R E F L E X I O N S A I

R E F L E X I O N S A I
Transportation Safety Board
of Canada
Bureau de la sécurité des transports
du Canada
TRANSPORTATION SAFETY
REFLEXIONS
Issue 25 – February 2002
A
I
R
Engine Failure in SEIFR
The Eyes Did Not Have It
Wind, Terrain, and Turbulence
Contents
Engine Failure in SEIFR . . . . . . . . 1
The Eyes Did Not Have It . . . . . . 6
Seaplane Drownings Continue . . 8
Wind, Terrain, and Turbulence . 11
Another CFIT Accident . . . . . . . 13
The Workload Piled Up . . . . . . . 15
Runway Incursions
on the Rise. . . . . . . . . . . . . . . . . 18
Jammed Rudder . . . . . . . . . . . . . 21
SR111 Firefighting
Recommendations . . . . . . . . . . . 24
Statistics . . . . . . . . . . . . . . . . . . . 28
Summaries . . . . . . . . . . . . . . . . . 30
Investigations. . . . . . . . . . . . . . . 35
1
6
11
Engine Failure
in SEIFR
The Eyes
Did Not Have It
Wind, Terrain,
and Turbulence
Final Reports . . . . . . . . . . . . . . . 44
Acknowledgements
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REFLEXIONS is a safety
digest providing feedback to the transportation community on
safety lessons learned,
based on the circumstances of occurrences
and the results of TSB
investigations.
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The articles in this issue
of REFLEXIONS have been
compiled from official text
of TSB reports by Hugh
Whittington, under
contract.
Cover photograph:
Robert S. Grant
Également disponible
en français
ISSN # 1192-8832
Acting on TSB
recommendations,
Transport Canada
initiated several
changes affecting
single-pilot IFR
operations after
this accident
involving a
Pilatus PC-12.
Engine Failure in SEIFR
The TSB forwarded six recommendations to Transport Canada (TC) as a result of the 18 May 1998 forced
landing of a Pilatus PC-12 into a Newfoundland bog following an engine failure. The Pratt & Whitney
PT6A-67B engine failed because of interrupted oil flow to the first-stage planet gear assembly. The cause
of the oil flow interruption could not be determined. The pilot, a company observer, and one of the
eight passengers on board sustained serious injuries in the forced landing. — Report No. A98A0067
The PC-12, operating as Kelner
Airways Flight 151, was approaching its planned cruising altitude
of 22 000 feet (FL220) en route
from St. John’s, Newfoundland,
to Goose Bay, Labrador, when
the pilot noted an unusually
low indication on the engine
oil pressure gauge. Just before
levelling off at FL220, approximately 39 nm from St. John’s
Airport, the low oil pressure
warning light activated. The
pilot radioed company maintenance personnel about the
low oil pressure indications,
and he was advised to return
to St. John’s. The relaying of
messages between the pilot
and maintenance took about
six minutes. The aircraft was,
by then, 71 nm from St. John’s
and 40 nm from Gander Airport.
The pilot then requested and
received a clearance back to St.
John’s Airport from Gander
Area Control Centre (ACC).
Four minutes after starting the
turn back towards St. John’s, an
engine vibration developed. The
aircraft was 44 nm from Gander
and descending through FL200.
The pilot declared an emergency
with Gander ACC and was cleared
direct to St. John’s. The pilot was
initially able to decrease the vibration by reducing the power setting; however, about four minutes
later, the vibration became so
severe that the pilot had to shut
down the engine. The aircraft
REFLEXIONS
February 2002
1
The vibration became so severe
that the pilot had to shut down
the engine.
was about 49 nm from St. John’s
at an approximate altitude of
13 000 feet when the engine was
shut down. The pilot then told
Gander that there was a complete engine failure and asked
for vectors to the nearest suitable
airport. The nearest suitable airport, St. John’s, was beyond the
glide range of the aircraft at its
present altitude. When the pilot
advised Gander ACC of this, the
controller provided him with
vectors to Clarenville Airport,
the only other airport in the
area, which was 20 nm back,
approximately 47 nm southeast of Gander.
The pilot slide-slipped
the aircraft to see out
the side window.
Approximately 15 minutes after
the engine was shut down, the
aircraft broke out of cloud cover
over a wooded area at an estimated altitude of 400 or 500
feet above ground level. The
front windscreen was obscured
with engine oil on the outside
and condensation on the inside;
consequently, the pilot slideslipped the aircraft to see out
the side window. The airport
was not visible, and the pilot
elected to force-land in a bog.
2
REFLEXIONS
February 2002
Insufficient Oxygen
The TSB’s analysis of this occurrence concentrated on equipment
requirements for single-engine
instrument flight (SEIFR) in
commercial passenger-carrying
operations and on pilot decisionmaking.
The PC-12 meets the requirement in the Canadian Aviation
Regulations for pressurized aircraft to carry a 10-minute supply
of oxygen for passengers and
crew, or an amount sufficient
to allow an emergency descent
to 13 000 feet, whichever is
greater. The SEIFR rule does not
stipulate any additional oxygen
equipment requirements.
The PC-12 pilot’s operating
handbook (POH) states that
the oxygen system “will supply
two crew and nine passengers
for a minimum of 10 minutes
in which time a descent from
30,000 feet to 10,000 feet is
performed.” A rapid descent is
the best course of action for air
contamination or depressurization while under power. However,
if the aircraft loses pressurization due to an engine failure, a
rapid descent would compromise
the aircraft’s glide profile and
lessen the chances of reaching
a suitable aerodrome.
Maintaining the aircraft’s optimal
glide profile is a fundamental
aspect of coping with a total
power loss. But, in a high-altitude
engine failure scenario, the need
to maintain optimal glide speed
is at odds with the requirement
to descend rapidly to below
13 000 feet. The POH states that
at the aircraft’s optimum engineout configuration, it would take
16 minutes to descend to 13 000
The need to maintain optimal
glide speed is at odds with the
requirement to descend rapidly
to below 13 000 feet.
feet from 30 000 feet (the maximum altitude for dual-pilot
operations). In a descent from
30 000 feet, supplemental oxygen would have been depleted
six minutes before reaching
13 000 feet; from 25 000 feet
(the maximum altitude for singlepilot operations), it would take
about 11.5 minutes for the
descent. Therefore, the standard
oxygen supply carried is insufficient to allow engine-out letdown using the optimal glide
profile while maintaining
oxygen reserves.
The oxygen equipment and
supply regulation predates the
1993 implementation of the
SEIFR policy. Other regulatory
authorities have recognized the
need for a specific oxygen equipment rule for SEIFR operations.
Australia requires that pressurized SEIFR airplanes be equipped
with “sufficient additional oxygen for all occupants to allow
the descent from cruising level
following engine failure to be
made at the best range gliding
speed and in the best gliding
configuration, assuming the
maximum cabin leak rate, until
a cabin altitude of 13,000 feet
is reached.” European Joint
Aviation Requirements—Operations
(JAR–OPS) SEIFR draft regulations
propose the same oxygen rule.
Although oxygen supply was not
a factor in this occurrence, it has
been demonstrated that pressurized SEIFR aircraft operating
in Canada may have insufficient
oxygen reserves to allow for an
optimal engine-out descent from
maximum operating level.
Therefore, the Board
recommended that:
The Department of Transport
require that pressurized SEIFR
aircraft have sufficient supplemental oxygen to allow for an
optimal glide profile during an
engine-out let-down from the
aircraft’s maximum operating
level until a cabin altitude of
13,000 feet is attained.
A00-01
Electrical Power
Insufficient
The PC-12, with two generators,
meets the SEIFR requirement for
two independent power generating sources. The POH states
that the battery provides power
for engine starting and can also
provide power to essential electrical systems for 20 minutes in
the event of a dual generator or
engine failure if the electrical
load is less than 60 amps, or
30 minutes if the load is reduced
to below 50 amps.
At the PC-12’s optimal glide speed
and configuration, it would take
about 32 minutes to descend
to sea level from 30 00 feet, or
28 minutes from 25 000 feet.
The typical electrical load from
essential equipment on the PC-12
is about 50 amps and, according to Pilatus, a 70%-capacity
battery with a rated battery power
of 40 amp hours can supply this
load for 31 minutes. Powering
only the essential instruments
and lights, battery power might
be nearly or completely spent
before touchdown. It may also
be necessary to power other electrical systems, further reducing
battery life. An attempted engine
relight or the use of a landing
light at night would place a large
draw on the battery. Electric
windshield heat may also be
required in instrument meteorological conditions. With the
pilot windshield heat continuously on light mode, the estimated battery life is 24 minutes; on
heavy mode, the estimated life
is only 22.5 minutes, which is
below the optimal gliding time
from the maximum operating
altitude.
(i) one attempt at engine
restart;
(ii) descent from maximum
operating altitude to be
made at the best range
gliding speed and in the
best gliding configuration,
or for a minimum of one
hour, whichever is greater;
(iii) continued safe landing;
and
(iv) if appropriate, the extension of landing gear and
flaps.
Australian regulations and
the JAR-OPS draft regulations
require an electrical system that
provides for the following:
The PC-12 pilot thought the oil pressure indications were not valid and
did not land as soon as possible.
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February 2002
3
TC has since advised operators
of the PC-12 to install an engine
chip detector that functions in
all flight regimes.
Along these lines, the Board
recommended that:
The Department of Transport
require that SEIFR aircraft have
a sufficient emergency electrical
supply to power essential electrical
systems following engine failure
throughout the entirety of descent,
at optimal glide speed and configuration, from the aircraft’s
maximum operating level to
ground level.
A00-02
Engine Performance
Monitoring
The SEIFR equipment standard
requires a chip detector system
to warn the pilot of excessive
ferrous material in the engine
lubrication system. The chip
detector on the accident PC-12
was designed to be disabled in
flight and did not meet the
intent of the equipment standard. TC has since advised operators of the PC-12 to install an
engine chip detector that functions in all flight regimes.
Further, the engine chip detecting system, as it is currently
configured on the PC-12, does
not monitor the entire engine
lubrication system for ferrous
particles, and other aircraft types
using the PT-6 may be similarly
configured. Therefore, the Board
recommended that:
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February 2002
The Department of Transport
require that the magnetic chip
detecting system on PT-6–equipped
single-engine aircraft be modified
to provide a warning to the pilot
of excessive ferrous material in
the entire engine oil lubricating
system.
A00-03
requirements that are more
stringent than the Canadian rule.
New aircraft equipment technologies and changes to how
old equipment is fitted on SEIFR
aircraft could serve to lessen the
occurrence or consequence of
a SEIFR engine failure. Therefore,
the Board recommended that:
Before the implementation of
the Canadian SEIFR regulation,
TC staff produced a position
paper that proposed means of
managing the associated risk.
One of the proposals was for
an engine performance monitoring system capable of monitoring engine parameters and
comparing actual engine performance against the ideal. This
system would provide operators
with early indications of engine
damage and deterioration and
of the necessity to conduct an
early removal and overhaul of
the engine. The final SEIFR rule,
however, did not include a
requirement for such a system.
The Department of Transport
review the equipment standard
for SEIFR and include equipment
technologies that would serve to
further minimize the risks associated with SEIFR flight.
A00-05
Other regulating authorities
have recognized the value of
these systems and have included
the requirement. Therefore,
the Board recommended that:
The Department of Transport
require that SEIFR operators have
in place an automatic system or an
approved program that will monitor
and record those engine parameters
critical to engine performance
and condition.
A00-04
The 1993 Canadian SEIFR policy
was ground-breaking and has
led the way for other regulatory
agencies to introduce SEIFR.
However, it appears that the
subsequent rule-making activity
by these other aviation authorities
is resulting in SEIFR equipment
The pilot misdiagnosed
the oil pressure indication.
Pilot Decision Making
In this occurrence, the pilot
misdiagnosed the oil pressure
indication—he did not think
the indications were valid—and
therefore did not see the need
to “land as soon as possible.”
The pilot encountered and failed
to recognized an “error trap” (an
unsafe action taken as a result
of wrongful assumptions). The
TSB has previously issued a recommendation (A95-11) on cockpit resource management and
pilot decision-making (PDM)
training for all operators and
aircrew involved in commercial
aviation. Ineffective PDM in
small air carrier operations is
still a matter of concern to the
TSB. No specific decision-making
course is required for SEIFR
qualification, yet this training
is required to receive operating
qualifications in less complex
environments, such as for flights
in reduced visual flight rules
limits.
The accident pilot did not have
formal PDM training, company
standard operating procedures,
or PC-12 simulator training to
help him formulate his decision.
Without a systemic approach to
improving PDM, accidents resulting from ineffective decisions in
complex situations will continue
to affect commercial operations.
The Board believes that improved
formal PDM training is a necessity for all commercial pilots.
The Board also believes that
standard operating procedures
and an increased emphasis on
appropriate decision making
throughout pilot training and
during all of a pilot’s flyingrelated activities will serve to
reduce the occurrence of PDMrelated accidents. Therefore, the
Board recommended that:
In support of recommendation
A00-01, NPA 2000-313 would
add a new subsection (g) to
CASS 123.22(2) as follows:
“sufficient supplemental oxygen
for an optimal glide profile
during an engine out let-down
from 25,000 feet until a cabin
altitude of 13,000 feet.”
The Department of Transport
improve the quality of pilot
decision making in commercial
air operations through appropriate training standards for crew
members.
A00-06
Concerning recommendation
A00-03, TC reviewed the consistency of certification and
operational requirements of the
chip detector system for singleengine aircraft. The CASO
Technical Committee accepted
NPA 2000-312, which would
amend CASS 723.22(2)(d) to
require “a chip detector system
to warn the pilot of excessive
ferrous material in the entire
engine lubrication system in
all regimes of flight.” In effect,
this would require the installation of a second chip detector
on engines used in SEIFR
operation.
TC’s Responses
In response to the TSB’s recommendations, TC developed
notices of proposed amendments (NPAs) to the Canadian
Aviation Regulations (CARs) and
the Commercial Air Services
Standards (CASSs) and submitted
them to the December 2000 and
June 2001 Canadian Aviation
Regulation Advisory Council
(CARAC)’s Commercial Air
Services Operations (CASO)
Technical Committee.
Although the committee
accepted each NPA, the pertinent articles in the CARs and
the CASSs have not yet been
amended.
NPA 2000-316 supported recommendation A00-02 and would
add subsection (i) to CASS
723.22(2) as follows: “sufficient
emergency electrical supply to
power essential electrical systems,
auto pilot flight instruments and
navigation systems following
engine failure throughout the
entirety of a descent at optimal
glide speed and configuration
from the aeroplane’s operating
level to mean sea level.”
NPA 2000-314 supported recommendation A00-04 and would
add subsection (h) to CASS
723.22(2) as follows: “a program that will monitor engine
parameters critical to engine
performance and condition”.
For unknown reasons, however,
this NPA was subsequently
withdrawn.
In response to recommendation
A00-05, the CASO Technical
Committe accepted TC’s NPA
2000-315 at the December 2000
meeting. The amendment would
add subsection (h) to CASS
723.22(2) as follows: “an electronic means of rapidly determining and navigating to the
nearest airfield for an emergency
landing”.
Concerning recommendation
A00-06, TC Commercial and
Business Aviation introduced
two NPAs (2001-134 and 2001135) at the June 2001 CASO
Technical Committee meeting.
These NPAs to mandate singlepilot standard operating procedures were accepted, and TC
contends that this will improve
the PDM process for single-pilot
operations. Standard operating
procedures should improve the
PDM process; however, CAR
703.107 has not yet been
amended.
REFLEXION
If a pilot suspects a faulty
gauge, it is better to carry out
a diagnosis once the airplane
is safely back on the ground.
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February 2002
5
Despite good visibility and proper
procedures in the
circuit, these two
Cessnas collided,
fatally injuring the
four occupants.
The Eyes Did Not Have It
The pilots of a Cessna 150H and a Cessna 172M flying the circuit at Mascouche Airport, Quebec, on
07 December 1997 followed the correct procedures almost to the letter, but the aircraft collided while
on final approach 450 feet above ground level. The four occupants of the aircraft were fatally injured.
— Report No. A97Q0250
The Cessna 150 joined the lefthand circuit downwind for
Runway 29 at Mascouche after
a local pleasure flight. At the
same time, the Cessna 172, with
an instructor and a student pilot
on board, took off from Runway
29 for touch-and-goes on the
runway following left-hand
circuits.
Here is the sequence of events
as reconstructed from radar data
at Montréal control centre:
1420:51
The Cessna 150, arriving from the
Saint-Hubert area, made a long
detour northwards to
6
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February 2002
approach Mascouche Airport
on the upwind side of the circuit
as the Cessna 172 took off from
Runway 29.
1421:49
When the Cessna 150 joined
the left-hand for Runway 29, it
was preceded by another aircraft that would be first in the
landing sequence. At that time,
the Cessna 172 began its turn
for the crosswind leg.
1423:11
The Cessna 150 stretched its
downwind leg while the aircraft
ahead turned on the final leg
for a full-stop landing. The
The lack of evasive action
indicates that neither aircraft
had noticed the other.
Cessna 172 began the left-hand
downwind leg for Runway 29.
1424:38
The Cessna 150 was now
established on final about 5.8
nm from the runway while the
Cessna 172 was established on
the base leg.
1425:17
When the Cessna 172 turned
on the final leg, it was 4 nm
from the end of the runway.
The Cessna 150 was ahead but
at a lower altitude and at a
slower speed.
1426:00
The radar identified only one
target and then none.
Regulations Were Followed
The information gathered
indicates that the pilots established radio communications
on entering the circuit, on the
downwind leg, and on the final
leg, as prescribed in the regulations. Neither aircraft appears
to have reported its position on
the base leg and was not required
to do so. Just before the collision, a third aircraft tried to
communicate with the two aircraft on the final leg to advise
them of the dangerous situation
they were in, but it was already
too late.
The crew of each aircraft could
have seen the other aircraft at
several places in the circuit. There
was broken cloud at 2300 feet,
and the visibility was 25 statute
miles. The pilot of the 150 could
have seen the 172 at turning
on the base leg and after his
turn to final. The pilot of the
172 could have seen the 150
while the 172 was on the downwind leg and during its descent
on the base leg. Several factors,
such as the appearance of the
aircraft, the environment, a lack
of attention, or operation of
the radios, could explain the
collision, but no single factor
could be identified in the investigation. The lack of evasive
action indicates that neither
aircraft had noticed the other.
Since this occurrence, Transport
Canada has delivered several
presentations on the subject of
circuit procedures at uncontrolled
aerodromes, emphasizing the
importance of communication
to ensure aircraft separation
and emphasizing the use of
landing lights to increase the
probability of being seen.
REFLEXION
How is your outside scan while
in an uncontrolled circuit? In
a student/instructor environment, who is responsible for
maintaining a lookout: the
student, the instructor, or
both?
The two aircraft crashed by the
bridge crossing Highway 640
at the exit for Mascouche
Airport, 2000 feet from the
threshold. Several laceration
marks—caused by a propeller—
were noted on the top of the
Cessna 150’s cabin.
REFLEXIONS
February 2002
7
When the Beaver
crashed, it flipped
over on its back,
leaving only the
bottom of the
floats visible.
Seaplane Drownings
Continue
Two TSB safety studies released in 1993 and 1994 included 16 recommendations aimed at reducing
the overall number of seaplane accidents and increasing the survivability of such accidents. Despite
the actions taken in response to both sets of recommendations, the number of seaplane accidents that
terminated in the water has remained fairly constant, and the ratio of fatal seaplane accidents to total
seaplane accidents has increased. — Report No. A98P0215
One such accident occurred on
04 August 1998 when the float(s)
of a Harbour Air Ltd. de Havilland
DHC-2 Beaver dug into the water
on landing at Kincolith, British
Columbia. The aircraft overturned and came to rest inverted with only the bottom of the
floats visible. Several people who
had been waiting for the aircraft
rushed to it in small boats but
were unable to rescue the pilot
and the four passengers, who
drowned.
8
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February 2002
The accident occurred on the
pilot’s fourth approach to the
landing area after a 25-minute
flight from Prince Rupert.
Witnesses reported that the
water surface was rough when
the aircraft attempted to land.
Therefore, it is most likely that
the pilot made the first three
approaches to assess the wind
and water conditions and to
determine the best water surface on which to land.
It could not be determined why
the occupants did not escape
from the aircraft.
Challenging Conditions
Experienced floatplane pilots
find that the wind and water
conditions in Kincolith are
generally challenging to land
in because of the water and
the topography surrounding
Nass Bay. Several times in the
month before the accident, pilots
had returned from Kincolith
because the landing conditions
were unfavourable. In the past,
the occurrence pilot, who had
1250 hours in the Beaver, had
also returned from unsuitable
water landing areas.
Harbour Air asserts that it emphasizes to its less experienced
pilots that if they are uncomfortable with the conditions,
another company pilot can be
called to complete the trip without prejudice to the pilots that
decline to fly. The occurrence
pilot lacked experience in outlying areas, and the company
had routinely scheduled him
to fly to less difficult water landing sites. In this instance, the
pilot assessed the conditions
as within his ability and declined
an offer to have another pilot
make the flight. However, he
indicated that he would assess
the conditions in Kincolith and
return to Prince Rupert if he
judged them unsuitable for
landing. The company maintains that he would still have
been paid had he decided to
let another pilot conduct this
flight.
In concert with the reported
wind and water conditions,
the brief accident sequence
observed is consistent with
two possible scenarios or a
combination of the two:
a) On initial touchdown in a
left-crosswind condition,
The doors were functional and operated without difficulty, yet the
pilot and the four passengers were unable to escape the aircraft
and drowned.
the left float struck a swell
or wave that forced the aircraft into an attitude that
the pilot was not able to
control before the float(s)
or wing dug into the water
and caused the aircraft to
overturn.
b) At or shortly after touchdown, the aircraft was upset
by a wind gust that the pilot
was not able to control
before the float(s) dug
into the water and caused
the aircraft to overturn.
A Survivable Accident
Rescuers found the five occupants
unrestrained in the inverted
cabin. Their injuries and the
damage to the aircraft are consistent with those of survivable
accidents. This aircraft was fitted
with three-point lap belt and
shoulder strap personnel restraints
for the two front seats and with
conventional two-point lap belts
for all cabin seats. The personnel
restraint for the right front-seat
passenger was found still fastened;
she may have slipped out of it
as the aircraft overturned. The
pilot personnel restraint and the
other three passengers’ seat belts
were found undone and serviceable. No conclusion about the
use of the restraint systems on
this flight can be made. The passengers were all frequent flyers
of floatplanes in the Prince Rupert
area and would have been familiar with general seat belt safety
and operation. In addition, it
was Harbour Air’s policy to
conduct a passenger safety
briefing, including seat belt
fastening and adjustment,
before all flights.
REFLEXIONS
February 2002
9
The normally easy action
of locating and operating
the door handles would have
been a most challenging task.
It could not be determined why
the occupants did not escape
from the aircraft. The doors were
found functional and without
defect. The interior and exterior handles on both cabin doors
were found to turn freely, and
the latching mechanisms functioned correctly. However, when
the aircraft overturned and rapidly
sank, it is probable that the
occupants became disoriented
in the dark and frigid water and
panicked. The confined and
inverted cabin would also have
made the normally easy action
of locating and operating the
door handles a most challenging task. After undoing their
seat belts, the passengers would
have lost reference to their relative locations, thus increasing
the challenge. Had the pilot been
“Dunk-tank” training is likely
the most effective means
of preparing pilots for
underwater egress.
10
REFLEXIONS
February 2002
trained in or exposed to underwater evacuation techniques, he
might have escaped and helped
others to escape. No existing
Canadian regulations require
floatplane operators to provide
underwater escape training for
pilots and cabin attendants. In
the past, on a voluntary basis,
Harbour Air had provided such
training to some of its floatplane pilots.
Physical impediments associated
with escaping from a submerged
seaplane are often surmountable,
despite shock and injury.
Occupant restraint systems are
required in aircraft. These systems reduce the likelihood of
injury on impact, thus increasing
the chances of egress. Commercial
operators are required to provide
preflight safety briefings, including information on the location
and operation of exits, to passengers. Despite these defences
against occupants not escaping
from a submerged seaplane after
a crash, accident histories indicate that the risk of drowning
due to inadequate preparation
for escape is still high.
Given some unnecessary risk
associated with underwater
escape from crashed seaplanes
and the apparent lack of initiatives within the seaplane community to address the issue, the
TSB sent Aviation Safety Advisory
A000003-1 to Transport Canada
(TC) on 02 March 2000. The
advisory suggested that TC
consider reviewing the previous
safety recommendations contained in the TSB safety studies
in order to develop effective
measures that would enhance
the likelihood of escape from
cabins of submerged seaplanes.
The Board assessed TC’s response
to this advisory as satisfactory
in part. TC has undertaken many
initiatives on this issue, including
articles in Aviation Safety Letter,
pamphlets, training programs,
a video, workshops, and enforcement actions. However, much
of this material was available
before the accident, which was
the catalyst for the safety advisory. Also, TC has not addressed
the issue of the provision of
“dunk-tank” training for seaplane pilots. This training is
likely the most effective means
of preparing pilots for underwater egress.
Impact with trees
caused considerable damage to
the Falcon’s left
wing.
Wind, Terrain,
and Turbulence
En route from Gander, Newfoundland, to St. John’s on 30 December 1998, the crew of a Dassault Falcon 20
cargo flight operated by Knighthawk Air Express Limited was informed that the glideslope for the instrument
landing system (ILS) to Runway 16 and the wind speed indicator (anemometer) at the airport were unserviceable. The crew was given an estimated wind of 150 o magnetic at 10 knots, gusting to 25 knots.
Although the ceiling was reported below landing minima for the localizer approach, the crew decided
to attempt the approach after receiving a pilot report (PIREP) from an aircraft that had just landed on
Runway 16. The PIREP did not contain any comment on turbulence. — Report No. A98A0191
During the initial part of the
descent into St. John’s, only light
turbulence was encountered. At
about 3000 feet above sea level
(asl), the captain, who was the
pilot flying, reduced the descent
rate and speed. Around this time,
there was a marked increase in
turbulence, followed by a rapid
increase in airspeed and drift.
The crew were not overly concerned; they had encountered
similar conditions during flights
to St. John’s in the previous
week. The crew configured the
aircraft for landing and had
begun a correction toward the
localizer when the turbulence
became severe. Shortly thereafter,
the aircraft uncontrollably and
rapidly lost altitude.
The first officer believed that,
during the rapid descent, he
saw the ocean, followed quickly
by terrain. He also believed he
shouted “terrain” to the captain.
The captain, who had taken
windshear recovery in a Falcon
20 simulator, applied maximum
REFLEXIONS
February 2002
11
The more appropriate warning
is that which advises of
the potential for dangerous
downdrafts.
power and increased the pitch
attitude until the stall warning
was heard. At about this time,
the aircraft descended into trees
atop a 920-foot (about 280-m)
hill 5.5 nm from the threshold
of Runway 16. After clipping
several trees, the aircraft began
to climb. The crew discontinued
the approach and declared an
emergency. During vectors for
a second approach, the glideslope became serviceable, and an
uneventful ILS approach and
landing were carried out. The
accompanying photograph
shows the damage caused to
the aircraft’s left wing by the
trees.
Inadequate Warnings
Most information regarding
downdrafts is generally associated with thunderstorms or
mountainous regions. Flight
crews are provided with information, strategies, and/or training for managing their flights
safely when such conditions
may be encountered. However,
available awareness training or
information is limited for the
circumstances this crew faced;
no thunderstorms were present,
and the terrain is not generally
considered mountainous.
A cautionary note on the
approach charts warns pilots that
they may anticipate moderate-tosevere turbulence when approaching St. John’s Airport. This is the
only advisory of the presence
of potentially adverse conditions
at St. John’s Airport. However,
12
REFLEXIONS
February 2002
previous issues of the charts
advised pilots that dangerous
downdrafts could exist on the
approaches. The more appropriate warning is that which advises
of the potential for dangerous
downdrafts.
Pilots who approach St. John’s
Airport under visual flight rules
may not have reference to the
instrument approach procedure
charts. Because turbulence is not
mentioned in Canada Flight
Supplement, visual flight rules
pilots may be unaware of turbulence hazards around the
airport.
Avoidance is the fundamental
strategy for operating safely in
conditions where severe weather
exists. This strategy can only be
implemented if the crew has
the correct information for the
area in which the flight will be
conducted. In this instance, the
area forecast that the crew received
before departure from Gander
was not the correct forecast for
the St. John’s area and only forecasted light-to-nil turbulence.
FAF Altitude Could Be
Increased
Aircraft on the localizer approach
for Runway 16 at St. John’s may
descend from 2000 feet asl at
the initial approach fix to 1600
feet asl and must maintain that
altitude until over the final
approach fix (FAF).
Transport Canada’s (TC) Criteria
for the Development of Instrument
Procedures would allow for an
increase in the intermediate
approach altitude and FAF crossing altitude for Runway 16. The
FAF altitude could be increased
to as much as 1900 feet and still
meet the maximum gradient
for the approach. This altitude
increase would help to position
aircraft above downdrafts and
would help to limit the time that
aircraft would be exposed to the
hazards of lee-side phenomena
associated with precipitous terrain. It would also give the aircraft more terrain clearance in
the event of an inadvertent
encounter with a downdraft.
The TSB sent two aviation safety
advisories to TC. One advisory
identified that the obstacle clearance height at St. John’s did not
take into consideration the wind
conditions and the precipitous
terrain. The other advisory identified the inadequacy of pilot
information regarding the potential hazardous weather/wind
conditions. Both advisories suggested that these circumstances
could be present at other airports
in Canada.
TC and Nav Canada concurred
with the advisories. Nav Canada
indicated to TC that it will
implement procedures to ensure
that information regarding
potential hazardous weather/
wind conditions is available to
pilots. Nav Canada will also
examine the obstacle clearance
criteria at St. John’s and will
include information on turbulence, windshear, and downdrafts
in Canada Flight Supplement.
The flight crew in this occurrence
reported that the lowest indicated
altimeter reading observed was
1300 feet asl, and the lowest
observed altitude on radar was
1200 feet asl. Because the aircraft struck the trees at 920 feet
asl, this indicates a likely altimeter
error of at least 280 feet. Altimeter
errors as much as 2500 feet have
been recorded in downdrafts.
Both pilots
heard and saw
the altitude alert
but did not react.
Another CFIT Accident
A Beech King Air C90 on an air ambulance flight crashed in a controlled-flight-into-terrain (CFIT) accident
during an overshoot on the night of 19 February 1999. Although there were no serious injuries, the emergency
medical technician, who was not strapped into his seat, was propelled forward onto the centre console
between the pilots. The four-year-old patient, who was lying in a fore-and-aft position on a stretcher,
unsecured by the shoulder harnesses, was ejected from the stretcher and landed in the arms of the medical
technician. — Report No. A99W0031
The flight, operated by Slave Air
(1998) Ltd., was returning to
Slave Lake, Alberta, from Red
Earth, where it had picked up
the patient, the medical technician, a paramedic, and the
patient’s sister.
During the flight, the pilots discussed options for alternate airports should the weather at Slave
Lake deteriorate before their
return. The crew received a report
from the Edmonton flight service
station based on the automatic
weather observation system
(AWOS) at Slave Lake. Although
a low ceiling and low visibility
were being reported (500 feet
overcast, visibility 2.5 miles),
the crew did not alter their plans
for a visual flight rules (VFR)
approach. Neither did they brief
for the eventuality of a missed
approach. The crew believed the
AWOS report was faulty because
they could see the lights of Slave
Lake through the undercast. They
also thought that missed approach
briefings were required only for
instrument flight rules (IFR)
flight.
Descent Continued in IMC
The aircraft entered a layer of
haze and mist at about 2900
feet above sea level (1000 feet
above ground level) and lost sight
of the lights. The crew continued
the descent even though they
had lost sight of all outside visual
references and were now operating
REFLEXIONS
February 2002
13
They thought that missed
approach briefings were
required only for IFR flight.
in instrument meteorological
conditions (IMC), contrary to
regulatory requirements. During
this time, the first officer was
flying and attempting to gain
visual contact by looking crosscockpit; the captain was attempting to provide verbal guidance
for the approach.
During the manoeuvring, the
aircraft crossed the centreline
of Runway 10 (the landing
The medevac patient was not
strapped in by the shoulder
straps and was ejected from
the stretcher upon impact
with the ground.
14
REFLEXIONS
February 2002
runway), and the first officer,
assessing that he could not
safely land, passed control
of the aircraft to the captain.
The captain turned the aircraft
left over the lake and away from
the lights of the town. Thus, he
placed himself into an area that
would have few ground lights
or references, even in clear air.
Additionally, the captain initiated a climb back into IMC and
would, therefore, be flying with
reference only to instruments. By
entering cloud and not changing to instrument flight, the
crew lost situational awareness.
Once the overshoot was initiated,
the captain and the first officer
did not brief or question the
other’s actions or verbally communicate their functions and
tasks. Without a stated plan and
intra-cockpit communications,
flying the aircraft effectively
became a one-pilot operation.
This may be due, in part, to
pilots regularly working in a
mix of single- and two-crew
operational environments and
the pilots’ limited training in
crew coordination. (Crews are
placed into a two-crew cockpit
without the benefit of training
specific to their duties as captain
and co-pilot.) Without the benefit
of such training, crews are less
apt to work effectively as a team.
While the aircraft was in the left
turn, the radio altimeter, set to
415 feet, activated. Both pilots
heard the altitude alert and saw
the altitude light activate; however, neither pilot reacted. The
aircraft struck the snow-covered
lake while in descent.
Patient Stretcher
The stretcher was fitted in accordance with the supplemental
type certificate at the midcabin
area on the right side. The medical team reported that they normally used the shoulder straps
when transporting patients. On
this flight, they believed that
the patient was showing some
signs of anxiety and that the
patient would be more comfortable if the shoulder straps
were not secured.
After the accident, the Emergency
Health Services Branch of Alberta
Health reminded its air ambulance medical crews that all
stretcher straps, including the
shoulder straps, must be fastened
during transport. Medical crews
were also reminded to follow
appropriate cabin safety procedures to ensure their own safety.
At Slave Air (1998) Ltd., where
the King Air C90 has been
replaced by a King Air 100,
emphasis is being placed on
standard operating procedures
for VFR and IFR operations,
with ad hoc flight checks by
the chief pilot to monitor the
flight crew. The company now
requires VFR approach briefings
and has instituted group ground
recurrent training. Since the
occurrence, all the company
crews have attended cockpit
resource management training.
The Workload Piled Up
The crew of the Cougar Helicopters Inc. Super Puma helicopter were conducting an instrument landing
system (ILS) approach to Runway 29 at St. John’s, Newfoundland, after a flight from an oil rig.
— Report No. A97A0136
As the helicopter was about to
touch down, the crew realized
that the helicopter was lower
than normal and that the landing gear was still retracted. The
crew began to bring the helicopter
into a hover; however, as collective pitch was applied, the nose
of the helicopter contacted the
runway surface. Once the hover
was established, the landing
gear was lowered, and the helicopter landed without further
incident. Damage was confined
to two communications antennae
and the supporting fuselage
structure. There were no injuries
to the 2 crew members and the
11 passengers in the 01 July
1997 occurrence.
The helicopter had departed
from St. John’s for a flight to
an oil rig; however, the weather
there was too poor to allow for
landing and refuelling. The crew
had sufficient fuel under the
regulations to return to St. John’s,
but the available time and options
for the return flight were more
restrictive than if they had landed
at the rig and refuelled. Several
factors combined in this occurrence to create a situation where
the crew inadvertently did not
complete the pre-landing check
and then did not recognize the
landing gear warning when it
activated before the intended
landing.
A97A0136: Mode C Altitude vs. ILS Glidepath
C-GQCH 01 July 1997 approx. 2235 UTC
3000
Altitude asl (feet)
2500
2000
1500
1000
500
0
0
1
2
3
4
5
6
7
8
9
Distance to threshold (nm)
Actual flightpath
ILS glidepath
REFLEXIONS
February 2002
15
The available time and options
for the return flight were more
restrictive.
Pre-landing Check Delayed
The flight proceeded uneventfully
while returning to St. John’s. Air
traffic control clearance to the
airport and then for descent
were received while the aircraft
was still a substantial distance
from landing. As a result, the
pre-landing check was delayed
until the aircraft was closer to
landing. The crew were advised
of the weather conditions and
found that the ceiling and visibility were expected to be near
approach limits by the time they
arrived, which further restricted
their options.
The approach was flown by
the co-pilot, who operated and
closely monitored the automated
flight control system. The pilot
conducted the radio communications and monitored the
overall progress of the approach.
The crew were aware that other
higher-speed aircraft were following them on the approach.
They decided to maintain cruising
speed and delay slowing down
to normal approach speed. In
this now time-restricted context,
the crew received their overshoot
instructions, requiring them to
go around and set up for another
approach. They knew the weather
was slightly better at their alternate of Long Pond. The captain
decided that if the approach
was unsuccessful, he wanted to
proceed to Long Pond rather
than expend precious fuel and
time on an extended procedure
to re-attempt an approach that
had already been unsuccessful.
The approach controller did not
16
REFLEXIONS
February 2002
initially comprehend what the
captain was requesting, and it
took several radio transmissions
during the next 45 seconds and
2 miles to get things sorted out.
This conversation took place
while the crew were transitioning
to final approach, between 11
and 6 miles from touchdown.
The pre-landing check would
normally have been completed
at approximately this point during the approach. The discussion
regarding the missed approach
intentions likely provided enough
of a distraction that the crew
failed to complete the pre-landing
check that they had previously
delayed.
Shortly thereafter, just before
intercepting the ILS glidepath,
the crew were instructed to change
to the St. John’s tower radio frequency. The aircraft then intercepted the glidepath, and because
of the higher-than-ideal speed,
the aircraft went high on the
glidepath. This required the crew
to make several power adjustments to slow down and regain
the desired approach profile.
Despite having an automatic
flight control system, the workload for both crew members
would be high in this situation.
The successful completion of
the approach likely became a
primary focus for the crew.
Altimeter, Landing Gear
Warnings
The crew regained the glidepath
shortly before the decision height
of 549 feet on the barometric
altimeter. Just before reaching
decision height, the captain
acquired visual reference and
assumed manual control of the
aircraft to conduct the landing.
The crew were conducting the
Category I ILS approach to a
100-foot decision height in
accordance with the Transport
Canada operations specification.
With no radar altimeter refer-
ence heights on the instrument
approach procedure chart, the
radar altimeter altitude alert was
set to the published height above
touchdown of 100 feet. When
the aircraft reached decision
height, it was still 164 feet above
ground level. Therefore, the radar
altitude warnings activated sometime after decision height was
reached, while the captain was
in manual control and slowing
down and flaring for the
touchdown.
The landing gear warning system
will activate whenever the landing
gear is retracted, the radar altimeter senses that the aircraft is less
than 300 feet above ground level,
and the airspeed is 60 knots or
less. When the aircraft reached
decision height, it was below
300 feet but travelling faster
than 60 knots, so the landing
gear warning did not activate.
However, the warning system
did activate sometime while the
captain was slowing down and
flaring for the touchdown.
To carry out the landing, the
captain was flying by visual references, which required looking
ahead through the windshield
and not directly at the instrument
panel. With the prevailing low
visibility, this manoeuvre required
a high level of concentration.
The red warning lights for the
radar altimeter and the landing
gear are in the lower portion
of the instrument panel and
thus would both be at the lower
edge of the captain’s peripheral
vision during the landing. It is
possible that the captain was
concentrating on the visual
landing manoeuvre to the extent
that, when these warnings illuminated in his peripheral vision,
he either did not notice them
or interpreted them as the radar
altimeter warning, which would
be a normal event during the
landing sequence.
After the captain took control,
the co-pilot monitored the flight
instruments and called out altitudes and airspeeds for the captain
until a stable hover or touchdown
was achieved. The warning lights
for the radar altimeter and the
landing gear are also in the lower
portion of the instrument panel
on the co-pilot’s side. The landing
gear control panel, with the gear
position indicators, was well
out of the co-pilot’s field of view,
on the opposite side of the centre console, next to the pilot’s
left knee. The co-pilot did not
recognize the landing gear warning when it activated, and he
likely misinterpreted the visual
warnings.
the crew through their headsets.
At the approximate time that
the tones would have activated,
several verbal calls were being
made by the co-pilot, and likely
some verbal acknowledgements
were being made by the captain.
It is very likely that both warning
systems activated at or about the
same time and that the crew
interpreted them as the radar
altimeter warning.
The aural warnings for the radar
altimeter and the landing gear
are close in frequency and are
both non-pulsating, constant
frequency tones. It was discovered that these tones, should
they activate concurrently or in
overlapping succession, could
easily be misinterpreted as one
tone. These tones are heard by
Aircraft goes
high on
ILS glidepath
St. John’s
Airport
Runway 29
Company Procedures
Changed
Company procedures now state
that the pre-landing check is
completed at 10 miles from the
landing site. The company
believes that this check is much
earlier in the approach phase
and that, as a result, this policy
should ensure the completion
of the pre-landing check at a
time when other high-priority
tasks are not competing for the
pilots’ attention.
final. The check covers landing
gear, warning lights, coupler, radar,
engine instruments, bleed valves,
and destination. The non-flying
pilot carries out this check and
reports to the flying pilot that
the “final check is complete.”
At the time of the occurrence,
the Long Pond approach was
an interim procedure that had
been used during previous offshore activities. The approach
has since been approved, and
the company has conducted
liaison visits to the air traffic
control centre to review unique
requirements and alternate landing sites. The company was also
investigating optional modifications to the radar altitude and
landing gear warning systems
to make them more distinct.
REFLEXION
Always take the time to complete the check, even when
you don't have the time.
The company introduced a final
landing check that is silently carried out from memory on short
TESOX
Repère intermédiaire
intermediate
TESOX fix
ILS glidepath
Left turn
to intercept
ILS localizer
Descent to
2400 feet
Descent to
3000 feet
Cougar 33 inbound
4000 feet,
145 knots
Legend
Flightpath
Track over surface
A combination of factors caused the helicopter to go high on the glidepath, requiring the crew to slow down
and regain the desired approach profile.
REFLEXIONS
February 2002
17
Runway Incursions
on the Rise
TSB occurrence data show that the five-year average for runway incursions rose slightly from a decade low
of 23 in 1995 to 30 in 1999. However, industry information indicates that in 1997–1999 there was
a significant rise in operating irregularities that had the potential to increase the risk of a collision to
aircraft during take-off and landing. — Report No. A98H0004
Nav Canada and Transport
Canada (TC) have both recently
studied the rise in runway
incursions. In February 2001,
Nav Canada released its Runway
Incursion Study at Nav Canada
ATS Facilities Final Report and
outlined strategies for reducing
the number of runway incursions. Several of these strategies
have already been implemented.
TC established a safety review
group to examine the problem
and, in September 2000, released
its Final Report—Sub-Committee
on Runway Incursion (TP13795).
The Incursion Prevention Action
Team (IPAT) has harmonized
the recommendations from both
reports. The team comprises representatives from both organizations and meets quarterly to
work on implementing the
recommendations.
One such runway incursion
incident led to the risk of collision between a Nav Canada
Canadair Challenger (Navcan
200) and a TC airport maintenance vehicle (Staff 61) at Terrace
Airport, British Columbia, on
17 December 1998. The quick
reaction of the vehicle operator
in moving his vehicle to the
edge of the runway in the few
seconds available most likely
prevented an accident.
Accidents or Reportable Incidents Involving a Runway Incursion
(Aircraft in Canada or Canadian-registered)
45
1995
1996
1997
1998
1999
2000
2001
40
35
30
25
20
Total 139
15
10
5
0
1995
1996
Figures as of 11 January 2002.
18
9
19
22
16
30
18
25
REFLEXIONS
February 2002
1997
1998
1999
2000
2001
The driver of Staff 61 was
about 10 feet from the vehicle
when he heard a jet engine
to the south.
The Situation
The Challenger was inbound to
Terrace after conducting flight
inspection of navaids near the
airport. At about 1116 local time,
above the airport, the pilot of
Navcan 200 advised the Flight
Service Station (FSS) specialist
on the mandatory frequency
(MF) that he was joining the
traffic circuit on a left-hand
downwind for landing on
Runway 33. The specialist
responded with a wind advisory
(wind calm). About one minute
later, the pilot advised turning
to final for a full-stop landing
on Runway 33, and the specialist
repeated the wind advisory.
Meanwhile, Staff 61 had been
authorized to inspect previous
snow-clearing work. The operator stopped a few times to pick
up small pieces of snow that had
fallen from a runway sweeper
during the previous clean-up.
Each time, while out of the vehicle, he left the vehicle door open
and switched his radio to the
rear exterior speaker.
Just before landing, the pilot
requested that the specialist
advise the aircraft refuelling
company that the aircraft was
landing. The specialist spent
the next 35 seconds on the
telephone with a refuelling
company employee. At one
point, the specialist commented
that he could not see the aircraft
after landing because it had
disappeared into a layer of fog
that partially obscured the
northern half of Runway 33.
At 1117:57, near the end of the
telephone conversation with the
refueller, the specialist received
a radio call from Staff 61. The
specialist did not immediately
answer Staff 61 because he was
still on the telephone. At 1118:03,
the pilot of Navcan 200 reported
to the FSS that a vehicle was at
the end of the runway. At no
time was information regarding
the presence of a vehicle on
the runway relayed to Navcan
200 by the FSS specialist.
Just before the incident, the driver of Staff 61 was about 10 feet
(about 3 m) away from the vehicle when he heard a jet engine
to the south. He quickly ran to
the vehicle, put it in reverse,
and backed over to the edge of
the runway. Approximately five
seconds had elapsed from the
time he heard the jet engines
until he saw the aircraft pass
by. No communication had
occurred between the specialist
and Staff 61 for the previous
6 minutes 28 seconds until the
call from Staff 61 to the FSS
at 1117:57.
Prompted by the radio calls from
Staff 61 at 1117:57 and the pilot
of Navcan 200 at 1118:03, the
specialist immediately instructed
Staff 61 to exit the runway (the
aircraft had already passed the
vehicle) and to report clear.
Staff 61 responded that the aircraft was already past his position and that he would follow
it to the ramp.
Different Radio
Frequencies
The objective of the vehicle control service provided by the FSS
is to control the movement of
ground traffic on the airport
manoeuvring area. Ground traffic
does not include aircraft; it
includes all other traffic, such
as vehicles, pedestrians, and construction equipment. A separate
frequency is established for the
control of ground traffic entering
the manoeuvring surfaces of the
airport. At airports where a vehicle control service is provided,
vehicles do not normally monitor the MF. As a result, the FSS
specialist is the focal point and
the exclusive repository for all
the available information on air
and ground traffic. The FSS has
the responsibility to ensure that
operators are apprised of essential information as required.
Whenever information is compartmentalized to the extent
that a single individual or system is the exclusive conduit for
that information, a lapse in
memory, a deviation from
standard procedures, or a technical failure has the potential
to result in an accident. In the
absence of a sufficient depth
of defence, a single lapse resulted
in this occurrence. It did not
become an accident only
because of an unanticipated
and unplanned defence: the
operator of Staff 61 received
information about a landing
aircraft from the sound of the
approaching jet engines.
The redundancy that would be
achieved by providing more than
one person/agency access to the
information necessary for safe
operation is lost when the information is restricted to only the
FSS. The capability of the aircrew or the vehicle operator to
listen to the other active frequency would have reduced
the likelihood of the occurrence happening.
Terrace Snow-Clearing
Procedures
At Terrace Airport, the term
“work area 15/33” is reserved
exclusively for snow-clearing
operations. Snow-clearing vehicles are permitted unrestricted
access by the FSS specialist to
REFLEXIONS
February 2002
19
System Defences
A more positive intervention is
required to change a specialist’s
established routine for gathering
information to ensure that the
pertinent facts are recalled into
working memory at the correct
time. For example, Nav Canada
has installed a SONALERT system at some of its FSS facilities
to actively remind specialists that
they have authorized a vehicle
to operate on a runway. Terrace
FSS and technical staff were also
developing another system that
would activate as soon as a vehicle strip was placed into the data
strip board. However, technological systems alone will not
be effective unless the FSS specialist consistently follows a disciplined approach to providing
air traffic services, that is, scanning the immediate work area
as well as the outside environment to gather all available
and required information.
the entire area. While in the area,
vehicles are not required to provide position reports to the FSS.
This procedure was instituted
because of the excessive amount
of snow-removal operations
at the Terrace Airport and the
number of vehicles normally
involved, often up to eight. The
reduction in radio transmissions
and workload between the FSS
and vehicle operators was seen
as a significant benefit.
The absence of radio communications to and from Staff 61
may have prevented the specialist from recalling the presence
of the vehicle at a critical time.
Routine communications
requirements, such as position
reports in the work areas, could
have reminded the specialist
that a vehicle was on the runway
when Navcan 200 initially
reported above the airport.
30
Other Follow-up Action
Through the Canadian Aviation
Regulation Advisory Council
(CARAC) Part III Technical
Committee, Transport Canada
was examining the extent to
which vehicles should be allowed
to use aircraft manoeuvring surfaces when transiting from one
aerodrome location to another,
with a view to reducing the
potential for aircraft/vehicle
conflicts. Additionally, the committee will determine whether
vehicles at uncontrolled airports
should be operating on the
same frequency as that used
by aircraft.
At Terrace Airport, all vehicles
that operate on aircraft movement areas have been equipped
with receive-only radios tuned
to the MF to increase the situational awareness of vehicle
operators.
Accidents or Reportable Incidents Involving a Runway Incursion - Major Canadian Airports
(Aircraft in Canada or Canadian-registered)
No. of Occurences
27
1995
1996
1997
1998
1999
24
21
18
15
2000
2001
12
9
Total
6
3
0
CYHZ
CYUL
CYYZ
CYOW
CYWG
CYYC
CYEG
CYVR
Airports
Halifax
Dorval
Toronto
Ottawa
Winnipeg
Calgary
Edmonton
Vancouver
CYHZ
CYUL
CYYZ
CYOW
CYWG
CYYC
CYEG
CYVR
1995
1996
1997
1998
1999
2000
2001
Total
0
0
3
1
0
1
0
1
1
1
3
1
0
1
1
2
0
1
4
0
1
2
0
3
0
1
2
1
1
3
0
1
1
2
4
1
5
6
0
2
0
2
3
1
0
4
0
1
1
0
10
3
2
0
0
4
3
7
29
8
9
17
1
14
Figures as of 11 January 2002.
20
REFLEXIONS
February 2002
Rudder jammed
at 34º deflection.
Jammed Rudder
The student pilot in the Cessna 152 pulled the elevator control fully aft, stepped on the left rudder pedal,
and the aircraft entered a left spin. Despite proper recovery actions by the student and the instructor,
the aircraft continued downward in a stabilized spin until it struck the surface of a lake. The student
pilot escaped the aircraft with serious injuries; the flight instructor was fatally injured in the 18 July
1998 accident at Lake Saint-François, Quebec. — Report No. A98Q0114
When the aircraft was recovered
from the water, the rudder was
found locked in the full left
position. It was observed that
the rudder stop plate on the
right-hand half of the rudder
horn was firmly jammed behind
its stop bolt on the fuselage. The
rudder was deflected 34o measured perpendicular to the hinge
line, whereas the maximum
allowable deflection for setting
the stops is 23o. When the rudder was released from its jam,
the deflection was 23o.
The day before the accident,
an apprentice mechanic from
Laurentide Aviation at Montréal /
Les Cèdres Aerodrome, where
the aircraft was based, carried
out a 50-hour inspection of the
aircraft. During the check, the
right pedal rudder bar return
spring and a spring attachment
for this spring, which was welded to the rudder bar assembly,
were found to be broken. The
return spring supplied a tension force of about 10 pounds
per inch of stretch and balanced the force exerted by the
matching left rudder bar return
spring. The two return springs
maintain tension in the rudder
cables that connect to the right
and left halves of the rudder
horn. Without the right pedal
REFLEXIONS
February 2002
21
The apprentice removed, but did
not replace, the broken pieces
of the rudder control system.
return spring, the right rudder
cable slackens. The left rudder
pedal return spring will then
tend to pull the right rudder
pedal toward the pilots, facilitating deflection of the rudder
to the left.
The Aircraft Was Not
Airworthy
The apprentice removed, but did
not replace, the broken pieces
of the rudder control system. He
then requested the opinion of
a company aircraft maintenance
engineer, who judged that the
absence of the spring and the
bracket would not affect the
flight characteristics of the aircraft and decided to release the
aircraft for service until replacement parts could be installed.
Because the spring was missing,
the aircraft was not airworthy.
Further, the required entries
were not made in the snag
book—used by instructors and
With the rudder jammed
the way it was, no amount
of right pedal force would
have released the jam.
22
REFLEXIONS
February 2002
other pilots to record aircraft
defects—or the journey logbook,
which was not available to students and instructor pilots for
viewing or recording times or
defects. Transport Canada (TC)
did not approve the use of a snag
book at Laurentide Aviation,
and TC inspectors were not
aware of its use.
Had the logbooks reflected the
defect and been available to the
pilots, the flight instructor likely
would have been aware that the
rudder bar return spring was
missing. The instructor then
would have had the option of
refusing to operate the aircraft
in that condition.
During a TC maintenance audit
of another flight school operator
at Saint-Hubert Airport, discrepancies were noted that led to
the grounding of several aircraft,
including five Cessna 152 aircraft with reported rudder overtravelling. The audit revealed that
there were scratches or score
marks on the five airplanes, indicating that the rudder horns had
overtravelled above and beyond
the stop bolt at some time.
Further tests led investigators to
conclude that the accident aircraft entered a left spin with the
rudder locked at a 34o deflection. With the rudder jammed
the way it was, no amount of
right pedal force would have
released the jam, because the
direction of cable pull tends to
increase the jamming by closing
the horn.
Safety Action Taken
and Required
On 14 March 2000, Cessna notified the TSB that it had designed
a rudder horn stop bolt with a
larger head diameter to prevent
overtravel of the rudder after
a hard rudder input. Cessna
notified the Federal Aviation
Administration (FAA) Certification Office about this manner
and expected to issue a service
bulletin offering the new configuration rudder stop bolt for
all Cessna 150’s and 152’s built
after 1996. A time frame for
these actions was not specified.
On 09 May 2000, TC issued a
service difficulty alert discussing
the accident circumstances and
outlining details regarding the
inspection of the rudder control
system.
While stated action by Cessna
is appropriate, the Board is concerned that since the proposed
service bulletin will be voluntary,
not all Canadian-registered
Cessna 150’s and 152’s will be
modified. Therefore, the Board
recommended that:
The Department of Transport issue
an Airworthiness Directive to all
Canadian owners and operators
of Cessna 150 and 152 aircraft
addressing a mandatory retrofit
design change of the rudder horn
stop bolt system to preclude overtravel and jamming of the rudder
following a full rudder input.
A00-09
The implications of the
broken or missing rudder
cable return spring were
not fully understood.
Any mandatory airworthiness
actions to retrofit Cessna 150
and 152 aircraft with newly
designed rudder horn stop bolt
systems will likely take considerable time to complete. In the
meantime, these aircraft will be
flying with a known safety deficiency. The circumstances of this
accident suggest that the implications of the broken or missing
rudder cable return spring were
not fully understood. Moreover,
the possibility of an irreversibly
jammed rudder during intentional spin entry by full rudder
deflection was not understood
until this accident investigation
was completed. Therefore, the
Board recommended that:
The required logbook entries
regarding the maintenance performed on the rudder system
were not made. It was evident
that the operator, in general,
did not maintain the aircraft
journey logbooks in accordance
with the Canadian Aviation
Regulations. Therefore, the
Board recommended that:
The Department of Transport
take steps to ensure that operators
and maintenance personnel are
aware, in the interests of safety,
of the importance of proper maintenance of aircraft journey logbooks
and aware of their responsibilities
in this regard.
A00-11
The FAA, as the regulatory
body in the State of design
and manufacture, has primary
responsibilities for continuing
airworthiness of the Cessna 150
and 152 aircraft. Therefore, the
Board recommended that:
The National Transportation Safety
Board review the circumstances
and findings of this investigation
and evaluate the need for mandatory airworthiness action by the
Federal Aviation Administration.
A00-12
Transport Canada issued an
airworthiness directive effective
04 August 2000 prohibiting
intentional spins / incipient
spins in Cessna 150 and 152
aircraft until a rudder system
inspection has been carried out
and any problems rectified. The
rudder system inspection is to
be completed at every 110 hours
or 12 months, whichever occurs
first. Aircraft not performing
intentional spins / incipient
spins are to be inspected not later
than 110 hours or 12 months,
whichever occurs first, from
the effective date of the airworthiness directive and thereafter
at every 110 hours or 12 months,
whichever occurs first.
The Department of Transport,
in conjunction with the Federal
Aviation Administration, take steps
to have all operators of Cessna 150
and 152 aircraft notified about the
circumstances and findings of this
accident investigation and the need
to restrict spin operations until
airworthiness action is taken to
prevent rudder jamming.
A00-10
REFLEXIONS
February 2002
23
SR111 Firefighting
Recommendations
In its ongoing investigation into the 02 September 1988 crash of Swissair Flight 111 (SR111), the TSB has
identified safety deficiencies in several aspects of the current government requirements and industry
standards involving in-flight firefighting. Each of these deficiencies has the potential to increase the time
for an aircraft crew to gain control of what could be a rapidly deteriorating situation. Time is a prime
consideration in the successful identification and control of an in-flight fire. — Occurrence No. A98H0003
SR111 crashed approximately
20 minutes after the crew detected an unusual odour. About
11 minutes elapsed between
the time the crew confirmed
the presence of smoke and the
time that the fire is known to
have begun to adversely affect
aircraft systems. The TSB
reviewed a number of databases
to look for events that had similarities to the scenario of SR111.
24
REFLEXIONS
February 2002
Fifteen such events were identified, the earliest of which
occurred in 1967. For these
events, the time from which
fire was first detected until the
aircraft crashed ranged from
5 to 35 minutes. Each of these
accidents had the same characteristic: the in-flight fire spread
rapidly and became uncontrollable.
More needs to be done
to develop an effective
•
dependence on human
sensory systems for the
detection of odours/
smoke; and
•
electronic equipment bays
(typically below the floor
beneath the cockpit and
forward passenger cabin);
•
inadequate appreciation for
how little time is available
to detect, analyze, and suppress an in-flight fire.
•
the areas behind interior
wall panels in the cockpit
and cabin areas;
•
the areas behind circuitbreaker and other
electronic panels; and
•
the area between the crown
of the aircraft and the dropdown ceiling (sometimes
referred to as the attic area).
firefighting system.
Integrated Firefighting
Measures
During the SR111 investigation,
the TSB has necessarily looked
beyond the specific circumstances of this single occurrence
to examine industry standards
in the area of in-flight firefighting. The Board believes that
industry efforts have fallen short
in this area and that the industry
should look at fire prevention,
detection, and suppression as
being the components of a coordinated and comprehensive
approach. More needs to be
done to develop an effective
firefighting system and to ensure
that all elements of such a system are fully integrated, compatible, and supported by all
the other elements. The SR111
investigation has revealed that
a number of safety deficiencies
could reduce the chances of an
in-flight fire being detected and
extinguished in time, such as
the following:
•
lack of effective fire detection
and suppression systems in
vulnerable areas of the aircraft fuselage;
Small fires can continue
to propagate and remain
undetected by cabin
occupants.
Therefore, the Board recommended that:
Appropriate regulatory authorities,
in conjunction with the aviation
community, review the adequacy
of in-flight firefighting as a whole,
to ensure that aircraft crews are
provided with a system whose
elements are complementary and
optimized to provide the maximum
probability of detecting and suppressing any in-flight fire.
A00-16
Smoke/Fire Detection
and Suppression
At present, built-in smoke/fire
detection and suppression systems in transport-category aircraft are required only in “designated fire zones,” which are
areas that are not readily accessible and that contain recognized
ignition and fuel sources. These
areas include powerplants, auxiliary power units, lavatories,
and cargo areas.
The Board believes that there
is the potential for a fire to ignite
and propagate without detection
in areas not designated as fire
zones, including, but not limited
to, the following:
The Board believes that the
present detection and suppression capabilities in these nondesignated fire zones of the
aircraft fuselage are inadequate.
Such smoke/fire detection is
primarily dependent on human
senses. In most transportcategory aircraft, the occupied
areas are isolated from the
inaccessible areas by highly
efficient ventilation/filtering
systems, which can effectively
remove combustion products
from small fires and impede
the timely detection of smoke by
human senses. Therefore, small
fires can continue to propagate
and remain undetected by cabin
occupants. Furthermore, any
attempt at smoke/fire suppression in these areas would require
direct human intervention using
handheld fire extinguishers. As
the SR111 accident and other
occurrences demonstrate, early
detection and suppression are
critical in controlling in-flight
fire.
REFLEXIONS
February 2002
25
The decision to initiate
a diversion and prepare
for a potential emergency
landing must be made quickly.
Therefore, the Board recommended that:
Appropriate regulatory authorities,
together with the aviation community, review the methodology
for establishing designated fire
zones within the pressurized portion of the aircraft, with a view
to providing improved detection
and suppression capability.
A00-17
Emergency Landing
Preparation
The SR111 accident has raised
awareness of the potential consequences of an odour/smoke
situation, and the rate for flight
diversions has increased as a
result. Some airlines have modified their policies, procedures,
checklists, and training programs
to facilitate timely diversions
and rapid preparations to land
immediately if smoke from an
unknown source appears and
cannot be readily eliminated.
It can take a long time
to complete the checklist,
including troubleshooting
actions.
26
REFLEXIONS
February 2002
Along with other initiatives,
Swissair amended its MD-11
checklist for Smoke/Fumes of
Unknown Origin to indicate
“Land at the nearest emergency
aerodrome” as the first action
item. While such initiatives
reduce the risk of an accident,
the Board believes that more
needs to be done industry-wide.
Within the aviation industry,
there is an experience-based
expectation that the source of
odours/smoke will be discovered
quickly and that troubleshooting
procedures will fix the problem.
Although in-flight fires like that
aboard SR111 are rare, the TSB
review shows that when an inflight fire continues to develop,
there is a limited amount of
time to land the aircraft. When
odour/smoke from an unknown
source occurs, the decision to
initiate a diversion and prepare
for a potential emergency landing
must be made quickly. Therefore,
the Board recommended that:
Appropriate regulatory authorities
take action to ensure that industry standards reflect a philosophy
that when odour/smoke from an
unknown source appears in an
aircraft, the most appropriate
course of action is to prepare to
land the aircraft expeditiously.
A00-18
Troubleshooting Time
In circumstances where the
source of odour/smoke is not
readily apparent, flight crews
are trained to follow troubleshooting procedures, contained
in checklists, to eliminate the
source of smoke/fumes. An
indeterminate amount of time
is required to assess the impact
of each action. It can take a long
time to complete the checklist,
including troubleshooting
actions. For example, the MD-11
Smoke/Fumes of Unknown
Origin checklist can take up to
30 minutes to complete. There
is no regulatory direction or
industry standard specifying
how much time it should take
to complete these checklists.
Therefore, the Board recommended that:
Appropriate regulatory authorities
ensure that emergency checklist
procedures for the condition of
odour/smoke of unknown origin
be designed so as to be completed
in a time frame that will minimize the possibility of an in-flight
fire being ignited or sustained.
A00-19
There is a lack of
coordinated cabin and
flight crew firefighting
training and procedures.
Fire Suppression in
Pressure Vessel
Current aviation requirements
and standards stipulate that
aircraft crews must be trained
to fight in-flight fires. However,
the TSB found that within the
industry there is a lack of coordinated cabin and flight crew
firefighting training and procedures to enable crews to quickly
locate, assess, control, and suppress an in-flight fire within the
fuselage of the aircraft. The
Board is also concerned that
aircraft crews are not trained
or equipped to have ready access
to spaces within the fuselage
where fires have the potential
to ignite and spread. The Board
believes that the lack of comprehensive in-flight firefighting
procedures and coordinated aircraft crew training to use these
procedures constitutes a safety
deficiency. Therefore, the Board
recommended that:
Appropriate regulatory authorities
review current in-flight firefighting
standards, including procedures,
training, equipment, and accessibility to spaces such as attic areas,
to ensure that aircraft crews are
prepared to respond immediately,
effectively and in a coordinated
manner to any in-flight fire.
A00-20
Responses
Transport Canada (TC), the US
Federal Aviation Administration
(FAA), and the UK Civil Aviation
Authority (CAA) support these
five firefighting recommendations. The agencies have noted
that these broad-reaching recommendations will require
international coordination and
cooperation among regulatory
authorities, aircraft manufacturers, and air operators. In October
2001, representatives from TC,
the FAA, and the European Joint
Aviation Authorities (JAA) met
to “discuss the recommendations, to identify existing initiatives and groups that may already
address some aspects covered
by the recommendations, and
to establish a team to develop
an appropriate action strategy.”
The TSB will closely monitor the
progress of these joint deliberations. The FAA has added the
TSB’s recommendations to its
Safety Recommendation Program,
and the CAA has taken several
steps in support of the recommendations.
It is apparent that TC and the
FAA agree with the thrust of
the deficiencies and are committed, at least in the short term,
to examine these issues and
map out a course of action.
Collectively, their responses
are adequate and constitute
a logical first step. Until such
time as the details of the proposed action plan are known,
it will remain unclear the extent
to which the identified deficiencies will be reduced or
eliminated. Since these declared
initiatives will not yield any
substantive change, the responses
are considered to show satisfactory intent.
Stay Tuned
The TSB has also identified
deficiencies and made recommendations concerning aircraft
material flammability standards.
Details will appear in our next
issue or check out our Web site
at www.tsb.gc.ca.
REFLEXIONS
February 2002
27
Aviation Occurrence Statistics
2001
2000
1999
1996–2000
Average
Canadian-Registered Aircraft Accidents*
295
319
341
349
Aeroplanes Involved**
Airliners
Commuters
Air Taxis / Aerial Work
Private/Corporate/State/Other
Helicopters Involved
Other Aircraft Involved***
242
5
8
55
174
47
9
257
9
4
64
180
53
12
287
6
13
89
171
45
15
286
8
10
101
166
54
13
3 860
7.6
4 260
7.5
4 100
8.3
3 942
9.2
Fatal Accidents
Aeroplanes Involved
Airliners
Commuters
Air Taxis / Aerial Work
Private/Corporate/State/Other
Helicopters Involved
Other Aircraft Involved
33
25
0
1
6
18
6
3
38
26
1
1
5
19
11
1
34
28
1
2
6
19
4
4
37
28
1
1
9
18
7
2
Fatalities
Serious Injuries
61
37
65
53
65
42
71
50
35
38
35
39
6
7
8
5
9
10
12
19
7
7
10
8
Hours Flown (thousands)****
Accident Rate (per 100 000 hours)
Canadian-Registered Ultralight
Aircraft Accidents
Fatal Accidents
Fatalities
Serious Injuries
28
REFLEXIONS
February 2002
Foreign-Registered Aircraft Accidents
in Canada
Fatal Accidents
Fatalities
Serious Injuries
All Aircraft: Reportable Incidents
Collision / Risk of Collision / Loss of Separation
Declared Emergency
Engine Failure
Smoke/Fire
Other
2001
2000
1999
1996–2000
Average
29
21
24
21
8
10
5
8
19
3
6
9
1
6
58
3
853
730
705
725
222
254
176
108
93
169
227
164
84
86
176
209
157
86
77
190
212
163
84
75
*
Ultralight aircraft excluded.
**
As some accidents may involve multiple aircraft, the number of aircraft involved may not sum to the number of accidents.
***
Includes gliders, balloons, and gyrocopters.
****
Source: Transport Canada. (Hours flown are estimated.)
Figures are preliminary as of 08 January 2002. All five-year averages have been rounded.
REFLEXIONS
February 2002
29
AIR Occurrence
Summaries
The following summaries highlight pertinent safety information
from TSB reports on these investigations.
JAMMED ELEVATORS
de Havilland DHC-8-102, Québec / Jean-Lesage International
Airport, Quebec, 25 April 1988 — Report No. A98Q0057
The elevators of the Air Alliance Dash 8 jammed as the aircraft climbed
through 12 000 feet above sea level (asl) during a flight to Montréal,
Quebec. The captain tried to disconnect the left and right elevators
by using the pitch disconnect handle, but that did not unjam the
controls.
The crew declared an emergency and requested clearance back to
Québec. The captain was able to control the attitude and the desired
vertical speed using elevator trim and engine power. While descending
through 6000 feet asl, the captain felt the aircraft’s nose suddenly
lift up. He immediately corrected the attitude by varying the engine
power and using the elevator trim. He continued the descent for
landing with 0o flaps so as not to disturb the attitude. The aircraft
landed without further incident. After landing, the controls were
free of any restriction.
The rivet heads and access
plugs are conducive to
the adherence of ice.
The carrier’s technical staff discovered that the space
between the leading edge of the elevators and the
trailing edge of the stabilizer was contaminated by
large dribbles of rough-textured paint. The technicians
sanded the paint drips from the elevators to restore
the space between the two surfaces to the manufacturer’s recommended standards of between 0.150 and
0.250 inch.
The trailing edge surface of the stabilizer is studded with rivet heads
and access plugs that reduce the space between the two surfaces.
The rivet heads and the access plugs are conducive to the adherence
of ice.
30
REFLEXIONS
February 2002
The observed weather conditions—wet snow and rain—during the
aircraft’s stop at Québec and on take-off met the icing-condition
criteria specified by the aircraft manufacturer, the operator, and
Transport Canada. The captain conducted two walk-around inspections
of the aircraft before take-off, did not see any snow accumulation,
and was confident that it was not necessary to de-ice the aircraft.
Given the weather conditions, the decision to take off without de-icing
the aircraft was questionable.
The use of the elevator trim to alleviate the normal pitch control
forces during the climb made it impossible to recognize the imminent jamming of the elevators sooner. It was a potentially dangerous
condition to control the aircraft using the elevator trim when the
elevators were jammed. Should the elevators have suddenly become
free with the trim in the full nose-down position, the aircraft would
have quickly nose-dived unless there was an immediate intervention
by the flight crew. On approach and especially at low altitude, the
situation could potentially lead to impact with the ground.
Following this occurrence, Bombardier sent a letter to all operators
and its regional representatives summarizing the occurrence and
reminding them of the proper use of elevator trim. Bombardier also
issued a Dash 8 safety of flight supplement reminding pilots that
the elevator trim does not have the authority to overcome a frozen
elevator.
NO INSTRUMENT RATING OR TYPE ENDORSEMENT
Mitsubishi MU-2B, 1 nm W of Parry Sound / Georgian Bay Airport,
Ontario, 24 May 1999 — Report No. A99O0126
The MU-2 crashed while in a turn following a downwind take-off
at night and in rain with little outside visual reference. The pilot
and his son were fatally injured.
Transport Canada records indicate that the pilot attempted,
but never successfully completed, the instrument rating
examination on several occasions. His US pilot certificate
(the MU-2 was US-registered) was issued on the basis of,
and valid only when accompanied by, a valid Canadian
licence. The pilot provided the US training provider with
licensing documentation that indicated he held an instrument rating when, in fact, he did not hold this rating.
Further, the pilot did not obtain a high-performance
type rating on his licence for this type of aircraft.
The pilot attempted, but
never successfully completed, the instrument rating
examination on several
occasions.
REFLEXIONS
February 2002
31
Remains of the MU-2 flown
by a non-instrumented pilot
on a dark, rainy night.
After this occurrence, Transport
Canada (TC) reviewed a crosssection of instrument flight rules
(IFR) flight plans from across
Canada against the instrument
qualifications of the pilot filing
the flight plan. Three of the 360
flight plans examined were found
to be questionable and required
further investigation. Some flight
plans were not completed properly and could not be validated.
TC determined that the flying of
IFR flights by non-instrumentrated pilots is not a widespread
or systemic problem in Canada.
Nevertheless, a zero-tolerance
approach is needed. TC has recommended that inspectors periodically check IFR flight plans
to ensure that the filing pilot has
a current instrument rating and
that offenders be prosecuted. TC also recommended that Nav Canada
ensure that flight plans are legible.
TOO MUCH WEATHER, TOO LITTLE EXPERIENCE
Piper PA-34-200T, Québec / Jean-Lesage International Airport,
Quebec, 28 March 1998 — Report No. A98Q0043
On initial contact with the Québec tower, the pilot was informed
by the controller that the runway visual range (RVR) was 1400 feet,
the observed visibility was 1/2 mile in fog, and the vertical visibility
was 100 feet.
While the aircraft was approaching, the crew of a Boeing 727, which
was four minutes ahead, announced that they were doing a missed
approach and that they wanted to turn back to Montréal without
attempting another approach. Later, during the approach, the pilot
of the Piper was informed that the RVR was 1200 feet. At 200 feet,
the published minimum approach height, the pilot initiated a
missed approach.
The pilot did not follow
the missed approach
procedure.
32
The pilot did not follow the missed approach procedure. The controller had to intervene to bring him
back south of the airport and eventually on a heading for a second approach. The instrument landing
system missed approach procedure at Québec is not
complicated. The first part of the procedure simply
requires staying on the runway’s centreline and
REFLEXIONS
February 2002
climbing to 3300 feet. This allows
the pilot to contact Air Traffic
Services and prepare for the second
part of the procedure. Although
this procedure is simple, it quickly
becomes complicated if the workload increases, as during a missed
approach. The situation can further
deteriorate if the pilot has little
experience and training and is the
only crew member. This pilot had
63 hours of instrument time but
only 1 hour in the previous 6
months.
The pilot also performed a missed
approach on the second approach.
The radar data indicate that the
aircraft’s speed increased while its
altitude continued to drop. The pilot did not modify the aircraft’s
attitude to begin a pull-up, and the aircraft crashed 3342 feet (about
1019 m) from the threshold of Runway 06. One of the five occupants
suffered minor injuries.
The Piper Seneca crashed
after a second missed
approach.
NOT CLEARED FOR TAKE-OFF
Airbus Industrie A319 / Cessna 172, Calgary International Airport,
Alberta, 27 February 1999 — Report No. A99W0036
The Cessna pilot advised the controller that he would backtrack on
Runway 25 for 400 feet. The controller replied that the Cessna would
be number one for departure because the other aircraft (another Cessna)
on Runway 25 was going to the end of the runway. According to the
example given in the Air Traffic Control Manual of Operations (ATC
MANOPS), the phraseology used should have been, “(Cessna), number
two for departure, traffic A319 departing Runway 16.” No mention
was made to the Cessna that the A319 would be the first to depart.
Twenty-one seconds later, the controller issued take-off clearance
to the A319.
The Cessna pilot was not aware that the A319 was in position on
Runway 16 and did not hear the take-off clearance issued to that aircraft, although they were on the same frequency. Believing he had
authorization to take off, he applied power and began the take-off
roll. He had second thoughts, however, and momentarily applied
brakes. He looked to his right and saw the A319, but was unsure
whether that aircraft was moving.
The controller told the Cessna pilot to abort; however, the pilot
continued the take-off. The controller also told the A319 to abort,
which it did.
REFLEXIONS
February 2002
33
He assumed that he
had similarly missed the
clearance amid the other
verbiage.
The Cessna pilot was relatively inexperienced and not
yet completely familiar with the speed and complexity
of radio communications and the radio monitoring
requirements at Calgary. He faced several distractions
on this take-off. First, he had planned on using Runway
16 but was offered Runway 25, which he accepted. He
did not expect to be authorized to follow the other
Cessna and did not expect to be offered take-off in
front of it.
His previous experience had prepared him to believe that, once on
a runway, he was expected to carry out the take-off procedure without delay. On several occasions in the past, he had also missed the
“cleared for take-off” instruction and had been prompted by his
instructor to begin take-off. In this situation, he assumed that he had
similarly missed the clearance amid the other verbiage. The runway
had just been made available to him, the only other traffic of which
he was aware (the other Cessna) was behind him, and he had been
told that he was number one.
The radio skills and the heightened situational awareness necessary
to operate on the surface or close to Calgary International Airport
are not specifically targeted during training. Rather, pilots are expected
to acquire these skills and awareness by exposure to the various situations encountered during training. This may not ensure sufficient
familiarity with all the common safety-related circumstances and
practices of which a student or newly licenced pilot should be aware.
Those situations that are experienced may not be presented with
enough emphasis to convince inexperienced pilots to devise methods
to assure themselves that all appropriate clearances and instructions
have been followed.
34
REFLEXIONS
February 2002
Investigations
The following is preliminary information on all occurrences under investigation by the TSB that were reported between
01 May 2000 and 31 December 2001. Final determination of events is subject to the TSB’s full investigation of these
occurrences.
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
MAY 2000
06
Sydney, N.S.
Piper PA-28
Take-off
Loss of control—stall
A00A0071
10
Cabot Island,
Nfld.
Bell 212
En route
Collision with water
A00A0076
10
Abbotsford,
B.C.
Bell 47G-2
Take-off
Tail-rotor gearbox
malfunction
A00P0077
11
Edmonton Int’l
Airport, Alta.
McDonnell
Douglas
DC-9-30
Take-off
Rejected take-off—
runway overrun
A00W0097
20
Resolute, Nun.,
35 nm SW
Bell 206L
Take-off
Loss of control—
collision with
level ice
A00C0099
27
Dorval /
Montréal Int’l
Airport, Que.,
5 nm W
Cessna 650
Approach
Loss of separation—
safety not assured
A00H0003
Boeing 767-233
Take-off
30
Calling Lake,
Alta.
Cessna 177B
Take-off
Loss of control—stall
A00W0109
30
Tofino, B.C.,
17 nm E
Boeing 747-400
En route
Loss of separation
A00P0090
McDonnell
Douglas MD-80
En route
Helmut, B.C.
Bell 206B
Approach
Collision with fence
A00W0105
01
Kamloops, B.C.,
3 nm N
Stits Playmate
SA-11A
En route
Collision with terrain
A00P0094
12
Kelowna, B.C.,
120 nm NNE
Boeing 737-200
En route
Cabin depressurization
A00P0101
13
Peterborough
Airport, Ont.,
0.5 nm W
Dassault-Breguet
Falcon 20E
Approach
Controlled flight
into terrain
A00O0111
JUNE
01
REFLEXIONS
February 2002
35
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
McIvor Lake,
B.C.
Cessna 180E
Manoeuvring
Loss of control
A00P0099
19
Hotnarko Lake,
B.C.
de Havilland
DHC-2
Take-off
Loss of control
A00P0103
22
Llewellyn
Glacier, B.C.
Bell 206L-3
Manoeuvring
Collision with terrain
A00P0107
JULY
01
Fort Steele, B.C.
Bellanca 65-CA
Take-off
Loss of control
A00P0115
17
Harding, Man.
Piper PA-25-150
Manoeuvring
Loss of control,
collision with terrain
A00C0162
19
Porters Lake,
N.S.
Cessna 150M
Manoeuvring
Collision with terrain
A00A0110
23
Dorval /
Montréal Int’l
Airport, Que.
Boeing 747-200
Landing
Runway excursion
A00Q0094
AUGUST
14
Teslin Lake, B.C.
Cessna 208
Take-off
Loss of control,
collision with water
A00W0177
17
Green Lake, B.C.
Cessna 185F
Take-off
Collision with water
A00P0157
26
Dorval /
Montréal Int’l
Airport, Que.
Canadair CL-600
Approach
Runway incursion
A00Q0114
Airbus A319-114
Taxiing
Dorval /
Montréal Int’l
Airport, Que.,
1 nm W
Airbus A319-114
Take-off
Risk of collision
A00Q0116
Cessna 152
En route
Lumsden,
Sask., 45 nm W
Boeing 747-400
En route
Loss of separation
A00C0211
Airbus A319-114
En route
13
Toronto /
Airbus A320-232
Lester B. Pearson
Int’l Airport, Ont.
Take-off
Fan cowl separation
A00O0199
13
Kingston, Ont.
Manoeuvring
Difficulty to control
A00O0210
JUNE
13
29
SEPTEMBER
06
36
REFLEXIONS
February 2002
Cessna 150G
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Vancouver
Harbour
Heliport, B.C.
Sikorsky
S-61N/SP
Take-off
Input freewheel
unit malfunction
A00P0182
15
Ottawa /
MacdonaldCartier Int’l
Airport, Ont.
Boeing 727-200A Landing
Runway overrun
A00H0004
22
Iqaluit Airport,
Nun.
Boeing 727-200
Landing
Runway excursion
A00H0005
22
Clearwater, B.C.,
18 nm NW
de Havilland
DHC-2T
Manoeuvring
Collision with terrain
A00P0184
27
La Grande 4,
Que.
Convair Liner
340/580
Landing
Runway excursion
A00Q0133
28
Smithers, B.C.,
80 nm NW
Cessna 185F
Manoeuvring
Controlled flight
into terrain
A00P0194
Golden, B.C.,
3 nm NNE
Cessna 310R
Manoeuvring
Loss of control
A00P0195
02
Fort Nelson,
B.C., 90 nm E
Eurocopter
AS 350BA
En route
Power loss—
A00W0215
mechanical malfunction
03
Ottawa, Ont.
Diamond
DA 20-A1
En route
Engine failure—
forced landing
A00O0214
06
Rouyn-Noranda,
Que., 5 nm S
Cessna 550
Take-off
Fire, explosion, fumes
A00Q0141
08
Vancouver, B.C.
de Havilland
DHC-8-200
Approach
Hazardous situation,
ATC irregularity
A00P0199
08
Port Radium,
N.W.T.
Short Brothers
SC-7
Approach
Collision with terrain
A00W0217
12
Rendell Creek
Lodge, B.C.
Piper PA-24-250
Take-off
Collision with terrain
A00P0197
25
Vancouver Int’l
Airport, B.C.
de Havilland
DHC-8-200
Take-off
Runway incursion
A00P0206
de Havilland
DHC-8-100
Standing
McDonnell
Douglas 369D
En route
Main-rotor blade
failure
A00P0208
SEPTEMBER
14
OCTOBER
02
31
Mt. Modeste,
B.C., 5 nm NW
REFLEXIONS
February 2002
37
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Vancouver
Harbour, B.C.
de Havilland
DHC-6-100
Take-off
Loss of propulsion,
collision with water
A00P0210
06
Winnipeg Int’l
Airport, Man.,
2 nm S
Piper PA-31-350
Approach
Collision with terrain
A00C0260
13
Fredericton,
N.B.
Boeing 737-217
Landing
Engine failure
A00A0176
28
Fredericton,
N.B.
Fokker F28
Mk 1000
Landing
Runway overrun
A00A0185
Vancouver, B.C.,
30 nm NW
Learjet 35A
En route
Loss of aileron control
A00P0225
04
Ottawa /
Gatineau
Airport, Que.
Beechcraft
King Air A100
Landing
Gear-up landing
A00H0007
18
Windsor
Airport, Ont.
Antonov
124-100
Landing
Runway overrun
A00O0279
31
Okanagan
Mountain, B.C.
Piper Aerostar
602P
Approach
Collision—flight into
terrain
A00P0244
31
Fox Creek,
Alta., 45 nm W
Hughes 369D
(500D)
Manoeuvring
Collision with trees
A00W0267
Mascouche,
Que
Piper PA-28-140
Take-off
Loss of control
A01Q0009
15
Porteau Cove,
B.C.
Sikorsky S-61N
Climb
Loss of main-rotor drive A01P0003
20
Victoria, B.C.,
6 nm S
Cessna 172M
En route
Loss of control—
pilot incapacitation
A01P0010
24
Toronto /
Boeing 747-430
Lester B. Pearson
Int’l Airport, Ont.
Taxiing
Collision
A01O0021
24
Near Edmonton, Cessna 560
Alta., VORTAC
Boeing 747-400
En route
ATS-related event
A01W0015
NOVEMBER
01
DECEMBER
02
JANUARY 2001
13
38
REFLEXIONS
February 2002
En route
DATE
FEBRUARY
15
20
MARCH
05
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Colombo,
Sri Lanka
Airbus A330-300
En route
Component/systemrelated incident
A01F0020
Val d’Or, Que.
Piper PA-31-350
Approach
Loss of control
A01Q0034
Sydney, N.S.,
23 nm SE
Boeing 767-300
En route
Loss of separation
A01H0002
Boeing 767-400
En route
14
St. John’s Int’l
Airport, Nfld.,
1.5 nm ESE
Piper PA-30
Take-off
Collision with terrain
A01A0022
15
Victoria Int’l
Airport, B.C.
Schweizer 269B
(300B)
Landing
Loss of control—
tail-rotor drive
decoupling
A01P0047
15
Vancouver Int’l
Airport, B.C.
de Havilland
DHC-8-200
Approach
Loss of separation
A01P0054
Airbus A319-114
Approach
Manoeuvring
Main-rotor blade
failure
A01P0061
Loss of separation
A01Q0053
25
Eclipse Camp,
B.C.
McDonnell
Douglas 369D
27
Massena, N.Y.
Canadair
En route
CL-600-2B19 (RJ)
Airbus A310-300
En route
Piaggio P.180
En route
Teslin, Y.T.
Cessna 215F
En route
Controlled flight
into terrain
A01W0073
Sydney, N.S.,
65 nm W
de Havilland
DHC-8-100
En route
Power loss—
first engine
A01A0030
04
St. John’s Int’l
Airport, Nfld.
Boeing 737-200
Landing
Landing event
A01A0028
04
Toronto /
Buttonville
Municipal
Airport, Ont.,
10 nm NW
Robinson
R22 BETA
Landing
Loss of control—
collision with terrain
A01O0099
30
APRIL
03
REFLEXIONS
February 2002
39
DATE
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Baker Lake, Nun., McDonnell
26 nm N
Douglas 369E
En route
Forced landing—
dynamic roll-over
A01C0064
New
Westminster,
B.C.
Airbus A320
Take-off
Air proximity—
safety not assured
A01P0111
Cessna 172M
Manoeuvring
16
Abbotsford,
B.C., 10 nm E
Robinson
R22 BETA
Manoeuvring
Loss of control
A01P0100
22
Yellowknife,
N.W.T.
Boeing 737-200
Landing
Landing event
A01W0117
25
Russell, Man.
Piper PA-28-140
Take-off
Engine power loss—
collision with trees
A01C0097
25
Red Earth Creek,
Alta., 33 nm NE
Cessna T310Q
Manoeuvring
Loss of control
A01W0118
31
Edmonton, Alta.
Boeing 747-200
En route
Loss of separation
A01W0129
Airbus A340-300
En route
Charlottetown,
P.E.I.
Piper PA-31
Take-off
Collision with terrain
A01A0058
Duxar
Intersection,
N.W.T.,
110 nm NW
Boeing 737-200
En route
ATS-related event
A01P0126
McDonnell
Douglas
DC-10-30
En route
Boeing 767
Approach
Air proximity
A01P0127
Airbus A340-300
Approach
Boeing 767-300
En route
Loss of separation
A01C0115
Boeing 747-300
En route
APRIL
28
MAY
12
JUNE
05
08
09
LOCATION
Vancouver Int’l
Airport, B.C.
10
Winnipeg ACC,
Man.
TYPE OF
AIRCRAFT
14
Victoria Int’l
Airport, B.C.
Bombardier
CL-600-2B19
Approach
ILS false localizer
capture
A01P0129
15
Empress, Alta.,
5 nm W
Boeing 737-200
En route
Loss of separation
A01W0144
Boeing 737-200
En route
40
REFLEXIONS
February 2002
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Toronto /
Buttonville
Municipal
Airport, Ont.,
1.4 nm WNW
Cessna 172N
Take-off
Engine stoppage
A01O0157
18
Lake Lavieille,
Ont.
Cessna 210
En route
Collision with terrain
A01O0165
20
Uxbridge, Ont.
Cessna 170B
Take-off
Collision with moving
aircraft
A01O0164
Robinson R22
En route
Roberval, Que.,
80 nm N
Bell 212
En route
Power loss—other
engine
A01Q0105
Empress, Alta.,
20 nm W
Boeing 737-200
En route
ATS-related event
A01W0160
Fokker F28
Mk 1000
En route
JUNE
17
27
JULY
04
07
Nestor Falls,
Ont., 2 nm NW
de Havilland
DHC-2 Mk. I
En route
Altitude-related event
A01C0152
13
Red Lake, Ont.,
35 nm SE
Boeing 757-200
En route
ATS-related event
A01C0155
Airbus A320-200
En route
Aerostar RX-7
Taxiing
Collision with object
A01O0200
14
Gloucester, Ont.
18
Cultus Lake, B.C. Cessna U206G
Landing
Overturned on water
landing
A01P0165
18
Dorval /
Montréal Int’l
Airport, Que.,
6 nm NE
Cessna 172N
En route
Risk of collision
A01Q0122
de Havilland
DHC-8-102
En route
20
Corcaigh Int’l
Airport, Cork,
Ireland
Boeing 727-200
Take-off
Component/system—
related incident
A01F0094
22
Abbotsford,
B.C.
Pilatus PC-6T
Take-off
Power loss—first
engine
A01H0003
23
Port Hardy, B.C., Cessna 421
48 nm E
de Havilland
DHC-7
En route
Air proximity
A01P0171
En route
REFLEXIONS
February 2002
41
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Haines Junction,
Y.T., 25 nm SW
Cessna 185F
En route
Collision with terrain
A01W0186
Grande Cache,
Alta., 13 nm W
Aerospatiale
AS 350BA
Approach
Operations-related
event
A01W0190
Timmins, Ont.,
1.2 nm N
Cessna 182Q
Approach
Collision with terrain
A01O0210
04
Fort Lauderdale,
Fla.
Boeing 737-200
En route
Power loss—first
engine
A01F0101
09
Baffin Island,
Nun.
McDonnell
Douglas 369D
(500D)
Manoeuvring
Collision with terrain
A01Q0139
13
Juniper Station,
N.B., 42 km NE
Bell 206B
Take-off
Loss of control
A01A0100
13
Mackenzie Lake,
B.C., 2.5 nm N
de Havilland
DHC-2 Mk. I
Manoeuvring
Weather-related event
A01P0194
20
Valemount,
B.C., 37 nm SE
Helio H-295
En route
Airframe failure
A01P0203
24
Invermere, B.C.
Pitts S2A-E
Take-off
Power loss
A01P0207
SEPTEMBER
02
Red Lake, Ont.
Pilatus PC-12
Take-off
Component/system
malfunction
A01C0217
13
Swan Lake
Airstrip, Y.T.
Beech UC45-J
Take-off
Collision with terrain
A01W0239
27
Winnipeg Int’l
Airport, Man.,
2 nm N
Beech 95
Approach
Loss of control
A01C0230
Fort Simpson,
N.W.T., 5.5 nm
WNW
McDonnell
Douglas 369HS
Approach
Operations-related event A01W0255
08
Mont-Joli, Que.,
23 nm S
Piper PA-23
En route
Collision with terrain
A01Q0165
08
Mollet Lake,
Que.
de Havilland
DHC-2 Mk. I
Landing
Collision with terrain
A01Q0166
JULY
26
30
AUGUST
03
OCTOBER
05
42
REFLEXIONS
February 2002
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
OCCURRENCE
NO.
Shamattawa,
Man., 1 nm N
Fairchild
SA226-TC
Approach
Collision with terrain
A01C0236
15
Fort Liard,
N.W.T.
Piper PA-31-350
Unknown
Collision with terrain
A01W0261
23
Toronto /
Boeing 767-200
Lester B. Pearson
Int’l Airport, Ont.
Landing
Runway incursion
A01O0299
24
Peace River, Alta. de Havilland
DHC-8-100
Approach
Diversion in-flight
A01H0004
Inuvik, N.W.T.,
4 nm NE
Approach
Loss of control—
fixed wing
A01W0269
Cranbrook, B.C., Aerospatiale
20 nm NW
AS 315G
Manoeuvring
Operations-related event A01P0282
Boundary Bay
Airport, B.C.
Cessna 152
Take-off
Component/systemrelated event
A01P0296
Victoria VOR,
B.C., 5 nm N
Piper PA-31-350
En route
ATS-related event
A01P0305
Cessna 208B
En route
OCTOBER
11
NOVEMBER
02
08
DECEMBER
03
11
Cessna 208B
18
Yellowknife
Airport, N.W.T.,
3 nm E
Eurocopter
EC 120B
Approach
Power loss—first
engine
A01W0297
31
Fort Good Hope,
N.W.T., 25 nm S
Cessna 172N
En route
Collision with terrain
A01W0304
REFLEXIONS
February 2002
43
Final Reports
The following investigation reports were approved between 01 May 2000 and 31 December 2001.
*See article or summary in this issue.
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
97-07-30
Bear Valley, B.C.
Bell 206B
En route
Collision with
terrain
A97P0207
97-09-06
Beijing, China
Boeing
767-375 ER
Take-off
Uncontained
engine failure
A97F0059
97-10-30
Comox Lake,
B.C.
Boeing
Vertol BV-234
Manoeuvring
Flight control
system
malfunction
A97P0303
98-02-26
Saint-Hubert
Airport, Que.
Cessna 172
Take-off
Midair collision
A98Q0029
Diamond
DA 20-A1
98-04-25
Québec /
Jean-Lesage Int’l
Airport, Que.
de Havilland
DHC-8-102
En route
Jamming of
elevators
in flight
A98Q0057*
98-06-20
Victoria, B.C.
Piper PA-24
Approach
Loss of
separation and
operating
irregularity
A98P0164
Piper PA-30
Fairchild
SA-226-TC
44
98-07-15
Saturna Island,
B.C.
de Havilland
DHC-2 Mk. I
Overshoot
Loss of control,
collision
with water
A98P0194
98-07-18
Lake SaintFrançois, Que.
Cessna 152
Manoeuvring
Spin, loss of
directional
control
A98Q0114
98-08-04
Kincolith, B.C.
de Havilland
DHC-2
Landing
Collision
with water
A98P0215*
98-08-13
Windsor, Ont.,
3 nm E
Bell 47G-2
Manoeuvring
In-flight mainrotor blade
separation
A98O0214
REFLEXIONS
February 2002
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
98-11-12
Toronto / City
Centre Airport,
Ont.
Piper PA-23-250
Manoeuvring
Loss of control,
stall
A98O0313
98-11-23
Mount Tuam,
B.C.
Cessna 208B
En route
Controlled
flight into
terrain
A98P0303
98-12-03
Iqaluit, Nun.
Hawker Siddeley
HS-748-2A
Take-off
Rejected takeoff, runway
overrun
A98Q0192
98-12-17
Terrace Airport,
B.C
Canadair
CL-600-2A12
Landing
Risk of collision
with airport
maintenance
vehicle
A98H0004*
98-12-30
St. John’s, Nfld.
Dassault-Breguet
Falcon 20 D
Approach
Collision with
trees
A98A0191*
99-01-04
Saint-Augustin,
Que.
Beech 1900C
Approach
Controlled
flight into
terrain
A99Q0005
99-01-13
Mayne Island,
B.C
Douglas DC-3C
En route
Controlled
flight
into terrain
A99P0006
99-01-18
Langruth, Man.,
35 nm W
Boeing 767-233
En route
Loss of
separation
A99H0001
Boeing 767-300
99-02-19
Slave Lake, Alta., Beech King
3 nm NW
Air C90
Approach
Controlled
flight into
terrain (lake)
A99W0031*
99-03-10
Calgary Int’l
Airport, Alta.
Landing
Wing strike
A99W0043
Boeing 727-200
REFLEXIONS
February 2002
45
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
99-03-19
Davis Inlet,
Nfld., 2 nm
NNE
de Havilland
DHC-6-300
Approach
Controlled
flight into
terrain
A99A0036
99-04-06
Valentia, Ont.
Cessna 152
Manoeuvring
Loss of control,
spiral
A99O0079
99-04-13
Gaspé, Que.
Cessna 335
Approach
Loss of control
A99Q0062
99-04-28
Fairview, Alta.,
10 nm E
Aerospatiale
AS 355 F1
Approach
In-flight fire
A99W0061
99-05-01
Points North
Landing, Sask.,
22 nm NW
de Havilland
DHC-3
Take-off
Collision with
terrain
A99C0087
99-05-01
Calgary, Alta.,
6 nm NE
Airbus A320
Approach
Loss of
separation
A99W0064
Boeing 737-200
46
99-05-16
108 Mile Airport, Cessna 172D
B.C.
Cessna 172
Approach
Midair collision
A99P0056
99-05-24
Parry Sound /
Georgian Bay
Airport, Ont.,
1 nm W
Mitsubishi
MU-2B-40
Unknown
Collision with
terrain
A99O0126*
99-06-07
Winnipeg Int’l
Airport, Man.,
5 nm W
Piper PA-31
En route
Loss
of separation
A99H0003
Mooney M20C
99-06-09
Pelican Narrows, Sikorsky S55B/T
Sask., 16 nm NW
Manoeuvring
Power loss,
forced landing
A99C0127
99-06-25
Long Haul Lake,
Man.
Landing
Loss of engine
power, collision
with terrain
A99C0137
REFLEXIONS
February 2002
de Havilland
DHC-3
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
99-07-04
Kaslo, B.C.,
35 nm NW
Bell 214B
Manoeuvring
Power loss,
fuel starvation
A99P0075
99-07-11
St. Andrews,
Man., 2 nm SE
Mooney M20F
Manoeuvring
Loss of control,
collision with
terrain
A99C0157
99-07-11
Saint-Mathiasde-Richelieu,
Que.
Cosmos
Phase II ES
Manoeuvring
Loss of control,
collision with
terrain
A99Q0134
99-08-15
Squamish,
B.C., 3 nm W
Eurocopter
AS 350BA
Manoeuvring
Collision with
terrain
A99P0105
99-08-20
Penticton, B.C.
Cessna 177RG
Manoeuvring
Midair collision
A99P0108
Mooney M20C
99-08-29
Princess
Harbour, Man.
Piper PA-31-350
En route
Engine power
loss, forced
landing
A99C0208
99-09-24
St. John’s, Nfld.
Airbus A320-211
Landing
Landing short
A99A0131
99-10-02
Pickle Lake,
Ont., 6 nm N
de Havilland
DHC-2
Approach
Fuel
contamination,
loss of engine
power
A99C0245
99-10-10
Bancroft, Ont.,
1 nm W
Cessna 172M
Approach
Collision with
terrain
A99O0242
99-10-13
Temagami,
Ont., 6 nm S
Cessna A185F
En route
Collision
with object
(wirestrike)
A99O0244
99-10-15
Halifax Int’l
Airport, N.S.
de Havilland
DHC-8-100
Approach
Operating
irregularity
A99H0005
ATR 42-300
REFLEXIONS
February 2002
47
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
99-11-20
Cloverdale, B.C.
ERCO
Aircoupe 415C
Manoeuvring
In-flight
collision
A99P0168
Cessna 152
48
99-11-22
Dryden, Ont.
Fairchild Metro
SA-227-AC
Landing
Runway
overrun,
collision with
approach lights
A99C0281
99-12-24
Calgary Int’l
Airport, Alta.
Airbus A320-211
En route
Engine fire
A99W0234
99-12-28
Abbotsford
Airport, B.C.
Cessna 208
Take-off
Loss of control
A99P0181
00-01-13
Lake Adonis,
Que.
de Havilland
DHC-2 Mk. I
Unknown
Collision with
terrain
A00Q0006
00-01-20
Goldbridge, B.C. Eurocopter SA
315B
En route
Power loss
A00P0010
00-02-07
Williston Lake,
B.C.
Piper PA-31-350
En route
Controlled
flight onto ice
A00P0019
00-02-21
Prince George,
B.C., 20 nm S
Schweizer 269C
Manoeuvring
Engine power
loss,
mechanical
malfunction
A00P0026
00-03-13
Toronto /
City Centre
Airport, Ont.,
18 nm NE
Cessna 172
En route
Midair collision
A00O0057
00-03-17
Ennadai Lake,
Nun.
Douglas DC-3
Take-off
Loss of control
on go-around
A00C0059
00-03-17
Smoothstone
Lake, Sask.,
10 nm SE
Cessna 180J
Approach
Loss of control,
collision with
terrain
A00C0060
00-03-23
Innisfail Airport, Rotorway Exec 90 Unknown
Alta.
Loss of control
A00W0072
REFLEXIONS
February 2002
Cessna 337
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
00-03-31
Victoria Int’l
Airport, B.C.,
8 nm N
de Havilland
DHC-6
En route
Air proximity
event
A00P0047
En route
Loss of
separation
A00H0002
Cessna 172
00-04-11
Sydney, N.S.,
95 nm N
Airbus A340
Airbus A340
00-04-11
Maniwaki, Que.
Cessna 172L
En route
Incorrect
assembly of
aileron control
system
A00Q0043
00-04-15
Fox Lake, Y.T.
Cessna 172RG
En route
VFR flight into
terrain, reduced
visibility
A00W0080
00-04-27
Beloeil, Que.
Bell 206B-III
Manoeuvring
In-flight break-up A00Q0046
00-05-06
Sydney, N.S
Piper PA-28
Take-off
Loss of control,
stall
A00A0071
00-05-10
Abbotsford, B.C. Bell 47G-2
Take-off
Tail-rotor
gearbox
malfunction
A00P0077
00-05-10
Cabot Island,
Nfld.
Bell 212
En route
Collision with
water
A00A0076
00-05-11
Edmonton Int’l
Airport, Alta.
Douglas DC-9
Take-off
Rejected take-off,
runway overrun
A00W0097
00-05-20
Resolute, Nun.,
35 nm SW
Bell 206L
Take-off
Loss of control,
collision with
level ice
A00C0099
00-05-27
Dorval /
Montréal Int’l
Airport, Que.,
5 nm W
Boeing 767-233
Approach
A00H0003
Cessna 650
Take-off
Loss of
separation,
safety not
assured
Cessna 177B
Take-off
Loss of control,
stall
A00W0109
00-05-30
Calling Lake,
Alta.
REFLEXIONS
February 2002
49
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
00-05-30
Tofino, B.C.,
17 nm E
McDonnell
Douglas MD-80
En route
Loss of
separation
A00P0090
Boeing 747-400
50
00-06-01
Kamloops, B.C.,
3 nm N
Stits Playmate
SA-11A
En route
Collision with
terrain
A00P0094
00-06-01
Helmut, B.C.
Bell 206B
Approach
Collision with
fence
A00W0105
00-06-12
Kelowna, B.C.,
120 nm NE
Boeing 737-200
En route
Cabin
depressurization
A00P0101
00-06-13
Peterborough
Airport, Ont.,
0.5 nm W
Dassault-Breguet
Falcon 20E
Approach
Controlled
flight into
terrain
A00O0111
00-06-13
McIvor Lake,
B.C.
Cessna 180E
Manoeuvring
Loss of control
A00P0099
00-06-19
Hotnarko Lake,
B.C.
de Havilland
DHC-2
Take-off
Loss of control
A00P0103
00-06-22
Llewellyn Glacier, Bell 206L-3
B.C.
Manoeuvring
Collision with
terrain
A00P0107
00-07-01
Fort Steele, B.C.
Bellanca 65-CA
Take-off
Loss of control
A00P0115
00-07-17
Harding, Man.
Piper PA-25-150
Manoeuvring
Loss of control,
collision with
terrain
A00C0162
00-07-23
Dorval /
Montréal Int’l
Airport, Que.
Boeing 747-200
Landing
Runway
excursion
A00Q0094
00-08-14
Teslin Lake, B.C.
Cessna 208
Take-off
Loss of control,
collision with
water
A00W0177
00-08-17
Green Lake, B.C. Cessna 185F
Take-off
Collision with
water
A00P0157
00-08-26
Dorval /
Montréal Int’l
Airport, Que.
Taxiing
Runway
incursion
A00Q0114
REFLEXIONS
February 2002
Airbus A319-114
Canadair CL-600 Approach
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
00-08-29
Dorval /
Montréal Int’l
Airport, Que.,
1 nm W
Airbus A319-114
Take-off
Risk
of collision
A00Q0116
Cessna 152
En route
Lumsden, Sask.,
45 nm W
Boeing 747-400
En route
Loss
of separation
A00C0211
00-09-06
Airbus A319-114
00-09-13
Toronto /
Airbus A320-232 Take-off
Lester B. Pearson
Int’l Airport,
Ont.
Fan cowl
separation
A00O0199
00-09-13
Kingston, Ont.
Cessna 150G
Manoeuvring
Difficulty to
control
A00O0210
00-09-14
Vancouver
Harbour
Heliport, B.C.
Sikorsky
S-61N/SP
Take-off
Input freewheel unit
malfunction
A00P0182
00-09-15
Ottawa /
MacdonaldCartier Int’l
Airport, Ont.
Boeing
727-200A
Landing
Runway
overrun
A00H0004
00-09-28
Smithers, B.C.,
80 nm NW
Cessna 185F
Manoeuvring
Controlled
flight into
terrain
A00P0194
00-10-02
Golden, B.C.,
3 nm NNE
Cessna 310R
Manoeuvring
Loss of control
A00P0195
00-10-02
Ottawa, Ont.
Diamond
DA 20-A1
En route
Engine failure,
forced landing
A00O0214
00-10-02
Fort Nelson,
B.C., 90 nm E
Eurocopter AS
350BA
En route
Power loss,
mechanical
malfunction
A00W0215
00-10-08
Port Radium,
N.W.T.
Short Brothers
SC-7
Approach
Collision with
terrain
A00W0217
00-10-12
Rendell Creek
Airstrip, B.C.
Piper PA-24-250
Take-off
Collision with
terrain
A00P0197
REFLEXIONS
February 2002
51
52
DATE
LOCATION
TYPE OF
AIRCRAFT
PHASE OF
FLIGHT
EVENT
REPORT NO.
00-10-25
Vancouver Int’l
Airport, B.C.
de Havilland
DHC-8-100
Standing
Runway
incursion
A00P0206
de Havilland
DHC-8-200
Take-off
00-10-31
Mt. Modeste,
B.C., 5 nm NW
McDonnell
Douglas
MD 369D
En route
Main-rotor
blade failure
A00P0208
00-11-06
Winnipeg Int’l
Airport, Man.,
2 nm S
Piper PA-31-350
Approach
Collision with
terrain
A00C0260
00-11-13
Fredericton,
N.B.
Boeing 737-217
Landing
Engine failure
A00A0176
00-12-02
Vancouver, B.C.,
30 nm NW
Learjet 35A
En route
Loss of
aileron control
A00P0225
00-12-04
Ottawa /
Gatineau
Airport, Que.
Beechcraft
King Air A100
Landing
Gear-up landing
A00H0007
00-12-31
Okanagan
Mountain, B.C.
Piper Aerostar
602P
Approach
Controlled
flight into
terrain
A00P0244
01-01-13
Mascouche, Que. Piper PA-28-140
Take-off
Loss of control
A01Q0009
01-01-20
Victoria, B.C.,
6 nm S
Cessna 172M
En route
Loss of control
A01P0010
01-03-15
Victoria Int’l
Airport, B.C.
Schweizer 269B
Landing
Loss of control,
tail-rotor drive
decoupling
A01P0047
01-03-30
Teslin, Y.T.
Cessna 210F
En route
Controlled flight
into terrain
A01W0073
REFLEXIONS
February 2002
TRANSPORTATION SAFETY
REFLEXIONS
A
I
R
THE CONFIDENTIAL
TRANSPORTATION SAFETY REPORTING PROGRAM
Issue 25 – February 2002
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Transportation Safety Board
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TSB aviation regional offices can be reached during working hours (local time)
at the following phone numbers:
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Phone:
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Fax:
(819) 997-2239
GREATER HALIFAX,
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Phone:
(902) 426-2348
Fax:
(902) 426-5143
MONTRÉAL, Quebec*
Phone:
(514) 633-3246
Fax:
(514) 633-2944
GREATER TORONTO, Ontario
Phone:
(905) 771-7676
Fax:
(905) 771-7709
WINNIPEG, Manitoba
Phone:
(204) 983-5991
Fax:
(204) 983-8026
EDMONTON, Alberta
Phone:
(780) 495-3865
Fax:
(780) 495-2079
GREATER VANCOUVER,
British Columbia
Phone:
(604) 666-4949
Fax:
(604) 666-7230
After-hours emergency
reporting: (819) 997-7887
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