aviation safety letter In this issue…

aviation safety letter In this issue…
TP 185E
Issue 4/2012
aviation safet y letter
In this issue…
COPA Corner: Can GPS Get You Lost?
NAV CANADA Online Store Reduces Costs, Boosts Convenience and Safety
Single-Pilot Resource Management (SRM) Competencies
Scenario-Based CRM Case Study: Stall Warning Device Event
The Flight Safety Foundation’s ALAR Tool Kit
Maintenance: Winter Operation Woes
Maintenance of Small Non-Commercial Aircraft
The Suspension or Cancellation of Canadian Aviation Documents
Due to “Incompetence”
DON’T WALK OUT... Stay in the Prime Search Area
Learn from the mistakes of others;
you’ll not live long enough to make them all yourself ...
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ISSN: 0709-8103
TP 185E
Table of Contents
sectionpage
Guest Editorial..............................................................................................................................................................................3
Pre-Flight...............................................................................................................................................................................4
Flight Operations..........................................................................................................................................................................7
Answers to the 2012 Self-Paced Study Program...............................................................................................................16
Maintenance and Certification............................................................................................................................................17
Recently Released TSB Reports.........................................................................................................................................20
Accident Synopses...............................................................................................................................................................31
Regulations and You............................................................................................................................................................... 34
Debrief: DON’T WALK OUT... Stay in the Prime Search Area.......................................................................................36
2012 Self-Paced Study Program............................................................................................................................... Tear-off
2
Table of Contents
ASL 4/2012
Guest Editorial
I am pleased to have this opportunity to introduce myself to all our stakeholders as the new director
of the Standards Branch in the Civil Aviation Directorate at Transport Canada.
In this editorial, I would like to briefly discuss some of the principles that I think are integral to
building a robust aviation safety program.
Aaron McCrorie
Ultimately, it is Canadian aviation document holders who are responsible for staying safe. This is achieved by complying with
the Canadian Aviation Regulations (CARs) and its associated Standards and, more specifically, by proactively identifying, assessing
and managing risks. In this context, Transport Canada’s role is to develop regulations that meet the public interest of improving
aviation safety and to oversee compliance with those regulations. We do this by taking a risk-based approach, collaborating with
stakeholders and looking at issues holistically and comprehensively.
Promoting the safe transportation of people and goods by air requires a risk-based approach. This means accepting that risk
cannot be eliminated; it does not, however, mean that we blindly accept risk. Rather, a strong aviation safety program is built
upon the identification, assessment and management of risks. As the nature of risk varies throughout the aviation industry,
applying a risk-based approach allows us to adapt our program to different sectors of the aviation industry, allowing for a more
effective mitigation of risks—one size does not always fit all. It also means applying our resources, whether in developing or
overseeing regulations, to the areas of greatest risk—those areas where an investment in safety will produce the greatest benefit
in terms of reducing risk.
Collaboration with all stakeholders is critical to identifying, developing and implementing the most effective approaches to
improving safety. Those who operate and work in the aviation industry have unique knowledge and expertise from which we,
at Transport Canada, need to benefit. We gather this information through formal and informal consultation with stakeholders.
These exchanges must be based on mutual respect and a willingness to engage and listen. Given different roles and responsibilities,
we may not always agree, but your views and knowledge are taken seriously when we make decisions and recommendations
to the Minister.
It is rare that the response to any given safety issue is confined to the organizational boundaries that we all create for ourselves.
For example, an effective response to many safety issues involves a number of different disciplines, including training, licensing,
flight operations, maintenance, and aircraft design and certification. That is one of the reasons why Transport Canada has
re-organized the Civil Aviation Directorate—to break down silos. As a result of this effort, all rule-making activities were
pulled together into a single branch—Standards. This allows us to develop more effective safety solutions by ensuring a more
holistic and comprehensive approach to program development and implementation.
In summary, I believe that an effective aviation safety program is built upon a clear understanding of roles and responsibilities; a
risk-based approach; program development through collaboration with all stakeholders; and a holistic and comprehensive approach.
Finally, I look forward to meeting and working with you. As I have suggested, I find it useful to hear from all stakeholders
to learn what are considered the challenges and opportunities that we face together. I firmly believe that it is only through
meaningful dialogue and effective co-operation between stakeholders and regulators that we can build an effective, balanced
and risk-based approach to aviation safety.
Aaron McCrorie
Director, Standards
Civil Aviation
ASL 4/2012
Guest Editorial
3
Pre-Flight
COPA Corner: Can GPS Get You Lost?............................................................................................................................... page 4
NAV CANADA Online Store Reduces Costs, Boosts Convenience and Safety ....................................................................... page 5
Transporting Bulk Fuel in compliance with the Certificate of Airworthiness......................................................................... page 6
COPA Corner: Can GPS Get You Lost?
by Dale Nielsen. This article was originally published in the “Chock to Chock” column
of the August 2007 issue of COPA Flight, and is reprinted with permission.
The answer is yes.
Many of us have become very dependent on these little gadgets.
They provide a lot of information and are very accurate. They
can however, fail. They can lose satellite coverage and batteries
in portable units can die.
One B.C. pilot on a flight from Vancouver to Nelson, B.C.
had to fly low through the valleys due to cloud cover. He
was unable to use his GPS as satellite coverage was sporadic
throughout the flight. He didn’t get lost but he had to rely
on map reading, at which he had become very rusty.
We should always be in a position to navigate by means
other than GPS—such as by map, VHF omnidirectional
range (VOR) or automatic direction finder (ADF). This
means that we must always know where we are on a map,
VFR or IFR.
When the GPS stops giving us information, the natural
tendency is to play with it to try to get some of the GPS
information back. While we are doing this, we are not paying
attention to where we are. When we revert to map reading,
nothing looks familiar.
A PA 28-160 Warrior was flying in the Yukon when his GPS
stopped giving him information. He became disoriented while
trying to locate his position on a map and started to run low
on fuel. His radio transmissions were heard by a PA 31 Navajo
pilot who relayed the call for help through the nearest flight
service station (FSS).
The Navajo pilot also cancelled his IFR clearance and tried to
locate the Warrior pilot. The Warrior pilot eventually found a
highway and landed on it.
In Canada’s far north, airports can be a long way apart. Time
spent searching for a position fix can deplete the fuel supply
to where the destination can no longer be made. Highways
and roads that may be suitable for landing an aircraft are also
few and far between.
A C-172 pilot in southern Ontario neglected to carry spare
batteries with him and became disoriented as to his position
after his GPS lost power. He was able to transmit his distress
to an FSS where the specialist gave him a Toronto area
control centre (ACC) frequency. The Toronto area controller
provided radar vectors to an airport for a safe landing.
4
Pre-Flight
When the GPS stops giving us information, the natural tendency
is to play with it to try to get some of the GPS information back.
While we are doing this, we are not paying attention to where we are.
When we revert to map reading, nothing looks familiar.
A PA 28-140 in northern Ontario lost satellite coverage for
his GPS and became concerned as to his position. He was
able to contact an FSS by radio and request a VHF direction
finding (VHF DF) steer to the airport. He was asked to give
the FSS specialist a 10 count so the specialist could home
in on his radio signals with direction finding equipment and
give him a heading to the airport. Not all FSSs and control
towers have this equipment.
There have been enough GPS failures in IFR flight that many
IFR pilots keep their VORs and ADFs tuned to the nearest
VOR and non-directional beacon (NDB) frequencies so they
can switch means of navigation quickly. It is a good practice
for VFR pilots as well if VOR or ADF equipment is installed
in their aircraft.
ASL 4/2012
The VOR or ADF can be used to home or track directly to a
VOR station or to an NDB. You can also use the VOR radial
or NDB track from the station to help locate yourself on a map.
ADFs can be tuned into any AM radio station as well as
NDBs. Local AM radio stations are often indicated on VFR
navigation chart (VNC) maps.
If you need navigational assistance and you are unable to contact
a flight information centre (FIC), FSS, control tower or ACC,
climb as high as the weather allows and keep trying. You can
select 7700 on your transponder and monitor 121.5 and
someone will contact you. Make some calls for assistance on
126.7 as well, aircraft flying in the vicinity may hear your
transmission and relay your request for assistance.
If the worst happens and you become “uncertain of your
position” (it would never do to admit you were lost), note
the time you last knew exactly where you were. Estimate the
distance you would have flown in the time since then and
draw an arc on your map across your approximate track.
You should be somewhere close to this arc.
Look on the map for readily identifiable features and then
look outside to locate one (watch, map, ground). If you try to
look at the ground first for a feature and then the map, you
won’t know where to look on the map as you don’t know
where you are and you will just confuse yourself further.
None of us want to admit to being disoriented or lost, but
the sooner we ask for help, the more fuel we will have to get
to a safe place to land. FIC specialists, FSS specialists, tower
controllers and ACC controllers are there to help. Use them
if you need them.
You are never lost if you don’t care where you are. Most of us
though, do care.
Dale Nielsen is an ex-Armed Forces pilot, air charter and flying
school owner/operator, corporate pilot, bush pilot, medevac pilot,
airline pilot and aerial photography pilot. He lives in Abbotsford,
B.C., and currently manages a small airline and teaches part-time for
a local aviation/university program. Nielsen is also the author of
eight flight training manuals published by Canuck West Holdings.
To know more about COPA, visit www.copanational.org.
NAV CANADA Online Store Reduces Costs, Boosts Convenience and Safety
by Janelle Denton, Manager, Customer Contact Centre and Aeronautical Publications, NAV CANADA
NAV CANADA is now offering a fast and easy way for pilots
to purchase the essential documents they need to fly safely to
their destinations.
The NAV CANADA Online Store went operational in early
2011. Today, customers can either order or download a range
of NAV CANADA aeronautical publications with just a few
clicks of the mouse.
With 7 000 active customer accounts, NAV CANADA has
seen steady demand for its publications over the Web. More
recently, with the added option of downloading some of its
key publications in PDF format, the company is anticipating
significant growth in the number of customers taking
advantage of this service.
Available for download, for example, are all seven volumes of the
Canada Air Pilot (CAP), the Restricted Canada Air Pilot (RCAP)
and the Canada Water Aerodrome Supplement (WAS). Customers
can purchase these products and then print their required
pages. These products are official aeronautical publications
and are suitable for air navigation purposes.
To meet customer demand, NAV CANADA plans to increase
the number of titles available for download in the near future.
One attraction is the cost. Downloaded products are priced
20 percent less than their paper equivalents. Customers also
save on shipping and handling costs.
To date, the Web-based store
has nearly 1 000 registered users, and about 20 percent
of all NAV CANADA publications are now ordered online.
The company believes that number will eventually grow to
75 percent of all orders.
Improving customer service may be the raison d’être of the
Online Store, but not to be discounted is the safety benefit.
By providing immediate access to downloadable aeronautical
publications, pilots planning their flights can obtain the most
up-to-date information in a timely manner. Moreover, the
publications are made available a full 10 days prior to their
effective date.
Also available at the Online Store, at no additional charge, are
the CAP General pages and a CAP Changes page that allows
customers to quickly identify all the aeronautical changes made
from one publication cycle to the next.
Before accessing the Online Store, all NAV CANADA
customers—including those with existing accounts—must
first register to obtain a User ID and password. Once registered,
customers can order all the publications they need from the
convenience of their desktop or laptop computer. To maximize
service, ordering these publications by phone or fax will remain
an option.
ASL 4/2012
Pre-Flight
5
Over the years, NAV CANADA has invested in an aeronautical
database system that has strengthened its focus on managing
aeronautical data, while providing a digital production
platform for documents and charts, and enabling more
flexible product delivery.
This includes a national inventory of more than 20 publications
and chart titles, including over 1 700 instrument procedures
and data for 1 800 airports across Canada, as well as charts,
maps, CDs, books and other documents.
To access the NAV CANADA Online Store go to:
http://products.navcanada.ca.
If you have any questions about ordering aeronautical
publications online, please contact AEROPUBS at
1-866-731-PUBS (7827).
Transporting Bulk Fuel in compliance with the Certificate of Airworthiness
by Micheline Paquette and Roger Lessard, Compliance and Response Branch, Transport Dangerous Goods, Transport Canada
The following article is meant to clarify the requirements of the Transportation of Dangerous Goods (TDG) Regulations for
transporting dangerous goods in large means of containment by aircraft.
The TDG Act and Regulations contain requirements for
handling, offering for transport or transporting dangerous goods
to, from or within Canada for all modes of transport (i.e. road,
rail, marine and air). The TDG Act and Regulations do not
permit the handling, offering for transport or transport of
dangerous goods in large means of containment by aircraft
unless an exemption applies. A large means of containment is
defined as any container with a capacity greater than 450 litres.
Section 12.9 of the TDG Regulations, Limited Access,
provides three exemptions that only apply to Class 3
Flammable Liquids:
• a tank, a container or an apparatus that is an integral part
of the aircraft or that is attached to the aircraft in accordance
with the Certificate of Airworthiness issued under the
Canadian Aviation Regulations;
• a cylindrical collapsible rubber drum that is transported in or
suspended from an aircraft and that is constructed, tested,
inspected and used in accordance with MIL-D-23119G; or
• a collapsible fabric tank that is transported suspended from
a helicopter and that is constructed of material and seamed
in accordance with MIL-T-52983G.
Section 12.12, Aerial Work, provides similar exemptions
for all classes of dangerous goods that are essential for aerial
work activities.
In both cases, a designated airworthiness representative or
an aircraft certification engineer at Transport Canada must
issue a Supplemental Type Certificate (STC) or a Limited
Supplemental Type Certificate (LSTC) for each aircraft in
order for a tank, a container or an apparatus to be considered
an integral part of the aircraft or to be attached to the aircraft.
When compliance with the TDG Regulations is impossible or
impractical, an operator may apply for an Equivalency Certificate
from the TDG Directorate in order to handle, offer for
transport, or transport dangerous goods in a manner that will
provide a level of safety at least equivalent to that provided
through compliance with the TDG Act and Regulations.
Air operators may not load and secure a tank, container or
apparatus to the aircraft floor without a STC, a LSTC or an
Equivalency Certificate.
The International Civil Aviation Organization (ICAO) has announced updates to the content of the internationally utilised flight
plan with a worldwide implementation date of November 15, 2012. For details visit: http://onboard-abord.ca/flight-plan-2012/.
6
Pre-Flight
ASL 4/2012
Flight Operations
Single-Pilot Resource Management (SRM) Competencies.................................................................................................... page 7
Scenario-Based CRM Case Study: Stall Warning Device Event......................................................................................... page 10
The Flight Safety Foundation’s ALAR Tool Kit.................................................................................................................. page 15
Answers to the 2012 Self-Paced Study Program................................................................................................................. page 16
Focus on CRM
The following two articles continue our campaign to promote Crew Resource Management (CRM) concepts and principles, in the
overall context of extending contemporary CRM Training to all commercial pilots. The first one, entitled “Single-Pilot Resource
Management (SRM) Competencies” is from Dr. Suzanne Kearns, an assistant professor teaching Commercial Aviation Management
at the University of Western Ontario. The second one is a typical scenario-based airline case study for CRM training programs.
Single-Pilot Resource Management (SRM) Competencies
by Dr. Suzanne Kearns
As a follow-up to the article written by Alexander Burton,
entitled “Single-Pilot Resource Management (SRM)” and
published in Aviation Safety Letter (ASL) 3/2012, this article
discusses SRM competencies. As mentioned in the previous
article, aviation has entered a curious time when the aircraft
we fly are statistically safer than the pilots who fly them.
The reality is that, following a mechanically caused aviation
accident, it is possible to identify a faulty component and then
fix the flaw on all operational aircraft. Following an accident
caused by pilot error, it is relatively complex to identify why
the human being made the mistake and then “fix” the flaw
in all operational pilots!
of time. This limitation is a natural part of being human. It is
important to recognize and understand these limitations, just
as we understand the limitations of our physical strength.
However, that is the ultimate goal of SRM—to understand the
characteristics and limitations of the human mind and body and
how these factors can lead to poor performance and, eventually,
accidents. SRM training is based on a large body of work
gathered by aviation safety researchers and accident investigators.
Situational awareness refers to a pilot’s ability to
Although it can be hard on a pilot’s ego to be reminded
of their limitations, it is not something to be embarrassed
by. Think of it this way: everyone knows that it would be
unreasonable if a chief pilot asked a new hire to go out to
the ramp, pick up an aircraft, and carry it inside the hangar.
Clearly, a pilot would not have enough physical strength
to carry out this ridiculous request. It is easy to understand
human physical limitations.
However, the same chief pilot may ask a new-hire pilot to
complete a trip that would require the pilot to stay awake
for a 24-hr period. This situation would cause fatigue, which
could result in increases in pilot errors. Yet, when it comes to
mental limitations such as fatigue, we often expect a pilot to
tough it out. The reality is that human beings are limited in
their ability to stay awake and alert for an extended period
SRM competencies are elements of pilot performance that
are impacted by natural human limitations. Broadly, some
SRM competencies include situational awareness, workload
management, fatigue management, and decision making. It is
helpful to understand these factors, as they can help us make
safer choices in the air and on the ground—which is the goal
of SRM training.
Situational awareness
1) perceive things in their environment,
2) understand their meaning, and
3) predict how they will impact the flight.
For example, was the pilot aware of the high terrain? Did they
understand how dangerous it was? Were they able to predict a
collision with terrain?
Situational awareness can be thought of as a pilot’s mental
picture of their environment. Researchers assess a pilot’s
situational awareness in a simulator by pausing mid-flight,
asking the pilot to close their eyes, and having them describe
elements of their environment by memory. This can be
replicated during your flights (with a co-pilot, of course) if
you close your eyes and challenge yourself to recall as many
details about your environment as possible.
Unfortunately, pilots sometimes lose situational awareness.
This can lead to a specific type of accident called controlled
flight into terrain (CFIT) (pronounced “see-fit”).
ASL 4/2012
Flight Operations
7
A CFIT accident occurs when a pilot
unintentionally flies a perfectly good
airplane into the ground. Unfortunately,
CFIT accounts for nearly 20 percent of
all general aviation accidents.
How can a pilot lose situational
awareness? Unlike a computer, human
memory has a limited capacity. You can
only remember a certain number of
things in your environment before items
begin to slip by unnoticed. Generally,
researchers suggest that humans can
remember approximately seven, plus
or minus two, chunks of information.
However, under high-stress conditions,
this capacity shrinks to about two or three
chunks of information.
You can think of workload capacity as a bucket—it can only hold so much before it begins to overflow.
Everyone has experienced the frustration of forgetting something. Fatigue management
Most of the time, the impact of this slip is minor. However,
The nature of aviation is that pilots are prone to sleep disruptions
when a pilot is forced to make a snap decision and they don’t
from jet lag, long duty days, or a lack of quality sleep while on
have an accurate mental picture of their environment, it can
the road. However, only relatively recently has the industry
lead to an accident such as CFIT. When flying, remember that come to appreciate the risk associated with fatigue. As an
your memory is limited. If you encounter a stressful situation
example, the following was reported anonymously to the U.S.
or get behind the aircraft, your ability to maintain a mental
National Aeronautics and Space Administration’s (NASA)
picture of your environment will be reduced. Don’t be shy about Aviation Safety Reporting System (ASRS):
asking for help, informing air traffic control (ATC) about your
situation, or climbing to a higher altitude until you mentally
In March of 2004, the captain and first officer of an Airbus 319
catch up with the aircraft.
headed to the Denver International Airport both fell asleep. The
pilot reported that he flew a red-eye (overnight) flight, after two
Workload management
previous red-eye flights, and after only a one-hour break, immediately
started the seven-hour flight back to Denver. In the last 45 min of
The amount of work a person can manage at a given time is
the flight, he fell asleep and so did the first officer. He missed all
influenced by another human characteristic that has a limited
of the calls from ATC, crossing a navigational intersection 16 000 ft
capacity: attention. Similar to memory, the number of things
too high and 350 NM/h too fast. The captain eventually woke up,
we can pay attention to is limited. You can think of workload
although he wasn’t sure what awoke him, and heard frantic calls
capacity as a bucket—it can only hold so much before it begins
from ATC. He then woke up the first officer and they were able
to overflow. With your mental bucket, as you begin to take on
to land the aircraft without further incident.
more tasks, the bucket fills. Eventually your mental bucket will
reach capacity and then spill over. When you have exceeded
Although falling asleep while flying is an extreme example,
your capacity, you will begin to make mistakes. What is less
fatigue imposes other threats. Researchers have identified that,
understood is where you will make those mistakes—though
when fatigued, people have a greater tolerance for risk. For
it is expected that you will make mistakes on the tasks you
example, fatigued drivers stop checking their blind spot—not
place at the lowest priority.
because they have forgotten how to properly drive a car, but
because fatigue is causing them to accept this risk. It is expected
For this reason, when teaching pilots how to manage their
that, when piloting an aircraft, fatigue will result in similar
mental workload, we introduce prioritization strategies.
corner cutting, which leads to increased errors.
The best-known strategy is known as ANCS, which stands
for aviate, navigate, communicate, and manage systems. This
Overall, humans are naturally effort conserving. This means
strategy is meant to serve as a reminder, when your mental
that it is in our nature to try and accomplish a task with as
bucket is full, to focus your attention on flying the aircraft.
little effort as possible. When we are fatigued, this is more
It doesn’t matter if you precisely manage the onboard
pronounced and can lead to very dangerous behaviour. In fact,
systems if you fail to fly the aircraft safely!
fatigue can impair a person’s performance similar to alcohol
intoxication. Once a person has been awake for 18–24 hr, their
8
Flight Operations
ASL 4/2012
performance may be impaired similar to a blood alcohol
concentration (BAC) of 0.1 percent. This BAC would be
experienced if an average-sized man drank six beers in an hour.
Understanding that fatigue is directly linked to an increase in
pilot error is important. This means that no one can choose to
tough it out and avoid the fatigue-related dip in performance.
It is important to be aware of your level of fatigue and appreciate
that it increases risk, so that you can make informed decisions
about when it is safe for you to fly.
Decision making
Even the best-trained pilots are prone to making poor decisions
in the heat of the moment. This SRM skill focuses on strategies
to help pilots make the most effective decisions in the cockpit.
Everyone likes to think of themselves as a rational decision
maker. However, this is not always true.
cuts safety corners. Human decisions are heavily influenced
by environment and past experiences.
In addition, human beings anchor on previous decisions. This
means that, after we have made one decision, it becomes much
easier for us to make the same decision in the future. If a student
pilot chose to complete training at the flight school with poor
safety standards, it would be easier for them to accept low levels
of safety throughout their entire professional career. Research
suggests that a single decision can impact decision making
years in the future. It is important that we critically evaluate
our decisions and consider how our habits were formed in the
first place—particularly in relation to safety.
The following is an example of bad decision making in action:
A story was in the media a while ago about
a pilot who was flying his Piper Tri-Pacer
from the Modesto Airport with a passenger
who had never flown in an airplane before.
Unfortunately, he had to make an emergency
landing due to smoke coming out of the engine.
For example, consider being in a checkout line
at a store, waiting to purchase a package
of computer paper for $11. While in line,
the person behind you says that there is a
big sale at an office store 15 min away where
you can get the same package of paper for
only $4. Would you drive the 15 min to
save the money? Most people in this situation
would choose to leave and purchase the
more affordable pack of paper.
In another situation, if you were lined up
in a store to purchase a new suit for $590
and a fellow shopper said you could travel
to another suit store 15 min away and
buy the suit for $583, would you leave the
store? Most people would choose to stay
and buy the $590 suit.
After the pilot performed an inspection,
he determined that a problematic hose
clamp was to blame. He went to his local
Wal-Mart to get a replacement, and then
“fixed” the problem himself. No mechanic
was called in to check the work.
The pilot took off again and, unfortunately,
the cockpit began to fill with smoke a second
time. An emergency was declared and the
pilot executed a second landing. When the
pilot investigated, he determined that the Understanding that fatigue is directly linked hose had a hole in it. He replaced the hose
to an increase in pilot error is important. and then took off a third time.
Consider for a moment if this decision is logical. In either case,
you would be saving $7. Logically, you are giving 15 min of
your time for $7 in both situations. However, when $7 is just
a small piece of a large purchase, people value the dollars less.
Another example of this is during negotiations to purchase
a house, where people who would otherwise pinch pennies
are easily willing to barter with thousands of dollars without
blinking an eye.
In an aviation context, it is important to understand human
bias in decision making as most decisions are not based on
a logical weighting of all options—as we would like to believe.
Similar to the $7 example, the amount of risk a pilot is willing
to accept varies depending on their situation and environment.
For example, your decision of whether or not to report a
fellow pilot skipping their walk-around may vary depending on
whether you are used to a flight school with a perfect safety
record and an open safety culture or a school that continually
Not surprisingly, this time the engine caught fire and the pilot
was forced to make a third emergency landing. The aircraft was
damaged by the hard landing, and the subsequent fire destroyed
the aircraft. The poor passenger was so frightened that, during
the landing, she threw herself from the aircraft onto the runway
and had to be taken to the hospital.
This example of bad decision making is rather ridiculous. It is
easy for us to consider the pilot crazy and dismiss the implications
of this event. However, if we knew more about the pilot’s past
experiences, these poor decisions were probably linked to those
experiences. For example, if fellow pilots in his club exhibited
similar decision making, or if he had acted in a similar way in
the past without incident, it could have led to this situation.
Ultimately, it is important to understand the biases that influence
our decision making and to critically consider whether or not
our choices are based on logic.
ASL 4/2012
Flight Operations
9
Improving SRM skills
After exploring examples of SRM, the question becomes how
these skills can be improved. Traditionally, the aviation industry
has relied on pilots naturally developing SRM skills by spending
time building hours in the real world. The perspective is that,
while building experience, pilots will be exposed to and manage
enough threats and errors that they will naturally develop
SRM skills.
However, there is a major challenge with the traditional approach
to building SRM skills. With the predicted pilot shortage on
the horizon, future pilots will begin to progress into senior
positions more quickly, with less time building skills naturally
during the hours-building phase of their career.
To compensate for this, the burden will fall on aviation training
organizations to identify methods of improving SRM skills
within a training environment. Many airlines around the world
develop safety training by using an observational strategy,
called a line operations safety audit (LOSA). Within a LOSA,
a company gathers data by hiring a trained observer pilot to
sit in the jump seat behind crews and write down all the threats
and errors that are faced. However, it can be difficult or impossible
to conduct a LOSA within general aviation operations as the
cost would be prohibitive, operations vary significantly, and
many aircraft lack jump seats altogether.
However, there is a more convenient option—hangar talk stories.
Stories are a powerful medium for learning. Storytelling is
the fundamental way knowledge has been passed down from
generation to generation—far preceding humans’ ability to
produce written word. Research has demonstrated that stories
are an extremely popular method of conveying information
across all cultures.
We often take what people learn from stories for granted
because it is something that happens naturally outside of a
classroom. However, junior pilots can develop SRM skills by
listening to the experiences of senior pilots. If you listen closely
when a senior pilot is chatting about a situation they faced,
which challenged their skills and required them to think
creatively to maintain flight safety, you may realize that they
utilized SRM skills. In a recent study, we examined 130 hangar
talk stories. Pilots were asked to describe a situation they
encountered which challenged them, and required them to
think outside the box to maintain flight safety. After analysis,
it was revealed that 39 percent of the stories involved
decision-making skills, 26 percent communication skills,
20 percent situational awareness, and 15 percent
task-management skills.
General aviation companies can gather this data in-house
through simple “hangar talk surveys” that ask pilots to share
their experiences. The results of hangar talk surveys can be
used to create scenario-based exercises within a simulator that
target specific SRM skills. Through this approach, it may be
possible to accelerate the development of SRM skills without
having to gather thousands of flight hours in the real world
and lead to SRM training becoming a standard component
of initial and recurrent pilot training.
Dr. Suzanne Kearns is an assistant professor teaching Commercial
Aviation Management at the University of Western Ontario.
Dr. Kearns is also a commercial airplane and helicopter pilot
and an aviation safety researcher. Her most recent project
is the development of a pilot safety app called “m-Safety”
which is available through iTunes. She can be reached at
skearns4@uwo.ca.
Scenario-Based CRM Case Study: Stall Warning Device Event
The following event, which occurred in Australia in March 2011, was recommended as an excellent case study for scenario-based crew
resource management (CRM) training programs. Operators are therefore encouraged to consider it for that purpose. The Aviation Safety
Letter (ASL) will include more of these examples, as we strongly believe the discussions generated by this training method yield great
benefits for the crews involved. This report has been slightly shortened and de-identified for use in the ASL.
Click on Report AO-2011-036 to read it in full.
Summary
On March 1, 2011, a Bombardier DHC-8-315 was conducting
a regular public transport flight from Tamworth Airport to
Sydney Airport, New South Wales, Australia. The crew were
conducting a Sydney Runway 16L area navigation global
navigation satellite system [RNAV (GNSS)] approach in
vertical speed (VS) mode. The aircraft’s stick shaker stall
warning was activated at about the final approach fix (FAF).
The crew continued the approach and landed on Runway 16L.
The stick shaker activated at a speed 10 kt higher than was
normal for the conditions. The stall warning system had
computed a potential stall on the incorrect basis that the
10
Flight Operations
aircraft was in icing conditions. The use of VS mode as part
of a line-training exercise for the first officer meant that the
crew had to make various changes to the aircraft’s rate of
descent to maintain a normal approach profile.
On a number of occasions during the approach, the autopilot
pitched the aircraft nose up to capture an assigned altitude set
by the pilot flying. The last recorded altitude capture occurred
at about the FAF, which coincided with the aircraft not being
configured, the propeller control levers being at maximum
RPM, and the power levers at a low power setting. This
resulted in a continued speed reduction in the lead-up to
the stick shaker activation.
ASL 4/2012
Each factor that contributed to the occurrence resulted
from individual actions or was specific to the occurrence.
The Australian Transport Safety Bureau (ATSB) is satisfied
that none of these safety factors indicate a need for systemic
action to change existing risk controls. Nevertheless, the
operator undertook a number of safety actions to minimize
the risk of a recurrence.
In addition, the occurrence highlights the importance of
effective CRM and of the option of conducting a go-around
should there be any doubt as to the safety of the aircraft.
Transport Canada, which regulates the aircraft manufacturer,
advised that it would publish a summary of this occurrence
and recommend that operators consider using it in their
scenario-based CRM training programs.
Factual information
Sequence of events
the approach. It was at this point that the captain identified
that the aircraft was no longer in icing conditions and so
turned off the ice protection switch, without informing the
first officer. During this action, the captain did not turn off
the increased reference speed switch. That switch is selected
ON for flight in icing conditions and sets the stall warning
to activate at a lower angle of attack (thus raising the speed
at which the stall warning activates).
The captain reported initially being high on profile during
the approach; however, by the ‘SYDLI’ intermediate fix
(Figure 1), the aircraft was back on profile but, as a result,
needed to slow down. In response, the captain selected the
propeller control levers to maximum RPM, which changed
the pitch of the propellers and effected a significant slowing
of the aircraft. In addition, the first officer reported that
the power levers were retarded to flight
It was at this point that the captain
identified that the aircraft was no longer idle from about
in icing conditions and so turned off the the SYDLI position fix until the FAF.
ice protection switch, without informing The use of maximum RPM at this point
the first officer. During this action, the in the approach, rather than at the FAF,
captain did not turn off the increased was not considered normal practice by
the operator.
reference speed switch.
At about 18:10 local time on
March 1, 2011, the flight crew
conducted the approach to land
at Sydney using the Runway 16L
RNAV (GNSS) approach. The
instrument landing system (ILS)
approach that was normally used for an approach and
landing on this runway was not operative at the time. The
captain was the pilot not flying (PNF), and the first officer
was the pilot flying (PF).
The first officer reported that, despite approaching the FAF,
they had not yet configured the aircraft for landing with flaps
extended or the landing gear down. In contrast, the captain
stated that the landing gear was down prior to the FAF but
the flaps were not extended.
Both pilots stated that an approach brief was completed and
that it included an overview of the approach chart procedure,
the missed approach procedure and the identification of any
additional restrictions or requirements. The approach was
conducted with the autopilot engaged and using the flight
director in VS mode, rather than the vertical navigation (VNAV)
mode. The VNAV mode uses a higher level of automation
than the VS mode, which maintains a constant descent profile
to an assigned altitude entered by the crew1. When the assigned
altitude is reached, the aircraft flight director and autopilot
automatically levels the aircraft off unless another, lower
altitude has already been entered.
Prior to the FAF, the captain noticed the airspeed was decreasing
through 130 kt and called “airspeed”. The recorded flight data
showed that at about this time the autopilot commenced pitching
the aircraft up in anticipation of capturing the preselected altitude
set by the first officer. This further reduced the airspeed to around
114 kt, the stick shaker activated, and the autopilot disconnected.
The flight crew reported that the approach was commenced
in instrument meteorological conditions (IMC) but as it
progressed, the conditions became visual and the approach
was operated in visual meteorological conditions (VMC)
until landing.
The captain called “stick shaker”, took over as PF and momentarily
advanced the power levers before continuing the descent. The
first officer reported assuming the role of PNF and conducted
the checklist items in preparation for landing, including
selecting flaps to 15°.
The captain stated that, approaching the initial approach
fix (IAF), the crew had started to feel some time pressure to
complete all of the necessary checklist items and actions for
The aircraft continued on the approach and the crew reported
they were stable by 500 ft, in accordance with the operator’s
stable approach procedure. They then conducted a landing
on Runway 16L. After landing, the first officer noticed the
increased reference speed switch was still in the ON position.
1 The VNAV mode utilizes the aircraft’s flight management system to
fly a pre-determined profile which conforms to the published approach
procedure, while the VS mode maintains a constant rate of descent to
an assigned altitude entered by the crew.
The first officer adjusted the assigned altitude in the flight
director system during the approach; however, the captain
indicated that these adjustments were not happening fast
enough to allow a continuous descent, and that the autopilot
kept capturing the assigned altitude and levelling off.
ASL 4/2012
Flight Operations
11
Approach procedures
The operator’s standard operating procedures (SOPs) required
that, when conducting an instrument approach, the relevant
aircraft speed and configuration should be accomplished prior
to a defined position in the approach. For an RNAV (GNSS)
approach, the crew was required to achieve a speed reduction
to 180 kt by the IAF. From the IAF, the aircraft was to be
slowed further to a speed below 163 kt and then to 150 kt,
with the PF expected to achieve a target speed of 120 to
130 kt by the FAF.
Before the aircraft passed the FAF, the operator’s SOPs required
that the PF would request the PNF to select the gear down,
set the flaps to 15° and initiate the landing checklist. The
crew reported that the aircraft’s speed was not stable and the
configuration was not finalized prior to reaching the FAF.
At the FAF, the propeller control levers were to be advanced
to provide maximum RPM, the landing checklist was to be
completed and the speed reduced to Vref3+5 to Vref+20 kt by
500 ft above ground level (AGL). If these conditions were
not met by 500 ft AGL, a go-around was to be conducted.
Additionally, according to the operator’s flight administration
manual (FAM):
Flight crew are encouraged to perform a missed approach
whenever any doubt exists as to the safe continuation of an
approach and landing.
Figure 1.
Pilots
Both the captain and first officer were properly licensed and
qualified for the flight. The captain had several thousand hours
on type, while the first officer had a total of 3 250 hours,
with about 26 on type. Those hours were line training and
had occurred within the last two weeks. The training notes
from the first officer’s endorsement indicated there had been
a recurring issue with speed, descent and power management
during approaches, and those exercises were successfully repeated
before undertaking the next training session. The first officer
satisfactorily completed the endorsement training program.
As part of the company’s training program, all pilots initially
completed CRM as well as threat and error management (TEM)
training as part of the induction program. CRM and TEM
training then formed part of flight crew’s annual recurrent
training. CRM is a strategy for pilots to use all available
resources effectively (including other crew, air traffic
control [ATC], equipment and information)2.
2 Salas E., Wilson, K.A. & Burke C.S (2006). “Does Crew Resource
Management Training Work? An Update, an Extension, and Some
Critical Needs”. Human Factors, 48(2) 392-412.
12
Flight Operations
Previous stick shaker occurrences prompted the operator to
issue a safety alert and safety investigation bulletins to all
operating crew. These notices highlighted the importance
of crews following SOPs and monitoring all stages of the
approach. They also highlighted the need for crews to adhere
to the SOPs for ceasing the use of all ice protection systems
after exiting icing conditions. In addition, the safety alert
detailed strategies for profile management and aids for
maintaining situational awareness.
With regard to the use of automation, the company’s DHC-8
flight crew operating manual (FCOM) stated:
Use of the autopilot is encouraged for all RNAV (GNSS)
approaches to reduce workload...
The autopilot can be used with the flight director in either
VNAV or VS mode for an RNAV approach.
Stall warning system
Based on the aircraft’s weight, and using data available in the
operator’s FCOM, the flap 15° stalling speed of the aircraft at
the time of the occurrence was 81 kt. In contrast, the flap 0°
stalling speed was 99 kt.
3Vref : Reference speed that is commonly used to determine an aircraft’s
approach speed. Vref is Vs multiplied by a factor of 1.3. Vs is the minimum
indicated airspeed at which the airplane exhibits the characteristics of an
aerodynamic stall.
ASL 4/2012
The aircraft’s stall warning system consisted of two stall
warning computers, an angle of attack (AOA) vane on each
side of the forward fuselage, a stick shaker on each control
column, and a stick push actuator.
The aircraft’s two stall warning computers received AOA data
from the respective AOA vanes, as well as true airspeed, flap
angle and pitch rate information. The computers used that
information to determine a compensated angle which, if greater
than the stall warning threshold angle, would activate the
stick shaker. That activation occurred at a speed of 6 to 8 kt
above the computed stall speed.
If action was not taken by the flight crew in response to the
stick shaker, and an aerodynamic stall was encountered, the
stall warning computer would activate a stick push actuator
to drive the control column forward. This would decrease the
aircraft’s AOA to aid in the recovery from the stall.
According to the operator’s SOPs, the recovery action following
a stick shaker was to simultaneously:
• Call “stick shaker”;
• Advance power levers to within 10 percent of maximum
take-off power (MTOP), then adjust for maximum power;
• Select flap 15 if flap 35 is extended;
• Gear up with positive rate of climb;
• Select flap zero when indicated airspeed (IAS) is above
flap retraction speed.
The aircraft manufacturer advised that recent updates to the
aircraft flight manual (AFM) include an immediate reduction
in pitch attitude in response to a stick shaker activation, as
well as stating that no configuration changes should be made.
Human factors
The first officer reported that, after passing the IAF, there was
an increase in workload, predominantly due to conducting
an unfamiliar approach as PF and commencing the approach
in IMC. In addition, the approach was being conducted in
VS mode, which the first officer had reportedly not used for
an approach during line flying. Use of the VS mode required
more mental calculations and data entry inputs by the PF
to meet the descent profile targets than would be necessary
using VNAV mode (where data entry is done before descent
and the autopilot flies the required descent path).
The captain reported that the use of VS mode was to increase
the first officer’s awareness of ground speed and vertical speed.
The aim was to increase the first officer’s skill at maintaining a
vertical profile without the use of VNAV mode.
The captain also stated that, as a result of previous flights with
the first officer, he anticipated an increase in his own workload
due to the need to monitor the approach and the actions of the
first officer. Both flight crew reported that the clearance to
conduct an RNAV (GNSS) approach caught them by surprise
as they were expecting another approach type.They both
commented that this increased the time pressure, as they had
to re-brief unexpectedly for the RNAV (GNSS) approach.
The first officer and captain both reported inter-personal
communication issues with the other pilot prior to the
commencement of the approach. The first officer reported not
feeling comfortable speaking up in the line-training environment.
As a result, the first officer had been scheduled to fly with
another line-training captain, which was to take effect in
the days following the occurrence.
Both of the flight crew also reported issues during the approach.
The use of non-standard phraseologies by the first officer, and
the fact that the captain was not aware the first officer was
feeling overloaded, affected the conduct of the approach.
When learning a new skill, individuals move from what is known
as knowledge-based performance to skill-based performance4.
Skill-based actions are possible once an individual is very
familiar with a task and they have repeated it to an extent
that the actions become predominantly automatic and do
not need conscious oversight. Knowledge-based performance
is typical during unfamiliar or novel situations and, by
contrast to skill-based performance, requires more conscious
oversight and typically uses greater mental resources, increasing
mental workload.
Analysis
The stick shaker activation was because the aircraft’s speed had
slowed to the computed stall reference speed. In this case, due
to the increased reference speed switch being left on, the stick
shaker activated 10 kt higher than normal for the aircraft’s
configuration. The aircraft was not configured in accordance
with the operator’s SOPs for the approach. This also contributed
to the stick shaker activating at a higher reference speed than
if the aircraft was appropriately configured.
In addition, the target airspeed range of 120 to 130 kt for this
stage of flight was not met and the action of the auto flight
system’s altitude capture feature, which raised the aircraft’s
nose to maintain altitude, resulted in a further decrease in
airspeed. This speed reduction also contributed to the stick
shaker activating.
4 Rasmussen, J. (1983). “Skills, Rules, and Knowledge; Signals, Signs,
and Symbols, and Other Distinctions in Human Performance Models”.
IEEE Transactions on Systems, Man & Cybernetics, SMC; 13(3).
ASL 4/2012
Flight Operations
13
Following the stick shaker activation at around the FAF, the
aircraft was not configured for landing and the speed was not
stable. According to the operator’s SOPs, if the safe continuation
of the flight is in doubt, a go-around is to be conducted. Given
a stick shaker activation is an indicator of an impending stall,
which could affect the safety of the flight, a lower risk option
for the crew was to have conducted a go-around.
The first officer’s training in the simulator
had identified performance issues with speed,
descent and power management during the
approach and landing phase. While the first
officer was successfully re-trained in the
simulator during the endorsement, some of
these issues reappeared during the approach.
The reported workload of the first officer during the approach,
combined with the level of unfamiliarity of both the approach
and the aircraft’s automation, is typical of knowledge-based
performance. That is, the first officer’s performance was
Although the decision of the indicative of increased mental effort and
captain to continue with the workload, as opposed to the predominantly
approach did not result in a automatic actions used when conducting
a highly familiar task.
further incident, the lower
risk option is for flight crew
to discontinue an approach or
landing if at any stage there
is any doubt as to the safe
continuation of the flight.
The use of VS mode for the approach was a
deliberate decision by the captain to make the
first officer consider the vertical profile and
power management. While this technique had reportedly
helped other first officers in this situation, it would appear
that for this first officer’s level of training and experience,
the use of VS mode was not appropriate and unnecessarily
increased the workload of both flight crew.
The flight crew reported feeling time pressured during the
approach, which increased their workload. As a result, the
captain turned off the ice protection system without informing
the first officer. While this action was done as a result of the
captain identifying and completing a required action, it was
not conducive to a shared understanding of the system state
by both crew. There is a need for clarity in operating roles and
close adherence to SOPs during normal operations and this is
particularly important in the line-training environment, given
the first officer’s level of experience.
Despite the mismanagement of the speed and power during
the approach by the first officer, which necessitated the
selection of maximum RPM by the captain in order to slow
down, the captain did not take over prior to the stick shaker
activation, nor was a go-around initiated when the activation
occurred. Although the decision of the captain to continue
with the approach did not result in a further incident, the
lower risk option is for flight crew to discontinue an approach
or landing if at any stage there is any doubt as to the safe
continuation of the flight.
The inter-personal communication issues reported by both crew
appears to have affected their interactions and the learning
opportunities for the first officer in the line-training environment.
This was supported by the fact that despite having completed
CRM training, the first officer reported feeling unable to report
feeling overloaded to the captain at the beginning of the
approach. The first officer’s performance during the approach
may have affected the captain’s decision to continue following
14
Flight Operations
the stick shaker activation, as conducting a missed approach
or go-around with the first officer overloaded may have
further increased the workload of both flight crew.
As set out below, the investigation identified
a number of factors that contributed to the
occurrence. Each resulted from individual
actions or was specific to the occurrence.
The ATSB has assessed each of these safety
factors and is satisfied that none of them
indicated a need for organizational or systemic action to
change existing risk controls. However, the investigation
did highlight the importance of effective CRM and of the
option of conducting a go-around should there be any doubt
as to the safety of the aircraft.
Findings
The ATSB issued the following findings:
Contributing safety factors
• The stick shaker system activated during the approach as a
result of the increased reference speed switch being in the
ON position, the associated computed reference speed being
reached, and the aircraft not being configured in accordance
with SOPs.
• A lack of communication and ineffective CRM between
the flight crew and non-adherence to the operator’s SOPs
adversely affected crew actions and coordination.
• Due to time pressure, inadequate CRM and the increased
workload of both flight crew, the RNAV approach was not
flown in accordance with SOPs.
Other safety factors
• Despite being aware that at the FAF the aircraft was not
appropriately configured, and the resulting stick shaker
activation, the crew did not initiate a go-around/missed
approach as recommended by the operator’s guidance material.
• The conduct of the approach in VS mode rather than VNAV
mode increased the workload of the first officer and captain.
Safety action
Operator
The operator has advised that, as a result of this incident the
following action was taken:
ASL 4/2012
• Relevant sections of the training and checking manual have
been reviewed and will, subject to Civil Aviation Safety
Authority approval, be revised as a result of this incident.
• The aircraft mechanical checklist was amended to include
an item known as “ice protection” to confirm the status of
the ice protection system.
• A procedure was implemented to identify and heighten flight
crew awareness of the minimum speed for the environmental
and aircraft configuration state.
• The Standards Department and Procedures Review Group
conducted a review of approach workload and submitted
the findings to the Flight Standards Review Group. These
included better clarity and role definitions within documented
procedures; and expanded timing and sequencing procedures
to aid in management during high workload periods.
• A group/industry workshop forum was organized to share
experiences and best practices in regard to situational
awareness on the flight deck. The workshop identified
additional human factors competencies that the operator
intends to incorporate into its training program.
Transport Canada
Transport Canada advised that given its current focus on
contemporary CRM training for all commercial pilots, once
the final report has been released, it will publish a summary
of the occurrence in the ASL, with a recommendation for
operators to consider using it in their scenario-based CRM
training programs.
The Flight Safety Foundation’s ALAR Tool Kit
The aim of this article is to build awareness of the Flight Safety Foundation (FSF) Approach and Landing Accident Reduction
(ALAR) Task Force recommendations, and the associated FSF ALAR Tool Kit, and to encourage its use by Canadian operators and pilots.
Background on the FSF ALAR Task Force
The FSF created the “FSF ALAR Task Force” in 1996 as
another phase of its controlled flight into terrain (CFIT)
accident reduction initiatives, launched in the early 1990s.
The task force final working group reports were presented
in November 1998 through a 288-page special issue of the
FSF Flight Safety Digest1, at the joint meeting of the
FSF 51st International Air Safety Seminar, the International
Federation of Airworthiness 25th International Conference,
and the International Air Transport Association (IATA),
in Cape Town, South Africa. The task force issued detailed
recommendations targeting the reduction and prevention
of the approach and landing accidents (ALAs). The
FSF ALAR Task Force recommendations have been
recognized internationally as practical tools for mitigating
the risks of ALAs.
Further to those recommendations, the FSF ALAR Tool Kit
was developed and distributed by the FSF as an aid to
education and training, and as a resource that could be
used by a variety of aviation professionals in company
management, flight operations and air traffic control.
The tool kit, which was updated in 2010, consists of a
multimedia resource on a compact disc (CD), and contains
the report of the FSF ALAR Task Force, conclusions
and recommendations, the FSF ALAR Briefing Notes,
videos, presentations, hazard checklists, and, lastly, other
documentary notes and products designed to prevent ALAs,
the leading causes of fatalities in commercial aviation.
1 Special Issue of the FSF Flight Safety Digest, “Killers in Aviation:
FSF Task Force Presents Facts About Approach-and-landing and
Controlled-flight-into-terrain (CFIT) Accidents”.
November-December 1998 / January-February 1999.
Fundamental components
of the tool kit are the 33 FSF
ALAR Briefing Notes. They
were produced to help
prevent ALAs, including
those involving CFIT. The
briefing notes are based on the data-driven conclusions
and recommendations of the FSF ALAR Task Force, as
well as data from the U.S. Commercial Aviation Safety
Team (CAST), the Joint Safety Analysis Team ( JSAT)
and the European Joint Aviation Authorities Safety
Strategy Initiative ( JSSI).
Generally, each briefing note includes the following:
• Statistical data related to the topic;
• Recommended standard operating procedures;
• Discussion of factors that contribute to excessive deviations
that cause ALAs;
• Suggested accident prevention strategies for companies and
personal lines of defense for individuals;
• Summary of facts;
• Cross-references to other briefing notes;
• Cross-references to selected FSF publications; and
• References to relevant ICAO standards and recommended
practices, U.S. Federal Aviation Regulations and European
Joint Aviation Requirements.
The briefing notes include key topics such as automation,
approach briefings, human factors, crew resource management,
altitude deviations and terrain avoidance manoeuvres, to
name just a few. As examples, check out Briefing Note 2.1 on
ASL 4/2012
Flight Operations
15
16
Flight Operations
ASL 4/2012
27. clothing and equipment; exposure
9. The surface wind is forecast to be from the east
(090° true) with a speed of 35 kt.
26. 20
8.Thunderstorm
25. potential hazards to air navigation; 500; 300
7. takeoff, climb, approach and landing
24. 5 years.
6. the operator of the aircraft
23. The FIR NOTAM file.
5.poor
22. When specified in a replacing or cancelling NOTAM.
4.10
21. 20 to 40
3. white or yellow X’s
20. 5; 5
2. 2 200; AGL; controlled.
19. level; good; very low
1. Regional TSB office; a NAV CANADA ATS unit
10. 040° at 15 kt, gusting to 25 kt.
11. 2 SM, temporarily 6 SM
28. insufficient rest; lack of sleep; overexertion
29. The AIC number according to the Web site.
12. greater than 6 SM visibility, no significant weather,
2 000 ft overcast
13. 3 400
30. 60 minutes
31. 62.9 litres; 2.787 hours or 2 hours 46 minutes
32. light on the ground; adequate celestial illumination
33. life preserver
14. As per Comparison Table.
34. The rotor will flap and the gyroplane will
become uncontrollable.
15. Moderate turbulence between 8 000 ft and
2 000 ft during descent; 18:30Z.
35. decreases; decreases
16. “have numbers”; runway; wind; altimeter
36. slack; under tension
17. Report departure intentions prior to moving onto
the take-off surface; report departing from the
aerodrome traffic circuit
37. same
38. A propane leak at the valve stem.
39. 105 ft
18. minutes
Answers to the 2012 Self-Paced Study Program
The IATA has endorsed the FSF ALAR Tool Kit and has
recommended that its members use it. In 2001, ICAO stated
expands on the human factors which
could be involved in ALAs, and Briefing Note 2.2 on Crew
Resource Management, which touches on critical aspects of
crew coordination and cooperation. All 33 briefing notes are
equally useful in preventing ALAs, and they are available for
free download on the FSF Web Site.
Human Factors, which
that the FSF ALAR Tool Kit contained extremely valid accident
prevention information and that member states should consider
incorporating the material into their training programs. ICAO
then purchased and distributed 10 000 copies of the tool kit
at its 33rd Assembly in the fall of 2001. To date, approximately
40 000 copies of the tool kit have been distributed worldwide.
The FSF ALAR Tool Kit on CD is available for online sale
from FSF in English, Spanish and Russian, at a cost of $95.00
for FSF members or $200.00 for non-members.
Maintenance and Certification
Winter Operation Woes..................................................................................................................................................... page 17
Maintenance of Small Non-Commercial Aircraft............................................................................................................... page 18
Winter Operation Woes
This article was originally published in Aviation Safety Maintainer Issue 4/1992.
What differences should we be aware of with winter operations? Why do we need extra vigilance? Here are a few accidents where
winter conditions were a contributing factor. I hope the results remind AMEs that, no matter how small or how large the aircraft,
it is often the very simple things that cause the most serious problems.
Lubrication
Everyone knows that grease and oil thicken up
with the onset of colder weather. Well, almost
everyone. Take the case of an Enstrom helicopter
operating in -30° conditions, where the pilot was
unable to maintain control during takeoff. The
subsequent accident investigation revealed that
the manufacturer had not taken into account
the fact that the grease used to lubricate the
flight controls lacked properties necessary
for cold weather operations. As a result, the
manufacturer was alerted to the problem, and
Transport Canada issued an Airworthiness
Directive CF-89-17, forbidding the use of
Almagard 3751 and Almaplex 1275 lubricants
in the Enstrom flight control system.
Engine lubricating oil can be a source of
Aircraft parked unprotected from ice and snow as shown above, require
trouble if the oil system is not properly winterized.
inspection for possible damage and for the presence of ice in the
Winterization includes changing to the correct
tailcone or elevator assembly prior to flight.
winter weight oil, then checking that the oil lines or oil
Fuel systems
tank are lagged (insulated), as specified by the manufacturer’s
manual, and that oil cooler doors operate correctly and freely.
The condition of the carburetor heat system and fuel system
are major concerns when preparing aircraft for winter operations.
The pilot of a Cessna 310 was proceeding en route in -30°
The Cessna 150 is most susceptible to carburetor icing and
temperatures when he noticed the oil pressure rising on the
fuel system ice. The following accidents illustrate some problems
right engine and oil on the cowling. The pilot feathered the
in this area.
right engine and diverted toward the nearest airport. A few
minutes later the left engine displayed similar problems. Oil
The pilot of a Cessna 182Q was flying from Resolute Bay,
pressure increased, then dropped to zero as the oil supply
N.W.T., at 11 500 ft and above cloud, when the engine
was forced overboard by excessive, crankcase pressure, and
started running rough and stopped despite the application
the left engine was feathered. The right engine was restarted
of full carburetor heat. The temperature and humidity were
and sufficient power was obtained to stabilize the flight.
conducive to the formation of carburetor ice. After the forced
Fortunately, a second aircraft appeared on the scene and
landing, investigators found that, although the pilot applied
managed to direct the troubled pilot to a nearby airstrip,
carburetor heat properly, the engine could not respond because
where he landed safely with smoke and oil pouring from the
of a malfunctioning carburetor heat valve. The carburetor heat
engine. The oil supply for both engines had been depleted due
shroud was found split and separated where nine of the 12 shroud
to ice formation blocking the inside of each engine crankcase
rivets had sheared. As a result, the carburetor heat system was
breather line. Most aircraft maintenance manuals refer to
unable to counter the carburetor icing. Maintenance personnel
special holes or other alternate crankcase breather methods
must ensure that the carburetor heat system works according
that should be in place to counter ice accumulation in these
to specifications.
lines during winter operations.
ASL 4/2012
Maintenance and Certification
17
A Cessna 150G was climbing out from St. Francois Xavier,
Manitoba airstrip, when the engine stopped. The pilot made
a successful force landing and no injuries occurred. Examination
of the fuel drain fitting located in the centre fuselage belly
area revealed signs of ice covering the fitting port. Since no
other cause could be determined, it is assumed that this area
iced over or became blocked with ice crystals suspended in
the fuel, preventing fuel flow. Numerous warnings and articles
have been published about the belly fuel drains on Cessna
aircraft. Some models of the Cessna 150 are particularly
vulnerable. This unobtrusive little drain cap, or set screw,
should be removed at every inspection, and the line drained
for a few seconds to remove any accumulated water or debris.
This is particularly important in the fall before freezing
temperatures are encountered.
Undercarriage
There are many cases on record where slush has frozen inside
wheel pants, locking the wheels and causing the aircraft to
nose over on landing. AMEs should also pay particular
attention to oleos and brakes because rubber seals and
“O” rings tend to leak and break down in extremely cold
temperatures. Retractable gear may require servicing with
winter weight grease and the removal of corrosive salts or
other contaminants from the mechanism if it is to continue
to function safely during winter.
Cabin heaters
Exhaust type cabin heaters must be monitored for exhaust
leakage into the cabin (see AD CF-90-03 for mandatory
requirements). The exhaust system should be inspected for
leaks at the beginning of the winter season. Janitrol type
heaters should be checked for correct operation and serviced
at the beginning of each winter season. A little preventive
maintenance is the best protection against in-flight explosion
of gas heaters or carbon monoxide impairment of the crew
from exhaust type heaters.
Cold weather operations are a fact of life in Canada, and can
be performed safely if everyone, including pilots, AMEs and
ramp attendants remain vigilant in detecting and correcting
winter operational differences before they cause big trouble
during flight.
Last but not least, do not forget to remove the obvious hazard
such as ice, snow, or freezing precipitation adhering to the
aircraft surfaces and possibly inside the turbine inlet ducts
prior to flight.
Maintenance of Small Non-Commercial Aircraft
by Joel Virtanen, Civil Aviation Safety Inspector, Operational Airworthiness, Standards Branch, Civil Aviation, Transport Canada
Section 605.86 of the Canadian Aviation Regulations (CARs)
requires that all aircraft be maintained in accordance with a
maintenance schedule that is approved by the Minister and
that meets the requirements of Standard 625—Aircraft
Equipment and Maintenance Standard. However, there are
exceptions; CAR 605.86 does not apply to ultralight
aeroplanes and hang gliders.
Maintenance schedules
Most small aircraft owners use a maintenance schedule found
in Standard 625, Appendix B, that is considered to be approved
by the Minister. Anyone using the maintenance schedule in
Appendix B needs to make an entry in the aircraft technical
record that the aircraft is maintained to that maintenance
schedule. Appendix B lists the areas that are to be inspected,
but it is not a checklist for the inspection.
Standard 625, Appendix C, is part of the maintenance schedule
for every aircraft. It lists the maintenance requirements for specific
equipment that are due at intervals specified in the Appendix.
Annual review of Appendix C items is required to ensure that
the equipment listed is inspected at the proper intervals.
18
Maintenance and Certification
Inspection checklist
In respect of an aircraft, “owner” means the person who has
legal custody and control of the aircraft. The aircraft owner
must develop a detailed inspection checklist that covers all
areas included in Standard 625, Appendix B, as the Appendix
in itself is not an inspection checklist. The owner can use the
manufacturer’s inspection checklist for the aircraft, where
the manufacturer has provided one. Where the manufacturer
has not provided an inspection checklist, the owner must
develop one.
It is important to review the checklist to ensure that it
contains all items included in Standard 625, Appendix B.
Manufacturers’ checklists may be deficient for several reasons.
For example, the manufacturer’s checklist may be out of date
with reference to the current standard. A checklist should also
include items covering any modifications carried out on the
aircraft. An inspection checklist should be detailed enough to
cover all wear items on the aircraft in order to maintain the
aircraft in a safe flying condition until the next inspection.
ASL 4/2012
Airworthiness directives
The most important thing to remember about airworthiness
directives is that compliance with them is mandatory for all
aircraft, except those in the owner-maintenance and amateur-built
classifications. It is the owner’s responsibility to determine
which airworthiness directives are applicable to the aircraft,
and to make them available to the maintenance provider. A
list of airworthiness directives that could be applicable to your
aircraft or equipment can be found on the Transport Canada
Web site. If you are not familiar with airworthiness directives,
ask your maintainer for help.
Life-limited parts
Some aircraft have life-limited parts that have to be replaced
when they reach their life limit based on elapsed time, calendar
time or operating cycles. Most turbine engines and helicopter
drive systems have parts that are life-limited. It is the owner’s
responsibility to ensure that these parts are replaced at proper
intervals. Life limits do not apply to aircraft operated under
a special certificate of airworthiness, to owner-maintained
aircraft or to amateur-built aircraft.
Inspection intervals
Most small aircraft owners are familiar with the
100-hr inspection or the annual inspection. In 2007,
Standard 625.86(2)(a) was modified with respect to the
meaning of “interval”. The “annual” inspection is no longer
due 12 months from the last inspection, but rather on
the last day of the 12th month. This means that if the last
“annual” inspection was carried out on January 1, 2011, the
next inspection is not due until January 31, 2012. In this case,
the effective inspection interval is 13 months less one day.
This applies to any interval that is stated in months in the
Standard. If the interval is stated as “annual”, it means 365
days. As tolerances are not permitted for aircraft maintained
under Standard 625, Appendix B, the inspection interval
cannot be exceeded.
Logbook entries
In some cases, all items with respect to the maintenance work
done on the aircraft are entered in the aircraft journey log.
This is permitted in the case of a balloon or a glider, or an
aircraft operated under a special certificate of airworthiness
in the owner-maintenance or amateur-built classification.
In all other cases, only maintenance items listed in CAR 605,
Schedule I, must be recorded in the aircraft journey log.
CAR 571.03 requires that the details of all maintenance
and elementary work be recorded in the aircraft technical
record. No logbook entry is required for servicing. An entry
must be made in the aircraft journey logbook for the date, air
time, operating cycle or landing at which the next scheduled
maintenance action is required. In this way, the pilot is kept
informed of the next maintenance action to be performed.
For more information on recreational aircraft in Canada,
visit the Transport Canada recreational aircraft Web site at
www.tc.gc.ca/eng/civilaviation/standards/maintenance-aarperecreational-menu-2753.htm.
2012-2013 Ground Icing Operations Update
In July 2012, the Winter 2012–2013 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/commerce-holdovertime-menu-1877.htm.
If you have any questions or comments regarding the above, please contact Doug Ingold at douglas.ingold@tc.gc.ca.
Worth Watching—Again! The FAA In-Flight Fire Fighting Video
Developed by the United States Federal Aviation Administration (FAA) with assistance from Transport Canada Civil
Aviation (TCCA) and other aviation authorities, this excellent video addresses how to prevent, react and deal with
in-flight fires. It’s time well spent!
ASL 4/2012
Maintenance and Certification
19
Recently Released TSB Reports
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. 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 A09W0021—Loss of Power
and Collision with Terrain
On January 30, 2009, a Robinson R44 helicopter was en route
from Grande Prairie, Alta., to Grande Cache, Alta., with one
pilot and one passenger on board. At approximately 17:02
Mountain Standard Time (MST), while climbing over rising
terrain, the helicopter lost engine power and main rotor
RPM. The pilot turned downhill in an effort to regain main
rotor RPM. When this failed, he carried out a forced landing
into the trees where the aircraft came to rest on its right side.
The pilot was seriously injured when the passenger fell on
top of him during impact. The passenger sustained no injury.
They spent more than 15 hr on site before being rescued.
The emergency locator transmitter (ELT) did not activate
during the impact sequence, thus delaying the search and
rescue (SAR) response.
The lack of a common communication frequency among SAR
responders also contributed to the delay in rescue. Faster
clarification of the accident location and coordination of tasks
would have shortened rescue time. The risk of serious injury
and death increases as SAR response time increases.
Finding as to causes and contributing factors
1. It is likely that carburetor ice formed resulting in the loss
of engine power and main rotor RPM from which the
pilot was unable to recover.
TSB Final Report A09O0207—Collision
with Terrain
On September 21, 2009, a Robinson R22 Alpha helicopter
departed Toronto City Centre Airport, Ont., on a short flight
to the pilot’s private helipad in the rural town of Norval, Ont.
At 20:00 Eastern Daylight Time (EDT), in the hours of
darkness, the helicopter crashed 1.8 NM northeast of the
final destination. The helicopter erupted into flames on
impact and was partially consumed by a post-crash fire.
The pilot was fatally injured.
Analysis
The weather at the time of the accident was conducive to the
formation of carburetor icing. The pilot had spent most of his
career flying turbine-powered helicopters, in which carburetor
icing is not a concern. The carburetor heat lever can move
away from the required position through movement of the
collective arm in flight. The reported loss of power was likely
the result of carburetor icing, which could not be corrected
by the pilot in the time available.
The different SPOT satellite GPS messenger functions activated
by the passenger, coupled with uncertainty among family
members during discussions with the joint rescue coordination
centre (JRCC), contributed to the delay in the SAR response.
20
Recently Released TSB Reports
Analysis
Examination of the helicopter engine indicates that it was not
running on impact and that the helicopter struck the ground in
a 50° nose-down attitude, suggesting an in-flight loss of control.
Although the helicopter was extensively damaged, there were
no signs of any pre-impact mechanical failure or system
malfunction that could have contributed to this accident. As
a result, this analysis focuses on possible scenarios for what
ASL 4/2012
caused the engine to stop running and why the helicopter
departed controlled flight and collided with terrain.
While it was not possible to determine accurately the position
of the carburetor heat control before impact, the mixture control
knob was found out and bent. With the push-button locking
feature, it is unlikely that the mixture control moved during the
impact. It was, therefore, likely in the idle cut-off position
on impact.
and would also provide tactile feedback that the pilot was
attempting to move the wrong control knob. In order for the
pilot to be able to pull the mixture control knob to the idle
cut-off position, it is likely that the plastic guard had not
been placed over the mixture control knob as required.
Mixture control pushed in to full rich with guard installed
Centre pedestal with mixture control (upper right) and
carburetor heat control (lower right)
Two scenarios were considered as to why the pilot inadvertently
pulled the mixture control to the idle cut-off position, causing
the engine to shut down:
• On approaching destination and in preparation for descent,
the pilot attempted to apply carburetor heat.
• The meteorological conditions were conducive to moderate
carburetor icing during cruise and descent. The Robinson R22
governor can easily mask carburetor icing by automatically
increasing the throttle to maintain engine RPM, which will
also result in a constant manifold pressure. It is possible that
the helicopter’s engine developed carburetor ice en route,
causing performance degradation or a total power loss. To
correct this situation, the pilot would have attempted to
apply carburetor heat.
The mixture control knob is shaped differently than the
carburetor heat knob. To reposition the mixture control, the
pilot needs to action the push-button locking feature. In addition,
to prevent its inadvertent actuation, the manufacturer also
requires that a cylindrical plastic guard be placed over the
mixture control knob from the time the engine is started until
such time as the engine is shut down. This plastic guard would
make it difficult to inadvertently action the mixture control
Mixture control pulled out to idle cut-off with guard removed
In the Robinson R22, the pilot must take immediate action
following a loss of power to ensure that rotor RPM is
maintained. Failure to do this can lead to a low rotor RPM
and rotor stall from which recovery may not be possible. The
Robinson R22 pilot operating handbook (POH) emergency
procedures for a power loss above 500 ft in part instructs the
pilot to immediately lower the collective to maintain rotor RPM
and enter a normal autorotation. A restart may be attempted
at the pilot’s discretion if sufficient time is available. If unable
to restart, the pilot should turn off unnecessary switches and
shut off the fuel.
Approximately 40 s before the crash, the helicopter started to
turn to the right, then immediately started turning sharply to
the left and climbed 300 ft. Approximately 20 s before the crash,
the helicopter began a rapid descent from 1 800 ft above sea
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Recently Released TSB Reports
21
level (ASL) to the crash site at 650 ft ASL; this equates to
a descent rate of approximately 3 450 ft/min. According to
Robinson Helicopter Company Safety Notices SN-18 and
SN-26, helicopters have less inherent stability and much
faster roll rates than airplanes. Loss of the pilot’s outside
visual references, even for a moment, can result in spatial
disorientation, wrong control inputs and an uncontrolled crash.
With a lack of visual reference at night, limited visibility due
to weather and the pilot’s relative inexperience, the pilot likely
became spatially disoriented while dealing with the power
loss emergency. Unable to determine the correct attitude of
the helicopter without visual reference, the pilot lost control,
resulting in uncontrolled flight into the terrain.
TSB Final Report A09P0397—Loss of
Control—Collision with Water
Note: The TSB investigation into this occurrence resulted in a
major report, with extensive discussions, analysis and recommendations
on emergency egress from floatplanes and the wearing of personal
floatation devices. Therefore we could only publish selected parts of
the report in the ASL. Readers are invited to read the full report,
hyperlinked in the title above. —Ed.
On November 29, 2009, a de Havilland DHC-2 MK 1 was
departing Lyall Harbour, Saturna Island, B.C., for the water
aerodrome at the Vancouver International Airport, B.C. After
an unsuccessful attempt at taking off downwind, the pilot took
off into the wind towards Lyall Harbour. At approximately
16:03 Pacific Standard Time (PST), the aircraft became airborne,
but remained below the surrounding terrain. The aircraft turned
left, then descended and collided with the water. Persons nearby
responded immediately; however, by the time they arrived at
the aircraft, the cabin was below the surface of the water. There
were eight persons on board—the pilot and an adult passenger
survived and suffered serious injuries; the other six occupants
drowned inside the aircraft. No signal from the emergency
locator transmitter (ELT) was heard.
Findings as to causes and contributing factors
1. It is likely that, while attempting to apply carburetor heat,
the pilot inadvertently pulled the mixture control knob to
the idle cut-off position, causing the engine to shut down.
2. It is likely that the plastic guard had not been placed over
the mixture control knob, resulting in the pilot being able
to pull the control to the cut-off position.
3. Following the engine shutdown, the rotor RPM was allowed
to decay, resulting in a loss of control and uncontrolled
flight into the terrain.
4. With few visual references, the pilot likely became spatially
disoriented, contributing to the inability to maintain control.
Other findings
1. The helicopter was being operated in Canada without
liability insurance as required by the Canadian Aviation
Regulations (CARs).
2. The helicopter had not been registered in Canada as
required by the CARs.
Analysis
The DHC-2 Beaver was originally certified without a stall
warning system. One had been installed on the occurrence
aircraft, but was later rendered unserviceable. The absence of
a functioning stall warning system, coupled with the known
benign stalling characteristics of the Beaver, precluded any
warning of an impending stall. Furthermore, the stall warning
horn had been filled with silicone to make it less noisy. It
is therefore possible that a horn would not be heard during
periods of loud engine noise, thereby increasing the risk of
inadvertent stalls.
The conditions in Lyall Harbour at the time of the occurrence
were conducive to the development of mechanical turbulence
and mountain waves. The turbulence associated with these
22
Recently Released TSB Reports
ASL 4/2012
phenomena likely contributed to vertical gusts, which
subjected the aircraft to temporary, but significant, increases
in aerodynamic load.
which included a brief loss of consciousness, caused a delay in
the pilot’s egress and limited his ability to provide assistance
to the passengers.
Following takeoff, after the initial climb, the pilot commenced
a left turn out of the harbour. The aircraft encountered down
flowing air, restricting its ability to gain altitude. As the
aircraft turned, it drifted towards terrain, causing the pilot to
increase the bank angle. To maintain altitude while banking,
the pilot likely had to increase the angle of attack, thereby
increasing the load factor and the speed at which the aircraft
would stall. While the use of flap may have increased the
wing area and consequently decreased its loading, it was likely
insufficient to counteract the combined loads brought about
by the atmospheric conditions and increase in bank.
With the exception of one adult, all passengers undid their
seatbelts, indicating that they likely remained conscious after
impact. Following the impact, the passengers would have had
a few seconds to locate a suitable egress point, release their
seat belts and exit the aircraft.
Seeing as the impact forces experienced by all onboard were
considered survivable, the issue of timely escape contributed
to the passengers drowning. Many persons could improve
their chances of survival by identifying the possible exits
and mentally rehearsing their actions, including identifying
alternate exits in the event of an accident. If passengers are
not provided with explicit safety briefings on how to egress
the aircraft when submerged, there is increased risk that they
will be unable to escape following an impact with the water.
Lyall Harbour with flight route and winds
A float-equipped Beaver with the flaps set in the landing
position was demonstrated to stall in straight and level flight
at 54 mph. In this occurrence, the combined effects of the
reduced airspeed during the climb, the bank angle during
the turn and the atmospheric conditions increased the load
factor of the aircraft to the point of aerodynamic stall.
The aircraft was under its maximum gross takeoff weight, but
loaded such that its centre of gravity (CG) was beyond the aft
limit for floatplane operations. The aircraft levelled off prior
to impact, indicating the pilot had initiated stall recovery.
Full recovery was compromised by the aft CG. Controllability
notwithstanding, the altitude from which recovery was made
was insufficient to arrest the descent, causing the aircraft to
strike the water.
The damage to the pilot’s seat rendered the restraint system
ineffective and contributed to the pilot’s injuries. These injuries,
In this occurrence, the aircraft was not equipped with jettisonable
doors or windows. As a result, the only possible egress points
were the four doors on the aircraft. However, impact damage
jammed two of the four doors and restricted egress from
the sinking aircraft, which meant all seven passengers and
the pilot would have had to exit via one of two usable egress
points. Rather than deliberately attempting to open a door,
the surviving passenger exited through the door that had
opened as a result of impact forces. It is likely that the pilot’s
recent egress training contributed to him being able to open
the door and escape from the aircraft. The lack of alternate
emergency exits, such as jettisonable windows, increases the
risk that passengers and pilots will be unable to escape a
submerged aircraft due to structural damage to primary
exits following an impact with the water.
Given the time involved in conducting a rescue, in cases when
an individual is successful in escaping an aircraft following
an impact, continued survival is a significant concern. This is
particularly true if the individual has been injured. Since it
is unlikely that persons faced with the urgency of escape in
water will retrieve life vests stored in the aircraft, passengers
and pilots not equipped with some type of flotation device
prior to an impact with the water are at increased risk of
drowning once they have escaped the aircraft.
Findings as to causes and contributing factors
1. The combined effects of the atmospheric conditions
and bank angle increased the load factor, causing an
aerodynamic stall.
2. Due to the absence of a functioning stall warning system,
in addition to the benign stalling characteristics of the
Beaver, the pilot was not warned of the impending stall.
ASL 4/2012
Recently Released TSB Reports
23
3. Because the aircraft was loaded in a manner that exceeded
the aft CG limit, full stall recovery was compromised.
4. The altitude from which recovery was attempted was
insufficient to arrest descent, causing the aircraft to
strike the water.
5. Impact damage jammed two of the four doors, restricting
egress from the sinking aircraft.
6. The pilot’s seat failed and he was unrestrained, contributing
to the seriousness of his injuries and limiting his ability to
assist passengers.
Findings as to risk
1. There is a risk that pilots will inadvertently stall aircraft
if the stall warning system is unserviceable or if the audio
warnings have been modified to reduce noise levels.
2. Pilots who do not undergo underwater egress training are
at greater risk of not escaping submerged aircraft.
3. The lack of alternate emergency exits, such as jettisonable
windows, increases the risk that passengers and pilots will
be unable to escape a submerged aircraft due to structural
damage to primary exits following an impact with the water.
4. If passengers are not provided with explicit safety briefings
on how to egress the aircraft when submerged, there is
increased risk that they will be unable to escape following
an impact with the water.
5. Passengers and pilots not wearing some type of flotation
device prior to an impact with the water are at increased
risk of drowning once they have escaped the aircraft.
Safety action taken
Operator
The operator has equipped each aircraft with hand-held
baggage scales to allow pilots to make more accurate weight
and balance calculations.
The operator has ordered new door latch release and window
modification kits from Viking Air Limited, the aircraft type
certificate holder.
The operator has enhanced its pre-flight safety briefing by
now including an independent demonstration of where to
find the life vests, what they look like and how to put them on.
A mannequin located at the operator’s Vancouver and Nanaimo
docks is used to perform this safety demonstration. Enlarged
photographs from the safety briefing cards are displayed on
the mannequin stand. A briefing is provided to passengers
before they head down to the aircraft at the dock and a second
safety briefing is provided once they are at the aircraft.
Viking Air Limited
Viking Air Limited, the aircraft type certificate holder, has
made push-out window and cabin and cockpit door latch
kits available for installation on Beaver aircraft.
24
Recently Released TSB Reports
Transport Canada
Since this accident, Transport Canada (TC) completed a
number of initiatives:
-- TC facilitated a meeting of floatplane operators in
October 2010, which resulted in the formation of an
industry-led safety association of B.C. floatplane operators.
-- TC ran an updated floatplane safety promotional campaign
during the summer of 2011, which included:
• publishing articles in the Aviation Safety Letter to promote
egress training and effective passenger briefings;
• developing posters and pamphlets for distribution to
floatplane passengers to increase awareness of their role
in safety;
• tasking its inspectors to ensure floatplane operators receive
the latest safety promotion materials, to emphasize the
importance of egress training and better passenger briefings
during their visits, and to conduct follow-up telephone
surveys of floatplane operators to verify that they are
using the safety promotion materials;
• developing a Web portal to centralize floatplane safety
information for use by operators and passengers and
encouraging floatplane operators to provide a link to
the portal from their Web sites;
• producing a video for use by operators promoting best
practices and lessons learned in floatplane operations; and
• producing a video for use by floatplane passengers on their
role in safety.
-- TC issued a Civil Aviation Safety Alert (CASA) on June 6, 2011,
with its focus on commercial and private floatplane operators
and pilots, recommending the following best practices in
relation to floatplane safety:
• Upper body restraints to be used by front seat occupants;
• Passenger briefings on the proper usage of floatation
devices during emergency egress;
• Underwater emergency egress training for flight crew; and
• Aircraft safety design improvements facilitating egress.
In August 2011, TC held a focus group with selected
members of industry to determine the most effective means
of addressing the TSB recommendations related to rapid
egress and the mandatory use of personal floatation devices
(TSB Recs A11-05 and A11-06). This process is ongoing.
TSB Final Report A09Q0203—Controlled Flight
into Terrain (CFIT)
Note: The TSB investigation into this CFIT occurrence resulted
in a major report, with extensive discussions, analysis and
recommendations on instrument approach design, instrument
approach depiction, instrument approach techniques, approach
and landing accidents, and approach and landing accident
reduction (ALAR) initiatives. Therefore we could only publish
ASL 4/2012
the summary, findings and some of the safety actions in the ASL.
Readers are invited to read the full report, hyperlinked in the title
above. This occurrence report also prompted the publication of the
article on the Flight Safety Foundation’s (FSF) ALAR Tool Kit in
this issue of the ASL. —Ed.
On December 9, 2009, a Beech A100 was on an instrument flight
rules (IFR) flight between Val-d’Or, Que., and Chicoutimi/
Saint-Honoré, Que., with two pilots and two passengers on
board. At 22:40 Eastern Standard Time (EST), the aircraft was
cleared for an RNAV (GNSS) Runway 12 approach and switched
to the aerodrome traffic frequency. At 22:50 EST, the International
satellite system for search and rescue detected the aircraft’s
emergency locator transmitter (ELT) signal. The aircraft was
located at 02:24 EST in a wooded area approximately 3 NM
from the threshold of Runway 12, on the approach centreline.
Rescuers arrived on the scene at 04:15 EST. The two pilots
were fatally injured, and the two passengers were seriously
injured. The aircraft was destroyed on impact; there was no
post-crash fire.
Canadian Aviation Regulations (CARs) for air taxi
operators1. Until the changes to the regulations are put
into effect, an important defense against ALAs is
not available.
4. Most air taxi operators are unaware of and have not
implemented the FSF ALAR Task Force recommendations,
which increases the risk of a CFIT accident.
5. Approach design based primarily on obstacle clearance
instead of the 3° optimum angle increases the risk of ALAs.
6. The lack of information on the SCDA technique in
Transport Canada reference manuals means that crews
are unfamiliar with this technique, thereby increasing
the risk of ALAs.
7. Use of the step-down descent technique prolongs the
time spent at minimum altitude, thereby increasing the
risk of ALAs.
8. Pilots are not sufficiently educated on instrument
approach procedure design criteria. Consequently, they
tend to use the CAP published altitudes as targets, and
place the aircraft at low altitude prematurely, thereby
increasing the risk of an ALA.
9. Where pilots do not have up-to-date information on
runway conditions needed to check runway contamination
and landing distance performance, there is an increased
risk of landing accidents.
10. Non-compliance with IFR reporting procedures at
uncontrolled airports increases the risk of collision with
other aircraft or vehicles.
11. If altimeter corrections for low temperature and remote
altimeter settings are not accurately applied, obstacle
clearance will be reduced, thereby increasing the CFIT risk.
Aircraft wreckage
Finding as to causes and contributing factors
1. For undetermined reasons, the crew continued its descent
prematurely below the published approach minima, leading
to a controlled flight into terrain (CFIT).
Findings as to risk
1. The use of the step-down descent technique rather than
the stabilized constant descent angle (SCDA) technique
for non-precision instrument approaches increases the
risk of an approach and landing accident (ALA).
2. The depiction of the RNAV (GNSS) Runway 12 approach
published in the Canada Air Pilot (CAP) does not
incorporate recognized visual elements for reducing
ALAs, as recommended in Annex 4 to the Convention
on International Civil Aviation, thereby reducing
awareness of the terrain.
3. The installation of a terrain awareness warning
system (TAWS) is not yet a requirement under the
12. When cockpit recordings are not available to an
investigation, this may preclude the identification
and communication of safety deficiencies to advance
transportation safety.
13. Task-induced fatigue has a negative effect on visual and
cognitive performance, which can diminish the ability
to concentrate, operational memory, perception and
visual acuity.
1 On July 4, 2012, Transport Canada announced new regulations requiring
the installation and operation of TAWS in private turbine-powered and
commercial airplanes configured with six or more passenger seats. The
regulatory amendments introduce requirements for the installation of
TAWS equipped with an enhanced altitude accuracy (EAA) function.
Most current TAWS equipment include this function; however, operators
who have previously installed older TAWS models may not have
equipment with this functionality. Operators have two years from the
date the regulations came into force to equip their airplanes with TAWS
and five years to equip with EAA.
ASL 4/2012
Recently Released TSB Reports
25
14. Where an ELT is not registered with the Canadian Beacon
Registry, the time needed to contact the owner or operator
is increased, which could affect occupant rescue and survival.
15. If the tracking of a call to 9-1-1 emergency services from
a cell phone is not accurate, search and rescue efforts may
be misdirected or delayed, which could affect occupant
rescue and survival.
Channel and overturned. Attempts to secure the aircraft failed
and it sank. There were no survivors. The emergency locator
transmitter (ELT) functioned but its signal was not received
until the wreckage was brought to the surface two days later.
Other findings
1. Weather conditions at the alternate airport did not meet
CARs requirements, thereby reducing the probability of a
successful approach and landing at the alternate airport if
a diversion became necessary.
2. Following the accident, none of the aircraft exits were usable.
Safety action taken
Operator
To minimize the risks of ALAs, the operator implemented
SCDA in its standard operating procedures (SOPs).
A program was set up to progressively install radio altimeters
on the company aircraft.
The company CFIT training was reviewed to integrate the
recommendations of the FSF ALAR Task Force.
The following measures have been, or will be, taken by the
operator to reduce the operational risks:
• A review of all departments related to flight operations.
• A complete review of SOPs.
• A review of operational limitations of the charter operations
(i.e. new restrictions for new captains and first officers as
well as equipment restrictions).
• All flying personnel will redo the company CFIT course.
• A risk analysis file is available to the flight crew to review
the level of risk associated with approaches in instrument
meteorological conditions (IMC) for all destinations.
This file is based on the FSF program.
• A flight safety awareness campaign called “Objectif Zéro”
was set up to involve all company employees. The aim is
to allow all employees to have a positive impact on flight
safety via the company safety management system (SMS).
TSB Final Report A10P0147—Loss of
Control—Collision with Water
On May 29, 2010, a float-equipped Cessna 185F took off
from Tofino, B.C., at 12:00 Pacific Daylight Time (PDT) for
a flight to Ahousat, B.C., with a pilot and three passengers.
The short flight was being carried out under visual flight
rules (VFR) at about 500 ft above sea level (ASL). About
2 NM from Ahousat, while in cruise flight, the aircraft descended
in a steep nose-down attitude until it hit the water in Millar
26
Recently Released TSB Reports
Analysis
The weather was suitable for the VFR flight; the wind direction
and speed would not have caused downdrafts or severe turbulence
on the flight route. There was no evidence to suggest that
any mechanical or environmental issue played a role in
this occurrence.
The aircraft struck the water at an angle and speed consistent
with a deliberate dive, or a loss of control. Based on the pilot’s
demeanour, there was no reason to dive to the point of impact
with the water. Therefore, the TSB concluded that the pilot
lost control of the aircraft.
The aircraft was trimmed for level cruising flight. Had the
pilot simply released the controls, the aircraft would have
remained more or less in level cruising flight, and it would
not have pitched down abruptly or to an angle of 45°. To
sustain a descent at a 45° angle from level attitude, a high
and continued pressure would have had to have been placed
on the control column.
The passengers were intoxicated at the time they boarded
the aircraft, and had previously been argumentative. The
final location of some beer cans and fragments of the beer
case indicate that the case of beer was in proximity to the
passengers just before impact.
It is not known if all the passengers were wearing their seat
belts at the start of the flight, but the physical evidence shows
that the seatbelts of the passenger in the right front seat
(beside the pilot) and of the passenger in the left rear seat
(behind the pilot) were not fastened at impact.
ASL 4/2012
What was happening in the cabin moments before the pilot
lost control cannot be accurately determined. However, the
TSB concluded that this probably involved activity by the
unsecured passengers that interfered with the pilot and his
control of the aircraft.
Other finding
The pilot’s broken right wrist and the bent V brace suggest
that the pilot was bracing or trying to resist a force imposed
from behind. The broken ankles of the passenger behind the
pilot are consistent with that person bracing with both feet,
or pushing forward with both feet, at the time of impact. It
is possible the passenger seated behind the pilot kicked the
pilot’s seatback forward and held it there, pushing the pilot
into the instrument panel and the controls forward, thereby
inducing a dive.
The British Columbia Coroners Service has made the following
recommendation to Transport Canada as a result of its
investigation into the deaths of the four individuals:
Because there was no locking mechanism on the pilot’s
seatback, and because the pilot was not wearing his shoulder
strap, he would have been unable to prevent his upper body
from being forced onto the instrument panel.
When aircraft controls are accessible to passengers there is a
risk of inadvertent control manipulation and a risk of the pilot
losing control of the aircraft at a critical time of flight operations.
It is also possible the level of the passengers’ intoxication
impaired their ability to recognize the gravity of the situation
and stop their interference in time for the pilot to regain
control of the aircraft before impact.
Findings as to causes and contributing factors
1. It is likely that passenger interference caused the pilot to
lose control of the aircraft, whereupon it descended in a
steep nose-down attitude until it struck the water.
2. It is possible the passengers’ level of intoxication contributed
to their inability to recognize the gravity of the situation
and stop the interference in time for the pilot to regain
control of the aircraft before impact.
3. Because there was no locking mechanism on the pilot’s
seatback, and because the pilot was not wearing his
shoulder strap, he would have been unable to prevent his
upper body from being forced onto the instrument panel. 1. Post-impact survival issues such as egress and flotation
were not relevant in this accident.
Safety action taken
British Columbia Coroners Service
It is recommended that all commercial air operators be required
to establish a policy, procedure, and training (based on the
Canadian [Aviation] Regulations) for all personnel, to assist
them in identifying inappropriate behaviour in passengers,
and take the necessary action to mitigate risk where there are
reasonable grounds to believe that the person’s faculties are
impaired by alcohol or drugs.
This recommendation is currently under review by
Transport Canada officials. In the meantime, we strongly
encourage all operators to review CAR 602.4 Alcohol
or Drugs – Passengers.
TSB Final Report A10Q0218—Engine Failure
and Hard Landing
On December 9, 2010, a Bell 206B, equipped with high skid
landing gear, departed Matane, Que., on a visual flight
rules (VFR) flight with the pilot and four passengers on
board. The aircraft was flying northeast at low altitude over
the south shore of the Saint Lawrence River so that the
passengers could evaluate and document damage caused by
high tides. At 11:31 Eastern Standard Time (EST), approximately
27 min after takeoff, the helicopter experienced an engine
(Rolls-Royce 250-C20B) failure. The pilot did an autorotation
with a right turn of more than 180°. The aircraft landed hard
on the beach, breaking the landing gear, and came to rest on
its belly. One of the occupants was seriously injured, two had
minor injuries and two were unharmed in the accident.
Findings as to risk
1. When controls are accessible to passengers there is a risk
of inadvertent control manipulation and a risk of the pilot
losing control of the aircraft.
2. When upper body restraint systems are not used, there is
a risk of serious head injury in the event of an accident.
3. When cargo or passengers’ baggage is not restrained, there
is a risk of unsecured items injuring persons on board in
the event of sudden aircraft stoppage or encounters with
severe turbulence.
ASL 4/2012
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27
Analysis
The No. 2 bearing assembly in the engine broke down due to
the fatigue failure of its cage. Because this bearing served as a
thrust bearing, its failure caused the compressor to move forward,
which in turn brought the impeller into contact with the shroud.
The resulting friction led to significant deceleration and a loss
of power. The propulsive movement of the compressor caused
it to stall, as demonstrated by the bangs it produced.
rotor RPM warning horn sounded during the descent. It can
be concluded that the collective was off the down stop and
that the rotor RPM fell below 90 percent.
The breaking of a gearbox stud, the crack in the compressor
scroll and the fatigue failure of three fingers in the vibration
damper may suggest that the damage was caused by abnormal
engine vibration. However, after the stud and scroll were repaired,
the engine was tested on a test bench, and no anomalies or
vibrations outside of the limit were noted. This suggests that it
is unlikely that engine vibration caused the anomalies. It can
also be concluded that the vibration damper was not fractured
at the time of the inspection on the test bench. Consequently,
the successive fractures of the damper fingers occurred during
the last 30 flight hours.
Because three fingers had fractured less than 30 flight hours
before the accident, the vibration damper was less effective.
It cannot be concluded beyond all doubt that the broken
damper caused the No. 2 bearing assembly to fail. However,
the partial failure of a component intended to absorb engine
vibration cannot be ruled out; it could have altered the vibration
load of the compressor, increasing the load on the No. 2 bearing
assembly and causing its cage to sustain a fatigue failure.
Although the gearbox had been disassembled three times less
than 35 flight hours before the accident, no anomalies were
observed. The ball bearings and the vibration damper were not
examined because the disassembly of the gearbox was not
meant to verify their condition. Therefore, the engine may have
been rebuilt with components that needed to be replaced.
The engine was equipped with a working chip-detection
system, but the pilot did not notice the warning light before
the loss of power, while significant spalling was generated
by the slippage of the ball bearings in the No. 2 bearing
assembly. However, 3.2 flight hours before the accident, the
chip detectors detected metallic debris in smaller quantities
from the engine ball bearings, which were starting to break
down. Consequently, the ENG CHIP warning light may
have been illuminated without the pilot noticing.
According to the height/speed chart, the loss of power occurred
in an operating range within which a safe emergency landing
was possible. At the time of the failure, there were three operating
conditions posing a greater challenge than usual for the pilot.
Given the height of the aircraft, the pilot had little time to
lower the collective, perform a 180° turn into the wind, and
begin the descent before landing on a slope. The power loss
caused a rapid drop in rotor RPM to the point where the low
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Recently Released TSB Reports
Findings as to causes and contributing factors
1. The No. 2 bearing assembly in the engine broke down
due to the fatigue failure of its cage. The failure of the
bearing assembly caused the engine to lose power.
2. The power loss caused a rapid drop in rotor RPM to the
point where the LOW ROTOR RPM warning horn
sounded during the descent. It can be deduced that the
collective was not completely lowered and that rotor RPM
dropped below 90 percent. This caused a hard landing.
Findings as to risk
1. Although the aircraft was operated outside of the high-risk
“to avoid” zone on the height/speed chart, the autorotation
resulted in a hard landing. Because of operating factors
other than speed and height, the operation of the helicopter
at low altitude posed a risk to safe landing in the event
of an engine failure.
2. Operating an aircraft outside of the weight and balance
limits set by the manufacturer can reduce aircraft
performance and cause a power surge, in turn causing
major damage to the engine, airframe and power train.
3. The aircraft can attain the performance figures in the
height/speed chart when it is loaded with its limit weight.
Operating the aircraft at a higher weight compromises
the success of an autorotation following an engine failure.
Other finding
1. The wear on the ball bearings and the vibration damper
was not observed when the gearbox was examined because
the three engine teardowns performed within the 31 flight
hours before the accident did not expose them and were
not intended to verify their condition.
ASL 4/2012
TSB Final Report A10A0122—Controlled Flight
Into Terrain
On December 14, 2012, at 19:41 Atlantic Standard Time (AST),
a Cessna 310R departed the Montréal/St-Hubert Airport, Que.,
on a night instrument flight rules (IFR) flight to the
Pokemouche Airport, N.B. Between 21:56 AST and 21:58 AST,
three transmissions were received from the occurrence
aircraft’s 406 MHz emergency locator transmitter (ELT);
however, the signal terminated before the location could be
determined. The wreckage was located two days later in a
wooded area, approximately 5.5 NM west-northwest of the
Pokemouche Airport. The aircraft was destroyed by the
impact and post-crash fire. The lone occupant was fatally injured.
Analysis
On the day of the occurrence, the departure altimeter setting
for St-Hubert was 29.61 in. Hg and the arrival altimeter
setting for Bathurst, N.B., was 29.41 in. Hg. If the Bathurst
altimeter setting was not applied prior to the commencement
of the instrument approach, the aircraft’s actual altitude
would have been 200 ft lower than indicated on the altimeter.
While an altimeter error of this nature would reduce safety
margins, levelling off at the minimum descent altitude with
the incorrect altimeter setting of 29.61 in. Hg would still
provide several hundred feet of clearance between the aircraft
and the terrain. As a result, it is unlikely that the aircraft
impacted the ground simply because the altimeter had not
been switched to the current Bathurst altimeter setting.
This occurrence involved several of the most common factors
associated with controlled flight into terrain (CFIT) accidents.
In particular, it involved flight conditions that would make it
nearly impossible to see the approaching terrain and it involved
an instrument approach procedure with multiple step-down
altitudes. As a result, each time that a descent is commenced,
the pilot must remain vigilant to ensure that the aircraft does
not descend below the appropriate minimum safe altitude,
which during this portion of the approach was 1 000 ft above
sea level (ASL). The combination of a non-precision instrument
approach, conducted at night, with low ceilings and limited
visibility significantly increases the risk of CFIT. The operator was not authorized to conduct GPS approaches
on revenue flights, and there was no evidence of the pilot
undergoing the required training for conducting GPS
approaches. While familiar with the aircraft and operating
environment around Pokemouche, the pilot was inexperienced
with the newly installed equipment. As a result, trying to use
the new and unfamiliar GPS with a terrain awareness feature
and audio panel in adverse weather at night would have
increased pilot workload and made it difficult to maintain
situational awareness. Based on the heading and location
of the aircraft at the time of the impact, it is likely that the
pilot was attempting to carry out the area navigation (RNAV)
approach to Runway 13 and inadvertently flew into terrain.
The pilot elected to return to Pokemouche on the evening of
December 14, 2010, so the aircraft would be available for an
unexpected charter flight booked for the following morning.
This influenced the pilot’s decision to depart, despite the
pilot’s lack of familiarity with the new GPS and unfavourable
weather at the destination. The pilot, under self-imposed pressure,
likely elected to carry out a GPS approach to Runway 13 in
IFR weather that was at or below landing limits. The other
two approaches available were on Runway 31, both having
the same landing limits as the approach to Runway 13.
Currently, there is no requirement for smaller Canadian-registered
aircraft to be equipped with terrain awareness and warning
systems (TAWS). Although Transport Canada has proposed
new regulations which will require TAWS for commercially
operated turbine-powered aircraft with six or more passenger
seats, the regulation will not require TAWS to be installed
on commercially operated turbine-powered aircraft with less
than six passenger seats. The lack of regulation requiring TAWS
on all commercially operated passenger aircraft places flight
crew and passengers travelling on those aircraft at increased
risk of CFIT.
The occurrence aircraft was fitted with a terrain awareness
feature which would visually warn the pilot of the aircraft’s
proximity to terrain if it got too low during an instrument
approach. This type of equipment is an example of recent
advances in technology designed to improve a pilot’s
situational awareness and reduce the risk of CFIT. However,
in order for its full potential to be realized, pilots must be
properly trained in the use of the terrain awareness feature.
In this occurrence, the pilot received a brief familiarization
session on the GPS, avionics, and terrain awareness feature
that had been newly installed in the aircraft. It is unknown
whether the terrain awareness feature was activated during
ASL 4/2012
Recently Released TSB Reports
29
the RNAV approach to Runway 13. It is possible that the
terrain awareness feature was activated and that the pilot
did not understand the information that was being presented.
The lack of adequate training on newly installed equipment,
such as a GPS with a terrain awareness feature, increases the
risk of improper use during flight.
It took two days for search and rescue (SAR) personnel to
locate the aircraft. This is due to the 406 MHz ELT, which
was not equipped with GPS encoding, only transmitting
briefly before it was rendered inoperative. If 406 MHz ELTs
are not GPS-encoded, there is increased risk that SAR services
will be delayed unnecessarily if the ELT is rendered
inoperative following an occurrence.
Findings as to causes and contributing factors
1. The pilot, under self-imposed pressure to meet an
unexpected charter request the next day, likely elected
to carry out an RNAV approach in IFR weather that
was at or below landing limits.
2. It is likely that the aircraft was inadvertently flown into
terrain while the pilot was attempting to carry out the
RNAV approach to Runway 13.
3. Attempting to use a new and unfamiliar GPS, terrain
awareness feature and audio panel in adverse weather
at night would have increased pilot workload, making
it difficult to maintain situational awareness.
Findings as to risk
1. The combination of a non-precision instrument approach,
conducted at night, with low ceilings and limited
visibility
significantly increases the risk of CFIT.
2. The lack of regulation requiring TAWS on all commercially
operated passenger aircraft places flight crew and passengers
travelling on those aircraft at increased risk of CFIT.
3. The lack of adequate training on newly installed
equipment, such as a GPS with a terrain awareness
feature, increases the risk of improper use during flight.
4. If 406 MHz ELTs are not GPS-encoded, there is increased
risk that SAR services will be delayed unnecessarily if the
ELT is rendered inoperative following an occurrence.
Other finding
Aircraft flight path to Pokemouche Airport
1. It is unlikely that the aircraft impacted the ground simply
because the altimeter had not been switched to the current
Bathurst altimeter setting.
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30
Recently Released TSB Reports
ASL 4/2012
Accident Synopses
Note: The following accident synopses are Transportation Safety Board of Canada (TSB) Class 5 events, which occurred between
February 1, 2012, and April 30, 2012. 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 by the TSB since
publication. For more information on any individual event, please contact the TSB.
— On February 10, 2012, a Diamond DV-20 aircraft was
on a VFR time-building flight from Moncton International
(CYQM) to Bathurst (CZBF) airports. The aircraft lost
control on landing and impacted a snow bank. The crew
and passenger sustained minor injuries and the aircraft
was substantially damaged. TSB File A12A0017.
chocks in hand and was struck by the propeller. The flight
attendant provided immediate first aid and fire rescue personnel
responded within one minute. The marshaller sustained serious
injuries but was stable enough for MEDEVAC transportation
to Edmonton. TSB File A12W0013.
— On February 11, 2012, a privately registered Cessna 150,
converted to a tail dragger, was operating on a sandbar in
the Fraser River north of Chilliwack Mountain, B.C. The
aircraft came into contact with water during the take-off run,
overturned, and came to rest partially submerged. There was
only the pilot on board and he was not injured. The pilot was
rescued by two other aircraft that landed at the same site.
TSB File A12P0019.
— On February 11, 2012, a privately registered ultralight
Beaver RX550 with one person on board was reported to
have crashed near Rosa Lake, B.C., 20 NM south of Williams
Lake VORTAC (YWL). A post-impact fire occurred. The
pilot was rescued and transported to hospital with serious
injuries. TSB File A12P0020.
Despite constant reminders, warnings, and on-the-job training,
marshallers sometimes forget about turning propellers.
— On February 13, 2012, a de Havilland DHC-8-100 was
operating from Cambridge Bay, Nun., to Yellowknife, N.W.T.
On arrival, the aircraft was marshalled in to parking spot 9
on the main apron. The left engine was shut down and the right
engine was feathered. The marshaller moved from the nose of
the aircraft towards the right main landing gear area with wheel
— On February 14, 2012, a Cessna 150, with one pilot on board,
was used to conduct a local VFR flight from the Montréal/
St-Hubert Airport (CYHU), Que., without authorization.
After takeoff, the aircraft climbed over the airport, nosed down,
and struck the ground approximately 1 200 ft east of the
Runway 24R threshold. The pilot was fatally injured and the
aircraft was destroyed. TSB File A12Q0022.
— On February 17, 2012, a Cessna T206H on amphibious
floats was about 10 NM from Springbank Alta., descending
through 6 000 ft on approach when smoke was noticed
coming from under the instrument panel. The pilot requested
priority for landing and was cleared to the threshold of
Runway 25. After advising the tower, the electrical system
was shut down, but the smoke continued to become thicker.
On short final the throttle control failed, and the aircraft
landed in the grass about 140 ft short of the runway. The
aircraft rolled onto the pavement and came to rest just
before Taxiway Delta, on the south side of the centreline.
The pilot and two passengers evacuated without injury, and
the airport operations staff contained the fire. Maintenance
determined that the turbocharger “V” clamp failed due to
corrosion and the hot exhaust gasses initiated a fire in the
engine compartment that breached the firewall. The aircraft
had about 1 000 hr TTSN, most of which had been float
operations on and over salt water. TSB File A12W0014.
— On March 5, 2012, a Lockheed 188A had departed from
Goose Lake, N.W.T for Yellowknife. After takeoff, the right
main landing gear jammed in a partially retracted position.
Several attempts were made to lower the right main landing gear
with alternate extension methods, but with no success. An
emergency was declared and the aircraft landed on Runway 34
with the left main landing gear and nose landing gear extended.
The aircraft departed the right side of the runway and came to
rest in the airport infield. There were no injuries to the six
flight crew members and no post-occurrence fire. The outboard
gear door strut is suspected to have jammed the gear mechanism
during landing gear retraction after takeoff. TSB File A12W0020.
ASL 4/2012
Accident Synopses
31
— On March 5, 2012, a Cessna 182RG, was on a VFR training
flight from the Chicoutimi/St-Honoré Airport (CYRC), Que.,
with one pilot and one instructor on board. During a touchand-go on Runway 12, the aircraft landed on its belly and
came to a stop on the runway. There was friction damage to
the aircraft’s belly and propeller blades. There were no injuries.
TSB File A12Q0031.
— On March 11, 2012, a Hughes 369D helicopter was
transporting three passengers to a seismic survey site about
60 NM southwest of Anchorage, Alaska. After landing on
snow the helicopter experienced a dynamic rollover and was
substantially damaged. The pilot and passengers were not
injured. The emergency locator transmitter (ELT) automatically
activated during the incident. TSB File A12F0023.
— On March 14, 2012, a Eurocopter EC 130-B4 helicopter
was conducting low-level wildlife management work in a heavily
wooded area near the Ameson (VOR) (YAN) in Northern
Ontario. While manoeuvring, the helicopter’s tail rotor struck
a tree. The helicopter became uncontrollable and collided with
the ground. The pilot and two crew members sustained minor
injuries and were airlifted
to safety by another helicopter. TSB File A12O0032.
— On March 17, 2012, a Citabria was conducting circuits at
Prince George Airport (CYXS), B.C., when the aircraft touched
down and ground-looped. The aircraft veered off the runway
and overturned in the snow. The aircraft was substantially
damaged. The pilot was the sole person on board and was
unharmed. TSB File A12P0044.
— On March 17, 2012 a private Helio Courier H-391B
was attempting a takeoff with a crosswind from Langley
Airport (CYNJ), B.C., when the aircraft veered hard and
ground-looped. The aircraft came to rest off the runway
surface in a soft field with the wheels sinking into the mud.
The right wing and horizontal stab contacted the ground
causing extensive damage. TSB File A12P0043.
— On March 18, 2012, an amateur-built Super Ben 160
was on a local flight on skis from a private property. During
the flight, fog formed on the ground, and the pilot turned
back. He recognized Lac Louvier and decided to conduct a
precautionary landing. The lake’s surface, measuring about
1 500 ft, was frozen. The aircraft did not slow down as
anticipated and came to a stop in the trees at the far end of
the lake. The aircraft impacted the trees at a reduced speed.
The engine cowl and the left wing were damaged. The pilot
and the passenger were uninjured. TSB File A12Q0037.
— On March 20, 2012, a Cessna 172N had taken off from
the St-Frédéric Airport (CSZ4), Que., to conduct a circuit.
This was the first solo flight for the student pilot. When
landing on Runway 23 with wind blowing from 300° at 10 kt,
the student pilot did not sufficiently deflect the ailerons against
32
Accident Synopses
the wind. The aircraft went off course to the left, the left
wheel struck a runway edge light and the left landing gear
collapsed. The aircraft spun 180° while sliding on the slope
at the edge of the runway. The propeller touched the ground
and the left wing crumpled, the rear fuselage folded in, and
the stabilizer was bent out of shape. The student pilot was
not injured and the emergency locator transmitter (ELT)
was not activated. TSB File A12Q0040.
— On March 22, 2012, a Hughes 500 helicopter had taken
off from Lac-à-la-Tortue (CSL3), Que., for Trois-Rivières,
Que. At approximately 1.5 NM from its destination, the
engine (Rolls-Royce, Allison C20B) shut down in flight.
The pilot conducted an autorotation toward a railroad track.
Upon landing, the skids slid next to the track and the aircraft
tipped onto its side. The aircraft was assessed and no anomalies
were found. The engine was placed on a test stand and showed
no operating anomalies under any operating conditions.
TSB File A12Q0043.
— On March 22, 2012, a Grob G120A was completing a
practice forced landing and experienced a hard landing at
Portage la Prairie Airport (CYPG), Man. The right main
wheel detached from the aircraft. The crew elected to
overshoot and returned to land on a different runway. On
touchdown the left main landing gear partially collapsed.
The aircraft departed the runway to the right and came to
rest beside the runway in the grass. The crew was uninjured.
Both main landing gear assemblies were damaged.
TSB File A12C0030.
— On March 24, 2012, an Air Création XPGT582S ultralight
on wheels took off from a field in Bury, Que., for a recreational
flight, with the pilot and one passenger on board. About 15 min
later, while cruising at low altitude, the left wing pointed
towards the ground and the aircraft nosed down. The ultralight
crashed into a forest and was severely damaged. The pilot did
not survive and the passenger was seriously injured. The TSB
is collaborating with the Quebec coroner’s office, which is
conducting an investigation. TSB File A12Q0044.
— On March 25, 2012, a private Cessna 170 on wheels was
attempting to land on a frozen lake 15 NM east of Smithers,
B.C. The aircraft touched down prior to the threshold of the
snowmobile compacted strip and nosed over onto its back.
There were no injuries to the sole occupant. The 406 emergency
locator transmitter (ELT) activated and was shut off by the
pilot. TSB File A12P0041.
— On March 27, 2012, a privately operated Cessna A185F
was on a local pleasure flight from the Cooking Lake
Airport (CEZ3), Alta. The wind was from the south-southeast
for arrival on Runway 10 with an estimated crosswind component
of 5-8 kt. The initial touchdown was smooth but as the tail
came down the aircraft swerved to the right resulting in the
left wing tip scraping the runway. The aircraft departed the
ASL 4/2012
right side of the runway and the left wheel dislodged a conduit
access cover and fell into the conduit. The aircraft came to rest
on the left wing tip resulting in significant damage to the wing
tip and left landing gear strut and wheel assembly. The pilot
and three passengers were not injured. TSB File A12W0032.
— On March 31, 2012, the pilot-owner of a Kangook
Th powered parachute was flying in the vicinity of
Saint-Henri-de-Taillon, Que. When the powered parachute
was at a very low altitude, the pilot was unable to avoid
hitting a tree. The pilot sustained minor injuries and the
aircraft was substantially damaged. TSB File A12Q0050.
— On April 5, 2012, a Van’s RV-6A had landed at a private
airstrip near Leask, Sask. While taxiing off the runway, the
aircraft’s nosewheel sank into a soft depression in the grass
taxiway. The aircraft overturned and its fuselage, propeller,
and vertical stabilizer were substantially damaged. The pilot
was not injured. TSB File A12C0032.
— On April 12, 2012, a Piper PA-18-150 Supercub was landing
on Runway 34 at Mackenzie Airport (CYZY), B.C. The aircraft
was observed descending steeply and touched down at the
mid-point of the runway at an estimated airspeed of 45-50 mph.
There was a crosswind at 310° and 8 kt. The aircraft bounced
and the pilot regained control with full throttle application.
The aircraft was pointing straight down the runway when a
wind gust reportedly picked up the left wing. It subsequently
stalled with a right wing drop; the aircraft punched through
a perimeter fence to the right of the runway, impacted a small
berm, and flipped over. The pilot of this tandem-seating plane
was in the front wearing a seat belt restraint system with
shoulder harness, and the passenger was wearing a lap belt.
Both occupants extricated themselves from the aircraft. The
passenger was taken to hospital for observation. The aircraft
was substantially damaged. TSB File A12P0050.
— On April 14, 2012, the pilot of a Piper PA-14 Family Cruiser
was performing circuits on Runway 25 at Boundary Bay
Airport (CZBB), B.C. On its third landing, the aircraft
touched down, bounced and porpoised before veering off
to the right side of the runway and into the grass. The pilot
shut off the engine, fuel valve, and electrics as the aircraft was
rolling but it entered a ditch and nosed over before coming to
a full stop. It came to rest inverted in the ditch. The pilot was
wearing only a lap seat belt and was able to exit the aircraft
uninjured. The aircraft was substantially damaged, and fuel
was leaking into the ditch. The aircraft was righted in short
time to prevent further contamination and the risk of fire.
TSB File A12P0052.
— On April 14, 2012, a Bellanca 7ECA Citabria tow
plane was landing beside Runway 06 at Pemberton
Airport (CYPS), B.C., when it flipped over. The pilot
was on the first approach to land for the season. The aircraft
was low and slow on final and touched down in the grass
area abeam the runway near the end, in an area with standing
water; there was no braking action but it decelerated rapidly
in the standing water and overturned. The pilot was wearing a
seat belt restraint system with shoulder harness and extricated
with minor leg scrapes. TSB File A12P0053.
— On April 15, 2012, a Schweizer SGS 2 33A glider landed
short of Runway 36 at Oliver Airport (CAU3), B.C., in a peach
tree orchard. The solo pilot was apparently not injured, but taken
to hospital for observation. The aircraft damage was limited to
the wings. TSB File A12P0054.
— On April 15, 2012, a Taylorcraft BC12-DX was hand started
at Finlay Air Park (CDH3), N.S. Once started, the engine RPM
continued to increase. Before the pilot could enter the cabin,
the unoccupied aircraft jumped the chocks and impacted the
side of a hangar. The hangar sustained minor damage while
the aircraft was substantially damaged. The pilot was uninjured.
It is likely that the throttle resistance was not adjusted properly
which allowed the engine power to increase above idle.
TSB File A12A0041.
— On April 15, 2012, a privately operated Kitfox Model 1
crashed after an attempted takeoff from a grass strip 10 MN
east of Manning, Alta. The pilot and passenger sustained minor
injuries. TSB File A12W0040.
— On April 18, 2012, a privately operated Grumman
Tiger AA-5B was on a local VFR training flight from
the Lachute Airport (CSE4), Que., with an instructor
and a student on board. While practicing touch-and-goes,
the aircraft bounced on the nose wheel during one of the
landings, and when the wheel touched down again the
aircraft momentarily left the runway and drove on the grass
before pulling back onto the runway. There were no injuries;
the damage to the aircraft was mainly to the propeller, which
had made contact with the runway. TSB File A12Q0055.
— On April 20, 2012, a privately owned Bellanca 7KCAB
tail-dragger aircraft was landing in crosswind conditions. Shortly
after touchdown the pilot lost directional control and the aircraft
ground-looped. The right-hand side wing, wing strut, and
landing gear were substantially damaged. TSB File A12O0053.
— On April 28, 2012, an Aeronca 7BCMX on floats was taking
off from Pelican Lake in the vicinity of Sioux Lookout, Ont.,
when a float strut bracket broke and the left strut collapsed.
The pilot aborted the takeoff immediately and the aircraft
remained upright. The aircraft was towed to shore. There
were no injuries and the damage was confined to the float
and strut assembly. TSB File A12C0042.
ASL 4/2012
Accident Synopses
33
Regulations and You
The Suspension or Cancellation of Canadian Aviation Documents Due to “Incompetence”
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
Previous issues of the ASL have contained articles that described
the recently published staff instructions SUR-014, 015 and
016—the Transport Canada Civil Aviation (TCCA) internal
guidance material related to the suspension or cancellation of a
Canadian aviation document (CAD) or revocation of managerial
positions approved by the Minister. The first article introduced
these TCCA staff instructions, and indicated that future articles
would delve further into the legal authorities that the Minister
has for “certificate action”, i.e., the suspension or cancelation
of CADs, such as licences or certificates. The second article
in this series detailed the suspension of a CAD under the
authority of section 7.(1) of the Aeronautics Act (the Act),
which enables a TCCA inspector to respond to an “immediate
threat to aviation safety”. This article will focus on the Minister’s
authority to take certificate action when “the holder of the
document is incompetent.”
Section 7.1(1) of the Act specifies that the Minister may take
certificate action for safety reasons other than a situation that
poses an immediate threat to aviation safety. The three reasons
are listed in paragraphs 7.1(1)(a), (b) and (c) of the Act:
a. the holder of the document is incompetent;
b. the holder or any aircraft, airport or other facility in respect
of which the document was issued ceases to meet the
qualifications necessary for the issuance of the document
or to fulfil the conditions subject to which the document
was issued; or
c. the Minister is of the opinion that the public interest
and, in particular, the aviation record of the holder of the
document or of any principal of the holder, as defined in
regulations...warrant it.
The meaning of “incompetent”—in terms of paragraph 7.1(1)(a)
of the Act—is a fundamental concept that must be clearly
understood. This key term is not specifically defined in the
Act or in the Canadian Aviation Regulations (CARs). For
guidance, we can consider dictionary definitions, as well as
past determinations of the Transportation Appeal Tribunal
of Canada (TATC).
The Concise Oxford Dictionary, Eighth Edition, defines
“incompetent” as:
• not qualified or able to perform a particular task or function
• showing a lack of skill
• not able to perform its function.1
1The Concise Oxford Dictionary, Eight Edition, Oxford University Press,
Oxford, U.K. 1990, p. 598
34
Regulations and You
The definition for “incompetent” in Merriam Webster’s Collegiate
Dictionary, Tenth Edition, includes:
• inadequate to or unsuitable for a particular purpose
• lacking the qualities needed for effective action
• unable to function properly”.2
In this context, “incompetence” refers to the inability to perform
required activities. Therefore, it is an inability to comply rather
than an unwillingness to comply.
The TATC3 has previously rendered decisions on the concept
of “incompetence” and has adhered to a set of principles that
were enumerated in Mason v. The Registered Nurses’ Association
of British Columbia:
1. The particular definition placed upon the word
‘incompetency’ should be molded by the object of the
enactment in which the word appears.
2. All the definitions of ‘incompetency’ focus on the lack of
ability, capacity or fitness for a particular purpose.
3. The want of capacity, ability or fitness may arise from a
lack of physical or mental attributes. However, a person not
lacking in physical or mental attributes may nonetheless
be incompetent by reason of a deficiency of disposition to
use his or her abilities and experience properly.
4. Negligence and incompetence are not interchangeable
terms. A competent person may sometimes be negligent
without being incompetent. However, habitual
negligence may amount to incompetence.
5. A single act of negligence unaccompanied by
circumstances tending to show incompetency will not of
itself amount to incompetence.4
The TATC has also further amplified the first principle:
“The object of the enactment in which incompetence appears
(i.e., Aeronautics Act) is aviation safety.”5
Evidence that collectively demonstrates an inability to comply
with the regulations and standards, over a reasonably lengthy
period of time, demonstrates a state of incompetence; one
or two incidents do not constitute sufficient grounds to
substantiate incompetence. The evidence used by the Minister
to support certificate action is itemized in the Notice of
Suspension (NoS) or Notice of Cancellation (NoC) served
to the document holder. The burden of proof rests with the
2 Merriam Webster’s Collegiate Dictionary, Tenth Edition, Merriam-Webster,
Springfield, MA, 1996, p. 588
3 TATC File No. C-3128-21
4 Mason v. Registered Nurses’ Assn. of British Columbia, 102 D.L.R. (3d) 225.
5 CAT File No. A 1789 25, p. 9
ASL 4/2012
Minister, who must prove on the balance of probabilities
[subsection 15.(5)] of the Transportation Appeal Tribunal
of Canada Act, that certificate action is warranted.
There are often similar characteristics or an interrelationship
between the circumstances and criteria cited to support
certificate action under the various provisions of section 7.1(1)
of the Act. For example, a significant history of non-compliance
may result in certificate action under Section 7.1(1)(a)
(incompetence), or Section 7.1(1)(c) (public interest). In order
to support a certificate action taken under Section 7.1(1)(a)
—based on the incompetence of a CAD holder—it must be
demonstrated that the repetitive non-compliant acts are the
result of an inability to comply rather than an unwillingness
to comply. In contrast, repetitive non-compliant behavior—
which was not based on incompetence, but instead conducted
to further other needs such as a business or financial goals—
would support certificate action under Section 7.1(1)(c), for
reason of public interest. In consideration of the available
evidence, TCCA will determine the appropriate course of
action to be taken.
There are a number of legislative requirements in both the Act
and the CARs that specify the form and content of an NoS or
NoC. Certificate action under any of the provisions of section
7.1(1) of the Act is not taken in response to an immediate threat
to aviation safety (section 7.(1) of the Act deals with immediate
threats to safety). Therefore, because an immediate threat to
aviation safety is not present, the CAD holder is provided an
effective date of the suspension or cancellation that is a later
date than the date of service of the notice (typically 30 days).
The notice will include a clear and accurate description of the
nature of the alleged incompetence. In the case of suspension,
because suspensions under the authority of this section of
the Act are intended to deal with safety related matters, no
duration for the suspension will be stipulated. However, an
NoS will include the conditions necessary to resolve or rectify
the incompetence (there may be more than one) in order to
terminate the suspension.
Due to the nature of “incompetence” as defined above, certificate
action for this reason is only applicable to an individual; it does
not apply to a corporation.
The NoS or NoC will include a notification that the recipient
must return the CAD to the Minister immediately after the
suspension or cancellation takes effect. This is a requirement of
section 103.03 of the CARs. Refusal (or failure) to return the
CAD to the Minister following a suspension or cancellation
constitutes a contravention of this section of the CARs.
This type of certificate action is subject to review by the TATC.
Any person who has been served with an NoS or NoC for
“incompetence” may request a review of the Minister’s decision
before the TATC.
For more information on the subject, please refer to
Staff Instruction SUR-014.
Invest a few minutes into your safe return home this winter...
...by reviewing section AIR 4.13 of the Transport Canada Aeronautical Information Manual (TC AIM), titled “First Aid
Kits on Privately Owned and Operated Aircraft.”
TC AIM Snapshot: Monitoring 126.7 MHz
and Position Reporting En route
Pilots operating VFR en route in uncontrolled airspace when not communicating on an MF, or an ATF, or VFR on
an airway should continuously monitor 126.7 MHz and whenever practicable, broadcast their identification, position,
altitude and intentions on this frequency to alert other VFR or IFR aircraft that may be in the vicinity. Although it is
not mandatory to monitor 126.7 MHz and broadcast reports during VFR or VFR-OTT flights, pilots are encouraged
to do so for their own protection.
(Ref: Transport Canada Aeronautical Information Manual (TC AIM), Section RAC 5.1)
ASL 4/2012
Regulations and You
35
Debrief
DON’T WALK OUT... Stay in the Prime Search Area
This is a slightly updated version of an article originally published in Aviation Safety Letter Issue 1/1997. Good advice!
Walking, they say, is as good as running.
But not always. If you’re trying to stay
in shape, walking can indeed be as good
as running. But if you’re trying to get your
shape back to the jungle we call civilization,
walking can be hazardous to your health.
Years ago, when luckless aviators found
themselves contemplating a wrecked biplane
zillions of miles from the nearest outpost,
they had no choice but to walk out. But it
was at least 50 years ago when such teaching
went out of style. With the advent of search
and rescue (SAR), radios, emergency locator
transmitters (ELT) and, more lately, GPS, the
advice is to stay with the aircraft.
Why? Because when SAR starts looking for people, it goes to
the last known point, then follows the proposed track. Although
they’re really looking for the people inside the airplane, they
have long since learned that the aircraft is easier to see than
the people. Thus the search tends to concentrate on that area
between the last known point and the proposed destination.
The search isn’t confined to that area, but it does start there,
and initially concentrates there. During the search, SAR
and Civil Air Search and Rescue Association (CASARA)
crews look for anything unusual. You might think that a
person wandering through the woods in a passionate purple
T-shirt and bright yellow stretch pants would stand out, but
such targets are pretty small. Even the larger remnants of, say,
a single-engine Cessna or Piper are hard to see. But they are
bigger than the average person.
Thus, SAR organizes the searches to find the downed aircraft.
What does this mean to restless campers who think that walking
out is showing admirable initiative? Unless they are retracing
their proposed flight route, it means that they are moving away
from the primary search area; away from possible detection.
Once in a while, there are valid reasons to move away from the
crash site. If the aircraft slides underwater, you shouldn’t go
much farther than the nearest shore. If you’re in the middle of a
forest fire, you’d probably want to move to the upwind side.
Most of the time, you should stay with or in proximity to the
wreckage. If you can get at the ELT, move its function switch
to ON. Then leave it there. The SAR tech who comes to your
rescue can make any further switch selections.
Of course, you want to make yourself visible to SAR or CASARA
crews. During the day, smoke gets attention. Your campfire,
covered with pine boughs, will have local environmentalists
on your case in no time. You can also add a touch of oil from
the engine crankcase, just to make the smoke smokier.
Shiny bits from the aircraft can make signalling mirrors that
you can use to attract the attention of SAR crews. Or, as one
pilot did recently, you can arrange larger chunks of aircraft in a
nearby clearing to make it show up better for airborne searches.
Search efforts taper off at night, as SAR crews are not wild
about flying into mountains. However, there are overflights,
and most pilots are pretty good about reporting fires in areas
where no fires had trodden before. Thus, an especially exuberant
signal fire should get attention.
If you’re an incorrigible Type A and think you must walk
out—don’t. Not unless you can see the lights of a nearby
town, and the road connecting you to it. Even then, remember
that distances are deceiving. If you must leave, leave a message
of some sort. Let SAR know that you survived, and that you
are walking northeast to salvation.
Salvation is fine. Too often however, it becomes eternity.
Stay with your aircraft.
36
Debrief
ASL 4/2012
2012 Flight Crew Recency Requirements
Self-Paced Study Program
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
This questionnaire is for use from November 1, 2012, to October 31, 2013. 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 29. In addition, aeroplane and ultralight aeroplane pilots are to answer questions 30 and 31;
helicopter pilots are to answer questions 32 and 33; gyroplane pilots are to answer question 34 and 35; glider
pilots are to answer questions 36 and 37; and balloon pilots are to answer questions 38 and 39.
Note: References are 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 or references, or both.
The TC AIM is available on-line at: www.tc.gc.ca/eng/civilaviation/publications/tp14371-menu-3092.htm
1. Reportable aviation accidents and incidents, and missing aircraft are to be reported to the _______________________
or alternatively through _____________________, which will forward the report.
(GEN 3.3.5)
2. A low level airway extends upwards from _______ ft ASL/AGL above the surface of the earth and is controlled/
uncontrolled airspace.
(GEN 5.1, RAC 2.8.5)
3. When a section of a runway or a heliport is closed, it is marked with _______________________________________.
(AGA 5.6)
4. A dry Transport Canada standard wind direction indicator blowing at an angle of 5° below horizontal indicates a wind
speed of ___ kt.
(AGA 5.9)
5. In communications checks, “strength 2” means ________________________________________________________.
(COM 5.10)
6. The onus for determining if passenger-operated electronic devices will cause interference is placed on _____________.
(COM Annex B 2.0)
7. Portable electronic devices, other than two-way radiocommunication devices, may be used on board aircraft except
during ________________________________________________________________________________________.
(COM Annex B 3.1)
_____________________________.
8. What does the following symbol on a graphic area forecast (GFA) represent?
(MET 3.3.5)
9. What does the following symbol on a GFA mean (direction and speed)?
_____________________________
______________________________________________________________________________________________.
(MET 3.3.11)
TAF CYOW 231438Z 2315/2412 02012G22KT 6SM -RA BR SCT005 OVC015 TEMPO 2315/2321 3SM -RA BR
BKN005 OVC015 BECMG 2315/2317 04015G25KT FM232200 07015KT 2SM -SHRA BR BKN005 OVC010
TEMPO 2322/2402 6SM -SHRA BR OVC010 BECMG 2400/2402 20012KT FM240200 20010G20KT 5SM -SHRA
BR FEW003 BKN010 OVC040 TEMPO 2402/2408 P6SM NSW OVC020 FM240800 18010KT P6SM BKN010
OVC040 RMK NXT FCST BY 231800Z=
10. According to the aerodrome forecast (TAF) above, what will the wind be at 1700Z on the 23rd? _________________.
(MET 3.9.3)
11. According to the TAF above, what is the visibility at 2200Z on the 23rd? ____________________________________.
(MET 3.9.3)
12. According to the TAF above, from 0200Z to 0800Z on the 24th there will be temporary periods of _______________.
(MET3.9.3)
METAR CYXU 032000Z 22015KT 5SM HZ SCT010 BKN025 12/09 A3000
RMK CU3SC2 SLP161=
13. While flying over London (CYXU), field elevation 912 ft, a pilot would expect to encounter the ceiling at an altitude
of approximately _____ ft ASL.
(MET 3.15.3)
14. State four (4) differences between human observations and automated weather observation system (AWOS)
observations. ___________________________________________________________________________________
______________________________________________________________________________________________.
(MET 3.15.5)
UACN10 CYQB 291835 UL UA/OV CYQB /TM 1830 /FLDURD /TP DH8 TB MDT 080-020
15. What is reported in the above pilot weather report (PIREP) and at what time was it reported?
_________________________________________________________________________________________________.
(MET 3.17)
16. To assist in reducing frequency congestion, pilots are encouraged to use the phrase ____________ on the initial call to a
ground station to indicate that they have received ____, ____, and ______ information from the previous aerodrome advisory.
(RAC 4.5.6)
17. What two radio transmissions are mandatory when departing from an uncontrolled aerodrome within a mandatory
frequency (MF) area? ____________________________________________________________________________.
(RAC 4.5.7, CAR 602.100)
18. Where possible, pilots are required to report at least five _______ prior to entering an MF area.
(RAC 4.5.7, CAR 602.101)
19. Wire-strikes account for a significant number of low-flying accidents. A number of these accidents occur over
__________ terrain, in ____ weather and at ________ altitudes.
(RAC 5.4)
20. Every few months, or as recommended by the manufacturer, pilots should test their emergency locator
transmitter (ELT). Testing of a 121.5/243 MHz ELT must be conducted only during the first ___ minutes of any
UTC hour and restricted in duration to not more than ___ seconds.
(SAR 3.8, CARs Standard 571 Appendix G)
21. Raising a portable ELT from ground level to 2.44 m (8 ft) increases its range by ________ percent.
(SAR 3.6)
120059 CYKZ TORONTO/BUTTONVILLE MUNICIPAL CYKZ RWY 33 CLSD 1210101900 TIL APRX 1210121700
22. When does the above NOTAM expire?_______________________________________________________________.
(MAP 5.6.1)
23. Closure of airspace due to forest fires can be found under which NOTAM file? ______________________________.
(MAP 5.6.8)
24. For how long is an aviation document booklet valid? ___________________________________________________.
(LRA 1.2, CAR 401.12)
25. Structures assessed as _____________________________________ are required to be marked. Special high intensity
strobe lighting is required for all structures ____ ft AGL and higher. The majority of aircraft collisions with man-made
structures occur at levels below ___ ft AGL.
(AIR 2.4)
26. Severe turbulence may extend up to ___ NM from severe thunderstorms.
(AIR 2.7.1)
27. In the event of a forced landing in sparsely settled areas, survival will depend on preparations and knowledge. The
need to carry ______________________ that will provide protection from insects in the summer and ________ in
the other seasons cannot be overstressed.
(AIR 2.14)
28. The most common causes of fatigue are ________________, _____________, and ____________________________.
(AIR 3.8)
29. Go to the NAV CANADA Aviation Weather Web Site (www.flightplanning.navcanada.ca/cgi-bin/CreePage.
pl?Langue=anglais&NoSession=NS_Inconnu&Page=forecast-observation&TypeDoc=html).
From the “Forecasts and Observations” page, open the AIC page and bring yourself up-to-date. Record the number of
the latest AIC here: _____________________________________________________________________________.
Aeroplane-specific questions (including ultralight)
30. On flights from Canada to the U.S., the U.S. Customs and Border Protection (CBP) requires a passenger manifest no
later than ___________ before an aircraft departs.
(FAL 2.3.2)
31. How many litres is 100 lbs of AvGAS at 15° C?_____. Your aircraft burns 6 U.S. gallons per hour, how long can you
fly on 100 lbs?_______.
(RAC 3.5.8, Canada Flight Supplement [CFS] General Section—Fuel and Oil Weights)
Helicopter-specific questions
32. Most rotorcraft flight manuals state in the limitation sections that at night the pilots must maintain visual reference to
the ground by one of the following means: ___________________ or ______________________________________.
(Rotorcraft flight manuals, rotorcraft references)
33. For an extended over-water flight, you should consider wearing your ________________ because preparation and
knowledge are paramount to survival in ditching events.
(Aviation Safety Letter [TP 185] 3/2010 “Take Five”, helicopter references)
Gyroplane-specific questions
34. What could happen if the gyroplane experiences “zero G”? ______________________________________________.
(Gyroplane references)
35. When a low rotor RPM produces an excessive coning angle, the disc area increases/decreases and the rotor thrust
increases/decreases.
(Gyroplane references)
Glider-specific questions
36. The release-hook check should be made twice: once with the launch cable _____ and once with the launch cable ____
______________________________________________________________________________________________.
(Glider references)
37. When joining another glider in a thermal, you are to circle in the opposite/same direction as the other glider.
(Glider references)
Balloon-specific questions
38. If frost develops at a propane tank valve stem, what should you suspect is the cause?
_________________________________________________________________________________________________.
(Balloon references)
39. To launch an 84-ft balloon within a built-up area, the diameter of the launch site may be no less than ____________.
(CAR 602.13)
Answers to this quiz are found on page 16 of ASL 4/2012.
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