debrief Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for...

debrief Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for...
2010 Flight Crew Recency Requirements
Self-Paced Study Program
All pilots are to answer questions 1 to 30. In addition, balloon pilots are to answer questions 31 and 32; glider pilots
are to answer questions 33 and 34; aeroplane and ultralight aeroplane pilots are to answer questions 35 and 36;
helicopter pilots are to answer questions 37 and 38; and gyroplane pilots are to answer questions 39 and 40.
STN YUL - MONTREAL/DORVAL. QUEBEC
FDCN01 CWAO FCST BASED ON 121200 DATA VALID 121800
for use
17-21 3000
0910
6000
0906-10
9000
9900-15
13. In the above upper level wind and temperature forecast (FD), what does 9900-15 represent? _____________________________________________________________________________________. (MET 3.11)
UACN10 CYXU 032133 YZ UA /OV YXU 090010 /TM 2120 /FL080 /TP PA31 /SK
020BKN040 110OVC /TA -12 /WV 030045 /TB MDT BLO 040 /IC LGT RIME
020/040 /RM NIL TURB CYYZ CYHM
14. What is the reported location in the above PIREP? __________________________________________. (MET 3.17)
15. If an ATC clearance is not acceptable, what should the pilot-in-command do immediately? _____________________
_____________________________________________________________________________________. (RAC 1.7)
Transport
Canada
Transports
Canada
Aviation Safety in History
TAF CYXE 281139Z 2812/2912 24010G25KT WS011/ 27050KT 3SM –SN BKN010
OVC040 TEMPO 2818/2901 1 1/2SM –SN BLSN BKN008
PROB30 2820/2822 1/2SM SN VV005
FM290130Z 28010KT 5SM –SN BKN020
BECMG 2906/2908 00000KT P6SM SKC
RMK NXT FCST BY 281800Z
11. What is the period covered by the above forecast? ____________________________________________. (MET 3.9.3)
12. Describe the wind shear in the above forecast. _______________________________________________. (MET 3.9.3)
In recent years, Transport Canada and the specialized
underwater-egress training industry have made
considerable efforts in educating pilots and operators
on the importance of underwater-egress procedures and
training. Through pamphlets, newsletter articles, posters,
videos and brochures, the aviation industry has received
the bulk of the information and awareness materials.
However, those education efforts have succeeded only
partially; while our crews and operators are aware and
ready, a very important segment of our industry—the
passengers—has not benefited to the same extent from
this awareness drive.
Most passengers will not seek specialized underwateregress training, and therein lies the challenge. It is
therefore the commercial operators—and their flight
crews—who are in the best position to transfer this
knowledge to them. The most effective and traditional
way of accomplishing this is to provide the best, most
comprehensive pre-flight briefing possible—supported by
a pre-flight video and reading material, such as a brochure
or pamphlet.
For passengers, the most difficult part of surviving a
ditching accident is the underwater egress. Accident
reports indicate that many people survive the initial
impact, but needlessly drown because they were unable
to extricate themselves from the aircraft. A study by the
Transportation Safety Board of Canada (TSB) suggested
that fatalities in seaplane accidents terminating in water
are frequently the result of post-impact drowning. Most
drownings occurred inside the cabin of the aircraft, and
occupants who survived often found exiting the aircraft
quite difficult. In fact, over two-thirds of the deaths
occurred to occupants who were not incapacitated during
the impact, but drowned trying to escape the aircraft.
Why do passengers encounter difficulties when trying
to get out of an aircraft that has submerged? Panic,
disorientation, unfamiliarity with escape hatches, and
lack of proper training are some of the major factors that
contribute to passenger drowning. During an emergency
situation, rather than pausing to think, most will react on
instinct and as a result of learned behaviours; if people
never acquired a learned behaviour that is appropriate for
this type of situation—such as the steps to follow in an
36
Typical underwater-egress training exercise, professionally
supervised and done with portable equipment in local pools.
underwater-egress scenario—then the odds of reacting
appropriately are much smaller. For example, when
getting out of a car, most of us release our seat belt before
opening the door. We do this without even thinking: it is
a learned behaviour. If we are strapped into an aircraft that
is sinking, a common reaction is to release our seat belt
first, then try to get out. We have reverted to the learned
behaviour we have acquired every time we get out of a car.
In many accidents, people have hastily and prematurely
removed their seat belts and, as a result, have been
moved around the inside of the aircraft due to the inrushing water. With the lack of gravitational reference,
disorientation can rapidly overwhelm a person. The end
result is panic and the inability to carry out a simple
procedure to find a way out of the aircraft.
An unfamiliar task, to be executed submerged, quite
possibly upside down, in the dark, and in very cold water:
what could seem like a simple undertaking suddenly
becomes monumental. To help prevent panic and
disorientation, we recommend that you brief passengers
thoroughly before each flight on the steps of underwater
egress described in the brochure entitled Seaplane/
Floatplane: A Passenger’s Guide (TP12365), available on
our new floatplane Web site at www.tc.gc.ca/floatplanes.
A thorough pre-flight briefing can make the difference
between life and death for your passengers. ASL 4/2010
aviation safety letter
In this Issue...
Occurrence Reports: Where Do They Come From and How Are They Used?
COPA Corner: Distractions Affect All of Us
An Ounce of Prevention…Corrective Action Plans
Aviation Safety in History
This article is a condensed version of The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers, by
Jackie Heiler of Pro Aviation Safety Training, and originally published in Aviation Safety Letter (ASL) 2/2009. We feel it is
worth repeating the value of underwater egress training and proper pre-flight passenger briefings, as part of our continued efforts
to promote floatplane safety. —Ed.
Flight Operations
1. When used in the text of a NOTAM, the date-time group is composed of ten figures, e.g. 1001191200. The first two digits
indicate the ___________; the second two, the ___________; the third two, the ___________; and the last four, the _______________.
(GEN 1.6.1)
2. Using the chart in GEN 1.6.2, find the end of evening civil twilight at Medicine Hat, Alta., (50°N 110°45’W) on May 29. _______________ .
(GEN 1.6.2)
3. No person shall displace, move or interfere with an aircraft involved in an accident, or disrupt an occurrence site without first having obtained permission from investigators, except to ________________, to ______________
________________________________, or to ______________________________________.
(GEN 3.4.1)
4. Except in the case of an emergency, what must a pilot do prior to using an aerodrome with PPR or PNR listed in the Canada Flight Supplement (CFS) or Water Aerodrome Supplement (WAS)?
PPR: __________________________________________________________________
PNR: __________________________________________________________________. (AGA 2.2)
5. What VHF direction-finding (VDF) services are available from stations offering VDF? ___________________________________________________________.
(COM 3.10)
6. Is a VFR GPS receiver with a current database acceptable as a replacement for aeronautical charts? ________.
(COM 3.16.16)
7. What information should be included on initial contact with a remote communications outlet (RCO)?
___________________________________________________________________________________. (COM 5.8.3)
8. In Southern Domestic Airspace (SDA) the correct frequency for two aircraft to use for air-to-air communication is _______MHz.
(COM 5.13.3)
9. Cloud-base heights in aviation routine weather reports (METAR) and aerodrome forecasts (TAF) are always stated
as height _________________. On the other hand, heights in graphic area forecasts (GFA) and pilot weather
reports (PIREP) are normally stated as height ___________________.
(MET 1.1.5)
10. What does the following represent in a GFA? ___________________________________________________________________________________. (MET 3.3.11)
Flight Operations
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 this publication may result in changes to answers and/or
references. The TC AIM is available on-line at: www.tc.gc.ca/eng/civilaviation/publications/tp14371-menu-3092.htm
Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers
TP 185E
Issue 4/2010
Debrief
This questionnaire is for use from November 1, 2010, to October 31, 2011. 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.
Debrief
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Transports
Canada
Transport
Canada
debrief
Major Accident Report: Bell 206 Down in Cranbrook, B.C.
What Went Wrong: In-Flight Blackout
Assumptions
Smoke in the Cabin—Landing Light Switch Failure
Oral Counselling
Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing
for Passengers
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
TC-1003998
*TC-1003998*
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Recently Released TSB Reports
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Table of Contents
section
Contraventions of aeronautics legislation can result in a
wide range of penalties, including fines, suspensions or
cancellations of Canadian aviation documents, and even
imprisonment in severe cases.
Regulations and You
ASL 4/2010
(1) encourage future compliance by the offender; and,
(2) deter others from contravening aeronautics legislation.
Another option available to Aviation Enforcement
inspectors is “oral counselling.” This option may be used
when the contravention is considered minor in nature or
inadvertent; is a violation where there is no direct flight
safety hazard; or when the imposition of a sanction would
not be appropriate. Aviation Enforcement inspectors
will assess all aspects of the contravention, including the
attitude of the alleged offender, to determine whether oral
counselling will promote future compliance.
In the last year, “oral counselling” was assessed in
43 percent of all cases where there was a violation. The
Aviation Enforcement Division recognizes that voluntary
compliance with Canadian aeronautics legislation 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 in, commitment to, and responsibility for aviation
safety, and will operate on the basis of common sense,
personal responsibility, and respect for others. Aviation
Enforcement inspectors use oral counselling with this
philosophy in mind.
Oral counselling is most appropriate in cases of ignorance
or misinterpretation of the law, provided aviation safety
was not jeopardized. Examples include situations where
a minor contravention is committed and it had little or
no impact on safety, and where there was no indication of
a wilful act. Oral counselling is not an option when the
alleged offender disputes the allegations.
Balloon-Specific Questions
31. If the balloon contacts a tree and is moving free of it, what should the pilot do to reduce the risk of adverse consequences? _____________________________________________________________. (Use balloon references)
32. A person may conduct a take-off in a balloon within a built-up area of a city or town if the diameter of the launch site is _______________________________________________________________________. [CAR 602.13 (3)(d)]
Glider-Specific Questions
33. The end of the validity period of a medical certificate is calculated from ____________________________________
_______________________________________________________________________________. [CAR 404.04(7)]
34. The _____________ is the indicated airspeed at which the glider loses altitude most slowly.(Use gyroplane references)
35. If you are approaching for a landing and the wind is gusting from 15 to 25 kt and you normally approach at 65 kt, what should your new approach speed be in those conditions? ______________________. (Use aeroplane references)
36. Typically, light aircraft are designed to withstand, on landing, 90° crosswinds up to a velocity equal to 20 percent of their stall speed. For an aircraft with a 50-kt stalling speed, what is the maximum permissible 90° crosswind wind speed? _______________________________.
(Use aeroplane references)
It should be noted that when Aviation Enforcement
inspectors conduct comprehensive investigations
that are concluded with oral counselling, no Aviation
Enforcement record is kept in the offender’s file.
Helicopter-Specific Questions
Canada continues to play a leadership role in the
international aviation safety community and within our
national borders. In supporting this role, the Aviation
Enforcement Division is committed to promoting and
applying a policy of fairness and firmness when dealing
with contraventions of aeronautics legislation.
Have a safe and enjoyable flight! ASL 4/2010
16. Which of the following classes of airspace requires that a VFR flight establish two-way communication with the
appropriate ATC agency prior to entering? Class C, D or E? _____________________________________________
______________________________________________________________________. (RAC 2.8.3, 2.8.4 and 2.8.5)
17. After asking the passengers for their personal weights, what weight should be added for clothing in winter?
______________________________________________________________________________.
(RAC 3.5.1)
18. After a flight plan or flight itinerary has been filed but not opened with the appropriate ATS unit, what will happen if
the flight is delayed or cancelled? ___________________________________________________
________________________________, unless it is known that the aircraft has not departed. (RAC 3.6.4)
19. If a pilot closes a flight plan or flight itinerary prior to landing, are the alerting services with respect to
search and rescue (SAR) notification still active until after the landing? _____________________.
(RAC 3.12.2)
20. When a mandatory frequency (MF) area exists at an aerodrome but the ground station is not in operation, all reporting procedures specified in CARs 602.97 to 602.103 shall be ________________________.
(RAC 4.5.4)
21. In Canada, the area covered in a visual search during a SAR operation will typically extend to a maximum of
___________________ on either side of the flight-planned route.
(SAR 2.1)
22. Only aircraft equipped with an emergency locator transmitter (ELT) operating on _____________ can be detected by
COSPAS-SARSAT satellites.
(SAR 3.1)
23. Where would you find the index and list of current Canadian aeronautical charts? ____________________________
___________________________________________________________________________________. (MAP 2.2)
24. New or revised VFR operations which are required to be depicted on VFR charts are advertised first by ____________ until published in the CFS _____________ section then finally updated on the _____________.
(MAP 2.4)
25. What information would you find in a NOTAM? ___________________________________________. (MAP 5.1)
26. A pilot renewing a category 4 medical declaration should complete the declaration form _____ days before the expiry
date of the medical certificate.
(LRA 3.4.1.1)
27. Name one recurrent training program you must have successfully completed within the previous 24 months in order to meet the 2-year requirement. _______________________________.
[LRA 3.9, CAR 421.05(2)]
28. An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error of more
than __________________ when compared to the known ground elevation.
(AIR 1.5.1)
29. If, after receiving routine immunizations, a pilot feels unwell or experiences an adverse reaction, the pilot should wait for ___________________________ and ______________________________________ prior to flying. (AIR 3.13)
30. Review AIR 4.13 and AIR Annex 1.0
List what is available in the aircraft that you typically fly that could aid you in the event of an injury or a need for shelter. ____________________________________________________________ (AIR 4.13 and AIR Annex 1.0)
Aeroplane-Specific Questions (including ultralight)
Regulations and You
Pre-Flight...........................................................................................................................................................................3
Flight Operations..............................................................................................................................................................9
Maintenance and Certification........................................................................................................................................17
Recently Released TSB Reports......................................................................................................................................21
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers..........................36
Self-Paced Study Program...............................................................................................................................................Tear-off
2
The major objectives of deterrent action are to:
Achieving these objectives will contribute to the
advancement of aviation safety, which is the Aviation
Enforcement Division’s primary aim.
page
The cases discussed above provide us with useful
information on what the definition of “farmer” is and
on when a pilot can be found to have operated for “hire
or reward.” by Jean-François Mathieu, LL.B, Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
Sécurité aérienne — Nouvelles est la version française
de cette publication.
Publication Mail Agreement Number 40063845
Similar to the appeal panel’s decision discussed in the
paragraph above, the TATC review member determined
that to suggest that the PIC piloted his own aircraft for
the benefit of the company in Case No. 1—a corporation
for which he is the sole shareholder—without receiving
some type of benefit is simply not believable.
Oral Counselling
The most important decision in the enforcement process
is determining which deterrent action would be most
appropriate when evidence indicates that a person has
contravened a provision of the Aeronautics Act or the
Canadian Aviation Regulations (CARs). This decision may
significantly affect the offender’s attitude towards safety
and future compliance.
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2010).
ISSN: 0709-8103
TP 185E
received no benefit was not believable. Therefore, it was
determined that Company A had received an indirect
benefit, bringing it within the purview of the definition
of “hire or reward.”
Accident Synopses
Copyright:
Some of the articles, photographs and graphics that appear
in the Aviation Safety Letter are subject to copyrights held
by other individuals and organizations. In such cases, some
restrictions on the reproduction of the material may apply,
and it may be necessary to seek permission from the rights
holder prior to reproducing it.
The TATC review member determined that the pilot
acted for “hire or reward” in Case No. 2. He cited a TATC
appeal decision where the appeal panel determined that
Company A, owner and operator of an aircraft used
for commercial air service, had contravened the CARs.
This determination was made even though Company B,
which shared some of the same directors as Company A,
demanded and received payments for the commercial
flights. No proof was made that any funds flowed from
Company B to Company A. The appeal panel held that,
although there was no direct benefit to Company A,
to suggest that Company A operated its aircraft and
The Order Desk
Transport Canada
Toll-free number (North America): 1-888-830-4911
Local number: 613-991-4071
E-mail: MPS@tc.gc.ca
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Internet: www.tc.gc.ca/Transact
Accident Synopses
Please address your correspondence to:
gratuity or benefit, directly or indirectly charged,
demanded, received or collected by any person for use
of an aircraft”.
Recently Released TSB Reports
Letters with comments and suggestions are invited.
All correspondence should include the author’s name,
address and telephone number. The editor reserves the
right to edit all published articles. The author’s name and
address will be withheld from publication upon request.
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact:
nd Certification
The Aviation Safety Letter is published quarterly by
Transport Canada, Civil Aviation. It is distributed to
all holders of a valid Canadian pilot licence or permit,
to all holders of a valid Canadian aircraft maintenance
engineer (AME) licence and to other interested
individuals free of charge. The contents do not necessarily
reflect official government policy and, unless stated, should
not be construed as regulations or directives.
35
37. When landing in snow and using a high-hover technique, the re-circulating snow will obscure the landing site and will rise. In this condition, what should the pilot do? ____________________________________________________
______________________________________ (Use helicopter references or Aviation Safety Letter [TP 185] 1/2008)
38. In a dynamic rollover situation, when the rollover starts, a correction should be done smoothly by ________________
_______________________________________________________________________. (Use helicopter references)
Gyroplane-Specific Questions
39. Statistics reveal that the major cause of gyroplane accidents is pilot error and it is often linked to the lack of _________
_______________________________________________________________________. (Use gyroplane references)
40. To minimize the possibility of pilot-induced oscillation (PIO), avoid [high/low] speed flight in gusty conditions, and
make only [large/small] control inputs. After making a control input, wait briefly and observe the reaction of the aircraft before making another input.
(Use gyroplane references)
Answers to this quiz are found on page 16 of ASL 4/2010.
pre-flight
Guest Editorial
Guest Editorial
A Word of Warning to All Operators Regarding Dangerous Goods............................................................................. page 3
Occurrence Reports: Where Do They Come From and How Are They Used?............................................................. page 4
COPA Corner: Distractions Affect All of Us.................................................................................................................. page 6
An Ounce of Prevention…Corrective Action Plans........................................................................................................ page 7
A Word of Warning to All Operators Regarding Dangerous Goods
by Micheline Paquette, Acting Program Manager, Dangerous Goods, Standards, Civil Aviation, Transport Canada
Undeclared dangerous goods are found daily in passenger
baggage, company materials, cargo, stores and airmail. A
small percentage is reported; however, Transport Canada
suspects that a considerable number of items entering
the aviation transportation system are not detected for
various reasons. To mitigate this hazard, and for the safety
of their staff as well as their operations, air operators must
ensure that company personnel know how to recognize
dangerous goods and the indicators that dangerous goods
are being presented for transport.
The Transportation of Dangerous Goods Act,
1992 (TDG Act) and the Transportation of Dangerous
Goods Regulations (TDG Regulations) apply to you
if you handle, offer for transport, import, or transport
dangerous goods to, from, or within Canada. The Act and
Regulations also apply to aircraft that are registered in
Canada but are operated outside Canada. This includes
the transportation of replacement parts (i.e. spares)
such as fire extinguishers, oxygen cylinders, engines,
fuel pumps, fuel control units, first aid kits, life vests,
etc. Activities carried out under a regulatory exemption
are also subject to the TDG Regulations. Regulatory
exemptions allow passengers to bring on board the aircraft
articles such as aerosols, toiletry articles, cellular phones,
International implications for Canadian non-dangerousgoods operators
Air operators who state in their operations manual
that they will not conduct dangerous-goods activities
and choose not to provide awareness training to their
employees may encounter some delays and/or difficulties
when operating outside Canada.
The International Civil Aviation Organization’s (ICAO)
Annex 6 to the Convention on International Civil Aviation
contains standards and recommended practices (SARP),
which are applicable to member States, to regulate the
aviation industry. The ICAO SARPs require that the
ground and flight crew member training program include
a section on the transport of dangerous goods. In the
United States, the Department of Transport has already
developed regulations in the Code of Federal Regulations,
Title 14 to require awareness training for “will-not-carry”
certificate holders. Other ICAO member States have also
included such requirements.
It should be noted that Canada has not yet incorporated
the ICAO SARPs into the Canadian Aviation
Regulations (CARs); however, this does not relieve
Canadian operators from complying with foreign
regulations when travelling within their jurisdictions.
Foreign authorities check foreign carriers more frequently,
and failing to meet ICAO or foreign requirements may
be problematic—even if the Canadian operator meets the
domestic regulations.
ASL 4/2010
3
Winter Operations
Winter Operations
Are you a dangerous-goods operator?
Training is the key to understanding and complying with
the TDG Regulations. This enables a person to determine
whether a product is considered to be dangerous goods,
whether the dangerous goods are regulated, and how to
use the TDG Regulations efficiently.
Pre-Flight
Pre-Flight
Undeclared dangerous goods take many forms, the classic
example being the chemical oxygen generators carried
on board in the crash of ValueJet Airlines Flight 592 on
May 11, 1996. The U.S. National Transportation Safety
Board (NTSB) aircraft accident report of Flight 592
identified the root cause as being a series of decisions that
lead to the inadvertent loading of the chemical oxygen
generators in the cargo hold. A fire ensued, engulfing
combustible materials nearby, and was proliferated by
the generation of oxygen gas. The aircraft crashed in
the Florida Everglades and everyone on board perished.
Measures had not been in place or communicated to
ensure that air operator personnel—including third party
personnel—were capable of recognizing dangerous goods.
portable computers, cigarette lighters, etc. The exemptions
also permit operators to stow electric wheelchairs in
the cargo hold and to carry dangerous goods such as
aerosols, alcoholic beverages and perfumes for use or sale
on board the aircraft during the flight. If any of these
regulatory exemptions apply to your operation, you are
in fact handling, offering for transport, or transporting
dangerous goods.
To the Letter
To the Letter
Transport Canada has identified a potential hazard
associated with the carriage of undeclared dangerous
goods on Canadian aircraft.
The general conditions of an air operator certificate
stipulate that the holder must conduct flight
operations safely and in accordance with the company
operations manual. Part of those general conditions
is Transport Canada’s approval of procedures for the
carriage of dangerous goods in the company operations
manual and the dangerous goods training program.
Transport Canada’s position
Air operators wanting to obtain more information
should contact their Transport Canada Civil Aviation
regional office. It is likely that most air operators are involved in the
transport of dangerous goods in some respect. The
To the Letter
To the Letter
A safety management system (SMS) is an explicit,
comprehensive and proactive process for managing
risks. Since dangerous goods entering the transportation
system present a variety of risks to aviation safety, it is
important that all air operators establish a comprehensive
and proactive process for dealing with dangerous goods
in their own contexts. Under the principals of SMS,
operators must ensure that their system as a whole
promotes safe operations.
great majority of air operators do take advantage of the
regulatory exemptions to transport dangerous goods
carried by passengers and to transport replacement
parts. Thus, they are subject to the regulations, and
Transport Canada requires, at a minimum, awareness
training for all personnel involved in the processing
of passengers, cargo, mail and stores; this includes
third party personnel and instructions to be provided
to employees in the company operations manual.
This training and information assist employees in the
recognition of dangerous goods and in understanding
their responsibilities in preventing non-compliant or
undeclared dangerous goods from entering the aviation
transportation system and compromising the safety of the
Canadian travelling public.
Guest Editorial
Guest Editorial
Safety management systems
Occurrence Reports: Where Do They Come From and How Are They Used?
by Ann Lindeis, Manager, Safety Management Planning and Analysis, NAV CANADA
In Canada, operating certificate and licence holders
have obligations when it comes to reporting aviation
occurrences. These obligations are set out in various acts
and regulations. However, many in the aviation industry are
likely unaware of how aviation occurrence reports (AOR)
are generated and disseminated. There are also many
misconceptions about how the information contained in
occurrence reports is used.
Transparency in how safety information will be employed
is an essential element to creating an effective safety
culture. The purpose of this article, therefore, is to
provide an overview of the occurrence reporting process
in Canada from the perspectives of NAV CANADA,
Transport Canada (TC), and the Transportation Safety
Board of Canada (TSB).
NAV CANADA has a mandatory reporting system
through which operational employees report specific
types of occurrences. Such AORs are entered into
NAV CANADA’s occurrence database.
The key information submitted is automatically distributed
via e-mail to TC’s Civil Aviation Contingency Operations
Division (CACO) and to the appropriate TSB regional
office.
4
NAV CANADA reviews all AORs submitted
and identifies those considered to be operating
irregularities (OI), which are defined as situations where:
air traffic services (ATS) are being provided and a
preliminary investigation indicates that safety may have
been jeopardized, less than minimum separation may have
existed, or both.
Any OI where the provision of ATS is thought to have
contributed to the outcome is investigated through
NAV CANADA’s operations safety investigation (OSI)
process. The results of the investigation are used to identify
potential mitigations to prevent recurrence.
In addition, NAV CANADA frequently exchanges
information and follows up with individual operators after
an aviation occurrence. Safety-specific inquiries may be
directed to NAV CANADA through the following e-mail
address: operationalsafety@navcanada.ca.
ASL 4/2010
Winter Operations
Winter Operations
NAV CANADA
In addition, a
summary of the
previous day’s entries
in the database is distributed every morning to an internal
and external mailing list. Personal information, such as the
names of individuals involved, is not included in the AORs.
Pre-Flight
Pre-Flight
Introduction
The holder of an ATS operations certificate shall report to
the Minister any aviation occurrence information specified
in the CADORS Manual in accordance with the criteria
and reporting procedures specified in that manual.
Annex A of the CADORS Manual lists the types of
occurrences that must be reported. Examples include
collisions or risks of collision; declared emergencies;
regulatory infractions; or any occurrence that deviates from
normal operating procedures, may generate a high degree
of public interest or concern, or could be of direct interest
to specific foreign aviation authorities. The CADORS
Manual is currently in the process of being updated.
Since the year 2000, almost 95 percent of the CADORS
information has consisted of reports filed in accordance
with the criteria for mandatory reporting. Other reports
have been obtained from sources such as the U.S. Federal
Aviation Administration (FAA), the TSB, airports,
operators and private individuals.
Efforts are taken to ensure quality, but because the
information found in the CADORS is preliminary and
subject to change, it is not always possible to guarantee the
accuracy of the information.
Identifiable information, such as the aircraft’s registration
number, is removed and licence-holder information, e.g.
pilot or controller names, is not entered in the CADORS.
It is possible to search occurrence data from 1993 on
using criteria such as date, aircraft make and model, or
information included in the narrative.
CADORS data is monitored and analyzed by Civil
Aviation employees to assist in the identification of hazards
and trends. It provides inspectors with information related
to operators under TC oversight.
Approximately 2 000 aviation-related transportation
occurrences are reported to the TSB each year. Any of these
occurrences may be investigated if they are deemed to meet
criteria based on risk, safety benefit and public expectations.
If the occurrence is not investigated, the information
provided will be stored in the TSB’s database for statistical
analysis. The database also allows the TSB to conduct trend
analyses and determine if a safety issues investigation may
be the appropriate vehicle to highlight a recurring problem.
If the occurrence is investigated, the TSB makes
available factual information about the circumstances
of the occurrence throughout the investigation. Safety
information is shared immediately with those who
can make changes to improve safety, and may take the
form of recommendations, safety advisories or safety
information letters.
However, for some types of information—including
on-board recordings, representations to the Board, and
personal information such as witness statements—there are
stringent restrictions on who may access the information
and how it may be used.
Conclusion
Information collected with respect to aviation occurrences
is shared throughout the aviation community and used by
operators, NAV CANADA, TC and the TSB to identify
hazards and to improve safety.
The collection and use of occurrence data provides
significant safety benefit to the aviation community.
We trust that this article has helped to clarify how this
information is collected and used, and to make clear that
personal information is not included in any of this data.
This article was prepared by NAV CANADA, but was a
collaborative effort between NAV CANADA, TC and the TSB.
—Ed. ASL 4/2010
5
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Winter Operations
In the interest of improving aviation safety,
CADORS reports are available on TC’s Web site, at www.tc.gc.ca/cadors.
Owners, operators, crew members and air traffic controllers
have an obligation to report accidents and reportable
aviation incidents to the TSB as soon as possible and by the
quickest means available.
Pre-Flight
Pre-Flight
NAV CANADA sends AOR information to CACO,
who then forwards it to one of TC’s five regional offices,
as appropriate. The information is then entered into
the CADORS.
Transportation Safety Board of Canada
To the Letter
To the Letter
TC uses the Civil Aviation Daily Occurrence Reporting
System (CADORS) to collect information on occurrences
in the National Civil Air Transportation System (NCATS).
Canadian Aviation Regulation (CAR) 807.01 prescribes the
requirement to report, as follows:
Inquiries regarding the CADORS may be sent to
TC through the following e-mail address: cadors-screaq@tc.gc.ca.
Guest Editorial
Guest Editorial
Transport Canada
by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the February 2009 issue of COPA Flight, and is
reprinted with permission.
Distractions are the number one cause of forgetting things.
There are two main reasons for this. The first is we are
always thinking ahead of what we are doing. Therefore,
when we are distracted, we tend to think we were further
along in our task than we actually were.
The aircraft was not ready. The chief mechanic was
working on the aircraft himself in an attempt to get it
out of the hangar. Shortly before the mechanic was to
replace the engine cowlings, he was called to the phone.
He glanced at the waiting pilot and called to another
mechanic to finish up and cowl the aircraft.
The second mechanic looked the engine compartment
over and everything appeared to be where it was
supposed to be so he replaced the engine cowlings. The
chief mechanic returned and saw the cowlings had been
replaced, so he signed out the logbooks and sent the
pilot on his way. The flight to the pilot’s home base was
Fortunately, the sparkplug wires did not all come loose
in flight.
A rental pilot was performing a pre-flight inspection
on a C-172 when the three friends he was taking on a
sightseeing flight arrived at the airfield fence. The young
pilot stopped what he was doing and let his friends
in through the FBO [fixed-base operator]. He then
completed his inspection, loaded his passengers and began
taxiing the aircraft.
The FBO owner saw the aircraft taxiing with the tow bar
still attached to the nose wheel and called the FSS [flight
service station] specialist to request that the aircraft be
stopped and shut down so the tow bar could be removed.
The phone is one of the most common distractions,
and most calls can wait.
6
ASL 4/2010
Both pilots returned to where they thought they
were in the inspection process. We usually think
about three steps ahead of where we are during any
task, so it is easy to forget steps when distracted. A
good rule to follow whenever we are distracted or
interrupted is to go back at least three steps from
where we thought we were when distracted. If
unsure, start over.
Winter Operations
Winter Operations
A commercial pilot was interrupted during his
pre‑flight inspection to answer a phone call
from IFR Flight Data regarding his flight plan.
After the call, he continued with the inspection.
After starting the engines he noted the engine
temperature in the right engine was climbing into
the red. He shut down the engine and went to take
a look. He had forgotten to remove the engine
intake covers from the right engine.
Pre-Flight
Pre-Flight
A pilot arrived at a maintenance hangar to pick up
his C-172, which should have been ready after a 100hour inspection. It was late afternoon and he had a
flight of about 100 miles back to his home airport
before grounding.
The distraction of the telephone, coupled with the
pressure to get the aircraft inspection completed, resulted
in the chief mechanic not giving a full hand-over briefing
to the second mechanic. He was thinking ahead to
replacing the cowlings and that is what he mentioned.
The second mechanic saw that the sparkplug wires were
connected, but did not check to see if they were tightened.
To the Letter
To the Letter
The second is our short-term memory is very short so any
distraction may cause us to lose what we were thinking of
when distracted.
uneventful, but the
next day he tried to
start the aircraft and
it would not start. He removed the engine cowlings and
noted that three of the four sparkplug wires had become
unattached from the sparkplugs.
Guest Editorial
Guest Editorial
COPA Corner: Distractions Affect All of Us
Fatigue and stress directly affect our ability to transfer
information to long-term memory and to access
information in our long-term memory. Therefore,
when we are tired or stressed, we increase our chances
significantly of forgetting to do things we intend to do.
We are all tired or stressed at times. When we are, we
must avoid distractions and multi-tasking. Multi-tasking
is actually self-distraction. We are not as capable of multitasking as we think we are. This is why some provinces are
banning cell phone use while driving.
The number one distraction for all of us is the phone/
cell phone. There are times when the phone should not
be answered and probably should be turned off. The vast
majority of the calls we receive could be missed without
the world ending. Most of the remaining calls can go to
voicemail and be returned at a more convenient time.
Guest Editorial
There are times, though, when we do not wish to be
disturbed and times when we should not be disturbed. Be
courteous and take the time to observe those you wish to
talk to, to determine if now is a good time to do so. If we
are not sure, we can ask if the individual has a moment.
This will give them the opportunity to complete a task
or to at least put themselves in a position to transfer
information to long-term memory and be prepared to pay
full attention to us.
Distractions affect all of us. The best we can do is to
minimize them. Mistakes caused by distractions are, at
least, embarrassing and, at worst, damaging.
Dale Nielsen is an ex-Armed Forces pilot and aerial
photography pilot. He lives in Abbotsford, B.C., and currently
flies air charters. He still freelances as a flying instructor and
seminar facilitator. 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 the Letter
To the Letter
The other problem with short-term memory is that it has
a limited capacity of six to seven unrelated items. Maybe
that is a good thing. When we get distracted, there are a
limited number of things we can forget.
The next most common distraction is people directly
wanting our attention. This includes friends, significant
others, co-workers and bosses. When we wish to talk to
someone, we seldom, if ever, observe what they are doing
before we interrupt them. We are a social society and
most of us do not mind being talked to.
Guest Editorial
The length of our short-term memories compounds
this. Our short-term memory is only about 30 seconds.
We must do something specific to transfer information
from short- to long-term memory. We normally do this
subconsciously, but it does take some concentration.
An Ounce of Prevention…Corrective Action Plans
Corrective action plans (CAP) are generally formal
responses to findings and are intended to map out
corrective measures. These findings can be generated from
several sources, such as a certificate holder’s internal quality
assurance system; investigations arising from a company’s
safety reports; or a regulator’s inspections and assessments.
In all cases, the findings identify a situation where a
company policy, procedure, or process does not conform to
either the organization’s internal policies or to regulatory
requirements. A CAP is a step-by-step plan of action and
schedule for correcting a finding.
Successful implementation of a CAP is highly dependent
on the planning that goes into it. To adequately address
non-conformances, the CAP must, at a minimum:
1) Define the problem: The definition should clearly
identify what happened, how significant it was, where
it occurred in the system, and what type of problem
it was (e.g. policy, process, procedure or culture).
Remember: “If you cannot say it simply, you do not
understand the problem.”
2) Analyze the problem: The analysis should include
a summary of the root cause as well as any causal
factors that may have contributed to the problem.
There are many techniques available to determine root
cause: “5 Why’s”, “Fishbone”, the maintenance error
decision aid (MEDA) process, etc. Certificate holders
must adopt a method that is appropriate for their
organization. Regardless of which method is used, the
organization must be able to demonstrate how they
arrived at the root cause and what caused the nonconformance.
Winter Operations
Winter Operations
Taking effective corrective action is an essential part of a
solid management system and central to a closed-loop,
continuous improvement process.
Pre-Flight
Pre-Flight
by Cliff Marshall, Technical Program Manager, Technical Program Evaluation and Co-ordination, Standards, Civil Aviation,
Transport Canada
3) Identify the corrective action(s) required: The CAP
should be documented and contain sufficient detail to
describe what actions will be taken to address not only
the specific examples of non-conformance and any
associated immediate safety issues, but also the causal
factors determined during the analysis of the problem.
ASL 4/2010
7
Guest Editorial
4) Set a clear timeline for the corrections to be
implemented: Timelines should be aimed at
implementing effective corrective actions in the
shortest reasonable time period. There should be
due dates, targets, and planned follow up to ensure
effectiveness of the proposed corrections.
6) Identify who is responsible for managerial approval:
Identify an individual within the management
structure who has the authority to commit the
necessary resources required to fulfill the plan and can
approve the CAP.
Taking the time to develop a comprehensive CAP will
not only help certificate holders address findings but,
more importantly, also help them continuously improve by
preventing those findings from reoccurring. Guest Editorial
If there are any induced hazards or risks associated
with the implementation of the corrective actions, they
should be assessed, mitigated or eliminated.
5) Identify responsibility for implementation: Clearly
identify the person or persons within the organization
who are responsible for implementing the actions.
The Prairie and Northern Region (PNR) encompasses
approximately 60 percent of Canada’s landmass, which
creates unique opportunities for communication.
“Communication between people working at
Transport Canada and those working in the aviation
industry is crucial to maintaining and enhancing safety,”
explains Kate Fletcher, the PNR’s Regional Director
of Civil Aviation. “Discussing current issues and
sharing thoughts and ideas in person builds a culture of
engagement conducive to achieving our shared goal of
aviation safety.”
Pre-Flight
Since the beginning, the ASC has remained true to its
original objective, which is to provide an opportunity
for participants to identify safety issues and exchange
information so regulators and industry can work
collaboratively to ensure Canada’s air transportation
system remains safe.
The 25th meeting of the ASC will take place on
Tuesday, November 30, 2010, in Calgary, Alta. To
attend, please register with Carol Beauchamp by e-mail
at carol.beauchamp@tc.gc.ca. This special event will be
limited to 125 participants, so please register as soon
as possible.
Winter Operations
www.tc.gc.ca/civilaviation/SMS/Info/menu.htm
8
ASL 4/2010
Winter Operations
Transport Canada’s Safety Management Systems (SMS)
Information Session
Fairmont The Queen Elizabeth Hotel
Montréal, Quebec
November 24–25, 2010
Pre-Flight
For this reason, the PNR formed the Aviation
Safety Council (ASC), which met for the first time
in Edmonton, Alta., on October 16, 1997. As the
number of participants increased, ASC meeting
locations were rotated between Edmonton, Calgary,
Winnipeg, Saskatoon, Yellowknife and Whitehorse.
Recent meetings have included representatives of
NAV CANADA, the Transportation Safety Board
of Canada (TSB), airport authorities, aerodrome
operators, airlines, small operators, flight training
units (FTU), aircraft maintenance organizations and
several industry associations.
The value of the ASC is clear to Herb Spear, the
occupational health and safety representative for
WestJet and a dedicated participant at the PNR’s
ASC meetings. “I value the ASC meetings because
Transport Canada encourages industry to raise
safety concerns,” explains Herb. “ I have witnessed
Transport Canada’s commitment to responding to
those concerns, whether voiced by an operator or
an individual.”
To the Letter
To the Letter
Celebrate the PNR’s “Silver Anniversary” of Safety Speak!
flight operations
Debrief
Debrief
Major Accident Report: Bell 206 Down in Cranbrook, B.C......................................................................................... page 9
What Went Wrong: In-Flight Blackout........................................................................................................................... page 12
Assumptions....................................................................................................................................................................... page 14
Major Accident Report: Bell 206 Down in Cranbrook, B.C.
The following is a condensed version of Transportation Safety Board of Canada (TSB) Final Report A08P0125, on the fatal
crash of a Bell 206B Jet Ranger helicopter in Cranbrook, British Columbia. Readers are encouraged to read the full report
on‑line at www.tsb.gc.ca.
The engine, fuel control unit (FCU) and power turbine
governor (PTG) were disassembled and examined in detail.
They had been exposed to extreme temperatures during
the post-crash fire and had suffered significant damage.
The TSB tests showed no mechanical anomaly that could
have affected their function; however, a latent malfunction
of either the FCU or the PTG could not be ruled out. (For
more details, including references to a 2005 investigation on a
similar PTG, readers should refer to the complete TSB Final
Report on the TSB’s Web site. —Ed.)
Helicopter autorotation
A critical aspect of autorotation is the entry manoeuvre
immediately following the loss of engine power because
the pilot must react quickly to conserve rotor RPM. Of the
other factors affecting autorotative flight, the altitude at the
The aircraft was flying south-southwest over
14th Avenue (midway between 7th and 10th Streets), at
about 120 ft above ground level (AGL) and 25 kt, when
the engine lost power. The final few seconds of flight were
uncontrollable and in free-fall from about 85 ft AGL.
The weather conditions did not contribute to the accident
circumstances, and the experienced pilot was certified
and qualified for the flight. The helicopter was certified,
equipped, and maintained in accordance with existing
regulations and procedures.
The accident site was generally an open area but there
were several obstructions that the pilot may have tried to
avoid during descent, namely the residential power lines,
tall trees, several houses, and vehicular traffic. Given those
obstructions, it is unlikely that the pilot saw either the
pedestrian or the car before impact. The airframe wreckage
was examined to the extent possible by the TSB, and for
the few airframe components that did survive the fire,
no indication was found of any pre-accident anomaly or
malfunction. The TSB also determined that the weight,
centre of gravity (CG), as well as hover out of ground
effect (HOGE) performance were all within prescribed
limits.
Aviation Safety in History
Aviation Safety in History
On May 13, 2008, a Bell 206B Jet Ranger with the pilot
and two passengers on board took off on a mission to
visually examine electrical power transmission lines that
ran through the city of Cranbrook, B.C. To accomplish
this task effectively, it was necessary for the inspection
to be carried out at about 20 to 30 ft above the line
or pole heights, at a ground speed of 25 kt. At about
13:06 Mountain Daylight Time (MDT), as the helicopter
was flying southbound at about 120 ft above the ground,
a sudden loss of engine power occurred causing rapid
loss of rotor RPM. The helicopter descended quickly and
landed heavily on a paved street below the flight path. The
helicopter struck a pedestrian on the sidewalk adjacent to
the impact point, as well as a motor vehicle. The helicopter
broke into several pieces and burst into flames. The three
occupants of the helicopter and the pedestrian were fatally
injured at impact.
Flight Operations
Flight Operations
Summary
Telemetry data from the helicopter allowed investigators
to recreate the flight path, depicted above.
time of the loss of engine power immediately establishes
several important elements of successful descent and
landing. The greater the height above the landing surface,
the greater choice of suitable landing areas, the more time
to establish and maintain control of the helicopter, and the
longer the glide distance. Low-altitude flight reduces all
these margins to the point where successful autorotative
flight and landing may be impossible.
The no-engine landing after an autorotative descent
is a challenging manoeuvre for any helicopter pilot
ASL 4/2010
9
Debrief
Flight Operations
The height velocity diagram (HVD) (see next page) shows,
in graph format, those combinations of airspeed and
height above the ground where either a fully developed
autorotative glide can be entered or a safe landing carried
out after the single-engine helicopter suffers an engine
power loss. The HVD is not a limitation in the flight
manual, but rather a guide to show the flight profiles where
pilots are exposed to the greatest risk resulting from engine
power loss, and so identifies height and speed combinations
to avoid or pass through quickly. The HVD for the
Bell 206B shows that a pilot should not expect to establish
full autorotation from heights between 40 and 200 ft AGL,
unless the airspeed is above 45 mph. In this case, the
helicopter was at about 120 ft AGL and travelling at about
30 mph; with such height and speed, the helicopter could
not have achieved full autorotation before it struck the
ground.
Regulatory requirements for flight over built-up areas
The following sections of the Canadian Aviation
Regulations (CARs) and Commercial Air Service
Standards (CASS) prescribe the altitudes at which aircraft
may be flown: CAR 602.14—Minimum Altitudes and
Distance; CAR 602.15—Permissible Low Altitude Flight;
CAR 702.22—Built-Up Area and Aerial Work Zone;
and CASS 722.22—Built up Area and Aerial Work Zone.
The accident flight was involved in aerial inspection as a
10
Low-altitude aerial inspection flights over built-up areas
have been undertaken in Canada for at least the past
30 years, and regulatory requirements for such flights
have existed in one form or another throughout. The TSB
determined that much misunderstanding exists regarding
the interpretation and application of altitude requirements
in the CARs and associated CASS. In all likelihood, lowaltitude aerial inspection flights are being carried out over
built-up areas in Canada without full compliance with
regulatory requirements.
Analysis
The cause of the loss of engine power was not determined.
No evidence was found to suggest that any of the engine
modules had suffered any pre-impact mechanical event
that would have contributed to a loss of engine power. The
accident FCU and PTG were damaged, and while it is
possible that either one malfunctioned, the TSB could not
make a definitive conclusion on them.
Several operational conditions existed to present the pilot
with a greater-than-usual challenge for an emergency
landing following the loss of engine power, namely:
• obstructions on the final flight path;
• low airspeed;
• low height above the terrain;
• low rotor RPM; and
• short time frame.
The above factors individually represent significant
difficulty for a pilot to achieve a successful outcome, but
when combined, they pose operational challenges that a
pilot may not overcome.
The HVD shows that low altitude and low airspeed
combinations present a significant challenge to pilots
ASL 4/2010
Aviation Safety in History
Aviation Safety in History
Height velocity diagram
The company was operating under the auspices of its
subpart 702 certificate—Aerial Work. Subsection 702.22(2)
allows a person to operate over a built-up area at altitudes
and distances less than the general prohibition if the
person: is so authorized by the Minister, or is authorized
to do so in an air operator certificate; and complies with
the CASS. To obtain such authority, subsection 722.22(1)
of the CASS requires an aerial work zone plan to be
submitted to the Transport Canada Aviation Regional
Office at least five working days in advance of the
operation, and prescribes the information that must
be submitted. Furthermore, subsection 722.22(3) lists
additional requirements related to this application. In
this case, the operator had not applied for, or received,
authorization from the Minister of Transport, nor had it
submitted an aerial work zone plan.
Flight Operations
Tail rotor unit shown at the accident scene. The main and tail
rotor blades were relatively undamaged.
commercial operation, in which case it would be bound
by the requirements of Part VII of the CARs.
Debrief
since it involves skills not frequently practiced within
an unforgiving flight regime. For this accident, several
obstacles greatly restricted the pilot’s manoeuvring and
choice of landing sites. Further, he was faced with the
dilemma of extending the glide to avoid the houses at the
expense of controlled flight. In these circumstances, the
pilot had insufficient altitude to maintain functional rotor
RPM following the engine power loss, and the final few
seconds of flight were uncontrollable and in free-fall from
about 85 ft above the road.
Debrief
are complex and subject to wide interpretation, such
as when an aircraft is or is not over a built-up area and
which requirements would apply where and under what
circumstances. The helicopter performed manoeuvres
over homes in the vicinity of the power lines. Therefore,
the accident flight took place over a built-up area. In the
absence of clear direction and guidance, companies may
select the requirements that impose the least stringent
conditions. Therefore, low-level aerial inspection flights
over built-up areas will continue, thereby creating a hazard
to persons and property on the surface.
Debrief
in landing successfully from an event that requires an
immediate landing. On the diagram, such higher-risk
zones are labelled “avoid” areas and represent the worst
circumstances for recovery. The accident helicopter was
frequently exposed to the higher-risk avoid zones of
the HVD during its passage over the built-up areas
of Cranbrook.
Findings as to causes and contributing factors
Flight Operations
2. The helicopter was being operated at a height and
airspeed combination that the helicopter manufacturer
had determined would, in the event of an engine power
loss, preclude a successful descent and landing.
Flight Operations
1. The engine lost power at an altitude and airspeed
combination that did not permit fully developed
autorotative flight, resulting in rapid loss of rotor RPM,
an extremely high rate of descent, and a severe collision
with the terrain.
4. The helicopter was not in a controlled descent and,
coupled with the decaying rotor RPM, the pilot’s
ability to control the helicopter was decreasing so
rapidly that the last 85 ft of height were in free-fall.
Aviation Safety in History
Aviation Safety in History
3. During the final seconds of the flight path, the pilot
was hindered by several obstacles that afforded him
only one clear landing site, which was beyond the
gliding range of the helicopter. The pilot’s efforts to
avoid the house and reach that site exacerbated the
already high rate of descent.
Findings as to risk
Height velocity diagram
The CARs prescribe conditions for low-altitude flight
in helicopters over built-up areas that, in general, ensure
the manner of operation does not create a hazard, and
that the altitude (height) of a flight is such that an
immediate landing can be made without creating a hazard.
Information contained in the flight manuals (such as the
HVD) assist operators and pilots in choosing the most
appropriate flight profiles for their missions and take into
account helicopter performance. Accordingly, the final
responsibility for safe operational practices remains with
individual helicopter operators and pilots. The severity
of this accident was influenced by the low altitude and
airspeed, and the landing site environment.
The requirements governing flights over built-up areas
are found in several areas of aviation regulation; they
1. Flights conducted at altitudes that do not permit
safe descent, manoeuvring and landing following
an event that requires a single-engine helicopter to
land immediately create risk to persons and property,
particularly in built-up areas.
2. The CARs requirements for low-level aerial inspection
flights over built-up areas are complex and subject to
wide interpretation. In the absence of clear direction
and guidance, companies may select the requirements
that impose the least stringent conditions. Therefore,
low-level aerial inspection flights over built-up areas
will continue, thereby creating a hazard to persons and
property on the surface.
Safety action taken
Transport Canada (TC) had considered the publication in
the ASL of a “logic chart” to guide pilots and operators in
correct decision making regarding the minimum altitudes
and distances over built-up areas prescribed by the CARs;
however, upon further review, it was determined to be
ASL 4/2010
11
Debrief
The operator revised its operational practices regarding
low-altitude flight and introduced a higher level of internal
oversight. Additionally, it embarked upon a dedicated safety
management system (SMS).
Finally, BC Hydro took immediate and long-term
actions to address its policies and associated procedures
concerning the use of helicopters, and the development
and implementation of a more extensive helicopter
management system. Debrief
inadvisable for the intended purpose, and that guidance in
this area would be better included in the Transport Canada
Aeronautical Information Manual (TC AIM). Therefore, TC
is now planning to publish updated guidance on flight over
built-up areas in a future update of the TC AIM.
What Went Wrong: In-Flight Blackout
by R. Wicks. The following article was originally published in the March-April 2007 issue of Flight Safety Australia and is reprinted
with permission.
Light misty rain streaked up the windscreen and I was
at 3 000 ft and had just been cleared for a Runway 05
VOR [VHF omnidirectional range] approach via the
10 NM arc.
The clunk was accompanied by the appearance of red
flags on the primary attitude indicator (AI), horizontal
situation indicator (HSI), and altimeter. The left-hand
engine instruments were out too (torque, EGT [exhaust gas
temperature], fuel flow, temperatures and pressures) and the
left-hand fuel computer had tripped as well.
Without the fuel computer, which controls engine RPM
and torque (among other things), the left-hand engine
RPM surged from 96 to 100 percent. To make matters
worse, the autopilot bell sounded to indicate that it had
disconnected.
The priority was to fly the aircraft and see if I could work
out what was happening. The artificial horizon (AH) on
the co-pilot’s side was operational, as was the co-pilot’s
directional gyro (DG).
I levelled the wings and increased the right-hand engine
RPM to 100 percent to get rid of the distracting drone
generated by the out-of-sync propellers.
With the aircraft stable, I had to make a decision about
what I was going to do next. I called Adelaide Approach
on COM1, but there was no response. I set the transponder
to 7600, and checked VOR1—another red flag. How
was I supposed to do an 05 VOR approach? Or even an
ILS [instrument landing system]?
12
I made another call on the radio but there was no reply. My
scan came to the GPS—yes, it was working! Thankfully, it
was wired to the hot bus.
I was now 6 NM from Adelaide with a groundspeed of
180 kt—just two minutes from the airport. I was high, but
that wouldn’t be a problem in the Conquest.
With my local knowledge of the airport and the fact
that I was arriving from the west, over the sea, I decided
to descend until I could see the coast and make a visual
approach.
Visibility was now about 2 km, and I could see the ocean
below. I entered “direct to” in the Trimble and quickly got
a bearing to the airport (I was surprised that I had turned
right and needed a left turn of 20° to compensate.)
A Boeing 737 had started a VOR approach a few minutes
before and I hoped the approach controller knew I was
experiencing problems and was keeping us separated.
I selected approach flap but the electrically driven flap
motor was silent. What about the landing gear? I moved
the lever to the down position—again, no response. On
top of everything else, I was going to have to carry out an
emergency gear extension and make a flapless approach. A
small bead of sweat formed on my lip—a sure sign of stress.
I checked that the gear selector was down, pulled the circuit
breaker and pulled the “T” handle—nothing!
I was barely a kilometre from the coast but still could not
see it. What now? I was approaching the very limit of my
reasoning ability with the intense pressure of the situation.
“Is everything alright?” asked the passenger next to me. I
figured he was wondering why I kept looking at the AH on
his side of the cabin. I answered, “Yes,” then really yanked
on the handle.
ASL 4/2010
Aviation Safety in History
Aviation Safety in History
I was transporting several passengers, and 10 NM from
Adelaide [South Australia] in instrument meteorological
conditions (IMC), when I heard a clunk from somewhere
on the left side of the Cessna Conquest C441’s cabin.
Flight Operations
Flight Operations
An electrical fault knocks out several key systems including engine computers, NAV and COM equipment, flight instruments, flap,
and landing gear.
Debrief
I flashed my landing lights and got a green flash in return
from the tower, indicating I was cleared to land.
Several passengers thanked me for a great flight as they
disembarked. If only they knew!
What happened? The rear bearing in the left-hand starter
generator failed, causing the armature to short on the
casing. Consequently, the 225-amp current-limiter blew
and all items on the left-hand main bus failed.
Following this incident, the company obtained a diagram
showing the aircraft’s electrical distribution. This diagram is
not included in the pilot’s operating handbook.
NAV2 had been working, though I didn’t realize it until I
was visual. I spoke to the approach controller later and he
told me there was no issue with the B737. He instructed
the jet to overshoot when he lost my paint and couldn’t
reach me on the radio. Well done!
Analysis (by Mike Smith, aviation consultant)
Good situational awareness, prioritization of tasks and
sound decision-making skills helped this pilot out of a
very unpleasant situation. It is often said that single-pilot
IFR flying is one of the most challenging tasks a pilot
can undertake and it is because of precisely this type of
occurrence that it is so challenging.
An instrument approach in cloud and rain, and in a
complex aircraft such as the Conquest, when everything
is going well is hard enough; add in the failure of some
essential equipment, and the workload can become so great
that sound decision making often goes out the window.
Were it just a straight-out generator failure, without a
short, the problem would be simple; in all likelihood, the
right engine starter-generator would have continued to
power most aircraft systems through the tie-bus. The pilot
would have been alerted to the off-line left-hand generator
and would simply have had to manage electrical load to
below the capacity of the remaining generator, in the case
of the Conquest, about 200 amps.
But the short apparently caused the current limiter to
isolate the left-hand main bus from the available electrical
supply. It may be possible that power could have been
restored but that would have required a detailed knowledge
of the electrical distribution system and that information
was not available to our pilot. It is pleasing to read that the
company has now made available the necessary information
for its pilots.
In any case, with the high workload occasioned by the
instrument approach and the loss of several aircraft systems,
including engine computers, NAV and COM equipment,
flight instruments, flap, and landing gear, this pilot made a
series of wise decisions that eased his workload and enabled
him to concentrate on a safe visual approach and landing.
How well do you know the systems on the aircraft you fly?
What’s it like to do an emergency gear extension for real?
What’s the effect on landing distance of having no flap or
engine reverse thrust available?
The airlines have comprehensive training and checking
regimes, and the advantage of flight simulators to ensure
their crews are current and equipped to deal with the sort
of emergency this pilot experienced. Most of us flying
single-pilot IFR, like the pilot in this story, do not have this
facility, so constant review of aircraft systems and drills is
necessary to ensure our mental workload is not too taxing
when something does go wrong. This pilot had good situational awareness and he used that
to his advantage to solve the problem caused by the loss
ASL 4/2010
13
Aviation Safety in History
Aviation Safety in History
Although COM2 was functioning, this aircraft had only
one audio panel and its “Emerg” position supplies power to
audio panel one for transmission on COM1.
The electrical system on the Conquest is designed to cope
with numerous failures and still retain the ability to operate
flight-critical systems. In this case, not only did the left
engine starter-generator fail but it also caused a short that
blew the associated current limiter.
Flight Operations
Flight Operations
We touched down safely and I remembered not to use
reverse thrust with the fuel computers not functioning.
After landing, I received a green light to taxi and park the
aircraft, though my troubles weren’t quite over. The “stop”
button failed to shut down the left engine and in the end
I had to use the condition lever, which cuts off the fuel, to
bring it to a halt.
of his primary VOR. Becoming visual over the sea and
making a visual approach over familiar terrain would have
eased his workload considerably. He also had a fair idea
about the position of the 737 and presumed correctly that
ATC would take care of the situation.
Debrief
Yes—I had three greens! I could also just make out the
faint outline of the coast. I did a quick landing check,
extended the landing lights and turned off the right-hand
fuel computer (both need to be off for a “manual” landing).
Assumptions
It was the mid-80’s and I’d just earned a level 2 (junior)
instructors’ ticket at a gliding field in central
Victoria [Australia]. The previous week had been wet,
and it was touch and go whether we operated at all.
“Well, if it were me I’d be planning for that Piper
backtracking on the runway where we wish to land.”
Debbie was my first customer for
To those on the ground, we “Smartass!” was the reply.
the day. She had been solo several
years earlier, but her attendance to
missed each other by feet.
the field had been dropping off and
We agreed to stay high in circuit to
her currency was decaying. Debbie could be described as
maximize our landing options.
a high maintenance pilot given to emotional outbursts
and stubbornness.
As we turned onto the base leg the Piper stopped, facing us.
“As large as the Blanik is, it still may be difficult to see. We
The single-glider operation resulted in a slow turnaround,
have no radio, so ‘S’ turns will profile the aircraft and should
and Debbie was obviously irritated by this. When I asked
make it easier to see us on base leg,” I advised. At the same
her to complete a pre-takeoff inspection of the aircraft I got
time the Piper did a 180-degree turn into wind and faced
an immediate and aggressive response.
the end of the strip.
“Why? I’ve just seen the glider take off and land without
mishap.” I responded with a pat answer and thought to
myself that it was not a good beginning for an experienced
pilot. I had a growing sense of foreboding.
The Piper had stopped and did not move for the duration
of our final leg. Debbie, who was now focused on the
task declared, “He’s stopped and waiting for us.” I agreed,
without further consideration.
We both jumped into the Blanik and strapped in. The
retrieve car was still running out the cables from the winch,
so we had plenty of time for a briefing.
Debbie established an aiming point for the landing
deep within the strip. She was landing long to avoid the
Piper and deployed the airbrakes to increase the descent
rate accordingly. My focus now, like Debbie’s, was on
her landing.
“The day is stable so there will be no lift. It’s a good
opportunity for circuit practice and
Airmanship should always
spot landing. I would like you to do
the launch, circuit and landing as
be practised. It’s sad, but like
you have done many times before,”
common sense, often such states
I briefed Debbie.
of mind seem very uncommon.
Propelled by the cable, she introduced
back elevator smoothly, and we were climbing. I was in the
back seat, where it is difficult to see at the best of times. As
we started the launch, I caught a movement on the taxiway
to our side. Once we had rotated into full climb, I could see
a Piper Cherokee approaching the strip along the taxiway.
The launch was nearly text-book perfect and as we neared
the top of the launch Debbie eased the elevator fractionally
forward to release the tension on the cable before releasing.
14
Unbeknown to both of us was the fact
that the Piper pilot, having completed
his run-ups into wind, had pushed
the throttle forward. To those on the
ground, we missed each other by feet.
Debbie’s landing was excellent, but my enthusiasm was
immediately crushed with the news of the near collision.
Later that evening the visibly shaking pilot of the Piper
approached me. He seemed sorry but asked, “Why didn’t
you stay up longer? I saw you launch and expected that I
had plenty of time to take off.”
I replied, “It was a winter’s day, stable and no lift except
from the winch, average circuit times are 6–8 minutes
depending upon the launch.”
ASL 4/2010
Aviation Safety in History
Aviation Safety in History
“No,” was her response.
Flight Operations
Flight Operations
We decided to operate with one aircraft—a two-seater
tandem trainer called a Blanik. It had medium performance
and behaved well on the winch. By operating only one
aircraft with an instructor required on board, the CFI [chief
flight instructor] was confident we could keep operations to
the centre of the landing strip and avoid getting bogged.
She established glide speed and completed her post-launch
checks. Without prompting, she spent a few moments
re-familiarising herself with the aircraft and entered the
circuit. She ran through her pre-landing checks early
and quickly. Once settled on the downwind leg I asked,
“Anything unusual about this circuit you may consider
planning for?”
Debrief
Debrief
by Steven Schmidt. This article was originally published in the November-December 2008 issue of Flight Safety Australia, and is reprinted
with permission.
With a little exasperation in my voice, I responded, “Our
gliders do not have electrical systems and the Blaniks,
which have been here for five years,
To which he replied, “ You are
have never had radios. We ‘S’ turned
on base so you could see us.” To which
too small to see.” I took this I recognize that I had been distracted
he replied, “You are too small to see.” I
by Debbie’s behaviour and a desire to
reply with a grain of salt. The pass on my training messages effectively,
took this reply with a grain of salt. The
Blanik is almost 28 ft long unfortunately at the cost of safety.
Blanik is almost 28 ft long with a wing
span of 53 ft. I thought to myself that
Although visibility from the back seat,
with a wing span of 53 ft.
he didn’t really look. I then asked, “Why,
especially underneath the glider, was
having turned into wind, did you not take off immediately?”
limited, I should have been more vigilant in checking her
He replied sheepishly that he had not done his prelookout, particularly in regards to the Piper. We still had
takeoff checks.
height, whilst crossing the airfield threshold, to make some
avoidance manoeuvres.
Twenty-five years later, I have different views. The Piper
pilot clearly demonstrated poor airmanship irrespective of
Airmanship should always be practised. It’s sad, but like
the breach of CARs [Australian Civil Aviation Regulations].
common sense, often such states of mind seem very
He did not think through his actions and put himself in
uncommon. Having said this, we must still always strive for
a position where he could not observe incoming traffic, or
that elusive goal, for all our sakes. Flight Operations
Flight Operations
give way to that traffic, as required by law and good sense.
For our part, our lack of understanding of the need for a
run-up into wind and pre-takeoff checks concluded in a
naive assumption that the Piper pilot had seen us on final
leg and was waiting for us to land.
Debrief
Debrief
He then asked, “Why didn’t you broadcast your intentions?”
An error in vision can occur when flying in rain. The presence of rain on the windscreen, in addition to causing
poor visibility, introduces a refraction error. This error is because of two things: firstly, the reduced transparency
of the rain-covered windscreen causes the eye to see a horizon below the true one (because of the eye response
to the relative brightness of the upper bright part and the lower dark part); and secondly, the shape and pattern
of the ripples formed on the windscreen, particularly on sloping ones, which cause objects to appear lower. The
error may be present as a result of one or other of the two causes, or of both, in which case it is cumulative and
is of the order of about 5° in angle. Therefore, a hilltop or peak ½ NM ahead of an aircraft could appear to be
approximately 260 ft lower, (230 ft lower at ½ SM) than it actually is.
Aviation Safety in History
Aviation Safety in History
TC AIM Snapshot—Flight Operations in Rain
Pilots should remember this additional hazard when flying in conditions of low visibility in rain and should
maintain sufficient altitude and take other precautions, as necessary, to allow for the presence of this error.
Also, pilots should ensure proper terrain clearance during enroute flight and on final approach to landing.
(Ref: Transport Canada Aeronautical Information Manual, Section AIR 2.5)
2010-2011 Ground Icing Operations Update
In July 2010, the Winter 2010–2011 Holdover Time (HOT) Guidelines were published by Transport Canada.
As per previous years, TP 14052, Guidelines for Aircraft Ground Icing Operations, should be used in conjunction
with the HOT Guidelines. Both documents are available for download at the following Transport Canada
Web site: www.tc.gc.ca/eng/civilaviation/standards/commerce-holdovertime-menu-1877.htm.
If you have any questions or comments regarding the above, please contact Doug Ingold at douglas.ingold@tc.gc.ca.
ASL 4/2010
15
ASL 4/2010
1. year, month, day, hour and minutes
2. 22:02 Mountain Daylight Time
3. extricate any person; prevent destruction by fire or other
cause; avoid danger to any person or property
4. PPR: Obtain the aerodrome operator’s permission prior
to use.
PNR: Notify the aerodrome owner or operator prior to
use in order that current information on the aerodrome
may be provided.
5. Bearing and heading information to the site.
6. No.
7. The identification of the ATS unit (FSS or FIC)
controlling the RCO, the aircraft identification and the
name of the location of the RCO followed by R-C-O in a
non-phonetic form.
8. 122.75.
9. above ground level (AGL); above sea level (ASL).
10. Unorganized scattered clouds are forecast based at
3 000 ft ASL with tops at 5 000 ft ASL.
11. From the 28th day of the month at 1200Z to the 29th day
of the month at 1200Z.
12. Wind shear is forecast to exist in the layer from the
surface to 1 100 ft AGL, with the wind at the shear
height of 270° true at 50 kt.
13. Wind light and variable, temperature -15°C.
14. YXU (London VOR) 090° radial at 10 NM.
15. Inform ATC of this fact, since acknowledgement of
the clearance alone will be taken by a controller as
indicating acceptance.
16. Class C requires a clearance, Class D requires
communication.
17. 14 lbs or 6.4 kg.
18. The ATS unit will activate the flight plan or flight
itinerary, using the estimated time of departure (ETD) as
the actual time of departure (ATD).
19. No.
20. broadcast.
16
21. 15 NM.
22. 406 MHz.
23. www.navcanada.ca under “Aeronautical Information
Products”.
24. NOTAM, VFR chart updating data, VFR chart.
25. Information concerning the establishment, condition
or change in any aeronautical facility, service, procedure
or hazard.
26. 60
27. Complete a flight review with an instructor, attend
a safety seminar conducted by Transport Canada,
participate in an approved recurrent training program,
complete this self-paced study program, complete a pilot
proficiency check (PPC), complete the requirements
for the issue or renewal of a licence, permit or rating, or
complete the written exam for a licence, permit or rating.
28. ± 50 ft
29. 24 hours; be assessed by a health-care provider
30. List might include kits, basic survival manual and other
resources.
31. Hold in all free lines, control lines and hoses to avoid
entanglement
32. no less than the greater of (i) 100 ft, and (ii) the greatest
dimension of the balloon, be it the length, width or
height, plus 25 percent.
33. the first day of the month following the day on which the
medical examination for the issuance or renewal of the
certificate is conducted.
34. minimum sink speed
35. 70 kt. Add an amount equal to half the gust factor of
10 kt.
36. 10 kt.
37. Stay above the rising snow and wait until solid references
appear beneath the aircraft.
38. lowering the collective
39. training
40. high; small
Answers to the 2010 Self-Paced Study Program
Any individual, group, company, organization, agency
or department may be nominated for this Award. The
nominee must be a Canadian-owned organization or a
resident of Canada.
Eligibility
The Award—a certificate and letter signed by the
Minister of Transport—is presented to the recipient the
week of National Aviation Day (February 23).
The Transport Canada Aviation Safety Award was
established in 1988 to recognize persons, groups,
companies, organizations, agencies or departments that
have contributed, in an exceptional way, to aviation
safety in Canada.
Do you know someone who deserves to be recognized?
The closing date for nominations for the 2011 award is
December 7, 2010. For complete details, including the
on-line nomination form, visit: www.tc.gc.ca/aviation-safety-award.
c. An outstanding act, effort, contribution or service to
aviation safety.
b. The successful completion of a program or research
project that has had a significant impact on
Canadian public aviation safety;
Nominations must demonstrate that the contribution to
aviation safety meets at least one of the following:
a. A demonstrated commitment and an exceptional
dedication to Canadian aviation safety over an
extended period of time (three years or longer);
Nomination categories
Call for Nominations for the 2011 Transport Canada Aviation Safety Award
Maintenance and Certification
Smoke in the Cabin—Landing Light Switch Failure
The following occurrence resulted in two aviation safety advisories from the Transportation Safety Board of Canada (TSB).
Background
On September 24, 2007, a Cessna 152 aircraft took off
from the Oshawa Municipal Airport, Ont., with the pilot
and passenger on board, destined to Kingston, Ont. Just
after clearing the control zone, the pilot and passenger
noticed an electrical odour and observed a small fire
and smoke emanating from the bottom of the left dash
panel where the aircraft lighting switches were located.
The passenger, sitting in the right front seat, reached for
and discharged the fire extinguisher. The fire was quickly
extinguished, but the extinguishing agent clouded the
cockpit, reducing visibility. The cockpit windows were
opened and visibility improved considerably. The aircraft
returned to the Oshawa airport and landed without
further incident. The pilot suffered a minor burn to his
leg when the plastic instrument panel melted and dripped
onto his jeans. The TSB issued Final Report A07O0264
on January 14, 2009, regarding this occurrence.
Advisory No. 1: Landing light switch failure
The landing light electrical circuit is composed of a
15-amp push-to-reset circuit breaker in series with
a single pole, single throw rocker switch, which is in
series with a 28 VDC 250-watt incandescent lamp. The
switch and the circuit breaker are located on the lower
instrument panel to the right of and above the pilot’s
knee when seated in the left-hand seat. The engine oil
pressure and temperature gauges are located directly
above the landing light switch. The oil pressure gauge
is connected to the oil-carrying pressure line, which is
directly connected to the engine. This type of circuit
and instrument panel layout are common amongst the
100-series Cessna aircraft.
Accident Synopses
ASL 4/2010
17
Regulations and You
The TSB determined that the landing light switch
installed in the occurrence aircraft was beyond its
design capability and therefore was unsuitable for the
circuit it was controlling. Excessive heat from arcing
and oxidization within the switch weakened the switch
structure and contact support, allowing the contacts to
fall out or be exposed. Arcing from the contacts caused oil
residue to flash, which ignited a nearby dust accumulation
and started the fire. Combustion was sustained by the
plastic instrument panel. The TSB stated that similar
landing light switch systems are incorporated on most
The landing light circuit wires remained attached to the
contact but showed evidence of fire damage near where
the contact enters the switch. The contact was coated
with the plastic casing material and when the surface was
examined there was evidence of repeated arcing, which
had severely eroded the contact’s surface. Arcing within
the landing light switch could have provided the ignition
source necessary for a fire to start. The dust covering
evident on the switch and the oil residue provided by
possible seepage from the oil pressure gauge line located
above the switch may have provided the kindling
necessary to start a fire. The oil would consistently reach
its flash point when exposed to arcing, and when it was
in proximity to the dust it would cause the dust to ignite.
A small section of the plastic instrument panel was tested
for flammability by introducing a direct flame to the
Accident Synopses
The switch was identified as a rocker-style switch rated
at 10A 250VAC, 15A 125VAC, 3/4HP125-250 VAC.
No DC ratings were found for this switch. The switch
showed evidence of melt damage beginning at the base
and progressing upward on both sides. The same damage
was evident on the interior of the switch. The switch
exterior had a thick coating of dust and an oily residue,
which was also found inside the switch. A scanning
electron microscope (SEM) and energy dispersive
spectroscopy (EDS) analysis of the residue indicated that
it might have been engine oil.
Front of instrument panel
Regulations and You
of the Cessna 100-series aircraft, thereby increasing the
likelihood of a similar event. The TSB issued two aviation
safety advisories as a result of their investigation.
Recently Released TSB Reports
Recently Released TSB Reports
Smoke in the Cabin—Landing Light Switch Failure...................................................................................................... page 17
Canada-U.S. Bilateral Aviation Safety Agreement......................................................................................................... page 19
Maintenance and Certification
maintenance and certification
Maintenance and Certification
Due to the number of these aircraft presently in use
worldwide, including in flight training schools, the
possibility that this type of event may recur on aircraft
that have the AC-rated landing light switch installed
cannot be discounted. If this type of event were to occur
to an inexperienced pilot, or to a student-pilot on a
solo flight, the pilot’s attention could be diverted from
flying the aircraft to focus on extinguishing the fire, with
possible dire consequences.
Rear of instrument panel
Accident Synopses
18
The pilot and passenger followed the emergency
procedures for an electrical fire in the cabin, as per the
pilot’s operating handbook (POH). The procedures were
performed from memory only. Acting on their own
instincts, they decided to open the two cabin windows
to quickly improve visibility and improve air quality in
the confined area of the cockpit. Their quick actions were
successful and the pilot was able to re-channel his full
attention to safely flying the aircraft back to the airport.
Reported cases of smoke in the cockpit abound in various
types of general aviation (GA) aircraft worldwide. A
pilot’s ability to fly the aircraft safely is degraded by
the presence of smoke and extinguishing agents in the
cockpit. Taking action to remove the smoke and fumes
from extinguishing agents would increase visibility and
improve the air quality within the aircraft.
To ensure that pilots can quickly eliminate smoke and
extinguishing agent fumes from the cockpit, further
checklist or procedural items may be required. The
TSB therefore suggested that TC, in concert with
manufacturers and the regulatory authorities of other
countries, may wish to review emergency checklist
procedures dealing with smoke and fire on GA aircraft
and to include an additional step to eliminate smoke
or fumes.
ASL 4/2010
Regulations and You
The circuit breaker was identified as a 15-amp push-toreset circuit breaker (CB), Cessna part number S1360-15L. The purpose of the CB in the circuit is to
protect the circuit wiring, not the components attached
to the wiring. The 15-amp thermal-type CB was found
to be suitable for the circuit. The CB did not trip after
the occurrence but, being the thermal-type of CB, it does
not react instantaneously to an over-current condition.
This feature is necessary because when the light switch
is selected “ON”, the initial current can be as high as
15 times its rated load. If the CB were to react instantly
Advisory No. 2: Smoke-in-cabin emergency procedures
Accident Synopses
According to the U.S. Federal Aviation
Administration (FAA) Advisory Circular 43.13-1B,
chapter 11 (pages 11–17), because of the initial current
encountered by switches controlling 28 VDC lamp
loads (incandescent lamps), the switches should have
a derating factor of 8. This aircraft’s switch controls a
250-watt lamp in a circuit powered by 28 VDC, and
should have a minimum DC current rating of 71 amps.
The switch from the aircraft had an AC rating. The
Advisory Circular has a warning that reads “Do not
use AC derated switches in DC circuits. AC switches
will not carry the same amperage as a DC switch.”
The switch manufacturer was contacted and provided
with the landing light circuit and switch information.
After evaluating the information, they confirmed
that the switch was not designed to handle the lamp
loads described.
Regulations and You
plastic. The piece of panel readily ignited and sustained
flame. It also produced gases that were quite harsh when
inhaled, and without sufficient ventilation may cause some
incapacitation to the pilot.
The TSB suggested that Transport Canada (TC),
in co-ordination with the FAA and the aircraft
manufacturer, may wish to take action to mitigate or
eliminate the threat of fire caused by AC-rated switches
in the landing light DC circuit of Cessna 152 aircraft.
Recently Released TSB Reports
Recently Released TSB Reports
A search of the FAA’s service difficulty report (SDR)
database by the TSB revealed 23 events similar to this
occurrence. The common terms were: smell or smoke in
cockpit, landing light switch hot, landing light switch
arcing, landing light switch melted, and circuit breaker
did not trip.
Maintenance and Certification
to the initial current it would trip every time the switch
was selected “ON”.
Maintenance and Certification
Landing light switch
The FAA took action to mitigate or eliminate the threat
of fire caused by AC-rated switches in the landing light
DC circuit of Cessna 152 aircraft. Cessna co-operated
with the FAA by issuing Mandatory Service Bulletins
MEB09-3 and SEB09-6 dated May 11, 2009, to remove
and replace all subject switches used in the landing light
as well as the taxi light and rotating beacon circuits
in the 100-, 200- and 300-series Cessna models with
service life greater than four years. This includes the
Cessna 152-series aircraft. These bulletins are to be
accomplished within the next 400 hours of operation,
or 12 calendar months, whichever comes first. A review
of the database shows less than 1 percent of the fleet
has been affected by this type of failure. Therefore, the
FAA’s course of action has been to disseminate the
concern by issuing a Special Airworthiness Information
Bulletin (SAIB) CE-09-42, which is available at www.faa.
gov/aircraft/safety/alerts/SAIB/.
Smoke-in-cabin emergency procedures
Considering the FAA’s issuance of the corresponding
SAIB and that Cessna has forwarded the applicable
service information to all subscribers of such publications,
TC has not taken any additional action at this time.
In closing, TC would like to remind the community that
defects, malfunctions and failures occurring on aeronautical
products should be reported to Transport Canada, Continuing
Airworthiness in accordance with Canadian Aviation
Regulation (CAR) 521 mandatory SDR requirements. These
reports will serve as supporting documentation to present to
the authority for the state of design or the manufacturer when
corrective action is necessary. Recently Released TSB Reports
Recently Released TSB Reports
TC contacted the FAA, the authority for the state of
design, requesting their position and possible corrective
action. The FAA approached Cessna who developed a
corrective action plan.
GA aircraft and including additional steps to eliminate
smoke or fumes. The FAA’s course of action has been to
disseminate this information by issuing SAIB CE‑10‑04,
which is available at www.faa.gov/aircraft/safety/alerts/SAIB/. It
recommends that owners and operators check their POH
or aircraft flight manual (AFM) and add a statement:
“to remove smoke and fumes from the cockpit, do the
following…” If such a statement does not exist in their
POH or AFM, owners and operators are encouraged to
contact the aircraft manufacturer for checklist instructions
for the removal of smoke or fumes from the cockpit (e.g.
closing or opening heating, air-conditioning, or air vents).
Maintenance and Certification
Safety action taken
The FAA took action by reviewing the emergency
checklist procedures dealing with smoke and fire in
Canada-U.S. Bilateral Aviation Safety Agreement
It has recently come to Transport Canada Civil
Aviation’s (TCCA) attention that more awareness is
required on the impact of international agreements on the
Canadian aviation industry. This article will help address
this concern by focusing on the Canada-U.S. Bilateral
Aviation Safety Agreement (BASA), its associated
maintenance implementation procedures (MIP), and how
they apply to aviation professionals in Canada.
The BASA provides for, among other things, the
reciprocal acceptance of airworthiness approvals and
environmental testing and approval of civil aeronautical
products, as well as approvals and monitoring
of maintenance, alteration and/or modification
facilities, maintenance training organizations, and
maintenance personnel.
The objective of the MIP is to outline the terms and
conditions under which the FAA and TCCA can accept
each other’s inspections and evaluations, including FAAapproved Federal Aviation Regulations (FARs) Part 145
repair stations and Canadian approved maintenance
organizations (AMO). The MIP also applies to FAAcertificated airmen and Canadian aircraft maintenance
engineers (AME). As a result, the findings of compliance
and regulatory oversight by either agency will be accepted
by the other agency. This will lead to a reduction in
redundant inspections without adversely affecting
aviation safety.
ASL 4/2010
19
Regulations and You
Regulations and You
On June 12, 2000, Canada and the United States signed
the BASA and designated their respective civil aviation
authorities as the executive agents for its implementation.
The Agreement can be viewed at: www.tc.gc.ca/eng/
civilaviation/standards/int-baa-usa-2000-3676.htm.
Article III (B) of the BASA required that the U.S.
Federal Aviation Administration (FAA) and TCCA—
being the executive agents for the Parties—draft written
methods by which such reciprocal acceptances would
be made. This documented process is referred to as the
Implementation Procedures generally, and the detailed
procedure for the reciprocal acceptance of maintenance
activities and personnel is described in the MIP. The MIP
can be viewed at: www.tc.gc.ca/eng/civilaviation/standards/intta-usaimp2006-menu-3700.htm.
Accident Synopses
Accident Synopses
by Joel Virtanen, Civil Aviation Safety Inspector, Maintenance and Manufacturing, Standards, Civil Aviation, Transport Canada
Maintenance and Certification
Recently Released TSB Reports
Any Canadian AMO working on U.S.-registered
Part 121 or 135 aircraft requires a TCCA-approved FAA
supplement to their Maintenance Policy Manual (MPM).
The supplement must meet all of the conditions outlined
in Chapter 3 of the MIP, which identifies the special
conditions set forth by each respective civil aviation
authority. Interestingly, it is TCCA that will approve the
FAA supplement, and not the FAA.
Any Canadian CAR Part VII operator who has work
done on their aircraft in the United States by an FAAapproved Part 145 repair station must ensure that
the repair station has an FAA-approved Canadian
supplement to their Repair Station Manual (RSM). It
is important to note that neither the FAA nor TCCA
will issue a supplement approval number in respect
of approved maintenance facilities. It is the operator’s
responsibility to ensure that the facilities that they intend
to use are approved.
The supplement is essentially a bridging document for
the differences between the requirements for Canadian
AMOs and FAA-approved Part 145 repair stations.
Some of the topics covered are: major repair reporting in
accordance with the registered authority’s requirements;
reporting of service difficulties and suspected unapproved
parts to the appropriate authority; requirements and
procedures for repairs to be done in accordance with
air carriers’ procedures and with data approved by the
authority of registry; requirements for major repairs to
be signed by an Inspection Authorization in the U.S.
20
How are components affected?
Overhauled and repaired components received from the
United States with an Authorized Release Certificate
(FAA form 8130-3, Airworthiness Approval Tag) are
acceptable for use on Canadian-registered aircraft as
long as the repaired parts or components are received
from repair stations located within the continental
United States, or the Districts of Columbia or
Puerto Rico.
Maintenance conducted by FAA-approved foreign repair
stations is not acceptable for use on Canadian aircraft
since foreign repair stations are not covered by the BASA.
Other international agreements should be consulted
to determine the eligibility of repaired or overhauled
aircraft, parts or components that originate from
foreign jurisdictions.
Since operators could be affected by changes, and
agreements are reviewed and revised from time to time,
it is important to stay informed of the latest changes
to the BASA. It is good practice to always check the
document’s revision date to see if amendments have been
made since the document was last reviewed. Compliance
with foreign agreements is necessary and relatively
simple as long as you are familiar with the requirements.
All international agreements are posted on the TCCA
Web site: www.tc.gc.ca/eng/civilaviation/standards/intmenu-3668.htm. For further details and guidance, please
refer to Advisory Circular (AC) 571-002—Canada
and United States Bilateral Aviation Safety Agreement
Maintenance Implementation Procedures at: www.tc.gc.ca/
eng/civilaviation/opssvs/managementservices-referencecentreacs-500-571-002-490.htm. ASL 4/2010
Regulations and You
Regulations and You
What is in a supplement?
Annual inspections are excluded from the application
of the BASA and MIP. A Canadian AME cannot sign
off an annual inspection on U.S.-registered aircraft,
and FAA-certificated airmen cannot sign off annual
inspections on Canadian-registered aircraft. This situation
exists due to the differences in our regulations and has
been recognized and mutually agreed to by TCCA and
the FAA.
Accident Synopses
Accident Synopses
Who needs a supplement?
Who can sign off an annual inspection?
Recently Released TSB Reports
AMOs and FAA-approved Part 145 repair stations
must develop and incorporate a supplement to their
own approved maintenance policy manual, or equivalent.
The supplement must address all of the other aviation
authority’s special requirements, as identified in the
MIP. The completed supplement must be submitted
to the organization’s own civil airworthiness authority
for approval.
and an independent AME in Canada; requirements
for procedures to address the registered authority’s
airworthiness directives; requirements for procedures to
control the maintenance; training program differences;
procedures to ensure separation of quality assurance
functions from maintenance functions; procedures to
ensure that the work does not exceed the ratings or
scope of the organization; a requirement to understand
the English language (for Canadian AMOs); and a
requirement to allow inspections by both authorities.
Maintenance and Certification
At the heart of the MIP is the requirement for a
Canadian operator or AMO performing maintenance
on U.S.-registered aircraft to first comply with its own
maintenance regulatory requirements—including those
prescribed by Canadian Aviation Regulations (CARs)
Part V, Subparts 71 and 73—and then with the special
requirements prescribed by the FAA and described in
the MIP. The reverse is true for FAA-approved Part 145
repair stations performing maintenance on Canadianregistered aircraft—they must first comply with U.S.
maintenance regulatory requirements, and then with the
special requirements prescribed by TCCA.
Maintenance and Certification
Recently Released TSB Reports
On November 26, 2006, a Learjet 35A aircraft
departed Brunswick, Georgia, United States, on a
medical evacuation (MEDEVAC) flight to Montréal/
Pierre Elliott Trudeau International Airport, Que. On
board the aircraft were two pilots, two flight nurses, and
two passengers. At 05:07 Eastern Standard Time (EST),
the aircraft landed on Runway 06R at Montréal and
overran the 9 600-ft runway, coming to rest approximately
600 ft off the end of the runway in a grass field. The
aircraft sustained damage to the left wing leading edge
and the fuselage. There were no injuries.
2. The flight crew’s adopted practice of performing
the “through-flight” checklist, when a normal preflight was required, allowed dispatching of the
aircraft without confirming a proper fluid level in the
hydraulic reservoir.
3. The pre-charged thrust reverser accumulator
was not serviced according to the manufacturer’s
specifications, and there was insufficient air pressure
to deploy the thrust reversers.
4. The aircraft flight manual (AFM) supplement for the
thrust reverser does not provide guidelines on how to
verify the accumulator air pressure. Consequently, the
crew did not know how to properly check the thrust
reverser accumulator pre-charge pressure.
5. The crew erroneously thought that the aircraft was
equipped with a low-hydraulic-pressure light that
would warn them in case of a loss of hydraulicsystem pressure.
6. The AFM and the quick reference handbook (QRH)
indicate that the low-hydraulic-pressure light
illuminates to indicate loss of hydraulic-system
pressure, although, in this aircraft, there was no lowhydraulic-pressure light.
Findings as to causes and contributing factors
1. A “B” nut loosened, resulting in a leak and depletion
of the hydraulic fluid and preventing normal
operation of the flaps, spoilers, thrust reversers, and
wheel brakes.
2. The crew did not notice that there was a loss of
hydraulic pressure and therefore did not plan for a
landing without normal stopping systems or for the
use of the emergency brake system.
Findings as to risk
1. The service and condition check carried out at
intervals of 15 days may not assure proper fluid level.
Therefore, confirmation of proper servicing rests on
the completeness of the pre-flight inspection by the
crew.
1. The aircraft departed for Montréal with an
identified and undocumented defect that required
maintenance action.
Safety action taken
As a result of the accident, the operator initiated an
administrative investigation. The following actions have
been taken:
• All company aircraft underwent extensive inspections
of their hydraulic systems.
• Placards have been installed on hydraulic system
accumulators indicating pressures and conditions that
must be met prior to checking. Checking hydraulic
accumulator pressure as well as thrust reverser
accumulator pressure (if applicable) is mandatory
during the normal exterior pre-flight and exterior
post-flight inspections.
• The company director of human resources, the
aviation safety officer, and the chief pilot discussed
the accident with company employees.
• Exterior pre-flight inspections have been expanded
beyond the manufacturer’s approved procedures.
ASL 4/2010
21
Regulations and You
3. When the aircraft landed, the flaps were extended
to only 20°, the spoilers did not deploy because there
was no hydraulic or backup air pressure, the thrust
reversers did not deploy, normal braking did not
work, and the emergency brake system was not used.
Consequently, the aircraft overran the runway.
Other finding
Accident Synopses
Accident Synopses
TSB Final Report A06Q0190—Runway Overrun
Recently Released TSB Reports
Regulations and You
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. We encourage our readers to read the complete reports on the TSB
Web site. For more information, contact the TSB or visit their Web site at www.tsb.gc.ca. -Ed.
Maintenance and Certification
RECENTLY RELEASED TSB REPORTS
Maintenance and Certification
•
•
•
•
On March 31, 2007, an Antonov AN 124-100 was on
a flight from Greer, South Carolina, United States, to
Gander, N.L. On arrival in Gander, the crew completed
an approach to Runway 03/21. The aircraft touched down
at 02:16 Newfoundland Daylight Time (NDT) but was
unable to stop before reaching the end of the runway.
It departed the left side of Runway 03/21, near the
departure end, and came to rest approximately 480 ft off
the runway surface, facing the opposite direction. Several
edge lights along the runway were broken. The nine crew
members and ten passengers on board the aircraft exited
without injury. Aircraft damage was limited to cuts in the
aircraft tires.
Analysis
There were no mechanical failures that contributed to
the occurrence. Therefore, the analysis will focus on the
awareness of runway conditions, the runway touchdown
point, the delay in wheel braking, and the reduction in
aircraft deceleration.
22
The automatic terminal information service (ATIS)
report received by the crew indicated that Runway 03/21
was bare and wet and that Runway 13/31 was the active
runway. Twelve minutes before landing, the crew received
a special weather observation indicating that light snow
was falling. The fact that the latest weather observation
was a special report and was reporting snowfall should
have alerted the crew that weather conditions had
changed and therefore the runway selected for landing
may be contaminated. However, the crew did not request
an updated runway surface condition (RSC) report.
Runway 13/31 had been designated as the active
runway since the winds were light from the west.
Active runways are chosen for various reasons, such as
surface wind direction, the predominate direction from
which aircraft are approaching, and taxi distance. Snow
removal personnel and equipment were maintaining only
Runway 13/31 before the occurrence.
The aircraft touched down approximately 2 400 ft
beyond the normal touchdown point (3 400 ft minus
1 000 ft). The fact that the aircraft touched down long
and at an airspeed 14 kt below the planned airspeed
indicates that the aircraft floated this additional distance
before touchdown. Considering that the runway was
contaminated with snow, the reduced stopping distance
ASL 4/2010
Regulations and You
Regulations and You
TSB Final Report A07A0029—Runway
Excursion
Final position of aircraft
Accident Synopses
Accident Synopses
•
Recently Released TSB Reports
Recently Released TSB Reports
•
Abnormal/emergency exercises that replicate this
event have been incorporated into the company initial
and recurrent flight training program.
A review of the manufacturer’s normal, abnormal,
and emergency procedures is ongoing.
Pilots have undergone additional training on
the following:
• standard operating procedures (SOPs);
• Learjet 35 differences training;
• emergency braking operating procedures;
• enhanced ground proximity warning
system (EGPWS) operation, alerts, and warnings;
• requirements of the normal exterior pre-flight
inspection, “through-flight” inspection, and postflight inspection;
• use of the minimum equipment list (MEL)
as well as defect reporting and recording
procedures; and
• enhanced crew resource management (CRM)
training with a focus on in-flight situation
awareness and recognition of impending failures
during all phases of flight.
A review of the cockpit checklists is ongoing.
The company aviation safety officer has been tasked
with accelerating the development of the company
safety management system (SMS) program.
A significant restructuring of the company
was undertaken.
Operational co-ordination centre procedures were
reviewed and refined to enhance operational control
and technical dispatch procedures.
Maintenance and Certification
•
Maintenance and Certification
Recently Released TSB Reports
Wheel braking was applied by both pilots five seconds
after the planned brake application speed of 135 kt. This
brake application occurred 2 000 ft after the touchdown
point, leaving only 4 800 ft of runway available for
stopping the aircraft. The fact that both pilots were
attempting to apply brake pressure simultaneously may
indicate that both pilots were concerned about the
stopping distance remaining.
On April 9, 2007, a Piper PA31 aircraft departed a
private grass strip with a pilot and passenger on board
for a short flight to the Cochrane, Ont., airport to pick
up another passenger. After departing Cochrane, the
pilot flew to Moosonee, Ont., and conducted a VFR
approach for Runway 32. Approximately 1.5 NM from
the runway, the pilot selected the landing gear down and
confirmed that the landing gear was indicating down and
locked. This was also verbally confirmed by the passenger,
another company pilot, who was sitting in the right seat.
The aircraft landed normally, and the pilot selected flaps
up and boost pumps off. The pilot was about to apply
brakes to slow down for Taxiway Bravo when the gear
horn sounded and the right main landing gear collapsed,
followed quickly by the collapse of the left-main and
nose landing gear. The aircraft came to rest approximately
1 550 ft from the threshold of Runway 32, just off the
right side of the runway. There were no injuries.
Analysis of the recorded aircraft flight data indicated that
the initial rate of deceleration may have been sufficient
to stop the aircraft before the runway end. The crew did
use reverse thrust after touchdown; however, it did not
maintain maximum available reverse thrust until ensured
of stopping on the available runway. Even though reverse
thrust has little effect below 90 kt, that limited effect and
the absence of residual forward thrust during the 15 s the
idle power setting was restored may have been enough to
prevent a runway overrun.
Findings as to causes and contributing factors
1. The aircraft touched down approximately 2 400 ft
past the normal touchdown point; this greatly
reduced the available stopping distance.
Recently Released TSB Reports
TSB Final Report A07O0095—Landing Gear
Collapse After Touchdown
Maintenance and Certification
available greatly increased the chance of the aircraft being
unable to stop on the remaining runway.
3. The delay in the application of wheel brakes,
combined with the failure to maintain maximum
available reverse thrust until it was ensured that
the aircraft would stop on the remaining runway,
contributed to the overrun.
Safety action taken
The operator has made arrangements with the Gander
International Airport Authority to have, upon request,
Canadian Runway Friction Index (CRFI) reporting for
each third of the runway.
A TSB Aviation Safety Information letter has been sent
to Transport Canada regarding Canadian differences
with International Civil Aviation Organization (ICAO)
recommended practices for reporting runway
friction measurements.
No faults were found with the aircraft that would
indicate any mechanical failure or improper rigging of
the landing gear. Retraction of the landing gear can only
be accomplished if the down locks are removed during
the retraction sequence. Therefore, due to the play in the
landing gear handle, and the ease with which it could
be bumped up, it is likely that the landing gear handle
was inadvertently positioned above the locking solenoid
before weight on wheels was achieved and that during the
landing roll the handle was inadvertently bumped up far
enough to begin the retraction sequence.
Findings as to causes and contributing factors
1. The spring in the landing gear handle was broken and
allowed easy movement of the landing gear handle
past the neutral stop.
ASL 4/2010
23
Regulations and You
Regulations and You
Following this accident, the operator completed its own
investigation and developed an in-house dedicated safety
assurance program for the company’s intensive flight
operations via Gander Airport.
Analysis
Accident Synopses
Accident Synopses
2. The contaminated runway surface condition increased
the distance required to stop the aircraft.
Maintenance and Certification
Site diagram
2. During the approach, the landing gear handle was
most likely placed in a position that bypassed the
anti-retraction system.
3. The landing gear handle inadvertently moved to
an “UP” selection during the landing roll, which
activated the gear warning horn and retracted the
landing gear.
Regulations and You
Other factual information
There was nothing found to indicate that there was any
airframe, engine, or system malfunction before or during
the flight; weather conditions were ideal for VFR flight
and were not considered a factor in the occurrence.
24
Major risk factors associated with cardiovascular disease
are age, family history, hypertension, obesity, diabetes,
abnormal blood lipids, and cigarette smoking. The
aim of monitoring these risk factors and applying the
cardiovascular guidelines is to ensure that the risk of
asymptomatic coronary artery disease causing sudden
incapacitation of a pilot remains extremely low.
The Transport Canada requirement for a Category 3
medical certificate is that the candidates undergo a
routine electrocardiogram (ECG) at the first examination
after age 40, and then subsequently within the four years
preceding the examination. However, in up to 50 percent
of people with advanced coronary artery disease, a routine
ECG may not show indications of coronary artery
disease. An exercise stress test increases the likelihood
the disease will be detected. However, it is not part of
the required screening process, but may form part of
the medical assessment in those candidates with major
risk factors.
Individuals with arterial fibrillation who have two or
more of the five major risk factors—age over 65 years,
ASL 4/2010
Regulations and You
On June 30, 2007, a privately owned Piper Cub J3C-65
departed a privately owned, grass-covered runway
near Essex, Ont., under visual meteorological
conditions (VMC). This was the first flight following the
annual maintenance inspection of the aircraft. Shortly
after departure, the aircraft made a planned low pass
parallel to the runway in an easterly direction. The aircraft
then climbed to approximately 1 500 ft above ground
level (AGL) in a northerly direction. Shortly afterwards,
the aircraft was observed in a gradual descent, flying in a
southeasterly direction. At approximately 14:20 Eastern
Daylight Time (EDT), the aircraft struck the ground
in a nearby field. The aircraft was destroyed by impact
forces and a post-crash fire. The pilot, who was the sole
occupant, did not survive.
Accident Synopses
Accident Synopses
TSB Final Report A07O0165—Collision with
Terrain
Recently Released TSB Reports
Recently Released TSB Reports
Maintenance and Certification
The highly experienced 80-year-old pilot had a history
of chronic arterial fibrillation and therefore underwent
periodic cardiovascular assessments. The post-mortem
examination revealed that the pilot had underlying
asymptomatic atherosclerotic coronary artery disease.
This put him at risk for a sudden coronary event.The
development of cardiovascular disease in licensed aviation
personnel is a major concern among aviation medical
practitioners. To address this concern, Transport Canada
has developed a set of cardiovascular guidelines intended
to assist in the medical assessment of cardiovascular
fitness of licensed aviation personnel. These guidelines
are published in Transport Canada’s Handbook for Civil
Aviation Medical Examiners (TP 13312E).
Maintenance and Certification
The aircraft, which had just undergone its annual
inspection, was observed in controlled flight before it
began a slow descending turn which ended when it struck
the ground. There were no mechanical deficiencies found
that could have contributed to the accident. It can be
concluded that the gradual descent was not the result
of an airframe or control system failure. Based on the
manner in which the aircraft descended to the ground and
on the post mortem examination which revealed wellestablished coronary artery disease, it is probable that the
pilot suffered an acute coronary event during the flight.
This resulted in incapacitation and the loss of control of
the aircraft.
Finding as to causes and contributing factors
1. The pilot most likely suffered an incapacitating
medical event due to well-established, underlying
coronary artery disease that resulted in the loss of
control of the aircraft.
Accident Synopses
There were no indications that weather or mechanical
abnormalities were involved in this occurrence. The pilot
was familiar with the site area and was experienced in
the operation of the helicopter. The area selected to land
the helicopter, although confined, was suitable for the
landing. The pilot’s decision to approach the landing site
by flying the helicopter sideways to his left restricted his
view of the approaching guy wires, significantly increasing
the possibility of contact between the main rotors and
the wires.
The structural damage to the main rotor blades rendered
the helicopter uncontrollable and it became inverted
and entangled on one of the wires during its descent to
the ground. It is possible that the wire entanglement
reduced the forces during ground impact and prevented
further structural damage to the aircraft and injuries to
the occupants.
The ELT did not activate even though impact forces
exceeded the threshold of the G-switch. The type of
G-switch used in this ELT was a single-axis, ball-andspring-type switch. This type of switch will automatically
activate the ELT only if a component of the impact force
is in the same direction as the orientation of the switch.
During examination of the switch, black powder
residue was found and the switch was seized within its
casing; thus, electrical contact was never established
and the ELT failed to activate. The ELT was properly
attached and located in the cockpit of the helicopter as
per current regulations, but the accident impact forces
were in a direction that may not have activated the
G-switch even if it had been serviceable. The failure of
the ELT did not affect the rescue of the three injured
persons because of the availability of phone service at the
communications tower.
ASL 4/2010
25
Regulations and You
The two passengers were able to extricate themselves,
but could not extricate the pilot. One of the passengers
knew about, and was able to get access to, a telephone
located at the site. He used it to call the air ambulance
unit in Moosonee. The air ambulance crew extricated the
pilot from the wreckage and then transported the pilot
and passengers to a local hospital. There was no fire. The
emergency locator transmitter (ELT) did not activate.
Analysis
Accident Synopses
On July 20, 2007, an Aerospatiale AS 350 B2 helicopter
was attempting to land at a remote site near Moosonee,
in northern Ontario. The selected landing area was
a driveway near a communications tower, which was
supported on three sides by multiple guy wires. The pilot
chose to approach the driveway landing area by flying
the helicopter sideways while maintaining forward visual
contact with the selected landing area. As the helicopter
moved sideways, the main rotor blades struck two of the
top guy wires at a height of about 100 ft above ground
level (AGL). The rotor blades were substantially damaged
and the helicopter quickly descended and struck the
ground in an inverted attitude.
One passenger received minor injuries. The pilot and the
second passenger were seriously injured.
Recently Released TSB Reports
Recently Released TSB Reports
Analysis
TSB Final Report A07O0190—Guy-Wire Strike
During Landing
Regulations and You
Maintenance and Certification
structural heart disease, diabetes, high blood pressure, and
previous thromboembolism—are considered above the
risk threshold limit for medical certification. The pilot
was over the age of 65, with no indication that any of
the other four risk factors were present at the time of the
occurrence. Therefore, the applicant was deemed fit for
medical certification.
Maintenance and Certification
Maintenance and Certification
Accident Synopses
1. The helicopter struck the guy wires supporting the
communications tower as a result of being flown in
a left sideward direction, which prevented the pilot
from viewing the approaching tower guy wires from
his position in the right front seat while focused on
the somewhat restricted landing area.
Findings as to risk
1. The single-axis, ball-and-spring G-switch in the
ELT meets current specifications, but it is not
effective when the impact forces are at angles that are
substantially different to switch orientation.
2. The ELT failed to activate on impact as a result of
a faulty internal G-switch. The internal parts of the
switch are susceptible to deterioration over time and
can prevent switch operation and ELT activation.
TSB Final Report A07C0148—Collision with
Power Line Tower
Analysis
The damage to the helicopter engine and rotor assemblies
indicates that the damage was sustained while the drivetrain was operating under power. The damage to the skid
gear and tower structure was consistent with flailing
26
The nature of the damage to the skid gear attachment
point indicates that the helicopter was hovering when
it became entangled in the tower structure. The reason
the helicopter was hovering so close to the tower was
not determined.
The VFR weather conditions that existed at the time of
the occurrence (visibility 15 mi. and a ceiling of 1 500 ft,
overcast with the possibility of light rain) would not
have affected the pilot’s perception of his position or
complicated the task of hovering near the tower.
The passenger’s injuries and the location of his body
indicated that he fell from or was ejected from the
helicopter during the accident sequence. The reason for
the fall or ejection was not determined.
Although there are hazards specific to helicopter
operations near power lines, Manitoba Hydro did not
have an audit process to ensure that safety standards and
quality of services provided by contract aviation services
were met. Such an audit procedure could have helped
identify the need for specialized training to reduce risks in
operations near power lines.
The operator did not offer or require its pilots to take any
specialized training to identify and reduce exposure to
power line hazards. It also had no procedure for line pilots
to report hazardous operating conditions. Such programs
could have reduced the risks associated with helicopter
power line operations.
ASL 4/2010
Regulations and You
On August 9, 2007, a Bell 206L-3 helicopter was
transporting a lineman to Tower 63 on the Sheridan
power line near Cranberry Portage, Man. While hovering
near the tower, the helicopter’s skid gear became
entangled in the uppermost cablespan. The helicopter
struck the tower and crashed on the adjacent power line
right-of-way. The helicopter was substantially damaged
by impact forces and fire; the pilot and passenger both
sustained fatal injuries. The accident occurred during
daylight hours at 09:03 Central Daylight Time (CDT).
damage sustained from an uncontrollable state of rotation
after the helicopter became entangled in the cable and
tower structure.
Accident Synopses
Regulations and You
Wreckage next to Tower 63
Finding as to causes and contributing factors
Recently Released TSB Reports
Recently Released TSB Reports
Accident site
Maintenance and Certification
Recently Released TSB Reports
Finding as to risk
1. The operator did not have training procedures specific
to helicopter operations in the vicinity of power lines
and did not have a procedure for reporting hazardous
operating conditions. Such programs could have
reduced the risks associated with helicopter power
line operations.
Other finding
1. Manitoba Hydro did not have an audit procedure
in place that might have identified the need for
specialized training for helicopter operations specific
to their contract requirements.
Safety action taken
In response to information revealed during the
investigation, Manitoba Hydro has taken the following
safety action:
• Manitoba Hydro forwarded “other finding” number 1
to its internal audit department in February 2008 for
review and implementation.
• Manitoba Hydro has undertaken to write and
implement a “safe work procedure standard”
for employees and pilots conducting power
line inspections.
TSB Final Report A07O0233—Loss of Control
and Impact with Runway
The pilot had been trained on and flown in other
glider types owned by the gliding club. Most of the
flying experience was in dual-seat trainers, which were
flown both with an instructor and solo. Solo flights
are monitored by an instructor on the ground via radio
communication. For undetermined reasons, the instructor
was not able to establish radio contact with the pilot at
the expected return time.
The examination of the glider revealed no pre-impact
mechanical failures. The weather was not a factor and
the pilot had been trained to perform the solo flight.
Unusual flight behaviour was first observed during the
final approach to the runway. At the altitude the glider
started the final approach, the air brakes would normally
be extended to reduce altitude. No air brake deployment
was observed. As a consequence, the aircraft speed and
altitude were high for this stage of the approach. The
first aircraft pitch-down was coincident with the air
brake deployment.
The significant pitch-down attitude that followed suggests
that the pilot was aware that the glider was high on
the approach and was attempting to lose altitude for
a successful approach and landing. The ensuing pitch
oscillations were a result of overcorrecting by excessive
stick inputs to try and arrest the rapid descent. Although
the pilot stabilized the oscillations, the glider remained
high, and due to the steep descent, it gained airspeed.
The pilot may have been hesitant to apply air brakes to
correct the situation because of the previous pitch control
issues. Consequently, the glider was now in a long-landing
situation. As the landing distance available decreased, the
pilot needed to deploy the air brakes in order to land on
the remaining runway. Sensing the urgency to land the
glider, the pilot may have applied forward stick coincident
with air brake deployment. The final pitch-down into the
runway may have been a result of these two actions.
Findings as to causes and contributing factors
1. The pilot may not have been familiar with the flight
characteristics of the glider because this was the first
ASL 4/2010
27
Regulations and You
On August 18, 2007, a single-seat Pezetel SZD-51-1
Junior glider was on a routine local flight from the
Rockton, Ont., airport with a student pilot on board.
The flight was scheduled to last approximately one
hour. At the end of the hour, the duty instructor at the
club attempted to contact the pilot via radio, but there
was no response. Shortly thereafter, the glider was seen
entering the circuit and was observed on final approach
to Runway 18/36. As it flew over the road near the end
of the runway, the air brakes were partially deployed
and then retracted. As it continued over the runway at a
height of approximately 25 ft above ground level (AGL),
the air brakes were fully deployed and the glider pitched
nose-down approximately 45° and struck the ground. The
cockpit was substantially damaged by the ground impact
and the student pilot sustained fatal injuries.
Analysis
Accident Synopses
Accident Synopses
1. The helicopter was hovering close to the power
line tower structure and became entangled in the
upper (non-energized) cable span. As a result, the
helicopter became uncontrollable, collided with the
tower structure, and crashed.
Recently Released TSB Reports
Regulations and You
Maintenance and Certification
Finding as to causes and contributing factors
Maintenance and Certification
TSB Final Report A07O0238—Collision with
Terrain in Deteriorating Weather
On August 28, 2007, a Bell 206L-1 helicopter was being
operated from a remote area located approximately
100 NM east of Webequie, Ont., and was destined
for Cochrane, Ont. The flight departed under visual
metrological conditions (VMC); however, deteriorating
weather conditions were encountered en route. At
approximately 21:00 Eastern Daylight Time (EDT) and
five miles west of Cochrane, the pilot lost outside visual
reference and the aircraft struck the ground. The aircraft
was on a flight plan and therefore a communication
search was started by the London flight information
centre (FIC). Personnel from the operator began a ground
search and located the aircraft approximately three hours
after the occurrence. The aircraft was destroyed and the
pilot, who was the only occupant, was seriously injured.
The aircraft departed T1 for Cochrane at approximately
18:00 EDT. Approximately 60 NM northwest of
Cochrane, the ceiling deteriorated to about 300 ft above
ground level (AGL).
The weather continued to deteriorate and eventually the
pilot was flying at near treetop level and navigating by
following a river that headed towards Cochrane. As the
aircraft approached its destination, there was a relatively
small area of improved visibility and ceiling in the general
direction of Cochrane. The pilot subsequently abandoned
the river navigation and attempted to fly towards
Cochrane; however, visual reference to the ground was
lost due to the poor weather conditions.
The aircraft struck the ground while flying in an easterly
direction and travelled through the brush upright for
approximately 108 ft before becoming airborne again for
a short distance. It then struck the terrain in a nose-down
attitude, flipped over and came to rest on its left side. The
total wreckage trail was 418 ft. The entire cockpit forward
of the pilot’s seat was destroyed.
Recently Released TSB Reports
Recently Released TSB Reports
2. The resultant long-landing situation may have caused
the pilot to utilize air brakes and forward stick input
to land the glider on the remaining runway. The final
pitch-down into the runway may have been a result of
these two actions.
At 17:35 EDT, a satellite telephone was used at T1 to
update the VFR flight plan on file with the London FIC;
however, no weather information was requested. There
was no contact made with the company base in Cochrane
to determine the local weather conditions.
Maintenance and Certification
flight on type. The glider was flown high and fast
on approach.
Analysis
Accident Synopses
On the day of the occurrence, the pilot received a weather
briefing from the London FIC for the series of flights
planned for that day. The aerodrome forecast (TAF) for
the Timmins, Ont., area indicated VMC. The forecast,
however, was only valid until 16:00 EDT. Another TAF
was expected to be issued at 10:00 EDT.
A VFR flight plan was filed for the flight to a remote
location referred to as Tango 1 (T1) and for the return leg
to Cochrane. The pilot departed the company’s facility in
Cochrane at 09:45 EDT.
28
The pilot received the minimum instrument training
required for the issuance of a commercial helicopter
licence. Four years had elapsed between the time the
pilot had taken this instrument training and the date
of the occurrence. If not practiced, instrument flying
skills deteriorate over time. In addition, because of the
malfunction of the directional gyro, the pilot referenced
the GPS for primary heading information. This most
likely hampered the proper scan of the primary flight
instruments. These two factors likely contributed to the
pilot’s difficulty in flying the aircraft with reference to
instruments only.
ASL 4/2010
Regulations and You
Regulations and You
Other factual information
Accident Synopses
The pilot did not obtain any weather update before
his departure from T1. He would not, therefore, have
been aware that conditions at destination had been
deteriorating throughout the day and that the latest
forecast was calling for conditions below limits for VFR
operations. Furthermore, the destination co-ordinates
were not used for the time of sunset calculations, resulting
in a 22-min error. This resulted in an arrival in the
Cochrane area after sunset, with poor weather conditions
present.
1. The flight was continued at night in deteriorating
weather conditions resulting in the pilot losing visual
reference with the ground and becoming disoriented,
which resulted in the aircraft being flown into
the ground.
Findings as to risk
1. Departing without the latest available weather
increases the possibility of inadvertent flight into
inclement weather.
2. Mounting the emergency locator transmitter (ELT)
in the area of the lower nose window made it
vulnerable to impact damage. As a result, the ELT
became detached and was separated from its external
antenna during the impact sequence, increasing the
risk of the ELT signal not being detected.
The operator issued an operational notice to all its
pilots concerning human factors, pilot decision making
and standard operating procedures, with emphasis on
VFR weather minima. The company also provided
recommendations on how to conduct cross-country
flights.
The operator has also implemented a satellite tracking
system on all of its aircraft. As a result, the location of
its entire fleet can be monitored from its main facility in
Cochrane, Ont.
The pilot was qualified for the flight. There was no
pressure on him to return to Lac César, particularly
because the flight would generate no revenue. The aircraft
had no known deficiencies and was maintained in good
condition for flight.
The pilot checked the local weather with the Lac César
camp before departing Sainte-Véronique. According to
the camp employee, the flying conditions were suitable
for the return flight. The pilot did not request a weather
briefing from the flight information centre (FIC), nor
was he in the habit of doing so. In any event, even if he
had checked with the FIC, there was nothing in the
forecast to suggest that the weather would be such as he
encountered en route. The pilot’s decision to make the
flight was justified. When the conditions deteriorated
en route, he delayed making a decision as to whether
to turn back or land. It is possible that being close to
his destination and being very familiar with the area
influenced his decision to continue the flight until he had
exhausted all options.
The pilot decided to set the emergency locator
transmitter (ELT) to “ON” even though he had decided
to leave the site. This decision may have had adverse
consequences if one of the accident aircraft occupants was
injured while walking, especially considering that there
was no means of communication available to them. As
well, with the main reason for activating an ELT being to
save lives, the search and rescue (SAR) team was deployed
in adverse weather, needlessly putting them at risk.
It was not unusual for aircraft to not arrive at the
destination at the expected time. Consequently, the
employee at Lac César was not overly concerned. She
ASL 4/2010
29
Regulations and You
Maintenance and Certification
Regulations and You
The company will continue developing and implementing
the safety management systems (SMS) approach,
including the addition of more Transport Canada training
aids, safety reports concerning human factors and causes
of occurrences. The company has completed a pilot survey
regarding company safety culture; the results will be
analyzed and used for future safety purposes.
Analysis
Accident Synopses
Accident Synopses
Safety action taken
On September 23, 2008, a float-equipped DHC-2 Mk 1
aircraft with the pilot and one passenger on board, was
on a VFR flight from Sainte-Véronique, Que., to an
outfitting operation on Lac César, Que. When the aircraft
was about 30 NM from the destination, the weather
deteriorated. After a few minutes, the pilot could neither
continue the flight nor reverse course. For several minutes,
the pilot tried to find a safe spot for a water landing,
without success. He then decided to set the aircraft
down in the trees. The two occupants were wearing
their seatbelts, were not injured, and had no difficulty
evacuating the aircraft. The aircraft sustained substantial
damage. The occurrence happened at approximately
15:30 Eastern Daylight Time (EDT).
Recently Released TSB Reports
Recently Released TSB Reports
Finding as to causes and contributing factors
TSB Final Report A08Q0187—VFR Flight into
Adverse Weather and Forced Landing
Maintenance and Certification
The above-mentioned instrument training is deemed
sufficient to allow non-instrument-rated pilots to
maintain control of the aircraft in case of inadvertent
flight into instrument meteorological conditions (IMC).
The pilot can then fly to an area of improving weather.
However, in this instance, the weather at destination had
deteriorated significantly. Returning to a previous location
along the route of flight was likely discounted because it
was dark and the pilot did not have a night rating or any
experience flying at night. The pilot attempted to fly on
instruments but became disoriented and the aircraft was
inadvertently flown into the ground.
Maintenance and Certification
Recently Released TSB Reports
Findings as to risk
1. Although the main reason for activating an ELT is
to save lives, the pilot decided to depart the site and
leave the ELT set to “ON”. As a result, the SAR team
was deployed in unfavourable weather conditions,
needlessly putting them at risk.
2. Not having activated the company emergency plan
could have led to grave consequences if the occupants
of the downed aircraft had been seriously injured.
Other finding
1. There was nothing in the forecast to suggest that
the weather would be as the pilot encountered en
route. The pilot’s decision to make the flight was
therefore justified.
On December 3, 2008, at approximately 17:21 Eastern
Standard Time (EST), a privately operated
Robinson R44 Raven I helicopter departed SainteAnne-des-Plaines, Que., with the pilot/owner and three
passengers on board for a night VFR flight to the pilot’s
cottage located at Lac Simon, Que. The 52-NM trip was
uneventful. To establish the helicopter on approach to
the lit landing pad positioned in front of the cottage, the
pilot turned right onto final approach at an altitude of
approximately 150 ft above the lake. On final approach,
the helicopter continued the descent and struck the
water. All occupants escaped uninjured. One passenger
successfully swam approximately 1 000 ft to shore, while
30
another was rescued by two persons in a rowboat. The
pilot and one passenger were unable to reach the shore
and drowned. The helicopter sank in 25 ft of water and
was substantially damaged. The occurrence took place at
approximately 18:05 EST under dark, night conditions.
Analysis
Visual cues in the environment, such as trees, buildings,
objects, terrain textures, and features, plus a cross-check
with the flight instruments are necessary for a pilot to
adequately assess a helicopter’s speed, attitude, altitude,
rate of descent, and rate of closure. The lack of visual cues
inherent at night in poorly lit areas can make night flying,
takeoffs, and landings challenging.
While the weather conditions were appropriate for
VFR flight at night, the dark lighting conditions of the
surrounding area and the approach over the dark surface
of the lake provided ideal conditions for the black hole
illusion. It is likely that as a result of this illusion, the pilot
believed the helicopter was higher than it was during
the approach to land. The pilot unknowingly flew the
helicopter lower than the intended approach path, causing
the helicopter to collide with the surface of the water well
before reaching the desired landing area.
The minimum requirements necessary to obtain a private
helicopter pilot night rating may not be sufficient to
adequately educate and demonstrate to private helicopter
pilots the risks involved in night flying, including visual
illusions. Present night rating requirements are the same
for private helicopter pilots as for private fixed-wing
pilots, yet the environments in which they may operate at
night can vary greatly.
Flying over the lake on approach at night ensures
a helicopter is away from obstacles and allows for a
shallower approach to land. However, in the event of an
ASL 4/2010
Regulations and You
Regulations and You
TSB Final Report A08Q0231—Controlled Flight
Into Water
Estimated Robinson R44 flight path before impact with water
Accident Synopses
Accident Synopses
1. The pilot delayed making a decision as to whether to
turn back or land when he saw that the weather was
deteriorating. Being close to his destination and being
very familiar with the area probably influenced his
decision to continue the flight until he had exhausted
all options.
Recently Released TSB Reports
Finding as to causes and contributing factors
Maintenance and Certification
did not know that the pilot was unable to contact her
and inform her of the occurrence because he had not
brought his satellite phone with him on this trip. The call
received that evening from Lac Gilberte, which became
disconnected, gave reason to believe that the flight had
diverted due to weather and had landed safely. However,
knowing that the aircraft had departed Sainte-Véronique,
that it was past its expected arrival time, and that no
call had been received to explain why it was late, the
emergency plan should have been activated automatically
in accordance with the procedure set out in the company
operations manual. Not having activated the company
emergency plan could have led to grave consequences if
the occupants had been seriously injured in this accident.
Maintenance and Certification
Recently Released TSB Reports
Findings as to causes and contributing factors
Maintenance and Certification
unforeseen problem, the helicopter may not be within
gliding distance from the shore, thereby posing a risk
to the aircraft and its occupants. It is unlikely that the
missing persons would have survived more than a few
minutes given the cold water temperatures.
Current regulations do not specify light intensity, colour,
number of lights, or approach path aids for private
helicopter landing pads. The three (of four) low-intensity,
solar-powered LED lights on the corners of the landing
pad and the bonfire in front of the landing area would not
have illuminated the surrounding area sufficiently to help
the pilot judge a safe and constant approach angle over
the dark, featureless surface of the water.
Recently Released TSB Reports
Findings as to risk
1. The minimum requirements necessary to obtain
a private helicopter pilot night rating may not be
sufficient to adequately educate and demonstrate to
private helicopter pilots the risks involved in night
flying, including visual illusions.
1. It is likely that the effect of the black hole illusion
caused the pilot, in full control of the aircraft, to
unknowingly fly the helicopter lower than the
intended approach path, causing the helicopter to
collide with the surface of the water well before
reaching the desired landing area.
2. Current regulations do not specify light intensity,
colour, number of lights, or approach path aids for
private helicopter landing pads, thereby increasing
the risk of accidents or incidents in degraded
environmental conditions. 2. The helicopter approached the landing pad over
water and, after colliding with the lake surface, the
occupants had to evacuate in near-freezing water
temperature, exposing them to hypothermia.
— On February 6, 2010, a privately registered
Stinson 108-2 had departed from the ice surface of
Lake Winnipeg, near the mouth of the Manigatogan River,
for a VFR flight with a pilot and one passenger to Lyncrest
airport near Winnipeg, Man. Shortly after takeoff, the pilot
noted that the visibility had deteriorated, and attempted
to return to his departure point. During the turn, the
pilot encountered whiteout conditions and was unable
to maintain visual reference to the ground. The aircraft
descended and collided with the ice surface approximately
4 NM southwest of the Manigatogan River. The pilot
sustained minor injuries and the passenger sustained
serious injuries. The aircraft sustained substantial damage
from the impact, and was later destroyed when the pilot lit
the wreckage to attract rescue personnel. The emergency
locator transmitter (ELT) was damaged in the fire.
TSB File A10C0017.
— On February 8, 2010, a Piper PA-44-180 Seminole
with an instructor and two students on board was
conducting single-engine approaches to the Toronto/
Markham, Ont., airport. During the occurrence approach,
the student was having difficulty with the approach and
the pilots forgot to lower the landing gear. The aircraft
touched down with the gear retracted and was substantially
damaged. There were no injuries. TSB File A10O0025.
— On February 21, 2010, an amateur-built Super
Ben 160 took off from a field around 5 mi. west of
Chicoutimi, Que., for a local flight in VFR conditions.
During takeoff, the aircraft was pushed out to the right
by a crosswind. The right wing hit a tree and the aircraft
pivoted and went into a ditch. The pilot was not injured.
The emergency locator transmitter (ELT) was triggered on
impact and was immediately turned off by the pilot. The
aircraft sustained damage to the wings, the propeller, the
engine cowl, and the engine. TSB File A10Q0020.
ASL 4/2010
31
Regulations and You
Regulations and You
Note: The following accident synopses are Transportation Safety Board of Canada (TSB) Class 5 events, which occurred between
February 1, 2010, and April 30, 2010. 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.
Accident Synopses
Accident Synopses
Accident synopses
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
— On March 22, 2010, a Bell 212 helicopter engaged in
heli-skiing operations reportedly encountered whiteout
conditions while attempting to land in mountainous terrain
to drop off skiers 20 mi. west of White Saddle Ranch,
near Alexis Creek, B.C. The aircraft drifted away from the
landing site, the main rotor blade struck a snow-covered
slope and the helicopter rolled onto its right side. The
pilot sustained minor injuries. The ten passengers were not
injured. TSB File A10P0073.
— On March 7, 2010, a Hiller UH-12E helicopter was
conducting tree cone harvesting approximately 10 NM
north of Hythe, Alta., when on an approach the tail rotor
struck branches. An attempt was made to pull up; however,
this led to an over-torque condition and the helicopter fell
to the ground in forested terrain. The pilot was the lone
occupant and was not injured. TSB File A10W0044.
32
The operator took extensive follow-up action and found it had
all the best “hard” safety measures in place, such as standards,
SOPs and competency-based training. Therefore, it focused on the
human factors side of things in order to prevent a recurrence.
— On March 27, 2010, the pilot of a Cessna 210B was
preparing to depart on a cross-country flight and decided
to fly a circuit before loading his passengers. When he
extended the gear during the circuit, the nose gear failed
to extend. After attempting a manual extension, the pilot
recycled the gear a couple of times with the same result.
He then phoned his maintenance facility and received
suggestions on other sequences to try, but the nose gear
did not extend. After circling the airport for about 3 hr
ASL 4/2010
Regulations and You
— On March 9, 2010, a ski-equipped PA11 Piper was
preparing for a private flight in the Gatineau, Que., area.
The aircraft was parked at the edge of a lake. The mooring
lines were not attached. Since the aircraft did not have an
electrical system, the engine was started using the propeller.
A second pilot started the engine while the pilot who
owned the aircraft was at the controls. The two pilots let the
engine warm up, standing away from the prop wash behind
the right wing. After a few minutes, under the combined
effect of the prop wash and the slight slope of the shoreline,
the aircraft began to slide toward the lake. Concerned
with the situation, the pilot who was not the owner ran
to the cockpit with the intention of stopping the engine.
He was unaware that the aircraft did not have a mixture
control with idle cut-off, and that the engine needed to
be shut off by cutting the magneto ignition. It seems that
the pilot’s clothing accidentally moved the gas control on
Accident Synopses
Regulations and You
— On March 7, 2010, the pilot of a Cessna 172 was
conducting a low-altitude waterfowl survey with two
passengers on board, approximately 14 NM east of
Yarmouth, N.S. While conducting the survey, the
engine (Lycoming O-320-B2D) lost power. The pilot then
elected to conduct a forced landing on a paved road. The
aircraft contacted a telephone line just prior to touchdown
with approximately 600 ft of road remaining. The aircraft
veered toward the right, and the right wing struck a stop
sign. The aircraft continued forward, crossing a ditch and
striking a tree before coming to rest. The pilot and the
two passengers were seriously injured. The aircraft was
substantially damaged. TSB File A10A0025.
— On March 16, 2010, the pilot of the Beaver RX 550
basic ultralight took off on skis from Lac Paré, Que., for a
local flight. The aircraft experienced downdraughts during
the initial climb. It hit some spruce trees then crashed
into the roof of a house. The passenger was not injured,
but the pilot sustained chest injuries. Firefighters removed
the aircraft from the roof since fuel was leaking from the
aircraft. Two rafters and the roof covering were damaged.
The aircraft sustained major damage. TSB File A10Q0032.
Recently Released TSB Reports
— On March 4, 2010, a wheel- and ski-equipped
de Havilland DHC-3T Turbo Otter was landing at
Webequie, Ont. Immediately after touchdown, the aircraft
nosed over, striking the propeller and damaging the
engine (Pratt & Whitney PT6A-35). The aircraft settled
back on its wheels and remained upright. Information
provided indicated that the brakes were frozen.
TSB File A10C0026.
the left wall of the cockpit. The engine accelerated, the
aircraft climbed over a snowbank and did a semi-circle
on the lake, hitting trees along the shoreline. The pilot on
board was not injured. The aircraft sustained major damage.
TSB File A10Q0029.
Maintenance and Certification
— On February 21, 2010, an RS Ultra Kangook B
powered parachute was flying above the Saint-CharlesBorromée Park in the Joliette, Que., area when the pilot
lost control of the aircraft and crashed upon landing. The
aircraft sustained major damage. The pilot sustained minor
injuries. TSB File A10Q0022.
— On April 14, 2010, a Cessna 172 was conducting a VFR
training flight with a student-pilot on board. The pilot lost
control of the aircraft during the landing roll on Runway 03
at Sorel, Que. The aircraft exited the runway on the left and
came to rest, nose down, in a drainage ditch. The pilot was
not injured in the accident. TSB File A10Q0043.
— On April 30, 2010, a privately registered Bellanca
8GCBC (Scout) was attempting to land northbound on
a private field near Comox, B.C., when control was lost.
The aircraft went through a fence and impacted a power
pole. The left wing was torn off and the aircraft came to
rest inverted in a drainage ditch. The pilot and passenger
were wearing five-point harnesses and reported no injuries.
TSB File A10P0108. Regulations and You
Maintenance and Certification
Recently Released TSB Reports
Regulations and You
— On April 16, 2010, a Bell 206LR helicopter was on
a re-positioning flight from Yellowknife, N.W.T., to
Whitehorse, Y.T. After departure from Watson Lake, Y.T.,
— On April 23, 2010, the amateur-built Diamant was
about to take off from St-Tite, Que., for a flight to the
Trois-Rivières, Que., airport, with the pilot and one
passenger on board. After giving full throttle for takeoff,
the pilot’s seat slid backward. The pilot was no longer able
to press the rudder pedals and lost control of the aircraft.
The aircraft veered to the right, went off the runway
and stopped after hitting a tree. The occupants were not
injured in the accident. The aircraft’s wings sustained major
damage. The pilot’s seat was not properly fitted to the track
after being lubricated. TSB File A10Q0048.
Accident Synopses
Accident Synopses
— On April 5, 2010, an ATR-42 was landing at
Pangnirtung, Nun., in good weather conditions. The aircraft
landed firmly and bounced once. After the flight, the crew
inspected the aircraft and noticed cosmetic damages to
the COMM2 antenna. After the following flight to the
maintenance base in Iqaluit, substantial structural damages
to the tail section were found, requiring repairs before the
next flight. TSB File A10Q0039.
— On April 18, 2010, a Cessna 185 on amphibious
landing gear was taking off on Runway 14 at
Salmon Arm, B.C., for a local flight. During the takeoff roll, the pilot perceived that the engine performance
was below par. He noted 25 in. of manifold pressure
and decided to abandon the takeoff when the aircraft
had used about two-thirds of the runway. The aircraft
overran the end of the runway, struck an embankment
between two ditches running at right angles to the
runway, and overturned. The aircraft was substantially
damaged. The four occupants sustained minor injuries.
TSB File A10P0096.
Recently Released TSB Reports
— On March 28, 2010, a Cessna 172M left Prince George,
B.C., for a dual cross-country flight via Quesnel and
Barkerville, back to Prince George. After a touch-and-go
landing at Quesnel, the aircraft continued to Barkerville.
When overhead Barkerville, the student and instructor
visually inspected the snow-covered runway and made a
low pass. The snow surface appeared to be compact and the
instructor decided to allow the student to land. The aircraft
landed on Runway 11, but during the landing roll the
wheels dug into the snow and the aircraft overturned. The
aircraft was substantially damaged but the two pilots were
not injured. TSB File A10P0082.
the aircraft was crossing a ridge at approximately 5 000 ft
above sea level (ASL) when a decision was made to land on
top of a mountain. After determining the wind direction,
the pilot approached the landing area into the wind. On
short final, the helicopter entered an unanticipated yaw to
the right. The aircraft landed hard and rolled onto its left
side. The aircraft sustained substantial damage. The pilot
and two passengers were uninjured. TSB File A10W0054.
Maintenance and Certification
to reduce the fuel load, the aircraft landed with the main
gear extended and the nose gear retracted. The pilot
was uninjured, but the aircraft sustained damage to the
propeller, engine, nose gear doors, lower cowl, and lower
forward fuselage. Maintenance lifted the forward fuselage,
pried open the doors, and manually released the nose gear
uplock. The gear extended normally and locked down.
Further tests were planned to try to duplicate the uplock
malfunction. TSB File A10W0046.
ASL 4/2010
33
Maintenance and Certification
Recently Released TSB Reports
Flying Farmers—Who Falls Within the Definition of a “Farmer” and When Does the Concept of
“Hire or Reward” Apply?
by Beverlie Caminsky, Chief, Advisory and Appeals, Policy and Regulatory Services, Civil Aviation, Transport Canada.
In this issue, the Advisory and Appeals Division wishes
to share two cases. Case No. 1 discusses the question of
determining when a company falls within the definition
of a “farmer,” as set out in section 700.01 of the Canadian
Aviation Regulations (CARs). Case No. 2 discusses the
question of “hire or reward.”
Pursuant to section 700.01 of the CARs:
“Farmer” means a person whose primary source of income
is derived from the tillage of the soil, the raising of
livestock or poultry, dairy farming, the growing of grain,
fruit, vegetables or tobacco, or any other operation of a
similar manner.
The company and the PIC both asked the Transportation
Appeal Tribunal of Canada (TATC) to hold a hearing to
review the Minister’s decision to assess the penalties.
With respect to Case No. 1, the company would have had
a defence to the charges of operating without an AOC if
it had met the definition of “farmer” under section 700.01
of the CARs (cited above). The company would have
had to have owned the aircraft used for spraying, and
34
If the company had met the above requirements, it would
not have needed an AOC. The company did not, however,
meet the definition of farmer, as its primary source of
income was not derived from farming, but rather from
crop spraying. In addition, the pilot owned the aircraft
and the spraying operations took place outside the
25-mile radius of the farm. The evidence revealed that the
pilot’s wife owned the farm.
In addition, the failure to maintain an up-to-date logbook
was proved and the TATC review member upheld the
Minister’s assessment of $7,500 against the company.
In Case No. 2, against the PIC, evidence was put forward
that the PIC held a private pilot licence but did not
hold a commercial pilot licence. With respect to the
questions of whether the PIC was operating for “hire or
reward,” evidence was put forward that he was registered
as a flying farmer in the provincial Aerial Applicators’
Association member directory. Evidence was also put
on the record that various clients made payments to the
company in Case No. 1 for the aerial work ($74,027.25).
The PIC was the sole shareholder of that company.
Subsection 3(1) of the Aeronautics Act defines “commercial
air service” as “any use of aircraft for hire or reward” and
defines “hire or reward” as “any payment, consideration,
ASL 4/2010
Regulations and You
Regulations and You
In Case No. 2, the pilot-in command (PIC)—and sole
shareholder of the company from Case No. 1—was
assessed a monetary penalty of $5,000 for contravening
subsection 401.03(1) of the CARs. Specifically, it was
alleged that the PIC acted for “hire or reward” when he
did not hold a commercial pilot licence.
the spraying would have had to have taken place within
25 miles of the centre of the company’s farm, as set out in
subsection 700.02(3) of the CARs.
Accident Synopses
In Case No. 1, a commercial aerial applicator used an
airplane to conduct aerial work for agricultural purposes,
which involved the dispersal of products or spraying
for various farmers. The Minister of Transport assessed
a monetary penalty for the contraventions. More
specifically, the company was charged with operating
without an air operator certificate (AOC) and with failure
to make entries in their journey log for flights over a
three-month period. There were 44 counts assessed at
$5,000 per count for contraventions of section 700.02
of the CARs and one count for a contravention of
section 605.94 of the CARs. The fine assessed for this last
contravention was $7,500. The total fine assessed against
the company was $227,500.
Recently Released TSB Reports
Accident Synopses
Flying Farmers—Who Falls Within the Definition of a “Farmer” and When Does the Concept of
“Hire or Reward” Apply?............................................................................................................................................. page 34
Oral Counselling................................................................................................................................................................ page 35
Maintenance and Certification
regulations and you
Maintenance a
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Fax: 613-998-1450 E-mail: copyright.droitdauteur@pwgsc.gc.ca
Recently Released TSB Reports
Note: Reprints of original Aviation Safety Letter
material are encouraged, but credit must be given to
Transport Canada’s Aviation Safety Letter. Please forward
one copy of the reprinted article to the editor.
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Table of Contents
section
Contraventions of aeronautics legislation can result in a
wide range of penalties, including fines, suspensions or
cancellations of Canadian aviation documents, and even
imprisonment in severe cases.
Regulations and You
ASL 4/2010
(1) encourage future compliance by the offender; and,
(2) deter others from contravening aeronautics legislation.
Another option available to Aviation Enforcement
inspectors is “oral counselling.” This option may be used
when the contravention is considered minor in nature or
inadvertent; is a violation where there is no direct flight
safety hazard; or when the imposition of a sanction would
not be appropriate. Aviation Enforcement inspectors
will assess all aspects of the contravention, including the
attitude of the alleged offender, to determine whether oral
counselling will promote future compliance.
In the last year, “oral counselling” was assessed in
43 percent of all cases where there was a violation. The
Aviation Enforcement Division recognizes that voluntary
compliance with Canadian aeronautics legislation 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 in, commitment to, and responsibility for aviation
safety, and will operate on the basis of common sense,
personal responsibility, and respect for others. Aviation
Enforcement inspectors use oral counselling with this
philosophy in mind.
Oral counselling is most appropriate in cases of ignorance
or misinterpretation of the law, provided aviation safety
was not jeopardized. Examples include situations where
a minor contravention is committed and it had little or
no impact on safety, and where there was no indication of
a wilful act. Oral counselling is not an option when the
alleged offender disputes the allegations.
Balloon-Specific Questions
31. If the balloon contacts a tree and is moving free of it, what should the pilot do to reduce the risk of adverse consequences? _____________________________________________________________. (Use balloon references)
32. A person may conduct a take-off in a balloon within a built-up area of a city or town if the diameter of the launch site is _______________________________________________________________________. [CAR 602.13 (3)(d)]
Glider-Specific Questions
33. The end of the validity period of a medical certificate is calculated from ____________________________________
_______________________________________________________________________________. [CAR 404.04(7)]
34. The _____________ is the indicated airspeed at which the glider loses altitude most slowly.(Use gyroplane references)
35. If you are approaching for a landing and the wind is gusting from 15 to 25 kt and you normally approach at 65 kt, what should your new approach speed be in those conditions? ______________________. (Use aeroplane references)
36. Typically, light aircraft are designed to withstand, on landing, 90° crosswinds up to a velocity equal to 20 percent of their stall speed. For an aircraft with a 50-kt stalling speed, what is the maximum permissible 90° crosswind wind speed? _______________________________.
(Use aeroplane references)
It should be noted that when Aviation Enforcement
inspectors conduct comprehensive investigations
that are concluded with oral counselling, no Aviation
Enforcement record is kept in the offender’s file.
Helicopter-Specific Questions
Canada continues to play a leadership role in the
international aviation safety community and within our
national borders. In supporting this role, the Aviation
Enforcement Division is committed to promoting and
applying a policy of fairness and firmness when dealing
with contraventions of aeronautics legislation.
Have a safe and enjoyable flight! ASL 4/2010
16. Which of the following classes of airspace requires that a VFR flight establish two-way communication with the
appropriate ATC agency prior to entering? Class C, D or E? _____________________________________________
______________________________________________________________________. (RAC 2.8.3, 2.8.4 and 2.8.5)
17. After asking the passengers for their personal weights, what weight should be added for clothing in winter?
______________________________________________________________________________.
(RAC 3.5.1)
18. After a flight plan or flight itinerary has been filed but not opened with the appropriate ATS unit, what will happen if
the flight is delayed or cancelled? ___________________________________________________
________________________________, unless it is known that the aircraft has not departed. (RAC 3.6.4)
19. If a pilot closes a flight plan or flight itinerary prior to landing, are the alerting services with respect to
search and rescue (SAR) notification still active until after the landing? _____________________.
(RAC 3.12.2)
20. When a mandatory frequency (MF) area exists at an aerodrome but the ground station is not in operation, all reporting procedures specified in CARs 602.97 to 602.103 shall be ________________________.
(RAC 4.5.4)
21. In Canada, the area covered in a visual search during a SAR operation will typically extend to a maximum of
___________________ on either side of the flight-planned route.
(SAR 2.1)
22. Only aircraft equipped with an emergency locator transmitter (ELT) operating on _____________ can be detected by
COSPAS-SARSAT satellites.
(SAR 3.1)
23. Where would you find the index and list of current Canadian aeronautical charts? ____________________________
___________________________________________________________________________________. (MAP 2.2)
24. New or revised VFR operations which are required to be depicted on VFR charts are advertised first by ____________ until published in the CFS _____________ section then finally updated on the _____________.
(MAP 2.4)
25. What information would you find in a NOTAM? ___________________________________________. (MAP 5.1)
26. A pilot renewing a category 4 medical declaration should complete the declaration form _____ days before the expiry
date of the medical certificate.
(LRA 3.4.1.1)
27. Name one recurrent training program you must have successfully completed within the previous 24 months in order to meet the 2-year requirement. _______________________________.
[LRA 3.9, CAR 421.05(2)]
28. An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error of more
than __________________ when compared to the known ground elevation.
(AIR 1.5.1)
29. If, after receiving routine immunizations, a pilot feels unwell or experiences an adverse reaction, the pilot should wait for ___________________________ and ______________________________________ prior to flying. (AIR 3.13)
30. Review AIR 4.13 and AIR Annex 1.0
List what is available in the aircraft that you typically fly that could aid you in the event of an injury or a need for shelter. ____________________________________________________________ (AIR 4.13 and AIR Annex 1.0)
Aeroplane-Specific Questions (including ultralight)
Regulations and You
Pre-Flight...........................................................................................................................................................................3
Flight Operations..............................................................................................................................................................9
Maintenance and Certification........................................................................................................................................17
Recently Released TSB Reports......................................................................................................................................21
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers..........................36
Self-Paced Study Program...............................................................................................................................................Tear-off
2
The major objectives of deterrent action are to:
Achieving these objectives will contribute to the
advancement of aviation safety, which is the Aviation
Enforcement Division’s primary aim.
page
The cases discussed above provide us with useful
information on what the definition of “farmer” is and
on when a pilot can be found to have operated for “hire
or reward.” by Jean-François Mathieu, LL.B, Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
Sécurité aérienne — Nouvelles est la version française
de cette publication.
Publication Mail Agreement Number 40063845
Similar to the appeal panel’s decision discussed in the
paragraph above, the TATC review member determined
that to suggest that the PIC piloted his own aircraft for
the benefit of the company in Case No. 1—a corporation
for which he is the sole shareholder—without receiving
some type of benefit is simply not believable.
Oral Counselling
The most important decision in the enforcement process
is determining which deterrent action would be most
appropriate when evidence indicates that a person has
contravened a provision of the Aeronautics Act or the
Canadian Aviation Regulations (CARs). This decision may
significantly affect the offender’s attitude towards safety
and future compliance.
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2010).
ISSN: 0709-8103
TP 185E
received no benefit was not believable. Therefore, it was
determined that Company A had received an indirect
benefit, bringing it within the purview of the definition
of “hire or reward.”
Accident Synopses
Copyright:
Some of the articles, photographs and graphics that appear
in the Aviation Safety Letter are subject to copyrights held
by other individuals and organizations. In such cases, some
restrictions on the reproduction of the material may apply,
and it may be necessary to seek permission from the rights
holder prior to reproducing it.
The TATC review member determined that the pilot
acted for “hire or reward” in Case No. 2. He cited a TATC
appeal decision where the appeal panel determined that
Company A, owner and operator of an aircraft used
for commercial air service, had contravened the CARs.
This determination was made even though Company B,
which shared some of the same directors as Company A,
demanded and received payments for the commercial
flights. No proof was made that any funds flowed from
Company B to Company A. The appeal panel held that,
although there was no direct benefit to Company A,
to suggest that Company A operated its aircraft and
The Order Desk
Transport Canada
Toll-free number (North America): 1-888-830-4911
Local number: 613-991-4071
E-mail: MPS@tc.gc.ca
Fax: 613-991-2081
Internet: www.tc.gc.ca/Transact
Accident Synopses
Please address your correspondence to:
gratuity or benefit, directly or indirectly charged,
demanded, received or collected by any person for use
of an aircraft”.
Recently Released TSB Reports
Letters with comments and suggestions are invited.
All correspondence should include the author’s name,
address and telephone number. The editor reserves the
right to edit all published articles. The author’s name and
address will be withheld from publication upon request.
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact:
nd Certification
The Aviation Safety Letter is published quarterly by
Transport Canada, Civil Aviation. It is distributed to
all holders of a valid Canadian pilot licence or permit,
to all holders of a valid Canadian aircraft maintenance
engineer (AME) licence and to other interested
individuals free of charge. The contents do not necessarily
reflect official government policy and, unless stated, should
not be construed as regulations or directives.
35
37. When landing in snow and using a high-hover technique, the re-circulating snow will obscure the landing site and will rise. In this condition, what should the pilot do? ____________________________________________________
______________________________________ (Use helicopter references or Aviation Safety Letter [TP 185] 1/2008)
38. In a dynamic rollover situation, when the rollover starts, a correction should be done smoothly by ________________
_______________________________________________________________________. (Use helicopter references)
Gyroplane-Specific Questions
39. Statistics reveal that the major cause of gyroplane accidents is pilot error and it is often linked to the lack of _________
_______________________________________________________________________. (Use gyroplane references)
40. To minimize the possibility of pilot-induced oscillation (PIO), avoid [high/low] speed flight in gusty conditions, and
make only [large/small] control inputs. After making a control input, wait briefly and observe the reaction of the aircraft before making another input.
(Use gyroplane references)
Answers to this quiz are found on page 16 of ASL 4/2010.
2010 Flight Crew Recency Requirements
Self-Paced Study Program
All pilots are to answer questions 1 to 30. In addition, balloon pilots are to answer questions 31 and 32; glider pilots
are to answer questions 33 and 34; aeroplane and ultralight aeroplane pilots are to answer questions 35 and 36;
helicopter pilots are to answer questions 37 and 38; and gyroplane pilots are to answer questions 39 and 40.
STN YUL - MONTREAL/DORVAL. QUEBEC
FDCN01 CWAO FCST BASED ON 121200 DATA VALID 121800
for use
17-21 3000
0910
6000
0906-10
9000
9900-15
13. In the above upper level wind and temperature forecast (FD), what does 9900-15 represent? _____________________________________________________________________________________. (MET 3.11)
UACN10 CYXU 032133 YZ UA /OV YXU 090010 /TM 2120 /FL080 /TP PA31 /SK
020BKN040 110OVC /TA -12 /WV 030045 /TB MDT BLO 040 /IC LGT RIME
020/040 /RM NIL TURB CYYZ CYHM
14. What is the reported location in the above PIREP? __________________________________________. (MET 3.17)
15. If an ATC clearance is not acceptable, what should the pilot-in-command do immediately? _____________________
_____________________________________________________________________________________. (RAC 1.7)
Transport
Canada
Transports
Canada
Aviation Safety in History
TAF CYXE 281139Z 2812/2912 24010G25KT WS011/ 27050KT 3SM –SN BKN010
OVC040 TEMPO 2818/2901 1 1/2SM –SN BLSN BKN008
PROB30 2820/2822 1/2SM SN VV005
FM290130Z 28010KT 5SM –SN BKN020
BECMG 2906/2908 00000KT P6SM SKC
RMK NXT FCST BY 281800Z
11. What is the period covered by the above forecast? ____________________________________________. (MET 3.9.3)
12. Describe the wind shear in the above forecast. _______________________________________________. (MET 3.9.3)
In recent years, Transport Canada and the specialized
underwater-egress training industry have made
considerable efforts in educating pilots and operators
on the importance of underwater-egress procedures and
training. Through pamphlets, newsletter articles, posters,
videos and brochures, the aviation industry has received
the bulk of the information and awareness materials.
However, those education efforts have succeeded only
partially; while our crews and operators are aware and
ready, a very important segment of our industry—the
passengers—has not benefited to the same extent from
this awareness drive.
Most passengers will not seek specialized underwateregress training, and therein lies the challenge. It is
therefore the commercial operators—and their flight
crews—who are in the best position to transfer this
knowledge to them. The most effective and traditional
way of accomplishing this is to provide the best, most
comprehensive pre-flight briefing possible—supported by
a pre-flight video and reading material, such as a brochure
or pamphlet.
For passengers, the most difficult part of surviving a
ditching accident is the underwater egress. Accident
reports indicate that many people survive the initial
impact, but needlessly drown because they were unable
to extricate themselves from the aircraft. A study by the
Transportation Safety Board of Canada (TSB) suggested
that fatalities in seaplane accidents terminating in water
are frequently the result of post-impact drowning. Most
drownings occurred inside the cabin of the aircraft, and
occupants who survived often found exiting the aircraft
quite difficult. In fact, over two-thirds of the deaths
occurred to occupants who were not incapacitated during
the impact, but drowned trying to escape the aircraft.
Why do passengers encounter difficulties when trying
to get out of an aircraft that has submerged? Panic,
disorientation, unfamiliarity with escape hatches, and
lack of proper training are some of the major factors that
contribute to passenger drowning. During an emergency
situation, rather than pausing to think, most will react on
instinct and as a result of learned behaviours; if people
never acquired a learned behaviour that is appropriate for
this type of situation—such as the steps to follow in an
36
Typical underwater-egress training exercise, professionally
supervised and done with portable equipment in local pools.
underwater-egress scenario—then the odds of reacting
appropriately are much smaller. For example, when
getting out of a car, most of us release our seat belt before
opening the door. We do this without even thinking: it is
a learned behaviour. If we are strapped into an aircraft that
is sinking, a common reaction is to release our seat belt
first, then try to get out. We have reverted to the learned
behaviour we have acquired every time we get out of a car.
In many accidents, people have hastily and prematurely
removed their seat belts and, as a result, have been
moved around the inside of the aircraft due to the inrushing water. With the lack of gravitational reference,
disorientation can rapidly overwhelm a person. The end
result is panic and the inability to carry out a simple
procedure to find a way out of the aircraft.
An unfamiliar task, to be executed submerged, quite
possibly upside down, in the dark, and in very cold water:
what could seem like a simple undertaking suddenly
becomes monumental. To help prevent panic and
disorientation, we recommend that you brief passengers
thoroughly before each flight on the steps of underwater
egress described in the brochure entitled Seaplane/
Floatplane: A Passenger’s Guide (TP12365), available on
our new floatplane Web site at www.tc.gc.ca/floatplanes.
A thorough pre-flight briefing can make the difference
between life and death for your passengers. ASL 4/2010
aviation safety letter
In this Issue...
Occurrence Reports: Where Do They Come From and How Are They Used?
COPA Corner: Distractions Affect All of Us
An Ounce of Prevention…Corrective Action Plans
Aviation Safety in History
This article is a condensed version of The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers, by
Jackie Heiler of Pro Aviation Safety Training, and originally published in Aviation Safety Letter (ASL) 2/2009. We feel it is
worth repeating the value of underwater egress training and proper pre-flight passenger briefings, as part of our continued efforts
to promote floatplane safety. —Ed.
Flight Operations
1. When used in the text of a NOTAM, the date-time group is composed of ten figures, e.g. 1001191200. The first two digits
indicate the ___________; the second two, the ___________; the third two, the ___________; and the last four, the _______________.
(GEN 1.6.1)
2. Using the chart in GEN 1.6.2, find the end of evening civil twilight at Medicine Hat, Alta., (50°N 110°45’W) on May 29. _______________ .
(GEN 1.6.2)
3. No person shall displace, move or interfere with an aircraft involved in an accident, or disrupt an occurrence site without first having obtained permission from investigators, except to ________________, to ______________
________________________________, or to ______________________________________.
(GEN 3.4.1)
4. Except in the case of an emergency, what must a pilot do prior to using an aerodrome with PPR or PNR listed in the Canada Flight Supplement (CFS) or Water Aerodrome Supplement (WAS)?
PPR: __________________________________________________________________
PNR: __________________________________________________________________. (AGA 2.2)
5. What VHF direction-finding (VDF) services are available from stations offering VDF? ___________________________________________________________.
(COM 3.10)
6. Is a VFR GPS receiver with a current database acceptable as a replacement for aeronautical charts? ________.
(COM 3.16.16)
7. What information should be included on initial contact with a remote communications outlet (RCO)?
___________________________________________________________________________________. (COM 5.8.3)
8. In Southern Domestic Airspace (SDA) the correct frequency for two aircraft to use for air-to-air communication is _______MHz.
(COM 5.13.3)
9. Cloud-base heights in aviation routine weather reports (METAR) and aerodrome forecasts (TAF) are always stated
as height _________________. On the other hand, heights in graphic area forecasts (GFA) and pilot weather
reports (PIREP) are normally stated as height ___________________.
(MET 1.1.5)
10. What does the following represent in a GFA? ___________________________________________________________________________________. (MET 3.3.11)
Flight Operations
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 this publication may result in changes to answers and/or
references. The TC AIM is available on-line at: www.tc.gc.ca/eng/civilaviation/publications/tp14371-menu-3092.htm
Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers
TP 185E
Issue 4/2010
Debrief
This questionnaire is for use from November 1, 2010, to October 31, 2011. 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.
Debrief
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Transports
Canada
Transport
Canada
debrief
Major Accident Report: Bell 206 Down in Cranbrook, B.C.
What Went Wrong: In-Flight Blackout
Assumptions
Smoke in the Cabin—Landing Light Switch Failure
Oral Counselling
Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing
for Passengers
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
TC-1003998
*TC-1003998*
2010 Flight Crew Recency Requirements
Self-Paced Study Program
All pilots are to answer questions 1 to 30. In addition, balloon pilots are to answer questions 31 and 32; glider pilots
are to answer questions 33 and 34; aeroplane and ultralight aeroplane pilots are to answer questions 35 and 36;
helicopter pilots are to answer questions 37 and 38; and gyroplane pilots are to answer questions 39 and 40.
STN YUL - MONTREAL/DORVAL. QUEBEC
FDCN01 CWAO FCST BASED ON 121200 DATA VALID 121800
for use
17-21 3000
0910
6000
0906-10
9000
9900-15
13. In the above upper level wind and temperature forecast (FD), what does 9900-15 represent? _____________________________________________________________________________________. (MET 3.11)
UACN10 CYXU 032133 YZ UA /OV YXU 090010 /TM 2120 /FL080 /TP PA31 /SK
020BKN040 110OVC /TA -12 /WV 030045 /TB MDT BLO 040 /IC LGT RIME
020/040 /RM NIL TURB CYYZ CYHM
14. What is the reported location in the above PIREP? __________________________________________. (MET 3.17)
15. If an ATC clearance is not acceptable, what should the pilot-in-command do immediately? _____________________
_____________________________________________________________________________________. (RAC 1.7)
Transport
Canada
Transports
Canada
Aviation Safety in History
TAF CYXE 281139Z 2812/2912 24010G25KT WS011/ 27050KT 3SM –SN BKN010
OVC040 TEMPO 2818/2901 1 1/2SM –SN BLSN BKN008
PROB30 2820/2822 1/2SM SN VV005
FM290130Z 28010KT 5SM –SN BKN020
BECMG 2906/2908 00000KT P6SM SKC
RMK NXT FCST BY 281800Z
11. What is the period covered by the above forecast? ____________________________________________. (MET 3.9.3)
12. Describe the wind shear in the above forecast. _______________________________________________. (MET 3.9.3)
In recent years, Transport Canada and the specialized
underwater-egress training industry have made
considerable efforts in educating pilots and operators
on the importance of underwater-egress procedures and
training. Through pamphlets, newsletter articles, posters,
videos and brochures, the aviation industry has received
the bulk of the information and awareness materials.
However, those education efforts have succeeded only
partially; while our crews and operators are aware and
ready, a very important segment of our industry—the
passengers—has not benefited to the same extent from
this awareness drive.
Most passengers will not seek specialized underwateregress training, and therein lies the challenge. It is
therefore the commercial operators—and their flight
crews—who are in the best position to transfer this
knowledge to them. The most effective and traditional
way of accomplishing this is to provide the best, most
comprehensive pre-flight briefing possible—supported by
a pre-flight video and reading material, such as a brochure
or pamphlet.
For passengers, the most difficult part of surviving a
ditching accident is the underwater egress. Accident
reports indicate that many people survive the initial
impact, but needlessly drown because they were unable
to extricate themselves from the aircraft. A study by the
Transportation Safety Board of Canada (TSB) suggested
that fatalities in seaplane accidents terminating in water
are frequently the result of post-impact drowning. Most
drownings occurred inside the cabin of the aircraft, and
occupants who survived often found exiting the aircraft
quite difficult. In fact, over two-thirds of the deaths
occurred to occupants who were not incapacitated during
the impact, but drowned trying to escape the aircraft.
Why do passengers encounter difficulties when trying
to get out of an aircraft that has submerged? Panic,
disorientation, unfamiliarity with escape hatches, and
lack of proper training are some of the major factors that
contribute to passenger drowning. During an emergency
situation, rather than pausing to think, most will react on
instinct and as a result of learned behaviours; if people
never acquired a learned behaviour that is appropriate for
this type of situation—such as the steps to follow in an
36
Typical underwater-egress training exercise, professionally
supervised and done with portable equipment in local pools.
underwater-egress scenario—then the odds of reacting
appropriately are much smaller. For example, when
getting out of a car, most of us release our seat belt before
opening the door. We do this without even thinking: it is
a learned behaviour. If we are strapped into an aircraft that
is sinking, a common reaction is to release our seat belt
first, then try to get out. We have reverted to the learned
behaviour we have acquired every time we get out of a car.
In many accidents, people have hastily and prematurely
removed their seat belts and, as a result, have been
moved around the inside of the aircraft due to the inrushing water. With the lack of gravitational reference,
disorientation can rapidly overwhelm a person. The end
result is panic and the inability to carry out a simple
procedure to find a way out of the aircraft.
An unfamiliar task, to be executed submerged, quite
possibly upside down, in the dark, and in very cold water:
what could seem like a simple undertaking suddenly
becomes monumental. To help prevent panic and
disorientation, we recommend that you brief passengers
thoroughly before each flight on the steps of underwater
egress described in the brochure entitled Seaplane/
Floatplane: A Passenger’s Guide (TP12365), available on
our new floatplane Web site at www.tc.gc.ca/floatplanes.
A thorough pre-flight briefing can make the difference
between life and death for your passengers. ASL 4/2010
aviation safety letter
In this Issue...
Occurrence Reports: Where Do They Come From and How Are They Used?
COPA Corner: Distractions Affect All of Us
An Ounce of Prevention…Corrective Action Plans
Aviation Safety in History
This article is a condensed version of The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers, by
Jackie Heiler of Pro Aviation Safety Training, and originally published in Aviation Safety Letter (ASL) 2/2009. We feel it is
worth repeating the value of underwater egress training and proper pre-flight passenger briefings, as part of our continued efforts
to promote floatplane safety. —Ed.
Flight Operations
1. When used in the text of a NOTAM, the date-time group is composed of ten figures, e.g. 1001191200. The first two digits
indicate the ___________; the second two, the ___________; the third two, the ___________; and the last four, the _______________.
(GEN 1.6.1)
2. Using the chart in GEN 1.6.2, find the end of evening civil twilight at Medicine Hat, Alta., (50°N 110°45’W) on May 29. _______________ .
(GEN 1.6.2)
3. No person shall displace, move or interfere with an aircraft involved in an accident, or disrupt an occurrence site without first having obtained permission from investigators, except to ________________, to ______________
________________________________, or to ______________________________________.
(GEN 3.4.1)
4. Except in the case of an emergency, what must a pilot do prior to using an aerodrome with PPR or PNR listed in the Canada Flight Supplement (CFS) or Water Aerodrome Supplement (WAS)?
PPR: __________________________________________________________________
PNR: __________________________________________________________________. (AGA 2.2)
5. What VHF direction-finding (VDF) services are available from stations offering VDF? ___________________________________________________________.
(COM 3.10)
6. Is a VFR GPS receiver with a current database acceptable as a replacement for aeronautical charts? ________.
(COM 3.16.16)
7. What information should be included on initial contact with a remote communications outlet (RCO)?
___________________________________________________________________________________. (COM 5.8.3)
8. In Southern Domestic Airspace (SDA) the correct frequency for two aircraft to use for air-to-air communication is _______MHz.
(COM 5.13.3)
9. Cloud-base heights in aviation routine weather reports (METAR) and aerodrome forecasts (TAF) are always stated
as height _________________. On the other hand, heights in graphic area forecasts (GFA) and pilot weather
reports (PIREP) are normally stated as height ___________________.
(MET 1.1.5)
10. What does the following represent in a GFA? ___________________________________________________________________________________. (MET 3.3.11)
Flight Operations
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 this publication may result in changes to answers and/or
references. The TC AIM is available on-line at: www.tc.gc.ca/eng/civilaviation/publications/tp14371-menu-3092.htm
Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers
TP 185E
Issue 4/2010
Debrief
This questionnaire is for use from November 1, 2010, to October 31, 2011. 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.
Debrief
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Transports
Canada
Transport
Canada
debrief
Major Accident Report: Bell 206 Down in Cranbrook, B.C.
What Went Wrong: In-Flight Blackout
Assumptions
Smoke in the Cabin—Landing Light Switch Failure
Oral Counselling
Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing
for Passengers
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
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Table of Contents
section
Contraventions of aeronautics legislation can result in a
wide range of penalties, including fines, suspensions or
cancellations of Canadian aviation documents, and even
imprisonment in severe cases.
Regulations and You
ASL 4/2010
(1) encourage future compliance by the offender; and,
(2) deter others from contravening aeronautics legislation.
Another option available to Aviation Enforcement
inspectors is “oral counselling.” This option may be used
when the contravention is considered minor in nature or
inadvertent; is a violation where there is no direct flight
safety hazard; or when the imposition of a sanction would
not be appropriate. Aviation Enforcement inspectors
will assess all aspects of the contravention, including the
attitude of the alleged offender, to determine whether oral
counselling will promote future compliance.
In the last year, “oral counselling” was assessed in
43 percent of all cases where there was a violation. The
Aviation Enforcement Division recognizes that voluntary
compliance with Canadian aeronautics legislation 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 in, commitment to, and responsibility for aviation
safety, and will operate on the basis of common sense,
personal responsibility, and respect for others. Aviation
Enforcement inspectors use oral counselling with this
philosophy in mind.
Oral counselling is most appropriate in cases of ignorance
or misinterpretation of the law, provided aviation safety
was not jeopardized. Examples include situations where
a minor contravention is committed and it had little or
no impact on safety, and where there was no indication of
a wilful act. Oral counselling is not an option when the
alleged offender disputes the allegations.
Balloon-Specific Questions
31. If the balloon contacts a tree and is moving free of it, what should the pilot do to reduce the risk of adverse consequences? _____________________________________________________________. (Use balloon references)
32. A person may conduct a take-off in a balloon within a built-up area of a city or town if the diameter of the launch site is _______________________________________________________________________. [CAR 602.13 (3)(d)]
Glider-Specific Questions
33. The end of the validity period of a medical certificate is calculated from ____________________________________
_______________________________________________________________________________. [CAR 404.04(7)]
34. The _____________ is the indicated airspeed at which the glider loses altitude most slowly.(Use gyroplane references)
35. If you are approaching for a landing and the wind is gusting from 15 to 25 kt and you normally approach at 65 kt, what should your new approach speed be in those conditions? ______________________. (Use aeroplane references)
36. Typically, light aircraft are designed to withstand, on landing, 90° crosswinds up to a velocity equal to 20 percent of their stall speed. For an aircraft with a 50-kt stalling speed, what is the maximum permissible 90° crosswind wind speed? _______________________________.
(Use aeroplane references)
It should be noted that when Aviation Enforcement
inspectors conduct comprehensive investigations
that are concluded with oral counselling, no Aviation
Enforcement record is kept in the offender’s file.
Helicopter-Specific Questions
Canada continues to play a leadership role in the
international aviation safety community and within our
national borders. In supporting this role, the Aviation
Enforcement Division is committed to promoting and
applying a policy of fairness and firmness when dealing
with contraventions of aeronautics legislation.
Have a safe and enjoyable flight! ASL 4/2010
16. Which of the following classes of airspace requires that a VFR flight establish two-way communication with the
appropriate ATC agency prior to entering? Class C, D or E? _____________________________________________
______________________________________________________________________. (RAC 2.8.3, 2.8.4 and 2.8.5)
17. After asking the passengers for their personal weights, what weight should be added for clothing in winter?
______________________________________________________________________________.
(RAC 3.5.1)
18. After a flight plan or flight itinerary has been filed but not opened with the appropriate ATS unit, what will happen if
the flight is delayed or cancelled? ___________________________________________________
________________________________, unless it is known that the aircraft has not departed. (RAC 3.6.4)
19. If a pilot closes a flight plan or flight itinerary prior to landing, are the alerting services with respect to
search and rescue (SAR) notification still active until after the landing? _____________________.
(RAC 3.12.2)
20. When a mandatory frequency (MF) area exists at an aerodrome but the ground station is not in operation, all reporting procedures specified in CARs 602.97 to 602.103 shall be ________________________.
(RAC 4.5.4)
21. In Canada, the area covered in a visual search during a SAR operation will typically extend to a maximum of
___________________ on either side of the flight-planned route.
(SAR 2.1)
22. Only aircraft equipped with an emergency locator transmitter (ELT) operating on _____________ can be detected by
COSPAS-SARSAT satellites.
(SAR 3.1)
23. Where would you find the index and list of current Canadian aeronautical charts? ____________________________
___________________________________________________________________________________. (MAP 2.2)
24. New or revised VFR operations which are required to be depicted on VFR charts are advertised first by ____________ until published in the CFS _____________ section then finally updated on the _____________.
(MAP 2.4)
25. What information would you find in a NOTAM? ___________________________________________. (MAP 5.1)
26. A pilot renewing a category 4 medical declaration should complete the declaration form _____ days before the expiry
date of the medical certificate.
(LRA 3.4.1.1)
27. Name one recurrent training program you must have successfully completed within the previous 24 months in order to meet the 2-year requirement. _______________________________.
[LRA 3.9, CAR 421.05(2)]
28. An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error of more
than __________________ when compared to the known ground elevation.
(AIR 1.5.1)
29. If, after receiving routine immunizations, a pilot feels unwell or experiences an adverse reaction, the pilot should wait for ___________________________ and ______________________________________ prior to flying. (AIR 3.13)
30. Review AIR 4.13 and AIR Annex 1.0
List what is available in the aircraft that you typically fly that could aid you in the event of an injury or a need for shelter. ____________________________________________________________ (AIR 4.13 and AIR Annex 1.0)
Aeroplane-Specific Questions (including ultralight)
Regulations and You
Pre-Flight...........................................................................................................................................................................3
Flight Operations..............................................................................................................................................................9
Maintenance and Certification........................................................................................................................................17
Recently Released TSB Reports......................................................................................................................................21
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers..........................36
Self-Paced Study Program...............................................................................................................................................Tear-off
2
The major objectives of deterrent action are to:
Achieving these objectives will contribute to the
advancement of aviation safety, which is the Aviation
Enforcement Division’s primary aim.
page
The cases discussed above provide us with useful
information on what the definition of “farmer” is and
on when a pilot can be found to have operated for “hire
or reward.” by Jean-François Mathieu, LL.B, Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
Sécurité aérienne — Nouvelles est la version française
de cette publication.
Publication Mail Agreement Number 40063845
Similar to the appeal panel’s decision discussed in the
paragraph above, the TATC review member determined
that to suggest that the PIC piloted his own aircraft for
the benefit of the company in Case No. 1—a corporation
for which he is the sole shareholder—without receiving
some type of benefit is simply not believable.
Oral Counselling
The most important decision in the enforcement process
is determining which deterrent action would be most
appropriate when evidence indicates that a person has
contravened a provision of the Aeronautics Act or the
Canadian Aviation Regulations (CARs). This decision may
significantly affect the offender’s attitude towards safety
and future compliance.
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2010).
ISSN: 0709-8103
TP 185E
received no benefit was not believable. Therefore, it was
determined that Company A had received an indirect
benefit, bringing it within the purview of the definition
of “hire or reward.”
Accident Synopses
Copyright:
Some of the articles, photographs and graphics that appear
in the Aviation Safety Letter are subject to copyrights held
by other individuals and organizations. In such cases, some
restrictions on the reproduction of the material may apply,
and it may be necessary to seek permission from the rights
holder prior to reproducing it.
The TATC review member determined that the pilot
acted for “hire or reward” in Case No. 2. He cited a TATC
appeal decision where the appeal panel determined that
Company A, owner and operator of an aircraft used
for commercial air service, had contravened the CARs.
This determination was made even though Company B,
which shared some of the same directors as Company A,
demanded and received payments for the commercial
flights. No proof was made that any funds flowed from
Company B to Company A. The appeal panel held that,
although there was no direct benefit to Company A,
to suggest that Company A operated its aircraft and
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Accident Synopses
Please address your correspondence to:
gratuity or benefit, directly or indirectly charged,
demanded, received or collected by any person for use
of an aircraft”.
Recently Released TSB Reports
Letters with comments and suggestions are invited.
All correspondence should include the author’s name,
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nd Certification
The Aviation Safety Letter is published quarterly by
Transport Canada, Civil Aviation. It is distributed to
all holders of a valid Canadian pilot licence or permit,
to all holders of a valid Canadian aircraft maintenance
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individuals free of charge. The contents do not necessarily
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not be construed as regulations or directives.
35
37. When landing in snow and using a high-hover technique, the re-circulating snow will obscure the landing site and will rise. In this condition, what should the pilot do? ____________________________________________________
______________________________________ (Use helicopter references or Aviation Safety Letter [TP 185] 1/2008)
38. In a dynamic rollover situation, when the rollover starts, a correction should be done smoothly by ________________
_______________________________________________________________________. (Use helicopter references)
Gyroplane-Specific Questions
39. Statistics reveal that the major cause of gyroplane accidents is pilot error and it is often linked to the lack of _________
_______________________________________________________________________. (Use gyroplane references)
40. To minimize the possibility of pilot-induced oscillation (PIO), avoid [high/low] speed flight in gusty conditions, and
make only [large/small] control inputs. After making a control input, wait briefly and observe the reaction of the aircraft before making another input.
(Use gyroplane references)
Answers to this quiz are found on page 16 of ASL 4/2010.
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