debrief

debrief
Transports
Canada
Debrief
Debrief
Examination of all fuel tubing did not reveal any
anomalies or restrictions. It was also outlined that the
aircraft had a similar previous engine stoppage two years
earlier. At that time, the aircraft was on skis over a snowy
field and made a successful forced landing. Shortly after,
the engine restarted and ran normally. Due to lack of
other tangible factors, it was felt that it may have been
caused by a fuel selector malfunction or positioning. The
owner also recalls that whenever operating with the fuel
selector on “both,” the left tank always fed at a slower rate
than the right. He further mentioned having heard air
rushing into the tank when opening the left fuel cap for
refuelling immediately after engine shutdown.
Debrief
After the most recent occurrence, the owner was
prompted to verify the adequacy of the venting system,
which is done through the fuel caps (Figure 1). Air
passage on the left fuel cap was found to be erratic;
sometimes it would let the air through, but sometimes it
would not. Information from the manufacturer indicates
that this type of cap is only to be installed on aircraft
having been modified with auxiliary wing tanks (located
outboard on the wings), as the modification includes the
plumbing for a different venting system.
Figure 1: Non-probed fuel cap
36
The caps used on the occurrence aircraft, shown in Figure 1,
had been ordered by the previous owner to replace the
original caps to which a ram air probe is fitted to assure
positive pressure within the fuel tanks (Figure 2). The order
voucher indicated that non-leaking caps (non-probed
caps) were requested. This was desired partly for aesthetic
reasons and also because probed caps allowed fuel to leak
out if the aircraft when it was parked on uneven ground.
The order voucher included the aircraft serial number. The
manufacturer forwarded the non-probed fuel caps without
challenging whether the aircraft fuel system was original or
it had been modified with auxiliary wing tanks. While the
probed caps assure a positive pressure inside the fuel tanks,
the air passage through the non-probed caps reduces the
pressure within the tank below that of the ambient pressure.
aviation safety letter
In this Issue...
Runway Safety and Incursion Prevention Panel
Thoughts on the New View of Human Error Part III:
“New View” Accounts of Human Error
Aviate—Navigate—Communicate
Figure 2: Probed fuel cap
Consequently, any blockage within the cap quickly results in stopping the fuel flow to the engine. As the
fuel system includes a small header tank, switching tanks
would normally restore the fuel flow, re-establishing
power to the engine. Test bench trials on similar systems,
operated by a skilled engine technician aware of the
intended fuel starvation test, have demonstrated that it
requires 30–45 seconds to restore full power following the engine stoppage.
The investigation into this occurrence has raised a concern
about the replacement of parts for different aircraft
models, which would affect the airworthiness of the
aircraft. The use of non-probed caps on an unmodified
airframe has shown that venting is possible when the
valve within the caps is working properly. However, as
demonstrated in this occurrence, there is no alternate
means of venting in case of malfunction. Any change to
original aircraft status, regardless how small, must first be
authorized by the manufacturer, unless it is approved via a
supplementary type certificate (STC)—as these changes
can and have created airworthiness disturbances.
ASL 2/2007
Safety Management Enhances Safety in Gliding Clubs
Near Collision on Runway 08R at Vancouver
Say Again! Communication Problems Between Controllers and Pilots
Ageing Airplane Rulemaking
Bilateral Agreements on Airworthiness—An Overview and Current Status
Exploring the Parameters of Negligence: Two Recent TATC Decisions
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
"Debrief"
• confined area
• awkward load
• marginal weather
• untrained groundcrew
• customer pressure
• tight schedule
• fatigue
• inadequate equipment
• uncertain field servicing
On September 30, 2004, a Maule-4 aircraft lost power
while cruising at 1 200 ft. The pilot changed tanks and
turned on the electric fuel pump, but power could not be
restored and the aircraft was forced to land. As the field
was too short, the aircraft sustained substantial damage
when it hit a fence at the end of the landing roll and
overturned. When the aircraft was recovered, the pilot
owner was somewhat surprised that fuel remained in the
right tank and very little was lost from the left tank after
the aircraft had been inverted overnight. The type of cap
installed includes an internal flapper valve, which closes,
thereby retaining the fuel in the tanks.
Debrief
Do these sound familiar?
An Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)
TP 185E
Issue 2/2007
Debrief
STAY ALERT!
Fuel Starvation Maule-4—Incorrect Fuel Caps
Transports
Canada
Debrief
Slinging accidents
happen mostly
to experienced
pilots.
Transport
Canada
debrief
Debrief
Transport
Canada
*TC-1002136*
TC-1002136
FOR CANADIAN RESIDENTS ONLY
Moving?
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact the Editor.
Sécurité aérienne — Nouvelles est la version française de
cette publication.
© Her Majesty the Queen in Right of Canada, as
represented by the Minister of Transport (2007).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Maintenance and Certification
by Franz Reinhardt, Director, Regulatory Services, Civil Aviation, Transport Canada
2
ASL 2/2007
Regulations and You
The Act last underwent a major overhaul in 1985. Many
of the amendments made at the time were aimed at
enhancing the compliance and enforcement provisions
of the Act, including the establishment of the Civil
Aviation Tribunal (CAT), which was later converted
into the multi-modal Transportation Appeal Tribunal
of Canada (TATC). As a result of discussions with
stakeholders, and in continuing efforts to enhance
aviation safety and security, the following changes are
proposed in Bill C-6.
The Department of Transport (TC) is re-shaping its
regulatory programs to be more “data-driven” and to
require aviation organizations to implement integrated
management systems (IMS). These types of programs
are increasingly required by the International Civil
Aviation Organization (ICAO) and implemented by
leading aviation nations. The enabling authority for
the safety management systems (SMS) regulation is
valid and authorized under the existing Aeronautics Act. However, for greater clarification and to provide the SMS
framework with additional statutory protections from
enforcement, as well as protection from access under
the Access to Information Act, TC needed to expand the
Minister’s authority under the Aeronautics Act. Amendments to the Aeronautics Act are also required to
provide expanded regulatory authority over such issues as
fatigue management and liability insurance. The current
enabling authority related to fatigue management does
not extend to all individuals who perform important
safety functions, such as air traffic controllers. The current
enabling authority related to liability insurance does not
extend, for example, to airport operators. The amendments
will also provide for the designation of industry bodies
that establish standards for, and certify, their members,
subject to appropriate safety oversight by TC.
In order to obtain as much safety data as possible, the
amendments also propose the establishment of a voluntary
non-punitive reporting program, allowing the reporting
of safety-related information, without fear of reprisal or
enforcement action taken against the reporting party.
Since the maximum level of penalties for non-compliance
has not been updated since 1985, amendments are
required not only to align them with similar legislation
recently enacted, but also to act as a deterrent to future
non-compliance. The proposed amendments will increase
the maximum penalties for corporations in administrative
and summary conviction proceedings (currently capped
at $25,000) to $250,000 and $1 million, respectively.
Civilian sectors are now delivering some flight services
to the Canadian Forces. These flights are considered
“military,” but as the Aeronautics Act is currently written,
the Department of National Defence (DND) does not
have all the authorities it needs to carry out a flight safety
investigation that may involve civilians in a military
aircraft occurrence. The proposed amendments would
provide DND flight safety accident investigators with
powers similar to those of civilian accident investigators
under the Canadian Transportation Accident Investigation
and Safety Board Act when investigating military aircraft
accidents involving civilians. The amendments would also
clarify the authorities of the Minister of Transport in
relation to those of NAV CANADA under the Civil Air
Navigation Services Commercialization Act.
For any additional information, please visit our Web site at www.tc.gc.ca/CivilAviation/RegServ/Affairs/menu.htm.
ASL 2/2007
35
the safety problem…
Here’s how accidents happen:
• getting pressured into a risky operation
• accepting hazards
• flying when fatigued
• lacking training for the task
• not sure of what’s required
• operating in marginal weather
• ignoring laid-down procedures
• becoming distracted and not spotting a hazard
The major hazards:
• obstacles in the operating area
• snagged sling gear
• equipment failure
• deficient pad housekeeping
• surface condition: snow, soft spots, etc.
• incorrectly rigged load
• wind condition not known beforehand
• overloading
the safety team…
the PILOT
• follows procedures; no corner-cutting
• ensures everyone is thoroughly briefed
• watches for dangerous practices and reports them
• rejects a job exceeding his skill
• knows fatigue is cumulative and gets plenty of rest
• checks release mechanism and sling gear serviceability
the GROUNDCREW
• knows the hand signals and emergency procedures
• watches for hazards—and reports them
• rejects a task beyond his skill or knowledge
• insists on proper training in load preparation and handling
the CUSTOMER
• reasonable in demands; doesn’t pressure pilot
• insists on safety first
• reports dangerous practices
Regulations and You
What’s New: Please visit the Civil Aviation Web site to view the online Risk-based
Business Model and Risk Management Principles presentation: www.tc.gc.ca/CivilAviation/risk/Breeze/menu.htm.
Bill C-6, an act to amend the Aeronautics Act and to
make consequential amendments to other acts, was
introduced in the House of Commons on April 27, 2006.
The Aeronautics Act establishes the Minister of Transport’s
responsibility for the development, regulation and
supervision of all matters connected with civil aeronautics
and the responsibility of the Minister of National
Defence with respect to aeronautics relating to defence.
Accident Synopses
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Flight Operations..............................................................................................................................................................12
Maintenance and Certification........................................................................................................................................21
Recently Released TSB Reports......................................................................................................................................26
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Fuel Starvation Maule-4—Incorrect Fuel Caps.............................................................................................36
Take 5 — Slinging With Safety......................................................................................................................................Tear-off
Accident Synopses
Go to www.smartmoves.ca
page
The essence of negligence has been described as,
“the omitting to do something that a reasonable person
The Aeronautics Act—The Latest News!
Change your address online
with Canada Post and notify
Transport Canada at the same time.
Table of Contents
section
Conclusion
Recently Released TSB Reports
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARPP)
Place de Ville, Tower C
Ottawa ON K1A 0N8 E-mail: marqupj@tc.gc.ca
Tel.: 613-990-1289
Fax: 613-991-4280
Internet: www.tc.gc.ca/ASL-SAN
Note: 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.
Recently Released TSB Reports
Please address your correspondence to: 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.
would do or the doing [of ] something which a reasonable
person would not do.” The two cases discussed above illustrate
how this basic principle is applied in aviation situations. It is
quite often simply an exercise in common sense. In both
cases, the pilots undertook actions that were ill-advised in the
sense that they created situations of unnecessary risk. The risk
was to others (as well as themselves) and to property. Given
the gravity of the potential consequences of unnecessary
risk within the aviation context, the decisions reached by the
TATC are not surprising. While the exercise of common
sense, prudence and the avoidance of negligent behaviour
are important characteristics in all our activities, they are
particularly so in the world of aviation.
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, and to
all holders of a valid Canadian aircraft maintenance
engineer (AME) licence. The contents do not necessarily
reflect official policy and, unless stated, should not be
construed as regulations or directives. 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.
The second charge was upheld largely because of the
safety implications resulting from the Applicant’s actions.
As he was approaching the airport in a non-standard
manner, it was incumbent on him to conform to the
pattern of traffic formed by the other approaching aircraft.
This, the Member implied, was what would be expected
of a reasonable pilot in the same situation. That meant
abandoning his training procedure, and by failing to do so,
he engaged in negligent conduct.
the MANAGER
• allows for weather and equipment delays
• sends the right pilot with the right equipment
• insists the pilot is thoroughly briefed on the requirements
• supports the pilot against customer pressures
• demands compliance with operating manual
• provides proper training
Remember, 60% of slinging accidents occur during pick-up
Guest Editorial
Guest Editorial
guest editorial
It is my pleasure to contribute to the Aviation Safety Letter (ASL). This quarterly
publication is a major element of the Civil Aviation Directorate’s overall communications
strategy, and has the potential to help all of us see how our own responsibilities mesh with
those of our colleagues in other branches. Such a broad viewpoint is essential as we move
into the more integrated world of safety management.
Like other branches, we are currently involved in the introduction of safety management systems (SMS) in accordance
with the civil aviation strategy outlined in Flight 2010. Like those other branches, we too have our own unique
challenges in this regard. On the one hand, because of our long experience with quality assurance (QA) programs, we
have a head start on some of the QA aspects of safety management. On the other hand, most of this experience was with
the reactive aspects of QA, and was focussed primarily on the actual man-machine interface. Only recently have we been
involved with the subtleties of human and organizational relationships, and proactive hazard identification across a wider
organizational spectrum. Also, some of the forward-looking program improvement elements of flight safety programs
are new to us. In this respect, the addition of expertise from other branches will be particularly welcome, which provides
a good illustration of the way in which the new organizational structure will support this new, more integrated approach
to safety management.
Pre-flight
Pre-flight
The Aircraft Maintenance and Manufacturing Branch consists of approximately 40 staff in headquarters, and a further
280 staff distributed across the regions. The Pacific, Prairie and Northern, Ontario and Atlantic Regions each have a
Manager of Maintenance and Manufacturing, while the Quebec Region, because of the concentration of manufacturing
activity in the Montréal area, has separate managers for the maintenance and the manufacturing functions. The Branch
is primarily responsible for the development and application of regulations and standards related to the production
and maintenance of aeronautical products, and their oversight in the field. That includes not only the performance of
maintenance by approved maintenance organizations (AMO) and aircraft maintenance engineers (AME), but also the
management and scheduling of maintenance by aircraft owners and operators. It encompasses such things as air operator
technical dispatch requirements, the licensing and training of AMEs, the approval of aircraft maintenance schedules,
and the oversight of industry activities related to these areas.
To the Letter
To the Letter
In preparation for the organizational changes that will position the Directorate to better deliver its programs in the
new safety management environment, the role of the Aircraft Maintenance and Manufacturing Branch is currently
changing to one in which it will form a part of a larger standards developing unit, concerned not only with maintenance
and manufacturing standards, but also with those relating to commercial and business aviation, airports, and air traffic
services (ATS). However, this is an ongoing process, and my colleagues have already covered some of these functions in other
editorials, so at this time I will restrict myself to the traditional role of the Branch within the Civil Aviation Directorate.
These truly are exiting times for our industry, and together with all of the staff of the Aircraft Maintenance and
Manufacturing Branch, I look forward to working closely with our colleagues from the other specialty areas to deliver a
truly effective, coordinated, Civil Aviation Program.
I invite you to take a look at the Aircraft Maintenance and Manufacturing Branch’s Web site at Flight Operations
Flight Operations
www.tc.gc.ca/CivilAviation/maintenance/menu.htm.
D. B. Sherritt
Director
Standards
ASL 2/2007
to the letter
I would like to share an experience with other aviators to
show the importance of being prepared. I was a low-hour
Notpilot
used with what I would
Flt. Ops
Maint. & Cert.
consider average cross-country
time. After careful planning and persuasion, I convinced
my wife to fly with me from Toronto, Ont., to the U.S.
east coast. The passengers on that flight included our one-year-old daughter.
Feature
Pre-flight
I had booked a Cessna 182 from a local flying school,
and completed a checkout flight and short written
evaluation on the aircraft prior to the trip. I reviewed the
aircraft documents and all appeared to be in order. I was
unable to get a copy of the pilot operating handbook
(POH) or the GPS manual (I was not familiar with a
Not used
Not used
Regs & you
moving map GPS at the time) until the day before the
flight. I had decided that I would spend as much time
as possible “chesterfield flying” before the actual trip.
I completed all of the flight planning, and flew the trip
several times, confirming every action necessary to get us to
our intended destination (about four hours). In addition to
this, I spent another
three hours going through
emergency
Not used
CivAv Med. Exam.
Not used
procedures for the 182. Having seen all of the preparation,
my wife was becoming a little nervous! I assured her that
accidents are extremely unlikely, but that I must consider all
possible scenarios.
I declared an emergency and requested vectors to the
nearest airstrip. The controller gave us vectors to a nearby
grass strip, which was identified as being “right below
us.” The only thing below us was forest with not a blade
of grass in sight. When taking my flight training, my
instructor was consistently reminding me that I should
always look for a place to land in the event of an
emergency. I always took this advice, and in this case,
I recalled a farmer’s field that we had passed immediately
prior to the emergency. I turned the aircraft 180°
and there it was, about 2 mi. from where we were.
The short, soft field landing was successfully completed
into a headwind, and we all climbed out of the aircraft.
The State Trooper at the scene asked how I managed
the land the aircraft safely. I said planning, training and
“chesterfield flying.”
The power loss and oil spill were caused by a massive
failure of the rear cylinder on the right side. I never did get
to the root cause of why the engine failed in such a severe
manner, I’m just glad the outcome was a positive one.
Nick Bartzis
Toronto, Ont.
Pre-flight
I took great care in ensuring that all of the baggage was
weighed, tagged and properly loaded for security, and that
we were within the operating limits of the aircraft for weight
and balance. The flight from Toronto to Buffalo, N.Y., went
well, then to Elizabeth City, N.C., for more fuel, and from
there to Cape Hatteras, N.C. The ceiling was unlimited,
and in fact it was a great day for flying. We requested flight
following, which was granted to us for the flight as well.
We were cruising at 7 500 ft, when there was a sudden
radical vibration, followed by an immediate loss of power,
followed by the right windshield getting covered with oil,
and smoke entering the cockpit. My wife simply asked two
questions: “What is going on,” and, “are we going to be OK?”
My answer was, “I don’t know what is wrong, but I do know
that we are going to be OK.”
To the Letter
To the Letter
Recently released
Dear Editor,
Not used
Pre-flight
Not used
The importance of being preparedTSB reports
Guest Editorial
Guest Editorial
To the letter
Words on Fuel Management…
Clarification—Blackfly Air Article in ASL 1/2007
The third paragraph of the article “Blackfly Air on Fleet Expansion” on page 11 of the Aviation Safety Letter (ASL)
1/2007 incorrectly implied that the principal operating inspector was the only appropriate person for operators to call at
Transport Canada in order to discuss regulatory requirements associated with a fleet expansion. In fact, the article should
have suggested that operators may contact any of their Transport Canada principal inspectors to assist in discussing
these requirements.
ASL 2/2007
Flight Operations
Flight Operations
Fuel management and system problem solving must be approached with a clear understanding of the fuel system.
Air operators’ pilot training syllabi should communicate all specific and appropriate system knowledge, with particular
attention to fuel system anomalies. For instance, helicopter pilots must be aware that when a boost pump malfunctions,
a loss of fuel pressure is observed, or an appreciable difference exists between the boost pump pressures, the fuel quantity
gage may indicate an erroneous fuel quantity and appropriate action(s) must be taken. They should also be aware that,
should a fuel boost pump caution light be followed by a ‘FUEL LOW’ caution light, it would be prudent to land
without delay at the nearest suitable area at which a safe approach and landing is reasonably assured.
pre-flight
Guest Editorial
Guest Editorial
Runway Safety and Incursion Prevention Panel.............................................................................................................. page 5
Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error................................ page 7
COPA Corner—Did You Really Get All Your ADs?.................................................................................................... page 9
Research Efforts on Survival Issues—Industry at Work................................................................................................. page 10
Deviations—Standard Instrument Departures (SID)................................................................................................... page 11
Pre-flight
Runway Safety and Incursion Prevention Panel
by Monica
Regs
& you
Mullane, Safety and System Performance, NAV CANADA
Pre-flight
In the course of its life, IPAT was tasked with implementing
recommendations contained in reports on runway incursions
produced by both Transport Canada and NAV CANADA.
Following the successful adoption of these recommendations,
it was decided not to extend IPAT beyond its April 2005,
expiry date. NAV CANADA identified a need to continue
oversight of runway incursion-prevention activities, and
this resulted in the formation of the Runway Safety and
Incursion Prevention Panel (RSIPP).
Membership in this multi-disciplinary group will remain
open, but is normally composed of one primary and
one back-up representative from NAV CANADA, the
Canadian Airports Council (CAC), the Canadian Owners
and Pilots Association (COPA), the Air Line Pilots
Association, International (ALPA), the Canadian Air Traffic
Control Association (CATCA), the Air Traffic Specialist
Association of Canada (ATSAC), and the Air Transport
Association of Canada (ATAC). Additional members
include other aviation stakeholders identified by the panel,
and observers with a direct interest in runway safety, such
as the Transport Canada Aerodrome and Air Navigation
Branch, the Transportation Safety Board of Canada (TSB),
and technical specialists from stakeholder organizations.
Differences to note: ICAO uses “aerodromes” rather
than “ airports.”
ICAO uses “incorrect” rather than
“unauthorized or unplanned.”
ICAO uses “landing and take-off of
aircraft” rather than “aircraft landings
and departures.”
It should be noted that NAV CANADA tracks
runway incursion statistics only at aerodromes where
NAV CANADA provides services.
RSIPP activities include:
a) Reviewing the current runway incursionprevention activities applicable to operations at
Canadian aerodromes;
b) Reviewing international runway incursion-prevention
activities with the objective of identifying and
promoting proven best practices, where feasible;
c) Recommending methods for sharing safety
information within the aviation community and
suggesting runway incursion strategies/initiatives;
d) Sharing available runway incursion data to identify and
analyze potential runway incursion safety issues or trends;
e) Making recommendations for runway safety and
incursion-prevention to supporting agencies; and
f ) Submitting an annual report that summarizes the
findings, recommendations and accomplishments
of the committee over the past year, for distribution
to member organizations by panel members.
ASL 2/2007
Flight Operations
The panel’s mandate is to provide a forum for the exchange
of safety-related information pertaining to the movement of
aircraft and vehicles in the vicinity of the runway, with the
aim of promoting runway safety and with a primary focus
on the reduction in the risk of runway incursions. This differs from the previous definition used by
NAV CANADA, which defined a runway incursion as:
Any occurrence at an airport involving the unauthorized or
unplanned presence of an aircraft, vehicle or person on the
protected area of a surface designated for aircraft landings
and departures.
Pre-flight
Flight Operations
Not used
In
2005, NAV CANADA invited stakeholders to
form an independent working group to oversee runway
incursion-prevention activities in Canada. This was as a
result of the dissolution of a previous group known as the
Incursion Prevention Action Team (IPAT), co-chaired by
Transport Canada and NAV CANADA.
Any occurrence at an aerodrome involving the incorrect
presence of an aircraft, vehicle, or person on the protected area
of a surface designated for the landing and take-off of aircraft.
To the Letter
To the Letter
The panel accepted the following International Civil
Aviation Organization (ICAO) definition of runway
incursion on April 27, 2006:
Runway incursions are classified as to the severity of the risk. Category A events are ones of extreme risk with
instantaneous action required to avoid a collision. Very few runway incursions are Category A. In Category B incursions,
there is a significant potential for collision. For example, action is required to prevent a vehicle entering a runway
where an aircraft is cleared to land. Category C is similar to B, but there is ample time and distance to avoid a potential
collision. Category D describes situations where there is little or no chance of collision. For example, this might be used
to classify a situation where a vehicle proceeds onto a runway without permission, but there are no aircraft landing or
taking off. Factors such as weather, speed of the involved aircraft, and time to take action are considered in a matrix in
order to determine the risk.
Chart 1 shows runway incursions in terms of the severity of the risk.
All Runway Incursions by Severity
300
A
B
C
Guest Editorial
Guest Editorial
Runway incursion statistics
D
250
200
To the Letter
To the Letter
150
100
50
0
2002
Severity
A
B
2003
1
2005
0
15
0
38
27
284
144
126
137
Total
405
365
352
345
83
204
All Runway Incursions by Severity
188
181
Chart 1
Runway incursions are also considered in terms of the source of the deviation. The current groupings are air traffic
services (ATS) deviations, pilot deviations and vehicle/pedestrian deviations. Different approaches must be used to
reduce these various types of deviations. Chart 2 shows a comparison of pilot deviations between Canadian-registered
aircraft and foreign-registered aircraft in 2005.
Year
2005
Quarter
Canadian
Foreign
Q2
39
10
24
7
Q1
39
Q3
39
Q4
Pilot Deviation—Canadian-Registered Aircraft versus Foreign-Registered Aircraft
6
8
Chart 2
All incursions involving ATS deviations are systematically investigated by NAV CANADA. These investigations provide
detailed information as to the contributing factors in terms of ATS and are used to prevent further incidents.
In summary, the mandate of RSIPP is to provide a forum for the exchange of safety-related information pertaining to runway incursions, with the aim of promoting runway safety.
ASL 2/2007
Flight Operations
Flight Operations
2004
2
37
2005
Pre-flight
Pre-flight
2002
2004
C
D
2003
Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error
The following article is the third in a three-part series describing some aspects of the “new view” of human error. (Dekker, 2002)
This new view was introduced in issue 3/2006 of the Aviation Safety Letter (ASL) in an interview with Sidney Dekker.
The series presented the following topics:
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist? (published in ASL 4/2006)
Thoughts on the New View of Human Error Part II: Hindsight Bias (published in ASL 1/2007)
Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error
“New View” Accounts of Human Error
Pre-flight
Flight Operations
“Old view” explanations of accidents can include things
like: somebody did not pay enough attention; if only
somebody had recognized the significance of this
indication, of that piece of data, then nothing would
Why is it so easy and comfortable to adopt the “old
view”? First, it is cheap and easy. The “old view” believes
failure is an aberration, a temporary hiccup in an
otherwise smoothly-performing, safe operation. Nothing
more fundamental, or more expensive, needs to be
changed. Second, in the aftermath of failure, pressure can
exist to save public image; to do something immediately
to return the system to a safe state. Taking out defective
practitioners is always a good start to recovering the
perception of safety. It tells people that the mishap is not
a systemic problem, but just a local glitch in an otherwise
smooth operation. You are doing something; you are
taking action. The fatal attribution error and the blame
cycle are alive and well. Third, personal responsibility
and the illusions of choice are two other reasons why it
is easy to adopt this view. Practitioners in safety-critical
systems usually assume great personal responsibility for
the outcomes of their actions. Practitioners are trained
and paid to carry this responsibility. But the flip side of
taking this responsibility is the assumption that they have
the authority, and the power, to match the responsibility.
The assumption is that people can simply choose between
making errors and not making them—independent of the
world around them. In reality, people are not immune to
ASL 2/2007
Flight Operations
What we have learned thus far though, is that the “old
view” is deeply counterproductive. It has been tried for
over two decades without noticeable effect (e.g. the Flight
Safety Foundation [FSF] still identifies 80 percent of
accidents as caused by human error); and it assumes the
system is safe, and that by removing the bad apples, the
system will continue to be safe. The basic attribution error
is the psychological way of describing the “old view.” All
humans have a tendency, when examining the behaviour
of other people, to overestimate the degree to which their
behaviour results from permanent characteristics, such as
attitude or personality, and to underestimate the influence
of the situation.
“Old view” investigations typically single out particularly
ill-performing practitioners; find evidence of erratic, wrong
or inappropriate behaviour; and bring to light people’s
bad decisions, their inaccurate assessments, and their
deviations from written guidance or procedures. They also
often conclude how frontline operators failed to notice
certain data, or did not adhere to procedures that appeared
relevant only after the fact. If this is what they conclude,
then it is logical to recommend the retraining of particular
individuals, and the tightening of procedures or oversight.
Pre-flight
The tenets of the “old view” include (Dekker, 2006):
- Human frailties lie behind the majority of
remaining accidents. Human errors are the
dominant cause of remaining trouble that hasn’t
been engineered or organized away yet.
- Safety rules, prescriptive procedures and
management policies are supposed to control this element of erratic human behaviour.
- However, this control is undercut by unreliable,
unpredictable people who still don’t do what they are supposed to do.
- Some bad apples keep having negative attitudes
toward safety, which adversely affects their
behaviour. So not attending to safety is a personal
problem; a motivational one; an issue of mere
individual choice.
- The basically safe system, of multiple defences
carefully constructed by the organization, is
undermined by erratic people. All we need to do is protect it better from the bad apples.
have happened; somebody should have put in a little
more effort; somebody thought that making a shortcut
on a safety rule was not such a big deal, and so on. These
explanations conform to the view that human error is a
cause of trouble in otherwise safe systems. In this case,
you stop looking any further as soon as you have found a
convenient “human error” to blame for the trouble. Such
a conclusion and its implications are thought to get to the
causes of system failure.
To the Letter
To the Letter
The “old view” of human error has its roots in human
nature and the culture of blame. We have an innate need
to make sense of uncertainty, and find someone who is at
fault. This need has its roots in humans needing to believe
“that it can’t happen to me.” (Dekker, 2006)
Guest Editorial
Guest Editorial
by Heather Parker, Human Factors Specialist, System Safety, Civil Aviation, Transport Canada
Guest Editorial
To the Letter
Pre-flight
Flight Operations
The tenets of the “new view” include (Dekker, 2006):
- Systems are not basically safe. People in them have
to create safety by tying together the patchwork of
“New view” explanations of accidents tend to have the
following characteristics:
- Overall goal: In “new view” accounts, the goal of the
investigation and accompanying report is clearly
stated at the very beginning of each report: to learn.
- Language used: In “new view” accounts, contextual
language is used to explain the actions, situations,
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Flight Operations
To adopt the “new view,” you must acknowledge that
failures are baked into the very nature of your work and
organization; that they are symptoms of deeper trouble or
by-products of systemic brittleness in the way you do your
business. (Dekker, 2006) It means having to acknowledge
that mishaps are the result of everyday influences on
everyday decision making, not isolated cases of erratic
individuals behaving unrepresentatively. (Dekker, 2006) It means having to find out why what people did back
there actually made sense, given the organization and
operation that surrounded them. (Dekker, 2006)
“New view” explanations of accidents can include things
like: why did it make sense to the mechanic to install
the flight controls as he did? What goals was the pilot
considering when he landed in an unstable configuration?
Why did it make sense for that baggage handler to load
the aircraft from that location? Systems are not basically
safe. People create safety while negotiating multiple
system goals. Human errors do not come unexpectedly.
They are the other side of human expertise—the human
ability to conduct these negotiations while faced with
ambiguous evidence and uncertain outcomes.
Pre-flight
The “new view” of human error was born out of recent
insights in the field of human factors, specifically the
study of human performance in complex systems and
normal work. What is striking about many mishaps is
that people were doing exactly the sorts of things they
would usually be doing—the things that usually lead to
success and safety. People were doing what made sense,
given the situational indications, operational pressures,
and organizational norms existing at the time. Accidents
are seldom preceded by bizarre behaviour.
The “new view” does not claim that people are perfect, that goals are always met, that situations are always assessed
correctly, etc. In the face of failure, the “new view” differs
from the “old view” in that it does not judge people for
failing; it goes beyond saying what people should have
noticed or could have done. Instead, the “new view” seeks
to explain “why.” It wants to understand why people
made the assessments or decisions they made—why these
assessments or decisions would have made sense from their
point of view, inside the situation. When you see people’s
situation from the inside, as much like these people did
themselves as you can reconstruct, you may begin to see that
they were trying to make the best of their circumstances,
under the uncertainty and ambiguity surrounding them.
When viewed from inside the situation, their behaviour
probably made sense—it was systematically connected to
features of the their tools, tasks, and environment.
To the Letter
To actually make progress on safety, Dekker (2006) argues
that you must realize that people come to work to do a
good job. The system is not basically safe—people create
safety during normal work in an imperfect system. This is
the premise of the local rationality principle: people are
doing reasonable things, given their point of view, focus of
attention, knowledge of the situation, objectives, and the
objectives of the larger organization in which they work.
People in safety-critical jobs are generally motivated to
stay alive and to keep their passengers and customers alive.
They do not go out of their way to fly into mountainsides,
to damage equipment, to install components backwards,
and so on. In the end, what they are doing makes sense
to them at that time. It has to make sense; otherwise,
they would not be doing it. So, if you want to understand
human error, your job is to understand why it made sense
to them, because if it made sense to them, it may well
make sense to others, which means that the problem
may show up again and again. If you want to understand
human error, you have to assume that people were doing
reasonable things, given the complexities, dilemmas, tradeoffs and uncertainty that surrounded them. Just finding
and highlighting people’s mistakes explains nothing.
Saying what people did not do, or what they should have
done, does not explain why they did what they did.
technologies, adapting under pressure, and acting
under uncertainty.
- Safety is never the only goal in systems that people
operate. Multiple interacting pressures and goals
are always at work. There are economic pressures,
and pressures that have to do with schedules,
competition, customer service, and public image.
- Trade-offs between safety and other goals often
have to be made with uncertainty and ambiguity.
Goals, other than safety, are easy to measure.
However, how much people borrow from safety to
achieve those goals is very difficult to measure.
- Trade-offs between safety and other goals enter,
recognizably or not, into thousands of little and
larger decisions and considerations that practitioners
make every day. These trades-offs are made with
uncertainty, and often under time pressure.
Guest Editorial
pressures, and organizations would not want them to be.
To err or not to err is not a choice. People’s work is subject
to and constrained by multiple factors.
“New view” investigations are driven by one unifying
principle: human errors are symptoms of deeper trouble.
This means a human error is a starting point in an
investigation. If you want to learn from failures, you must
look at human errors as:
- A window on a problem that every practitioner in
the system might have;
- A marker in the system’s everyday behaviour; and
- An opportunity to learn more about organizational,
operational and technological features that create
error potential.
To the Letter
Guest Editorial
To the Letter
and detailed because this level of analysis and detail
is necessary to reconstruct the actions, situations,
context and circumstances.
- Length and development of arguments (“leave a
trace”): “New view” accounts typically leave a
trace throughout the report from data (sequence
of events), analysis, findings, conclusion and
recommendations/corrective actions. As a reader of
a “new view” account, it is possible to follow from
the contextual descriptions to the descriptions of
why events and actions made sense to the people at
the time, to in some cases, conceptual explanations.
By clearly outlining the data, the analysis, and the
conclusions, the reader is made fully aware of how
the investigator drew their conclusions.
Guest Editorial
context and circumstances. Judgment of these
actions, situations, and circumstances is not present.
Describing the context, the situation surrounding
the human actions is critical to understanding why
those human actions made sense at the time.
- Hindsight bias control employed: The “new view”
approach demands that hindsight bias be controlled
to ensure investigators understand and reconstruct
why things made sense at the time to the
operational personnel experiencing the situation,
rather than saying what they should have done or
could have done.
- Depth of system issues explored: “New view” accounts
are complete descriptions of the accidents from the
one or two human operators whose actions directly
related to the harm, including the contextual
situation and circumstances surrounding their
actions and decisions. The goal of “new view”
investigations is to reform the situation and learn;
the circumstances are investigated to the level of
detail necessary to change the system for the better.
- Amount of data collected and analyzed: “New view”
accounts often contain significant amounts of data
and analysis. All sources of data necessary to explain
the conclusions are to be included in the accounts,
along with supporting evidence. In addition,
“new view” accounts often contain photos, court
statements, and extensive background about the
technical and organizational factors involved in the
accidents. “New view” accounts are typically long Reference:
Dekker, S., The Field Guide to Understanding Human Error, Ashgate, England, 2006.
COPA Corner—Did You Really Get All Your ADs?
Every year, as part of the preparation for an aircraft’s
annual inspection, most diligent owners of certified
aircraft will go to the Transport Canada (TC) Web site
and search for the airworthiness directives (AD) that are
applicable to their aircraft.
This is accomplished by clicking on “Airworthiness
Directives” on TC’s Continuing Airworthiness Web
Information System (CAWIS) Web site, www.tc.gc.ca/aviation/applications/cawis-swimn/, entering the aircraft’s registration into the search box,
and then checking the AD list that the CAWIS system
produces. Some ADs that come up will be old, nonrepetitive ones that are already signed off, and others will
be repetitive ones that need doing on a regular basis. The
list also has to be checked for applicability, as not all ADs
will apply to your individual aircraft serial number, but
pretty quickly you can pare the list down to those that
need doing.
Field maintenance on a Cessna 172
Flight Operations
Flight Operations
Pre-flight
Pre-flight
by Adam Hunt, Canadian Owners and Pilots Association (COPA)
So, if you do that search by aircraft registration, you
should get all the ADs for your aircraft, right? Wrong!
The list that you just searched will give you all applicable
ADs for your airframe, engine and propeller. It does
ASL 2/2007
Guest Editorial
Guest Editorial
not give you the ADs that are applicable to anything
else, such as carburetors, seat belts or any after-market
supplemental type certificate (STC) installed equipment,
such as autopilots, doors or wing-tip fairings. Those items
are contained in a separate miscellaneous equipment AD
list. Because TC has no way of knowing which accessories
are installed on your aircraft, you have to check this list to
see which ones are applicable.
A good example is AD 96-12-22. This is a repetitive AD
on Cessna engine oil filter adapters assemblies. These
are commonly installed on any brand of aircraft (not just
Cessnas) equipped with a Teledyne Continental Motors
aircraft engine, including O-200, O-470, IO-470, TSIO-470, O-520, IO-520, TSIO-520, GTSIO-520,
IO-550, TSIO-550 powerplants. It requires an inspection
with the first 100 hr time-in-service and then every time
the engine oil filter is removed. You won’t find this AD
without checking the miscellaneous equipment AD list.
Setting valve clearances
As well as doing a search by the aircraft registration,
aircraft owners need to check the miscellaneous
equipment AD list to make sure no ADs are missed. The miscellaneous equipment AD list on the TC CAWIS
system can only be found by clicking on “Advanced
Search” and then “All ADs” beside “List Miscellaneous
Equipment ADs.” You can find out more about COPA at www.copanational.org.
To the Letter
To the Letter
As of October 2006, there were 551 ADs on that list!
Many are items like escape slides for airliners, but some are
definitely equipment that could be found on small aircraft.
Research Efforts on Survival Issues—Industry at Work
by Jason Leggatt, Engineer-In-Training (EIT), SAFE Association
SAFE
SAFE provides a common meeting ground for the sharing
of problems, ideas and information. The Association’s
members represent the fields of engineering, psychology,
medicine, physiology, management, education, industrial
safety, survival training, fire and rescue, human factors,
equipment design, and the many sub-fields associated
with the design and operation of aircraft, automobiles,
buses, trucks, trains, spacecraft and watercraft. Individual
and corporate members include equipment manufacturers,
college professors, students, airline employees, government
officials, aviators and military life support specialists. This
broad representation provides a unique meeting ground
10
for basic and applied scientists, the design engineer, the
government representative, the training specialist and the
ultimate user/operator to discuss and solve problems in
safety and survival.
SAFE’s regional chapters sponsor meetings and workshops
that provide an exchange of ideas, information on
members’ activities and presentations of new equipment
and procedures encompassing governmental, private and
commercial application in the field of safety and survival.
From August 29–30, 2006 the Canadian and U.S. East
Coast chapters of SAFE hosted a joint meeting in
Ottawa, Ont., to further promote the exchange of ideas
between North American members. Government and
industry experts briefed current programs, such as the
ejection seat upgrade for the CF-18 Hornet. Aviation
life support equipment and pilot flight equipment is also
undergoing redesign and integration qualification to
provide Canadian aircrew with state-of-the-art technology.
SAFE culminates each year’s activities with the annual
SAFE Symposium, which was held in Reno, Nev., the week of October 23, 2006. The Symposium is
ASL 2/2007
Flight Operations
Flight Operations
Founded in 1956 as the Space and Flight Equipment
Association, the name was changed to the Survival and
Flight Equipment Association in 1969, to better reflect
the immerging group of core members. Any ambiguity
was dropped in 1976 when the name was finally changed
to the SAFE Association. SAFE is headquartered in
Oregon, but boasts an international group of members
and maintains chapters through the world, most notably,
regional chapters in the United States, SAFE Europe and,
of course, the Canadian chapter of SAFE.
Canada
Pre-flight
Pre-flight
The Survival and Flight Equipment (SAFE) Association
is a non-profit, professional association, dedicated to the
preservation of human life, and in particular, increasing
survivability of those faced with the dangers associated with
all aspects of recreational, commercial and military aviation.
Guest Editorial
The proceedings of the Annual Symposium and other
publications, such as journals and newsletters, are valuable
reference sources for the professional involved in the fields
of aviation safety and survival. For more information
about the activities of the SAFE Association and regional
and international chapters, please go to www.safeassociation.com.
Guest Editorial
attended by an international group of professionals
who share problems and solutions in the field of safety
and survival. Presentation topics ranged from cockpit
design, restraint systems and injury reduction, on-board
oxygen generation systems (OBOGS), improved personal
protective equipment concepts, to the latest aircraft
passenger egress aids, safety and crew training.
Deviations—Standard Instrument Departures (SID)
Many of our busier airports have published SIDs.
Air traffic controllers issue these SIDs to pilots operating
on IFR flight plans to ensure that there is IFR separation
between the departing aircraft and other IFR flights.
The use of SIDs allows pilots to know the departure
routing in advance and reduces voice communication.
Most SIDs are radar vector procedures that require
further air traffic control action to get the departing
aircraft to the flight-planned route. In the future, there
will be more Pilot Navigation (Pilot Nav) SIDs that
provide the most efficient path from the runway to the
en-route structure.
A review of incident reports has revealed an increase in
SID deviations this year as compared to the average over
the past three years. In many cases, pilots read back the
SID as issued, but did not comply with the published
SID and followed a different route. In most of these cases,
there was a heading deviation, but there were also altitude
busts. These all resulted in an actual or potential loss of
IFR separation, which could lead to a collision. Pilots are reminded to review each SID issued and
to follow the procedure as published. If there are any
questions, please ask for clarification.
The Transport Canada Aeronautical Information
Manual (TC AIM) section on SIDs is being re-written
to make it very clear as to what is expected of a pilot
receiving a SID clearance. As well, contact is being made
with specific companies that have a high proportion of
deviations, to share these findings with them.
To the Letter
To the Letter
by Doug Buchanan, NAV CANADA
Forest fire season is once again upon us, and each year there are aircraft violating the airspace in and around forest fires.
This includes private, commercial and military aircraft. Section 601.15 of the Canadian Aviation Regulations (CARs)
provides that no unauthorized person shall operate an aircraft over a forest fire area, or over any area that is located
within 5 NM of one, at an altitude of less than 3 000 ft AGL. Refer to the “Take Five” originally published in ASL 3/99,
which can also be found at www.tc.gc.ca/CivilAviation/SystemSafety/Newsletters/tp185/3-99/T5_forestfire.htm.
Pre-flight
Pre-flight
Forest Fire Season Reminder!
Flight Operations
Flight Operations
Birdstrikes don’t matter? Think again!
ASL 2/2007
11
TSB reports
flight operations
Guest Editorial
Feature
Aviate—Navigate—Communicate.
................................................................................................................................. page 12
Maint. & Cert.
Flight Planning Issues........................................................................................................................................................ page 14
Safety Management Enhances Safety in Gliding Clubs.................................................................................................. page 15
Near Collision on Runway 08R at Vancouver................................................................................................................ page 16
Say Again! Communication Problems Between Controllers and Pilots......................................................................... page 17
Checklist Actions After Engine Failure on Takeoff.......................................................................................................... page 18
Pre-flight
Computers in Aviation: Friend or Foe?............................................................................................................................ page 19
Guest Editorial
Flt. Ops
Aviate—Navigate—Communicate
by Captain Robert Kostecka, Civil Aviation Safety Inspector, Foreign Inspection, International Aviation, Civil Aviation, Transport Canada
To the Letter
Pre-flight
One of the first things that we learn as fledgling pilots
is that improper airspeed management can lead to a
stall. Nevertheless, data gathered from accident/incident
investigations clearly shows how easily a stall can occur
Recent innovations like global positioning system (GPS)
navigation and electronic flight instrument systems (EFIS)
have brought tremendous sophistication to modern general
aviation aircraft. But the latest avionics have also brought
new potential hazards for pilots. In this environment, it is
all too easy for the pilot to “remain heads down” for far too
long. It is also possible for a pilot to become complacent
and overly dependant on automated systems. This can
cause the deterioration of basic skills.
The problem of distractions also exists in multi-crew
aircraft. In this environment, the pilot flying (PF) must focus on flying the aircraft and must guard against
allowing too much of his attention to be diverted by the
tasks being performed by the pilot not flying (PNF). An excellent example of the consequences of distraction
is the L-1011 that crashed into the Florida Everglades,
killing all on board. The NTSB, “cited as a causal factor the
diversion of the crew’s attention to a burned out light bulb.
The crew had been so intent on the bulb that they had not
noticed the descent of their aircraft nor had they heard
various alarms warning of their closeness to the ground.”3
FAA Advisory Circular No. AC 61-67B, Subject: Stall and Spin Awareness Training, p. ii
Human Factors for Aviation—Basic Handbook (TP 12863), p. 38
3
Human Factors for Aviation—Basic Handbook (TP 12863), p. 37
1
2
12
ASL 2/2007
Flight Operations
Flight Operations
It is easy to determine how distractions can occur
in a single-pilot aircraft. The Federal Aviation
Administration (FAA) determined, “that stall/spin related
accidents accounted for approximately one-quarter of all
fatal general aviation accidents. National Transportation
Safety Board [NTSB] statistics indicate that most
stall/spin accidents result when a pilot is distracted
momentarily from the primary task of flying the aircraft.”1
The obvious conclusion is that learning how to prioritize
effectively and not succumb to distractions is a tremendously
important skill. “Through training and experience, you
can learn to discipline your attention mechanisms so as to
focus on important items.”2 Unfortunately, in the current
environment, maintaining effective priorities and avoiding
distractions is not getting easier.
Pre-flight
A distraction can divert the pilot’s attention from primary tasks
to experienced pilots who are distracted by one or more
other tasks. Distractions can be almost anything—
even some tasks considered routine—during normal
operations: locating a checklist, retrieving something
from behind your seat, looking up a frequency or other
aeronautical data, or becoming engrossed in navigation
calculations. The list is almost endless. These actions all
have the potential to divert a pilot from the primary task
of flying the aircraft. To the Letter
“Aviate—navigate—communicate.” This time-honoured
axiom continues to be as relevant and instructive today as
Not used
Regs & you
when it was first coined many decades ago. It succinctly
sums up in three words the tasking priorities that are
essential for a pilot to successfully handle any non-routine
situation or occurrence. These priorities are equally
applicable for all aircraft, from small, single-engine
training aircraft, right up to large, transport category jets.
expression may have
CivAv This
Med. Exam.
Not been
used coined in the early days
by an enlightened (or frustrated) flight instructor in a J-3 Cub or Fleet Canuck, but it is more applicable than
ever for the pilots of today’s automated aircraft.
Flight Operations
Guest Editorial
To the Letter
Pre-flight
Flight Operations
In the 1940s, an aircraft like the Boeing Stratocruiser
would typically accommodate as many as 81 passengers
and would cruise at 280 kt. Today, an A340 can carry
more than 300 passengers and will cruise at 470 kt. The
flight crew of a Stratocruiser consisted of five members:
a radio operator, a navigator, a flight engineer, and
two pilots. As the years progressed, improvements in
electronics resulted in the radio operator no longer being
needed. Long range navigation systems like inertial
navigation systems (INS) eventually made navigators
unnecessary. Ultimately, the two-pilot flight deck
emerged during the early 1980s, when increases in system
automation eliminated the need for a flight engineer.
Today, virtually all transport category aircraft have only
two pilots.
Copyright Airbus; photographer H. Goussé.
Transport category aircraft have seen tremendous increases in their complexity, performance capabilities and size.
At the same time, technological innovations have steadily reduced the number of flight crew members.
4
5
Transportation Safety Board of Canada (TSB) Aviation Investigation Report A05W0109, p. 2
Transportation Safety Board of Canada (TSB) Aviation Investigation Report A05W0109, p. 3
ASL 2/2007
Pre-flight
Photo of Boeing Stratocruiser courtesy
of www.aviation-history.com, with permission.
To help us understand the critically important roles of the
PF and PNF, let’s review how the modern flight deck of
a transport category aircraft evolved. In the last 60 years,
from the post-war boom in air transportation until today,
transport category aircraft have seen tremendous increases
in their complexity, performance capabilities and size. At
the same time, technological innovations have steadily
reduced the number of flight crew members.
To the Letter
A recent incident illustrated how easily distractions can
result in improper airspeed management with serious
consequences. The crew of a transport category jet was
flying at flight level (FL) 400 and had been diverted west
of their planned route. The pilot reduced thrust to slow the
aircraft in anticipation of traffic delays. “The captain then
focused attention to the flight management system (FMS)
on the centre console to help the first officer determine
fuel reserves for a possible hold.”4 While both members
of the crew were occupied with the fuel calculations for a
possible hold, the airspeed decreased and the stick shaker
activated. “Both pilots pushed the control yoke forward
to reduce the pitch attitude, which resulted in a descent
and an increase in airspeed. This was followed by the
crew returning the aircraft to a pitch-up attitude, with an
increase in body angle of attack (AOA) and G. (Author’s
note: For bodies undergoing acceleration and deceleration, G is
used as a unit of load measurement.) A second stick shaker
activation occurred 11 seconds after the first. Buffeting
and roll oscillations of about 10° accompanied the stick
shaker events. The pitch attitude was further reduced and
the airspeed recovered [...] The altitude stabilized briefly
at FL 386 before the crew coordinated with ATC for a
further descent to FL 380 due to conflicting traffic.”5
Fortunately, there was no damage to the aircraft, or
injuries to passengers or crew, and the flight landed safely
without further incident. Had there been traffic below
this aircraft, or had a similar airspeed mismanagement
and approach to stall occurred close to the ground, the
consequences may have been catastrophic. Incidents such
as this serve to remind all of us of the need to focus on
the essential priorities: “aviate—navigate—communicate.”
Guest Editorial
New technologies have created new opportunities for
pilots to be distracted. The programming of the flight
management system (FMS), or completion of an
electronic checklist can lure the PF away from their
primary task. It is all too easy for the electronic displays
to divert one’s attention. Remember that the various
electronic displays can act like “face magnets.” Make sure
that you maintain situational awareness and don’t allow
yourself to get sidetracked.
13
Guest Editorial
Simulators provide an outstanding tool for learning. In
the simulator, we can safely gain first-hand experience
with windshear, catastrophic engine failures, jammed
flight controls, as well as losses of electrical and hydraulic
power; things that we would never want to experience
in a real aircraft. In addition to learning about technical
issues, the simulator provides a powerful tool for learning
about human factors. The simulator provides an excellent
opportunity for us to learn the essential skill of prioritizing.
Modern two-crew flight deck
The two-crew flight deck brings certain challenges,
which are especially apparent during periods of high
workload. Depending on the circumstances, the PNF may
also need to perform the functions of one of the crew
members that was eliminated by advances in technology.
For example, when an aircraft is being re-routed and it is
necessary to calculate fuel reserves, the PNF takes on the
responsibilities that were previously those of the navigator.
The primary task of flying the aircraft can never become
secondary. There is nothing more important. Ultimately,
we need to remain focused and maintain our priorities:
“aviate – navigate – communicate”.
Prior to joining Transport Canada, Captain Kostecka worked
as a pilot and instructor for several Canadian airlines. He has
flown over 12 000 hr and holds a Class 1 Flight Instructor
Rating as well as type ratings on the A320, A330, A340,
B757, B767, CRJ, DHC-8 and B-25.
To the Letter
To the Letter
Copyright Airbus; photographer H. Goussé.
Guest Editorial
If an abnormal or emergency situation occurs, the PNF
completes the appropriate checklists and essentially
performs the tasks of a flight engineer. A problem can
arise when the PF depends on automation and becomes
overly involved in the PNF’s activities. Adhering to the
correct priorities will ensure that one crew member always
focuses on flying the aircraft. Flight Planning Issues
On page 29 of Aviation Safety Letter (ASL) 3/2006,
Michael Oxner provided an excellent article on how VFR
pilots can benefit from the use of “flight following” while
flying in Canada. The air traffic services (ATS) system
also provides an additional service by keeping an eye on
the status or location of pilots who have filed a proposed
flight plan. This is done in case an aircraft is overdue and
it becomes necessary to alert the Canadian Armed Forces
rescue coordination centre (RCC). Let’s call this activity
search and rescue (SAR) tracking.
The vast majority of pilots perform the correct actions
regarding VFR flight plans; however, there are some pilots
who are causing unnecessary workloads and occasionally
misusing very scarce resources because they do not
understand (or completely ignore) the proper procedures
for opening, amending or closing VFR flight plans.
Therefore, it would seem to be a good idea to review what
should take place when a pilot files a VFR flight plan.
14
This differs from the United States, where the Federal
Aviation Administration (FAA) does not start SAR
tracking unless the pilot activates the flight plan on
departure. Note that in Canada, the SAR tracking for a
VFR flight plan will continue from the proposed departure
time until a specified time, or one hour after the estimated
time of arrival (ETA). At this prescribed time, if the
location of the flight is unknown, the airplane is reported
missing and a search for the “missing” airplane begins.
Canadian Armed Forces RCCs, at various locations across
Canada, are notified of the missing aircraft.
In some instances, SAR aircraft have been launched to
look for a “missing” aircraft when, in fact, the pilot had
ASL 2/2007
Flight Operations
Flight Operations
While the treatment of IFR and VFR flight plans have
many similarities, there are some differences. This article
will address VFR flight plan activities.
To begin, the pilot submits a VFR flight plan that contains
a proposed time of departure and an estimated elapsed
time en route. In Canada, and many parts of the world,
the ATS system will begin SAR tracking based on the
proposed departure time—this is done because there are
circumstances under which the pilot departs from a remote
location and the ATS system will not know the actual time
of departure. This is the beginning of the safety net.
Pre-flight
Pre-flight
by Sydney Rennick, Civil Aviation Safety Inspector, Aerodromes and Air Navigation, Civil Aviation, Transport Canada
Between February 2005, and February 2006, there were
at least 96 incidents involving VFR flight plans. Problems
arose for a variety of reasons. A breakdown of the
incidents follows:
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•
•
•
•
Safety Management Enhances Safety in Gliding Clubs
by Ian Oldaker, Director of Operations, Soaring Association of Canada (SAC)
The SAC SMS and safety program are in their early
stages of development. The relevant documents are
available on the SAC Web site at www.sac.ca.
ASL 2/2007
15
Flight Operations
Workshops were run across the country last spring,
at which point the program was introduced and the
participants were taken through the process of hazard
identification and risk assessment for typical club
operations. Although there were some questions about
the value of this program at the time, clubs have had a
positive attitude regarding the need for improvements.
Club representatives were asked to return to their clubs
and involve members in these tasks, which include a
requirement to define strategies to address and reduce
or mitigate the identified risks. If you, as a reader of this
Aviation Safety Letter (ASL), have not been involved at
the club level, or are unaware of this program, now is the
time to act—before you flex your wings again at the start
of the new soaring season. Start thinking of how you can
contribute to a safer club environment, and hence safer
flying operation; ask about the club’s safety program, and
how you can take part.
It is too early to attribute the excellent safety record
for gliding in 2006 to this program, but a heightened
awareness of the need to remain vigilant about hazards
may have played a part. Hazard identification is one
of the first essential tasks of this safety initiative,
followed by the design of a club strategy to reduce
the safety risks. There can be hazards in the following
areas: Administrative (lack of emergency procedures),
Supervisory (at the flight line), the Safety Program
(poor feedback of lessons learned), Airport/Airfield
Infrastructure (public access/signage), Airport/Airfield
(poor overshoot and undershoot areas, grass cutting),
Pilots (recurrent training/checks, advanced/cross-country
training), Pilot Experience (efforts/strategies to maintain
currency levels), Weather Conditions (flight planning
and preparation for the anticipated conditions). You can
probably think of more. If not, look back on past incidents
and learn from them.
Pre-flight
Pre-flight
Approximately one year ago, the Soaring Association of
Canada (SAC) Board of Directors made the decision to
implement a safety management system (SMS) at the
national level. Although we have had a safety program in
place for many years, an SMS would insert some additional
safety-management methods; it would be based largely on
the Transport Canada SMS for small operators. The SAC
program includes a standard for improvements to existing
club programs or the implementation of a new program. Flight Operations
We are very lucky in Canada to have an efficient and
effective SAR tracking and activation service. In some
countries, the cost of SAR activity is charged to the
“missing” pilot—think about that!
To the Letter
To the Letter
•
26 transborder flights arrived from the USA
without a flight plan (the reasons are undetermined,
but it may be that pilots failed to activate the VFR
flight plan);
43 flights did not file an arrival report;
9 flights changed flight duration without
notifying anyone;
3 flights filed flight plans by fax, but the pilot did not confirm receipt;
3 flights had pilots who changed aircraft without
amending the flight plan; and
12 flights did not depart, and the pilot did not cancel the flight plan.
There may be good reasons for some of the errors noted
above; however, it is very unlikely that every incident
occurred for a good reason. Given that the Canadian
topography and weather conditions can sometimes be
quite harsh, I personally like the warm and fuzzy feeling
I get from knowing that someone is watching over me
who will alert an RCC in the event that I am forced
to land or crash while en route and do not arrive at my
destination at the scheduled time. Unfortunately, because
of the scarcity of resources, it is possible that SAR aircraft
would not be able to search for an actual downed airplane
because they are looking for one or more of the “missing”
aircraft described above.
Guest Editorial
Guest Editorial
decided not to fly the proposed trip and did not cancel,
close, or report changes to the VFR flight plan.
Near Collision on Runway 08R at Vancouver
To the Letter
As the Dash-8 at L2 was moving toward Runway 08R,
the crew was still unable to see the Islander they were
instructed to line-up behind, and became uneasy about
the situation. The crew elected to turn the aircraft to their
right, to look toward the threshold of 08R. They then saw
the landing lights of the Islander coming down the runway
on the take-off run. The crew stopped the Dash-8 and
displayed all exterior aircraft lights as the Islander rotated
in front of them.
It was still dark; the visibility was 8 SM and improving.
After the first Dash-8 on Taxiway L departed, the first
arrival landed. The controller then cleared the Islander on
Taxiway A to taxi to position and hold on Runway 08R
and requested that the pilot move ahead to permit a
Dash-8 to line up behind. The controller then cleared the
Dash-8 (believed to be on Taxiway L) to take position
behind the Islander, without realizing that the Dash-8
was down the runway at L2. Since the controller thought
the Dash-8 and the Islander were both at the threshold
of 08R, he did not state the specific entry point for either
one, nor was he required to do so.
Analysis—Following the routine pre-shift review and
briefing, the controller was not aware that Taxiway L2
was open; on the controller’s two previous night shifts, L2
had been closed for maintenance. When the controller
scanned the departure flight progress strips for the taxiway
designators assigned by the ground controller, it was not
recognized that the digit “2” was partially obscured by
Aircraft Positions Before the Incident
other information
for the one departure on Taxiway L2.
Aircraft Positions Before the Incident
*
Control Tower
(position approximate)
L
Islander
Islander
Dash-8
Dash-8
*
The airport controlL tower is equipped with
airport
surface
Control
Tower
(position approximate)
Islander
detection
equipment
(ASDE).
This
ground
surveillance
Dash-8
Islander
L2
radar system
displays targets
on the airport, but it has
Dash-8
Dash-8
some inherent limitations and some unresolved technical
Islander
anomalies.
The tower controller did not rely on this
MU-2
A did not associate a targetA4
system, and
on Taxiway L2 with
the Dash-8, or monitor the ASDE when the Dash-8 was
cleared to position behind the Islander.
08
R
Pre-flight
Immediately prior to the occurrence, the tower controller
had seven departing aircraft holding short for departure
on Runway 08R and two on final. On the south side
of the threshold, on Taxiway A (see illustration), was
a BN2P Islander followed by a Mitsubishi MU-2.
Opposite, on Taxiway L, was a Dash-8 followed by two
more Islanders, and a second Dash-8. There was a third
Dash-8 holding short of Runway 08R on L2. Taxiway L2
is also a high-speed exit for the reciprocal Runway 26L.
Pre-flight
After the blocked transmission, the controller asked who
made the last call. A transmission came from “the Dash-8
behind the Islander,” which matched the controller’s mindset
of the situation, but it was not the same Dash-8. A comment
was made about the Islander’s lights not working (there
were still two more Islanders waiting to depart). A series
of confusing and mostly unsolicited transmissions from
unidentified sources took place regarding navigation lights
on Islanders. It was during this series of transmissions that
the Islander in position at the threshold of Runway 08R was
cleared for takeoff and complied with that clearance.
To the Letter
On October 29, 2004, a potentially catastrophic near
collision occurred between a departing BN2P Islander
and a taxiing Dash-8, on Runway 08R at the Vancouver
International Airport. At 06:53 Pacific Daylight
Time (PDT), the Vancouver tower south controller
cleared the Islander for takeoff from the threshold of
Runway 08R. The Islander was in the rotation for liftoff when it went by a Dash-8 that was partially on the
runway, abeam the Islander’s left wingtip, at Taxiway L2.
The final report on this occurrence (TSB file A04P0397)
was released on November 6, 2006.
Guest Editorial
Guest Editorial
by Glen Friesen, Senior investigator, Transportation Safety Board of Canada (TSB), Pacific Region
30
L2
Islander on Take-off Roll
08
R
Dash-8
Islander
MU-2
A
Dash-8
Islander
Islander on Take-off Roll
08
R
The Dash-8 crew at L2 apparently acknowledged their
clearance to position; however, it was blocked by another
*
Control Tower
transmission.
The LDash-8 at L2 began(position
taxiing
toward
approximate)
Dash-8
Runway
08R,
while
looking
ahead
for
the
Islander
it was
Islander
L2
Islander
to follow—which was in fact behind it.
Islander
A
A6
Dash-8
A4
Islander
MU-2
ASL 2/2007
A
A6
Dash-8
A4
30
Flight Operations
30
MU-2
L2
08
R
Flight Operations
Islander
16
*
Control Tower
(position approximate)
L
A4
It is not a requirement for a pilot to read back or otherwise
state their runway entry location; however, if pilots are
aware of the controller’s requirement, it would be reasonable
to expect that a pilot would challenge the controller if
the clearance onto a runway, not at the threshold, did not
include the intersection name or taxiway location.
Guest Editorial
It has been a long-standing argument that a common
frequency allows pilots to maintain better situational
awareness. Numerous aircraft were tuned in to the
Vancouver tower south frequency. No one advised the
controller that there was no Dash-8 at the threshold able
to line up behind the Islander. It is unknown why the sole
pilot of the Islander did not see the Dash-8 at L2 taxiing
onto the runway ahead.
Following this incident, the Vancouver tower implemented
an operations bulletin to remind controllers of the
requirement to specify the name of the taxiway or
intersection when issuing a clearance to position or
for takeoff, other than at the threshold, and further
recommended that the procedure be applied to the
threshold as well. In the immediate term, the TSB is
working with NAV CANADA and Transport Canada to
encourage good airmanship practices to supplement this air
traffic control (ATC) requirement and enhance safety while
more permanent requirements are being considered.
To the Letter
To the Letter
As a point of interest for all pilots departing from any
entry location along a runway, controllers are required to
specify the runway entry location at an intersection or
taxiway other than at the threshold, which is mentioned
in the Transport Canada Aeronautical Information
Manual (TC AIM) RAC 4.2.5.
Therefore, in theory, the Dash-8 crew could have noticed
the absence of this requirement in the controller’s clearance
to line-up on 08R when they were at Taxiway L2.
Guest Editorial
Prior to the incident, the controller was stating
runway entry positions in all clearances onto the active
Runway 08R, and these positions were being read back by
flight crews. Although not a requirement for entry at the
threshold, this appeared to be a common practice, but it
ceased in the minutes leading up to this incident. In the
specific take-off clearance leading to this occurrence, the
controller did not state the runway entry position on 08R,
nor did the Islander pilot voluntarily state it, which
precluded the opportunity of alerting the Dash-8 at L2. Say Again! Communication Problems Between Controllers and Pilots
by Gerard van Es, National Aerospace Laboratory (NLR), Amsterdam, The Netherlands
Each year, millions of transmissions are made between
controllers and pilots. Most of these transmissions relate
to instructions given by controllers, and the responses
from the pilots to these instructions. Analysis of
samples of pilot-controller communications recorded
in different ATC centres revealed that some kind of
miscommunication occurred in only 0.7 percent of all
transmissions made. In more than half of these, the
problems were detected and solved by the controller
or pilot. These are very good numbers, considering
the fact that at least two humans are involved in the
communication process.
So what can go wrong? In order to answer this question,
the National Aerospace Laboratory NLR conducted
a study on air-ground communication problems,
using recorded incidents in Europe. This study was
commissioned by EUROCONTROL as part of their
safety improvement initiative. Although this study was
limited to the situation in Europe, many of the identified
issues apply to other parts of the world (e.g. North
America). The results of this study were published in two
reports that can be obtained from EUROCONTROL
(see the end of this article). This article will briefly discuss
some of the important results from these studies.
The most typical communication problem identified was
related to the so-called readback and hearback errors. These
come in two flavours: one in which the pilot reads back the
clearance incorrectly and the controller fails to correct the
error (readback/hearback error), and the other in which
the controller fails to notice his or her own error in the
pilot’s correct readback or fails to correct critical erroneous
information in a pilot’s statement of intent. The following
is an example of a typical readback/hearback error: “the
B737 was outbound from XX maintaining 6 000 ft. The
Tu154 was outbound from YY, and on initial call to the
KK sector, was cleared to 5 000 ft. However, the pilot read
back the clearance as 6 000 ft, which was unnoticed by the
ASL 2/2007
17
Flight Operations
Flight Operations
Voice communications between controllers and pilots
are a vital part of air traffic control (ATC) operations.
Miscommunication can result in hazardous situations.
For instance, miscommunication has been identified
as a primary factor causing runway incursions. The
collision between two Boeing 747s at Tenerife in 1977,
demonstrates the potentially fatal consequences of
inadequate communication.
Pre-flight
Pre-flight
“Regardless of the level of sophistication that the air traffic system achieves by the turn of the century, the effectiveness of our
system will always come down to how successfully we communicate.”
Linter and Buckles, 1993
Guest Editorial
To the Letter
References used for this article:
Gerard van Es, Air-ground Communication Safety
Study: An analysis of pilot-controller occurrences,
EUROCONTROL/NLR, 2004 (www.eurocontrol.int/safety/
gallery/content/public/library/com_report_1.0.pdf).
Gerard van Es et al., Air-Ground Communication
Safety Study: Causes and Recommendations,
EUROCONTROL/NLR, 2005 (www.eurocontrol.int/safety/
gallery/content/public/library/AGC%20safety%20study%20causes
_recommendations.pdf).
Pre-flight
Pre-flight
In the future, some of the air-ground communication
problems could be eliminated by the introduction of data
link, for instance. However, such a system (and others)
cannot eliminate all of our communication problems.
To the Letter
What is causing all these problems? Like many safetyrelated occurrences, the answer is not simple, as there are
a large number of factors that have played a role in the
chain of events leading to air-ground communication
problems. However, a number of factors really showed
to be significant contributors to the problem. First,
similar call signs on the same frequency was by far the
most frequently cited factor. In such cases, pilots picked
up an instruction intended for another aircraft that had
a similar call sign. For the controller, it is not easy to
identify this error, as the transmission may be blocked
when two aircraft respond to the instruction. There were
even a few cases in which four aircraft responded to the
same instruction. The use of similar call signs should be
avoided as much as possible. When this is inevitable,
the following should be considered to mitigate the
problem: pilots should use full calls signs (no clipping) in
their readbacks; when there are similar call signs on the
frequency, controllers should inform the pilots about it;
pilots should actively monitor at critical flight stages using
their headsets (instead of flight deck speakers). In Europe,
the problem of similar call signs is being addressed by
EUROCONTROL. Another important factor is related
to frequency changes. In a large number of air-ground
communication incidents analyzed, pilots forgot to
change the frequency as instructed, or changed to the
wrong frequency. Pilots should always check the selected
frequency whenever the radio has gone unnaturally quiet
in a busy sector. The NLR study identified many more
factors, such as the use of non-standard phraseology (by
controllers), radio interference, frequency congestion, and
blocked transmissions. The vast majority of the factors
identified are not new. Many of them have been there
since controllers on the ground started to communicate
with pilots using a radio.
Guest Editorial
controller. A short term conflict alert (STCA) warned the
controller of the situation, and avoiding action was issued
to both aircraft.” An example that illustrates a hearback
error is the following: “the aircraft was cleared to descend
to FL 150, but acknowledged a descent to FL 180. This
was challenged by the controller, who then inadvertently
cleared the aircraft to FL 130. This incorrect flight level
was read back by the pilot, and was not corrected by the
controller.” Other typical problems found, were related to
cases where there was a complete loss of communication, or
there were problems with the communication equipment
on the ground or in the aircraft itself. An example of loss of
communications is the following: “a B777 was transferred
from frequency 129.22 to the XX sector frequency, 134.77,
and readback appeared to be correct. Approximately 5
min later, the XX sector controller telephoned to ask for
the B777 to be transferred, and was informed that it had
been. Subsequently, the B777 called frequency 129.22 to
advise of having gone to the wrong frequency. The B777
was absent from the frequency for about 10–15min.”
Loss of communication in any form or duration is always
a hazardous situation, but it is even more so after the
9/11 events.
Checklist Actions After Engine Failure on Takeoff
On December 20, 2005, an MU-2B-36 aircraft was taking
off from runway 15 at Terrace, B.C., on a courier flight
to Vancouver, B.C., with two pilots on board. The aircraft
crashed in a heavily wooded area approximately 500 m east,
abeam of the south end of Runway 15; about 300 m
beyond the airport perimeter. A post-crash fire occurred.
The aircraft was destroyed and the two pilots were fatally
injured. The accident happened at 18:35 Pacific Standard
Time (PST), in dark conditions. The investigation into this
occurrence is ongoing (TSB file A05P0298).
To date, the investigation has revealed that the left
engine (Honeywell TPE331-6-252M) failed as a
result of the combustion case assembly (plenum)
rupturing. This engine had accumulated 4 742 hr since
18
the last continuous airworthiness maintenance (CAM)
inspection. Investigation of the wreckage also revealed
that the left engine was not delivering power and its
associated propeller was not feathered at the time of
impact. The flaps were also found at 20°, in the maximum
deflection position. Tree damage revealed the aircraft had
descended into the trees laterally, at a nose down angle of
approximately 23°.
The following make up the checklist actions prescribed in
the MU-2B pilot operating manual (POM) for an engine
failure:
• Dead (failed) engine condition lever—EMERG
STOP (to feather the propeller and shut off fuel
at the fuel control)
ASL 2/2007
Flight Operations
Flight Operations
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)
•
•
•
•
•
Dead (failed) engine power lever—TAKEOFF
(to assist full feathering of the propeller)
Landing gear switch—UP
Flap switch—UP (after reaching a safe altitude
and airspeed)
Airspeed—BEST RATE OF CLIMB (150 kt calibrated airspeed [CAS])
Trim ailerons—SET (to ensure no spoiler
extension and loss of lift)
Power (operating engine)—MAXIMUM
CONTINUOUS POWER
If one engine fails after takeoff, the resulting loss of climb
performance caused by the extended flaps would result in
the aircraft not being able to achieve the climb gradient
requirements specified for a given departure runway. The
increased drag caused by an un-feathered propeller would
The MU-2B aircraft is a high-performance twin
turboprop aircraft. About 400 MU-2 aircraft are active
worldwide, including 309 in the United States and 16 in
Canada. A number of them have crashed following engine
failures during takeoff or immediately after becoming
airborne. In situations in which an engine fails at a
critical stage of the takeoff, the crew must take rapid and
positive action to reduce the drag on the aircraft in order
to maintain a positive rate of climb. Unless appropriate
action is taken, there is a risk of loss of aircraft and related
fatalities, such as were observed in this accident.
Based on the circumstances of this occurrence,
Transport Canada may wish to remind MU-2B and other
twin-engine operators of the importance of ensuring the
required checklist actions are carried out immediately
after recognizing an engine has failed on takeoff.
To the Letter
To the Letter
The POM for the MU-2B permits takeoff using either
flap 5 or 20. The advantage of using flap 20 for takeoff is
that the aircraft will become airborne sooner; however,
because of the greater drag caused by the higher flap
setting, the aircraft’s climb performance will be reduced.
further reduce performance. According to the POM, the
combination of the loss of engine power, the extended
flaps and the un-feathered propeller would result in the
aircraft not being able to maintain altitude.
Guest Editorial
Guest Editorial
•
Computers in Aviation: Friend or Foe?
In days gone by, aviation was about stick and rudder;
pilot skills were paramount in handling an airplane.
These days, things are getting more complicated.
Aircraft systems are becoming increasingly automated;
flight information, such as flight status and weather
conditions, is more readily available; and aircraft
navigation systems are changing, allowing more flexible
routes of flight, and less dependence on the ability of
a pilot to fly a particular course from a ground-based
navigation aid (NAVAID).
With all these advances in computer technology entering
the cockpit, it’s no wonder that sometimes the computers
get the best of us. Each of us has, at some point or
another, been in the position of being “behind the curve”
with a computer of some kind. Whether it comes down to
programming the clock on the VCR, playing a game on a
computer, or dealing with a high-tech piece of hardware,
we’ve all discovered that computers do exactly what
they’re told to do—even if we make a mistake in telling
them what we want them to do.
Sometimes it’s an inadvertent error; sometimes it’s getting
carried away with the navigation equipment’s capabilities;
and other times it’s a misunderstanding of the system and
its effect. Here are a few examples of when things can
go awry, and the reasons may be obvious, or they may be
fairly subtle.
As a controller, I have witnessed a few of the subtleties of
such errors. Once, a pilot had asked for direct BIMKU,
the intermediate approach fix (IF) for an approach at an
airport only 30 NM away. It should have amounted to
a left turn of approximately 10°; however, the aircraft’s
track on radar appeared to change 110° to the left. When
queried, the pilot told me he had inadvertently selected
BIMTU from the database, a fix associated with another
airport, about 100 NM north of his intended destination.
If another aircraft had been on a parallel vector on his left
side, this could have been very interesting, to say the least.
A similar error can be made when entering geographical
coordinates. Accidentally entering 45°05’32” for latitude
instead of 45°50’32” is a whopping error of 45 NM—
all because two digits were transposed. Similarly, close
placement of keys on a keypad can result in accidental
ASL 2/2007
19
Flight Operations
Flight Operations
Computers make all of this possible; they receive
information via data link rather than requiring a pilot
to communicate by voice with dispatchers; they display
the status of aircraft systems and position in more
logical ways; and they do complex calculations for
aircraft navigation, including automated guidance along
programmed courses.
There are few areas, however, where simple mistakes, such
as transposing a digit, can result in serious consequences.
Aircraft navigation is one of those places where danger
can lurk in unexpected places.
Pre-flight
Pre-flight
by Michael Oxner. Mr. Oxner is a terminal/enroute controller in Moncton, N.B., with 15 years of experience. He is a freelance aviation
safety correspondent for www.aviation.ca.
Guest Editorial
To the Letter
Sometimes, pilots may make unintentional entries
into navigation systems. While perusing a database
for approaches, a pilot may inadvertently activate an
approach and make a turn that ATC does not expect.
Even a slight turn may compromise separation with
surrounding aircraft, especially in a terminal environment
where controllers apply minimum separation to use
airspace as efficiently as possible.
Yes, computers can be our friends; they can offload a
lot of work from a flight crew, especially those menial
and repetitive calculations, but there are many pitfalls
that can turn into big issues without proper care and
attention. Familiarity with how a system operates, and
what erroneous keystrokes may do, can literally save lives.
Take care in the skies, and watch the computers carefully.
They do what they’re told to do, even if we don’t realize
what we’re telling them to do.
Hail Damage…
Flight Operations
Flight Operations
While in cruise at FL 300 after departing Calgary, Alta., this Boeing 727 sustained extensive hail damage after
an encounter with a severe thunderstorm. In addition to the damage shown, wing leading edges, engine inlets
and landing lights lenses were also damaged. The aircraft returned to Calgary for an uneventful landing and was
later repaired.
Pre-flight
Pre-flight
Also, restricted airspaces may come into play during
the transition from the en-route phase of flight to
the approach phase. Saint John, N.B., for example,
is located very close to the Gagetown, N.B., restricted
area (CYR724), an area of live firing. Many pilots of
Another common error is when a pilot asks for clearance
to an IF for an approach. If a turn of more than 90°
is required for the aircraft to turn onto the final approach
course, a pilot will sometimes program the autopilot to
project a waypoint beside the IF, in effect making a base
leg for the autopilot to fly. Some pilots doing this don’t
ask for approval for such a manoeuvre, and navigate to a
point that ATC is not expecting, which may affect other
traffic. Also, if the approach plate does not provide for
such a manoeuvre, as an RNAV approach may, how does
the pilot know what altitude is safe that far away from the
final approach course?
To the Letter
Other errors that can occur can also be derived from
complacency. Trusting the navigation system to get you
where you want to go can be a mistake. Quite frequently,
pilots ask for routings through restricted airspaces simply
because a direct routing, made possible by GPS and other
systems, is much easier to enter into a system. Looking at
charts and picking out points takes time, and the practice
also tends to take an aircraft off an optimal direct routing.
However, a look at the charts during the flight planning
stage may reveal reasons why a direct route is simply not
acceptable to pilots or controllers.
varying experience have asked for clearances allowing
navigation directly to fixes associated with an approach,
only to have ATC deny the clearance. The reason is
that many pilots tend to rely on the navigation gear to
take them where they want to go, but forget about the
possibility of obstacles or restricted areas between where
they are at the time and where the desired fix is. The
approach plates may have too narrow a focus to show
the proximity of the restricted airspace, leading a pilot to
believe there is no reason not to fly to a particular fix.
Guest Editorial
selection of a nearby key—perhaps entering 48° instead
of 45° in the previous example, which would have been
even worse. One method of crosschecking such an entry
for error is to compare the geographical coordinate to the
desired entry backwards, helping to take the complacency
factor out of data entry. It may take a little time, but it
may also be well worth the investment.
20
ASL 2/2007
Recently Released TSB Reports
Ageing Airplane Rulemaking
by Blake Cheney, Acting Manager, Domestic Regulations, Regulatory Standards, Aircraft Certification, Civil Aviation, Transport Canada
When
Pre-flight many of us think of ageing airplanes, images come
to mind of proudly displayed vintage warbirds and other
enduring examples of aviation’s first century of flight.
However, perhaps less obvious is the world of transport
and commuter category airplanes that each day transport
passengers and cargo to diverse destinations around the
globe. Yes, even the stylishly painted and freshly washed
Regs & you
passenger
jets transporting us for business, pleasure and
to holiday destinations could be considered in the same
breath as those vintage warbirds.
While the Aloha Airlines accident was not the first ageing
airplane fatal accident, it was the one that brought the
issue to public attention. The Boeing 737-200 was a highcycle aircraft that suffered a partial in-flight disintegration
in which an 18-ft crown section of the fuselage was torn
apart in flight. The accident investigation revealed the
presence of small cracks at multiple rivet locations in a
disbonded lap joint, which were sufficient in size and
density to cause the accident. This phenomenon is referred
to as widespread fatigue damage (WFD).
For those following the progress of the Federal Aviation
Administration (FAA) rulemaking activities, collectively
known as the Aging Airplane Program, launched
Not used
following the Aloha Airlines Boeing 737-200 accident
of 1988, the subject of ageing airplanes will be hardly
new. In many respects, the term “ageing airplane” itself is
getting long in the tooth. What is new is the approach
now being taken to address design and maintenance
issues associated with ageing structures, wiring and fuel
tank safety.
Recent regulatory activity by the FAA, the European
Aviation Safety Agency (EASA), the Brazilian Agência
Nacional de Aviação Civil (ANAC) and Transport Canada
Civil Aviation (TCCA), has brought to bear a focus
on enhancing the safety of the current and expected
future fleet of ageing airplanes. The current rulemaking
initiatives recognize that many airplanes are still in service
beyond their design life goal. The design life goal is a
“life expectancy” in flight cycles or hours that is generally
established early in the development of a new airplane and
based on economic analysis, past experience with other
models, and in some cases, fatigue testing. In addition,
numerous accidents have raised awareness of safety issues
associated with the design and maintenance of ageing
airplane structures and systems.
Historically, we may look back to 1977 for what could
be argued as the first ageing-airplane related accident; a
Dan-Air Services Boeing 707-321C that crashed on final
approach in Lusaka, Zambia. The airplane, engaged in
a non-scheduled international cargo flight, happened to
be the first aircraft off the 707-300C series convertible
passenger/freighter production line. On approach, the
airplane pitched rapidly nose down, dived vertically into
the ground from a height of about 800 ft, and caught
fire. The accident was determined to be caused by a loss
of pitch control following the in-flight separation of the
right-hand horizontal stabilizer and elevator as a result of
a combination of metal fatigue and inadequate fail-safe
design in the rear spar structure. Shortcomings in design
assessment, certification, and inspection procedures were
contributory factors. A post-accident survey of the 707-300
fleet worldwide revealed a total of 38 aircraft with fatigue
cracks present in the stabilizer rear spar top chord.
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21
Regulations and You
New requirements will focus on re-evaluations of existing
designs against new airworthiness standards, revising
maintenance and inspection programs, and imposing flight
operations requirements that would prohibit the operation
of airplanes that do not incorporate required modifications
and/or changes to their maintenance programs.
April 28, 1988: Aloha Airlines flight 243,
Boeing 737-200 near Maui, Hawaii, fuselage
upper crown skin and structure separated in flight.
Accident Synopses
Accident Synopses
Ageing Airplane Rulemaking............................................................................................................................................ page 21
Bilateral Agreements on Airworthiness—An Overview and Current Status............................................................... page 24
Maint. & Cert.
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maintenance and certification
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Maintenance and Certification
TSB reports
22
Maintenance and Certification
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Accident Synopses
Regulations and You
The TWA flight 800 accident investigation was still in
progress when, on September 2, 1998, Swissair (SR) flight
111, a McDonnell Douglas MD-11, experienced an inflight fire approximately 53 min after departure from New
York, that would ultimately lead to the aircraft colliding
with water near Peggy’s Cove, N.S., and would result in
229 fatalities. The accident investigation, conducted by
the Transportation Safety Board of Canada (TSB AIR
Report No. A98H0003), identified the cockpit attic and
forward cabin drop-ceiling areas as being the primary
fire-damaged area, and that the most prevalent potential
ignition source was electrical energy.
It should be noted that the SR flight 111 occurrence
aircraft was manufactured in 1991, and therefore,
should not be considered an aged airplane. In addition,
a historical review conducted by the FAA of fuel tank
explosions prior to the TWA flight 800 accident revealed
that ageing was not the only contributing factor in the
development of potential ignition sources. In particular,
in May 1990, the centre wing tank of a Boeing 737-300
exploded during push back from a terminal gate prior
ASL 2/2007
Regulations and You
Whereas the accidents to date were raising awareness
to ageing structural issues, it was not yet realized that
aircraft systems ageing-related failures could be just as
This accident prompted the NTSB, the FAA and industry
to examine the underlying safety issues surrounding fuel
tank explosions, the adequacy of the existing regulations,
the service history of airplanes certificated to these
regulations, and existing fuel tank system maintenance
practices. The NTSB/FAA accident investigation
included:
• Review of fuel tank system design features of Boeing 747 and certain other models; and
• Inspection of in-service and retired airplanes.
Accident Synopses
Subsequent to the 1988 accident, the FAA greatly
expanded its structural integrity inspection program
and formed the Airworthiness Assurance Working
Group (AAWG) with five focus areas to examine
structural issues related to widespread fatigue damage
and corrosion (www.faa.gov/regulations_policies/rulemaking/
committees/arac/issue_areas/tae/aa/):
• Service Bulletin Review
• Supplemental Inspections
• Maintenance Programs
• Corrosion Prevention and Control Programs
• Repair Assessment Programs.
July 17, 1996: Trans World Airlines flight 800,
a Boeing 747-131, in-flight break-up over the Atlantic Ocean,
near East Moriches, N.Y., 230 fatalities.
Recently Released TSB Reports
Our own Canadian experience involved a Douglas DC-3C
wing separation near Pickle Lake, Ont., in 1987. Two other
pilots flying in the vicinity at the time described the final
moments of the aircraft flight as having been in an inverted
attitude descent with the left wing folded upwards. The
Canadian Aviation Safety Board (CASB Report No. 87C70022) determined that the left wing failed under normal
flight loads as a result of a fatigue crack in the centre section
of the lower wing skin. It was also found that anomalies
in the radiographs previously taken during mandatory
non-destructive testing inspections were not correctly
interpreted. As a result, Transport Canada conducted the
Study of Non-Destructive Testing in Canadian Civil Aviation,
which was completed in January 1988. The study identified
a number of shortcomings, and recommended that nondestructive testing (NDT) personnel certification standards
(CGSB, MIL-STD-410, ATA 105) be recognized as
airworthiness standards, and that NDT work be done
under an approved maintenance organization (AMO).
Canadian Aviation Regulations (CARs) 571 and 573 were amended to include these requirements. In 1996,
TCCA published CAR 511.34—Supplemental Structural
Integrity Items to require, for all principle structural
elements, the development of any change or procedure
necessary to preclude the loss of the airplane or a significant
reduction in the overall structural strength of its airframe.
Maintenance and Certification
A Dan-Air Services Boeing 707-300C, similar to the aircraft
that crashed near Lusaka, Zambia, on May 14, 1977.
catastrophic. That all changed on July 17, 1996, when Trans World Airlines (TWA) flight 800, a 25-year old
Boeing model 747-131, was involved in an in-flight
break-up after takeoff from John F. Kennedy International
Airport in New York, resulting in 230 fatalities. The
accident investigation conducted by the National
Transportation Safety Board (NTSB/AAR-00/03)
indicated that the centre wing fuel tank (CWT) exploded
due to an unknown ignition source. However, of the
ignition sources evaluated by the investigation, the most
likely cause was a short circuit outside of the CWT that
allowed excessive voltage to enter it through electrical
wiring associated with the fuel quantity indication system.
Maintenance and Certification
➀
Accident Synopses
Through their participation in the AAWG, ATSRAC
and/or the FAA’s Transport Airplane and Engines Issue
Group (TAEIG), EASA, TCCA and ANAC (then called
Centro Técnico Aeroespacial [CTA]) have monitored and/or
participated in the development of proposals for the
Aging Airplane Program rulemaking initiatives.
Photos courtesy of FAA SFAR 88 Workshop, June 2001:
Potential ignition sources discovered by fleet inspection.
1. Frayed fuel pump wire; 2. Main tank over pressure;
3. Arc through conduit; 4. Arc through pump housing.
The Aging Airplane Program initiatives consist of multidisciplinary regulatory activities including:
In January 1999, the FAA chartered the Aging Transport
Systems Rulemaking Advisory Committee (ATSRAC).
Whereas the AAWG’s focus had been on structural
integrity and the effects of structural corrosion and
fatigue, ATSRAC (www.mitrecaasd.org/atsrac/) was
tasked to “propose such revisions to the Federal Aviation
Regulations (FARS) and associated guidance material as
may be appropriate to ensure that non-structural systems in
transport airplanes are designed, maintained, and modified
in a manner that ensures their continuing operational
safety throughout the service life of the airplanes.”
In parallel, the Aerospace Industries Association (AIA)/
Air Transport Association of America (ATA) conducted
an aircraft fuel system safety investigation. The team
inspected multiple in-service airplanes, and this industry
program gathered significant information about the
overall integrity of the design and maintenance of these
aircraft. Well over 100 000 labour-hours were reportedly
expended performing inspections of the world fleet.
As of June 1, 2000, inspections had been completed on
990 airplanes, with a further 30 airplanes to be completed
shortly thereafter, operated by 160 air carriers in diverse
operating environments on six continents.
Other related FAA regulatory initiatives include:
(6) Repair Assessment of Pressurized Fuselages; Final Rule
(issued April 19, 2000); and
(7) The new approach for requirements for design
approval holders (part of Aging Airplane Program
Update, issued on July 21, 2004).
TCCA has recently initiated Canadian-specific
rulemaking activities and has invoked a Canadian
Aviation Regulation Advisory Council (CARAC)
Working Group on Ageing Aeroplane Rulemaking
and Harmonization Initiatives (AARHI), covering the
structural and non-structural subjects. The Working
Group is a joint undertaking of government and the
aviation community, representing an overall aviation
viewpoint. The Working Group will disposition into
ASL 2/2007
Regulations and You
On April 21, 2001, after 18 months of deliberation,
including 3 months of public consultation (including
inputs from Transport Canada and other civil aviation
authorities [CAA]), the FAA issued the Final Rule
of Special Federal Aviation Regulation (SFAR) No. 88.
This new rule promulgated improved design standards
for transport category (large) airplanes, developed
(1) Transport Airplane Fuel Tank System Design
Review, Flammability Reduction and Maintenance
and Inspection Requirements; Final Rule (issued
April 19, 2001) and the Fuel Tank Safety Compliance
Extension; Final Rule (issued July 21, 2004);
(2) Enhanced Airworthiness Program for Airplane Systems /
Fuel Tank Safety; Notice of Proposed Rulemaking
(NPRM) (issued September 22, 2005);
(3) Aging Airplane Safety; Final Rule (issued
January 25, 2005);
(4) Aging Aircraft Program: Widespread Fatigue Damage;
NPRM (issued April 11, 2006); and
(5) Damage Tolerance Data for Repairs and Alterations;
NPRM (issued April 13, 2006)
Accident Synopses
Regulations and You
➃
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➂
➋
with the knowledge gained following the tragedy of
TWA flight 800. SFAR No. 88 included a comprehensive
requirement for manufacturers, owners and operators
to conduct a one-time fleet-wide re-evaluation of all
large airplanes of the jet age, with respect to their fuel
system designs and maintenance practices, against the
revised and improved safety standards. TCCA, the Joint
Aviation Authorities ( JAA), and other CAAs supported
this important safety initiative. Manufacturers conducted
extensive design reviews, and their findings were reviewed
by the airworthiness authorities to verify compliance with
the new requirements and to mandate corrective actions
where necessary (www.fire.tc.faa.gov/systems/fueltank/intro.stm).
Maintenance and Certification
to flight, as the result of an unknown electrical ignition
source; the aircraft was less than a year old. Hence, the
development of such failures may be related to both
the design and maintenance of the airplane systems.
23
Maintenance and Certification
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Bilateral Agreements on Airworthiness—An Overview and Current Status
by Carlos Carreiro, International Regulations, Regulatory Standards, Aircraft Certification, Civil Aviation, Transport Canada
What is a bilateral agreement on airworthiness?
A bilateral agreement on airworthiness is an
administrative arrangement that has the objective of
promoting aviation safety by strengthening technical
cooperation and mutual acceptance of tasks related to the
airworthiness of aeronautical products.
For the purpose of this article, we will simply use the
term “agreement” whenever we want to refer to a bilateral
agreement on airworthiness.
Why do we enter into an agreement?
The Canadian Aeronautics Act has the purpose of
providing for safe, efficient and environmentallyresponsible aeronautical activities, by means that
include ensuring that Canada can meet its international
obligations relating to aeronautical activities.
Before entry into Canada, aeronautical products
designed in a foreign state require approval to ensure
24
In summary, the presence of an agreement on
airworthiness or certification of aeronautical products is not only very cost-beneficial for Canadian organizations
exporting aeronautical products to other foreign States,
but it also promotes a significant exchange of technical
cooperation among States.
Characteristics of an agreement
An agreement can be entered between:
• Canada and another government under a Treaty
(legally binding); or
• The Minister of Transport or Transport
Canada Civil Aviation (TCCA) and their
counterpart office, as an administrative or
technical cooperation arrangement (not legally
binding). Examples of this kind of agreement
are: Technical Arrangements and Memoranda of
Understanding, among others.
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Regulations and You
Paragraph 4.2 (1)(j) of the Aeronautics Act prescribes
that the Minister (to be considered the Minister of
Transport for the purpose of this article) may enter
into administrative arrangements with the aeronautics
authorities of other governments or with organizations
acting on behalf of other governments, in Canada or
abroad, with respect to any matter relating to aeronautics.
Canadian airworthiness design standards are fully
satisfied, regardless of whether the product received prior
certification by a foreign airworthiness authority.
Conversely, the certification of aeronautical products
that are designed in Canada must be validated by foreign
airworthiness authorities upon exportation from Canada.
This review, at times, may be very lengthy and require a lot of resources from the civil aviation authority (CAA)
from both the exporting and importing States.
Accident Synopses
Accident Synopses
Following presentation of the CARAC AARHI Working
Group recommendations, TCCA will seek to publish
new regulations and standards that will parallel those
of the FAA’s Aging Airplane Program. It is anticipated
that the TCCA rulemaking will include new design
TCCA, EASA, ANAC and the FAA have agreed to
work together on the ageing airplane initiatives in an
effort to foster a common understanding of the respective
rulemaking activities, to provide for coordinated
implementation, and to coordinate the eventual
compliance findings between the appropriate CAAs,
where possible using procedures developed under the
bilateral agreements.
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Regulations and You
EASA has also initiated regulatory activities that
will strive to be harmonized with the FAA by
creating the European Ageing Systems Coordination
Group (EASCG). EASA has separately examined the
ageing structures issues, but is anticipated to convene a
Working Group this year to disposition those issues with
input from the European industry.
approval holder (DAH) requirements, specifically for type
certificate (TC) and supplemental type certificate (STC)
holders, to supply data and documents in support of
operator compliance with related flight operations rules.
In some cases, repair design certificate (RDC) and limited
STC (LSTC) holders may also be affected. The DAH
requirements would reference technical standards, and
include consideration for compliance planning applicable
to existing DAHs and applicants for new and amended
design approvals, to ensure that an acceptable level of
safety is maintained for the affected airplanes.
Maintenance and Certification
the Canadian regulatory framework the findings of
both AAWG and ATSRAC. At the same time, the
Working Group will seek to maximize compatibility with
other regulatory authorities. (For more information on
CARAC, please see www.tc.gc.ca/civilaviation/regserv/affairs/
carac/menu.htm)
Maintenance and Certification
4) Competence and capability of a bilateral partner must
be assessed as to their ability to achieve results similar
to those obtained by TCCA.
Foreign Affairs Canada (FAC) has primary responsibility
in legally-binding agreements. For other agreements,
the Minister of Transport or TCCA can engage directly.
5) Compliance with the Chicago Convention must be assessed.
An agreement cannot relieve the Minister of
Transport of their statutory responsibilities, which,
under the Aeronautics Act and the Canadian Aviation
Regulations (CARs), cannot be transferred.
7) Once confidence is established with steps 1 to 6,
negotiations and a draft agreement may proceed.
The following steps are required in order for Canada to
enter into an agreement with another State or organization:
1) There must be a mutual desire to strengthen and
formalize technical cooperation in promoting safety,
which would increase efficiency in matters relating to
safety, and reduce economic burden due to redundant
airworthiness reviews (technical inspections,
evaluations, testing).
3) Each State’s legislation and regulatory system must
be assessed and deemed to be equivalent. The civil
aviation regulatory framework shown below, is used
when assessing equivalency.
In terms of the time required to conclude an agreement,
it may take up to 3 years for a legally-binding agreement
(due to the lengthy review process and legal nature), and 3 months to 2 years for an agreement that is not
legally binding (depending on the complexity and scope
of the agreement).
Status of agreements on airworthiness
Please refer to the following Web site for information on agreements on airworthiness that have been signed
by TCCA or the Government of Canada (in the case of a legally-binding agreement):
www.tc.gc.ca/CivilAviation/certification/Int/menu.htm.
For further questions or clarifications, please contact the
author at carreic@tc.gc.ca.
Accident Synopses
2) Areas of cooperation must be defined:
• Technical assistance to bilateral partner in their
approval and certification activities;
• Harmonization of standards and processes;
• Facilitation of the exchange of civil aeronautical
products and services;
• Mutual recognition and reciprocal acceptance
of approval and certificates;
• Other areas, as mutually agreed.
The conclusion of an agreement is reached in the
following manner:
• For Treaties—Signatures by both governments (States).
• For non-Treaty (not legally binding)—
Signatures by Minister of Transport of Canada
and bilateral partner equivalent. (The signature of the Minister commits Transport Canada, and not the Canadian Government.)
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Steps to an agreement
Accident Synopses
6) Effectiveness of oversight and enforcement programs
must be assessed.
Maintenance and Certification
An agreement can only relate to civil aviation safety issues
(not commerce or trade issues), and it should be within the
current scope and authority of the Canadian regulations.
Aeronautics Act
Regulations
(Canadian Aviation Regulations [CARs])
Standards
Regulations and You
Regulations and You
(Airworthiness Manual [AWM])
Advisory Materials
(Advisory Circulars)
Policies and Procedures
(Policy Letters, Staff Instructions)
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25
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.
to the controllers scanning the radar or relying on
information on the flight data strips.
Maint.Final
& Cert. Report A04Q0003—Loss
TSB
of Separation
On January 13, 2004, a Boeing 777, en route from
John F. Kennedy Airport, N.Y., to Narita, Japan,
wasPre-flight
at flight level (FL) 350 on a converging track
with a Boeing 767, at FL 350 en route from
Paris, France, to Chicago, Ill. Both aircraft received a
traffic alert and collision avoidance system (TCAS)
resolution advisory (RA), to which they responded.
The two aircraft passed each other at 13:22 Eastern
Standard Time (EST), within 600 ft laterally and 1 100 ft
Regs & you of one another, approximately 160 NM south
vertically
of La Grande Rivière, Que., in radar-controlled airspace.
The air traffic controllers had not detected the conflict until
alerted by the ATC conflict alert program. The required
separation was 5 NM laterally or 2 000 ft vertically.
Findings as to causes and contributing factors
Other findings
1. The lack of realistic and recurrent simulation training
may have delayed the OJI’s quick and efficient
recovery from a loss of separation situation, or may
have contributed to his inappropriate response to the
conflict alert warning.
2. The OJI’s training course focussed mainly on the
interpersonal aspects of monitoring a trainee. It did
not cover practical aspects, such as how to effectively
share work knowledge and practices with a trainee
or how to quickly take over a control position from a
trainee when required.
2. After accepting the handover of the CYGL
sector, neither the trainee nor the on-the-job
instructor (OJI) conducted a review of all aircraft
under their control to ensure there were no potential
conflicts; the conflict between the B767 and the B777
was not detected, which placed them in a potential
risk of collision situation.
The Montréal area control centre (ACC) published an operations bulletin containing information to ensure
that all controllers involved in on-the-job training know
how to operate their communications equipment and gain immediate access to their frequencies. This operations bulletin was a mandatory verbal briefing
item for all controllers.
Findings as to risk
1. There is no medium-term conflict probe for radarcontrolled airspace to provide an additional backup
26
TSB Final Report A04Q0041—Control Difficulty
On March 31, 2004, a DHC-8-300 was proceeding
from Montréal, Que., to Québec, Que., with three crew
members and three passengers on board. After takeoff,
at about 3 000 ft above sea level (ASL), the aircraft
banked left and force had to be applied on the steering
wheel to keep the wings level. The checklist for a runaway
aileron trim tab was completed, which corrected the
situation; however, the flight crew found that the trim tab
indication, which was fully to the right, was not normal.
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Regulations and You
3. After the ATC conflict alert program warned
the trainee and the OJI of the impending loss of
separation, the OJI was unable to communicate
instructions to the involved aircraft because he used
the foot pedal instead of the press-to-talk switch to
activate the radios. As a result, the aircraft progressed
to the point where only the TCAS RA prevented a
potential collision.
Safety action taken
Accident Synopses
Accident Synopses
3. Because the TCAS is not mandatory in Canada,
there continues to be an unnecessary risk of mid-air
collisions within Canadian airspace.
1. The potential conflict between the B767 and the
B777 was not detected when the B767 first contacted
the La Grande Rivière (CYGL) sector, and no action
was taken by the first CYGL controller to remind
the next controller that a conflict probe had not
been completed. This allowed a potential conflict to
progress to the point of a risk of collision.
Not used
Regulations and You
2. The current operational conflict alert system provides
minimal warning time for the controller and requires
immediate and often drastic action by both the
controller and the aircrew to avoid a mid-air collision.
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Maintenance and Certification
1. The aileron trim tab was improperly aligned, which
contributed to the tendency of the aircraft to roll on
departure from Montréal.
2. The absence of a placard near the indicator, and
the arrangement of information in the logbook,
contributed to the crew being unaware of the
defective aileron trim tab indicator.
Findings as to risk
1. Poor task distribution between the assistant chief
dispatcher and the flight dispatcher created confusion
in the telephone conversations with the tower
controller, which delayed transmission of the second
order to execute a missed approach, resulting in a missed approach at very low altitude.
½ NM
separation
Dash-8
Beaver
Findings as to causes and contributing factors
Safety action taken
1. The TS controller cleared the Dash-8 for takeoff from
the Runway 08R threshold without considering the
change to the aircraft’s departure profile from the usual
intersection departure. As a result, an air proximity
occurred between the Dash-8 and the Beaver.
TSB Final Report A04P0153—Air Proximity—
Safety Not Assured
2. The coordination among the TS, traffic advisory (TA),
and DS controllers that is necessary to fulfill the
requirement for traffic information and conflict
resolution did not take place. As a result, the two
departing aircraft did not receive the ATC services
specified for the class of airspace within which they
were flying.
As part of its safety management system (SMS), the operator initiated an internal investigation to draw
lessons from this occurrence in order to use them for crew
resource management (CRM) training.
3. The TA controller’s attention was diverted to other
traffic under his responsibility, and he did not see the Dash-8 coming up behind the Beaver. As a result,
the two aircraft came into close proximity before the Dash-8 crew saw the other aircraft and took
evasive action.
4. Because the Dash-8 crew expected a clearance to
remain at 2 000 ft, they substantially decreased their
rate of climb, creating the conflict with the Beaver
and extending its duration.
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27
Regulations and You
On May 5, 2004, a float-equipped de Havilland DHC2, Mk 1 Beaver was authorized by the Vancouver tower
south (TS) controller for an eastbound takeoff, on a
VFR flight plan, from the Fraser River just south of the
Vancouver International Airport, B.C., with a right turn to
the Vancouver (YVR) VHF omnidirectional range (VOR)
at 1 000 ft. A de Havilland DHC-8-100 (Dash-8) was
subsequently cleared for takeoff from the Vancouver
International Airport on an IFR flight plan to Nanaimo, B.C.,
using Runway 08R, with a Richmond 8 standard instrument
departure (SID). The Richmond 8 SID calls for a right turn
at 500 ft and a climb on heading 141° magnetic (M) to
2 000 ft. The Dash-8 climbed to 500 ft and initiated a right
Accident Synopses
Accident Synopses
2. The trim tab had been improperly adjusted during
prior service; an incorrect indication of the position of the aileron trim tab in the cockpit might have
resulted if the indicator had been serviceable.
Regulations and You
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Findings as to causes and contributing factors
turn well before the end of the runway. The crew reported
through 1 000 ft, heading 140°M, and substantially reduced
their rate of climb, which brought them into close vertical
proximity with the Beaver. Subsequently, the pilot took evasive
action when he observed the Beaver below on the left side.
The Vancouver departure south (DS) controller noticed the
conflict and advised the Dash-8 crew of “unverified” traffic on
their left side at 1 100 ft. He instructed the Dash-8 crew to
turn at their discretion to avoid the traffic. The Dash-8 crew
turned right and climbed on a heading of 190°M to resolve
the conflict. The occurrence took place at 08:18:47 Pacific
Daylight Time (PDT).
Maintenance and Certification
Emergency services were requested and the aircraft
continued on its flight to Québec. On final approach
for Runway 24 at Québec, the crew was advised by the
controller that the airline required it to not continue with
the approach. A missed approach was executed and it was
suggested to the captain that he come back for a no-flaps
landing. The aircraft came back and landed with no flaps
without incident at 10:52 EST.
Maintenance and Certification
Findings as to causes and contributing factors
2. The aircraft landing was smooth; this most likely
contributed to the aircraft hydroplaning on touchdown.
3. The anti-skid system most likely prevented the brake
pressures from rising to normal values until 16 to
19 seconds after weight on wheels, resulting in little
or no braking action immediately after landing.
4. The flight crew were slow to recognize and react
to the lack of normal deceleration. This delayed
the transfer of control to the captain and may have
contributed to the runway overrun.
1. It could not be determined if an electrical,
mechanical, or hydraulic brake problem existed at the
time of the landing.
2. The flight crew did not take appropriate measures
to preserve evidence related to the occurrence and,
therefore, failed to meet the requirements of the U.S.
Federal Aviation Regulations (FARs), the Canadian
28
Findings as to causes and contributing factors
1. Because the flight crew did not have sufficient
familiarity with the C90A electronic flight instrument
system (EFIS) equipment’s presentations and
operation, they used improper electronic horizontal
situation indicator (EHSI) course settings and
flight director mode selection on three successive
instrument approaches.
2. The inability of the crew to perform at the expected
standard resulted from limited recent flying time and
inadequate transition training in using the new avionics.
3. While flying a missed approach procedure, the pilot
flying (PF) was unable to transition to effective
manual control of the aircraft. As a result, the aircraft
speed decreased significantly below a safe level, and
the ATC-assigned altitudes and headings were not
adhered to.
ASL 2/2007
Regulations and You
Regulations and You
Other findings
On September 10, 2004, a Beech King Air C90A
was en route to the Edmonton City Centre Airport
(Blatchford Field), Alta., from Winnipeg, Man., via
Regina, Sask., under IFR. After descending into the
Edmonton terminal control area (TCA) in instrument
meteorological conditions (IMC), the aircraft was vectored
for a straight-in LOC(BC)/DME RWY 16 approach.
Shortly after intercepting the localizer (LOC) near the
LEFAT intermediate approach fix (IF), the aircraft
descended about 400 ft below the minimum step-down
altitude, and deviated 69° to the left of the final approach
course. The crew conducted a missed approach 8 NM from
the airport. During the missed approach, the airspeed
decreased from 130 to 90 knots indicated airspeed (KIAS),
and the aircraft climbed above three successive altitudes
assigned by ATC. The aircraft also deviated 43° from
its assigned heading while being vectored to rejoin the
localizer for Runway 16. Upon intercepting the localizer
for the second time, the aircraft turned to the right of the
approach centreline and descended below the minimum
step-down altitude. After the aircraft descended below the
cloud base, the crew gained sight of the airport, continued
the approach visually, and landed at 16:17 Mountain
Daylight Time (MDT).
Accident Synopses
Accident Synopses
1. The approach to Runway 25 was high, fast, and not
stabilized, resulting in the aircraft touching down
almost halfway down the 8 000-ft runway.
TSB Final Report A04W0200—
Navigation Deviation
Recently Released TSB Reports
Recently Released TSB Reports
On July 14, 2004, an Embraer 145LR aircraft departed
Pittsburgh, Pa., on a flight to Ottawa/Macdonald
Cartier International Airport, Ont., with two flight crew,
one flight attendant, and 28 passengers on board. At
17:20 Eastern Daylight Time (EDT), the aircraft landed
on Runway 25 at Ottawa and overran the runway, coming
to rest approximately 300 ft off the end of the runway in
a grass field. There were no injuries. The aircraft sustained
minor damage to the inboard left main landing gear tire.
When the aircraft landed, there were light rain showers.
After the rain subsided, the passengers were deplaned and
bussed to the terminal.
Maintenance and Certification
Aviation Regulations (CARs), and the Canadian
Transportation Accident Investigation and Safety Board
Act (CTAISB Act). Interference with the cockpit
voice recorder (CVR) obstructs TSB investigations
and may prevent the Board from reporting publicly
on causes and safety deficiencies.
TSB Final Report A04O0188—Runway Overrun
Maintenance and Certification
5. The crew’s resource management in preparation for
and during the three approaches was not sufficient to prevent the hazardous deviations from the required
flight paths.
1. The operator did not encourage pilots to use manual
flying skills in operational flying, thus creating the
potential for manual flying skills degradation from
non-use.
Recently Released TSB Reports
Recently Released TSB Reports
Finding as to risk
with two pilots and one passenger on board. At
11:26 EST, following a Runway 06 RNAV (GPS)
instrument approach, the aircraft was too high to be
landed safely, and the crew carried out a missed approach.
The crew members advised the Montréal Centre that they
would attempt a Runway 24 RNAV (GPS) instrument
approach. At 11:46 EST, the aircraft touched down
over 2 400 ft past the Runway 24 threshold. As soon
as it touched down, the aircraft started to turn left on
the snow-covered runway. Full right rudder was used in
an attempt to regain directional control. However, the
aircraft continued to turn left, departed the runway, and
came to rest in a ditch about 50 ft south of the runway.
The aircraft sustained substantial damage. There were no injuries.
Maintenance and Certification
4. On the second approach at Edmonton, the crew
focused on the GPS distance reading from the final
approach fix (FAF), instead of the distance-measuring
equipment (DME) display. This led to a premature
descent, and the aircraft was operated below the minimum published step-down altitudes for the approach.
Other finding
A post-incident audit revealed a number of examples of non-compliance with the operator’s Flight Operations
Manual, including a lack of appropriate pilot-training
record keeping. Therefore, there was no assurance that
pilots would receive required training within specified
time frames.
An internal safety bulletin distributed to the operator’s
pilots addressed the following issues associated with this occurrence:
• errors in managing automatic flight systems;
• encouraging periodic autopilot disconnect to improve monitoring vigilance;
• flight director/autopilot management;
• flight path deviations induced by autopilot
activation; and
• timely pilot intervention to correct flight path deviations.
Findings as to causes and contributing factors
1. Because the aircraft’s trajectory was not stabilized
on the final phase of the approach, the aircraft was
drifting to the left when the wheels touched down.
The pilot-in-command was unable to keep the aircraft
in the centre of the snow-covered runway, which had
been cleared of snow to only 36 ft of its width.
2. The left main landing gear, then the nose wheel,
struck a snow bank left on the runway by the snowremoval vehicle, and the pilot-in-command was
unable to regain control of the aircraft.
Findings as to risk
1. The operator’s pilots and ground personnel
demonstrated inadequate knowledge of the SMS
program by not recognizing the risk elements
previously identified by the company.
TSB Final Report A04Q0188—Runway
Excursion on Landing
2. Neither the pilot-in-command nor the co-pilot had
received CRM training, which could explain their
non-compliance with procedures and regulations.
On December 1, 2004, a Beech B300 was on an IFR
flight from Saint-Hubert, Que., to Saint-Georges, Que.,
3. Knowing that a snow-removal vehicle might be on
the runway, the crew attempted to land on Runway 06
ASL 2/2007
29
Regulations and You
Regulations and You
The operator has corrected operational and training
deficiencies that were revealed in a post-incident
operations audit of the Edmonton base. Pilots who
had not received the minimum flight training schedule
mandated in the Fixed Wing Operations Manual were
required to complete this training before their next
operational flights. In addition, operational control of
all flights was improved through a revised dispatch and
flight-following system.
Accident Synopses
Accident Synopses
Safety action taken
Maintenance and Certification
5. The aircraft’s altimeters were not set on the altimeter
setting for Saint-Georges.
Other finding
1. The proposed approach ban would not have prevented
the crew from initiating the approach because the
proposed ban does not apply to private companies,
and the Saint-Georges aerodrome does not meet the
meteorological observation requirements.
Safety action taken
Following this accident, the operator modified its
company organization chart. The position of assistant
director of operations was created to provide leadership at
the company’s main base when the director of operations
is absent. Also, the company appointed a chief pilot for
the Lear 60, responsible for the Montréal base, and check
pilots were appointed for the Lear 45, the Lear 35, and
the Beech B300.
The operator established visual references to enable the
universal communications (UNICOM) personnel to
estimate as accurately as possible the visibility and cloud
ceiling at the Saint-Georges aerodrome. Furthermore,
to avoid any confusion as to the snow-removal need, a
call sequence was established to reach snow-removal
employees. Also, the radio equipment in the snowremoval vehicles at Saint-Georges was modified to allow
communication with the base and aircraft at all times.
The Canadian Business Aviation Association (CBAA)
modified its symposium education program to promote
a better understanding of the factors that lead pilots (and
others) to not follow established procedures.
30
1. The flight crew attempted a night landing in the
absence of runway edge lights. The aircraft touched
down 300 ft to the left of Runway 05L and 1 800 ft
beyond the threshold.
2. The runway was not closed for night use despite
the absence of runway edge lights. Nothing required
it to be closed.
3. Poor flight planning, non-compliance with
regulations and standard operating procedures (SOP),
and lack of communication between the two pilots
reveal a lack of airmanship on the part of the crew,
which contributed to the accident.
Findings as to risk
1. Because they had not been given a safety briefing, the
passengers were not familiar with the use of the main
door or the emergency exit, which could have delayed
the evacuation, with serious consequences.
2. The armrest of the side seat had not been removed as
required and was blocking access to the emergency
exit, which could have delayed the evacuation, with
serious consequences.
ASL 2/2007
Regulations and You
Regulations and You
The operator will provide an annual winter operations
awareness program for its pilots and ground personnel.
Findings as to causes and contributing factors
Accident Synopses
Accident Synopses
The operator established new criteria for runway
acceptability. No approaches will be allowed until the
runway is fully cleared of snow and is clear of traffic.
A runway report for Saint-Georges aerodrome will be
provided to the flight service station (FSS) and sent to the
pilot where possible.
On February 21, 2005, an HS 125-600A aircraft, with
two crew members and four passengers on board, took
off from Montréal, Que., at 17:56 EST, for a night IFR
flight to Bromont, Que. Upon approaching Bromont, the
co-pilot activated the lighting system and contacted the
approach UNICOM (private advisory service). The flight
crew was advised that the runway edge lights were out
of order. However, the approach lights and the visual
approach slope indicator (VASI) did turn on. The flight
crew executed the approach and the aircraft touched
down at 18:25 EST, 300 ft to the left of Runway 05L
and 1 800 ft beyond the threshold. It continued on its
course for a distance of approximately 1 800 ft before
coming to a stop in a ditch. The crew tried to stop the
engines, but the left engine did not stop. The co-pilot
entered the cabin to direct the evacuation. One of the
passengers tried to open the emergency exit door, but was
unsuccessful. All of the aircraft’s occupants exited through
the main entrance door. Both pilots and one passenger
sustained serious injuries, and the three remaining
passengers received minor injuries. The aircraft sustained
major damage.
Recently Released TSB Reports
Recently Released TSB Reports
4. On the Runway 24 approach, the crew descended
below the minimum descent altitude (MDA) without
having acquired the required references.
TSB Final Report A05Q0024—Landing Beside
the Runway
Maintenance and Certification
and, after the missed approach, the aircraft did not follow the published missed approach path.
Maintenance and Certification
4. The possibility of flying to an airport that does not
meet the standards for night use gives pilots the
opportunity to attempt to land there, which in itself
increases the risk of an accident.
5. The landing performance diagrams and the chart
used to determine the landing distance did not enable
the flight crew to ensure that the runway was long
enough for a safe landing on a snow-covered surface.
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 and October 31, 2006, are all “Class 5,”
and are unlikely to be followed by a TSB Final Report.
—On August 5, 2006, a Bell B206-B3 helicopter had
landed on a log pad in the muskeg and, after a settling
check, the throttle was turned down to idle. After about
30 seconds, the aft fuselage dropped, and the pilot placed
the cyclic in the forward position. Mast bumping was felt,
and the engine was shut down immediately. The tail rotor
did not contact the ground, but there was considerable
damage to the dynamic components. There were no
injuries. TSB File A06W0136.
—On August 7, 2006, an amateur-built basic ultralight
Hipps J-3 Kitten was manoeuvring in the vicinity of
St. Andrews, Man. The pilot had difficulty controlling
the pitch attitude, and forced-landed in a field. After
touchdown, the aircraft nosed over on its back. The pilot/
owner/builder was not injured. Examination by the pilot
after the incident indicated that part of the elevator control
mechanism had failed in flight. TSB File A06C0128.
—On August 20, 2006, a Bell 206L-3 helicopter was
conducting oil field operations 40 NM northeast of Lac
La Biche, Alta. During departure from an oil well site, the
engine (Allison 250-C30P) lost power. The pilot entered
autorotation, and the helicopter struck the ground at a
high rate of descent. The main rotor severed the tail boom
at impact and the pilot sustained serious injuries. The
wreckage is being recovered to the TSB Pacific Region
compound, and the engine will be examined at a local
engine overhaul facility. TSB File A06W0143.
—On August 21, 2006, an Aerospatiale AS350 BA
helicopter was departing from a drill site with a 60-ft
ASL 2/2007
31
Regulations and You
Regulations and You
—On August 5, 2006, a PA-25-235 Piper Pawnee was
spreading chemicals when the aircraft severed an electrical
wire. The pilot headed toward the Rougemont, Que.,
airport, and landed normally. The pilot was not injured.
The aircraft’s propeller and right wing were damaged.
TSB File A06Q0134.
—On August 11, 2006, the pilot of the Grumman
AA1 Tiger was ferrying his newly-purchased aircraft
to Bellingham, Wash., when he encountered mountain
weather, and the aircraft descended rapidly and
crashed into trees. The pilot had been flying at about
6 500 ft ASL, was clear of clouds, and was about 1 mi.
away from a ridge. He escaped with minor injuries, but
the aircraft was destroyed. He broadcast Mayday calls and
a search and rescue (SAR) Cormorant helicopter picked
him up from the hillside about 3 hr after the crash. He
was taken to hospital for evaluation. TSB File A06P0159.
Accident Synopses
Accident Synopses
On July 19, 2005, the TSB sent an aviation safety advisory
to Transport Canada. The safety advisory states that, in
this occurrence, the precautions embodied in the various
civil aviation regulations did not prevent this night
Pursuant to this safety advisory, Transport Canada
determined that it would be very difficult to prepare
guidelines that would cover all factors that are directly
or indirectly associated with airport certification or
operations. Moreover, Transport Canada believes that
requiring aerodrome operators to evaluate the impact
of a reduced level of service on aerodrome use would be
a particularly complex task that could greatly increase
the possibility of errors in assessment or interpretation.
However, Transport Canada is examining the possibility of
adding information on the level of runway certification to
the Canada Flight Supplement (CFS), which would provide
more information and details to pilots regarding any
change to the certification status of a given runway.
Recently Released TSB Reports
Recently Released TSB Reports
Safety action taken
landing when the runway edge lights were unserviceable.
Consequently, Transport Canada might wish to review
the regulations with the goal of giving airport operators
guidelines on how to evaluate the impact of a reduced
level of service on airport use.
Maintenance and Certification
3. Because they had not been given a safety briefing, the
passengers seated in the side seats did not know that
they were required to wear shoulder straps and did
not wear them; so they were not properly protected.
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
—On August 24, 2006, a Cessna 180 on floats collided
with the embankment of a privately-owned, man-made
water runway during takeoff at the Tofino, B.C., airport.
The aircraft was departing westbound (Runway 28) from
the 1 400 x 80 ft-wide water runway. The wind was from
210°M at 5 kt. The water rudders were retracted for the
take-off run. The pilot lost directional control as the aircraft
was getting on the step and collided with the embankment
on the left side. There were no injuries. There was
substantial damage to the aircraft. TSB File A06P0154.
—On August 26, 2006, a Bell 206B helicopter
descended into a tree during a longline operation, while
manoeuvring to pick up a load. Both main rotor blades
sustained substantial damage and had to be replaced prior
to a maintenance ferry flight. There were no injuries. A
shorter-than-normal longline was in use, the tree was in
the seven o’clock position relative to the pilot, and the
pilot had been instructed to move left of his intended
position by the ground crew. TSB File A06W0152.
32
—On September 9, 2006, a Cessna U206G had departed
Copper Point, Y.T. (north of Mayo), for a hunting camp.
While en route through mountainous terrain, the pilot
realized that the aircraft could not outclimb the rising
terrain of the canyon floor. As the passage was too narrow
to permit a 180° turn, the pilot force-landed into the trees.
The pilot suffered minor injuries, the passenger suffered
serious injuries, and the aircraft was substantially damaged.
A helicopter evacuated the pilot and passenger after the
rescue coordination centre (RCC) tracked the emergency
locator transmitter (ELT) signal. TSB File A06W0166.
—On September 12, 2006, a PA28-180 was on the
base leg for Runway 06R at St-Hubert, Que., returning
from a recreational flight, when the engine (Lycoming
O360-3A3) stopped. The aircraft struck some cables and
cars before coming to a stop inverted on a street in an
industrial neighbourhood. The two occupants, as well as
four people on the ground, received minor injuries. The
aircraft was substantially damaged, but did not catch fire.
The emergency locator transmitter (ELT) went off upon
impact. Four cars were also damaged. TSB File A06Q0160.
ASL 2/2007
Regulations and You
—On August 27, 2006, a float-equipped Cessna
175A crashed approximately 10 NM south of Lac
Beauregard, Que. The pilot, alone on board, died. A weak
emergency locator transmitter (ELT) signal had been heard
at approximately 10:32; however, the weather conditions
made it impossible to reach the accident site, and the
aircraft was found the following day. The information
gathered indicates that before departure, the pilot was
—On September 2, 2006, a Bell 206L-1 helicopter
was picking up a group of kayakers at the confluence of
the Tulsequah and Taku rivers, about 60 NM south of
Atlin, B.C. A sling load of about 700 lbs of gear on the
river bank was attached to the longline before a decision
was made to return the passengers to the Tulsequah Chief
exploration mine camp before flying their gear out.
The helicopter took off with four of the passengers, but
crashed into the river when it came to the end of the
longline, which had remained attached to the aircraft.
Two passengers received minor injuries and the helicopter
was destroyed. TSB File A06P0180.
Accident Synopses
Regulations and You
—On August 23, 2006, a DHC-2 Beaver on floats
took off from Lac Louise, Que., for a VFR flight to
Labrador City, Nfld. Shortly after takeoff, with crosswinds
of approximately 15 kt, the pilot turned to the left. The
aircraft ended up with a tail wind, and the rate of climb
did not allow it to clear the obstacles. The aircraft struck
some trees before crashing. The aircraft did not catch fire,
but it did sustain substantial damage. The three occupants
on board received minor injuries. TSB File A06Q0147.
—On August 28, 2006, a Jabiru Calypso 3300 advanced
ultralight crashed one hour after takeoff from the
Maniwaki, Que., airport. The pilot, alone on board, was
conducting a local VFR flight. The aircraft struck and
severed the upper wire of a residential hydro line. The
aircraft crashed in a corn field approximately 400 ft away.
The pilot sustained fatal injuries. The aircraft wreckage
was transported to the TSB laboratory in Ottawa, Ont.,
for examination. TSB File A06Q0149.
Recently Released TSB Reports
—On August 21, 2006, a rented Champion 7ECA
Citabria was taxiing from the ramp to the runway at
Steinbach South, Man. Before the aircraft reached the
runway, it was observed making a wide turn, and then
departing the taxiway and striking a Cessna Ag Truck,
which was parked in the grass beside the taxiway.
The Citabria sustained substantial damage; the Ag Truck
sustained minor damage. TSB File A06C0140.
unable to check the weather, which was forecast to be IFR
conditions on his route. However, upon takeoff, despite
storms to the west, the conditions on his route to the south
were VFR. The angle at which the aircraft entered the forest
at the accident site, indicates that at the time of impact,
the aircraft was out of control. The evidence supports
the hypothesis that the pilot had encountered weather
conditions for which he was not prepared. There was no
evidence of a mechanical failure. TSB File A06Q0148.
Maintenance and Certification
longline, on a local flight. On departure, the longline hook
snagged a tree, and then broke free, flew up and fouled
the tail rotor and tail boom. The helicopter lost tail rotor
authority and rotated several times before the pilot made
a forced landing in a wooded area. The pilot suffered
minor injuries. The helicopter sustained substantial
damage. TSB File A06C0139.
Maintenance and Certification
Recently Released TSB Reports
Accident Synopses
—On September 29, 2006, a Bell 206B helicopter was
repositioning in front of a temporary hangar in Mayo, Y.T, when the tail rotor struck the structure. The tail rotor blades, tail rotor gearbox and tail rotor drive
shaft required replacement. There were no injuries to the
pilot or ground personnel. TSB File A06W0178.
—On October 5, 2006, while taxiing for takeoff at
Toronto/Buttonville, Ont., a Piper PA-28-161 Cherokee
struck a Cessna 150M; both were being operated by solo
student pilots. The collision occurred at the intersection
Hold-on a minute,
Pa. Let's hear
the whole story
before jumping
to conclusions,
OK?
Son, you did the
right thing by telling
us. Why don't you
explain what
happened, and in
particular, what
you were thinking?
—On October 15, 2006, a Lake LA-4-200 aircraft was on
a flight from Winnipeg, Man., to St. Andrews, Man., with a planned stop at Selkirk, Man. While landing in
glassy-water conditions, the aircraft landed hard and
swerved. The aircraft came to rest upright on the surface
of the water. The pilot was not injured. The aircraft
incurred damage to the left sponson and the wing
outboard of the sponson. TSB File A06C0170.
...I'll tell you
what he was
thinking...
nothing!!
Well, Betty's
nephew was
visiting, and
she asked if
I could do a
fly-by because
the kid loves
planes...
you know...
Hmm...I see...you almost
bought the farm to please
your girlfriend and impress
her nephew. Now, tell me, what
have you learned from this?
Regulations and You
Ma, Pa, I kind of
screwed up...I hit
an antenna while
flying over Betty's
farm and
damaged a float...
—On October 9, 2006, an Aerospatiale AS 350B helicopter
was landing at a remote, confined and unprepared site.
Prior to touchdown, the tail rotor struck a rise of ground
near the centre of the site. The helicopter began to rotate
around the vertical axis, directional control could not be
regained, and the skids and tail boom broke away from the
fuselage during the ensuing hard landing. The pilot and one
passenger sustained injuries while the second passenger was
uninjured. TSB File A06W0186.
What?! Why,
you reckless little...
ASL 2/2007
Accident Synopses
Regulations and You
—On September 29, 2006, an amateur-built Searey
amphibian aircraft took off from Victoria International
Airport, B.C., for a local flight, which was to include
several water landings. The pilot did not retract the
landing gear after takeoff. While flying over Saltspring
Island, the pilot decided to make a practice water landing
on St. Mary Lake. On touch down on the water, the nose
dug in and the aircraft flipped over. The pilot was able to
egress the aircraft and was picked up by a Beaver aircraft.
The pilot sustained minor injuries. The aircraft was
substantially damaged. TSB File A06P0202.
Recently Released TSB Reports
—On September 19, 2006, a float-equipped Piper PA-18-150 was departing from a private grass strip. The pilot was using
a dolly towed behind a pick-up truck to takeoff. At lift-off,
a float snagged the dolly. The aircraft veered and crashed in
the field at the side of the strip. There were no injuries and the
aircraft was substantially damaged. TSB File A06C0149.
of Taxiways Charlie and Alpha. The 150 had been cleared
southeastbound on Taxiway Charlie to turn right onto
Taxiway Alpha to the holding bay for Runway 03. The
Cherokee was southwestbound on Taxiway Alpha and
had been held northeast of Runway 33. The Cherokee was
cleared to cross Runway 33 on Taxiway Alpha, and follow
the 150 southbound on Taxiway Charlie to the holding
bay for Runway 03. The Cherokee missed the reference
to the 150 in the clearance, and acknowledged without
readback. It proceeded across Runway 33 paying attention
to an aircraft on the left at the south end of Runway 33.
At the intersection of the taxiways, the Cherokee overtook
the 150 from approximately the 8 o’clock position while
the 150 was in the turn. The propeller of the Cherokee
caused substantial damage to the outer portion of the left
wing of the 150, and the right wing tip of the Cherokee
rode up over the left horizontal stabilizer of the 150, and
over the aft fuselage of the 150, just in front of the vertical
stabilizer. TSB investigators were deployed the following
day to review ATC communications, examine the aircraft,
and gather relevant information. TSB File A06O0257.
Maintenance and Certification
—On September 12, 2006, a PA-44-180, with an
instructor and student on board, was doing circuits at the
Cornwall, Ont., regional airport in preparation for a multiengine flight test. While on a touch-and-go, just prior to
lift-off, the landing gear handle was mistakenly selected to
the up position. The nose gear retracted and both propellers
contacted the ground. The aircraft became airborne,
completed a circuit, and landed normally with the gear
down. Both propellers were damaged beyond repair and
the engines were sent for overhaul. TSB File A06O0243.
33
Recently Released TSB Reports
Exploring the Parameters of Negligence: Two Recent TATC Decisions
by Beverlie Caminsky, Chief, Advisory and Appeals (Transportation Appeal Tribunal of Canada—TATC), Regulatory Services, Civil Aviation,
Transport Canada
In this issue, the Advisory and Appeals Division of
Regulatory
Services again wishes to share with our
Not used
readers some interesting developments in Canadian
aviation case law. Two recent cases released by the
Transportation Appeal Tribunal of Canada (TATC) deal
with the issue of negligent conduct on the part of pilots.
In one of the cases, the TATC Review Hearing findings
are being appealed by the pilot. In the other, the pilot
chose not to appeal. As is our practice, the names of the
people involved have been deleted, as our goal remains
simply to be educational.
Case #1
In the first case, the Applicant was the pilot-in-command
of a small private aircraft approaching a rural airport.
Two other aircraft were conducting circuits around the
airport. The pilot joined the circuit, and it was agreed by
all three aircraft that in the order of landing, the Applicant
would be last. However, after joining the circuit, the
Applicant made a sudden hard right turn on right base for
the runway, ahead of the other planes. This action caused
the other two aircraft to take evasive action. The Applicant
was charged with flying in a “reckless or negligent manner”
contrary to Canadian Aviation Regulation (CAR) 602.01.
At the Review Hearing, the Member upheld the
Minister’s decision. She found that the Applicant’s actions
were negligent and they endangered life and property.
Both elements have to be established to uphold a
violation of CAR 602.01. She also found that the defence
of necessity was not established. However, the fine was
reduced, given the fact that one of the other two planes
was flying circuits in the wrong direction, which partially
contributed to the situation.
The defence of necessity was raised by the Applicant,
who argued that he initiated the turn because he was low
on fuel and had to make an immediate landing. Existing
jurisprudence identifies three elements that must be
established by those seeking to plead necessity. First, a
situation of imminent peril existed. Second, no reasonable
legal alternative to the actions taken existed. Third, the
34
The Member found that the Applicant’s actions belied
the imminence of the danger, as the pilot flew for
several minutes after the evasive action before landing.
Consequently, the defence failed.
Case #2
The second case concerns an Applicant who, while taxiing
to take off, hit a runway threshold light at another small
rural airport. A few months later, the same individual
was involved in an alleged near-miss incident, at the
same location while failing to conform to the pattern of
traffic. These incidents led, respectively, to charges under
CAR 602.01 and CAR 602.96(3).
At the Review Hearing, the Member upheld both
charges, but reduced the length of the licence suspension.
With regard to the first charge, the Member found that
the Applicant was taxiing closely behind another plane.
When that plane suddenly stopped, the Applicant’s plane,
in part due to an unfortunate brake malfunction, veered to
the right and hit the runway threshold light. The Member
found that the Applicant was “attempting to rush” the
take-off process, and that such conduct falls below the
standard expected of a reasonable and prudent pilot.
The second charge resulted from the Applicant’s conduct
of a practice forced-landing procedure while a second
aircraft was approaching the airport at the same time.
The Member found the Applicant to have been
unreasonable in not breaking off his training procedure
in order to conform to the standard traffic pattern.
After considering various mitigating and aggravating
factors, the Member reduced the total length of the
licence suspension from 44 days to 21 days.
The first charge is a standard example of the workings
of the negligence provisions of CAR 602.01. The charge
was sustained because the evidence established that
the Applicant’s conduct fell below the standard of care
expected of a reasonable pilot and it resulted in the
endangerment of life or property.
ASL 2/2007
Regulations and You
The evidence established that the Applicant’s sudden
turn out of the circuit created a hazard. As there was
no intention to create a conflict, the actions did not
constitute recklessness, only negligence. The fact that all
the pilots felt compelled to take evasive action proved that
the situation endangered life and property.
danger caused by the contravention must have been
less than the danger caused by complying with the law.
Additionally, the defence is not available to those who,
through their own actions, create the danger complained of.
Accident Synopses
Accident Synopses
Exploring the Parameters of Negligence: Two Recent TATC Decisions........................................................................ page 34
The Aeronautics Act—The Latest News!....................................................................................................................... page 35
Recently Released TSB Reports
Regulations and You
Regs & you
Maintenance and Certification
Maintenance and Certification
regulations and you
FOR CANADIAN RESIDENTS ONLY
Moving?
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact the Editor.
Sécurité aérienne — Nouvelles est la version française de
cette publication.
© Her Majesty the Queen in Right of Canada, as
represented by the Minister of Transport (2007).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Maintenance and Certification
by Franz Reinhardt, Director, Regulatory Services, Civil Aviation, Transport Canada
2
ASL 2/2007
Regulations and You
The Act last underwent a major overhaul in 1985. Many
of the amendments made at the time were aimed at
enhancing the compliance and enforcement provisions
of the Act, including the establishment of the Civil
Aviation Tribunal (CAT), which was later converted
into the multi-modal Transportation Appeal Tribunal
of Canada (TATC). As a result of discussions with
stakeholders, and in continuing efforts to enhance
aviation safety and security, the following changes are
proposed in Bill C-6.
The Department of Transport (TC) is re-shaping its
regulatory programs to be more “data-driven” and to
require aviation organizations to implement integrated
management systems (IMS). These types of programs
are increasingly required by the International Civil
Aviation Organization (ICAO) and implemented by
leading aviation nations. The enabling authority for
the safety management systems (SMS) regulation is
valid and authorized under the existing Aeronautics Act. However, for greater clarification and to provide the SMS
framework with additional statutory protections from
enforcement, as well as protection from access under
the Access to Information Act, TC needed to expand the
Minister’s authority under the Aeronautics Act. Amendments to the Aeronautics Act are also required to
provide expanded regulatory authority over such issues as
fatigue management and liability insurance. The current
enabling authority related to fatigue management does
not extend to all individuals who perform important
safety functions, such as air traffic controllers. The current
enabling authority related to liability insurance does not
extend, for example, to airport operators. The amendments
will also provide for the designation of industry bodies
that establish standards for, and certify, their members,
subject to appropriate safety oversight by TC.
In order to obtain as much safety data as possible, the
amendments also propose the establishment of a voluntary
non-punitive reporting program, allowing the reporting
of safety-related information, without fear of reprisal or
enforcement action taken against the reporting party.
Since the maximum level of penalties for non-compliance
has not been updated since 1985, amendments are
required not only to align them with similar legislation
recently enacted, but also to act as a deterrent to future
non-compliance. The proposed amendments will increase
the maximum penalties for corporations in administrative
and summary conviction proceedings (currently capped
at $25,000) to $250,000 and $1 million, respectively.
Civilian sectors are now delivering some flight services
to the Canadian Forces. These flights are considered
“military,” but as the Aeronautics Act is currently written,
the Department of National Defence (DND) does not
have all the authorities it needs to carry out a flight safety
investigation that may involve civilians in a military
aircraft occurrence. The proposed amendments would
provide DND flight safety accident investigators with
powers similar to those of civilian accident investigators
under the Canadian Transportation Accident Investigation
and Safety Board Act when investigating military aircraft
accidents involving civilians. The amendments would also
clarify the authorities of the Minister of Transport in
relation to those of NAV CANADA under the Civil Air
Navigation Services Commercialization Act.
For any additional information, please visit our Web site at www.tc.gc.ca/CivilAviation/RegServ/Affairs/menu.htm.
ASL 2/2007
35
the safety problem…
Here’s how accidents happen:
• getting pressured into a risky operation
• accepting hazards
• flying when fatigued
• lacking training for the task
• not sure of what’s required
• operating in marginal weather
• ignoring laid-down procedures
• becoming distracted and not spotting a hazard
The major hazards:
• obstacles in the operating area
• snagged sling gear
• equipment failure
• deficient pad housekeeping
• surface condition: snow, soft spots, etc.
• incorrectly rigged load
• wind condition not known beforehand
• overloading
the safety team…
the PILOT
• follows procedures; no corner-cutting
• ensures everyone is thoroughly briefed
• watches for dangerous practices and reports them
• rejects a job exceeding his skill
• knows fatigue is cumulative and gets plenty of rest
• checks release mechanism and sling gear serviceability
the GROUNDCREW
• knows the hand signals and emergency procedures
• watches for hazards—and reports them
• rejects a task beyond his skill or knowledge
• insists on proper training in load preparation and handling
the CUSTOMER
• reasonable in demands; doesn’t pressure pilot
• insists on safety first
• reports dangerous practices
Regulations and You
What’s New: Please visit the Civil Aviation Web site to view the online Risk-based
Business Model and Risk Management Principles presentation: www.tc.gc.ca/CivilAviation/risk/Breeze/menu.htm.
Bill C-6, an act to amend the Aeronautics Act and to
make consequential amendments to other acts, was
introduced in the House of Commons on April 27, 2006.
The Aeronautics Act establishes the Minister of Transport’s
responsibility for the development, regulation and
supervision of all matters connected with civil aeronautics
and the responsibility of the Minister of National
Defence with respect to aeronautics relating to defence.
Accident Synopses
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Flight Operations..............................................................................................................................................................12
Maintenance and Certification........................................................................................................................................21
Recently Released TSB Reports......................................................................................................................................26
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Fuel Starvation Maule-4—Incorrect Fuel Caps.............................................................................................36
Take 5 — Slinging With Safety......................................................................................................................................Tear-off
Accident Synopses
Go to www.smartmoves.ca
page
The essence of negligence has been described as,
“the omitting to do something that a reasonable person
The Aeronautics Act—The Latest News!
Change your address online
with Canada Post and notify
Transport Canada at the same time.
Table of Contents
section
Conclusion
Recently Released TSB Reports
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARPP)
Place de Ville, Tower C
Ottawa ON K1A 0N8 E-mail: marqupj@tc.gc.ca
Tel.: 613-990-1289
Fax: 613-991-4280
Internet: www.tc.gc.ca/ASL-SAN
Note: 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.
Recently Released TSB Reports
Please address your correspondence to: 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.
would do or the doing [of ] something which a reasonable
person would not do.” The two cases discussed above illustrate
how this basic principle is applied in aviation situations. It is
quite often simply an exercise in common sense. In both
cases, the pilots undertook actions that were ill-advised in the
sense that they created situations of unnecessary risk. The risk
was to others (as well as themselves) and to property. Given
the gravity of the potential consequences of unnecessary
risk within the aviation context, the decisions reached by the
TATC are not surprising. While the exercise of common
sense, prudence and the avoidance of negligent behaviour
are important characteristics in all our activities, they are
particularly so in the world of aviation.
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, and to
all holders of a valid Canadian aircraft maintenance
engineer (AME) licence. The contents do not necessarily
reflect official policy and, unless stated, should not be
construed as regulations or directives. 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.
The second charge was upheld largely because of the
safety implications resulting from the Applicant’s actions.
As he was approaching the airport in a non-standard
manner, it was incumbent on him to conform to the
pattern of traffic formed by the other approaching aircraft.
This, the Member implied, was what would be expected
of a reasonable pilot in the same situation. That meant
abandoning his training procedure, and by failing to do so,
he engaged in negligent conduct.
the MANAGER
• allows for weather and equipment delays
• sends the right pilot with the right equipment
• insists the pilot is thoroughly briefed on the requirements
• supports the pilot against customer pressures
• demands compliance with operating manual
• provides proper training
Remember, 60% of slinging accidents occur during pick-up
Transports
Canada
Debrief
Debrief
Examination of all fuel tubing did not reveal any
anomalies or restrictions. It was also outlined that the
aircraft had a similar previous engine stoppage two years
earlier. At that time, the aircraft was on skis over a snowy
field and made a successful forced landing. Shortly after,
the engine restarted and ran normally. Due to lack of
other tangible factors, it was felt that it may have been
caused by a fuel selector malfunction or positioning. The
owner also recalls that whenever operating with the fuel
selector on “both,” the left tank always fed at a slower rate
than the right. He further mentioned having heard air
rushing into the tank when opening the left fuel cap for
refuelling immediately after engine shutdown.
Debrief
After the most recent occurrence, the owner was
prompted to verify the adequacy of the venting system,
which is done through the fuel caps (Figure 1). Air
passage on the left fuel cap was found to be erratic;
sometimes it would let the air through, but sometimes it
would not. Information from the manufacturer indicates
that this type of cap is only to be installed on aircraft
having been modified with auxiliary wing tanks (located
outboard on the wings), as the modification includes the
plumbing for a different venting system.
Figure 1: Non-probed fuel cap
36
The caps used on the occurrence aircraft, shown in Figure 1,
had been ordered by the previous owner to replace the
original caps to which a ram air probe is fitted to assure
positive pressure within the fuel tanks (Figure 2). The order
voucher indicated that non-leaking caps (non-probed
caps) were requested. This was desired partly for aesthetic
reasons and also because probed caps allowed fuel to leak
out if the aircraft when it was parked on uneven ground.
The order voucher included the aircraft serial number. The
manufacturer forwarded the non-probed fuel caps without
challenging whether the aircraft fuel system was original or
it had been modified with auxiliary wing tanks. While the
probed caps assure a positive pressure inside the fuel tanks,
the air passage through the non-probed caps reduces the
pressure within the tank below that of the ambient pressure.
aviation safety letter
In this Issue...
Runway Safety and Incursion Prevention Panel
Thoughts on the New View of Human Error Part III:
“New View” Accounts of Human Error
Aviate—Navigate—Communicate
Figure 2: Probed fuel cap
Consequently, any blockage within the cap quickly results in stopping the fuel flow to the engine. As the
fuel system includes a small header tank, switching tanks
would normally restore the fuel flow, re-establishing
power to the engine. Test bench trials on similar systems,
operated by a skilled engine technician aware of the
intended fuel starvation test, have demonstrated that it
requires 30–45 seconds to restore full power following the engine stoppage.
The investigation into this occurrence has raised a concern
about the replacement of parts for different aircraft
models, which would affect the airworthiness of the
aircraft. The use of non-probed caps on an unmodified
airframe has shown that venting is possible when the
valve within the caps is working properly. However, as
demonstrated in this occurrence, there is no alternate
means of venting in case of malfunction. Any change to
original aircraft status, regardless how small, must first be
authorized by the manufacturer, unless it is approved via a
supplementary type certificate (STC)—as these changes
can and have created airworthiness disturbances.
ASL 2/2007
Safety Management Enhances Safety in Gliding Clubs
Near Collision on Runway 08R at Vancouver
Say Again! Communication Problems Between Controllers and Pilots
Ageing Airplane Rulemaking
Bilateral Agreements on Airworthiness—An Overview and Current Status
Exploring the Parameters of Negligence: Two Recent TATC Decisions
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
"Debrief"
• confined area
• awkward load
• marginal weather
• untrained groundcrew
• customer pressure
• tight schedule
• fatigue
• inadequate equipment
• uncertain field servicing
On September 30, 2004, a Maule-4 aircraft lost power
while cruising at 1 200 ft. The pilot changed tanks and
turned on the electric fuel pump, but power could not be
restored and the aircraft was forced to land. As the field
was too short, the aircraft sustained substantial damage
when it hit a fence at the end of the landing roll and
overturned. When the aircraft was recovered, the pilot
owner was somewhat surprised that fuel remained in the
right tank and very little was lost from the left tank after
the aircraft had been inverted overnight. The type of cap
installed includes an internal flapper valve, which closes,
thereby retaining the fuel in the tanks.
Debrief
Do these sound familiar?
An Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)
TP 185E
Issue 2/2007
Debrief
STAY ALERT!
Fuel Starvation Maule-4—Incorrect Fuel Caps
Transports
Canada
Debrief
Slinging accidents
happen mostly
to experienced
pilots.
Transport
Canada
debrief
Debrief
Transport
Canada
*TC-1002136*
TC-1002136
Transports
Canada
Debrief
Debrief
Examination of all fuel tubing did not reveal any
anomalies or restrictions. It was also outlined that the
aircraft had a similar previous engine stoppage two years
earlier. At that time, the aircraft was on skis over a snowy
field and made a successful forced landing. Shortly after,
the engine restarted and ran normally. Due to lack of
other tangible factors, it was felt that it may have been
caused by a fuel selector malfunction or positioning. The
owner also recalls that whenever operating with the fuel
selector on “both,” the left tank always fed at a slower rate
than the right. He further mentioned having heard air
rushing into the tank when opening the left fuel cap for
refuelling immediately after engine shutdown.
Debrief
After the most recent occurrence, the owner was
prompted to verify the adequacy of the venting system,
which is done through the fuel caps (Figure 1). Air
passage on the left fuel cap was found to be erratic;
sometimes it would let the air through, but sometimes it
would not. Information from the manufacturer indicates
that this type of cap is only to be installed on aircraft
having been modified with auxiliary wing tanks (located
outboard on the wings), as the modification includes the
plumbing for a different venting system.
Figure 1: Non-probed fuel cap
36
The caps used on the occurrence aircraft, shown in Figure 1,
had been ordered by the previous owner to replace the
original caps to which a ram air probe is fitted to assure
positive pressure within the fuel tanks (Figure 2). The order
voucher indicated that non-leaking caps (non-probed
caps) were requested. This was desired partly for aesthetic
reasons and also because probed caps allowed fuel to leak
out if the aircraft when it was parked on uneven ground.
The order voucher included the aircraft serial number. The
manufacturer forwarded the non-probed fuel caps without
challenging whether the aircraft fuel system was original or
it had been modified with auxiliary wing tanks. While the
probed caps assure a positive pressure inside the fuel tanks,
the air passage through the non-probed caps reduces the
pressure within the tank below that of the ambient pressure.
aviation safety letter
In this Issue...
Runway Safety and Incursion Prevention Panel
Thoughts on the New View of Human Error Part III:
“New View” Accounts of Human Error
Aviate—Navigate—Communicate
Figure 2: Probed fuel cap
Consequently, any blockage within the cap quickly results in stopping the fuel flow to the engine. As the
fuel system includes a small header tank, switching tanks
would normally restore the fuel flow, re-establishing
power to the engine. Test bench trials on similar systems,
operated by a skilled engine technician aware of the
intended fuel starvation test, have demonstrated that it
requires 30–45 seconds to restore full power following the engine stoppage.
The investigation into this occurrence has raised a concern
about the replacement of parts for different aircraft
models, which would affect the airworthiness of the
aircraft. The use of non-probed caps on an unmodified
airframe has shown that venting is possible when the
valve within the caps is working properly. However, as
demonstrated in this occurrence, there is no alternate
means of venting in case of malfunction. Any change to
original aircraft status, regardless how small, must first be
authorized by the manufacturer, unless it is approved via a
supplementary type certificate (STC)—as these changes
can and have created airworthiness disturbances.
ASL 2/2007
Safety Management Enhances Safety in Gliding Clubs
Near Collision on Runway 08R at Vancouver
Say Again! Communication Problems Between Controllers and Pilots
Ageing Airplane Rulemaking
Bilateral Agreements on Airworthiness—An Overview and Current Status
Exploring the Parameters of Negligence: Two Recent TATC Decisions
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
"Debrief"
• confined area
• awkward load
• marginal weather
• untrained groundcrew
• customer pressure
• tight schedule
• fatigue
• inadequate equipment
• uncertain field servicing
On September 30, 2004, a Maule-4 aircraft lost power
while cruising at 1 200 ft. The pilot changed tanks and
turned on the electric fuel pump, but power could not be
restored and the aircraft was forced to land. As the field
was too short, the aircraft sustained substantial damage
when it hit a fence at the end of the landing roll and
overturned. When the aircraft was recovered, the pilot
owner was somewhat surprised that fuel remained in the
right tank and very little was lost from the left tank after
the aircraft had been inverted overnight. The type of cap
installed includes an internal flapper valve, which closes,
thereby retaining the fuel in the tanks.
Debrief
Do these sound familiar?
An Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)
TP 185E
Issue 2/2007
Debrief
STAY ALERT!
Fuel Starvation Maule-4—Incorrect Fuel Caps
Transports
Canada
Debrief
Slinging accidents
happen mostly
to experienced
pilots.
Transport
Canada
debrief
Debrief
Transport
Canada
*TC-1002136*
TC-1002136
FOR CANADIAN RESIDENTS ONLY
Moving?
To obtain information concerning copyright ownership
and restrictions on reproduction of the material,
please contact the Editor.
Sécurité aérienne — Nouvelles est la version française de
cette publication.
© Her Majesty the Queen in Right of Canada, as
represented by the Minister of Transport (2007).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Maintenance and Certification
by Franz Reinhardt, Director, Regulatory Services, Civil Aviation, Transport Canada
2
ASL 2/2007
Regulations and You
The Act last underwent a major overhaul in 1985. Many
of the amendments made at the time were aimed at
enhancing the compliance and enforcement provisions
of the Act, including the establishment of the Civil
Aviation Tribunal (CAT), which was later converted
into the multi-modal Transportation Appeal Tribunal
of Canada (TATC). As a result of discussions with
stakeholders, and in continuing efforts to enhance
aviation safety and security, the following changes are
proposed in Bill C-6.
The Department of Transport (TC) is re-shaping its
regulatory programs to be more “data-driven” and to
require aviation organizations to implement integrated
management systems (IMS). These types of programs
are increasingly required by the International Civil
Aviation Organization (ICAO) and implemented by
leading aviation nations. The enabling authority for
the safety management systems (SMS) regulation is
valid and authorized under the existing Aeronautics Act. However, for greater clarification and to provide the SMS
framework with additional statutory protections from
enforcement, as well as protection from access under
the Access to Information Act, TC needed to expand the
Minister’s authority under the Aeronautics Act. Amendments to the Aeronautics Act are also required to
provide expanded regulatory authority over such issues as
fatigue management and liability insurance. The current
enabling authority related to fatigue management does
not extend to all individuals who perform important
safety functions, such as air traffic controllers. The current
enabling authority related to liability insurance does not
extend, for example, to airport operators. The amendments
will also provide for the designation of industry bodies
that establish standards for, and certify, their members,
subject to appropriate safety oversight by TC.
In order to obtain as much safety data as possible, the
amendments also propose the establishment of a voluntary
non-punitive reporting program, allowing the reporting
of safety-related information, without fear of reprisal or
enforcement action taken against the reporting party.
Since the maximum level of penalties for non-compliance
has not been updated since 1985, amendments are
required not only to align them with similar legislation
recently enacted, but also to act as a deterrent to future
non-compliance. The proposed amendments will increase
the maximum penalties for corporations in administrative
and summary conviction proceedings (currently capped
at $25,000) to $250,000 and $1 million, respectively.
Civilian sectors are now delivering some flight services
to the Canadian Forces. These flights are considered
“military,” but as the Aeronautics Act is currently written,
the Department of National Defence (DND) does not
have all the authorities it needs to carry out a flight safety
investigation that may involve civilians in a military
aircraft occurrence. The proposed amendments would
provide DND flight safety accident investigators with
powers similar to those of civilian accident investigators
under the Canadian Transportation Accident Investigation
and Safety Board Act when investigating military aircraft
accidents involving civilians. The amendments would also
clarify the authorities of the Minister of Transport in
relation to those of NAV CANADA under the Civil Air
Navigation Services Commercialization Act.
For any additional information, please visit our Web site at www.tc.gc.ca/CivilAviation/RegServ/Affairs/menu.htm.
ASL 2/2007
35
the safety problem…
Here’s how accidents happen:
• getting pressured into a risky operation
• accepting hazards
• flying when fatigued
• lacking training for the task
• not sure of what’s required
• operating in marginal weather
• ignoring laid-down procedures
• becoming distracted and not spotting a hazard
The major hazards:
• obstacles in the operating area
• snagged sling gear
• equipment failure
• deficient pad housekeeping
• surface condition: snow, soft spots, etc.
• incorrectly rigged load
• wind condition not known beforehand
• overloading
the safety team…
the PILOT
• follows procedures; no corner-cutting
• ensures everyone is thoroughly briefed
• watches for dangerous practices and reports them
• rejects a job exceeding his skill
• knows fatigue is cumulative and gets plenty of rest
• checks release mechanism and sling gear serviceability
the GROUNDCREW
• knows the hand signals and emergency procedures
• watches for hazards—and reports them
• rejects a task beyond his skill or knowledge
• insists on proper training in load preparation and handling
the CUSTOMER
• reasonable in demands; doesn’t pressure pilot
• insists on safety first
• reports dangerous practices
Regulations and You
What’s New: Please visit the Civil Aviation Web site to view the online Risk-based
Business Model and Risk Management Principles presentation: www.tc.gc.ca/CivilAviation/risk/Breeze/menu.htm.
Bill C-6, an act to amend the Aeronautics Act and to
make consequential amendments to other acts, was
introduced in the House of Commons on April 27, 2006.
The Aeronautics Act establishes the Minister of Transport’s
responsibility for the development, regulation and
supervision of all matters connected with civil aeronautics
and the responsibility of the Minister of National
Defence with respect to aeronautics relating to defence.
Accident Synopses
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Flight Operations..............................................................................................................................................................12
Maintenance and Certification........................................................................................................................................21
Recently Released TSB Reports......................................................................................................................................26
Accident Synopses............................................................................................................................................................31
Regulations and You.........................................................................................................................................................34
Debrief: Fuel Starvation Maule-4—Incorrect Fuel Caps.............................................................................................36
Take 5 — Slinging With Safety......................................................................................................................................Tear-off
Accident Synopses
Go to www.smartmoves.ca
page
The essence of negligence has been described as,
“the omitting to do something that a reasonable person
The Aeronautics Act—The Latest News!
Change your address online
with Canada Post and notify
Transport Canada at the same time.
Table of Contents
section
Conclusion
Recently Released TSB Reports
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARPP)
Place de Ville, Tower C
Ottawa ON K1A 0N8 E-mail: marqupj@tc.gc.ca
Tel.: 613-990-1289
Fax: 613-991-4280
Internet: www.tc.gc.ca/ASL-SAN
Note: 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.
Recently Released TSB Reports
Please address your correspondence to: 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.
would do or the doing [of ] something which a reasonable
person would not do.” The two cases discussed above illustrate
how this basic principle is applied in aviation situations. It is
quite often simply an exercise in common sense. In both
cases, the pilots undertook actions that were ill-advised in the
sense that they created situations of unnecessary risk. The risk
was to others (as well as themselves) and to property. Given
the gravity of the potential consequences of unnecessary
risk within the aviation context, the decisions reached by the
TATC are not surprising. While the exercise of common
sense, prudence and the avoidance of negligent behaviour
are important characteristics in all our activities, they are
particularly so in the world of aviation.
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, and to
all holders of a valid Canadian aircraft maintenance
engineer (AME) licence. The contents do not necessarily
reflect official policy and, unless stated, should not be
construed as regulations or directives. 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.
The second charge was upheld largely because of the
safety implications resulting from the Applicant’s actions.
As he was approaching the airport in a non-standard
manner, it was incumbent on him to conform to the
pattern of traffic formed by the other approaching aircraft.
This, the Member implied, was what would be expected
of a reasonable pilot in the same situation. That meant
abandoning his training procedure, and by failing to do so,
he engaged in negligent conduct.
the MANAGER
• allows for weather and equipment delays
• sends the right pilot with the right equipment
• insists the pilot is thoroughly briefed on the requirements
• supports the pilot against customer pressures
• demands compliance with operating manual
• provides proper training
Remember, 60% of slinging accidents occur during pick-up
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