debrief
Transport
Canada
debrief
Transports
Canada
TP 185E
Issue 2/2008
Debrief
•
•
•
The International Civil Aviation Organization (ICAO)
Convention on International Civil Aviation, to which Canada
is a signatory, currently requires that aircraft engaged
in international operations carry at least one automatic
ELT that operates simultaneously on both 406 MHz and
121.5 MHz. Since Canada has an obligation to adopt these
standards, Transport Canada’s Civil Aviation Directorate
convened an Issue Analysis and Risk Assessment Team
on February 5, 2007, to determine how the Canadian
Aviation Regulations (CARs) can best accommodate these
changes, while being responsive to the concerns of the
Twenty-eight highly qualified participants from industry and
government, having a wide range of technical and operational
expertise, met over eighteen formally scheduled meetings
between February and June 2007. The Team consisted of
representatives from the Canadian Forces, the National
Search and Rescue Secretariat (NSS), Transport Canada,
the Canadian Owners and Pilots Association (COPA),
the Air Line Pilots Association (ALPA), the Air Transport
Association of Canada (ATAC), and the Air Canada Pilots
Association (ACPA).
Based on the results of their work, Transport Canada
has drafted a performance-based regulation to include
406 MHz ELTs as well as acceptable alternative
systems. The ultimate objective is to ensure that after
February 1, 2009, SAR authorities can continue to be
promptly notified of the occurrence and location of an
aircraft accident. The proposed changes to the CARs were
presented in Ottawa on November 20, 2007, at a special
meeting of the Canadian Aviation Regulation Advisory
Council (CARAC) Part VI Technical Committee—
General Operating and Flight Rules. The regulatory
proposal is currently being prepared for submission to the
Department of Justice for subsequent publication in the
Canada Gazette.
Updates on the regulatory process will be covered in future
issues of the Aviation Safety Letter (ASL), and are available
on the CARAC Web site at: www.tc.gc.ca/civilaviation/
regserv/affairs/carac/menu.htm. For more information on the
COSPAS-SARSAT system and the switch to 406 MHz,
visit www.cospas-sarsat.org and the NSS Web site at:
www.nss.gc.ca.
aviation safety letter
In this Issue...
Best Practices in Controller—Pilot Communications
Disruptive Passenger Behaviour—Creating a Safer Environment
Declaring an Emergency
Longline Accidents—Another Perspective
Hot Air Balloon Fuel Cylinders
Dangerous Goods in Transport: Reporting Requirements
Goodbye, 121.5: Major Changes Are Coming
to the SAR Satellite System on February 1, 2009
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
"Debrief"
Transport
Canada
I Chose to Live: A Moving Account by an Air Tragedy Survivor
Inspection Levels Part 2: Detailed Inspection Please!
Air Traffic Services–Pilot Communications Working Group
Debrief
•
Always use proper phraseology.
Give full readbacks, including your call sign.
Reduce multi-tasking while communicating:
– Pilots—have both crew members listen to clearances whenever possible;
– Air traffic services—actively listen to readbacks.
If in doubt—ask! Do not clarify ambiguity within the cockpit and do not use a readback
as confirmation.
If you think a transmission has been blocked, say something.
Be vigilant for similar call signs on the frequency.
Do not accept poor communication practices from others—insist on proper phraseology..
With these changes, after February 1, 2009, the 121.5 MHz
ELT from a downed aircraft will not be detected by the
satellite system. Alerting of the SAR system could be
significantly delayed, adversely affecting the survival of pilots
and passengers and causing anguish to friends and families.
Since the Government of Canada has an obligation to search
for missing aircraft, delayed notification and the possibility
of extended visual search missions also strains resources
and increases the exposure to risk for SAR personnel,
including the Canadian Forces and the volunteers of the
Civil Air Search and Rescue Association (CASARA).
While equipping aircraft with 406 MHz ELTs ensures
uninterrupted access to the COSPAS-SARSAT system,
concerns have been expressed by aircraft owners about the
high cost to buy and install this equipment.
aviation community. This included evaluating alternative
technologies for ensuring the prompt notification and
location of downed aircraft.
Debrief
•
•
•
Debrief
You can help to prevent them!
On February 1, 2009, the international search and
rescue (SAR) satellite system, COSPAS-SARSAT, will no
longer process signals from 121.5 or 243 MHz emergency
locator transmitters (ELT). Why? As of that date, the
system will complete its transition to digital 406 MHz-only
technology, which presents a faster, more capable, and more
reliable form of distress alerting. The switch to 406 MHz
emergency beacons has been made across Canada and around
the world by marine and land-based users.
Debrief
Communication errors are leading contributors
to losses of separation and runway incursions
by Nancy Lugg, Aerodrome Safety Engineer, Policy and Regulatory Services, Civil Aviation, Transport Canada
Debrief
Debrief
Goodbye, 121.5: Major Changes Are Coming to the SAR Satellite System on February 1, 2009
Transports
Canada
*TC-1002613*
40
ASL 2/2008
TC-1002613
Please address your correspondence to:
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
Sécurité aérienne — Nouvelles est la version française
de cette publication.
Copyright:
Some of the articles, photographs and graphics that
appear in the Aviation Safety Letter are subject to
copyrights held by other individuals and organizations.
In such cases, some restrictions on the reproduction of
the material may apply, and it may be necessary to seek
permission from the rights holder prior to reproducing it.
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2008).
ISSN: 0709-8103
TP 185E
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Regulations and You
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Table of Contents
section
2
ASL 2/2008
— On October 4, 2007, the pilot of a Champion
Aeronca 7AC tried to start the engine with the
propeller because the aircraft is not equipped with a
starter. Beforehand, the pilot had put chocks in front
of the main wheels. The engine did not start on the
first attempts, which led to the need to use the priming
pump and readjust the throttle. When the engine
started, it was at high power. The main wheels jumped
over the chocks and the aircraft turned and struck a
parked advanced ultralight. TSB File A07Q0197.
— On October 5, 2007, an EC120B helicopter was in
cruising flight when the engine (a Turbomeca Arius 2)
chip detector light turned on. Since the aircraft was
only two minutes away from its destination, the pilot
continued the flight. A few seconds later, the low
engine oil pressure light turned on, followed by the low
main rotor rpm warning horn. The pilot conducted an
autorotation toward an old logging road. During the
flare, the vertical stabilizer under the enclosed tail rotor
broke. The aircraft occupants were not injured. The
chip detector had turned on three weeks prior to this
incident. TSB File A07Q0198.
— On October 6, 2007, a Bell 204C helicopter was helilogging when the pilot smelled something burning.
The burning smell very quickly became stronger and
the helicopter began to rotate. The rotation increased
abruptly. The pilot rolled off the throttle and entered
an autorotation from about 200 ft above ground
level (AGL). The rate of descent increased during
the approach, and collective had little effect. The
helicopter landed hard in the chosen landing area
and was substantially damaged. There was no fire.
— On October 11, 2007, the pilot of a Cessna U206F
was circling Kearns Lake, Ont., to look for a missing
boat for an outpost camp. Hunters in the area observed
the aircraft circle the lake several times at low altitude.
During one tight turn at low altitude and high engine
power, the nose of the aircraft dropped and the aircraft
struck the lake. The pilot, who was alone in the aircraft,
sustained fatal injuries. TSB File A07C0189.
— On October 13, 2007, a Piper J-3 floatplane
stalled while circling a moose at 500–600 ft above
ground level (AGL). The pilot increased power, but
there was insufficient altitude to avoid hitting the
trees. The floats hit the trees first, then the aircraft
flipped over. The two occupants were not injured.
TSB File A07Q0206.
— On October 28, 2007, a Cessna 172L took off VFR
from Golden, B.C., for Edmonton City Centre, Alta.
The weather was poor with low ceilings and visibility.
A severe lee wave significant meteorological
information (SIGMET) advisory was in effect.
The aircraft was located by a ground search in the
Redburn Creek, B.C., area about 10 NM north of
Golden. The pilot and one passenger were fatally
injured. The second passenger sustained serious
injuries. TSB File A07P0369.
— On October 30, 2007, an Aerospatiale Astar AS350 D
helicopter was executing longline geodetic surveying
operations with a “bird” (an aerodynamically-shaped
pod full of electronic gear and sensors carried on a
longline). While manoeuvring to regain sight of the
sling load, the longline struck the tail rotor; a loss
of control ensued. The aircraft was destroyed when
it crash-landed in a swamp. The pilot and passenger
were not injured. TSB File A07Q0220.
— On October 31, 2007, a Beech 99 was departing
from the John F. Kennedy International Airport
in New York City, N.Y., for Hamilton, Ont., on a
scheduled cargo flight, with two pilots on board.
The flight crew were cleared for an intersection
takeoff on Runway 31R from Taxiway Echo. On the
take-off roll, both pilots heard and felt a single bang,
followed shortly after by several more intense noises
and bangs. The aircraft was aligned with the runway
lights on the right edge of the runway, instead of
the runway centerline lights. The crew aborted
the takeoff and taxied clear of the runway. Initial
inspection revealed damage to the nose landing gear
wheel and the propellers. TSB File A07F0186.
ASL 2/2008
39
Look out — Listen out — Speak out
The risk of mid-air collision is greatest from takeoff to top of climb, and again from start of descent to
landing. Don’t assume you’ll always be able to “see and avoid.’’ You, the pilot, are responsible for your own
separation and lookout. These tips will help.
Look out: Stay focused on looking outside.
Don’t let routine tasks (programming GPS, paperwork, etc.) or familiarity with an aerodrome
cause you to relax your lookout. Consider adopting “sterile cockpit” procedures while climbing or
descending. Cockpit activities should focus on lookout.
Complete most checks and briefings prior to descent so you can concentrate on procedures
and lookout.
Listen out: Let your ears be your eyes.
Always monitor the recommended or mandatory frequency (MF).
Get on frequency well before entering the aerodrome traffic frequency (ATF) or MF zone to
establish traffic awareness.
Monitor the ATF or MF throughout climb and descent.
Speak out: By verbal, visual and electronic means.
Keep others aware of your position.
Transmit initial advisories and updates on the recommended or mandatory frequency giving your
position, altitude, intentions and estimated time of arrival (ETA).
Accident Synopses
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Flight Operations..............................................................................................................................................................15
Maintenance and Certification........................................................................................................................................24
Recently Released TSB Reports......................................................................................................................................27
Regulations and You.........................................................................................................................................................33
Accident Synopses............................................................................................................................................................38
Debrief: Goodbye, 121.5: Major Changes Are Coming to the SAR Satellite System on February 1, 2009..............40
Communication errors are leading contributors to losses of separation and runway incursions.................................Tear-off
Look out—Listen out—Speak out.................................................................................................................................Tear-off
Accident Synopses
page
— On October 2, 2007, the Back Bone Silver 125
powered parachute was on takeoff, when the
pilot noticed that his aircraft was drifting. He
compensated by using the opposite elevator to
maintain control of his aircraft, and at the same
time, attempted to reposition himself in his harness.
While doing this, he accidentally reduced the engine
power, and the aircraft stalled at approximately
15 ft above ground. The pilot broke his shoulder.
TSB File A07Q0196.
The pilot sustained back injuries, but was released
from hospital a day later. Inspection of the helicopter
revealed that the tail-rotor drive had disconnected
from the main transmission. TSB File A07P0344.
Regulations and You
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact:
— On September 16, 2007, a privately-owned, floatequipped, BushCaddy L-160 touched down on
Wolverine Lake, Ont., and immediately a gust
of wind lifted the aircraft off the water surface. A
second touchdown attempt was also unsuccessful. The
aircraft began to veer towards some cottages near the
shoreline, and the pilot managed to get the aircraft
to fly over the cottages, before the aircraft pitched
nose down and struck the ground. Both occupants
evacuated the aircraft and received no injuries.
TSB File A07O0256.
Recently Released TSB Reports
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Recently Released TSB Reports
Letters with comments and suggestions are invited.
All correspondence should include the author’s name,
address and telephone number. The editor reserves the
right to edit all published articles. The author’s name and
address will be withheld from publication upon request.
Note: Reprints of original Aviation Safety Letter
material are encouraged, but credit must be given to
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one copy of the reprinted article to the editor.
Transports
Canada
Maintenance and Certification
The Aviation Safety Letter is published quarterly by
Transport Canada, Civil Aviation. It is distributed to
all holders of a valid Canadian pilot licence or permit,
to all holders of a valid Canadian aircraft maintenance
engineer (AME) licence and to other interested
individuals free of charge. The contents do not necessarily
reflect official government policy and, unless stated,
should not be construed as regulations or directives.
Transport
Canada
Be conspicuous. Select position/strobes/landing lights “ON.” Transponders provide ATS and
traffic alert and collision avoidance system (TCAS) equipped aircraft with traffic avoidance
information. Turn them “ON.”
You can make flying safer—remember to:
Look out, Listen out, Speak out.
Guest Editorial
Guest Editorial
guest editorial
I would like to update you on a subject about which there has been much discussion for some
time now—the noise caused by seaplanes, and the increasing number of complaints and legal
action undertaken by residents and municipalities against this type of operation. It is an extremely
delicate subject, and the opinions of seaplane operators and residents are often diametrically
opposed. Transport Canada is regularly called upon to intervene in this kind of situation to help
the parties find tailor-made solutions. It turns out that, with a little co-operation, proper planning,
and by implementing some simple precautions, it is possible to reduce the number of decibels (the measure of sound) that
affect residents, and maintain or re-establish good neighbourly relations.
Let’s review some established facts about noise. I put them into three categories: the source, the surrounding factors, and
the hearer. This is not a complete list, and you may already know all the facts, but you may also learn new ones, or reflect
on them after making the list.
•
•
•
•
Two-bladed propellers make more noise than propellers with three blades;
Some types of engines produce higher decibels, especially at full throttle;
The intensity of the noise is less bothersome than repeated exposure, that is to say, a very loud noise for a short
amount of time is less bothersome than repetitive medium-intensity noise (touch-and-goes, for example);
The number of decibels decreases with distance, that is to say, if you take off further from shore, or fly over
residences at a higher altitude, the noise heard by the residents will be not be as loud.
To the Letter
To the Letter
Source
Surrounding factors
•
•
Hearer
•
What do we do with this information? Whether you’re a private pilot who uses a seaplane occasionally, or an operator
who carries out aerial sightseeing, be proactive. Consider the “noise” factor when choosing the type of aircraft being
used, contact the municipality and residents in the area before beginning your activities to find out their concerns, avoid
carrying out activities at “risky” times of the day; plan your take-off run in order to move away from the more densely
populated areas, and reduce climb power as soon as possible; adjust your path in order to have a steeper approach
angle (reduced engine) instead of conducting a low approach with a lot of power; avoid unnecessarily approaching or
overflying houses; maintain good communication with people; take the time to explain your safety requirements to
them; and lastly, try to find amicable solutions. In our experience, there is nothing more effective than communication,
respect, and trust to prevent the situation from getting out of hand. By following this advice, you will be able to fully
enjoy your favourite pastime as a private pilot, and if you work in the field, you will avoid negative publicity for your
company, and all kinds of legal procedures that result from conflicts.
Of course, you should never compromise safety to reduce noise at all costs, but it is often possible to integrate good
practices to manage noise without putting your safety at risk.
Flight Operations
Flight Operations
Noise tolerance differs from person to person. Studies show that some people are more sensitive to, and
bothered by, noise;
Noise tolerance varies depending on the activity being done, and the time of day. For example, noise at 6 a.m.
on a Sunday morning when we’re trying to sleep is much more annoying than the same noise at 2 p.m. on a
Saturday afternoon, when we’re working in the yard.
Pre-flight
Pre-flight
•
Wind carries sound downwind;
The landscape may prevent noise from dissipating. Thus, the hills that often surround lakes act as an amplifier.
Have a safe flight!
Diane Desmarais
Regional Director, Civil Aviation
Quebec Region
ASL 2/2008
to the letter
Recently released
Dear Editor,
We completed the pushback from gate X at airport Y. As
the pushback was completed, “Apron” gave permission to
Notan
used
Ops same gate. We were
Maint. positioned
& Cert.
airliner to taxi ontoFlt.the
directly in line with the lead-in line to the gate, as
instructed. As the other aircraft taxied onto the gate, our
ground crew and our aircraft were subjected to significant
jet blast, along with blowing snow and flying debris, as
been treated with chemicals
Notthe
usedramp had recentlyFeature
Pre-flight due to
icing conditions.
We said something on the radio to Apron about this
being ill-advised, but there was no meaningful response
and they gave us taxi instructions toward the de-icing
pad. The crew of the other aircraft never said a word.
Not used
Not used
Regs & you
There was no attempt by the ramp crew working the other
flight to stop their aircraft from entering the gate while
we (and our ground crew) were sitting directly in their jet
blast zone. Had they waited a minute or two, we and our
ground crew would have been clear of the area.
Our attempts to address
this issue with the other
airline
CivAv Med. Exam.
Not used
and with the airport were unsuccessful. One tried to
deflect the responsibility for this incident onto the other,
and the other gave no response at all. I would argue that
they certainly weren’t in keeping with the spirit of safety
management systems (SMS).
There were opportunities to prevent this. Apron could
have asked them to hold until we were clear, but even
prior to that point, the pushback should never be done
“straight back” behind the gate, and the aircraft should
never be allowed to taxi directly in front before the
departing aircraft has cleared the line. At most major
airports, ground crews will be instructed to push an
aircraft “around the corner” so that access to the gate is
clear for the next arrival. This also prevents a situation
where two aircraft are pushed back in parallel, potentially
Name withheld by request
Vectors in the air, progressive taxi on the ground
Dear Editor,
I would like to clarify a comment made in the article
“COPA Corner—Runway Incursions—Your Part,”
published in Aviation Safety Letter (ASL) 4/2007. In
the second-last paragraph, the author suggests that “At
controlled airports, you have help available—don’t be
afraid to ask ATC ground control for vectors to the
runway or ramp to avoid ending up in the wrong place.”
Controllers are not permitted to provide directional
guidance in the form of vector headings, even if using
airport surface detection equipment (ASDE) (ATC
MANOPS 307.5). They are, however, permitted to
provide directional instruction (also known as progressive
taxi) such as: “TURN LEFT/RIGHT AT THE NEXT
TAXIWAY/RUNWAY,” or “TURN LEFT/RIGHT ON
TAXIWAY/RUNWAY (number) APPROXIMATELY
(number) FEET AHEAD.” We felt that the distinction
should be made to the ASL readership.
Ann Lindeis, Ph.D.
Manager, Planning and Analysis, Safety and System
Performance Development
NAV CANADA
Thank you Dr. Lindeis. The Canadian Owners and Pilots
Association (COPA) confirmed that the intent was to let
readers know that at unfamiliar or complex airports, pilots
should not be afraid to ask for assistance so as to minimize
runway incursions. “Progressive taxi” is a term that is better
known and employed more often in the U.S. than it is in
Canada, so the author probably wanted to use another term
that better described the intent. —Ed.
ASL 2/2008
Flight Operations
Flight Operations
Many pilots refer to the Apron folks as “apron control,”
when in fact they are an advisory service. They do not
“control” the flow of traffic on the ramp. It is their job
to encourage a smooth and efficient (and hopefully safe)
flow of traffic on the ramp. As per section RAC 1.2.4 of the Transport Canada Aeronautical Information
Manual (TC AIM), “This service normally includes gate
assignment, push-back instructions, and advisories on other
aircraft and vehicles on the apron.” So, it must be up to all
parties involved (airport management, “Apron,” pilots and
ground crews) to watch out for areas of potential risk to
other persons and equipment on the ramp.
Finally, ground crews should be able to recognize such a
developing scenario and stop it. They can cross the wands
for a couple of minutes until the departing aircraft and
their ground crews are no longer in the jet-blast danger
zone. Let’s be careful out there!
Pre-flight
Pre-flight
Not used
forcing one crew to blast the other aircraft as they taxi
away from the ramp. I’ve seen this happen at this airport
on several occasions. Crews should also know it is unsafe
to taxi in front of another aircraft lined-up with the gate.
To the Letter
To the Letter
Not used
TSB reports
Apron jet-blast—let’s be careful out
there
Guest Editorial
Guest Editorial
To the letter
pre-flight
Guest Editorial
Guest Editorial
Best Practices in Controller-Pilot Communications......................................................................................................... page 5
Disruptive Passenger Behaviour—Creating a Safer Environment................................................................................ page 7
The SAC Column—Book Report: Blink......................................................................................................................... page 9
Doing the Right Thing....................................................................................................................................................... page 10
COPA Corner—Ramp Rash (Hangar Rash)................................................................................................................. page 12
Transport Canada Civil Aviation: An Update on the Reorganization......................................................................... page 13
Pre-flight
Best Practices in Controller-Pilot Communications
Regs & you
As an aviation professional, you learned the fundamentals
of proper radio communication early on in your training.
As a fledgling pilot, air traffic controller or flight service
specialist, you wrote exams on the phonetic alphabet
and
the meaning of certain key words and phrases,
Not used
while your instructors tried to instill good practices in
communicating over the radio.
The simple answer
is quite frequently.
And as you progressed in your career, you were regularly
tested, and during those times you did things the way you
were taught. Between tests, however, in the real world,
things are often done a little differently…
Typical errors
Direct controller-pilot communications are a critical link in
the safe, expeditious flow of air traffic. To provide separation,
it is imperative that controllers and pilots have the same
understanding of the trajectory the aircraft will follow.
Built-in checks
Controller-Pilot Communication Loop
Acknowledge or
Correct
ATC Clearance
Sidney Dekker describes the reasons for drift within a
system and the possible impact. We drift because we
depart slowly from the ideal, and we get away with it.
Transmit
It is a quiet day and there is not a lot of traffic so, as a pilot,
you drop your call sign when reading back a clearance. The
controller knows your voice anyway, and nothing happens…
Others may notice the non-standard phraseology, but they
don’t say anything.
Pilot’s
Readback
Transmit
Take a moment to consider how frequently practices
differ from the ideal we learned early in our careers, when
it comes to controller-pilot communications.
How often do we hear non-standard phraseology,
readbacks that are “close-enough,” incomplete call signs
being used, or no call signs at all?
This represents a considerable drift from the way the
system was designed to function to the way it actually
functions.
As a controller, you notice and you are frustrated by it, but
you either don’t have the time, or don’t take the time, to insist
on a full readback. You figure there is no point, because if you
took the time to correct every pilot using poor phraseology,
you wouldn’t have time to do anything else!
Prinzo, O. M. (1996). An Analysis of Approach Control/Pilot Voice
Communications. DOT/FAA/AM-96/26.
Dekker, S.W.A. (2004) “Why we need new accident models.” Journal
of Human Factors and Aerospace Safety, 4(1), 1-18. Ashgate Publishing.
ASL 2/2008
Flight Operations
Flight Operations
Listen
A significant portion of communications are non-standard.
Put another way, these non-standard communications are
not taking full advantage of all the checks in place within
the air transportation system.
Why we drift
Listen
Controller’s
Hearback
These errors included the incorrect grouping of numbers,
omitting elements of a message, substituting words or
phrases, transposing elements of a message, excessively long
messages, partial readbacks, trouble speaking, and difficulties
with pronunciation.
Pre-flight
Pre-flight
This is why controller-pilot communications contain
built-in checks to ensure understanding, including
standard phraseology and required readbacks of clearances
and instructions.
One study completed in the United States found that
over 40 percent of controller communications and
59 percent of pilot communication contained at least one
communication error!
To the Letter
To the Letter
by Joel Morley, Operational Safety and Human Factors Specialist, NAV CANADA
Guest Editorial
To the Letter
One of the reasons we continue to get away with it is that
the system is robust to such errors. There are multiple checks
in place to catch errors, and these checks work well most of
the time, so most of the time the errors are inconsequential.
1. Communication errors are common in aviation.
There is drift.
2. Few of these errors are consequential. The system is
robust to these errors.
. Communication errors have the potential for
significant consequences. There is risk.
In fact, one European study found the rate of communication
problems leading to a reported occurrence was quite low,
with an estimated 2.44 communication-related occurrences
per million instructions or clearances delivered. In other
words, not doing things “by the book” when it comes to
communication carries no real consequence.
From drift to problem
All of this leads to three conclusions:
So, what is being done to address this risk?
Working Group
To address this issue, NAV CANADA is forming the Air
Traffic Services-Pilot Communications Working Group.
There will, however, come a time when we won’t get away
with it. As Sidney Dekker points out, drift slowly erodes
defences, reducing the effectiveness of the checks that are
in place to maintain safety, and thus increasing risk.
Made up of representatives from across the aviation
industry, the Working Group will identify means to raise
awareness of the potential impact of communication
errors on safety.
What if that clearance you read back without including
your call sign wasn’t for you? What if you responded to it
simply because you were nearing top of descent and you were
expecting it? And what if, as a controller, you didn’t notice
that it was not the right voice accepting the clearance?
The output of the Working Group will be materials
designed to raise awareness of the importance of employing
best practices in controller-pilot communications.
Van Es, G. (2004). Air-Ground Communication Safety Study: An
Analysis of Pilot-Controller Occurrences. Brussels: Eurocontrol.
An ATS OPERATING IRREGULARITY is defined as: a situation
which occurs when air traffic services are being provided and when
a preliminary investigation indicates that safety may have been
jeopardized, less than minimum separation may have existed, or both.
The following Web sites have more information: www.allclear.
aero or www.caa.co.uk/docs/33/SRG-NATS_RTDISCIP.PDF.
There are some simple steps we can all take to begin
addressing this issue:
1. Examine your own communication practices. Are you
using standard phraseology? Are you providing full
readbacks to clearances and instructions, including
your call sign? Are you keeping the controller fully
informed of your intentions?
2. Insist on best practices from others in your cockpit and
your company. Help stop the drift by saying something
when you see non-standard communication practices.
We all know how to communicate properly on the radio.
We learned early on in our careers. We need to make sure
we are doing things right!
ASL 2/2008
Flight Operations
Although the occurrences investigated by NAV CANADA
did not result in loss of life, their potential should not be
underestimated. Communication errors have been shown
to contribute to the types of occurrences that carry the
greatest risk to aviation safety, including altitude busts,
runway incursions, and losses of separation.
This issue is not unique to Canada, and other countries
have recognized this problem as well. Similar working
groups have already been formed in the UK and Europe,
and have produced some interesting material on
communication errors.
Pre-flight
As part of our ongoing safety management activity,
NAV CANADA investigates more than 300 operating
irregularities each year. These investigations are clearly
indicating that communication errors are a problem that
requires our attention.
Almost one-third of operating irregularities investigated
by NAV CANADA in 2005, had communication error
as a contributing factor. And almost one-third of these
communication problems were related to readback/
hearback errors on the part of the controller or the pilot.
Flight Operations
Conclusions
To the Letter
Pre-flight
It should also be remembered that the worst accident in
the history of aviation, in terms of loss of life, resulted
from the use of non-standard phraseology, when two 747s
collided on a runway in Tenerife in 1977.
Guest Editorial
Or, perhaps you are the flying pilot listening to your
colleague on the other side of the cockpit. You know it
is not quite right, but you don’t say anything because you
don’t want to look uptight, and everybody does that when
it is quiet. There is no adverse consequence, and nobody
seems put out by it, so we continue the practice and we
continue to get away with it.
Guest Editorial
To the Letter
by Erin Johnson, Cabin Safety Project Officer, Cabin Safety Standards, Standards, Civil Aviation, Transport Canada
Have you ever been on a flight that was disrupted by an irate,
intoxicated, or stressed-out passenger? If so, you were most
likely bothered by the increase in noise and commotion that
ensued. Perhaps you even experienced a sense of fear and
anxiety from the disruption. Not only do unruly passengers
create an annoyance for fellow passengers, they are also a
serious threat to the safety and security of the entire aircraft
operation. Unruly passengers hinder crew members’ ability
to carry out their duties, maintain order, and provide for
the safety of other passengers, other crew members, and the
aircraft itself. This, in short, is the aviation safety concern that
arises from disruptive passenger behaviour.
Background
In the mid-1990s, media headlines drew public attention
to several incidents involving unruly passenger behaviour.
The Air Transport Association of Canada (ATAC)
raised concerns about the increase in unruly passenger
incidents. ATAC also drew attention to the fact that there
was a lack of regulatory provisions to aid crew members
in responding to situations where passengers exhibited
unruly or harmful behaviour.
The public and air operators—sharing the responsibility
The two main areas of focus of the Working Group’s
recommendations included raising the travelling
public’s awareness and amending the Canadian
Aviation Regulations (CARs) with respect to unruly
passenger behaviour.
A public awareness campaign to inform the travelling
public of the dangers of interference with crew members
was launched in June 1999, and continues to be in place
today. Posters, brochures, and ticket stuffers—identifying
which behaviours would not be tolerated on board an
aircraft, and possible consequences to those behaviours—
are posted at airports and distributed to travellers.
Following this, in 1998, a Prohibition Against Interference
with Crew Members Working Group was formed, which
included members representing a variety of expertise. The
mandate of the Working Group was to define instances
of abusive and unruly passenger behaviour, determine the
need for a zero-tolerance policy for unruly passengers, and
recommend an effective strategy to reduce the number
of incidents of interference with crew members. Upon
completion of their mandate, the Working Group filed a
final report containing 11 recommendations, all of which
were accepted by the Canadian Aviation Regulation
Advisory Council (CARAC).
Pre-flight
Pre-flight
Disruptive Passenger Behaviour—Creating a Safer Environment
To the Letter
Following the events of September 11, 2001, the Public
Safety Act, 2002, was enacted by the Parliament of Canada,
which brought about amendments to the Aeronautics Act.
These amendments facilitate action against unruly passengers
and make it an offence to engage in any behaviour that
endangers the safety or security of a flight, or persons
on board, by interfering with crew members or persons
following crew members’ instructions.
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Flight Operations
please contact Joel Morley at NAV CANADA by e-mail
at morleyj@navcanada.ca.
Poster “Interference with crew members
is NOT tolerated” (TP 3382)
www.tc.gc.ca/CivilAviation/Publications/menu.htm#posters
Guest Editorial
If you would like more information about the Air
Traffic Services-Pilot Communications Working
Group, or would like your organization to be involved,
ASL 2/2008
Guest Editorial
Guest Editorial
are unruly. The regulations target the problem of unruly or
disruptive passenger behaviour, or what is often referred to as
“air rage.” They are directed at those passengers who indicate
by their words or actions that they may behave in a manner
that may create an unpremeditated hazard, rather than at
those individuals who board, or attempt to board, an aircraft
with the deliberate goal of destruction.
Zero tolerance
To the Letter
To the Letter
With these new regulations, air operators and private
operators are responsible for refusing to allow any person on
board who is displaying behaviour that may present a risk
to the safety of the aircraft, persons on board the aircraft,
or their property. All employees who meet the definition of
“operational personnel” will have the same decision-making
authority with respect to refusing passengers. “Operational
personnel” refers to the air operator’s employees whose duties
require that they interact directly with a person on board,
or about to board, an aircraft, and includes crew members,
gate and check-in staff, and their direct supervisors. This
definition does not immediately include baggage handlers
or catering personnel, unless the operator decides to include
them in its training.
The regulations will introduce a definition of “interference
with a crew member.” This phrase will be interpreted
as any action or statement, set out in the four levels
listed below, by a person on board, or about to board, an
aircraft that distracts or prevents a crew member from the
performance of their assigned safety responsibilities.
Pre-flight
www.tc.gc.ca/ CivilAviation/commerce/CabinSafety/RelatedSites.htm
In addition to the awareness campaign, new regulations
were drafted and published in the Canada Gazette, Part I,
in May 2007. The new regulations and their accompanying
standards are intended to address a need for provisions in the
CARs that will enhance the ability of air operators, private
operators, and their employees to deal with passengers who
An ounce of prevention is worth a pound of cure…
The new regulations focus on prevention through
the establishment of clear and precise procedures.
ASL 2/2008
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Flight Operations
Ticket stuffer “Interference on board an aircraft
will not be tolerated” (TP 13378)
All such incidents of interference with crew members will
require intervention by the affected operational personnel;
however, the response will be different depending on the
level. It will also be mandatory for all unruly passenger
incidents, except those categorized as level 1, to be
reported to the air operator. For level 1 incidents, a report
may be submitted voluntarily.
Pre-flight
The four levels of interference with crew members have
been identified and are harmonized with levels used by
other countries, such as the United States. They range
in seriousness from a minor incident (level 1) to an
incident causing a threat to safety (level 4). Examples of
interference with crew members include unacceptable
language, obscene or lewd behaviour, threats, tampering
with emergency or safety equipment, attempting to enter
the flight deck, and use of weapons. Essentially, it is any
behaviour that in its nature hinders the work of crew
members and poses a possible threat to the safety of a
flight and the travelling public.
The regulations will provide both travellers and crew
members with better resources and recourse, should an
Guest Editorial
Finally, with the new regulations, reporting will become
mandatory, and statistics will be required to be submitted
to Transport Canada every six months. These statistics
will provide the necessary information to track trends
and determine if the number of incidents has increased
or decreased.
A safer environment for passengers and crew members
With the launch of the awareness campaign and the
proposed new regulations in the CARs, Transport Canada
continues to work towards providing both passengers
and cabin crew members with a safe and hazard-free
environment by eliminating potential hazards associated
with unruly passenger behaviour.
The SAC Column—Book Report: Blink
by Dan Cook, Soaring Association of Canada (SAC)
To the Letter
To the Letter
Another new regulation will make it a requirement
for operational personnel to be trained on their
responsibilities and the company’s procedures in both
their initial and annual training. Such procedures should
include ways to avoid situations where passengers may
become unruly, and provide all employees with the means
and knowledge necessary to respond appropriately to
such situations. By recognizing signs that could lead to a
possible incident of interference, employees will be better
apt to diffuse it before it escalates. By reacting promptly,
incidents of greater safety threat will be lessened.
incident occur. They are not intended to ban passengers
for life, but rather to offer crew members a safe workplace,
and passengers safe transport to their destination.
Guest Editorial
Accordingly, air operators will be required to establish
procedures in their operations and flight attendant
manuals to assist employees in dealing with occurrences
of unruly behaviour, and to ensure that occurrences of
such behaviour are reported to the air operator.
The SAC submitted the following book report for publication in the Aviation Safety Letter (ASL). One of the issues the SAC
has been wrestling with in gliding flight safety has been why some pilots react and others don’t. In addition, the quality of the
pilot’s response in high-stress situations varies greatly. This is often labelled as pilot error in subsequent occurrence reports, but the
nagging question is, why? The book Blink discusses potential reasons, and it is why Dan Cook wrote the report. I personally find
it applicable to all pilots, not only to the gliding community. —Ed.
The book Blink explains how unconscious thinking
can have an impact on our decision-making process in
the “blink of an eye.” It shows why some people make
brilliant snap decisions, while others make less successful
ones. The book is recommended reading for pilots if they
want to help themselves understand human factors in
how we make decisions under pressure.
The author speaks about “adaptive unconscious” decision
making, and states, “we make very quick judgments based
on very little information. The adaptive unconscious
does an excellent job of sizing up the world, warning
people of danger, setting goals, and initiating action in a
sophisticated and efficient manner.” In flight, we use the
frontal lobe of our brain to analyze and make decisions,
but we are often making many more rapid decisions that
we are not consciously aware of. Gladwell states, “our
unconscious is a powerful force. But it is fallible. It’s not
a case that our internal computer always shines through,
instantly decoding the truth of a situation.” He further
explains that it is possible to learn when we can use this
ability and when we should be careful.
Gladwell points out that we use a process called “thin
slicing,” which is in our adaptive unconscious to make
snap decisions accurately. He gives examples of many
experts who can look at certain criteria and make accurate,
fast decisions. He points out that the quick decision is
often more accurate, since a detailed study often leads
to other factors or doubts clouding the issue. He states,
“thin slicing refers to the ability of our unconscious to
find patterns in situations and behavior based on very
narrow slices of experience,” and, “the truth is that our
unconscious is really good at this, to the point where thin
slicing often delivers a better answer than more deliberate
and exhaustive ways of thinking.”
Gladwell explains that we often function (most of the
time for some) on a kind of autopilot. We believe we are
making rational decisions, but we are often using thin
ASL 2/2008
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Flight Operations
Malcolm Gladwell is a staff writer for The New Yorker magazine, and formerly a business and science reporter at the Washington Post.
Pre-flight
Pre-flight
Book Report: Blink
Author:
Malcolm Gladwell
Publisher:
Little, Brown and Company, Time Warner Book Group, New York, NY, 2005
The last area the author touched on that I believe is
important to us as pilots was the physiology of acute stress.
Gladwell writes about how acute stress and the adrenaline
In summary, the author states that “our unconscious
thinking is, in one critical respect, no different from our
conscious thinking: in both, we are able to develop our
rapid decision making with training and experience.” I
believe this is a good human factors book to read and
add to your pilot library. It will give all pilots and flight
instructors food for thought; an insight into how they
perform and how training may be improved.
Pre-flight
Guest Editorial
To the Letter
Pre-flight
What does this mean for us as trainers of student pilots who
are learning to make decisions that will have to be made
quickly in the future? One could argue, based on Gladwell’s
book, that to be effective we need to do some analysis to
try to identify the underlying patterns that are important
in a situation. We may not be able to accurately identify all
the criteria for a thin-slice decision for the many aviation
situations that might constitute an emergency. Gladwell
explains that creating scenarios as close to real life as possible,
which would safely allow the student to experience what
should be done, could unconsciously develop thin-slicing
criteria for snap decision making. In aviation instruction,
scenario-based training (SBT) can help develop these useful
criteria in our student’s unconscious.
To the Letter
He discusses the issues of training for development of the
cognitive subconscious for decision making. He states, “I
think two important lessons are here. The first is that truly
successful decision making relies on a balance between
deliberate and instinctive thinking…. Deliberate thinking
is a wonderful tool when we have the luxury of time, and
the fruits of that type of analysis can set the stage for
rapid cognition. The second lesson is that in good decision
making, frugality matters.” Here, Gladwell explains
that “the most complicated problems have identifiable
underlying patterns, and when identifying these patterns
less is more…. To be a successful decision maker, we have
to edit.” This editing would have to be done unconsciously
for thin-slicing decision making.
we produce can affect our thinking. He writes that “Dave
Grossman, a former army lieutenant colonel and author of
On Killing, argues that the optimal state of ‘arousal’—the
range in which stress improves performance—is when our
heart rate is between 115 and 145 beats per minute (bpm).
After 145 bpm, bad things begin to happen. Complex
motor skills start to break down.” This is where many of us
feel as though things are happening in slow motion. He
continues with, “doing something with one hand and not
the other becomes very difficult…. At 175 bpm, we begin
to see an absolute breakdown of cognitive processing….
The fore brain shuts down, and the mid brain takes
over. Vision then becomes even more restricted.” At this
point some of us experience tunnel vision, “behavior can
become aggressive. At heart rates above 175 bpm the body
considers physiological control a non-essential activity.
Blood is withdrawn from our outer muscle layer, and
concentrated in the core muscle mass. This is to reduce
bleeding in case of injury. But that leaves us clumsy and
helpless.” He describes people having had difficulty dialing
9-1-1 or moving away from an approaching vehicle. You
will recall the discussion earlier on the brain injury in the
frontal lobe. Here they describe the fore brain shutting
down at 175 bpm, which has similar symptoms to the
“ventromedial” patient experiencing a lack of ability to
make a decision and take action. Sometimes we call it pilot
error, but we are victims of our own biology.
Guest Editorial
slicing and the previous associations we have made. Poor
decision making is often identified in human factors
following an aviation accident.
Doing the Right Thing
by Armin Shafai, Flight Operations Specialist, Mesa Airlines
If this had been a check ride, I am confident that this
pilot would have failed on the spot; and yet, here he was,
preparing to pilot a regional jet aircraft on a revenue
flight. Even worse is that I’m sure others were also
watching—possibly even a few of his passengers! Now,
what kind of confidence does that instill?
10
So here is my question: as pilots, why do so many of us
become complacent and lose the edge in our approach to
safety or the application of procedures—or put another way,
fail to do the right things consistently, 100 percent of the
time? I’m sure that at one point in his training days, this pilot
was shown that a proper walk around involves carrying a
checklist, and perhaps a flashlight, in one hand while actively
checking the condition and serviceability of the aircraft.
Let’s think of it this way, would we ever see a surgeon
sauntering into the operating room minutes before an
operation, holding a cup of coffee to see the patient
before starting the operation? If surgeons—highly skilled
and trained professionals—fail to observe the basic
precautions prior to an operation, they may risk causing
ASL 2/2008
Flight Operations
Flight Operations
During a recent visit to the Phoenix, Ariz., airport ramp,
I had the opportunity to observe a pilot conducting a
pre-flight walk around. Two things gravely concerned me
as I watched. First, the pilot was holding a cup of coffee in
his hand, and second, he was applying the concept of walk
around literally—a casual stroll around the aircraft.
Guest Editorial
To the Letter
For some pilots, it seems that each move up the aviation
career ladder signifies that standards can be relaxed and
a different approach can be adopted towards following
polices and procedures, and in the application of safety.
However, the challenge then becomes overcoming this
change in attitude or mindset, considering that nobody
forces them to cut corners during the walk around, take
off without a current weather briefing, or ignore a known
or suspected discrepancy prior to takeoff. In a sense,
this change in attitude is a form of self-induced barrier
towards doing things the right way.
One reason for this change in attitude could be the
belief that, “now that we’ve made it in the ‘big leagues,’
we no longer need to do the things we used to do
during our training days.” Perhaps we adopt this attitude
because we no longer need to demonstrate to someone
(instructor, flight test examiner) that we are proficient
in these skills. Perhaps since we are no longer assessed
on performing these minor—yet important—tasks, we
give less importance to completing them consistently
and effectively. Another self-induced barrier could be the
perception that others will view us as too “by the book”
or “going overboard.” Would we criticize our doctor or
surgeon for that?
Professionalism—when incorporated as part of our core
competencies—becomes the primary driving force in
overcoming the self-induced barriers towards complacency.
In wanting to be a professional, we will want to do the
right thing consistently, every time. The best part is that it
moves with us from job to job and is recognizable by all,
so whether we remain in our current position, or plan on
moving on to bigger and faster aircraft, professionalism
becomes our most notable and visible attribute. One of
the by-products of doing things the right way all the
time (professionalism) is consistency. When we become
consistent, we almost eliminate surprises, or—put
differently—we reduce or eliminate the “error” element
when paired with the word “human.”
Pre-flight
As our notable attribute, others who fly with us will
recognize this consistency and approach to doing
the job right, every time. It will encourage others to
emulate this attribute, or it will let them know they
can’t cut corners or skimp over policy or procedures,
thereby jeopardizing safety.
The author may be contacted via e-mail at
armin.shafai@mesa-air.com.
Flight Operations
Flight Operations
Here is where the often over-used word “professionalism”
comes into play. In my opinion, professionals are those who
apply their knowledge and skills in striving to do the right
thing consistently, every time. We cannot take a course in
“professionalism” to gain this attribute. Like any other skill,
professionalism must be learned, practiced, maintained
and built upon; if not, it will erode with time. The good
news is that our “professionalism” teachers are all around
us. We should simply look around, and while observing our
peers doing their job, ask ourselves who performs their job
correctly and consistently all the time, and who gets by with
performing the minimum required tasks, or uses shortcuts
all the time? Now, whom should we emulate?
The pilot was applying the concept of walk around literally
—a casual stroll around the aircraft.
To the Letter
Pre-flight
Guest Editorial
injury or possible death to their patient. If pilots—highly
skilled and trained professionals—fail to notice low
tire pressure during the walk around, they could risk
damaging the aircraft or causing injury or death not only
to themselves, but to the rest of the crew and passengers.
ASL 2/2008
11
COPA Corner—Ramp Rash (Hangar Rash)
Ramp or hangar rash is that mysterious set of dents that
appear on aircraft after ice storms (caused by too-zealous
line staff who don’t necessarily understand that broomsticks
and shovels are not the way to de-ice aircraft). Hangar
rash is also the dents in the wings, rudders, and tail caused
by aircraft being stacked closely together in hangars,
overlaid like a jigsaw puzzle, where the only person who
can untangle them is the one who put them together so
intricately in the first place.
Student-pilots jockeying their aircraft around the gas
pumps is another source of ramp rash. Trying to move an
aircraft around the fuel pumps, without contacting the ones
crowded in behind it, can be a task that goes beyond the
skills of most mortal humans. All in all, it sometimes seems
as though parking control on airport and flight-school
ramps is the thing we do worst in general aviation.
So what are the statistics? There really aren’t any because
the regulations don’t specify any reporting unless the
aircraft is under its own power. Damage caused by pushing
or pulling other aircraft into an aircraft is not reported, and
neither is hitting poles, fences, hangar doors, etc., with an
aircraft. Even when the aircraft is under its own power, the
need to report only comes if some major damage affecting
airworthiness takes place. We can also surmise that in some
cases major damage goes unreported—how much and what
percentage is unknown.
The fact that this kind of damage goes unreported does not
mean that there isn’t a problem. The aircraft maintenance
engineer (AME) at a particular flight school that has about
12
So what to do?
Well, one answer is efficient ramp organization. It should
be possible to refuel an aircraft after a flight without
having to move three other aircraft. Some careful planning,
good signage, and ramp painting clearly indicating which
way to go, as well as good training for all the pilots and
ground personnel are all ways to minimize the potential
for damage. Placement of the aircraft refuelling area is, of
course, critical!
Aircraft in the hangar for winter pre-heat should have
a clear way to move in and out of the hangar space,
minimizing the unnecessary movement of other aircraft.
Another answer is co-operation. Having enough people
to move aircraft in and out of the ramp area, placing
personnel so that the aircraft being moved is wellmonitored for clearance around the wings and tail, and
getting that extra set of eyes to watch and supervise the
whole process can help prevent an expensive mistake.
The last answer is attitude. Being aware and careful can
prevent expensive ramp rash.
As for the flight school I mentioned, it now has a
carefully-planned and painted circular refuelling
movement pattern instituted on its ramp; movement
and handling of aircraft is much safer and damage is
much more unlikely. This has apparently resulted in fewer
incidents of ramp and hangar rash, all of which means
more money for other uses.
Notes on abnormal occurrences
Pilots are advised that ramp or hangar rash should always
be followed by inspection by a competent person, usually
an AME.
Canadian Aviation Regulations (CARs): (see: www.tc.gc.
ca/CivilAviation/Regserv/Affairs/cars/PART6/605.htm#605_88)
605.88 (1) No person shall conduct a take-off in an aircraft
that has been subjected to any abnormal occurrence unless
the aircraft has been inspected for damage in accordance
ASL 2/2008
Flight Operations
Flight Operations
Well, it seems that the major problem comes from the
lack of planning in ramp layouts, and pilot and groundstaff training in ramp movements. We, in the pilot
population, have all been trained to taxi, communicate, fly,
land, take off, deal with emergencies, and even deal with a
forced landing, but we haven’t been trained to run a ramp
properly. In the ground-staff contingent, all too often, the
training comes on the job and from learning the hard way
by breaking aircraft.
For a flight school with razor-thin operating margins, this
amount was way beyond “affordable.”
Pre-flight
Pre-flight
All of the above begs the question: why don’t we do better?
10 aircraft was asked
recently, “what is
your estimated cost
of ramp rash every
year?” The reply was stunning: “About $20,000.”
To the Letter
To the Letter
Accidents and incidents are tracked across the aviation
system by Transport Canada (TC), NAV CANADA,
and of course, the Transportation Safety Board of
Canada (TSB). But who tracks ramp and hangar rash?
Most of us who have been around aviation long enough
know about it, have seen the results, and may even have
been responsible for it.
Guest Editorial
Guest Editorial
by John Quarterman, Manager, Member Assistance and Programs, Canadian Owners and Pilots Association (COPA)
Guest Editorial
CARs Standard 625, Appendix G—Inspection after
Abnormal Occurrences spells out what occurrences MUST
be followed by an inspection, and what must be inspected
(see: www.tc.gc.ca/CivilAviation/Regserv/Affairs/cars/Part6/
Standards/a625g.htm).
Guest Editorial
with Appendix G of the Aircraft Equipment and
Maintenance Standards.
(2) Where the inspection referred to in subsection (1) does not
involve disassembly, it may be performed by the pilot-incommand.
For more information on COPA, visit www.copanational.org.
Transport Canada Civil Aviation: An Update on the Reorganization
Pre-flight
While regulatory compliance and excellence within
the various technical areas within a company remain
fundamental components of any company’s approach
to safety, elements, such as recognizing the impacts of
organizational inter-relationships between various areas
of the company, proactive hazard identification and risk
analysis, and active monitoring/quality management
processes, will all contribute to a systemic approach to
safety within the Canadian aviation system. Such an
approach holds significant promise for improving the
Canadian aviation system’s already excellent safety record.
But what about Transport Canada Civil Aviation (TCCA)
itself? Throughout its history of regulating and overseeing
the Canadian civil aviation system, TCCA’s structure has
very much paralleled that of industry, with organizations
based on specific and technical aspects of the industry—
aircraft operations, maintenance activities, manufacturing
and engineering, air traffic services (ATS), etc. With the
requirement for industry to implement SMS, and with the
requirements of our own internal Integrated Management
System (IMS), TCCA has to ensure that it has the capacity
and the culture to work at the same systemic level that we
are demanding of industry.
Transport Canada’s
Headquarters: in Place de Ville,
Tower C, in Ottawa, Ont.
Multidisciplinary teams
As indicated above, TCCA has traditionally been
organized along functional and technical lines. Under
this organizational structure, companies involved in more
than one facet of the aviation industry would be audited
and inspected (“overseen”) by various Transport Canada
groups. For example, a national airline with a maintenance
organization would be overseen by separate, Headquartersbased groups involved with air operations and cabin safety,
while at the same time being overseen by regionally-based
maintenance, aviation occupational safety and health, and
dangerous goods groups.
As one of the foundational criteria for the TCCA
reorganization, we are moving to multidisciplinary
teams—integrated groups of personnel charged with all
aspects of oversight for the particular company involved.
Such changes have been reflected in the creation of a
National Operations Branch in Headquarters (charged
with the oversight of nationally-based airlines and air
navigation service providers), and in the creation of a
Combined Operations Group in some Regions (tasked
with oversight of regionally-based companies).
ASL 2/2008
13
Flight Operations
As part of this, TCCA undertook a review of its
organizational structure and is now in the process of
making transitional steps toward that new organization
through the National Organization Transition
Implementation Project (NOTIP). While NOTIP is
charged with the overall reorganization of TCCA, this
article examines the concepts of oversight of and services
provided to the aviation industry. Over the course of the
past year, several transitional organizational steps have
been taken in these activity areas, both at regional levels
and at Headquarters.
While these transitional
organizations will definitely
be subject to change as the
broader organization rolls
out, an understanding of
two of the major criteria
underpinning these steps
will give the reader a broader
view of the TCCA oversight
role in 2010 and beyond.
Pre-flight
Flight Operations
The implementation of safety management systems (SMS)
has brought, and will continue to bring, significant changes
to the way in which the holders of Canadian operations
certificates perceive and manage safety. SMS is moving
Canadian aviation companies from an environment that
focuses on safety within the individual, technical facets of a
company (operations, maintenance, air traffic control, etc.),
to one where a company manages safety at a systemic and
organizational level.
To the Letter
To the Letter
by Derek Howes, Program Manager, Business Planning and Quality Assurance, Program Management, National Operations, Civil Aviation,
Transport Canada
Guest Editorial
To the Letter
One of the other basic criteria established for the
reorganization is the idea of accountability. In a concept
closely related to multidisciplinary teams, TCCA intends
to have “accountable managers” or “enterprise managers”
assigned to specific companies. Under such a concept,
companies will be able to deal with one Transport Canada
enterprise manager for “one-stop-shopping” in areas such
as certification, on-going Transport Canada oversight, etc.
As indicated in the above section on multidisciplinary
teams, Transport Canada responsibilities are currently
split amongst a number of groups—often between
Headquarters and Regions.
Such enterprise teams and enterprise managers have been
established in Headquarters as part of the formation
of the transitional National Operations Branch.
Major national airlines have been assigned to specific
enterprise team leaders (ETL). In turn, each ETL has
a multidisciplinary team to support Transport Canada
activities with that company. Similarly, an accountable
manager, along with a team of diverse experts, is
responsible for Transport Canada’s work with Canadian
air navigation service providers.
Implications
While there are clear benefits associated with the two
above organizational criteria, there are also certain
implications that must be examined and planned for.
One of the major benefits in the existing TCCA
organization was the grouping of similar functional
experts. By having functional experts (pilots, aircraft
maintenance engineers [AME], etc.) working together,
work standardization was facilitated. An inspector had
14
Similarly to the response to work standardization, a “safety
intelligence” function has been identified as a fundamental
component of the new TCCA organization. Teams of
personnel, with appropriate analytical and risk analysis
background, will be put together in both Headquarters and
Regions, with a mandate to provide the risk information
needed to formulate the longer-term, strategic direction for
TCCA and the short-term annual plans.
Program management
Two issues were identified—work standardization across
multiple enterprise teams, and the need to gather and
analyze the “safety intelligence” point to a broader need
for strong and effective horizontal co-ordination amongst
the various enterprise teams. In response to this need,
the TCCA reorganization has identified the need for a
strong “program management” component in each of the
Regions and the Headquarters branches.
Summary
In implementing Flight 2010, SMS, and IMS, TCCA
is in the midst of a significant culture change—from a
technically-focused, transactional-based model of oversight
and regulation to a model that, while maintaining touch
with the technical aspects of the aviation industry, focuses on
overall companies and on the overall civil aviation system.
The transitional steps taken to implement enterprise
managers, enterprise teams, and put in place strong crossfunctional program management functions, are the first
steps in that cultural change.
We look forward to the rest of the journey!
ASL 2/2008
Flight Operations
Flight Operations
Work standardization
While the enterprise model facilitates the gathering of
system intelligence and the identification of hazards
at a company level, there is a need to integrate this
information at an overall, “civil aviation” system level.
Pre-flight
While such specific implementations of enterprise
management and enterprise teams will no doubt undergo
refinement and change as TCCA’s reorganization is
fully realized, clear benefits are immediately apparent—
companies receive one-stop service through one
accountable point of contact. At the same time, from
Transport Canada’s point of view, these teams facilitate the
systemic focus on the overall company.
System level intelligence
To the Letter
Pre-flight
Accountability
immediate access to a pool of other experts with the
same technical skills. Subject matter expert (SME)
managers were in place to ensure standard approaches
in that functional area. All of this facilitated common
work practices throughout the organization. With
cross-functional or multidisciplinary teams, such support
mechanisms are not “built-in,” and work standardization is
more difficult to achieve. This challenge has been recognized
and will be addressed as the reorganization rolls out.
Guest Editorial
Such a multidisciplinary team brings a more systematic
focus to the oversight of that company; TCCA is more
clearly able to see the linkages between all components of
the company and the broader challenges and risks facing
that organization.
TSB reports
Declaring
an Emergency.................................................................................................................................................... page 15
Maint. & Cert.
Longline Accidents—Another Perspective....................................................................................................................... page 16
Use of Incorrect Power-Setting References........................................................................................................................ page 18
I Chose to Live: A Moving Account by an Air Tragedy Survivor................................................................................. page 19
Inadequate Cargo Restraint............................................................................................................................................... page 21
The Importance of Proper Weight and Balance............................................................................................................... page 22
Pre-flight
David Charles Abramson Memorial (DCAM) Flight Instructor Safety Award......................................................... page 23
Flt. Ops
Feature
Guest Editorial
Guest Editorial
flight operations
Declaring an Emergency
by Mark Dixon, Civil Aviation Safety Inspector, General Aviation, Ontario Region, Civil Aviation, Transport Canada
What does it mean to declare an emergency? Is the pilot-incommand (PIC) going to have to face an inquiry? Does the
PIC have to pay for emergency services? Does the PIC need
permission to do this? Is declaring an emergency a really big
inconvenience to air traffic control (ATC) and other aircraft?
CivAv Med. Exam.
Not used
This article will look at declaring an emergency from a
decision-making standpoint, and shed some light on the
why and when to declare an emergency.
The (a/c type) turbojet aircraft (operating as XXXX) was
on an IFR flight from Chicago (O’Hare) International
Airport (KORD) to Ottawa MacDonald-Cartier
International Airport (CYOW). The flight crew reported
that they had a flap problem and requested to land on
Runway 32. They advised that they were not declaring
an emergency and that no emergency equipment would be
required. However, NAV CANADA tower staff declared an
emergency and the crash crews and airport duty manager
were advised. The aircraft landed without incident at
0329Z, and aircraft rescue and firefighting (ARFF) stood
down at 0330Z. Operational impact—unknown.
A CADORS report is generated by NAV CANADA and
is followed up by Transport Canada or the Transportation
Safety Board of Canada (TSB). When contacted, we like to
get details and discuss the incident. For all of the CADORS
reports that I have followed up, I have told the PIC that
declaring an emergency was a good decision, and that we
are following up from an “educational safety” point of view.
For the purposes of this newsletter, I ran the above
CADORS report by a wide variety of Transport Canada
inspectors, private pilots, flight instructors and senior
airline check pilots.
Pre-flight
Pre-flight
First, read the following report taken from the Civil Aviation
Daily Occurrence Reporting System (CADORS) and,
assuming you were the PIC, make a quick decision if you
would declare an emergency or not:
an emergency” or a “small emergency” leaves a lot of
uncertainty. You owe it to your passengers, crew, and
the aircraft owner to declare an emergency if you have a
problem that warrants it. ATC will only be able to coordinate emergency resources and help out if they know
you have a problem. If they are left out, or uncertain of
the degree of the situation, it makes it difficult to help.
Emergency services personnel are professionals who will
not give you a hard time about declaring the emergency—
it’s their job, and they are always happy to help. You will not
face an inquiry or be liable for fees or fines.
To the Letter
To the Letter
“TOWER, THIS IS HOTEL ECHO LIMA PAPA, WE ARE DECLARING AN EMERGENCY 10 MILES OUT,
4 PEOPLE
ON BOARD,
Not
used
Regs 1 000
& you POUNDS OF FUEL AND NO HAZARDOUS MATERIALS.”
Having declared many emergencies over the years, I feel
there is no such thing as a “slight” or “kind of ” emergency.
It is either an emergency or it is not. To decide if you
should declare an emergency depends on the situation. The
decision to declare should be made as early as possible, and
communicated to ATC right away. Generally speaking,
you should never be afraid to declare the emergency. If
the situation that you are experiencing is in any way, or
could become, unsafe or dangerous, declare the emergency.
Humming and hawing, delaying, declaring “kind of
Emergency vehicles responding to an aircraft emergency
Not surprisingly, the opinions varied wildly. Some pilots will
declare an emergency if their watch stops working within
a control zone on a VFR day; others would only declare if
ASL 2/2008
15
Flight Operations
Flight Operations
Well, would you or not? Let’s look at the situation.
Guest Editorial
To the Letter
When an emergency is declared, flight priority is also
being requested. It is then up to the pilot to decide if
emergency response vehicles (fire, ambulance) are needed
on site for the landing. This decision essentially rests
with the pilot, although NAV CANADA or the airport
authority may also call for emergency response vehicles
(as was the case in our CADORS report). Declaring an
emergency is not exactly the same as a MAYDAY or
PAN PAN call; however, they do often come together. A
MAYDAY is a situation of distress where safety is being
threatened by grave and imminent danger, and requires
immediate assistance. A PAN PAN call is used in a
situation of urgency where safety is threatened, but does
not require immediate assistance. To sum up, MAYDAY
and PAN PAN calls are the communication tools, and
declaring an emergency is the request for “flight priority.”
Whatever type of aircraft you are flying, chances are there
is another pilot or controller within radio range who has
been there and done that, and I have yet to meet one who
would not lend a hand.
When in doubt, don’t worry about it, and declare!
The answers to the five questions at the beginning, then,
are respectively: a bit of excitement, no, no, no and no.
Longline Accidents—Another Perspective
by Rob Freeman, Acting Program Manager, Rotorcraft Standard, Certification and Operational Standards, Standards, Civil Aviation,
Transport Canada
Since external load longline operations were invented,
there have been accidents due to the sling equipment
becoming snagged and then dragging down the
helicopter. Usually the aircraft ends up on its nose, with
high vertical g loading and fatal consequences for the
pilot, who (statistically) is likely not wearing an upperbody restraint, or helmet.
During the subsequent investigation, one question is
always asked, “why didn’t the pilot drop the load?” Friends
and associates are left puzzled by the apparent oversight
to do the obvious: if the load is snagged, release it! Some
of these snagged loads have occurred subsequent to
system malfunctions, and some were simply a result of the
crew not maintaining sufficient terrain clearance. In the
Transportation Safety Board of Canada (TSB) accident
16
report A03P0247, which began as an engine compressor/gas
producer problem and ended up as a complete engine failure
during the turnaround and approach to land, the TSB noted:
“The location of the external cargo release switch varies on
different helicopters and with different operators…. In the
accident helicopter, the switch position on the cyclic control grip
was not what the pilot was accustomed to…. Therefore, it is
probable that the pilot’s action during the emergency did not
activate the external cargo hook release mechanism and, rather,
that the trailing longline snagged a tree while the helicopter was
still airborne. This factor was an additional complication to the
survivability aspects of this accident; it could not be speculated
whether items such as the pilot’s safety harness or seat, or the
aircraft’s vulnerability to impact forces or post-impact fire would
have permitted the pilot to survive the impact.”
ASL 2/2008
Flight Operations
Flight Operations
Here’s an analogy to consider: You live next door to a
neurosurgeon, and someone in your house just slipped,
fell, and is unconscious. You look out the window and
your neighbour is washing his Lexus in the driveway.
Would you hesitate to run out and ask him to get his
wife to come over and diagnose your friend? (He is an
Embraer 145 first officer on three-months unpaid leave
for not declaring an emergency and not following SOPs
during a pilot proficiency check, so you wouldn’t want to
take his advice about any kind of emergency situation!)
Pre-flight
Every sound decision requires an assessment of the
situation and the various options. Sometimes you have
very little time to make a choice. Let’s assume time was
limited for our crew in the CADORS report; therefore,
the best choice in my opinion is the safest one—declare
the emergency and get ARFF on site. Taking the high
In general aviation, the need to declare the emergency
should be elevated. If you are a private pilot with 100 hr,
but only flew 15 hr in the past year, you should never
hesitate to get help. From my inquiries, the bulk of our
professional pilots have no problem requesting assistance.
To the Letter
Pre-flight
The Transport Canada Aeronautical Information
Manual (TC AIM) makes several references to
emergencies—SAR 4.1, COM 5.11, and RAC 1.8. Go
and look up these references, I’ll wait while you do this…
road will generate less second-guessing and doubt from
the crew, and allow you to proceed with checklists,
standard operating procedures (SOPs), briefings,
abnormalities, and ensure everyone is clear on the plan.
This should lead to the least risk to passengers, crew,
and others. Money concerns should be very low on the
consideration pole.
Guest Editorial
three of the four engines were on fire, the first officer was
incapacitated while doing an ADF approach to minima,
with no electrics, hydraulics, or hand held radio, 10 min of
fuel remaining, and no suitable alternate within 1 000 mi.
OK, that’s an exaggeration, but the feedback clearly makes
declaring an emergency a pilot decision-making topic.
Guest Editorial
To the Letter
ASL 2/2008
17
Flight Operations
I mention this accident because of the very sudden and
severe departure from controlled flight. Anyone who has
worked around a sling operation can tell you the ground
crew will normally watch the arrival and departure. Once
the helicopter is established in a climbout, interest wanes,
and people return to whatever it was they were doing. In
this case, the one witness stated that he turned, noticed a
splash, and couldn’t see the helicopter anymore. The fact that
the helicopter contacted the water in sight of the departure
point, after being initially monitored by several people,
means that the complete accident—from event initiation
Think about it. You are flying along at low level with a
load, and suddenly have to deal with some malfunction
or distraction, i.e. strange engine noises. Your mind is
occupied with the problem, what you are going to do,
plus where you are going, and the radio calls that need
to be made. It is normal pilot behaviour in this situation,
perhaps at the subconscious level, to instinctively lower
the collective to begin to reduce airspeed and altitude. This
may be the last link in the accident chain, as the clearance
between the ground and the load is inadvertently zeroed
out. There is a sudden and violent rearward tug on the
airframe, with banging noises due to fuselage contact
with the sling hook or gear. As the nose suddenly and
Pre-flight
In another longline accident (TSB report A00A0076), a
Bell 212 was slinging empty drums from a lighthouse. It
was the last load of the day, and the weather conditions
were favourable—clear, with a strong wind. For some
reason, shortly after takeoff, the helicopter descended until
water contact was made with the load, and all was lost. The
hook assembly was violently displaced 30° to the rear at
water contact. The rotor system suffered mast bumping and
shearing during the accident sequence. The tail boom and
the tail rotor assemblies separated from the aircraft in flight.
If you are lucky enough to be moving forward slowly
when the snag occurs, you may have time to recognize
the problem and save yourself. A helicopter with a 100-ft
longline, travelling forward at a relatively slow 30 kt, or
approximately 50 ft/s horizontally, will strike the ground
or water two seconds after snagging the load. At 60 kt,
you have one second. That’s not much time to react, even
for the best of pilots. Forward momentum is translated
into a circular acceleration vector toward the ground. This
phenomenon is dynamic pitch over, with the same causal
factors and potential for catastrophe as dynamic rollover.
To the Letter
Pre-flight
During external cargo operations, the load acts like a
pendulum, oscillating around the point of attachment—
the cargo hook. The pilot, through the judicious use of
the flight controls and a healthy measure of concentration
and skill, minimizes the oscillations. A good longline pilot
makes it look smooth and easy. It most definitely is not
either of those things, and is an area of helicopter flying
where good training, experience, and “seat-of-the-pants”
talent are irreplaceable.
Sadly, all of this can change very suddenly when the load
gets snagged on a tree or other ground-level object. The
delicate balancing act falls apart. As the line becomes taut,
the pendulum is reversed, and the helicopter effectively
becomes the “load.” All movement now occurs around
the fixed ground pivot point (the snag), and the resulting
flight path is an arc, until the helicopter strikes the
surface in a nose-low position. At the exact moment the
snagged line becomes taut, the centre of gravity will be
dramatically shifted far outside the limits of what can be
countered by the flight controls. Unless the line can be
slackened or the load released, recovery is impossible, and
the time to impact is only a few seconds away.
Artist’s impression of catastrophic contact between
a light sling load and the tail rotor assembly
Flight Operations
to crash—probably occurred in a matter of seconds. The
point here is that the reaction time to save the aircraft must
have been almost zero. Load/water contact, violent aircraft
pitching, mast shearing, and airframe immersion occurred
so quickly that only a single splash was seen. Again, why did
the experienced pilot not release the load?
Guest Editorial
It is true that the release switch placement may have
delayed or prevented the pilot from jettisoning the load.
However, this pilot had time to realize a problem was
developing with the engine, and had actually turned back
toward the take-off pad before snagging the line. There
was a reasonable amount of time to locate and activate
the release, and yet this was not done. Wouldn’t the wellexperienced pilot have depressed the emergency foot
release, if the primary emergency release could not be
quickly located? Another thought: no one wants to pickle
a load unless it is unavoidable. It may be that rather than
searching for the switch, the pilot was trying to get back
to the pad with the load intact, and delayed the release.
When the load became caught, the decision may have
been out of his hands, literally.
Guest Editorial
To the Letter
I encourage all pilots and operators who are involved in
external load operations, to have a look at the three TSB
reports referenced below for starters (A05Q0119 is also
profiled in the Recently Released TSB Reports section, on
page 29.) Make sure that everyone involved is clear on the
dangers and risks of longlining too close to Mother Earth,
and delaying the decision to release the load when things
start to go wrong. Otherwise, you could be next.
References:
www.tsb.gc.ca/en/reports/air/2000/a00a0076/a00a0076.asp
www.tsb.gc.ca/en/reports/air/2003/a03p0247/a03p0247.asp
www.tsb.gc.ca/en/reports/air/2005/a05q0119/a05q0119.asp
Use of Incorrect Power-Setting References
To the Letter
If your company only conducts external load operations
seasonally, such as on forest fires, it is especially important
that your training syllabus include some quality hands-on
practice to establish competency. Learning slinging skills
without a thorough qualification program is a very large
gamble. And all pilots are not created equal. Schedulers
and management should take into account individual
experience and ability before assigning personnel to these
activities. Slinging is a specialized skill that not everyone
can do well. In fact, some other countries’ aviation
authorities require special pilot licensing endorsements to
conduct external load operations. In Canada, we leave it
to the air operators to establish programs and training for
this potentially difficult task.
Guest Editorial
dramatically drops, and you sense an uncommanded,
steepening descent, wouldn’t your first reaction be to apply
aft cyclic, rather than releasing the load? And when the
nose drops further, wouldn’t the contradiction between
your aft control movement and the opposing airframe
reaction confuse and delay any other response? With only a
second or two between initiating event and surface contact,
this may preclude any other reaction until it is too late.
Is this “time crunch” during pitch over the root cause for
these accidents? You might recall how quickly a rollover
accident becomes inevitable once collective is increased for
comparison. It is a chilling thought.
Matheson Island is a registered aerodrome, elevation
725 ft, with one gravel-surfaced Runway 03/21, 3 500 ft
long, oriented 028° and 208° respectively. The observed
weather at Berens River, Man., 38 NM north of
Matheson Island, was as follows: temperature 18°C, winds
north-northeast at 4 kt. The winds at Matheson Island
were estimated as northwest at 10 kt, gusting to 18 kt,
producing a left crosswind component on Runway 03.
The aircraft had been modified, and the modification
increased the maximum approved gross take-off weight of
the aircraft from 7 000 lbs to 7 368 lbs. The aircraft’s gross
weight at takeoff was 6 978 lbs and the centre of gravity
was within approved limits.
On departure, the pilot conducted a rolling takeoff on
Runway 03 with a flap setting of 15° and an engine power
set to 2 575 rpm and 42 in. of manifold pressure. The
18
aircraft rotated near the departure end of Runway 03 at
about 72 kt. Almost immediately after liftoff, the right
engine lost power. The pilot raised the landing gear and
flaps, shut down the engine, and feathered the propeller.
The pilot completed several gradual turns to return to
Matheson Island. The aircraft did not climb above about
200 ft during the flight and did not accelerate to its
best rate-of-climb airspeed of 107 kt. The aircraft lost
altitude during the turns and the pilot was required to
carry out a forced landing. The right engine was recovered
and examined, and its turbocharger differential pressure
controller was found to be faulty. The fault would have
shut down the turbocharger and led to a significant
power loss. The aircraft was not equipped with any flight
recorders, nor were they required by regulation.
The aircraft’s engines were equipped with turbocharger
controllers designed to set maximum take-off power
automatically when the throttles are fully advanced.
The approved aircraft flight manual (AFM), Procedures
section, indicates that the take-off procedure is, in part:
“a. Throttles—full forward,” and, “b. Manifold pressure
(43 in. normal-static sea level, std. temp.)—checked.”
The AFM Limitations section indicates that each engine
is rated to produce 350 hp at 2 575 rpm and that the
maximum allowed manifold pressure below 15 000 ft is
49 in. The single-engine climb performance chart in the
AFM is based on a functioning-engine power setting
of 2 575 rpm, full throttle, landing gear up and flaps up.
The emergency procedure for an engine failure specifies
a power setting of “props—forward” and “throttles—
ASL 2/2008
Flight Operations
Flight Operations
On July 10, 2007, a Piper PA31-350 departed from
Matheson Island, Man., en route to Poplar River, Man.
Shortly after liftoff, the right engine (Lycoming LTIO540-J2BD) lost power. The pilot secured the engine
and turned the flight back to Matheson Island. The
aircraft lost altitude in the turns, and the pilot carried
out a forced landing in a marsh. The pilot and seven
passengers exited the aircraft and were taken to a
medical facility. One passenger suffered serious injuries.
The pilot and three passengers sustained minor injuries.
Three passengers were not injured. The aircraft sustained
substantial damage. The TSB investigation (A07C0119)
into this occurrence is ongoing.
Pre-flight
Pre-flight
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB).
Guest Editorial
To the Letter
The operator was using a quick reference handbook (QRH)
that had been compiled by the previous operator, and which
was provided to them when the aircraft was purchased.
The QRH listed various procedures and limitations,
including a take-off power setting of 2 575 rpm and
37 in. to 42 in. of manifold pressure. The QRH was not
approved by Transport Canada for their operation, and
it does not supersede the AFM. The operator’s use of
the QRH procedures had the effect of reducing manifold
pressure and engine power during the occurrence takeoff,
increasing the take-off distance and reducing the aircraft’s
airspeed and altitude, thereby placing the aircraft in closer
proximity to obstacles at the time of the engine power loss
during the initial climb.
Although this TSB investigation is still in progress and
findings as to causes and contributing factors have yet
to be determined by the Board, the operator’s use of
the unapproved QRH may have been a factor in the
occurrence, in that the aircraft was likely at a lower altitude
and airspeed at the time of the power loss than it would
have been had the correct procedures been followed.
I Chose to Live: A Moving Account by an Air Tragedy Survivor
This article is a first for our newsletter; it is the brave and poignant story of the survivor of a serious aircraft accident. Lina Ouellet
has graciously agreed to share her harrowing experience with Aviation Safety Letter (ASL) readers. This was doubly difficult for her
because of the physical and emotional damage that she had to face with great courage over the last two years. We often publish articles
about tragic events, but rarely about the consequences. This article is intended to fill this void by conveying the human side of the story.
But first, a little background.
St‑Lambert‑de‑Lauzon, Que. The pilot, accompanied by his
wife and their small dog, reported engine trouble and had to
make an emergency landing in a field near Saint‑Ubalde.
The landing was rough and the aircraft caught fire. The pilot
helped his wife evacuate, but he was trapped in the cockpit and
died. The passenger was seriously injured, and the aircraft was
destroyed by the fire.
Nearly two years later, the woman from St‑Ubalde who was
looking for the accident report told me that the survivor had
spent nearly two years in rehabilitation, including treatment
at the severe burn unit in Québec City and a long‑term
rehabilitation centre, and that she had finally returned home.
It was then that I decided to ask this brave woman if she
would be willing to share her story. She agreed, and sent me a
very moving story. A translated version is reprinted below:
Accident aircraft pictured at an air rally prior to the accident
Photo: Pierre Langlois
My husband had organized a day of swimming at
Lac‑aux‑Sables. Two couples who were friends of ours
joined us in their own aircraft. We left the house around
8:45 a.m. When I closed the door behind me that morning,
I never imagined that such a tragedy was about to occur.
ASL 2/2008
19
Flight Operations
It was July 16, 2005; finally Saturday was here. My
husband got up and looked out the window. A wide grin
came over his face. The day was going to be nice and hot,
which wasn’t really surprising, since it was the middle of
July. It was the perfect day for a nice flight.
Pre-flight
A little over a year ago, a resident of St‑Ubalde‑dePortneuf, Que., contacted me to ask if she could get a copy of
the report on a deadly accident involving a small aircraft that
occurred on July 16, 2005, near her home. She had a special
interest in this accident because her son was the first witness on
the scene and the first one to assist the survivor. After checking
with the Transportation Safety Board of Canada (TSB), we
quickly identified the accident in question (file A05Q0120),
which was not subject to an in‑depth Class 3 investigation,
but rather a Class 5 investigation (see page 38 to read about
the difference between a Class 3 and a Class 5 investigation).
The aircraft was an amateur‑built Zenair Super Zodiac
CH601‑HDS, which was conducting a visual flight
rules (VFR) flight between Lac‑aux‑Sables, Que., and
Flight Operations
Therefore it is suggested that Transport Canada may wish
to take action to ensure that operators are aware of the
need to use approved flight operations reference material,
and that they ensure that crews are using the correct flight
operations references.
To the Letter
Pre-flight
It was not determined how many other operators are using
unapproved reference material in their flight operations, or
how many operators are aware of the differences between
approved and unapproved reference materials.
Guest Editorial
forward.” The ambient temperature and elevation would
have induced the turbocharger controllers to increase
power above the minimum of 43 in. manifold pressure,
had full throttle been selected during the takeoff.
Guest Editorial
Pre-flight
First, my husband contacted a friend, who was on board
another aircraft, and told him that we had a mechanical
problem and that we had to make an emergency landing
immediately. Then, my husband said to me, “don’t talk to
me now. I have to concentrate on making an emergency
landing.” I looked at the ground and I felt the aircraft
moving into position for its approach. I was so scared that
I started kissing my grandmother’s ring that I had on my
finger and I kept repeating, “grandma, grandma please
save us.” And then…nothing. The stress was so high that
I blacked out. When I regained consciousness, the aircraft
had crashed and was in flames.
20
I was conscious during the entire ambulance ride. I also
knew that I was about to begin the biggest fight of my life:
to survive, because I had chosen to live. I was admitted
to the severe burn unit at Enfant‑Jésus Hospital. I had
suffered burns to 70 percent of my body—my face, my
arms and my legs. I had also suffered a compound fracture
of my left ankle. After I woke up from being in a coma for
a few weeks, I remembered everything: my husband’s death,
the details of the accident and that I was severely burned.
On October 18, 2005, after three months in the severe
burn unit at Enfant‑Jésus Hospital, I was transferred to
Centre François‑Charron. A few days after I arrived, I
started intensive treatment with several therapists. I wore
compression garments, a chin strap, a mask, and orthotic
devices for over a year and a half. Wearing compression
garments helps the skin’s healing process. I still wear the
chin strap, mask, and orthotic devices even today.
During my rehabilitation, I had to grieve for three deaths:
my husband, my mother and my body. The extraordinary
support of my family and my many therapists gave me the
strength to overcome these challenges. After 18 months
of dedication, motivation, determination, physiotherapy,
occupational therapy, speech therapy, and 20 surgeries, I
left Centre François‑Charron on January 27, 2007, and I
finally went home.
ASL 2/2008
Flight Operations
I yelled, “we’re on fire! we’re on fire!” and tried to undo
my seatbelt but I couldn’t because it was too hot and
it was burning my fingers. I tried again and this time I
managed to undo it. My husband opened the door and
pushed me out of the aircraft. I fell onto the wing and
ended up on the ground. I rolled away from the burning
aircraft, afraid that it was going to explode. I yelled to my
husband, “hurry, get out! Get out! Please, get out!” But he
didn’t come out. I was all alone in the middle of a field. I
didn’t see anything in the distance. There were no houses
or people anywhere. My hero couldn’t do anything for me
now. He was trapped inside the burning aircraft. I knew
then that my husband was dead.
Thanks to his composure and courage, my husband did
everything he could to save me, and succeeded. It is also
thanks to the composure, extraordinary courage and the
calm of an Olympian displayed by fire chief Serge Auger
and Michel Hardy (who was only 16 years old at the
time) that I am alive today.
Pre-flight
Flight Operations
Indeed, we did have a wonderful day, and it was now time
to leave. My husband walked around the aircraft, going
through his checklist. I put Capitaine Crochet on my lap
and I buckled him in with me again. We took off at about
5:00 p.m. The takeoff was very smooth and we were flying
at 2 000 ft. There wasn’t a lot of turbulence and everything
was going well. Then the propeller suddenly started to
slow down; it was turning very slowly. I couldn’t believe
what was happening. I told myself that it was going to
start turning normally again, but it didn’t. There was
nothing I could do. It was like being in a nightmare.
He told me to stay calm and that the ambulance and fire
trucks were on their way. I asked him if I was seriously
burned, and he said, “no.” I asked him if I still had my
left leg, and he said, “yes.” He left me for a few seconds
and approached the burning aircraft to try to help my
husband. He saw my husband’s body in the aircraft, but
there were small explosions coming from the aircraft so
he couldn’t get any closer. He couldn’t do anything for my
husband and quickly came back to me. He didn’t leave me
until the ambulance arrived.
To the Letter
To the Letter
We arrived at our destination at about 11:30 a.m. All
three aircraft landed on the runway at Lac‑aux‑Sables,
and everything seemed perfect for a wonderful day.
I couldn’t see the fire, but I could hear it. The aircraft was
a few feet away from me, and I had a very strong taste
of fuel in my mouth. I heard a sound, a car and finally
a voice. About 3 minutes after the crash, Michel Hardy
arrived on the scene of the accident. Despite the horrific
scene, he didn’t hesitate for one second and he came
towards me. He stayed behind me, put his hands on either
side of my face and he spoke to me in a trembling, but
reassuring voice.
Guest Editorial
Once we arrived at our hangar at the St. Lambert airport,
we started preparing for departure. As usual, my husband
inspected his aircraft. We were ready to leave, and for
safety reasons, my husband always puts our little dog,
Capitaine Crochet, in his carrier on board the aircraft;
but our dog was very hot, so I let him out of his carrier so
that he would be more comfortable. I put him on my lap
and I buckled him in with me. My husband, our little dog,
Capitaine Crochet, and I took off from the St. Lambert
airport at about 10:30 a.m. Everything went well during
the flight, and I didn’t notice anything out of the ordinary.
With great joy, on July 13, 2007, I was finally able to meet
my rescuers Michel Hardy, his father Réginald Hardy
and Serge Auger. It was a real privilege for me to share a
meal with the entire Hardy family, who are a very special
family. At this meal, I also met the fire chief Serge Auger.
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB).
The cargo area for the occurrence aircraft was approximately
16 ft 5 in. long, and the cargo consisted of lumber varying
in length from 10 ft to 16 ft. The aircraft’s take-off weight
was determined to be below the maximum certified take-off
weight (MCTOW) for this aircraft, and the centre of gravity
was calculated to be about 2 ½ in. aft of the aft limit. The
load was secured using one 1-in. cargo strap that was placed
over the top of the load. The load was not restrained in a
manner that would prevent longitudinal movement. It was
determined that during takeoff, the load shifted aft, which
resulted in the aircraft entering an extreme nose-up attitude,
and stalling. The pilot was not able to recover the aircraft
from the stall.
The restraint of cargo is critical toward ensuring that the
aircraft remains within its certified balance limitations.
A Canadian Aviation Safety Board (CASB) [now
the TSB] investigation (A83-O30045) issued a
safety recommendation to Transport Canada in
1985 (CASB 85‑002), where it was recommended that
Transport Canada:
1. Review its audit system to ensure emphasis on the area
of aircraft weight and balance and security of cargo.
Transport Canada responded that articles on aircraft
overloading were included at intervals in Transport Canada
publications that are distributed nationally. A national
campaign against overloading would continue to be part
of Transport Canada’s master surveillance plan. However,
Transport Canada’s response did not specifically address
the security of cargo issue raised in recommendation
CASB 85-002.
Transport Canada’s Canadian Aviation Regulation (CAR)
602.86(1) does state in part that “no person shall operate an
aircraft with…cargo on board, unless the…cargo [is]
“(b)restrained so as to prevent them from shifting during
movement of the aircraft on the surface and during
take-off, landing and in-flight turbulence.”
ASL 2/2008
21
Flight Operations
Following this accident, the TSB Aviation Safety
Information System (ASIS) database was searched for
accidents and incidents that were a result of load shifts.
Four such accidents were identified, all of which resulted
in substantial aircraft damage, death, or serious injury.
These accidents occurred in the period from 1985 to 2007.
Failure to do so can result in the cargo moving outside of
these limits. The act of securing the load against vertical
movement did not prevent the load from shifting toward
the rear of the aircraft.
Pre-flight
Guest Editorial
Pre-flight
A big thank you to Lina Ouellet, and to all the people who
helped prepare this special article, especially Dr. Hélène
Berlinguet of St-Ubalde, mother of Michel Hardy and partner
of Réginald Hardy. Your compassion was the reason this
article was written. —Ed.
Inadequate Cargo Restraint
On June 2, 2007, a de Havilland DHC-3T was
transporting lumber from Mayo, Y.T. During the takeoff roll, the aircraft entered an extreme nose-up pitch
attitude, rotated to the right, and crashed onto the
ramp abeam the runway. The aircraft was substantially
damaged. The pilot and sole occupant of the aircraft
sustained fatal injuries. The investigation into this
occurrence (TSB file A07W0099) is ongoing.
Flight Operations
Lina Ouellet,
Québec City, August 2007
To the Letter
To the Letter
I am now driving my car. I have even taken an aircraft twice
to visit my brother and his family in Florida. I still go for
treatment twice a week at Centre François‑Charron. And I
will have to have more surgery. I’m very proud of how far I’ve
come so far. I can now say, “mission accomplished.” Believe
me, people will start calling me a “firecracker” again soon.
I want to give a big thank you from the bottom of my
heart to all the people who were involved in any way in
helping me through this ordeal. Michel Hardy and his
father Réginald Hardy, the ambulance attendants, the
fire chief Serge Auger, the firefighters, the police officers,
the severe burn unit at Enfant‑Jésus Hospital, and the
Centre François‑Charron. I send my love to my husband
Léonard Corbeil and my family. Without you, I wouldn’t
be here today to tell my story.
Guest Editorial
It has been over two years since the aircraft crash. Today,
I have reclaimed my life and my personality. I live in a
condo with my little dog. Yes, Capitaine Crochet was
found two days after the crash by a woman in St‑Ubalde.
Capitaine Crochet managed to escape and was wearing a
tag on his neck with his address.
Guest Editorial
To the Letter
The Importance of Proper Weight and Balance
by Gerard van Es, National Aerospace Laboratory (NLR), Amsterdam, The Netherlands
Many pilots (both commercial and private) tend to
underestimate the importance of proper weight and
balance of their aircraft. Load sheets are taken for granted,
and hasty calculations are made of the aircraft’s centre of
gravity (CG). Unfortunately, each year there are a number
of accidents related to weight and balance issues. Many
of these occurrences could have been avoided if more
attention was given to the weight and balance.
Static longitudinal stability is the most important factor
in determining the aft CG limit. At the aft CG limit
position, the aircraft should demonstrate that a positive
22
What happens if the certified limits as defined in the
CG envelope are exceeded? From design, the aircraft
flight characteristics will be adversely affected whenever
the certified limits are exceeded. For instance, as the
CG moves aft, the aircraft will become less stable as the
CG approaches the neutral point. If the CG lies aft of
the neutral point, the coordination and control motions
required to maintain a stable flight condition will exceed
the capability of the pilot, and the aircraft will become
uncontrollable. On the ground, CG aft of the aft limit can
result in a tail strike due to the pitch-up of an aircraft with
a tricycle gear configuration (even at low speeds during
the take-off roll when power is applied to the engines).
The effect of a CG position forward of the forward limit
is evidenced by a decrease in elevator control capability.
Because of excessive stability, the elevator control required
to manoeuvre the aircraft is increased. At some point,
elevator control might become insufficient to perform
required manoeuvres, such as the flare during landing
and a go-around. During takeoff, the CG position can be
moved forward until it reaches the point where the aircraft
is very stable but cannot be rotated, or can only be rotated
ASL 2/2008
Flight Operations
Aircraft are designed and certified to operate within
certain weight and balance limits (see Canadian Aviation
Regulations (CARs) Standard 527.27—Centre of Gravity
Limits). Exceeding these limits can be dangerous. The
regulations provide the stability, controllability, and
strength requirements at all allowable CG positions and
corresponding weights. The extreme forward and aft CGs
must be established for all certified weight limits. The
condition that typically determines the forward CG limit is
that the aircraft shall be controllable on landing. This means
that the aircraft shall be able to be trimmed at the high lift
values required for the desired landing speeds (including
abuse cases). Other flight control cases that can influence
the forward limit of the CG are the capability to make
a prompt avoidance pitch-up manoeuvre, the capability
to make a prompt nose-down recovery at low speed, and
adequate pitch control in abnormal configurations (failure
cases). The above-mentioned conditions all apply to free
air. On the ground, the forward CG limit is basically
determined by the maximum loads on the nose landing
gear for an aircraft with a tricycle gear configuration.
natural stability exists, that the aircraft is capable of
pitch control at low speeds and high thrust (e.g. during
a go-around), and that an adequate control is possible in
abnormal configurations. On the ground, the aft CG limit
is determined by the minimum loads on the nose landing
gear required for good nose wheel steering, the maximum
loads on the main landing gears, the tipping tendency of
the aircraft, and adequate directional control during the
take-off run after an engine failure. These last conditions
apply to aircraft with a tricycle gear, and not to those with
a taildragger configuration.
Pre-flight
Pre-flight
Operators should develop procedures and provide the appropriate
training to their personnel to ensure they understand how
to properly secure cargo in their aircraft and verify that load
shifting will not take place. —Ed.
To the Letter
Flight Operations
While the frequency of this type of event remains
relatively low, the result of a load shift as a result of
improperly restrained cargo can result in a loss of control,
resulting in substantial aircraft damage, serious injury, or
death. Transport Canada may wish to inform industry of
the significance of load shifting on aircraft performance
and the need to effectively secure cargo in order to reduce
the risk of in-flight load shift.
CARs Standards 723.105(q) and 724.121(q) require
information on securing cargo to be included in the company
operations manual (COM). There are several references
to cargo in the Standards, and the most notable one is the
requirement to have the securing of cargo in the COM. Since
part of the operational training is to cover the contents of
the COM, the operator is required to train their personnel
accordingly. While the Standards do not specifically state
any training on how to secure a load, CAR 602.86(1) is
clear that a load must be restrained to prevent shifting.
Transport Canada does not believe there is a need to change
any regulations or standards.
Guest Editorial
The company operations manual stated that all cargo had
to be secured to prevent shifting in flight. The aircraft
was equipped with multiple tie-down points, and eight
cargo straps. The company aircraft ground training exam
contained a weight and balance exercise. However, there
was no indication of load security training.
Guest Editorial
To the Letter
Aircraft that have wing-mounted propellers can be faced
with a unique problem when flying with a CG close to
the aft limit. Control can be lost during the approach after
selecting landing flaps followed by the initiation of power
More information on weight and balance issues can be
found in a safety study conducted by the author, “Analysis
of aircraft weight and balance related safety occurrences,”
(Report No. NLR TP-2007-153). —Ed.
To the Letter
increase and/or a go-around. Lowering the flap will move
the neutral point forward and change the pitching moment
(this effect is not limited to propeller aircraft). The pilot feels
this as a tendency for the aircraft to pitch-up, and needs
to push forward on the control column to hold a steady
flight path by lowering the elevator. The pilot will re-trim
the aircraft by winding the trim wheel forward, which
moves the trim tab to keep the elevator in the new position
without the pilot having to maintain a push force on the
control column. One feature of aircraft with wing-mounted
propellers is that when the engines accelerate from idle
power to full power, the neutral point moves forward (up
to 10 percent of the mean aerodynamic chord!). When the
actual CG position is close to or slightly aft of the certified
aft limit due to incorrect loading, the aircraft may be just
stable during takeoff and cruise. However, this situation
can change during landing, in which case the aircraft may
become unstable after lowering the flaps to landing position,
and may show a very strong pitch-up tendency. The normal
reaction to increase power to recover from the pitch-up or
to make a go-around will make things even worse as the
neutral point moves forward significantly with the increase
in power on aircraft with wing-mounted propellers.
Guest Editorial
with great difficulty because the elevator has reached
its maximum deflection. An adverse CG position can
also have significant effects on the loads imposed on the
aircraft’s structural components and could cause structural
failure. Exceeding the maximum weights as specified in the
aircraft flight manual (AFM) does not necessarily adversely
affect the flight characteristics. For instance, exceeding the
maximum landing weight could result in a landing gear
collapse. However, the landing gear structure is designed
with a standard safety margin assuming a higher load
than obtained during a normal landing at maximum
landing weight. With this, it could be possible to land the
aircraft somewhat beyond the maximum landing weight.
Overweight landings are often made during emergency or
precautionary landings. Exceeding the maximum takeoff weight (MTOW) will affect the flight performance
characteristics. The take-off ground-roll distance increases
and the climb performance decreases. As long as the
aircraft is not significantly overweight, it should be able to
take off safely. However, the margins reduce rapidly when
an engine failure occurs during an overweight takeoff, if the
runway is short for the aircraft, or if there are high obstacles
along the take-off flight path that the aircraft has to clear.
this segment of our industry upholds a safety consciousness
that hopefully will be passed on for many years to come.
The deadline for nominations for the 2008 award is
September 14, 2008. For details, please visit www.dcamaward.com.
John had an extensive career in the Canadian military, where
he trained on the Sea King helicopter and the Tutor Jet.
Among many of his distinguished accomplishments in the
military was being the chief flight instructor (CFI) at the
Moose Jaw, Sask., military flight training base. “His passion
for flight, vast amount of knowledge and enthusiasm for
teaching has made him a role model,” quote his students.
He is also a designated Transport Canada pilot examiner.
The annual DCAM Award promotes flight safety by
recognizing exceptional flight instructors in Canada, and
has brought much recognition and awareness to the flight
instructor community. Recognition of excellence within
From left to right: Rikki Abramson, John Robertson,
Jane Abramson, and Mike Doiron, Acting Chairman of ATAC
ASL 2/2008
23
Flight Operations
Flight Operations
The recipient of the 2007 DCAM Flight Instructor
Safety Award is John Robertson, Chief Flight Instructor
and Professor of Human Factors and Safety Systems at
the School of Aviation and Flight Technology, Seneca
College, Toronto, Ont. Jane and Rikki Abramson
presented the award on November 5, 2007, at the Air
Transport Association of Canada’s (ATAC) Annual
General Meeting and Convention held in Halifax, N.S.
Pre-flight
Pre-flight
David Charles Abramson Memorial (DCAM) Flight Instructor Safety Award
Recently Released TSB Reports
Hot Air Balloon Fuel Cylinders........................................................................................................................................ page 24
CL-215 Water Door Up-Lock Actuators: The SDR is for Your Benefit...................................................................... page 25
Inspection Levels Part 2: Detailed Inspection Please!...................................................................................................... page 26
Hot Air Balloon Fuel Cylinders
by Peter von Moos, Senior Engineer—Domestic Regulations, Aircraft Certification Standards, Standards, Civil Aviation, Transport Canada
Pre-flight
Attention hot air balloon owners, operators, and maintainers!
Did you know that the transport of propane to a hot air
balloon launch site, or from a hot air balloon landing site,
as well as filling a cylinder with propane for the purposes
of such transportation are activities subject to the
Regs & you
Transportation
of Dangerous Goods Regulations (TDGR)?
Under the TDGR, the kind of cylinder that may be
used for propane transport, and requirements for its
filling and maintenance, are strictly prescribed. The
TDGR requirements are in addition to the certification
of the cylinders pursuant to the Canadian Aviation
Not used
Regulations (CARs) 511 and 513, and in accordance
with Airworthiness Manual (AWM) Chapter 531, the
airworthiness standard for manned free balloons.
Recently, a Canadian balloon operator was fined for illegal
land transport of balloon fuel cylinders that did not meet
TDGR requirements. The operator was unaware that
AWM 531 compliance was not sufficient to transport and
fill fuel cylinders.
Road, railway, ship or aircraft transport of balloon fuel in
cylinders is an inherent characteristic of hot air balloon
operations. However, balloon operators should be aware
that compliance with AWM 531 alone is NOT sufficient
to permit the transportation, inspection, maintenance,
and filling of the fuel cylinders outside their intended use
as fuel storage during balloon flight. In the certification
of aircraft, Transport Canada Civil Aviation (TCCA),
just like other airworthiness authorities, is responsible
only for the airworthiness aspects of an aircraft or any
of its installed components. It is the user’s responsibility
to meet any additional requirements, e.g. the operating
regulations, and in the case of hot air balloons, the TDGR
requirements for the surface transportation of propane.
The TDGR require that cylinders manufactured after
1992, and used to transport compressed gas must
24
If your current cylinders do not comply with the TDGR,
i.e. have no “TC” stamp markings, you may apply for a
permit for equivalent level of safety under the TDGR. The
Transport Canada Transportation of Dangerous Goods
Directorate may, through such a permit, allow existing
non-conforming hot air balloon cylinders to continue to
be used during a phase-out period of specified duration. A
permit may be granted to members of an association or to
an individual. It is important to realize that such a permit
applies only to the cylinders, and does not relieve the holder
from their obligation to have a balloon configuration that
conforms to the approved type design.
For more information on applying for a permit of equivalent
level of safety, see Part 14 of the TDGR at the following
Web address: www.tc.gc.ca/tdg/clear/part14.htm.
You may submit an application for a permit along with
supporting rationale and documentation, by mail, fax, or
e-mail to:
Director, Regulatory Affairs
Tower C (ASDD)
Place de Ville, 330 Sparks St.
Ottawa ON K1A 0N9
Fax:
613-993-5925
E-mail: TDGPermits@tc.gc.ca
If not covered under a permit, non-conforming cylinders
may not be used for the transport of compressed gas
within the scope of the TDGR.
ASL 2/2008
Accident Synopses
Balloon owners and operators should verify that they satisfy
the requirements of the TDGR for surface transport of
propane, including the requirements pertaining to the
cylinders used for that purpose.
comply with, and be certified to, the Canadian Standards
Association (CSA) Standard CAN/CSA B339. Such
cylinders can be recognized by their stamp markings, which
begin with the letters “TC.” Requirements for periodic reinspection are included within Standard CAN/CSA B339.
Cylinder use, including pre-fill and post-fill inspection, and
limits on the degree of filling, are specified in a companion
Standard, CAN/CSA B340. These standards may be
purchased from the CSA, while the Transportation of
Dangerous Goods Act, 1992 (TDG Act) and TDGR may be
viewed on the Transport Canada Web site.
Regulations and You
Regulations and You
Maint. & Cert.
Recently Released TSB Reports
Accident Synopses
maintenance and certification
Maintenance and Certification
Maintenance and Certification
TSB reports
Maintenance and Certification
Recently Released TSB Reports
Human factors training teaches us that an aviation incident
or accident typically involves more than one causal factor.
The events are like layers of Swiss cheese in which the
holes eventually line up, allowing the final margin of safety
to be penetrated. This penetration permits the incident
or accident to occur. A positive action by one person can
disrupt the layers, block the holes, and stop the sequence of
events. The filing of a service difficulty report (SDR) can be
that one positive action.
It is logical to conclude that, at some point in time, an
operator not having all the necessary information readily
available to fully evaluate the maintenance requirements
Accident Synopses
Accident Synopses
In the course of a routine Transport Canada follow-up,
several aspects of this SDR were revealed, some unexpected.
Quite often, there are two cracks on each shaft at the
chamfer between the body of the shaft and the threaded end.
The two cracks are typically about 180° from each other. The
type certificate holder’s recommendations call for magnetic
particle inspection (MPI). All of the NDT-rated AMO
shops contacted stated that they do this type of inspection on
these parts, but have also found, through experience, that the
fluorescent liquid penetrant inspection (LPI) method gives a
stronger and more positive indication of a defect in this part.
The Transport Canada routine follow-up included checking
the SDR national database. Including the most recent
submission, only three SDRs regarding this part have been
filed. The first two were in the early months of 2000. The
relatively small number of reports in the database raises
several questions. Is the type certificate holder aware of the
actual rate of defects found in this part, and the average
time in service? Are they aware of the different NDT
processes being used in the field, and why they are used?
The SDR reporting process would allow them to assess
what is happening, evaluate the data, and take appropriate
action, if necessary. Are all the operators of this aircraft type
in Canada aware of the additional information? Unless
another operator happened to inform them in some way,
it is not likely. Is there a way a new or foreign operator can
obtain this information in a readily-accessible fashion?
Again, unless another operator happened to inform them
in some way, it is not likely.
Regulations and You
Recently, an operator of CL-215 water bombers was
involved in a scheduled C-check of one of their aircraft.
The type certificate holder’s recommendations do not
call for a non-destructive testing (NDT) inspection of
the water door up-lock actuators in this particular check.
The actuators do, however, have a 5 000-hr time between
overhauls (TBO), which had not yet been reached.
The operator contracted a local NDT-rated approved
maintenance organization (AMO) to do the NDT
inspection portions of the C-check. The NDT technician
informed the operator that he had recently been
contracted by another operator to inspect their water door
up-lock actuators, and had found some actuator piston
shaft defects. The operator immediately requested that
the NDT technician check their actuators. The result was
that defects were discovered in approximately 83 percent
of the actuator shafts in their fleet. At this point, the
operator filed an SDR with Transport Canada.
They all stated that they do the inspection twice: once with
the recommended MPI method for initial indications, and
then the second time with the LPI method for confirmation
and fail-safe purposes. Even though the type certificate
holder’s recommendations call for a 5 000-hr TBO for the
up-lock actuator, some operators are overhauling, and NDT
inspecting, their actuators annually. This is a significant
reduction of time between overhauls. This would also suggest
the operator evaluated the information, and modified their
maintenance requirements to ensure the reliability of the
parts involved, and thus, safety. Another aspect revealed was
that some operators have been aware of the defect issue since
about 2004, apparently having communicated the relevant
information amongst themselves. Unfortunately, not all
operators are equally aware. It appears to depend on who
is on individual e-mail and telephone lists, rather than a
national information system such as the SDR database.
Recently Released TSB Reports
Regulations and You
by Rob Adamchuk, Civil Aviation Safety Inspector, Aircraft Maintenance and Manufacturing, Prairie and Northern Region, Civil Aviation,
Transport Canada
Maintenance and Certification
CL-215 Water Door Up-Lock Actuators: The SDR is for Your Benefit
Up-lock actuator, part number 215750098
Shaft, part number 33130131, with a defect shown
ASL 2/2008
25
Maintenance and Certification
the information is available to everyone. That action of
filing an SDR may close the holes in one or more layers
of the Swiss cheese. If someone downplays or complains
about filing an SDR, ask yourself one question: “is all the
relevant information readily available to me?” The SDR is
for everyone’s benefit.
Inspection Levels Part 2: Detailed Inspection Please!
by John Tasseron, Civil Aviation Safety Inspector, Aircraft Evaluation, Standards, Civil Aviation, Transport Canada
Maintenance and Certification
of their aircraft will experience an unexpected failure of
the up-lock actuator shaft. If the failure occurs, in this
case, during a high force-loaded part of the flight, such
as takeoff, landing or while scooping water, the result
may be catastrophic. If everyone shares information using
the available process, which is the SDR database, then
The term detailed inspection has been assigned the
acronym DET. This does not conform to the usual concept
of using the first letter of each word of a term to derive the
acronym, but has come into common usage through the
Air Transport Association of America (ATA). Perhaps the
intent was to differentiate between this term and the term
daily inspection (DI). The problem is partially caused by the
fact that the word “visual” has been deleted from the term.
Had this been retained, DVI would have been the result.
The definition of the term detailed inspection is as follows:
“An intensive examination of a specific item, installation or
assembly to detect damage, failure, or irregularity. Available
lighting is normally supplemented with a direct source of good
lighting at an intensity deemed appropriate. Inspection aids, such
as mirrors, magnifying lenses, or other means, may be necessary.
Surface cleaning and elaborate procedures may be required.”
The word “intensive” alerts us to the fact that this
inspection demands a higher level of scrutiny in order to
find unsatisfactory conditions that are more difficult to
detect. The emphasis has shifted from general inspection
to detailed inspection. An assumption is made here that
an intensive examination would only be possible by
26
The definition for the term “detailed inspection” appears
to be fairly concise and easy to understand, and has not
been the subject of significant controversy. This is partly
due to the fact that it is almost automatically compared
to the definition of GVI because both terms are used
frequently in large aircraft maintenance schedules. Note
that the term lends itself to use in any maintenance
schedule, as long as the corresponding definition is clearly
explained. Since problems occur when a definition is
chosen to describe a term not normally associated with
it, or vice versa, it is best to maintain consistency in the
applicability of ATA terms and their definitions, before
using them in other maintenance schedules.
The final article will look at the highest inspection
level, and how it sometimes creates controversy in the
inspection level selection process.
ASL 2/2008
Accident Synopses
Accident Synopses
Some key words in this definition are intended to
differentiate this level of inspection from that of the GVI.
Let’s look at these words more closely.
moving the eyeball closer to the surfaces to be inspected,
and that the need for specifying a distance is therefore
waived. Furthermore, the intensive examination is
directed towards “a specific item” (note the singular).
Since this is not the same as looking at a number of
items, as is done during a GVI, the specific item to be
inspected needs to be clearly identified as part of the
inspection task. Supplemental lighting is specified as a
“normal” requirement here, so one can assume that at least
a flashlight should be available. The intent is to direct
the light to a specific area so that smaller defects can
be more easily detected. The reference made to “surface
cleaning” relates to having to pay particular attention to
the fact that the general cleaning carried out prior to the
start of the inspection may not have been adequate to
permit intensive examination of a small detail. Finally, the
mention of “elaborate procedures” raises an awareness of a
possible need to gain additional access by moving adjacent
items, defuelling tanks, etc.
Regulations and You
Regulations and You
This is the second article concerning aircraft maintenance
inspection levels. The first covered the term “general visual
inspection” (GVI). When discussing inspection levels,
it must be remembered that the topic concerns how
closely an item is inspected, which in turn translates into
how small a defect or unsatisfactory condition we hope
to find. The idea is to first assign an appropriate level
of inspection to a task, and then prescribe an effective
inspection interval.
Recently Released TSB Reports
Recently Released TSB Reports
This is the second of three articles on the topic of inspection levels.
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.
Maint.Final
& Cert. Report A04A0110—Runway Excursion
TSB
On August 31, 2004, a Boeing 727-200 cargo aircraft
was on a scheduled cargo flight from Toronto, Ont.,
to Halifax, N.S., with stops at Montréal, Que., and
Moncton, N.B.
The aircraft landed on Runway 29 at
Pre-flight
Moncton at about 12:22 Atlantic Daylight Time (ADT).
After touchdown, the aircraft hydroplaned and departed
the runway at the Taxiway Charlie intersection. It crossed
the taxiway and came to rest on an abandoned runway
threshold, a short distance from the taxiway. Damage was
limited to tread damage to the four main landing gear tires,
Regs
& you
and
destruction
of a taxiway light. There were no injuries.
Regulations and You
Findings as to causes and contributing factors
1. The crew did not anticipate the effects of the adverse
landing conditions and elected to continue the
approach and landing.
2. The pilot was unable to maintain directional control
of the aircraft because of the combination of
hydroplaning and a crosswind.
. Once the tires contacted the runway, there
was insufficient time for the pilot to avoid the
runway excursion.
Since the occurrence, the operator has modified flight
operations procedures and training with respect to
slippery runway conditions. Also, flight crew and
maintenance procedures have been amended for the
maintenance and testing portions of the CVFDR.
TSB Final Report A05Q0008—Collision
with Terrain
On January 24, 2005, at approximately
15:00 Eastern Standard Time (EST), the pilot of an
Aérospatiale AS 350 BA helicopter, with four hunters
and one guide on board, was conducting an approach to
an unserviced landing area on the edge of a lake, located
in the James Bay area, 60 NM from La Grande-4, Que.
At the end of the approach, the helicopter began to hover,
and then started to descend into whiteout and loose
snow conditions. The downdraught of the main rotor
lifted the snow, causing a total loss of visual reference.
After the left ski touched the snow-covered surface, the
helicopter rolled onto its left side into snow that was
several feet deep. During the rollover, the rotor blades
struck the ground and the gearbox partly separated from
the fasteners. Some blades penetrated the cockpit, fatally
injuring the guide and the pilot, who was wearing a
helmet. The four passengers sitting it the rear seats were
not wearing seat belts, and received minor injuries. Two of
the passengers were ejected from the aircraft, and ended
up approximately 10 ft from the wreckage; the two others
remained in the cabin. The survivors were evacuated by
two other helicopters at approximately 16:30 EST.
1. The flight data recorder (FDR) portion of the cockpit
voice and flight data recorder (CVFDR) had not been
checked in accordance with regulations, and therefore,
poor data quality with some of the parameters on the
recorder had not been identified.
ASL 2/2008
Accident Synopses
Finding as to risk
Regulations and You
Aircraft moments after runway excursion
Safety action taken
Recently Released TSB Reports
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Recently released
TSB reports
Not used
Accident Synopses
Maintenance and Certification
recently released tsb reports
View of wreckage and accident site
27
Other findings
1. Service Bulletin 25.00.63, relating to the strengthening
of the front seats, had not been carried out on the
helicopter, but this did not contribute to the injuries
suffered by the occupants of those seats.
2. The investigation found that the other pilots who
transported the occupants of the accident helicopter
did not give the passengers a safety briefing, as required
by the Canadian Aviation Regulations (CARs.)
. The survival equipment, which was in the left-hand
baggage hold, was not accessible after the accident
because the aircraft was resting on its left side.
TSB Final Report A05A0059—Stall and Loss of
Control During Climb
On May 27, 2005, a de Havilland DHC-8-100
(Dash‑8) aircraft was a passenger revenue flight from
St. John’s, N.L., to Deer Lake, N.L., with 36 passengers
and 3 crew on board. During the climb-out from St. John’s,
the indicated airspeed (IAS) gradually decreased to the
point that the aircraft entered an aerodynamic stall. The
aircraft descended rapidly, out of control, losing 4 200 ft
before recovery was effected, approximately 40 s later. The
incident occurred during daylight hours in instrument
meteorological conditions (IMC). There were no injuries,
and the aircraft was not damaged.
Findings as to causes and contributing factors
1. During the climb, the captain inadvertently selected
vertical speed (VS) mode on the automatic flight control
system (AFCS) instead of the intended IAS mode, and
neither flight crew detected the selection error.
28
Maintenance and Certification
Findings as to risk
1. Typically, flight crews receive only limited training
in stall recognition and recovery, where recovery is
initiated at the first indication of a stall. Such training
does not allow pilots to become familiar with natural
stall symptoms, such as buffet, or allow for practice in
recovering from a full aerodynamic stall.
2. A significant proportion of Dash-8 pilots may
hold outdated beliefs on the use of pneumatic
de‑icing equipment.
Safety action taken
The TSB issued Safety Advisory A050019-1 on
July 22, 2005, on the subject of inadvertent selection
of inappropriate AFCS modes of operation. The letter
suggested that Transport Canada (TC) ensure that operators
have incorporated measures into their procedures to ensure
the correct selection and monitoring of AFCS climb modes.
On October 4, 2005, TC responded, advising that a copy of
the advisory had been passed on to all TC Regions, and that
the Department would take the necessary action, as required.
Since the occurrence, the operator has revised its SOPs to
contain a challenge and response action whenever AFCS
modes are engaged in the climb.
The TSB also issued Safety Advisory A50018-1 on
July 22, 2005, on the subject of timely selection of
pneumatic de-icing equipment. The advisory suggested
that TC consider additional action to ensure that pilots are
conforming to published de-icing procedures, and to dispel
old beliefs about the proper use of pneumatic de-icing
equipment. On October 4, 2005, TC responded, advising of
additional efforts to move this information into published
guidance material in the near future. As well, TC published
an article in Aviation Safety Letter (ASL) 2/2006. This
article informed pilots of the need to conform to published
de-icing procedures, and attempted to dispel old beliefs
about the use of pneumatic de-icing equipment.
ASL 2/2008
Accident Synopses
Accident Synopses
1. The front seats did not conform to Service
Bulletin 25.00.63, and separated from their anchorages
when the helicopter rolled onto its left side.
2. The occupants seated in the rear seats were not given
a safety briefing before departure. They were not
wearing seat belts, did not know where the emergency
locator transmitter (ELT) is found or how to use
it, and they did not know that the helicopter had
survival equipment on board.
Regulations and You
Regulations and You
Recently Released TSB Reports
Findings as to risk
2. The operator’s standard operating procedures (SOPs)
did not have a prescribed method for ensuring the
correct selection of AFCS climb modes.
. The flight crew did not activate the pneumatic de-ice
equipment while climbing in icing conditions.
. The flight crew did not detect the decreased airspeed
until the aircraft was near the stall.
5. The aircraft stalled at a higher-than-normal airspeed,
with little advance warning, most likely due to
accumulated ice on critical surfaces.
6. The captain, believing that they had encountered
severe turbulence, did not recognize that the aircraft
had stalled, and did not apply the standard stall
recovery technique.
Recently Released TSB Reports
1. The pilot did not detect that the slope on the landing
area exceeded the maximum bank angle allowed for
the aircraft, because the existing whiteout conditions
made him lose his sense of depth. The helicopter
rolled onto its left side following a dynamic rollover.
2. The pilot did not notice the helicopter’s lateral
displacement because the snow lifted by the rotor
downdraught and the icing on the aircraft’s windows
prevented him from seeing external references.
Maintenance and Certification
Findings as to causes and contributing factors
Maintenance and Certification
Recently Released TSB Reports
TSB Final Report A05O0120—Aircraft
Control Difficulty
On June 9, 2005, a Cessna TU206G was departing
Hamilton, Ont., for Burlington Airpark, Ont. The aircraft
departed from Runway 30 at approximately 12:00 Eastern
Daylight Time (EDT) with only the pilot on board.
During the take-off rotation and the initial climb, the
aircraft had an increasing tendency to pitch nose-up. The
pilot applied full nose-down trim, but the aircraft tendency
to pitch nose-up continued. Excessive forward pressure on
the control wheel was required to maintain an appropriate
pitch attitude during the climb-out, and subsequent return
to the Hamilton airport. The aircraft landed without
further incident.
1. The aircraft maintenance engineer (AME)
misinterpreted the elevator trim tab travel limits and
mis-rigged the elevator trim tab such that limited
nose-down trim was available.
2. The second AME did not detect the rigging error
during the independent inspection because he relied on
the first AME’s explanation of the rigging procedure.
Safety action taken
TSB Final Report A05Q0119—Collision
with Water
On July 16, 2005, a Bell 205 A-1 helicopter, with a pilot
and a loadmaster on board, was engaged in forest fire
suppression operations at Solitude Lake, Que., about
25 NM northwest of Port-Cartier, Que. At approximately
12:20 Eastern Daylight Time (EDT), the helicopter
hover taxied from a fuel cache site located at the south
Findings as to risk
1. Although there was no effect on engine performance,
the presence of unauthorized parts and the unbent
first stage compressor blade locking tabs denote a lack
of quality control on the part of both maintenance
facilities involved.
2. Although the fuel product identifying stickers met
provincial regulations, the similarity between the stickers
may lead to misidentification of the fuel product.
. The crew members were not wearing lifejackets,
as stipulated in the company operations manual.
Although both survived their injuries, the pilot did
not know how to swim, and may have drowned had
he not been rescued by nearby firefighters.
Other findings
1. Many military and commercial parts share the same
part numbers, and therefore, the accompanying tag is
not sufficient to confirm that the part is authorized
for commercial use. Its validity must be cross-
ASL 2/2008
29
Accident Synopses
Accident Synopses
In an effort to minimize the risk of a mis-rigged control
system, the operator included the requirements of
Airworthiness Notice (AN) C010 in the maintenance
control manual.
1. The helicopter was positioned too far from shore
to provide adequate visual references for longline
operations, and it is likely that the water bucket
inadvertently entered the water while the helicopter
was transitioning from a hover taxi to a hover.
2. The anchor effect of the water bucket may have
caused the helicopter to swing downwards, and there
was insufficient time, altitude, or visual references to
prevent the helicopter from striking the water.
. The pilot was not wearing the available shoulder
harness during longline operations, which likely
contributed to the severity of his injuries.
Regulations and You
Findings as to causes and contributing factors
Findings as to causes and contributing factors
Recently Released TSB Reports
Regulations and You
As a result of recent stall and upset occurrences in turbojet
airplanes, TC has reinforced the need for appropriate
training for the prevention of an airplane stall and for stall
recovery. TC released Commercial and Business Aviation
Advisory Circular (CBAAC) No. 0247—Training and
Checking Practices for Stall Recovery on August 24, 2005.
end of the lake. The helicopter was slinging an empty
water bucket on a 100-ft longline. While decreasing
power to bring the helicopter to a hover, the pilot felt a
vibration, followed by a loud bang, and what seemed to
be a loss of power. The helicopter quickly lost altitude
and pitched nose down and to the right before striking
the water. The pilot and loadmaster managed to exit
the helicopter while it was sinking, and were rescued by
nearby firefighters. The pilot-in-command was seriously
injured. The loadmaster sustained minor injuries. The
helicopter was substantially damaged.
Maintenance and Certification
Since the occurrence, the operator has directed its trainers
to re-emphasize procedures for activation of pneumatic
boots, as described in its SOPs and the aircraft flight
manual (AFM). To reduce the likelihood of monitoring
errors, the operator has directed all crews not to conduct
paperwork during critical phases of flight. These duties are
to be performed during level flight only while en route.
Maintenance and Certification
Recently Released TSB Reports
Safety action taken
On June 5, 2006, the TSB issued Safety Information
Letter A060026-1—Inadequate Identification of Fuel
Barrels to the Director General of Civil Aviation. The
Safety Information Letter highlighted the criticality
of proper identification of fuel barrels. The use of fuel
barrels for remote helicopter operations is widespread
throughout Canada.
Findings as to causes and contributing factors
On April 11, 2007, the TSB issued Aviation Safety
Information Letter A070004—Inadequate Identification of
Parts to the Director General of Civil Aviation. The Aviation
Safety Information Letter highlighted the fact that the
identification on a data plate or the scribe on a part, along
with its tag confirming its traceability, are not sufficient to
attest that the part is authorized for commercial use. Its
validity must be checked against a CAGE code, which
identifies the manufacturer and the purchaser. These codes
are available on the Business Identification Number Crossreference System (BINCS) Web site.
TSB Final Report A05A0161—Wing Contact
with Runway During Landing
1. The touchdown point, in conjunction with the delay
in application of reverse thrust, increased the risk of a
runway overrun.
Other finding
1. Significant data were lost to the investigation because
the cockpit voice recorder (CVR) was not shut down
after it was determined that the aircraft wing had
struck the ground, depriving the investigation team of
possible important information.
Safety action taken
Operator
The flight crew were given simulator training in lowvisibility approaches, and completed line checks with a
company check pilot.
A memorandum was issued to all dispatch personnel,
advising them that, when passing on runway visual
range (RVR) information to flight crew, they must also
include the applicable runway along with the time and
30
ASL 2/2008
Accident Synopses
Accident Synopses
On December 25, 2005, a Boeing 737-700 was on
a scheduled passenger flight from Toronto, Ont., to
Halifax, N.S. Just before touchdown on Runway 14, in
low-visibility conditions, the aircraft rolled right and
moved toward the right side of the runway. The aircraft
then rolled to the left, and the left wing struck the runway.
None of the passengers or crew members was injured, and
the aircraft taxied to the terminal. The incident occurred
at 19:24 Atlantic Standard Time (AST), during the hours
of darkness.
Finding as to risk
Regulations and You
Transport Canada published an article entitled
“Inadequate Identification of Fuel Barrels” in the Aviation
Safety Letter (ASL) 4/2006. The ASL is distributed
worldwide to over 90 000 readers.
1. The crew did not carry out a pilot-monitored approach
in accordance with company procedures, and therefore,
disabled a critical safety defence established to manage
landing safely in the low-visibility conditions.
2. The transition from the approach to the landing phase
became destabilized when the co-pilot disconnected
the autopilot, resulting in the aircraft wing contacting
the runway when the aircraft was being manoeuvred
to correct the situation.
. The co-pilot’s inability to keep the aircraft stabilized
during the transition to landing and his selection of
the take-off/go-around (TOGA) mode were likely
the result of his limited experience on type, and the
stress from the low-visibility and relatively-high
workload conditions.
. The captain did not take control or command a goaround once the transition became destabilized.
Recently Released TSB Reports
Regulations and You
Maintenance and Certification
referenced with the Commercial and Government
Entity (CAGE) code. It is not mandatory to indicate
the CAGE code on the accompanying tag.
2. The lack of a CAGE code on the accompanying
tag resulted in the issuance of a certificate of
airworthiness (C of A) without the benefit of
complete and adequate documentation.
Maintenance and Certification
Recently Released TSB Reports
The approach procedures for Category I and II instrument
landing system (ILS) approaches are being harmonized to
make both procedures as similar as possible.
Amendments to the operator’s company operations
manual have been issued, outlining the changes to the
approach ban limits.
The operator has completed an internal risk assessment
and has entered into discussions with NAV CANADA,
Transport Canada, and other industry organizations to
explore the possibility of conducting auto-landings on
Category I ILS approaches.
On July 3, 2006, a Bell 206B Jet Ranger helicopter was
departing from a prepared helicopter landing area adjacent
to the Nose Mountain, Alta., fire observation tower at
approximately 18:15 Mountain Daylight Time (MDT). A
pilot and three initial attack firefighters were on board. The
landing area was located in a clearing, on a mountain plateau,
situated at the north edge of a steep escarpment. After lifting
off, the pilot hover taxied around a pile of brush on the west
side of the clearing and departed in a westerly direction,
toward the escarpment. When the helicopter overflew the
rim of the escarpment, it began to yaw to the right. The
pilot was unable to control the yaw with the application of
full left pedal. As the helicopter rotated through 180°, the
pilot lowered the collective to regain directional control. The
helicopter descended onto the escarpment, rolled over, and
came to rest on its left side. One firefighter sustained fatal
injuries and another firefighter sustained serious injuries.
The pilot and the third firefighter sustained minor injuries.
The impact forces activated the onboard emergency locator
transmitter (ELT). The helicopter was substantially damaged,
but there was no post-impact fire.
Regulations and You
Transport Canada
Aviation regulations have been amended to prohibit
commercial air operators from beginning an approach
when visibility is so poor that a successful approach to a
landing is unlikely.
The regulations establish, for all runways where visibility
is reported, the minimum visibility for the crew to begin
an approach in what is termed an approach ban.
The amendments also extend the requirements to runways
where conditions are reported by an instrument-rated
pilot or qualified person rather than a sensor. In addition,
the regulations help harmonize Canadian regulations with
international standards, and respond to recommendations
from the TSB.
These changes came into force December 1, 2006, and affect
commercial air operators. The most significant changes to
the approach ban affect commercial air operators holding
operating certificates under the Subparts 702, 703, 704 and
705 of the Canadian Aviation Regulations (CARs), operating
airplanes in instrument flight rules (IFR). Minimal changes
to the approach ban affect IFR commercial helicopter
operations, and IFR aircraft operations by private operators
and general aviation.
Findings as to causes and contributing factors
1. The conditions of a shifting tailwind, over-gross weight,
and high-density altitude collectively exceeded the
rotor and engine performance limits of the helicopter,
and the helicopter was unable to take off in the
distance available.
2. Rotor performance was further lost when the helicopter
flew out of ground effect over the rim of the escarpment,
precipitating a degenerating situation of insufficient
power available, and the helicopter could not
sustain flight.
ASL 2/2008
31
Accident Synopses
Accident Synopses
TSB Final Report A06W0104—Loss of Control
and Collision with Terrain
Recently Released TSB Reports
Regulations and You
Revisions to flight crew training procedures have been
introduced that place additional emphasis on hazards
associated with low-visibility transition to visual references
during instrument approaches, and on the requirement to
use monitored approach procedures in these conditions.
In addition, training will involve discussion of procedures
to be carried out in the event of loss of visual reference
below decision height (DH), such as missed approach and
rejected landing procedures.
For more information regarding the new approach ban
regulations, visit the Transport Canada Web site.
Maintenance and Certification
date. The memorandum will be included in the next
flight dispatch operations guide revision. Guidance on
the required information will be given during training for
dispatch personnel.
Maintenance and Certification
•
•
•
•
Safety action taken
On December 11, 2006, the TSB issued Safety Information
Letter A060041—Passenger and Equipment Weights
in Helicopter Fire-Fighting Operations to the Director,
Wildfire Operations, Alberta Ministry of Sustainable
Resource Development. The Safety Information Letter
identified that assiduous monitoring of passenger and
32
On May 14, 2007, the FPB advised that all the proposed
remedial actions had been implemented. As well,
aviation audits were conducted at three of the four major
Mountain Pine Beetle controls within Alberta, and
the issue of providing accurate weights was reviewed
and stressed at a recent training course for Type 1 and
Type 1F initial attack leaders.
ASL 2/2008
Accident Synopses
Accident Synopses
Forward left view of main rotor strike damage to cockpit
Regulations and You
Regulations and You
•
The “Equipment List and Weights” in the
ASRD-FPB’s pilot’s handbook will be reviewed.
The elevation of the tower and fuel cache sites
will be added to the ASRD-FPB publications
and 2007 air operations maps.
High-quality weigh scales will be purchased for use
by crews at the primary fire bases and warehouses.
A copy of the Safety Information Letter has been
distributed to all ASRD-FPB area offices.
The pilot responsibilities and ASRD
representative responsibilities have been clarified
in sections 6.10 and 6.11 of the ASRD-FPB
standard operating procedures (SOPs), as follows:
– The pilot is responsible for completing the
load calculation correctly, using the proper
performance chart information, as per the
company’s operations manual, Canadian
Aviation Regulations (CARs) and the
Commercial Air Service Standards (CASS).
– The pilot is responsible for computing the
allowable payload.
– The pilot shall check, or be informed of,
any subsequent passenger/cargo manifested
weights completed under the initial load
calculation, to ensure that allowable payloads
are not exceeded.
– The ASRD representative responsible for a
flight (for example, crew leader, loadmaster,
wildfire ranger, forest officer) is responsible
for providing the pilot with a complete
passenger/cargo manifest, including accurate
weights, and advising the pilot of all
dangerous goods being carried.
– The passenger/cargo manifest/weights form
can be used to record the information given
to the pilot.
Recently Released TSB Reports
Recently Released TSB Reports
equipment loads is the sole solution to prevent overloading
of helicopters, and that a process to provide pilots with
accurate firefighter crew and gear weights may help to
ensure that helicopters involved in firefighting activities
in Alberta are flown within prescribed weight and balance
limits. In response to Safety Information Letter A060041,
the ASRD-FPB advised that it was taking the
following actions:
Maintenance and Certification
. In the conditions encountered during the takeoff,
the helicopter entered a vulnerable regime where
unanticipated right yaw occurs. There was insufficient
tail rotor thrust to counter the torque from the main
rotor, and the helicopter turned right.
. Although the pilot’s recovery actions arrested the
right turn, there was insufficient height to prevent the
helicopter from striking the terrain.
5. The inhospitable characteristics of the terrain
immediately below the helicopter prevented the pilot
from carrying out an uneventful landing, and the
helicopter rolled over on touchdown.
6. The weight of the helicopter at takeoff was incorrect
because of inaccurate estimates of the weights of the
firefighters, their gear, and the equipment. For the
existing conditions, the take-off weight exceeded both
the maximum gross weight limit and the hover out of
ground effect (HOGE) ceiling limit.
7. The main rotor penetrated the left-side cockpit and
cabin, contributing to the severity of the injuries to
the passengers.
8. It is probable that the passenger in the rear left seat
was not wearing the available shoulder harness; this
likely increased the severity of his injuries.
9. There was no system in place for the Alberta
Ministry of Sustainable Resource Development,
Forest Protection Branch (ASRD-FPB) to provide
helicopter pilots with actual individual weights of fire
crew and their personal gear.
Maintenance and Certification
Recently Released TSB Reports
Regulatory File on the Extension of Validity Periods for Certain Medical Certificates
In the “Regulations and You” article published in
issue 4/2007,
we mapped out the steps that a regulatory
Not used
initiative has to follow before it can be incorporated into
the Canadian Aviation Regulations (CARs). In this article,
we will explain the process followed by the regulatory
file dealing with the extension of validity periods of
medical certificates attached to private pilot licences
(aeroplane and helicopter), balloon pilot licences, and
gyroplane pilot permits.
On December 7, 1944, Canada signed the Chicago
Convention, committing to bring its regulations and
standards in line with the standards proposed by the United
Nations agency that later became the International Civil
Aviation Organization (ICAO). Canadian standards
regarding medical requirements associated with Canadian
aviation documents for personnel are, therefore, based on
the standards proposed in ICAO’s Annex 1.
Following consultations held by the working group with,
among others, Canadian aviation industry representatives,
Civil Aviation doctors, and other medical experts, it
was recommended that CARAC propose a regulatory
modification that would increase the validity periods
of medical certificates attached to private pilot licences
(aeroplane and helicopter), balloon pilot licences, and
gyroplane pilot permits, from 24 months to 60 months
for pilots under the age of 40, and from 12 months to
24 months for pilots age 40 and over.
Type of document
Pilot Permit—Gyroplane
Pilot Licence—Balloon
Private Pilot Licence—Aeroplane
Private Pilot Licence—Helicopter
On July 14, 2000, following the approval of the NPAs,
the Director General of Civil Aviation at the time issued
a ministerial exemption under subsection 5.9(2) of the
Aeronautics Act to allow for a reduction in the frequency
of medical examinations that validate the four documents
concerned to periods similar to those proposed by ICAO.
The table below shows the validity periods for medical
certificates attached to private pilot licences (aeroplane
and helicopter), balloon pilot licences, and gyroplane pilot
permits before and after the ministerial exemption, as well
as ICAO’s proposed periods. Please note that the gyroplane
pilot permit is a national document, and therefore, there is
no equivalent ICAO proposal.
At the end of the summer, a triage, a Regulatory Impact
Analysis Statement (RIAS) and the regulatory amendments
were submitted to the Treasury Board of Canada
Secretariat (TBS) for approval and publishing in the
Canada Gazette. Barring any unavoidable circumstances,
this regulatory file should be closed soon.
Canada (before the exemption)
Pilots under the
age of 40
24
24
24
24
ICAO
Canada (proposal)
An Pilots
explanation
regulatory
in which
Pilots age 40
underof the
Pilots
age 40process
Pilots
underthe triage
Pilotsand
age
explained
published
in the “Regulations
and over RIAS
the are
agedefined
of 40 and and
over was the
age of 40
40 and over
12
and You” section of Aviation Safety Letter (ASL) 4/2007.
12
12
12
N/A
N/A
60
24
60
24
60
24
60
60
24
24
60
60
24
24
An explanation of the regulatory process in which the triage and RIAS are defined and explained was published in the “Regulations and You”
section of Aviation Safety Letter (ASL) 4/2007.
ASL 2/2008
33
Accident Synopses
Accident Synopses
Validity Periods (months)
The Part IV Technical Committee is made up of
representatives of the government, pilot associations
(e.g. the Air Line Pilots Association—Canada [ALPA];
the Canadian Owners and Pilots Association [COPA];
the Ultralight Pilots Association of Canada [UPAC]; the
Aircraft Owners and Pilots Association [AOPA]), unions
(e.g. Teamsters Canada), airlines (e.g. Air Canada), and air
transport associations (e.g. the Air Transport Association
of Canada [ATAC]). CARC is made up of the Director
General and various Civil Aviation directors.
Regulations and You
When ICAO changed the validity periods of medical
certificates required to obtain a licence, Canada wanted
to harmonize its standards with those proposed. Thus,
in 1998, the Canadian Aviation Regulation Advisory
Council (CARAC) Part IV Technical Committee
commissioned a working group to study the possibility of
reducing the frequency of medical examinations required
for Canadian pilots to validate their licences and permits.
Notices of Proposed Amendment (NPA) were presented to
the members of the CARAC Part IV Technical Committee
on March 28, 2000, and were approved by the members
of the Civil Aviation Regulatory Committee (CARC)
on April 25, 2000.
Recently Released TSB Reports
Regulations and You
Regulatory File on the Extension of Validity Periods for Certain Medical Certificates................................................ page 33
Dangerous Goods in Transport: Reporting Requirements.............................................................................................. page 34
Enforcement Case Study: Suspension Under Section 7.21 of the Aeronautics Act..................................................... page 35
The Hazards Are Wild..................................................................................................................................................... page 36
Regs & you
Maintenance and Certification
regulations and you
Maintenance and Certification
Recently Released TSB Reports
Only a trained person may classify, select the means of
containment, package, label, mark, and document a shipment
of dangerous goods in compliance with the TDGR,
therefore, mitigating the risks associated with dangerous
goods in transport. In Canada, the consignor, also called the
shipper, is responsible for the dangerous goods shipment
from the time it is offered for transport until it reaches the
consignee, referred to as the receiver. The consignor is also
responsible for submitting an emergency response assistance
plan (ERAP) for the most hazardous dangerous goods
for approval before considering any transport activities,
domestically or internationally. Under the TDGR, a person
is also a consignor when requesting that a foreign entity ship
dangerous goods or other dangerous articles or substances
into Canada.
The air operator must also be trained to recognize, load,
and secure dangerous goods according to Canadian
standards; display the dangerous goods safety marks in
compliance with TDGR Part 4—Dangerous Goods Safety
Marks; and report dangerous goods accidents/incidents in
compliance with TDGR Part 8—Accidental Release and
Imminent Accidental Release Report Requirements.
The TDG Act, 1992 and TDGR adopt by reference
other documents that can be used as an alternative way
of complying with the regulations, as long as the TDGR
requirements are met. This is the case for the International
Civil Aviation Organization (ICAO) Doc 9284—
Technical Instructions for the Safe Transport of Dangerous
Goods by Air (ICAO TIs). Anyone handling, offering for
transport, transporting, or importing dangerous goods by
air must be trained to meet the TDGR requirements and
the ICAO TIs provisions.
34
The ICAO TIs Part 7—Operator Responsibilities requires
the air operator to report undeclared and misdeclared
dangerous goods found on passenger or cargo-only aircraft.
It also requires reporting of articles or substances that are
dangerous goods not permitted in passenger carry-on or
checked baggage under the ICAO TIs Part 8—Provisions
Concerning Passengers and Crew. What is a passenger?
The definition is different between the TDG Act, 1992
and the Aeronautics Act. When dealing with dangerous
goods, however, a passenger is defined in section 1.4 of the
TDGR, and reads:
“(b)for a road vehicle, a railway vehicle or an aircraft, a
person carried on board the means of transport but
does not include
(i) a crew member,
(ii) a person who is accompanying dangerous goods
or other cargo,
(iii)an operator, owner or charterer of the means
of transport,
(iv)an employee of the operator, owner or charterer
of the means of transport, who is acting in the
course of employment, or
(v) a person carrying out inspection or investigation
duties under an Act of Parliament or of a
provincial legislature.”
The 1996 crash of a ValuJet aircraft into the Florida
Everglades is an example of a reportable dangerous goods
accident, which, by definition, results in fatal or serious
injury to persons or major property damage. This particular
accident was caused by the improper handling, offering for
transport, or transporting of oxygen generators. Dangerous
goods incidents or undeclared/misdeclared dangerous goods
shipments are also reportable. A dangerous goods incident
is an occurrence, other than a dangerous goods accident,
associated with, and related to, the transport of dangerous
goods by air, not necessarily occurring on board an aircraft,
which results in injury to a person, property damage, fire,
breakage, spillage, leakage of fluid or radiation, or other
evidence that the integrity of the package has not been
maintained. Any occurrence relating to the transport of
dangerous goods that seriously jeopardizes an aircraft or its
occupants is also deemed to be a dangerous goods incident.
ASL 2/2008
Accident Synopses
A person is an individual, a corporation, or any other entity
carrying on a business, who has possession of dangerous
goods for the purposes of transportation, or for the purposes
of storing them in the course of transportation. A person
must report accidental release or imminent accidental
release found on an aircraft, at an aerodrome, or in an air
cargo facility to CANUTEC (613-996-6666) and the
nearest Transport Canada Regional Civil Aviation Office.
If the aerodrome is an airport, a report must also be made
to the airport operator, in compliance with TDGR Part 8.
A 30-day follow-up report must be made in writing to the
Director General, Transportation of Dangerous Goods
Directorate if an immediate report was required to be made
on an accidental release.
Regulations and You
Regulations and You
The Transportation of Dangerous Goods Act, 1992 (TDG Act,
1992) and the Transportation of Dangerous Goods Regulations
(TDGR) provide the Canadian legislative environment for
handling, offering for transport, transporting or importing
dangerous goods. In Canada, anyone handling, offering for
transport, or transporting dangerous goods must be trained
or working under the direct supervision of a trained person,
as stipulated in the TDGR Part 6—Training.
Recently Released TSB Reports
Accident Synopses
by Roger Lessard, Inspector, Dangerous Goods Standards, Standards, Civil Aviation, Transport Canada
Maintenance and Certification
Dangerous Goods in Transport: Reporting Requirements
Maintenance and Certification
Recently Released TSB Reports
The following is a list of phone numbers for
Transport Canada Civil Aviation Regional Dangerous
Goods Offices:
Atlantic
Quebec
Ontario
Prairie and Northern
Pacific
Airline Inspection
The TDG Act, 1992 does not occupy the whole field of
aviation safety. The Aeronautics Act, for instance, requires
Canadian air operators to hold a valid air operator
certificate (AOC). To obtain an AOC, the air operator
Recently Released TSB Reports
The Notices may be consulted at the following Web site:
www.tc.gc.ca/CivilAviation/commerce/DangerousGoods/news/
notices/menu.htm.
must meet the Canadian Aviation Regulations (CARs)
and the Commercial Air Services Standards (CASS), such
as submitting the procedures for the carriage of dangerous
goods, with the corresponding training programs part of
its company operations manual, including the reporting
requirements, for review and approval by Transport
Canada. As such, Transport Canada recently published
Advisory Circular AC 700-001—Procedures for the
Carriage of Dangerous Goods to the Company Operations
Manual to assist air operators in documenting such
procedures. It is available on the following Web site:
www.tc.gc.ca/CivilAviation/IMSdoc/ACs/700/700-001.htm.
Maintenance and Certification
The Dangerous Goods Standards Division of the Transport
Canada Civil Aviation Directorate published Dangerous
Goods Standards Notices No. 2—Dangerous Goods Carried
by Sports Teams; No. 3—Hand, Body and Filming Equipment
Warmers; No. 12—Quick Lighting Charcoal Tablets; No. 15—
Dangerous Goods Carried by Passengers—Outdoor Activities;
No. 16—Dangerous Goods Carried in Toolboxes; No. 17—
Carriage of Ammunition on Board an Aircraft; No. 19—First
Aid Kits; and No. 24—Individual Meal Packages, Flameless
Ration Heater, and Self-Heating Beverages to inform the
travelling public and air operators of targeted prohibited
items in passenger carry-on or checked baggage. Such items
must be reported to Transport Canada if they are found in
passenger baggage or as undeclared shipments.
506-851-7247
418-877-8868
416-952-0000
780-495-4022
604-666-5655
514-633-3116
Enforcement Case Study: Suspension Under Section 7.21 of the Aeronautics Act
Four months before, Peter had received a Notice of
Monetary Penalty for contravening Canadian Aviation
Regulation (CAR) 602.101 because he had landed
at a mandatory frequency (MF) aerodrome without
communicating his intentions.
Peter had not fully appreciated that the clock had started
ticking the moment he received the Notice of Monetary
Penalty. Upon receipt of that Notice, Peter ignored the
invitation for an informal meeting with the Regional
Manager, Aviation Enforcement. Further, he did not
file a request for a Transportation Appeal Tribunal of
Canada (TATC) review within 30 days and was then,
under the Aeronautics Act, deemed to have committed
the contravention for which he was charged.
Peter was not aware that the Act addresses the matter of
unpaid fines. Under section 7.21 of the Act, a person’s
Canadian aviation document, in this case Peter’s commercial
pilot licence—helicopter, can be suspended for not paying an
assessed monetary penalty. The suspension meant that Peter
could not exercise the privileges of his licence.
On receipt of the Notice of Suspension for non-payment
of a monetary penalty, Peter would be well advised to pay
the amount of the penalty immediately. A failure to do so
invokes the suspension of his licence and requires him to
return his document. If Peter elects not to surrender his
licence, he will expose himself to a further contravention
of CAR 103.03, and additional punitive enforcement
action could be brought against him.
At this point, Peter understood that the matter was
serious and that he should have dealt with it in a timely
fashion. He then decided to immediately pay the fine and
have the suspension lifted.
ASL 2/2008
Accident Synopses
Accident Synopses
Peter awoke early one morning after a long tour in northern
Quebec. He was troubled by a call from his wife the night
before. She had just received a Notice of Suspension
from Transport Canada, Aviation Enforcement. Peter’s
commercial pilot licence—helicopter had been suspended
for non-payment of a monetary penalty, and the suspension
would remain in effect until the monetary penalty was
paid in full.
Regulations and You
Regulations and You
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Standards, Civil Aviation, Transport Canada
35
Maintenance and Certification
by Bruce MacKinnon, Program Manager, Wildlife Control, Aerodrome and Air Navigation Standards, Standards, Civil Aviation, Transport Canada
No matter how much flight time you’ve logged as a pilot,
chances are that you’re not among that small group of
aviators who have experienced the shock of a bird strike
firsthand. It’s more likely that you know of someone who
has. And without a doubt, you’ve noticed hawks perched
on runway markers, flocks of Canada geese taking flight
from fields adjacent to runways, or even deer lurking in
the woods on the edge of airport properties.
The animal population isn’t the only factor that is
increasing; the number of aircraft operations is on the
rise. As a result, the risk of collisions between aircraft
and wildlife continues to grow—and the potential
severity associated with such collisions is high.
More than 70 percent of all bird strikes, and more than
65 percent of strikes that cause substantial aircraft
damage, occur below 500 ft above ground level (AGL).
Since aircraft at these altitudes are most likely to be at or
near airports, Transport Canada’s recent efforts to reduce
safety risks include Canadian Aviation Regulation (CAR)
302—Wildlife Planning and Management. In full force
since December 30, 2006, CAR 302 requires most certified
Canadian airports to develop, implement and maintain
plans for the management of wildlife.
These plans are based on site-specific risk—a recognition
that each airport faces unique wildlife challenges and must
have the capacity to implement site-appropriate mitigation.
Where risk is determined to be low, wildlife management
intervention can be minimal. As the level of risk rises, so too
must airport operators’ ongoing actions to minimize risk.
The words risk and hazard are often used interchangeably,
but in safety lingo there’s an important distinction between
them. A hazard is a factor that may lead to risk. Put another
way, risks arise from encounters with hazards. For example,
a ring-billed gull is generally not a hazard and poses little
risk. But in the airport environment, it is a potential hazard
because the risk of striking aircraft exists. Flying in the path
of a B727 on approach, the gull is a definite hazard at high
risk of causing a strike.
The goal of an airport wildlife management plan is to keep
risks to a minimum, primarily by identifying and countering
36
The data is compiled from wildlife strike reports submitted
to Transport Canada. (More on reporting at the end of this
article.) Under the new regulation, all airports must report
all wildlife strikes to Transport Canada and keep records
of these events. But anyone can file a wildlife strike report:
airlines, ground crews and pilots. It’s one of the most
valuable contributions you can make to the effort to reduce
wildlife risks.
Be sure to report any knowledge of wildlife strikes—no
matter how inconsequential the events may seem. Even
information about a near miss can help authorities learn
more about the presence of potentially hazardous species,
and the nuances of encounters between aircraft and animals.
An important regulatory trigger
Unfortunately, estimates indicate that approximately
80 percent of wildlife strikes go unreported in some
jurisdictions—a statistic that points to a glaring loss of
valuable knowledge and suggests a great deal more could
be done to improve safety. CAR 302 helps bridge this
gap by requiring airport operators to amend their wildlife
management plan and submit it to Transport Canada
for review within 30 days of a strike if a turbinepowered aircraft:
•
•
•
suffers damage as a result of a collision with
wildlife other than a bird;
collides with more than one bird; or
ingests a bird through an engine.
For pilots, this is a compelling reason to file a wildlife
strike report. In cases where CAR 302.305(6)(b) is
called into force, the process of review and amendment
helps ensure wildlife management plans are as current as
ASL 2/2008
Accident Synopses
Accident Synopses
A few words about the words
A risk analysis is a crucial first step in the creation of
an airport wildlife management plan—and mandatory
under CAR 302. Pilots should be aware of two key related
points: first, risk analyses must include consultations with
representative samples of airport users, such as flight
schools, airlines and pilots. Second, airport operators
cannot conduct thorough risk analyses without current
wildlife strike data, which is made available through
Transport Canada. This data is vital to national and
international airport wildlife management efforts, and one
of the most important tools in tracking wildlife trends
and determining hazards at locations across Canada.
Regulations and You
Regulations and You
Birds and other animals are a growing aviation hazard across
Canada and around the world. In particular, goose and deer
populations are skyrocketing in North America, and lands on
and around airports are often attractive locations that offer
food and protection for these species.
Assessing the risks
Recently Released TSB Reports
Recently Released TSB Reports
Key factors on the rise
resident hazards. This process of pinpointing hazards and
measuring the risks they pose is called risk analysis.
Maintenance and Certification
The Hazards Are Wild
Maintenance and Certification
Recently Released TSB Reports
Regulations and You
Pilots’ roles in SMS are defined in part by aviation
regulations in both Canada and the U.S.—regulations that
require you to familiarize yourself with all potential risks
and to operate aircraft in a manner that minimizes the
probability of wildlife strikes. From an operational point of
view, pilots can meet this obligation through prudent flight
planning. For instance, avoid flights over areas that are
known to attract birds, such as wildlife sanctuaries, landfills,
and shorelines. Aim to achieve cruise altitude as soon as
possible, since the probability of bird strikes decreases
dramatically above 3 000 ft AGL. And remember that
birds tend to be more active at dawn and dusk, and that
risks peak during spring and fall migration periods.
The review-and-amendment process is also set in motion
under CAR 302.305(6)(c), when a variation in the presence
of wildlife hazards is observed in an airport’s flight pattern
or movement area. You can help mitigate risk by reporting
to Transport Canada any significant changes in the
numbers or behaviour of hazardous wildlife at airports you
visit regularly.
Keeping you informed
Provisions of the new regulation also require airport
operators to put in place effective communication and
alerting procedures to quickly notify pilots of wildlife
hazards. These communications may be provided through
air traffic services (ATS), direct radio contact, broadcast of
airport advisories, and UNICOM.
Collision Course
Building on the benefits of CAR 302, Transport Canada
is currently developing new training resources to help
pilots gain a better appreciation of wildlife hazards. The
Collision Course package will feature an introductory video
that outlines the scope of the wildlife-hazard problem.
An interactive CD-ROM will also be included, featuring
many operational tips for avoiding and responding to
wildlife strikes.
Collision Course is the first product of its kind—the result
of a unique partnership between Transport Canada and
the Federal Aviation Administration (FAA), and clear
acknowledgement that wildlife hazards are a crossborder concern.
What else can you do?
The aviation industry in Canada is increasingly undertaking
the management of risk by incorporating safety
management systems (SMS). Essentially, this approach
holds that aviation safety can be best achieved through
system-wide, non-punitive efforts in which all stakeholders
Take the time to report
By conducting risk assessments, developing management
plans and training staff, airports across Canada have been
doing their part to address wildlife hazards and meet the
requirements of CAR 302. Pilots can take three simple
steps to help accelerate this move to safer skies: raise
your awareness of wildlife and the hazards they pose to
aviation; learn what measures are in place at the airports
you frequent; and take a few minutes to become familiar
with the quick and easy-to-complete bird/wildlife strike
report form (see below), and be sure to file a report in the
event of any wildlife encounter.
Bird/wildlife strike report form
Hard copy forms (form number 51-0272) are available in
bulk from the Transport Canada Order Desk:
Web site:
Toll-free (North America):
Local (Ottawa):
Fax:
E-mail:
www.tc.gc.ca/transact
1-888-830-4911
613-991-4071
613-991-2081
Accident Synopses
Pilots are also encouraged to read Sharing the Skies: An
Aviation Industry Guide to the Management of Wildlife
Hazards. Chapter 10 targets pilots directly, outlining their
roles and responsibilities, flight-planning tips, and operating
techniques for avoiding and responding to wildlife strikes.
If you encounter wildlife at an airport, notify ATS
immediately and take appropriate steps to minimize the
risk. For example, if you observe birds on the runway
while taxiing, do not hesitate to take position and hold
until the hazard is removed. Those birds may not occupy
your flight path, but they could well stray directly into
the path of another aircraft. In one of the worst bird strike
accidents on record, 24 lives were lost when an aircraft on
takeoff flushed geese into the path of an E-3B AWACS
at Elmendorf air force base (AFB), Alaska.
Regulations and You
Accident Synopses
During the fall of 2006, serious wildlife strikes triggered
enforcement of CAR 302.305(6)(b) at no less than four
Canadian airports—including three of the country’s
largest. Transport Canada inspectors have instructed these
airport operators to revisit their wildlife management
plans and address any shortcomings that may have
contributed to the strikes.
Recently Released TSB Reports
contribute—whether they are pilots, ATS providers or
ground personnel.
Maintenance and Certification
possible, addressing continual fluctuations in the wildlife
hazards at airports.
mps@tc.gc.ca
Bird/wildlife strike reports may be submitted online at:
www.tc.gc.ca/aviation/applications/birds/en/default.asp
Reports can also be made through a toll-free hotline: 1-888-282-BIRD
ASL 2/2008
37
Maintenance and Certification
Recently Released TSB Reports
The pilot flew the approach at 70 kt and full flap for a
planned short field landing on Runway 32. The main
wheels of the aircraft touched down about one foot
short of the runway edge, which tore both main gears
rearward, then the aircraft slid to a stop on the runway
surface. TSB File A07A0093.
— On August 7, 2007, the pilot of a Hughes 369D
helicopter was about to leave a logging site to refuel,
when he was requested to pull a small stump down the
hill to a safer position. He noted his fuel quantity and
believed he had adequate fuel to complete this job. The
pilot hooked onto the choker and pulled backwards
downhill, with the helicopter facing uphill in a nosehigh attitude, but was unable to move the stump.
He began to reposition over the load to release the
choker when the engine flamed out and the main rotor
RPM began to decrease. Due to the steep terrain, the
helicopter contacted the ground and rolled over to the
left three times. There was no fire, but the helicopter was
substantially damaged. TSB File A07P0271.
— On August 30, 2007, the private pilot of a
Cessna 172N was conducting night solo circuits in
Medicine Hat, Alta. While touching down for a fullstop landing, a mule deer ran in front of the aircraft.
The pilot was able to apply the brakes, but unable
to avoid contacting the deer at approximately 45–
50 knots indicated airspeed (KIAS). The deer hit the
front-left portion of the cowling, causing substantial
damage to the engine, firewall, and cowling. The pilot
was able to maintain directional control, and kept the
aircraft on the runway. TSB File A07W0159.
— On August 18, 2007, a privately-owned Lake LA‑4‑200
was taking off from Lake Rosseau, Ont., when, at
approximately 40 mph, the aircraft struck a boat
wake, bounced, and struck the water hard in a nosedown attitude. Engine power was reduced as the pilot
noted water entering through the hull area. The pilot
applied power and was heading to shore in an effort
to beach the aircraft, but the water level in the aircraft
was increasing rapidly. The pilot shut down the engine
and electrical power, and all three occupants exited
the aircraft and were picked-up by nearby boaters. The
aircraft eventually sank. TSB File A07O0232.
— On August 22, 2007, a Piper Warrior PA-28-151 was
on final approach to land at Cape Argos, N.S., for a
full-stop landing on a privately-owned turf airstrip.
38
— On September 3, 2007, a Cessna 140 was taxiing
from the Edmonton, Alta., Flying Club ramp to
Taxiway Alpha, when the aircraft collided with a
tractor attached to a helicopter dolly, which was
parked on the access road. The propeller, engine, and
cowlings were damaged, but the pilot (sole occupant)
was uninjured. TSB File A07W0160.
— On September 12, 2007, a Hughes 369E helicopter
was being used to move exploration crews to and
from a base camp situated near MacIntyre Lake, Sask.
The pilot picked up three passengers for a flight back
to the camp. After takeoff from a confined area, the
helicopter descended into the trees and rolled onto its
left side. The pilot and passengers were not injured.
The helicopter was operating near its maximum gross
weight. TSB File A07C0173.
ASL 2/2008
Accident Synopses
— On August 18, 2007, a Cessna 172 was rented from
a flying school, and departed the Pitt Meadows, B.C.,
airport for Squamish, B.C., a flight of about 50 NM
through mountainous terrain. The weather at the time of
the flight was marginal VFR. Search and rescue (SAR)
teams found the accident site in relatively high terrain.
There were three survivors, two with serious injuries. The
pilot sustained fatal injuries. TSB File A07P0286.
— On August 31, 2007, during the turbine cooling period
after a Bell 206 B3 helicopter landed on a roundwood
platform, one of the skids slid off a log while the
passengers were unloading their belongings. The back of
the helicopter sagged, and the tail rotor touched some
dried branches. Since one of the blades was slightly bent,
all the dynamic components connected to the tail rotor
had to be removed and checked. TSB File A07Q0177.
Regulations and You
Regulations and You
— On August 6, 2007, a Cessna 188B was manoeuvring
during an application flight, when the aircraft struck a
wire with its vertical fin. The aircraft then crashed into
a stand of trees, and sustained substantial damage;
there was no post-impact fire. The pilot sustained
minor injuries. TSB File A07C0145.
Recently Released TSB Reports
Accident Synopses
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 August 1, 2007, and October 31, 2007, are all
“Class 5,” and are unlikely to be followed by a TSB Final Report.
Maintenance and Certification
accident synopses
Please address your correspondence to:
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
Sécurité aérienne — Nouvelles est la version française
de cette publication.
Copyright:
Some of the articles, photographs and graphics that
appear in the Aviation Safety Letter are subject to
copyrights held by other individuals and organizations.
In such cases, some restrictions on the reproduction of
the material may apply, and it may be necessary to seek
permission from the rights holder prior to reproducing it.
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2008).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Regulations and You
Public Works and Government Services Canada
Publishing and Depository Services
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Fax: 613-998-1450 E-mail: copyright.droitdauteur@pwgsc.gc.ca
Table of Contents
section
2
ASL 2/2008
— On October 4, 2007, the pilot of a Champion
Aeronca 7AC tried to start the engine with the
propeller because the aircraft is not equipped with a
starter. Beforehand, the pilot had put chocks in front
of the main wheels. The engine did not start on the
first attempts, which led to the need to use the priming
pump and readjust the throttle. When the engine
started, it was at high power. The main wheels jumped
over the chocks and the aircraft turned and struck a
parked advanced ultralight. TSB File A07Q0197.
— On October 5, 2007, an EC120B helicopter was in
cruising flight when the engine (a Turbomeca Arius 2)
chip detector light turned on. Since the aircraft was
only two minutes away from its destination, the pilot
continued the flight. A few seconds later, the low
engine oil pressure light turned on, followed by the low
main rotor rpm warning horn. The pilot conducted an
autorotation toward an old logging road. During the
flare, the vertical stabilizer under the enclosed tail rotor
broke. The aircraft occupants were not injured. The
chip detector had turned on three weeks prior to this
incident. TSB File A07Q0198.
— On October 6, 2007, a Bell 204C helicopter was helilogging when the pilot smelled something burning.
The burning smell very quickly became stronger and
the helicopter began to rotate. The rotation increased
abruptly. The pilot rolled off the throttle and entered
an autorotation from about 200 ft above ground
level (AGL). The rate of descent increased during
the approach, and collective had little effect. The
helicopter landed hard in the chosen landing area
and was substantially damaged. There was no fire.
— On October 11, 2007, the pilot of a Cessna U206F
was circling Kearns Lake, Ont., to look for a missing
boat for an outpost camp. Hunters in the area observed
the aircraft circle the lake several times at low altitude.
During one tight turn at low altitude and high engine
power, the nose of the aircraft dropped and the aircraft
struck the lake. The pilot, who was alone in the aircraft,
sustained fatal injuries. TSB File A07C0189.
— On October 13, 2007, a Piper J-3 floatplane
stalled while circling a moose at 500–600 ft above
ground level (AGL). The pilot increased power, but
there was insufficient altitude to avoid hitting the
trees. The floats hit the trees first, then the aircraft
flipped over. The two occupants were not injured.
TSB File A07Q0206.
— On October 28, 2007, a Cessna 172L took off VFR
from Golden, B.C., for Edmonton City Centre, Alta.
The weather was poor with low ceilings and visibility.
A severe lee wave significant meteorological
information (SIGMET) advisory was in effect.
The aircraft was located by a ground search in the
Redburn Creek, B.C., area about 10 NM north of
Golden. The pilot and one passenger were fatally
injured. The second passenger sustained serious
injuries. TSB File A07P0369.
— On October 30, 2007, an Aerospatiale Astar AS350 D
helicopter was executing longline geodetic surveying
operations with a “bird” (an aerodynamically-shaped
pod full of electronic gear and sensors carried on a
longline). While manoeuvring to regain sight of the
sling load, the longline struck the tail rotor; a loss
of control ensued. The aircraft was destroyed when
it crash-landed in a swamp. The pilot and passenger
were not injured. TSB File A07Q0220.
— On October 31, 2007, a Beech 99 was departing
from the John F. Kennedy International Airport
in New York City, N.Y., for Hamilton, Ont., on a
scheduled cargo flight, with two pilots on board.
The flight crew were cleared for an intersection
takeoff on Runway 31R from Taxiway Echo. On the
take-off roll, both pilots heard and felt a single bang,
followed shortly after by several more intense noises
and bangs. The aircraft was aligned with the runway
lights on the right edge of the runway, instead of
the runway centerline lights. The crew aborted
the takeoff and taxied clear of the runway. Initial
inspection revealed damage to the nose landing gear
wheel and the propellers. TSB File A07F0186.
ASL 2/2008
39
Look out — Listen out — Speak out
The risk of mid-air collision is greatest from takeoff to top of climb, and again from start of descent to
landing. Don’t assume you’ll always be able to “see and avoid.’’ You, the pilot, are responsible for your own
separation and lookout. These tips will help.
Look out: Stay focused on looking outside.
Don’t let routine tasks (programming GPS, paperwork, etc.) or familiarity with an aerodrome
cause you to relax your lookout. Consider adopting “sterile cockpit” procedures while climbing or
descending. Cockpit activities should focus on lookout.
Complete most checks and briefings prior to descent so you can concentrate on procedures
and lookout.
Listen out: Let your ears be your eyes.
Always monitor the recommended or mandatory frequency (MF).
Get on frequency well before entering the aerodrome traffic frequency (ATF) or MF zone to
establish traffic awareness.
Monitor the ATF or MF throughout climb and descent.
Speak out: By verbal, visual and electronic means.
Keep others aware of your position.
Transmit initial advisories and updates on the recommended or mandatory frequency giving your
position, altitude, intentions and estimated time of arrival (ETA).
Accident Synopses
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Flight Operations..............................................................................................................................................................15
Maintenance and Certification........................................................................................................................................24
Recently Released TSB Reports......................................................................................................................................27
Regulations and You.........................................................................................................................................................33
Accident Synopses............................................................................................................................................................38
Debrief: Goodbye, 121.5: Major Changes Are Coming to the SAR Satellite System on February 1, 2009..............40
Communication errors are leading contributors to losses of separation and runway incursions.................................Tear-off
Look out—Listen out—Speak out.................................................................................................................................Tear-off
Accident Synopses
page
— On October 2, 2007, the Back Bone Silver 125
powered parachute was on takeoff, when the
pilot noticed that his aircraft was drifting. He
compensated by using the opposite elevator to
maintain control of his aircraft, and at the same
time, attempted to reposition himself in his harness.
While doing this, he accidentally reduced the engine
power, and the aircraft stalled at approximately
15 ft above ground. The pilot broke his shoulder.
TSB File A07Q0196.
The pilot sustained back injuries, but was released
from hospital a day later. Inspection of the helicopter
revealed that the tail-rotor drive had disconnected
from the main transmission. TSB File A07P0344.
Regulations and You
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact:
— On September 16, 2007, a privately-owned, floatequipped, BushCaddy L-160 touched down on
Wolverine Lake, Ont., and immediately a gust
of wind lifted the aircraft off the water surface. A
second touchdown attempt was also unsuccessful. The
aircraft began to veer towards some cottages near the
shoreline, and the pilot managed to get the aircraft
to fly over the cottages, before the aircraft pitched
nose down and struck the ground. Both occupants
evacuated the aircraft and received no injuries.
TSB File A07O0256.
Recently Released TSB Reports
The Order Desk
Transport Canada
Toll-free number (North America): 1-888-830-4911
Local number: 613-991-4071
E-mail: MPS@tc.gc.ca
Fax: 613-991-2081
Internet: www.tc.gc.ca/Transact
Maintenance and Certification
Change of address or format:
To notify us of a change of address, to receive the Aviation Safety Letter by e-Bulletin instead of a paper
copy, or for any related mailing issue (i.e. duplication,
request to be removed from our distribution list, language
profile change, etc.), please contact:
Recently Released TSB Reports
Letters with comments and suggestions are invited.
All correspondence should include the author’s name,
address and telephone number. The editor reserves the
right to edit all published articles. The author’s name and
address will be withheld from publication upon request.
Note: Reprints of original Aviation Safety Letter
material are encouraged, but credit must be given to
Transport Canada’s Aviation Safety Letter. Please forward
one copy of the reprinted article to the editor.
Transports
Canada
Maintenance and Certification
The Aviation Safety Letter is published quarterly by
Transport Canada, Civil Aviation. It is distributed to
all holders of a valid Canadian pilot licence or permit,
to all holders of a valid Canadian aircraft maintenance
engineer (AME) licence and to other interested
individuals free of charge. The contents do not necessarily
reflect official government policy and, unless stated,
should not be construed as regulations or directives.
Transport
Canada
Be conspicuous. Select position/strobes/landing lights “ON.” Transponders provide ATS and
traffic alert and collision avoidance system (TCAS) equipped aircraft with traffic avoidance
information. Turn them “ON.”
You can make flying safer—remember to:
Look out, Listen out, Speak out.
Transport
Canada
debrief
Transports
Canada
TP 185E
Issue 2/2008
Debrief
•
•
•
The International Civil Aviation Organization (ICAO)
Convention on International Civil Aviation, to which Canada
is a signatory, currently requires that aircraft engaged
in international operations carry at least one automatic
ELT that operates simultaneously on both 406 MHz and
121.5 MHz. Since Canada has an obligation to adopt these
standards, Transport Canada’s Civil Aviation Directorate
convened an Issue Analysis and Risk Assessment Team
on February 5, 2007, to determine how the Canadian
Aviation Regulations (CARs) can best accommodate these
changes, while being responsive to the concerns of the
Twenty-eight highly qualified participants from industry and
government, having a wide range of technical and operational
expertise, met over eighteen formally scheduled meetings
between February and June 2007. The Team consisted of
representatives from the Canadian Forces, the National
Search and Rescue Secretariat (NSS), Transport Canada,
the Canadian Owners and Pilots Association (COPA),
the Air Line Pilots Association (ALPA), the Air Transport
Association of Canada (ATAC), and the Air Canada Pilots
Association (ACPA).
Based on the results of their work, Transport Canada
has drafted a performance-based regulation to include
406 MHz ELTs as well as acceptable alternative
systems. The ultimate objective is to ensure that after
February 1, 2009, SAR authorities can continue to be
promptly notified of the occurrence and location of an
aircraft accident. The proposed changes to the CARs were
presented in Ottawa on November 20, 2007, at a special
meeting of the Canadian Aviation Regulation Advisory
Council (CARAC) Part VI Technical Committee—
General Operating and Flight Rules. The regulatory
proposal is currently being prepared for submission to the
Department of Justice for subsequent publication in the
Canada Gazette.
Updates on the regulatory process will be covered in future
issues of the Aviation Safety Letter (ASL), and are available
on the CARAC Web site at: www.tc.gc.ca/civilaviation/
regserv/affairs/carac/menu.htm. For more information on the
COSPAS-SARSAT system and the switch to 406 MHz,
visit www.cospas-sarsat.org and the NSS Web site at:
www.nss.gc.ca.
aviation safety letter
In this Issue...
Best Practices in Controller—Pilot Communications
Disruptive Passenger Behaviour—Creating a Safer Environment
Declaring an Emergency
Longline Accidents—Another Perspective
Hot Air Balloon Fuel Cylinders
Dangerous Goods in Transport: Reporting Requirements
Goodbye, 121.5: Major Changes Are Coming
to the SAR Satellite System on February 1, 2009
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
"Debrief"
Transport
Canada
I Chose to Live: A Moving Account by an Air Tragedy Survivor
Inspection Levels Part 2: Detailed Inspection Please!
Air Traffic Services–Pilot Communications Working Group
Debrief
•
Always use proper phraseology.
Give full readbacks, including your call sign.
Reduce multi-tasking while communicating:
– Pilots—have both crew members listen to clearances whenever possible;
– Air traffic services—actively listen to readbacks.
If in doubt—ask! Do not clarify ambiguity within the cockpit and do not use a readback
as confirmation.
If you think a transmission has been blocked, say something.
Be vigilant for similar call signs on the frequency.
Do not accept poor communication practices from others—insist on proper phraseology..
With these changes, after February 1, 2009, the 121.5 MHz
ELT from a downed aircraft will not be detected by the
satellite system. Alerting of the SAR system could be
significantly delayed, adversely affecting the survival of pilots
and passengers and causing anguish to friends and families.
Since the Government of Canada has an obligation to search
for missing aircraft, delayed notification and the possibility
of extended visual search missions also strains resources
and increases the exposure to risk for SAR personnel,
including the Canadian Forces and the volunteers of the
Civil Air Search and Rescue Association (CASARA).
While equipping aircraft with 406 MHz ELTs ensures
uninterrupted access to the COSPAS-SARSAT system,
concerns have been expressed by aircraft owners about the
high cost to buy and install this equipment.
aviation community. This included evaluating alternative
technologies for ensuring the prompt notification and
location of downed aircraft.
Debrief
•
•
•
Debrief
You can help to prevent them!
On February 1, 2009, the international search and
rescue (SAR) satellite system, COSPAS-SARSAT, will no
longer process signals from 121.5 or 243 MHz emergency
locator transmitters (ELT). Why? As of that date, the
system will complete its transition to digital 406 MHz-only
technology, which presents a faster, more capable, and more
reliable form of distress alerting. The switch to 406 MHz
emergency beacons has been made across Canada and around
the world by marine and land-based users.
Debrief
Communication errors are leading contributors
to losses of separation and runway incursions
by Nancy Lugg, Aerodrome Safety Engineer, Policy and Regulatory Services, Civil Aviation, Transport Canada
Debrief
Debrief
Goodbye, 121.5: Major Changes Are Coming to the SAR Satellite System on February 1, 2009
Transports
Canada
*TC-1002613*
40
ASL 2/2008
TC-1002613
Transport
Canada
debrief
Transports
Canada
TP 185E
Issue 2/2008
Debrief
•
•
•
The International Civil Aviation Organization (ICAO)
Convention on International Civil Aviation, to which Canada
is a signatory, currently requires that aircraft engaged
in international operations carry at least one automatic
ELT that operates simultaneously on both 406 MHz and
121.5 MHz. Since Canada has an obligation to adopt these
standards, Transport Canada’s Civil Aviation Directorate
convened an Issue Analysis and Risk Assessment Team
on February 5, 2007, to determine how the Canadian
Aviation Regulations (CARs) can best accommodate these
changes, while being responsive to the concerns of the
Twenty-eight highly qualified participants from industry and
government, having a wide range of technical and operational
expertise, met over eighteen formally scheduled meetings
between February and June 2007. The Team consisted of
representatives from the Canadian Forces, the National
Search and Rescue Secretariat (NSS), Transport Canada,
the Canadian Owners and Pilots Association (COPA),
the Air Line Pilots Association (ALPA), the Air Transport
Association of Canada (ATAC), and the Air Canada Pilots
Association (ACPA).
Based on the results of their work, Transport Canada
has drafted a performance-based regulation to include
406 MHz ELTs as well as acceptable alternative
systems. The ultimate objective is to ensure that after
February 1, 2009, SAR authorities can continue to be
promptly notified of the occurrence and location of an
aircraft accident. The proposed changes to the CARs were
presented in Ottawa on November 20, 2007, at a special
meeting of the Canadian Aviation Regulation Advisory
Council (CARAC) Part VI Technical Committee—
General Operating and Flight Rules. The regulatory
proposal is currently being prepared for submission to the
Department of Justice for subsequent publication in the
Canada Gazette.
Updates on the regulatory process will be covered in future
issues of the Aviation Safety Letter (ASL), and are available
on the CARAC Web site at: www.tc.gc.ca/civilaviation/
regserv/affairs/carac/menu.htm. For more information on the
COSPAS-SARSAT system and the switch to 406 MHz,
visit www.cospas-sarsat.org and the NSS Web site at:
www.nss.gc.ca.
aviation safety letter
In this Issue...
Best Practices in Controller—Pilot Communications
Disruptive Passenger Behaviour—Creating a Safer Environment
Declaring an Emergency
Longline Accidents—Another Perspective
Hot Air Balloon Fuel Cylinders
Dangerous Goods in Transport: Reporting Requirements
Goodbye, 121.5: Major Changes Are Coming
to the SAR Satellite System on February 1, 2009
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
"Debrief"
Transport
Canada
I Chose to Live: A Moving Account by an Air Tragedy Survivor
Inspection Levels Part 2: Detailed Inspection Please!
Air Traffic Services–Pilot Communications Working Group
Debrief
•
Always use proper phraseology.
Give full readbacks, including your call sign.
Reduce multi-tasking while communicating:
– Pilots—have both crew members listen to clearances whenever possible;
– Air traffic services—actively listen to readbacks.
If in doubt—ask! Do not clarify ambiguity within the cockpit and do not use a readback
as confirmation.
If you think a transmission has been blocked, say something.
Be vigilant for similar call signs on the frequency.
Do not accept poor communication practices from others—insist on proper phraseology..
With these changes, after February 1, 2009, the 121.5 MHz
ELT from a downed aircraft will not be detected by the
satellite system. Alerting of the SAR system could be
significantly delayed, adversely affecting the survival of pilots
and passengers and causing anguish to friends and families.
Since the Government of Canada has an obligation to search
for missing aircraft, delayed notification and the possibility
of extended visual search missions also strains resources
and increases the exposure to risk for SAR personnel,
including the Canadian Forces and the volunteers of the
Civil Air Search and Rescue Association (CASARA).
While equipping aircraft with 406 MHz ELTs ensures
uninterrupted access to the COSPAS-SARSAT system,
concerns have been expressed by aircraft owners about the
high cost to buy and install this equipment.
aviation community. This included evaluating alternative
technologies for ensuring the prompt notification and
location of downed aircraft.
Debrief
•
•
•
Debrief
You can help to prevent them!
On February 1, 2009, the international search and
rescue (SAR) satellite system, COSPAS-SARSAT, will no
longer process signals from 121.5 or 243 MHz emergency
locator transmitters (ELT). Why? As of that date, the
system will complete its transition to digital 406 MHz-only
technology, which presents a faster, more capable, and more
reliable form of distress alerting. The switch to 406 MHz
emergency beacons has been made across Canada and around
the world by marine and land-based users.
Debrief
Communication errors are leading contributors
to losses of separation and runway incursions
by Nancy Lugg, Aerodrome Safety Engineer, Policy and Regulatory Services, Civil Aviation, Transport Canada
Debrief
Debrief
Goodbye, 121.5: Major Changes Are Coming to the SAR Satellite System on February 1, 2009
Transports
Canada
*TC-1002613*
40
ASL 2/2008
TC-1002613
Please address your correspondence to:
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
Sécurité aérienne — Nouvelles est la version française
de cette publication.
Copyright:
Some of the articles, photographs and graphics that
appear in the Aviation Safety Letter are subject to
copyrights held by other individuals and organizations.
In such cases, some restrictions on the reproduction of
the material may apply, and it may be necessary to seek
permission from the rights holder prior to reproducing it.
© Her Majesty the Queen in Right of Canada,
as represented by the Minister of Transport (2008).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Regulations and You
Public Works and Government Services Canada
Publishing and Depository Services
350 Albert Street, 4th Floor, Ottawa ON K1A 0S5
Fax: 613-998-1450 E-mail: copyright.droitdauteur@pwgsc.gc.ca
Table of Contents
section
2
ASL 2/2008
— On October 4, 2007, the pilot of a Champion
Aeronca 7AC tried to start the engine with the
propeller because the aircraft is not equipped with a
starter. Beforehand, the pilot had put chocks in front
of the main wheels. The engine did not start on the
first attempts, which led to the need to use the priming
pump and readjust the throttle. When the engine
started, it was at high power. The main wheels jumped
over the chocks and the aircraft turned and struck a
parked advanced ultralight. TSB File A07Q0197.
— On October 5, 2007, an EC120B helicopter was in
cruising flight when the engine (a Turbomeca Arius 2)
chip detector light turned on. Since the aircraft was
only two minutes away from its destination, the pilot
continued the flight. A few seconds later, the low
engine oil pressure light turned on, followed by the low
main rotor rpm warning horn. The pilot conducted an
autorotation toward an old logging road. During the
flare, the vertical stabilizer under the enclosed tail rotor
broke. The aircraft occupants were not injured. The
chip detector had turned on three weeks prior to this
incident. TSB File A07Q0198.
— On October 6, 2007, a Bell 204C helicopter was helilogging when the pilot smelled something burning.
The burning smell very quickly became stronger and
the helicopter began to rotate. The rotation increased
abruptly. The pilot rolled off the throttle and entered
an autorotation from about 200 ft above ground
level (AGL). The rate of descent increased during
the approach, and collective had little effect. The
helicopter landed hard in the chosen landing area
and was substantially damaged. There was no fire.
— On October 11, 2007, the pilot of a Cessna U206F
was circling Kearns Lake, Ont., to look for a missing
boat for an outpost camp. Hunters in the area observed
the aircraft circle the lake several times at low altitude.
During one tight turn at low altitude and high engine
power, the nose of the aircraft dropped and the aircraft
struck the lake. The pilot, who was alone in the aircraft,
sustained fatal injuries. TSB File A07C0189.
— On October 13, 2007, a Piper J-3 floatplane
stalled while circling a moose at 500–600 ft above
ground level (AGL). The pilot increased power, but
there was insufficient altitude to avoid hitting the
trees. The floats hit the trees first, then the aircraft
flipped over. The two occupants were not injured.
TSB File A07Q0206.
— On October 28, 2007, a Cessna 172L took off VFR
from Golden, B.C., for Edmonton City Centre, Alta.
The weather was poor with low ceilings and visibility.
A severe lee wave significant meteorological
information (SIGMET) advisory was in effect.
The aircraft was located by a ground search in the
Redburn Creek, B.C., area about 10 NM north of
Golden. The pilot and one passenger were fatally
injured. The second passenger sustained serious
injuries. TSB File A07P0369.
— On October 30, 2007, an Aerospatiale Astar AS350 D
helicopter was executing longline geodetic surveying
operations with a “bird” (an aerodynamically-shaped
pod full of electronic gear and sensors carried on a
longline). While manoeuvring to regain sight of the
sling load, the longline struck the tail rotor; a loss
of control ensued. The aircraft was destroyed when
it crash-landed in a swamp. The pilot and passenger
were not injured. TSB File A07Q0220.
— On October 31, 2007, a Beech 99 was departing
from the John F. Kennedy International Airport
in New York City, N.Y., for Hamilton, Ont., on a
scheduled cargo flight, with two pilots on board.
The flight crew were cleared for an intersection
takeoff on Runway 31R from Taxiway Echo. On the
take-off roll, both pilots heard and felt a single bang,
followed shortly after by several more intense noises
and bangs. The aircraft was aligned with the runway
lights on the right edge of the runway, instead of
the runway centerline lights. The crew aborted
the takeoff and taxied clear of the runway. Initial
inspection revealed damage to the nose landing gear
wheel and the propellers. TSB File A07F0186.
ASL 2/2008
39
Look out — Listen out — Speak out
The risk of mid-air collision is greatest from takeoff to top of climb, and again from start of descent to
landing. Don’t assume you’ll always be able to “see and avoid.’’ You, the pilot, are responsible for your own
separation and lookout. These tips will help.
Look out: Stay focused on looking outside.
Don’t let routine tasks (programming GPS, paperwork, etc.) or familiarity with an aerodrome
cause you to relax your lookout. Consider adopting “sterile cockpit” procedures while climbing or
descending. Cockpit activities should focus on lookout.
Complete most checks and briefings prior to descent so you can concentrate on procedures
and lookout.
Listen out: Let your ears be your eyes.
Always monitor the recommended or mandatory frequency (MF).
Get on frequency well before entering the aerodrome traffic frequency (ATF) or MF zone to
establish traffic awareness.
Monitor the ATF or MF throughout climb and descent.
Speak out: By verbal, visual and electronic means.
Keep others aware of your position.
Transmit initial advisories and updates on the recommended or mandatory frequency giving your
position, altitude, intentions and estimated time of arrival (ETA).
Accident Synopses
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Flight Operations..............................................................................................................................................................15
Maintenance and Certification........................................................................................................................................24
Recently Released TSB Reports......................................................................................................................................27
Regulations and You.........................................................................................................................................................33
Accident Synopses............................................................................................................................................................38
Debrief: Goodbye, 121.5: Major Changes Are Coming to the SAR Satellite System on February 1, 2009..............40
Communication errors are leading contributors to losses of separation and runway incursions.................................Tear-off
Look out—Listen out—Speak out.................................................................................................................................Tear-off
Accident Synopses
page
— On October 2, 2007, the Back Bone Silver 125
powered parachute was on takeoff, when the
pilot noticed that his aircraft was drifting. He
compensated by using the opposite elevator to
maintain control of his aircraft, and at the same
time, attempted to reposition himself in his harness.
While doing this, he accidentally reduced the engine
power, and the aircraft stalled at approximately
15 ft above ground. The pilot broke his shoulder.
TSB File A07Q0196.
The pilot sustained back injuries, but was released
from hospital a day later. Inspection of the helicopter
revealed that the tail-rotor drive had disconnected
from the main transmission. TSB File A07P0344.
Regulations and You
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact:
— On September 16, 2007, a privately-owned, floatequipped, BushCaddy L-160 touched down on
Wolverine Lake, Ont., and immediately a gust
of wind lifted the aircraft off the water surface. A
second touchdown attempt was also unsuccessful. The
aircraft began to veer towards some cottages near the
shoreline, and the pilot managed to get the aircraft
to fly over the cottages, before the aircraft pitched
nose down and struck the ground. Both occupants
evacuated the aircraft and received no injuries.
TSB File A07O0256.
Recently Released TSB Reports
The Order Desk
Transport Canada
Toll-free number (North America): 1-888-830-4911
Local number: 613-991-4071
E-mail: MPS@tc.gc.ca
Fax: 613-991-2081
Internet: www.tc.gc.ca/Transact
Maintenance and Certification
Change of address or format:
To notify us of a change of address, to receive the Aviation Safety Letter by e-Bulletin instead of a paper
copy, or for any related mailing issue (i.e. duplication,
request to be removed from our distribution list, language
profile change, etc.), please contact:
Recently Released TSB Reports
Letters with comments and suggestions are invited.
All correspondence should include the author’s name,
address and telephone number. The editor reserves the
right to edit all published articles. The author’s name and
address will be withheld from publication upon request.
Note: Reprints of original Aviation Safety Letter
material are encouraged, but credit must be given to
Transport Canada’s Aviation Safety Letter. Please forward
one copy of the reprinted article to the editor.
Transports
Canada
Maintenance and Certification
The Aviation Safety Letter is published quarterly by
Transport Canada, Civil Aviation. It is distributed to
all holders of a valid Canadian pilot licence or permit,
to all holders of a valid Canadian aircraft maintenance
engineer (AME) licence and to other interested
individuals free of charge. The contents do not necessarily
reflect official government policy and, unless stated,
should not be construed as regulations or directives.
Transport
Canada
Be conspicuous. Select position/strobes/landing lights “ON.” Transponders provide ATS and
traffic alert and collision avoidance system (TCAS) equipped aircraft with traffic avoidance
information. Turn them “ON.”
You can make flying safer—remember to:
Look out, Listen out, Speak out.
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