aviation safety letter In this Issue...

aviation safety letter In this Issue...
TP 185E
Issue 4/2011
aviation safety letter
In this Issue...
The Cycle of Improvement in Aviation Safety
Update: Floatplane Operators Association of British Columbia
Reducing the Risk of Runway Excursions
CFIT in Algonquin Park: a “Get-Home Itis” Case Study?
Rotorcraft Technology and Safety
Wildlife Hazards: Updates and Advice
Do the Right Thing
Issuance of Maintenance Authorizations
False Representation and Entries
Learn from the mistakes of others;
you’ll not live long enough to make them all yourself ...
TC-1004403
*TC-1004403*
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ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Table of Contents
sectionpage
Guest Editorial..................................................................................................................................................................3
Pre-Flight...........................................................................................................................................................................5
Flight Operations..............................................................................................................................................................11
Maintenance and Certification........................................................................................................................................18
Recently Released TSB Reports......................................................................................................................................23
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Three R44 Helicopters Fuelled with Jet Fuel!................................................................................................36
2011 Self-Paced Study Program.....................................................................................................................................Tear-off
2
ASL 4/2011
The Cycle of Improvement in Aviation Safety
Guest Editorial
Guest Editorial
guest editorial
On June 3, 2011, near Bedwell Harbour, B.C., a privately registered Cessna 180 yawed during
take-off causing one wing to touch the water, flipping the aircraft and its passengers into the sea.
“The pilot and the only other occupant had read and used Transport Canada’s seaplane safety
literature,” noted the Transportation Safety Board of Canada (TSB) occurrence report. “They were
both able to escape with little or no injury.”
Gerard McDonald
Last year, in July, after a floatplane accident, two passengers claimed the only reason they survived was due to the preflight safety briefing. C-FAX 1070, one of the highest rated news/talk radio stations in B.C., aired a segment featuring
our own Nicole Girard, Director, Policy and Regulatory Services, to discuss the passengers’ story and TC’s role in the
well-being of those passengers.
To the Letter
To the Letter
At Transport Canada (TC), our employees picked up on that line and it was acknowledged that the collaborative work
between TC and industry was benefiting Canadians.
“That’s why Transport Canada recently increased awareness in this regard,” said Nicole. “As we’ve seen, certainly a good
pre-flight briefing can help save lives.”
The above incidents represent the end-results of the collective efforts of our employees and those at the TSB. Together,
our goal is to minimize incident occurrences and maximize survivability in the event that an accident does occur.
That is the reason for the interdependent relationship between TC and the TSB.
It is about real results for Canadians and perpetual progress in transportation safety.
The TC-TSB relationship
The TSB investigates air, marine, rail and pipeline incidents. From these investigations, the TSB identifies causes and
recommends improvements to avoid future occurrences. TC uses these recommendations and data from other sources to
determine ways to strengthen the aviation safety program.
On March 16, 2010, the TSB released a watchlist of safety recommendations to enhance the safety of transportation.
On that watchlist, the TSB highlighted the risk of aircraft under crew control colliding with land and water.
Pre-flight
Pre-flight
TC and the TSB share a common goal: maintaining and improving transportation safety for Canadians.
Not long after, the Minister of Transport, Infrastructure and Communities committed a series of initiatives aimed
not only at preventing the type of accident that caused the Cessna to collide with the water, but also at improving a
passenger’s chances of surviving.
This cycle—from the initial TSB recommendation to the work of our employees to the implementation of floatplane
safety initiatives—represents the process whereby together we enhance aviation safety in Canada. It is how we realize
our shared vision of an improving, evolving transportation safety system for Canadians.
Winter Operations
Winter Operations
In June of that year, our Civil Aviation employees launched a floatplane safety awareness campaign for passengers and
commercial operators. Through this campaign, our employees produced the floatplane safety literature that the pilot and
passenger of the Cessna noted reading before takeoff.
TC is also in the final stages of implementing regulations that would require the installation and operation of Terrain
Awareness Warning Systems in commercial air taxi, commuter and airline operations. If implemented, this would
drastically reduce the risk of aircraft under crew control colliding with land or water.
ASL 4/2011
3
In the next year, TC is moving to modernize our process to respond to TSB recommendations. Our consultative,
transparent approach to rulemaking is one of the best. Yet, this process needs to be quicker. We want to speed up
the recommendation-consultation-action cycle, thereby implementing safety initiatives at a much quicker rate and
potentially avoiding would-be-accidents.
When this process is complete, we aim for our rulemaking process to be more efficient, more effective and more
responsive to safety priorities. We will do this by bringing together the right people at the right time on the right issues
through a focus group. This group will then determine the best course of action for a given TSB recommendation. The
proposed actions of the focus group will then be put to the larger aviation community.
Guest Editorial
Guest Editorial
How we intend to make the TC-TSB relationship stronger
This model is being tested for a set of recommendations released by the TSB in February, 2011.
A closer look at TC’s rulemaking modernization project
This summer, TC created a small, specialized group of stakeholders directly involved in offshore helicopter operations
to review the TSB’s recommendations. The group will produce a complete package of proposed actions. If a proposed
action requires a rule change, TC will consult the larger aviation community.
At the Leading Edge of Aviation Safety
To the Letter
To the Letter
On 12 March, 2009, a Sikorsky S-92A on a flight to the Hibernia oil rig struck the water at a high rate of descent after
it had a total loss of oil in the transmission’s main gear box. Two years later, the TSB concluded its investigation and
released its accident report, which contained four recommendations to enhance safety.
Our business is risk management. We are in the business of percentages. An accident is the result of a single factor or a
combination of factors, usually the latter. These factors increase the risk of an incident occurring. Therefore, our mandate
is to seek out those contributory factors and eliminate them, thereby reducing the chance of an adverse incident. TSB
recommendations support this process. TSB investigations outline the sources of risk; we put the regulatory framework
and the oversight structure in place to eliminate those risks.
That is how we manage risks, manage percentages and advance aviation safety.
Gerard McDonald
Assistant Deputy Minister, Safety and Security
Transport Canada, Civil Aviation
Pre-flight
Pre-flight
Canada has one of the safest aviation systems in the world. Together, TC, the TSB and you can make it even better.
2011-2012 Ground Icing Operations Update
Winter Operations
If you have any questions or comments regarding the above, please contact Doug Ingold at douglas.ingold@tc.gc.ca.
4
ASL 4/2011
Winter Operations
In July 2011, the Winter 2011–2012 Holdover Time (HOT) Guidelines were published by Transport Canada. As
per previous years, TP 14052, Guidelines for Aircraft Ground Icing Operations, should be used in conjunction with
the HOT Guidelines. Both documents are available for download at the following Transport Canada Web site:
www.tc.gc.ca/eng/civilaviation/standards/commerce-holdovertime-menu-1877.htm.
To the Letter
by Lyle Soetaert, President, Floatplane Operators Association of British Columbia
The Floatplane Operators Association of
British Columbia (FOA) is up and running! Our status
as a not-for-profit organization was approved in early
March 2011, and we held our first annual general meeting
on April 12, 2011. Our mandate is to establish best
practices, together with a consistent culture of safety
across the industry. The successful launch is due to the
tremendous support we have received from the industry,
Transport Canada (TC) and the Transportation Safety
Board of Canada.
Our members consist of all commercial floatplane
operators in the province, organizations with a vested
interest in the B.C. floatplane industry (associate
members), and individuals from across the province.
Our elected board of nine members represents all sizes
of operators and the entire geography of B.C. floatplane
activity. Additionally, one of the board members
represents our associate members with full input with
respect to discussions and decision-making processes. We
are proud to announce that our associate members elected
Viking Air Ltd. of Victoria, B.C., to hold this position.
As with any new organization, we need to “put the rubber
to the road” and demonstrate value to our members. So,
what have we been doing? Our first order of business was
to establish several committees to perform research and
provide recommendations to the board. We immediately
formed our Safety Committee and charged it with
investigating options and recommending best practices
for the use of life preservers by our passengers. We are
very happy to report that the committee came back with
several options, all of which meet the existing standards
and can be readily adopted by our members (details can
be found on our Web site, please see below). The committee is
continuing to work on this issue and is improving on the
existing recommendations to ensure our passengers’ safety.
operational issues. We made contact with the Medallion
Foundation of Alaska and have begun discussing how our
organizations can collaborate to reduce aviation accidents
and improve safety.
We then participated in the Civil Aviation Safety Officer
Partnership sponsored by NAV CANADA. Operators,
airport managers, and NAV CANADA specialists
gathered to share safety information and discuss methods
of improvement. Our participation brought forward
industry concerns regarding webcam placement and
usage, wake turbulence concerns around airports, and our
ability to provide feedback about proposed changes. The
forum was very productive; we now have input regarding
issues directly affecting us and we have regular contact
with NAV CANADA.
As the word about us spread, the Air Transport
Association of Canada (ATAC) invited us to participate
in their Special Flight Operations Committee meeting to
establish a position on the work of the Transport Canada
Flight Duty Times & Fatigue Management Working
Group. We were able to provide a different perspective as
703 and 704 operators, and we voiced our concerns with
respect to this very important issue, which continues to be
examined. Following this meeting, we attended ATAC’s
Industry Symposium on Regulatory Services. Our
ASL 4/2011
5
Winter Operations
We have also been very busy connecting with similar
organizations both here and in the United States, and
with our partners in government. We attended the
Federal Aviation Administration (FAA)-TC Cross
Border Aviation Summit in Anchorage, AK, which was
the first time the B.C. floatplane industry was represented
at this meeting. We were able to share best practices
with our northern cousins and discuss similar safety and
Viking Air Ltd. provided this Beaver door mounted with a
popout emergency exit window.
Pre-flight
Pre-flight
Update: Floatplane Operators Association of British Columbia
To the Letter
Winter Operations
Update: Floatplane Operators Association of British Columbia.................................................................................... page 5
COPA Corner: Flying is Fun, Flying an Ice Cube is Not............................................................................................... page 6
Reducing the Risk of Runway Excursions........................................................................................................................ page 7
Fuel Cargo System in a Canadian Aircraft...................................................................................................................... page 9
Guest Editorial
Guest Editorial
pre-flight
Last, but definitely not least, we attended the Civil
Aviation Executives Safety Network meeting sponsored
by TC. Over 100 individuals from across all aspects of
aviation and aerospace were in attendance. The subject,
“Leading for Tomorrow: Setting the Course for Aviation
in Canada”, involved a remarkable discussion on how the
aviation industry and TC can work together to ensure a
vibrant and sustainable future. We brought forward our
unique industry concerns and helped develop priorities
for TC and the aviation and aerospace sector.
Contact info:
Floatplane Operators Association of British Columbia
PO Box 32366, YVR Domestic Terminal RPO
Richmond, BC V7B 1W2
www.floatplaneoperators.org The information shared and the personal contacts forged
at these events are invaluable. We are working diligently
to foster more relationships and expand our ability to
make commercial passenger floatplane travel the safest it
COPA Corner: Flying is Fun, Flying an Ice Cube is Not
by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the October 2009 issue of COPA Flight, and is
reprinted with permission.
Like it or not, colder weather is coming and airframe
icing doesn’t just happen to IFR aircraft flying in cloud.
It has happened to me in clear air with the cloud cover at
least 3 000 ft above me, and it could happen to you.
We were flying under
a winter warm front
where the air above us
was above freezing and
the air we were flying in was below freezing, giving us
freezing rain.
This ice was mixed ice (rime and clear) and added
considerable weight to the aircraft as well as considerable
drag. Also, our windshield was covered with ice reducing
forward visibility to zero.
Winter Warm Front
SN
SN
Icing in cloud
SN
SN
SN
SN
0 degreesC
RA
RA
RA
RA
Winter Operations
FZRA
FZRA
SN
SN
FZRA
PL
FZRA
PL
Cold
Air Mass
Clear ice is formed from very
large super cooled droplets that
spread out on impact making
a glassy heavy coating over the
Figure 1
6
SN
Rime ice is formed by small
water droplets that freeze on
contact without spreading,
making it look opaque, milky
and rough. As it occurs, it
disrupts the airflow, causing
an immediate loss of lift.
Fortunately, it easy to see as
it forms.
ASL 4/2011
Winter Operations
RA
Warm
Air Mass
RA
Airframe icing can occur any
time there is an inversion and
you are flying in cold air below
warmer air aloft and there is
cloud above you.
Pre-flight
Pre-flight
I was flying a C-170 with a student in the practice area
in late October when it started to rain. The rain froze all
over our aircraft. We descended and turned back to the
airport. The ice continued to build until we were about
4 mi. from landing when the rain stopped.
SN
To the Letter
To the Letter
can be. We will continue to provide added value to all our
members and to the travelling public. We are in the midst
of a membership drive and encourage all interested parties
to contact us. The Board is energized and focused on
developing a successful and leading organization devoted
to commercial floatplane safety. Please see our Web site
below or contact us directly for further information.
We would also like to thank the British Columbia
Aviation Council for the support they have given us and
the partnership we are developing. We look forward to
serving you on the waters of B.C.!
Guest Editorial
Guest Editorial
concerns joined our industry partners’ concerns regarding
the level of service supplied by the regulator.
Guest Editorial
To the Letter
The Cessna Supplement for light Cessna aircraft suggests
that if visibility is impaired, perform a forward slip to gain
better visibility. It also states that the approach should
be flapless at 70 mph. Piper has no recommendations
for flight with airframe icing and other light aircraft
manufacturers may not have any advice either.
I would be careful about slipping with airframe icing.
Drag has already been increased by an unknown amount.
A forward slip is normally performed to increase drag to
lose altitude. Do we really want to increase drag any more
at this point? Even with an increase in power to maintain
airspeed we may possibly stall at the approach speed.
If it is possible to open a side window or slide the canopy
back a little, you may be able to scrape enough ice from
the windshield to see ahead. I was not able to scrape
enough ice off the windshield to see ahead so I flew a
little to one side of the approach path and leaned my
Lowering the flaps changes the camber and angle of
attack of the wing. This change in angle of attack with ice
on the wing could precipitate an immediate stall.
I flew the aircraft onto the runway, raising the nose of the
aircraft only enough to avoid landing nose wheel first.
I reduced the power very slowly and just enough to get
the aircraft to land and then I reduced the power to idle.
Flaring the aircraft for landing may increase the angle of
attack of the wings to beyond the critical angle of attack
with the ice build-up. A rapid power reduction as the
aircraft nears the ground may also precipitate a stall.
If you are landing on a short or icy runway, you may have
to modify this procedure some, but carefully. It is better
to use all of the runway or even go off the end rather than
stall short of or over the runway.
Watch for and try to avoid flying under a winter warm
front or inversion with a cloud cover. At the first sign of
airframe icing, get away from it. Flying is supposed to be
fun. Flying an ice cube is not.
Dale Nielsen is an ex-Armed Forces pilot and aerial
photography pilot. He lives in Abbotsford, B.C., and currently
flies MEDEVACs from Victoria in a Lear 25. Nielsen is
also the author of seven flight training manuals published by
Canuck West Holdings. Dale can be contacted via e-mail:
dale@flighttrainingmanuals.com. To know more about COPA,
visit www.copanational.org. Pre-flight
A 70 mph approach with the flaps up may not be enough.
An experience in the Air Force taught me that an aircraft
may stall at an airspeed 20 kt above the normal indicated
stall speed. This would not leave much margin at 70 mph
with the flaps up.
I flew the approach at 80 mph with the flaps up. I had
5 000 ft of runway and I did not want to even think about
a stall.
To the Letter
Pre-flight
When airframe icing is encountered, it is imperative to
leave the area immediately and select pitot heat and cabin
or windshield heat “on.” If it is possible to descend to
warmer air, do so and the ice will melt off quickly. If it
is not possible to descend, turn around to leave the area.
With luck the icing will melt off. In my case, luck was not
with us. We remained in cold air and the ice was too thick
for the cabin heat to melt.
head as far to the left as possible. This enabled me to see
enough to perform an approach. As I approached the
runway, I moved the aircraft left and used my peripheral
vision to stay in the centre of the runway.
Guest Editorial
leading edge of aircraft surfaces and a fair distance back
over the upper surface of the wing. Clear ice is heavy and
very hard to see forming. It eventually also changes the
shape of the wing causing a loss of lift and an increase
in drag.
Reducing the Risk of Runway Excursions
by Monica Mullane, Performance Indicators Analyst, NAV CANADA
•
•
•
commercial transport aircraft were involved in
1 429 accidents,
30 percent (431) occurred on runways, and
97 percent of these were runway excursions.
A runway excursion occurs when an aircraft fails to
confine its takeoff or landing to the designated runway.
This may
result from
the aircraft undershooting or over‑running the runway
during landing, the aircraft failing to become airborne in
the available runway during takeoff or a loss of directional
control during takeoff or landing.
The Air France accident at Toronto’s Pearson
International Airport in August 2005 and the Antonov
incident at the Windsor airport in December 2000 are
examples of runway excursions in Canada.
ASL 4/2011
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Winter Operations
Winter Operations
The Flight Safety Foundation’s May 2009 Report on the
Runway Safety Initiative entitled “Reducing the Risk of
Runway Excursions” reported that from 1995 to 2008:
Guest Editorial
Canadian statistics
through the NAV CANADA Aviation Occurrence
Reporting process. Unlike the figures mentioned earlier
for commercial aircraft accidents, the charts below include
all types of aircraft in all types of operation from private
to commercial. In addition, some of the excursions do not
meet the definition of an aviation accident.
The first chart compares runway excursions with runway
incursions for the past ten years.
Guest Editorial
Although runway incursions have been identified as an
aviation safety risk for many years, runway excursions
have not received the same attention. For example, in
1999 a joint subcommittee of Transport Canada and
NAV CANADA was formed and made recommendations
for the prevention of runway incursions and improving
runway safety. Runway excursions were not discussed in
the final report, TP 13795.
The following charts show the situation with respect to
Canadian runway excursions and incursions, as identified
To the Letter
450
400
350
300
250
200
150
100
50
0
To the Letter
count
Runway Excursions vs Runway Incursions
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
Excursions
Incursions
The second chart compares the type of Runway
Excursions observed in 2010. Given that this data
contains all types of operation and not just accidents, it is
not surprising that the pattern is somewhat different from
the worldwide statistics. The Flight Safety Foundation’s
May 2009 Report showed roughly equal number of veeroffs and overruns.
Pre-flight
Pre-flight
Chart 1. Canadian Runway Excursions and Incursions
Canadian Runway Excursions
2010
70
60
50
count
40
30
20
10
Winter Operations
Directional Control
(Veer-off )
Takeoff
Landing
Overrun
Take-Off
Overrun
Landing
Undershoot
on Landing
Undetermined
Undetermined: This is counted where the report does not give sufficient information to
determine where the the landing and departing sequence, the excursion took place.
Chart 2. Breakout of Canadian Runway Excursions for 2010
8
ASL 4/2011
Winter Operations
0
To the Letter
“The amount and type of RCR [runway condition
reports] information varies between countries and
even airports themselves. A major matter of concern is
that lack of harmonization leads to surface condition
information provided by airports to air carriers and
• stabilized approach criteria;
aviators, especially for operational reporting, being
• true “no fault” go-around policy;
generated using a variety of inspection methods and
• training for crew in handling the excursion
friction measurement procedures without uniform
risk factors; and
quality standards. Airplane manufacturers and air
• policies, procedures and knowledge to assist
carriers, therefore, have a limited ability to provide
decision‑making in the cockpit.
precise airplane landing and take-off performance
NAV CANADA’s role in reducing the risk of runway
instructions to pilots for contaminated runways. This
excursions lies in two main areas:
in turn may lead to greater than necessary
safety margins which financially penalize
• by providing air traffic services that
NAV CANADA
operators through operational limitations, or
allow flight crews to fly a stabilized
has expanded the
it may lead to misinterpretation of condition
approach, and;
Runway Safety
reports resulting in compromised safety.”
• by NAV CANADA procedures that
Web site to include
require both controllers and specialists
information on
Current efforts in Canada and internationally
to provide current Runway Surface
runway excursions
are focused on standardizing runway surface
Condition (RSC) and Canadian Runway
–visit the site at
report information.
Friction Index (CRFI) reports to
www.navcanada.ca.
arriving and departing aircraft, allowing
Runway excursions are an industry challenge,
flight crews to make informed decisions.
requiring coordination and cooperation at
For air operators, the Flight Safety Foundation’s top four
recommendations were:
NAV CANADA has an information exchange with
safety officers of airlines to improve safety. One question
raised was why conditions upon landing appeared to differ
from those expected based on the pilot’s understanding
of the Runway Surface Condition (RSC) report. There
the local, national and international levels. All industry
stakeholders described in the Flight Safety Foundation
report have a responsibility to implement mitigations that
will ensure a safe landing or departure. Pre-flight
Pre-flight
are limitations to the RSC reports and these must be
taken into consideration as you plan your approach and
landing. The European Aviation Safety Agency – EASO
2008-4 reports:
Fuel Cargo System in a Canadian Aircraft
by Roger Lessard, Civil Aviation Safety Inspector, Dangerous Goods Standards, Standards, Civil Aviation, Transport Canada
Transport Canada published Advisory Circular (AC)
500-013 – Carriage of Bulk Liquids in Aircraft,
Issue 01, in 2004. This AC summarizes the criteria for
the certification of design and installation of systems
for the carriage of bulk liquids in aircraft, including
liquids classified as dangerous goods. The AC is available
online at: www.tc.gc.ca/eng/civilaviation/certification/
guidance-500-500-013-899.htm.
With respect to the fuel cargo systems, Section 5.0 of
the AC indicates that in addition to the criteria set out
in this AC, bulk liquids carriage systems designed for the
transportation of liquids classified as dangerous goods
must comply with the requirements of the Transportation
of Dangerous Goods Regulations. It makes no reference
to the Canadian Aviation Regulations (CARs) Part
VII Commercial Air Services, Division IX, Manuals,
Requirements Relating to Company Operations Manuals.
ASL 4/2011
9
Winter Operations
During a Program Validation Inspection, a Civil Aviation
Safety Inspector–Dangerous Goods (CASI-DG)
discovered that an air operator, with a valid Air Operator
Certificate (AOC) issued in the Prairie and Northern
Region, was using an aircraft to carry dangerous goods
in large means of containment without the appropriate
dangerous goods procedures and training program
approvals. The aircraft was issued a Supplemental Type
Certificate (STC) for a fuel cargo system in an existing
Class E cargo compartment from the Ontario Region.
The system consists of twelve (12) fuel tanks each capable
of containing 202 U.S. gal (approximately 780 litres (L)
each).
To the Letter
Winter Operations
The Flight Safety Foundation report identified the role
of five groups in helping to reduce the risk of runway
excursions: Flight Operations, Air Traffic Management,
Airports, Aircraft Manufacturers, and Regulators.
Guest Editorial
Guest Editorial
Actions to address
In Canada, section 12.9 of the TDG Regulations
provides a domestic exemption to air operators holding
a valid AOC under the CARs Part VII, Subpart 2,
3 or 4, or CARs Part 6, Subpart 4 for the transport
of specific Class 3 Flammable Liquids.
Subsection 12.9(5) states:
Section 12.12 of the TDG Regulations provides a
similar exemption for all liquid dangerous goods
that are used or are to be used at the location
where aerial work activities are conducted.
The handling, offering for transport, or transporting
dangerous goods to, from or within Canada must be
in compliance with the Transportation of Dangerous
Goods Regulations (TDG Regulations), Part 12 and
the ICAO Technical Instructions for the Safe Transport of
Dangerous Goods by Air (ICAO TI). They provide for the
classification, packaging, documentation, safety marks,
and training requirements. The TDG Regulations use
the term means of containment (MOC) rather than
packaging. A small MOC is an MOC with a capacity less
than or equal to 450 L, whereas a large MOC is an MOC
with a capacity greater than 450 L.
Each one of the fuel tanks installed under the STC is a
large MOC. Large MOCs containing 3 000 L or less are
called Intermediate Bulk Containers (IBC). However,
the ICAO TI prohibits the transport of flammable
An air operator holding a valid AOC issued under CARs
Part VII, Subpart 2, 3 or 4, can transport dangerous goods
in a fuel cargo system in compliance with the TDG
Regulations, section 12.9 or 12.12. The air operator must
submit for review and approval procedures for the carriage
of dangerous goods part of the Company Operations
Manual, and the corresponding dangerous goods training
program. An air operator holding a Private Operator
Certificate issued under CARs Part VI, Subpart 4 needs
to comply with Section 12.9 of the TDG Regulations.
In all other instances, the transport of dangerous goods
by air in large MOCs is prohibited. The transport of
dangerous goods by air in large MOCs (including an IBC)
may be permitted under an Equivalency Certificate (EC)
under Part 14 of the TDG Regulations. Pre-flight
Pre-flight
TDG Regulations
To the Letter
“When the Class 3, Flammable Liquids…are
contained in a large means of containment, that
large means of containment must be…a tank, a
container or an apparatus that is an integral part
of the aircraft or that is attached to the aircraft in
accordance with the Certificate of Airworthiness
issued under the Canadian Aviation Regulations.”
To the Letter
Guest Editorial
liquids in large MOCs, including IBCs, by air unless the
State Authority provides a domestic exemption. Such an
exemption is provided for the aircraft fuel tank used for
the propulsion of the aircraft.
Guest Editorial
Section 9.3 of the AC indicates that each operating
limitation resulting from the installation of bulk
liquids carriage system on an aircraft and any
additional information necessary for safe operation
must be developed and included in a Flight Manual
Supplement (FMS). For the carriage of liquids
classified as dangerous goods, the FMS must restrict the
operation of the aircraft to essential crew only, with no
passenger permitted.
The Instrument Procedures Manual (TP2076) is no longer produced by Transport Canada. The rights to the
book have been assigned to Aviation Publishers (www.aviationpublishers.com), the same people who produce
From the Ground Up. Trainers and students will be happy to know that Aviation Publishers has updated the
Instrument Procedures Manual and released it for sale. The Instrument Procedures Manual is now available from
commercial booksellers.
10
ASL 4/2011
Winter Operations
Winter Operations
NOTICE: Instrument Procedures Manual (TP2076)
flight operations
Debrief
Debrief
CFIT in Algonquin Park: a “Get-Home Itis” Case Study?............................................................................................ page 11
Rotorcraft Technology and Safety...................................................................................................................................... page 15
Wildlife Hazards: Updates and Advice........................................................................................................................... page 16
Restrictions Affecting Seaplanes........................................................................................................................................ page 17
CFIT in Algonquin Park: a “Get-Home Itis” Case Study?
The following is a condensed version of Transportation Safety Board of Canada (TSB) Final Report A09O0217, relating
to the tragic aviation accident, which happened to a family going home in a private aircraft, with an inexperienced pilot, in
deteriorating night-VFR weather conditions, and over featureless terrain. There is so much to learn in this report alone. The
full report is available on the TSB website at www.tsb.gc.ca.
the return flight to Sudbury. The aircraft departed Sudbury
at 12:08 and arrived in Kingston at 13:57.
At 16:55, the pilot phoned the London FIC to obtain a
weather briefing for the return flight from Kingston to
Sudbury. The pilot planned on departing Kingston at 18:00,
with an estimated time of arrival in Sudbury between
20:00 and 20:30. At 17:55, the pilot placed a second call to
the London FIC to file a VFR flight plan. The flight plan
indicated that it was to be a VFR flight direct to Sudbury,
with airspeed of 135 kt and a time en route of 2 hr and
15 min. The estimated time of arrival in Sudbury was 20:42,
with 3.5 hr of fuel on board. The aircraft departed Kingston
at 18:27. The last radio contact occurred as the aircraft was
leaving the Kingston control zone.
The Montréal Area Control Centre (ACC) radar recorded
the first 30 min of the flight, and its last radar hit recorded
was at 18:52. The aircraft was on a direct track to Sudbury
at 3 000 ft ASL.
On the day of the occurrence, the pilot contacted the
London Flight Information Centre (FIC) to obtain
a weather briefing for a VFR flight from Sudbury to
Kingston, with a view to returning to Sudbury in the
evening. During the briefing, the pilot was informed
that a cold front was moving in from the west, extending
north to south, and would reach Sudbury at approximately
20:00. Ahead of the front, the forecast was for showers
and a ceiling of 3 000 ft ASL. As the briefing continued,
the pilot was advised that if the arrival in Sudbury was
before dark, the weather would remain suitable for a VFR
flight. However, after dark, the forecast called for isolated,
towering cumulus clouds and a visibility of 3 mi. in light
snow showers. In Sudbury, the sunset was to be at 18:47
and twilight at 19:17. At 11:32, the pilot contacted the
London FIC for a second time, filed a flight plan for
Kingston and also obtained an updated weather forecast for
The aircraft first appeared on the North Bay radar at
19:37. It was approximately 30 NM north of the direct
track to Sudbury and at 2 400 ft ASL. The last radar
contact occurred at 19:41. The aircraft was approximately
3 NM south east of the accident site at 2 100 ft ASL.
During the last 4 min of radar coverage, there were several
heading changes, mainly from westerly to northwesterly
in direction.
The aircraft was located on October 11, at 03:02 near
the western boundary of Algonquin Park, in hilly terrain
with ground elevations up to 1 750 ft ASL. The hills were
covered with 80- to 100-foot tall hardwood trees. The main
wreckage was located approximately at the mid-point of
a tree covered hill, at an elevation of 1 660 ft ASL. The
aircraft was at a near-level altitude when it began to strike
the tops of trees, which were located at the base of a gulley
prior to rising terrain.
The aircraft was certified, equipped and maintained
in accordance with existing regulations and approved
procedures. Navigation equipment included a Garmin
ASL 4/2011
11
Aviation Safety in History
Aviation Safety in History
On October 10, 2009, a Piper PA-28R-180 aircraft
departed Kingston, Ont., at 18:27 EDT on a night
visual flight rules (VFR) flight to Sudbury, Ont. On
board the aircraft were the pilot and three passengers.
The estimated time of arrival at Sudbury was 20:42. At
20:52, an emergency locator transmitter (ELT) signal was
reported by an overflying aircraft. The aircraft was located
the following day at 03:02, approximately 22 SM east of
South River, Ont. All four occupants were fatally injured.
Flight Operations
Flight Operations
Summary
Debrief
Debrief
GPSMAP 696. This model offered the satellite weather
option (subject to a 15 min delay) as well as a terrain/
moving map feature. Damage to the GPS unit precluded
the downloading of data. It is therefore unknown whether
these features were used.
The pilot held a valid private pilot licence for single engine
land and seaplanes. The last pilot logbook entry was dated
23 August 2009. The pilot had accumulated 205.4 hr of
total time, broken down as follows:
Day/PIC
79.9
Night/Dual
17.2
Night/PIC
5.5
The pilot had completed the required training and
applied for a night rating; however, there were no records
to indicate that Transport Canada had received the
application. A rating had not been issued either. Part of
this night training included a night time cross-country
flight from Sudbury to Kingston with an instructor. This
was done on June 5, 2009, which was the last time the pilot
had flown at night prior to the accident. Based on logbook
entries, this occurrence was to be the pilot’s first night time
cross-country flight as pilot-in-command. The pilot did not
hold an instrument flight rules (IFR) rating.
At 16:55, the pilot phoned the London FIC to confirm
if the forecast weather for Sudbury had improved. The
London FIC provided information derived from the
Graphical Area Forecast (GFA) for the Ontario/Quebec
region at 13:41, which was valid for use from 20:00
onward (see Figure 1).
Immediately west of the cold front, the GFA was
calling for:
•
•
•
•
•
ceilings of 500 ft AGL;
visibility of ¾ SM in light snow showers;
scattered, towering cumulus clouds with tops at
18 000 ft ASL;
intermittent visibilities from 3 to 6 SM in light
snow; and
layer of broken cloud based at 3 000 ft ASL and
topped at 16 000 ft ASL.
Further west, the GFA called for:
•
•
visibilities of 3 SM in light snow showers;
isolated, towering cumulus clouds topped at
8 000 ft ASL;
elsewhere visibilities greater than 6 SM; and
broken cloud layer based at 3 000 ft ASL and topped
at 8 000 ft ASL.
A cold front stretching from east of Sault Ste. Marie
northward to Timmins was the major
meteorological influence.
•
•
East of the cold front, in the area stretching from
Algonquin Park southeast toward Kingston, the GFA
was forecasting:
The cold front was moving east at 30 kt, doubling in speed
from the previous GFA. It was estimated to arrive in the
Sudbury area at about the same time as the flight. The
cold front had passed Sault Ste. Marie earlier. The ceiling
was recorded as 800 ft AGL, with a visibility of 3 SM in
snow showers.
•
•
scattered clouds based at 4 000 ft, with tops between
6 000 and 7 000 ft ASL; and
visibility of more than 6 mi.
Immediately east of the cold front, the GFA was
forecasting the following:
•
•
•
•
12
ceilings of 800 ft AGL;
visibility of 4 SM in light rain showers and mist;
scattered, towering cumulus clouds with tops at
18 000 ft ASL; and
intermittent visibilities from 5 to more than 6 SM in
light rain and mist.
The pilot and the London FIC discussed departing
Kingston to arrive in Sudbury before the front moved
in and considered North Bay as an alternate destination,
which was 59 NM to the east of Sudbury.
At 17:55, the pilot placed a second call to the London
FIC to file a VFR flight plan. When asked if weather or
other information was needed, the pilot referred to the
previously obtained briefing. Having already acquired
weather information and made the decision to undertake
ASL 4/2011
Aviation Safety in History
Aviation Safety in History
Weather information
Figure 1. GFA showing intended route and point of departure.
Destination is end of line.
Flight Operations
Flight Operations
Day/Dual
102.8
Debrief
The TAF for Sudbury, within the timeframe of the flight,
was as follows:
•
The NAV CANADA Flight Services Manual of
Operations (FS MANOPS) requires flight service
specialists to acquire insight into a pilot’s intentions and
requirements, as well as provide the necessary related
briefings. The pilot did not request the aviation routine
weather reports (METAR) or special reports (SPECI)
in full for various stations near the route of flight,
including reported altimeter settings and winds aloft.
Paragraph 305.4E of the FS MANOPS requires flight
service specialists to provide “details of surface weather
observations, aerodrome forecast, forecast winds and
temperatures.” However, the specialist has the discretion to
provide additional weather information, even if it may not
be entirely consistent with the pilot’s stated requirements;
no additional information was provided.
At the time of the occurrence, the weather in the vicinity of
the accident included a mixture of rain and snow, as well as
gusting wind conditions, estimated to be in excess of 25 kt.
Route information
The pilot planned a direct route from Kingston to Sudbury.
Initial radar returns indicate that the pilot was following
the planned route and with such precision as to suggest
the on board GPS was used as the primary navigational
aid. The flight departed Kingston at 18:27. Civil twilight
for the Kingston area was calculated to end at 18:59. With
the exception of the first 32 min, the flight was conducted
at night.
The selected route took the aircraft over terrain that
provided fewer and fewer features as the flight progressed
northwest of Kingston. Visual navigation would have
Analysis
The major part of the occurrence flight was to be conducted
at night. While documents indicated the required training
to obtain a night rating had been completed, the pilot’s
license had not yet been endorsed. The pilot had minimal
experience flying at night. The pilot had flown this trip
before with his instructor, and the aircraft was equipped
with a GPS. The pilot likely felt capable of undertaking the
flight, notwithstanding the navigational challenges of flying
at night over areas that provided few useable visual aids.
Good VFR weather persisted in Kingston for the entire day
of October 10, 2009. Before calling the London FIC for a
weather briefing prior to departing Kingston, the pilot had
already inferred that the forecast conditions for Sudbury
were improving.
The pilot’s first phone call to the London FIC for a
weather briefing occurred 1.5 hr prior to the actual
departure from Kingston. The briefer informed the pilot of
the forecast weather that could be encountered ahead and
behind the cold font. The briefer also indicated that the
front was expected in the Sudbury area at about the same
time as the aircraft’s planned arrival.
The pilot obtained a weather briefing by phone and, in
all likelihood, did not have the GFA to refer to, thereby
precluding any visualization of the weather. Otherwise, the
pilot would have seen that the forecast weather associated
with the front would be encountered en route, well before
reaching the frontal surface and destination. The pilot likely
assumed the weather to be strictly associated with frontal
passage, hence the decision to leave as soon as possible to
ASL 4/2011
13
Aviation Safety in History
Aviation Safety in History
The weather radar at Sudbury displayed weak returns
toward the west, indicating isolated rain showers. The
London FIC also provided abbreviated weather reports for
Gore Bay and a variety of airports to the west of Sudbury.
The London FIC indicated that the weather conditions
for Sudbury, at the time of arrival, were forecast to be
favourable and that any precipitations would be very light.
The planned route of flight provided few ground stations
from which the pilot could obtain updated weather
information or ask for assistance. These ground stations
were Kingston, North Bay, Muskoka and Sudbury.
Successful radio communications would be subject to the
line-of-sight limitations; if the aircraft were to maintain
an altitude of 3 000 ft ASL, the theoretical radio range
would have precluded communications with both North
Bay, located 50 NM northwest of the accident site, and
Muskoka, located 65 NM southwest of the accident site.
Flight Operations
Flight Operations
•
from 18:00, wind 220° true at 12 kt gusting 22,
visibility of greater than 6 SM and cloud at 5 000 ft
broken; and
temporarily from 18:00 to 22:00, visibility of 5 SM
with light rain showers and mist, as well as a broken
cloud layer at 20:00.
been challenging at night. Any lights on the ground that
could have assisted the pilot would have been sparse and,
based on forecast and reported weather conditions, may
not have been visible. The planned route would take the
aircraft over higher terrain. The Kingston airport elevation
is 303 ft ASL. The flight would have overflown areas, with
maximum elevation figures ranging from 1 700 ft ASL to
as high as 2 400 ft ASL. A direct route would have taken
the aircraft over spot elevations as high as 1 875 ft ASL in
Algonquin Park.
Debrief
the flight, the pilot inquired about any changes for Sudbury.
Information derived from the Sudbury terminal aerodrome
forecast (TAF) and weather radar was provided.
Debrief
Flight Operations
The pilot had not obtained altimeter settings for stations
along the flight route during the weather briefings. The
planned route would take the aircraft over rising terrain
and toward an area of lower pressure. The temperatures
were also below International Standard Atmosphere (ISA)
conditions. Therefore, if left untouched, the altimeter would
have read approximately 130 feet higher than the actual
altitude of the aircraft.
The initial part of the flight was along a direct line from
Kingston to Sudbury, indicating the pilot was likely
navigating via the onboard GPS. When the aircraft was
subsequently picked up by the North Bay radar, it was
significantly north of the desired track. The aircraft was
also descending with frequent heading changes. This
suggests the pilot was navigating around cloud and/or
terrain, trying to find a clear route between the clouds and
the hills. Although the aircraft was north of the initial
Sudbury track, it was on a westerly heading when it struck
trees, rather than a northerly heading towards the alternate
airport in North Bay. This suggests the pilot was still
attempting to proceed to the destination.
Findings as to causes and contributing factors
Originally shaped as a line from north to south, the
weather system was moving from west to east. It covered
an area from Southwest Ontario to north of Sudbury. The
heaviest concentration of precipitation was at the front,
where there were no weather reporting stations. A mixture
of rain, snow and strong winds were also present. As it
moved east, the front began to change shape and appeared
to be more convex. This meant that, at the outer tips, the
weather was not as severe and any available weather reports
were not indicative of the actual weather likely encountered
by the pilot.
14
1. The pilot, with minimal night flying experience, took
off at night without fully appreciating the marginal
weather that was forecast en route.
2. The pilot planned the flight over inhospitable terrain
that afforded few visual cues for VFR navigation and
continued flying into deteriorating weather conditions.
3. The pilot likely encountered conditions where ground
reference was lost and altitude was not maintained,
resulting in the aircraft striking trees in an area of
rising terrain.
Findings as to risk
1. The altitude at which the aircraft was flown precluded
radio communication with ground stations along the
flight route. This increases the risk that pilots may
be unable to obtain critical flight information on a
timely basis.
2. The failure to apply current altimeter settings along the
flight route, particularly from an area of high to low
pressure, may result in reduced obstacle clearance.
Other finding
1. Although the pilot had the required training for a
night rating, there was no documentation found that a
night rating had been issued by Transport Canada. ASL 4/2011
Aviation Safety in History
Aviation Safety in History
The aircraft altitude likely did not exceed 3 000 ft ASL
throughout the duration of the flight. Flight at that
altitude would have made radio contact with en route
ground stations difficult, if not impossible. Even if radio
contact was possible, there were few weather reporting
stations from which the pilot could had made a reasonable
reassessment of the conditions and reviewed the decision to
continue toward the destination.
Flight Operations
Having created a weather image an hour earlier, the pilot’s
subsequent conversation with the London FIC suggested
more favourable forecast conditions in Sudbury. This may
have served to confirm the pilot’s initial decision. Here
again, the exchanges between the pilot and the briefer
focused exclusively on the forecast at the destination and
not en route.
The front was changing in appearance while the aircraft
was en route and there were no weather updates available
to compel a re-evaluation of the pilot’s decision. The
aircraft was flying from good night VFR weather
conditions into deteriorating weather conditions. Visibility
would have been reduced as the cloud deck dropped and
the precipitation increased. This, combined with the fact
that Algonquin Park has very few light sources to provide
ground reference, would have made it difficult for the pilot
to maintain visual reference with the ground. The pilot was
not IFR rated, so climbing into and, perhaps, above the
cloud to divert to North Bay was not an option.
Debrief
arrive in Sudbury before the front. Moreover, based on
the briefing, the pilot focused almost exclusively on the
destination forecast weather, to the exclusion of the weather
forecast reported elsewhere along the flight route.
Rotorcraft Technology and Safety
This past spring, the rotorcraft industry met at their annual
tradeshow followed by a safety summit, in Vancouver. The
trade show is organized by the Helicopter Association of
Canada (HAC) and the safety summit is the brainchild of
the hosts, the Canadian Helicopter Corporation (CHC).
From a regulator’s point of view, it gives
Transport Canada (TC) new challenges, but these trends
clearly point towards increasing the safety of the travelling
public, which to TC includes all of the crews flying in and
around those helicopters. While there is no denying that
recent global financial downturns have affected aviation, the
demand for new technology and safer operations remains
strong and shows no sign of letting up.
The HAC trade show provided an excellent opportunity
to mingle with operators and manufacturers to see the full
spectrum of new technologies available. Of course, there
are always the new aircraft and engines, but there were also
a great deal of software solutions to track aircraft in the
field in addition to software used for tracking maintenance
and logistics. All of this adds to the effectiveness of any
business and provides great tools that dovetail nicely
with a company’s SMS. There were excellent breakout
sessions covering safety, operations and government
regulations topics. What was particularly interesting was
the requirement for proper regulations governing the use
of Night Vision Imaging Systems (NVIS) in Canada.
Many operators already use NVG and the demand
continues to grow. Demand for the use of Enhanced Vision
The HAC forums provided an opportunity for members
of organizations, such as the Airborne Law Enforcement
Association (ALEA), to voice their concerns regarding
regulatory changes in the Canadian Air Regulations (CARs)
Subpart 4, for Private Operator Passenger Transportation.
They feel that the recent renewal of the TC oversight
of Subpart 4 operators does not entirely address private
rotorcraft operations in law enforcement, including some
provincial forestry and wildlife departments. TC listened to
the ALEA concerns and will continue to work with private
rotorcraft operators towards a solution for appropriate
regulatory oversight of their niche operations.
At the CHC Safety Summit, it was particularly pleasing to
see representation from across a broad spectrum of aviation.
The ever-growing attendance of this event clearly supports
the idea that safety is not only important, but also leads to
better revenues. The CHC hosts did an outstanding job,
as this was by far the best-organized event I’ve attended in
my aviation career. Topics covered diverse subjects such as
SMS, new technology in the cockpit, accident investigation,
fatigue management and human factors. This event is a
must for pilots, dispatchers, maintenance and management
alike. It was pleasantly surprising to see so many aviation
experts in person after having previously seen them so
often on television or in training films.
In summary, it is clear that technology drives safety and
that safety drives technology. The new gadgets mean better
and safer flying at lower operating costs, and safety systems
enhance operations providing a safer environment for
everyone, including increased productivity, which leads
to better profits. You could almost put safety, technology
and profit into one of those little diagrams like we use
for recycling, as those three are all connected in an
infinite loop. ASL 4/2011
15
Aviation Safety in History
Aviation Safety in History
Customer demand and a direct impact on profit margins
have been driving the industry to embrace these changes.
As SMS settle and mature into our aviation fibre, it
is becoming an expected part of the aviation asset the
customer demands, in addition to new technology. Not so
long ago, you would never have expected to see an older
light helicopter with a glass panel, but this is becoming
more of a norm as operators keep up with customer
expectations. It is becoming difficult to find a new machine
with anything other than a glass panel, often with complete
night vision goggle (NVG) compatibility, directly from
the manufacturer. Similarly, the layers of safety—improved
through the implementation of an SMS—are no longer
only for offshore operators, as customers also expect this
from many aerial work or air taxi operators.
Flight Operations
Flight Operations
After these events, it was clear that the helicopter industry
today is focused on two key factors: technology and safety.
During the HAC trade show, I saw that modern cockpits,
advanced maintenance and operating software, and safety
management systems (SMS) were the lead influences for
today’s operators.
Systems (EVS) using infrared imagery is also growing.
The emergence of these new optic systems highlighted a
void in our regulations that TC is addressing with keen
involvement from industry. TC has been working diligently
with operators, training providers and the National
Research Council (NRC) to develop regulations that will
fully embrace the enhanced capabilities of NVG and EVS.
Much like global positioning systems (GPS) have become
the norm in nearly all cockpits today, it may well be the
same for NVG and EVS within the next 5 to 10 years.
The acceptance and availability of these imaging solutions
may lead to more revenue work being conducted at night,
while enhancing the safety of current night operations,
particularly in the Arctic. As these imaging systems mature,
we could even “see” an end to unaided night flying.
Debrief
Debrief
by Stéphane Demers, Civil Aviation Safety Inspector, Rotorcraft Standards, Standards Branch, Civil Aviation, Transport Canada
Wildlife Hazards: Updates and Advice
Birds are not the only threat to aviation safety, especially
at smaller airports that have no form of fencing. In
Steinbach, Man. in October, a Cessna 152 struck a deer
during landing. There were no reported injuries; however,
the aircraft sustained substantial damage to its propeller
and engine mount.
Effectively managing wildlife at an airport is an important
part of reducing the risk of wildlife strikes and is a
regulatory requirement at certain airports. However, there
are also important actions that pilots can take to further
reduce the risks or to successfully deal with a strike should
one occur.
Nearly 75 percent of all bird strikes occur within 500 ft of
the ground, which also happens to be when aircraft are in
the most critical phases of flight and are most vulnerable
to loss of control. The probability of bird strikes decreases
dramatically after 3 000 ft AGL. Pilots should therefore
aim to achieve cruise altitude as soon as possible at the best
rate of climb. Flights over areas such as land fills, shorelines
16
Deer Incursion on Runway
or wildlife sanctuaries that are known to attract birds
should be avoided. It is important to remember that birds
are more active at dawn or dusk and during spring and fall
migrations. If a flock of birds is encountered during flight,
and it is safe to take evasive action, pilots should consider
climbing above them since anecdotal evidence suggests
birds will bank downward or laterally.
If a bird strike does occur, aircraft control needs to be
maintained. Pilots should refer to checklists and carry out
prescribed procedures. An assessment of the damage and its
effects on landing performance is required. A controllability
check prior to attempting to land should be considered.
If the windshield is penetrated, the aircraft needs to be
slowed to reduce windblast. Pilots should use sunglasses or
goggles for protection against debris or precipitation and
if drag becomes an issue, a rear or side window should be
opened. Before returning to the air, the aircraft needs to be
inspected by a certified maintenance engineer. The strike is
to be reported using the Transport Canada (TC) bird strike
reporting system at wwwapps.tc.gc.ca/Saf-Sec-Sur/2/bsis/s_r.
aspx?lang=eng. The data collected through the submission
of strike reports is used to create trend analyses, which
reveal problem areas, species, and times of year and day.
TC, in cooperation with the Federal Aviation
Administration, has created a DVD and an interactive
CD-ROM entitled Collision Course, which provides
detailed information about wildlife hazards for pilots
in commercial, general and rotary wing aviation as
well as for instructors at flight training schools. These
instructional tools can be obtained by contacting the
Wildlife Management Specialist at TC at WildlifeControlControledelafaune@tc.gc.ca or 613‑990‑4869. ASL 4/2011
Aviation Safety in History
In October of 2010, at Edmonton International Airport, an
ERJ 190 experienced a multiple Canada goose strike while
climbing through 2 000 ft AGL and was forced to declare
an emergency and make a return landing. The aircraft
sustained significant damage to the engines, cowlings, fan
blades and wings.
O’Malley
Flight Operations
In Canada, there have also been critical, though less
public, bird strikes over the last year. In September of 2010
at the airport in Montmagny, Que., a Beech King Air
struck fifteen gulls during climb and lost power in both
engines. The aircraft was ditched 1 000 ft off the end of the
runway, where everyone on board was evacuated safely and
without injury.
Birds should not be your only concern around
some airports, as shown here.
Flight Operations
Aviation Safety in History
The risk that wildlife activity on and around an airport
poses to flight safety has commonly been understood and
respected by the aviation community. However, the general
public has remained mostly unaware of the potential
hazard that increases in problem species populations, such
as Canada geese, create. That is, until January 15, 2009,
when the event commonly referred to as the “Miracle on
the Hudson” occurred. The ingestion of Canada geese into
the engines of US Airways Flight 1549 shortly after taking
off from LaGuardia Airport in New York City caused
the pilots to ditch the Airbus 320 in the Hudson River.
Miraculously, everyone was safely evacuated and media
coverage of the event was extremely high, educating those
who were previously unaware of the risk wildlife posed to
aviation safety.
Debrief
Debrief
by Adrienne Labrosse, Wildlife Management Specialist, Aerodromes Standards, Standards, Civil Aviation, Transport Canada
Restrictions Affecting Seaplanes
If you are one of the lucky few that have the opportunity
to fly a seaplane, you may have asked yourself at one point,
“is it okay if I land here?” This article contains several
references that you can use to help answer this question.
The Canada National Parks Act, through its regulations,
imposes restrictions on the operations of aircraft within
national parks. Before you decide to fly into a place
such as Lake Louise, check with the authorities at Banff
National Park and find out if they would mind. I assume
that the authorities would mind, and by “mind” I mean
probably seize your seaplane and/or fine you. Contact the
appropriate Parks Canada office.
What about lakes? How would you know if a lake
was used as a drinking water source for a city or town
As a seaplane is considered a vessel while operating on the
surface of a body of water, the Vessel Operation Restriction
Regulations apply. The Regulations are published under
the Canada Shipping Act, 2001.
Have you ever heard of any of these canals: Rideau, Tay,
Trent-Severn, Murray, Sault Ste. Marie, Saint-Ours,
Chambly, Sainte-Anne-de-Bellevue, Carillon, Lachine,
or St. Peters? If you wish to operate a seaplane on any
of them, you should take a look at the Historic Canal
Regulations. There may be restrictions on these canals that
you should be aware of before doing so.
Recently, a new section— Restrictions Affecting
Seaplanes— was added to both the CFS and the WAS.
This section is intended to raise awareness among
seaplane pilots that restrictions exist on some bodies
of water.
Aviation Safety in History
Aviation Safety in History
For locations not contained in the CFS or WAS, but
with more obvious “ownership”, such as ports (harbours),
seaways, or National Parks, you should contact the
appropriate authority and ask. The Canada Marine Act and
its associated regulations may restrict (approval required)
or prohibit seaplane operations in ports and seaways.
Contact the applicable Port Authority.
laws-lois.justice.gc.ca/eng/regulations/SOR-2008-120/?showtoc
=&instrumentnumber=SOR-2008-120.
My recommendation is simple: check before you go. ASL 4/2011
Flight Operations
Flight Operations
When the location is listed in the Canada Flight
Supplement (CFS) or Water Aerodrome Supplement (WAS),
it is pretty straight forward, almost pilot proof, I would
say. Restrictions are listed whether prior permission
is required or not, and a contact name and telephone
number are provided.
resulting in all vessels being prohibited? Some lakes
have prohibitions on powered vessels, horsepower
restrictions, or speed limits. How do you find out? The
Schedules to the Vessel Operation Restriction Regulations
list, by province, the different types of restrictions (vessel
prohibitions, horsepower restrictions, speed limits, etc.)
and the bodies of water affected. These can be found at:
Debrief
Debrief
by Mark Laurence, Civil Aviation Safety Inspector, Standards Branch, Civil Aviation, Transport Canada
17
Maintenance and Certification
Do the Right Thing
by Robert I. Baron. This article was originally published in the February 2011 issue of AeroSafety World magazine and is reprinted with the
permission of the Flight Safety Foundation.
Professionalism and integrity are the last barriers
against unapproved or unwise short cuts.
An experienced and qualified aircraft maintenance
technician (AMT) with a tight deadline discovered that
he needed a special jig to drill a new door torque tube
on a Boeing 747. The jig was not available, so he decided
to drill the holes by hand with a pillar drill—a fixed
workshop drill and an unapproved procedure.
Subsequently, the door came open in flight and the flight
crew had to make an emergency landing. The AMT, being
a “company man” and trying to get the aircraft out on
time, committed what is known as a situational violation.
A situational violation occurs when an AMT, typically
with good intentions, deviates from a procedure to get the
job done.
747 Cargo Door Opening in Flight
The European Aviation Safety Agency (EASA), in
its suggested syllabus for human factors training for
maintenance, specifically mentions professionalism and
integrity as a training topic. But what are “professionalism
and integrity,” and can they even be taught? The MerriamWebster dictionary defines professionalism as “the
conduct, aims or qualities that characterize or mark a
While financial scandals on a corporate level are rare
in aviation, significant events have occasionally led to
deviations from integrity, typically in the normal pursuit
of cost savings and efficiency. For instance, the crash of
American Airlines Flight 191, a McDonnell Douglas
DC-10-10, at Chicago O’Hare International Airport on
May 25, 1979, was precipitated by procedures that were
put in place by the company’s maintenance management.
ASL 4/2011
Regulations and You
Regulations and You
CAP 716 does not elaborate on the topic of integrity as it
does with professionalism, perhaps because it is assumed
that they overlap. That is partly true, but integrity still
warrants a bit more elucidation.
Based on the definition of integrity as “a firm adherence
to a code of moral values,” this is where things can get
interesting. How can an employee adhere firmly to a code
of moral values that is largely unwritten and not available
to look up in the employee handbook? A code of values
is something that is learned through upbringing and
life experiences. By the time a person becomes gainfully
employed, he or she should have a good idea of what
is morally or ethically right. Yet corporate greed and
power can cause otherwise good people to cross the line,
sometimes hazy, between right and wrong.
A door came open in flight as a result of a desire to get the
aircraft out on time.
18
Regulations offer some aviation-specific guidance on
teaching professionalism and integrity. For instance, the
U.K. Civil Aviation Authority has a small section in Civil
Aviation Publication (CAP) 716, Aviation Maintenance
Human Factors (EASA Part 145) about the subject. Two
key points discussed are, first, that employees basically
know how to behave in a professional manner but may
be limited in doing so due to organizational issues such
as pressure, lack of resources, poor training, etc.; and that,
in a human factors training course, it is up to the trainer
to determine whether problems with professionalism are
on an individual or organizational level and tailor the
training accordingly.
Accident Synopses
Accident Synopses
The reason for a procedural deviation may stem from time
pressure, working conditions or a lack of resources. This
example is not only a classic maintenance human factors
error, but also speaks to the issue of professionalism and
integrity conflicting with efficiency.
profession or a professional person” and defines integrity
as “a firm adherence to a code of moral values.” The topic
can be nebulous and difficult to develop into a training
module, yet is unquestionably a critical part of a healthy
safety culture.
Recently Released TSB Reports
Recently Released TSB Reports
Do the Right Thing............................................................................................................................................................ page 18
Issuance of Maintenance Authorizations......................................................................................................................... page 20
Fatigue Risk Management System for the Canadian Aviation Industry: Trainer’s Handbook (TP 14578E).... page 21
Maintenance and Certification
maintenance and certification
Maintenance management failed to discover that using
the forklift was creating an unseen crack in the accident
aircraft’s engine pylon. This crack continued to propagate
and eventually caused the left engine to depart from the
aircraft on its take-off rotation and the aircraft to crash
shortly after becoming airborne. Two hundred and fifty
Such failures can be extrapolated to a fundamental
question about personal integrity. Why would employees,
as individual professionals, go “along for the ride” with
these types of breaches in integrity if they know they are
working contrary to approved procedures? Sometimes this
is a matter of norms of the safety culture, or the “normal”
way work is being conducted, whether right or wrong.
Social psychological phenomena such as cognitive
dissonance and conformity also may be involved.
Cognitive dissonance occurs when reasoning is consonant
(in agreement) and dissonant (incongruous) at the same
time. This might happen when an employee knows that
an incorrect procedure is being used universally but,
at the same time, does not want to speak up for fear
of castigation.
Similarly, conformity is a strong social psychological
phenomenon that occurs when an employee chooses to
“go with the crowd” rather than stand out as a complainer,
loner, non–team player, etc. Conformity can be further
exacerbated by the tremendous peer pressure that often
develops in groups. Individual employees need to realize
that, although these pressures are commonplace and
perhaps inevitable, they do not relieve the employee
ASL 4/2011
19
Regulations and You
Maintenance and Certification
Recently Released TSB Reports
“The evidence indicated that American Airlines’
engineering and maintenance personnel implemented
the procedure without a thorough evaluation to insure
that it could be conducted without difficulty and without
the risk of damaging the pylon structure. The [NTSB]
believes that a close examination of the procedure might
have disclosed difficulties that would have concerned the
engineering staff. In order to remove the load from the
forward and aft bulkhead’s spherical joints simultaneously,
the lifting forks had to be placed precisely to insure that
the load distribution on each fork was such that the
resultant forklift load was exactly beneath the center of
gravity of the engine and pylon assembly. To accomplish
this, the forklift operator had to control the horizontal,
vertical and tilt movements with extreme precision.
The failure … to emphasize the precision this operation
required indicates that engineering personnel did not
consider either the degree of difficulty involved or the
consequences of placing the lift improperly. Forklift
operators apparently did not receive instruction on
the necessity for precision, and the maintenance and
engineering staff apparently did not conduct an adequate
evaluation of the forklift to ascertain that it was capable of
providing the required precision.”
Integrity also encompasses adequate company and
regulatory oversight of a maintenance procedure.
This issue was involved in the crash of Continental
Express Flight 2574 in 1991, in which 47 screws were
not re-installed on the horizontal stabilizer during a
shift turnover. The NTSB said, “The probable cause of
this accident was the failure of Continental Express
maintenance and inspection personnel to adhere to
proper maintenance and quality assurance procedures
for the airplane’s horizontal stabilizer deice boots that
led to the sudden in-flight loss of the partially secured
left horizontal stabilizer leading edge and the immediate
severe nose-down pitchover and breakup of the airplane.
Contributing to the cause of the accident was the failure
of the Continental Express management to ensure
compliance with the approved maintenance procedures,
and the failure of FAA surveillance to detect and verify
compliance with approved procedures.”
Accident Synopses
Accident Synopses
“Thus, in what they perceived to be in the interest of
efficiency, safety and economy, three major carriers
developed procedures to comply with the changes
required in [service bulletins] by removing the engine
and pylon assembly as a single unit. … Both American
Airlines and Continental Airlines employed a procedure
which damaged a critical structural member of
the aircraft. …
The crash of American Flight 191 can be interpreted
as an example of the integrity line being crossed in one
respect. The forklift procedure was designed so that the
aircraft would spend less time in maintenance and more
time generating income. When management changed
a procedure without adequate safety analysis, however,
lower level employees were “along for the ride.”
Recently Released TSB Reports
Regulations and You
“Carriers are permitted to develop their own step-bystep maintenance procedures for a specific task without
obtaining the approval of either the manufacturer
of the aircraft or the FAA [U.S. Federal Aviation
Administration]. It is not unusual for a carrier to
develop procedures which deviate from those specified
by the manufacturer if its engineering and maintenance
personnel believe that the task can be accomplished more
efficiently by using an alternate method.
eight people (including 13 crew members) aboard the
aircraft and two people on the ground were killed.
Maintenance and Certification
Management accepted the use of a forklift to change
engines on the aircraft. The U.S. National Transportation
Safety Board (NTSB) found serious omissions, however,
in its final report on the accident:
Maintenance and Certification
Recently Released TSB Reports
The topic of professionalism and integrity is clearly
not popular in the field of aviation human factors. It
is reasonable to assume that this is due to the topic’s
socially awkward nature and the diversity of opinion and
work experiences. Trying to “teach” the topic also can be
confounding because many instructors have a hard time
compiling relevant information. Overall, there is not
much guidance compared with that available for other
human factors topics.
•
So, again, can professionalism and integrity be taught?
Perhaps in principle, but applying them in the workplace
is largely the responsibility of the individual, since they
are based on values, not a technical process that can be
measured and supervised.
•
What should be the baseline expectation for
professionalism and integrity among AMTs? From my
•
•
•
•
•
•
•
Arrive at work on time and be prepared to work.
Stay current on procedures, and strive to increase
your knowledge.
Respect your peers—even if you don’t particularly care
for them.
Be part of the team effort to make safety the
no. 1 priority.
Be assertive with management whenever necessary
for safety.
Watch for opportunities to draw the line between
right and wrong.
Be alert for business expediency that drives unsafe
deviations from approved procedures.
Do not “go with the flow” when the flow is going the
wrong way.
Ask yourself if actions deemed legally or technically
acceptable could be morally wrong.
Robert I. Baron, Ph.D., is the president and chief consultant
of The Aviation Consulting Group. He has more than 23 years
of experience in the aviation industry and is an adjunct
professor at Embry-Riddle Aeronautical University and
Everglades University. Recently Released TSB Reports
own search for common principles, I propose these as
starting points:
Maintenance and Certification
from the responsibility to speak up and challenge unsafe
instructions. Otherwise, on a personal level, they are
overstepping the bounds of integrity and their actions
may become a contributing factor in an aircraft accident
or incident.
Issuance of Maintenance Authorizations
Regulations and You
Please refer to CAR Std. 573.06 for more details on ACA
training requirements.
CAR Std. 573.05(1) states that, “an AMO shall issue
an authorization to those individuals who will sign
a maintenance release in respect of work performed
on an aircraft.” This authorization is called aircraft
certification authority (ACA) and can be issued to an
aircraft maintenance engineer (AME). As referenced in
CAR 571.11, the work on an aircraft must be released for
return to service by an AME who holds ACA.
Another characteristic of the ACA system is that an
organization may choose to further limit individual
maintenance release privileges or the work scope to an
aircraft system, subsystem or process. This is very often
the case in large organizations where maintenance release
control is supported by a highly specialized work force.
Notwithstanding the basic privileges of the licence,
in a commercial environment, the AMO determines
who and to what degree a qualified ACA can issue a
maintenance release.
It is the AMO’s responsibility to ensure that the person
being nominated for ACA is a holder of a valid AME
licence rated for the aircraft type (CAR 571.11), and
has satisfied all of the training requirements related to
the aircraft type(s) for both initial and update training.
20
Once the AMO is satisfied that the candidate ACA
meets all the requirements, the organization is in a
position to issue ACA to the AME. However, it should
be noted that not all qualified AMEs necessarily receive
ACA from the AMO and under CAR 573.07(1)(a), the
AMO must identify which of the qualified AMEs have
been granted that authority and document it.
Some Canadian operators conduct business in countries
that do not have aviation safety agreements with Canada.
In these instances the AMO can extend its own quality
assurance system to that location and issue an ACA
ASL 4/2011
Regulations and You
Section 571.05 of the Canadian Aviation
Regulations (CARs) requires that all commercially
operated aircraft have maintenance performed
and certified by an approved maintenance
organization (AMO) or a foreign equivalent that
is appropriately rated for the scope of work to be
undertaken. In addition, all specialized work, regardless
of whether it involves commercial or private aircraft,
must also be performed by an AMO that is rated for that
particular specialty.
Accident Synopses
Accident Synopses
by Joel Virtanen, Civil Aviation Safety Inspector, Operational Airworthiness, Standards Branch, Civil Aviation, Transport Canada
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
Both ACA and SCA serve distinctive yet complementary
roles in a commercial environment where work
performance and maintenance release contribute equally
to a safety-oriented aviation maintenance industry. Fatigue Risk Management System for the Canadian Aviation Industry:
Trainer’s Handbook (TP 14578E)
This is the seventh and last of a seven-part series highlighting the Fatigue Risk Management System (FRMS) Toolbox for
Canadian Aviation, developed by Transport Canada and fatigue consultants Edu.au of Adeliade, Australia. This article briefly
introduces TP 14578E—Trainer’s Handbook. In addition to a training presentation on fatigue, fatigue management systems,
and individual fatigue management strategies, the package includes background information for delivery of the workshop,
learning outcomes, and questions frequently asked by participants. The complete FRMS toolbox can be found at www.tc.gc.ca/eng/
civilaviation/standards/sms-frms-menu-634.htm. —Ed.
Purpose of the Trainer’s Handbook
An important part of a fatigue risk management
system (FRMS) consists of training all employees in
the management of fatigue as a safety hazard. Training
materials have been designed to meet the business
needs of participating organizations and the skills
development needs of their employees in relation to
fatigue risk management.
This handbook is intended to provide you, as a trainer,
with the tools and strategies to prepare and deliver
the face-to-face component of the employee training,
Fatigue Management Strategies for Employees:
• slideshow presentation;
• speaking notes;
• information on how to prepare the workshop;
• frequently asked questions; and
• bibliography of reference material.
Training format
The slideshow presentation (available for download on the
FRMS Web site) is structured so that it can be tailored to
different employee groups (e.g., maintenance employees,
flight crew, cabin crew). The presentation provides a good
ASL 4/2011
21
Regulations and You
Regulations and You
Prior to the issuance of SCA, the AMO shall ensure that
the person holding the qualification understands his/
her responsibilities in accordance with the applicable
regulations, and has demonstrated levels of knowledge
and experience that meet the applicable requirements in
Std. 573.05(2).
Accident Synopses
Now, let’s look at shop certification authority (SCA)
to better understand what it is and how it differs from
ACA. To begin with, just as in the case of ACA, SCA is
It is important to remember that in all instances following
SCA certification, once the item is pulled from stores
or the shop and installed on the aircraft, a maintenance
release must be signed by the holder of an ACA within
that organization. If the item is sent out for outside use,
maintenance release becomes a third party responsibility
following installation. In this manner, system integrity is
assured and confirmed by the holder of the broader based
on-aircraft licence.
Recently Released TSB Reports
Foreign ACAs may only be granted to persons working
under the direct control of the granting organization
and it is not acceptable for an AMO to issue ACA to an
employee of a contracting organization that is performing
the work under its own domestic approval. However,
ACA may be made conditional upon the holder working
within the framework of a contracting organization.
In these cases (where the ACA relies in part on the
oversight or support services of a foreign organization),
the Canadian AMO may ensure the necessary direct
control by adopting (and obtaining TC approval for)
the applicable sections of the foreign organization’s
procedures as its own, with regard to maintenance
performed at the foreign base. Under these circumstances,
ACA will only be valid while the foreign ACA holder has
ACA privileges issued by the contracting organization.
The scope of privileges of foreign licences may vary
widely. Some, like the Canadian AME licence, may have
very broad privileges. Others may be limited to particular
aircraft systems or components.
a controlling instrument that is used within the AMO
process. However, a significant difference between the
two privileges is that while ACA is associated with
“on-aircraft” maintenance release, SCA is limited to offaircraft certification. In other words, a qualified individual
may certify an aeronautical product(s) for which SCA
has been issued, but the privilege will be limited to offaircraft work. This is the highly specialized individual
who certifies after repair, modification or overhaul,
at the rotable, appliance, or component level within a
shop environment.
Maintenance and Certification
based on the foreign licence with privileges limited to
line maintenance, as defined in Std. 573.02. Advisory
Circular (AC) No. 573-002 provides guidance to an
AMO to issue an ACA based on a foreign licence. This is
to enable the issuance of ACA, outside of Canada, based
on foreign qualifications equivalent to a Canadian AME
licence, pursuant to subparagraph 571.11(2)(a)(ii) of
the CARs.
Maintenance and Certification
The presentation is most effective for groups of 10 to
20 people to allow for participant interaction. Participants
in groups this size tend to retain more knowledge and get
greater benefit from the face-to-face training sessions.
The most important component of this handbook is the
slideshow presentation. The presentation is approximately
180 minutes long, and has been divided into three modules:
1. Causes and Consequences of Fatigue
2. Fatigue Risk Management
3. Personal Fatigue Countermeasures
The presentation should be casual, and participants
encouraged to ask questions and/or share personal
anecdotes. Group activities are provided throughout
to encourage interaction. You should use a whiteboard
or flipchart to document participant responses to the
group activities.
The notes section of the presentation contains a
comprehensive set of speaking notes for each slide. You
should use the text as a guide, and adjust the words,
phrasing, and examples to your own presentation style
and experience.
Prepare for the workshop
You should be familiar with the organization’s FRMS.
Review the training material and make changes as required
to ensure the slides are consistent with company policy. Pay
particular attention to slides 19 and 20, which are intended
to outline the specific responsibilities of employees and
management under the organization’s FRMS.
Make yourself familiar with the training material—in
particular, the frequently asked questions section of this
handbook. It’s a good idea to become familiar with the
other manuals, guides, and workbooks in this series.
Consult the list of reference material if you would like to
know more about certain topics.
We conclude this overview of TP 14578E by encouraging
our readers to view the entire document at www.tc.gc.ca/
Publications/en/TP14576/PDF/HR/TP14576E.pdf. Recently Released TSB Reports
Recently Released TSB Reports
Slideshow presentation
Speaking notes
Maintenance and Certification
overview of fatigue risk management and is intended to be
used in conjunction with the paper or web-based employee
training tools and assessment to ensure that participants
have understood and can apply the knowledge presented in
the workshop.
20. receiving acknowledgement that it has
been received
21. see CFS
22. 5; 6; 2; 5
23. March 21, 2011 at 2359 UTC
24. NAV CANADA
25. 2 to 4 inclusive
26.high
27.contrast
28. 48 hrs
29. Mirror, fire, smoke, pyrotechnics, etc. as per
annex 1.0
30. higher; lower
31.lowest
32.123.4
33.80/200
34. tendency to further decrease airspeed, leading to a
loss of translational lift
35. rate of descent
36. Main rotor vortex interference
37. A decreased rate of climb unless more heat is added
38. turn off the valve that controls the leaking or
burning fuel
Regulations and You
1. It is a means for individuals to report incidents and
potentially unsafe acts or conditions relating to the
Canadian transportation system to the TSB.
2. 50
3. altitude encoding transponder
4. in use at the time
5. 24; 1-866-WXBRIEF
6. hatched areas enclosed by a dashed green line
7. 6; dashed orange line
8. 200 ft overcast
9. After 1300Z
10. one hour, one hour, FM, BECMG
11. Degrees true
12. A “SPECI” report is issued to report significant
changes in weather conditions which occur off
the hour.
13.SIGMET
14. four; too rapidly or too slowly
15. On navigation charts, in the CFS, and
in NOTAMs.
16. Gliders and balloons, 10 000, 12 500
17. landing or about to land
18. 2 000 ft AGL
19. 2 000 ft horizontally and 500 ft vertically
ASL 4/2011
Regulations and You
22
Accident Synopses
Accident Synopses
Answers to the 2011 Self-Paced Study Program
Maintenance and Certification
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 more information, contact the TSB or visit their Web site at
www.tsb.gc.ca. —Ed.
TSB Final Report A07P0209—Tail Rotor
Driveshaft Fracture
Findings as to causes and contributing factors
2. The reduction in the strength and stiffness of the tail
boom skin in the area damaged by exhaust gas heating
likely allowed the tail boom to distort excessively under
high-power settings.
3. The No. 3 tail rotor driveshaft segment broke as
a result of severe scoring caused by heavy contact
with the tail boom, which was precipitated by tail
boom distortion.
4. The No. 3 tail rotor driveshaft was also subject to
in-flight bending that likely exacerbated the heavy
contact with the distorted tail boom.
5. Had the pilot-in-command been wearing the available
upper body restraint (shoulder harness), his injuries
would have been lessened.
Findings as to risk
1. The lack of documented service history for the tail
rotor driveshaft prevented effective traceability of a
condition-monitored component that was essential to
the continued operation of the helicopter.
2. Vertical reference flying necessitates upper body
freedom of movement, typically resulting in the
non-use of the shoulder harness. This exposes pilots
to greater injury in the event of a collision with
the terrain.
Accident Synopses
On July 2, 2007, a Bell 214B1 helicopter was carrying
out heli-logging operations in Ramsay Arm, B.C. At
about 08:00 PDT, the helicopter was in a 200-foot hover
and starting to pick up the 11th load when the two pilots
noted a loud growling sound from within the helicopter.
Immediately, the flying pilot discontinued the lift and
released the load from the longline hook. He then flew
the helicopter back towards the nearby service area to
have the noise investigated. About 20 sec later, just as
the helicopter entered a high hover above the service
landing site, the growling noise stopped, the low oil
pressure warning lights for the two tail rotor gearboxes
illuminated, and the helicopter rotated quickly to the
right. The pilot was unable to stop the rotation using
the tail rotor control pedals and the helicopter made
two or three 360° turns to the right. The pilot rolled
off the throttle on the collective stick and attempted to
land in trees adjacent to the service area. The helicopter
descended upright and struck several trees before landing
hard on the uneven terrain. The flying pilot, seated in
the left hand seat, was seriously injured and the co-pilot
received minor injuries. The helicopter was substantially
damaged during the landing and there was no fire. The
emergency locator transmitter activated at impact and
survived the crash.
1. The tail boom had been subjected to extreme heat
from the engine exhaust during its service life and,
over time, certain tail boom skin panels developed
structural weaknesses.
Recently Released TSB Reports
Accident Synopses
Maintenance and Certification
RECENTLY RELEASED TSB REPORTS
3. Most helicopters are not designed to accommodate
vertical reference flying techniques, and certification
for external load operations does not take them into
account, thus increasing the risk of injury in a collision.
Regulations and You
Other finding
Bell 214B1 wreckage
1. The pilot’s flight helmet prevented life-threatening
head injuries during the collision with terrain; many
Canadian helicopter operators encourage their pilots
to wear helmets in most operational environments.
ASL 4/2011
23
Regulations and You
4. The withholding of engineering information and
tests by manufacturers impairs the timely discovery of
accident causes, denying operators vital information
and the opportunity to avoid their re-occurrence.
Maintenance and Certification
TSB Final Report A07W0128—Collision at
Takeoff
The weather conditions were suitable for visual flight and
field examination of the wreckage gave no indication that a
pre-occurrence mechanical problem had contributed to the
accident. Although the performance of the left engine was
slightly less than that of the right engine during the takeoff roll, the torque pressure on both engines exceeded the
expected take-off power setting of 39.5 psi torque pressure
for the existing temperature and pressure altitude, and the
propeller rpms compared favourably with normal take-off
values. The analysis will therefore discuss the organizational
and management factors that contributed to the aircraft
24
The operational control and the risk management practices
that existed within the operator did not recognize and
reduce or eliminate the risks associated with takeoffs
from the lodge airstrip. The operator was in a state of
administrative transition at the time of the accident due
to several recent changes in key personnel; the Twin Otter
operation was most affected by this transition.
A number of organizational policies and procedures that
may have prevented the accident were either violated, not
used, or missing. The operator’s operations manual was
written to ensure safe flight operations and to eliminate
potential errors in flight crew judgement. Although a
weight and balance calculation had been accomplished
prior to the accident flight, the aircraft weight was not
used to calculate take-off performance, as required by the
operations manual. Takeoffs from the lodge airstrip had
come to be regarded as routine, without a need to calculate
take-off performance prior to each departure, and aircraft
loading was based mostly on the intuition and judgement
of the owner and/or flight crews.
The operator had an unwritten company policy that
the lodge airstrip would be used primarily to store the
Twin Otter and that Twin Otter departures from the
airstrip would be carried out with crew only and minimum
fuel on board. Records of previous takeoffs from the airstrip
indicated that the policy of not carrying passengers out of
the lodge airstrip was rarely violated, although takeoffs were
occasionally accomplished with heavy fuel loads. On the
day of the accident, this policy was violated in two ways:
the takeoff was attempted with three passengers and the
aircraft had a full load of fuel.
Training provided by the owner to the captain emphasized
the use of 30° of flap for short-field takeoffs when 10° of
flap would have resulted in lesser distance to climb to 50 ft.
Considering the elevation, length, slope, and gravel surface
at the lodge airstrip, maximum performance short takeoff
and landing (MPS) procedures may have been required
at times for higher weight takeoffs; however, neither
the company nor the aircraft were approved for MPS
operations and neither flight crew member had received
appropriate MPS training.
The operator’s owner was the main decision-maker
within the company. He was entirely familiar with the
company’s daily operations, he was highly influential with
respect to how flights were to be carried out, and he had
significant experience with Twin Otter operations on the
lodge airstrip. These elements, combined with his direct
ASL 4/2011
Regulations and You
Regulations and You
Analysis
Organizational and management factors
Accident Synopses
Accident Synopses
On July 8, 2007, at approximately 12:35 PDT, a de
Havilland DHC-6-100 Twin Otter was taking off
from a gravel airstrip near the Northern Rockies
Lodge at Muncho Lake on a visual flight rules flight to
Prince George, B.C. After becoming airborne, the aircraft
entered a right turn and the right outboard flap hanger
contacted the Alaska Highway. The aircraft subsequently
struck a telephone pole and a telephone cable, impacted
the edge of the highway a second time, and crashed onto
a rocky embankment adjacent to a dry creek channel. The
aircraft came to rest upright approximately 600 ft from
the departure end of the airstrip. An intense post-impact
fire ensued and the aircraft was destroyed. One passenger
suffered fatal burn injuries, one pilot was seriously burned,
the other pilot sustained serious impact injuries, and the
other two passengers received minor injuries.
being operated outside of its performance capabilities on
the accident takeoff.
Recently Released TSB Reports
Recently Released TSB Reports
As a result of the investigation into this Bell 214B1
accident, the operator has voluntarily chosen to replace its
Bell 214B1 tail boom skins every 5 000 flight hr. Another
operator, which is also a maintenance, repair and overhaul
facility for this model, said it will replace its tail boom skins
every 3 000 hr.
Maintenance and Certification
Safety action taken
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
The first officer was more familiar than the captain with the
circumstances leading up to the flight, having taken most
of the morning to prepare the aircraft. His expectation of
a successful takeoff was likely based on his conversations
with the owner and the captain. He verbally provided the
captain with weight and balance information; aside from
that, he appears to have placed full responsibility for the
decision to attempt the takeoff on the captain, who was
only peripherally involved with the flight planning.
Lodge airstrip in direction of takeoff
Work setting
Pre-flight planning
Pre-flight planning is an essential component of any
flight and flight crews are required by regulation to avail
themselves of all obtainable information pertinent to a
flight prior to departure. Because the DHC‑6 Twin Otter
is a very capable short-field aircraft, it is commonly used on
short, unprepared airstrips where there is little margin for
error in flight crew judgement or performance. In all cases
when operating in short-field environments, it is imperative
that flight crews recognize and operate within the take-off
performance limitations of the aircraft.
Pre-flight load planning for the accident flight primarily
involved the owner and the first officer. The captain agreed
to take off from the lodge airstrip with one passenger. He
went flying soon after and had no direct input into the
ASL 4/2011
25
Regulations and You
The work setting and work expectations at the operator
were unlike those found in the corporate or airline
environments that were most recently familiar to the
captain and the first officer. The operational support
provided in corporate and airline operations, in the form
of dispatchers, ground crews, locally available maintenance
personnel, and highly-formalized operational procedures
rarely exist in similar small, seasonal bush-flying operations.
As a result, flight crews working for seasonal bush-flying
operators often rely heavily on local knowledge gained
through experience with a particular operator and are
typically more self-reliant when it comes to making
day-to-day operational decisions. As well, the operational
challenges encountered in confined, short-airstrip
environments can be significantly different from those
encountered in corporate and airline operations, where
longer runways and obstacle-free climb-out corridors are
the norm.
The captain had recently been flying DHC-6-300 series
aircraft in the Maldives. Although that experience involved
only float-equipped Twin Otters, his recent familiarity with
the higher performance capabilities of the DHC‑6‑300
series aircraft may have conditioned him to anticipate
a higher level of aircraft performance in the operator’s
DHC‑6-100 series operations. As well, both pilots were
aware that the aircraft had been operating out of the lodge
airstrip for several years, which reinforced their expectation
that the takeoff should be successful.
Accident Synopses
Regulations and You
The captain and the first officer were themselves the final
line of defence in the system. Both were relatively new to
the operator’s working environment and to lodge airstrip
operations. The captain had been hired and appointed
chief pilot about five weeks prior to the accident. His
initial administrative workload as chief pilot and his flight
duty obligations were significant, which may have reduced
the time available to experience, recognize, and evaluate
the risks associated with the operator’s flight operations
from the lodge airstrip. Critical information regarding the
accident flight was provided to the captain in a somewhat
piecemeal fashion between the time of the original early
morning discussion and the departure; however, the captain
expected the takeoff would be successful, based on his belief
that both the owner and the first officer had discussed and
considered the take-off weight.
Recently Released TSB Reports
Despite regular use of the lodge airstrip and recognition
by the owner that take-off weights were a critical
consideration in these operations, there was no standard
operating procedure (SOP) for Twin Otter short-field
operations. An applicable SOP would have formalized and
set the non-MPS limits for short field operations, thereby
reducing the risk associated with lodge airstrip operations.
Flight crew
Maintenance and Certification
input at the pre-flight planning phase of the accident
flight, contributed to the flight crew expectation that the
takeoff could be accomplished successfully. As well, the
regular direct oversight that he provided in the Twin Otter
operation may have resulted in ambiguity with regard to
the duties and responsibilities of those involved with the
Twin Otter operation.
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
The aircraft was not positioned so as to use the entire
airstrip before commencing the takeoff and the brakes
were released prior to the engines achieving take-off power.
Both of these elements made it less likely that the aircraft
would achieve the necessary obstacle clearance altitude. The
use of the lodge airstrip left no margin for error and once
the take-off roll began, there was little time to evaluate the
aircraft’s performance and if necessary reject the takeoff.
Had the flight crew identified a suitable reject point for the
takeoff and had the takeoff been rejected due to the aircraft
not being airborne at that point, the accident risk would
have been reduced.
The aircraft used most of the available airstrip during the
takeoff and drifted approximately 20° to the left during the
latter part of the takeoff for unknown reasons. This required
the initiation of a steep bank to remain over the highway
corridor on climb-out that reduced the climb performance
of the aircraft and increased the likelihood of the aircraft
contacting the telephone cable.
Findings as to causes and contributing factors
1. The takeoff was attempted at an aircraft weight that
did not meet the performance capabilities of the
26
4. The takeoff was attempted in an upslope direction and
in light tailwind, both of which increased the distance
necessary to clear the existing obstacles.
Safety action taken
Following the accident, Transport Canada conducted a
regulatory audit on the company. The Twin Otter was not
replaced and the operator voluntarily gave up the Canadian
Aviation Regulation section 704 privileges on the company’s
air operator certificate.
Following this accident, the owner initiated the following
corrective action within the operation:
1. Every pilot employed by the operator will receive and
be required to read and sign a letter that summarizes
the pilot’s responsibilities in the operation of the
operator’s aeroplanes.
2. The operator purchased and installed satellite
telephones in each floatplane to improve direct
communication between pilots.
3. The operator’s Maintenance Control Manual has
been amended to require any seatbelt in any company
aircraft to be replaced after 10 years, even if the
manufacturer has not put a life on the seatbelt.
4. Weight and balance samples for various loading
configurations in company aircraft have been calculated
and a computer program is now in use for weight and
balance calculations at the home base. The weight and
balance calculations and the formulas used will only be
the ones issued by the aeroplane manufacturer.
TSB Final Report A07O0314—In-flight
Engine Failure
On November 23, 2007, an Aerospatiale AS 350
B3 helicopter was en route from London, Ont. to
Windsor, Ont. at 2 000 ft ASL. At approximately 07:55
EST, the helicopter yawed sharply to the right, the
rotor rpm dropped, the engine chip and governor light
illuminated, and the warning horn sounded. The engine (a
ASL 4/2011
Regulations and You
Considering the airstrip length and slope, the wind and the
temperature conditions, the location of the telephone cable,
and the take-off procedures that were used, the takeoff was
attempted at a weight that exceeded the obstacle clearance
performance capabilities of the aircraft. Had a take-off
performance calculation been accomplished prior to take
off, it would have identified that the distance available was
inadequate for takeoff under these conditions.
3. The southeast end of the airstrip was not clearly
marked; as a result, the takeoff was initiated with
approximately 86 ft of usable airstrip behind
the aircraft.
Accident Synopses
Regulations and You
Takeoff
2. A takeoff and climb to 50 ft performance calculation
was not completed prior to take off; therefore, the
flight crew was unaware of the distance required to
clear the telephone cable.
Recently Released TSB Reports
Critical information regarding the significance of surface
wind, temperature, and aircraft weight on operations
specific to the lodge airstrip may not have been
communicated to the flight crew during training. Despite
changes in wind and temperature conditions and the much
higher than normal take-off weight for lodge airstrip
departures, neither pilot recognized the need to reconsider
the take-off weight. The final decision to attempt the takeoff represented a collective failure on the part of the owner,
the captain, and the first officer to recognize and manage
the risks associated with lodge airstrip operations.
aircraft to clear an obstacle and, as a result, the aircraft
struck a telephone pole and a telephone cable during
the initial climb.
Maintenance and Certification
later decisions to add full fuel and two extra passengers to
the flight. The owner also went flying and was therefore no
longer in a position to closely monitor the progress of the
pre-flight preparations or consider the addition of a third
passenger on the aircraft. Although the first officer spent
most of the morning preparing the aircraft, he prepared
only a weight and balance report and did not complete a
take-off performance calculation.
Maintenance and Certification
oscillations (vibration) under certain operational
conditions. This most likely contributed to the
high‑cycle fatigue failure of the 41-tooth bevel gear.
Safety action taken
Eurocopter has issued the following two alert service
bulletins to check for the proper adjustment of the torque
dampening system on Unison starter-generators installed
on the Eurocopter fleet of aircraft:
•
Accident Synopses
In July 2008, Turbomeca issued Service Bulletins (SB)
No. 292 72 0325 and No. 292 72 2090 regarding,
respectively, TU 325 modification for Arriel 1 and TU 90
modification for Arriel 2 engines. According to Turbomeca,
the aim of these modifications, which introduce a 41-tooth
bevel gear with a thickened rim, was to improve the
tolerance of the 41-tooth bevel gear to dynamic stress
caused by high or excessive levels of electrical power
tapped from the generator. The application of the SB was
as follows:
•
•
•
systematic on the new engines for Sikorsky S76 and
single-engine Eurocopter helicopters;
at the operators’ request for engines in service; and
in case of replacement of the 41-tooth bevel gear
during repair of module 01.
However, given the results of its investigations, Turbomeca
has concluded that TU 90 and TU 325 do not resolve
the last two occurrences of 41-tooth bevel gear failures or
other situations where a starter-generator is installed with
an incorrectly adjusted dampening system. Turbomeca
can only confirm that the new design is at least as robust
as the current design relative to abnormal vibration and
torsional oscillation.
Accident Synopses
An examination of the engine determined that the
41-tooth bevel gear (part number 0292127330) had
fractured due to high-cycle fatigue cracking. The gear
was installed during engine manufacture and had
accumulated a total of 1 644 hr since new. Metallurgical
examination (TSB Laboratory report LP 005/2008) of the
bevel gear revealed numerous fatigue cracks radiating from
the roots of many of the gear teeth. Circumferential fatigue
cracks were also observed in the rim of the gear. There were
no relevant manufacturing flaws found in the gear that
could contribute to the failure.
AS 350 Alert Service Bulletin No. 80.00.07 Rev.0
dated 19 December 2008
EC 130 Alert Service Bulletin No. 80A003 Rev.0
dated 19 December 2008
Recently Released TSB Reports
Recently Released TSB Reports
•
AS 350 sitting in the field after the successful autorotation
with no damage at all. Great job by the pilot!
Maintenance and Certification
Turbomeca Arriel 2B) had failed and the pilot commenced
an autorotation landing into a farm field. During the
descent, the pilot transmitted a mayday call and activated
the emergency locator transmitter. The helicopter landed
without further incident. There were no injuries and the
helicopter was not damaged. The pilot completed the
shutdown checklist and switched off the battery.
TSB Final Report A08A0095—Engine Failure and
Collision with Terrain
Fractured 41-tooth bevel gear shown with other parts
from the accessory gearbox
Findings as to causes and contributing factors
1. The 41-tooth bevel gear of the accessory gearbox
module 1 (MO1) accessory gear box failed due to
high-cycle fatigue causing an uncommanded in-flight
engine shutdown.
2. The dampening system of the starter-generator was
found to be over-tightened which caused torsional
On July 14, 2008, a float-equipped de Havilland
DHC-2 (Beaver) aircraft departed Crossroads Lake, N.L.,
at approximately 0:813 ADT with the pilot and six
passengers on board. About three minutes after takeoff as
the aircraft continued in the climb-out, the engine failed
abruptly. When the engine failed, the aircraft was about
350 ft above ground with a ground speed of about 85 mph.
The pilot initiated a left turn and, shortly after, the aircraft
ASL 4/2011
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Regulations and You
Regulations and You
As well, the European Aviation Safety Agency has issued
Airworthiness Directive (AD) 2009-0004 requiring
mandatory compliance with the service bulletins.
Maintenance and Certification
Recently Released TSB Reports
Findings as to causes and contributing factors
1. The linkpin plugs had not been installed in the recently
overhauled engine, causing inadequate lubrication to
the linkpin bushings, increased heat, and eventually an
abrupt engine failure.
2. Immediately following the engine failure, while the
pilot manoeuvred the aircraft for a forced landing, the
aircraft entered an aerodynamic stall at a height from
which recovery was not possible.
Findings as to causes and contributing factors
1. Contamination on the wings of the aircraft was
not fully removed before takeoff. It is likely that
asymmetric contamination of the wings created a lift
differential and a loss of lateral control.
Finding as to risk
2. Although the operator was not authorized for short
takeoff and landing (STOL) takeoff on this aircraft,
the crew conducted a STOL takeoff, which reduced
the aircraft’s safety margin relative to its stalling speed
and minimum control speed.
TSB Final Report A09C0017—Collision with
Terrain at Takeoff
3. As a result of the loss of lateral control, the slow STOL
take-off speed, and the manipulation of the flaps, the
aircraft did not remain airborne and veered right,
colliding with obstacles beside the ski strip.
1. The failure to utilize available shoulder harnesses
increases the risk and severity of injury.
28
Findings as to risk
1. The out of phase task requirements regarding the
engine vibration isolator assembly, as listed in the
operator’s maintenance schedule approval, results in a
less than thorough inspection requirement, increasing
the likelihood of fatigue cracks remaining undetected.
2. The right engine inboard and top engine mounts
had pre-existing fatigue cracks, increasing the risk of
catastrophic failure.
Other findings
1. The cockpit voice recorder (CVR) contained audio of
a previous flight and was not in operation during the
occurrence flight. Minimum equipment list (MEL)
procedures for logbook entries and placarding were
not followed.
ASL 4/2011
Regulations and You
On February 4, 2009, a ski-equipped de Havilland DHC-6
Series 100 was taking off from a ski strip east of and
parallel to Runway 36 at La Ronge, Sask. After the nose
ski cleared the snow, the left wing rose and the aircraft
veered to the right and the captain, who was the pilot
flying, continued the takeoff. However, the right ski was
still in contact with the snow. The aircraft became airborne
briefly as it cleared a deep gully to the right of the runway.
The aircraft remained in a steep right bank and the right
wing contacted the snow-covered ground. The aircraft
flew through a chain link fence and, at approximately
09:15 CST, crashed into trees surrounding the airport.
The five passengers and two crew members evacuated the
aircraft with minor injuries. There was a small fire near the
right engine exhaust that was immediately extinguished by
the crew.
Accident Synopses
Accident Synopses
The damaged aircraft after the accident
Recently Released TSB Reports
Regulations and You
Maintenance and Certification
crashed in a bog. The pilot and four of the occupants were
seriously injured; two occupants received minor injuries.
The aircraft was substantially damaged, but there was no
post-impact fire. The impact forces activated the onboard
emergency locator transmitter.
Maintenance and Certification
Safety action taken
The operator has taken the following actions:
•
•
TSB Final Report A09Q0181—Fuel Starvation
On October 11, 2009, a privately operated
Piper PA‑34‑200T took off from Saint-Georges
Airport, Que., and was headed for Gatineau, Que., on an
instrument flight plan. The aircraft was in cruising flight
at an altitude of 10 000 ft and was 7.4 NM southwest of
Mirabel Airport, Que., when both engines simultaneously
lost power. The aircraft entered a 180° right turn. The
pilot informed air traffic control that he was having
engine problems but did not declare an emergency. Radar
vectoring was provided to the pilot to direct him to
Mirabel Airport. During the descent, the aircraft deviated
southward before turning back toward the airport. The
aircraft had insufficient altitude to glide to the airport
and crashed in a maple bush 1.2 NM from the threshold
of Runway 06 at Mirabel Airport at 17:32 EDT. The
aircraft was located by a helicopter several minutes later.
The pilot, who was the sole occupant of the aircraft, was
seriously injured.
Findings as to causes and contributing factors
1. The right fuel selector was left in the XFEED position,
probably because the pilot was distracted and/or failed
to follow the checklist. As a result, both engines were
being fuelled by the left tank until it was completely
empty, causing both engines to stop simultaneously.
2. The pilot relied on a fuel quantity indicator system that
was based on the engine’s fuel consumption and not on
the quantity of fuel remaining indicated by the gauges.
1. The aircraft’s emergency locator transmitter (ELT)
broadcast signals on 121.5 MHz and 406 MHz. The
ELT was not damaged on impact, but its antenna was
broken, making it difficult to capture signals.
2. The pilot did not declare an emergency and did not
clearly indicate the nature of the problem; therefore air
traffic control (ATC) could not anticipate his needs.
TSB Final Report A10Q0070—Collision with
Terrain
On May 19, 2010, the pilot rented a Cessna 172 for a
2-hour period from 14:00 to 16:00, for a pleasure flight
under visual flight rules from Québec City/Jean-Lesage
International Airport to L’Isle-aux-Grues, Que. The
aircraft was carrying the pilot and three passengers. At
approximately 15:18 EDT, the aircraft made a touchand-go on Runway 25 at L’Isle-aux-Grues airport. On the
climb-out, the aircraft halted its climb and started flying
around the island at low altitude. At 15:22, a quarter of a
mile south of the runway, the aircraft struck a pile of rocks
and earth in a field, then crashed and caught fire. The
aircraft was partly destroyed by fire. The four occupants
died as a result of the accident. The emergency locator
transmitter (ELT) activated on impact; satellites received a
signal a few seconds after the accident and Canada Search
and Rescue was notified.
History of the flight following the touch-and-go
The Cessna halted its climb shortly after its touch-and-go
on Runway 25 and continued flying at low altitude. It
disappeared behind the trees on the western tip of the
island, then proceeded east along the south shore of the
ASL 4/2011
29
Regulations and You
3. The pilot did not recognize the power loss as being a
failure of both engines. The emergency checklist for
engine failure was not completed.
Other findings
Accident Synopses
Accident Synopses
All DHC-6 engine mounts have been inspected.
The operator’s inspection program has been amended
to include the manufacturer’s recommendation to
overhaul or replace the engine mounts every 3 000 hr.
Short take-off and landing (STOL) procedures have
been suspended.
Recently Released TSB Reports
Recently Released TSB Reports
•
Regulations and You
Maintenance and Certification
2. The operator’s safety management system (SMS)
did not identify deviations from standard
operating procedures.
Maintenance and Certification
Two hypotheses may explain why the pilot made a lowaltitude flight which, resulted in a collision with the terrain.
Technical deficiency with the aircraft
It is possible that, after encountering mechanical trouble,
the pilot was attempting to make an emergency landing
when the aircraft struck the mound. The elements that
support this hypothesis are:
•
•
Flying at low altitude can be dangerous: the field of view
is more limited and the background landscape can conceal
obstructions if it does not provide sufficient contrast. In
this occurrence, the low-altitude flight was made over a
non built-up area and, in large part, over water. Just before
ground impact, the aircraft overflew a small wooded area at
low altitude then descended to just above a cultivated field.
Section 602.14 of the Canadian Aviation
Regulations (CARs) about low-altitude flight states,
with regards to flight over a non built-up area:
However, no mechanical deficiency which could have
caused the engine to lose power or the aircraft to become
uncontrollable in flight were noted or discovered prior to
the flight or on examination of the aircraft. In fact, damage
to the propeller indicates that the engine was producing
power at the time of impact.
Based on the damage to the aircraft, the impact marks on
the mound and the trajectory of the debris trail, the Cessna
was configured for cruise flight and the pilot had control of
the aircraft until the time of impact. The aircraft was flying
at over 57 mph at the time of initial impact, the aircraft did
not stall. The marks on the engine tachometer were made
when the engine rpm decreased as a result of the propeller
striking the ground.
Accident Synopses
Except where conducting a take-off, approach or
landing or where permitted under section 602.15,
no person shall operate an aircraft [...] at a distance
less than 500 feet from any person, vessel, vehicle
or structure.
Pleasure flight just above ground without intent to land
The aircraft occupants intended to land at L’Isle-aux-Grues
airport for sightseeing. To that end, the pilot had rented
the aircraft for 2 hr (from 14:00 to 16:00). But because the
aircraft did not take off from Québec City until 14:47, it
was impossible to make the stopover as planned and return
on time. In fact, the pilot had less than 10 min to spend in
the area before departing on the return leg. It is possible the
pilot decided to overfly the island to give his passengers a
view of the landscape from the air in lieu of stopping over;
a low-altitude flight would have provided an exceptional
view. None of these hypotheses could be proven with a
degree of certainty.
The accident occurred because the aircraft, while flying just
above the ground, struck a mound 8 ft in height. Due to a
lack of evidence, the investigation was unable to determine
why the pilot stopped the climb after the touch-and-go
landing and continued flying at low altitude. Nor could
it be determined why the aircraft descended to a few feet
above terrain, which was unsuitable for landing, just before
the initial impact.
30
It is likely the pilot was looking straight ahead while
descending over the field. By extension, the pilot likely did
not see the mound when the aircraft flared to level flight.
Finding as to causes and contributing factors
1. For undetermined reasons, the aircraft was flying low,
just above the ground, when it struck an 8-foot mound
in a field and crashed. ASL 4/2011
Regulations and You
Analysis
Accident Synopses
Regulations and You
•
Recently Released TSB Reports
Recently Released TSB Reports
Low-altitude flight
the pilot was not known to fly at low altitude;
the marks on the engine tachometer dial indicate
that the engine was running between 1 800 rpm and
1 900 rpm at the time of impact, which is below the
normal cruise power level;
the pilot sent an unintelligible radio message shortly
before the collision.
Maintenance and Certification
island about 200 ft above the ground. Abeam the airport,
the aircraft turned left and headed northwest on a track
perpendicular to the runway centre line. The aircraft
overflew a small wood then descended to a few feet above a
field. The aircraft flew just above the ground for a distance
of 350 ft before striking a mound of rocks and earth. The
aircraft partly broke up and continued in the air until it
struck the terrain and caught fire. The final impact was in
a field about 255 ft from the mound. The pilot and two
passengers were fatally injured. The other passenger died in
hospital a few hours later.
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
— On February 18, 2011, a Piper PA28-140 was landing
on Runway 15 at Saskatoon John G. Diefenbaker
International Airport, Saskatoon, Sask., following a local
flight. The wind was 340° at 2 kt. The landing was flat, on
all three wheels, and the aircraft began to steer to the side
of the runway immediately after touchdown. Then the
aircraft departed the other side of the runway and tipped
nose down when it entered the snow. The propeller was
damaged and the nose gear strut was bent. The pilot was
uninjured. TSB File A11C0024.
— On February 4, 2011, a privately operated
ski‑equipped Piper PA20X (Pacer) was executing
touch-and-go landings from Lake Otis, Que., with two
people on board. After takeoff, the left ski struck a snow
windrow and broke. The left wing touched the snow and
the aircraft ground looped. No one was injured, but the
propeller and fuselage sustained major damage. There was
no fire following impact. TSB File A11Q0027.
— On February 22, 2011, a privately registered
Cessna 310 was arriving in Peterborough, Ont., on a VFR
flight from Goderich, Ont. Upon touchdown the nose
wheel tire blew and after a strong shimmy, the aircraft
came to a rest 700 ft down the runway. The nose wheel
rim was damaged and several significant wrinkles were
found on the fuselage area surrounding the nose gear.
Both occupants were uninjured. TSB File A11O0021.
— On February 8, 2011, a Found Brothers FBA-2C1
aircraft was on approach for Runway 34 at the
Sioux Lookout airport. Immediately after touchdown,
the aircraft veered to the left and then nosed down. The
aircraft did not overturn and came to a rest in a nose
down position on the runway. There were no injuries, but
the aircraft was substantially damaged. The runway was
closed for approximately 15 min to tow the aircraft off
the runway. Runway conditions were bare and dry. Wind
conditions at the time were 270° at 12 kt gusting to 17 kt.
TSB File A11C0016.
— On February 24, 2011, a Cessna U206G was
conducting wildlife telemetry services in the vicinity of
Wabasca, Alta. The pilot elected to land at the Buffalo
Creek airstrip (abandoned) and during the landing, the
aircraft encountered deep snow, resulting in both wing
tips and the propeller contacting the ground. There was
approximately 24 in. of snow on the airstrip. The aircraft’s
406 ELT activated and the pilot also selected 911 on the
SPOT. In addition, the aircraft was equipped with satellite
tracking equipment, which gave the accident location to
Alberta Sustainable Resources flight following centre. A
helicopter associated with the wildlife operation retrieved
the pilot within 30 min. The pilot sustained minor injuries
and was transported to the medical facilities in Wabasca.
There was substantial damage to fuselage and wings.
TSB File A11W0026.
— On March 7, 2011 a Diamond DA40 aircraft was en
route from Halifax, N.S. to Québec City, Que. While
flying in American airspace over Maine, the aircraft
encountered icing conditions and the pilot declared
an emergency. The aircraft eventually descended below
minimum vectoring altitude (MVA). After losing
communications, the Montréal Centre attempted to
reach the pilot via relay without success. Canadian and
American search and rescue centres were then notified.
The aircraft was located at 46°45’4”N, 069°5’3”W
(Maine, U.S.) 2 mi. from the Que. border. The aircraft was
ASL 4/2011
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Regulations and You
— On February 9, 2011, an amateur built Van’s RV-4
took off from Runway 13 at Courtenay Airpark, B.C.
Shortly after takeoff, at about 50 ft altitude, the
engine (Lycoming O-320D2A) stopped. The pilot headed
straight ahead and landed hard along the shoreline.
The main landing gear was damaged and the propeller
struck the ground. The tide was low at the time and the
aircraft was out of the water. The RCMP and fire crews
responded. The aircraft was moved to keep it out of the
water at high tide. The pilot observed a white crystalline
substance in suspension when he dipped the tanks during
an earlier stop at Port Alberni, and noted a relatively dark
blue tint to the fuel from that location. The engine and
fuel system will be examined further to assess any possible
fuel blockage or contamination. TSB File A11P0028.
Accident Synopses
— On February 3, 2011, a Bell 206B helicopter was
harvesting pine cones and was descending to unload. At
about 100 ft above ground, as the pilot was checking his
descent and turning into wind, tail rotor authority was
lost and the helicopter began to rotate. The main rotor
contacted trees and the helicopter crashed on its left side.
The pilot was the sole occupant and sustained minor
injuries. He was transported to Peace River by ground
ambulance. Winds were reported to have been from the
northwest at about 5 to 10 kt. TSB File A11W0018.
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
February 1, 2011, and April 30, 2011. 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
— On March 13, 2011, a McDonnell Douglas 369D
helicopter was landing at a remote well lease site
approximately 15 NM south east of Conklin, Alta., to
pick up a seismic crew. The sky conditions were clear, the
visibility was good, and the winds were light to calm. The
lease site was approximately the size of a football field;
however, most of the surface within the cleared area was
very rough and only the outer edges of the site, adjacent
to the perimeter trees, were suitable for landing. On
short final to the usual touchdown area, the pilot elected
to change the touchdown point. As the helicopter was
being manoeuvred towards the new touchdown point
the tail rotor struck a large rock. The tail rotor drive shaft
sheared and the tail rotor sustained substantial damage;
however, the helicopter remained upright on landing.
The pilot, who was the only occupant, was not injured.
TSB File A11W0037.
32
Maintenance and Certification
Recently Released TSB Reports
— On April 1, 2011, a privately operated Cessna 177
was on a VFR flight from Claxton-Evans County
Airport (KCWV) to Columbia Metropolitan
Airport (KCAE) in the United States with two people
on board. During a hard landing on Runway 29,
the nosewheel collapsed and the propeller touched
the surface of the runway. No one was injured, but
the aircraft sustained major damage to the fuselage.
TSB File A11F0069.
— On April 8, 2011, a Cessna 172S was returning to
Cooking Lake airport from a solo training flight. The
initial approach was attempted on Runway 28; however,
winds appeared to favour Runway 10. An overshoot
was completed and the student made a number of
attempts to land on Runway 28 while encountering a
strong crosswind. On the final attempt for landing on
Runway 10, the student pilot lost control of the aircraft
and veered to the left. The aircraft departed the runway
at about the midpoint of the runway and collided with a
snowbank. The aircraft flipped onto its back. The pilot was
uninjured. TSB File A11W0053.
— On April 12, 2011, a privately registered Cessna 182
was parked in a drive-through hangar on a private airstrip
near Williams Lake, B.C. A start was attempted and the
propellor would not turn over. The master switch was
turned off and the pilot attempted to turn the propeller
by hand to loosen the oil. The magnetos were live, the
throttle was at maximum, the mixture was rich, the
ASL 4/2011
Regulations and You
— On March 15, 2011, a ski-equipped Piper PA-18-150
Super Cub took off from Lac des Trois Caribous, Que.,
using the packed snow of a skidoo trail. The destination
was St-Mathieu de Beloeil (CSB3). The trail ran along
the edge of the lake. Immediately after takeoff, the
aircraft was carried off course to the right and crashed
into the trees. It sustained major damage. The pilot, who
was alone on board, was able to get out through the
broken windshield and suffered only minor injuries. The
emergency locator transmitter began transmitting a signal
— On March 29, 2011, a private Rockwell International
Aero Commander 112 was to carry out a training flight
with an instructor and a student pilot on board. The
aircraft was getting ready to taxi when the landing gear
alarm sounded. The instructor retracted the landing
gear in order to resolve the problem. The nose wheel
retracted and the aircraft fell onto its nose. The propeller,
the engine, and the landing gear door sustained major
damage. The instructor and student pilot were uninjured.
TSB File A11Q0062.
Accident Synopses
Accident Synopses
— On March 8, 2011, a Eurocopter AS350 B2
helicopter was engaged in survey operations near
Pellet Lake, N.W.T. The flight was operating an altitude
of approximately 150 ft AGL and following a survey line,
which was near the snow covered surface of Pellet Lake.
The flight encountered white-out conditions and the pilot
lost visual reference with lake surface. Shortly afterward,
the helicopter contacted the lake surface and rolled over.
The pilot and 2 passengers were able to exit the helicopter
without injuries; however, a post crash fire ensued, which
destroyed most of the fuselage and all survival gear
onboard. TSB File A11C0038.
— On March 20, 2011, a Rand-Kar advanced ultralight had flown approximately 6 hr throughout the day.
Approximately 5 NM from destination, the pilot realized
that fuel was low. A precautionary landing was executed
in a field. During the initial landing roll, the front skis
hit a ditch made by a snowmobile. The front ski’s strut
collapsed, causing the aircraft to flip over. Neither of
the two occupants was injured. The aircraft front ski and
propeller were damaged. The aircraft has a fuel autonomy
of 6 to 7 hr. TSB File A11Q0057.
Recently Released TSB Reports
Regulations and You
— On March 8, 2011, a ski-equipped Cessna 185
was on the take-off roll from a private airstrip at
Scroggie Creek, Y.T., when control was lost and the
aircraft departed the left side of the runway, crossing a
ditch. The aircraft sustained substantial damage to the
main landing gear, empennage and propeller. The pilot,
who was the only person on board, was not injured.
TSB File A11W0034.
on 406 MHz at 13:24 and it indicated the crash site at
13:30. TSB File A11Q0054.
Maintenance and Certification
destroyed when it struck a hill. One occupant was fatally
injured and the other had serious injuries. The U.S. NTSB
is investigating and an Accredited Representative from
the TSB has been appointed. TSB File A11F0038.
— On April 24, 2011, a Cessna 210H was on final
approach to Cochrane, Ont., when the right main landing
gear failed to extend. The aircraft continued to land and
touched down on the nose and left main landing gear.
The aircraft came to rest on the right wing tip and right
horizontal stabilizer. Maintenance found the right brake
hydraulic line had moved away from the landing gear
Maintenance and Certification
Recently Released TSB Reports
— On April 30, 2011, a Beech BE24 Super Musketeer
had just touched down and was taxiing to the aerodrome
in St-Hyacinthe, Que., when the nosewheel collapsed
and the aircraft left the runway. The aircraft was stationary
for a while on the runway and it sustained major
damage. The TSB is awaiting additional information.
TSB File A11Q0081.
— On April 30, 2011, a Piper PA18 was waiting for
the runway at the aerodrome in St-Hyacinthe, Que.,
to clear so that it could land. There was a Beech BE24
on the runway (see report #A11Q0081 above) whose
nosewheel had collapsed while taxiing. The pilot of the
Piper reported that his passenger was ill and that he had
decided to land on the grass next to the runway. The Piper
nosed over upon landing. The aircraft sustained major
damage but no one was injured. TSB File A11Q0082. IMPORTANT NOTICE: The ASL is moving to the Web!
Starting with Issue 1/2012, Transport Canada’s Aviation Safety Letter (ASL) will officially become an online
publication only. The decision to end the printing and distribution of paper copies of the ASL was not taken lightly,
and was made in order to reduce our environmental footprint and to better manage public funds.
Accident Synopses
Accident Synopses
— On April 23, 2011, a Hughes 500 helicopter was
spraying when it struck the top of a tree during a turn.
The pilot’s vision was affected by windshield glare from
the rising sun. The lower chin bubble windshield was
shattered and the mount for the anti-torque control
pedals was broken. The helicopter landed without further
incident. TSB File A11P0081.
— On April 27, 2011, a Cessna 180 departed
Vulcan, Alta. for Springhouse, B.C. with an ETA of
09:00 PDT. When the aircraft was reported late, the
rescue co-ordination centre (RCC) was notified and a
search was initiated. With the help of the Golden, B.C.
RCMP detachment, an ELT 406 signal, “Spot Tracker”
information, SAR aircraft, and a Parks Canada helicopter,
the wreckage was located at 5 000 ft ASL in an area with
a high risk of avalanche. There was no fire and the pilot
sustained fatal injuries. The TSB has offered assistance to
the Coroner. TSB File A11P0077.
Recently Released TSB Reports
— On April 19, 2011, a Cessna 310K was on an
IFR flight from Toronto/Buttonville municipal
airport (CYKZ), Ont., to Mirabel International
Airport (CYMX), Que. When the aircraft was on short
final, the control centre was notified of a problem with
the front landing gear. The pilot confirmed his intention
to land on Runway 06. Upon landing, the front landing
gear folded and the aircraft slid along the runway before
coming to a stop. No one was injured. The aircraft
sustained damage to the nosewheel and two propellers.
TSB File A11Q0075.
strut and had caught in the release mechanism, preventing
landing gear extension. TSB File A11O0053.
Maintenance and Certification
parking brake was off, and the chocks were out. When the
propeller was turned, the engine started and the empty
aircraft shot out of the hangar, skipped 400 ft attempting
to fly and struck a berm. The pilot was not injured. The
aircraft was substantially damaged. TSB File A11P0067.
The good news is that this transition offers new possibilities for our publication, such as unrestricted use of colours,
length of magazine, interactivity, and exploring the use of social media. Safety awareness activities need to adapt to
current industry trends to become as effective as possible. This shift moves us in the right direction and highlights
Transport Canada’s continual progression and growth in its safety awareness strategy.
Thousands of ASL readers have already made the transition to electronic delivery, and subscribe to our e-Bulletin
notification service. We invite all others to do so, by visiting www.tc.gc.ca/ASL and follow the easy steps to be on our
electronic mailing list. Once signed-up, you will receive an e-mail announcing the release of each new issue of the
ASL, as well as a link to the main ASL Web page. For those that prefer a printed copy, you will be able to receive a
print-on-demand version (black and white) through Transport Canada’s Publication Order Desk at 1-888-830-4911
or by e-mail at MPS1@tc.gc.ca.
Regulations and You
Regulations and You
Time to sign-up for the e-Bulletin!
Transport Canada values the opinions of ASL readers and will soon issue a reader survey to collect ideas on
enhancing the ASL. We look forward to welcoming you online at www.tc.gc.ca/ASL.
ASL 4/2011
33
Maintenance and Certification
Recently Released TSB Reports
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
and training records for the purpose of obtaining ratings
or for upgrading licences. These individuals knowingly
embellish their own flight times for the sake of simplicity
or time constraints. A few pilots have also consciously
made false declarations or have wilfully omitted critical
information on their medical applications to hide certain
medical facts. Some aircraft mechanics have purposely
made false statements or declarations on their applications
in the interest of obtaining a licence or rating. There
have been some aircraft maintenance engineers that have
signed another aircraft maintenance engineer’s name
in a maintenance release applicable to an independent
inspection, when in fact the work was either not carried out
or wasn’t up to the applicable standard. Some corporations
have also falsified training records for unqualified crew so
they could carry out flight duties without going through
the expense of qualifying them. These are all serious
offences that were wilfully and knowingly carried out by
the offenders for the purpose of obtaining some degree of
personal gain or advantage.
In simple terms, we are referring to voluntary actions
committed by a person that could be considered “fraud.”
The common understanding of “fraud” is dishonesty
calculated for personal gain or advantage. Offences under
7.3(1)(a) and 7.3(1)(c) of the AA are two offences that have
serious consequences, and a person who is found to be in
contravention of these paragraphs is guilty of an indictable
offence or an offence punishable on summary conviction.
These offences could subject the person to a comprehensive
investigation by Transport Canada, which may result in the
person appearing in court. An individual who is convicted
of this type of offence is punishable on summary conviction
to a fine not exceeding $5,000 or to imprisonment for
a term not exceeding one year, or to both a fine and
imprisonment. A corporation that is convicted of this type
of offence is punishable on summary conviction to a fine
not exceeding $25,000. Aviation Enforcement also has the
option of assessing a punitive suspension of a Canadian
Aviation Document (CAD) rather than proceeding by
summary conviction or indictment, and depending on the
circumstances and other factors surrounding the offence,
may take this course of action.
While it may seem like a very innocuous and outwardly
harmless act at the time, committing these fraudulent
types of offences can, in fact, turn out to have very serious
consequences down the road. Some of these consequences,
upon conviction, can range from a record of the offence on
the person’s file, to imprisonment, fines, licence suspensions
and even limitations to future employment opportunities.
Many of the most recent cases surrounding 7.3(1)
offences of the AA typically involve pilots, student pilots
and aircraft maintenance engineers. Some pilots and
student pilots have knowingly falsified flight records
34
Section 8.4 of the AA also stipulates that another person
who has responsibility or influence over an individual
who has committed an offence under 7.3(1) may also
be proceeded against in respect of and found to have
committed an offence under this section using the doctrine
of vicarious liability.
The AA also requires, under section 7.31, that where the
offence is committed or continued on more than one flight
or segment of a flight, it shall be deemed to be a separate
offence for each flight or segment of the flight. Therefore,
multiple offences could be charged to a person for the sake
of one act.
Aviation Enforcement has and will continue to rigorously
investigate these serious allegations and determine the
appropriate penalties that will deter others from embarking
on this same path. Those few persons who elect to
engage in these types of activities run the risk of not only
ASL 4/2011
Regulations and You
Aviation Enforcement has devoted many of its previous
articles in this publication to information regarding the
enforcement of the Canadian Aviation Regulations (CARs).
The Aeronautics Act (AA) is the legislation that authorizes
the creation of these regulations and also establishes
specific and serious prohibitions and offences and the
associated punishments for violations. The purpose of this
article is to focus on subsection 7.3(1) of the AA, and
specifically paragraphs 7.3(1)(a) and 7.3(1)(c) which, are
very serious offences related to “False Representation” and
“False Entries.” Paragraph 7.3(1)(a) of the AA states: “No
person shall knowingly make any false representation for
the purpose of obtaining a Canadian aviation document or
any privilege accorded thereby.” Paragraph 7.3(1)(c) states:
“No person shall make or cause to be made any false entry
in a record required under this Part to be kept with intent
to mislead or wilfully omit to make any entry in any such
record.” Offences in this subsection of the AA involve
intent by the person, a deliberate act on the part of the
offender to wilfully carry out an act or omission of an act.
Accident Synopses
Accident Synopses
False Representation and Entries
Recently Released TSB Reports
Regulations and You
False Representation and Entries...................................................................................................................................... page 34
Tribunal Case Review: Responsibility of Crew to Determine Fuel Quantity in Tanks................................................ page 35
Maintenance and Certification
regulations and you
Maintenance and Certification
We recognize that voluntary compliance with the
regulations is the most progressive and effective approach
to aviation safety. Voluntary compliance is based on
the idea that members of the aviation community have
a shared interest, commitment, and responsibility to
aviation safety, and that they will operate on the basis of
common sense, personal responsibility, and respect for
others. When users fail to meet their obligations and
contraventions occur, Aviation Enforcement is committed
to enforcing the aeronautic legislation in Canada in a fair
and firm manner. Tribunal Case Review: Responsibility of Crew to Determine Fuel Quantity in Tanks
Maintenance and Certification
tarnishing their own personal records, but could possibly
be limiting their future job opportunities and advancement,
and consequently their incomes.
Accident Synopses
The Minister assessed a monetary penalty of $750 against
the pilot-in-command for a contravention of paragraph
605.14(j)(i) of the Canadian Aviation Regulations (CARs)
which reads as follows:
605.14 No person shall conduct a take-off in a power
driven aircraft for the purpose of day VFR flight
unless it is equipped with
...
(j) a means for the flight crew, when seated at the
flight controls to determine
(i) the fuel quantity in each main fuel tank.
In this case the Cessna 172 was forced to execute an
emergency landing on a busy street in the city, possibly
because it had run out of fuel.
The pilot-in-command at the time of the forced landing
held the position of operations manager, chief pilot and
maintenance coordinator within the company which was
the registered owner of the aircraft. Evidence was given by
the Minister’s witnesses, at the review hearing, that the left
fuel gauge had been unserviceable for almost a year prior to
the forced landing. One of the Minister’s witnesses pointed
out that, with only one working gauge, the flight crew
could never know if the weight was unbalanced or if more
fuel was coming from one wing. The pilot-in-command
had plenty of time to take action to ensure that the left fuel
gauge was repaired before he took off.
The importance of aviation safety for the protection of the
public cannot be understated. It is crucial that an aircraft is
in condition for safe operation, which it was not in the facts
of this case.
In the case described above, even when the fuel tanks are
linked at the top and bottom, the crew members must be
able to determine the fuel quantity in each fuel tank. The
flight crew, with an unserviceable left fuel gauge, could
not ascertain how much fuel was in the left wing tank and
allowing the aircraft to remain in service in that condition
presented a hazard that was unacceptable. ASL 4/2011
35
Regulations and You
The pilot-in-command had argued that there was only
one fuel tank. His position was that the fuel system, as
it appears in the owner’s manual, does not include two
fuel tanks but only one that is linked at the top and the
bottom. The TATC Member, at the initial review hearing
on January 28, 2008, determined that there were two (2)
distinct fuel tanks, each one having its own gauge, which
was clearly contained in the aircraft owner’s manual, which
described the FUEL SYSTEM. Neither the Minister of
Transport, nor the pilot-in-command, had introduced
an expert witness in the design and functioning of the
aircraft’s fuel tanks and fuel system. The TATC Member
at the review level confirmed the $750 monetary penalty
saying that the pilot-in-command had contravened CAR
605.14(j)(i) because he had not been able to determine the
quantity of fuel in one of the main fuel tanks.
The pilot-in–command appealed the Review Member’s
decision to the appeal panel of the Transportation Appeal
Tribunal of Canada (TATC). He argued that the Review
Member had relied on inaccurate information about the
Cessna 172. The three (3) members of the appeal panel
stated that, on the day of the infraction, it was not contested
that one of the two fuel gauges was not operating. The
appeal panel also stated that CAR 605.14(j)(i) sets out the
necessity of having a fuel gauge that allows the quantity
of fuel in each tank to be determined. The appeal panel
concluded that the Review Member’s findings of fact were
reasonable and his decision was confirmed.
Accident Synopses
Regulations and You
In a decision of the Transportation Appeal Tribunal
of Canada (TATC), on March 28, 2008, the tribunal
pointed out the importance of properly functioning flight
equipment in an airplane. In the case discussed below, a
Cessna 172, according to the aircraft owner’s manual, was
equipped with two (2) fuel tanks, one in each wing. The
Minister of Transport’s witnesses confirmed that, at the
time of the infraction, the left fuel gauge in the airplane was
unserviceable while the right fuel gauge was operational.
Recently Released TSB Reports
Recently Released TSB Reports
by Beverlie Caminsky, Chief, Advisory and Appeals, Policy and Regulatory Services, Civil Aviation, Transport Canada
debrief
Flight Operations
permissible fuel, the inside diameter of the fuel filler
opening must be no larger than 2.36 in., whereas for
aeroplanes with turbine engines, the inside diameter of
the fuel filler opening must be no smaller than 2.95 in.
However, there is no standard for helicopters.
When fuelling, the pilots were present and were helping
the refueller, without ever noticing that the pump being
used was for fuel type Jet A-1. The three pilots then
each signed their individual fuel vouchers, which clearly
specified that Jet A-1 fuel had been pumped into the fuel
tanks. There are instructions on all three aircraft, by the
tanks, outlining the maximum capacity of the tank and
the type of fuel to use. These measures were not enough
to prevent the error. It should be noted that the aircraft
refueller was a new employee, who had only been there
since December 2010, and his training was limited.
The AVGAS-running Robinson R44 II is equipped with
a 1.5 in. fuel filler opening, while the turbine-equipped
Bell 206 helicopter has a fuel filler opening of 3.25 in.
However, the Aerospatiale AS350 helicopter, which
also runs on jet fuel, has a 2.28 in. fuel filler opening.
Therefore in order to refuel an AS350 with Jet A-1, the
3 in. nozzle has to be modified or changed to a smaller
nozzle. Considering that there are over 450 AS350
aircraft registered in Canada, it is feasible that several
refuelling stations in Canada had to modify the fuel
nozzles, just like at the Forestville airport, in order to
accommodate these helicopters.
The fuel nozzle for Jet A-1 fuel in this instance had
a 1 in. diameter, which is why the refueller was able
to insert it into the AVGAS fuel filler opening of the
three R44s.
While there are no fuel nozzle dimension standards
for aircraft refuelling at Canadian airports, there are
airworthiness standards for obtaining type approval and
changes to type certificates for normal, utility, aerobatic,
and commuter type aeroplanes. Section 523.973 of the
Canadian Aviation Regulations (CARs) specifies that for
aeroplanes with engines requiring gasoline as the only
36
During the initial installation of equipment at
aerodromes and airports, several gas and fuel providers
equip refuelling stations with fuel nozzles of varying
dimensions to avoid errors of this nature. Normally, the
nozzles used for AVGAS have a 1 in. diameter, while
the refuelling nozzles for Jet A-1 have a minimum
3 in. diameter. That way, even if the refueller makes a
mistake in the selection of the appropriate fuel, the 3 in.
refuelling nozzle cannot be inserted into the smaller
fuel filler openings, which the majority of piston engine
aeroplanes are equipped with.
Similar events have occurred in the last few years, not
only with helicopters but with aeroplanes equipped with
piston engines. This latest event shows that despite the
precautionary measures in place, it is still possible that
the wrong fuel type will be pumped into aircraft fuel
tanks. Fuel providers and refuelling stations are therefore
reminded of the risks associated with fuel nozzle sizes
and the importance of training refuellers accordingly. In
closing, we also remindpilots to pay close attention to the
fuelling of their aircraft with the proper fuel. ASL 4/2011
Aviation Safety in History
On March 1, 2011, a privately owned Robinson R44 II
helicopter with two people on board was on a VFR
flight from Port-Menier, Que., to Jean-Lesage
International Airport in Québec City, with a stopover at
the Forestville airport, Que., for refuelling. The R44 II
was accompanied by two other Robinson R44 IIs.
During the stopover in Forestville, the three aircraft
were erroneously refuelled with jet fuel ( Jet A-1) rather
than the required Aviation Gasoline (AVGAS) 100LL.
During its initial climb, the R44 II lost engine power
and the pilot made a forced landing in a residential
neighbourhood in Forestville. Both people on board
sustained minor injuries and were taken to hospital. The
aircraft did not catch fire but it was heavily damaged.
The two other aircraft landed near the same site and
sustained no damage, although both necessitated an
engine check.
Flight Operations
Aviation Safety in History
This article is based on an Aviation Safety Advisory issued by the Transportation Safety Board of Canada (TSB), and
TSB (Class 5) File A11Q0036.
Debrief
Debrief
Three R44 Helicopters Fuelled with Jet Fuel!
2011 Flight Crew Recency Requirements
Self-Paced Study Program
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
This questionnaire is for use from November 1, 2011, to October 31, 2012. Completion of this questionnaire satisfies
the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.
All pilots are to answer questions 1 to 29. In addition: aeroplane and ultra-light aeroplane pilots are to answer
questions 30 and 31; glider pilots are to answer questions 32 and 33; gyroplane pilots are to answer question 34;
helicopter pilots are to answer questions 35 and 36 and balloon pilots are to answer questions 37 and 38.
Note: Many answers may be found in the Transport Canada Aeronautical Information Manual (TC AIM).
TC AIM references are at the end of each question. Amendments to that publication may result in changes to
answers or references, or both. The TC AIM is available online at:
www.tc.gc.ca/eng/civilaviation/publications/tp14371-menu-3092.htm
1. What is the SECURITAS Program? ______________________________________________________
__________________________________________________________________________ (GEN 3.5)
2. VOR/VHF reception at an altitude of 1 500 ft AGL is about ________NM.
(COM 3.5)
3. Secondary surveillance radar (SSR) provides positive identification and aircraft altitude only when the
aircraft has an _____________________________________________________________.(COM 3.14)
4. The first transmission of a distress call should be made on the frequency ________________.(COM 5.11)
5. All FICs provide hour service and can be reached by dialling ________________________.(MET 1.3.2)
6. On a GFA “Clouds and Weather Chart”, areas of showery or intermittent precipitation are shown as ____
_________________________________________________________________________.(MET 3.3.11)
7. On a GFA “Clouds and Weather Chart”, areas of obstruction to vision not associated with precipitation,
where visibility is _______ SM or less, are enclosed by a __________________________. (MET 3.3.11)
TAF CYJT 041136Z 0412/0512 24010KT ½ SM -SHRA -DZ FG OVC002 TEMPO 0412/0413 3SM
BR OVC008 FM1300 29012G22KT P6SM SCT006 BKN015 BECMG 0422/0500 30010KT SCT020
RMK NXT FCST BY 18Z=
8. In the above TAF, what is the lowest forecast ceiling for CYJT? ______________________ (MET 3.9.3)
9. In the above TAF, at what time could you first expect to have VFR weather conditions in the CYJT
control zone? _____________________________________________________(MET 3.9.3, RAC 2.7.3)
10. “TEMPO” is only used on a TAF when the modified forecast condition is expected to last less than
________________ in each instance. When the modified forecast is expected to last more than
________________, either “________________” or “__________________” must be used. (MET 3.9.3)
11. Are the winds in GFAs, TAFs, METARs and FDs given in degrees true or magnetic? ________________
_______________________________________ (MET 3.3.11; MET 3.9.3; MET 3.11; MET 3.15.3)
12. Why is a special weather report (SPECI) issued? _____________________________________________
______________________________________________________________________ (MET 3.15.4)
13. A message that is intended to provide short-term warning of certain potentially hazardous weather
phenomena is called a ________________________________________________________.(MET 3.18)
14. When using a dial-up remote communications outlet (DRCO), if a microphone is keyed more than
___________ times, or ________________________________, the system will not activate. (RAC 1.1.3)
15. Besides the Designated Airspace Handbook, where could you find out if certain airspace requires a
transponder? __________________________________________________________________________
16. Which aircraft are not required to have a transponder in designated transponder airspace?
________________________. Transponder airspace includes all Class E airspace from________________
ft up to and including ____________________ ft ASL within radar coverage.(CARs 605.35, RAC 1.9.2)
17. According to the right of way regulations (CAR 602.19), where an aircraft is in flight or manoeuvring on
the surface, the pilot-in-command of the aircraft shall give way to an aircraft that is _________________
___________________________________________________________.(RAC 1.10 & CAR 602.19)
18. To preserve the natural environment of national, provincial and municipal parks, reserves and refuges,
and to minimize the disturbance to the natural habitat, overflights of these areas should not be
conducted below ___________________________________________________________.(RAC 1.14.5)
Transport
Canada
Transports
Canada
19. What is the minimum distance from cloud for aircraft flying VFR in uncontrolled airspace above 1 000 ft
AGL? ___________________________________________________(RAC Figure 2.7 & CAR 602.115)
20. A flight plan or flight itinerary shall be filed by sending, delivering or otherwise communicating it to the
appropriate agency or person, and ________________________________. (RAC 3.6.2 and CAR 602.75)
21. Find a copy of the Canada Flight Supplement and locate the “Planning” section (section C). In the “VFR
Chart Updating Data”, read the information on Conservation or Air Traffic Advisory Frequencies in your
region of Canada. Record one of the topic names: _____________________ (Canada Flight Supplement)
22. For aeronautical charts covering the areas outside the more densely populated area, the topographic base
maps are reviewed every ____________ or ___________ years and the aeronautical overlays are reviewed
every ____________ or ___________ years.
(MAP 2.3)
110052 CYUL MONTREAL/MASCOUCHE
CSK3 OBST LGT U/S TOWER 454352N 732712W (APRX 6 NM E AD)
205 FT AGL 245 MSL
TIL 1103212359.
23. The above NOTAM was in effect until ___________________________________________. (MAP 5.6)
24. A summary of current Aeronautical Information Circulars (AIC) is kept up to date on the ____________
____________________________________________________________________Web site. (MAP 6.1)
25. Hand-held fire extinguishers using extinguishing agents having an Underwriter’s Laboratories toxicity
rating in Groups _________________________________ should not be installed in aircraft. (AIR 1.4.1)
26. An altimeter setting that is too high results in an altimeter reading that is too ____________. (AIR 1.5.3)
27. When flying near power lines, if the background landscape does not provide sufficient _______________
_________________________________________________ you will not see a wire or cable. (AIR 2.4.1)
(AIR 3.12)
28. A pilot should not fly for at least __________________ after donating blood.
29. As per the Survival Advisory Information in TC AIM AIR Annex 1.0, what is the suggested equipment
for providing signalling in your geographic area? _______________________________ (AIR annexe 1.0)
AEROPLANE
30. A forward centre of gravity location will cause the stalling angle of attack to be reached at a __________
airspeed, while a rearward centre of gravity will cause the stalling angle of attack to be reached at a
________ airspeed.
(Aeroplane references)
31. To achieve a turn of the smallest radius and greatest rate for a given angle of bank, fly at the _______
possible airspeed for the angle of bank. (Aeroplane references)
GLIDER
32. Frequency ___________ MHz is allocated for the use of soaring activities.
(COM 5.13.2)
33. The breaking strength of a glider tow rope must be more than ____% and less than ____% of the gross
weight of the glider been towed.
(Glider references)
GYROPLANE
34. When operating at low level into a strong head wind at a reduced airspeed, a 180º turn to fly downwind
could be potentially dangerous because of the _____________________________.(Gyroplane references)
HELICOPTER
35. Settling with power is most likely to occur due to poor management of the helicopter’s
_____________________.(Helicopter references)
36. What type of aerodynamic interference, which can result in a loss of tail rotor effectiveness, is most likely
to occur when the wind is coming from a relative angle between 285º and 315º? ____________________
_______________(Helicopter references)
BALLOON
37. When a balloon climbs from cold calm air through an inversion, what should the pilot expect in terms
of performance? _____________________________________________
(Balloon references)
38. The first action to stop an uncontrolled fuel leak or fire should be to ______________________________
________________________________.(Balloon references)
Answers to this quiz are found on page 22 of ASL 4/2011.
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