 23
2 hours, which included the CAM channel and a mixed radio channel (all radio channels
combined). By switching the battery to OFF just prior to evacuation, the crew preserved the
CVR recording, which is an important investigation tool.
The aircraft was not equipped with a flight data recorder (FDR) and none was required by
regulations. 40
1.12
Wreckage and impact information
The aircraft impacted rock-strewn, snow-covered terrain approximately 525 feet beyond the
departure end of Runway 27, and 98 feet south of the extended runway centreline. After
initial impact, the aircraft travelled 1050 feet further to the west while slewing to the right
before coming to rest on an approximate heading of 60°M.
All damage to the aircraft structure was due to contact with the ground. All principal
structural components of the aircraft were accounted for at the site. After examination and
documentation of the wreckage, it was placed in storage containers until it could be
transported out of Sanikiluaq.
Various instruments, 41 including the altimeters, annunciator panel, and GPS, were recovered
and sent to the TSB laboratory for examination. Due to damage, it could not be determined if
the static altimeters were serviceable and properly calibrated at the time of the occurrence.
The serviceability of the remaining instruments at the time of the occurrence could not be
determined, nor could indication at impact be confirmed. A microscopic examination of the
annunciator lights, including the lights for the landing gear position indicator, to confirm if
any lights were ON at impact, was inconclusive.
1.13
Medical and pathological information
The investigation determined that there was nothing to indicate that the captain’s or FO’s
performance was degraded by medical or pathological factors.
1.14
Fire
Not applicable.
40
Canadian Aviation Regulations (CAR) 605.33 (1).
41
Other instruments included the left and right torque gauges, tachometers, fuel flow gauges, and
airspeed indicators.
24 | Transportation Safety Board of Canada
1.15
Survival aspects
1.15.1
Perimeter emergency response
Perimeter’s CARs Subpart 703 (Air Taxi) and Subpart 704 (Commuter) flight operations use a
Type C self-dispatch system. 42 Under this system, the captain is responsible for flight
watch, 43 the captain must communicate landing and departure, en-route stops, and arrival at
destination. Perimeter, as the operator, must support the captain by providing a flight
following system. 44 Perimeter flight following was advised of the occurrence by the captain
at 2320 UTC. The company emergency response plan was put into action at that time.
42
Pilot Self-Dispatch - means Type C Operational Control where the pilot-in-command is solely
responsible for flight watch but supported by flight following. The pilot-in-command has the sole
authority over the formulation, execution, and amendment of an operational flight plan (OFP) in
respect of a flight. Commercial Air Service Standards (CASS) 723.16.
43
Flight Watch - means maintaining current information on the progress of the flight and
monitoring all factors and conditions that might affect the OFP [operational flight plan]. Flight
Watch begins at brake-release of the aircraft. Perimeter Aviation LP, Company Operations Manual,
Section 6.3 Interpretations, p. 6-3.
44
Flight Following - means the monitoring of a flight’s progress, the provision of such operational
information as may be requested by the PIC [pilot-in-command], and the notification of appropriate
Company and search-and-rescue authorities if the flight is overdue or missing. Perimeter Aviation
LP, Company Operations Manual (COM), Section 6.3 Interpretations, p. 6-3.
Aviation Investigation Report A12Q0216 | 25
1.15.2
Cabin safety/aircraft occupant seats
1.15.2.1 General
The aircraft was configured with
a moveable bulkhead that
divided the main cabin into aft
cargo and forward passenger
compartments as depicted in
Figure 8. Passenger seating was
arranged with 5 single seats on
each side of the cabin. The cargo
compartment (hatched area on
Figure 8), aft of the bulkhead,
was loaded through a cargo door
on the left side of the aircraft.
Two nets were used to secure the
cargo into 3 different sections.
Figure 8. Seating depiction
Both the captain and FO were
wearing their 4-point harness
restraint system, which
comprises a lap belt and double
shoulder harnesses. The captain’s
seat remained partially attached
to the damaged cockpit floor. The
captain received chest, face, and
leg injuries.
The FO’s seat was completely
detached, and the cockpit floor
beneath the seat was destroyed. The FO received chest and face injuries.
Passengers comprised 6 adults and 1 infant. Adult passengers were all restrained by their lap
belt-style safety belt. The infant was held on the mother’s lap without any restraint system.
Although Transport Canada (TC) recommends that infants be restrained in an approved
child restraint system (CRS), it is not mandatory to do so.
Cabin seat legs and floor attachment points were broken for seats 2L, 3L, 3R, 4L and 4R. 45 All
adult passengers received minor injuries except for the adult passenger seated in 3L, who
45
Seat identification is indicated as seat 1L = first seat on the left when looking towards the front of
the aircraft, 1R=first seat on the right, etc. The applicable aircraft certification requirements at the
time of manufacture of the occurrence Metro III required that seats and their supporting
structures be designed to sustain ultimate upward acceleration loads of 4.5 g, forward acceleration
loads of 9.0 g, and sideward acceleration loads of 1.5 g.
26 | Transportation Safety Board of Canada
received a fractured ankle. Seat support and attachment failures can subject occupants to
unfavourable positions that greatly reduce tolerance to injury. When a seat does not remain
securely attached to the floor, occupant injury protection offered either by the seat or by the
safety belt and shoulder harness is considerably reduced.
The rear moveable bulkhead that separated the passenger cabin from the aft cargo
compartment was partially detached at the floor, and cargo items, such as cans of pop, were
present in the cabin.
The belly of the aircraft was compressed, and the deflection had been transmitted to the
passenger cabin floor during the impact and subsequent travel across the ground. This
damage also deformed the hinge structure of the forward main cabin door and placed
abnormal loads on the door latching mechanism. The main cabin door, located on the left
side aft of the cockpit bulkhead, was hinged on the bottom with steps and a hinged handrail
incorporated into the door construction. When the cabin door is closed, the steps and
handrail are immediately forward of the first seat on the left (seat 1L), where the mother and
infant were seated. After impact, the orientation of the fuselage and proximity to the ground
prevented the door from opening fully.
The aircraft was equipped with 3 overwing exits; 1 on the left side and 2 on the right. The
forward right overwing exit was the only exit used during the evacuation. It was opened by
a passenger, assisted by the FO. The FO experienced difficulty reaching the exit as the
narrow aisle was blocked by the passengers, broken seats, strewn carry-on baggage and
other items. The FO used the light from his personal phone to illuminate the cabin area. 46
1.15.2.2 Mother and infant
The mother holding the infant was
seated in seat 1L. Because it was located
directly aft of the main cabin door, this
seat did not have a seatback ahead.
Consequently, there was limited
energy-absorbing material directly in
front of the seat’s occupants. The
aircraft main stairway folded into the
aircraft when the cabin door was
closed, positioning it directly in front of
their seat (Photo 2).
Photo 2. Door stair in front of seat 1L
The 6-month old lap-held infant
weighed 23.2 pounds and measured
46
Canadian Aviation Regulations (CAR) 602.60 (l)(g) requires a flashlight that is readily available to
each crew member, if the aircraft is operated at night. The crew members carried a flashlight in
their flight bags, but the first officer used what was readily available.
Aviation Investigation Report A12Q0216 | 27
75 cm. Although the mother had not been instructed on how to correctly hold her infant
during takeoff and landing prior to the occurrence flight, she had been shown how to hold
an infant on previous flights. As instructed previously, for approach and landing, she was
holding her infant against her chest, with the infant facing aft. During the impact and crash
sequence, the infant was expelled from her arms and was later found next to the captain’s
rudder pedals. The cause of death listed by the coroner was closed head injury with multiple
injuries.
1.15.2.3 Briefings
Commercial Air Service Standard (CASS) 724.34(2)(b)(vii) details the individual passenger
briefing pertaining to a person holding an infant:
For a passenger who is responsible for another person on board, information
pertinent to the needs of the other person as applicable:
(A) in the case of an infant:
(I) seat belt instructions;
(II) method of holding infant for take-off and landing;
(III) instructions pertaining to the use of a child restraint system;
(IV) oxygen mask donning instructions;
(V) recommended brace position;
(VI) location and use of life preservers, as required.
For Subpart 704 operations, passenger briefings are given upon boarding, prior to departure,
and, upon arrival, prior to disembarking. Individual passenger briefings are completed as
per the CARs and the company operations manual (COM). 47 Perimeter standard operating
procedures (SOP), applicable at the time of the occurrence and for 704 operations, make no
mention of individual passenger briefings. Information pertinent to individual passenger
briefings was not included in the training provided. The content of the COM pertaining to
individual passenger briefings is not included in the training syllabus.
47
Canadian Aviation Regulations (CAR) 704.34, Commercial Air Service Standards (CASS) 724.34(2), and
Perimeter Aviation LP, Company Operations Manual, Chapter 10, Section 10.8.7. The normal safety
briefing may be inadequate if a passenger has physical, sensory or comprehension limitations, or
if a passenger is responsible for another person on board the aircraft.
28 | Transportation Safety Board of Canada
1.15.2.4 Emergency brace position
TC recommends 48 that Canadian air
operators establish emergency
procedures that include brace
positions. Additionally, operators
are required to supply a passenger
safety features card that depicts the
passenger brace-for-impact position,
including the brace position for an
adult holding an infant. 49 The
Perimeter safety features card met
this requirement (Figure 9).
Figure 9. Perimeter safety features card—brace position with
infant
Brace position information is not
required to be provided to
passengers during the pre-flight
safety briefing prior to departure.
Passengers are advised, however, to
consult the safety features card on
board the aircraft.
Recommended brace-for-impact positions made by the Flight Safety Foundation (FSF) in
1988 50 were based on brace positions developed by Dr. Richard Chandler of the FAA. 51 Brace
information was incorporated into the TC guidance for bracing.
The recommended brace position for an adult holding an infant has the same 2 main goals as
any recommended brace-for-impact position, namely
•
to reduce the effect of any secondary impact 52 of the occupant’s body with the interior
of an aircraft, and
48
Transport Canada, Commercial and Business Aviation Advisory Circular No. 0155 (1999).
Available at: http://www.tc.gc.ca/eng/civilaviation/standards/commerce-circulars-ac01551633.htm (last accessed 18 June 2015).
49
Commercial Air Service Standards (CASS) 724.35(1)(b)(vii) Safety Features Card. Available at:
http://www.tc.gc.ca/eng/civilaviation/regserv/cars/part7-standards-724a-2172.htm#724a_35
(last accessed 18 June 2015).
50
Flight Safety Foundation, Cabin Crew Safety, “Positions Brace Passengers for Impact To Reduce
Injuries and Fatalities,” Vol.23(1), January/February 1988. Available at:
http://flightsafety.org/ccs/ccs_jan-feb88.pdf (last accessed 18 June 2015).
51
R.F. Chandler, Brace for impact positions. Protection and Survival Laboratory, p. 5, Civil
Aeromedical Institute, Federal Aviation Administration (FAA): February 1988. Available at:
http://www.unitedafa.org/safety/training/docs/brace.pdf (last accessed 18 June 2015).
52
Refers to an impact between a body segment, such as one’s head, and whatever it might hit in a
crash.
Aviation Investigation Report A12Q0216 | 29
•
to reduce flailing of body segments during a crash and the adverse effects that would
otherwise result by positioning the occupant’s body, or body segments, in close
proximity to the aircraft surface.
These goals are also based on the premise that the interior aircraft surface with which an
occupant is likely to come into contact is deformable. 53 For example, aircraft seatbacks
directly in front of passengers are made to be easily crushable, are covered with foam
padding to distribute the impact load, and have table trays that are constructed of light,
breakable material.
Following passenger injuries in the US Airways Flight 1549 emergency ditching on the
Hudson River, Weehawken, New Jersey (15 January 2009), the United States National
Transportation Safety Board (NTSB) recommended (REC A-10-78) that the FAA conduct
research to determine the most beneficial passenger brace position in airplanes with
nonbreakover seats installed. The FAA has completed its research; results and
recommendations are expected to be made public in the near future.
Biomechanical research conducted in 1979 54 found that, due to limitations in human clasping
strength, it is not always possible for adults to restrain children adequately in their laps by
holding onto them, and that children under 2 years old travelling in airplanes were being
exposed to undue risks of injury by seating them on an adult’s lap. The NTSB’s 2004 analysis
of the need for child restraint systems (CRS) noted that
... arm strength is not sufficient to protect even a small child. That’s because
commercial aircraft are designed to withstand tremendous g-forces, but
humans are not. Therefore a 25-pound baby could easily weigh 3 or 4 times
that amount when attempting to hold onto it during an emergency.
Additionally, in crash or turbulence situations, lap-held infants were likely to
contact hard structures consequently injuring them. 55
Similarly, research conducted in 1992 by the United Kingdom Civil Aviation
Authority (CAA) concluded that: “The carrying of infants and young children on the lap of
an adult sitting on a forward-facing seat, without any recognized or approved form of
restraint, is likely to promote fatalities and injuries to these children during impact
situations.” 56
53
Deformable: capable of being reshaped.
54
D. Mohan and L.W. Schneider, 1979, “An evaluation of adult clasping strength for restraining lapheld infants,” Human Factors, 21(6), pp. 635-645.
55
Bill McGee, “Why you should never fly with a child in your lap,” USA Today, 30 July 2008.
Available at: http://usatoday30.usatoday.com/travel/columnist/mcgee/2008-07-29-lapchildren_N.htm (last accessed 18 June 2015).
56
R.N. Hardy, 1992, CAA paper 92020: The restraint of infants and young children in aircraft.
30 | Transportation Safety Board of Canada
1.15.2.5 Emergency exits
TC Advisory Circular (AC) 700-014 defines an aircraft emergency exit seat 57 as follows:
(a) Each seat having direct access to an exit;
(b) Each seat in a row of seats through which passengers would have to pass
to gain access to an exit, from the first seat inboard of the exit to the first
aisle inboard of the exit; and
(c) A seat from which a passenger can proceed directly to an exit without
entering an aisle or passing around an obstacle.
In Canada, air operators are required to ensure that aircraft seats located at emergency exits
are not occupied by passengers whose presence in those seats could adversely affect the
safety of passengers or crew members during an emergency evacuation. 58
AC 700-014 states that a passenger’s presence would be considered to adversely affect the
safety of passengers and crew members during an emergency evacuation where he or she
does not meet the criteria stated in the AC. Passengers seated at emergency exits must not be
responsible for another person as this can hinder the opening of the emergency exit.
Although the Perimeter
aircraft safety features card
indicated that the main cabin
door could be used as an
emergency exit, for the
purposes of passenger
seating, Perimeter did not
consider the main cabin door
to be an emergency exit
(Figure 10).
Figure 10. Perimeter safety features card—emergency exits and
equipment
Limited-mobility passengers,
as well as adult passengers
holding an infant, had been
seated in seat 1L on previous
company flights. Space
between seats and in the aisle limits movement in the Metro III. Seat 1L is viewed as being
the better place to seat this type of passenger; it is close to the main exit for embarking and
disembarking, and allows more space for those persons providing assistance to others to
move around.
57
Transport Canada, Advisory Circular (AC) 700-014, Passenger Seating Requirements and
Accessible Air Transportation, Issue 1, 21 August 2009. Available at:
http://www.tc.gc.ca/media/documents/ca-opssvs/700-014.pdf (last accessed 18 June 2015).
58
Canadian Aviation Regulations (CAR) 704.33(1)(d), Apron and cabin safety procedures.
Aviation Investigation Report A12Q0216 | 31
The COM directs that: “The PIC [pilot-in-command] shall ensure that …seats located at
emergency exits may not be occupied by passengers whose presence in those seats could
adversely affect the safety of passengers or crew members during an emergency
evacuation.” 59
Perimeter SOPs require the FO “to keep in mind that only passengers capable of operating
the emergency exits are to be seated at the exits.” 60 The issue of seating a person assisting
another next to an emergency exit is not mentioned in the SOPs. In the case where
passengers with limited mobility or those assisting others are present on a flight, no
guidance is offered in the COM or SOPs. Although some mention as to who should be
allowed to sit next to emergency exits is made in the SOPs, the practical application of these
instructions in line operations had not been verified by the company or by TC.
1.15.2.6 Carry-on baggage
Carry-on baggage is defined as the personal belongings that accompany a passenger on
board an aircraft. To prevent the boarding of carry-on baggage that may exceed the weight,
size, shape, and total volume limitations of the approved stowage areas of the aircraft,
Perimeter has a Carry-On Baggage Control Program 61 for screening, weighing, and
determining which baggage is acceptable as carry-on baggage. Actual weights are used
when calculating passenger carry-on baggage weights; however, if weight is not available,
then a standard 13 pounds is used.
For operations under Subpart 703 or 704, TC also requires 62 that all carry-on baggage on
board an aircraft be
•
stowed in a bin, compartment, rack, or other certified location; or
•
restrained so as to prevent them from shifting during movement of the aircraft on the
surface and during takeoff, landing and in-flight turbulence.
In addition, any carry-on baggage that is brought on board an aircraft must be stowed so that
it does not obstruct access to safety equipment, exits, or the aisles of the aircraft.
The Metro III is not equipped with overhead bins to stow carry-on baggage, and the space
under each seat is limited. Therefore, carry-on baggage is at times placed in the open-door
closet or on empty seats, if available.
59
Perimeter Aviation LP, Company Operations Manual, Section 10.8.4.
60
Perimeter SA227 Standard Operating Procedures, Section 5 Operational Notes and Directives,
Subsection 5.8 Before Start and Passenger Briefing. Subpart 704 operations do not require a flight
attendant to be on board.
61
Only Subpart 705 air operators are required to have a carry-on baggage control program in
accordance with Section 705.42 of the Canadian Aviation Regulations (CARs).
62
Canadian Aviation Regulations (CAR) 602.86(1), Carry-on Baggage, Equipment and Cargo.
32 | Transportation Safety Board of Canada
In this occurrence, most of the carry-on baggage, including coats, hats, and mittens, was
placed on the empty seats. Snacks and beverages for the passengers were placed in a box on
seat 1R; this box was not secured, and items were strewn throughout the cabin after the
occurrence. An open-door closet partition is located directly in front of seat 1R. Passengers
and crew had to step on or over the carry-on and strewn items to evacuate the aircraft. Loose
items, such as personal backpacks, water bottles, and pop cans, were free to move during the
crash sequence, creating a hazard for the passengers and crew.
COM, Section 10.7, Carry-On, does not stipulate how the crew are to execute or ensure that
the carry-on baggage is stowed according to regulations and company procedures, given
that there is limited space under the seats and there are no overhead bins in the Metro.
However, crews are told to ensure that carry-on is placed under the seats, in the closet or in
the cargo compartment. There is no requirement for the presence of a flight attendant for this
size aircraft, and the flight crew must remain in the cockpit during the flight, except for
emergency situations. Therefore, there is no way of ensuring that carry-on baggage has been
re-secured prior to landing.
1.15.2.7 Child restraint systems
The Australian Civil Aviation Safety Authority (CASA) discussion paper 63 on the carriage of
infants and children aboard aircraft states that: “whilst the restraint of adult occupants has
steadily improved, the method of carrying infants and small children in aircraft has not
really changed since the start of aviation. Consequently, the minimum standards of restraint
offered to infants and small children are lower than that offered to adults.”
Most jurisdictions recommend that infants and small children travel restrained in an
approved CRS; however, its use is not mandatory. TC and the FAA support the use of
approved CRS on commercial and general aviation flights. Nonetheless, in many countries,
infants are permitted to travel on the lap of an adult. In addition, young children (2 to
12 years old) 64 may not be properly restrained while using only the seatbelt provided
(Appendix F).
Operational regulations pertaining to the safe transportation of occupants using approved
CRS were introduced upon publication of the Canadian Aviation Regulations (CARs) in 1996.
Sections 605.26 and 605.28 of the CARs establish criteria for the use of passenger safety belts
and restraint systems, and CRS. Infant and child restraint systems approved for use on
aircraft in Canada and the United States are certified by Canada and US Federal Motor
Vehicle Safety Standard (CMVSS 213.1 and 213, and FMVSS 213.1 and 213).
63
Australian Government, Civil Aviation Safety Authority, Carriage of Infants and Children – A
review of Section 13 of Civil Aviation Order (CAO) 20.16.3, Document DP 1301CS, July 2014.
64
The category 2 to 12 years old distinguishes a child from an adult due to their body development
and biomechanical dimensions. The European Aviation Safety Agency (EASA) study states
children under the age of 7. EASA.2007.C.28, Study on Child Restraint Systems, TÜV Rheinland
Kraftfahrt GmbH, Team Aviation, November 2008.
Aviation Investigation Report A12Q0216 | 33
TC has indicated that several factors preclude mandating the use of appropriate CRS on
board Canadian aircraft at this time. Currently approved infant/child restraint systems are
designed primarily for use in an automobile. They may or may not be compatible in fit and
function with aircraft seats. Therefore, in some cases, the CRS cannot be installed properly
and may not perform as intended.
Not all car safety seats fit in all aircraft passenger seats. Therefore, parents have no assurance
that their automobile child restraint can be used on board a particular flight. Car safety seats
are not configured to be fully compatible with an aircraft seat (e.g., break-forward seatbacks;
no attachment point for a tether strap), nor are car safety seats fully tested with aircraft seats
in mind.
TC funded an innovative research and development project to develop a prototype restraint
system that would be compatible with all aircraft seats and take into account the challenges
posed by the particular design and construction of aircraft seats. This project, which began in
1993, was completed in 1996 with the publication of TP 12523E, Child safety system for
commercial aircraft. Results and conclusions on TP 12523E are no longer available on the TC
website nor are they available at the TC library. Useful information or recommendations
following this study are unknown. No similar studies or research and development are
presently underway.
TC is also a member of the SAE S-9 Cabin Safety Provisions, Aerospace Standards committee
that developed AS5276/l — Performance Standard for Child Restraint Systems in Transport
Category Airplanes. 65 Additionally, TC is monitoring research conducted by other civil
aviation authorities, such as integrated infant/child seats.
The FAA and TC recommend, but do not require, the use of CRS on commercial aircraft
because they maintain that such a mandatory requirement would require parents to
purchase an airline ticket for their infant, forcing some families who cannot afford the extra
ticket to drive, which is a statistically more dangerous way to travel. 66 The NTSB analysed
the FAA’s argument and concluded that such a requirement would not result in an
unreasonable burden on passengers or air carriers. 67 The NTSB stated that results of
laboratory data and real-world accident data demonstrated that lap-held children could not
be adequately protected during a crash, and that considerable analysis of real-world air and
65
Federal Aviation Administration (FAA) report DOTIFAAJAM-1 1/3 — Aviation Child Safety
Device Performance Standards Review identified recommended changes applicable to AS5276/l,
and consideration is being given to these recommendations.
66
Federal Aviation Administration (FAA) customer help FAQ site [online], Does the FAA require
children on commercial flights to be in child restraint systems (CRS)?. Available at:
http://faa.custhelp.com/app/answers/detail/a_id/29/kw/child/session (last accessed on
18 June 2015.)
67
National Transportation Safety Board (NTSB), Analysis of Diversion to Automobile in Regard to
the Disposition of Safety Recommendation A-95-51, at 1 (03 August 2004).
34 | Transportation Safety Board of Canada
road vehicle data found no clearly defined relationship between diversion from air travel
and highway accidents or injuries. 68
At present TC does not anticipate making any changes to the regulations for the use of CRS
in aircraft, nor are there any studies being conducted or education programs for operators
and parents on the benefits of using CRS. Only minor changes, relevant to the content but
not the direction, were made to the recent third issue of Child Restraint Systems Advisory
Circular. 69 TC does anticipate that a review of the existing standards of airworthiness for
CRS will be conducted in the near future; however, no date or deadline has been specified.
The goal of TC’s intended review will be to identify those CRS approved under United
Nations standards or by a foreign government that will be deemed acceptable for use on
board Canadian-registered aircraft. Following completion of the review, proposed regulatory
change, if any, will be presented to the Canadian Aviation Regulation Advisory
Council (CARAC) for consideration. Priorities set by TC’s Standard Project Planning
Application (SPPA) and a rolling 4-year work plan do not expect to table the subject of CRS
for at least another 2 to 3 years.
TC does recommend the use of CRS on its website page for travel with children. No other
educational programs aimed at the travelling public have been developed by TC on the
recommended use of CRS. Instead TC defers to the air carriers to educate the travelling
public and to promote the use of CRS. The majority of air carriers state the recommended use
of CRS on their websites, but do not require their use.
See Appendix F for a discussion of policies and recommendations related to the use of CRS
in other jurisdictions.
1.15.2.8 Lack of data
During its study on child occupant safety in general aviation (GA) accidents and incidents,
the NTSB found that there was little information in its database on children in GA aircraft
(Appendix F). Questions about how often children are involved in GA accidents, how the
children are restrained, and what injuries they sustain, could not be answered due to lack of
data. The NTSB noted that information on injury data is important especially if the injuries
sustained by children are significantly different from those sustained by other occupants.
The NTSB tracks the pilot ages for all aviation accidents in the United States, but ages for
passengers are not recorded. In addition, data about the number of children who fly in GA
aircraft are not available. The NTSB concluded that this type of information is needed in
order to conduct research, identify risks, and outline emerging trends. Intended
improvements to the NTSB aviation data management system should enable the collection of
68
National Transportation Safety Board (2010). Safety Recommendations A-10-121 through -123.
69
Transport Canada, Advisory Circular 605-003, issue No. 3, Child Restraint Systems, effective
30 October 2013.
Aviation Investigation Report A12Q0216 | 35
this information and evaluation of the data regarding passengers, in general, but also child
passengers over the long term. 70
Similarly, the TSB’s database lacks information on children. There is little information
pertaining to the age of passengers or injuries sustained.
In 2007, a Cessna 172L accident occurred in which the pilot and 1 passenger seated in the
front right seat sustained fatal injuries; the 3-year-old child seated in the rear seat was
restrained in a CRS and, although injured, survived the accident. 71 A search of the TSB
database did not reveal any occurrences involving infants; this does not mean that infants
have not been involved in aviation occurrences, just that the information available in the
database does not reveal any occurrences involving infants.
Currently, under the Transportation Information Regulations, 72 Canadian air carriers must
provide a wide range of information on their overall operations to the Minister of Transport.
The number of revenue passengers and non-revenue passengers arriving, departing, and
transiting, is also provided. Passenger information collected is not broken down to reflect the
number of infants or children using this mode of transportation, nor is it required to be.
The passenger count on board an aircraft does not always include infants. As stated in TC
Air Carrier Advisory Circular No. 0116, dated 11 April 1997:
An infant secured in a lap-held position by a parent or guardian passenger is
not counted as a passenger for purposes of determining the minimum number
of flight attendants required on board an aircraft, and the maximum number
of occupants authorized to be on board an aircraft. An infant secured in a
restraint system is counted as a passenger for purposes of determining the
minimum number of flight attendants required on board an aircraft,
determining the maximum number of occupants authorized to be on board an
aircraft, and applying regulatory requirements such as those pertaining to
oxygen, life preservers and survival equipment.
Therefore, data relevant to the number of infants may be available, but not stored for easy
retrieval.
Data relevant to children (under 12 years old) travelling are contained within the number of
passengers and are stored in such a way that their numbers are not easily retrievable. It
required some effort on the part of the air carriers questioned as part of the investigation into
this occurrence, to obtain the data provided and stated in Tables 4 and 5 (Section 1.15.2.9)
70
K. Poland and N.M. Marshall, A Study of General Aviation Accidents Involving Children in 2011,
National Transportation Safety Board, Washington, D.C., United States.
71
TSB aviation occurrence number A07P0369.
72
Transportation Information Regulations (SOR/96-334), last amended 01 April 2015. Available at:
http:// http://laws-lois.justice.gc.ca/eng/regulations/sor-96-334/ (last accessed 18 June 2015).
36 | Transportation Safety Board of Canada
because, although the information may be available in their records, it is not readily
retrievable from their respective databases.
Furthermore, there is no data on how many infants are travelling secured in a CRS versus
those who are not. Therefore, it is not possible to confirm how many guardians have already
opted to travel with a CRS. There were two recent events in the United States where
guardians had chosen to purchase a separate seat for their infant in order to use a CRS. In
one of the two events, it was noted that cabin crew were not familiar with the FAA rules
pertaining to the use of aircraft-approved CRS. In the other event , the cabin crew, being
pressed to depart on time, chose not take the time necessary for the parent to install the
CRS. 73 There is a need to educate flight crews and cabin crews on CRS-related regulations
and the use of CRS.
1.15.2.9 Prevalence of infant and child passengers
To determine the exposure of infants and children to commercial air travel in Canada, data
were voluntarily provided by Perimeter and 3 other Canadian commercial air carriers
operating in different regions of the country (operations pursuant to Subpart 703, 704, and
705 of the CARs).
These companies, although different in fleet size from Perimeter, conduct operations in
similar geographical areas, and service a similar passenger population. As is the case for
many communities in northern Canada, Sanikiluaq is isolated. Most travel in and out of the
community is by air. As part of the Belcher Islands, it is surrounded by water. Travelling by
ice roads or ferry is not always an option, depending on the season.
Perimeter’s passenger load data showed that a total of 160 000 passengers were flown in
2012. Of those passengers, 10 300 were children (2 to 12 years old). During the same period,
there were 11 000 infants (0 to 2 years old) flown. The number of children travelling per year
is approximately 6.4% of Perimeter’s passenger loads. The number of infants travelling per
year is equivalent to approximately 6.9% of their passenger loads. The other 3 air carriers had
a combined passenger count of approximately 177 375 passengers for the year 2012,
including 16 845 children (2 to 12 years old) and 8709 infants (0 to 2 years old), which
represents approximately 14.4% of their passenger loads (Table 4).74 These numbers reflect
only a portion of the number of infants and children who travel by air as there are presently
583 registered commercial fixed-wing operators in Canada.
73
Curt Lewis News-Flight Safety Information No. 143, 17 July 2014 and No. 157, 31 July 2014.
74
Percentage of infant and child passenger loads may be higher for these operators in comparison to
air carriers operating in southern regions of Canada, as they serve northern communities where
travel in and out is mainly by air.
Aviation Investigation Report A12Q0216 | 37
Table 4 . Prevalence of infant and child passengers in a sample of Subpart 703, 704 and 705
operations in Canada, 1 year (2012)
Company
Total child
passengers (2 to 12
years old)
Total infant
passengers (under
2 years old)
Number
Percent
Number
Percent
160 000
10 300
6.4
11 000
6.9
Company #2
2 150
220
10.2
144
6.7
Company #3
21 009
1 203
5.7
854
4.1
Company #4
154 216
15 422
10.0
7 711
5.0
Total
337 375
27 145
8.1
19 709
5.7
Perimeter Aviation
Total
passengers
- Includes scheduled flights and charter flights
- Data reported directly by operators
Table 5. Prevalence of infant and child passengers in a sample of Subpart 703, 704 and 705
operations in Canada, 10 years (2003–2012)
Company
Total child
passengers (2 to 12
years old)
Total infant
passengers (under
2 years old)
Number
Percent
Number
Percent
1 300 000
85 000
6.5
90 000
6.9
Company #2
115 100
9 000
7.8
5 100
4.4
Company #3*
265 395*
12 123*
4.6
11 530*
4.3
Company #4
1 346 046
134 605
10.0
67 302
5.0
Total
3 026 541
240 728
8.0
173 932
5.7
Perimeter Aviation
Total
passengers
- Includes scheduled flights and charter flights
- Data reported directly by operators
* The company provided data for 6 years only (2007–2012); the data in the table are those data extrapolated to 10
years.
1.16
Tests and research
1.16.1
Stabilized constant descent angle instrument approach techniques
There are 2 techniques typically used to complete the final descent on a non-precision
approach (NPA): step-down descent and final descent on a stabilized constant descent
angle (SCDA).
The step-down descent technique involves flying an aircraft to a series of published
minimum altitudes. This requires multiple changes in attitude and power to maintain a
constant speed throughout the descent. This technique requires a heavier workload and
more cognitive effort than the SCDA technique. Consequently, whether a crew is tired or not,
they are more vulnerable to making errors inherent in the execution of the step-down
descent. There is an elevated risk that the minimum altitudes that must be followed during a
step-down descent will be compromised, especially if the approach is being flown manually.
38 | Transportation Safety Board of Canada
A stabilized approach means a final approach flown to achieve a constant rate of descent, at
an approximate 3-degree descent flight path angle, on the prescribed course to land, with
stable airspeed, power setting, and attitude, and with the aircraft configured for landing.
The SCDA technique involves intercepting and maintaining an optimum descent angle to
MDA, which is used as a decision altitude. The descent is therefore flown at a constant angle
and constant rate of descent, requiring no aircraft configuration change. At MDA, the aircraft
does not level off. Therefore, at that moment, either the required visual references are
available to continue the approach and land, or a missed approach is initiated. The task
simplification associated with the SCDA technique reduces the cognitive effort required for
executing the approach, thereby reducing the workload and, consequently, the risk of error. 75
Additionally, the decision at which a go-around must be initiated is less subjective.
The advantages of the SCDA technique have been accepted throughout the aviation industry
as being a safer way of conducting approaches. Although some Canadian operators have
opted to use SCDA, several others do not, as present regulations do not require its use. TC
estimates, based on informal contact with air operators and association members, that about
50% of aircraft operated under Subpart 704 of the CARs and about 20% of aircraft operated
under Subpart 703 of the CARs are currently using SCDA techniques with vertical guidance
as the normal procedure for an NPA. NPAs with vertical guidance, when made available for
all runways, eliminate the risks associated with circling manoeuvres, and permit full
realization of the safety benefits of SCDA.
Prior to the occurrence, Perimeter had not incorporated the use of the SCDA technique in its
training or operations, nor was it mandatory to do so by regulations. The occurrence crew
was familiar with the SCDA technique. The only reference made to similar criteria as the
SCDA is within the SOPs, Section 2, Normal Operations, 2.24 Night Landings, which states,
“If no glideslope guidance is available, approaches shall follow a 3-degree slope calculated
by the flight crew (usually 3 miles final at 1000 feet AGL and 600-700 feet/min descent).“ The
SOPs, Section 2, Normal Operations, 2.25 Landing, states, “A stable approach is essential for
a safe landing so therefore the rate of descent should not be greater than 800 fpm below
1000 ‘ AGL.”
Following the TSB investigation into a controlled flight into terrain (CFIT) occurrence (TSB
Aviation Report Number A09Q0203), the Board recommended that:
The Department of Transport require the use of the stabilized constant
descent angle approach technique in the conduct of non-precision approaches
by Canadian operators.
TSB Recommendation A12-02
75
J. Rasmussen, “Rules, knowledge; signals, signs, and symbols, and other distinctions in human
performance models,” IEEE Transactions on Systems, Man and Cybernetics, 13 (1983).
Aviation Investigation Report A12Q0216 | 39
TC has indicated that it does not intend to require operators to use the SCDA technique, but
recommends its use when conducting NPAs. Since TSB Recommendation A12-02 was issued,
TC has done the following in order to promote SCDA:
•
Issued Advisory Circular 700-028 entitled “Vertical Path Control on Non-Precision
Approaches.”
•
Completed pilot examiner (PE) workshops, from coast to coast, for PEs authorized to
conduct instrument rating initial and renewal flight tests, which included
explanations on the new instrument approach chart depiction format being
introduced by NAV CANADA.
•
Revised the Aeronautical Information Manual (AIM) to address the Canada Air
Pilot (CAP) approach procedures depiction changes that NAV CANADA introduced
in February 2014.
•
Revised the existing text in the Flight Test Guide-Pilot Proficiency Check and Aircraft
Type Rating included in Exercise 15-16.
Also, as TC now requires the depiction of SCDA approaches, pilots will no longer routinely
use the step-down technique. In April 2014, the TSB assessed TC’s response to
Recommendation A12-02 to be Fully Satisfactory.
1.16.2
TSB laboratory reports
The TSB completed the following laboratory reports in support of this investigation:
•
LP 001/2013 – CVR [Cockpit Voice Recorder] Download & Transcript
•
LP 011/2013 – Instruments Analysis
•
LP 175/2013 – Seating Diagram Creation
•
LP 070/2014 – Aircraft Performance Evaluation
•
LP 086/2014 – Flight Path Diagrams
1.17
Organizational and management information
1.17.1
General
Reference in this report to company manuals, procedures and checklists, or sections thereof,
refers to information within these documents which was applicable on the date of the
occurrence.
1.17.2
Perimeter Aviation LP
Perimeter Aviation LP is the trademark name used by Perimeter Aviation GP Inc. Perimeter
Aviation LP corporate offices and its main operating base are located in Winnipeg, Manitoba.
Perimeter Aviation LP also has a sub-base in Thompson, Manitoba.
The organization provides both scheduled and non-scheduled air transportation services for
passengers and cargo including dangerous goods. Perimeter Aviation LP has numerous
certificates and operates under Subparts 703, 704, and 705 of the CARs.
40 | Transportation Safety Board of Canada
Perimeter had experienced a period of rapid growth from 2005 to 2008 when 3 Dash 8s were
added to the fleet. These changes required moving and training personnel from within the
company and the hiring of new personnel. The company also implemented a Type B
operational control system, which is considered a major change to the day-to-day
Subpart 705 operations.
1.17.2.1 Dispatch/flight following
The company operates all its Subpart 705 flights (revenue, non-revenue, ferry, maintenance
test, and training flights) under Type B operational control. The Type B operational control
system uses co-authority dispatch and shared flight watch between the pilot-incommand (PIC) and the flight dispatcher.
The COM, Chapter 6, Operational Control System – Type B (705), Section 6.3, page 6-3,
provides the following interpretations:
Co-authority Dispatch - means the shared authority between the PIC [pilot in
command] and the flight dispatcher in a Type B operational control system,
for decisions respecting the Operational Flight Plan (OFP) prior to acceptance
of the OFP by the PIC. Co-authority is in effect until brake-release of the
aircraft.
Operational Control – means the exercise of authority over the formulation,
execution, and amendment of an Operational Flight Plan (OFP) in respect of a
flight.
The role of flight dispatch in Subpart 705 operations is to exercise safe and efficient
operational control over flights in conjunction with the PIC. By handling a significant portion
of operational flight duties, dispatch services can significantly reduce the workload
experienced by a pilot before, during and after a flight. As defined in the COM, Chapter 4,
Section 4.5.4.2, dispatch activities for Subpart 705 operations at Perimeter include
•
flight planning;
•
pre-flight preparations;
•
monitoring maintenance issues;
•
calculating fuel load requirements;
•
complying with regulations;
•
monitoring weather;
•
updating crew on changes in weather;
•
selecting routes and altitude;
•
briefing flight crews; and
•
flight following.
Flights operating under Subparts 703 and 704 of the CARs use a Type C operational control
system, wherein the PIC is authorized to self-dispatch. The PIC may dispatch a flight when
he is satisfied that flight preparation has been completed in accordance with the COM and
the flight can be conducted in accordance with the Company’s Air Operator’s
Aviation Investigation Report A12Q0216 | 41
Certificate (AOC), OpSpecs, the CARs, and associated standards. The flight follower for
Subpart 704 operations does not assist crew in pre-flight preparations as the dispatcher does
for Subpart 705 operations, nor does the flight follower provide other services such as
monitoring weather. However, for safety reasons, the flight follower does provide flight
following. Flight crew, regardless of whether they are operating under Subpart 703, 704 or
705, must provide the flight follower/dispatcher with the following information:
•
check-in; dispatch will provide assigned aircraft, routing, scheduled loads;
•
inform dispatch if they will be late for check-in;
•
advise of fuel load needed;
•
provide an OFP;
•
report any delays due to weather or issues with aircraft; and
•
report ready to depart.
For Subpart 703 and 704 operations, flight following is involved and consulted in several
aspects of the flight but not in others. In contrast with Perimeter aircraft operating under
Subpart 705, Subpart 703 and 704 aircraft are not equipped with email or satellite phone.
Once a flight operating under Subpart 703 or 704 has departed and is out of range for very
high frequency (VHF) radio communication, there is no direct means of communication
between crew and flight followers, as the aircraft are not equipped with other means of
communication such as satellite phone.
The captain had worked for a number of commercial operators after leaving Perimeter in
August 2008, where he flew under Type B (Subpart 705) operational control systems before
returning to Perimeter in October 2012. Consequently, he had been able to rely on dispatch
services assisting in flight preparations and en route for more than 4 years. As evidenced in
its use for Subpart 705 operations, dispatch can play a significant role in helping to identify
and manage any threats related to a flight.
1.17.3
Route and charter packages
Perimeter had developed route packages for all scheduled flights with the objective of
lessening the flight crew workload during preparation of a flight. The packages include
logistics information about a trip, such as crew pairing, routing, time of departure and
return, number of passengers, accomodations if relevant, duty/rest time associated with the
planned routing, airport facilities information, frequencies, and contact information.
At the time of the occurrence, similar packages had not been developed for charter flights
and, therefore, were not available to the occurrence crew. Route or charter packages are not
required by regulations. Although helpful, route or charter packages, as constructed, may
not necessarily assist the crew, or even dispatch, with regards to identifying any possible
threats or risks associated with a particular flight or destination.
1.17.4
Flight planning
The COM, Chapter 7, Section 7.6.2, explains the division of roles between the captain and the
FO in regards to pre-flight preparation. While the FO verifies the airworthiness of the
42 | Transportation Safety Board of Canada
aircraft, fueling, and loading of freight, flight planning takes place prior to departure and is
completed by the captain. The captain must ensure that all necessary documentation and
equipment is on board the aircraft, determine fuel and oil requirements, calculate the aircraft
weight and balance, verify applicable NOTAMs, check the weather for departure, en route,
destination and alternate airports, and complete an operational flight plan or flight itinerary.
The captain must also brief the FO on such information as the weather expected en route, at
destination, and the chosen alternate.
The captain verified the weather on the NAV CANADA aviation weather website. The
METAR for CYSK consulted at the time of flight planning showed weather was above
minima for the approach. Although the instrument approach charts for CYSK were not
available to the captain for flight planning, he remembered the MDA value for the approach,
from having flown there before.
CAR 602.122 stipulates that any pilot operating an aircraft in IFR flight must file an IFR flight
plan or flight itinerary that includes an alternate aerodrome. Weather information for the
chosen alternate aerodrome must indicate that, at the expected time of arrival at the alternate
aerodrome, weather will be at or above the alternate aerodrome weather minimum criteria
specified in the Canada Air Pilot instrument approach charts procedures.
In order to decide on an alternate airport, the captain consulted the TAF for CYGW, the
closest airport to CYSK. Using that weather information, the captain was able to determine
the suitability of CYGW as an alternate airport. 76 The choice of CYGW, at the time of flight
planning, was acceptable, given the forecast weather for the estimated time of arrival at
CYGW (2330 UTC), if a diversion to the alternate was deemed necessary.
A pre-flight briefing between flight crew members allows them to discuss and consult on
specifics affecting the flight, and assists in maintaining common situational awareness. The
crew did not discuss weather conditions for the flight prior to departure.
1.17.5
Perimeter Aviation LP operational manuals
Perimeter policies, applicable to all company flight operations, are contained in the COM.
The COM provides guidance for company personnel in the execution of their duties. The
manual contains information required by the CARs and CASS, and is intended to
supplement but not replace existing regulations. Employees are expected to be familiar with
the contents of the COM, and apply the policies and procedures accordingly. Training
provided by the company to its employees is expected to cover the necessary information
detailed within the company manuals, procedures, and TC regulations.
Aircraft type-specific information pertaining to the Metro III is contained in the applicable
airplane flight manual (AFM) issued by the aircraft manufacturer, and in the company SOP
manual. Pilots are required to have a working knowledge of these documents.
76
NAV CANADA, Canada Air Pilot, Alternate weather minima, pp. 28-29.
Aviation Investigation Report A12Q0216 | 43
The COM and SOPs comply with the CASS. The COM and the flight training manual are
approved by TC. With the exception of a few sections, 77 the SOPs are not subject to TC
approval; however, they are subject to TC review.
SOPs and checklists provide procedural guidance to pilots for the operation of the aircraft.
They assist with decision making and establishing shared mental models between flight crew
members, and provide them with pre-determined solutions to various situations, whether
they be associated with normal, abnormal, or emergency operations.
SOPs include division of duties and standard calls to be made by the PF and PNF; these
include standard calls associated with the approach and, if necessary, the missed approach
phases of flight. Checklists associated with normal and abnormal operations are in a
challenge-and-response format.
1.17.6
Standard operating procedures
1.17.6.1 Standard calls
The SOPs, Section 1 Introduction, 1.6 Standard Calls and Briefings (Table 6), details the
standard calls for various aircraft deviations that may occur during a flight. There are no
standard calls or responses stated in the case of the GPWS sounding SINK RATE or
PULL UP. There are no standard calls or reponses for conducting an NPA that involves
leveling the aircraft at MDA and reaching the MAP decision point. The SOPs only contain
calls for a precision approach with a decision height (DH).
Table 6. Standard operating procedures (SOP) standard deviation calls (modified to eliminate calls not pertinent
to this occurrence)
General observations
Observations
77
Call (pilot not flying)
Response (pilot flying)
Any time bank angle exceeds
30 degrees
BANK
CORRECTING
Speed deviations +/- 10 kts
AIRSPEED PLUS
DEVIATION
CORRECTING
Altitude deviations +/- 100 ft
ALTITUDE PLUS
DEVIATION
CORRECTING
Heading deviations +/10 degrees
HEADING
CORRECTING
Operations Specification 100 (OpSpec 100), Part IV – Authorization of GPS-based instrument
approaches are approved by TC.
44 | Transportation Safety Board of Canada
Observations during climb and descent
Observations
Call (pilot not flying)
Response (pilot flying)
Climb or descent
ALTITUDE SELECTED
LEAVING 17000 for 7000
Approaching altitude
1000 ABOVE/BELOW
200 ABOVE/BELOW
CHECK
Observations during takeoff and missed approach
Observations
Call (pilot not flying)
Response (pilot flying)
Rate of climb (takeoff)
POSITIVE RATE
GEAR UP
Missed approach
POSITIVE RATE or
NEGATIVE RATE
MAX PWR
GEAR UP, FLAPS ¼
Observations during approach
Observations
Call (pilot not flying)
Response (pilot flying)
Below 140 kts, speeds will be
called out every 5 kts of
decreasing or increasing
airspeed above VREF
VREF plus +/- speed
deviation. (i.e. VREF plus
15, VREF plus 10)
CHECK
Rate of descent exceed
1000 ft/min
SINK RATE
CORRECTING
1000 ft above minimums
1000 ABOVE
CHECK NO FLAGS
500 ft above minimums
500 ABOVE
CHECK
100 ft above minimums
100 ABOVE
CHECK
Visual contact with runway
environment
ANNOUNCES VISUAL
CUES (lights–runway
position)
COUNTINUING/LANDING
At decision height
MINIMUMS
(announces visual cues)
LANDING
OR
NEGATIVE CONTACT
GO AROUND
On the occurrence flight, from descent to the end of the first approach, the crew made
standard deviation calls and corrections and completed other required checks. However,
when visual reference to the runway was lost, while flying close to the ground, standard
calls, checks, and corrections began to be omitted. These omissions indicate task saturation
and a breakdown of situational awareness for both crew members.
These are a few important examples (Appendix B):
•
The first circling procedure (orange flight path), following the first approach to
Runway 27, was conducted at 400 feet asl, 220 feet below the circling MDA. The FO
called the altitude deviation. The captain executed a climb, but then descended back
to 400 feet asl. The FO called the altitude again. The captain did not respond with the
standard call.
Aviation Investigation Report A12Q0216 | 45
•
At 2255:18 UTC, following the captain’s go-around call to initiate a missed approach
(No. 6, yellow flight path), the standard calls for maximum power, gear up and
flaps ¼ were made. However, neither crew member made the standard positive rate
of climb call.
•
On the climb to sector altitude of 1600 feet during the missed approach (yellow flight
path nos. 6 and 7), the missed approach procedure of tracking 278° was not followed.
Instead, a steady left turn was maintained during the climb. No calls or corrections
were made for this deviation.
•
While on the second approach to Runway 27, at 2305:05 UTC (red flight path), the FO
made the standard 100 feet below minimums altitude call when the aircraft
descended below the MDA of 600 feet to an altitude of 500 feet. Although the captain
replied levelling, the aircraft continued down to 400 feet. The FO called 400 feet. The
captain did not respond to this call but remained level at 400 feet. The FO did not
question this deviation.
•
At 2306:11 UTC, when the GPWS SINK RATE alert was generated, and at
2306:13 UTC, when the first of 6 PULL UP warnings were generated, neither crew
member acknowledged the alerts. Neither crew member reacted to the GPWS
warnings.
•
At 2306:18 UTC, 1 second after the PULL UP warning ceased, while the aircraft was
approximately 725 feet past the threshold, the FO indicated field conditions looked
good. However, the aircraft altitude, high rate of descent, and the airspeed being too
high were not raised as a concern to the captain.
•
At 2306:23 UTC, when the captain called go-around, the FO prompted him with the
appropriate sequence of required go-around actions as the standard calls were not
forthcoming. Neither crew members made the positive rate of climb call.
These examples also highlight a lack of assertiveness on the part of the FO.
1.17.7
Approaches
1.17.7.1 Approach and circling briefings
The SOPs state that the PF must conduct an approach briefing to be completed well in
advance of commencing the approach, usually prior to descent. 78 This briefing should
include details on
78
•
which approach will be executed;
•
how the approach will be completed; and
•
how the missed approach will be conducted, if deemed necessary.
Perimeter SA227 Standard Operating Procedures, Section 2 Normal Operations, 2.20 Approach
Briefing, p.2-12.
46 | Transportation Safety Board of Canada
Prior to descent from en-route cruise on the occurrence flight, the captain completed an
approach briefing for the NDB Runway 27 approach with circling for Runway 09. The
missed approach briefed was the missed approach procedure obtained and described on the
instrument approach chart; however, neither of the 2 missed approaches was executed as
briefed. The captain’s approach briefing included the criteria for executing the missed
approach if not visual by the MAP; however, this was not followed.
In reference to briefings for circling, the SOPs, Section 2 Normal Operations, 2.23 Circling,
states:
When briefing for a circling approach, the captain will determine who will be
the flying pilot. Deciding factors will include:
• Geography and associated weather conditions.
• With crosswinds, turning base should be done with headwind to
minimize drift, when practicable.
• Circling restrictions on approach charts
The role of the flying pilot will be to fly the aircraft with visual reference to
terrain and also include flight instruments in their scan.
The primary role of the pilot not flying is to monitor the flight instruments. He
may also assist the flying pilot in determining when to turn or descend
(vectors). The pilot not flying must advise of any airspeed and altitude
deviations without delay.
None of the abovementioned circling issues, such as rising terrain to the southwest of the
airport, were considered or briefed by the crew.
General procedural guidance for instrument flying in Canada 79 states that:
There are no standard procedures to conduct a missed approach after starting
visual manoeuvres. Unless the pilot is familiar with the terrain, it is
recommended that:
a) a climb be initiated;
b) the aircraft be turned towards the centre of the airport; and
c) the aircraft be established, as closely as possible, on the missed approach
procedure track published for the instrument approach procedure just
completed.
Even with the airport in sight at circling MDA, the pilot should execute the
missed approach if there is any doubt that the ceiling and visibility are
adequate for manoeuvring safely to the point of touchdown.
79
Transport Canada, TP 2076 – Instrument Procedures Manual (4th edition, November 1997),
Section 4.6.3(d).
Aviation Investigation Report A12Q0216 | 47
1.17.7.2 Night approaches
The SOPs, Section 2 Normal Operations, 2.26 Night Landing, states:
Night Flying has always been, and continues to be, more dangerous than
flying during the day. This is, for the most part, because of a lack of visual
cues and our vulnerability as humans to be affected by illusions.
Night departures in dark conditions require full use of the aircraft flight
instruments, and it is essential that the pilot achieves and maintains a positive
rate-of-climb. In the absence of outside visual cues, the pilot must rely on
aircraft instruments to maintain airspeed and attitude to overcome any false
sensations of a climb. Night landings MUST be completed on or above
glideslope guidance (ILS glideslopes, PAPI’s, or VASIS’s indicators) until
touchdown. At no time shall a night approach be continued below glideslope
guidance. If no glideslope guidance is available, approaches shall follow a
3 degree slope calculated by the flight crew (usually 3 miles final at 1000ft
AGL and 600-700 ft/min descent)
1.17.8
Stable approach criteria
A stable approach involves controlling, and stabilizing several key criteria before the aircraft
reaches a predefined point – usually several miles back from the airport, at 1000 feet agl.
These criteria include: 80
A. Course – The aircraft is on the prescribed track to land. This avoids
any excessive bank angles during the final moments before landing;
B. Speed – Should be within a few nautical miles per hour of appropriate
speed for approach conditions of weight and weather. This provides
the slowest speed for landing, but with built in safety margin;
C. Rate of descent – Should be set to maintain the glide path. This avoids
excessive changes and allows an optimum closure rate to the runway
surface;
D. Power setting – Should be set to maintain optimum airspeed and rate
of descent previously mentioned. This prevents excessive changes to
airspeed and rate of descent and ensures the engines are in a power
range that allows for rapid acceleration should a go-around be
required; and
80
From a recent TSB blog article, referencing the Resolute Bay, Nunavut, controlled flight into
terrain/unstable approach occurrence (TSB Aviation Investigation Report A11H0002). Blog
available at: http://www.bloguebst-tsbblog.com/2014/03/28/one-unstable-approachmany/#.VW8V_nrD-70 (last accessed 18 June 2015).
48 | Transportation Safety Board of Canada
E. Aircraft configuration – The landing gear should be down and final
flap selection completed. This avoids configuration changes in the final
moments of the approach which could in turn adversely affect speed,
rate of descent and power setting.
The COM does not outline the criteria for a stable approach. The SOPs, Section 2 Normal
Operations, 2.25 Landing, simply states that, “A stable approach is essential for a safe
landing so therefore the rate of descent should not be greater than 800 fpm below
1000 ‘ AGL.” Good stable approach policies and procedures serve as an administrative
defense against possible negative outcomes, such as runway overruns and CFIT occurrences.
Approaching the threshold of Runway 27 at approximately 180 feet agl, the aircraft was
unstable in several of these parameters:
•
Rate of descent – above 1800 ft/min
•
Speed – VREF + 25
•
Throttles – idle.
1.17.9
Discontinued approach and landings
1.17.9.1 General
In flight operations, a distinction is made between a go-around, missed approach, rejected
landing, and balked landing. Transport Canada AC 700-016 (2010), Compliance with
Regulations and Standards for Engine-Inoperative Obstacle Avoidance, defines the terms as
follows:
Go-Around -
A transition from an approach to a stabilized climb.
Missed Approach - The flight path followed by an aircraft after discontinuation
of an approach procedure and initiation of a go-around.
Typically a “missed approach” follows a published missed
approach segment of an instrument approach procedure, or
follows radar vectors to a missed approach point, return to
landing, or diversion to an alternate.
Rejected Landing - A discontinued landing attempt. A rejected landing
typically is initiated at low altitude but prior to touchdown.
If from or following an instrument approach it typically is
considered to be initiated below DA(H) [decision
altitude/height] or MDA(H) [minimum descent altitude/height].
A rejected landing may be initiated in either VMC [visual
meteorological conditions] or Instrument Meteorological
Conditions (IMC). A rejected landing typically leads to or
results in a “go-around” and if following an instrument
approach, a “Missed Approach”. If related to the
consideration of aircraft configuration(s) or performance it
is sometimes referred to as a “Balked Landing”.
Aviation Investigation Report A12Q0216 | 49
Balked Landing -
A discontinued landing attempt. The term is often used in
conjunction with aircraft configuration or performance
assessment, as in ”Balked landing climb gradient”. 81
A balked landing is considered to be distinctly different from a low-energy landing regime.
AC 700-016 explains:
A low energy landing regime is defined as a condition where a rejected or
balked landing is commenced after a commitment to a landing has been
made. In a low-energy landing regime the aircraft is in a descent at a height of
50 feet or less above the runway, gear and flaps are in the landing
configuration, thrust is stabilized in the idle range, and airspeed is decreasing.
An attempt to conduct a rejected or balked landing from a low-energy landing
regime may result in ground contact. 82
1.17.9.2 Company missed approach/balked landing procedure
The SOPs, Section 2 Normal Operations, 2.24 Missed Approach/Balked Landing, explains
the duties and calls to be executed, but does not state the criteria or point (decision point or
gate) at which to initiate a missed approach should the need arise. Criteria for initiating a
missed approach at MDA or DH are stated, however, in the SOPs, Section 5 Operational
Notes and Directives, 5.18 Pilot Monitored Approach (PMA). Additionally, the SOPs do not
indicate that the PNF can also command a go-around. From a crew resource
management (CRM) perspective, the ability of either pilot (PF or PNF) to command a goaround is fundamental to reducing approach-and-landing accidents (ALAs).
The SOPs stipulate the steps and standard calls shown in Table 7 when executing a missed
approach:
Table 7. Missed approach (crew coordination)
Pilot flying duties
Pilot not flying duties
Calls “GO AROUND”
Acknowledge “Check Go Around”
Calls “Max Power, Gear up, flaps ¼
Selects go around on flight director and
rotates aircraft at a rate of 2 degrees per
second to match flight director or rotates to
10 degrees nose up attitude simultaneously
advancing the power levers to max power
Taps PF hands and sets power to briefed
power setting and selects gear up and flaps
up
Calls “Max Power Set” and
States V2 speed
Either Pilot Observes and Calls “POSITIVE RATE”
81
Transport Canada, Advisory Circular (AC) 700-016 (2010), Compliance with Regulations and
Standards for Engine-Inoperative Obstacle Avoidance.
82
Transport Canada, Advisory Circular (AC) 700-016 (2010), Compliance with Regulations and
Standards for Engine-Inoperative Obstacle Avoidance.
50 | Transportation Safety Board of Canada
Confirms and Calls
“Three Positive Rates of Climb”
Calls Level Off
Accelerates to VYSE and Calls
“FLAPS UP”
Retracts Flaps
States “I have the Powers”
States “You have the Powers”
Source: Standard Operating Procedures, Section 2 Normal Operations, p. 2–14
Following the captain’s go-around call, power was set to maximum, gear was retracted, and
the flaps set to ¼ position. The positive rate of climb calls were not made by either pilot.
Flaps were not brought to the full-up position as the aircraft impacted the ground before this
item could be executed (Appendix G).
The balked landing climb performance for the SA227-AC (Metro III) published in the AFM
uses the gear-down and full-flaps configuration to provide climb data at specified climb
speeds. These data are based on the balked landing procedure below (Figure 11).
Figure 11. Fairchild SA227-AC Airplane Flight Manual, Section 2, Balked Landing
BALKED LANDING
NOTE
When required for obstacle clearance, this procedure is used to obtain the climb performance
depicted in Section 4G.
1. Power Levers ............. 650°C EGT OR 100% TORQUE (WHICHEVER OCCURS FIRST)
2. Climb Speed ............................................................. ATTAIN (SEE FIGURE 4G-5 OR 4G-6)
3. Rate of Climb ....................................................... ESTABLISH POSITIVE RATE OF CLIMB
4. Landing Gear ......................................................................................................................... UP
5. Flaps .............................................................................................................. RETRACT TO 1/2
6. Airspeed .................................................................................... ACCELERATE TO 125 KIAS
7. Flaps ......................................................................................................................................... UP
8. Engine and Propeller Heat Switches ............................................................ AS REQUIRED
9. Ignition Mode Switches ...................................................... NORMAL OR AS REQUIRED
OR
Auto/Cont Ignition Switches ....................................................................... AUTO OR CONT
(SEE PAGES 2-27 OR 2-28, 2-50, 2-53 AND 2-55)
Aviation Investigation Report A12Q0216 | 51
The AFM balked landing procedure states that a positive rate of climb must be established
prior to retracting the gear, then the flaps to ½, while the company SOPs missed
approach/balked landing procedure calls for retract gear and flaps to ¼ immediately after
applying maximum power. A change in configuration can alter the aircraft’s performance by
decreasing lift at a critical moment while close to the ground.
The company tested the AFM procedure in a controlled environment in the late 1990s, early
2000s. Testing was done in a Metro II aircraft, as Perimeter did not acquire a Metro III until
2005. Although the company SOPs do not distinguish between high-energy and low-energy
states, training includes go-arounds from low-energy states. The AFM for the Metro II
suggested an initial climb speed of 96 knots, which was considered by the company as very
slow for a Metro II with the gear and flaps deployed. The company also felt that on a hot day
with a fully loaded aircraft, a positive rate of climb in the landing configuration would not be
possible. The company felt the best procedure to ensure the aircraft was climbing away from
the ground was to emphasize the pitch-up and immediate configuration change. In 2005
when Perimeter acquired a Metro III, most of the Metro II procedures, culture, and
philosophy carried over to the Metro III.
Crews were trained to wait for the positive rate of climb call to reconfigure the aircraft after a
go-around mainly when windshear was encountered. This was not necessarily the case for
balked landings and go-arounds in other situations. However, for the previous 3 years the
company had been training pilots to wait for a positive rate of climb before requesting the
configuration change. Although this change was not reflected in the SOPs or training at the
time, training now emphasizes the need to confirm a positive rate of climb, in any go-around
situation, before requesting any configuration change. In the fall 2013, the company initiated
work to incorporate this change in the SOPs.
1.17.9.3 Balked landing climb performance
The aircraft trajectory and performance were calculated based on the following information:
•
the CVR
•
Skytrax GPS positions
•
GPWS alerts
•
airport information
•
the AFM
•
observation of the passing aircraft over the runway
•
meteorological data at the time of the occurrence.
The AFM balked landing climb performance charts 83 indicate the expected rate of climb that
can be obtained following a balked landing using the specified procedure. This performance
83
Fairchild, SA227-AC Airplane Flight Manual, Performance chart, Figure 4G-4, p. 4G-5 8AC,
equipped with McCauley propellers.
52 | Transportation Safety Board of Canada
is obtained with all engines operating at a specified speed with the aircraft in the landing
configuration.
The weather conditions in which the aircraft was operating were conducive to icing, and
both the CVR and wreckage indicate the presence of a thin line of ice accumulation on the
leading edge of the wings. This accumulation was considered negligible by the crew. The
AFM84 provides the balked landing performance for the aircraft being encumbered by ice
accretions, to the extent tested during aircraft certification. According to the AFM, chart 4H7, the expected rate of climb would be 1280 ft/min, at a speed of 122 knots indicated
airspeed (KIAS) when using the following occurrence conditions:
•
temperature of -5°C
•
pressure altitude of 800 feet
•
engine anti-ice ON
•
encumbered by ice accumulation
•
calculated aircraft weight of 14 200 pounds.
Achieving the manufacturer’s performance parameters requires adhering to the landing and
balked landing procedures in the AFM that were developed during aircraft certification. The
landing procedure was developed to ensure a stabilized approach where the airspeed,
descent rate, and attitude are within an acceptable range for a safe touchdown. The balked
landing procedure was developed from these specified landing conditions to ensure that the
aircraft is capable of safely transitioning to a climb should the pilot need to abort the landing
for any reason. If the actual conditions and/or procedures followed in service differ from
those established during certification, the stabilized landing condition and/or the published
balked landing performance may not be achieved.
1.17.10
Ground proximity warning system training
As specified in the company flight training manual, GPWS awareness training is covered in
the 1-hour CFIT training module, and in the Metro flight training as part of the systems
management portion of the flight training.
Chapter 8 of the COM, Section 8.9.6, states that, in the event of a GPWS warning, “[…] pilots
should immediately, and without hesitating to evaluate the warning, execute the appropriate
pull-up action.” It also specifies that, “This immediate pull-up procedure should be followed
except in clear daylight visual meteorological conditions when the flight crew can
immediately and unequivocally confirm a false GPWS warning.” The content of the COM
pertinent to GPWS is not reviewed in training; however, crew reaction to warnings is
reviewed during the annual CFIT training.
84
Ibid., Figure 4H-7, p. 4H-9 8AC.
Aviation Investigation Report A12Q0216 | 53
The SOPs for the SA227 do not provide direction on necessary actions to take in the event of
a GPWS warning or alert. There are no standard calls or responses stated in the case of the
GPWS generating SINK RATE or PULL UP warnings.
The AFM contains a supplement for the GPWS that comprises the same information in
regards to the operation of the system as in the Mark VI Warning System Pilot’s Guide. The
guide lists the recommended procedures to be followed after an in-flight activation of the
alerts or warnings. Information pertaining to the parameters that cause activation of the
different GPWS warning was covered in Section 1.6.4 of this report.
For in-flight activation of the SINK RATE alerts, page 29 of the guide recommends to level
the wings and reduce the rate of descent until the visual and aural alerts stop. For in-flight
activation of the PULL UP warning, page 28 of the guide recommends:
If the aircraft is in instrument meteorological conditions (IMC) or at night
when the warnings or alerts are activated:
1. Level the wings and simultaneously pitch up at a rotation rate of 2 to
3 degrees per second to the best angle of climb attitude.
2. Apply maximum power.
3. Monitor radio altimeter for trend toward terrain contact and adjust pitch
attitude accordingly upward as necessary, honoring pre-stall buffet
warning.
4. Continue maximum climb straight ahead until visual and aural warnings
cease.
5. Advise ATC [air traffic control]as necessary.
The investigation concluded that current company pilots’ knowledge on the aircraft
parameters that will trigger GPWS alerts and warnings is limited. However, crew do know
that if the runway is visual and a warning or alert is received, they should first acknowledge
the warning or alert and then state their intent to continue the approach or not.
1.17.11
Safety management systems
The following information regarding safety management systems (SMS) is taken in part from
International Civil Aviation Organization (ICAO), Document 9859, Safety Management
Manual, Chapter 5. The principles of SMS expect operators to proactively manage their safety
risks and to have the necessary systems in place to ensure their operations comply with
regulatory requirements on an ongoing basis. The system is designed to improve safety
continuously by identifying hazards, collecting and analysing data in order to continuously
assess safety risks. SMS seeks to proactively contain or mitigate risks before they result in
aviation accidents and incidents.
SMS integrates operations and technical systems with the management of financial and
human resources to ensure aviation safety or the safety of the public. Having an SMS in place
implies constant measurement, evaluation, and feedback into the system in order to be
proactive about safety.
54 | Transportation Safety Board of Canada
With the help of SMS reporting, many operators are collecting, analysing, and using their
own safety data relevant to the different phases of flight to target specific areas of an
operation that pose the greatest risk. Flight operational quality assurance (FOQA) 85 is one
example of data collection and analysis with the purpose of advancing safety within a
company.
ICAO mandated its 190 member states, including Canada, to develop and implement SMS to
achieve an acceptable level of safety in aviation operations. Transport Canada committed to
the implementation of SMS in aviation organizations in 2005. Canadian operators
functioning under Subpart 705 of the CARs were given until 2010 to implement SMS.
Perimeter’s SMS was finalized and accepted by TC in May 2010. The company’s SMS manual
describes the policies and procedures directing SMS activities within its operations.
Although Perimeter developed an SMS to comply with the requirements for the
implementation of SMS for Subpart 705 operations, the company applies SMS to all its
operations, including Subpart 703 and 704 operations.
An integral component of an SMS is a non-punitive reporting system. With a non-punitive
reporting system, employees of an organization are given qualified immunity from punitive
actions to encourage them to report any safety-related events or concerns. SMS reporting is
considered as a positive approach to safety and is encouraged.
While management response to issues raised through Perimeter’s SMS reporting system was
generally considered adequate by staff, one ongoing concern raised relates to the issue of
extensions to flight crew duty day. CAR 700.17 allows for an extension of the flight crew
duty day for unforeseen circumstances. Perimeter had recently expanded the description and
clarified the meaning of “unforeseen circumstances” in the COM to assist crews in
determining if these conditions were applicable. The parameters that define “unforeseen
operational circumstances” are contained in the CARs and in Perimeter’s pilot contract.
Also, extension of the duty day can be planned by changing a flight designated as a
Subpart 704 operation on the outgoing trip to a Subpart 703 operation on the return trip.
Extension of a duty day in this manner is apparently common practice within the company.
This practice is also common to many other operators, as current TC regulations allow
operators to do so. Pilots at Perimeter, including the occurrence captain, had reported this
safety concern through the SMS reporting system, but at the time of the occurrence, flight
crews did not consider that it had been adequately addressed.
1.17.12
Safety case
Perimeter’s SMS manual defines a safety case as:
85
Flight Operational Quality Assurance (FOQA) is a voluntary safety program designed to improve
aviation safety through the proactive use of flight recorded data. Operators use these data to
identify and correct deficiencies in all areas of flight operations. Properly used, FOQA data can
reduce or eliminate safety risks, as well as minimize deviations from regulations.
Aviation Investigation Report A12Q0216 | 55
A risk assessment exercise completed by the operations group to ensure that
certain existant risks are assessed, addressed and mitigated as much as
possible before deployment. Safety case studies are used as a proactive means
to anticipate, prepare for, and mitigate potential and possible latent hazards
caused by corporate or regulatory change. Safety cases shall, whenever
possible, employ a team approach involving front-line employees and
managers with the SMS Manager providing facilitation. A safety case study
shall be completed during any of the following changes:
• prior to significant changes in operations or maintenance systems,
processes or procedures;
• as soon as possible in changes in key personnel;
• prior to new routes or a change to the existing route structures;
• prior to the introduction of a new type of aircraft into the fleet;
• prior to new or substantially different avionics systems being introduced;
• prior to new destination areas and/or airports; and,
• prior to, or as soon as possible to, major changes in requirement in
applicable regulations.
The above list is not necessarily exhaustive and therefore a safety case may be
initiated at any time that a manager thinks it is appropriate. If the risks remain
assessed as too high, then the flight(s) would normally be cancelled.
CYSK is similar to many other airports at which Perimeter operates on a daily basis. The
number of Perimeter flights into CYSK had increased from January 2012 to December 2012;
initially starting with just a few flights per month going up to 11 flights per month for both
November and December 2012, for a total of 62 flights in 2012. As a result, CYSK was not
considered a new destination when the 22 December 2012 charter request was made.
Therefore, management did not consider it necessary to conduct a safety case for that
destination.
TC had not required that a safety case be completed for other CYSK charter flights prior to
this occurrence. The possible risk factors associated with flights conducted to CYSK, whether
by day or by night, had not previously been identified by TC or Perimeter.
1.17.13
Transport Canada oversight
The objective of Transport Canada Civil Aviation’s (TCCA) surveillance program 86 is to
confirm that the holder of a Canadian Aviation Document (CAD) complies with the CARs.
Where a CAD holder maintains more than one certificate (approved maintenance
organization, Air Operator’s Certificate, airport certificate, etc.), TCCA takes an enterprise
approach to surveillance. That is, all certificates held by the enterprise are subject to the same
86
Transport Canada, Staff Instructions, SI SUR-001, Issue No. 4 came into effect on
17 November 2010, and governed the surveillance activities described here. It was superseded by
Issue No. 5 on 28 June 2013. This document refers to Issue No. 4, unless otherwise specified.
56 | Transportation Safety Board of Canada
surveillance activity. TCCA expects that the enterprise complies with all the required areas
of the CARs, including SMS.
TCCA’s surveillance program comprised 3 main surveillance activities: SMS assessments,
program validation inspections (PVI); 87 and process inspections (PI). 88 SMS assessments and
PVIs are system surveillance activities whereas PIs are a process surveillance activity.
The company’s SMS is assessed, as well as the company’s ability to maintain effective
compliance with all regulatory requirements. The CARs, Part I - General Provisions,
CAR 107.03, states that an SMS shall include:
(a) a safety policy on which the system is based;
(b) a process for setting goals for the improvement of aviation safety and for
measuring the attainment of those goals;
(c) a process for identifying hazards to aviation safety and for evaluating and
managing the associated risks;
(d) a process for ensuring that personnel are trained and competent to
perform their duties;
(e) a process for the internal reporting and analyzing of hazards, incidents
and accidents and for taking corrective actions to prevent their recurrence;
(f) a document containing all safety management system processes and a
process for making personnel aware of their responsibilities with respect
to them;
(g) a quality assurance program;
(h) a process for conducting periodic reviews or audits of the safety
management system and reviews or audits, for cause, of the safety
management system; and
(i) any additional requirements for the safety management system that are
prescribed under these Regulations.
TC’s Staff Instructions, SI SUR-001, Issue No. 4, explains that:
A Program Validation Inspection (PVI) is intended to provide a review of
sufficient depth to determine the level of compliance and effectiveness of a
component. The use of a PVI will provide sufficient assurance that the
certificate holder has employed effective policies, processes and procedures to
meet regulatory requirements.
A PVI differs from an assessment in that it does not look at the entire SMS. It
is used to determine that all the requirements of a particular component of the
SMS model or other parts of the regulations are documented, implemented, in
87
A process comprising research and an on-site review of one or more components of a safety
management system or other regulated areas of an enterprise. Transport Canada, Staff Instructions,
SI SUR-001, Issue No. 4, Definitions, p. 8.
88
An in-depth review of an enterprise process utilized to produce an output. Transport Canada,
Staff Instructions, SI SUR-001, Issue No. 4, Definitions, p. 9.
Aviation Investigation Report A12Q0216 | 57
use and effective. PVI will be used as the routine surveillance method in place
of traditional inspections. 89
A PVI is a smaller, more focused surveillance activity directed at a component, for example,
a quality assurance program. If the inspection has identified findings of non-compliance then
the company must submit a corrective action plan to rectify items defined in the findings
within a certain timeframe. The corrective action plan may be short term or long term.
Follow-up inspections are completed to ensure ongoing compliance with regulatory
requirements and that the approved corrective action plan has been implemented.
A PI examines a single process to determine if it meets regulatory requirements. It is
intended to provide information to support decisions related to the level of risk associated
with a certificate holder and what additional surveillance may be required. A PI will be
conducted to follow up on observations from a previous PI or on items that have been
specifically identified as being possible hazards, after changes to a particular division of the
operation. A PI shall only be conducted for cause. For example, following an occurrence, or
when there is growth or change within a company, a PI will be conducted on an as-needed
basis.
TC conducts these surveillance activities to ensure that the policies and procedures 90 put in
place and written in the company manuals such as the SMS, COM and SOPs, are in fact put
into practice. 91 The objective is to ensure that a company’s operations are conducted in
compliance with the regulations, but also to ensure that the company’s operations are run
safely. The identification of any possible hazards 92 is also part of the surveillance activities.
Risk assessments are conducted for any hazards that may be identified. Findings resulting
from a surveillance activity identify areas that are not compliant with regulatory
requirements. If a procedure or practice does not go beyond the confines of the regulatory
requirements, then it will not necessarily result in a finding.
89
Transport Canada, Aviation Safety Oversight, Staff Instructions, SI-SUR-001, Issue No. 4, Sections
13.1 and 15.1.
90
An organization’s procedures dictate the specific steps an individual should take to accomplish a
task. They operationalize the philosophy and policies by indicating how work will be carried out.
(Transportation Safety Board of Canada, A Guide to Investigating for Organizational and Management
Factors, Version 1, February 2002.)
91
An organization’s practices represent what actually happens in day-to-day operations. In an ideal
world, practices and procedures would be identical. However, in reality, practices may differ from
procedures for a number of reasons. (Transportation Safety Board of Canada, A Guide to
Investigating for Organizational and Management Factors, Version 1, February 2002.)
92
A hazard is a condition that could cause or contribute to an aircraft incident or accident. Transport
Canada, Aviation Safety Oversight, Staff Instructions, SI SUR-001, Issue No. 4, Definitions. The
Canadian Transportation Accident and Safety Board Act defines accident as an occurrence that results
directly from the operation of an aircraft, (i) a person is killed or sustains a serious injury.
58 | Transportation Safety Board of Canada
TC conducted an annual PVI for Perimeter, from 10 to 14 September 2012, for the purpose of
verifying if Perimeter had an effective quality assurance program (QAP) and safety oversight
system. The PVI identified 6 findings in the following areas:
•
Documentation/records management: noted were certain sections in the COM that
were out of date or incomplete.
•
Safety oversight/risk management (2 findings): noted was that the SMS manual did
not contain timelines for long-term corrective action plans.
•
Training/training, awareness and competency: noted for Subpart 705 operations;
flight attendant records did not contain information pertaining to flight deck
admission control training or certain information relevant to dangerous goods
training.
•
Quality assurance program (2 findings): noted were missing or omitted details
relevant to the QAP applicable to the maintenance program inspections timelines and
manual.
•
Perimeter submitted its corrective action plan, and it was approved by TC on
10 December 2012. Regular discussions and an exchange of emails took place
between the company and TC to keep abreast of expectations and corrective action
plan timelines for the different items to be addressed.
TC monitored the Type B operational control system throughout December 2012, and
dispatcher competency checks were done in May 2013. Although not all items defined in the
2012 corrective action plan could be rectified before the deadlines, TC was kept aware and
new reasonable deadlines were discussed.
As a result of this occurrence, TC called for a “post-occurrence PI”, which was conducted at
the end of January 2013. This PI, based on preliminary information on factors that could
possibly have contributed to the occurrence, was conducted solely to evaluate the process
used by Perimeter for oversight of its charter operations. The January 2013 PI made
2 observations:
•
Non-compliance with Perimeter’s own policy on conducting safety cases
•
A gap in Perimeter’s cabin safety training program documentation with respect to
missing key regulatory requirements (i.e., written procedures for briefings existed;
however, there was a lack of training with regards to the required safety briefing, exit
seating/briefing, individual passenger briefing).
TC was aware that the mother and infant had been seated in seat 1L next to the exit during
the occurrence flight. However, the post-occurrence PI did not identify the practice of seating
a passenger assisting another next to an emergency exit on this particular charter flight as
being non-compliant with regulations. 93
93
Canadian Aviation Regulations (CAR) 704.33(1)(d) Apron and cabin safety procedures; Transport
Canada, Advisory Circular (AC) 700-014 Passenger Seating Requirements and Accessible Air
Transportation, Section 4.0 Emergency Exit Seats (4)(g).
Aviation Investigation Report A12Q0216 | 59
The hazard of not restraining the infant was not identified. Given that the use of CRS is not
required by current regulations, there was no non-conformity to regulatory requirements.
1.18
Additional information
1.18.1
Human performance issues
A number of factors, such as frustration, fatigue and stress, can influence human
performance in carrying out safety-critical activities. These factors can result in the following
behaviours:
•
irritability,
•
willingness to take risks,
•
normal checks or procedures ignored,
•
inappropriate corrective action (problem-solving abilities),
•
mis-interpretation of the situation, and
•
poor judgement of distance, speed, and/or time.
The operation of the aircraft outside of learned procedures and published requirements is an
indication that both crew members’ behaviour, especially the captain’s, had been negatively
affected by frustration, fatigue and stress.
1.18.1.1 Frustration
Frustration is defined as the feeling of anger or annoyance caused by being unable to do
something.94 Time pressure increases the likelihood of risky decision making, with less time
spent accessing information when one is under time pressure compared to when under no
time pressure. 95 As well, time pressure amplifies frustration or anger that is associated with
delay, and results in the frustration or anger persisting across multiple situations even once
the delay-causing agent has been removed. Frustration or anger can lead to one
underestimating the likelihood of risky events occurring, and to choosing a more risky
option than would be chosen in the absence of frustration or anger. 96
People most commonly use swear words to express anger or frustration. 97 Estimated average
spoken word rates of swearing range from 0.5 to 0.7%, or between 80 and 90 swear words
94
Merriam-Webster Online Dictionary [online]. Available at: http://www.merriamwebster.com/dictionary/frustration (last accessed 18 June 2015).
95
A.J. Maule, G.R.J. Hockey and L. Bdzola, 2000, “Effects of time-pressure on decision-making
under uncertainty: changes in affective state and information processing strategy,” Acta
Psychologica, 104, pp. 283–301.
96
A.N. Stephens and J.A. Groeger, 2011, “Anger-congruent behavior transfers across driving
situations,” Cognition & Emotion, 25(8), pp. 1423-1438.
97
T. Jay, 2000, Why we curse, Philadelphia: John Benjamins.
60 | Transportation Safety Board of Canada
per day (5.3 per hour). 98 The captain used 43 expletives in conversation with the FO during
the 2-hour period preceding the occurrence, a rate of approximately 21.5 swear words per
hour. This type of behaviour was seen as being out of character for the captain.
1.18.1.2 Fatigue
Fatigue was examined to verify if it may have affected the crew’s ability to perform their
duties. Analysis of their 72-hour work/rest history did not point to fatigue as a performancealtering factor. Neither crew member felt that fatigue was an issue before the flight.
However, both crew members had expressed feeling tired during the flight as it had been a
long day. Additionally, the occurrence took place towards the end of the afternoon circadian
dip, when feelings of fatigue are more pronounced and can affect performance. 99
Although he had been in bed for 8 hours the night before the occurrence flight, the captain
had 6.5 hours of sleep, considering the 1.5-hour wake period he experienced during the
night. Based on the captain’s 1.5-hour wake period and resultant shortened sleep duration
the night before the flight, acute sleep disruption 100 may have played a role in the captain’s
behaviour during the flight by increasing the risk for fatigue and its associated performance
decrements. Furthermore, circadian rhythm timing may have exacerbated the fatigue
brought on by the acute sleep disruption. The FO had approximately 8 hours of sleep the
night before the occurrence flight. As he had not experienced sleep disruption during the
night, fatigue was considered less of a risk factor for the FO. At the time of the occurrence,
both crew members had been awake for approximately 11 hours.
1.18.1.3 Stress and performance
Increased stress levels can adversely impact a pilot’s ability to perceive and evaluate cues
from the environment, and may result in attentional narrowing. Studies have shown that
individuals under stress tend to limit their attention to stimuli they perceive to be most
important or most relevant to the task at hand. 101 This may result in pilots only paying
98
T. Jay, 2009, “The utility and ubiquity of taboo words,” Perspectives on Psychological Science, 4(2),
pp. 153-161.
99
Circadian rhythm timing (circadian dip): fatigue will increase slightly in the middle of the
afternoon and significantly during the circadian rhythm trough between 22:30 and 04:30 body
time.
100
Acute reductions in the quantity of sleep are normally considered remarkable when they are at
least 30 minutes in duration. Reductions in the quality of sleep result from awakenings or other
significant changes to the normal textbook pattern of sleep due to such things as changes to the
time the person goes to bed or wakes up, arousing sleep environments (e.g., noisy bunk rooms),
food choices (e.g., caffeine, alcohol) or mental stress. Qualitative sleep reductions are normally
considered remarkable when the amount of deep sleep is curtailed to less than the required 10 to
20% or rapid eye movement (REM) sleep is curtailed to less than the required 15 to 20% but the
total sleep time may remain unchanged.
101
Crew Resource Management (CRM) Standing Group, Crew Resource Management, Royal
Aeronautical Society, London, United Kingdom, 1999.
Aviation Investigation Report A12Q0216 | 61
attention to certain cues while excluding others, which in turn leads to a loss of situational
awareness. It is crucial that pilots continually re-evaluate the situation in which they find
themselves in order to determine whether they accurately perceive it, and if the plan is
working out as expected, or if a change in the plan is required.
1.18.2
Crew resource management
1.18.2.1 General
For each and every flight, pilots must successfully interact with each other, their aircraft,
associated checklists, manuals, and their environment to effectively manage threats, errors,
or undesired aircraft states that may be encountered. The objective of CRM is to reduce
human error in aviation by ensuring better crew coordination. CRM is widely accepted as
the use of all resources available to the flight crew to ensure safe and efficient flight
operations.
One skill associated with good CRM is effective crew communication. With good
communication comes good decision making, workload management, problem solving, and
better situational awareness. Crew members must have a common mental model of the
current aircraft state and environmental information, which will lead to better anticipation
and coordination of their actions towards a common goal.
1.18.2.2 Crew resource management training
Appropriate, representative CRM training has been shown to improve attitudes towards
crew coordination and to allow for more effective team work. It has also been shown to
improve flight crew performance and the ability to cope with non-routine situations. 102
Research has also shown that recurrent training is necessary to maintain the concepts learned
during CRM training. If these concepts and, consequently, the positive effects of CRM
training are not reinforced, they tend to disappear.
Following a TSB investigation into a runway excursion in British Columbia in July 1993 (TSB
Aviation Investigation Report A93P0131), the TSB recommended (A95-11) that TC establish
guidelines for CRM and decision-making training for all operators and aircrew involved in
commercial aviation. TC’s response to the recommendation addressed only Subpart 705
operations 103 and did not require CRM training for Subpart 703 and 704 operations.
Following a CFIT accident in Saskatchewan in January 2007 (TSB Aviation Investigation
Report A07C0001), the TSB recommended (A09-02) that TC require commercial air operators
to provide contemporary CRM training for Subpart 703 and Subpart 704 pilots.
102
Federal Aviation Administration, Crew Resource Management Training, 2004, Advisory
Circular AC 120-51E.
103
Commercial Air Service Standards (CASS) 725.124(39) Crew Resource Management Training,
Advisory Circular (AC) 120-51E.
62 | Transportation Safety Board of Canada
Since its initial response to Recommendation A09-02 in 2010, TC has worked on developing a
contemporary CRM training standard to replace the existing standard, which does not reflect
modern CRM training concepts. TC intends to extend this training to Subpart 702, 703, and
704 operations, and would include threat and error management (TEM) as the most recent
and widely accepted approach for CRM training.
The TSB investigation into a Boeing 737-210C CFIT occurrence in Resolute Bay, Nunavut, in
August 2011 (TSB Aviation Investigation Report A11H0002), again addressed the need for
better up-to-date regulatory action, training, and guidance in regards to CRM. The report
explains how CRM training has evolved since its introduction in the late 1970s, and how the
TEM model recognizes the importance of undesired aircraft state management as it
represents the last opportunity for flight crews to prevent an adverse outcome. 104 As a
consequence, the TSB issued a Safety Concern in its final report on that accident, stating that,
without a comprehensive and integrated approach to CRM by TC and aviation operators,
flight crews may not routinely practise effective CRM.
Initial research has supported links between TEM and CRM and has shown that:
•
crews who develop contingency management plans, such as
proactively discussing strategies for anticipated threats, tend to have
fewer mismanaged threats;
•
crews who exhibit good monitoring and cross-checking usually
commit fewer errors and have fewer mismanaged errors; and
•
crews who exhibit strong leadership, inquiry, and workload
management are typically observed to have fewer mismanaged errors
and undesired aircraft states than other crews. 105
TC has initiated measures to change the CRM training standard. A focus group consisting of
TC and industry representatives met in January 2012 and submitted a final report in
February 2012. The focus group report proposed components of a contemporary CRM
training standard for CARs Part VII commercial operators, but recommended against a set
time for CRM course duration and any formal accreditation for CRM instructors. The Civil
Aviation Regulatory Committee (CARC) accepted the TC focus group recommendations,
and, on 24 April 2012, directed that a contemporary CRM training regulations and standard
be developed for CARs Subpart 702, 703, 704, and 705 operations.
It is not yet known how detailed TC’s new training standard and guidance material will be
compared to the existing standard, or when the new standard will come into effect. Nor is it
104
D. Maurino, Coordinator, Flight Safety and Human Factors Programme, Threat and Error
Management (TEM), – International Civil Aviation Organization (ICAO), Canadian Aviation Safety
Seminar, Vancouver, British Columbia, 18-20 April 2005.
105
A. Merritt and J. Klinect, 2006, Defensive Flying for Pilots: An Introduction to Threat and Error
Management, The University of Texas Human Factors Research Project. The LOSA Collaborative.
Aviation Investigation Report A12Q0216 | 63
known how TC will monitor if operators apply the new training standard to ensure that
flight crews acquire and maintain effective CRM skills.
As of January 2015, TC, in its review of Recommendation A09-02, agrees with the intent of
the recommendation.
TC continues to work on the development of standards and guidance material for CRM and
updated pilot decision making (PDM) to be incorporated in the CRM modules. Public
consultation on proposed amendments to the standards is underway, and the standards are
expected to come into effect in late 2015.
The Board is encouraged that action on this recommendation is nearing completion. The
proposed course of action should substantially reduce or eliminate the safety deficiency
identified in Recommendation A09-02. Until the standards are amended and fully
implemented, this safety deficiency will continue to exist. In its annual review of responses
to its recommendations in 2015, the Board considered that TC’s response on this issue
indicates Satisfactory Intent. 106
Although not mandatory for Subpart 703 and 704 operations, Perimeter recognizes the
benefits of CRM training and provides it to its flight crews. CRM training is given during the
annual ground school training and the content is approved by TC. Information collected for
this investigation indicated that crews were somewhat bored with the recurrent CRM
training, and did not find it to be a productive exercise as the same examples and subjects
were reviewed every year.
The occurrence captain had received CRM training while employed with his previous
employer for Subpart 705 operations, and was expected to receive CRM training with
Perimeter within a year. The FO had received Perimeter’s CRM training in 2011. Although
they had not worked together before, both the captain and the FO felt that they had a good
rapport and did not perceive any CRM or communication difficulties throughout the flight.
1.18.2.3 Crew communication
In order to align crew situational awareness and optimize the decision-making process, crew
members must be effective communicators and must feel comfortable in providing input to
each other. This can be a challenge in the cockpit when faced with time pressures, competing
priorities, or an inappropriately balanced trans-cockpit authority gradient. Trans-cockpit
authority gradient refers to the manner in which the captain and the FO interact. If a steep
trans-cockpit authority gradient exists, either due to experience levels or personality types,
106
A Satisfactory Intent assessment is assigned if the stakeholder has proposed action that, if
implemented in full, will substantially reduce or eliminate the safety deficiency. Associated
recommendations are A00-06 and A07-03.
64 | Transportation Safety Board of Canada
there is an increased risk that decisions will be made based on incomplete or inaccurate
information. 107
It is important for a captain to recognize that, in most cases, inexperienced FOs will be
predisposed to use subtle, non-aggressive communication strategies to voice concerns that
they are afraid to raise for fear of being wrong, or of being chastised for questioning a more
experienced individual.
Practising assertiveness techniques can enhance CRM training. It is important because it
trains less senior team members to feel comfortable providing input to a more senior team
member, and to communicate this information in an effective way. It also trains senior team
members to accept input without feeling threatened. 108
1.18.2.4 Threat and error management
In order to understand the chain of events that led to this occurrence, the investigation used
the TEM model. The following information on the TEM model and associated table are taken
from papers written on the subject. 109,110
TEM is defined as the analysis of potential hazards and the taking of appropriate steps to
avoid, trap, or mitigate threats and errors before they lead to an undesired aircraft state. The
key principles behind TEM are anticipation, recognition, and recovery.
When applying TEM to analyse the relationship between safety and human performance in a
context such as flying, it is important to keep the user’s perspective in mind. The user can be
the flight crew, management, senior management, flight operations, maintenance, or air
traffic control.
For flight crews, threats are defined as events or errors that occur beyond the influence of the
flight crew. They increase operational complexity and must be managed to maintain a
certain level of safety. During typical flight operations, flight crews need to manage various
and, at times complex, events. For example, events could include dealing with adverse
meteorological conditions, aircraft malfunctions, and errors committed by other people
outside of the cockpit, such as air traffic controllers or maintenance workers. These events
107
A. Gupta, “Trans-Cockpit Authority Gradient in Flying Training: A Case Report,” Indian Journal of
Aerospace Medicine, 48(1), 2004.
108
K.A. Wilson, J.W. Guthrie, E. Salas and W.R. Howse, 2010, “Team process.” In J.A. Wise,
V.D. Hopkin and D.J. Garland (Eds.), Handbook of Aviation Human Factors, Second Edition. Boca
Raton, Florida: CRC Press, pp .9-1 to 9-22.
109
A. Merritt and J. Klinect, 2006, Defensive Flying for Pilots: An Introduction to Threat and Error
Management, The University of Texas Human Factors Research Project. The LOSA Collaborative.
110
D. Maurino, Coordinator, Flight Safety and Human Factors Programme, Threat and Error
Management (TEM), International Civil Aviation Organization (ICAO), Canadian Aviation Safety
Seminar, Vancouver, British Columbia, 18-20 April 2005.
Aviation Investigation Report A12Q0216 | 65
can be viewed as threats because they have the potential to negatively affect flight operations
by reducing safety margins.
The TEM model groups threats under 2 basic categories: environmental threats and
organizational threats.
Some environmental threats can be planned for and some will occur unexpectedly, but they
all have to be managed by flight crews in real time. Organizational threats, on the other
hand, can be controlled by the operator and are usually latent in nature. Although flight
crews remain the last line of defense, there are usually earlier opportunities for the operator
to mitigate organizational threats. Examples of environmental and organizational threats
appear in Table 8.
Table 8. Examples* of threats 111
Environmental threats
Organizational threats
• Weather: thunderstorms, turbulence, icing,
wind shear, cross/tailwind, very low/high
temperatures.
• ATC: traffic congestion, TCAS RA/TA,
ATC command, ATC error, ATC language
difficulty, ATC non-standard phraseology,
ATC runway change, ATIS
communication.
• Airport: contaminated/short runway;
contaminated taxiway, lack
of/confusing/faded signage/markings,
birds, aids U/S, complex surface
navigation procedures, airport
constructions.
• Terrain: High ground, slope, lack of
references, black hole.
• Other: similar call-signs.
• Operational pressure: delays, late arrivals,
equipment changes.
• Aircraft: aircraft malfunction, automation
event/anomaly, MEL/CDL.
• Cabin: flight attendant error, cabin event
distraction, interruption, cabin door
security.
• Maintenance: maintenance event/error.
• Ground: ground handling event, de-icing,
ground crew error.
• Dispatch: dispatch paperwork
event/error.
• Documentation: manual error, chart error.
Other: crew scheduling event.
* List not inclusive
Errors are defined as actions or inactions by the flight crew that lead to deviations from
organizational or flight crew intentions and/or expectations. Unmanaged and/or
mismanaged errors frequently lead to undesired aircraft states. Therefore, errors in the
operational setting tend to reduce margins of safety and increase the probability of adverse
events.
The effect an error will have on safety depends on whether the flight crew detects and
responds to the error before it leads to an undesired aircraft state and to a potential unsafe
111
D. Maurino, Coordinator, Flight Safety and Human Factors Programme, Threat and Error
Management (TEM), International Civil Aviation Organization (ICAO), Canadian Aviation Safety
Seminar, Vancouver, British Columbia, 18-20 April 2005.
66 | Transportation Safety Board of Canada
outcome; an error that is not detected cannot be managed. An error that is detected and
effectively managed has no adverse impact on the flight. Examples of errors would include
the inability to maintain stabilized approach parameters and failing to give a required
callout.
TEM divides flight crew errors into 3 types:
•
aircraft handling
•
procedural
•
communication.
Aircraft handling errors are deviations associated with aircraft parameters, such as the
direction, speed, and configuration of the aircraft. They can involve automation errors, or
hand-flying errors, such as being too fast and high during an approach. Procedural errors are
flight crew deviations from regulations, flight manual requirements, or SOPs.
Communication errors involve a miscommunication between the pilots, or between the crew
and external agents such as maintenance, ATC controllers, flight attendants, dispatch, and
ground personnel.
An undesired aircraft state may include flight crew-induced aircraft position or speed
deviations, misapplication of flight controls or incorrect systems configuration, all of which
are associated with a reduction in margins of safety. As with errors, undesired aircraft states
can be managed effectively, returning the aircraft to safe flight. If mismanaged, they can lead
to an additional error, undesired aircraft state, or worse, an incident or accident.
The use of the TEM model assists in educating, not only flight crews, but all those involved
in flight operations, on the anticipation, recognition, and recovery from existing threats and
errors.
Based on information on threats and errors collected in the Line Operations Safety
Audits (LOSA) 112 Archive, the following statistics are of interest:
Threats:
• The typical flight (regularly scheduled, normal operations) encounters an
average of 4.2 threats per flight; 3 are likely to be environmental threats
and 1 is likely to be an organizational threat. Seventeen percent of flights
encounter 7 or more threats per flight. Therefore, multiple threats are the
standard and need to be managed.
• About 40% of all threats occur during the predeparture/taxi-out phases of
the flight and 30% occur during descent/approach/land phases. For
environmental threats, the busiest phase of flight is
112
The Line Operations Safety Audits (LOSA) Archive is a database containing observers’ narratives
and coded observations from all 25 participating airlines that have conducted a LOSA with the
LOSA Collaborative (from 2002 to 2006). Results from different airlines are pooled to derive
industry averages.
Aviation Investigation Report A12Q0216 | 67
•
descent/approach/land, while for organizational threats, the busiest
phase is predeparture/taxi-out.
Most threats are successfully managed (85-95%). The average across the
LOSA Archive is 90%. Therefore about one tenth of all threats are
mismanaged by crews.
Errors:
• 80% of flights have 1 or more errors, with an average of approximately
3 per flight.
• 20% of flights have no observable errors.
• 40% of all observed errors occur during the descent/approach/land
phases of flight. 30% of errors occur during predeparture/taxi-out when
crews are preparing the flight.
• Procedural errors make up half of all errors, but less than one-quarter of
mismanaged errors.
• Three-quarters of all mismanaged errors are aircraft handling errors with
communication errors comprising the remaining few percent.
• Checklist errors are the most common procedural error, followed closely
by callout and SOP cross-verification errors. Briefing errors are less
common.
• About 25% of all errors are mismanaged. 6% of all errors lead to
additional error and 19% result directly in an undesired aircraft state.
• 36% of all mismanaged errors are manual handling/flight control errors.
16% of mismanaged errors are automation and system/instrument/radio
errors,
• 5% are checklist errors and 3% are crew–ATC communication errors.
Undesired aircraft state:
• About 30% of all undesired aircraft states occur as part of a chain of events
that starts with a threat that is not managed well and leads to a crew error,
which in turn is mismanaged, leading to an undesired aircraft state.
Essentially, from the pre-flight preparation to engine shutdown after landing, flight crews
are constantly working on threat, error, and undesired aircraft state management. If threats
and errors are not detected and managed throughout the whole flight, the probability of
adverse consequences increases.
1.18.3
Instrument approach design
1.18.3.1 General
Instrument approach procedures in Canada are developed based on a TC manual entitled
Criteria for the Development of Instrument Procedures (TP308/GPH209). According to TP308,
“obstacle clearance is the primary safety consideration in the development of instrument
procedures.”
TP308 states that the optimum descent path for a non-precision final approach segment is
318 feet per nautical mile, or an angle of 3 degrees, and its use is recommended.
68 | Transportation Safety Board of Canada
In the case of the CYSK NDB Runway 27 approach, the NDB is the MAP and is located
0.9 nm from the threshold of Runway 27 (Figure 12). Using a threshold crossing height of
40 feet, the descent angle from the MDA of 560 feet, is 4.7 degrees. 113 If flight crews choose to
land when they reach the MAP, at MDA, the resulting descent path would be steep and lead
to a rate of descent of approximately 1240 fpm. Under industry accepted stable approach
criteria, this would be considered unstable, as it is greater than 1000 fpm. Therefore, any
decision to land should be made prior to the MAP in order to maintain an approximate 3degree approach path and remain on a stable approach.
Figure 12. Actual descent path versus optimal descent path
1.18.3.2 Instrument approaches for CYSK
As with many small airports, CYSK had only 1 non-precision NDB approach (Runway 27)
with the option of circling to the opposite runway (Runway 09).
In February 2014, NAV CANADA issued 2 new RNAV (area navigation) GNSS approaches
for CYSK, 1 for Runway 09 and 1 for Runway 27. ICAO defines area navigation as a method
of navigation that permits aircraft operation on any desired flight path within the coverage
of ground or space-based navigation aids or within the limits of the capability of selfcontained aids, or a combination of these. 114 With RNAV approaches, pilots have the option
of straight-in approaches and localizer performance with vertical guidance (LPV) capability.
This offers better situational awareness than conventional NPAs thereby reducing the risk of
an ALA. The 2 new CYSK approaches include LPV minima that provide both lateral and
vertical guidance to 250 feel agl. The NDB Runway 27 approach is still available.
113
Transport Canada, Advisory Circular (AC) 302-009.
114
International Civil Aviation Organization (ICAO), Document 9613, Performance-based Navigation
Manual, Volume 1, Concept and Implementation Guidance, Explanation of terms.
Aviation Investigation Report A12Q0216 | 69
Changes to the approach chart depiction were put into effect for various reasons, one of
which was the need to be in line with Flight Safety Foundation (FSF) principles and ICAO
guidance material. Changes to the approach charts were not in response to this accident.
Since 2010, Perimeter worked with the Manitoba Aviation Council (MAC), Northern Air
Transport Association (NATA), and sat as a member on the NAV CANADA Advisory
Committee, with the sole purpose of requesting that NAV CANADA design GNSS
approaches at busy northern airports. The design of GNSS approaches is ongoing.
1.18.4
Approach and landing accidents
In 1996, the FSF formed its Approach-and-Landing Accident Reduction (ALAR) Task Force.
By focusing on approach and landing, the task force was able to work outside the strict
definition of CFIT accidents, which does not include landing short or long, runway overruns,
or loss of control following an unstable approach. In 1998, the FSF task force issued
recommendations targeting the reduction and prevention of ALAs.
The statistical data collected by the FSF ALAR Task Force at that time revealed that ALAs
represented approximately 55% of total hull losses and 50% of fatalities. The flight segment
from the initiation of the approach to the completion of the landing roll represented only 4%
of the flight time but 45% of hull losses. CFIT (including landing short of the runway), loss of
control, runway overrun, runway excursion, and unstable approaches are the 5 types of
events that account for 75% of approach-and-landing incidents and accidents.
Although the majority of the statistics cited by the task force are pertinent to this occurrence
and operation, several statistics cited in the study stand out as being particularly applicable
to this event:
•
CRM issues, including decision making under stress, are observed as circumstantial
factors in more than 70% of ALAs.
•
More than 70% of ALAs contained elements that should have been recognized by the
crew as improper and should have prompted a go-around.
•
When an unstable approach warrants a go-around decision, less than 20% of flight
crews actually initiate a go-around.
•
Continuing an unstable approach is a causal factor in 40% of all ALAs.
•
Approximately 70% of rushed and unstable approaches involve an incorrect
management of the descent-and-approach profile and/or energy level (i.e., being
slow and/or low, being fast and/or high).
•
The risk of an ALA is higher in operations conducted in low light and/or visibility,
on wet or otherwise contaminated runways, and with the presence of optical or
physiological illusions.
•
The lack of acquisition or the loss of visual references is the most common primary
causal factor in ALAs.
70 | Transportation Safety Board of Canada
In 1998, a special FSF report 115 concluded that the failure to recognize the need for and then
execute a missed approach was an important contributor to ALAs. An FSF-sponsored GoAround Forum held in Brussels, Belgium, in June 2013, discussed results from the
2011 Go-Around Decision Making and Execution Project 116 and survey. The study tried to
determine why pilots choose to salvage a bad approach rather than try another that might
lead to a better outcome, and what can be done to assist crews in making the decision to
execute a go-around.
Results of this study and analysis presented at the FSF Forum in Belgium indicated that
•
between 3 and 4% of all approaches are reported/recorded as unstabilized;
•
only 3% of these results in a go-around being flown; and
•
97% of unstabilized approaches continue to be flown to a landing contrary to SOPs.
The study also revealed that pilots who continued on unstable approaches perceived far less
risk than pilots who decided to go around. Pilots failing to execute a go-around
•
had degraded representations and awareness of the situation;
•
were more tolerant of deviations from operational limits and procedures;
•
were less likely to perform required checklists and calls; and
•
were less likely to take advantage of other crew members or seek their advice about
the best course of action.
The study stated that
Because their situational awareness was dimmed, the pilots (in the study)
who chose to continue on an unstable approach, experienced not seeing
certain threats (anticipatory awareness) such as aircraft instabilities; weather
and aircraft configuration; selectively leveraging their ‘stick and rudder’
experiences (critical awareness) as permission to continue; and finally,
perceiving or assuming crew dynamics (relational awareness) to support noncompliant behavior.
The TSB report on its investigation into a CFIT occurrence in Quebec in December 2009
(A09Q0203) cited information relevant to the FSF’s ALAR Task Force findings and
recommendations. The recommendations are reiterated in this report as they remain
applicable to the circumstances surrounding this occurrence (Appendix H).
The TSB database shows that in 2012 in Canada, there were 34 ALAs; 3 of these were
operating under Subpart 705; 4 were operating under Subpart 704; and 16 were operating
115
Flight Safety Foundation, Flight Safety Digest, “Killers in Aviation: FSF Task Force Presents Facts
About Approach-and-landing and Controlled-flight-into-terrain Accidents,” November-December
1998/January-February 1999. Available at:
http://www.skybrary.aero/bookshelf/books/1542.pdf (last accessed 18 June 2015).
116
J.M. Smith, D.W. Jameson and W.F. Curtis, “Inspiring the Decision to Go Around,” AeroSafety
World, June 2013.
Aviation Investigation Report A12Q0216 | 71
under Subpart 703. The other 11 occurrences were in the ‘other commercial operations ALAs’
category.
The FSF ALAR task force determined that the risk of ALAs was 5 times higher for nonprecision approaches than for precision approaches.
1.18.5
TSB Watchlist
Approach-and-landing accidents are a 2014 TSB Watchlist issue. The Watchlist is a list of
issues posing the greatest risk to Canada’s transportation system; the TSB publishes this list
to focus the attention of industry and regulators on the problems that need addressing today.
As this occurrence demonstrates, landing accidents continue to occur at Canadian airports.
1.18.6
Flight Safety Foundation Approach and Landing Accident Reduction Tool Kit
In addition to the recommendations put forth by the FSF ALAR Task Force in 1998, the FSF
developed and distributed an ALAR Tool Kit. It is a resource that can be modified as
required to fit the particulars of an operation, and it can also be used for training in the
various positions within a company. The objective of the tool kit is to help highlight,
evaluate, and mitigate the associated risks of a flight before departure. If the risk level is
deemed too high after using the tool kit checklist, then the flight could be turned down or
delayed until risks are mitigated to maintain an acceptable level of safety. Although
promoted, and its use encouraged by TC, 117 many Canadian operators are not aware of the
existence of the FSF ALAR Tool Kit, or if aware of it, are not using it. Perimeter, although
aware of the tool kit, had not used it, nor was it mandatory to do so.
1.18.7
Go-around – Flight Safety Foundation European Advisory Committee
1.18.7.1 General
An article in Aviation International News 118 stated that the FSF European Advisory
Committee’s results, after analysing 66 go-around related accidents that occurred between
2002 and 2013, showed that the go-around itself was usually the consequence of something
that went wrong on the approach. Several trends were noted:
•
Significant procedure non-compliance was likely to precede the go-around attempt;
•
In half of the fatal accidents, there was significant violation of approach minima;
•
Nearly three quarters of all go-around decisions were made when the aircraft was
below 500 feet agl;
•
In 5 out of 10 fatal accidents, the PF flew below minimums with little negative input
from the PNF;
•
Most of the go-arounds were flown manually by the PF.
117
Transport Canada, Air Carrier Advisory Circular No. 0161.
118
“Safety experts advise: use the go-around option,” Aviation International News, August 2013.
72 | Transportation Safety Board of Canada
The International Air Transport Association (IATA) conducted the Go-around Web Survey
in 2005 using its Safety Trend Evaluation, Analysis & Data Exchange System (STEADES).
Respondents to the survey provided information on their go-around experience. In the case
of landing in adverse weather conditions, of the 265 respondents, 59% answered that
although they had continued the landing, they felt that a go-around would have been called
for but none was performed. Also, 72% indicated that a member of the crew or ATC never
suggested a go-around during the approach.
Most missed approaches are executed due to bad weather conditions and require particular
attention in order to immediately transition back to flying with reference to the instruments.
The procedure may be further complicated if airspeed and/or thrust settings are low. 119
1.18.7.2 Go-around training
Go-arounds are not common and, therefore, can entail some risk. One in 10 go-around
attempts has a potentially hazardous outcome, including exceeding aircraft performance
limits. Go-around manoeuvres are often flown poorly and are more likely to be fatal than
common runway excursion accidents. 120
Perimeter flight crews practise go-around procedures in a static flight training device prior to
initial training on the aircraft. These procedures are also trained during every initial and
recurrent aircraft training session. A minimum of 2 missed approaches in the recurrent
training and an average of 5 to 6 missed approaches in an initial training program are
conducted. At least 1 missed approach is conducted at altitude, simulating an engine failure
at the point of go-around. A 2-engine go-around at a very low altitude (balked landing)
following a circling manoeuvre may also be conducted during training.
1.18.7.3 Low-energy training
Following the TSB investigation of a Canadair CL-600-2B19 loss of control on go-around
(rejected landing) occurrence in New Brunswick in December 1997 (TSB Aviation
Investigation Report A97H0011), the Board recommended that:
The Department of Transport ensure that pilots operating turbo-jet aircraft
receive training in, and maintain their awareness of, the risks of low-energy
conditions, particularly low-energy go-arounds.
TSB Recommendation A99-06
Under existing regulations (CAR 704.115), air carriers operating under Subpart 704 shall
establish and maintain a ground and flight training program which includes low-energy
awareness training (CASS 724.115 (34)). This training requirement, however, applies to
119
Skybrary article “Flying a Manual Go-around” [online]. Available at:
http://www.skybrary.aero/index.php/Flying_a_Manual_Go-around (last accessed on
18 June 2015)
120
“Safety experts advise: use the go-around option,” Aviation International News, August 2013.
Aviation Investigation Report A12Q0216 | 73
turbojet aircraft operations only, and does not include turboprop aircraft such as the
Metro III.
On 13 May 1998, TC issued Commercial and Business Aviation Advisory Circular (AC)
No. 141 to notify pilots and air operators of the potential hazards associated with a balked
landing or go-around. The circular states that, “an aircraft is not certified to successfully
complete a go-around without ground contact once it has entered the low-energy landing
regime.”
The AC also advises that air operators should immediately ensure that their pilots and
training personnel are aware of the hazards associated with low-energy go-arounds, and
verify that their training programs address these hazards and provide procedures for dealing
with them. The AC does not distinguish between training aimed at operators of turbojet
aircraft and turboprop aircraft.
Executing a low-energy go-around is a demanding manoeuvre and is often accompanied by
additional stress. Although periodically practised in simulator training, executing a lowenergy go-around in real life situations is a rare event.
Perimeter does not address low-energy rejected landings for the Metro II or III in flight
training or in simulator training. However, a simulated visual missed approach at altitude is
practised. The aircraft is allowed to slow for landing, then a go-around is conducted using
the go-around procedure; a full-flap, gear-down configuration is used, in a slow airspeed
situation, with an engine failure. This exercise allows the candidate to execute the procedure
and it demonstrates degraded aircraft performance.
1.18.7.4 Putting go-around information to good use
The FSF Go-Around Forum found that for better go-around decision making to happen,
pilots need to
121
•
enhance crew dynamic situational awareness;
•
have better refined and defined go-around policy (stable approach parameters and
stable approach height);
•
be better guided by SOPs, which helps minimize the subjectivity of the go-around
decision;
•
obtain improved go-around training, including the recognition of threat factors and
difficulties associated with the go-around decision. Go-around training should
include execution from other-than-decision height, MDA or designated stabilized
approach gate. 121 Also, training must keep in mind that the majority of go-arounds
are made because of weather (forward visibility, ceiling, wind velocity, and
turbulence).
Skybrary article “Go-around Decision Making” [online]. Available at:
http://www.skybrary.aero/index.php/Go-around_Decision_Making (last accessed 18 June 2015).
74 | Transportation Safety Board of Canada
The FSF Forum concluded that go-arounds should be considered a normal phase of flight,
and that crews should be encouraged to use the option when it is warranted. Crews need to
be mentally prepared to execute a go-around on every approach as it might be needed, and
training must ensure crew proficiency in conducting such manoeuvres in different phases of
flight and aircraft configurations.
1.18.8
Aircraft performance
The TSB laboratory looked at the aircraft performance effects of raising the landing gear
during the go-around. The landing gear was selected UP immediately upon the go-around
call, which is earlier than specified in the AFM balked landing procedure. The wreckage
indicates that the gear was in the process of retracting when the aircraft collided with terrain.
Given the available data, it was not possible to quantify the effects upon performance and
trim/control throughout the full retraction cycle, but the effects can be discussed in general.
When the landing gear is retracted, the total aerodynamic drag of the aircraft is reduced,
allowing greater acceleration and rate of climb. The published performance data for balked
landing conservatively assumes that the landing gear remains extended. Retracting the
landing gear should further increase the aircraft’s climb and acceleration capability
compared with the published performance.
Airworthiness certification requires that raising of landing gear be a smooth transition that
does not have an unacceptable effect on aircraft control and trim in normal and emergency
situations. It is therefore expected that the action of raising the landing gear would not
diminish the ability to execute the published balked landing procedure. The manufacturer
confirms that there is a negligible change in aircraft pitch when retracting the landing gear.
Therefore, raising the landing gear earlier than specified in the published procedure is
expected to have had no detrimental effects upon controlling the aircraft or achieving the
published balked landing performance.
1.19
Useful or effective investigation techniques
Not applicable.
Aviation Investigation Report A12Q0216 | 75
2.0
Analysis
2.1
General
The analysis will focus on the circumstances affecting the flight and the factors that could
have led the crew to deviate from learned procedures and regulations, to descend below
minimum descent altitude (MDA) before acquiring the required visual references, and to
miss critical cues warranting the initiation of a missed approach.
Additionally, the analysis will address the lack of readily available data on the number of
infant and child passengers travelling by air, and the lack of regulations for the mandatory
use of suitable restraint devices that would provide an equivalent level of safety for infants
and children compared to adult passengers.
2.2
Weather
Weather obtained for flight planning, although marginal, was forecast to be above minima
for the approach at Sanikiluaq (CYSK), and the weather forecast for Kuujjuarapik (CYGW)
was appropriate for its use as an alternate airport. The captain had verified weather prior to
departure and knew of the low pressure system expected to pass through the area of CYSK
that afternoon, and that the same weather system would affect the airports located to the east
of Hudson Bay. Weather, at the time of planning, was not seen as a threat; ceilings and
visibility were above the published minima.
While the aircraft was preparing for takeoff, the aviation routine weather reports (METAR)
for CYGW deteriorated, and the aerodrome forecast (TAF) was amended at 1936 UTC. The
amended TAF forecasted weather below approach minima during the initial period, but
improving to 2 statute miles (sm) visibility and overcast cloud at 1500 feet above ground
level (agl) prior to the estimated time of arrival at the alternate. The crew did not obtain this
updated weather forecast.
During the flight, the METARs showed poor weather consistent with the initial forecast
period. The TAF for CYGW was amended again at 2211 UTC, and this time the forecast
improvement of 2 sm visibility and overcast cloud at 1500 feet agl was delayed until
2400 UTC, making CYGW unsuitable as an alternate.
As forecast weather was initially not deemed a threat, the crew did not obtain updated
weather for destination and alternate airports while en route, and were surprised, upon
obtaining an update prior to descent at CYSK, that weather at CYGW was below minima for
the approach. The 2200 UTC METAR for CYGW had dropped to ½ sm in snow with a
vertical ceiling of 400 feet. This weather activity was occurring during the en-route portion of
the flight. The crew received the 2200 UTC METAR at 2228 UTC. This was the first time the
crew realized the weather at the alternate was below approach minima. The crew was
surprised by the low weather conditions in CYGW, and also realized that a forecast
improvement in the weather would only occur shortly after the estimated time of arrival at
the alternate airport. Upon realizing the weather at the alternate was no longer favourable
76 | Transportation Safety Board of Canada
for landing, the crew discussed using La Grande Rivière (CYGL) as an alternate if a landing
at CYSK was not possible. However, total fuel on board at that time did not accommodate
this option. This likely increased the pressure to land at CYSK.
The winds were favouring an approach to Runway 09; however, CYSK did not have a
published instrument approach procedure for this runway. The weather did not allow for
visual manoeuvring to Runway 09, and the crew decided to land on Runway 27 with the
associated risks of landing with a 14-knot tailwind on a 3807-foot runway. Lack of a
published instrument approach for Runway 09 led to the crew’s decision to attempt a
downwind landing.
2.3
Human performance issues
2.3.1
Cumulative effects of frustration, fatigue and stress
The number of MEDEVAC and charter flights to areas in Nunavut on 22 December was
greater than the number of Canada Air Pilot instrument approach charts available to
Perimeter flight crews. The chosen solution to this problem was to pick up the necessary
documents at the Keewatin Air hangar where the passengers were to embark. This meant,
however, that the approach chart information was not available for pre-flight preparation.
Under Type B operational control, dispatch would have a responsibility to find a way to
provide the necessary charts, chart information (copy), or to cancel the flight. Under Type C,
the captain has that responsibility. The lack of charts was an operational shortfall and an
irritant for the captain. This placed pressure on the captain to develop a work-around
solution in a short period of time; a solution that would entail cancelling the flight, delaying
the flight, or proceeding without the necessary publications until just prior to departure. The
captain chose the third option as it had the least impact on operations.
Shortly after takeoff, the captain realized the instrument approach charts had been forgotten
and chose not to return to Winnipeg (CYWG), as this would have resulted in further delay
and necessitated addressing dispatch and management about extending the duty day or
finding a replacement crew. This also would have had a negative impact on operations.
The crew had received some of the approach chart information via radio from another pilot.
However, without reference to the actual chart, the crew did not have a visual reminder of
altitude limits or approach diagrams to assist with orientation of the aircraft in time and
space. This made the crew more susceptible to error and loss of situational awareness, such
as the incorrect direction of the procedure turn and incorrect turn on the missed approach.
The lack of required flight documents, such as instrument approach charts, placed pressure
on the captain to find a work-around solution during flight planning, and negatively affected
the crew’s situational awareness during the approaches at CYSK.
If instrument approaches are conducted without reference to an approach chart, there is a
risk of weakened situational awareness and of error in following required procedures,
possibly resulting in the loss of obstacle clearance and an accident.
Aviation Investigation Report A12Q0216 | 77
Several unforeseen issues arose during the flight preparation, which likely had a negative
effect on the crew’s mental readiness for the flight. The aircraft did not have the required
survival kit and this had to be obtained at the Keewatin Air hangar and properly stowed.
The single redline limit minimum equipment list (SRL MEL) deferred maintenance issue was
due to expire at midnight local time that night (0600 UTC on 23 December 2012). There was
also the delay caused by the replacement of the cargo door handle position switch, which
necessitated a re-filing of the flight plan. The change to the cargo load resulted in a change of
fuel quantity and subsequent choice of alternate airport. All of these created additional work
for the crew in this Type C dispatch environment. As the delay for departure was extended,
the flight crew duty day was being stretched. Any additional extension to the duty day
would have had to be addressed with management.
Although delays and changes in scheduling and logistics are not uncommon in airline
operations, frustrations can arise if crews do not feel they have control over operational
matters, and if they feel that the company is not providing support. Increased levels of
frustration can decrease performance and increase risk-taking behaviour; behaviours that
would not normally be present under other circumstances.
As described in the company operations manual (COM), dispatch does not provide the same
assistance to Subpart 703 or 704 flight crews. The type of services offered by dispatch to
Subpart 705 flight crews would reduce the workload of Subpart 703 and 704 crews during
pre-departure planning. These services likely would have reduced the occurrence crew’s
workload and stressors related to scheduling changes.
The captain felt frustrated as a result of the pre-flight preparation issues, and it is evident
from analysis of his speech that signs of frustration persisted after takeoff. The captain’s use
of 43 expletives in conversation with the first officer (FO) during the non emergency, non
stressful, 2-hour period preceding the occurrence, showed a rate of approximately
21.5 swear words per hour. This type of behaviour was seen as being out of character for the
captain. 122
The long day and circadian rhythm timing at the time of the occurrence may have had a
compound effect, adding to the level of fatigue resulting from acute sleep disruption. Based
on the captain’s 1.5-hour wake period and resultant shortened sleep duration the night
before the occurrence, acute sleep disruption may have played a role in the captain’s
behaviour during the flight by increasing the risk for fatigue and its associated performance
decrements. The FO did not experience the same sleep disruption; therefore, fatigue was not
considered as high a risk factor.
The weather was worse than anticipated and created difficulties in visually acquiring the
runway environment and aligning the aircraft to land. The excursions in controlling altitude
and airspeed were likely due to an increased stress level, and added to the sense that the
122
T. Jay, 2009, “The utility and ubiquity of taboo words,” Perspectives on Psychological Science, 4(2),
pp. 153-161.
78 | Transportation Safety Board of Canada
situation was deteriorating. Additionally, the weather at the alternate airport was reported to
be worse than at CYSK. All these factors would have increased the level of stress and
workload as the crew attempted to solve their predicament.
Increased stress levels can adversely impact a pilot’s ability to perceive and evaluate cues
from the environment, and may result in attentional narrowing. This may result in pilots
paying attention only to certain cues while excluding others, which in turn leads to a loss of
situational awareness. Under extremely stressful conditions, this can lead to an unintentional
shift away from well-learned, highly practised, essentially automatic actions. The crew was
very focused on landing the aircraft at CYSK, and an increase in workload and stress during
the instrument approaches resulted in attentional narrowing and a shift away from welllearned, highly practised procedures.
2.4
Crew resource management
2.4.1
Crew resource management training standards
Transport Canada (TC) standards for crew resource management (CRM) training are based
on outdated concepts. This has been discussed in previous TSB investigation reports, most
recently the Boeing 737-210C controlled flight into terrain (CFIT) occurrence in Resolute Bay,
Nunavut (TSB Aviation Investigation Report A11H0002). Although TC is in the process of
developing a new training standard, one that will apply to Subpart 702, 703, 704, and 705
operations, the changes have yet to be promulgated.
As stated in the Safety Concern highlighted in TSB report A11H0002, until such time as the
new regulatory framework for CRM training is in place and its effectiveness is validated,
there remains a risk that flight crews may not routinely practise effective CRM.
If TC CRM training requirements do not reflect advances in CRM training, such as threat and
error management (TEM) and assertiveness training, there is an increased risk that crews
will not effectively employ CRM to assess conditions and make appropriate decisions in
critical situations.
2.4.2
Training received by the crew
The flight was operated under Subpart 704 of the Canadian Aviation Regulations (CARs); as
such, CRM training was not required. The company was required to provide CRM training
to its crews that operate aircraft under Subpart 705, and had elected to extend this training to
its Subpart 703 and Subpart 704 crews as well. The FO had received this training. The captain
had received CRM training while working for a different operator. Training provided by
Perimeter is in line with TC CRM training requirements for Subpart 705 operations.
2.4.3
Crew resource management during the approaches
2.4.3.1
Initial approach plan
As the crew discussed the fuel remaining and weather at the possible alternates, they
realized that they had enough fuel only for the flight-planned alternate, which was below
Aviation Investigation Report A12Q0216 | 79
approach minima at the time they were descending to commence the initial approach at
CYSK. Multiple approaches at CYSK was considered as a plan of action rather than diverting
to the alternate airport; however, the crew did not commit to a particular plan as they likely
expected to land at CYSK given that weather was above approach minima.
The captain briefed that the initial plan would be a straight-in visual approach to Runway 09
and, if the runway was not visible, that they would continue direct to the YSK nondirectional beacon (NDB) for an NDB approach to Runway 27.
The lack of an instrument approach to one of the two runways resulted in the crew not
having the option of landing into wind without conducting a circling manoeuvre. This,
combined with the unsuccessful attempt at circling, led the crew to accept a strong tailwind
approach and landing on Runway 27.
The approach briefing included the procedure turn altitude and distance, but did not include
whether the procedure turn would be executed north or south of the inbound track. The FO
queried the direction for the procedure turn; however, the discussion went on to the targeted
altitude, and no response was given. The global positioning system (GPS) was used to
determine distance from the NDB.
The missed approach was briefed as runway heading to minimum safe altitude (MSA). A
decision on what course of action to take afterwards was deferred. Missing from this briefing
was the final part of the published missed approach instruction, a right turn back to the
YSK NDB. Some of these errors were likely due to the lack of an instrument approach chart.
Furthermore, no decision had been reached regarding what the crew would do at the missed
approach point (MAP) for Runway 27, i.e., land or circle for Runway 09. The crew had
discussed the possible effects of landing on Runway 27 with a tailwind, but there was no
confirmation of any of the circling considerations. Circling was confirmed only once the
runway was visible.
The crew were expecting to acquire visual reference with the ground during the approach to
Runway 27 as the cloud ceiling and visibility were reported to be above minima for the
approach. This may also explain why the aforementioned items remained unresolved.
The cold temperature correction was considered and applied to the minimum descent
altitude (MDA) for NDB Runway 27 and the other procedure altitudes. Corrections were not
made to the circling MDA since it had not been obtained. Although not required by
regulations, if temperature corrections are not applied to all altitudes on the approach chart,
there is an increased risk of CFIT due to a reduction of obstacle clearance.
2.4.3.2
First approach to Runway 27
On arrival in the vicinity of the CYSK airport, the runway was not visible and the crew
commenced the NDB Runway 27 approach. The captain executed a teardrop turn to the
right, opposite to the published direction. However, since the crew used the 25 nautical
miles (nm) altitude, obstacle clearance was provided.
80 | Transportation Safety Board of Canada
As the aircraft approached the MDA on the inbound track, the crew saw the lights from the
town and, shortly after, the runway. The aircraft was not in a position to land on Runway 27,
so the captain initiated a circling procedure for Runway 09, and the FO concurred.
2.4.3.3
Circling procedure following first approach to Runway 27
The captain was the pilot flying (PF) and the FO was the pilot not flying (PNF). In a circling
procedure, the PF must maintain visual reference with the runway as well as the published
circling altitude to ensure obstacle clearance. The PNF monitors the instruments and advises
of any airspeed and altitude deviations. The crew did not have the approach chart and had
not received the circling minimum altitude of 620 feet; the captain chose to maintain 500 feet
above sea level (asl) while circling, although 600 feet asl had been briefed and set on the
altimeter.
Shortly after initiating the circling procedure, the captain lost visual reference with the
runway. A missed approach must be initiated when visual reference is lost; however, the
crew continued to circle in instrument meteorological conditions (IMC). At this point, it was
no longer a circling procedure, but rather a manoeuvre to position the aircraft to regain
visual contact with the runway. At one point during this manoeuvre, the aircraft was as low
as 155 feet agl. As the aircraft was returning towards the airport at an altitude of
approximately 400 feet asl, the captain saw the runway, but again the aircraft was not in a
position to land.
During the circling for Runway 09, signs of stress interfering with crew performance and
CRM were displayed. Communication calls were omitted or not responded to, flight
parameter corrections were not initiated or made at all, decision making was altered, and
deviations from regulations and procedures occurred. Missed opportunities to manage
threats and errors are a known reaction to stress. The accumulation of mismanaged threats
and errors affected the level of stress experienced by the crew, and likely resulted in the
required missed approach procedure not being executed when visual contact with the
runway was lost during the circling procedure to Runway 09. Not initiating a missed
approach at the point where visual reference to the runway was lost during the circling
increased the risk of CFIT.
2.4.3.4
Second circling procedure
The crew decided to initiate a circling procedure for Runway 27. During the initial stage of
this manoeuvre, there were excursions in altitude and airspeed:
•
Climb from 400 feet asl to 900 feet asl
•
Descent from 900 feet asl to 560 feet asl
•
Airspeed 140 knots indicated airspeed (KIAS) to 160 KIAS.
This is likely an indication of crew performance degradation, including scanning of
instruments, brought on by the stress of diminishing options and the difficulties aligning the
aircraft for a landing. There was no autopilot available on the aircraft; therefore, all flying
was done manually. This added to the crew workload in an already stressful environment.
Aviation Investigation Report A12Q0216 | 81
The captain lost sight of the runway again and initiated a missed approach in the vicinity of
the YSK NDB. If it becomes necessary to conduct a missed approach after starting visual
manoeuvres, the Instrument Procedures Manual 123 recommends a climb be initiated followed
by a turn back to the centre of the airport. The aircraft should then be established as closely
as possible on the missed approach procedure track for the approach flown (NDB
Runway 27). Although the published missed approach procedure for Runway 27 was not
followed, the crew flew a wide arcing left turn to the YSK NDB, climbing to the minimum
25 nm safe altitude. This was not fully in accordance with the recommended procedure;
however, obstacle clearance was assured.
Twice in quick succession the FO reminded the captain that the altitude was 1600 feet, but
the captain responded 1500 feet. The FO did not correct the error. This is another indication
of unresolved communications.
2.4.3.5
Second NDB Runway 27 approach
During the second approach, there were indications of the crew deviating even further from
learned procedural norms and regulations:
•
The procedure turn was flown at 1500 feet asl versus the briefed 1600 feet asl.
•
The descent was 197 feet below published MDA without the required visual
reference.
•
Despite being high in relation to the runway threshold when visual references were
established, the final descent was delayed.
•
Excessive airspeed (VREF + 30) and rate of descent (>1800 feet per minute) were used
once the decision to land was made.
•
The threshold crossing height was high (approximately 180 feet agl).
The captain had indicated this was to be the last approach before proceeding to the alternate.
The FO, however, was not convinced a diversion to the alternate airport was viable. Both
pilots were very focused on landing on this approach as they did not feel they had another
option. The captain chose to descend below MDA, likely in an attempt to be in a more
favourable position to land. The FO advised of the deviation, but did not voice concern when
a correction was not applied, indicating tacit acceptance of the captain’s action. Although the
FO, at times, exhibited better situational awareness than the captain, he was not assertive in
underlining important deviations from procedures and regulations.
The runway was sighted when the aircraft was approximately 0.7 nm from the threshold at a
height of 253 feet agl (400 feet indicated). The captain called for full flaps 1 second after
sighting the runway. The FO performed the remaining landing checklist items with no call or
response from the captain. This omission of the required responses is evidence of task
saturation and stress.
123
Transport Canada, Instrument Procedures Manual, TP 2076 (4th edition, November 1997),
Section 4.6.3(d).
82 | Transportation Safety Board of Canada
The captain flew beyond the MAP without visual reference to the runway although,
procedurally, a missed approach was warranted. This was likely a conscious decision based
on late sighting of the runway on the previous approach and lack of an alternate option. The
crew felt pressured to land on this approach.
The descent for landing was initiated late. Engine power was decreased to idle 10 seconds
after visual reference was acquired. It is not known why there was a delay between sighting
the runway and initiating the descent. It is possible that the captain was starting to see some
of the runway environment, but was not yet comfortable that there was sufficient visual
reference to initiate the descent.
As a consequence, the aircraft had less distance in which to descend and a steeper approach
angle was required to execute the landing within the confines of the runway. This resulted in
a high rate of descent (>1800 ft/min) and high airspeed (150 knots) as the captain tried to
reach the threshold of the runway. This attempt was exacerbated by the high ground speed
due to the high airspeed and the strong tailwind. The final descent was initiated beyond the
MAP and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the
desired 3-degree descent path.
During this landing attempt, the first ground proximity warning system (GPWS) PULL UP
warning was generated as the rate of descent exceeded 1800 ft/min. The aircraft approached
the threshold of the runway at a height of approximately 180 feet agl and an estimated
ground speed of 159 knots. The GPWS warning continued until the aircraft was
approximately 900 feet past the threshold at a height of approximately 60 feet agl. The
captain was focused on the landing despite the growing instability of the approach. The
captain no longer had the overall perspective of the extent to which the approach and chance
of landing safely had deteriorated.
The FO was monitoring airspeed and calling deviations, but did not express concern
regarding aircraft speed and height at the threshold. The FO had also lost perspective
regarding the aircraft’s state and the developing risks associated with the approach.
Both the captain and FO were concentrated on a very specific aspect of the approach, and
lost sight of the threat associated with the high sink rate and airspeed as the aircraft crossed
the threshold. This, and the lack of response to the GPWS warnings, are indications of
attentional narrowing.
Both pilots were focused on landing the aircraft to the exclusion of other indicators that
warranted alternative action.
2.5
Stable approach criteria
Company standard operating procedures (SOP) did not provide detailed criteria for
stabilized approaches or guidance for action to take in the event of an unstable approach.
The SOPs mention that the rate of descent should not be greater than 800 ft/min below
1000 feet agl.
Aviation Investigation Report A12Q0216 | 83
Section 1.17.8 of the SOPs describes criteria that characterize a stable approach. Approaching
the threshold of Runway 27 at approximately 180 feet agl, the aircraft was unstable in several
of these parameters:
•
Rate of descent: above 1800 ft/min
•
Speed: VREF + 25
•
Throttles: idle.
As a result, the aircraft passed the runway midpoint at a height of 20 to 50 feet agl and with a
ground speed of approximately 135 knots.
This instability on final approach contributed to the aircraft being half-way down the
runway with excessive speed and altitude.
The aircraft was not in a position to land and stop within the confines of the runway, and a
go-around was initiated.
2.6
Descent technique for non-precision approaches
The CYSK non-precision approach is designed such that a descent from the MAP at MDA
results in a steeper-than-optimum descent path. If visual references are not acquired until
close to the MAP, at MDA, crews may be tempted to intiate a steep, unstable descent to the
threshold in order to land. If the MAP on non-precision instrument approaches is located
beyond the 3-degree descent path, there is an increased risk that a landing attempt will result
in a steep, unstable descent, and possible approach-and-landing accident.
2.7
Rejected landing
2.7.1
General
At the time of the captain’s go-around call, the aircraft was considered to be in a low-energy
landing regime because of the following parameters:
•
The aircraft was below 50 feet over the runway.
•
Gear and flaps were in landing configuration.
•
Thrust was at idle and airspeed was decreasing.
The crew used the go-around procedure described in the SOPs. The company procedure
called for re-configuration of the aircraft (landing gear retracted, flaps ¼) prior to
establishing a positive rate of climb. The action of raising the flaps resulted in a reduction of
lift, a loss that would need to be compensated for by an increase in either speed or pitch
attitude. This reduction in lift occurred during the critical transition from a low-energy
landing regime to a stabilized climb. The TSB laboratory evaluated the effects of landing gear
retraction on aircraft performance and concluded that this had no detrimental effects upon
aircraft control and climb performance.
At the time of the go-around call (10 seconds prior to impact), the FO was busy setting power
and reconfiguring the aircraft as per procedure. These actions could preclude the monitoring
84 | Transportation Safety Board of Canada
of airspeed and vertical speed at a critical phase of flight. Any reduction of pitch during this
transition period reduces the ability of the aircraft to establish a positive rate of climb.
The manufacturer’s balked landing procedure requires confirmation of a positive rate of
climb prior to retracting the gear and setting the flaps. This ensures the aircraft is safely
climbing away from the ground before initiating any other actions.
After re-configuring the aircraft, the FO made a speed call (105 knots). The airspeed was
therefore below the target climb speed of 110 knots. The low speed call may have prompted
the captain to unintentionally release back pressure on the control column to accelerate to the
desired average target climb speed. This would be a normal reaction to a low speed call in a
climb attitude; however, it may not be appropriate given that the aircraft was attempting to
clear terrain. It is also possible that the captain’s visual scan was momentarily diverted from
the attitude indicator to the airspeed indicator at a time when pitch attitude was critical. A
slight release of the control column would likely have been sufficient to stop a positive rate
of climb. The aircraft struck terrain 4 seconds after the speed call.
The configuration change at a critical phase of flight, possibly combined with a slight pitch
reduction, may have contributed to the aircraft’s poor climb performance. A rate of climb
sufficient to ensure clearance from obstacles was not established, and the aircraft collided
with terrain.
2.8
Cabin safety
2.8.1
In-cabin seating
2.8.1.1
Passenger seating location
As with all Perimeter flights in the Metro III, there was no pre-arranged seating for this
flight, and passengers were free to choose their own seat. The Metro III affords little leg room
between seats, the aisle is narrow, and there are no overhead bins to store carry-on baggage.
Seat 1L is the seat that has the most leg room, and the main doorstair which folds into the
cabin is situated immediately in front of it. The mother holding the infant chose to sit in
seat 1L and had not been directed to sit elsewhere, although she was responsible for another.
Without a seatback in front of seat 1L, the mother would not have been able to adopt the
recommended bracing position had it been commanded. Additionally, the lack of a seat in
front of the mother meant there was limited energy-absorbing material in front of her and
her infant. Furthermore, the aircraft main doorstair was positioned directly in front of her
seat, creating a hazard for the infant.
The absence of an energy-absorbent seatback in front, combined with the presence of the
hard, sharp, metal stairs, ceiling and cockpit partitions, likely resulted in the lap-held infant
coming into contact with hard, non-deformable interior surfaces during the dynamics of the
impact sequence.
If a person holding an infant is seated in a row with no seatback in front of them, there is an
increased risk of injury to the infant as no recommended brace position is available.
Aviation Investigation Report A12Q0216 | 85
2.8.1.2
Emergency exit seating
Both Perimeter’s safety features card and TC define the main door of the aircraft as an
emergency exit. Company practice in regards to the seating of passengers assisting others
next to the main exit was inconsistent with this definition. Perimeter’s interpretation of the
definition of an emergency exit meant that, on occasion, occupants assisting another person
might have been sitting in seat 1L. Seating a passenger who is responsible for another in a
seat adjacent to an emergency exit could adversely affect the safety of passengers or crew
members during an emergency evacuation.
In this occurrence, egress took place via the forward right overwing exit. The main door
could not be opened due to damage incurred during the impact with the ground. The
presence of the infant’s mother next to the main door exit did not hinder the evacuation of
the other occupants.
If a person assisting another is seated next to an emergency exit, there is an increased risk
that the use of the exit will be hindered during an evacuation.
2.8.2
Passenger briefings
No individual passenger briefing was given to the mother of the infant before takeoff.
Company procedures and training regarding individual briefings and briefing content were
lacking. Amongst other items, the briefing should include how to hold the infant for takeoff
and landing. Although the mother of the infant had not been given an individual safety
briefing prior to this flight, she had travelled often with her other children, and held her
infant as described by the safety features card and as instructed in previously provided
briefings. The lack of an individual briefing for the occurrence flight did not directly affect
the safety of the infant.
2.8.3
Restraint systems
2.8.3.1
Carry-on baggage control programs
Much effort, time and money is put into air carrier carry-on baggage control programs,
which are required by TC. Carry-on baggage programs applicable to Subpart 705 operations
include ensuring that baggage remains under a certain weight and size, and that it is safely
stowed during all phases of flight. Similar requirements for restraining carry-on baggage
apply to Subpart 703 and 704 operations under CAR 602.86. Additionally, TC has
emphasized the importance of ensuring that passengers wear seatbelts at all times, and cabin
crew are directed to restrain all cabin equipment in case of sudden, unexpected in-flight
turbulence.
2.8.3.2
Restraint of young children
Research has shown that, due to anthropomorphic differences (i.e., body proportions
including height, weight, head size, and pelvic development) between adults and children,
the standard lap belt is not suited for the safe restraint of small children. A child may either
slip under the seatbelt to the floor, or sustain severe abdominal injuries in the event of in-
86 | Transportation Safety Board of Canada
flight turbulence or an emergency landing. Furthermore, given their smaller size, a young
child may be unable to assume the recommended brace position for adults. If young children
are not adequately restrained, there is a risk that injuries sustained will be more severe.
2.8.3.3
Infant restraint
Biomechanical research has found that, due to limitations in human clasping strength, it is
not always possible for adults to restrain children adequately in their laps by holding onto
them. Infants are therefore exposed to undue risks of injury when seated on an adult’s lap.
Much effort and many recommendations have been made, particularly by the National
Transportation Safety Board (NTSB), to mandate the use of age- and size-appropriate child
restraint systems (CRS) for children and infants. However, in most countries around the
world, including Canada, infants are not required to be restrained in an age- and sizeappropriate CRS at any time during a flight. Despite publishing safety information on inflight turbulence events and the risk of death or injury to passengers if objects are not
restrained, TC has not changed the regulations concerning the requirements for CRS for
infants.
In this occurrence, the infant passenger was not restrained in a CRS, nor was one required by
regulations. The infant was ejected from the mother’s arms during the impact sequence, and
contact with the interior surfaces of the aircraft contributed to the fatal injuries.
Infants are not required to be restrained at any time during a flight. If a lap-held infant is
ejected from its guardian’s arms, there is an increased risk the infant may be injured, or cause
injury or death to other occupants.
At present, TC does not anticipate making any changes to the regulations for the use of CRS
for infants or young children. For now, TC recommends the use of CRS on board aircraft, but
defers to the air carriers to educate the travelling public and promote their use. Therefore,
infants and young children do not benefit from an equivalent level of safety compared to
adult passengers.
2.8.4
Lack of data regarding infant and child passengers
The Transportation Information Regulations do not currently require operators to gather or
provide to the Minister of Transport information on the number or ages of children and
infants travelling by air. Infants are not included in the total passenger count when secured
in a lap-held position by a parent or guardian passenger. Data collected on the number of
passengers do not separately identify children under 12 years old and, therefore, this
information is not easy to extract from the total passenger count. As a result, it is difficult to
properly assess infant and child passenger exposure to air travel.
International Civil Aviation Organization (ICAO) and TC statistics show that passenger
travel is on the rise; however, the proportion of child or infant passengers is not available.
Information supplied by Perimeter and 3 other air carriers indicated that infants and children
make up nearly 14% of their total passenger loads.
Aviation Investigation Report A12Q0216 | 87
Risk assessment exercises and safety initiatives are data-driven. Without adequate data
collection, the exposure to risk for this population of individuals cannot be adequately
assessed. The number of children and infants travelling with these carriers could be higher
than for carriers servicing destinations in the southern part of the country, as air travel for
residents of northern communities is often the only means of travel. Nonetheless, an
equivalent level of safety should be provided for any traveller regardless of age.
Additionally, better data collection is needed on the age, size, use of restraints, and injury
patterns for infants and children, to better assess their risk exposure and to assist in the
development of effective restraint systems for these travellers. The TSB cannot analyse trends
without data.
If more complete data on the number of infants and children travelling by air are not
available, there is a risk that their exposure to injury or death in the event of turbulence or a
survivable accident will not be adequately assessed and mitigated.
2.9
Organizational issues
2.9.1
Company ground proximity warning system training
In the company operations manual (COM) and the airplane flight manual (AFM), sounding
of the GPWS warning requires immediate pull-up action. However, the SOPs do not provide
standard calls and responses or necessary actions to take in the event of a warning. If there is
not sufficient guidance in the SOPs, there is a risk that crews will not react and perform the
required actions in the event that GPWS warnings are generated.
2.9.2
Airplane flight manual procedure for balked landing versus standard operating
procedures for go-around
The company SOPs contain a single procedure for a 2-engine go-around, regardless of
energy state or stage of approach and landing. Although the SOP does not include
consideration for a balked landing from a low-energy landing regime, training with this SOP
was conducted during go-arounds from a low-energy state.
The procedure calls for raising the flaps at a critical transition from a landing attempt (close
to the ground) to a stabilized climb, and contributed to an insufficient climb gradient to
ensure obstacle clearance.
The AFM has a separate procedure for a balked landing to address this critical phase of
flight.
If SOPs, the AFM and training are not aligned with respect to low-energy go-arounds, there
is a risk that crews may perform inappropriate actions at a critical phase of flight.
2.9.3
Safety case
The company’s safety case process was developed as a proactive tool to identify and mitigate
risks. Identification of risk factors allows for better situational awareness and better planning
88 | Transportation Safety Board of Canada
prior to departure, and assists in the effective management of such risks. However, as
constructed, the process is an arduous one involving several company representatives, which
does not accommodate impromptu requests for charter flights. Operations to CYSK were
frequent enough that the company did not regard the request for the charter as a new
destination; therefore, a safety case was not conducted.
2.9.4
Extra fuel
The investigation determined that an additional 200 pounds of fuel had been loaded on the
aircraft as a safety buffer in case of unexpected delays. The practice of loading extra fuel was
known within the company. As was the case in the occurrence flight, this may mean that the
manufacturer’s approved maximum take-off weight for the aircraft is exceeded by this 200pound additional fuel load. The additional weight did not play a role on aircraft
performance during the approach, landing or go-around at CYSK. The fuel consumed during
the 3-hour flight resulted in the total weight being well below maximum gross weight. If
additional contingency fuel is not accounted for in the aircraft weight, there is a risk that the
aircraft may not be operated in accordance with its certificate of airworthiness or may not
meet the certified performance criteria.
2.10
Transport Canada oversight
Perimeter had not found it necessary to complete a safety case prior to the occurrence charter
because operations to CYSK are similar to the majority of airports the company services. TC
works closely with Perimeter to ensure the company remains compliant with regulatory
requirements. A steady flow of information and communication exists. Although TC was
aware that the company was operating charter or MEDEVAC flights to CYSK on a frequent
basis, it had not required that Perimeter complete a safety case to identify any risk factors
associated with operations there prior to the occurrence flight. The purpose of completing a
safety case is to evaluate feasibility of conducting a particular charter flight while
maintaining a certain level of safety. Although an administrative exercise, the safety case is
meant to identify risk factors associated with a destination, and mitigate any existing threats
to a reasonable extent. Threats may vary depending on the destination, weather, and time of
day; therefore, threats inherent to the type of operation may be foreseeable and manageable.
The safety case is part of the company safety management system (SMS), which is overseen
by TC.
The company had at times seated passengers with limited mobility or those assisting others
next to the main door exit as this seat offers the most room to assist and/or manoeuvre. The
company’s own SMS had not captured this non-compliant practice. If non-compliant
practices are not identified, reported, and dealt with by a company’s SMS, there is a risk that
they will not be addressed in a timely manner.
Process inspections (PI) conducted by TC at Perimeter prior to the occurrence did not
identify the non-compliant practice of seating passengers with limited mobility or those
assisting others next to an emergency exit. The likely reason for TC not identifying this
hazard is that, at the time the PIs were conducted, the seating of passengers with limited
mobility or those assisting others next to emergency exits was not witnessed. PIs are most
Aviation Investigation Report A12Q0216 | 89
often related to administrative requirements and proper documentation outlined in the
company SMS. If TC’s oversight is dependent on the effectiveness of a company’s SMS
reporting of safety issues, there is a risk that important safety issues will be missed.
Program validation inspections (PVI) and process inspections (PI) are conducted to identify
any non-conformity to regulatory requirements; however, they are also meant to identify any
hazards that could affect the safety of a flight or that could cause injury or death. The postoccurrence PI did not produce any findings or conclusions regarding the seating of the
mother and infant in the exit row, or make any recommendations regarding the safety issue
of the non-use of CRS for the infant.
90 | Transportation Safety Board of Canada
3.0
Findings
3.1
Findings as to causes and contributing factors
1.
The lack of required flight documents, such as instrument approach charts,
compromised thoroughness and placed pressure on the captain to find a workaround solution during flight planning. It also negatively affected the crew’s
situational awareness during the approaches at CYSK (Sanikiluaq).
2.
Weather conditions below published landing minima for the approach at the
alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL
(La Grande Rivière) eliminated any favourable diversion options. The possibility of a
successful landing at CYGW was considered unlikely and put pressure on the crew to
land at CYSK (Sanikiluaq).
3.
Frustration, fatigue, and an increase in workload and stress during the instrument
approaches resulted in crew attentional narrowing and a shift away from welllearned, highly practised procedures.
4.
Due to the lack of an instrument approach for the into-wind runway and the
unsuccessful attempts at circling, the crew chose the option of landing with a
tailwind, resulting in a steep, unstable approach.
5.
The final descent was initiated beyond the missed approach point and, combined
with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3degree descent path.
6.
Neither pilot heard the ground proximity warning system warnings; both were
focused on landing the aircraft to the exclusion of other indicators that warranted
alternative action.
7.
During the final approach, the aircraft was unstable in several parameters. This
instability contributed to the aircraft being half-way down the runway with excessive
speed and altitude.
8.
The aircraft was not in a position to land and stop within the confines of the runway,
and a go-around was initiated from a low-energy landing regime.
9.
The captain possibly eased off on the control column in the climb due to the low
airspeed. This, in combination with the configuration change at a critical phase of
flight, as called for in the company procedures, may have contributed to the aircraft’s
poor climb performance.
10.
A rate of climb sufficient to ensure clearance from obstacles was not established, and
the aircraft collided with terrain.
Aviation Investigation Report A12Q0216 | 91
11.
3.2
The infant passenger was not restrained in a child restraint system, nor was one
required by regulations. The infant was ejected from the mother’s arms during the
impact sequence, and contact with the interior surfaces of the aircraft contributed to
the fatal injuries.
Findings as to risk
1.
If instrument approaches are conducted without reference to an approach chart, there
is a risk of weakened situational awareness and of error in following required
procedures, possibly resulting in the loss of obstacle clearance and an accident.
2.
If additional contingency fuel is not accounted for in the aircraft weight, there is a risk
that the aircraft may not be operated in accordance with its certificate of
airworthiness or may not meet the certified performance criteria.
3.
If Transport Canada crew resource management (CRM) training requirements do not
reflect advances in CRM training, such as threat and error management and
assertiveness training, there is an increased risk that crews will not effectively employ
CRM to assess conditions and make appropriate decisions in critical situations.
4.
If a person assisting another is seated next to an emergency exit, there is an increased
risk that the use of the exit will be hindered during an evacuation.
5.
If a person holding an infant is seated in a row with no seatback in front of them,
there is an increased risk of injury to the infant as no recommended brace position is
available.
6.
If young children are not adequately restrained, there is a risk that injuries sustained
will be more severe.
7.
If a lap-held infant is ejected from its guardian’s arms, there is an increased risk the
infant may be injured, or cause injury or death to other occupants.
8.
If more complete data on the number of infants and children travelling by air are not
available, there is a risk that their exposure to injury or death in the event of
turbulence or a survivable accident will not be adequately assessed and mitigated.
9.
If temperature corrections are not applied to all altitudes on the approach chart, there
is an increased risk of controlled flight into terrain due to a reduction of obstacle
clearance.
10.
If the missed approach point on non-precision instrument approaches is located
beyond the 3-degree descent path, there is an increased risk that a landing attempt
will result in a steep, unstable descent, and possible approach-and-landing accident.
11.
If there is not sufficient guidance in the standard operating procedures, there is a risk
that crews will not react and perform the required actions in the event that ground
proximity warning system warnings are generated.
92 | Transportation Safety Board of Canada
12.
If standard operating procedures, the Airplane Flight Manual and training are not
aligned with respect to low-energy go-arounds, there is a risk that crews may
perform inappropriate actions at a critical phase of flight.
13.
If non-compliant practices are not identified, reported, and dealt with by a company’s
safety management system, there is a risk that they will not be addressed in a timely
manner.
14.
If Transport Canada’s oversight is dependent on the effectiveness of a company’s
safety management system’s reporting of safety issues, there is a risk that important
issues will be missed.
3.3
1.
Other findings
The quick response of the people on the ground reduced the exposure of passengers
and crew to the elements.
Aviation Investigation Report A12Q0216 | 93
4.0
Safety action
4.1
Safety action taken
4.1.1
Perimeter Aviation LP
4.1.1.1
Operational planning issues
Various dispatch/operations functions are now centralized in a systems operations control
centre (SOCC) at the Winnipeg (CYWG) main base. The Flight Dispatch Centre, Winnipeg
YWG Ops, Thompson YTH Ops, MEDEVAC Dispatch, and Charter Coordination are under
one roof, communicating and sharing information with each other. Specific procedures have
been developed for communicating (over the radio) to the various operational units.
Although the 703/704 and 705 program are authorized in the company operations manual
(COM) as separate operational control functions, operations conducted under Subpart 703
and 704 benefit from all the advantages of the Type B dispatcher flow since the creation of
the SOCC.
4.1.1.2
Resource management
To address concerns with resource management, Perimeter enhanced the procedure whereby
flight crews access the Canada Air Pilot (CAP) instrument approach charts by increasing the
subscription numbers and locations (Canada and United States) to the CAP, and by making
them accessible in the SOCC, 24 hours a day, 7 days a week. An electronic version of the
charts is now available to flight crews on the company intranet site.
Route/charter packages have been developed and populated on the company intranet site to
further enhance communication and resources available to the flight crews when conducting
charter flights. The charters checklist has been improved to enhance communication on what
is required for any given trip and where to retrieve the required items.
4.1.1.3
Passenger briefings
In March 2013, Perimeter changed its passenger briefings procedure in order to ensure
uniformity in the briefing delivered. Passenger briefing Q-cards were produced and placed
in each aircraft. The first officer now reads the briefing verbatim from this card to ensure that
all items are covered. A first review of the new briefing was completed in June 2013.
Auditing of this new briefing content and conduct was executed through the company safety
management system (SMS). Employee feedback has been positive. Passenger briefings are
now part of the annual pilot proficiency check.
4.1.1.4
Stabilized approach
In December 2013, Perimeter added a Stabilized Approach section to the Metro II and
Metro III standard operating procedures. This section defines the conditions for a stabilized
approach for a visual flight rules arrival and an instrument flight rules arrival. Stabilized
approach criteria are detailed. Any deviation from a stabilized approach profile must result
in a missed approach.
94 | Transportation Safety Board of Canada
4.1.1.5
Stabilized constant descent angle approaches
In December 2013, Metro II and Metro III SOPs were modified to include a section defining
stabilized constant descent angle non-precision approaches criteria and its use in flight
operations.
4.1.1.6
Ground proximity warning system training
In August 2013, Perimeter introduced a more detailed version of the ground proximity
warning system (GPWS) training in order to highlight the operating features and parameters
of the system. This will increase flight crews’ understanding of the various warnings
provided, and the necessary actions to be taken when these warnings are activated.
In December 2013, SOPs applicable to the Metro II and Metro III were modified to include
each of the GPWS warnings, and associated mandatory action. The training department has
put emphasis on the importance of the stabilized go-around procedure and its sequential
steps.
4.1.1.7
Standard calls for go-around (crew coordination)
In December 2013, the SOPs were revised to emphasize the roles of the pilot flying and pilot
not flying (crew coordination) and standardized phraseology to be used during the goaround procedure for a missed approach, balked landing or when encountering windshear.
The go-around procedure was changed so as to wait for a positive rate of climb and prior to
retracting gear and raising flaps to the ½ position. Better definition of flight parameters was
provided to help crews with the go-around decision-making process and improve the
execution of go-around procedures.
4.1.1.8
Charter packages
Since the accident, Perimeter has produced charter packages for charter flights. These are
similar to those prepared for scheduled routes.
4.1.1.9
Crew resource management training
In 2013, Perimeter used reports from its own SMS for the first time to build more realistic
examples of crew interactions, and also used crew input. Feedback on this crew resource
management training approach was positive.
Aviation Investigation Report A12Q0216 | 95
4.2
Safety action required
4.2.1
Reporting of number of infant and child passengers travelling by air
According to the International Civil Aviation Organization, in 2013, the number of
passengers carried rose to 3.1 billion, which is 4.5% higher than for 2012. 124 In terms of
domestic scheduled air services, all regions experienced an increase in traffic, and markets
overall grew by 5.1% in 2013. North America is still the world’s largest domestic market with
45% of the world domestic scheduled traffic. There are no statistics on the number of infants
and children travelling.
Transport Canada statistics show that passenger traffic at Canadian airports increased 2.9%
in 2013, to reach 85.2 million enplaned and deplaned passengers. Domestic, Canada–U.S.,
and other international traffic increased year-over-year by 2.8%, 4.4%, and 1.6%,
respectively. 125 The number of infants and child passengers travelling by air is not available.
Currently, under the Transportation Information Regulations, Canadian air carriers must
provide a wide range of information on their overall operations to the Minister of Transport.
However, information on the number of infant and child passengers travelling is not
required to be reported. Historical information supplied by Perimeter and 3 other air carriers
in the course of this investigation indicated that infants 0 to 2 years old and children 2 to
12 years old made up nearly 14% of their total passenger loads.
Data relevant to the number of infants may be available but not stored for easy retrieval, and
the number of children (under 12 years old) travelling is contained within the number of
passengers. As a result, the exact number of infants and young children travelling on board
an aircraft, and whether or not infants are carried on a guardian’s lap or in a separate seat, is
not available and makes it difficult to properly assess infant and child passenger exposure to
air travel.
Until better data collection is required, the industry will be unable to conduct research,
assess risks, and outline emerging trends related to the carriage of infants and children. If
more complete data on the number of infants and children travelling are not available, there
is a risk that their exposure to injury or death in the event of in-flight turbulence or a
survivable accident will not be adequately assessed and mitigated.
124
International Civil Aviation Organization (ICAO), Annual Report of the ICAO Council: 2013.
Available at: http://www.icao.int/annual-report-2013/Pages/default.aspx (last accessed
18 June 2015).
125
Transport Canada, Transportation in Canada 2013, TP 14816. Available at:
https://www.tc.gc.ca/media/documents/policy/Transportation_in_Canada_2013_eng_ACCESS
.pdf(last accessed 18 June 2015).
96 | Transportation Safety Board of Canada
Therefore, the Board recommends that:
The Department of Transport require commercial air carriers to collect and
report, on a routine basis, the number of infants (under 2 years old), including
lap-held, and young children (2 to 12 years old) travelling.
TSB Recommendation A15-01
4.2.2
Required use of child restraint systems
Although there is a lack of data readily available on the number of infants and child
passengers travelling, data retrieved from a sample of 4 Canadian operators in the course of
this investigation show that children and infants make up a significant portion (nearly 14%)
of their total passengers. These numbers reflect only a portion of the number of infants and
children travelling by air. There are currently 583 registered commercial fixed-wing
operators in Canada. TC statistics show that passenger traffic at Canadian airports increased
2.9% in 2013, to reach 85.2 million enplaned and deplaned passengers.
Biomechanical research has found that, due to limitations in human clasping strength, it is
not always possible for adults to restrain children adequately in their laps by holding onto
them. Infants are therefore exposed to undue risk of injury when seated on an adult’s lap. In
most countries around the world, including Canada, infants are not required to be restrained
in an age- and size-appropriate child restraint system (CRS) at any time during a flight.
Research has also shown that, given the specific physical features of young children, the
standard adult seatbelt does not provide a suitable method of restraint.
Most jurisdictions recommend that infants and young children travel restrained in an
approved CRS during a flight; however, its use is not mandatory. Although research has
been conducted over the last 25 years, and participation in the development of CRS
standards and training standards has taken place and is ongoing, there has been no progress
on the required use of appropriate CRS on commercial aircraft.
Although passengers are required to securely stow all carry-on baggage during takeoff and
landing because of the potential risk of injury to other passengers should an unexpected
hazardous event occur, passengers continue to be permitted to hold in their lap a child of a
size and weight equal to carry-on baggage. If children under 2 years old are not required to
be restrained for their own safety, the safety of other passengers also becomes an issue. 126
The National Transportation Safety Board of the United States has identified several
occurrences where crew, adult passengers, and children have sustained injury during
unexpected moderate-to-severe turbulence, and described how lap-held infants and children
would likely have survived the occurrences or suffered less severe injury had they been
126
National Transportation Safety Board (2010). Safety Recommendations A-10-121 through -123.
Aviation Investigation Report A12Q0216 | 97
properly restrained. 127 A number of aircraft accidents, including the occurrence under
investigation, have demonstrated the risk to infants and young children who are not
properly restrained. Given the overall safety performance of commercial aviation, passengers
may underestimate the risks associated with unexpected in-flight turbulence and emergency
situations.
TC has no further plans to educate the travelling public or promote the use of CRS at this
time. The Board is concerned that until such time as the use of age- and size-appropriate CRS
is required, parents and guardians will continue to travel with infants and children without
the safety benefits provided by CRS.
Infants and children who are not properly restrained are at risk of injury and possibly death,
and may cause injury or death to other passengers. Until new regulations on the use of CRS
are implemented, lap-held infants and young children are exposed to undue risk and are not
provided with an equivalent level of safety compared to adult passengers.
Therefore, the Board recommends that:
The Department of Transport work with industry to develop age- and sizeappropriate child restraint systems for infants and young children travelling
on commercial aircraft, and mandate their use to provide an equivalent level
of safety compared to adults.
TSB Recommendation A15-02
This report concludes the Transportation Safety Board’s investigation into this occurrence. The Board
authorized the release of this report on 10 June 2015. It was released on 29 June 2015.
Visit the Transportation Safety Board’s website (www.tsb.gc.ca) for information about the TSB and
its products and services. You will also find the Watchlist, which identifies the transportation safety
issues that pose the greatest risk to Canadians. In each case, the TSB has found that actions taken to
date are inadequate, and that industry and regulators need to take additional concrete measures to
eliminate the risks.
127
United Airlines Flight 232-Sioux City, IA 1989; US Air Flight 1016-Charlotte, NC 1994; Continental
Flight 267-Severe turbulence 1995; American Airlines Flight 903-Inflight upset 1997; Southwest
Airlines Flight 2809-Severe turbulence 2008; General Aviation occurrence, Butte, MT 2009.
98 | Transportation Safety Board of Canada
Appendices
Appendix A – Sanikiluaq, NU, NDB RWY 27 (GNSS)
Source: NAV CANADA, Canada Air Pilot
NOT FOR NAVIGATION
Aviation Investigation Report A12Q0216 | 99
Appendix B – Flight path
Source: Google Earth, with TSB annotations
100 | Transportation Safety Board of Canada
Appendix C – Sanikiluaq, NU (CYSK) aerodrome chart
Source: NAV CANADA, Canada Air Pilot
NOT FOR NAVIGATION
Aviation Investigation Report A12Q0216 | 101
Appendix D – Flight path profile
102 | Transportation Safety Board of Canada
Appendix E – Graphic area forecast (GFA)
Source: NAV CANADA / Environment Canada
Aviation Investigation Report A12Q0216 | 103
Appendix F – International policy and efforts regarding child restraint
systems and in-flight safety
International policies regarding the use of child restraint systems
Many jurisdictions (e.g., European Union, Australia, New Zealand) permit, or even require,
lap-held infants to be restrained with a supplementary or a belly loop belt, which attaches to
the adult’s seatbelt and goes around the infant’s abdomen. Canada and the United States do
not allow the supplementary loop belt because research has shown that infants so restrained
fare worse than unrestrained infants because of the adult’s forward movement during severe
impact and the concentrated forces of the supplementary loop belt on the infant’s abdominal
region. 128
A 2004 Australian study found that, although the infant anthropomorphic dummy attached
with a supplementary loop belt was restrained during dynamic testing, it underwent
significant forward excursion resulting in severe impact of the infant dummy’s head with the
forward seatback. In addition, the adult dummy folded over the infant dummy trapping and
crushing it in the process. 129 A comprehensive review 130 of the scientific literature on child
restraint systems (CRS) in aviation, specifically that addressing the protection from injuries
in survivable aviation occurrences for children under 2 years old, as well as accident reports,
concluded that in order to provide safety equivalent to that of adult passengers, infants
“should be seated in a suitable CRS on a seat of their own.” The report authors further
conclude that, “the transport of lap-held infants secured with or without a loop belt does not
provide any protection to the infant.”
Previous recommendations for child restraint systems
National Transportation Safety Board
The National Transportation Safety Board (NTSB) has issued several recommendations 131 on
the subject of the mandatory use of CRS for infant passengers, the appropriate use of safety
harnesses for children, and educating the public on the risks associated with not using a CRS
for children under the age of 2.
128
V. Gowdy and R. DeWeese, The performance of child restraint devices in transport airplane passenger
seats, Federal Aviation Administration (FAA) Office of Aviation Medicine, Report
No. DOT/FAA/AM-94/19. September 1994.
129
T. Gibson, K. Thai and M. Lumley, Child restraint in Australian commercial aircraft, Aviation safety
research grant report B2004/0241: February 2006.
130
European Aviation Safety Agency (EASA.2007.C.28), Study on Child Restraint Systems, TÜV
Rheinland Kraftfahrt GmbH, Team Aviation, November 2008. Available at:
http://easa.europa.eu/rulemaking/docs/research/Final%20Report%20EASA%202007.C.28.pdf
(last accessed 18 June 2015).
131
National Transportation Safety Board (NTSB) (2010). Safety Recommendations A-90-078, A-93106, A-93-107, A-93-108, A-93-109, A-10-122, and A-10-123.
104 | Transportation Safety Board of Canada
The NTSB’s Child and Youth Transportation Safety Initiative promotes child occupant safety
in all modes of transportation with a focus on educating parents and caregivers about ways
to keep children safe when travelling. The NTSB declared 2011 the Year of the Child and
initiated a study on children involved in general aviation (GA) accidents and incidents.
During 2011, the NTSB collected data on 19 GA accidents and incidents, which included
39 children who were 14 years old and younger. In total, 26 children sustained fatal injuries,
2 sustained serious injuries, 5 sustained minor injuries, and 6 sustained no injuries. All of the
children under 2 years old were restrained in a CRS and sustained no injuries in the
accidents. 132
The NTSB has also put forward the argument that, although passengers are required to
securely stow all carry-on baggage during takeoff and landing because of the potential risk
of injury to other passengers in the event of an unexpected hazardous event, passengers
continue to be permitted to hold a child of equal size and weight in their lap. When children
under the age of 2 are not required to be restrained for their own safety, the safety of other
passengers also becomes an issue. 133
Additionally, the NTSB has highlighted several occurrences where crew, passengers and
children have sustained injury during unexpected moderate-to-severe turbulence and
described how lap-held infants and children would have likely survived the occurrences or
suffered less severe injury had they been properly restrained. 134
The most recent sudden in-flight turbulence event happened on 17 February 2014, when a
Boeing 737-700 encountered sudden severe turbulence while on descent to land in Billings,
Montana. A flight attendant was critically injured. A lap-held infant flew out of its mother’s
arms to land in an empty seat 2 rows away; the infant was not injured. A total of 3 flight
attendants and 2 passengers were taken to hospital.
European Aviation Safety Agency
The European Aviation Safety Agency (EASA) conducted a study on CRS in 2007. 135 Phase II
of the study, involving the evaluation of available solutions for restraining infants and
children, states that the standard lap belt is not suited for a safe restraint of infants/children.
The iliac crest of infants/children is not yet fully developed and, therefore, there is a danger
132
K. Poland and N.M. Marshall, A Study of General Aviation Accidents Involving Children in 2011,
National Transportation Safety Board (NTSB), Washington, D.C., United States.
133
National Transportation Safety Board (NTSB) (2010). Safety Recommendations A-10-121 through 123.
134
United Airlines Flight 232-Sioux City, IA 1989; US Air Flight 1016-Charlotte, NC 1994; Continental
Flight 267-Severe turbulence 1995; American Airlines Flight 903-Inflight upset 1997; Southwest
Airlines Flight 2809-Severe turbulence 2008; General Aviation occurrence Butte, MT, 2009.
135
European Aviation Safety Agency (EASA.2007.C.28), Study on Child Restraint Systems, TÜV
Rheinland Kraftfahrt GmbH, Team Aviation, November 2008, pp. 49-51. Available at:
http://easa.europa.eu/rulemaking/docs/research/Final%20Report%20EASA%202007.C.28.pdf
(last accessed 18 June 2015).
Aviation Investigation Report A12Q0216 | 105
that the lap belt will slip into the infant/child abdominal region in an accident or turbulence,
resulting in severe internal injuries. In addition, tests revealed that in the dynamics of a
crash, the upper torso of an infant/child can hit against the femurs. The head can hit against
the seat in front or the structure of its own seat. The study concludes by stating that:
Child seats must be adapted to the infant /child development in order to
provide safe restraint. Child Restraint Device 136 requirements must include (in
part):
• Infants up to a weight of approx. 9 kg must be transported backwardfacing in a CRS.
• Forward-facing CRD must be equipped with restraint systems which are
appropriate for children, i. e. either with a belt restraint system or with an
impact shield. A belt restraint system which is appropriate for children
restrains the pelvis and the upper torso safely in an accident and is
adaptable to the infant’s / child’s size. In an impact shield system, the
infant’s / child’s pelvis and thorax (sternum) are supported by the impact
shield.
• The belt restraint system of forward-facing CRD must be equipped with
an additional crotch belt preventing the infant/child from slipping under
the lap belt.
Safety efforts pertaining to in-flight turbulence
Transport Canada
In-flight turbulence is the leading cause of injuries to passengers and flight attendants. There
have been several accidents and incidents over the years involving clear air turbulence that
highlight the importance of keeping loose objects restrained and safety belts fastened
throughout a flight. In January 2012, Transport Canada (TC) issued Advisory
Circular (AC) 605-004, Issue No. 1 – Use of Safety Belts, in order to emphasize the
importance of using the proper restraints during all phases of flight, as sudden, moderate-tosevere turbulence can be the cause of injuries to all on board. It also states that lap-held
infants remain subject to injury if not secured during periods of turbulence.
136
The European Aviation Safety Agency (EASA) study refers to CRS as a Child Restraint System
tested and approved for motor vehicles held in place with the vehicle restraints. Child Restraint
Device (CRD) is referred to as a CRS used in an aircraft and held in place with the provided
aircraft restraints.
106 | Transportation Safety Board of Canada
Federal Aviation Administration
In 1995, after several serious and unexpected events of turbulence, the Federal Aviation
Administration (FAA) issued a public advisory to airlines urging the use of seatbelts at all
times when passengers are seated. Most airlines now comply, but the requirement does not
apply to children younger than 2 years because they are not required to be restrained at any
time during the flight.
Following several occurrences involving fatalities and/or injuries during moderate-to-severe
turbulence in flight, the FAA issued an Advisory Circular 137 in 2006 addressing the subject of
Preventing Injuries Caused by Turbulence. The AC provided information and practices that
were known to be effective in preventing injuries caused by turbulence, which includes
prompt and clear communication between flight crew and flight attendants, and with
passengers on staying seated with seatbelts fastened. It also stressed the importance for flight
attendants to secure the cabin equipment so that loose objects will not be thrown about the
cabin. The AC also suggested that air carriers develop and implement practices to encourage
the use of an approved CRS to secure an infant or a small child that is appropriate for that
child’s size and weight; regulations on CRS, however, have not changed. The AC states:
Parents and guardians should be encouraged to have children under 2 occupy
an approved CRS any time the fasten seatbelt sign is illuminated. Flight
attendants are encouraged to verify that the CRS is secured properly in a
forward facing seat and that the child appears to be properly secured in the
CRS.
On 17 September 2010, the FAA issued Advisory Circular AC 120-87B – Use of Child
Restraint Systems (CRS) on Aircraft. The AC was intended to be a resource for the
development, implementation and revision of air carriers’ standard operating procedures
and training programs regarding the use of CRS. Although this AC provides considerable
information regarding CRS for children over the age of 2, it does not address children under
the age of 2. The AC indicates that children under the age of 2 may be held in an adult’s lap
during takeoff, landing or movement on the surface.
Efforts by the International Civil Aviation Organization
The International Civil Aviation Organization (ICAO) stated138 that, in 2013, the number of
passengers carried rose to 3.1 billion, which is 4.5% higher than for 2012.
137
Federal Aviation Administration (FAA), AC No. 120-88A, Preventing Injuries Caused by
Turbulence, 19 January 2006. Available at
https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.informa
tion/documentID/99831 (last accessed 18 June 2015)
138
International Civil Aviation Organization (ICAO), Annual Report of the ICAO Council: 2013.
Available at http://www.icao.int/annual-report-2013/Pages/default.aspx (last accessed
18 June 2015).
Aviation Investigation Report A12Q0216 | 107
In terms of domestic scheduled air services, all regions experienced an increase in traffic, and
markets overall grew by 5.1% in 2013. North America is still the world’s largest domestic
market with 45% of the world domestic scheduled traffic. There are no statistics on the
number of infants and children travelling.
Transport Canada (TC) statistics show that passenger traffic at Canadian airports increased
2.9% in 2013, to reach 85.2 million enplaned and deplaned passengers. Domestic, Canada–
U.S. and other international traffic increased year-over-year by 2.8%, 4.4%, and 1.6%,
respectively. 139 These statistics are in line with those reported by ICAO. The number of
infants and children passengers travelling by air is not available.
The issue of child safety restraints was recently raised by ICAO member states. ICAO was
asked to lead the states on how to best approach the issue. The issue of child safety restraints
is included in the 2014-2016 triennium work program for the assigned ICAO Cabin Safety
Group (ICSG). The group is composed of 28 participants from various member states,
representing various international groups, such as airlines, regulators (including TC), flight
attendant respresentatives, and aircraft manufacturers. The working group met in April 2014
to pursue work on the development of guidance on the safety of infants and the use of child
restraint systems. 140
The International Transport Workers’ Federation presented a working paper to ICAO for the
Assembly – 38th Session Technical Commission, addressing the child restraint issue. The
Executive Summary states:
One of the goals of aviation safety is that all reasonable steps be taken to
ensure safe air travel for the flying public and crew members. Cabin crew are
responsible for the safety, health and security of all occupants in the cabin of
commercial airplanes. While fairness dictates that all passengers be afforded
the same level of protection, in many countries the youngest and most
vulnerable may be allowed to travel on the lap of an adult for taxi, take-off,
landing, and during periods of turbulence, if they are under a certain age. In
order to ensure that these youngest passengers remain secured during critical
phases of flight and turbulence, the exception to international aviation
regulations that allows children to travel in the laps of adults must be
eliminated. 141
139
Transport Canada, Transportation in Canada 2013, TP 14816. Available at:
https://www.tc.gc.ca/media/documents/policy/Transportation_in_Canada_2013_eng_ACCESS
.pdf (last accessed 18 June 2015).
140
International Civil Aviation Organization (ICAO) working paper of the Assembly – 38th Session
Technical Commission, Agenda Item 31: Aviation Safety – Emerging Issues, Child Restraint. A38WP/287, TE/130, 12/9/13. Available at:
http://www.icao.int/Meetings/a38/Documents/WP/wp287_en.pdf (last accessed 18 June 2015).
141
International Civil Aviation Organization (ICAO) working paper of the Assembly – 38th Session
Technical Commission, Agenda Item 31: Aviation Safety – Emerging Issues, Child Restraint. A38WP/99, TE/31, 22/8/13.
108 | Transportation Safety Board of Canada
Appendix G – Perimeter Metro III go-around procedure
Source: Perimeter Aviation LP, Standard Operating Procedures (SOP) SA227 Metro III, Section 4 Flight
Training Procedures, p. 4–13
Aviation Investigation Report A12Q0216 | 109
Appendix H – Approach-and-Landing Accident Reduction Task Force
recommendations
Recommendations concerning company policies
•
Operators should specify well-defined 142 approach gates.
•
Operators should define the parameters of a stabilized approach in their company
flight operations manuals (FOM) and aircraft operating manuals (AOM).
•
The stabilized approach policy should at least cover the flight path, speed, power
setting, altitude and rate of descent, as well as configuration and flight crew landing
readiness.
•
All flights should be stabilized by 1000 feet agl [above ground level] in
IMC [instrument meteorological conditions] and by 500 feet agl in VMC [visual
meteorological conditions].
•
Operators should develop and support “no-fault” go-around and missed approach
policies.
•
FOMs or SOPs [standard operating procedures] should require a go-around if an
aircraft becomes unstable during approach.
•
Operators should implement SCDA [stabilized constant descent angle] procedures
for non-precision approaches.
•
Operators should develop and implement a policy on appropriate autopilot use in
conditions of reduced visibility, at night or in the presence of optical or physiological
illusions.
•
Operators should establish clear directives for TAWS [terrain awareness warning
system] alerts.
Recommendations concerning standard operating procedures
•
States should mandate, and operators should develop and implement, SOPs for
approach-and-landing operations.
•
States should mandate the use of SOPs for approach-and-landing operations.
•
Operators should develop SOPs for autopilot use during approaches and landings.
•
Operators should have a clear policy on the role of the pilot-in-command in complex
situations and train accordingly.
•
A risk assessment checklist should be used to identify approach and landing hazards.
Recommendations concerning training
•
142
Crews should be trained to identify operational risks associated with adverse
conditions, such as reduced visibility, visual illusions, contaminated runways and
cross-winds.
A point that an aircraft must overfly at a defined height before manoeuvring for final approach.
110 | Transportation Safety Board of Canada
•
The training should deal with non-precision approaches, especially those that involve
shallow approach paths or stepped descents.
•
Crews should be trained to take the time to implement corrective actions when the
cockpit situation becomes confusing, ambiguous or task saturated.
•
Operators should develop and implement a policy on appropriate autopilot use along
with navigation aids for the approaches being flown.
•
Crews should receive training on SCDA approach procedures.
•
Crews should be educated about approach design criteria and minimum obstacle
clearance requirements.
Recommendations concerning decision making
•
Operators should provide education and training that enhance decision making and
risk (error) management.
•
Operators should develop a decision-making model for use in time-critical situations
(where the time available for decision making is limited).
•
Operators should provide improved training on error management and risk
assessment as well as on mitigating the consequences of errors.
Recommendations concerning cockpit voice recorders and flight data recorders
•
Regulatory authorities should encourage the installation of FDRs [flight data
recorder] and CVRs [cockpit voice recorder] on aircraft for which they are currently
not required.
Recommendations concerning autopilot
•
The FSF [Flight Safety Foundation] Task Force recommended that the autopilot be
used, especially in conditions of reduced visibility, at night or in the presence of
optical or physiological illusions.
Recommendations concerning radio altimeter
•
Operators should state that the radio altimeter is to be used during approach
operations and specify procedures for its use.
•
Train crews to correct the radio altimeter bug to 200 feet agl on all approaches except
for CAT [Category] II and III.
•
Train crews to initiate an aggressive go-around if the alarm sounds without visual
contact being established with the runway.
•
Operators should activate automatic callouts or require callouts from their crews, at
2500, 1000 and 500 feet agl as well as at the minimums.
Recommendations concerning the stabilized constant descent angle approach technique
•
Implement use of SCDA procedure for non-precision approaches.
•
Crews should receive training on SCDA approach procedures.
•
Crews should be educated on approach design criteria and minimum obstacle
clearance requirements.
Aviation Investigation Report A12Q0216 | 111
Appendix I – List of acronyms and abbreviations
AC
AFM
agl
AIM
ALA
ALAR
AMO
AOC
AOM
APAPI
ARCAL
ARFF
asl
ATC
ATIS
ATPL
Advisory Circular
airplane flight manual
above ground level
Aeronautical Information Manual (Transport Canada publication)
approach-and-landing accident
approach-and-landing accident reduction (Flight Safety Foundation
ALAR Task Force)
approved maintenance organization
Air Operator’s Certificate
aircraft operating manual
abbreviated precision approach path indicator
aircraft radio control of aerodrome lighting
aircraft rescue and fire fighting
above sea level
air traffic control
automatic terminal information service
airline transport pilot licence
C
CAA
CAD
CAM
CAO
CAP
CAP GEN
CARAC
CARC
CARs
CARS
CASA
CASS
CFIT
CFS
COM
CPL
CRD
CRM
CRS
CVR
CYBR
CYDN
CYGL
CYGW
CYMO
CYPL
CYQK
CYSK
Celsius (degrees)
Civil Aviation Authority (United Kingdom)
Canadian Aviation Document
cockpit area microphone
Civil Aviation Order
Canada Air Pilot
Canada Air Pilot General Pages
Canadian Aviation Regulation Advisory Council
Civil Aviation Regulatory Committee (part of CARAC)
Canadian Aviation Regulations
community aerodrome radio station
Civil Aviation Safety Authority (Australia)
Commercial Air Service Standards
controlled flight into terrain
Canada Flight Supplement
company operations manual
commercial pilot licence
child restraint device
crew resource management
child restraint system
cockpit voice recorder
Brandon
Dauphin
La Grande Rivière
Kuujjuarapik
Moosonee
Pickle Lake
Kenora
Sanikiluaq
112 | Transportation Safety Board of Canada
CYWG
Winnipeg/James Armstrong Richardson International Airport
DA(H)
DH
decision altitude/height
decision height
EASA
EGT
EIC
European Aviation Safety Agency
exhaust gas temperature
Exchange Income Corporation
FAA
FDR
FIC
FO
FOM
FOQA
ft/min
FSF
FTM
Federal Aviation Administration (United States)
flight data recorder
flight information centre
first officer
flight operations manual
flight operational quality assurance
feet per minute
Flight Safety Foundation
flight training manual
g
GA
GFA
GNSS
GPS
GPWS
gravitational acceleration
general aviation
graphic area forecast
global navigation satellite system (approach)
global positioning system
ground proximity warning system
IAS
IATA
ICAO
ICSG
IFR
ILS
IMC
in. Hg
ISA
indicated airspeed
International Air Transport Association
International Civil Aviation Organization
ICAO Cabin Safety Group
instrument flight rules
instrument landing system
instrument meteorological conditions
inches of mercury
international standard atmosphere
kg
KIAS
kilogram
knots indicated airspeed
LOSA
LPV
Line Operations Safety Audit
localizer performance with vertical guidance
M
MAC
MANAIR
MAP
MCTOW
MDA
MDA (H)
MEDEVAC
Magnetic (degrees)
Manitoba Aviation Council
Manual of Standards and Procedures for Aviation Weather Forecasts
missed approach point
maximum certificated take-off weight
minimum descent altitude
minimum descent altitude/height
medical evacuation
Aviation Investigation Report A12Q0216 | 113
MEL
MEL/CDL
METAR
MHz
MSA
minimum equipment list
minimum equipment list/configuration deviation list
aviation routine weather report
megahertz
minimum safe altitude
NATA
NDB
NDB RWY 27 (GNSS)
nm
NOTAM
NPA
NTSB
Northern Air Transport Association
non-directional beacon
non-directional beacon Runway 27 global navigation satellite system
(approach)
nautical mile
Notice to Airmen
non-precision approach
National Transportation Safety Board (United States)
OFP
OpSpec/OPS Spec
operational flight plan
operations specification
PAG
PAPI
PDM
PE
Perimeter
PF
PI
PIC
PMA
PNF
PVI
Perimeter charter flight PAG 993
precision approach patch indicator
pilot decision making
pilot examiner
Perimeter Aviation LP
pilot flying
process inspection
pilot-in-command
pilot monitored approach
pilot not flying
program validation inspection
QAP
quality assurance program
RA/TA
RCMP
REM
RNAV
RSC
resolution advisory/traffic advisory
Royal Canadian Mounted Police
rapid eye movement (sleep)
area navigation (approach)
runway surface condition
SCDA
sm
SMS
SOCC
SOP
SPPA
SRL
STEADES
stabilized constant descent angle
statute mile
safety management system
Systems Operations Control Centre
standard operating procedures
Standard Project Planning Application
single redline limit
Safety Trend Evaluation, Analysis & Data Exchange System
(IATA system)
T
TAF
True (degrees)
aerodrome forecast
114 | Transportation Safety Board of Canada
TAWS
TC
TCAS
TCCA
TCU
TEM
TSB
TSO
terrain awareness and warning system
Transport Canada
traffic alert and collision avoidance system
Transport Canada Civil Aviation
towering cumulus (cloud)
threat and error management
Transportation Safety Board of Canada
Technical Standard Order (issued by the FAA)
U/S
UTC
unserviceable
Coordinated Universal Time (Central Standard Time plus 6 hours;
Eastern Standard Time plus 5 hours)
VASIS
VFR
VHF
VMC
VREF
VYSE
YSK
visual approach slope indicator system
visual flight rules
very high frequency
visual meteorological conditions
reference speed
one engine inoperative best rate-of-climb speed
3-letter identifier for the Sanikiluaq non-directional beacon
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