AVIATION SAFETY LETTER In this issue...

AVIATION SAFETY LETTER In this issue...
TP 185E
Issue 3/2014
AVIATION SAFETY LETTER
In this issue...
Guest Editorial—Unmanned Air Vehicles (UAVs)
To The Letter—A Life Saving Course
COPA Corner—Winter Flying Woes
Situations That Could Lead to Mistakes
A Squirrel, a Moose and Loss of Control in
Helicopter Accidents
Bell 204 Tail Rotor Pitch Link Bolt Failure…
CASA 2014-03: Using SMS to Address Hazards and Risks
Associated With Unstable Approaches
Inadvertent IMC and Spatial Disorientation: Deadly
Combination for Low-Time Pilot
TSB Final Report Summaries and Accident Synopses
2014 Flight Crew Recency Requirements—Self-Paced
Study Program
Learn from the mistakes of others;
You’ll not live long enough to make them all yourself…
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Aviation Safety Letter
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ISSN: 0709-8103
TP 185E
Table of Contents
Section
page
Guest Editorial ......................................................................................................................................................................
To The Letter ........................................................................................................................................................................
COPA Corner—Winter Flying Woes ...................................................................................................................................
Situations That Could Lead to Mistakes ...............................................................................................................................
A Squirrel, a Moose and Loss of Control in Helicopter Accidents .......................................................................................
Bell 204 Tail Rotor Pitch Link Bolt Failure… ......................................................................................................................
CASA 2014-03: Using SMS to Address Hazards and Risks Associated With Unstable Approaches ..................................
Answers to the 2014 Self-Paced Study Program ..................................................................................................................
Poster—Interference With Crew Members Will Not Be Tolerated ......................................................................................
Inadvertent IMC and Spatial Disorientation: Deadly Combination for Low-Time Pilot ......................................................
TSB Final Report Summaries ...............................................................................................................................................
Accident Synopses ................................................................................................................................................................
Poster—Cats Can See in The Dark… You Can't. .................................................................................................................
Poster—Each Taxi Scenario is Different! Be Sure!..........................................................................................................….
2014 Flight Crew Recency Requirements—Self-Paced Study Program……………………………………………… .......
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Guest Editorial
Unmanned Air Vehicles (UAVs)
Transport Canada (TC) has seen a significant increase in the number of media calls and
inquiries related to safety and the regulatory processes which govern the use of UAVs in
Canada. UAVs are regulated under the Canadian Aviation Regulations (CARs). There are
two fundamental streams based on intended use, which in turn affects the terminology. Any
unmanned aircraft used for recreational purposes only is known as a “model aircraft”. Any
unmanned aircraft used for non-recreational or commercial purposes only is known as an
“unmanned air vehicle (UAV) system”.
A UAV System operator, regardless of UAV weight, is required to apply for a Special Flight
Operations Certificate (SFOC). A SFOC details the operating conditions and identifies the
safety parameters within which the operator will fly the UAV. A model aircraft operator does
not need a SFOC as long as the aircraft weighs 35 kg (77 lbs) or less. Once a Model Aircraft
weighs more than 35 kg (77 lbs), it falls under the rules of a UAV System, and its operator is
then required to apply for a SFOC.
A lack of understanding and clarity existed around when a SFOC was required, and the SFOC
application process. This, combined with recent incidents involving UAVs flying too close to
airports and other aircraft, has suggested that all operators—both recreational and nonrecreational—required improved guidance to: encourage the safe operation of UAVs; reduce
Martin J. Eley
the risk to the public, property, and other airspace users; and encourage regulatory compliance among
non-recreational operators. A working group was put together to address those issues in early summer 2014.
To improve awareness and encourage compliance without delay, TC launched a variety of communications tools to support this
including: a new comprehensive Web site—www.tc.gc.ca/safetyfirst—and social media messaging; increased outreach and
communication with operator associations and interest groups; the development of new published materials to support awareness of
the SFOC process; and increased participation at UAV industry events. The new Web site includes an easy-to-use infographic chart to
help UAV operators or prospective operators to understand the rules and find out if they need permission to fly, and also provides a
link to the SFOC application instructions.
A longer-term plan included the development and implementation of a risk-based UAV strategy. The strategy supports the
consideration of key factors—location and complexity of UAV operations—as opposed to the type of operation (recreational vs. nonrecreational) in determining suitability for or requirement of an SFOC as these physical characteristics most often influence a UAV’s
risk to people or property on the ground and to other airspace users. The objective of this approach is to facilitate all UAV operations,
reduce the administrative burden of the SFOC process, preserve the department’s enforcement capacity and allow inspectors to focus
on high-risk operations.
As a result, on November 27, 2014, TC issued two new advisory circulars (AC) in support of the UAV strategy. AC No. 600-002,
titled “General Safety Practices—Model Aircraft and Unmanned Air Vehicle Systems”, and AC No. 600-004 titled “Guidance Material
for Operating Unmanned Air Vehicle Systems under an Exemption”. The two ACs should be read in conjunction with each other and
are must-read materials for all UAV operators. They are the result of an extensive review by our UAV and regulatory specialists.
These new documents address—among other issues—terminology, safety considerations, applicability and two new SFOC
exemptions for operations of UAV systems. The first SFOC exemption is for UAVs with a maximum take-off weight not exceeding
2 kg (4.4 lbs); and the second exemption is for UAVs with a maximum take-off weight exceeding 2 kg (4.4 lbs), but not exceeding
25 kg (55 lbs). There is no change to the model aircraft category, which requires a SFOC only if the model aircraft has a maximum
take-off weight exceeding 35 kg (77 lbs).
ASL 3/2014
3
We invite all current and prospective UAV operators to familiarize themselves with both new ACs and the www.tc.gc.ca/safetyfirst
Web site. We look forward to continue building awareness and improve regulatory processes—both activities which contribute to
improved understanding among UAV operators across Canada and, in turn, support a safe airspace for all aviators and Canadians.
Martin J. Eley
Director General
Transport Canada, Civil Aviation
To The Letter
A life saving course
So there I was, hanging upside down in an
inverted C180 floatplane, water over my head,
and pondering my next move. First on the list
was selecting an available exit route. Sliding
my hand along the door till I felt the handle,
I figured I now had it made. Moving the door
lever went fine right up to the part where the
door refused to open. I wasn't sure if it was bent
and therefore jammed shut, or if water pressure
was the culprit. Either way, it was not the most
encouraging development and necessitated a
brief suppression of severe anxiety in order to
concentrate on plan B.
Knowing that the window latch was nearby,
I slid my hand along to it and with a quick twist
and push was greeted with a deluge of seawater
flooding into the cockpit. It was at that point
that I'd just about had enough excitement;
I pulled the seat belt latch with one hand while
Don't wait for this to happen before taking underwater egress training…
firmly grasping the exit window with my other
harnesses, a serious impact injury might have hindered my
hand so as not to get lost on the way out. Half way out the
physical ability to escape. Without the egress training, there
window, while I was partly blind, totally immersed and still
would have been no routine to follow and panic would most
holding my breath, came the last challenge!
certainly have become the order of the day, followed by
drowning.
My headset was still attached and although it kept my ears
warm, the cords were still plugged in and didn't want to let go.
Alex Foley
One final rush of adrenaline, a pull on the headset, a kick
Vancouver, B.C.
against the seat and I was out the window and suddenly
Thank you Alex for your testimonial in support of underwater
paddling above water between the inverted floats.
egress training, shoulder harnesses and the wearing of life
The float spreader bar offered a nice place to sit while waiting
jackets at all times when flying over water. We can never
for a nearby boater to pick me up. Although I was wearing a
repeat these messages enough.—Ed.
life jacket, I realized that I'd never inflated it! In fact, the
personal flotation device (PFD) was not a hindrance to my

escape, even though I went out the window.
The moral of this story is that I owe my life to Bryan Webster
and his team of egress training experts along with the
installation of shoulder harnesses in the airplane. Without the
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ASL 3/2014
COPA Corner—Winter Flying Woes
by Ken Armstrong
Winter flying is less understood and more hazardous to pilots
than summer aviating for many reasons. The weather tends to
be worse; the aircraft requires extra attention before it is ready
for flight; and poor weather days generally make pilots less
proficient and more impatient. As a result, more care must be
taken with preflight planning and aircraft handling.
Nonetheless, it is not necessary to be like many aviators who
hang up their wings when the temperature nears freezing.
Some of the best flying weather occurs during the clear, cool
winter months. In these conditions, the air is smooth, the
visibility outstanding and aircraft performance seems
"supercharged".
Preflight planning
Weather makes a big difference; it forces us to consider many
aspects during flight planning that we normally wouldn't think
about. Are the runways at your departure and arrival airports
clear of snow? If there is residual ice on the runway, will your
directional control be jeopardized by actual or forecast
crosswinds? These are factors you may not be inclined to
consider in the summer months. Are forecast fronts
approaching that will reduce ceilings and visibilities to
impassable limits? Remember that moderate snow will
typically produce a half mile visibility.
During your preflight checks, ensure that the static ports are
clear, the pitot heat is functioning and that the aircraft lighting
(including backup flashlight) is serviceable as limited hours of
daylight could lead to a flight in darkness. The entire
aircraft—not just the wings and control surfaces—should be
free of ice and snow. Accumulations of ice can drastically
affect the centre of gravity and the controllability of the
aircraft. Because you shouldn't use scrapers or chemically
aggressive de-icers on the windshield, it is wise to cover these
areas with a water-shedding cover if your aircraft is stored
outside. Ensure that the hidden areas around the brakes and
controls are free of ice that might impede their operation.
adequate—especially if a quilted or insulated blanket is placed
over the cowling to retain the heat. Consider preheating the
cabin to avoid the misting/frosting of windows and the
instrument panel that occurs when occupants exhale in a cold
cabin. Wheel pants should be removed lest snow or slush melt
on the hot brakes and then refreeze later. I accomplished a
short field landing of less than 50 ft in a Cessna 206 with
frozen brakes during a sales demo. The clients were very
impressed with the shortness of the Super Skywagon's skid—
unfortunately the tires needed replacing due to the resulting
flat spots.
To protect your engine, ensure that the winter kit is installed
on your aircraft to avoid a super-cooled engine during descent
and a vapour-ice clogged oil breather. The latter can often be
avoided by making a small hole part way up the breather tube,
but be sure to follow the advice offered by the manufacturer's
instructions or your qualified mechanic.
Before attempting to start, pull the propeller through numerous
times to reduce your oil's friction and thereby increase starting
ease. Be sure to follow the manufacturer's starting instructions,
and stroke hard on the primer for maximum fuel atomization
to ensure combustion.
Consider preheating the battery, spark plugs and oil if really
cold weather is forecast. Ensure your aviation fuel has
anti-icing additives. A 1% concentration of isopropyl alcohol
per volume of fuel should absorb water. Avoid letting water
accumulate in the aircraft fuel tank. When flying in cold
weather, the water may freeze in the lines and stop fuel flow.
It is wise to carry jumper cables in case of emergency as it is
very difficult to hand start an engine when the oil is cold and
viscous like glue. If your battery does become drained, take it
into warm storage for charging as it could freeze and split the
case if left out in sub-zero weather when it is discharged.
And while you're checking your aircraft over, be sure to check
out the central processing unit—you! Be sure to have
sunglasses available to avoid the intense glare of
snow-reflected light. With shorter days, a pilot should polish
up his night flying skills lest his planned flight be delayed,
thereby necessitating a night landing.
Use a multi-viscosity oil (such as 20W50) to ensure all
temperature lubrication. This oil will be thin enough to start a
cold engine and thick enough to provide good lubrication
when operating temperatures are reached. Preheat the engine if
below freezing temperatures are anticipated prior to your
flight. A light bulb or car heater under the oil pan is usually
Keep up to date with forecasts as they often change rapidly,
and be sure to dress in suitable clothes for weather conditions
on the ground and in the air. Also, consider the possibility of
being forced to land at a location other than your destination
due to weather or unserviceability and carry clothing that
would be acceptable for a survival situation.
ASL 3/2014
5
Warm up, taxi and take off considerations
Air-cooled engines have larger tolerances than their liquidcooled brethren because they go through more contractions
and expansions with temperature changes. Treat your engine
like your life depended on it, and use low power settings until
the engine warms up. Taxi slowly and turn slower than you
normally would on dry pavement. Use small amounts of
power to avoid skids and tossing slush and snow onto the
airframe where it might stick and freeze. Be sure to check
brakes and traction often, but avoid heating the brakes up as
they might melt snow into the brake mechanism which may
subsequently freeze. If the ground surface is slippery, be
prepared to do the high power portion of the engine run-up on
the roll. The take-off technique should be similar to the
soft/short field method, allowing the aircraft to quickly climb
out of the snow/slush. Otherwise, there will be wheel drag and
the take-off distance will be significantly extended. Level off
after lift-off to blow snow and slush off the wheels and brakes.
If you are flying a retractable, leave the gear down to avoid a
snow job.
Watch out for signs of possible congealing in the oil cooler by
monitoring oil temperature and pressure readings. If the oil
becomes too cold in the cooler, it will thicken to the point
where it no longer flows. In these conditions, the oil
temperature will start to rise rapidly and the pressure will
begin to drop. To overcome this situation, raise the nose to
reduce the cooling effect of the airflow and land as soon as
possible if the temperature and pressure do not return to
normal.
Descent and landing considerations
Use partial power descents to keep engine temperatures within
limits and to avoid cracked cylinders in air temperatures that
create shock-cooling scenarios that can demand expensive
overhauls. If the landing surface is snow covered, make a low
pass at manoeuvring speed to check the depth and for signs of
use. If you see tracks, ensure they are made by an aircraft
similar to the one you are flying and not by two-tracked, fourwheeled vehicles that can handle much deeper snow. Check
for snow drifts across the runway and for snow banks
alongside the runways or taxiways that are high enough to
damage your aircraft. Beware of flat light that could adversely
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ASL 3/2014
ZGuest Editorial
ASL/3/2014
affect your depth perception. Your approach should be similar
to a soft/short landing with touchdown occurring at the
minimum flying speed to minimize possible undercarriage
damage. Landing at the minimum speed will also reduce the
risk of hydroplaning on wet slush and the stopping distance on
ice-covered surfaces. One inch of slush can add 50% to your
landing distance requirement. The low touchdown speed also
puts more weight on the wheels, thereby improving braking.
Pilots should employ as much flap as possible (considering
crosswind limits) to minimize touchdown speed, and these
flaps should be raised as soon as practical after touchdown to
improve braking. If you are not down on the runway, in full
control, on the first third or less of the runway, go around for a
better approach/touchdown. Decrease speed as quickly as
possible to a slow taxi. You don't want to roll quickly to the
end of the runway only to find that it is ice covered and that
you have an imminent appointment with the approach light
supports.
Survival considerations
Winter weather can be unfriendly. Be sure to carry not only
suitable clothing for the cockpit and the bush, but also
sleeping bags and other pertinent survival gear in case you get
marooned at an unattended airport or your car breaks down on
the airport road. People die needlessly every year because they
don't think of the "what if" possibilities. With modern aircraft,
it is highly unlikely you will ever enter a survival situation;
but wouldn't it be wise to carry suitable gear just to be sure
you don't tempt fate?
Cool conclusions
Winter flying can provide the most pleasurable flying
experiences possible. Your Cessna 172 will perform like a 182
and you will often have the airports to yourself. The extra
flying hours will increase your proficiency and effectively
reduce your per-hour fixed aircraft ownership costs.
All it takes to enter this winter wonderland is a little more
preflight planning and some extra care and attention. Not
much to ask in exchange for new vistas and flying fun. To
know more about COPA, visit www.copanational.org 
Situations That Could Lead to Mistakes
By Jean-Gabriel Charrier. The following text is a translation of a chapter on accidents from Jean-Gabriel Charrier’s fine book
L’intelligence du pilote.
The same old traps
A pilot, with both his experience and his weaknesses, may
face tough environments. In such situations, certain attitudes
and conditions often arise: they are traps, regardless of a
pilot’s level of experience. These traps have been analyzed
and are discussed below. Even though the examples below
involve powered aircraft, there are various factors conducive
to accidents that are common to all activities, regardless of
whether or not an engine is involved.
External pressure
This is undoubtedly one of the biggest factors that lead to
accidents. You promised to take your friends out, but would
you call them to cancel? You went all the way to the field, but
would you go back home without having flown? Everyone
flies in 10-kt crosswinds, why wouldn’t you? You absolutely
have to fly?
Resistance to change
The pilot falls behind the airplane
With a relatively fast airplane and/or a relatively
inexperienced pilot, tasks are completed too slowly. The pilot
is not sure of his navigation, has not mastered the avionics and
is checking his documents for frequencies. Too preoccupied
by these tasks, he does not notice changes in his surroundings
—the upcoming entry point, the worsening weather…
Loss of situational awareness
There comes a moment when the pilot is completely
overwhelmed by the situation. He no longer knows where he
is; his attention is taken up by tasks that keep him from
noticing certain truths such as the worsening circumstances.
Equipped with a GPS, his aircraft accidentally ends up above a
seemingly endless cloud or under a cloud ceiling that touches
the hill tops.
Fuel shortage
Sometimes it is necessary to adapt to change, even if it’s a
hassle—it’s not that easy to choose a less direct route that
better matches the day’s weather; to delay a departure or
cancel it entirely; or to use a new procedure.
There are many reasons why a fuel shortage may occur:
overconfidence, under-preparation, the pilot’s “first time”
conducting such a long flight. These reasons lead to situations
that are at best stressful and at worst dangerous and conducive
to accidents.
Carelessness
Taking a look
On the one hand, is precision when planning for and carrying
out a flight, and on the other, is slackness which comes with
routine and some experience. Checklists are completed with a
few shortcuts and safety margins are reduced more or less
consciously.
Goal: Destination
A pilot is determined to arrive at his destination. His
judgement is altered by this bias. Before his departure, he sees
the forecasted improvement in the weather but neglects to read
carefully and analyze what is in fact a middling situation. In
flight, he cannot think of a solution other than continuing to
his destination.
ASL 3/2014
The conditions are marginal, the terrain rising and the ceiling
lowering, but beyond there is a clearing. I’m going to take a
look. The weather is poor with a strong crosswind and wind
gusts. I’m going to take a look. Taking a look involves having
a very reliable way out, a Plan B. If you don’t have one, it
must be avoided.
Entering IMC
Not nice, not high—a brush up against one stratus cloud, then
another before inadvertently entering IMC. Flying IMC
requires training, without which, the outcome could be fatal. A
study of about 20 inexperienced pilots showed that loss of
control occurred between 20 and 480 seconds into IMC. The
average time before loss of control is about 3 min. Every pilot
in the study lost control of their aircraft!
7
Exiting the flight envelope
The pilot is faced with a situation that he is no longer able to
technically control. The outcome might be an exit from the
flight envelope, with a stall or breakage in flight. Machines
require differing levels of exactitude; some of them are less
forgiving than others.
Often the same story
Some of you may have noticed that almost all these
components can be arranged chronologically and linked
together. In fact, many accidents are a perfect synthesis of
these components. I planned my flight with friends well in
advance and, despite the poor weather, I wait until the last
minute to decide what to do. My passengers are on hand. The
weather isn’t great, but we could get by. In flight, I encounter
bad weather. I descend but even with the GPS I’m not too sure
where I am. I see the sky clearing ahead. I continue, it would
be silly not to…
The impact of stress on a pilot’s mental performance—the
ability to analyze, discern, make decisions—is found in most
pilots in each link in the chain, and it only gets worse.
Jean Marie, a very experienced private pilot, described a
cross-country flight during which he faced deteriorating
weather. Once he reached a certain height above the ground,
when others would have continued, he turned around. He had
reached the limit that he had set, beyond which he would not
descend in navigation (even his passengers were surprised by
the turn around).
At once, everything became much simpler for him. The
questions that need to be asked are: How many times would a
more impetuous pilot have arrived at his destination in the
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ASL 3/2014
same conditions? Probably a few. And would the risk have
been worth it? No, certainly not.
When confronted with this type of situation, think of the sense
of well-being and relief that you will feel, along with the
satisfaction of having made the right decision, when, after
cancelling your flight to your destination, you shut down your
engine in the parking lot at your alternate. Using your alternate
is not a big deal. What is important is not being exposed to
unnecessary risks. Even airline pilots use alternates.
The bottom line!
 When it happens to you… think about these different
factors and how they might link together. Be aware that when
difficulties pile up one after the other, your judgment skills
will diminish as your stress levels rise. 
A Squirrel, a Moose and Loss of Control in Helicopter Accidents
by Lee Roskop, International Helicopter Safety Team (IHST) member. Article republished with the kind
permission of the IHST.
Years ago, many kids used to watch the TV cartoon Rocky and
Bullwinkle. For those who have never heard of them, Rocky
was a reasonable-minded squirrel and Bullwinkle was a dimwitted moose. One of the running gags on the show was a
scene where Bullwinkle would say, “Hey Rocky, watch me
pull a rabbit out of a hat.” One of Rocky’s typical responses
was “But that trick never works!” Bullwinkle was not deterred
by Rocky’s comment and would respond, “Nothing up my
sleeve…Presto!” as he proceeded to try the trick anyway.
Inevitably, Rocky was always right. The trick never worked.
Every time, Bullwinkle would end up pulling a lion, bear or
something he hadn’t planned on out of the hat instead of a
rabbit. However, the unsuccessful outcome never stopped him
from trying the same trick again and again.
What do Rocky and Bullwinkle have to do with helicopters?
The repetition of Bullwinkle’s failed magic act reflects the
data involving loss of control helicopter accidents due to
performance management. The International Helicopter Safety
Team (IHST) defined these accidents as events precipitated by
either insufficient engine power or main rotor rpm that were
NOT attributable to a mechanical failure. In each accident, the
situation deteriorated as the performance demands that were
required progressed beyond what the helicopter could provide.
The resulting condition exceeded the pilot’s ability to control
the aircraft. By that point, it would have taken nothing short of
magic to stop the accident. Case after case of these accidents
progressed in a similar manner, just like Bullwinkle’s act.
ASL 3/2014
Unfortunately, also just like his
act, in the end, it never worked.
This accident data was analyzed
by the Joint Helicopter Safety
Analysis Team, a sub-committee
of the IHST. The IHST was
formed in 2005 to lead a
government
and
industry
cooperative effort to address factors that were affecting an
unacceptable helicopter accident rate. The group’s mission is
to reduce the international civil helicopter accident rate by 80
percent by 2016. From 2006 to 2011, the analysis team
completed an analytical review of three years of U.S.
helicopter accident data from 523 different accidents.
The IHST’s analysis team cited loss of control as an accident
occurrence category more frequently than any other. The team
noted that loss of control was evident in 217 (41 percent) of
the 523 accidents they analyzed, and the following chart
shows how loss of control compared to other occurrence
categories. Note that percentages in the chart do not add up to
100 percent because the team’s methodology allowed for any
accident to be categorized in multiple occurrence categories.
One accident may have been included simultaneously in the
loss of control, autorotation and abrupt manoeuvre categories
if each category was applicable.
9
There were a number of more detailed occurrence
subcategories encompassed under loss of control. However,
performance management was selected more than twice as
often as any other (79 out of 217 loss of control accidents).
According to the National Transportation Safety Board
(NTSB) investigations for each of these cases, many of the
performance management problems in the accidents involved
one of three scenarios:
 low main rotor rpm during practice autorotation;
 tailwind during hovering, takeoff or landing; or
 high density altitude operations.
The analysis team assessed the series of problems that were
evident in each event and determined that pilot judgment and
actions were contributory to 99 percent of the accidents where
loss of control due to performance management occurred. For
the three scenarios previously listed, a lapse in pilot judgment
and actions manifested itself in the following ways:
 Practice autorotation
 The instructor allowed low main rotor rpm
during their demonstration of the manoeuvre.
A power recovery was necessary, but was either
not attempted or was delayed until it was too
late.
 The student allowed low main rotor rpm during
the manoeuvre and the instructor either chose not
to intervene or intervened too late.
 Tailwind
 The pilot either underestimated or did not
consider the increased power demands of
hovering, taking off or landing with a tailwind.
 High density altitude

10
The pilot underestimated the effect of density
altitude on the power required during an
ASL 3/2014
approach and was unable to arrest the descent
rate with the power available.
In perhaps the most important part of the IHST work, a
number of interventions were suggested that could have
prevented the accidents. The chart shows the intervention
recommendations as they applied to the 79 accidents
categorized as loss of control due to performance
management.
The analysis team made more detailed and specific
intervention recommendations that expand upon the broader,
high-level recommendations shown in the chart. For the
97 percent of loss of control accidents due to performance
management where training/instructional methods is cited as
an intervention, some of the more specific recommendations
the team highlighted were:
 inflight power/energy management training;
 simulator training—advanced manoeuvres;
 enhanced aircraft performance and limitations
training;
 chief flying instructor (CFI) training and refresher on
advanced handling, cues and procedures;
 emphasis on maintaining cues critical to safe flight.
The IHST is leading an effort to keep members of the
helicopter community from trying the same tricks over and
over again even when they don’t work. If we can take some of
the insight from the accident analysis and apply it to how we
go about our day-to-day business, we can be part of a change
for the better. The outcome we are pursuing doesn’t involve a
reasonable-minded squirrel or a dim-witted moose, and
hopefully, no attempts at bad magic—just safer flying.
Bell 204 Tail Rotor Pitch Link Bolt Failure…
It happened twice and it could happen again…
Two nearly identical incidents of Bell 204 tail rotor pitch link
bolt failure—one in 2003 and one in 2013—resulted in
detached tail rotor pitch links, severe vibrations and thumping,
followed by emergency landings in swampy areas.
Fortunately, nobody got hurt in those two incidents but there is
the potential for catastrophic loss of control and loss of life.
Further, the helicopter manufacturer informed the TSB back in
2003 that it was aware of at least three previous similar
occurrences; in one of these previous occurrences, the
consequences were severe as the tail rotor and gear box
assembly were torn free from the helicopter.
The 2003 event—TSB file A03C0133
On May 31, 2003, a Bell 204B had departed Norway House
Airport (CYNE), Man., on a smoke patrol in support of forest
fire fighting operations. The helicopter was established in
cruise flight at 100 kt and 3 000 ft ASL (2 200 ft AGL) when,
approximately 15 to 20 min into the flight, a sudden and
constant shudder with an intermittent thumping noise was
heard coming from the tail area followed by a slow and
smooth 30° to 45° repetitive yaw in both directions. The pilot
gently applied pedal and was able to eventually correct the
repetitive yaw condition. The thumping was not repetitive but
appeared as pedal was applied. The pilot landed the helicopter
straight ahead in a swampy area approximately ¼ NM north of
Molsen Lake Lodge, Man. The helicopter landed without
incurring further damage or injury to the occupants. According
to the TSB, the attaching hardware fell out and was never
located.
Photo 1: Detached pitch link—2003 occurrence
Post-flight examination revealed that one of the tail rotor pitch
change link bolts was missing; the pitch change link was
hanging free from the tail rotor blade grip horn (see Photo 1),
but the link was still attached on the opposite end of the
crosshead assembly. The disconnected tail rotor blade had
struck the vertical stabilizer several times in flight, causing the
banging noise heard by the pilot and the damage to the
stabilizer.
The 2013 event—TSB file A13C0099*
The tail rotor assembly was installed as an overhauled unit on
July 7, 2002, and had accumulated approximately 211 hr of
time in service. The tail rotor pitch link bolts and attachment
hardware were transferred from the old tail rotor assembly to
the new one at the time of installation. The pitch change link
bolts are not lifed items and are controlled as on-condition
items. As such, it is not known how long the bolts had been in
service at the time of occurrence. Although the pitch change
link bolt was not recovered, the wear pattern on the tail rotor
blade grip horn pitch change bushings was indicative of an
under-torqued or loose bolt arrangement.
On August 15, 2013, a Bell 204B helicopter departed Pelican
Narrows (CJW4), Sask., on a smoke patrol, cruising at 2 500 ft
ASL. The aircraft encountered turbulence, followed by
porpoising, accompanied by left and right yawing and strong
vibrations. The pilot initiated a descent to an open area near a
lake. During the descent, the aircraft began to yaw to the right.
The aircraft landed at the shoreline with the front of the skid
gear and nose in the water. The helicopter was shut down and
evacuated. Inspection revealed that a bolt securing the pitch
change link to the pitch change horn of one tail rotor blade had
ASL 3/2014
Photo 2: Close-up of the fractured bolt.
*This event was featured in the Accident Synopses section of
Aviation Safety Letter 2/2014.
11
Photo 3: Tail rotor assembly with view of the fractured bolt.
failed. The blade had struck the side of the vertical stabilizer
(pylon). Inspection of the failed bolt indicated that it had failed
due to fatigue. There were indications that the bolt had been
loose at some time in the past and further investigation of the
damaged components indicated reverse bending damage, as
would be expected in a loose bolt.
As a result of this occurrence, the operator changed their
maintenance practices to ensure that the bolts are replaced at
each tail rotor installation. Bolts will also be replaced if they
are subsequently found to be loose during service.
On the 2013 flight, there were a total of five people on board.
The tail rotor had been installed about 45 hr prior to the
occurrence. As it had been the case in the 2003 occurrence, the
aircraft maintenance engineer (AME) used the existing
attachment hardware. Examination of the hardware by the
TSB indicated that the bolt had likely been operated, at some
time previous, in a loose condition and probably already had a
fatigue crack when the new tail rotor was installed. There was
a step worn in both bolts (very small 0.002 in.) and there
Photo 4: Detached pitch link—2013 occurrence
were signs that the bolts had been rotating. The attaching
washers also had recessed rings worn into them from the bolt
heads and the bearing shoulders. These were the indications
mentioned in the summary above.
Conclusion
Given the repeated occurrences and the potential serious
outcome of such an event, we felt that it was important to
highlight this issue. These events demonstrate the value of
replacing attachment hardware at each component installation
as well as replacing hardware if looseness is ever noted. 
2014-2015 Ground Icing Operations Update
In August 2014, the Winter 2014–2015 Holdover Time (HOT) Guidelines were published by Transport Canada. As per previous years,
TP 14052, Guidelines for Aircraft Ground Icing Operations, should be used in conjunction with the HOT Guidelines. Both documents
are available for download at the following Transport Canada Web site: www.tc.gc.ca/eng/civilaviation/standards/commerceholdovertime-menu-1877.htm.
To receive e-mail notifications of HOT Guidelines updates, subscribe to or update your “e-news” subscription, and select “Holdover
Time (HOT) Guidelines” under Publications / Air Transportation / Aviation Safety / Safety Information.
If you have any questions or comments regarding the above, please contact Yvan Chabot at yvan.chabot@tc.gc.ca.
12
ASL 3/2014
CASA 2014-03: Using SMS to Address Hazards and Risks Associated With
Unstable Approaches
As mentioned at the end of our summary of Transportation Safety Board of Canada (TSB) Final Report A11H0002, found in the “TSB
Final Report Summaries” section of this issue of the ASL, on June 27, 2014, Transport Canada has released Civil Aviation Safety
Alert (CASA) 2014-03, in response to TSB Recommendation A14-01. We elected to reproduce the CASA in full below, in addition to a
link to it, given the importance of addressing the risks associated with unstable approaches.—Ed.
measures developed to manage the associated risks. TCCA
committed to issue this CASA to advise industry accordingly.
ATTENTION:


CANADIAN AVIATION REGULATIONS (CAR)
SUBPARTS 705 OPERATORS
CANADIAN AVIATION REGULATIONS (CAR)
SUBPARTS 703 and 704 OPERATORS
USING SMS TO ADDRESS HAZARDS AND RISKS
ASSOCIATED WITH UNSTABLE APPROACHES
PURPOSE:
The purpose of this Civil Aviation Safety Alert (CASA) is
threefold:
1.
To request Canadian air operators operating under
subpart 705 of the Canadian Aviation Regulations
(CARs) that they use their existing Safety
Management System (SMS) to address and mitigate
hazards and risks associated with unstable approaches;
2.
To advise 705 operators that beginning approximately
one year after the publication of this CASA, Transport
Canada Civil Aviation (TCCA) plans to direct
specific surveillance activities to evaluate the
effectiveness of voluntary compliance with this
document and will begin looking for evidence of
effective mitigations of this hazard; and,
3.
As the hazards and risks associated with unstable
approaches are not limited to 705 operators, this
CASA also serves to raise the concern to 703 and 704
operators who are not yet required to have a SMS, and
encourage them to address the issue voluntarily.
BACKGROUND:
In its Final Report A11H0002, concerning the August 20,
2011, fatal Boeing 737 accident at Resolute Bay, NU, the
Transportation Safety Board of Canada (TSB) determined that
unstable approaches are a significant hazard, and has
recommended that TCCA require CAR Subpart 705 operators
to monitor and reduce the incidence of unstable approaches
that continue to a landing. (TSB A14-01)
TCCA has determined that this hazard can be mitigated
through an air operator’s existing SMS, and mitigations
ASL 3/2014
TCCA is committed to reviewing the effectiveness of the
recommendations contained in the CASA through inspection
activities.
RECOMMENDED ACTION:
TCCA requests that this hazard be assessed and mitigated
through appropriate use of the following (but not limited to)
SMS components:



safety oversight (reactive and proactive
processes);
training and awareness (promotions);
voluntary use of Flight Data Monitoring (in
order to gain a greater understanding of unstable
approaches and the causes.)
This may be determined by performing a proactive assessment
of unstable approach hazards (including situations where this
is more likely to occur), a review of SMS database to verify
the rate of occurrence and to ensure this is being reported and
finally, follow up with the pilot community to verify it is
being reported and monitored through the SMS in order to
verify a decrease in incidents and increased awareness of the
hazard and attendant risks.
Alternatively, air operators who indicate that they do not have
a problem with unstable approaches in their operation will be
asked to demonstrate how they have reached this conclusion.
Air operators with an established flight data monitoring
program (FDM) are encouraged to use this program to gather
and analyze this data.
TCCA will determine if an air operator’s SMS is capturing all
risks including unstable approaches, and if so, if this risk is
being analyzed and addressed properly.
CONTACT OFFICE:
For more information concerning this issue, contact
Transport Canada, Civil Aviation Communications Centre
by telephone at 1-800-305-2059 or by e-mail at
services@tc.gc.ca.
13
Answers to the 2014 Self-Paced Study Program
21. 3; 1 mi.; 500 ft
1.
an aircraft, vehicle or person
2.
with flags, cones or wing bar lights
3.
15 kt or above
4.
ATS unit; the name of the location of the RCO
followed by the individual letters R-C-O in a nonphonetic form
5.
follow normal communications failure procedures;
7600
25. 6.4 kg or 14 lb for each passenger
6.
24 hours; 0000Z, 0600Z, 1200Z, 1800Z
7.
(As per CFS)
27. the termination of all alerting services with respect to
search and rescue notification
8.
hatched areas enclosed by a dashed green line
9.
200 ft overcast
22. a clearance; establish two-way communication with
the appropriate
23. permission has been obtained from the user agency
24. 1-866-WXBRIEF (1-866-992-7433);
1-866-GOMÉTÉO (1-866-466-3836)
26. an ATC unit, an FSS, a CARS, or a RCC
28. 5
29. 14:00; March 26, 2014
30. +/- 50 ft
10. 1300Z
31. 100
11. 6+ SM
32. will not
12. 9 900
33. (Most recent AIC)
13. true
34. water depth; tire pressure; lower
14. ⅝ SM, 700 ft AGL
15. the pilot
16. inform ATC of this fact since acknowledgement of the
clearance alone will be taken by a controller as
indicating acceptance
35. lowest (Ref. Flight Training Manual, Chapter 9 &
From the Ground Up, “Turns”, pg. 28)
36. water-fog whiteout; blowing snow whiteout; or
precipitation whiteout
17. A, B, and C; D or E
37. mast bumping (Ref: Fatal Traps for Helicopter Pilots)
18. (a) a power-driven, heavier-than-air aircraft shall give
way to airships, gliders and balloons;
(b) an airship shall give way to gliders and balloons;
(c) a glider shall give way to balloons;
(d) a power-driven aircraft shall give way to aircraft
that are seen to be towing gliders or other objects or
carrying a slung load
39. upper wing tip (Ref: Soar, 6th Ed)
19. 2 000 ft AGL
20. odd thousands plus 500 ft ASL
38. Increasing forward speed; entering autorotation
(Ref: Fatal Traps for Helicopter Pilot, pg. 42 and
Principles of Helicopter Flight, pg. 155)
40. immediately release from the aerotow. (Ref: FAA
Glider Flying Handbook, pg. 8-13)
41. forward (Ref. “14-5. Longitudinal Balance” in
Gyroplane Pilot’s Manual by Jean-Pierre Harrison)
42. ambient temperature; actual and forecast winds
Aviation Safety Letter (ASL) on DVD!
The ASL DVD includes all English and French issues of the ASL, from 1973 through 2013! These back issues are in PDF only.
The search function makes this an invaluable tool for flight schools and training departments. The ASL DVD is available for purchase
for only $11.50 + applicable taxes and shipping. Click here to purchase your copy of this DVD.
14
ASL 3/2014
Poster—Interference With
Crew Members Will Not
Be Tolerated
Inadvertent IMC and Spatial Disorientation: Deadly Combination for
Low-Time Pilot
Investigators from the Transportation Safety Board of Canada (TSB) attended the site of a fatal Cessna 172C accident near Torquay,
Sask., on June 15, 2014 (TSB File A14C0049). A review of the details gathered at the site, as well as information resulting from
subsequent follow-up work, indicated that a full Class 3 investigation was not likely to provide new information that would lead to a
reduction of risk to persons, property, or the environment. However, given the lessons that can be drawn from this accident, the TSB
provided us the following information for the benefit of the ASL audience and for accident prevention purposes.—Ed.
Summary
On June 15, 2014, a privately registered Cessna 172C was one
of two aircraft en route from Hoffer, Sask., to an event at
Lampman, Sask., with a pilot and one passenger on board. The
second aircraft lost radio contact with the Cessna 172C, whose
wreckage was found beside a municipal road near Torquay,
Sask. The two occupants of the 172C did not survive and the
aircraft was destroyed by impact forces. There was no fire.
licence on March 14, 2014. His flying logbook indicates he
had accumulated 104 hr of flying experience as of May 7,
2014, including 100 hr in his Cessna 172C.
The passenger had no piloting experience and was seated in
the right forward passenger seat.
History of flight
The flight was conducted under VFR on a flight itinerary from
a private aerodrome at Hoffer, Sask., to Lampman, Sask.
(see Figure 1). The purpose of the pleasure flight was to attend
a breakfast being held at the Lampman airport. A group in a
second aircraft was also going to the breakfast and departed
from the Hoffer aerodrome first, with the accident aircraft
departing shortly afterward, at approximately 07:30.2
Pilot and passenger
The pilot-in-command (PIC) was seated in the left forward
pilot seat. He held a Transport Canada (TC) Category 3
Medical Certificate valid until May 1, 2016, and a private pilot
licence that was valid for single-engine land airplanes in day
visual meteorological conditions (VMC).1
Figure 1: Area of planned flight
The PIC received his private pilot training from March 2011
to February 2014 in Estevan, Sask. After four initial training
flights, he purchased the Cessna 172C and completed the
remainder of his training in it. He passed a private pilot flight
test on February 27, 2014, and was issued a private pilot
1
When operating in uncontrolled airspace below 1 000 ft
AGL, meteorological conditions must permit pilots operating under
VFR to operate their aircraft with visual reference to the surface,
clear of cloud, and in no less than 2 mi. flight visibility during the day
(Canadian Aviation Regulation 602.115).
16
ASL 3/2014
2
All times Central standard time (coordinated universal time
minus 6 hr)
The Cessna 172C climbed steadily, reaching 3 700 ft ASL
about halfway from Oungre to Bromhead. In the vicinity of
Bromhead, both flights encountered clouds and the pilots
descended below them to maintain visual reference to the
surface. The flight visibility under the clouds was
approximately 6 mi.
To ensure separation between the two flights, the second
aircraft flew approximately 1 mi. left of the planned flight path
shown in Figure 1 and the Cessna 172C turned right and flew
about ½ mi. right of the track.
As the second aircraft continued northeast, the cloud base
became lower and the pilot continued to descend to 2 300 ft
ASL (approximately 400 ft AGL). During this period, the PIC
of the Cessna 172C reported by radio that it was at 2 300 ft
ASL over a specific farm known to both pilots. Shortly
afterward, the pilot of the second aircraft began a climb
straight ahead in instrument meteorological conditions (IMC). 3
At about the same time, the Cessna 172C also commenced a
climb straight ahead. It climbed to about 2 700 ft ASL,
descended slightly and turned right about 90°. A much steeper
climb commenced, with the aircraft reaching about 2 900 ft
ASL and then commencing another descent. No further
information was available regarding the flight path of the
172C.
At about 07:45, once above the clouds at 3 100 ft ASL, the
pilot of the second aircraft made a radio call to the Cessna
172C but did not receive any reply.
Weight and balance
No weight and balance calculation was found for the accident
flight. The empty aircraft weight was 1 405 lb. The weight of
the pilot, passenger and items on board was estimated at
475 lb. The estimated fuel weight for departure on the accident
flight was 200 lb. The take-off weight is calculated to have
been approximately 2 100 lb, which is less than the certified
maximum take-off weight of 2 250 lb. The centre of gravity
was calculated to be within limits for flight.
Crash site and wreckage
The crash site was a flat, marshy area in a field adjacent to a
grid road. There were no observable obstacles in the area. The
site was wet and soft with surface water present in the field.
Portions of the wreckage came to rest in 3 ft of water, in a
drainage ditch adjacent and parallel to the grid road.
Ground scars at the initial point of impact show that the left
wing tip contacted the ground first, followed by the leading
edge of the left wing and then the nose of the aircraft. The
wreckage trail extended 270 ft from the point of contact to
where the aircraft came to rest, indicating that the aircraft
contacted the ground at high speed with substantial forward
momentum.
The aircraft was equipped with a Garmin Aera 510 global
positioning system (GPS), and the TSB Engineering
Laboratory recovered GPS data from the accident flight
(see Figure 2 for the flight path). The final GPS position
recorded was about ¾ mi. before the initial point of impact.
The second aircraft returned to Hoffer, and the occupants
immediately initiated a ground and communications
search. The aircraft wreckage was subsequently found in
a field northeast of Torquay, Sask., and both the PIC and
the passenger were deceased.
Aircraft
The aircraft was a 1962 Cessna 172C and had about
3 865 hr total air time. It was purchased by the PIC in
November 2011. The aircraft had undergone an annual
maintenance inspection on March 6, 2014, in Estevan,
Sask. A review of aircraft records indicated that the
aircraft was maintained in accordance with applicable
airworthiness standards. On May 7, 2014, the PIC flew
the aircraft from Estevan to the Hoffer aerodrome, and it
was not subsequently flown until the day of the accident.
Figure 2: Cessna 172C flight path
3
In IMC, visual reference is not possible and pilots must
maintain aircraft control using only the instruments.
ASL 3/2014
17
The impact forces destroyed the structure of the aircraft, with
the engine detaching from the airframe at the initial point of
impact. The cabin structure was destroyed and both forward
seats and their seat belts were torn from the structural attach
points. Both seat belts were fastened, indicating they had been
in use. The aircraft was not equipped with shoulder harnesses.
Examination of the wreckage revealed that there were most
likely no pre-impact control anomalies. All flight control
surfaces were present and control system continuity was
confirmed. The engine and propeller examination revealed
that the engine was likely developing power at the time of
impact.
Weather
On June 14 and 15, a frontal system was affecting southern
Saskatchewan and Manitoba. Estevan airport (CYEN), 20 mi.
east of the crash site, is the closest location with an aviation
weather report and forecast. The weather at CYEN
deteriorated quickly after midnight on June 14, with observed
visibility of ⅛ mi. in fog from 00:24 to 07:00. At 07:00,
visibility began improving. At 08:00, the observed weather at
CYEN was: wind 310° true (T) at 2 kt, visibility of 1 mi. in
mist, sky overcast with the cloud base at 400 ft AGL,
temperature of 11°C, dew point of 11°C, and altimeter setting
at 29.61 in. Hg.
An aviation meteorological advisory issued at 03:58 on
June 15 stated that surface visibility would be ½ to 2 mi. in
fog within an area that included Hoffer, Estevan and
Lampman. A graphical area forecast covering the Prairie
Provinces, issued at 05:31, called for extensive areas of low
cloud with drizzle and poor visibility throughout southern
Saskatchewan.
An aerodrome forecast for CYEN, issued at 05:38, indicated
that the fog and poor visibility would persist until about 09:00.
This forecast was subsequently revised as the weather
improved during the course of the morning.
they must be able to transition to using instruments to fly the
aircraft. In order to fly using instruments, instrument flight
training is necessary.
Pilots who transition from VMC to IMC may suffer
disorientation due to the lack of visual cues and vestibular
illusions.4 The effects of these illusions can give pilots the
perception that they are flying straight and level when they are
not. Many loss of control accidents have occurred due to these
effects. A successful transition is only assured when a pilot is
able to fly using flight instruments and to ignore the illusions.
The TC private pilot training syllabus requires that 5 hr of
instrument training be completed prior to admittance to the
flight test. The pilot must be able to demonstrate straight and
level flight for 2 min on an assigned heading, complete a 180°
turn and proceed 2 min on the reciprocal heading. Also, the
pilot must be able to recover from a nose-down and a nose-up
unusual attitude solely by referencing the aircraft flight
instruments.
Available records show the PIC received a total of 5.3 hr of
instrument training in the Cessna 172C. He successfully
demonstrated the manoeuvres described above to a flight test
examiner during the private pilot flight test in his Cessna 172C
on February 27, 2014.
The aircraft flight path suggests that the PIC successfully
climbed in IMC to 2 700 ft ASL before experiencing difficulty
controlling the aircraft. The information available is
insufficient to determine whether the aircraft was in an
uncontrolled descent or under the control of the pilot at the
time of the crash.
Thank you again to TSB Central for providing this additional
information. We would like to highlight two safety lessons
from this tragedy:
1.
2.
Low cloud and fog had been present at Hoffer during the
evening of June 14, but the local weather improved overnight
and the sky was clear with good visibility on the morning of
June 15.
Check the weather en route before you depart so you
can make an informed decision.
Practise basic instrument flying, at least once a year,
to maintain proficiency. This is best accomplished by
booking a dual flight with a certified instructor.
—Ed. 
The PIC had been monitoring weather on the NAV CANADA
Aviation Weather Web Site on the night of June 14, but there
was no information as to whether he checked the Web site
prior to the flight on the morning of June 15. He did not obtain
a pre-flight weather briefing from NAV CANADA by
telephone.
Pilot disorientation
Pilots flying in VMC use external visual cues to fly their
aircraft and to maintain orientation. When pilots enter IMC,
18
ASL 3/2014
ZGuest Editorial
ASL/3/2014
4
FAA Brochure AM-400-03/1, Spatial Disorientation, Why You
Shouldn’t Fly By the Seat of Your Pants
TSB Final Report Summaries
The following summaries are extracted from final reports issued by the Transportation Safety Board of Canada (TSB). They have been
de-identified and include the TSB’s synopsis and selected findings. Some excerpts from the analysis section may be included, where
needed, to better understand the findings. Unless otherwise specified, all photos and illustrations were provided by the TSB. For the
benefit of our readers, all the occurrence titles below are now hyperlinked to the full TSB report on the TSB Web site. —Ed.
TSB Final Report A11W0048—Loss of control—In-flight
Breakup
Note: The TSB investigation into this occurrence resulted in a
major report, with extensive discussion and analysis on many
issues such as flight duty times, fatigue, company
management, flight recorders, turbine conversion, overspeed
operation, tailplane flutter/structural failure, pilot
disorientation, pilot incapacitation, and more. Therefore we
could only publish the summary, findings and safety action in
the ASL. Readers are invited to read the full report,
hyperlinked in the title above. —Ed.
On March 31, 2011, a turbine powered de Havilland DHC-3
Otter departed Mayo, Y.T., on a 94 mi. day VFR flight to the
Rackla Airstrip, Y.T. At 1507 Pacific Daylight Time (PDT),
approximately 19 min after the aircraft had left Mayo, a
406 MHz ELT alert was received and SAR officials
dispatched a commercial helicopter from Ross River, Y.T. The
wreckage was located on a hillside 38 NM northeast of Mayo
at 1833 PDT. The wheel-ski equipped aircraft had experienced
a catastrophic in-flight breakup and the pilot, who was the sole
occupant, had sustained fatal injuries. There was no postimpact fire. The TSB authorized the release of this report on
March 6, 2013.
Main wreckage site where most of the fuselage
and cargo were found.
ASL 3/2014
Finding as to causes and contributing factors
1. The aircraft departed controlled flight for reasons
which could not be determined, and broke up due to
high speed.
Findings as to risk
1. Inaccurate journey log time entries by pilots may
have a negative bearing on pilot duty time monitoring
and aircraft maintenance schedules.
2. Pilot exceedance of duty time, such as the 60 hours
flight time allowed by regulation for the 7-day
period, may increase the risk of fatigue.
3. Non-adherence to Federal Aviation Administration
(FAA) Advisory Circular (AC) 23-14 during both the
supplemental type certificate (STC) approval process
and the familiarization of the STC by Transport
Canada may have reduced the safety margins
envisaged by AC 23-14, in turn increasing risk for
loss of aircraft structural integrity.
4. The operation of unpressurized aircraft at higher
altitudes without supplementary oxygen may increase
the risk of adverse effect on reaction time and
judgment.
5. If owners of a DHC-3 Otter converted in accordance
with STC SA02-15 are unaware of or have not
complied with AD 2011-12-02, the aircraft may be at
risk for loss of structural integrity due to operation at
speeds in excess of those determined to be safe by the
FAA.
6. The company practice of reconciling flight time and
flight duty times on a monthly rather than a daily
basis was inadequate to ensure compliance with
CARs flight time and flight duty time limitations and
rest period requirements.
7. If cockpit or data recordings are not available to an
investigation, the identification and communication
of safety deficiencies to advance transportation safety
may be precluded.
8. If companies do not proactively monitor flight data,
the identification and correction of safety deficiencies
may be precluded.
9. Identifying human factors is critical to understanding
why accidents happen. If companies cannot use voice
and video recordings proactively for safety purposes,
they are deprived of opportunities to reduce risk and
improve safety before an accident occurs.
19
Other findings
1. While not considered a factor in the occurrence, the
threaded barrel on the aileron balance cable
turnbuckle was not lockwired.
2. While not considered a factor in the occurrence, the
P2T2 loading spring assembly in the FCU contained
incorrect parts from an unknown source.
That condition could lead to loss of tab control linkage and
severe elevator flutter, which could lead to a loss of control.
Operator
As a result of this accident, the operator established a system
that correlates flight duty times to flight ticket invoice
numbers. The information is entered on a new flight duty form
which is delivered to company dispatch daily and entered into
company Flight Time/Duty Time/Rest Period records daily.
Safety action required
The development of lightweight flight recording system
technology presents an opportunity to extend FDM approaches
to smaller operations. Using this technology and FDM, these
operations will be able to monitor, among other things,
standard operating procedure compliance, pilot decision
making, and adherence to operational limitations. Review of
this information will allow operators to identify problems in
their operations and initiate corrective actions before an
accident takes place.
Temporary hangar where the wreckage was recovered for
initial examination, before it was moved to the
TSB lab in Ottawa.
Safety action taken
Federal Aviation Administration (FAA)
On May 25, 2011, the FAA issued AD 2011-12-02. Effective
on June 2, 2011, the AD applied to Viking Air Limited Model
DHC-3 Otter airplanes (all serial numbers) that were equipped
with a Honeywell TPE331-10 or -12JR turboprop engine
installed per Supplemental Type Certificate (STC)
SA09866SC (Texas Turbines Conversions, Inc.) and certified
in any category.
The AD was prompted by analysis that showed airspeed
limitations for the affected airplanes were not adjusted for the
installation of a turboprop engine as stated in the regulations.
The AD was issued to prevent the loss of airplane structural
integrity due to the affected airplanes being able to operate at
speeds exceeding those determined to be safe by the FAA.The
AD imposed a maximum operating speed (V MO) of 144 mph
for DHC-3 Otter land/ski aircraft and 134 mph (V MO) for
DHC-3 Otter seaplanes.
On August 19, 2011, the FAA issued AD 2011-18-11, which
became effective on October 3, 2011. The AD applied to all
Viking Air Limited Model DHC-3 Otter airplanes that were
certified in any category. The AD resulted from an evaluation
of revisions to the manufacturer's maintenance manual that
added new repetitive inspections to the elevator control tabs.
The AD stated that if these inspections were not done,
excessive free-play in the elevator control tabs could develop
20
ASL 3/2014
Furthermore, given the combined accident statistics for CARs
Subparts 702, 703, and 704 operations, there is a compelling
case for industry and the regulator to proactively identify
hazards and manage the risks inherent in these operations. In
order to manage risk effectively, they need to know why
incidents happen and what the contributing safety deficiencies
may be. Moreover, routine monitoring of normal operations
can help these operators both improve the efficiency of their
operations and identify safety deficiencies before they result in
an accident. In the event that an accident does occur,
recordings from lightweight flight recording systems will
provide useful information to enhance the identification of
safety deficiencies in the investigation. Therefore the TSB
recommended that :
The Department of Transport work with industry to remove
obstacles and develop recommended practices for the
implementation of flight data monitoring and the installation
of lightweight flight recording systems for commercial
operators not required to carry these systems. (TSB A13-01)
Transport Canada action
TC supports the voluntary implementation of FDM programs
in all sectors of commercial aviation. TC will proceed with
the development of a new Advisory Circular in 2015/16 to
describe recommended practices regarding FDM programs.
This new AC will replace Commercial and Business Aviation
Advisory Circular (CBAAC) No.0193–Flight Data Monitoring
(FDM) Programs, last issued in 2001. TC will also consider
adding FDM principles in future regulatory initiatives/
amendments, which will be consulted through focus groups at
that time.
TSB Final Report A11P0117—Main Rotor Strike and
Collision With Terrain
On July 31, 2011, a Bell 407 helicopter departed Stewart
Airport (CZST), B.C., at about 9:43 PDT, with the pilot and
two passengers on board. The helicopter flew to a geological
exploration site 14 NM north of Stewart, B.C., adjacent to the
Nelson Glacier. There were no further voice communications
with the occurrence aircraft following departure, and flight
tracking data stopped at 10:04. Approximately 6 hr later, the
wreckage was discovered strewn down the steep mountain
side at the exploration site. There were no survivors. The
406 MHz ELT had activated, but the antenna and antenna
cable were damaged and a signal was not received by the
Canadian Mission Control Centre. There was no fire. The TSB
authorized the release of this report on April 17, 2013.
Photo of GPS data showing the flight track
(Image: Google Earth; diagram added by TSB)
History of the flight
Using information retrieved from handheld cameras, a
portable global positioning system (GPS) and an on-board
GPS tracking system (which sends tracking information to the
operator), the investigation determined that, at approximately
9:58, the occurrence helicopter performed a left-skid, toe-in
landing on a mountain ledge at 5 100 ft ASL. One passenger
was seated in the left front seat adjacent to the pilot; the other
was seated in the left rear forward-facing seat. The passengers
had flown once before with this pilot.
Both passengers were familiar with helicopter operations and
were proficient with hover-entry and -exit procedures. The
passenger in the rear seat performed a hover exit to retrieve a
climbing rope that had been left behind the previous day. The
other passenger remained on board. The helicopter lifted off
and backed away to allow the passenger to retrieve the rope.
The helicopter then landed a second time to pick up that
passenger. This takeoff and subsequent landing were not
reported by the GPS tracking system, as the reporting criteria
were not met.
ASL 3/2014
At 10:01, the helicopter lifted off again, with both passengers
on board. The GPS tracking system reported the takeoff. The
helicopter was manoeuvred slowly across the face of the
mountain from left to right (when facing the mountain),
circled to the left around the peak, and made another slow pass
in the same direction across the mountain face. At 10:04, the
GPS tracking system reported that the occurrence helicopter
had landed about 760 ft above the rope pick-up location. That
was the last position and altitude reported by the GPS tracking
system. At 10:14, the GPS tracking system software generated
an inactive status display, indicating that the system had not
received a position report for 10 min.
Aircrew duty times
With the exception of one 15.1-hour duty day on
July 17, 2011, recorded flight- and duty-times did not exceed
limitations during the pilot's tour (see Crew
Scheduling). In the 15 days preceding the accident, the
average length of the pilot's duty day was 12.75 hours.
Duty days on July 28 and 29 were 12.75 hours each,
with 5.6 hours of flight time each day. On July 30, the
pilot was on duty for 11.5 hours, flying 6 flights and
logging 3.8 hours of flight time. These recorded dutyday times cover the daily period between first departure
and last landing, and do not include allowance for preflight or post-flight duties. The operator’s company
operations manual (COM) (in accordance with CARs
700.16 [1]) limits a pilot's workday to 14 hours in any
24-hour period. The operator provides forms that record
the entire duty day. The pilot had not yet completed the
form, which was to be submitted monthly. Every day
included several periods of more than 30 minutes
between flights. On one occasion, there was a break of
4.5 hours between flights. These break periods, as well as
departure times, were completely random. During the
occurrence pilot's tour, approximately 100 flight hours were
accumulated, reaching a maximum of 40 hours over any
7-day period.
The occurrence pilot stayed at base camps during the tour. The
camps were described as comfortable, with good bedding and
good food. The pilot stayed at an operator staff house in
Stewart on the night before the accident. On the morning of
the accident, the pilot appeared to be rested and in good
spirits.
Crew Scheduling
The normal rotation for this project was a 4-week tour
followed by 2 weeks of leave. In some cases, tour lengths
were extended to meet operational requirements or to
accommodate leave requests of other pilots. The occurrence
pilot commenced a 3-week tour on July 12, 2011, after an
extended leave of 27 days off. The pilot had requested the
extended period of leave, which was approved by the
employer. The 3-week tour was part of an operator effort to
realign pilots' schedules back to the 4-on/2-off rotation. On
July 28, 2011, the occurrence pilot was advised that the tour
21
Operator
In its safety policy, the operator considers safety to be a core
value, and imposes upon its employees not only a right but a
responsibility to refuse work when unsafe conditions or risk of
imminent harm exist. The investigation determined that the
operator had previously supported employees who identified
unsafe working conditions and had taken the necessary steps
to mitigate risk to acceptable levels.
Analysis
There is no indication that a helicopter system failure or
malfunction contributed to this occurrence.
Strewn wreckage on the steep mountain side
would have to be extended by 10 days. The pilot was to report
to Stewart on July 30 to accommodate a leave request made by
another pilot. In response to this request, the pilot expressed
deep frustration with the extension and the short notice of it.
The area surrounding Stewart is an active area for mineral
exploration. The terrain is very rugged, and pilots perform
operations such as toe-in landings and hover exits/entries, as
well as external-load operations in support of mineralexploration activities. Many flying days are lost because of
weather. The investigation determined that the occurrence
pilot felt that the work in Stewart was very demanding, and
that pilot fatigue could make it unsafe near the end of a
four-week tour. The pilot had also expressed displeasure about
the fact that the tour had been extended just before the pilot
was scheduled to leave, and felt that such an extension
affected a person's ability to focus on the job and also caused
problems at home. On at least one previous occasion, the pilot
had requested to be relieved due to fatigue. In that instance,
the operator’s scheduler arranged for a relief pilot to arrive
within 2 days. The investigation determined that the operator
supported a pilot's decision not to fly due to concerns about
being tired, and it was not an issue for the exploration group to
postpone work to allow a pilot to get some additional rest. The
occurrence pilot did not request that work be postponed, nor
indicate a need to be relieved from the current tour due to
fatigue.
The pilot arrived in Stewart on the day before the accident,
which was the pilot's nineteenth day of work. The pilot was
new to the Nelson Glacier project. A crew-change briefing
was provided by the outgoing pilot; it covered the location and
description of the work sites, and provided a map review of
low weather routes. The occurrence pilot declined an offer of a
familiarization flight. At the end of that day, the occurrence
pilot picked up 4 passengers at other sites, plus the 2-person
exploration crew from the Nelson Glacier site, and returned
them to Stewart. The occurrence flight was the pilot's second
trip to that site.
22
ASL 3/2014
The recorded GPS data showed the helicopter in, or near, a
stationary hover for 54 seconds until electrical power was
interrupted, or the GPS signal was lost. The ECU data
indicated a small, gradual power reduction, followed by a
sudden reduction in main-rotor rpm. It is likely that the
decrease in main-rotor speed occurred as a result of the mainrotor blades making contact with an obstacle as the helicopter
manoeuvred in close proximity to the rock face. Any damage
to rotor blades, which provide both a supporting and a control
surface, is likely to result in an unstable control condition or a
complete loss of control. The sudden increase in torque to
150% is consistent with a significant rotor strike. The
subsequent divergence of the main-rotor speed (decreased)
and power turbine speed (increased) is indicative of a sudden
release of torque due to severing of the driveshaft between the
engine and the transmission. While working in close proximity
to steep terrain, for undetermined reasons, the helicopter's
main-rotor blades made contact with terrain, causing a
subsequent loss of control and collision with terrain.
Flight following is a defence against potential adverse
consequences when an aircraft goes missing or is overdue.
This defence began to break down when the verbal flight plan
did not provide a specific time of return to Stewart. In the
absence of a documented operational flight plan, a means of
recording changes to that flight plan, and explicit guidance on
when a flight is to be considered overdue, assumptions made
by ground personnel about the status of an aircraft may lead to
delays in initiating the overdue-aircraft response plan.
An emergency locator transmitter (ELT) is another defence
that can aid in reducing delays in the initiation of search and
rescue. This defence failed when the antenna was broken and
the antenna cable was severed. As a result, the ELT signal was
not detected by the Canadian Mission Control Centre. The
operator's ground personnel believed that they would have
been contacted by the Joint Rescue Coordination Centre
(JRCC) if the occurrence helicopter had been in an accident.
Damage to the ELT or its antenna increases the likelihood that
a distress signal will not be detected. As a result, injured flight
crew and passengers will be at elevated risk for death due to
delays in life-saving search-and-rescue services. Operator
procedures and personnel involved in flight following need to
take account of the limitations of ELTs.
According to the COM, the overdue-aircraft response plan
should have been initiated when the aircraft was considered to
be overdue. However, the absence of a reported ELT signal,
combined with having not received an emergency notification
via the GPS tracking system, led ground personnel to believe
that the situation did not warrant initiating the overdue-aircraft
response plan. This belief contributed to the delay in initiation
of search-and-rescue action. The operator's overdue-aircraft
response plan required that the JRCC be notified that searchand-rescue services may be required. This step did not occur,
and the JRCC was not notified of the overdue aircraft.
Consecutive days of work can have a cumulative effect on
fatigue in helicopter pilots, particularly when the work
involves tasks that require high levels of concentration,
increasing the pilot's workload. Cumulative fatigue can build
up when a sleep debt is carried over from preceding days of
inadequate sleep.
The occurrence pilot had indicated concerns about four-week
tour lengths, due to the demanding nature of the job. The
investigation determined that there may have been a conflict
between the pilot's personal plans and the employer's
operational needs. This conflict may have been the catalyst for
the pilot to express frustration to operator personnel and relate
it to flight-safety concerns. However, there was no indication
that the pilot was experiencing the effects of fatigue at the
time of the occurrence. In the days before the occurrence, the
pilot's flying times and duty days were within the prescribed
limits as per regulations. On the morning of the occurrence,
the pilot was in good spirits and appeared well rested. In
addition, the pilot had not indicated to the operator or the
exploration group, as he had done on a previous tour, that he
was experiencing the effects of fatigue. The investigation did
not establish a link between 4-week tour lengths and pilot
fatigue in this occurrence.
Finding as to causes and contributing factors
While working in close proximity to steep terrain, the
helicopter’s main rotor blades made contact with terrain,
causing a subsequent loss of control and collision with terrain.
Findings as to risk
1. When there is a gap between operator procedures and
actual practice, flight crew and passengers may be
placed at increased risk of injury or death following
an accident.
2. If the joint rescue coordination centre (JRCC) is not
notified in a timely manner once an aircraft is
determined to be overdue or has been involved in an
accident, the flight crew and passengers of that
aircraft are placed at increased risk of injury or death
as a result of delays in potentially critical, life-saving
search-and-rescue (SAR) services.
3. Damage to the ELT or its antenna increases the
likelihood that a distress signal will not be detected.
As a result, injured flight crew and passengers will be
ASL 3/2014
4.
5.
at elevated risk of death due to delays in life-saving
SAR services.
Procedures such as toe-in landings and hover exits
require passengers to release their restraint systems.
Passengers conducting hover exits are at increased
risk of injury if restraint systems are unfastened for
periods longer than necessary.
If cockpit or data recordings are not available to an
investigation, this may preclude the identification and
communication of safety deficiencies to advance
transportation safety.
Other finding
1. The investigation did not establish a link between
four-week tour lengths and pilot fatigue in this
occurrence.
Safety action taken
The operator has undertaken efforts to work with
manufacturers of flight data monitoring systems to develop
and test vendor hardware and software that would further meet
the needs of VFR helicopter operations.
TSB Final Report A11H0002—Controlled Flight Into
Terrain
Note: The TSB investigation into this occurrence resulted in a
major report, with extensive discussion and analysis on many
issues. Therefore we could only publish the summary, findings
and safety action in the ASL. Readers are invited to read the
full report, hyperlinked in the title above. —Ed.
On August 20, 2011, a Boeing 737-210C combi aircraft was
being flown from Yellowknife, N.W.T., to Resolute Bay, Nun.
At 1642 Coordinated Universal Time (1142 Central Daylight
Time), during the approach to Runway 35T, the aircraft struck
a hill about 1 NM east of the runway. The aircraft was
destroyed by impact forces and an ensuing post-crash fire.
Eight passengers and all 4 crew members sustained fatal
injuries. The remaining 3 passengers sustained serious injuries
and were rescued by Canadian military personnel, who were
in Resolute Bay as part of a military exercise. The accident
23
occurred during daylight hours. No emergency locator
transmitter signal was emitted by the aircraft. The TSB
authorized the release of this report on March 5, 2014.
5.
Accident site
Findings as to causes and contributing factors
1. The late initiation and subsequent management of the
descent resulted in the aircraft turning onto final
approach 600 feet above the glideslope, increasing
the crew's workload and reducing their capacity to
assess and resolve the navigational issues during the
remainder of the approach.
2. When the heading reference from the compass
systems was set during initial descent, there was an
error of −8°. For undetermined reasons, further
compass drift during the arrival and approach
resulted in compass errors of at least −17° on final
approach.
3. As the aircraft rolled out of the turn onto final
approach to the right of the localizer, the captain
likely made a control wheel roll input that caused the
autopilot to revert from VOR/LOC capture to MAN
and HDG HOLD mode. The mode change was not
detected by the crew.
4. On rolling out of the turn, the captain's horizontal
situation indicator displayed a heading of 330°,
providing a perceived initial intercept angle of 17° to
the inbound localizer track of 347°. However, due to
24
ASL 3/2014
10.
11.
12.
13.
the compass error, the aircraft's true heading
was 346°. With 3° of wind drift to the right, the
aircraft diverged further right of the localizer.
The crew's workload increased as they attempted to
understand and resolve the ambiguity of the
track divergence, which was incongruent
with the perceived intercept angle and
expected results.
6. Undetected by the pilots, the flight directors
likely reverted to AUTO APP intercept mode
as the aircraft passed through 2.5° right of
the localizer, providing roll guidance to the
selected heading (wings-level command)
rather than to the localizer (left-turn
command).
7. A divergence in mental models degraded the
crew's ability to resolve the navigational
issues. The wings-level command on the
flight director likely assured the captain that
the intercept angle was sufficient to return
the aircraft to the selected course; however,
the first officer likely put more weight on the
positional information of the track bar and
GPS.
8. The crew's attention was devoted to solving
the navigational problem, which delayed the
configuration of the aircraft for landing. This
problem solving was an additional task, not
normally associated with this critical phase
of flight, which escalated the workload.
9. The first officer indicated to the captain that
they had full localizer deflection. In the
absence of standard phraseology applicable
to his current situation, he had to improvise
the go-around suggestion. Although full
deflection is an undesired aircraft state requiring a
go-around, the captain continued the approach.
The crew did not maintain a shared situational
awareness. As the approach continued, the pilots did
not effectively communicate their respective
perception, understanding, and future projection of
the aircraft state.
Although the company had a policy that required an
immediate go-around in the event that an approach
was unstable below 1000 feet above field elevation,
no go-around was initiated. This policy had not been
operationalized with any procedural guidance in the
standard operating procedures.
The captain did not interpret the first officer's
statement of “3 mile and not configged” as guidance
to initiate a go-around. The captain continued the
approach and called for additional steps to configure
the aircraft.
The first officer was task-saturated, and he thus had
less time and cognitive capacity to develop and
execute a communication strategy that would result
in the captain changing his course of action.
14. Due to attentional narrowing and task
saturation, the captain likely did not have a
high-level overview of the situation. This
lack of overview compromised his ability to
identify and manage risk.
15. The crew initiated a go-around after the
ground proximity warning system “sink
rate” alert occurred, but there was
insufficient altitude and time to execute the
manoeuvre and avoid collision with terrain.
16. The first officer made many attempts to
communicate his concerns and suggest a goaround. Outside of the two-communication
rule, there was no guidance provided to
address a situation in which the pilot flying
is responsive but is not changing an unsafe course of
action. In the absence of clear policies or procedures
allowing a first officer to escalate from an advisory
role to taking control, this first officer likely felt
inhibited from doing so.
17. The crew's crew resource management was
ineffective. The operator’s initial and recurrent crew
resource management training did not provide the
crew with sufficient practical strategies to assist with
decision
making
and
problem
solving,
communication, and workload management.
18. Standard operating procedure adaptations on the
accident flight resulted in ineffective crew
communication, escalated workload leading to task
saturation, and breakdown in shared situational
awareness. The operator’s supervisory activities did
not detect the standard operating procedure
adaptations within the Yellowknife B737 crew base.
Findings as to risk
1. If standard operating procedures do not include
specific guidance regarding where and how the
transition from en route to final approach navigation
occurs, pilots will adopt non-standard practices,
which may introduce a hazard to safe completion of
the approach.
2. Adaptations of standard operating procedures can
impair shared situational awareness and crew
resource management effectiveness.
3. Without policies and procedures clearly authorizing
escalation of intervention to the point of taking
aircraft control, some first officers may feel inhibited
from doing so.
4. If hazardous situations are not reported, they are
unlikely to be identified or investigated by a
company's safety management system; consequently,
corrective action may not be taken.
5. Current Transport Canada crew resource management
training standards and guidance material have not
been updated to reflect advances in crew resource
management training, and there is no requirement for
accreditation of crew resource management
ASL 3/2014
Accident site looking north
facilitators/instructors in Canada. This situation
increases the risk that flight crews will not receive
effective crew resource management training.
6. If initial crew resource management training does not
develop effective crew resource management skills,
and if there is inadequate reinforcement of these
skills during recurrent training, flight crews may not
adequately manage risk on the flight deck.
7. If operators do not take steps to ensure that flight
crews routinely apply effective crew resource
management practices during flight operations, risk
to aviation safety will persist.
8. Transport Canada's flight data recorder maintenance
guidance (CAR Standard 625, Appendix C) does not
refer to the current flight recorder maintenance
specification, and therefore provides insufficient
guidance to ensure the serviceability of flight data
recorders. This insufficiency increases the risk that
information needed to identify and communicate
safety deficiencies will not be available.
9. If aircraft are not equipped with newer-generation
terrain awareness and warning systems, there is a risk
that a warning will not alert crews in time to avoid
terrain.
10. If air carriers do not monitor flight data to identify
and correct problems, there is a risk that adaptations
of standard operating procedures will not be detected.
11. Unless further action is taken to reduce the incidence
of unstable approaches that continue to a landing, the
risk of controlled flight into terrain and of approach
and landing accidents will persist.
Other findings
1. It is likely that both pilots switched from GPS to
VHF NAV during the final portion of the in-range
check before the turn at MUSAT.
2. The flight crew was not navigating using the YRB
VOR or intentionally tracking toward the VOR.
3. There was no interference with the normal
functionality of the instrument landing system for
Runway 35T at CYRB.
25
4.
5.
6.
7.
8.
Neither the military tower nor the military terminal
controller at CYRB had sufficient valid information
available to cause them to issue a position advisory
to the B737.
The temporary Class D control zone established by
the military at CYRB was operating without any
capability to provide instrument flight rules
separation.
The delay in notification of the joint rescue
coordination centre did not delay the emergency
response to the crash site.
The NOTAMs issued concerning the establishment of
the military terminal control area did not succeed in
communicating the information needed by the
airspace users.
The ceiling at the airport at the time of the accident
could not be determined. The visibility at the airport
at the time of the accident likely did not decrease
below approach minimums at any time during the
arrival of the B737. The cloud layer at the crash site
was surface-based less than 200 feet above the airport
elevation.
Safety actions (selected items only; see all on TSB Web site)
Safety actions taken
Transportation Safety Board of Canada
On April 26, 2012, TSB investigators presented a briefing to
the operator’s senior management personnel regarding the
company's CRM training. The operator conducts its initial
CRM training during type training for newly hired pilots. TSB
investigators attended an initial CRM training course from the
operator on April 3, 2012; this was the first initial CRM
course conducted since the accident. The course was timecompressed, and did not address all of the modules required
under CAR 705.124—Training Program, and Commercial Air
Service Standards (CASS) 725.124(39)—Crew Resource
Management Training. Additionally, the content of the
material presented was dated and did not include practical
tools and strategies. It was suggested that the company may
want to allocate more time to CRM training and update the
course content.
Operator
Standard operating procedures
The operator completed a review of B737, B767, ATR42,
ATR72, and L382 standard operating procedures (SOPs)
to identify adaptations of SOPs. Knowledge and procedural
deficiencies were identified as areas for review and
improvement.
Ongoing actions
The chief pilots of all aircraft types met for several days in the
second half of 2012 to discuss common calls and procedures
across all fleets. SOPs for all aircraft types have been rewritten
in a common format.
26
ASL 3/2014
Accident site at the surface
Crew resource management
The crew resource management training was reviewed and
updated with more modern content. The length of the initial
course was increased to one full day.
Reporting system
A review of the reporting system and requirements was
conducted. As part of the review, it was identified that certain
policies in force may have contributed to reporting fatigue in
limited areas. Several policies in place required items that
were part of normal operations to be reported regularly, such
as a normal diversion due to weather. Given the complex
nature of the operating environment, other items may not have
been reported due to the workload and the complexity of the
policy andform used.
The air safety report has been amended to remove the
requirements to report expected normal operations items,
decluttering it to provide more opportunity to describe any
events that require attention. The importance of ongoing
reporting of hazards was included within the notification to the
crews of the air safety report form and policy changes. These
actions were completed in October 2012.
Additionally, the manager of flight safety published two
articles in the company newsletter promoting reporting in all
aspects of flight operations.
Training standards
A review and revision of the Line Check Pilot Course was
completed. The aim of this course is to ensure that all training
and check personnel have a common standard by which to
validate the training and to ensure that all company procedures
are understood and followed. The first course was delivered
on July 24 2012.
Maintenance
Maintenance Services has initiated a program to determine the
drift rate of the directional gyros while on the ground. If
excessive drift rates are detected, an enhanced maintenance
program will be put in place to provide acceptable
performance. Coupled with this program will be feedback to
flight crews to increase awareness of the operation of this
system and of the reports required to maintain reliability.
Flight data monitoring program
The operator’s flight data monitoring (FDM) program has
been reviewed, and an outside company has been contracted to
provide assistance and guidance in detecting SOP adaptations
and other areas requiring training enhancement. The manager
of the program produces quarterly reports, which are reviewed
at the executive safety management meetings on a quarterly
basis. This initiative has provided data for improvements in
training and day-to-day operations for all aircraft types in the
operator’s fleet.
These mainly administrative defences include:




A company stabilized-approach policy, including nofault go-around policy;
Operationalized stable approach criteria and standard
operating procedures (SOPs), including crew
phraseology;
Effective crew resource management (CRM),
including empowering of first officers to take control
in an unsafe situation;
Use of flight data monitoring (FDM) programs to
monitor SOP compliance with stabilized approach
criteria;
Safety action required
Unstable approaches
In this accident, the aircraft arrived high and fast on final
approach, was not configured for landing on a timely basis,
had not intercepted the localizer and was diverging to the
right. This approach was not considered stabilized in
accordance with the company's stabilized approach criteria,
and the situation required a go-around. Instead, the approach
was continued. When the crew initiated a go-around, it was
too late to avoid the impact with terrain. Unstable approaches
continue to be a high risk to safe flight operations in Canada
and worldwide.
Flight Safety Foundation research concluded that 3.5% to 4%
of approaches are unstable. Of these, 97% are continued to a
landing, with only 3% resulting in a go-around. To put these
figures in context, there were, in 2012, 24.4 million flights
worldwide in a fleet of civilian, commercial, western-built jet
airplanes heavier than 60 000 lb. This means that between
854 000 and 976 000 of those flights terminated with an
unstable approach, and approximately 828 000 to
945 000 continued to a landing. The potential negative
consequences of continuing an unstable approach to a landing
include CFIT, runway overruns, landing short of the runway
and tail-strike accidents.
Occurrences in which an unstable approach was a contributing
factor demonstrate that the severity can range from no injuries
or damage to multiple fatalities and aircraft destruction. In
Resolute Bay, the continuation of an unstable approach led to
a CFIT accident and the loss of 12 lives. Without
improvements in stable approach policy compliance, most
unstable approaches will continue to a landing, increasing the
risk of CFIT and approach and landing accidents.
In this investigation, the Board examined in detail the
defences available to air carriers to mitigate the risks
associated with unstable approaches and their consequences.
Final approach track relative to runway
(image: Google Earth, with annotations by TSB)
ASL 3/2014
27



Use of line-oriented safety audits (LOSA) or other
means, such as proficiency and line checks, to assess
CRM practices and identify crew adaptations of
SOPs;
Non-punitive
reporting
systems (to report
occurrences or unsafe practices);
Use of terrain awareness and warning systems
(TAWS).
While the operator had some of these defences in place,
including a stabilized approach policy and criteria, a no-fault
go-around policy, safety management system (SMS) hazard
and occurrence reporting, the two-communication rule and an
older-generation ground proximity warning system (GPWS),
these defences were not robust enough to prevent the
continuation of the unstable approach or collision with terrain.
Other TSB investigations have shown that non-adherence to
company SOPs related to stabilized approaches is not unique
to the operator.
In addition, the use of newer-generation TAWS with forwardlooking terrain avoidance features will enhance a flight crew's
situational awareness and provide increased time for crew
reaction. However, if the risk in the system is to be reduced
significantly, the industry must take other steps and not rely on
purely technological solutions.
many carriers have had the program for years. Some
helicopter operators have it already, and the Federal Aviation
Administration (FAA) has recommended it.
Worldwide, FDM has proven to benefit safety by giving
operators the tools to look carefully at individual flights and,
ultimately, at the operation of their fleets over time. This
review of objective data, especially as an integral and nonpunitive component of a company safety management system,
has proven beneficial in proactive identification and correction
of safety deficiencies and in prevention of accidents.
Current defences against continuing unstable approaches have
proven less than adequate. In Canada, while many CAR 705
operators have voluntarily implemented FDM programs, there
is no requirement to do so. The operator was not conducting
FDM at the time of this accident. Furthermore, FDM programs
must specifically look at why unstable approaches are
occurring, how crews handle them, whether or not crews
comply with company stabilized-approach criteria and
procedures, and why crews continue an unstable approach to a
landing. Unless further action is taken to reduce the incidence
of unstable approaches that continue to a landing, the risk of
approach and landing accidents will persist.
Therefore, the Board recommends (A14-01) that:
The first step is for operators to have practical and explicit
policies, criteria, and SOPs for stabilized approach that are
enshrined in the company operating culture.
Transport Canada require CARs Subpart 705
operators to monitor and reduce the incidence of
unstable approaches that continue to a landing.
The second step is for companies to have contemporary initial
and recurrent CRM training programs delivered by qualified
trainers and to monitor and reinforce effective CRM skills in
day-to-day flight operations. Effective CRM is a defence
against risks present in all phases of flight, including unstable
approaches.
Transport Canada response
Since 2005, Canadian air operators operating under subpart
705 of the Canadian Aviation Regulations (CARs) must have
a safety management system (SMS). Transport Canada (TC)
has determined that this hazard can be mitigated through an air
operator’s SMS. On June 27, 2014, TC issued Civil Aviation
Safety Alert (CASA) No. 2014-03 to communicate this
information to each air operator operating under subpart 705
of the CARs.
The third step involves monitoring of SOP compliance
through programs such as flight data monitoring (FDM) and
line-oriented safety audits (LOSA). In Canada, TC requires
large commercial carriers to have SMS, cockpit voice
recorders (CVRs), and flight data recorders (FDRs). However,
these carriers are not required to have an FDM program. Even
so, many of these operators routinely download their flight
data to conduct FDM of normal operations. Air carriers with
flight data monitoring programs have used flight data to
identify problems such as unstabilized approaches and rushed
approaches, exceedance of flap limit speeds, excessive bank
angles after take-off, engine over-temperature events,
exceedance of recommended speed thresholds, GPWS/TAWS
warnings, onset of stall conditions, excessive rates of rotation,
glide path excursions, and vertical acceleration.
FDM has been implemented in many countries, and it is
widely recognized as a cost-effective tool for improving
safety. In the United States and Europe—thanks to ICAO—
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ZGuest Editorial
ASL/3/2014
TC is committed to reviewing the effectiveness of the
recommendations contained in the CASA through inspection
activities. TC will determine if an air operator’s SMS is
capturing all risks including unstable approaches, and if so, if
this risk is being analyzed and addressed properly.
Alternatively, operators who indicate that they do not have a
problem with unstable approaches in their operation will be
asked to demonstrate how they have reached this conclusion.
Finally, as the issue of unstable approaches is not limited to
705 operators, the CASA was also addressed to 703 and 704
operators to encourage them to address the issue voluntarily.
TSB Final Report A11Q0168—Collision With Terrain
Following Night-Time Takeoff
On August 27, 2011, at approximately 2100 Eastern Daylight
Time, a Robinson R44 Raven II, a privately-owned helicopter,
departed from the Saint-Ferdinand Aerodrome (CSH5), Que.,
with the pilot and 3 passengers on board for a night flight to
Saint-Nicolas, Que., under visual flight rules. At 2109, a
distress signal emitted by the emergency locator transmitter
was detected by the SARSAT (search and rescue satelliteaided tracking) system. The aircraft was found approximately
2 hours and 35 minutes later in a wooded area, about 3 940
feet from its point of departure. The helicopter was destroyed
on impact, but did not catch fire. All of the occupants perished
in the crash. The TSB authorized the release of this report on
June 26, 2013.
Analysis
General
The pilot had the necessary licence and qualifications to fly
the aircraft, and there is no evidence that the pilot’s capacities
were diminished by physiological factors. There is nothing to
indicate that fatigue, weather conditions, or the airworthiness
of the aircraft played a role in this accident. Consequently, this
analysis will focus on plausible scenarios that could have
caused the crash, and on the risks associated with night flight.

The approach of post-tropical storm Irene would have
affected flight conditions the next day.
In the absence of eye witnesses, radar data, and global
positioning system (GPS) data, the take-off path could not be
determined. However, it is reasonable to believe that the
aircraft crashed shortly after take-off. The occupants arrived at
the aerodrome around 2050, and the first emergency locator
transmitter (ELT) signal was received at 2109. The 19 minutes
between the arrival at the aerodrome and the first ELT signal
can be explained as follows:






Time required for a pre-departure walk-around
inspection of the aircraft
Time required for the pilot and passengers to board
the aircraft
Time required to start and warm up the engine
Time required for the GPS receiver to collect the
satellite data and establish the aircraft’s current
position, which can take up to 5 minutes
Time required to enter the route in the GPS
Fifty-second delay between the impact and the coded
message transmitted by the ELT
Due to light, variable surface wind, the pilot had 4 take-off
options:
1.
2.
3.
4.
Take off from the current position and proceed
directly to the destination
Take off following the Runway 05 centreline before
turning left
Backtrack Runway 23 and take off following the
runway centreline
Take off from the current position following the
departure path of Runway 23 and turn right
Scenarios 1 and 2 are unlikely for the following reasons:


Plausible scenarios
Given that it was night and that the aerodrome was not
equipped with a lighting system, take-off was not allowed
under the Canadian Aviation Regulations (CARs). It is not
known why the pilot would have chosen to fly knowing that
the aerodrome did not have a lighting system; however, the
following may have influenced the pilot’s decision:



The occupants of the aircraft had planned to return
home the same day.
The weather conditions were conducive to visual
flight.
It was a short flight.
ASL 3/2014

The departure in these directions offered few visual
references.
The rising terrain reduced obstacle clearance during
the initial climb.
The area was more wooded, offering less chance of a
forced landing in the event of engine failure during
the initial climb.
Scenario 3 is also unlikely. It would have been difficult for the
pilot to hover-taxi and make a 180° turn above a runway
without markings, particularly when it was dark in the
aerodrome’s immediate surroundings.
Scenario 4 was the best choice and is the assumption used, for
the following reasons:

Hover-taxiing was not required.
29




There was a 1 400-foot unobstructed field at the end
of the runway.
The terrain was descending, which increased the
obstacle clearance during the initial climb.
The villages of Bernierville and Saint-Ferdinand
provided visual references for the initial climb.
There were more fields in the area in the event that a
forced landing became necessary.
By following the extended centreline of Runway 23, the pilot
had the choice of turning left or right. Since a left-hand circuit
is standard, if the pilot wanted to turn right, a climb should
have been performed on the extended centreline of the runway
to 1 000 ft above ground level (AGL), before turning right
toward the destination. It would have been unwise to do so
below 1 000 ft AGL, given the rising terrain in this direction.
Moreover, the aircraft crashed east of the threshold of
Runway 23, which is not the path of a right turn after take-off.
However, a left turn after take-off, which is part of a left-hand
circuit, was possible at 500 ft AGL. In addition, the crash site
and the wreckage path are consistent with a left turn after takeoff to intercept the desired track. On its arrival in SaintFerdinand, the aircraft disappeared from the radar screen at
about 500 ft AGL. Since on departure, no target was captured
by radar, it is highly likely that the aircraft did not reach
500 ft AGL after take-off.
Other than the fact that the CLUTCH warning light had come
on, as indicated by the stretched filament, an examination of
the aircraft, the engine, and its accessories did not reveal any
reason to believe that an anomaly had occurred requiring an
emergency landing. While it is possible that the CLUTCH
warning light came on during the flight, it is impossible to
conclude from the examination of the wreckage and the clutch
whether the warning light was on for more than 7 or 8
seconds. The clutch circuit breaker was found “IN”,
suggesting that the appropriate procedure had not been
initiated or was not necessary. However, the location of the
breaker panel requires the pilot to bend to the left to touch the
breakers and to find the one with the red ring, which could
take some time. If this happened while the pilot was making a
turn with little visual reference, it could have caused spatial
disorientation attributable to the Coreolis illusion.
If the light comes on for more than 7 or 8 seconds, the
procedure calls for an immediate landing. If this happened, the
pilot was in a dangerous situation, since a return to an unlit
runway or a safe emergency landing in a field was practically
impossible. The environment offered few visual references,
and there was insufficient moonlight to allow for a clear view
of the terrain and obstacles.
Risks associated with helicopter night flights
The lack of visual cues inherent at night in poorly lit areas can
make night flying, take-offs, and landings challenging. In fact,
one of the safety notices issued by the manufacturer indicates
that one should never fly at night unless one has clear weather
30
ASL 3/2014
Aerial view of the Saint-Ferdinand area
with unlimited or very high ceilings, and plenty of celestial or
ground lights for reference. While the ceiling was high the
night of the accident, there were few ground lights and no
celestial light, increasing the risk of spatial disorientation.
Being aware that disorientation can occur during flight and
conducting a proper instrument check can prevent these
problems. Awareness of the risk of spatial disorientation is
one of the best ways to prevent related accidents, and most of
the strategies to reduce the risk of spatial disorientation
involve pre-flight preparation. Just because a pilot becomes
spatially disoriented does not necessarily mean loss control of
the aircraft will occur. That said, in all likelihood, the pilot of
the helicopter lost control of the aircraft shortly after take-off
due to spatial disorientation.
If taking off down the centreline of Runway 23, the pilot
would have had visual references provided by the villages of
Bernierville and Saint-Ferdinand. However, assuming the pilot
made a left turn after take-off, visual references would have
been greatly reduced, and the pilot would have found himself
in a black hole. The pilot’s night vision may have been
affected by the transition from the bright lights of the village
to darkness. Although the Transportation Safety Board (TSB)
could not determine the light intensity provided by the
instrument panel and the GPS696 in the cockpit, inappropriate
settings can also hamper night vision, making it difficult for
the pilot to make out the few outside visual references
available to help maintain spatial orientation. Moreover, the
angular acceleration created during the left turn may have
given the pilot the impression of turning in the opposite
direction once the aircraft had finished turning, an impression
than can last anywhere from 10 to 20 seconds. That length of
time would have been enough for the pilot to lose control of
the aircraft, especially when coupled with the fact that there
were few outside visual references.
The pilot may have tried to control the helicopter with
reference to flight instruments, as trained to do. However, the
pilot did not have practical instrument flying experience, and
had had little exposure to night flying outside metropolitan
areas. As a result, the pilot may have become rapidly spatially
disoriented.
The number of private helicopter licence holders in Canada
more than doubled in the space of 20 years. This number has
continued to grow, and could increase even more if the current
320 student-pilot permit holders obtain their licences. Sixty
percent of private helicopter pilots in Quebec are night rated,
which may explain why 5 out of the 6 accidents that occurred
at night were in Quebec.
The popularity of the R44 has grown in recent years, as
evidenced by the number manufactured. Almost 60% of the
R44s in the country are privately operated, and 43% of these
are operated in Quebec. Although 35% of private helicopter
accidents in Canada over a 10-year period involved the R44,
the majority were due to pilots having trouble controlling the
aircraft rather than to mechanical problems.
Given the growing number of private helicopter pilots, it is
reasonable to assume that there will be an increase in nightrated pilots. It is difficult to predict the impact that this
increase could have on the number or rate of night-flying
accidents involving all types of helicopters combined.
However, it is reasonable to believe that the minimum
requirements necessary to obtain a private helicopter pilot
night rating may not be sufficient to adequately educate and
demonstrate to private helicopter pilots the risks involved in
night flying, including visual illusions that could lead to
spatial disorientation. Present night-rating requirements are the
same for private helicopter pilots as for private fixed-wing
aircraft pilots, yet the environments in which they may operate
at night can vary greatly.
Findings as to causes and contributing factors
1. The pilot had few outside visual references during the
night flight.
2. The pilot probably lost control of the aircraft shortly
after take-off due to spatial disorientation.
Findings as to risk
1. Take-off at night from an unlit aerodrome increases
the risk of collision with obstacles or the ground.
2. Pilots without extensive night flight experience
outside well-lit areas are at higher risk for spatial
disorientation.
3. When information in the Canadian Beacon Registry
is not updated following a change in owner or
registration, additional efforts are required to find the
owner’s contact information, which could delay the
deployment of search-and-rescue services.
4. It is possible that the minimum requirements to
obtain a private helicopter-pilot night rating may not
be sufficient to adequately educate and demonstrate
to private helicopter pilots the risks involved in night
flying, including visual illusions that could lead to
spatial disorientation.
TSB Final Report A12A0085—Engine Failure and Hard
Landing
On August 12, 2012, a Bell 407 helicopter was slinging a drill
tower approximately 4 NM southwest of Wabush, N.L. While
approaching the drill base frame, the helicopter lost engine
power, then immediately descended and yawed to the left. The
pilot released the drill tower before the helicopter struck the
terrain. The pilot, who was the sole occupant, sustained minor
injuries and was able to exit the aircraft. The helicopter was
substantially damaged, and the 406-megahertz emergency
locator transmitter activated as a result of the impact. There
was no post-crash fire. The accident occurred in daylight
hours at 1300 Atlantic Daylight Time. The TSB authorized the
release of this report on October 2, 2013.
According to Robinson Helicopter Company Safety
Notices SN-18 and SN-26, helicopters have less inherent
stability and much faster roll rates than aeroplanes. Loss of the
pilot’s outside visual references, even for a moment, can result
in spatial disorientation, wrong control inputs, and loss of
control.
The circumstances surrounding this accident attest to the risk
of spatial disorientation during night visual flight rules (VFR)
operations, and reinforce the importance of the warnings
included in safety notices SN-18 and SN-26 issued by the
manufacturer.
ASL 3/2014
Occurence third-stage power turbine wheel
31
Analysis
The third-stage turbine wheel failed due to the overstress
extension of high-cycle fatigue cracks in the blade trailing
edges, in a manner consistent with a known pattern, resulting
in a loss of engine power. Rolls-Royce Corporation (RRC) has
not been able to specifically identify what engine operating
condition, or conditions, cause the tensile residual stresses to
be induced at the blade hub trailing edges. Also, it is unknown
what extended engine operations are being conducted in the
68.4% to 87.1% power turbine speed (N 2) range. As a result,
there is a continued possibility of engine failure, in turn
increasing the risk of injury and helicopter damage.
After the power loss occurred, the collective lever was not
immediately lowered, and no action was taken to correct the
left yaw. When the collective lever is not immediately
lowered, main rotor speed (NR) may decrease to a point where
loss of control of the helicopter may result. Additionally, antitorque input must be applied to maintain directional control.
The engine power loss occurred with the helicopter operating
in the height-velocity diagram (HVD) “avoid” range, and it
cannot be determined whether immediate action to maintain
NR and directional control would have reduced injury or
helicopter damage. When there is a delay in carrying out the
required actions to maintain control following an engine
power loss, there is an increased risk of injury and helicopter
damage.
2.
3.
When there is a delay in carrying out the required
actions to maintain rotor speed following an engine
power loss, there is an increased risk of injury and
helicopter damage.
When helicopter pilots do not wear flight helmets,
they are at a higher risk of head injuries incurred in a
crash.
TSB Final Report A12O0138—Collision with Terrain
On August 24, 2012, a Cessna 172S rented from a local flying
club departed the Kitchener/Waterloo Airport (CYKF), Ont.,
at 1815 Eastern Daylight Time, under visual meteorological
conditions. The aircraft flew to Niagara Falls, Ont., then to the
city of Toronto, Ont., and back to a practice area north of
Kitchener Waterloo. At approximately 2016 Eastern Daylight
Time, the aircraft crashed into a field, 25 NM north of CYKF.
The aircraft was destroyed; the pilot and 3 passengers were
fatally injured. There was no post impact fire. The emergency
locator transmitter activated upon impact. The TSB authorized
the release of this report on December 18, 2013.
The helicopter was operating within the HVD avoid range.
The engine power loss occurred at an altitude from which a
safe landing could not be assured, resulting in minor injury
and substantial helicopter damage.
The pilot was not wearing a flight helmet, and no head injuries
were sustained. Despite the recognized benefits of head
protection, there are no regulations for helicopter pilots to
wear helmets. When helicopter pilots do not wear flight
helmets, they are at a higher risk of head injuries incurred in a
crash.
Findings as to causes and contributing factors
1. The third-stage turbine wheel failed due to the
overstress extension of high-cycle fatigue cracks in
the blade trailing edges in a manner consistent with a
known pattern, resulting in a loss of engine power.
2. The engine power loss occurred at an altitude from
which a safe landing could not be assured, resulting
in minor injury and substantial helicopter damage.
Findings as to risk
1. Rolls-Royce Corporation has not been able to
specifically identify what engine operating condition,
or conditions cause the tensile residual stresses to be
induced at the blade hub trailing edges. As a result
there is a continued possibility of engine failure, in
turn increasing the risk of injury and helicopter
damage.
32
ASL 3/2014
Analysis
The aircraft was complete and intact before the impact. There
was a fracture with the stall warning system, but the effect of
the fracture on the stall warning system operation could not be
determined. No other abnormalities with the aircraft or its
systems were discovered. The pilot was appropriately
licensed, and was certified and qualified in accordance with
the applicable regulations.
It was determined that the passengers switched seats during
the flight. Currently, no regulation prohibits passengers from
exchanging seat positions while the aircraft is airborne.
However, because of the confined cabin space and proximity
to the pilot and the flight controls, it is not a safe practice;
switching seats could lead to inadvertent contact with the
flight controls or the pilot, affecting the controllability of the
aircraft. Movement within the cabin would also shift the
aircraft's centre of gravity, possibly adding to control issues.
The seat exchange was not a factor in the occurrence, as all
occupants were seated and wore their seat belts and shoulder
harnesses.
policies. If the spin was entered intentionally, then the
limitations and policies were ignored. The pilot may not have
realized that exceeding these limitations may change the stall
recovery characteristics of the aircraft.
The aircraft was not approved for spins when operated in the
normal category. This limitation was stated in the pilot's
operating handbook (POH) and on a placard located in the
aircraft. The flying club’s policies also prohibited spins
without an instructor on-board.
The spin may have been entered unintentionally. As discussed,
a stall must precede a spin manoeuver. If an aircraft is slowed,
the airspeed can decrease to a point that a stall may occur.
Additionally, the stall speed increases with the angle of bank.
While manoeuvering, the aircraft may have been intentionally
slowed and/or banked, resulting in an unanticipated stall
occurring with an aft centre of gravity (CG). Also, if the stall
warning was either erroneous or absent, the aircraft may have
stalled with little or no prior warning from the stall warning
horn.
The aircraft climbed to a higher altitude and broadcast the
intention of performing airwork in the practise area, indicating
that the pilot intended to perform some type of manoeuver
(airwork). However, it could not be determined whether the
spin was entered intentionally or unintentionally; both
possibilities are discussed in this analysis.
During the spin, the angle of attack increased due to an aft
CG. As a result, the horizontal tail likely blanketed the airflow
over the rudder, reducing its efficiency and delaying spin
recovery. In the normal category, the aircraft is certified to
recover from a one-turn spin in less than one additional turn,
assuming the proper control inputs are applied.
The pilot held a Commercial license, was experienced on the
aircraft type, and was aware of the limitations and company
Finding as to causes and contributing factors
1. The aircraft entered a spin in a weight and balance
configuration for which spins were not authorized;
the pilot did not recover from the spin prior to ground
impact.
The investigation determined that the aircraft entered a spin.
Therefore, this analysis focuses on reasons for stall/spin entry
and non-recovery.
Findings as to risk
1. If passengers switch seat positions during flight in a
small aircraft, there is an increased risk of inadvertent
flight control movement as well as a risk of causing
the centre of gravity to shift, possibly adding to
control issues.
2. If a stall warning horn is damaged, it may activate too
late or fail to activate, increasing the risk that pilots
are not warned of an impending stall in a timely
manner.
Safety Action Taken
Flying club
Since this occurrence, the flying club implemented the
following measures to its flight program and aircraft:
 Re-emphasized to all pilots the difference between
operations in the “Normal” and “Utility” categories
as well as the club’s policies regarding the
requirement that an instructor be on-board to perform
airwork;
 Strengthened the airwork component of their
groundschool programs.
The flying club’s entire fleet will also be equipped with a
global positioning system (GPS) tracker and a cockpit voice
recorder.
ASL 3/2014
33
TSB Final Report A13C0014—Continued Visual Flight
Into Instrument Meteorological Conditions—Collision
With Terrain
This accident received additional media attention due to the
fact that the three passengers were young local boys from the
small community of Waskada, Man. Knowing a little more
about the real impact the accident had on their community
seems to bring the safety message a little closer to home, and
personal. —Ed.
On February 10, 2013, at approximately 12:30 CST, a
privately registered Cessna 210C departed a private airstrip
located at Waskada, Man., with a pilot and three passengers on
board for a sightseeing flight in the local area. Approximately
30 min after the aircraft departed, fog moved into the area. At
13:17 CST, an ELT signal was received in the area. A search
was undertaken and the wreckage was located 3 NM north of
Waskada. All occupants suffered fatal injuries. There was nopost crash fire. The TSB authorized the release of this report
on January 29, 2014.
Winter weather conditions and whiteout
The accident occurred in an area of gently rolling hills, which
were completely snow covered. There were few trees or other
features to provide visual references. The terrain, coupled with
the reported meteorological conditions, was conducive to
whiteout. Section AIR 2.12.7 of the Transport Canada
Aeronautical Information Manual (TC AIM) states:
Whiteout (also called milky weather) is defined in the
Glossary of Meteorology (published by the American
Meteorological Society) as:
An atmospheric optical phenomenon of the polar
regions in which the observer appears to be engulfed
in a uniformly white glow. Neither shadows, horizon,
nor clouds are discernible; sense of depth and
orientation is lost; only very dark, nearby objects can
be seen. Whiteout occurs over an unbroken snow
cover and beneath a uniformly overcast sky, when
with the aid of the snowblink effect, the light from the
sky is about equal to that from the snow surface.
Blowing snow may be an additional cause.
Flight in whiteout conditions may result in a poorly defined
visual horizon that affects the pilot’s ability to judge and
stabilize aircraft attitude or reduces the pilot’s ability to detect
changes in altitude, airspeed and position. If visual cues are
sufficiently degraded, the pilot may lose control of the aircraft
or fly into the ground or surface of the water.
The TC AIM recommends that pilots avoid such conditions
unless the aircraft is equipped with the suitable instruments,
and they are sufficiently experienced. In order for a pilot to
escape from whiteout conditions, it is necessary to either
effectively transition from visual to instrument flight or be
able to quickly regain sight of visual contrast. If at low level, a
climb or a turn toward an area where sharp terrain features can
be seen should be initiated. It is generally considered to be a
difficult task for even an experienced instrument pilot to make
a successful transition from visual to instrument flight after
inadvertent entry into instrument meteorological conditions
(IMC).
History of the flight
The pilot had recently acquired the aircraft and had
accumulated approximately 5 hr of flight time on it since its
purchase. Although aware of the reported poor weather in the
area, the pilot wanted to get some more flight hours on his
new aircraft and considered that the local weather was suitable
for a VFR flight. The pilot was planning to tour the local area,
then fly to Brandon, Man., for lunch.
34
ASL 3/2014
Vision is the dominant sense enabling pilot spatial orientation.
Peripheral vision is the primary source of spatial orientation,
with vestibular organs and kinesthetic sensors also
contributing. In the absence of adequate visual cues when
peripheral vision is limited, vestibular and kinesthetic illusions
or false impressions can occur. This sometimes results in pilot
disorientation and loss of situational awareness, which can
lead to loss of aircraft control. In IMC, the pilot must rely on
instruments instead of instinct to overcome illusions or false
impressions. In visual meteorological conditions (VMC), the
pilot relies on outside references to control the aircraft.
The snow-covered terrain, combined with the meteorological
conditions, was conducive to whiteout. In whiteout conditions,
the snow and fog would blend together and under these
conditions, the pilot would not be able to fly using visual
references. Whiteout would also make it more difficult to
identify an area of local fog and more difficult to exit such an
area if it were encountered.
It is therefore probable that the pilot encountered whiteout
conditions and was unable to accurately judge, through visual
reference, his altitude above the ground. In the absence of a
visible horizon, the pilot likely experienced spatial
disorientation, particularly if he initiated a turn to avoid the
deteriorating weather. The pilot’s lack of instrument training
and experience would have made him more susceptible to the
effects of whiteout and spatial disorientation.
Emergency personnel and TSB investigators at the crash site
near Waskada, Manitoba. This photo of the accident site
illustrates how the area was conducive to whiteout.
Inadvertent flight into IMC and loss of control
Transport Canada has published many articles concerning
whiteout and flight into IMC with no instrument rating
endorsement. The information available concerning
inadvertent flight into IMC by unqualified pilots and the
inevitable outcome is widely available in documents such as
Transport Canada publication number TP 2228E-1: Take Five
for Safety—178 Seconds.
Findings as to causes and contributing factors
1. The meteorological conditions in the area were
conducive to whiteout.
2. The pilot likely flew inadvertently into IMC and lost
situational awareness and control of the aircraft,
resulting in impact with terrain.
Finding as to risk
1. Aircraft equipped with 121.5 MHz ELTs, which
require procedures to be followed that take more time
than 406 MHz ELTs, are at increased risk of delay in
the initiation of search and rescue procedures.
Analysis
No aircraft technical malfunction was identified.
The meteorological conditions at takeoff were VMC, but some
areas of IMC were forecast in the graphic area forecast (GFA).
ASL 3/2014
35
Accident Synopses
Note: The following accident synopses are recent Transportation Safety Board of Canada (TSB) Class 5 events. These occurrences do
not meet the criteria of classes 1 through 4, and are recorded by the TSB for possible safety analysis, statistical reporting, or archival
purposes. The narratives may have been updated since publication. Unless otherwise specified, photos are provided by the TSB. For
more information on any individual occurrence, please contact the TSB.
— On November 1, 2013, a de Havilland DHC6 Twin Otter
landed on Runway 09 at Sanikiluaq Airport (CYSK), Nun.
During the landing roll, the pilot lost directional control. The
aircraft came to rest approximately 100 ft off the runway and
sustained substantial damage. The two pilots on board were
not injured. The wind at the time of the occurrence was from
010º at 25 kt, with gusts up to 35 kt. The aircraft
manufacturer’s crosswind limitation listed in the flight manual
was 26 kt. After the accident, a special weather reading was
taken and it reported winds coming from 350º at 25 kt, with
gusts of 37 kt. The operator performed a safety management
system (SMS) investigation of the event and of company
policies. The investigation resulted in the implementation of
many corrective actions to prevent similar incidents from
occurring. TSB File A13Q0185.
— On November 3, 2013, an amateur-built Murphy Elite
was in the landing phase for Runway 24 at St-Georges-deBeauce Airport (CYSG), Que., when its right landing gear
broke. The aircraft veered off the runway and, at the same
time, the left gear separated from the fuselage. The propeller
and wing tips touched the ground before the aircraft came to a
stop. The pilot and owner of the aircraft had installed a
conventional wheeled landing gear the day before. A postaccident aircraft examination revealed that the landing gear's
mounting bolts (AN4-23) were unscrewed. No washers had
been installed under the nuts and the bolts were a bit too short
to keep the nuts from loosening. The pilot was not injured; the
passenger suffered minor injuries. TSB File A13Q0189.
— On November 4, 2013, a Calidus AutoGyro gyroplane,
with only the pilot on board, was conducting touch-and-gos at
Rivière-du-Loup Airport (CYRI), Que. During landing, one of
the wheels hit the ground hard and the aircraft fell on its right
side. The pilot was not injured. The aircraft was substantially
damaged. TSB File A13Q0193.
— On November 7, 2013, privately-owned Cessna 182P with
one person on board departed Cornwall, Ont., for Owen
Sound, Ont. A VFR flight plan was filed prior to departure
with an estimated time of arrival (ETA) in Owen Sound of
0040 UTC. The last radio communication with the aircraft
occurred approximately 85 NM east of Midland, Ont., while
the aircraft was at 6 500 ft AGL, with a ground speed of
110 kt and in marginal weather conditions including snow
squalls. Due to the location of the flight path, radar coverage
was lost around the same time as the last communication. At
0140 UTC, approximately one hour after the ETA, the London
flight information centre (FIC) contacted the Trenton Joint
36
ASL 3/2014
ZGuest Editorial
ASL/3/2014
Rescue Coordination Centre (JRCC Trenton) and a search was
initiated along the estimated flight path. The following day,
aircraft debris was found on the water approximately 4.8 NM
north of Wasaga Beach, Ont., along the direct path to Owen
Sound airport. Aircraft identification was based on the colours
of the debris found on the water. The search for the aircraft
had been hampered by the weather. Human remains were
found on April 30, 2014, in the area of Big Sand Bay,
Christian Island, Ont. Forensic examination positively
identified the remains as those of the missing pilot. TSB File
A13O0213.
— On November 13, 2013, a float-equipped Cessna R172K
with only the pilot on board was taxiing on Lake Beverly,
located south of Smiths Falls, Ont. Wind conditions were 15
to 20 kt with higher wind gust values. As the aircraft was
turning for the takeoff run, a gust lifted the tail of the aircraft;
it nosed over in the water and became inverted. The pilot was
wearing a three-point harness and was not injured. The pilot
evacuated and sat on the floats until search and rescue (SAR)
personnel arrived at the scene. TSB File A13O0214.
— On November 14, 2013, a privately owned Cessna 150G
took off from Victoriaville Airport (CSR3), Que., for SainteCroix de Lotbinière, Que., on a VFR flight with two occupants
on board. At Laurier Station, the pilot conducted an approach
on a road in a field to see whether a landing was possible.
After pulling up to go-around, the aircraft turned right. The
right stabilizer struck a power line and the aircraft crashed in a
wooded area. The two occupants suffered minor injuries. The
aircraft was substantially damaged. TSB File A13Q0194.
— On November 16, 2013, a Pezetel SZD-50-3 glider was
being towed for takeoff; it was approximately 10 ft in the air
when the speed brakes partially deployed. The tow cable was
released and the glider landed hard, damaging the fuselage and
the spoilers. There were no reported injuries. TSB File
A13O0218.
— On November 18, 2013, a Pipistrel Virus 912SW was
returning to Abbotsford, B.C., due to poor weather about
3 min after departing for Pitt Meadows, B.C. ATC cleared the
pilot to land on any runway and saw the aircraft circle and
proceed westbound along Highway 1 before it disappeared off
radar. ATC was unable to re-establish communication with the
pilot. Search and rescue (SAR) helicopters were dispatched to
an area where a faint and erratic emergency locator transmitter
(ELT) signal was picked up. Ground SAR technicians located
the wreckage on the north side of Maclure Road about 4 mi.
from Abbotsford airport. The sole occupant was fatally
injured. TSB File A13P0291.
— On November 20, 2013, a privately owned Piper PA-28R200 took off on a VFR flight from St-Hyacinthe Airport
(CSU3), Que., to Mascouche Airport (CSK3), Que., with only
the pilot on board. On arrival at his destination, the pilot did
not extend the landing gear and the aircraft landed on its belly.
No anomaly was noted before or after the accident. The
propeller was substantially damaged. The pilot was not hurt.
TSB File A13Q0197.
— On November 22, 2013, a M20BX Mooney was landing at
Yorkton Municipal Airport (CYQV), Sask. The landing gear
was selected down. The GUMPS (Gas, Undercarriage,
Mixture, Propeller, Seat belts and Switches) check was
performed on the downwind leg and again on final approach.
The initial touchdown and landing rollout were uneventful.
Toward the end of the landing roll, the landing gear handle
became unlatched and moved to the gear up position. The
landing gear collapsed as the aircraft came to a stop.
TSB File A13C0162.
— On December 6, 2013, a Beechcraft C23 was conducting a
VFR flight from Rivière-du-Loup Airport (CYRI), Que., to
Rimouski Airport (CYXK), Que., with a pilot and a passenger
on board. While the aircraft was cruising, the engine (Avco
Lycoming O-360-A4K) started to vibrate and lose power. The
pilot conducted an emergency landing on Route 132, heading
west. After landing, the aircraft veered off the road to avoid a
vehicle and came to a stop in a ditch. No one was hurt but the
aircraft was substantially damaged. There was no post-impact
fire. The engine will be examined in order to find the cause of
the problem. TSB File A13Q0205.
— On December 14, 2013, a Cessna 421B, with two persons
on board, was flying IFR en route from Abbotsford, B.C., to
Tofino, B.C. The aircraft was lost on ATC radar in the vicinity
of Tofino. A search commenced and the aircraft wreckage was
located the following morning on Vargas Island, about 11 NM
northwest of Tofino Airport. Both persons on board are
assumed fatally injured as the aircraft was partially buried in a
marsh, and the bodies were not visible. There was no fire.
TSB File A13P0305.
— On November 29, 2013, a Quad City Challenger II
ultralight was completing circuits at Baldwin Airport (CPB9),
Ont. During takeoff from Runway 01, while climbing through
200 ft to 300 ft, the aircraft suffered a power loss (Rotax 503)
and the pilot attempted to turn right to return to the field.
During this turn, the aircraft stalled and impacted the ground
in a wooded area 200 m west of the departure end of the
runway. The aircraft was destroyed on impact; however, the
pilot, who was wearing a helmet and four-point seatbelt,
suffered only minor injuries. TSB File A13O0223.
The Cessna 421B that crashed on Vargas Island, B.C.
(photo: Ray Barber / Airport-data.com)
— On December 14, 2013, a Cessna P210N was departing
Lloydminster Airport (CYLL), Alta., on an IFR flight to High
River Airport (CEN4), Alta. Shortly after departure, the
aircraft collided with terrain 1.6 NM northeast of CYLL. The
aircraft tumbled and slid into a residential home causing some
damage to the home. No occupants of the home were injured.
The pilot, who was the sole occupant of the aircraft, was
fatally injured. There was a small post-impact fire that was
extinguished by first responders. TSB File A13W0188.
— On December 22, 2013, a Sikorsky S76A helicopter had
been dispatched to a private residence. The crew performed
two low reconnaissance passes and chose an approach to the
east over some wires to land on a wide part of the driveway
near the house. The on-board medics were placed on live
intercom and were briefed to report on any observed obstacles.
TSB File A13O0223
ASL 3/2014
37
The crew selected continuous ignition and entered a high
hover to blow away snow accumulation at the scene. The crew
was avoiding a park bench to the left. During the manoeuvre, a
whiteout condition was created. As the visibility cleared, the
crew descended but the helicopter inadvertently drifted aft and
to the right. The crew received a warning that trees were in
close proximity at the four o'clock position immediately prior
to main rotor contact with the trees. Control was maintained
and the helicopter was moved away. A landing was performed
straight ahead. The rotor was unbalanced, and the crew were
briefed not to exit until the helicopter had been shut down.
There were no injuries. The helicopter sustained damage to all
four rotor blades. TSB File A13C0182.
— On January 14, 2014, a Cessna 337G was returning from
an aerial survey with the pilot and one passenger on board.
The aircraft was on approach for Runway 30 at Dryden
Regional Airport (CYHD), Ont., and landed with the landing
gear retracted. There were no injuries and the aircraft
sustained substantial damage. Information indicated that the
pilot was very busy during the final approach and did not hear
the gear warning horn. TSB File A14C0011.
site about two hours later and transported the pilot to hospital
with injuries. Examination of the wreckage determined that
the aircraft lost power due to fuel exhaustion. TSB File
A14A0004.
— On January 23, 2014, a Bell 206B helicopter had just been
started with a ground power unit (GPU) at Haines Junction
Airport (CYHT), Y.T. The pilot exited the aircraft in order to
disconnect the GPU, when a gust of wind pushed the
helicopter into the trees next to the helipad. The pilot was not
injured. TSB File A14W0010.
— On January 25, 2014, a Cessna 152 was on a flight from
St. Andrews, Man., to Lac du Bonnet Regional Airport
(CYAX), Man. The pilot conducted a low pass to inspect the
runway before landing. On touchdown, the aircraft
encountered snow up to 12 in. deep. The aircraft veered left to
the edge of the runway, struck a snow drift and overturned.
The pilot and passenger exited without injuries. The aircraft
sustained substantial damage to its wings, tail and propeller.
TSB File A14C0018.
— On January 15, 2014, a privately owned Piper PA-20-115
was conducting a training flight on Runway 23 at TroisRivières Airport (CYRI), Que., with two pilots on board.
During the second touch-and-go, the aircraft veered to the left
during the landing roll. The pilot tried to correct the aircraft's
trajectory using the control column. The aircraft veered off the
runway, struck a snow bank and flipped over. The two
occupants were uninjured in the accident. TSB File
A14Q0006.
— On January 19, 2014, a Cessna 150M was taxiing for a
local training flight at Saskatoon/John G. Diefenbaker
International Airport (CYXE), Sask. The aircraft was taxied
behind an ATR completing an engine run-up. The instructor
estimated the distance between the Cessna and the ATR to be
about 120 to 150 m. The propeller wash from the ATR lifted
the left wing of the Cessna 150, causing the right wing tip and
propeller to strike the ground and sustain substantial damage.
There were no injuries. TSB File A14C0014.
— On January 21, 2014, a Diamond DA 20-C1 was on a
round trip training flight, from Fredericton, N.B., to Moncton,
N.B., with the student pilot as the sole occupant. At about
10 NM northeast of Fredericton International Airport (CYFC),
the aircraft engine lost power and the pilot declared a
MAYDAY before the aircraft impacted terrain. The pilot used
a cellular telephone to alert first responders who located the
38
ASL 3/2014
TSB File A14C0018
— On January 27, 2014, a Schweizer 269C-1 helicopter with
two persons on board was operating at low level along the Pitt
River, B.C., north of Pitt Lake, B.C. The helicopter struck
something on the ground. The pilot lost control and the
helicopter rolled over. Both persons on board escaped with
minor injuries. The 406 ELT activated, and the aircraft was
located by search and rescue (SAR). The two occupants were
hoisted aboard and flown to Abbotsford. TSB File A14P0010.
Cats Can See in The Dark… You Can’t.
Cats Can See in The Dark… You Can’t.
Each Taxi Scenario is Different! Be Sure! Runway Incursion
Poster
Each Taxi Scenario is Different. Be
Sure!
2014 Flight Crew Recency Requirements
Self-Paced Study Program
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Completion of this questionnaire satisfies the 24-month recurrent training program requirements of
CAR 401.05(2)(a). It is to be retained by the pilot.
All pilots are to answer questions 1 to 33. In addition, aeroplane and ultra-light aeroplane pilots are to answer
questions 34, 35 and 36; helicopter pilots are to answer questions 36, 37 and 38; glider pilots are to answer
questions 39 and 40; gyroplane pilots are to answer question 41; and balloon pilots are to answer question 42.
Note: References are listed at the end of each question. Many answers may be found in the Transport Canada
Aeronautical Information Manual (TC AIM). Amendments to that publication may result in changes to answers
and/or references. The TC AIM is available online at:
http://www.tc.gc.ca/eng/civilaviation/publications/tp14371-menu-3092.htm
1.
A runway incursion is any occurrence at an aerodrome involving the incorrect presence of
_____________________________________on the protected area of a surface designated for the landing
and takeoff of aircraft.
(GEN 5.1)
2.
How are temporarily displaced thresholds marked?_________________________________________
(AGA 5.4.1 NOTE)
3.
At a Transport Canada certified airport, a dry wind direction indicator (windsock) that is blown horizontal
indicates a wind speed of __________.
4.
On initial contact with an FSS through an RCO, pilots should state the name of the ________ controlling the
RCO, the aircraft identification, and
______________________________________________________________________________________.
(AGA 5.9)
(COM 5.8.3)
5.
Before using a cell phone to contact ATS in the event of an in-flight radio communications failure, you
should ________________________________________and squawk Code _____.
(COM 5.15)
6.
Refer to a recent copy of the Canada Flight Supplement (CFS). What is the TAF period of coverage and
issue times for Whitehorse/Erik Nielson Intl Airport? _____________________________________
(MET 3.2.1 and CFS)
7.
Open a recent copy of the Canada Flight Supplement (CFS) and locate the “Planning” section (section C).
In the “VFR Chart Updating Data”, read the information for your region of Canada.
Record one of the topic names here: _________________________
(CFS)
8.
Areas of showery or intermittent precipitation are shown on a GFA Clouds and Weather Chart as
__________________________________________.
(MET 3.3.11)
TAF CYJT 041136Z 041212 24010KT ½ SM -SHRA -DZ FG OVC002 TEMPO 1213 3SM BR
OVC008 FM 1300Z 29012G22KT P6SM SCT006 BKN015 BECMG 2123 30010KT SCT020 RMK
NXT FCST BY 18Z=
9.
From the preceding TAF, what is the lowest forecast ceiling for CYJT? __________
(MET 3.9.3)
10. From the preceding TAF, at what time could you first expect to have VFR weather in the CYJT control
zone? ___________
(MET 3.9.3)
11. From the preceding TAF, what is the forecast visibility for CYJT after 2300Z? _____________
(MET 3.9.3)
12. What coded group is used, in an Upper Level Wind and Temperature Forecast (FD), when the wind speed is
less than 5 kt? ______
(MET 3.11)
13. In a METAR, wind direction is given in degrees true/magnetic.
(MET 3.15.3)
14. METAR CYBC 211700Z 0912G20 5/8SM BLSN VV007 M03/M05 A2969 RMK SN8 SLP105
In the preceding weather report, the prevailing visibility is ________ and the ceiling is _________.
(MET 3.15.3)
15. Who is responsible for obstacle avoidance when a VFR aircraft is being radar vectored? __________
(RAC 1.5.5)
16. If an ATC clearance is not acceptable, what should the pilot-in-command immediately do?
______________________________________________________________________________________.
(RAC 1.7)
17. Which classes of airspace require the use of a functioning transponder? All Class _____________ airspace
and any Class _______ airspace specified as transponder airspace.
(RAC 1.9.2)
18. When two aircraft are converging at approximately the same altitude, the pilot-in-command of the aircraft
that has the other on its right shall give way, except as follows:
(a)___________________________________________________________________________________;
(b) _________________________________________________;
(c) ____________________________________; and
(d)___________________________________________________________________________________.
(RAC 1.10)
19. To preserve the natural environment of national, provincial and municipal parks, reserves and refuges, and
to minimize the disturbance to the natural habitat, overflights of these areas should not be conducted below
______________.
(RAC 1.14.5)
20. What are the VFR cruising altitudes appropriate to an eastbound track above 3 000 ft AGL?
______________________________
(RAC 2.3.1)
21. In controlled airspace, the minimum VFR flight visibility is _____ mi., and the minimum distance from
cloud is _____ horizontally and _____ vertically.
(RAC 2.7.3)
22. Before entering Class C airspace, VFR flights require _____________ from ATC and before entering Class
D airspace, VFR flights must _______________________________________________________ ATC
unit.
(RAC 2.8.3 and 2.8.4)
23. An aircraft could be permitted in Class F restricted airspace only if_________________________________.
(RAC 2.8.6)
24. Pilot Briefing Services are available at telephone number _____________________________.
Bilingual Pilot Briefing Services are available at telephone number _____________________________.
(RAC 3.2)
25. After asking the passengers for their personal weights, what weight should be added for clothing on a winter
flight? ___________________________________
(RAC 3.5.1)
26. A flight itinerary may be filed with a responsible person. A “responsible person” means an individual who
has agreed to ensure that an overdue aircraft is reported to
_____________________________________________________________________________________.
(RAC 3.6.2)
27. The closing of a flight plan or flight itinerary prior to landing is considered as filing an arrival report, and as
such, it will result in
________________________________________________________________________.
(RAC 3.12.2)
28. Where possible, pilots are required to report at least _____ min prior to entering an MF or ATF area.
(RAC 4.5.7)
29. 140230 CYUL ST-JEAN
CYJN UNMANNED AERIAL VEHICLE OPS RADIUS 1.1 NM CENTRE
451813N 732553W (APRX 6 NM WNW AD) SFC TO 600 FT MSL
1400-1900 DLY
1403261400 TIL 1403271900
Refer to the NOTAM above. The UAV activity is expected to start at ________ UTC on _______________
(date).
(MAP 5.6.1)
30. An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error
of more than _______ when compared to the known ground elevation.
(AIR 1.5.1)
31. The effect of a mountain wave often extends as far as _____ NM downwind of the mountains.
(AIR 1.5.6)
32. If the background landscape does not provide sufficient contrast you will/will not see a wire or cable while
flying near power lines.
(AIR 2.4.1)
33. The NAV CANADA Aviation Weather Web Site is found at
https://flightplanning.navcanada.ca/cgibin/CreePage.pl?Langue=anglais&NoSession=NS_Inconnu&Page=forecast-observation&TypeDoc=html
Go to the Forecasts and Observations Web page and familiarize yourself with the Aeronautical Information
Circulars (AICs) and AIP Supplements. Record the most recent AIC number here: _____
(NAV CANADA Web site)
Aeroplane
34. Hydroplaning is a function of the ___________, _____________ and speed. Moreover, the minimum speed
at which a non-rotating tire will begin to hydroplane is _____ than the speed at which a rotating tire will
begin to hydroplane.
(AIR 1.6.5)
35. To achieve a turn of the smallest radius and greatest rate for a given angle of bank, fly at the _______ safe
airspeed for the angle of bank.
(Use aeroplane references)
Aeroplane and helicoptor
36. In addition to the classic whiteout condition of unbroken snow cover beneath a uniformly overcast sky,
name two other phenomena that are known to cause whiteout. ___________________, and
________________________________________________.
(AIR 2.12.7)
Helicopter
37. On a two-bladed helicopter with a teetering rotor system, a flight manoeuvre that causes even a small
amount negative G force could result in ______________.
(Use helicopter references)
38. What are the two methods of recovery from a vortex ring state? _________________________ or
_______________________.
(Use helicopter references)
Glider
39. During a medium banked turn on tow, the glider's nose should be pointed towards the towplane's
_______________.
(Use glider references)
40. What should you do when slack in the towline is excessive or beyond a pilot’s capability to safely recover?
_____________________________________
(Use glider references)
Gyroplane
41. If a gyroplane took off with its centre of gravity aft of the longitudinal limit, the aircraft may not be able to
establish level flight, even with maximum ________ cyclic.
(Use gyroplane references)
Balloons
42. No person shall operate a balloon over a built-up area without carrying on board sufficient fuel to permit the
balloon to fly clear of the built-up area, taking into consideration the take-off weight of the balloon, the
___________________ and _________________________, and possible variations of those factors.
(CAR 602.18)
Answers to this quiz are found on page 14 of ASL 3/2014.
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