aviation safety letter In this Issue...

aviation safety letter In this Issue...
TP 185E
Issue 3/2012
aviation safety letter
In this Issue...
Guest Editorial: Improving Safety by Focusing on the Basics
COPA Corner: Single-Pilot Resource Management (SRM)
Overdue?
Visual Flight—Safe and Legal
Focus on CRM—Threat and Error Management (TEM)
Top 10 Tips for Turbines
Double or Triple Release?
Suspension of Canadian Aviation Documents—Immediate Threat to Aviation Safety
A Just Culture
Learn from the mistakes of others;
you’ll not live long enough to make them all yourself ...
TC-1004719
*TC-1004719*
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ISSN: 0709-8103
TP 185E
Table of Contents
sectionpage
Guest Editorial..................................................................................................................................................................3
Pre-Flight...........................................................................................................................................................................5
Flight Operations..............................................................................................................................................................10
Maintenance and Certification........................................................................................................................................20
Recently Released TSB Reports......................................................................................................................................24
Accident Synopses............................................................................................................................................................37
Regulations and You.........................................................................................................................................................40
Debrief: A Just Culture....................................................................................................................................................42
Authorized? Be sure! Runway Incursions Are Real!.....................................................................................................Poster
Safety in the air starts on the ground—Maintenance...................................................................................................Poster
2
ASL 3/2012
Improving Safety by Focusing on the Basics
Guest Editorial
Guest Editorial
guest editorial
The aviation industry has always made steady progress in identifying and managing safety
risks by focusing on the basics.
In the provision of safe and efficient air navigation services, communications, navigation and
surveillance (CNS) form the core of those basics. That is why at NAV CANADA we continue
to place much of our emphasis for improvements on these three areas.
John Crichton
Communications
In 2004 we tackled the tough issue of frequency congestion on 126.7 MHz. Communications on this frequency—whose
primary purpose was to facilitate air-to-air advisories between pilots in uncontrolled airspace—had become so congested
in particular areas that the purpose of the frequency was compromised.
The solution was to take flight information service enroute (FISE), which can involve lengthy communications between
the pilot and the flight service specialist, off of 126.7. We established a new network of additional frequencies which
pilots could use to directly access our flight information centres (FIC).
To the Letter
To the Letter
Timely communications between air traffic services (ATS) personnel and pilots is essential for both safe and efficient
air operations. By expanding the availability and type of communications, and by making them more effective, we have
sought to improve safety through better service and reduced errors.
We then added additional remote communications outlets (RCO) in areas where communications coverage was sparse,
thus further improving access to essential information for pilots. Finally, we undertook pilot awareness efforts on good
communications practices to reduce unnecessary communications and ensure the availability of any frequency when it
was needed.
These sites were in addition to the long-range VHF PALs that were installed around Hudson Bay and in southern
Greenland to support automatic dependent surveillance-broadcast (ADS-B) operations.
Pre-Flight
Pre-Flight
We have also made significant investments to improve communications in northern, remote, and oceanic areas.
In 2007, we added 15 new VHF peripheral stations (PAL) in northern Canada to provide direct controller-pilot
communications (DCPC), allowing reduced separation and faster response time to flight requests.
Any discussion of advances in pilot-ATS communications would not be complete without reference to data link.
Controller-pilot data link communications (CPDLC) enables altitude and speed clearances, change requests and other
related ATS information to be exchanged via direct text communication between controllers and pilots, resulting in
fewer communication errors.
The quality of our communications practices is another area where we have been proactive. The NAV CANADA‑led
ATS-Pilot Communications Working Group has actively sought to raise awareness of the risks of non-standard
communications and the importance of active monitoring and accurate readbacks.
Flight Operations
Flight Operations
Common on the North Atlantic for years, NAV CANADA has now deployed CPDLC in domestic airspace in the
Montréal and Edmonton flight information regions (FIR). We expect further expansion of this capability in the coming
years, with associated safety and efficiency benefits.
We are also trying to influence behaviour by encouraging pilots to request confirmation when a communication is
unclear, or to indicate if they do not have in sight traffic that has been identified to them.
We will be taking further action on the issue of pilot-ATS communications by developing guidance material on good
communication practices and standardized, common phraseology.
ASL 3/2012
3
Satellite navigation is often referred to as the biggest game changer for aviation. There is no doubt that the proliferation
of satellite navigation throughout the world is providing significant benefits to both customers and air navigation system
providers.
It is becoming the cornerstone of enroute and terminal navigation and is a key enabler of the performance-based
navigation (PBN) concept, which includes both area navigation (RNAV) and required navigation performance (RNP).
Guest Editorial
Guest Editorial
Navigation
The improved aircraft navigation performance that stems from use of the global navigation satellite system (GNSS)
also has a positive impact on safety and efficiency. Designing airways and instrument procedures without the limitation
of ground-based navigational aids allows improved designs that increase airspace capacity, provide more flexibility and
predictability, and allow more efficient flight profiles.
We are committed to expanding PBN in Canada, and we continue to work with our customers, Transport Canada,
and the International Civil Aviation Organization (ICAO) to implement PBN specifications where it makes sense to
do so. In the future, equipage with GNSS may become mandatory in high traffic density terminal areas because of the
efficiencies it brings to airspace management.
Surveillance
To the Letter
To the Letter
Satellite navigation has also enabled improved airport accessibility, resulting in fewer diversions, and has brought the
safety benefits of straight-in instrument approaches with vertical guidance to airports where they were previously
unavailable due to the lack of ground-based navigation infrastructure.
Further to this, multilateration has been deployed to provide infill surveillance for specific operating areas, as well as to
improve surface surveillance at airports. We are also expanding our use of intelligent video surveillance and are excited
about the potential of this technology as a cost-effective surface surveillance solution for many airports.
While our focus on expanding surveillance coverage in all areas is requiring our customers to be suitably equipped, the
benefits far outweigh the cost of this equipage. The result is a measurable enhancement of both safety and efficiency.
Pre-Flight
Pre-Flight
Surveillance is a key enabler to improving efficiency by enabling reduced separation standards to be employed, as
compared to procedural airspace. That is why improving and expanding surveillance capability by using both existing
and emerging technologies has been a focus of much of our capital investment in recent years. We have expanded
radar coverage with the addition of seven new northern radars; we have expanded access to surveillance information
by deploying auxiliary radar displays to flight service stations (FSS); and, we have introduced ADS‑B—a cost-effective
alternative to radar, but one that requires special aircraft equipage—in select areas where it will deliver clear benefits to
our customers.
In summary, NAV CANADA will continue to adopt new technologies and to modernize the air navigation system in
collaboration with our people, our customers and our stakeholders.
In the past 15 years, a strong emphasis on the three core areas of communications, navigation and surveillance has been
central to that work.
4
John Crichton
President and CEO
NAV CANADA
ASL 3/2012
Flight Operations
Flight Operations
We look forward to finding ways to deliver even greater benefits for the safety and efficiency of the air traffic we manage
by building on the innovations of the past 15 years.
To the Letter
by Dan Cook, Chairman, Flight Training & Safety Committee, Soaring Association of Canada (SAC)
Last year, two gliders collided head-on over the Rockies
near Invermere, B.C., and sadly both pilots were killed.
Both gliders carried GPS data loggers, which are common
in cross-country gliding; this has helped in the accident
analysis. It appears that one glider was flying towards the
setting sun and the other had the sun behind it. Based on
their altitudes, it is likely that the glider flying into the
sun would have had the mountains behind it, making it
more difficult to identify the glider given that it would
have appeared stationary against the rough background
terrain of the mountain.
Gliding also has unique challenges compared to powered
flight. Generally, when a power pilot identifies another
aircraft, the pilots try to avoid each other or maintain
maximum separation. With gliders, the presence of
another glider generally indicates the potential for lift; as
soon as a glider circles or climbs, other gliders are drawn
to the source of lift and separation decreases, sometimes to
a few hundred feet. Separation and safety are maintained
by communications and/or thermal and ridge protocols
as the gliders circle together or dolphin fly along the lift.
This becomes more difficult to manage in popular soaring
locations with dozens of gliders or during soaring contests.
A few years ago, the gliding community in Switzerland
experienced several fatal accidents due to glider collisions
over the Alps; since voluntarily implementing FLARM,
they have not reported any more fatal accidents due
to collisions. For the North American market, Power
FLARM was developed due to different spectrum
management requirements and a desire to include the
ability to detect Mode C/S and automatic dependent
surveillance-broadcast (ADS-B) signals up to 100 km
away to provide glider pilots with a greater capacity to
avoid general aviation or commercial airline traffic. In
addition, the device is certified as an International Gliding
Commission (IGC) data logger to keep downloadable
track information. It can store and warn of obstacles in a
database, comes in portable or panel-mount variations, and
can feed different display devices.
It is not known if Power FLARM would have prevented
the accident last year, but users of the devices are satisfied
they work well. With the addition of any devices to
improve warning, it is up to the pilot to maintain a proper
scan and not let a disciplined approach break down. There
will always be obstacles, non-equipped aircraft, birds, and
malfunctions that will require vigilance. Also, once the
information is received, the pilot must take action.
Power FLARM is now approved for use in Canada
and in the U.S.A. The Flight Training and Safety
Committee for the Soaring Association of Canada is
recommending that all glider owners equip their aircraft
with Power FLARM (at a cost of less than $2,000),
especially those used in competitions or congested
soaring areas where ridge or wave soaring is common.
In addition, aircraft operating near gliding operations
or involved in close‑proximity flying with other aircraft
in the context of flight schools, parachute operations,
helicopter operations, aerobatics or formation flying
would greatly benefit from this technology. Contest
operations are introducing safety management
systems (SMS), and it is hoped the process will reinforce
the need for Power FLARM in competitions. ASL 3/2012
Flight Operations
In Europe, which has more gliders and less usable
airspace, this challenge was heightened. It reached
a point where the European gliding community
identified mid-air collision as their number-one
hazard for gliding. Conventional airborne collision
avoidance systems (ACAS) were of little use due to
their false alarm rates caused by the close proximity
necessary for gliding without being in danger of
collision. This requirement should not be confused
with transponders used for collision avoidance in
controlled airspace or with commercial aviation. Low
power consumption transponders are now available
to meet glider requirements, and some soaring clubs
near high commercial traffic areas are now equipping
their gliders with transponders. However, this does not
ensure the glider-to-glider alerting required at most of
our more remote gliding locations, which are away from
commercial air traffic and often in ground radar shadows.
An inexpensive flight alarm (FLARM) was specifically
developed in Europe to address the glider-to-glider or
close proximity warning requirement without false alarms.
The device uses GPS and an altitude barometric sensor
to transmit 3D information at a distance of 3–5 km to
other FLARM units. The FLARM’s
close-formation motion-prediction
algorithms identify potential conflicts
for up to 50 other signals and warn
the pilot using sound and visual cues.
Pre-Flight
Pre-Flight
The SAC Column: Power FLARM
To the Letter
Flight Operations
The SAC Column: Power FLARM ................................................................................................................................ page 5
COPA Corner: Single-Pilot Resource Management (SRM).......................................................................................... page 6
Overdue?............................................................................................................................................................................. page 8
Guest Editorial
Guest Editorial
pre-flight
5
COPA Corner: Single-Pilot Resource Management (SRM)
Single-Pilot Resource Management (SRM), first
introduced in 2005 by the National Business Aviation
Association2 and now gaining significant ground in the
U.S., is a system designed to help reduce the number of
aviation accidents resulting from human error by teaching
pilots about their own limitations and providing training
guidelines for single pilots operating the new very light
jets (VLJ).
Accidents statistics for both GA and commercial
operations demonstrate clearly: pilot error is the most
common cause of aviation accidents. In the United States,
between 70 and 90% of all airline and military aviation
accidents are traced back to pilot error.3
In Canada, pilot error was found to be a “broad cause/
factor” in 84% of all aviation accidents and 96% of fatal
accidents.4 As a good friend of mine likes to say, “The
biggest threat to aviation safety is the loose link between
the yoke and the rudder pedals.”
Hopkins, Jay. “The Professional Pilot”, Flying, Jan. 10, 2010.
“NBAA Training Guidelines for Single Pilot Operations of Very
Light Jets and Technically Advanced Aircraft”. National Business
Aviation Association. 2005, www.nbaa.org/ops/safety/vlj/.
3 Wiegmann, D. A., S.A. Shappell (2001), “Human Error Analysis
of Commercial Aviation Accidents Using the Human Factors
Analysis and Classification System (HFACS)” (pdf ) Federal
Aviation Administration. www.faa.gov/data_research/research/
med_humanfacs/oamtechreports/2000s/media/0103.pdf.
4Transport Canada, Human Factors for Aviation, Basic Handbook
(TP 12863) p. 3.
6
A significant proportion of all aviation and a
disproportionate percentage of fatal accidents, at least in
North America, involve single-pilot operations.
The practical application of SRM centres on what are
called the “5 P’s”. The 5 P’s are based on the idea that
five essential variables impact a pilot’s environment and
can cause him or her to make a single critical decision or
several less critical decisions that when added together
can create a critical outcome. 6
The 5 P variables are: the Plan, the Plane, the Pilot, the
Passengers and the Programming.
Using the 5 P’s, the pilot will review the essential variables
of the flight, the 5 P’s, at those points during the flight
sequence when decisions are typically most likely to be
effective: during the pre-flight planning session; prior to
takeoff; at mid point during the flight unless the flight
is longer than two hours, in which case an hourly review
is suggested; prior to descent for landing and just prior
to the final approach fix or, if on a VFR flight, just prior
to entering the traffic pattern as preparations for landing
begin.
Using this system helps the pilot remain alert and aware
of the variables that directly affect the safety of the flight
and gives him or her scheduled and regular opportunities
5
6
ASL 3/2012
Kane, Robert (2002), Air Transportation (14th ed.), Kendall/Hunt
Publishing Company, p. 751, ISBN 0787288810.
“Managing Risk through Scenario Based Training, Single
Pilot Resource Management, and Learner Centered Grading,”
Summers, Michele M; Ayers, Frank; Connolly, Thomas;
Robertson, Charles. Sept. 2007, www.faa.gov/training_testing/
training/fits/guidance/media/RM_thorugh_SBT.pdf.
Flight Operations
Flight Operations
1
2
SRM training is designed to provide the assistance
needed by pilots operating in a single crew environment
and, just for perspective, in the United States GA
accounts for 96% of the total number of aircraft, 60%
of the total flight hours and 94% of the fatal aviation
accidents.5
Pre-Flight
Pre-Flight
While the system was originally developed for training
VLJ pilots, it has rapidly been adapted for other
technically advanced aircraft (TAA) and it is entirely
compatible with the needs of all pilots flying single-pilot
aircraft, technically advanced or not. The principles of
SRM apply just as well to the single pilot flying at 60 kt
as to the single pilot flying at 250 kt.
Most pilots are familiar
with the concept
of Crew Resource
Management (CRM)
which focuses on the interactions occurring in the two
crew environment. CRM training has been successful in
reducing the number and frequency of aviation accidents
resulting from the difficulties encountered in a multi-crew
environment.
To the Letter
To the Letter
Aviation safety is always a question of risk management.
Each flight involves both risk and benefit. Our job as
pilots is to maximize the benefit and manage the inherent
risk using the best tools at our disposal. The success of
how we go about managing risk and the level of risk we
are willing to accept can often be traced back to the type
and extent of the training we receive or choose to seek
out. As Jay Hopkins wrote, “One of the basic attributes of
professionals is that they are always seeking to learn more
about their profession.”1
Guest Editorial
Guest Editorial
by Alexander Burton. This article was previously published in the July 2011 issue of COPA Flight, and is reprinted with permission.
To the Letter
The “Plan” contains all the basic elements of cross-country
planning including weather, routing, fuel requirements
and required publications and other information. The
Plan is not completed and fixed for all time prior to the
flight; it must be reviewed on a regular basis as a flight
progresses.
Things change: takeoff can be delayed; unexpected
changes in the weather may occur; NOTAMS due to
forest fires or police activity may be issued; the extra cup
of coffee you drank before jumping in the machine may
not allow you to continue for the initially planned time of
the flight.
The “Passengers” on a flight can also be a critical variable
in safety. Particularly for GA and business aviation,
passengers can have significant influence over what a pilot
does or does not do and their influence on the pilot can
significantly affect how a flight is carried out.
The worst scenario, perhaps, is when one or more of the
passengers is also a pilot. There is an old saying: if you
ask four rabbis the same question you will get at least
five different answers. The same, no doubt, is true of pilots.
While the initial plan stage is a perfect time to evaluate
whether or not a flight should be carried out, it is also
an ongoing critical variable of
“We are what we repeatedly do.
the flight that must be reviewed
as the flight progresses and new
Excellence, then, is not an act
information becomes available.
but a habit.”- Aristotle
Pilot proficiency and currency may also be included
when inventorying and reviewing the “Plane” or may be
included in the following P, the “Pilot”.
The “Programming”, most applicable to TAA aircraft, also
has importance for less well equipped machines. While
pilots of TAA aircraft enjoy many benefits from the
new technology, that very technology itself can become
a challenge. For VFR flight, particularly, pilots may
become so engrossed in their screens and devices they
may become distracted and forget to look outside and
maintain positive situational awareness.
Pilots flying TAA aircraft must be familiar and
comfortable with their fancy devices prior to flight.
A good time to learn use of an unfamiliar piece of
equipment is on the ground not during a difficult flight
segment.
7
ASL 3/2012
Flight Operations
Just as the weather and the condition of the aircraft
change throughout the duration of the flight, so too does
the condition of the pilot. Fatigue, stress, the effects of
low altitude hypoxia and the cumulative effects of noise
and vibration all reduce the effectiveness of the person
driving the aircraft.
When interacting with non-pilots,
the pilot in command of the flight
must remember passengers do not
always understand or appreciate the
risks involved in a particular flight. We’ve all heard some
variation on the story of the hunters who wanted to get
just one more case of beer or one more trophy deer on the
aircraft. Setting and maintaining a positive and clearly
defined relationship between the pilot and passengers is a
critical factor in flight safety.
Pre-Flight
The “Plane” incorporates all the elements of mechanical
and functional aspects of the machine itself. Is the plane
capable of the planned flight? Is all maintenance up to
date? Do we have sufficient fuel, equipment, avionics,
survival supplies, charts and clothing? In TAA aircraft a
review of the Plane expands to include items like database
currency, automation status and emergency backup
systems that were not at all common only a few years ago.
The “Pilot” is a critical variable in all flights. Traditionally,
most of us have been taught the IMSAFE acronym and it
is a good place to start. Once again, however, a one-time
assessment of the pilot, the person on whom all others in
the aircraft and all those poor, non-aviating souls walking
about below are dependent, is really not sufficient.
Flight Operations
A review of the condition of the pilot at regular, planned
intervals during any flight is one excellent way to increase
air safety.
To the Letter
Pre-Flight
Disciplined use of the 5 P’s is, essentially, a “wake up and
smell the coffee” prod for the pilot at each of the critical
points in the flight sequence.
There are reasons why 61% of all aviation accidents occur
on landing. At the end of a flight pilot performance
is at its lowest point. According to a study carried out
by the Australian Bureau of Air Safety Investigation,
Department of Transport and Regional Development, the
most commonly assigned factor in fatal aviation accidents
was poor judgement; judgement is a human capability
very susceptible to fatigue.7
Guest Editorial
Guest Editorial
to review and re-evaluate how the flight is progressing
and whether or not a new plan may be required.
“Human Factors in Fatal Aircraft Accidents,” Department of
Transport and Regional Development Bureau of Air Safety
Investigation. www.atsb.gov.au/media/28363/sir199604_001.pdf.
7
The theory of Risk Homeostasis, in short, states that
people become accustomed to and comfortable with a
particular level of risk. If that level of risk is reduced by
some change in the environment, the addition of anti-lock
braking systems for example, people tend to respond by
driving faster and reducing the distance behind the next
vehicle in order to maintain the level of risk with which
they are comfortable: people adapt their behaviour to
8
Wilde, Gerald J.S. (2001). Target Risk 2: A New Psychology of
Safety and Health.
Guest Editorial
As Wilde says, “...safety and lifestyle dependent health is
unlikely to improve unless the amount of risk people are
willing to take is reduced.”9
Systematically implementing SRM into a pilot’s personal
procedures is one way to guide and assist him or her
toward becoming more safety conscious and toward
consciously reducing the level of risk he or she is willing
to accept as normal.
Alexander Burton is a Class I instructor, pilot examiner
and a regular contributor to several aviation publications
both in Canada and in the U.S. He is currently Base
Manager for Selair Pilots’ Association in cooperation with
Selkirk College, operating their satellite base in beautiful
Abbotsford, B.C. (CYXX). He can be contacted at:
info@selair.ca. 9
Wilde, Gerald J.S. “Risk homeostasis theory: an overview”,
Injury Prevention, 1998; 4:89-91.
To the Letter
To the Letter
In his book, Target Risk 2: A New Psychology of Safety
and Health, Gerald J. S. Wilde, a professor emeritus of
psychology at Queen’s University in Kingston, Ontario,
proposes what he refers to as the Risk Homeostasis
theory.8
changes in environmental conditions. Few of us willingly
embrace change regardless of its form or stated purpose.
Guest Editorial
For all flights, organizing the navigational equipment
and instrumentation you will use to assist your efforts to
achieve safe flight must be evaluated and re-evaluated at
appropriate intervals during the flight, whether that is
modern, electronic wizardry or maps, watches and pencils.
Overdue?
Canada’s rugged terrain and immense size often
result in challenging flights. Throw in our diverse and
unpredictable weather conditions, and those challenges
intensify. Aircrew have their hands full; however,
one thing that pilots do not have to worry about is
the provision of alerting service to activate search
and rescue (SAR) when an incident occurs. Why?
NAV CANADA provides alerting protection to all
portions of the flight information region (FIR) where
they provide service.
If an arrival report is not received at the expected
time, ACC air traffic operations specialists (ATOS)
are required to notify the appropriate joint rescue
coordination centre ( JRCC) of the overdue aircraft and
commence a communications search on a priority basis.
Initial calls actually begin as early as 15 minutes prior
to the overdue time, enabling the ATOS to potentially
locate the pilot prior to involvement of the JRCC, and
respond quickly to the JRCC at the overdue time. The
8
What many may not be aware of is that in addition
to providing pilots with enroute and destination
SAR protection, ACC ATOS also provide departure
alerting to proposed flights on an IFR flight plan. If
an aerodrome does not have air traffic services onsite
that are able to observe the safe departure, then ACC
ATOS are required to monitor the flight to ensure it
departs safely and initiates communications with ATC
as expected. Onsite air traffic services include an open
control tower, an FIC or an FSS with visibility to the
runways. For example, when London Tower closes in
the evening; even though the London FIC is open,
they do not provide aerodrome advisory service and
do not have the required visibility. Since the Sault Ste.
Marie FSS, which is responsible for providing remote
aerodrome advisory service (RAAS) during that time, is
ASL 3/2012
Flight Operations
Flight Operations
The Canadian Aviation Regulations (CARs) require
pilots to file an arrival report as soon as practicable after
landing, but not later than one hour after their estimated
time of arrival (ETA) (24 hours for a flight itinerary)
or by the specified SAR time if non-standard. But what
exactly does the provision of SAR “alerting service” by
an area control centre (ACC) entail?
communications search
involves advising the
company and contacting all facilities or contacts at
the destination or last reported point. It may involve
requesting a police search of the destination airport.
During this time, any filed phone numbers will be
called, and airports along the route of flight will also
be contacted. Within one hour of the overdue time, the
ACC must report on the results of the search to the
JRCC. If the communications search is unsuccessful,
the JRCC will take further actions as required, such as
launching search aircraft.
Pre-Flight
Pre-Flight
By Brooke Hutchings, NAV CANADA
What further complicates the search activity is when
the aircraft has one call-sign inbound (e.g. ABC123)
and has a proposed departure outbound with a change
in call-sign (e.g. ABC124). The aircraft can still be
inbound when the ACC ATOS is notified by an overdue
departure warning to search for the outbound aircraft.
Remember, once airborne, if you cancel your IFR but
retain your flight plan, you are still being provided with
alerting services.
In the aviation world, as in life, plans often change
unexpectedly. If you find yourself in this position, simply
call a NAV CANADA facility and update or cancel your
flight plan. Even if you are departing an aerodrome with
a control tower, it is important to keep your flight plan
up to date.
Updating your “flight plan on file” on a regular basis,
and including cell phone numbers, will help reduce the
time spent in the communications search stage and may
reduce the time required to initiate rescue assistance
when actually needed.
Your timely call will help ensure continuous and
expeditious service for all and prevent unnecessary
activation of SAR operations. Flight Operations
Guest Editorial
Flight Operations
Pre-Flight
Pre-Flight
Pilots flying VFR on one leg and IFR on another should
also be aware of the differences between VFR and IFR
alerting services. A FIC will “assume departure” for
VFR flights departing remote uncontrolled aerodromes,
and VFR alerting service is initiated automatically,
but the ACC does not have that luxury. The ACC
cannot “assume departure” for IFR flights departing
Some companies use satellite tracking for their aircraft.
This can be especially handy if the dispatcher has realtime data available for the ACC ATOS when contacted.
Better yet, if those companies could be proactive and call
to amend their flight plans when running late, it would
help reduce the number of unnecessary communications
searches.
To the Letter
To the Letter
Often, the ACC ATOS will find that an aircraft
overdue on departure never even arrived at the proposed
departure point. The ACC is still obligated to locate the
aircraft and ensure its safety. More often, the flight is
simply running late.
uncontrolled aerodromes as this can negatively affect
IFR clearances, separation standards and conflict
prediction in the IFR environment. The only exception
to this is IFR flight itineraries that remain outside
controlled airspace.
Guest Editorial
not onsite, responsibility for departure alerting reverts to
the Toronto ACC. The flight will be considered overdue
one hour after the estimated time of departure (ETD)
and the JRCC must be notified. Initial calls to the pilot,
company or departure facility may be made as early as 45
minutes after the proposed departure time.
ASL 3/2012
9
Visual Flight—Safe and Legal
by Don Taylor, Civil Aviation Safety Inspector, National Operations Branch, Civil Aviation, Transport Canada
You’ve been flying for an hour and a half in what can
best be described as marginal VFR weather. You left
Kenora, Ont., at 1300Z this morning in the club’s 172 on a
VFR flight to Brandon, Man. An approaching warm front
has kept you low, but you’ve been able to keep the flight
safe and legal. It’s been Class G (uncontrolled) airspace all
the way once you cleared the Kenora zone. When flying
above 1 000 ft AGL, you have been able to maintain at
least 1 mi. flight visibility, as well as 2 000 ft horizontally
and 500 ft vertically from cloud. When the ceiling forced
you down below 1 000 ft AGL, you were able to maintain
2 mi. flight visibility and stay clear of cloud. By keeping the
ground in sight and avoiding built-up areas, you were able
to keep it all legal, but just barely.
By diverting a bit to the south, you avoided the controlled
airspace at Winnipeg and Portage la Prairie, but now
you are approaching Brandon, your destination. You
want to enter the control zone to land. The last weather
information you have is:
Control zones, VFR and SVFR
As pilots, air traffic controllers and flight service
specialists, we should all know the rules on VFR and
SVFR. Why do so many of us misunderstand these
concepts? For one thing, some of the rules have changed
since we first learned them. Air traffic services (ATS)
procedures have been a bit slow to adjust to the new rules,
but now the dust has settled. Let’s try to answer some of
the questions aviation professionals have on the subject,
such as: Why do we have control zones? Why are the
weather rules different in control zones? What’s so special
about special VFR anyway? If a pilot gets SVFR from
ATS, does that mean it’s safe and legal to fly?
Let’s take a look at control zones, VFR and SVFR and
the weather minima that go with them to determine what
it all means to you, the pilot.
10
Along airways, the base of controlled airspace is
normally 2 200 ft AGL. A number of airports with
an instrument approach procedure (IAP) do not have a
control zone. This would mean, for example, that if you
are conducting an IFR approach for the Carp Airport,
you will finish the approach in Class G (uncontrolled)
airspace.
So where are these control zones? Certainly every airport
control tower is located in one, because by definition,
controllers cannot do their job in uncontrolled airspace.
Most flight service stations (FSS) are in control zones, but
not all: the Rankin Inlet FSS and the La Grande Rivière
FSS are exceptions. Most community aerodrome radio
stations (CARS) are not in control zones, but many are:
the Fort Simpson and the Fort Smith CARS are located
in control zones.
We have many control zones at airports where there are
no local ATS or CARS services: Sarnia and Wiarton
in Ontario and Princeton in British Columbia are
examples.
Above Rocky Mountain House Airport (CYRM), you
are in uncontrolled airspace from the runway right up
to 18 000 ft. This means that the VFR weather minima
at CYRM are much lower than they would be at a
Princeton, where there is a control zone.
ASL 3/2012
Flight Operations
Flight Operations
Is it VFR? Will they let you in? Will you need
special VFR (SVFR)? Can you get SVFR?
Why would you want SVFR?
Control zones have been a fact of life in Canadian
aviation for a long time. We have 130 aerodrome control
zones in Canada. According to the Transport Canada
Aeronautical Information Manual (TC AIM), control
zones are there in order to “keep IFR aircraft within
controlled airspace during approaches and to facilitate
the control of VFR and IFR traffic.” Perhaps more
importantly, it also means that the weather minima are
more restrictive. This gives aircraft on an IFR approach
a better chance to see and be seen in order to avoid
conflict with VFR aircraft in the control zone. A control
zone normally has a 5- or 7-NM radius and extends
from the surface to about 3 000 ft AGL. This fills the
gap nicely, extending controlled airspace right down to
the runway.
Pre-Flight
Pre-Flight
METAR CYBR 091400Z 19008KT 4SM BR
FEW005 BKN009 M01/M02 A3033 RMK
SF2SF3 SLP278=
Control zones
To the Letter
To the Letter
Visual Flight—Safe and Legal.......................................................................................................................................... page 10
Focus on CRM—Threat And Error Management (TEM).......................................................................................... page 13
Bounce Back! Train Your Crews for Bounced Landing Recovery Techniques! ............................................................. page 19
Guest Editorial
Guest Editorial
flight operations
Guest Editorial
Guest Editorial
• In a control zone, you must
have both 3 mi. flight visibility
and 3 mi. ground visibility (if
reported).
• ATC, FSS or CARS will tell
you that “IFR OR SVFR IS
REQUIRED” any time the
ground visibility is below 3 mi. It’s
the pilot’s responsibility to ensure
you can comply with all the
minima, so if any of the other five
are a problem, you need SVFR
or IFR.
SVFR regulations
Control zones place stricter weather
minima on VFR aircraft to allow “see
and avoid” to work between IFR and
VFR aircraft.
For VFR flight in a control zone, you are required to
maintain:
SVFR allows ATS to relax these more stringent rules
when there is no conflicting IFR traffic. In this way,
VFR traffic is not unnecessarily restricted. There are still
weather minima for SVFR. For your daytime SVFR
flight, you can fly provided you can maintain these
minima:
1. Visual reference to the surface;
2. Flight visibility of 3 mi.;
3. 1 mi. horizontally clear of cloud;
4. At least 500 ft vertically clear of cloud;
1. Visual reference with the surface;
5. At least 500 ft AGL, except for takeoff and
landing; and
6. Ground visibility (if reported) must be at least
3 mi.
As we said, these stricter rules are to help VFR and IFR
aircraft avoid collisions in control zones. For example,
an IFR aircraft in a control zone should not expect to
encounter VFR aircraft in the first 500 ft after descending
out of a cloud deck.
2. Height above ground in compliance with
CAR 602.14;
3. Clear of cloud;
4. Flight visibility of 1 mi.*; and
5. Ground visibility 1 mi.*
(if reported).
Pre-Flight
Pre-Flight
To the Letter
To the Letter
Control zone VFR regulations
Here are a few things to keep in mind
when flying VFR in a control zone:
•
There is no minimum reported ceiling
for VFR flight in a control zone. It
is left up to the pilot to ensure he
can maintain at least 500 ft below
cloud and legal altitude above ground
regardless of the METAR reported
ceiling.
Canadian Aviation Regulation (CAR)
602.14 still applies. For example, if
you are over a “built-up area”, you
will need to maintain at least 1 000 ft
above obstacles.
Flight Operations
Flight Operations
•
ASL 3/2012
11
So how does all this work?
1. You are flying VFR down the Skeena River Valley
through the Terrace, B.C., control zone westbound
towards Prince Rupert. The Terrace weather is:
METAR CYXT 091700Z 00000KT 8SM OVC007
M02/M03 A3024 RMK SF8 INTMT -SN
SLP241=
If you were going to Terrace Airport, you might have
trouble maintaining the 500 ft below cloud and 500 ft
above ground required for VFR flight in the control
zone. If that were the case, you should request SVFR.
But since you are just passing through the control
zone along the river (which is over 500 ft below the
airport elevation), you may very well find you can
legally fly VFR in that portion of the control zone.
SVFR would not be required.
Guest Editorial
Pre-Flight
The Terrace FSS will not tell you that “IFR OR
SVFR IS REQUIRED” because the ground visibility
is over 3 mi.
2. As you approach the Terrace control zone on your
return trip, you find the weather has changed a bit:
METAR CYXT 091900Z 00000KT 2SM BR
OVC012 M02/M02 A3024 RMK SF8 SLP241=
12
You still have good ceilings and flight visibility of
4 mi. along the river valley, but because the reported
ground visibility has dropped below 3 mi., VFR is
no longer possible anywhere in the control zone.
The Terrace FSS will tell you “IFR OR SVFR IS
REQUIRED”, and you will need to request and
obtain SVFR to proceed. Your other option is to stay
outside the control zone, safe and legal in Class G
airspace.
Your departure path looks good, with visibility to the
east at least 5 mi., but because the reported ground
visibility is 2 mi., you cannot legally fly VFR in the
Sarnia control zone; SVFR is required. Since there is
no ATS unit at Sarnia, you will have to obtain SVFR
from the London Flight Information Centre on
frequency 123.475 MHz. If you get SVFR, you can
be sure no IFR aircraft will be popping out of those
snow showers.
4. You roll your plane out of the hanger at Springbank.
When you call the tower for your taxi clearance, they
tell you the weather is:
METAR CYBW 091800Z 33002KT 4SM -FZDZ
BR OVC004 M02/M03 A3026 RMK
ST8 SLP258=
In this case, the tower won’t say “IFR OR SVFR IS
REQUIRED” because the ground visibility is over
3 mi. You know that you won’t be able fly legally
VFR or SVFR with a 400-ft overcast. IFR is your
only option, but take another look at that weather.
You really don’t want to fly today.
Back to Manitoba. You’re now 15 mi. from Brandon. It’s
time to call the FSS for the advisory. They give you the
latest weather information:
METAR CYBR 091500Z 19008KT 4SM BR
SCT005 BKN008 M01/M02 A3033 RMK
SF3SF4 SLP278=
The flight service specialist knows that the reported
visibility is good for VFR at 4 mi., but she doesn’t know if
your flight conditions make VFR legal or not. She won’t
say “IFR OR SVFR IS REQUIRED” because the ground
visibility is over 3 mi. With all that low cloud, you know
you won’t be able to stay 500 ft above ground and 500 ft
below cloud. You know you need SVFR to stay legal. You
make the request, and Winnipeg Area Control Centre
approves it. Once you have it, you know you won’t come
into conflict with any IFR aircraft. You can maintain
the SVFR minima without a problem. Your arrival at
Brandon is safe and legal.
ASL 3/2012
Flight Operations
Flight Operations
Pre-Flight
SPECI CYZR 091756Z AUTO 30010KT 2SM
-SNSH OVC026 M02/M04 A3015 RMK
SLP217 MAX WND 31017KT AT 1706Z=
To the Letter
To the Letter
If you request it and the ground visibility at the airport
is 1 mi.* or more, CAR 602.117 requires ATC to grant
SVFR (traffic permitting). They do not have a choice.
If you receive SVFR approval from ATC or an FSS, it
does not mean that it is legal or safe to fly in the control
zone. ATC only knows what the ground visibility is; the
other four criteria for SVFR are flight conditions, and it’s
your responsibility as the pilot to know and respect these
minima.
3. You want to depart from Sarnia on a VFR flight to
Toronto. The Sarnia weather is:
Guest Editorial
Note that the SVFR minima are similar to uncontrolled
airspace minima. This makes sense. Since there is no
conflicting IFR traffic, we don’t really need the more
restrictive control zone minima. When you request and
obtain SVFR, you are guaranteed protection from IFR
traffic conflicts.
The bottom line(s)
•
Control zones extend controlled airspace down to the
runway. Control zone weather regulations provide
better conditions for IFR and VFR aircraft to see and
be seen.
Control zone weather limits are based on reported
ground visibility and your flight conditions. ATS will
tell you if reported ground visibility makes it illegal to
fly VFR (less than 3 mi.) or SVFR (less than 1 mi.*).
It is your responsibility to observe and comply with
the specified flight conditions.
•
•
•
•
When you request it, ATS will provide SVFR (traffic
permitting) when the reported ground visibility is
1 mi.* or more.
SVFR guarantees protection from conflicting IFR
traffic. It’s there for the pilot’s protection. Request it
when you need it.
Check out CAR 602.14 (minimum altitudes),
CAR 602.114 (VFR) and CAR 602.117 (SVFR).
Stay safe, stay legal, and have fun. Guest Editorial
Guest Editorial
•
*½ mi. for helicopters
The following article was presented by Captain Dan Maurino, then Coordinator, Flight Safety and Human Factors
Programme—ICAO, at the 2005 edition of the Canadian Aviation Safety Seminar (CASS) held in Vancouver, B.C.,
April 18–20 2005. It is an excellent article on threat and error management (TEM), and it serves our audience well in
furthering our current awareness campaign on TEM theory and principles, in the context of extending CRM training for
all commercial pilots.
To the Letter
To the Letter
Focus on CRM
Threat and Error Management
by Captain Dan Maurino (2005)
TEM developed as a product of the collective industry
experience. Such experience fostered the recognition
that past studies and, most importantly, operational
consideration of human performance in aviation had
largely overlooked the most important factor influencing
human performance in dynamic work environments: the
interaction between people and the operational context
(i.e., organizational, regulatory and environmental factors)
within which people discharge their operational duties.
The recognition of the influence of the operational
context in human performance further led to the
conclusion that study and consideration of human
performance in aviation operations must not be an end
in itself. In regard to the improvement of margins of
safety in avaition operations, the study and consideration
of human performance without context address only
part of a larger issue. TEM therefore aims to provide
a principled approach to the broad examination of the
dynamic and challenging complexities of the operational
context in human performance, for it is the influence of
these complexities that generates consequences directly
affecting safety.
The TEM model
The TEM model is a conceptual framework that assists in
understanding, from an operational perspective, the interrelationship between safety and human performance in
dynamic and challenging operational contexts.
The TEM model focuses simultaneously on the
operational context and the people discharging
operational duties in such context. The model is
descriptive and diagnostic of both human and system
performance. It is descriptive because it captures human
and system performance in the normal operational
context, resulting in realistic descriptions. It is diagnostic
because it allows quantifying complexities of the
operational context in relation to the description of
human performance in that context, and vice-versa.
The TEM model can be used in several ways. As a safety
analysis tool, the model can focus on a single event, as
is the case with accident/incident analysis; or it can be
used to understand systemic patterns within a large set of
events, as is the case with operational audits. The TEM
model can be used as a licensing tool, helping clarify
human performance needs, strengths and vulnerabilities,
allowing the definition of competencies from a broader
ASL 3/2012
13
Flight Operations
Flight Operations
Threat and error management (TEM) is an overarching
safety concept regarding aviation operations and human
performance. TEM is not a revolutionary concept, but it
evolved gradually, as a consequence of the constant drive
to improve the margins of safety in aviation operations
through the practical integration of Human Factors
knowledge.
Pre-Flight
Pre-Flight
Introduction
Guest Editorial
To the Letter
There are three basic components in the TEM model,
from the perspective of flight crews: threats, errors and
undesired aircraft states. The model proposes that threats
and errors are part of everyday aviation operations that
must be managed by flight crews, since both threats and
errors carry the potential to generate undesired aircraft
states. Flight crews must also manage undesired aircraft
states, since they carry the potential for unsafe outcomes.
Undesired state management is an essential component
of the TEM model, as important as threat and error
management. Undesired aircraft state management
largely represents the last opportunity to avoid an unsafe
outcome and thus maintain safety margins in flight
operations.
Threats
Some threats can be anticipated, since they are expected
or known to the flight crew. For example, flight crews can
anticipate the consequences of a thunderstorm by briefing
14
Regardless of whether threats are expected, unexpected, or
latent, one measure of the effectiveness of a flight crew’s
ability to manage threats is whether threats are detected
with the necessary anticipation to enable the flight crew
to respond to them through deployment of appropriate
countermeasures.
Threat management is a building block to error
management and undesired aircraft state management.
Although the threat-error linkage is not necessarily
straightforward, although it may not be always possible
to establish a linear relationship, or one-to-one
mapping between threats, errors and undesired states,
archival data demonstrates that mismanaged threats are
normally linked to flight crew errors, which in turn are
oftentimes linked to undesired aircraft states. Threat
management provides the most proactive option to
maintain margins of safety in flight operations, by voiding
safety-compromising situations at their roots. As threat
managers, flight crews are the last line of defense to keep
threats from impacting flight operations.
Table 1 presents examples of threats, grouped under
two basic categories derived from the TEM model.
Environmental threats occur due to the environment in
which flight operations take place. Some environmental
threats can be planned for and some will arise
spontaneously, but they all have to be managed by
flight crews in real time. Organizational threats, on
the other hand, can be controlled (i.e., removed or, at
least, minimised) at source by aviation organizations.
Organizational threats are usually latent in nature. Flight
crews still remain the last line of defense, but there are
earlier opportunities for these threats to be mitigated by
aviation organizations themselves.
ASL 3/2012
Flight Operations
Threats are defined as “events or errors that occur beyond
the influence of the flight crew, increase operational
complexity, and which must be managed to maintain the
margins of safety.” During typical flight operations, flight
crews have to manage various contextual complexities.
Such complexities would include, for example, dealing
with adverse meteorological conditions, airports
surrounded by high mountains, congested airspace,
aircraft malfunctions, errors committed by other people
outside of the cockpit, such as air traffic controllers,
flight attendants or maintenance workers, and so forth.
The TEM model considers these complexities as threats
because they all have the potential to negatively affect
flight operations by reducing margins of safety.
Lastly, some threats may not be directly obvious to, or
observable by, flight crews immersed in the operational
context, and may need to be uncovered by safety analyses.
These are considered latent threats. Examples of latent
threats include equipment design issues, optical illusions,
or shortened turn-around schedules.
Pre-Flight
Pre-Flight
The components of the TEM model
Some threats can occur unexpectedly, such as an in-flight
aircraft malfunction that happens suddenly and without
warning. In this case, flight crews must apply skills and
knowledge acquired through training and operational
experience.
To the Letter
Flight Operations
Originally developed for flight deck operations, the
TEM model can nonetheless be used at different levels
and sectors within an organization, and across different
organizations within the aviation industry. It is therefore
important, when applying TEM, to keep the user’s
perspective in the forefront. Depending on “who” is using
TEM (front-line personnel, intermediate management,
senior management; flight operations, maintenance, air
traffic control), slight adjustments to related definitions
may be required. This paper focuses on the flight crew as
“user”, and the discussion herein presents the perspective
of flight crews’ use of TEM.
their response in advance, or prepare for a congested
airport by making sure they keep a watchful eye for other
aircraft as they execute the approach.
Guest Editorial
safety management perspective. The TEM model can be
used as a training tool, helping an organization improve
the effectiveness of its training interventions, and
consequently of its organizational safeguards.
Environmental Threats
•
•
•
Pre-Flight
Errors
Errors are defined “actions or inactions by the flight
crew that lead to deviations from organizational or flight
crew intentions or expectations.” Unmanaged and/or
mismanaged errors frequently lead to undesired aircraft
states. Errors in the operational context thus tend to
reduce the margins of safety and increase the probability
of adverse events.
Errors can be spontaneous (i.e., without direct linkage to
specific, obvious threats), linked to threats, or part of an
error chain. Examples of errors would include the inability
to maintain stabilized approach parameters, executing a
wrong automation mode, failing to give a required callout,
or misinterpreting an ATC clearance.
Capturing how errors are managed is then as important,
if not more so, than capturing the prevalence of different
types of errors. It is of interest to capture if and when
errors are detected and by whom, the response(s) upon
•
•
•
•
•
•
•
Operational pressure: delays, late arrivals,
equipment changes.
Aircraft: aircraft malfunction, automation event/
anomaly, MEL/CDL.
Cabin: flight attendant error, cabin event distraction,
interruption, cabin door security.
Maintenance: maintenance event/error.
Ground: ground handling event, de-icing, ground
crew error.
Dispatch: dispatch paperwork event/error.
Documentation: manual error, chart error.
Other: crew scheduling event.
detecting errors, and the outcome of errors. Some
errors are quickly detected and resolved, thus becoming
operationally inconsequential, while others go undetected
or are mismanaged. A mismanaged error is defined as an
error that is linked to or induces an additional error or
undesired aircraft state.
Table 2 presents examples of errors, grouped under
three basic categories derived from the TEM model. In
the TEM concept, errors have to be “observable” and
therefore, the TEM model uses the “primary interaction”
as the point of reference for defining the error categories.
The TEM model classifies errors based upon the primary
interaction of the pilot or flight crew at the moment
the error is committed. Thus, in order to be classified
as an aircraft handling error, the pilot or flight crew
must be interacting with the aircraft (e.g. through its
controls, automation or systems). In order to be classified
as a procedural error, the pilot or flight crew must be
interacting with a procedure (e.g. checklists; SOPs; etc).
In order to be classified as a communication error, the
pilot or flight crew must be interacting with people (ATC;
groundcrew; other crew members, etc.).
Aircraft handling errors, procedural errors and
communication errors may be unintentional or involve
intentional non-compliance. Similarly, proficiency
considerations (i.e., skill or knowledge deficiencies,
training system deficiencies) may underlie all three
categories of error. In order to keep the approach simple
and avoid confusion, the TEM model does not consider
intentional non-compliance and proficiency as separate
categories of error, but rather as sub-sets of the three
major categories of error.
ASL 3/2012
Flight Operations
Regardless of the type of error, an error’s effect on safety
depends on whether the flight crew detects and responds
to the error before it leads to an undesired aircraft state
and to a potential unsafe outcome. This is why one of the
objectives of TEM is to understand error management
(i.e., detection and response), rather than solely focusing
on error causality (i.e., causation and commission).
From the safety perspective, operational errors that are
timely detected and promptly responded to (i.e., properly
managed), errors that do not lead to undesired aircraft
states, do not reduce margins of safety in flight operations,
and thus become operationally inconsequential. In
addition to its safety value, proper error management
represents an example of successful human performance,
presenting both learning and training value.
•
Pre-Flight
Flight Operations
•
Weather: thunderstorms, turbulence, icing, wind
shear, cross/tailwind, very low/high temperatures.
ATC: traffic congestion, TCAS RA/TA, ATC
command, ATC error, ATC language difficulty, ATC
non-standard phraseology, ATC runway change,
ATIS communication, units of measurement (QFE/
meters).
Airport: contaminated/short runway; contaminated
taxiway, lack of/confusing/faded signage/markings,
birds, aids U/S, complex surface navigation
procedures, airport constructions.
Terrain: High ground, slope, lack of references, “black
hole”.
Other: similar call-signs.
To the Letter
To the Letter
•
Organizational Threats
Guest Editorial
Guest Editorial
Table 1. Examples of threats (List not inclusive)
15
Aircraft handling errors
•
•
•
•
•
•
•
•
•
Communication errors
•
Undesired aircraft states
Undesired aircraft states are defined as “flight
crew-induced aircraft position or speed deviations,
misapplication of flight controls, or incorrect systems
configuration, associated with a reduction in margins
of safety.” Undesired aircraft states that result from
ineffective threat and/or error management may lead
to compromising situations and reduce margins of
safety in flight operations. Often considered at the
cusp of becoming an incident or accident, undesired
aircraft states must be managed by flight crews.
Examples of undesired aircraft states would include
lining up for the incorrect runway during approach
16
to landing, exceeding ATC speed restrictions
during an approach, or landing long on a short
runway requiring maximum braking. Events such as
equipment malfunctions or ATC controller errors
can also reduce margins of safety in flight operations,
but these would be considered threats.
Undesired states can be managed effectively,
restoring margins of safety, or flight crew response(s)
can induce an additional error, incident, or accident.
Table 3 presents examples of undesired aircraft states,
grouped under three basic categories derived from
the TEM model.
ASL 3/2012
Flight Operations
Flight Operations
Crew to external: missed calls, misinterpretations of
instructions, incorrect readback, wrong clearance, taxiway, gate
or runway communicated.
Pilot to pilot: within crew miscommunication or
misinterpretation.
Pre-Flight
Pre-Flight
•
SOPs: failure to cross-verify automation inputs.
Checklists: wrong challenge and response; items missed,
checklist performed late or at the wrong time.
Callouts: omitted/incorrect callouts.
Briefings: omitted briefings; items missed.
Documentation: wrong weight and balance, fuel information,
ATIS, or clearance information recorded, misinterpreted
items on paperwork; incorrect logbook entries, incorrect
application of MEL procedures.
To the Letter
To the Letter
Procedural errors
Manual handling/flight controls: vertical/lateral and/or speed
deviations, incorrect flaps/speedbrakes, thrust reverser or
power settings.
Automation: incorrect altitude, speed, heading, autothrottle
settings, incorrect mode executed, or incorrect entries.
Systems/radio/instruments: incorrect packs, incorrect
anti‑icing, incorrect altimeter, incorrect fuel switches settings,
incorrect speed bug, incorrect radio frequency dialled.
Ground navigation: attempting to turn down wrong
taxiway/runway, taxi too fast, failure to hold short,
missed taxiway/runway.
Guest Editorial
Guest Editorial
Table 2. Examples of errors (List not inclusive)
Aircraft control (attitude).
Vertical, lateral or speed deviations.
Unnecessary weather penetration.
Unauthorized airspace penetration.
Operation outside aircraft limitations.
Unstable approach.
Continued landing after unstable approach.
Long, floated, firm or off-centreline landing.
Ground navigation
•
•
Proceeding towards wrong taxiway/runway.
Wrong taxiway, ramp, gate or hold spot.
Incorrect aircraft configurations
•
•
•
•
•
Incorrect systems configuration.
Incorrect flight controls configuration.
Incorrect automation configuration.
Incorrect engine configuration.
Incorrect weight and balance configuration.
Flight Operations
Also from a learning and training perspective, it is
important to establish a clear differentiation between
undesired aircraft states and outcomes. Undesired
aircraft states are transitional states between a
normal operational state (i.e., a stabilised approach)
and an outcome. Outcomes, on the other hand, are
end states, most notably, reportable occurrences
(i.e., incidents and accidents). An example would be
as follows: a stabilised approach (normal operational
state) turns into an unstablised approach (undesired
aircraft state) that results in a runway excursion
(outcome).
The training and remedial implications of this
differentiation are of significance. While at the
undesired aircraft state stage, the flight crew has the
possibility, through appropriate TEM, of recovering
the situation, returning to a normal operational state,
thus restoring margins of safety. Once the undesired
aircraft state becomes an outcome, recovery of the
situation, return to a normal operational state, and
restoration of margins of safety is not possible.
Countermeasures
Flight crews must, as part of the normal discharge
of their operational duties, employ countermeasures
to keep threats, errors and undesired aircraft
states from reducing margins of safety in flight
operations. Examples of countermeasures would
include checklists, briefings, call-outs and SOPs, as
well as personal strategies and tactics. Flight crews
dedicate significant amounts of time and energies
to the application of countermeasures to ensure
margins of safety during flight operations. Empirical
ASL 3/2012
17
Flight Operations
An important learning and training point for
flight crews is the timely switching from error
management to undesired aircraft state management.
An example would be as follows: a flight crew
selects a wrong approach in the Flight Management
Computer (FMC). The flight crew subsequently
identifies the error during a crosscheck prior to the
Final Approach Fix (FAF). However, instead of
using a basic mode (e.g. heading) or manually flying
the desired track, both flight crew become involved
in attempting to reprogram the correct approach
prior to reaching the FAF. As a result, the aircraft
“stitches” through the localiser, descends late, and
goes into an unstable approach. This would be an
example of the flight crew getting “locked in” to
error management, rather than switching to
undesired aircraft state management. The use of the
TEM model assists in educating flight crews that,
when the aircraft is in an undesired state, the basic
task of the flight crew is undesired aircraft state
management instead of error management. It also
illustrates how easy it is to get locked in to the
error management phase.
Pre-Flight
Pre-Flight
To the Letter
•
•
•
•
•
•
•
•
To the Letter
Aircraft handling
Guest Editorial
Guest Editorial
Table 3. Examples of undesired aircraft states (List not inclusive)
•
•
•
•
•
•
Airborne Collision Avoidance System (ACAS);
Ground Proximity Warning System (GPWS);
Standard operation procedures (SOPs);
Checklists;
Briefings;
Training.
•
•
•
Planning countermeasures: essential for managing
anticipated and unexpected threats;
Execution countermeasures: essential for error
detection and error response;
Review countermeasures: essential for managing the
changing conditions of a flight.
Enhanced TEM is the product of the combined
use of systemic-based and individual and team
countermeasures. Table 4 presents detailed examples
of individual and team countermeasures.
To the Letter
Guest Editorial
To the Letter
All countermeasures are necessarily flight crew
actions. However, some countermeasures to threats,
errors and undesired aircraft states that flight crews
employ build upon “hard” resources provided by
the aviation system. These resources are already in
place in the system before flight crews report for
duty, and are therefore considered as systemic-based
countermeasures. The following would be examples
of “hard” resources that flight crews employ as
systemic-based countermeasures:
Other countermeasures are more directly related
to the human contribution to the safety of flight
operations. These are personal strategies and tactics,
individual and team countermeasures, that typically
include canvassed skills, knowledge and attitudes
developed by human performance training, most
notably, by crew resource management (CRM)
training. There are basically three categories of
individual and team countermeasures:
Guest Editorial
observations during training and checking suggest
that as much as 70% of flight crew activities may be
countermeasures-related activities.
Table 4. Examples of individual and team countermeasures
SOP BRIEFING
The required briefing was interactive
and operationally thorough
–– Concise, not rushed, and met SOP requirements
–– Bottom lines were established
PLANS STATED
Operational plans and decisions were
communicated and acknowledged
–– Shared understanding about plans
–– “Everybody on the same page”
WORKLOAD
ASSIGNMENT
Roles and responsibilities were defined
for normal and non-normal situations
–– Workload assignments were communicated and
acknowledged
CONTINGENCY
MANAGEMENT
Crew members developed effective
strategies to manage threats to safety
–– Threats and their consequences were anticipated
–– Used all available resources to manage threats
Pre-Flight
Pre-Flight
Planning Countermeasures
MONITOR /
CROSS-CHECK
Crew members actively monitored and
cross-checked systems and other crew
members
–– Aircraft position, settings, and crew actions
were verified
WORKLOAD
MANAGEMENT
Operational tasks were prioritized and
properly managed to handle primary
flight duties
–– Avoided task fixation
–– Did not allow work overload
AUTOMATION
MANAGEMENT
Automation was properly managed to
balance situational and/or workload
requirements
–– Automation setup was briefed to other members
–– Effective recovery techniques from automation
anomalies
18
ASL 3/2012
Flight Operations
Flight Operations
Execution Countermeasures
To the Letter
EVALUATION/
MODIFICATION
OF PLANS
Existing plans were reviewed and
modified when necessary
–– Crew decisions and actions were openly
analyzed to make sure the existing plan was the
best plan
INQUIRY
Crew members asked questions to
investigate and/or clarify current plans
of action
–– Crew members not afraid to express a lack
of knowledge
–– “Nothing taken for granted” attitude
ASSERTIVENESS
Crew members stated critical information and/or solutions with appropriate
persistence
–– Crew members spoke up without hesitation
Bounce Back! Train Your Crews for Bounced Landing Recovery Techniques!
Incorrect recoveries from bounced landings have
contributed to several accidents in which aeroplanes
operated by Canadian Subpart 705 air operators have
sustained substantial damage. After investigating the
bounced landing and subsequent tail strike during the
go-around of a Boeing 727 at the Hamilton International
Airport, the Transportation Safety Board of Canada
(TSB) has recommended, in TSB Final Report A08O0189,
that air operators “…incorporate bounced landing
recovery techniques in the flight manuals and to teach
these techniques during initial and recurrent training.”
(TSB A09-01)
Landing Accident Reduction (ALAR) Tool Kit, 6.4 Bounce
Recovery – Rejected Landing. In fact, while you’re at it, you
may want to re-familiarize yourself with the entire ALAR
Tool Kit, which received a significant update in 2010. Just
visit this link: FSF ALAR.
Transport Canada is currently assessing the effectiveness
of the voluntary approach to bounced landing recovery
training. We encourage all air operators, not only 705 but
also 703 and 704, to add this important training to their
annual and recurrent training syllabus.
Pre-Flight
As a result of this recommendation, on January 1, 2010,
Transport Canada issued Advisory Circular (AC) 705-007,
which encouraged Canadian Subpart 705 air operators
to voluntarily institute bounced landing recovery training
into their flight crew training syllabus, and to provide
bounced landing information in their company operations
manual (COM). The AC includes excellent references,
including accident reports for review. A must-read
reference is the Flight Safety Foundation’s Approach and
To the Letter
Pre-Flight
Review Countermeasures
Guest Editorial
Guest Editorial
Table 4 (continued). Examples of individual and team countermeasures
Got time for a quick refresher on uncontrolled aerodrome procedures?
Flight Operations
Flight Operations
...take five minutes to review the UNCONTROLLED AERODROME VFR CIRCUIT
PROCEDURES poster, and take five more to review the UNCONTROLLED
AERODROME IFR PROCEDURES poster!
ASL 3/2012
19
Maintenance and Certification
Top 10 Tips for Turbines
by James Careless, Aircraft Maintenance Technology (AMT) contributor. This article was originally published in the July 2008 issue of AMT
magazine, and is reprinted with permission.
Turbine engines are many aircraft technicians’ breadand-butter. But even the most experienced technician
can benefit from some sage advice on turbine repair and
servicing, as provided by the experts at Dallas Airmotive
and Standard Aero. Here is the cream of their collected
wisdom, distilled into 10 Top Tips for Turbines!
1. Before you start, think
Troubleshooting an intermittent fault is a technician’s
worst nightmare, especially when it can’t be recreated in
the shop. This is why it is important to thoroughly debrief
the flight crew to find out the conditions under which the
fault occurred. “Does it only occur at 18 000 ft or when
the anti-icing system is on? These are details that can
help you pinpoint a problem,” says Larry Galarza, Dallas
Airmotive’s 731 field service manager. “But you can only
learn about these details if you talk to the flight crew and
get comprehensive answers first. So get out there and ask
questions; lots of questions.”
3. Let’s say it again—read the manual
When it comes to making mistakes in turbine repair, “the
most common error is not to read the manual first,” says
Olson. “I know we’re guys and that we like to assemble
things before we ever look at a manual, but turbine
engines are complicated. Read first, then act.”
4. Troubleshoot carefully
When you are troubleshooting a turbine, take your time
and be careful not to jump to conclusions. “Every detail
counts,” explains Olson. “Depending on the symptoms
and evidence you find, troubleshooting will lead you to
draw different conclusions. Rush through the process, and
you could end up drawing the wrong conclusions; to the
detriment of the engine and possibly yourself.”
5. Work methodically
Accident Synopses
Accident Synopses
Tearing a turbine engine apart when you haven’t
formulated a plan of attack first is a recipe for disaster.
Not only could you miss the problem you are trying to fix,
but you could even make matters worse, not better. This
is why Standard Aero SVP of Technology Kim Olson
stresses “getting your overall mindset together first. You
need to go over the fault reports you’ve got, then pull out
the manuals and look them over carefully,” he tells AMT.
“Next, you have to use this information to put together
a comprehensive plan of attack, making sure that you
take the right tools for the job and follow the proper
precautions as well. Do your homework before you start
diving in and turning wrenches!”
2. Talk to the flight crew
Recently Released TSB Reports
Recently Released TSB Reports
Top 10 Tips for Turbines.................................................................................................................................................. page 20
Double or Triple Release?.................................................................................................................................................. page 21
Distractions........................................................................................................................................................................ page 22
Maintenance and Certification
maintenance and certification
Turbine engines are complex, so be sure to approach them
in a logical manner. In particular, work in a methodical,
step-by-step basis. You don’t want to find yourself at job’s
end with a few unexplained spare parts!
Before you start working on a turbine, put together
a plan of attack with the right tools and manuals.
(Photo: Dallas Airmotive)
20
It is important to know what you are capable of doing on
a turbine engine, and when you are out of your league.
“Don’t be afraid to pick up the phone to ask someone for
qualified advice,” says Terry Huecker, Dallas Airmotive’s
Pratt & Whitney 300/500 field service manager. “Many
companies such as Pratt & Whitney and Honeywell
have excellent help desks. As well, it makes sense to
ASL 3/2012
Regulations and You
Regulations and You
6. Know your limitations
Maintenance and Certification
Recently Released TSB Reports
8. Take the turbine’s temperature
10. Finally, a clean turbine is a happy turbine
Well, maybe not happy, but taking the time to do
compressor washes on a regular basis can reduce blade
corrosion. In turn, reduced blade corrosion means longer
life and more efficient fuel usage; a critical concern given
today’s sky-high fuel prices.
“I have seen a number of engines that were stored for
future repair without having their compressors washed,”
Olson says. “The resulting corrosion can be so bad that
the engine may end up being irreparable by the time it
gets pulled out of storage for servicing.” He adds that
fuel nozzle cleaning “is also very important for a turbine
engine’s health and longevity.” Tracking down an elusive problem? Try checking the
turbine’s inlet temperature over time—using data
downloaded from the aircraft’s monitoring system—
“can guide you as to where you should start looking,”
Olson says.
Double or Triple Release?
by Brad Taylor, Civil Aviation Safety Inspector, Operational Airworthiness, Standards Branch, Civil Aviation, Transport Canada
Maintaining a stores department for an air operator
or distributor is not a simple task! Ensuring that high
demand spares are always available requires a systematic
approach for processing rotables and replenishing
consumable materials. Success or failure in this discipline
can mean the difference between profit and loss for an
organization.
The personnel working in this capacity must be
experienced in the handling and shipping of aviation
components, ranging from lead acid or nickel cadmium
batteries, static sensitive components, chemicals, and a
wide variety of hazardous materials. Then, just to make
the job just a bit more demanding, personnel are often
called upon to be inspectors and are expected to be well
versed on the regulatory requirements associated with
the job, such as segregating serviceable and unserviceable
products, purchase orders, eligibility and international
agreements for maintenance acceptance.
Aeronautical products maintained under any regulatory
system receive a maintenance release after the
maintenance is complete, which states the pertinent
data by which the work was completed and under
which regulatory system the work is acceptable. The
regulatory reference and the approval number of the
organization that performed the work are also essential
to the subsequent installer in order to determine whether
the product has been maintained in accordance with the
applicable standards of airworthiness for the aircraft or
assembly on which the product is to be installed. This
determination (eligibility) is the aircraft maintenance
engineer’s (AME) responsibility and the basis for this
decision is the country in which the aircraft or assembly
is registered. Of course there are more factors involved in
the decision, including parts numbers, mod status of the
aircraft/component, etc., but the first step is determining
the applicable regulatory system by which the aircraft or
component must be maintained.
Approved maintenance organizations (AMO) and
distributors find that having “maintained” aeronautical
products in their inventory that have dual releases
ASL 3/2012
21
Regulations and You
The purpose of this article is to focus specifically on
maintenance releases for rotable (repairable) parts that,
on occasion, must be maintained by organizations located
outside of Canada. This genre of spare parts represents
a large investment for an organization and therefore
demands the most attention by the stores personnel to
ensure that it is managed as efficiently as possible.
Accident Synopses
Accident Synopses
When in doubt, it makes sense to get a closer look at
possible problem areas inside an engine using a borescope.
“If you go in early enough, you can often catch a problem
such as a cracked blade before it becomes serious,”
says Olson. “Problems caught early are easier and less
expensive to fix, and don’t result in additional problems
such as having damaged blade fragment and damaging
the entire engine.”
When it comes to troubleshooting and then repairing
a turbine engine, give yourself the time to do the job
correctly. “A lot of times aircraft technicians get caught
up in the hurry to get an aircraft back into service,” says
Galarza. “Don’t let them put a flight schedule in front of
you. Stick to your skills and your expertise, and do the job
properly at the right pace.”
Recently Released TSB Reports
Regulations and You
7. Get out your borescope
9. Don’t be rushed
Maintenance and Certification
build a community of technicians who you can consult
and who can consult you. You can meet them at training
courses, conventions, or even social events. Wherever you
find them, get networking today to have people to call
tomorrow.”
Maintenance and Certification
Recently Released TSB Reports
The issue with this practice isn’t that the organization
doesn’t have the authority; it’s more of a technicality
So what can an organization receiving, selling or using
maintained aeronautical products do? Firstly, in the short
term, we recommend a discussion take place with your
staff to ensure that everyone knows how to identify a
discrepant authorized release certificate. Secondly, if an
organization wishes to maintain this flexibility within its
spares pool, it must be specified on the work order that
the repair organization issued separate authorized release
certificates in order to respect international agreements.
This may add cost and paperwork to the process, but it
will ensure that an organization has a spare part which is
of maximum value to it. Recently Released TSB Reports
Recently, we (Transport Canada [TC]) have been
receiving some comments from EASA-based Part 145
AMOs, informing us that they were no longer allowed to
issue a triple release. Some organizations hold EASA Part
145 approvals as well as FAA and Canadian approvals for
repairing aeronautical products. They have often certified
the work performed on an authorized release certificate
with all three regulatory references so the customers could
install the item on a wide variety of aircraft or distribute
them to a broader customer base. It was a service that
provided the customer with more flexibility with respect
to their spares.
within the international agreements. The agreements are
bilateral between parties such as Canada and EASA, or
EASA and the FAA; they are not trilateral. Therefore,
the agreements were never intended to be applied at
the same time, which means the application of all three
approvals on one authorized release certificate would not
be appropriate or acceptable. This is also evident when
examining the authorized release certificate forms or
templates recognized by TC, the FAA or EASA. None
of them allow for more than two regulatory references
because the document is intended to be used with a
maximum of two parties.
Maintenance and Certification
to be advantageous; these products are accepted for
installation by two regulatory authorities, the European
Aviation Safety Agency (EASA)/Transport Canada
Civil Aviation (TCCA) or the U.S. Federal Aviation
Administration (FAA)/EASA. A dual release adds value
to the product in the resale market and provides flexibility
to large operators when aircraft are registered in different
countries. Applying the same logic, a part with a triple
release would be of even more value, if it were possible.
Distractions
Over the last couple of years, I have run several recurrent
training sessions on human factors in maintenance.
Through the use of a quick poll, I asked people which of
the dirty dozen they find to be most significant in their
workplaces. The results have been quite consistent, with
distraction being the most significant issue that people
are currently facing. This is certainly a sign of our times,
as the prevalence of smart phones and the expectation of
immediate responses to e-mails and phone calls has led to
frequent disruptions in the workplace for all of us.
22
There is a fallacy that we are becoming better at multitasking and can therefore handle these disruptions.
The truth is, multi-tasking is an illusion that our brain
generates as we rapidly switch our attention between
various tasks. We can only focus our conscious attention
on one thing at a time, and while we focus on one thing,
we lose our focus on whatever else we are supposed to be
doing. This creates an opportunity for errors of omission.
Managing distractions is obviously a significant topic of
discussion that we need to have in our workplace. During
my last human factors course, I facilitated a discussion on
managing distractions and promised to write an article
based on that discussion. I am indebted to that class of
experienced maintenance technicians for the following
ideas on how to manage distractions.
Perhaps the first and most significant idea is to get rid
of the belief that we are capable of multi-tasking. If you
are conducting maintenance while also engaging in some
other activity that requires your conscious attention, then
you are setting yourself up for failure. Create rules in the
workplace regarding common distractions such as phones,
ASL 3/2012
Regulations and You
Regulations and You
One of the greatest fears an aircraft maintenance
technician has is making an error that leads to a fatal
accident. Maintenance errors occur every day; fortunately
these errors are usually caught well before anything
terrible happens. The most common maintenance errors
are errors of omission: the technician knows what to do,
intends to do the right thing, but for some reason, a step
is overlooked. A bolt doesn’t get properly torqued, a nut
doesn’t get a cotter pin, or an assembly lacks an O-ring.
A distraction at a critical moment is often a contributing
factor to such errors.
Accident Synopses
Accident Synopses
by Gerry Binnema. Gerry is a renowned consultant and facilitator in all aviation safety management topics.
For more information, visit www.gjbconsulting.com.
Maintenance and Certification
Recently Released TSB Reports
None of these suggestions are especially difficult to
execute, but they require a great deal of discipline to
actually follow consistently. By taking the threat of
distractions seriously, we can create a culture in our
workplace that encourages good habits. I encourage you
to bring up the threat of distraction at your next pre-shift
briefing to discuss some of these ideas. Regulations and You
Regulations and You
Accident Synopses
Accident Synopses
If you are distracted, or step away from the job even for
a moment, review the last three steps of the job to make
sure they were completed before you move on. Our minds
Finally, plan ahead to avoid distractions. You may have
many different responsibilities at your workplace and
these may lead to conflicting priorities. If you are a crew
chief or a manager, ensure that you set up your day so
that you can deal with your managerial responsibilities
during certain hours and then focus on your maintenance
responsibilities when you are on the hangar floor.
Recently Released TSB Reports
Another idea is creating an atmosphere and culture in
the workplace that makes it okay to say “not right now.”
Maintenance tasks often require an extra set of hands
so we are often asked to help move an airplane, hold a
propeller or provide other types of support. We all want to
be good team members and we are always willing to help,
but when those distractions come at critical moments, the
possibility of an error of omission is introduced. We need
to support the person who says “not right now” under those
circumstances. Often we just need a couple of minutes
to complete a step and then are able to help out, thereby
eliminating the fear that something critical may be missed.
are always thinking several steps ahead in the job we
are doing and when we are distracted and then return
to the job, it is often easy for us to believe that we were
several steps further ahead than we actually are. Use the
maintenance task card or checklist as they were intended
to be used by signing off on each task as it is completed.
This will help ensure that we don’t get too far ahead of
ourselves.
Maintenance and Certification
tablets, or other technology near a working technician.
Even if a person says they will ignore incoming messages,
a flashing light or soft beeping signalling a new message
will distract the technician, affecting their focus on the
work at hand. Keep this in mind driving around the ramp
and for run-ups. If you are talking on a cell phone you are
not focusing on the task at hand.
ASL 3/2012
23
Maintenance and Certification
TSB Final Report A08P0241—Aerodynamic
Stall—Collision with Terrain
Regulations and You
Nothing was found to indicate that there was any airframe
or system malfunction before or during the flight.
The weather at Port Hardy was VFR, consistent with the
forecast. Even though the ceiling was at 1 000 ft AGL,
the visibility was very good at 20 SM. The pilot likely
expected the clouds observed along the mountain ridge
It is unknown whether the pilot attempted to contact
flight following in the moments before the accident.
The fact that the aircraft could not be reached did not
alarm the company flight following because it was not
unusual for aircraft to be out of radio range of the flight
watch facility. It was also not unusual for pilots to land
somewhere along their route to wait for weather to
ASL 3/2012
Regulations and You
The failure of the ELT to activate upon impact
significantly increased the risk to survivors. In this case,
the ELT was destroyed on impact, which hindered SAR
efforts to locate the downed aircraft.
Analysis
24
As the flight proceeded towards the higher terrain, the
pilot likely discovered that the cloud coverage was more
extensive than observed from the ground, with hilltops
obscured. Considering that the pilot was not instrument
rated and the aircraft was not certified for IFR flight, he
would have rejected the idea of climbing into the clouds
and proceeding under IFR. Instead, his options would
have been to turn around (either return to Port Hardy
or double-back to follow the low-level route along the
coast), continue towards a pass that would allow him to
cross the ridge into better weather, or try to fly above
the clouds on the ridge and below the overcast ceiling.
It is likely that he found the weather conditions at the
pass to be unsuitable and instead elected to climb above
the ridge and below the overcast ceiling. The climb
began, gently at first, then more abruptly with what was
probably full climb power. With clouds obscuring the
ridge, the pilot would have recognized the risk of flight
into terrain if he allowed the aircraft to penetrate the
clouds. During the climb, the aircraft reached the stall
angle and the left wing dropped. This caused the aircraft
to lose considerable height. The pilot was able to recover
from the stall in a nose-down attitude. Before he could
raise the nose to the level position, the aircraft struck the
tops of several trees, which slowed the aircraft before it
fell to the ground.
Accident Synopses
Accident Synopses
On August 3, 2008, at 07:08 Pacific Daylight
Time (PDT), a Grumman G-21A Goose amphibian
operating as a charter flight departed Port Hardy Airport,
B.C., on a VFR flight to Chamiss Bay, B.C. At 08:49
and again at 09:08, the flight follower attempted to
contact the tugboat meeting the aircraft at Chamiss
Bay by radiotelephone but was unsuccessful. At 09:53,
the flight follower reported the aircraft overdue to the
joint rescue coordination centre ( JRCC) in Victoria,
B.C., and an aerial search was initiated. A search and
rescue (SAR) aircraft located the wreckage on a hillside
near Alice Lake, approximately 14 NM from its departure
point. A post-crash fire had ignited. The emergency
locator transmitter (ELT) had been destroyed in the
crash and did not transmit. The accident happened at
about 07:22. Of the seven occupants, the pilot and four
passengers were fatally injured, one passenger suffered
serious injuries, while another suffered minor injuries. The
two survivors were evacuated from the accident site at
approximately 16:10.
to the south and southwest of the airport to be patchy as
per the graphic area forecast (GFA). Knowing that the
weather at Chamiss Bay was sunny with good visibility,
the pilot likely considered the clouds on the mountain
tops as local phenomena, which he could negotiate
to successfully cross the ridge. This assessment of the
weather likely led the pilot to choose the direct route.
Recently Released TSB Reports
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.
Maintenance and Certification
Recently Released TSB Reports
Maintenance and Certification
1. While likely climbing to fly above a cloud-covered
ridge and below the overcast ceiling, the aircraft
stalled aerodynamically at a height from which full
recovery could not be made before striking the trees.
2. The aircraft broke apart upon impact, and electrical
arcing from exposed wires in the presence of spilled
fuel caused a fire that consumed most of the aircraft.
Findings as to risk
1. While the company’s established communications
procedures and infrastructure met the regulatory
requirements, they were not effective in ascertaining
an aircraft’s position and flight progress, which
delayed critical SAR action.
2. The ELT was destroyed in the crash and failed to
operate, making it difficult for SAR to find the
aircraft. This prolonged the time the injured survivors
had to wait for rescue and medical attention.
TSB Final Report A08W0162—Controlled Flight
Into Water
On August 9, 2008, the pilot and sole occupant of the
Bell 206B helicopter was departing from its base on the
west bank of the Yukon River at Carmacks, Y.T., at about
07:00 Pacific Daylight Time (PDT). After lifting off the
pad into a low hover facing away from the river, the pilot
pedal-turned through 180 degrees to the left and departed
over the river on an easterly heading. Shortly thereafter,
there was a loud impact and splash, and pieces of
wreckage drifted down the river. A pilot and two aircraft
maintenance engineers (AME), who were preparing
a Bell 205 helicopter for flight from an adjacent pad,
immediately started the aircraft, tracked the aft fuselage
section that was floating down the river, and assisted in its
recovery. The submerged forward fuselage section, engine,
and transmission were not recovered until located by sidescan sonar on August 17, 2008. The pilot drowned.
Recently Released TSB Reports
Recently Released TSB Reports
Findings as to causes and contributing factors
consultants to conduct three days of accident investigation
and risk assessment training for company management
and supervisors.
Maintenance and Certification
improve before continuing to destination. As a result, the
company did not notify the Victoria JRCC until 09:53,
about one hour after the aircraft’s expected arrival time
back at Port Hardy. The lack of an effective means of
tracking the flight progress led to delays in SAR action.
These delays increased the risk to survivors.
The operator has recognized the need for a tailored
pilot decision making (PDM) course for its subpart 703
VFR floatplane pilots. A flight training unit has been
contracted to create a special PDM course for single-pilot
float operations, and the company has worked closely
with them to develop the course outline. The course is
to consist of one day of classroom instruction and one
of practical instruction in a simulator. Emphasis will be
on cockpit resources for a single pilot, decision-making
processes, physiological and psychological effects, GPS
issues, and a review of relevant accidents.
The operator has instituted VFR line checks as part of its
monitoring and quality control, which are similar to its
subpart 704 and subpart 705 operations.
The operator reviewed its safety management
system (SMS) manual and included revised risk
assessment procedures. It also reviewed accident
investigation procedures and contracted with outside
Analysis
A normal helicopter departure requires the pilot to lower
the nose of the aircraft slightly and to increase collective
pitch to initiate forward flight and begin to climb. During
the departure/climb phase of the flight, any problems,
such as a loss of power, would be countered by raising the
nose to initiate a flare to slow the helicopter for landing.
In this occurrence, the pilot accelerated to about 40 knots
through translation in a level or slightly nose-down
attitude, flying in a straight line for about 14 seconds
until impact. Engine and rotor sounds were normal,
and wreckage examination did not reveal mechanical
or control anomalies that would have prevented the
helicopter from accelerating and climbing.
ASL 3/2012
25
Regulations and You
Regulations and You
After conducting a risk assessment of its routes, the
operator selected the latitude system, which provides an
ELT-like function. This system has been installed on all
company floatplanes.
Accident Synopses
Accident Synopses
Safety action taken
Operator
Maintenance and Certification
Recently Released TSB Reports
During this period, the helicopter would have been
accelerating. Somatogravic illusion would likely have
caused the pilot to sense that the aircraft was climbing at
about an 8.5-degree angle when, in fact, the aircraft was
descending slightly until impact.
2. The pilot most likely lost visual reference with terrain
and descended into the surface of the river.
3. It is likely that the pilot did not realize that the
helicopter was descending instead of climbing due to
somatogravic illusion.
Finding as to risk
1. Departing over water, instead of accelerating and
climbing along the shoreline, increases the risk of
losing visual references and the risk of ditching into
water in the event of a power train failure.
TSB Final Report A08A0106—Loss of Control—
Stall/Spin
26
With no eyewitness accounts and without the pilot
being able to recall any significant moments of the
accident flight, investigators had to rely on an analysis
of information from the accident site and the pilot’s
experience/currency to determine the most likely cause of
the accident.
The aircraft’s impact orientation indicates there was a
departure from controlled flight, resulting from a stall/
spin scenario. The stall/spin scenario was not a result of a
structural failure in flight, no engine or control anomalies
were noted during the wreckage examination, the weather
was determined not to be a factor, and a stall/spin scenario
would not have been deliberately initiated at such a low
altitude. The most likely scenario leading to the accident
would be the pilot’s lack of currency and inexperience on
type, leading to a failure to detect the symptoms of an
approaching stall and apply the appropriate corrections in
a timely manner, resulting in an unintentional stall/spin
situation. Once the aircraft had departed controlled flight,
there was insufficient altitude to recover. Within seconds,
the flight profile would have changed from horizontal to
vertical with the aircraft contacting the ground shortly
after.
The pilot was inexperienced on this aircraft type and was
not very familiar with the symptoms that it would display
prior to a stall. The pilot was inexperienced on tail-wheel
aircraft handling and had not flown this aircraft from his
airstrip prior to this flight. During the course of a practice
touch-and-go, the pilot would have been preoccupied
with controlling the aircraft directionally on the ground
and initial climb out. It is possible that due to this
distraction, the pilot’s unfamiliarity with the aircraft, and
the lack of a stall warning device, the decreasing airspeed
ASL 3/2012
Regulations and You
On August 18, 2008, the amateur-built Denney Kitfox IV,
a single-engine tail-wheel configured aircraft, had
departed from a private airstrip on a local flight near the
community of Huntington, N.S. The aircraft flew in
the local area for approximately 15 minutes until a local
resident heard the sound of impact at approximately
11:30 Atlantic Daylight Time (ADT). There were no
eyewitnesses to the accident. Within minutes of the
impact, the aircraft was found along the edge of the access
road to the pilot’s residence. The pilot was critically injured
Analysis
Accident Synopses
Accident Synopses
1. The pilot’s forward vision was obscured by the bright
sunlight and glare from the surface of the river.
Aircraft impact orientation
Recently Released TSB Reports
The sun was at a low angle above his horizon and the
bright sunlight was compounded by its strong reflection
off the water. The resulting glare on and through the
windscreen would have obscured the pilot’s forward vision
before his eyes could react to the sudden brightness,
especially because he was not wearing sunglasses. The
bright light would also have obscured the instrument
panel in shadow, depriving the pilot of backup instrument
information.
Findings as to causes and contributing factors
Regulations and You
and was transported to hospital. The aircraft came to rest
directly along the extended centreline of Runway 20 of the
private airstrip, about 275 ft beyond the departure end. The
aircraft was destroyed and there was no fire.
Maintenance and Certification
The pilot had lifted off facing away from the sun and
then had turned to face directly into the sun as he began
forward flight. A more common departure procedure in
a single-engine helicopter would be to turn 90 degrees
to the left or right, to accelerate and climb along the
riverbank before turning out over the water. This would
decrease the risk of having to ditch in the fast-flowing
river in case of an engine or power train failure.
The pilot survived his extensive injuries as a result of
timely medical care because a local resident heard the
impact and quickly located the accident site.
Findings as to causes and contributing factors
1. The pilot was inexperienced on the aircraft type
and had not flown it in the previous ten months; he
may have been unfamiliar with the symptoms of an
impending aircraft stall and the proper corrective
action.
2. The aircraft was operating at the departure end of
Runway 20 at low altitude when it stalled and entered
an incipient spin from which there was insufficient
height to recover before it collided with terrain.
Maintenance and Certification
Findings as to risk
2. With an emergency locator transmitter (ELT) switch
in the OFF position during an aircraft accident, it is
possible that a seriously injured pilot might succumb
to injuries before help arrives.
TSB Final Report A09W0037—Risk of Collision
Findings as to causes and contributing factors
1. Communication transfers between the Edmonton
area control centre (ACC) and Whitehorse tower
did not take place in accordance with the Inter Unit
Arrangement between the two facilities, resulting in
a wide variation in aircraft position at the time of the
communication transfer.
2. The relieving tower controller did not establish
the position of the CL-600 on initial contact. The
relieving tower controller assumed that the CL‑600
was 45 NM from the airport and this resulted in an
inaccurate assessment of the flight time left prior to
the aircraft’s arrival.
3. Information that the CL-600 would have to hold was
not communicated to the relieving tower controller
during the position transfer briefing and the flight
progress strip did not contain holding information,
a fix reference or an airport ETA for the CL-600.
This reduced the opportunity for the relieving tower
controller to establish accurate initial situational
awareness and allowed the 45 mile from airport
assumption to persist.
ASL 3/2012
27
Regulations and You
On March 6, 2009, a Bombardier CL-600-2D15 had
been cleared to the Whitehorse International Airport,
Y.T., for an approach. Whitehorse International Airport
is located in a mountainous, non-radar environment
and at the time of the occurrence a winter snow storm
was moving through the area. An instrument landing
system (ILS) approach to Runway 31L was hand-flown
by the captain using the head-up guidance system (HGS).
On initial contact, no current position report or estimate
for the airport was given by the crew or requested by the
tower. Whitehorse tower requested the aircraft to report
10 mi. final, and advised that sweeping was in progress.
Artist’s impression of risk of collision event, as the CL-600
overflew the two snow sweepers on final approach
Accident Synopses
Accident Synopses
1. In the absence of a stall warning device on amateurbuilt aircraft, pilots may not be able to detect an
impending stall.
Regulations and You
Recently Released TSB Reports
Recently Released TSB Reports
The onset of the stall would likely have been abrupt and
without warning, leaving little time or altitude to effect a
recovery. In this accident, if the aircraft was so equipped, a
stall warning horn may have sounded early enough to give
the pilot time to take action to avoid the stall.
The crew acknowledged the request. The aircraft landed
approximately nine minutes later, at 13:50 Pacific Standard
Time (PST), after flying over two runway snow sweepers
operating on the portion of the runway located before the
displaced threshold for Runway 31L. A position report
was not provided to Whitehorse tower at 10 mi. final
and no landing clearance was issued. The weather report
issued 10 minutes after landing reported the ceiling as
vertical visibility 600 ft, visibility of 3/4 SM in light snow
and drifting snow with a runway visual range (RVR) of
4 500 ft.
Maintenance and Certification
in the climb and the approaching stall symptoms may
have been missed. With a low airspeed, a high angle of
attack, and the engine at climb power, if a stall occurred,
a right wing drop and associated spin is likely. Based on
the location of the crash site, the proximity of the aircraft
to the surrounding trees and power wires, an indication
of right-hand rotation at impact, and the aircraft’s
orientation make this scenario the most plausible.
Maintenance and Certification
Recently Released TSB Reports
6. Whitehorse tower’s instruction to call 10 mi. final
became a prospective memory task with no relevant
memory reminder cue for the first officer. As well, the
significance of the instruction to report 10 mi. final
as a cue for the relieving tower controller to remove
the trucks from the runway and issue the landing
clearance was not recognized by the flight crew; thus
the call was missed.
7. The relieving tower controller relied entirely on the
instruction for the CL-600 to report 10 mi. final to
establish situational awareness prior to the aircraft
entering the Whitehorse control zone. When the crew
did not comply with the instruction to report 10 mi.
final, the relieving tower controller did not receive the
necessary trigger to issue a landing clearance.
Other findings
1. The cockpit voice recorder (CVR) was not secured
following the incident and the incident was not
reported to the TSB by the quickest available means,
which resulted in the loss of beneficial investigative
evidence.
2. Wide area multilateration and automatic dependent
surveillance-broadcast (ADS-B) technology may be
useful tools to enhance tower controller situational
awareness of traffic and reduce the risk of collision
between arriving aircraft and ground vehicles in
non‑radar environments.
Safety action taken
NAV CANADA
On May 15, 2009, as a result of this incident,
NAV CANADA issued Whitehorse Control Tower
Operations Letter 09-04. The letter stated that the
following procedure will be in effect:
On initial contact and in addition to the usual
information (e.g. aircraft identity, type and altitude)
the following must also be obtained from pilots:
• position report from VFR and IFR aircraft which
might include a VFR reporting point, an IFR
navigation aid or distance (DME or GPS) back
from an IFR navigation aid and,
• from IFR aircraft the pilot’s ETA for the airport.
9. The flight crew’s perception was that there were no
vehicles or obstructions in the touchdown zone. The
captain, believing that the trucks were holding until
the flight landed, elected to land without the flight
receiving a landing clearance.
1. There were differences in how the relieving tower
controller, compared to other Whitehorse tower
controllers, routinely handled IFR arrivals which
created the potential for situational ambiguity
between controllers, especially during position
transfers.
Transport Canada
2. A pilot flying’s (PF) attention resources may be
fully occupied, due to moderate to high perceived
workload, when hand-flying an approach using
the HGS under instrument meteorological
conditions (IMC), resulting in a significantly reduced
capacity to monitor radio communications and
provide support to the pilot not flying (PNF).
28
Transport Canada has undertaken, through its National
Operations Branch Oversight Plan, to monitor Whitehorse
tower and other units within uncontrolled or non-radar
environments, in order to identify possible systemic issues
related to communication protocols and the adherence to
those protocols by all air traffic controllers.
Operator
The operator has taken the following safety actions:
•
ASL 3/2012
Increased emphasis on HGS usage for the CRJ fleet.
On November 1, 2009, the CRJ aircraft operating
Regulations and You
Regulations and You
Findings as to risk
Accident Synopses
8. The flight crew’s perception that the approach
clearance meant there was no equipment on the
runway demonstrated a misunderstanding of the
difference between an approach clearance and a
landing clearance relative to the status of the active
runway.
4. The crew had no assurance that other maintenance
vehicles were not on the runway beyond its field of
view. Had there been another vehicle on the unseen
portion of the runway, the decision to continue the
landing would have exacerbated the risk of collision.
Recently Released TSB Reports
Accident Synopses
5. The first officer handled all aircraft-ATC
communications following the decision to conduct
an HGS approach, and several communication errors
subsequently occurred. The pattern of communication
errors was consistent with task saturation.
3. To properly assess applicants for pilot positions,
operators need access to information on experience
and performance that is factual, objective, and
(preferably) standardized. Transport Canada pilot
records are not available to employers—this may lead
to the appointment of pilots to positions for which
they are unsuited, thereby compromising safety.
Maintenance and Certification
4. The mental models of the flight crew and the
Whitehorse tower controller were not aligned;
the flight crew believed the Whitehorse controller
knew their location when tower communication
was established and their current position was not
requested.
Maintenance and Certification
Recently Released TSB Reports
(* This is a major accident report and only the summary and
findings as to causes and contributing factors are listed in the
ASL. Readers are encouraged to read the complete report on
the TSB Web site.)
1. Galling on a titanium attachment stud holding the
filter bowl assembly to the main gearbox (MGB)
prevented the correct preload from being applied
during installation. This condition was exacerbated by
the number of oil filter replacements and the re-use of
the original nuts.
2. Titanium alloy oil filter bowl mounting studs had
been used successfully in previous Sikorsky helicopter
designs; in the S-92A, however, the number of
unexpected oil filter changes resulted in excessive
galling.
3. Reduced preload led to an increase of the cyclic load
experienced by one of the titanium MGB oil filter
bowl assembly attachment studs during operation of
CHI91, and to fatigue cracking of the stud, which
then developed in a second stud due to increased
loading resulting from the initial stud failure. The two
studs broke in cruise flight resulting in a sudden loss
of oil in the MGB.
4. Following the Australian occurrence, Sikorsky and the
U.S. Federal Aviation Administration (FAA) relied on
new maintenance procedures to mitigate the risk of
failure of damaged mounting studs on the MGB filter
bowl assembly and did not require their immediate
replacement.
5. The operator did not effectively implement the
mandatory maintenance procedures in aircraft
maintenance manual (AMM) revision 13 and,
therefore, damaged studs on the filter bowl assembly
were not detected or replaced.
6. Ten minutes after the red MGB OIL PRES warning,
the loss of lubricant caused a catastrophic failure of
ASL 3/2012
29
Regulations and You
On March 12, 2009, at 09:17 Newfoundland Daylight
Time (NDT), a Sikorsky S-92A departed St. John’s
International Airport, N.L., with 16 passengers and 2
flight crew, to the Hibernia oil production platform. At
approximately 09:45, 13 minutes after levelling off at a
flight-planned altitude of 9 000 ft above sea level (ASL),
a main gearbox oil pressure warning light illuminated.
The helicopter was about 54 NM from the St. John’s
International Airport. The flight crew declared an
emergency, began a descent, and diverted back towards
St. John’s. The crew descended to, and levelled off at,
800 ft ASL on a heading of 293° Magnetic with an
airspeed of 133 kt. At 09:55, approximately 35 NM from
St. John’s, the crew reported that they were ditching. Less
than 1 minute later, the helicopter struck the water in
a slight right-bank, nose-high attitude, with low speed
and a high rate of descent. The fuselage was severely
compromised and sank quickly in 169 metres of water.
One passenger survived with serious injuries and was
rescued approximately 1 hour and 20 minutes after the
accident. The other 17 occupants of the helicopter died
of drowning. There were no signals detected from either
the emergency locator transmitter (ELT) or the personal
locator beacons (PLB) worn by the occupants of the
helicopter.
Findings as to causes and contributing factors
Accident Synopses
Accident Synopses
TSB Final Report A09A0016—Main Gearbox
Malfunction/Collision with Water
Wreckage layout: A—Cockpit; B—Upper deck/engines;
C—Sponson; D—Tail rotor; E—Main rotor blades;
F—Cabin area
Recently Released TSB Reports
Regulations and You
•
Maintenance and Certification
•
manual was modified to state that the captain shall
utilize the HGS, when serviceable, for all phases of
flight as both the PF and PNF.
On June 11, 2010, the new Section 7.3.6 of the Flight
Operations Control Manual (New Hire-Line Pilot
Employment Follow-Up Procedure) was published.
This procedure describes the process to evaluate
the performance of new pilots and validate the
effectiveness of training.
Recurrent training on uncontrolled airport
operations has been added as a pre-briefing item.
The training will include procedures published
in the Transport Canada Aeronautical Information
Manual (TC AIM) and will also include reference to
the forthcoming language in the company operations
manual (COM) with respect to supplemental
information that must be communicated to air traffic
services (ATS).
Maintenance and Certification
Recently Released TSB Reports
9. By the time the helicopter crew had established
that MGB oil pressure of less than 5 psi warranted
a “land immediately” condition, the captain had
dismissed ditching in the absence of other compelling
indications such as unusual noises or vibrations.
10. The captain’s decision to carry out pilot flying (PF)
duties, as well as several pilot not flying (PNF) duties,
resulted in excessive workload levels that delayed
checklist completion and prevented the captain from
recognizing critical cues available to him.
11. The pilots had been taught during initial and recurrent
S-92A simulator training that a gearbox failure would
be gradual and always preceded by noise and vibration.
This likely contributed to the captain’s decision to
continue towards St. John’s International Airport.
12. Rather than continuing with the descent and ditching
as per the RFM, the helicopter was levelled off at
800 ft ASL, using a higher power setting and airspeed
than required. This likely accelerated the loss of
drive to the tail rotor and significantly reduced the
probability of a successful, controlled ditching.
TSB Final Report A09P0187—Wake Turbulence
Encounter—Collision with Terrain
On July 9, 2009, a Piper PA-31-350 Chieftain
aircraft was operating under VFR on the final leg of a
multi‑leg cargo flight from Vancouver to Nanaimo and
Victoria, B.C., with a return to Vancouver. The weather
was visual meteorological conditions (VMC) and the
last 9 minutes of the flight took place during official
darkness. The flight was third for landing and turned
onto the final approach course 1.5 NM behind and
700 ft below the flight path of a heavier Airbus A321,
approaching Runway 26R at the Vancouver International
Airport. At 22:08, Pacific Daylight Time (PDT), the
target for the Chieftain disappeared from tower radar.
The aircraft impacted the ground in an industrial area of
Richmond, B.C., 3 NM short of the runway. There was a
post-impact explosion and fire. The two crew members on
board were fatally injured. There was property damage, but
no injuries on the ground. The onboard emergency locator
transmitter (ELT) was destroyed in the accident and no
signal was detected.
14. The throttles were shut off prior to lowering the
collective, in response to the loss of tail rotor thrust.
This caused significant main rotor RPM droop.
15. The pilots experienced difficulties controlling the
helicopter following the engine shut-down, placing
30
ASL 3/2012
Aircraft traffic pattern at 22:04:42
Regulations and You
13. The captain’s fixation on reaching shore, combined
with the first officer’s non-assertiveness, prevented
concerns about the helicopter’s flight profile from
being incorporated into the captain’s decision-making
process. The lack of recent, modern, crew resource
management (CRM) training likely contributed to
the communication and decision-making breakdowns
which led to the selection of an unsafe flight profile.
Accident Synopses
Accident Synopses
8. The pilots misdiagnosed the emergency due to a
lack of understanding of the MGB oil system and
an over‑reliance on prevalent expectations that a loss
of oil would result in an increase in oil temperature.
This led the pilots to incorrectly rely on MGB
oil temperature as a secondary indication of an
impending MGB failure.
16. The severity of the impact likely rendered some
passengers unconscious. The other occupants seated
in the helicopter likely remained conscious for a short
period of time, but became incapacitated due to the
impact and cold water shock, and lost their breath
hold ability before they could escape the rapidly
sinking helicopter.
Recently Released TSB Reports
Regulations and You
7. The S-92A rotorcraft flight manual (RFM) MGB
oil system failure procedure was ambiguous and
lacked clearly defined symptoms of either a massive
loss of MGB oil or a single MGB oil pump failure.
This ambiguity contributed to the flight crew’s
misdiagnosis that a faulty oil pump or sensor was the
source of the problem.
the helicopter in a downwind autorotative descent
with main rotor RPM and airspeed well below
prescribed RFM limits. This led to an excessive rate of
descent from which the pilots could not recover prior
to impact.
Maintenance and Certification
the tail take-off pinion, which resulted in the loss of
drive to the tail rotor shafts.
Maintenance and Certification
Transportation Safety Board of Canada (TSB)
On January 12, 2011, the TSB issued Aviation Safety
Advisory A09P0187-D3-A1, entitled Wake Turbulence
Encounters During Visual Operations in Darkness, to NAV
CANADA and copied to Transport Canada. The advisory
suggested that NAV CANADA may wish to address ways
to reduce the possibilities of hazardous encounters with
wake turbulence within radar service areas during VMC
in darkness.
At 22:06:09, the Chieftain intercepts the localizer 1.5 NM
behind the Airbus, approximately 2.6 NM from the crash site.
Findings as to causes and contributing factors
1. The Piper Chieftain turned onto the final approach
course within the wake turbulence area behind and
below the heavier aircraft and encountered its wake,
resulting in an upset and loss of control at an altitude
that precluded recovery.
2. The proximity of the faster trailing traffic limited
the space available for the Chieftain to join the final
approach course, requiring the Chieftain not to lag
too far behind the preceding aircraft.
1. The current wake turbulence separation standards
may be inadequate. As air traffic volume continues to
grow, there is a risk that wake turbulence encounters
will increase.
2. Visual separation may not be an adequate defence to
ensure that appropriate spacing for wake turbulence
can be established or maintained, particularly in
darkness.
The response indicated that the Working Group has
begun to discuss prescriptive requirements and that the
matter raised in this Advisory has already been discussed
extensively and will be considered further in their
deliberations.
3. Neither the pilots nor the operator were required by
regulation to account for employee duty time acquired
at other non-aviation related places of employment.
As a result, there was increased risk that pilots were
operating while fatigued.
TSB Final Report A09Q0190—Collision with
Cable
4. Not maintaining engine accessories in accordance
with manufacturers’ recommendations can lead to
failure of systems critical to safety.
Other finding
1. The Piper Chieftain was not equipped with any
type of cockpit recording devices, nor was it required
to be. As a result, the level of collaboration and
decision-making discussion between the two pilots
remains unknown.
On November 12, 2009, a privately owned and operated
Robinson R44 II Raven helicopter took off for a VFR
flight from a work site at Baie-Trinité, to Baie-Comeau,
Que. At 12:49 Eastern Standard Time (EST), the
helicopter struck a ground wire atop a power line crossing
the Franquelin River and crashed on the river bank below.
The pilot sustained fatal injuries and the two passengers
on board were seriously injured. A pedestrian discovered
the wreckage at approximately 14:10 and advised the
authorities.
ASL 3/2012
31
Regulations and You
Regulations and You
On March 31, 2011, Transport Canada responded and
advised that in the summer of 2010, the Canadian
Aviation Regulatory Advisory Council (CARAC)
established the Flight Crew Fatigue Management
Working Group. The Working Group has a mandate to
review the Canadian Aviation Regulations (CARs) flight
and duty time limitation and rest period requirements, as
well as make recommendations for change where it is felt
necessary.
Accident Synopses
Accident Synopses
Findings as to risk
The TSB also issued Aviation Safety Advisory
A09P0187-D2-A1, entitled Pilot Fatigue, to Transport
Canada. The advisory suggested that Transport Canada
may wish to consider ways to ensure that all operators
and flight crew take into account non-carrier time
commitments for the purpose of flight crew fatigue
management.
Recently Released TSB Reports
Recently Released TSB Reports
On July 24, 2009, the operator held a wake turbulence
refresher session for all of its pilots.
Maintenance and Certification
Safety action taken
Operator
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
While the aircraft was equipped with a GPS capable of
providing the pilot with obstacle and terrain warnings
when flying at low altitude, only the terrain display
feature was functional in the area the flight took place. In
addition, it could not be determined if the pilot was aware
of those features and associated limitations when used in
Canada. The GPS is an aid to navigation and should not
replace the use of authorized navigation charts.
The 406 MHz emergency locator transmitters (ELT) are
relatively new to the aviation industry. The helicopter’s
ELT installation included a programmable dongle,
information which did not appear on the aircraft
equipment list. The owner completed the required
32
An improperly programmed dongle may result in the
transmission of incorrect information, thereby delaying
search and rescue.
Aerial view of accident site
Findings as to causes and contributing factors
1. The helicopter was flown at low altitude, increasing its
exposure to a collision with obstacles.
2. The sun’s glare likely degraded the pilot’s ability to
detect the unmarked power lines and ground wires in
time to avoid a collision.
ASL 3/2012
Regulations and You
Cables and wires may be unmarked if they are not
considered to be an aeronautical or marine hazard. The
towers atop the cliffs on either side of the river and the
ground wire lines and main power lines were not deemed
a hazard. While the location where Line 1615 crosses
the Franquelin River is not close to an aerodrome, it
is situated on the VFR GPS route from Baie-Comeau
to Sept-Îles. Without careful flight planning, flights
conducted at low level are at increased risk of collision
with unmarked hazards such as wires or other obstacles.
The 406 and 121.5 MHz signals were significantly
attenuated due to the severed antenna cable. The failure
of the Q8 amplifier resulted in an additional attenuation
of the 406 MHz signal. Activation of this type of ELT,
even for test purposes, without a proper load such as an
antenna, can result in damage to its circuitry, rendering
the device unserviceable.
Accident Synopses
Regulations and You
Low flying increases the risk of collision with wires or
other obstacles. The direction of flight into the sun would
have caused glare on the windscreen and would have most
likely decreased the pilot’s forward visibility and ability to
see the wires. Also, the wires were unmarked, rendering
them more difficult to detect. A thorough scan for
obstacles in front and in periphery of the aircraft might
have helped to detect the towers of Line 1615 situated
atop the cliffs on either side of the river. Although the
pilot saw the wires immediately prior to colliding with
them and attempted evasive action, a collision with the
first of the two ground wires ensued.
Recently Released TSB Reports
Analysis
Maintenance and Certification
Cable marking on control tubes
registering of the ELT unit but had not done a periodic
self-test as recommended by the ELT manufacturer.
The maintenance facility had confirmed the ELT unit
tested serviceable but did not know the dongle was
programmable and therefore had not programmed it
or had it programmed to match the owner and aircraft
information. No self-test or transmission test had been
completed since the owner acquiring the aircraft. The fact
that the programmed dongle information supersedes the
ELT-programmed information was not widely known.
The ELT manufacturer recommends a self-test once a
month to verify the integrity of the installation; however,
there are no regulatory requirements to conduct this
self-test. A signal received by the COSPAS-SARSAT
Canadian Mission Control Centre (CMCC) in the test
mode would not necessarily initiate search and rescue in
the same manner as that of a signal received in the normal
mode.
Maintenance and Certification
1. Given the difficulty in seeing unmarked wires, pilots
must plan their flight path appropriately before
operating at low levels, especially in valleys.
2. A dongle that has not been properly programmed
may result in the transmission of incorrect
information, thereby delaying search and rescue. An
ELT self-test would confirm a programming fault.
3. The ELT antenna cable became severed during the
impact sequence, increasing the risk of the signal not
being detected.
Other finding
1. Turning an ELT ON or conducting a self-test
without installing a load (antenna) may overload
the transmission amplifier rendering the unit
unserviceable.
•
On July 12, 2010, the TSB sent an aviation safety
information letter to Transport Canada on the 406 MHz
ELT programmable dongle issue. It highlighted the
importance of informing aircraft operators, owners,
maintainers and avionics facilities of the purpose of the
programmable dongle. A comprehensive article regarding
the ELT programmable dongle was published in Issue 3/2011
of the Aviation Safety Letter.
TSB Final Report A10P0244—Collision with
Terrain
It was established that the aircraft descended more than
400 ft early in the circuit and was flying in a slow climb
toward the edge of the ravine. A slow climb, rising terrain
and the lack of a good horizon reference, are criteria that
could contribute to the development of a low energy
condition. Regardless of engine power, the low energy
condition may not have allowed the aircraft sufficient time
to pull up and establish an adequate climb, even with the
benefit of the partial retardant drop. Airspeed and angle
of attack (AOA) indicators should have provided visual
indications of low energy conditions and impending stall
awareness. But there was no audible or visual alert that
would have drawn the crew’s attention to these indicators.
If the airspeed was low and an overshoot was commanded,
the flaps would have to be retracted to 15°. This would
result in a reduction in the initial rate of climb. The aircraft
was interpreted as going into a descent when observed
by the bird dog crew. However, the bird dog crew did
not know that the Convair was climbing. Without a
horizon reference, a reduction of the climb angle could
appear to the bird dog crew as a change from level flight
to a descent. Maximum power and 12° of flap, as found,
would be consistent with an attempted go-around. While
retracting flaps for a go-around, inadvertently holding the
flap selector switch for one additional second would result
in 2° or 3° more flap retraction than the target setting of
15°. There is no performance data in the aircraft operating
manual (AOM) to determine a potential rate of climb.
ASL 3/2012
33
Regulations and You
On July 31, 2010, at 20:02 Pacific Daylight Time (PDT),
a Convair 580 departed Kamloops to fight a wildfire
near Lytton, B.C. The bombing run required crossing the
edge of a ravine in the side of the Fraser River canyon
before descending on the fire located in the ravine. About
22 minutes after departure, the aircraft approached the
ravine and struck trees. An unanticipated retardant drop
occurred coincident with the tree strikes. Seconds later,
the aircraft entered a left-hand spin and collided with
terrain. A post-impact explosion and fire consumed
much of the wreckage. A signal was not received from
the on-board emergency locator transmitter; nor was it
recovered. Both crew members were fatally injured.
The flight inadvertently entered a low energy
condition approaching the ravine in an attempt to
recover altitude.
A visual illusion affected the crew’s ability to
recognize and assess the aircraft’s proximity to the
rising terrain resulting in this being a controlled flight
into terrain (CFIT) accident.
Accident Synopses
Accident Synopses
In the absence of concrete data from recorders, the
investigation looked at two possible operational factors:
•
2. The GPS terrain display feature was operational
in the area the flight took place; however, the
obstacle warning feature was not. The GPS is an
aid to navigation and should not replace the use of
authorized navigation charts.
Analysis—Operational Factors
Recently Released TSB Reports
Recently Released TSB Reports
Findings as to risk
Safety action taken
Regulations and You
Maintenance and Certification
3. The helicopter struck the ground wire likely rendering
the helicopter partially uncontrollable and it crashed
in the river below.
Maintenance and Certification
Recently Released TSB Reports
3. Visual illusion may have contributed to the
development of a low energy condition which
impaired the aircraft performance when overshoot
action was initiated.
Estimated flight path
However, this should not be an issue because the plan to
climb out following the first intended drop and accelerate
from 120 knots to 140 knots in the 20° flap configuration,
with 7/8 of the load remaining on board, is indicative of the
airplane capability at an appropriate airspeed.
Furthermore, a visual illusion may have affected the crew’s
ability to recognize, or accurately assess, the aircraft’s
flight path relative to the elevation of the rising terrain
which, unbeknownst to the crew, put the aircraft too low
before the edge of the ravine.
The local terrain was mountainous and precluded a good
horizon reference. The flight occurred during the last hour
of daylight in growing shadows and some smoke, which
are factors that affect visibility. The action to continue the
bombing run rather than take the exit route and circle
for another attempt or to jettison the retardant load to
improve the climb performance suggests the crew did not
recognize the imminent danger ahead of them and may
have neglected the altimeter, believing it was reasonable
to continue and assess their progress visually. The criteria
(a slow climb, rising terrain, lack of a good horizon
reference) conducive to a low energy condition can also
be conducive to a visual illusion producing a false sense of
height, as observed during the TSB investigation flight.
The bird dog pilot, however, had the benefit of flying
consecutively lower circuits in the development of the
bombing run to the target fire, and lighting conditions
may have been slightly different. This opportunity may
have reduced the likelihood of a height- or depthperception illusion, and illusions were not discussed in any
briefings to the Convair crew.
34
Findings as to risk
1. Visual illusions give false impressions or
misconceptions of actual conditions. Unrecognized
and uncorrected spatial disorientation, caused by
illusions, carries a high risk of incident or accident.
2. Flight operations outside the approved weight and
balance envelope increase the risk of unanticipated
aircraft behaviour.
3. The recommended maintenance check of the
emergency drop (E–drop) system may not be
performed and there is no requirement for flight
crews to test the E–drop system, thereby increasing
the risk that an unserviceable system will go
undetected.
4. The location of the E–drop selector requires crews
to divert significant time and attention to identify
and confirm the correct switch before operating it.
This increases the risk of collision with terrain while
attention is distracted.
Safety action taken
Operator
Since the accident, the operator has taken further action
to mitigate the risks of recurrence.
1. The glare shield over the flight instrument panel in
the Convair 580 has been modified to improve both
pilots’ view of the top row of flight instruments,
which include the airspeed indicators and the AOA
indicator.
2. A project has been initiated to change the E-drop
selector from a guarded toggle switch to a large pushbutton type switch and relocate it to the middle of
the glare shield, in full view and within reach of both
pilots.
3. A project is underway to modify the existing load
release button on the left-hand control wheel to
ASL 3/2012
Regulations and You
Given the last-second response to avoid a collision with
terrain at the edge of the ravine, and the partial retardant
load drop, it is likely the crew was under the influence of
a visual illusion. The aircraft’s proximity to terrain came as
a surprise to the crew and as a result, affected the crew’s
decisions and actions leading up to the event.
4. The aircraft entered an aerodynamic stall and spin
from which recovery was not possible at such a low
altitude.
Accident Synopses
Accident Synopses
2. Visual illusion may have precluded recognition, or
an accurate assessment, of the flight path profile in
sufficient time to avoid the trees on rising terrain.
Recently Released TSB Reports
Regulations and You
1. It could not be determined to what extent the initial
collision with trees caused damage to the aircraft
which may have affected its controllability.
Maintenance and Certification
Findings as to causes and contributing factors
Maintenance and Certification
Maintenance and Certification
include a safety function which will jettison the entire
retardant load if the button is depressed five times
within three seconds.
4. The operator’s pilot training program is being
amended to incorporate more emphasis on emergency
drop procedures.
5. The operator is developing a stall–g–speed (SgS)1
system for air tanker operations. This system will be
initially installed on the Lockheed L–188 Electra
air tanker.
Accident Synopses
The analysis will focus on the environmental conditions
at the location of the occurrence, and provide a plausible
scenario for the deviation in the flight path that led to
the loss of directional control and rapid descent with no
recovery prior to ground impact.
Deteriorating weather conditions encountered en route
prompted the flight crew to cancel the planned flight
to Kingston and return to Toronto/Buttonville. Radar
data and recorded voice communications indicate that
the return flight was normal until the climbing right
turn. During that turn, airspeed was allowed to decrease
suggesting that engine power was not increased to
maintain a safe airspeed. The aircraft rolled into a steep
1
SgS defines a safety flight envelope for “low speed warning”,
“vertical acceleration (g) warning” and “overspeed warning”. This
system will provide flight crews with trend information relating
airspeed, angle–of–attack, and “g” load information in a visual
display with audio warnings and a stick–shaker function.
left turn with a high rate of descent. The flight manoeuvre
that was observed on radar and further supported
by engineering estimations indicates a left wing stall
followed by an abrupt left wing drop. The abruptness
of the wing stall could have been exacerbated by any
airframe icing which may have accumulated on the wings.
Weather information from other aircraft in the vicinity
and from ground observations indicated that local
weather conditions which included rain, snow, and
freezing rain, were quite different from the conditions
at either Oshawa airport or Toronto/Buttonville
municipal airport. Encountering these weather conditions
unexpectedly may have influenced the crew’s decision to
intentionally deviate to the north to find better weather.
Outside visual reference may have also been hampered by
these weather conditions and by darkness.
Although it is impossible to ascertain who was controlling
the aircraft at the time, it is logical to assume that the
student was at the controls while the instructor was
requesting the approach clearance. When the aircraft
stalled, the instructor would have been attempting to
recover control. The rapidity of the stall, the airspeed
during the descent and the lack of available altitude
prevented a full recovery before the aircraft struck the
ground. This would have been compounded by limited
visual reference due to the weather conditions and
the lack of flight instruments on the right side of the
instrument panel.
There were approximately eight seconds between the
loss of control and when the aircraft struck the ground
assuming a constant rate of descent of 9 600 ft/min.
Ground impact marks show that, although the aircraft
was nose down, it was in a near wings-level attitude,
ASL 3/2012
35
Regulations and You
Regulations and You
Analysis
Location of accident site and weather conditions
Accident Synopses
On November 18, 2010, at approximately 18:19 Eastern
Standard Time (EST), a Beechcraft F33A aircraft
departed Toronto/Buttonville Municipal Airport for
Kingston Airport, Ont., on a night VFR flight with
an instructor and two commercially qualified students
on board. Weather en route began to deteriorate and
the aircraft was headed back to Toronto/Buttonville
Municipal Airport. The aircraft was observed on radar
to be westbound in level flight before it turned north
and began to climb. The aircraft then turned abruptly
to the left and descended; radar contact was lost. The
aircraft was subsequently located in a ploughed level field
approximately 10 NM east of the Toronto/Buttonville
Municipal Airport. It was destroyed on ground impact
and the three occupants were fatally injured. There was
no fire and the emergency locator transmitter (ELT)
did not activate. The accident occurred at approximately
18:44 EST during the hours of darkness.
Recently Released TSB Reports
Recently Released TSB Reports
TSB Final Report A10O0240—Loss of Control
and Collision with Terrain
Maintenance and Certification
The school’s aviation training program is broken up
into different phases. An expanded training program
is being developed for instructors who start training
in a new phase of the program based on their past
experience.
Standby attitude indicators to be installed in
aircraft—The plan is for standby attitude indicators
to be installed in all aircraft that require them. This is
in the event there is a failure of the primary attitude
indicator; the standby attitude indicator can be used
to aid in flying the aircraft.
1. After encountering adverse weather conditions,
a climbing right turn was initiated. During the
climbing turn, engine power was likely not increased
and the airspeed decayed. The angle of attack on the
left wing was allowed to increase until it stalled and
dropped unexpectedly.
•
2. The location of the flight instruments made it more
difficult for the instructor in the right seat to see
and react to them and control of the aircraft was not
regained before the aircraft struck the ground in a
non-survivable impact.
The school has instituted the limits shown below for
single-engine at-night operations:
Safety action taken
Flying school
The flying school has instituted the following changes to
its training program to enhance flight safety:
•
•
•
36
•
•
•
•
•
ASL 3/2012
Regulations and You
Regulations and You
•
•
All night flying is to be conducted in VFR weather
only.
Instrument or IFR training may be conducted at
night in visual meteorological conditions (VMC)
only.
VFR flight plans are to be filed at night outside of the
circuit (no IFR filing even in VMC).
Reported and forecast visibility shall not be less
than 6 SM. Authorized ceiling remains as per its
Operations Manual Section 2.6.
There shall be no visible or forecast precipitation in
the area of operation when flying in temperatures of
5°C or colder (at operating altitude).
No observers are permitted on board training flights
at night, i.e., one student and one instructor only.
Combined lessons where more than one student
participates will be restricted to daytime flying.
Any exceptions to this policy will be at the sole
discretion of the certificated flight instructor (CFI) or
delegate on a case-by-case basis. Accident Synopses
•
Group weather briefing—This is attended by all
instructors and students who will be flying on that
particular shift. By doing this, it is ensured that
everyone has looked at the weather prior to their
flight. The only exception is if a student is going on a
Transport Canada flight test where the student will
be graded by an examiner for checking weather.
Recurrent upset training for instructors—All
instructors to go through upset training in flight
training devices to assist them in any given
circumstances where they need to take control of an
aircraft and recover from an unusual attitude. This
training is done with certain flight instruments failed.
Night flying ground briefing for instructors—A
recurrent training session regarding night flying.
Weather briefing for instructors—A recurrent
training session regarding weather hazards with a
focus on icing.
Briefing on spatial disorientation for instructors—A
recurrent training session reviewing different types of
illusions and preventative measures.
Expanded indoctrination training for new
instructors—New instructors to have an expanded
indoctrination checklist they complete when they
start teaching at the college.
•
Recently Released TSB Reports
Recently Released TSB Reports
Findings as to causes and contributing factors
•
Accident Synopses
•
Maintenance and Certification
suggesting that the recovery had been initiated
but altitude and excessive descent speed precluded
full recovery.
Maintenance and Certification
Recently Released TSB Reports
— On November 6, 2011, a privately operated
Cessna A185E approached a private landing strip at
McKellar, Ont., with a slight tailwind, resulting in the
aircraft floating beyond the intended touchdown point.
An overshoot was initiated and shortly thereafter, the
aircraft stalled, dropping the left wing. The aircraft
struck the ground adjacent to the left side of the
runway and sustained substantial damage to the
landing gear and propeller. The pilot, wearing a threepoint harness, was uninjured. The emergency locator
transmitter (ELT) activated and was turned off by the
pilot. TSB File A11O0211.
— On November 17, 2011, the pilot of a Cessna 172
was flying locally and practising circuits at the airport at
Ottawa/Rockcliffe (CYRO), Ont. During the landing
approach, at a height of approximately 10 ft over
Runway 27, the stall warning horn sounded and the pilot
added power. The added power was insufficient and the
aircraft stalled and hit the ground hard, bending the nose
gear and right main landing gear. The aircraft veered
off the runway and struck its right wing and stabilizer
before coming to a rest near Taxiway Bravo. The pilot and
two passengers were uninjured, but the aircraft suffered
substantial damage. TSB File A11O0215.
— On November 22, 2011, a student pilot was receiving
tail-wheel training in a Bellanca 7ECA in the circuit
at Bassano (CEN2), Alta. The exercise was crosswind
landings and departures, with a crosswind of about 45°
from the left. On climb-out after a touch-and-go, the
instructor in the rear seat failed the engine for a forced
landing. He expected the pilot to turn left into wind for
a landing in the adjacent open field. Instead, the pilot
attempted to land straight ahead as he had been taught.
The instructor took control just prior to a hard landing
that resulted in damage to the right-hand fuselage,
landing gear, propeller and engine. There were no injuries.
TSB File A11W0178.
— On November 23, 2011, a private Piper PA24‑250
was on a VFR flight from Kitchener/Waterloo (CYKF),
Ont., to Burlington (CZBA), Ont. During the approach,
the landing gear was not selected down and the aircraft
landed with the gear fully retracted. The aircraft
sustained damage to the propeller, engine and lower
fuselage skin. The pilot, the sole occupant, was uninjured.
TSB File A11O0233.
— On November 26, 2011, a Cessna 150L had departed
on a VFR flight from the airport at Bromont (CZBM),
Que., to Québec/Jean Lesage International Airport
(CYQB), Que. Approximately 15 min after takeoff, the
engine (Teledyne Continental O-200-A) lost power,
decreasing from 2 400 RPM to 2 000 RPM and then
to 1 200 RPM. The pilot made a forced landing in a
field. During the final landing phase of the flight, the
left wing was sectioned when it hit a telephone pole,
causing the aircraft to pivot left. The right main landing
gear collapsed and the tail section was bent. The two
occupants sustained minor injuries. The aircraft was
substantially damaged. The temperature and dew point
were conducive to serious carburetor icing conditions.
TSB File A11Q0218.
— On November 26, 2011, an AS350 B2 helicopter was
supporting drill operations from a staging area located
6 NM west of the airport at Wabush (CYWK), N.L.
The pilot landed the aircraft, keeping the main rotor at
ASL 3/2012
37
Regulations and You
— On November 19, 2011, a Piper J-3C-65 was on a
VFR flight in the Boisbriand, Que., region. The pilot
was accompanied by one passenger. The pilot had earlier
landed without incident in an adjoining field. Although
the wind was from the northwest, the final approach to
the field being used as a landing strip was conducted in
a southerly direction. Although its speed was 50 mph,
the aircraft pitched nose-down at a height at which the
pilot was unable to regain control. The aircraft crashed but
did not catch fire. Both occupants were quickly rescued
and were transported to hospital with serious injuries.
TSB File A11Q0212.
Accident Synopses
Accident Synopses
— On November 4, 2011, a privately operated
Cessna 182G experienced a brake failure while being
taxied into a parking position at the airport at Sudbury/
Coniston (CSC9), Ont., resulting in a collision with an
adjacent Cessna 172L, and causing substantial damage
to the right wing and propeller of the 182 and damage to
the left wing and propeller of the 172. The 182 had been
brought to a complete stop without any braking difficulty
after taxiing clear of the runway. After the mishap,
the right brake pedal went completely to the floor.
TSB File A11O0209.
Recently Released TSB Reports
Regulations and You
Note: The following accident synopses are Transportation Safety Board of Canada (TSB) Class 5 events, which occurred between
November 1, 2011, and January 31, 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.
Maintenance and Certification
Accident Synopses
38
— On January 3, 2012, an R44 II helicopter was
repositioning in a hover along a tree-lined road about
75 NM north of Fort St. John, B.C., when the main rotor
blades clipped a tree. Control was lost, and the helicopter
rolled on its side. The aircraft was substantially damaged,
and the pilot and passenger sustained minor injuries. The
406 MHz emergency locator transmitter (ELT) activated.
TSB File A12W0001.
— On January 5, 2012, a Cessna 172I was on a local
flight in the vicinity of St. Claude, Man., with only the
pilot on board. The pilot landed the aircraft in a northerly
ASL 3/2012
Regulations and You
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
— On December 4, 2011, a Piper PA-44-180 aircraft
was on a local flight with a pilot and instructor on board.
During an approach to land at Gander, N.L., the landing
gear was selected down and an unsafe nose indication
was received. The pilot observed the nose gear down in
the mirror on the cowling, and the tower confirmed the
gear was down when the aircraft did a fly-by. The gear was
cycled a few times and although an emergency extension
was carried out, the nose gear still did not show down
and locked. Numerous attempts were made to jolt the
nose gear down into the locked position, but all were
unsuccessful. The pilot declared an emergency and was
cleared to land on Runway 21 with emergency response
services (ERS) on standby. After touchdown, the nose
gear collapsed and the aircraft came to rest about 3 200 ft
from the intersection of runways 13 and 34. There were
no injuries and the aircraft sustained damage to the
nose landing gear doors, nose gear and lower fuselage.
Company maintenance noted that one of the nose gear
door rods had fractured, which would have prevented the
nose gear from coming down. TSB File A11A0093.
— On December 15, 2011, a Beech King Air 100 took
off, with two pilots on board, from Val-d’Or, Que., on an
IFR flight to Rouyn, Que. Having carried out a missed
approach procedure because of bad weather at Rouyn,
the aircraft returned to land at Val-d’Or. During the
ground run, around 500 ft from the touchdown point,
the landing gear lever was inadvertently pulled instead
of the flap lever. The main gear retracted during the
ground run. The propeller of the right engine struck the
runway surface, the flaps and gear doors were damaged
as well as a part of the belly surface. The aircraft came to
rest on the runway and both pilots walked away unhurt.
TSB File A11Q0231.
Accident Synopses
Regulations and You
— On December 3, 2011, a Cessna 172 was overturned
by the propeller blast from a Convair 340 that was doing
a maintenance-related full-power run-up at Kelowna
Airport (CYLW), B.C. The Cessna was taxiing on an
uncontrolled section of the airport, en route for takeoff
to conduct flight training. The flight instructor and the
student on board the Cessna were not injured, but the
aircraft was substantially damaged. TSB File A11P0163.
— On December 8, 2011, an amateur-built CUBY
aircraft ground-looped upon landing at the airport in
Sorel, Que. The pilot, who was the only person on board,
was not injured. The aircraft was significantly damaged.
TSB File A11Q0227.
Recently Released TSB Reports
— On December 3, 2011, a privately operated Luscombe
Silvaire 8F airplane on floats was being taxied for
takeoff on Smiths Mill Pond, near Scotland, Ont. After
taxiing a short distance, the pilot attempted to turn back
to shore because of ice on the intended take-off path.
During the turn, the outside float caught beneath the ice,
resulting in the aircraft nosing over and coming to rest
inverted. Neither the pilot nor the passenger was injured;
both egressed safely. Both floats sustained damage,
allowing water to leak into the forward compartments.
TSB File A11O0232.
— On December 6, 2011, a DHC-6-300 was on a
night cargo flight from Iqaluit, Nun., to Kimmirut,
Nun. During the area navigation (RNAV) approach to
Runway 34, the crew noticed an increase in the ground
speed due to an estimated 10-to-15-kt tailwind. The
reported surface wind was from the east and estimated
to be 10 kt. In an attempt to land as close as possible to
the runway threshold, the pilot at the controls reduced
the power to idle when the aircraft was on short final.
However, the aircraft touched down on rocky ground
approximately 5 to 10 ft before the runway threshold. The
right wheel struck a large rock and the right landing gear
strut broke. Having spun 180°, the aircraft came to rest in
the middle of the runway. Neither of the two pilots, the
sole occupants of the aircraft, sustained any injury. Repairs
were carried out and the aircraft was ferried to Iqaluit for
further repairs. The crew was aware of a NOTAM stating
that the light on the wind direction indicator was out of
service. The emergency locator transmitter (ELT) did not
activate. TSB File A11Q0220.
Maintenance and Certification
full RPM, but while he turned in his seat to retrieve his
gloves from behind him, the helicopter lifted and abruptly
turned right. The pilot was unable to reach the collective,
cyclic and pedal controls in time to arrest the lift-off and
right turn. The collective lock latch had not been secured.
The helicopter turned over and came to rest on its right
side approximately 30 ft from the original landing spot.
The pilot was seriously injured. One person working on
the ground was not injured. The aircraft was substantially
damaged. TSB File A11Q0217.
Maintenance and Certification
Recently Released TSB Reports
— On January 30, 2012, a Bell 212HP helicopter on
heli-ski operations near McBride, B.C., was struck by
an avalanche. The helicopter had dropped off skiers at
the top of the ski run and the pilot was in the process of
shutting down the Pratt &Whitney PT6T “twin-pack”
engines after landing at the staging area at the bottom of
the hill. The rotors were turning at idle RPM when the
helicopter was struck by the avalanche. The snow pushed
the helicopter onto its side and broke the tail boom. The
pilot was the only person on board and he escaped with
minor injuries. The avalanche did not affect the skiers.
TSB File A12P0014. Accident Synopses
— On January 22, 2012, a Cessna 205 departed
Springhouse Airpark (CAQ4), B.C., around 08:30 Pacific
Standard Time (PST) to conduct moose inventory in
the Big Creek area, about 70 NM southwest of Williams
Lake, B.C. About an hour later, Caribou Fire Centre
noticed the aircraft’s on-board tracking system was
displaying a red icon, and the pilot had not radioed in as
required. The appropriate authorities were notified and a
company aircraft departed CAQ4 to locate the missing
aircraft. The search aircraft received an emergency locator
transmitter (ELT) signal, but was forced to return to
CAQ4 due to turbulence. A search and rescue (SAR)
Buffalo aircraft located the crash site at about 13:00 PST
and paradropped SAR technicians. A SAR Cormorant
helicopter and a Bell 206B arrived about half an hour
later and transported the pilot, three passengers and
SAR technicians to Williams Lake. At the time of the
accident the sky was overcast and as a result of the flat
— On January 29, 2012, a Cessna A185F equipped with
Fluidyne 3600-type retractable skis was taxiing on the
snow-covered surface of Lake Mercier, Que., to go to the
take-off area. Because there was water under the snow
covering, the pilot had to maintain a speed of around
25 kt. The right ski went under the snow, which caused
the aircraft to flip over. There was damage to the propeller,
the right wing and the empennage. None of the four
occupants was injured. TSB File A12Q0016.
Recently Released TSB Reports
Accident Synopses
— On January 7, 2012, a Eurocopter AS350 BA
helicopter had lifted off to reposition for refuelling
in a seismic operation staging area 20 NM west of
Steen River, Alta., when the long line became entangled
in the tail rotor. The aircraft landed with no injuries to the
pilot, and substantial damage to the helicopter’s tail rotor
system and tail boom. TSB File A12W0002.
light, the aircraft was flown low over the snow-covered
terrain to allow the spotters to identify moose tracks.
At the end of a run heading toward rising terrain, the
aircraft encountered a strong downdraft and was unable
to outclimb the terrain. It struck the hillside at about
7 300 ft above sea level (ASL), overturned and was
significantly damaged. One spotter was thrown from
the aircraft on impact and received minor injuries.
The pilot and the other two spotters were not injured.
TSB File A12P0010.
Maintenance and Certification
direction on a provincial road and the left wing came
up during the landing roll. The pilot lost directional
control of the aircraft and hit a utility pole. The pilot
was not injured and the aircraft was substantially
damaged. The winds were from the west, gusting to 18 kt.
TSB File A12C0003.
On July 4, 2012, Transport Canada announced new regulations requiring the
installation and operation of Terrain Awareness and Warning Systems (TAWS)
in private turbine-powered and commercial airplanes configured with six or
more passenger seats.
Regulations and You
Regulations and You
Terrain Awareness and Warning Systems - Regulations Published in
Canada Gazette Part 2
For details, click HERE, and also consult Advisory Circular (AC) No. 600-003. ASL 3/2012
39
Maintenance and Certification
Recently Released TSB Reports
In a previous Aviation Safety Letter (ASL) article, we
indicated that Transport Canada Civil Aviation (TCCA)
has recently published internal guidance material related
to the suspension or cancellation of a Canadian aviation
document (CAD), typically a licence or certificate issued
by TCCA. This information was published in TCCA
staff instructions SUR-014, SUR-015 and SUR-016. In that
article, we indicated that we would delve further into the
legal authority the Minister has to suspend or cancel these
documents.
unless immediate action is taken to neutralize the threat,
an aircraft accident causing death, injury or significant
damage to property is likely to occur imminently.
40
ASL 3/2012
Regulations and You
An example of an “immediate threat to safety” would
be a pilot who refused to de-ice and who proceeded for
takeoff after he had been made aware that there was ice
or snow adhering to the critical surfaces of his aircraft.
In this context, the “threat” that is likely to pose a risk
of death, injury or significant property damage is an
aircraft accident resulting from the imminent attempt
We would now like to provide some detail regarding the
to take off in the knowledge that the performance of the
suspension of a CAD under the authority of section 7
aircraft would be degraded by the ice or snow adhesion.
of the Aeronautics Act (the Act), that is to say—the
Therefore, a TCCA inspector could, where verbal
suspension of a CAD in response to an “immediate threat
notification of the surface contamination was being
to aviation safety”.
ignored by the pilot, serve the pilot with notice of pilot
licence suspension. Wilfully disregarding a suspension
While the Act gives the
is an additional offence of a
An immediate threat to aviation safety is a
Minister of Transport
serious nature under section 7.3
threat to the safety of an aircraft that creates a of the Act.
the authority to suspend
a CAD when there are
reasonable expectation that unless immediate
grounds to believe there
Due to the immediate nature
action is taken to neutralize the threat, an aircraft of such a threat, a CAD
is an immediate threat to
accident causing death, injury or significant
aviation safety, the Act
suspension under this section
does not provide much
damage to property is likely to occur imminently. takes effect immediately, and
detail in describing what
no procedural constraints
an “immediate threat to
delay the coming-into-effect
aviation safety” is. For that reason, we have attempted to
of this type of suspension—except for the requirement
define it by rationalizing the two key words used in the
to provide a notice to the holder of the CAD whose
phrase, those being: “immediate” and “threat”, as they
CAD is being suspended. Additionally, once the threat
relate to aviation safety.
has been neutralized, the suspension is to be withdrawn.
This authority is used only if an immediate threat to
While a common use of the word “threat” can be
aviation safety exists. The Act recognizes and identifies
interpreted rather broadly, in the context of aviation
the transient nature of such threats by providing authority
safety, and for the purpose of providing guidance to
to suspend only; cancellation of a CAD is not authorized
TCCA inspectors, we have defined “threat” as a condition
under this section of the Act. A CAD suspension under
that is likely to pose a risk of injury, death or significant
section 7 is not used to address past regulatory nonproperty damage, as a result of an aircraft accident. While
compliance or any other identified safety deficiencies that
other threats may exist within aviation, such as risks to the
are not of an urgent or immediate nature; it is used only
health of ground personnel related to working conditions,
to address existing and identifiable threats to safety that
or financial risks related to business operations, the
are of an urgent or immediate nature. Other actions can
“aviation safety” context limits the scope of the section 7
be taken with regard to the circumstances that lead to the
authority. The word “immediate” can be interpreted as
immediate threat developing, but any other action would
qualifying something that currently exists or is about
have to be taken under different sections of the Act, and
to exist imminently or without delay. Therefore, an
such actions would take longer to implement and would
immediate threat to aviation safety is a threat to the safety
involve more procedural fairness in their application.
of an aircraft that creates a reasonable expectation that
Accident Synopses
Accident Synopses
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
Recently Released TSB Reports
Regulations and You
Suspension of Canadian Aviation Documents—Immediate Threat to Aviation Safety
Maintenance and Certification
regulations and you
Maintenance and Certification
For more information on the subject, please refer to Staff
Instruction SUR-014. In light aviation, this protection is provided to pilots
who report an event to the Recueil d’Événements
Confidentiels (REC) [confidential reporting system]
created by France’s Bureau d’Enquêtes et d’Analyses pour la
Sécurité de l’Aviation Civile (BEA) [civil aviation accident
investigation agency]. The report is not anonymous, but
it is confidential; those involved are not identified in the
reports of the REC.
Accident Synopses
In order to promote trust, it is essential that reported
occurrences are dealt with in the strictest confidence.
In a small organization like a flying club, this is the
responsibility of the “flight safety representative”, as
distinct from the chief pilot.
In this environment, a “just culture” means:
•
•
•
•
•
In cases of error or involuntary infringement, no
sanction is imposed.
All events involving flight safety must be reported to
the flight safety representative.
Reported incidents are treated as confidential
(no public confession!) and feedback is used in a
depersonalized form.
Sanction is imposed in cases of deliberate or repeated
breach of safety regulations, or of failure to report any
obviously significant incident.
Since all those involved are called upon to
acknowledge their errors and omissions, a request for
retraining is not seen as a sanction, but as a normal
part of the process.
Often, these aspects of a “just culture” are already
in place, but they should be set down in specific
internal regulations that everyone is aware of and
that are applied. Regulations and You
1
Establishing a “just culture” in a flying club
www.rcaf-arc.forces.gc.ca/dfs-dsv/page-eng.asp?id=1464.
ASL 3/2012
Accident Synopses
- The main focus of the FS Program is on the
prevention of occurrences. Although cause factors
are assigned to occurrences, this is only done to
assist in the development of effective preventive
measures (PMs).
- Personnel involved in conducting and
supporting flying operations are expected to
freely and openly report all FS occurrences and
FS concerns.
- In order to determine the cause of occurrences
so that appropriate and effective PMs can be
developed and implemented, personnel involved
in conducting and supporting flying operations
are expected to voluntarily acknowledge their own
errors and omissions.
- In order to facilitate free and open reporting
and voluntary acknowledgement of errors and
omissions, the FS Program does not assign
blame. Personnel involved in a FS occurrence
are de-identified in the final reports and the
reports themselves cannot be used for legal,
administrative, disciplinary or other proceedings.
Recently Released TSB Reports
Recently Released TSB Reports
And so, while this authority is rarely used by TCCA, it
is important that it exists and that CAD holders know
that TCCA inspectors have the legal authority to take
immediate action, and will do so whenever necessary to
neutralize an immediate threat to aviation safety.
(A Just Culture...continued from page 42)
The four basic principles of the Canadian Air Force’s
Flight Safety (FS) Program provide another interesting
example1:
Regulations and You
detain the aircraft until the safety issue can be dealt with
in another way.
Maintenance and Certification
Certainly, it would be a rare circumstance where this
authority would need to be used; there are not many
CAD holders (pilots, operators, etc.) who, when apprised
of an immediate threat to aviation safety, would continue
the aircraft operation, knowing that an accident is
imminent. In fact, should such a circumstance arise, that
is—where a CAD holder is not concerned enough about
their own safety or the safety of their passengers to put
a stop to a flight that is likely to end in an accident—a
suspension of a licence or certificate may not be a strong
enough response to eliminate the immediate threat.
In these cases, it may be necessary to use the authority
under a different section of the Act (section 8.7) to
41
The Civil Aviation Medical Examiner and You
By Arnaud Delmas. This article is one of many excellent articles published by Jean Gabriel Charrier and his team on the
French www.mentalpilote.com Web site. It was translated from its original version and is reproduced with permission.
From a “punitive culture” to a “just culture”
Since ancient times, people have always been held
responsible for their actions, even unintentional errors.
Is it the notion of “an eye for an eye, a tooth for a
tooth” that holds in check the desire for justice—or
vengeance—felt by victims’ families and the public? As
human beings, we believe that the person responsible is
also the person to blame.
This interpretation of justice or the “punitive culture”
has not evolved very much, except regarding the types of
punishment, which are far less barbaric! Under the French
penal code, not only negligence or carelessness, but also
clumsiness or lack of attention are considered just cause to
impose a heavy penalty, such as death or serious injury, on
the person responsible for an accident.
- unjust, because a mishap and the deliberate
violation of rules are condemned in equal
measure;
- ineffective, because contrary to the “one rotten
apple theory”, we all, without exception, make
mistakes. It is unrealistic to claim that human
error can be eradicated!
In fact, a “punitive culture” does not differentiate between
the mistake that constitutes a deliberate infringement of a
rule and the error that is unintentional. Error can be seen
as an unintentional infringement.
In our increasingly litigious society, where we are all
trying—quite rightly—to protect ourselves, the “punitive
culture” has two adverse effects on aviation:
And yet, to achieve progress in the field of safety, it is
much more effective to analyze the errors made by those
who were lucky enough to escape and who are willing to
talk about it, rather than to try to get the wrecks and the
42
Flight safety is based, therefore, on transparency and
on the sharing of information. Indeed, to be effective,
all feedback systems rely on each person’s willingness to
provide essential safety information, which often means
being prepared to report one’s own mistakes and errors.
It is essential to establish a “just culture” in order to
create a climate of trust that encourages and facilitates
communication and the sharing of information.
A “just culture”
The concept of a “just culture” is based on a non-punitive
attitude toward human error. Voluntary transgression on
the other hand must be punished.
Professor James Reason defines a just culture as “an
atmosphere of trust in which those who provide essential
safety-related information are encouraged and even
rewarded, but in which people are clear about where
the line is drawn between acceptable and unacceptable
behaviour.”
European Union states and organizations have proposed
the following definition: “A culture in which front‑line
players are not punished for actions, omissions or
decisions proportional to their experience and training,
but also a culture in which serious negligence, deliberate
violation and destructive acts are not tolerated.”
France’s Civil Aviation Code (s. L 722-3) states that: “No
administrative, disciplinary or professional sanction can
be imposed on persons who have reported a civil aviation
accident or incident or an event..., under the conditions
stated in section L. 722‑2, whether or not those persons
were involved in the accident, incident or event, unless
those persons were themselves guilty of a deliberate or
repeated breach of the safety regulations.” [Translation]
continued on page 41...
ASL 3/2012
Debrief
Debrief
- refusal to take risks, which is arguably an
application of the “precautionary principle”;
- failure to divulge errors so as to “preserve the
right of defence”.
Serious accidents are only the tip of an iceberg of
accidents, incidents and events that are significant for
flight safety. By reducing the number of these events,
it is hoped that the likelihood of a serious accident can
also be reduced. To achieve this reduction, it is first
necessary to acquire a good understanding of the causes
of each event.
Debrief
Debrief
Aviation is one of the high-risk activities in which
complex systems are in play, and safety is a determining
factor. This “punitive culture” is increasingly perceived by
the operators of these systems as unjust and ineffective:
witnesses to give up their secrets when those involved in
the tragedy are dead.
Debrief
Debrief
A Just Culture
The Civil Aviation Medical Examiner and You
debrief
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