debrief The Luck Meter—Don’t Leave Home Without It!

debrief The Luck Meter—Don’t Leave Home Without It!
The Civil Aviation Medical Examiner and You
Debrief
Transport Canada
It is interesting to note that in 2008, the average life of
many electronic items is now measured in mere months,
before they become outdated. A three-year-old computer
may as well have been unearthed in an archaeological dig
when you try to get it serviced. “Sorry, pal; we don’t support
that model any longer. It’s way out of date.” Technology and
change surround us at an ever-quickening pace. All the
same, we still cling to ancient dark concepts of chance,
luck and inexplicable things that go bump in the night.
Granted, there is an undeniable element of randomness
to events. Bad things do happen to good pilots, like
lightning strikes on a relatively clear day, for example.
However, accidents are more commonly a result of poor
planning and multiple factors—many of which could
have been mitigated earlier—than bad karma. Yet, how
often do we hear the rationalization, “it was just bad
luck that caused the accident ”? It wasn’t bad planning,
questionable decision making, or pressing on into forecast
bad weather, but rather, some malevolent force that
determined the outcome of the flight. “It wouldn’t have
mattered what the pilot had done—their time was up.”
In this Issue...
The CBAA Column: Audits, Audits, Audits, Audits, Audits
Understanding Altitude Deviations
Houston, Transport Canada Is on the Line...
See, Hear, Comply and Avoid—Maintaining Separation at Uncontrolled Aerodromes
Top-Level Inspections!
Heads Up! Aeroplane Design and Operations in Icing Conditions
Removal of Sanctions
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
Debrief
Debrief
New Manufacturing Regulations
Issues with FDR and CVR Data Identified as a Result of TSB Reviews
A few months back, I had the pleasure of joining an old
friend, whom I had not seen for a long time, for coffee.
As it happens, he is now a regional manager for the
Transportation Safety Board of Canada (TSB). We were
discussing some of the more recent accidents, and trying
to figure out if there is any common thread among them
that might alleviate the toll. After a thoughtful pause, he
a serviette. He reasoned that since so many folks believe
in luck, and perception is reality, there should be such
an instrument in every helicopter. Rather than a pilot
having vague unpleasant feelings about how the flight
is progressing, a luck meter would clearly indicate the
current state of affairs. The common reaction of denial
until it’s too late when things aren’t going well, would be
vanquished forever!
TP 185E
Issue 3/2008
aviation safety letter
Debrief
An old novel about unlikely aviation accidents and
inevitability, entitled Fate is the Hunter by Ernest K. Gann,
is one of the first and best of the “mysterious airplane
crash” genre. It explores the consequences of luck running
out and being in the wrong place at the wrong time. It is
still available, and a good read if you want to delve a little
deeper into the subject.
Transports
Canada
Debrief
Debrief
The Luck Meter—Don’t Leave Home Without It!
The Civil Aviation Medical Examiner and You
debrief
Transport
Canada
*TC-1002714*
40
TC-1002714
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARTT)
330 Sparks Street, Ottawa ON K1A 0N8
E-mail: marqupj@tc.gc.ca
Tel.: 613-990-1289 / Fax: 613-952-3298
Internet: www.tc.gc.ca/ASL-SAN
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Table of Contents
section
ASL 3/2008
In the meantime,
you would be best
advised to discuss
the situation with
your physician.
Discontinuing the
medication should
only be done under
the supervision
of your physician
and only when
the situation has
stabilized. Contact
one of our offices to
discuss the returnto-flying parameters
for your particular
situation, or for
any other aviation
Aviation
TP 2228E-3
(06/2008)
Below 10 000 ft
www.tc.gc.ca/CivilAviation/
, and the FAQ section at www.tc.gc.ca/
.
39
The ear
To put it simply — as you go up, gas expands and as you come down, gas contracts. In the ear there is a small
air space behind the eardrum that is connected with the throat through two narrow tubes. It’s through these
narrow tubes that the air behind the eardrum is equalized to the outside atmospheric pressure.
As you climb and the outside pressure decreases, the eardrum will bulge and may give a fullness sensation and
pain. You may feel a “clicking” when the eardrum bounces back into place as the air is ventilated into the throat
through the narrow tubes — now the pressure is equalized.
The sinuses
Those wretched holes in the head can create serious difficulty for some people. A blocked sinus can create
visual problems, toothache, or other severe head pain. Unlike the ear, the air in the sinus is free to come and
go during ascent and descent. An infection or allergy tends to close the sinus aperture; this can result in air
escaping on ascent, but not being able to enter on descent. It is advisable that:
• ifoneorbothsinusesarecompletelyblockedandwillnotclearbyasimplesniff—don’tfly!
• ifoneorbothnostrilscanbepartiallyclearedbysniffing—proceedwithcaution.Sniffhardonascent
and at altitude to get the passages as clear as possible. Plan for discomfort on descent.
• ifthecongestionisassociatedwithanykindoffeverormalaise—don’tfly!
The vision
The retina of the eye is more sensitive than any other part of the body to an insufficiency of oxygen in the
blood. Night vision is especially affected as there is a reduction of 25 percent by the time you reach 8 000 ft.
Breathing oxygen will alleviate the problem. But here’s more — since blood absorbs carbon monoxide more
readily than oxygen, smoking three cigarettes in a row will reduce your night vision by 25 percent as well.
Alcohol intake will also severely reduce night vision.
Debrief
2
Debrief
page
Guest Editorial .................................................................................................................................................................3
To the Letter .....................................................................................................................................................................4
Pre-flight ...........................................................................................................................................................................5
Flight Operations .............................................................................................................................................................13
Maintenance and Certification .......................................................................................................................................18
Recently Released TSB Reports.....................................................................................................................................25
Accident Synopses ...........................................................................................................................................................33
Regulations and You ........................................................................................................................................................36
The Civil Aviation Medical Examiner and You ............................................................................................................39
Debrief: The Luck Meter—Don’t Leave Home Without It! ......................................................................................40
Don’t Let It Get This Far! Runway Incursions Are Real! (poster) .............................................................................Tear-out
Take Five: Below 10 000 ft..............................................................................................................................................Tear-out
Transports
Canada
During descent, the reverse happens. However, the flutter valve at the end of the narrow tubes might not work
so well. You can usually alleviate the problem by swallowing, yawning or closing your mouth, holding your
nose and blowing gently (valsalva). The big problem will arise if you have a headcold, sore throat, ear infection,
sinus trouble or any condition that will cause the tubes to swell. This will prevent the inner ear air pressure
from equalizing with the outside, causing severe pain. A simple rule:
• ifyoucannot“click”youreardrumsbyvalsalvaontheground—don’tfly.
• ifyoucanclearyourearswithslightdifficultyontheground,youmaydecidetofly—butbeprepared.
Assume that you will have trouble on descent.
Debrief
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2008).
ISSN: 0709-8103
TP 185E
Transport
Canada
When we consider that the change in atmospheric pressure is greater at the lower altitudes, where most
of general aviation’s flying is done, then we must take some time studying its effects.
Debrief
Change of address or format:
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The Civil Aviation Medical Examiner and You
Note: Reprints of original Aviation Safety Letter
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Transport Canada’s Aviation Safety Letter. Please forward
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Debrief
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Debrief
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To obtain information concerning copyright ownership
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The Civil Aviation Medical Examiner and You
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.
The brain
Since the brain needs oxygen for proper functioning, and alcohol reduces the amount of oxygen that the blood
can carry, any ascent will further impair the brain. After some alcohol consumption if you fly at 8 000 ft, your
brain may be flying at 20 000 ft—in this case you may pass out within 10 min. If you consider that your body
may take up to 48 hrs to recover from excessive alcohol consumption, planning a flight takes more than just
looking at the weather.
According to the Transportation Safety Board of Canada (TSB) statistics, the aviation
accident rate in Canada has been in steady decline. More specifically, aviation safety in the
air taxi sector has shown marked improvement. These gains are likely a direct result of a
number of initiatives bringing an improved safety culture to our industry. Initiatives such as
the Safety of Air Taxi Operations (SATOPS)1 — initiated by Transport Canada in 1996 —
have brought forward changes to the way in which air operators and approved maintenance
organizations are conducting their day-to-day operations.
Guest Editorial
Guest Editorial
guest editorial
In an Aviation Safety Letter (ASL) article written last year 2, author Adam Hunt suggests that “…if you [the pilot]
are rusty, invest wisely in a checkout with an instructor and make sure you fly regularly to maintain your skills.” This
conclusion comes from a report into the findings of a review of insurance claims submitted to the Canadian Owners
and Pilots Association (COPA) aviation insurance program. An analysis revealed that 33.9 percent of accidents
reviewed were due to skill-based errors and 6.5 percent were the results of poor decision making. Furthermore,
10 percent of the accidents surveyed were the result of engine failure, leading the author to question if owners are “…
getting their planes properly serviced when they should.” Mr. Hunt’s article—in my opinion—delivers sound advice
and poses a fair question!
To the Letter
To the Letter
While Canada has an enviable aviation safety record, I can’t help but feel a responsibility in particular to the recreational
aviation community. In spite of the fact that over the last decade the number of hours flown by this sector has been steadily
decreasing, there has been no downward trend in accidents according to TSB statistics. Ontario is home to over one third
of all aviation activity in Canada and nearly 40 percent of the recreational aviation fleet resides within its borders.
How can we work together on improving safety records? Could the principles of safety management systems (SMS)
permeate the flying clubs, the associations and the recreational pilots themselves? Could an initiative such as SATOPS
realize the same level of success in this sector? What steps can the recreational aviation community take to significantly
improve its safety performance?
In Ontario, I have had opportunities over the last three years to attend Monthly Aviation Safety Seminars (MASS),
where my regional staff meet regularly with 150 to 200 recreational pilots and owners to discuss exactly these kinds
of issues, and share best practices. An inspector has been identified as the point of contact at each Transport Canada
Centre (TCC) in Ontario and I have assigned one of our superintendents as the regional champion for recreational
aviation. The Ontario Region has created an e-mail address specifically for the use of this community (RecAvOnt@tc.gc.ca)
of which many people have taken advantage. These are just a few examples of ways in which we are trying to engage the
recreational aviation community.
Pre-flight
Pre-flight
Clearly, to improve the safety record of recreational aviation in Ontario and throughout Canada we must focus on some key
initiatives. A collaborative environment between the regulator and the industry is essential. Improving safety can only be
achieved if the recreational aviation community is able to identify the issues and work on solutions between themselves and
with Transport Canada.
Flight Operations
Flight Operations
Let’s work on this together. Talk to your local TCC or send your suggestions directly through the Civil Aviation Issues
Reporting System (CAIRS) at www.tc.gc.ca/CAIRS. Your suggestions, comments and issues will be viewed as opportunities
to build a more collaborative relationship between yourselves and Transport Canada Civil Aviation. Improvements in the
safety culture of your community can only happen with your participation.
Michael R. Stephenson
Regional Director
Civil Aviation
Ontario Region
1
2
SATOPS - www.tc.gc.ca/civilaviation/systemsafety/pubs/tp13158/menu.htm
ASL - www.tc.gc.ca/CivilAviation/publications/tp185/1-07/Pre-flight.htm#COPA
ASL 3/2008
3
To the Letter
Dear Editor,
Recently, one of our base pilots discovered an
accumulation of water in the fuel tank and filter of his
Bell 206. The previous day, he had refuelled from a drum
near Stewart, B.C. Approximately one litre of water was
discovered in the fuel filter—almost enough to cause
engine failure. The chief pilot examined the fuel filter and
discovered that it would allow the entry of water up to
one percent of the fuel flow rate before shutting off the
fuel flow. With a fuel flow rate of 25 gallons per minute,
the filter would allow 0.25 gallons or one litre of water.
That is practically the full capacity of the airframe fuel
filter. I have been in the industry for over 30 years and was
not aware of this. I am sure that many other pilots are also
not aware of this.
Part of the problem is that this particular filter unit is in
a casing with no glass sediment bowl; therefore, the pilot
cannot perform a visual check of the fuel as it starts to
pump. Older filters equipped with a glass sediment bowl
were more effective for detecting water visually.
Name withheld on request.
The airport firefighter responding to the incident also
recommended the hard surface because it had rained
quite a bit during the previous week. Not only would it be
trickier for the aircraft, but the soft ground presented an
additional risk that the fire truck might get stuck. After
relaying this information back to the pilot, he agreed to
land on the runway. All resources were deployed in the
staging area; the pilot landed the aircraft on Runway 19
and walked away unharmed. Teamwork played an
important role in this incident. As a result, I understand
that the Airport Manager and other interested parties
are discussing the feasibility of making precautionary
landings on the hard surface mandatory.
I would like to see an article in the ASL regarding the
best choice to be made under different circumstances
where a precautionary or forced landing is required.
I have witnessed several incidents over the years, and a
recurring theme seems to be a desire to minimize damage
to the aircraft.
Pascal Liebault
Chilliwack, B.C.
Selection of Precautionary Landing Site
I am an air traffic controller currently working at the
Abbotsford Airport, B.C. I am writing you today with
regards to a particular accident synopsis, published in the
Aviation Safety Letter (ASL) 4/2007. The article mentions
the sequence of events regarding a Cessna 177RG
returning to the airport with partially deployed landing
gear. The pilot tried unsuccessfully to deploy the gear and
ended up landing gear-up on Runway 19. I was working
at the Air position that day and remember the event
quite well.
4
Thank you, Mr. Liebault. Your comments do provide for
good discussions between pilots, controllers, flight service
station (FSS) specialists, and rescue personnel. In this
particular event, you and your colleagues were able to assist
a pilot in a period of elevated stress, with a most favourable
outcome. The publication of your letter should raise the level of
awareness on this issue, and encourage pilots to discuss it with
their peers, particularly with their instructors. —Ed.
ASL 3/2008
Flight Operations
Flight Operations
Dear Editor,
Pre-flight
I have noticed over the years that when there is a small
quantity of water in a drum, it can be spotted using
a flashlight, since water separates from the fuel and
can be seen even if the water is clean. However, I once
encountered a drum that had enough clear water to
cover the bottom of the drum, even when tilted over
for inspection. In this case, the water could not be seen.
I am now convinced that the only sure-fire way to detect
water is to use water-finding paste on a dipstick. I keep a
lightweight dipstick made of white plastic, and use it with
a bit of water-finding paste on the end to check for water.
What wasn’t mentioned was that the pilot initially
insisted on landing in the grassy area adjacent to
Runway 19. A fly-by was conducted in accordance
with our Manual of Operations and our Unit Operations
Manual, and also to buy us some time. I remembered
a conversation regarding precautionary landings with
a fellow controller who was also an experienced pilot.
We had discussed that landing in long or wet grass, or
on any other soft surface, involved a risk of digging into
the soft ground and the potential of cart-wheeling, or
having a wing dig in, resulting in more severe injuries or
structural damage. During the fly-by, we confirmed to the
pilot that his gear was partially deployed, and that all of
the controllers present suggested that the best course of
action would be to land on the hard surface.
To the Letter
Pre-flight
Detection of Water in Fuel Drums—
Use of Filters and/or Dipstick
Guest Editorial
Guest Editorial
to the letter
pre-flight
Guest Editorial
Guest Editorial
The CBAA Column: Audits, Audits, Audits, Audits, Audits....................................................................................... page 5
Understanding Altitude Deviations.................................................................................................................................. page 6
COPA Corner—Those Darn Charts: How Do We Update Them?............................................................................. page 7
Cabin Safety: Did You Know…....................................................................................................................................... page 8
Aviation Document Booklet.............................................................................................................................................. page 10
Houston, Transport Canada Is on the Line…................................................................................................................ page 11
General Aviation On-Line Services.................................................................................................................................. page 12
The CBAA Column: Audits, Audits, Audits, Audits, Audits
Pre-flight
Private operator certificate (POC) holders are required
to develop, implement and operate a safety management
system (SMS) that is sound, appropriate and effective for
their operation. An integral evaluation tool of SMS is
the operator risk profile that, when completed, provides
the operator with an understanding of their exposure
to operational risks. The operator’s risk profile forms
the framework for developing processes and policies
to address day-to-day operational requirements and to
mitigate identified areas within the risk profile.
What needs to be understood is that, by nature, an
effective SMS is essentially a live, ever-evolving system
that needs to be routinely reassessed, challenged and
revised where necessary. Whenever revisions are made to
the SMS, they are initially evaluated to ensure that the
changes are sound, appropriate and effective. Over time,
the operator’s profile should evolve, creating the need to
make additions or amendments to the SMS. To ensure
that this is done appropriately and effectively, a system of
checks and balances needs to be utilized.
Internal audits, if properly implemented, can:
• demonstrate an operation’s credibility;
• minimize the gaps between required audit cycles;
• demonstrate due diligence regarding liabilities;
• improve staff understanding of the systems
in place in the organization;
• ensure that everyone is following policies
and procedures;
• provide motivation for ongoing improvement
and streamlining of systems; and
• demonstrate to external parties that the policies
and procedures are sound, appropriate and effective.
Ongoing internal audits do not have to be complex,
lengthy or involved. They can be structured to focus on
a single department, a single area of responsibility or a
single item of the business aviation safety standards. An
audit implementation plan can be developed, illustrating
an internal audit schedule that is a gradual, phased
approach over a period of time. An internal audit can
focus on areas that require the most attention and can
be dealt with on a priority and frequency scale over the
course of the internal audit schedule.
By undertaking an internal audit process, operators will
have an up-to-date understanding of their operation’s
position; the hidden unknowns will have been identified
and resolved long before a formal external audit takes
place. Best practices indicate that ongoing internal
audits enable companies to operate consistently at peak
performance, as risk management becomes the way of
doing business.
ASL 3/2008
Flight Operations
So, how do we know that what has been implemented
through policy and procedures is indeed appropriate for the
identified situations? The simplest, most effective method is
to conduct internal audits. Initially, a POC holder engages
a CBAA-accredited auditor to evaluate the operator’s SMS.
Following the initial certification audit, and in conjunction
with the operator’s risk profile, a predetermined periodicity
for the reoccurring audit is determined, which shall not
exceed three years. But those are the required audits.
More and more organizations are discovering the multiple
benefits of implementing ongoing internal audit systems.
One cannot underestimate the business efficiencies realized
by compliance with operational and regulatory standards.
Pre-flight
Flight Operations
At the recent CBAA Safety Seminar held in Montréal, Que.,
the words ‘‘audits, audits, audits, audits’’ resounded in
the room. Mr. Gordon Graham, renowned expert on
organizational and operational risk management, was
the speaker. Mr. Graham was addressing the way an
organization can truly understand and quantify its overall
operational health. An internal audit process provides the
means of checking and rechecking all of the policies and
procedures that are in place to support the direction and
mandate of the responsible executive.
To the Letter
To the Letter
by Peter Saunders, Manager, Private Operator Certificate (POC) Program, Canadian Business Aviation Association (CBAA)
This article was previously published in CBAA Newsbrief #118. Reprinted with permission.
5
by Ann Lindeis, Manager, Safety Management Planning and Analysis, Operational Support,
NAV CANADA
Altitude deviations1 are serious events which, if undetected, can lead to losses of separation and the potential for
collision with both aircraft and terrain. Figure 1 shows the altitudes where deviations were reported through NAV
CANADA’s aviation occurrence reporting (AOR) Figure
system1 for the last two years for which complete data is available.
The figure is broken down by altitude and shows, not surprisingly, that most altitude deviations take place in the lower
60
altitudes, where aircraft are involved in making step climbs
Figure 1and descents.
Guest Editorial
Guest Editorial
Understanding Altitude Deviations
40
50
Sept ’05 to Aug ’06
30 40
Count
Count
50 60
20
Sept ’06 to Aug ’07
Sept ’05 to Aug ’06
30
Sept ’06 to Aug ’07
0
10 < 3000 < 6000 < 9000 < 12000 < 15000< FL180 < FL210 < FL240 < FL270 < FL300 < FL330< FL360 < FL390 < FL420 < FL450
0
< 3000 < 6000 < 9000 < 12000 < 15000< FL180 < FL210 < FL240 < FL270 < FL300 < FL330< FL360 < FL390 < FL420 < FL450
To the Letter
To the Letter
10 20
Figure 1
Figure 2 shows the number of altitude deviations reported over the last two years, broken down by flight information
Figure 2 across Canada.
region (FIR), and demonstrates that this issue is pertinent
80
70
60
Pre-flight
40
Count
30
20
10
0
80
Sept ’05 to Aug ’06
70
Sept ’06 to Aug ’07
60
50
40
30
20
10
Gander
Moncton
Montreal
0
Gander
Moncton
Montreal
Toronto
Winnipeg
Figure 2
Toronto
These data were presented and discussed at
NAV CANADA safety forums held recently in Toronto, Ont.,
and Vancouver, B.C. This initiative was described in a
previous Aviation Safety Letter (ASL) article (issue 3/2007),
and provides an opportunity for NAV CANADA to discuss
specific safety issues with customers. The discussions led to
a clear understanding that altitude deviations are a concern
to both operators and NAV CANADA, and that decreasing
the safety risk they represent will require an integrated
Winnipeg
Edmonton
Edmonton
Vancouver
Vancouver
approach. Some of the potential contributing factors leading
to altitude deviations, which were discussed, include:
•
The challenges of complying with late descent
clearances in modern, highly-automated aircraft
when the aircraft is relatively high and close to
the airport;
Altitude deviations include events where the aircraft deviated from an assigned or designated altitude. This may include deviations due to
turbulence or other weather events. Flights may be conducted under instrument flight rules (IFR) or visual flight rules (VFR). For the
purposes of this analysis, these do not include standard instrument departure (SID) deviations, as these are analyzed separately.
1
6
ASL 3/2008
Flight Operations
Flight Operations
Sept ’06 to Aug ’07
Pre-flight
Count
50
Figure 2
Sept ’05 to Aug ’06
•
The increased numbers of altitude clearances
received when aircraft are vectored off the
standard terminal arrival (STAR);
The fact that most altitude clearances come in the
terminal environment when the crew are
in a period of high workload;
•
The potential for communication problems in
receiving altitude clearances (see related article in
ASL 2/2008 on communication errors).
If you or your organization are interested in working with
NAV CANADA to better understand and mitigate the
problem of altitude deviations, please contact Ann Lindeis
at lindeia@navcanada.ca or 613-563-7626.
Guest Editorial
Guest Editorial
•
COPA Corner—Those Darn Charts: How Do We Update Them?
by John Quarterman, Manager, Member Assistance and Programs, Canadian Owners and Pilots Association (COPA)
602.71 The pilot-in-command of an aircraft shall,
before commencing a flight, be familiar with the
available information that is appropriate to the
intended flight.
So, we are safe…right? Of course, the local grapevine
in the flying club or flight school that helps pilots stay
informed may obscure the fact that a pilot has become
somewhat lax about their sources of aviation information.
We all know, or have heard of, pilots who carry a twoyear-old CFS, or who fly with 1969 highway maps, or
Since May 2003, NAV CANADA has been selling and
distributing aeronautical publications. In March 2007,
they became responsible for all aeronautical publications,
including VFR charts, which had previously been
published by Natural Resources Canada (NRCAN).
VFR charts include aeronautical VNCs, aeronautical
VFR terminal area charts (VTA) and world aeronautical
charts (WAC). VTAs are published once a year and
VNCs are revised on a one-year, two-year or five-year
cycle. This means, for example, that a one-year chart
revised in January can be expected to be revised again
at approximately the same time the following year. The
same applies to two- and five-year charts. WACs are on
a similar cycle, but have not been updated in many years.
NAV CANADA will begin updating them in 2008.
All VFR charts include an edition number, the month
and year that they are issued, and the effective date for
airspace amendments. Changes to a VFR chart, after it
has been published, are compiled throughout the year(s)
for inclusion in the next edition (see below for more
information). The current VFR chart list is available on
NAV CANADA’s Aeronautical Publication, Sales and
Distribution Unit (AEROPUBS) Web site:
www.navcanada.ca/NavCanada.asp?Language=EN&Content=
ContentDefinitionFiles%5CPublications%5CAeronauticalInfoProducts
%5CCharts%5CAeroCharts%5CListOfVFR.xml.
ASL 3/2008
7
Flight Operations
Flight Operations
Most pilots are diligent and make a credible effort to
achieve this standard on each flight. We obtain weather
information and NOTAMs from the NAV CANADA
Web site. We contact the flight information centre (FIC)
for a last-minute update, then grab our flight bag full
of the latest (or nearly latest) visual flight rules (VFR)
navigation charts (VNCs) and recent CFS. We often
include our VFR global positioning system (GPS), which
most pilots update once a year. Then we go flying—
usually with great success. Adding to the implicit safety
factor is the fact that we normally fly locally, and local
conditions are passed on throughout the pilot population
by word-of-mouth, without necessarily referring to official
sources. Pilots often receive informal reports about local
aviation information, even critical NOTAMs, from other
pilots. Of course, there is nothing wrong with passing
on information to each other, provided we do not stop
reading and updating the official sources of information
that we are required to use.
The informal system that pilots sometimes get away
with locally certainly breaks down as soon as pilots
wander away from their familiar haunts, territory and
airspace. Now the pilot has no word-of-mouth sources,
and suddenly has to revert back to basics and use official
sources. This requires a bit of understanding on how
aeronautical charts are updated.
Pre-flight
Pre-flight
602.72 The pilot-in-command of an aircraft shall,
before commencing a flight, be familiar with the
available weather information that is appropriate to
the intended flight.
who use the Weather Network as their weather source.
Fortunately, this does not always show up as a problem, as
long as these individuals stick close to home; however, it
can lead to disastrous circumstances when pilots travel far
from their home base.
To the Letter
To the Letter
As pilots, we are all aware from our flight training
that we are required by regulation to equip ourselves
with up-to-date charts, databases, the Canada Flight
Supplement (CFS), weather information and NOTAMs
before we take off. This requirement is stipulated
in the following sections of the Canadian Aviation
Regulations (CARs):
If a change is listed in the CFS, it means that the
information on the (current) chart is out of date, and a
notation and correction need to be made to the chart.
Of course, the longer a chart circulates before it is
replaced, the longer the potential list of corrections to
the chart. Many of these changes may be critical to flight
safety, such as a new antenna that creates an obstruction
close to an airport. Normally, a NOTAM that lists a
correction or addition to a chart is cancelled when the
information is added to CFS Section C, so until a new
chart is issued, the CFS is the only place where the
information is available.
What, then, is the correct approach to planning and flying
VFR (even for local flights)?
Obtain, read and carry the latest CFS and the latest chart.
Familiarize yourself with corrections from CFS Section C
and transcribe them onto the VNC chart.
Check and incorporate the following into your planning,
before you decide to take off:
1. NOTAMs;
2. aviation information circulars and supplements
(www.navcanada.ca/ContentDefinitionFiles/Publications/
AeronauticalInfoProducts/AIP/Current/PDF/EN/part_5_
aic/5aic_eng.pdf);
To the Letter
To the Letter
Most pilots consider an up-to-date chart as the last
word in aviation data, along with pertinent NOTAMs.
Many do not know that this is not quite the last word.
In fact, the CFS, which is issued every 56 days, has a
section called Planning (Section C). If you look up the
table of contents under the Planning section, you will
find a heading called “VFR Chart Updating Data.” In
this subsection, the latest changes to VFR charts are
listed by province. Under Ontario, for example, the
heading “ONTARIO – DANGER, RESTRICTED
& ADVISORY AREAS” might provide you with
information such as:
CYA532(A) Lake Simcoe – Time of Designation
changed to Ocsl (Occasional) by NOTAM.”
It is not appropriate for NOTAMs to communicate
temporary changes that will be in effect for a long
period (three months or longer) or information that is
relevant for a short period, which contains extensive
text or graphics. In these instances, the changes shall be
published as AIP Canada (ICAO) supplements, which
are available on the NAV CANADA Web site on
Aeronautical Information Products.
Guest Editorial
Guest Editorial
The last word—VFR chart updating data
3. weather information.
With proper planning and the right information to plan
with, every flight will be that much safer! Have a great
flight. For more information on COPA,
visit: www.copanational.org.
Cabin Safety: Did You Know…
Flight Operations
Did you know that the law requires that passengers obey
the instructions given throughout a flight? It’s true. It is
your responsibility, as a passenger, to pay attention to the
8
standard safety briefing given by the flight attendants and
to follow their instructions, otherwise you could be held
accountable in a court of law, just like any other passenger.
Checked luggage and carry-on baggage
When it comes to packing a suitcase, most people like
to have the same personal items that they are used to,
whenever they travel. This can make packing an arduous
task. Also, with the new security rules in effect, at times
you may feel totally lost when it comes to choosing which
items to include in carry-on baggage and which ones to
stow in checked baggage. Take care not to include any
non-permitted items in your carry-on baggage, so that
you are not delayed when going through security. Some
items are permitted when they are carried by a working
member of the flight crew, but not permitted when flight
crew members travel as passengers.
Did you know that some products that we use regularly
are considered to be dangerous goods when carried on
board an aircraft? Did you know that matches are not
permitted in carry-on baggage?
ASL 3/2008
Flight Operations
Travelling by plane for a ferry flight or to reach a holiday
destination is probably commonplace for those of you
who work in the field of aviation. Since travelling this
way is a part of your life, it is natural that you feel very
comfortable in an airplane, and you probably pay less
attention to your surroundings, as well as the instructions
and safety tips given by the flight crew. Although some of
their instructions may not seem to matter much, especially
after you’ve heard them so many times before—perhaps
even told them to others—all information pertaining to
safety on an aircraft is governed by regulations and must
be stated upon each takeoff and landing, and whenever
turbulence is encountered, etc. In addition, although the
instructions may appear to be the same, they are actually
different from one airplane to the next, since most aircraft
are different. For instance, you will find variances in the
location of emergency exits, as well as the safety features
card and the life jackets used.
Pre-flight
Pre-flight
by Pascale Lachance, Program Manager, Cabin Safety Standards, Standards, Civil Aviation, Transport Canada
Guest Editorial
Guest Editorial
Note also that CARES™ child aviation restraint system
is now accepted on aircraft through a global exemption.
Since airlines have a choice of whether or not to take
advantage of this exemption, it is a good idea to check with
your airline to find out if they accept the restraint system.
You will find more information on the CARES™ child
restraint system by visiting the appropriate link below.
Disorderly conduct
Photo: CATSA
Did you know that different types of aircraft have
different size and weight limitations for carry-on
baggage? It is therefore important to check with your
airline to determine their carry-on baggage allowances,
since they may be different from what you are used to.
Did you know that child restraint systems purchased
abroad, with the exception of the United States, are
not approved in Canada and cannot be used on board
Canadian aircraft? Only child restraint systems made
in Canada, that meet Canadian Motor Vehicle Safety
Standards (CMVSS) 213 or 213.1 are accepted for use
on board an aircraft. A statement of compliance label
must be affixed to the restraint system, indicating that the
device complies with CMVSS 213 or 213.1 and may be
used on board an aircraft.
Some child restraint devices made in the United States
are also accepted on board aircraft if they meet certain
criteria. However, it is important to note that child
restraint systems made in the United States are not
approved for use in Canadian automobiles. In either case,
it is important to double-check that the proper label is
affixed to the child restraint system.
Your health is very important and small gestures or
changes in habits can make your trip much more enjoyable.
Did you know that alcohol, tea and coffee are diuretic
beverages that actually have a dehydrating effect on you?
The air circulating in an aircraft is very dry. It is therefore
vital that you drink plenty of water or juice. Also, as a
passenger, you are much more sedentary than you would
be if you were working as a flight attendant. It is therefore
important that you try to exercise a bit on the plane,
especially during long flights. This also applies to the flight
crew members working in the cockpit. You can easily do
exercises in your seat without having to get up and move
around. Simple movements like rotating your ankles, head
and shoulders will improve your circulation and prevent
problems such as deep vein thrombosis (DVT).
Listed below are several links where you will find detailed
information on the topics discussed above, which might
prove very useful for your next trip. Have a good flight!
Transport Canada’s Cabin Safety Standards Web site:
www.tc.gc.ca/CivilAviation/commerce/CabinSafety/menu.htm
Passenger T.I.P.S. (Travelling In Planes Safely) and FAQ:
www.tc.gc.ca/CivilAviation/commerce/CabinSafety/tips/menu.
htm#tips
ASL 3/2008
9
Flight Operations
Flight Operations
Travelling with young children can present additional
challenges. Although restraint systems are not mandatory
for children under two, and infants may be held in an
adult’s arms, it is strongly recommended that you use an
approved child restraint system on board an aircraft. These
devices are much safer than simply holding the child in
your arms. It is recommended that child restraint systems
be used upon takeoff and landing, whenever turbulence is
encountered, and whenever the “fasten seatbelts” light is
turned on.
Indeed, if any of these behaviours are observed on an
aircraft, the flight crew may decide to divert the aircraft,
if deemed necessary, and the person(s) involved may be
arrested, detained and tried when the aircraft lands, or
once they have returned to their point of origin. A new
regulation on unruly passengers and interference with a
crew member was published in May 2007 in the Canada
Gazette, Part I.
Pre-flight
Pre-flight
Travelling with children
To the Letter
To the Letter
Pre-boarding security screening goes smoothly for educated
and prepared passengers.
All passengers and crew members have the right to fly
in a safe and secure environment. Disorderly conduct
such as harassment, intimidation, verbal or physical
abuse, refusal to comply with flight crew instructions,
and consumption of personal alcoholic beverages, are all
examples of behaviour that is not tolerated on an aircraft.
Passengers displaying such behaviour are liable to a fine
or imprisonment under the Criminal Code of Canada and
the Aeronautics Act.
Tips for Travellers—Air:
Permitted and Non-Permitted Items:
Canadian Transportation Agency (CTA):
Flying with children links:
www.catsa.ca/english/travel_voyage/list.shtml
www.cta.gc.ca/air-aerien/index_e.html
www.tc.gc.ca/CivilAviation/commerce/circulars/AC0177.htm;
www.kidsflysafe.com
Canadian Air Transport Security Authority (CATSA)
www.catsa-acsta.gc.ca/english/
Info on dangerous goods in carry-on or checked baggage:
www.tc.gc.ca/CivilAviation/commerce/DangerousGoods/
RegOverview/PassLugg/menu.htm
New regulations on unruly passengers and interference
with crew members:
Guest Editorial
Guest Editorial
www.tc.gc.ca/aboutus/travel/travellerinfo.htm#air
http://canadagazette.gc.ca/partI/2007/20070519/html/regle2-e.html;
www.tc.gc.ca/mediaroom/releases/nat/2002/02_gc001e.htm
Aviation Document Booklet
It’s here!
Transport Canada Civil Aviation is proud to present
the new Aviation Document Booklet for all holders of
Canadian air traffic controller licences and flight crew
licences and permits.
The new Aviation Document Booklet will now
incorporate a photograph of the holder, machine-readable
security features and the International Civil Aviation
Organization’s (ICAO) language proficiency requirement.
During the life of the booklet, the status of individual
licences, permits, ratings and medical certificates is likely
to change. Adhesive labels, similar to the stickers provided
by many provinces for motor vehicle licence plate
renewals, will be provided to reflect changes in licensing
status. These labels must be affixed to the booklet in order
for the licence or permit to be valid.
Transport Canada has begun replacing existing licences and
permits with the new Aviation Document Booklet. The
first documents to be replaced are those with the greatest
potential for international use. Transport Canada has already
started issuing new booklets to holders of airline transport
pilot licences (ATPL) and commercial pilot licences (CPL)
who have submitted the required application.
Eventually, all holders of Canadian air traffic controller
licences and flight crew licences and permits will receive
the Aviation Document Booklet. Transport Canada
licensing offices will continue to administer all licensing
action for flight crew and air traffic controllers.
10
Replacement of existing licences and permits in the
current format will be phased in over a three-year
period. A schedule for replacing existing documents
with the new Aviation Document Booklet can be found
in Advisory Circular (AC) 400-001, which is available
on the Transport Canada Flight Crew Licensing Web site
listed below.
Replacement of ATPLs and CPLs with the Aviation
Document Booklet format will be completed by
early 2009. Private pilot, air traffic controller, and flight
engineer licences will be replaced through 2009. The
remaining pilot licences (glider and balloon) and all
permits will be replaced by the end of 2010.
Please visit the Transport Canada Flight Crew Licensing
Web site for more information:
www.tc.gc.ca/civilaviation/general/personnel/changes.htm.
ASL 3/2008
Flight Operations
Flight Operations
Moving towards the new booklet
All new applicants for licences and permits will be issued an
Aviation Document Booklet.
Pre-flight
Pre-flight
This is a follow-up to the article “Transport Canada Update—Personnel Licence Booklet,” published in Aviation Safety
Letter (ASL) 1/2007.
To the Letter
To the Letter
by the Flight Crew Licensing Division, General Aviation, Civil Aviation, Transport Canada
Houston, Transport Canada Is on the Line…
Transport Canada has been involved in the space program
since 1995, when NASA formally requested the use of
selected airports along the Canadian east coast in the event
of an aborted shuttle launch, because the shuttle’s trajectory
runs along the east coast of Canada. Today, because of their
strategic locations and available facilities, Gander, N.L.,
St. John’s, N.L., Stephenville, N.L., Goose Bay, N.L.,
Halifax, N.S., and, on occasion, Greenwood, N.S., airports
are the designated sites. Additionally, the Halifax joint
rescue co-ordination centre ( JRCC) provides search and
rescue capability in the event the astronauts have to bail out
over the Atlantic Ocean. Transport Canada, in conjunction
with NASA, the Canadian Department of National
Defence (DND) and NAV CANADA, has developed and
tested the procedures that would be used if a shuttle was
forced to land at one of these sites.
In total, recovery operations would take some
400 NASA personnel up to 40 days—requiring
approximately 19 flights utilizing C5 and C17
aircraft. Finally, the shuttle would be loaded onto
NASA’s Boeing 747 and flown back to KSC in Florida.
The airport authorities are keenly aware of the important
role they play in providing support to the NASA
program, and have developed contingency plans for
an ECAL. Recently, representatives from NASA and
Transport Canada visited each Canadian site, provided
an updated technical briefing on shuttle hazards for their
emergency response and management personnel, and
presented them with a commemorative montage, which
included a Canadian flag that was previously flown in
space. During the presentation, Marty Linde, Landing
Support Officer, JSC, indicated the montage was a
ASL 3/2008
11
Flight Operations
CACO acts as the Canadian co-ordination facility during
a launch. Two hours prior to lift-off, using pre-determined
criteria, CACO officers begin their detailed operational
assessment on the suitability of each of the designated
Canadian landing sites, and report their status to
NASA. CACO initiates a communication link with the
designated airports, NAV CANADA, Halifax JRCC, the
Canadian Space Agency and the Government Operations
Centre. Live communication is then established with
mission control at the Johnson Space Centre ( JSC) in
Houston, Tex., approximately 30 min before lift-off, and
remains operational until the window for an east coast
abort landing (ECAL) has passed.
To the Letter
Within 8 to 10 hr of an emergency landing, NASA would
deploy their rapid response team from the Kennedy Space
Centre (KSC) and their crew recovery team from the JSC
to begin recovery operations. In addition to the safing and
reconfiguration of the shuttle for transportation back to
the KSC in Florida, the extensive recovery process involves
diplomatic co-ordination and co-operation between
various Canadian and U.S. government departments and
agencies, as well as the airport and local community.
Pre-flight
Pre-flight
Apart from the highly acclaimed “Canadarm,” Canadian
astronauts participate in various shuttle missions; but
Canada also participates in another important role:
providing a suitable, safe landing site in case of an
emergency. Personnel from Transport Canada’s Civil
Aviation Contingency Operations (CACO), a division
of the National Operations Branch in Ottawa, Ont.,
participate in all space shuttle launches to the International
Space Station, and remain on standby until the shuttle is
in orbit.
The window of exposure for an ECAL implicating the
Canadian east coast landing sites comes during an 80-s
timeframe, approximately 6 to 8 min after takeoff. Should
a problem develop, a quick decision would have to be
made to select the most suitable airport, based on weather
and operational conditions. If the shuttle were unable to
land at one of the airports, the crew would have to bail
out into the Atlantic Ocean, triggering a rescue response
from Halifax JRCC.
To the Letter
Flight Operations
The National Aeronautics and Space
Administration (NASA) began flying its current space
shuttles in April 1981. Having flown only 120 times, some
would still consider the orbiter to be an experimental
vehicle. Safety is of paramount concern to those involved
in the space program, where every item is checked with
painstaking care to ensure the success of each mission.
Procedures and backups are put in place to help the crew
and give them options in the event of an emergency.
Guest Editorial
Guest Editorial
by Denis Brunelle and Sarah Jardine, Civil Aviation Contingency Operations, National Operations, Civil Aviation, Transport Canada
To the Letter
Keith Collins, President and CEO of the St. John’s International
Airport (centre), having received a commemorative montage
from Dennis Gagen, Director Ground Operations, Kennedy
Space Centre (left) and Marty Linde, Landing Support Officer,
Johnson Space Centre (right).
To the Letter
Guest Editorial
Guest Editorial
small token of appreciation from everyone at NASA,
in particular the astronauts, who felt more comfortable
knowing that should a problem occur they have options to
land in Canada rather than having to bail out.
By the end of 2007, Transport Canada and the Canadian
airports had supported 33 launches. The shuttle program
is scheduled to end in 2010. Until that time, CACO
will continue to play a role in each launch, as part of the
international effort to explore space—an extraordinary
achievement that, due to all the activity behind the scenes,
almost seems routine.
General Aviation On-Line Services
If you already have an epass account for other government
services, simply sign in to that account and you will be
re-directed to the General Aviation On-Line Services
site. If you do not have an epass account, you will be
directed to the epass page where you can obtain an epass
user ID and password. Epass will then re-direct you to the
General Aviation On-Line Services site.
When you enter the General Aviation site for the first
time, you must submit a new user request to obtain an
activation key that will allow access to your records. This
activation key will be mailed to you at the address on file
with Transport Canada. Once you receive your activation
key, you can sign-in, enter the activation key and access
your records.
Registered aircraft owners will be able to:
• view marks, registrations, and leasing activities;
• reserve registration marks;
• renew a mark reservation;
• submit a notification of a change of ownership;
• change their address; and
• submit a Leasing Advisory (LF-5).
Holders of flight crew licences and permits will be able to:
• view flight crew licensing information
(including the status of their new language
proficiency assessment);
• change their address; and
• access licensing application forms.
Flight Operations
Fatigue Risk Management System Toolbox!
Take a few minutes to explore the Fatigue Risk Management System (FRMS) toolbox for Canadian aviation at:
www.tc.gc.ca/civilaviation/SMS/frms/menu.htm.
ASL 3/2008
Flight Operations
New!
Nouveau!
12
Pre-flight
Pre-flight
The General Aviation Branch now offers a variety of
services on-line. To access the General Aviation On-Line
Services site, you must have a Government of Canada
epass account. Click on www.tc.gc.ca/GeneralAviationServices ,
and it will direct you to the epass sign-in page.
To the Letter
by Mike Paddon, Civil Aviation Safety Inspector, System Safety, Atlantic Region, Civil Aviation,Transport Canada
A search of the aviation investigation reports published
by the Transportation Safety Board of Canada (TSB)
indicates that there have been several instances of in-flight
collision and risk of collision in Canada in recent years.
The consequence of aircraft occupying the same location
in time and space rarely yields results that are less than
tragic. Many in the aviation community may harbour vivid
recollections of close encounters with other aircraft in
otherwise unremarkable or outright benign circumstances.
The range of potential scenarios is extensive and, on
occasion, the occurrence venue is airspace in close
proximity to uncontrolled aerodromes. There are
recorded instances of aircraft departing from or arriving
at uncontrolled aerodromes under VFR, or under
IFR in visual meteorological conditions (VMC), and
unexpectedly finding themselves in close quarters with
other traffic. Aircraft in the VFR traffic circuit have
been known to conflict with one another even when
operating with the benefit of air traffic services (ATS).
Fixed-wing and rotary-wing traffic operating in relatively
remote settings have historically found themselves in
close quarters, both in the field and at nearby community
aerodromes typically served by aerodrome traffic
frequency (ATF) communication procedures. Examples
of periods of heightened activity in terms of traffic volume
would include major forest fire fighting efforts and the
initial stages of natural resource development projects.
The predominant failing that arises in the vast majority of
in-flight collisions is the failure to see and be seen as well
as hear and be heard (i.e. avoid). So, what can be done to
alleviate or mitigate the risk of collision? Does the answer
lie in maintaining vigilance in our visual scanning, being
alert to rapid and unacceptable loss of separation, and
reacting well in advance of a deteriorating traffic situation;
or in adherence to established regulations and procedures
and communicating with other aircraft that we share
airspace with? The answer likely rests in a combination of
each of these defences.
Maintaining vigilance in our visual scanning is critical
to the see and be seen (or see and avoid) concept.
In an unrelated but pertinent study conducted by the
Lincoln Laboratory2 during traffic alert and collision
avoidance system (TCAS) flight testing, data showed
that a pilot alerted to the presence of other aircraft
visually acquired the other aircraft in 57 of 66 cases; the
median range of visual acquisition was 1.7 NM. In cases
where the pilot was not alerted to the presence of the
other aircraft, visual acquisition of the other aircraft was
achieved in only 36 of 64 encounters. In the successful
ASL 3/2008
Flight Operations
In general, pilots will agree that visually detecting other
aircraft can sometimes be very difficult. Most cockpits
present challenges to effective visual scanning and the
ability to search for and detect other aircraft. Impediments
to the process include vision-obstructing struts, posts,
doorframes, glareshields, and perhaps a fellow pilot
or passenger. In addition, dirty, fogged, scratched and
bug-splattered windshields, as well as flight in reduced
visibility due to weather, or other obscuring phenomena
such as smoke, can further complicate the task, as can
vibration, fatigue and workload. Increased attention to
cockpit automation and instrumentation can take away
from time spent scanning the surrounding airspace for
threats to safe separation. Accessibility of sunglasses to
combat glare and choice of headgear are also part of the
equation. A peaked ball cap may shade the eyes, but it
might also restrict peripheral vision in the vertical plane;
a factor of particular relevance when operating aircraft
that, by virtue of cockpit design, would otherwise provide
for enhanced peripheral vision in the vertical axis. Even
detection of aircraft in a clear sky can be hindered by
what is known as “empty-field myopia.” Shari Stamford
Krause, PhD1, herself a pilot, describes this as a condition
whereby, in the absence of a visual stimulus (for example,
empty space), the muscles in the eye relax, preventing the
eye from focusing. This creates a problem for a pilot who
is attempting to scan for traffic in a clear, featureless sky.
Because the eye cannot focus on empty space, it remains
in a state of unfocused, or blurred, vision.
Pre-flight
Pre-flight
See, Hear, Comply and Avoid—Maintaining Separation at Uncontrolled Aerodromes
To the Letter
Flight Operations
See, Hear, Comply and Avoid—Maintaining Separation at Uncontrolled Aerodromes.............................................. page 13
Back to Basics: Weight and Balance................................................................................................................................. page 16
Guest Editorial
Guest Editorial
flight operations
13
Guest Editorial
To the Letter
Pre-flight
An MF area will be established at
an aerodrome if the traffic volume
and mix of aircraft traffic at that
aerodrome is such that there would
be a safety benefit derived from
implementing MF procedures.
There may or may not be a ground
station in operation at the aerodrome
for which the MF area has been
established. When a ground station
is in operation, for example, an FSS
[flight service station], an RCO
[remote communications outlet]
through which RAAS [remote
aerodrome advisory service] is
provided, a CARS [community
aerodrome radio station], or an approach UNICOM, then all
aircraft reports that are required for operating within, and
prior to entering an MF area, shall be directed to the ground
station. However, when the ground station is not in operation,
then all aircraft reports that are required for operating within
and prior to entering an MF area shall be broadcast. The MF
will normally be the frequency of the ground station which
provides the air traffic advisory services for the aerodrome….
“A pilot alerted
to the presence of
other aircraft visually
acquired the other
aircraft in 57 of
66 cases.”
Any area of land, water (including the frozen surface thereof )
or other supporting surface used, designed, prepared, equipped
or set apart for use either in whole or in part for the arrival,
departure, movement or servicing of aircraft and includes any
buildings, installations and equipment situated thereon or
associated therewith.
CAR 602.19(10) states that:
No person shall conduct or attempt to conduct a take-off
or landing in an aircraft until there is no apparent risk of
collision with any aircraft, person, vessel, vehicle or structure
in the take-off or landing path.
The following extract is taken from the RAC section of
the TC AIM and is summarized for easy reference in the
General section of the Canada Flight Supplement (CFS)
under the Communications (COMM) sub-section.
Note: Although lengthy in content, it is considered to
be in the interests of aviation safety to reproduce the
pertinent references.
14
An [ATF] is normally designated for active uncontrolled
aerodromes that do not meet the criteria listed in RAC 4.5.4
for an MF. The ATF is established to ensure that all radioequipped aircraft operating on the ground or within the area
are listening on a common frequency and following common
reporting procedures. The ATF will normally be the frequency
of the UNICOM where one exists or 123.2 MHz where a
UNICOM does not exist….The designation of an ATF is not
limited to aerodromes only. An ATF may also be designated
for use in certain areas other than the area immediately
surrounding an aerodrome, where VFR traffic activity is
high, and there is a safety benefit to ensuring that all traffic
monitor the same frequency. For example, an ATF area could
be established along a frequently flown corridor between two
uncontrolled aerodromes....
ASL 3/2008
Flight Operations
Flight Operations
Mandatory frequency (MF) vs. aerodrome traffic
frequency (ATF)…What’s the difference?
4.5.5 Aerodrome Traffic Frequency
Pre-flight
As pilots, we have a responsibility
to read and know the Canadian
Aviation Regulations (CARs).
Procedures in place for effectively
maintaining separation around
uncontrolled aerodromes can be
found in the Transport Canada
Aeronautical Information Manual
(TC AIM). This publication is
available in print and on-line
at: www.tc.gc.ca/CivilAviation/
publications/tp14371/menu.htm.
The published procedures are, in
fact, regulations and adherence
is required. Traffic that complies
with the prescribed procedures will
have the expectation that other aircraft are acting in a
similar manner. It should be noted that the Aeronautics Act
defines an aerodrome as:
Transport Canada has designated [an MF] for use at selected
uncontrolled aerodromes, or aerodromes that are uncontrolled
between certain hours. Aircraft operating within the area in
which the MF is applicable (MF area), on the ground or in
the air, shall be equipped with a functioning radio capable
of maintaining two-way communication. Reporting
procedures shall be followed, as specified in CARs 602.97 to
602.103 inclusive.
To the Letter
4.5.4 Mandatory Frequency
Guest Editorial
encounters, the median acquisition range dropped to
0.99 NM. These studies showed that verbal guidance as to
where to look increased the acquisition probability for the
pilots, and found that a pilot who had been alerted to the
presence of another aircraft was eight times more likely to
see the aircraft than the pilot who had not been alerted.
The test aircraft involved in the study were light twinengine aeroplanes. Radio advisory calls, TCAS, if fitted,
and strobe/landing lights are all means of communicating
an aircraft’s position to other traffic.
(vi) Flying Through an MF Area (CAR 602.103)
(a) Radio-equipped Aircraft: The following reporting
procedures shall be followed by the pilot-in-command of radioequipped aircraft at uncontrolled aerodromes within an MF
area and should also be followed by the pilot-in-command at
aerodromes with an ATF:
(A) Report before entering the MF or ATF area and,
where circumstances permit, shall do so at least five
minutes before entering the area, giving the aircraft’s
position and altitude and the pilot-in-command’s
intentions; and,
(B) Report when clear of the MF or ATF area.
(i) Listening Watch and Local Flying [CAR 602.97(2)]
Maintain a listening watch on the mandatory frequency
specified for use in the MF area. This should apply to ATF
areas as well.
NOTE: In the interest of minimizing possible conflict
with local traffic and minimizing radio congestion
on the MF or ATF, pilots of en-route VFR aircraft
should avoid passing through MF or ATF areas.
(ii) Before Entering Manoeuvring Area (CAR 602.99)
Report the pilot-in-command’s intentions before entering
the manoeuvring area.
(b) NORDO: NORDO [no radio] aircraft will only be
included as traffic to other aircraft and ground traffic as follows:
(iv) Arrival (CAR 602.101)
(A) Report before entering the MF area and, where
circumstances permit, shall do so at least five minutes
before entering the area, giving the aircraft’s position,
altitude and estimated time of landing and the pilotin-command’s arrival procedure intentions;
(B) Report when joining the aerodrome traffic circuit,
giving the aircraft’s position in the circuit;
(C) Report when on downwind leg, if applicable;
(D) Report when on final approach; and,
(E) Report when clear of the surface on which the
aircraft has landed.
(v) Continuous Circuits (CAR 602.102)
(A) Report when joining the downwind leg
of the circuit;
(B) Report when on final approach; stating the pilotin-command’s intentions; and,
(C) Report when clear of the surface on which the
aircraft has landed.
Carrying and referring to updated charts and a current
copy of the CFS will help to ensure that correct
frequencies for flight in the vicinity of uncontrolled
aerodromes are selected on the aircraft radio. Relying on
memory to recall MFs and ATFs for specific uncontrolled
aerodromes can be problematic, especially at times
of increased workload, and in light of the fact that
frequencies may be subject to change. Global positioning
system (GPS) data cards can provide a great deal of
information at the push of a button, but that information
can be a contributing factor to disaster if it is not accurate,
hence the need for a current data card.
In conclusion, it is perhaps realistic to note that
operational and self-imposed pressures to meet timelines
and objectives can sometimes influence and cloud
our perception of the airspace environment around
us and how we fit into it. Risk factors associated with
flight in the vicinity of uncontrolled aerodromes can
be greatly reduced with the application of acute visual
and aural awareness combined with familiarity with,
and adherence to, the established rules and procedures.
Used in conjunction with timely position reports and
the communication of intentions between aircraft, these
defences build and reinforce situational awareness and,
ultimately, serve to assist aircraft in their avoidance of
one another.
References:
1. Shari Stamford Krause, PhD, Flight Safety Digest,
May 1997.
2. J.W. Andrews, “Modeling of Air-to-Air Visual
Acquisition,” The Lincoln Laboratory Journal,
Volume 2, Number 3, 1989, p.478.
ASL 3/2008
15
Flight Operations
Flight Operations
(A) Before moving onto the take-off surface, report
the pilot-in-command’s departure intentions on the
MF or ATF frequency. If a delay is encountered,
broadcast intentions and expected length of delay,
then rebroadcast departure intentions prior to
moving onto the take-off surface;
(B) Before takeoff, ascertain by radio on the MF or
ATF frequency and by visual observation that there
is no likelihood of collision with another aircraft or a
vehicle during takeoff; and,
(C) After takeoff, report departing from the aerodrome
traffic circuit, and maintain a listening watch on the
MF or ATF frequency until clear of the area.
Pre-flight
Pre-flight
To the Letter
(iii) Departure (CAR 602.100)
To the Letter
(i) Arrival: from five minutes before the ETA [estimated
time of arrival] until ten minutes after the ETA, and
(ii) Departure: from just prior to the aircraft departing
until ten minutes after the departure, or until the aircraft
is observed/reported clear of the MF area.
Guest Editorial
Guest Editorial
4.5.7 VFR Communication Procedures at Uncontrolled
Aerodromes with MF and ATF Areas
Back to Basics: Weight and Balance
To the Letter
While it may be covered under that ubiquitous
[U.S. Federal Aviation Regulation (FAR)] concerning
doing everything to make sure the flight can be conducted
safely, it’s safe to conclude that weight and balance is
one of the most overlooked aspects of flying. There are
some who might pay more attention to it than others.
I understand that pilots of V-Tail Doctor Killers had
better pay attention. I’ve also read that pilots of 182s and
Cherokee-Sixes don’t need to be as concerned. But let’s
face it. You can load any airplane wrong and it will crash.
Seems like the pilots of a 707 learned that in Miami, Fla.,
a few years ago.
One of the problems with doing a weight and balance
is that the things are so complicated. Moment and arm
and datum. What is all this stuff? If somebody would just
simplify the process. You say something like, “If Bubba is
the pilot, and he weights 250, and Charlie is in the right
seat, and he weighs 220, and if Martha and Myrtle are in
the back seat, and they weigh 375 together, and you have
100 pounds of luggage, and you try to fly that bugger, you
better make sure your will is current, because you’re about to
use it.” That language I can understand. It makes much more
of an impact than all those charts and graphs and lines.
With all the computer technology that’s out there, you’d
think that at least the manufacturers of new airplanes
would come up with an automated system. They could put
an electronic scale in each seat. Same with the luggage.
Fuel sensors detect how much fuel is on board and where.
Everything is calculated by a computer, which plays
“Lord, I’m Coming Home” if the airplane won’t fly. That
should get people’s attention.
It’s probably a good thing that I took my check ride with
old Earl Sharp in a Cessna 150. It’s good because Earl
wasn’t too strict anyway, and it’s also good because there’s
not a lot of [CG] questions you can ask about weight and
balance on a 150. Seems to me like he asked something
about whether or not I had checked the weight, but at
If you get the feeling that your aircraft is near or above its weight and balance limits, you are probably right.
16
ASL 3/2008
Flight Operations
Shortly after Dr. Tim Williams became a partner in our
Bellanca, he called me and said, “I’ve been doing a weight
and balance on this plane, and it appears that if you have
four people on board and full fuel, you’ll be beyond the aft
[centre of gravity (CG)]. Is that right?” “Beats me,” I told
him, “I’ve never done
one. What I do know
is that I’ve had four
big folks on board
with full fuel and
it flew.” And it did.
I’ve done it several
times with no clue
as to what the charts
would show. I don’t
think we were too
far off, but I didn’t
know for sure on
the [CG]. Addition
and subtraction are
easy enough, so I
was pretty sure on
the weight, but balance? That’s another matter. The guy
we bought the plane from told me it would be ok, and
I believed him.
Pre-flight
Pre-flight
It’s confession time. Let’s see the hands of everyone
who will not leave the ground without doing a proper
weight and balance. About one in 20? That’s about what
I thought. Now, let’s see the hands of everyone who has
ever seen another pilot perform a weight and balance
before the flight. Let’s see. One out of 300. That’s about
right. Now, let’s see the hands of all those who would be
dead if someone put a gun to their head and said they
were going to shoot them if they couldn’t show them the
proper way to do a weight and balance. About four out of
five of you should admit to that one.
To the Letter
Flight Operations
This article is an authorized reprint from the November/December 2001 issue of Southwest Aviator Magazine. This and many
other excellent safety articles can be found on their Web site at www.swaviator.com.
Guest Editorial
Guest Editorial
by Jay Wischkaemper
There are a couple rules of flying etiquette that need to
be mentioned here. Rule number one is that when daddy
is the pilot, you always get to ride shotgun. Rule number
two is that you never ask a big woman to do anything that
would reveal that you noticed how big she is, at least not
if you value your health.
I pushed forward on the yoke, and the nose came down and
stayed down. Everything was still under control, and the
closer we got to home, the more normal the trim became.
I had flown the plane before with four big people on
board, but never with two little people and two big people.
My assumption that everything would be the same wasn’t
true. Everything turned out ok, but it could have been a
recipe for disaster.
So, have I started doing a weight and balance before every
takeoff? Of course not. Most of the time, I’m the only
person on board, and it hardly seems necessary. Even with
two on board, I’m not sure I would learn a lot. But the
next time I have four on board? Well, I might be more
prone to dusting off that old book and seeing if I can
figure out some of those graphs.
“Did you know?” The arrival of civil aircraft flying VFR from the United States without search and rescue (SAR)
being activated is a concern. Differences between Canada and the United States can lead pilots to believe their flight
plans have been opened. These differences are highlighted in the article “Flight Planning Issues,” published in
Aviation Safety Letter (ASL) 2/2007. One of the differences discussed in the article is that after filing a flight plan
in the United States, you need to activate it with an American flight service station (AFSS). The article can be found
on-line, at www.tc.gc.ca/CivilAviation/publications/tp185/2-07/Operations.htm#Flight…it’s worth reading!
ASL 3/2008
17
Flight Operations
Guest Editorial
To the Letter
Flight Operations
Since it was a Sunday, I knew that the probability of
fuel being available in a town like Clifton was iffy at
best. Even if it hadn’t been a Sunday, it would have been
iffy. Accordingly, I topped off every tank before I left. I
climbed out on the left, burned the 15-gal. [auxiliary]
tank for one hour, which should have almost burned it
dry, and landed on the right.
Liftoff was smooth and the plane flew normally. I had
told myself that if anything at all didn’t feel right, I was
setting it back down, but everything was fine. The climb
was slow due to the load and the 90°F temperature, but
otherwise normal. The fun began when I started to trim
the nose down to level off. The trim tab, which is on the
top of the cabin in a Bellanca, stopped turning after a
couple of turns. My immediate thought was that the
trim mechanism had jammed, but when I looked up at
the ceiling, I noticed the problem was something quite
different. The trim tab was at its full nose down stop. There
was nothing wrong with the trim. I had just run out of it.
Pre-flight
Pre-flight
That’s not to say that I’ve never had [CG] concerns.
About a year ago, my daughter and two of her friends
went on a “road trip” to Waco, Tex. On the way back, in
the little town of Clifton, Tex., a little old lady on her
way to church ran a stop sign and hit them. Nobody was
hurt, but that car wasn’t driving home. Clifton is about
six hours from Lubbock, Tex., so for someone to drive to
get them would have been a long adventure. The obvious
solution was for me to fly down.
Having flown the plane with weight in the back before,
I was expecting the plane to fly differently. I had a little
extra nose down trim cranked in. The pull on the yoke to
make it fly would be a lot less. I was ready.
To the Letter
Now don’t get me wrong. I have done a weight and balance.
About a year and a half ago, Robin, John and I were going
to Houston, Tex. Robin was kind of short on experience and
confidence in the plane, so he invited along some company.
Robin was flying, because he was paying for the gas, or
rather one of his clients was. John was riding front seat to
keep us all safe from Robin, and I was relegated to the back.
Sitting there, I noticed the operations manual in the seat
back in front of me, and since it had been a while since I
had perused it in detail, I decided to do so. I came across
the section on weight and balance, and decided to try to
do one. Pulling out my trusty pocket calculator, I plugged
in the numbers, only to find out that when we took off, we
were 100 pounds over gross, and a couple of inches past the
aft [CG], assuming I knew what I was doing, which might
be questionable. I didn’t bother Robin with my newfound
knowledge. It would have just depressed him.
There are times in life when you can’t win. You see, Susan
is a big girl. She’s not fat. She’s just big. Put another
30 pounds on her and she can play middle linebacker. I
had this gut feeling that Susan should be up front with
me, but she dutifully climbed in the back where any
passenger who isn’t related to the pilot is supposed to
be. Trying to justify taking off with her there, I reasoned
that Lisa and Sara were about the same weight, and that
hopefully I weighed about the same as Susan, or at least
close. That should balance, I thought. The [auxiliary] tank,
which sits under the rear seat, was empty. They hadn’t
taken a lot of luggage with them. We should be ok.
Guest Editorial
least the question about how much weight we could
put in the back seat was moot, and he didn’t ask about
luggage. Gratefully, he also didn’t ask me to do a weight
and balance problem for him. If he had, I’d probably still
be a student pilot.
Maintenance and Certification
Recently Released TSB Reports
by Brian Whitehead, Chief, Policy Development, Standards, Civil Aviation, Transport Canada
On December 1, 2007, the new Canadian Aviation
Regulations (CAR) 561 came into effect. This is a major
milestone in the introduction of the CARs and one of the
final stages in the replacement of the old Airworthiness
Manual with the new CARs. The new requirements are
very similar to those of the earlier Airworthiness Manual
but, being regulations, they are more formal in structure,
and unlike the Airworthiness Manual, are directly
enforceable. Many of the sections have been identified
as designated provisions, with maximum penalties
established for both individuals and corporations.
Along with the introduction of CAR 561 itself, there
was an associated standard (STD 561) and changes in
Part I of the CARs to enable the application of safety
management systems (SMS) to manufacturers. Changes
to the definitions of “maintenance” and “manufacture”
should eliminate any conflict between the application
of CARs 561 and 571. Essentially, CAR 561 will apply
to any work performed on an aircraft prior to the
first issuance of a standard certificate of airworthiness
or export airworthiness certificate. Following the
issuance of either of those certificates, CAR 571 will
apply. For example, the making of a repair part under
CAR 571.06(4) will be exempt from any of the provisions
of CAR 561.
The new regulations follow the same general format as the
approved maintenance organization (AMO) requirements
of CAR 573. They provide for separate production control
and quality audit systems, and include requirements for
18
The regulations specify a manufacturer’s responsibility
for the control of suppliers, and make a clear distinction
between the oversight of suppliers who are approved
in their own right, and suppliers who work under the
umbrella of the prime manufacturer. This should facilitate
the control of “direct delivery”, which may only be
authorized in conjunction with a release certificate.
Manufacturer facilities may be located in a foreign
state, subject to the agreement of the foreign authority,
but the applicant must undertake the responsibility to
allow Transport Canada inspectors access to the foreign
facilities, and pay for the expenses incurred.
The manufacturer’s means of compliance with the various
requirements must be set out in a manual that is signed by
the accountable executive and approved by the Minister.
Unlike the introduction of some previous CARs, such as
those relating to air operators and AMOs, there will be no
grace period enabled by exemption. When earlier chapters
were incorporated into the CARs, the new requirements
were published as soon as they were available, and a
general exemption was issued to enable certificate holders
to transition to full compliance over a period of time, in
accordance with a predetermined implementation program.
In this instance, the process has been reversed. Existing
approval holders were notified of the new requirements
some two years in advance of the effective date, and they
must be in full compliance with them on that date.
With the introduction of CAR 561, the implementation
of airworthiness-related CARs is almost complete. The
final major piece of the puzzle will be CAR 563, applying
to distributors of aeronautical products. That chapter is
expected to be incorporated into the CARs later in 2008.
ASL 3/2008
Regulations and You
The privilege of a manufacturer certificate is not actually
to manufacture aeronautical products—anyone may do
that—but rather, to authorize the issuance of a statement
of conformity attesting that the products conform to
approved data, and are in condition for safe operation.
CAR 571, in turn, prohibits the installation of parts (other
than commercial or standard parts, and parts made during
the course of a repair) unless they have been certified
with such a statement. The statement in question usually
takes the form of the familiar Authorized Release Certificate
(form 24-0078, soon to be retitled Form One). The repair
parts mentioned above may not be released on a Form One,
but instead are certified by means of the maintenance release
covering the repair for which they were created.
training and record keeping. Issuance of a manufacturer
certificate is directly tied to the applicable aeronautical
product type certificate. Applicants must either hold the
type certificate personally, or have entered into a licensing
agreement with the holder. A limited approval may be
granted if the type certificate has not yet been issued, or where
the licensing agreement is still being negotiated; however, in
such cases, the finished products may not be released until the
type certificate provisions have been fully met.
Accident Synopses
Accident Synopses
New Manufacturing Regulations
Recently Released TSB Reports
Regulations and You
New Manufacturing Regulations .................................................................................................................................... page 18
Icing in Fuel Injection System Distribution Manifolds.................................................................................................... page 19
Top-Level Inspections!....................................................................................................................................................... page 20
Issues with FDR and CVR Data Identified as a Result of TSB Reviews..................................................................... page 21
Heads Up! Airplane Design and Operations in Icing Conditions.................................................................................. page 23
Maintenance and Certification
maintenance and certification
Maintenance and Certification
Recently Released TSB Reports
An examination of the Lycoming I0-540-B1A5 engines
determined that there was a blockage in the fuel supply
to both engines. The left engine had a partial blockage
with no fuel supply to the forward cylinder nozzles;
the right engine had a complete blockage with no fuel
supply to any of the cylinder nozzles. The blockage was
determined to be within the fuel distributor valve(s)
because fuel pressure was present upstream of the valves.
The right engine fuel distributor valve was removed and
examined. There was ice found adhering to the internal
main metering well surface. Ice formed from super-cooled
water droplets was also found adhering to the servo bleed
screen, fully covering and blocking the return-to-tank
bleed orifice.
The aircraft had been stored in a heated hangar and
had been fully fuelled from a commercial fuel supplier,
approximately two months prior to the occurrence. The
fuel tanks and strainers were drained during the pre-flight
inspection and no visible water was noted. The aircraft
was operated without a fuel additive icing inhibiter.
Figure 2: Ice on main metering well
Figure 3: Super-cooled droplet ice-formation
on the servo bleed screen
Figure 4: Return-to-tank bleed orifice
(shown frozen and thawed for comparison)
ASL 3/2008
Regulations and You
Figure 1: Fuel distributor valve installation in the lower front
engine area
Accident Synopses
Accident Synopses
On November 30, 2007, an Aero Commander 500B
departed from Dryden, Ont., en route to Geraldton, Ont.,
with a crew of two and one passenger. Approximately
40 min after departure, the crew observed an abnormal
right engine fuel flow indication. Shortly thereafter, the
right engine’s RPM and fuel flow began to decrease. The
crew diverted towards Armstrong, Ont. A short time later,
the left engine RPM and fuel flow began to decrease and
the aircraft could no longer maintain level flight. The crew
made a forced landing into a marshy wooded area 20 NM
southwest of Armstrong. The captain sustained serious
injuries and the co-pilot and passenger sustained minor
injuries. The aircraft sustained substantial damage. The
investigation into this occurrence (TSB File A07C0225)
is ongoing.
Recently Released TSB Reports
Regulations and You
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)
Maintenance and Certification
Icing in Fuel Injection System Distribution Manifolds
19
Maintenance and Certification
Recently Released TSB Reports
1
The TSB is concerned about the possibility of aircraft
engine power loss at low ambient temperatures. Some
issues, such as the compatibility of the available fuel
icing inhibitors with various aircraft types, have not yet
been fully resolved. This investigation is still in progress
and findings as to causes and contributing factors have
yet to be determined by the Board. Nevertheless, the
investigation to date has shown that the freezing of
dissolved water, precipitated out of solution in fuel
injection system distribution manifolds and related areas,
can endanger life and property. Therefore, the aviation
community should be aware of the effect of ice in aircraft
engines’ fuel systems during winter operations.
Transport Canada may wish to remind operators of
the possibility of engine power loss due to icing in
fuel systems, and of the importance of following the
procedures and precautions contained within aircraft
and engine operating manuals for the prevention of fuel
system icing in cold weather environments.
Aviation Gasolines, a Candid Appraisal: a paper presented at the SAE Committee AE-5 Aerospace Fuel, Oil and Oxidizer Systems
Meeting No. 51 at Monterey, California, on October 31, 1979.
Recently Released TSB Reports
The precipitated moisture in the form of super-cooled
water droplets emerged from the pump and was carried
through the fuel injection metering unit to the fuel
distributor valve. A significant reduction in flow velocity
occurred at the bottom of the distributor valve plunger
well. This, combined with a reduced fuel distributor valve
surface temperature (due to the cooling air blast against the
forward face of the valve), promoted the formation of ice
crystals. These ice crystals continued to capture the supercooled water droplets until the ice build-up blocked the
forward fuel injection lines, causing a reduction in engine
power. In extreme cases, all the nozzle ports could become
blocked, causing a complete loss of engine power. Small
ice formations were also observed at the bottom and side
surfaces of the fuel distributor plunger (main metering)
well. When melted, the ice accumulation represented less
than two drops of water. This ice blockage phenomenon
was considered capable of affecting most fuel injection
systems in service at the time, and was eliminated in part
by the adoption of fuel additive icing inhibiters.
Maintenance and Certification
High-altitude testing of piston engines on pressurized
aircraft was carried out by a major aircraft manufacturer
during the early 1970s1. This testing found that numerous
partial and isolated total engine power losses were
experienced. The tests concluded that as an aircraft
climbed to the colder altitudes, dissolved water in the fuel
precipitated out of solution, due to agitation of the fuel as
it passed through the fuel pump and/or vapour separator.
Top-Level Inspections!
Having dealt with the first level of inspection (general
visual inspection [GVI]) and the second level (detailed
inspection [DET]) of an aircraft maintenance schedule
in earlier articles, we are now ready to look at the last and
highest level, namely the special detailed inspection, or
SDI. Since only a small percentage of the total number of
inspection tasks in an aircraft maintenance schedule fall
into the SDI category, and since these tasks are typically
performed long after the aircraft has entered service, SDIs
are not well known. Luckily, we have the Air Transport
Association of America (ATA) definition to help us out:
“An intensive examination of a specific item,
installation or assembly to detect damage, failure
or irregularity. The examination is likely to make
extensive use of specialized inspection techniques
and/ or equipment. Intricate cleaning and substantial
access or disassembly procedure [sic] may be required.”
If we compare the above definition to that of a detailed
inspection, we see that the first sentences are identical.
The word “intensive” clearly translates into “looking
20
for small irregularities.” The rest of the definition is
completely different. No mention is made of lighting
requirements. Instead, the emphasis is on “extensive use
of specialized inspection techniques and/or equipment,”
“intricate cleaning” and “substantial access or disassembly.”
Some of this terminology needs explaining.
Historically, the SDI label has been attached to
inspections that require the application of non-destructive
inspection (NDI) methods (penetrant, magnetic particle,
eddy current, ultrasonic and radiographic inspection). The
rationale was (and still is) that these methods are done in
accordance with specialized inspection techniques. In the
NDI world, the term “techniques” is used to describe the
procedure that must be followed to apply the inspection
method. Another rationale used was to “reserve” the
acronym SDI for any inspection task that required the
work to be done by an NDI-certified specialist.
On the surface, this logic seemed practical, given that
virtually all NDI inspection preparation includes cleaning
requirements and the use of specialized equipment
ASL 3/2008
Regulations and You
Regulations and You
This is the third and last of three articles on the topic of inspection levels.
Accident Synopses
Accident Synopses
by John Tasseron, Civil Aviation Safety Inspector, Aircraft Evaluation, Standards, Civil Aviation, Transport Canada
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
Issues with FDR and CVR Data Identified as a Result of TSB Reviews
by Dave White, Civil Aviation Safety Inspector, Aircraft Maintenance and Manufacturing, Prairie and Northern Region, Civil Aviation,
Transport Canada
Annual requirements to maintain cockpit voice
recorder (CVR) and flight data recorder (FDR) systems
are not being consistently and effectively applied.
Sometimes the previous intelligibility test (CVR) and
correlation check (FDR) results are not available from
the aircraft records. This lack of information is usually not
discovered during an annual review of company records
or during an aircraft import process. In all cases, data
available to the investigators from the black boxes at the
time of an accident or incident may not be as readable or
ultimately useful as it could be. To address this data issue,
let us look at these two very different—but related—black
box system annual inspection requirements.
CVR Issue: Transportation Safety Board of Canada (TSB)
investigations following accidents and incidents have revealed
discrepancies with available CVR recordings. These issues
are often related to the quality of the recording channels—an
element that could have been previously identified and
rectified through the annual inspection requirements.
Background
The purpose of the CVR intelligibility test is to ensure
“intelligible recorded audio information from all the
various input sources.” With this in mind, it is the aircraft
sources and their interconnection, as well as the black
box, that affect the intelligibility. Often, the discrepancies
are with the peripherals and the interconnection, as
opposed to the unit (black box) itself. Examples include:
poorly-positioned area microphones that are covered
in the actual day-to-day operations of the aircraft;
crossed microphone wires that will not noticeably affect
the microphone performance but will cause cancelling
on the CVR summing amp; and less-than-acceptable
performance of channels that does not get rectified even
after identification.
Since this inspection is not based solely on the CVR unit
itself, but rather the state of the recordings, it is important
to have a test procedure that addresses all areas of
the inspection:
(i) upon initial installation;
(ii) at every 3,000 hours, or 12 months, whichever
comes first.”
ASL 3/2008
•
•
•
an easy-to-follow descriptive checksheet;
a means of scheduling the test to ensure that
sufficient time is allowed to have the recording
verified before the next 12-month intelligibility
check is due;
a means of ensuring timely communications with
the readback facility to quickly identify issues
with the system;
21
Regulations and You
Canadian Aviation Regulations CARs Standard 625
Appendix C 15(d) states that:
“d) An intelligibility check shall be performed by
means of a test procedure which, when completed
under operational conditions, shall enable verification
of intelligible recorded audio information from all the
various input sources required by the regulations:
Accident Synopses
Regulations and You
It matters little what inspection level is assigned to the
task, as long as it is clearly spelled out what must be done.
If a borescope inspection is classified as an SDI or a DET,
and is then performed by a person who has no borescope
inspection training or special instructions, the level of
inspection performed may be no better than that of a
GVI. Incidentally, new initiatives are underway to apply
the latest borescope technologies to large-area (GVItype) inspections of inaccessible areas, such as the internal
surfaces of flight controls. Perhaps some new ideas, such
as a new inspection level with its own term and definition,
may appear (remote visual inspection, or RVI?). Again,
there will be room for argument, and it will be necessary
to ensure that whatever is chosen will be clearly explained.
In the meantime, the understanding of the currentlyused terms and definitions will have to be relied upon to
maintain consistency.
Recently Released TSB Reports
Currently, some newer inspection technologies also
appear to qualify for SDI status. These often fall outside
of the traditional NDI realm and do not require the use
of specially-certified personnel. The most prominent one
of these involves procedures that include the application
of borescope technology. Borescope inspection falls
somewhere between visual inspection with the naked
eye and inspection done with complex specialized test
equipment. In some cases, during the construction of
an aircraft maintenance schedule to ATA standards, the
working groups doing the maintenance analysis made
decisions to allocate the DET level to all borescope
inspection tasks, while in other cases, these tasks were
deemed to be SDIs. The logic supporting classification
to a DET included the fact that borescope inspections
usually concentrated on small areas; the logic supporting
an SDI classification came from the fact that special
procedures and training of specialists were required. The
discussion is still on-going.
Maintenance and Certification
as well. “Substantial access or disassembly” applies
occasionally, and could perhaps be replaced by “substantial
preparation” (aircraft jacking, de-fuelling, radiation safety
precautions, etc.).
Maintenance and Certification
•
a two-part process to ensure that issues identified during the playback of the recording, as well as issues with the
CVR unit, are addressed through the company defect rectification system;
a means to ensure that issues requiring rectification are addressed and an intelligibility test is completed to verify
that all parameters are recording as required at the end of the process.
FDR Issue: TSB investigations following accidents and incidents have revealed discrepancies with the FDR data
available. These issues are often related to missing or unreadable parameters of the FDR system that should have
been previously identified and rectified through the annual correlation check requirements. Sometimes the previous
correlation test results were not available or attained during the import process.
CARs Standard 625 Appendix C 17—FDR Maintenance Schedule states in part:
•
Background
The purpose of the FDR correlation check is to ensure “all
required parameters are being recorded and usable.” With
this in mind, it is the aircraft inputs, their interconnection
and the black box itself that affect the usability of the
data. Often, the discrepancies are with the peripherals and
the interconnections, as opposed to the unit (black box)
itself. Additionally, continued correlated positions and
data readout for known flight control position or other
input position must be ensured on FDR readings. For
example, position transmitters can be moved from their
previous null value during flight control maintenance.
Following the maintenance, the flight control continues
to operate normally; however, the associated position
readings are no longer accurate for previously recorded
data. There are some incidents of parameters not being
recorded at all due to various malfunctions. In extreme
cases, the annual correlation, which was needed to
determine the serviceability of the parameters, was not
being conducted at all. The purpose of this correlation
is to determine the observed relationship between the
annual readings and those taken at the time of installation
of the devices.
Since this inspection is not based solely on the FDR unit
itself, but rather the state of the inputs, it is important to
have a test procedure that addresses the following issues:
an easy-to-follow descriptive maintenance
procedure which includes a procedural checksheet;
•
•
•
Regulations are in place governing the requirement to
maintain CVR/FDR systems. This brief overview of
the purpose and means of conducting an “intelligibility”
test and a “correlation” check will hopefully prompt you,
as an operator or maintainer, to revisit your last CVR/
FDR results. If these results are not available or contain
discrepancies, such as unclear CVR channels or nonfunctioning FDR parameters, do your part to ensure
that black box systems meet the CARs requirements by
locating these results or redoing the test without delay. Also,
remember that when importing an aircraft, you must ensure
that the appropriate data was recorded and is available, and
that the systems meet the current requirements.
Regulations and You
Regulations and You
•
•
access to the tools required to complete the tasks
for the inputs;
access to the last correlation readout; an original
installation correlation report may be appropriate
here, but be aware—some changes may have
occurred since the installation;
access to the original installation readouts and
tolerances allowed;
a process to ensure that issues identified during
the reading of the download, as well as issues
with the FDR unit, are addressed through the
company defect rectification system;
a means to ensure that input issues requiring
rectification are addressed and a complete
correlation check is completed to ensure that all
parameters are recording prior to the required
12-month due date.
Accident Synopses
Accident Synopses
3,000 flight hours, or 12 months, whichever occurs first
Recently Released TSB Reports
Recently Released TSB Reports
Correlation check to ensure all required parameters are
being recorded and usable.
Maintenance and Certification
•
22
ASL 3/2008
Maintenance and Certification
Recently Released TSB Reports
When certifying an airplane for flight in icing conditions,
many design, flight performance and handling
characteristics need to be addressed, including those
that apply to the powerplant. The design standards in
Chapter 525 of the Airworthiness Manual (AWM)
include a definition of the atmospheric icing conditions
(in Appendix C1), which are defined by the variables of
the cloud liquid water content (LWC), the mean effective
diameter (MVD) of the cloud drops, and the ambient
air temperature (from 0°C to -40°C). The limits of
Appendix C include liquid water drops up to 50 microns
MVD in size and typically at altitudes of up to 22 000 ft.
In Chapter 533 of the AWM, additional design standards
are specified for engine certification to conditions such as
rain and hail.
In 1994, an accident involving an Aerospatiale
Model ATR-72 series aircraft, near Roselawn,
Indiana, resulted in significant icing-related safety
recommendations being issued by the U.S. National
Transportation Safety Board (NTSB). These
recommendations focused on the need to improve
airplane designs and operations for icing conditions.
The NTSB concluded that the ATR-72 accident
occurred in icing conditions that exceeded the icing
certification envelope. These conditions have been
commonly termed super-cooled large drops (SLD) and
may include freezing drizzle (100–500 microns MVD)
or freezing rain (above 500 microns MVD). The U.S.
Federal Aviation Administration (FAA) response to the
NTSB recommendations was to provide a mandate to
its Aviation Rulemaking Advisory Committee (ARAC)
to form a government and industry committee, the Ice
Protection Harmonization Working Group (IPHWG),
to examine airplane and engine design and operation
in an icing environment that includes SLD and mixed
phase/ice crystal conditions.
1
In support of the IPHWG mandate, the engine subgroup
of the government and industry committee, the Engine
Harmonization Working Group (EHWG), studied over
60 large transport airplane engine power loss events
that occurred between 1988 and 2005 due to engine
icing in ice crystal with mixed phase conditions. The
engines exhibited various symptoms, including vibrations,
flameout, rollback, surge and core blade damage. Over
two-thirds of the events occurred at altitudes between
22 000 and 39 000 ft. At these high altitudes, water is
most likely to exist in the form of frozen ice particles
or crystals rather than super-cooled liquid water drops.
In general, these engine events occurred near convective
clouds at ambient temperature warmer than the
International Standard Atmosphere (ISA) and outside
the current Appendix C of Chapter 525 of the AWM
certification envelope. These events affected multiple
models of airplanes and engines. The events occurred in
climb, cruise and descent.
The ice crystal or mixed phase icing threat to engines is a
major concern since engines are relied upon to continue
to operate in any kind of icing conditions.
Previously, a commuter type airplane suffered engine
rollback events at altitudes between 28 000 and 31 000 feet.
Extensive investigation, including flight testing, led to the
understanding that ice particles were accreting on warm
surfaces in the engine core. In 2003, the EHWG compared
the commuter airplane events to the large transport events.
Based on this comparison, the industry has recognized that
these high altitude large transport airplane engine events
are most likely due to ice particle or crystal icing.
Appendix C: www.tc.gc.ca/civilaviation/RegServ/Affairs/cars/Part5/Standards/525/a525sc.htm
ASL 3/2008
23
Regulations and You
Mixed phase conditions occur when super-cooled liquid
water drops, or SLD, as referred to in Appendix C, and
ice particles co-exist in a cloud, often around the outskirts
of a deep convective cloud formation. Ice crystal icing
exists when all of the liquid water drops in the cloud have
frozen into ice particles, typically occurring at the higher
flight altitudes. Mixed phase/ice crystal conditions are
also outside the present Appendix C icing environment.
Ice crystal/mixed phase icing threat to engines—
In-service events
Accident Synopses
Accident Synopses
Engine icing due to ice crystal and mixed phase conditions
Recently Released TSB Reports
Regulations and You
by Michael Hamer, Senior Engineer, Powerplants and Emissions, Engineering, National Aircraft Certification, Civil Aviation,
Transport Canada
Maintenance and Certification
Heads Up! Airplane Design and Operations in Icing Conditions
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
Deep convective clouds
Deep convective clouds can lift high concentrations of
water thousands of feet into the atmosphere. This warm,
humid air is rapidly lifted to high altitudes where the
very low ambient temperatures result in ice particle/
crystal formation. In theory, the ice water content can
be four times greater than the certification standard for
super-cooled liquid water. Limited measurements exist of
the microphysical properties of deep convective clouds.
Existing measurements are confounded by uncertain
accuracy of ice water content measurements. Ice particle
or crystal size may be concentrated at much smaller sizes
than previously thought.
Hypothesis of ice accretion mechanism
Frozen ice crystals bounce off cold surfaces. This explains
why airframe icing is not noticed during airplane
operation in high altitude ice crystal environments. The
physics of ice particle or crystal accretion in the engine is
•
•
•
•
ice crystals enter engine primary flowpath,
upstream surfaces are dry and cooler (below
freezing) so there is no accretion;
at some point in the turbomachinery, air
temperatures increase above freezing and warmer
surfaces become wetted due to impacts with
crystals and their melting into liquid water;
a combination of further crystal impacts into wet
surface layer and evaporation brings the surface
temperature back down to the freezing point;
ice begins to form with further crystal impacts;
ice can continue to accrete, or it may shed,
affecting the engine’s normal operation.
This phenomenon means that ice accretion can occur well
behind the fan in the engine core.
Industry challenges—Making the engine more capable
Zones of high ice particle or crystal concentration are
not easily identifiable by pilots in-flight, nor are they
predicted on weather forecasts. The most effective
solution is to make the engine more capable of flight in
these conditions. Flight research measurements of these
conditions are needed to characterize the ice particle/
crystal environment. Facilities for testing engines in
these conditions do not exist and need to be developed.
Manufacturers also need to conduct more research into
the physics of the ice particle or crystal accretion and
shedding mechanisms within the engine, as this is still not
fully understood.
Government and industry committee (EHWG) activities
In support of the work done by the FAA ARAC IPHWG
committee, the EHWG committee has created a draft
Appendix D to FAR Part 33, Airworthiness Standards:
Aircraft Engines, for the ice crystal envelope, and has
written draft rules and guidance for engine compliance
in the ice crystal environment. The committee has also
written a Technology Plan (Research and Regulatory
Road Map) to address the industry challenges. The work
of these two committees has been submitted to the FAA
through the ARAC process for consideration and possible
future regulatory directions.
As a reminder to all pilots and operators, AIP Canada (ICAO) supplements
and AICs are found on-line on the NAV CANADA Web site (www.navcanada.ca). Pilots and operators
are strongly encouraged to stay up to date with these documents by visiting the NAV CANADA Web site,
and following the link to “Aeronautical Information Products.”
24
ASL 3/2008
Regulations and You
Looking for AIP Canada (ICAO) Sup ements
and Aeronautical Information Circulars (AIC)?
Accident Synopses
Regulations and You
The ice crystal or mixed phase icing threat to engines is a
major concern since engines are relied upon to continue
to operate in any kind of icing conditions, even if the
airplane is not certified for flight in those conditions.
•
Recently Released TSB Reports
Significance
still not completely understood by the industry, but the
mechanism is commonly thought to be:
Maintenance and Certification
Analysis by the engine manufacturers determined that ice
particles can accrete further aft (in the core) of the engine,
resulting in effects not seen during certification testing
with super-cooled liquid water, rain, or hail. In addition,
these engine events seemed to involve no significant
observations of any appreciable airframe icing, nor were
there any ice detector responses, if installed. However,
malfunctioning of the total air temperature (TAT) probe
occurred during many of the engine events and is now
a known indicator of ice particle or crystal accretion in
engines. The events typically occurred in visible moisture
conditions in cloud with light to moderate turbulence.
Pilots report precipitation on the windscreen, often
described as “rain” and no weather radar echoes at the
location and altitude of the airplane engine event.
Maintenance and Certification
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.
TSB Final Report A05F0025—Hydraulic Flight
Control Malfunction
Findings as to risk
2. The two printed circuit boards (22-alpha and
30-alpha) in the centre pedestal were contaminated
by debris accumulation. This could lead to an
electrical short-circuit resulting in a malfunction of
the hydraulic system and its warning systems.
3. The main rotor hydraulic servo actuators were outof-tolerance for extension and retraction rates and
internal leakage, a circumstance that may cause
asymmetric servo operation.
4. The lateral hydraulic servo accumulators differed
remarkably in the time required to exhaust them
of hydraulic pressure, leading to asymmetric
servo operation.
5. The hydraulic test (HYD TEST) switch is vulnerable
to inadvertent operation that has been shown to
cause loss of control of the helicopter. The helicopter
manufacturer has issued a voluntary Service Bulletin
to install a protective cover device over the HYD
TEST switch to prevent inadvertent operation.
Without the cover, the risk of unintentional use is
always present.
Accident Synopses
Accident Synopses
On February 6, 2005, a Canadian-registered
Eurocopter AS 350 B2 helicopter was engaged in various
mining support activities in the jungle and terrain in
the Kamarang area, Guyana. At 17:25 local time, with a
120-ft longline attached, the pilot entered a stable, outof-ground-effect hover to begin coiling the longline onto
the ground below the helicopter. As the pilot gradually
descended, and at a height of about 10 ft above ground
level (AGL), he experienced significant binding in the
flight controls. The pilot was unable to rectify the control
binding and had considerable difficulty maintaining
attitude and altitude control of the helicopter. During
15 seconds of random, uncontrolled hover flight, the
helicopter turned and climbed to about 20 ft AGL,
whereupon the pilot retarded the throttle lever, causing
the main rotor rpm to decay rapidly. As a result, the
helicopter descended quickly, struck the ground, bounced,
and landed upright, causing substantial damage to the
skids, the tail boom, and the main rotor head. The pilot
was not injured and the impact forces were insufficient to
activate the emergency locator transmitter (ELT).
1. The hydraulic cut-off (HYD CUT OFF) switch is
underrated for its application in the AS 350, and as
a result, is exposed to higher-than-design electrical
current draw, leading to intermittent function and
premature failure. Failure of the switch can lead
to improper operation of the hydraulic system or
warning devices.
Recently Released TSB Reports
Recently Released TSB Reports
Maintenance and Certification
recently released tsb reports
Finding as to causes and contributing factors
1. The helicopter had a flight control malfunction and the
pilot was unable to effectively control the helicopter
before it collided with the terrain. The cause of the
malfunction could not be determined with certainty,
but was most likely a loss of hydraulic pressure.
7. The gross particulate contamination found in the
hydraulic system fluid presents a clear risk of servo
malfunction and could lead to loss of control; the
source of the contamination was not found.
8. Although the AS 350 B2 can be controlled without
hydraulic servo actuators, it requires the pilot to exert
ASL 3/2008
25
Regulations and You
Regulations and You
6. The aural warning horn to alert the pilot of low
main rotor speed also functions as the low hydraulic
pressure warning, a situation that leads to ambiguity
and potentially inappropriate response to the
actual emergency.
Maintenance and Certification
Maintenance and Certification
considerable muscular effort, which is difficult to
gauge accurately. The required effort may exceed the
physical strength or endurance of some pilots.
9. The lack of a requirement for recurrent AS 350
training may result in unacceptable loss of familiarity
with the emergency procedures, a loss of awareness
of hydraulic system malfunctions, and the unusually
high control forces that result. Collectively, these
issues could result in a loss-of-control situation.
Findings as to causes and contributing factors
TSB Final Report A05F0047—Loss of Rudder
in Flight
On March 6, 2005, at 0645 Coordinated Universal
Time (UTC), an Airbus A310-308 aircraft, departed
Varadero, Cuba, for Québec City, Que., with 9 crew
members and 262 passengers on board. At approximately
0702 UTC, the aircraft was 90 NM south of Miami,
Fla., and in level flight at FL350, when the flight crew
heard a loud bang and felt some vibration. The aircraft
entered a Dutch roll and the captain disconnected the
autopilot to manually fly the aircraft. The aircraft climbed
nearly 1 000 ft while the captain tried to control the
Dutch roll. The crew initiated a descent back to FL350
and requested further descent and a possible diversion
to Fort Lauderdale, Fla. During the descent, the Dutch
roll intensity lessened and then stopped when the aircraft
descended through FL280. No emergency was declared.
When the aircraft was abeam Miami, the crew decided to
return to Varadero. During the landing flare, the rudder
control inputs were not effective in correcting for a slight
crab. The aircraft landed and taxied to the gate. After
shutdown, it was discovered that the aircraft rudder was
missing. Small pieces of the rudder were still attached
to the vertical stabilizer. One flight attendant suffered a
minor back injury during the event.
1. The aircraft took off from Varadero with a preexisting disbond or in-plane core fracture damage to
the rudder, caused by either a discrete event, but not
a blunt impact, or a weak bond at the z-section of
the left side panel. This damage deteriorated in flight,
ultimately resulting in the loss of the rudder.
2. The manufacturer’s recommended inspection program
for the aircraft was not adequate to detect all rudder
defects; the damage may have been present for many
flights before the occurrence flight.
3. This model of rudder does not include any design
features in the sandwich panels to mechanically arrest
the growth of disbond damage or in-plane core failure
before the damaged area reaches critical size (such a
feature was not specifically demanded
for certification).
Findings as to risk
1. A cockpit voice recorder (CVR) with a 30-min
recording capacity was installed on the aircraft, and
its length was insufficient to capture the rudder-loss
event, resulting in critical information concerning the
rudder failure not being available to investigators.
2. There was no published procedure for disabling
the recorders once the aircraft was on the ground;
valuable investigation information can be lost if the
data are not preserved.
ASL 3/2008
Regulations and You
Regulations and You
3. The sampling intervals for lateral and longitudinal
acceleration captured by the digital flight data
recorder (FDR) were insufficient to record the
highly dynamic conditions present at the time of the
occurrence. This resulted in incomplete information
being recorded.
26
Accident Synopses
Accident Synopses
Due to space limitations, we cannot publish the safety
action taken section, which includes an aviation safety
recommendation from the TSB. Readers are invited to
read this section, and the entire final report of this major
investigation, on the TSB Web site at: www.tsb.gc.ca/en/
reports/air/2005/a05f0025/a05f0025.asp. —Ed.
Recently Released TSB Reports
Recently Released TSB Reports
Safety action taken
Maintenance and Certification
6. Declaring an emergency and clearly communicating the
nature of the problem allows air traffic control (ATC) to
more easily co-ordinate between units and anticipate
the needs of the crew in planning traffic management.
7. Procedures and practices that do not facilitate
information sharing between crew members increase
the likelihood that decisions will be based on
incomplete or inaccurate information, potentially
placing passengers and crew at risk.
Other findings
1. Throughout the event, the crew received no electronic
centralized aircraft monitor (ECAM) message
relating to the control problem that the aircraft had
experienced, and there were no other warning lights
or cockpit indications of an aircraft malfunction.
During the flare, the aircraft travelled through an
area of heavy rain, and visual contact with the runway
environment was significantly reduced. There were
numerous lightning strikes occurring, particularly at the
far end of the runway. The aircraft touched down about
3 800 ft down the runway, reverse thrust was selected
about 12.8 seconds after landing, and full reverse was
selected 16.4 seconds after touchdown. The aircraft was
not able to stop on the 9 000-ft runway and departed
the far end at a groundspeed of about 80 kt. The aircraft
stopped in a ravine at 2002 UTC (16:02 Eastern Daylight
Time [EDT]) and caught fire. All passengers and crew
members were able to evacuate the aircraft before the fire
reached the escape routes. A total of 2 crew members and
10 passengers were seriously injured during the crash and
the ensuing evacuation.
Recently Released TSB Reports
Recently Released TSB Reports
5. There are insufficient published procedures available
to flight crew members to assist in recovering from a
Dutch roll.
northwest. At about 200 ft above the runway threshold,
while on the instrument landing system (ILS) approach to
Runway 24L with autopilot and auto thrust disconnected,
the aircraft deviated above the glide slope and the
groundspeed began to increase. The aircraft crossed the
runway threshold about 40 ft above the glide slope.
Maintenance and Certification
4. The rudder position filtering and the necessity for
additional analysis adversely affected the accuracy and
effectiveness of the investigation efforts.
2. After the rudder-separation event, the aircraft was
not in danger of losing the vertical tail plane during
the flight, either through loss of static strength or loss
of stiffness.
Due to space limitations, we cannot publish the safety
action taken section, which includes two aviation safety
recommendations from the TSB. Readers are invited to
read this section, and the entire final report of this major
investigation, on the TSB Web site at: www.tsb.gc.ca/en/
reports/air/2005/a05f0047/a05f0047.asp. —Ed.
Accident Synopses
Accident Synopses
Safety action taken
On August 2, 2005, an Airbus A340-313 aircraft
departed Paris, France, at 1153 Coordinated Universal
Time (UTC) on a scheduled flight to Toronto, Ont.,
with 297 passengers and 12 crew members on board.
Before departure, the flight crew members obtained their
arrival weather forecast, which included the possibility
of thunderstorms. While approaching Toronto, the flight
crew members were advised of weather-related delays.
On final approach, they were advised that the crew of an
aircraft landing ahead of them had reported poor braking
action, and the A340’s weather radar was displaying
heavy precipitation encroaching on the runway from the
Findings as to causes and contributing factors
1. The crew conducted an approach and landing in the
midst of a severe and rapidly changing thunderstorm.
The operator did not have procedures related to
the distance required from thunderstorms during
approaches and landing, nor were these required
by regulations.
2. After the autopilot and auto thrust systems were
disengaged, the pilot flying (PF) increased the
thrust in reaction to a decrease in the airspeed and a
perception that the aircraft was sinking. The power
increase contributed to an increase in aircraft energy
and the aircraft deviated above the glide path.
ASL 3/2008
27
Regulations and You
Regulations and You
TSB Final Report A05H0002—Runway Overrun
and Fire
5. When the aircraft was near the threshold, the crew
members became committed to the landing and
believed their go-around option no longer existed.
6. The touchdown was long because the aircraft floated
due to its excess speed over the threshold and because
the intense rain and lightning made visual contact
with the runway very difficult.
7. The aircraft touched down about 3 800 ft from the
threshold of Runway 24L, which left about 5 100 ft
of runway available to stop. The aircraft overran the
end of Runway 24L at about 80 kt and was destroyed
by fire when it entered the ravine.
9. The pilot not flying (PNF) did not make the standard
callouts concerning the spoilers and thrust reversers
during the landing roll. This further contributed to
the delay in the PF selecting the thrust reversers.
10. Because the runway was contaminated by water, the
strength of the crosswind at touchdown exceeded the
landing limits of the aircraft.
12. Despite aviation routine weather reports (METAR)
calling for thunderstorms at CYYZ at the expected
time of landing, the crew did not calculate the landing
distance required for Runway 24L. Consequently,
they were not aware of the margin of error available
for the landing runway, or that it was eliminated once
the tailwind was experienced.
13. Although the area up to 150 m beyond the end of
Runway 24L was compliant with Aerodrome Standards
28
1. In the absence of clear guidelines with respect to the
conduct of approaches into convective weather, there
is a greater likelihood that crews will continue to
conduct approaches into such conditions, increasing
the risk of an approach and landing accident.
2. A policy where only the captain can make the
decision to conduct a missed approach can increase
the likelihood that an unsafe condition will not be
recognized early and, therefore, increase the time it
might otherwise take to initiate a missed approach.
3. Although it could not be determined whether the use
of the rain repellent system would have improved the
forward visibility in the downpour, the crew did not
have adequate information about the capabilities and
operation of the rain repellent system and did not
consider using it.
4. The information available to flight crews on initial
approach in convective weather does not optimally
assist them in developing a clear idea of the weather
that may be encountered later in the approach.
5. During approaches in convective weather, crews may
falsely rely on air traffic control (ATC) to provide
them with suggestions and directions as to whether to
land or not.
6. Some pilots are under the impression that ATC will
close the airport if weather conditions make landings
unsafe; ATC has no such mandate.
7. Wind information from ground-based measuring
systems (anemometers) is critical to the safe landing
of aircraft. Redundancy of the system should prevent
a single-point failure from causing a total loss of
relevant wind information.
8. The emergency power for both the public address (PA)
and evacuation (EVAC) alert systems are located
in the avionics bay. A less vulnerable system and/or
location would reduce the risk of these systems failing
during a survivable crash.
ASL 3/2008
Regulations and You
Maintenance and Certification
Regulations and You
11. There were no landing distances indicated on
the operational flight plan for a contaminated
runway condition at the Toronto/Lester B. Pearson
International Airport (CYYZ).
Findings as to risk
Accident Synopses
Accident Synopses
8. Selection of the thrust reversers was delayed, as was
the subsequent application of full reverse thrust.
14. The downpour diluted the firefighting foam agent
and reduced its efficiency in dousing the fuel-fed fire,
which eventually destroyed most of the aircraft.
Recently Released TSB Reports
Recently Released TSB Reports
4. Approaching the threshold, the aircraft entered an
intense downpour, and the forward visibility became
severely reduced.
and Recommended Practices (TP 312E), the
topography of the terrain beyond this point, along the
extended runway centreline, contributed to aircraft
damage and to the injuries to crew and passengers.
Maintenance and Certification
3. At about 300 ft above ground level (AGL), the
surface wind began to shift from a headwind
component to a 10-kt tailwind component, increasing
the aircraft’s groundspeed and effectively changing
the flight path. The aircraft crossed the runway
threshold about 40 ft above the normal threshold
crossing height.
Maintenance and Certification
Recently Released TSB Reports
10. Safety information cards given to passengers
travelling in the flight decks of the operator’s
Airbus A340-313 aircraft do not include illustrations
depicting emergency exit windows, descent ropes or
the evacuation panel in the flight deck doors.
8. There is no information to indicate that the aircraft
encountered wind shear during its approach
and landing.
11. There are no clear visual cues to indicate that some
dual-lane slides actually have two lanes. As a result,
these slides were used mostly as single-lane slides.
This likely slowed the evacuation, but this fact was not
seen as a contributing factor to the injuries suffered by
the passengers.
12. Although all passengers managed to evacuate, the
evacuation was impeded because nearly 50 percent of
the passengers retrieved carry-on baggage.
Other findings
1. There is no indication that the captain’s medical
condition or fatigue played a role in this occurrence.
3. The possibility of a diversion required the flight crew
to check the weather for various potential alternates
and to complete fuel calculations. Although these
activities consumed considerable time and energy, there
is no indication that they were unusual for this type of
operation or that they overtaxed the flight crew.
9. The flight crew seats are certified to a lower standard
than the cabin seats, which may have been a factor in
the injuries incurred by the captain.
Safety action taken
Due to space limitations, we cannot publish the safety
action taken section, which includes seven aviation safety
recommendations from the TSB. Readers are invited to
read this section, and the entire final report of this major
investigation, on the TSB Web site at: www.tsb.gc.ca/en/
reports/air/2005/a05h0002/a05h0002.asp. —Ed.
TSB Final Report A06P0010—Engine Power
Loss—Forced Landing
On January 21, 2006, a Cessna 208B aircraft was en route
at 9 000 ft above sea level (ASL), from Tofino, B.C.,
to the Vancouver International Airport, B.C., when the
engine failed. The pilot began a glide in the direction
of the Port Alberni Regional Airport, B.C., before
attempting an emergency landing on a logging road.
The aircraft struck trees during a steep right-hand turn
and crashed. The accident occurred at about 14:20 Pacific
Standard Time (PST), approximately 11 NM southsoutheast of the Port Alberni Regional Airport. Five
passengers survived with serious injuries; the pilot and the
other two passengers were fatally injured.
Accident Synopses
2. The crew did not request long aerodrome forecast (TAF)
information while en route. This did not affect the
outcome of this occurrence because the CYYZ forecast
did not change appreciably from information the flight
crew members received before departure, and they
received updated METARs for CYYZ and the Niagara
Falls International Airport (KIAG).
7. There is no indication that the aircraft was struck
by lightning.
Recently Released TSB Reports
Accident Synopses
6. It could not be determined why door L2 opened
before the aircraft came to a stop.
Maintenance and Certification
9. Brace commands were not given by the cabin crew
during this unexpected emergency condition. Although
it could not be determined if some of the passengers
were injured as a result, research shows that the risk of
injury is reduced if passengers brace properly.
Regulations and You
Regulations and You
4. The decision to continue with the approach was
consistent with normal industry practice, in that the
crew could continue with the intent to land while
maintaining the option to discontinue the approach if
they assessed that the conditions were becoming unsafe.
5. There is no indication that more sophisticated ATC
weather radar information, had it been available and
communicated to the crew, would have altered their
decision to continue to land.
ASL 3/2008
29
Maintenance and Certification
Recently Released TSB Reports
1. Single-engine instrument flight rules (SEIFR)
operations in designated mountainous regions have
unique obstacle risks in the event of an engine
failure. Canadian equipment requirements for such
operations do not currently include independent
terrain mapping, such as terrain awareness and
warning systems (TAWS).
2. Airline operators are not currently required to
conduct any additional route evaluation or structuring
to ensure that the risk of an off-field landing is
minimized during SEIFR operations.
3. Pilots involved in commercial SEIFR operations
do not receive training in how to conduct a forced
landing under instrument flight conditions; such
training would likely improve a pilot’s ability to
respond to an engine failure when operating in
instrument meteorological conditions (IMC).
4. Mean time between failure (MTBF) calculations do
not take into account in flight shut downs (IFSD)
not directly attributable to the engine itself; it may be
more appropriate to monitor all IFSD events.
5. The design of the Cessna 208B Caravan fuel shutoff
valves increases the risk that the valves will open
on impact, allowing fuel spillage and increasing the
potential for fire.
1. The operator was not providing downloaded
engine parameter data for engine condition trend
monitoring (ECTM) evaluation at appropriate
intervals.
30
Enhanced Pilot Training Requirement
On June 6, 2007, the TSB sent a Safety Advisory to TC,
suggesting that TC consider incorporating additional
pilot training requirements into subsection 723.98(24) of
the Commercial Air Service Standards (CASS) to ensure
that SEIFR pilots receive practical training on engine
failure procedures in IMC. The training would include
the pilot’s initial response to the failure, the descent in
instrument conditions, the avoidance of terrain hazards
during the descent, and the practice of forced landings
under various degraded surface weather conditions.
TC responded to this Safety Advisory on July 25, 2007.
The response outlined a number of difficulties involved in
establishing a specific standard that could cover a myriad
of circumstances that a pilot may meet in the event of an
engine failure under SEIFR operations.
TC’s position is that air operators should be proactive
in reviewing their SEIFR operations, specific to their
individual training program, to ensure that this possible
training gap or related hazard is addressed within the
company operations manual.
TC’s Civil Aviation Standards Branch will prepare an
issue paper with the recommendation that air operators
review their company training programs to ensure that
SEIFR pilots receive practical training on engine failure
procedures in IMC specific to the air operator operations
and geographic location.
Due to space limitations, we cannot publish the remainder of
the safety action taken section, which includes two aviation
safety recommendations from the TSB. Readers are invited
to read this section, and the entire final report of this major
investigation, on the TSB Web site at: www.tsb.gc.ca/en/reports/
air/2005/a06P0010/a06p0010-.asp. —Ed.
ASL 3/2008
Regulations and You
Regulations and You
Other finding
Terrain Awareness and Warning System (TAWS)
Equipment Requirement
A requirement for the installation and use of TAWS
has been supported by Transport Canada (TC). This
installation and use of TAWS equipment will enhance
a pilot’s ability to identify and avoid terrain risks in the
event of a loss of propulsion under IMC. Information
about the TAWS equipment requirements that are being
approved for Canada can be found in TC’s Commercial
and Business Aviation Advisory Circular (CBAAC) 0236
dated 29 July 2005, which is available on the TC Web site
at www.tc.gc.ca/CivilAviation/commerce/circulars/menu.htm.
Accident Synopses
Accident Synopses
2. The combination of aircraft position at the time of
the engine failure, the lack of equipment enabling
the pilot to locate and identify high terrain, and the
resultant manoeuvring required to avoid entering
instrument flight conditions likely prevented the pilot
from attempting to glide to the nearest airfield.
Safety action taken
Recently Released TSB Reports
Findings as to risk
1. The engine lost power when a compressor turbine
blade failed as a result of the overstress extension of
a fatigue-generated crack. The fracture initiated at a
metallurgical anomaly in the parent blade material
and progressed, eventually resulting in blade failure
due to overstress rupture.
Maintenance and Certification
Findings as to causes and contributing factors
Maintenance and Certification
Recently Released TSB Reports
Recently Released TSB Reports
On August 7, 2006, a float-equipped Cessna A185F
departed Nimpo Lake, B.C., at 12:45 Pacific Daylight
Time (PDT), with only the pilot on board. The pilot was
to pick up a passenger at Kluskoil Lake, B.C., and then
return to Nimpo Lake. The aircraft was reported overdue
at 15:00 PDT, and a search operation was initiated. An
emergency locator transmitter (ELT) signal was received,
and the aircraft wreckage was located on a hillside in the
vicinity of Mount Downton, at an elevation of 6 824 ft
above sea level (ASL). The aircraft was destroyed, but
there was no fire. Both occupants received fatal injuries.
The accident happened at about 14:00 PDT.
The pilot tried to restart it, but without success. The
pilot transmitted a distress message and quickly reported
the situation to the control tower. The aircraft was
approximately 1 250 ft above ground level (AGL) at the
time. The pilot landed the aircraft on the northbound side
of Parc Avenue, in Montréal. On landing, the left wing tip
struck a traffic light post before the aircraft came to rest.
The aircraft was substantially damaged, but there were
no injuries.
Maintenance and Certification
TSB Final Report A06P0157—
Collision with Terrain
Findings as to causes and contributing factors
2. The water accumulated in the right fuel tank migrated
to the gascolator bowl, saturating it, and causing the
engine to stop.
Aerial view of accident site, with TSB investigators at the
approximate impact point
Findings as to causes and contributing factors
1. While flying in mountainous terrain, the pilot was
manoeuvring close to terrain, and struck the ground
at slow speed, with the aircraft in a nose-down
attitude, possibly after a stall.
1. The inspections done by the approved maintenance
organization (AMO) and the pilot did not find that
the fuel filler cap chain for the right fuel tank was
missing. As a result, the chain was exposed to the
water in the bottom of the tank, and the fuel was
contaminated by corrosion from the chain hooks.
TSB Final Report A06Q0157—Engine Failure
2. On the Cessna 172, the location of the gascolator
drain valve makes it hard to collect fuel for visual
examination before flight.
On September 10, 2006, a Cessna 172M, with the
pilot and two passengers on board, took off at 15:45
Eastern Daylight Time (EDT) from Saint-Hubert,
Que., for a flight according to visual flight rules
(VFR) over Montréal, Que. About 15 min after
takeoff, when the aircraft was over the city, the engine
(Lycoming O320- H2AD) lost power and stopped.
3. The Canadian Aviation Regulations (CARs) do
not require aircraft owners to comply with service
bulletins. As a result, Service Bulletin SEB 92-26
was not completed on the occurrence aircraft. This
upgrade would have made it possible to properly
drain the water that had accumulated in the right
fuel tank before the flight.
ASL 3/2008
Regulations and You
Regulations and You
2. The pilot’s lack of experience in mountain flying likely
caused him to misjudge how close to the terrain he
could safely fly. The strong wind from the southeast
may have been a factor.
Findings as to risk
Accident Synopses
Accident Synopses
1. The aircraft was not on level ground when the
draining was done before the flight. Consequently, the
water in the fuel tank was lower than the drain valve
and could not be removed with the pipette.
31
Maintenance and Certification
Recently Released TSB Reports
Finding as to risk
1. The crew rounded the decision height (DH) figure
for the instrument landing system (ILS) approach
downward, and did not apply a cold temperature
correction factor. The combined error could have
resulted in a descent of 74 ft below the DH on an ILS
approach to minimums, with a risk of undershoot.
Other finding
This picture taken shortly after the occurrence
illustrates the poor visibility
1. The cockpit voice recorder (CVR) was returned to
service following an intelligibility test that indicated
that the first officer’s hot boom microphone intercom
channel did not record. Although the first officer’s
voice was recorded by other means, a potential
existed for loss of information, which was key to
the investigation.
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In early fall 2008, Transport Canada will be launching two national external selection processes to establish a pool of
qualified candidates to staff permanent positions throughout Canada in Aircraft Maintenance and Manufacturing as
well as Aircraft Certification.
Accident Synopses
Accident Synopses
2. After the approach lights were sighted at low altitude,
both pilots discontinued monitoring instruments,
including the glide slope indicator. A significant
deviation below the optimum glide slope in low
visibility went unnoticed by the crew until the aircraft
descended into the approach lights.
Recently Released TSB Reports
On January 9, 2007, a British Aerospace Jetstream 3112
was conducting an instrument approach to Runway 29
at Fort St. John, B.C., on a scheduled instrument
flight rules (IFR) flight from Grande Prairie, Alta. At
11:33 Mountain Standard Time (MST), the aircraft
touched down 320 ft short of the runway, striking
approach and runway threshold lights. The right main
and nose landing gear collapsed, and the aircraft came
to rest on the right side of the runway, 380 ft from the
threshold. There were no injuries to the two pilots or
10 passengers. At the time of the occurrence, the runway
visual range (RVR) was fluctuating between 1 800 ft and
2 800 ft in snow and blowing snow, with winds gusting
to 40 kt.
1. A late full flap selection at 300 ft above ground
level (AGL) likely destabilized the aircraft’s pitch
attitude, descent rate, and speed in the critical final
stage of the precision approach, resulting in an
increased descent rate before reaching the runway
threshold.
Maintenance and Certification
Findings as to causes and contributing factors
TSB Final Report A07W0005—Landing Short
of Runway
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32
ASL 3/2008
Regulations and You
Regulations and You
People living in Canada and Canadian citizens residing abroad will have an opportunity to apply. Language
requirements will vary according to the position to be filled. Interested candidates are encouraged to submit an
on-line application at www.jobs-emplois.gc.ca during the application period. Detailed information regarding the
qualification requirements will also be available on the Web site above, or by calling the Infotel line
at 1-800-645-5605 during the application period. Interested candidates will have two weeks to apply once the
openings are posted on-line.
Maintenance and Certification
Recently Released TSB Reports
On November 4, 2007, an ultralight Lincoln Ultra Sport
took off from a field for a local recreational flight. The
pilot was the only occupant on board. The aircraft lost
power in level flight, approximately 200 ft above ground
level (AGL). The pilot banked right and headed to the
field where he had taken off. Shortly after the turn, at
approximately 45 ft AGL, the aircraft nosed over and
crashed into a business parking lot. The pilot died after
the accident. The site of the accident is approximately
800 ft from the field where he took off. Weather
conditions were favourable for conducting a visual flight
rules (VFR) flight. TSB File A07Q0225.
On November 7, 2007, a Beechcraft 200 was on approach
to Toronto/City Centre Airport, Ont., when the landing
gear was selected down. The right main and nose landing
On November 10, 2007, a Diamond DV20 departed
Runway 33 at the Fredericton, N.B., airport for a first
solo circuit. The pilot reported downwind and final for
Runway 33. After touchdown, the aircraft bounced
heavily then veered left and off the runway surface. It
continued across the grass and into an irrigation ditch
that runs parallel to the runway. The aircraft crossed the
ditch and contacted a wall of turf on the opposite side.
The impact was sufficient to activate the emergency
locator transmitter (ELT) and compromise the aircraft
fuselage and empennage. The flight service specialist
activated the crash alarm; upon arrival at the scene,
emergency personnel advised an ambulance was necessary.
The pilot was seriously injured and transported to hospital
by ambulance. TSB File A07A0133.
On November 14, 2007, a Cessna 172 took off from the
Saint-Hubert, Que., airport for a local flight. While the
aircraft was on approach for Runway 24L, the controller
informed the pilot that winds were from 200º at 15 kt,
gusting to 22 kt. The aircraft landed with its flaps at 40°.
The aircraft bounced after the wheels touched down,
then nosed over. The nose wheel broke off and the front
landing gear bent backward. The front landing gear,
propeller and engine sustained major damages. The pilot
was not injured. TSB File A07Q0235.
Regulations and You
On November 6, 2007, an Agusta A119 helicopter was
on a flight from Helena, Montana, to Riverton, Wyoming,
with the pilot and three passengers on board. About
25 NM southeast of Cody, Wyoming, the pilot
decided to land on a mountaintop at an elevation of
11 900 ft to allow the passengers to stretch their legs.
When descending through about 100 ft AGL, the pilot
heard the low rotor rpm warning horn and lowered
the collective. The helicopter impacted the ground
hard, resulting in collapsed skid gear and a tail rotor
strike. An emergency was called in and the pilot and
passengers were rescued by a Montana Air National
Guard Blackhawk helicopter. The pilot suffered a hairline
fracture of a vertebrae, and the three passengers were
uninjured. The engine was returned to the manufacturer
for testing, and it revealed some free turbine rpm (Nf )
and gas generator rpm (Ng) instability pointing to a
possible issue with the fuel control unit (FCU).
TSB File A07F0194.
gears extended, but the left main landing gear remained
retracted. After three fly-bys next to the tower, the left
main landing gear was confirmed to have remained in the
retracted position. The flight crew decided to return to
Toronto/Lester B. Pearson Airport and Toronto ATC was
advised of the emergency situation. Emergency vehicles
were standing by for the landing. The aircraft landed
on Runway 15L and the flight crew minimized aircraft
damage by maintaining aircraft weight on the nose and
right main gear after touchdown. The aircraft came to
a stop on the centerline of the runway, resting on the
bottom of the right engine’s nacelle. There was no fire and
both crew exited the aircraft with no reported injuries.
TSB File A07O0300.
On November 22, 2007, a Eurocopter AS350B-2
helicopter departed the airstrip at Silver Spruce camp
(80 NM north of Goose Bay, N.L.) in day visual
meteorological conditions (VMC) with the pilot on
ASL 3/2008
Accident Synopses
Accident Synopses
On November 3, 2007, the pilot of a Turbo Lancair 4P
had departed Springbank, Alta., on a local flight. As the
flight was returning to the airport, the engine began to
lose power. The pilot attempted to switch tanks, but had
problems with the fuel selector valve, and decided to
attempt a forced landing in a farm field. Shortly after
touchdown, the aircraft contacted a ravine and was
substantially damaged. The pilot, the sole occupant, was
not injured. TSB File A07W0191.
Recently Released TSB Reports
Regulations and You
Note: All aviation accidents are investigated by the Transportation Safety Board of Canada (TSB). Each occurrence is assigned
a level, from 1 to 5, which indicates the depth of investigation. Class 5 investigations consist of data collection pertaining
to occurrences that do not meet the criteria of classes 1 through 4, and will be recorded for possible safety analysis, statistical
reporting, or archival purposes. The narratives below, which occurred between November 1, 2007, and January 31, 2008, are all
“Class 5,” and are unlikely to be followed by a TSB Final Report.
Maintenance and Certification
accident synopses
33
34
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
Regulations and You
On January 4, 2008, a Robinson 44 helicopter, with
two passengers on board, was flying low over Lac des
Deux Montagnes, Que. At approximately 16:00 EDT,
the helicopter struck the frozen surface of the lake.
The helicopter sustained major damages and the three
occupants suffered serious injuries. Local weather
observations included a visibility of 15 mi., scattered
clouds at 2 500 ft, and a covered ceiling at 4 800 ft.
TSB File A08Q0001.
On January 5, 2008, an ultralight Cumulus, approximately
4 mi. south of Dolbeau, Que., took off with only the pilot
on board, to conduct a recreational flight. On the take-off
roll, the aircraft abruptly nosed up, then took off. Then,
during the initial climb, the ultralight aircraft veered and
nosed over before crashing into the frozen surface of the
river. The aircraft sustained major damages and the pilot
suffered fatal injuries. TSB File A08Q0002.
On January 18, 2008, a Beech 95-B55 Baron was on the
landing roll on Runway 26 at Red Lake, Ont., when the
landing gear was unintentionally retracted. The pilot was
not injured and the aircraft sustained substantial damage.
The operator will investigate the occurrence by way of its
safety management system (SMS). TSB File A08C0007.
On January 21, 2008, a DHC-2 MK.1 Beaver was landing
at a private airstrip near Montney, B.C., following a local
flight. The main landing gear struck a snow bank short of
the runway, and the aircraft slid to a stop on the runway
with substantial damage to the landing gear, propeller, and
ASL 3/2008
Regulations and You
On December 21, 2007, after landing long at
Valcourt, Que., the pilot of a Beechcraft BE23 was unable
to brake the aircraft, which became stuck in the snow at
On December 26, 2007, a Cessna 177B was landing
at night on Runway 09 at Corman Air Park, Sask. The
aircraft landed on the left side of the runway and the left
main gear entered the snow alongside of the runway. The
aircraft veered to the left and the nose gear collapsed in
the snow. The pilot, the sole occupant, was not injured.
TSB File A07C0237.
Accident Synopses
On November 30, 2007, a Piper PA-24-260 Comanche
was landing on Runway 28 at Carp, Ont. During the
approach and landing, the landing gear was inadvertently
left in the retracted position, resulting in the aircraft
landing wheels up. The aircraft came to rest approximately
three-quarters of the way down and to the north of
Runway 28. The aircraft was lifted and the landing gear
was successfully pulled down and locked. There were no
injuries. TSB File A07O0318.
On December 22, 2007, the pilot of a ski-equipped
Norman Aviation Nordic VI was executing touch-and-go
manoeuvres. On the third landing, the aircraft slid on
the soft snow as it reduced speed. The skis sunk into the
snow and the aircraft overturned. The occupants were not
injured, but the aircraft sustained damages to the propeller,
engine cowl and left wing ribs. TSB File A07Q0253.
Recently Released TSB Reports
On November 22, 2007, an American Aviation AA-1B
was en route from Marathon, Ont., to Thunder Bay, Ont.
At an altitude of approximately 4 500 ft, the engine began
to run rough. The pilot then successfully completed a
precautionary landing on a dirt road near Hurkett, Ont.
After completing an inspection of the aircraft, the pilot
decided to take off. During the take-off roll, directional
control of the aircraft was lost and the aircraft veered off
the left side of the road and collided with the ditch. The
pilot was not injured and the aircraft sustained substantial
damage. It was reported that the dirt road was snow- and
ice-packed. TSB File A07C0216.
the end of the runway. The occupants were not injured.
The left wing sustained major damage. The runway was
90 percent snow-covered. The same aircraft was involved
in a runway excursion on October 26, 2007 (A07Q0217).
This was the aircraft’s first flight since undergoing repairs.
TSB File A07Q0252.
Maintenance and Certification
board, slinging four drums of fuel in a net on an 80-ft
longline. At approximately 200 yd northwest of the strip,
and at 150 ft AGL and 40 kt, the pilot recognized that he
had reached the right lateral cyclic control stop without
the expected disk response in roll attitude. The pilot
attempted twice to physically achieve more right lateral
cyclic input, but without success. The pilot turned back
toward the strip in a slow right turn; however, at about
100 yd back on short final at about 150 ft and 40 kt, the
nose suddenly dropped and the aircraft entered a rapid,
right spiral and descended quickly. Despite full aft and
left cyclic input, the pilot was unable to control the nosedown attitude or right turn. However, just before impact
with the ground, the helicopter leveled somewhat and
struck the ground on the right skid and fuselage, before
coming to rest on its left side. Immediately after the nose
dropped, the cockpit warning horn sounded and remained
on until silenced by the pilot on the ground. After impact
with the ground, the pilot shut down the still-running
engine, turned off the battery master, and escaped the
cockpit with minor injuries. There was no fire and the
emergency locator transmitter (ELT) activated on impact.
During the brief flight, the sling load was not erratic and
flew normally beneath the helicopter with no oscillation.
It was revealed that the longline had inadvertently
wrapped around the rear of the left skid during the
departure. TSB File A07A0137.
On January 26, 2008, a Cessna 152, with an instructor
and student on board, was on its way back from the
training area south of the Jean Lesage International
Airport in Québec City, Que. While the aircraft was
over the Québec City bridge, on final for Runway 30, the
flight crew detected a loss of power. They tried several
times, in vain, to regain power. The aircraft continued to
lose altitude. Seeing that they could not reach the airport,
the flight crew attempted an emergency landing on the
Duplessis highway. As the pilot attempted to avoid an
automobile while landing, the right main wheel became
stuck in a snowbank and the aircraft came to rest on the
On January 31, 2008, a Hughes 369D helicopter was
conducting a wildlife survey approximately 20 NM
south of Empress, Alta. During touchdown, the tail rotor
struck the ground, resulting in a loss of rotational control.
The pilot reduced the collective immediately and the
helicopter landed heavily but remained upright. There
was substantial damage to the tail rotor, tail rotor drive
train, tail boom, and skid gear. The pilot and observer were
uninjured. TSB File A08W0027.
TC Publications
O rdering
Forms
Accident Synopses
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
On January 25, 2008, an HS 748-2A aircraft was
being prepared for a flight from Vancouver, B.C., to
Smithers, B.C. As the captain was performing his preflight walk-around inspection, he found that the left
elevator was substantially damaged. The aircraft had been
parked overnight at Gate 18. A maintenance engineer had
performed an inspection of the aircraft the previous day,
and had determined that the left elevator was undamaged
at that time. The damage is consistent with the aircraft
being struck by a vehicle. TSB File A08P0028.
On January 30, 2008, a Eurocopter AS350BA was
conducting training at the Springbank, Alta., airport.
The first training exercise was a simulated hydraulic
failure. The exercise was being conducted in the circuit for
Runway 16. The first two simulations were successful. On
the third attempt, the forward speed decayed to 0 kt at
approximately 10 ft AGL. During the attempt to regain
forward speed, the trainee (flying from the right seat) lost
control of the helicopter and the helicopter came to rest
on its left side just east of the threshold for Runway 16.
The training pilot and trainee exited the helicopter with no
injuries and there was no post-impact fire. The simulated
loss of hydraulics exercise was performed according to the
aircraft flight manual (AFM). The console hydraulic test
switch was depressed and the helicopter slowed to 60 kt.
The console switch was selected off and the hydraulic
cutoff switch on the right side collective was then
activated. When control was lost, it was not feasible for
the instructor to reach over and turn the hydraulics back
on. Prior to departure, the hydraulic accumulators did not
pass the pre-flight check. The helicopter was shutdown and
maintenance recharged and balanced the accumulators in
accordance with maintenance instructions based on the
outside air temperature (OAT) of -19°C. The helicopter
was released by maintenance and the hydraulic check was
successfully completed on the subsequent pre-flight check.
TSB File A08W0025.
Recently Released TSB Reports
On January 24, 2008, a Van’s RV9 departed Delta
Heritage Air Park, B.C., for a flight up the Fraser Valley
and was returning to Delta Heritage Air Park. While on
final, the pilot was unable to retard the throttle enough
to complete the landing, and he overshot to attempt a
second approach. While turning from base to final, the
pilot needed more power but it was not available due to
a stuck and unresponsive throttle. The pilot aborted the
turn onto final, leveled the wings and went through a
wire fence. The aircraft eventually settled enough that the
main gear impacted the far side of a deep ditch and was
torn back. The aircraft came to rest on its belly just past
the ditch, and was substantially damaged. There were no
injuries. TSB File A08P0024.
side of a ditch, overturned. The instructor and student got
out of the aircraft. The instructor was taken to the hospital
as a precautionary measure. The aircraft did not catch on
fire. TSB File A08Q0020.
Maintenance and Certification
engine cowling. There were no injuries to the pilot, who
was the only person on board. Flat light conditions existed
at the time of the occurrence. TSB File A08W0017.
Regulations and You
Regulations and You
and
*
A wide range of Transport Canada’s Publications
are now available through Transact or by phone
through the Order Desk.
Transact can be found at www.tc.gc.ca/transact/
To place orders, call:
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National Capital Region:
E-Mail:
Fax:
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Publications include; videos, CDs and DVDs.
ASL 3/2008
35
Maintenance and Certification
Policy Instruments
by Pierre-Laurent Samson, Civil Aviation Safety Inspector, Regulatory Affairs, Policy and Regulatory Services, Civil Aviation,
Transport Canada
The Cabinet Directive on Streamlining Regulation (CDSR)
issued by the Treasury Board of Canada Secretariat (TBS)
came into effect on April 1, 2007. It introduces specific
requirements for the development, implementation,
evaluation and review of regulations that federal
departments (i.e. Transport Canada) must comply with.
One of the requirements the CDSR re-affirms is the
obligation federal departments have to identify and justify
the appropriateness of regulatory and non-regulatory
instrument(s) they choose to achieve policy objectives.
This article will categorize instruments and explain
where, in the Civil Aviation regulatory process, they
should be identified and justified.
The Guide to Making Federal Acts and Regulations divides
instruments in five groups (see chart):
•
laws and regulations;
information;
capacity building;
economic instruments (including taxes, fees
and public expenditure); and
organizational structures.
Laws and regulations guide behaviour by telling people how
things are to be done. They may be formulated as precise
requirements or as performance standards, setting objectives
that people or organizations are responsible for meeting.
Organizational structures support the use of other
instruments by providing for their administration.
Organizational instruments include departmental
structures to deliver programs, framework agreements and
partnerships with other governments or organizations,
privatization or commercialization of government
services, public investment in private enterprises, etc.
As instruments are mutually supportive and are often
more effective when used in conjunction, they can be
optimized through combination and timing. For example,
an information campaign can develop awareness of a
problem and prepare the way for a regulatory solution, or
a combination of economic incentives with information
and education may be enough to solve an issue without
turning to regulations as a solution.
Though the TBS does not prescribe the manner in
which departments and agencies demonstrate and justify
their choice of instrument(s), the CDSR makes the
instrument’s identification and justification one of the
first steps regulators must take when implementing policy
objectives.
“Departments and agencies are to…
identify the appropriate instrument or
mix of instruments, including regulatory
and non-regulatory measures, and justify
their application before submitting a
regulatory proposal…”
Capacity building increases the ability of people
and organizations to achieve their goals. It includes
employment skills training programs, programs to support
scientific research and public education about the results
of research, information-gathering through consultation
and monitoring, and working with industries to help them
develop voluntary codes governing their practices, etc.
Economic instruments affect how people behave in the
marketplace. They include taxes, fees, public expenditure,
the creation of exclusive or limited rights (i.e. marketable
36
CDSR—Selecting the appropriate mix of
government instruments
Civil Aviation has chosen risk assessments as its
means of identifying viable instruments. The TBS will,
therefore, expect Civil Aviation to demonstrate through
a risk assessment that all applicable instruments were
considered before choosing the regulatory option.
ASL 3/2008
Regulations and You
Regulations and You
Information helps people modify their behaviour. It
includes advertising, education, awareness campaigns,
consumer information programs, etc.
Accident Synopses
Accident Synopses
•
•
•
•
permits, licences or marketing quotas that acquire
value because they can be bought and sold), insurance
requirements, which can compel industries to assess and
reduce risks to ensure that their products are priced to
cover the costs of insurance or preventive measures, etc.
Recently Released TSB Reports
Recently Released TSB Reports
Policy Instruments.............................................................................................................................................................. page 36
Removal of Sanctions......................................................................................................................................................... page 38
Maintenance and Certification
regulations and you
Maintenance and Certification
•
•
•
For more information on policy instruments,
visit Assessing, Selecting, and Implementing Instruments for
Government Action at www.regulation.gc.ca/documents/gl-ld/
asses-eval/asses-eval00-eng.asp. For more information on
the CDSR, visit www.regulation.gc.ca/directive/directive00eng.asp. The Guide to Making Federal Acts and Regulations
can be found on the Privy Council Office Web site,
at www.pco-bcp.gc.ca.
CDSR 3.1—Regulatory Process Requirements
Policy Instruments
• Advertising
• Education campaigns
• Promotional campaigns
• Awareness programs
• Consumer information
• Symbolic gestures
• Statutes
• Regulations (prescriptive
and performance-based)
• Information through
consultation and monitoring
• Scientific research programs
• Helping industries develop
codes and standards
• Employment skills
training programs
Recently Released TSB Reports
Recently Released TSB Reports
•
“potential impact of the regulation on health and
safety, security, the environment, and the social
and economic well-being of Canadians;
cost or savings to government, business, or
Canadians and the potential impact on the
Canadian economy and its international
competitiveness;
potential impact on other federal departments
or agencies, other governments in Canada, or on
Canada’s foreign affairs; and
degree of interest, contention, and support among
affected parties and Canadians.”
The risk assessment will, therefore, have to provide
an estimate of the expected impact the considered
instruments would have on different aspects of the
Canadian fabric (i.e. health, safety, security, the
environment) and on the Canadian economy (i.e. the
cost or savings to government, business, and Canadians
through the cost/benefit analysis of each appropriate
instrument).
Maintenance and Certification
The CDSR further requires departments and agencies
to consider the potential impact of regulation at an early
stage in the process. The following four points will have to
be assessed every time Civil Aviation is confronted with a
policy issue:
LAWS
Accident Synopses
Accident Synopses
INFORMATION
AND EDUCATION
CAPACITY BUILDING
INSTRUMENTS
Means by which policy
objectives are pursued
ORGANIZATIONAL
STRUCTURES
ECONOMIC INSTRUMENTS
Regulations and You
ASL 3/2008
Regulations and You
• Public expenditure
• Public ownership
• Taxes and fees
• User charges
• Loans
• Loan guarantees
• Limited rights
• Insurance requirements
• Contracts
• Public investment
in private enterprises
• Privatization
• Agreements and partnerships
• Networks
• Department structures
37
Maintenance and Certification
Removing a notation of sanction from a person’s
enforcement file is applicable to any person holding a
Canadian aviation document. The word person includes
an individual or corporation.
Pursuant to section 8.3 of the Aeronautics Act, any
notation of suspension of a Canadian aviation document
by the Minister or any notation of a monetary penalty
imposed may be removed from the record on request
from the person affected by the suspension or monetary
penalty, provided that:
1. at least two years have transpired since the date the
suspension expired or the penalty amount was paid;
2. no additional suspension or monetary penalty has
been recorded against that person after that date; and
3. the removal of the record would not be contrary to
the interest of aviation safety or security.
Where a person is the subject of an investigation at the
time of the request for the removal of sanction, the request
may be denied in the interest of aviation safety or security.
A removal of a notation of sanction means the
de-identification of the enforcement file by erasing
the person’s name and related personal information, as
well as any reference to the notation of sanction from
other records.
To initiate the action of removing a notation of sanction
from a person’s enforcement file, the person must make
a request in writing to the Regional Manager, Aviation
Enforcement. The Chief, Aviation Enforcement will
notify the applicant, on behalf of the Minister, by
registered mail as to whether or not the notation of
sanction has been removed.
Accident Synopses
Accident Synopses
A person who has requested the removal of a notation
of sanction that has been denied by the Minister may
request a review before the Transportation Appeal
Tribunal of Canada (TATC). A denied application for
a removal of sanction cannot be resubmitted until an
additional two-year period has expired from the date of
the original application. If a person makes an application
for the removal of a notation of sanction within a
reasonable time before the two-year waiting period has
expired, the application will be retained and acted on
when the two-year limit has been reached.
Recently Released TSB Reports
Recently Released TSB Reports
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
Maintenance and Certification
Removal of Sanctions
Regulations and You
Hilton Toronto Airport Hotel
September 24–25, 2008
www.tc.gc.ca/civilaviation/SMS/Info/menu.htm
38
ASL 3/2008
Regulations and You
Transport Canada’s
Safety Management Systems (SMS) Information Session
The Civil Aviation Medical Examiner and You
Debrief
The question below is listed in the Frequently Asked
Questions (FAQ) section of our Web site. There is a lot
of use of SSRIs in the general population, and in pilot
communities. We hope that this article will be of interest
to aircrew and perhaps lead to more interaction between
aircrew and our offices.
Question: I’ve been under a lot of stress recently
and my family physician has started me on “Zoloft”
to help me get through this difficult time. I’m actually
feeling better and I’m ready to fly but I understand
that these medications (called SSRIs) are not
compatible with flying. Why is this?
Answer: There are a number of SSRIs and related
medications presently on the market. These go under
trade names such as Prozac, Paxil, Zoloft, Luvox, Serzone
and Effexor, to name a few. (Similar classes of medications
that are equally important will soon be listed in a
table on the Civil Aviation Medicine Web site). There
has been a steady increase in their use in the general
population. These medications are mainly used in the
treatment of major
depression, but they
can also be useful
in other disorders
such as minor
depression, social
phobias, anxiety, and
premenstrual or other
mood disorders.
As far as the side effect profile is concerned, anyone taking
these medications should be aware of the wide array of
potential side effects. While most of the effects are of
little significance, a small number of pilots may experience
some serious alterations in thinking, mood, judgment and
personality. Of even greater concern is the possibility that
these effects may go unrecognized by the pilot.
At the present time, all aircrew using mood-altering
medications will be refused medical certification until the
circumstances of the case are reviewed. Transport Canada
continues to review the literature and conduct studies
to determine whether certain medical conditions and
medications may be considered safe.
In the meantime,
you would be best
advised to discuss
the situation with
your physician.
Discontinuing the
medication should
only be done under
the supervision
of your physician
and only when
the situation has
stabilized. Contact
one of our offices to
discuss the returnto-flying parameters
for your particular
situation, or for
any other aviation
medical question you may have. The list of Civil Aviation
Medicine offices can be found at www.tc.gc.ca/CivilAviation/
Cam/offices.htm, and the FAQ section at www.tc.gc.ca/
CivilAviation/Cam/questions.htm.
ASL 3/2008
39
Debrief
Transport Canada
must determine if
the medical situation
represents a threat
to flight safety. We
are concerned with
both the underlying
medical condition for
which the medication
has been prescribed
and the side effects arising from that medication. When
we learn that a pilot has been prescribed one of these
classes of medication, we will request reports from the
attending physician. This helps us to better understand
the reason for prescribing, as well as the severity of the
illness. While major depression exists, we consider the
pilot unfit. A return to flying can be considered based
on a satisfactory follow-up report from the attending
psychiatrist following an appropriate interval of
treatment. For other conditions, it may be possible for
the pilot to resume flying (normally after discontinuing
medication) once we have received a satisfactory report
from the physician.
Debrief
Debrief
by the Education, Training and Safety Division, Civil Aviation Medicine, Transport Canada
Debrief
Debrief
A Word About Selective Serotonin Reuptake Inhibitors (SSRIs)…
The Civil Aviation Medical Examiner and You
the civil aviation medical examiner and you
The Civil Aviation Medical Examiner and You
Debrief
It is interesting to note that in 2008, the average life of
many electronic items is now measured in mere months,
before they become outdated. A three-year-old computer
may as well have been unearthed in an archaeological dig
when you try to get it serviced. “Sorry, pal; we don’t support
that model any longer. It’s way out of date.” Technology and
change surround us at an ever-quickening pace. All the
same, we still cling to ancient dark concepts of chance,
luck and inexplicable things that go bump in the night.
Granted, there is an undeniable element of randomness
to events. Bad things do happen to good pilots, like
lightning strikes on a relatively clear day, for example.
However, accidents are more commonly a result of poor
planning and multiple factors—many of which could
have been mitigated earlier—than bad karma. Yet, how
often do we hear the rationalization, “it was just bad
luck that caused the accident ”? It wasn’t bad planning,
questionable decision making, or pressing on into forecast
bad weather, but rather, some malevolent force that
determined the outcome of the flight. “It wouldn’t have
mattered what the pilot had done—their time was up.”
An old novel about unlikely aviation accidents and
inevitability, entitled Fate is the Hunter by Ernest K. Gann,
is one of the first and best of the “mysterious airplane
crash” genre. It explores the consequences of luck running
out and being in the wrong place at the wrong time. It is
still available, and a good read if you want to delve a little
deeper into the subject.
Good
Fatigue
Personal problems
Worsening weather
Low fuel
Unseen wires
New on type
Low experience
Pushy customer
Outstanding snags
Well-rested
Happy
Good weather
Lots of fuel
Familiar area
Experienced
Respected
Well-maintained aircraft
LUCK
% x 10
Luck Percent
0-30 percent continuous operation
30-100 percent 30 minute operation
100 percent maximum luck calibration
Note:
Continuous operation in caution range
will result in reduced pilot life.
A luck meter: think about it! Because of the obvious
connection between high-risk activities and resulting
bad luck (cause and effect?), such an instrument would
be without equal for keeping us safe. As good luck—not
surprisingly—most often follows solid safety practices,
the luck meter would indicate movement into the realm
of chance, which is really a loss of control of one’s destiny.
The readout would let pilots know when they are on
relatively safe ground, or rolling the dice.
Accordingly, I have listed some of the common causes of
good and bad luck on the appropriate sides of the luck
meter. There are many more, but you get the idea. The
grey arc indicates a minimum level of risk that leaves little
to chance. The idea is to start a flight with solid safety
practices in place, and to minimize dependence on luck
wherever possible.
The likelihood (I almost said “chance”) of unpleasantries
increases as the needle moves away from the grey arc— and
a predictable conclusion—into the beige, and finally into the
purple. At 100 percent, you are flying completely on luck. This
is the point where the guardian angels bail out. Brief forays
beyond 100 percent may leave pilots with an interesting story
for the bar crowd—if they survive. Most of us have one or two
of those life- and consciousness-altering moments when the
luck almost ran out. Some others didn’t come back.
The hard work’s done. Now we just need an avionics whiz
to put this concept into action! With any luck, we should
make a million.
With thanks to Bill Yearwood, Regional Manager,
Transportation Safety Board of Canada, Pacific Region
40
ASL 3/2008
Debrief
A few months back, I had the pleasure of joining an old
friend, whom I had not seen for a long time, for coffee.
As it happens, he is now a regional manager for the
Transportation Safety Board of Canada (TSB). We were
discussing some of the more recent accidents, and trying
to figure out if there is any common thread among them
that might alleviate the toll. After a thoughtful pause, he
proceeded to sketch out a rough draft of a “luck meter”
on a paper napkin. He reasoned that since so many folks
believe in luck, and perception is reality, there should
be such an instrument in every helicopter. Rather than
a pilot having vague unpleasant feelings about how the
flight is progressing, a luck meter would clearly indicate
the current state of affairs. The common reaction of denial
until it’s too late when things aren’t going well, would be
vanquished forever!
Bad
Debrief
Debrief
by Rob Freeman, Program Manager, Rotorcraft Standard, Operational and Certification Standards, Standards, Civil Aviation,
Transport Canada
Debrief
Debrief
The Luck Meter—Don’t Leave Home Without It!
The Civil Aviation Medical Examiner and You
debrief
Transport
Canada
Transports
Canada
TP 2228E-3
(06/2008)
Below 10 000 ft
When we consider that the change in atmospheric pressure is greater at the lower altitudes, where most
of general aviation’s flying is done, we must take some time studying its effects.
The ear
To put it simply — as you go up, gas expands, and as you come down, gas contracts. In the ear there is a small
air space behind the eardrum that is connected with the throat through two narrow tubes. It’s through these
narrow tubes that the air behind the eardrum is equalized to the outside atmospheric pressure.
As you climb and the outside pressure decreases, the eardrum will bulge and may give a fullness sensation and
pain. You may feel a “clicking” when the eardrum bounces back into place as the air is ventilated into the throat
through the narrow tubes — now the pressure is equalized.
During descent, the reverse happens. However, the flutter valve at the end of the narrow tubes might not work
so well. You can usually alleviate the problem by swallowing, yawning or closing your mouth, holding your
nose and blowing gently (valsalva). The big problem will arise if you have a headcold, sore throat, ear infection,
sinus trouble or any condition that will cause the tubes to swell. This will prevent the inner ear air pressure
from equalizing with the outside, causing severe pain. A simple rule:
• ifyoucannot“click”youreardrumsbyvalsalvaontheground—don’tfly.
• ifyoucanclearyourearswithslightdifficultyontheground,youmaydecidetofly—butbeprepared.
Assume that you will have trouble on descent.
The sinuses
Those wretched holes in the head can create serious difficulty for some people. A blocked sinus can create
visual problems, toothache, or other severe head pain. Unlike the ear, the air in the sinus is free to come and
go during ascent and descent. An infection or allergy tends to close the sinus aperture; this can result in air
escaping on ascent, but not being able to enter on descent. It is advisable that:
• ifoneorbothsinusesarecompletelyblockedandwillnotclearbyasimplesniff—don’tfly!
• ifoneorbothnostrilscanbepartiallyclearedbysniffing—proceedwithcaution.Sniffhardonascent
and at altitude to get the passages as clear as possible. Plan for discomfort on descent.
• ifthecongestionisassociatedwithanykindoffeverormalaise—don’tfly!
The vision
The retina of the eye is more sensitive than any other part of the body to an insufficiency of oxygen in the
blood. Night vision is especially affected as there is a reduction of 25 percent by the time you reach 8 000 ft.
Breathing oxygen will alleviate the problem. But here’s more — since blood absorbs carbon monoxide more
readily than oxygen, smoking three cigarettes in a row will reduce your night vision by 25 percent as well.
Alcohol intake will also severely reduce night vision.
The brain
Since the brain needs oxygen for proper functioning, and alcohol reduces the amount of oxygen that the blood
can carry, any ascent will further impair the brain. After some alcohol consumption if you fly at 8 000 ft, your
brain may be flying at 20 000 ft—in this case you may pass out within 10 min. If you consider that your body
may take up to 48 hr to recover from excessive alcohol consumption, planning a flight takes more than just
looking at the weather.
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