debrief 7.625” 8.375” 8.5”

debrief 7.625” 8.375” 8.5”
This questionnaire is for use from November 1, 2006, to October 31, 2007. Completion of this questionnaire satisfies
the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.
Note: The answers may be found in the Transport Canada Aeronautical Information Manual (TC AIM).
TC AIM references are at the end of each question. Amendments to this publication may result in changes to
answers and/or references.
Post-Accident Survivability—Direct-to-Airframe Helmet Cord Connections
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)
On December 7, 2005, an MBB-BO105 helicopter was operating near Marystown, N.L. The helicopter was observed
flying along the shoreline, at low altitude, in snow, and in darkening conditions. The helicopter struck the water about
1 000 ft from shore, and sank to the bottom of Mortier Bay. The pilot and passenger escaped from the helicopter;
however, they later perished in the frigid water. The TSB investigation into this accident (A05A0155) is ongoing. After
the accident, an examination of the pilot’s aviation helmet found that the end fitting of the communication cord was
fractured at the point where it attaches to the helicopter (see Figure 1).
Figure 1. Fractured cord end fitting
The communication cords for front-seat occupants connect to receptacles located on the overhead center console.
When the helicopter was recovered, the metal pins from the end fitting were still inside the receptacle. Metal
remnants from the connection show that the cord was being pulled sideways, towards the pilot’s door, when the
fracture occurred. A downward pull is required to release the connection. A break test of a similar fitting required a
70-lb pull before the cord failed. After ditching or water impact, the occupants of a capsized helicopter are prone to
disorientation. Therefore, unimpeded egress through any available exit is vital to survival. An attached communication
cord that will not release cleanly may impede this egress.
Transports
Canada
TP 185E
Issue 4/2006
aviation safety letter
In this Issue...
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?
In the past, similar BO-105 helicopters have been fitted with an intermediate “pig-tail” communication cord for
helmet connections. Instead of plugging the helmet cord into the helicopter’s receptacle, the helmet cord is instead
plugged into this intermediate cord (see Figure 2).
The helmet connection plug can release cleanly from the intermediate “pig-tail” cord receptacle as it is pulled in the
direction of travel during egress. Over a period of years, the use of the intermediate helmet cords at this operator
declined, perhaps because pilots were not aware that the cords ensure separation in an emergency. However, since this
accident, the operator has indicated that the use of intermediate “pig-tail” cords for helmet connections will now be
re-instituted where necessary.
Transport
Canada
Safety Hazard Alert—Call Sign Confusion
Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)
Recently Released TSB Reports
Debrief
Convert 1020.5 millibars into inches of mercury. ______ (GEN 1.9.2)
The SECURITAS program provides a means for individuals to report ________________ and
____________________________________ relating to the Canadian transportation system. (GEN 3.6)
Runway contaminants such as water, snow or ice will (increase/decrease) the landing distance. (AGA 1.1.5)
When a section of runway or heliport is closed, it is marked with an ___. (AGA 3.3 and AGA 5.6)
Control of ARCAL lights should be possible when aircraft are within ___ NM of the aerodrome. (AGA 7.19)
Retroreflective markers (will/will not) provide the pilot with the same visual presentation as normal runway
lighting when the aircraft is lined up on final approach. (AGA 7.20)
The removal of the audio identification from non-directional beacons (NDB), VHF omnidirectional ranges
(VOR), distance measuring equipment (DME) or instrument landing systems (ILS) warns pilots that the facility may be __________ even though ____________. (COM 3.2)
A wide area augmentation system (WAAS) NOTAM will be issued when a WAAS service is predicted not
to be available for a duration of more than ______ min. (COM 3.16.6.2)
What does the equipment suffix “G” indicate in item 10 (equipment) on a flight plan? _________________________________________________________
(COM 3.16.7)
Can VFR GPS receivers be used to replace current charts? ___ (COM 3.16.16)
For air-to-air communications between pilots in the Northern Domestic Airspace (NDA), what is the correct frequency to use? ______ MHz. (COM 5.13.3)
An aerodrome forecast (TAF) provides expected conditions for ___________________ at specific aerodromes,
whereas an area forecast chart (GFA) depicts _________________________ affecting flight at a specific time over a particular area. (MET 3.2.1)
Areas of showery or intermittent precipitation are shown on a GFA Clouds and Weather Chart as ______
____________________________________. (MET 3.3.11)
In a TAF, any cases of strong, non-conductive low level wind shear within _____ ft AGL will be coded as
“__”. (MET 3.9.3)
In a TAF, “TEMPO” is only used when the modified forecast condition is expected to last less than ________ in each instance. (MET 3.9.3)
TAF CYXU 011035Z 011123 27015G25KT 3SM RA OVC005
BECMG 1314 OVC 020
FM 1700Z 29005KT P6SM OVC030 TEMPO 1723 BKN030
RMK NXT FCST BY 17Z =
In the weather report above, the forecast wind for 1500Z is _________________________________.
(MET 3.9.3)
SPECI CYSJ 221650Z 08017G24 3/8SM R23/2000FT/N –SN DRSN VV006 M03/M05 A2953 RMK SN8 VSBY VRBL 3/4 11/2
In the weather report above, the prevailing visibility is _____ and the visibility is obscured by _____________________________________. (MET 3.15.3)
Are the winds in aviation weather forecasts and reports given in degrees true or magnetic? GFA: _____; TAF: _____; FD: _____; METAR: _____. (MET 3.3.11, 3.9.3, 3.11, 3.15.3)
Does ATC assume responsibility for obstacle clearance when you are radar identified? ___ (RAC 1.5.2)
If you observe suspicious ground activities at an abandoned airstrip, what report should you make? _____________ (RAC 1.12.2)
debrief
Regulations and You
1.
2.
3.
4.
5.
6.
7.
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The Civil Aviation Medical Examiner
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Regulations and You
Flight Crew Recency Requirements
Self-Paced Study Program
Debrief
Transports
Canada
The Civil Aviation Medical Examiner
Transport
Canada
Near Repeat of Mirabel De-Icing Mishap
Cold Weather Altimeter Error—Getting Cold Feet?
How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions
Aircraft Maintenance Operational and Functional Checks
Flight Crew Recency Requirements Self-Paced Study Program
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
Figure 2. Intermediate helmet “pig tail” connection cords
Other operators may have aircraft with similar direct-to-airframe connections, and may be unaware that these can
impede egress in an emergency. Therefore, Transport Canada may wish to advise the aviation community that these
connection types may impede egress, and that an intermediate cord can help to mitigate this hazard.
Done. —Ed.
40
ASL 4/2006
TC-1001878
TC-1001878
FOR CANADIAN RESIDENTS ONLY
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The Civil Aviation Medical Examiner
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 (2006).
ISSN: 0709-8103
TP 185E
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Transport Canada at the same time.
The new Transport Canada Aeronautical Information Manual (TC AIM) was introduced in October 2005. All Canadian-registered pilots received two free paper copies, the last of which was delivered in April 2006. The next release of the TC AIM is scheduled for October 2006. There are a few options on how to subscribe to this publication:
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and ask to be added to the TC AIM e-Bulletin list. Please state your name, postal address and e-mail address.
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada
A safety management system (SMS) is a structure of
systems designed to identify and eliminate risks and
improve the safety performance of air operators. SMS
is intended to increase industry accountability, and to
nurture and sustain a safety culture, whereby employees
can confidentially report safety deficiencies without fear
of subsequent punitive action. Regulation will eventually
require all Transport Canada operating certificate holders
to implement an SMS.
The following event illustrates the value of an SMS
in advancing aviation safety when there has been a
contravention of the regulations.
On a clear January morning, an Airbus 310 departed
Halifax, N.S., for Calgary, Alta., and climbed to a cruising
altitude of 34 000 ft. After completing the routine cruise
checks, the crew settled back and the 256 passengers
relaxed and enjoyed a light breakfast. As they were
approaching Montreal, Que., the captain checked the
en-route weather while the first officer took fuel quantity
readings and compared them with the flight plan figures
required to complete the flight to destination. The first
officer suddenly realized that they had not taken on
enough fuel prior to their departure from Halifax. After
confirming the readings and manually recalculating the
minimum required fuel to complete the flight to Calgary,
he informed the captain. They both double-checked the
fuel remaining against the fuel required. The insufficient
fuel state was confirmed and they agreed to plan an
unscheduled refuelling stop in Toronto, Ont. Montreal
Centre and company dispatch were both advised of
the fuel condition and they respectively authorized and
concurred with the revised routing.
From a regulatory standpoint, the pilot-in-command and
the operator, contravened Canadian Aviation Regulation
(CAR) 602.88(2) for not carrying sufficient fuel for
the planned route. The enforcement process initiated
following this contravention is typical of what would
happen within any aviation company that operates in
accordance with an SMS.
The Aviation Enforcement Division became aware of the
event through an occurrence report in the Civil Aviation
Daily Occurrence Reporting System (CADORS),
and notified the Transport Canada principal inspector
responsible for the operator. The principal inspector
confirmed that the crew had, as required under SMS,
internally reported the incident to the operator.
In line with SMS philosophy, the operator developed
and submitted a corrective action plan (CAP) to the
principal inspector, outlining a systematic approach
to address the fuel mismanagement and to prevent a
recurrence. The CAP included revised pre-flight and
in-flight standard operating procedures (SOP) designed
to ensure accurate flight-planned fuel calculations and
accurate fuel-on-board monitoring prior to, and during,
flight. These procedures for proper fuel management were
incorporated into a mandatory training seminar for all
flight crew members. The principal inspector reviewed the CAP and was confident that it addressed the issues
that led to the initial contravention. In consultation
with the principal inspector, the Aviation Enforcement
Division could have reactivated the investigation at any
time during the process leading up to the acceptance of
the CAP, and would have, if:
the contravention had been intentional;
the incident had not been internally reported; or the principal inspector had found the CAP to be
unacceptable, and the operator had refused to address the issue.
Debrief
Don’t Forget to Subscribe to the Transport Canada Aeronautical Information Manual !
Debrief
Go to www.smartmoves.ca
Safety Management Systems—Raising the Bar on Aviation Safety
Regulations and You
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARQ)
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.
Regulations and You
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.
The Civil Aviation Medical Examiner
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.
regulations and you
Had the decision been to continue the investigation, a
letter of investigation would have been sent directly to
the operator, and the principal inspector would have been
notified. In this specific case, the investigation was closed
without further enforcement action.
Although the story in this article does not depict an
actual event, it does serve to illustrate a typical SMS
response, designed to raise the bar on aviation safety
following a regulatory contravention. For further clarification, we invite you to consult the
Aviation Enforcement Policy and Procedures—Safety
Management Systems Web site at www.tc.gc.ca/civilaviation/SMS/policy.htm.
As a reminder to all, the online version of the TC AIM is available for viewing and free download at all times. You can access it from Transport Canada’s online publications storefront at www.tc.gc.ca/transact.
2
ASL 4/2006
21.
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40.
Taxi authorizations that contain the instructions “hold” or “hold short” (shall/need not) be read back by the pilot. (RAC 4.2.5)
Where possible, pilots are required to report at least ____ min before entering an MF area. (RAC 4.5.7)
A ___________ must be filed for all flights between Canada and a foreign state. (FAL 2.3.2)
On flights from Canada to the U.S., at least ________ advance notice of arrival must be provided to U.S. Customs. (FAL 2.3.2)
On flights to Canada, pilots must land at a Canada Customs authorized airport of entry (AOE). Pilots must make their own customs arrangements by calling ______________ at least _________ before flying into Canada. (FAL 2.3.2)
Pilots receiving a MANOT message are requested to maintain a radio watch on ______ MHz when operating in the vicinity of the track of the missing aircraft. (SAR 2.3)
List the four steps that should be accomplished (where practicable) during your preflight inspection of the emergency locator transmitter (ELT).
(a) __________________________________________________________________________________;
(b) ____________________________________________________________;
(c) _____________________________________________; and
(d) ____________________________________________.
(SAR 3.4)
When an ELT signal is heard in flight, the nearest ATS unit should be advised of what four pieces
of information?
(a) ________________________________________________________;
(b) ___________________;
(c) _____________________________________________; and
(d) ____________________________________________.
Answers to this quiz are found on page 38 of this ASL 4/2006.
ASL 4/2006
39
(SAR 3.4)
In the event of a crash, what should you do with the ELT’s function switch, and when? ____________________________________________________________________
(SAR 3.5)
061234 NOTAMN CYSB SUBDURY
RWY 04/22 CLOSED TIL APRX 0612151530
Runway 04/22 is expected to open at _____Z on (date) ___________. (MAP 5.6.1)
What is the significance of the term “APRX” in the above NOTAM? _____________________________
(MAP 5.6.1)
060210 NOTAMR 060202 CYND WINCHESTER
CNA8 UNMANNED AERIAL VEHICLE OPS 3NM RADIUS 450610N 752854W (APRX 9 NM NW AD) SFC TO 2400 FT MSL
0605051700 TIL 0605052300
What is the significance of the letter “R” at the end of the word “NOTAM” above? __________________
(MAP 5.6.2)
A Canadian medical certificate for a private pilot licence is valid in Canada for ___ months if under age 40,
and for ___ months if age 40 or older. (LRA 3.2.4)
In accordance with CAR 401.08, every applicant for, and every holder of, a flight crew permit, licence or rating shall maintain a ______________. (LRA 3.7.6)
The flight crew recency requirements address three time periods. To act as pilot-in-command or co-pilot you must meet the ___________________ recency requirements. If you wish to carry passengers, you must also meet the ________ requirements. (LRA 3.9)
In order to carry passengers, you must have completed __ takeoffs and landings in the same category and class of aircraft in the previous __ months. (LRA 3.9)
Class A fires are fires in ______________________________. (AIR 1.4.2)
An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error of more than ___ ft when compared on the ground against a known aerodrome or runway elevation. (AIR 1.5.1)
By ______ ft ASL the partial pressure of oxygen is such that all pilots will experience mild hypoxia and some will become symptomatic. (AIR 3.2.1)
If, on descent, the pressure in the ears (or sinuses) cannot be relieved by swallowing, yawning or Valsalva manoeuvre, it is best to _________________________________________________________. (AIR 3.8)
As the Director of the National Organization Transition Implementation Project (NOTIP),
it is my pleasure to provide you with an update of this project in this edition of the Aviation
Safety Letter (ASL). The NOTIP is responsible for determining and implementing changes
to the Civil Aviation organization and workforce to enable the successful implementation
of a sustainable safety management system (SMS) oversight framework for the industry, in
accordance with the Transport Canada Civil Aviation (TCCA) Integrated Management
System (IMS).
Civil Aviation has undergone many changes since the organizational restructuring in 1995. New concepts and
approaches have been introduced in successive key strategic documents such as Challenge ‘98, Flight 2005, and more
recently, Flight 2010. In early 2005, TCCA had begun a review of its organizational structure in response to evolving
realities in both the industry and the government. By 2013, 46 percent of the current Civil Aviation workforce will be
eligible for retirement, or will have already retired. Given the current and predicted workforce demographics, replacing
our employees to continue the current safety oversight regime is not feasible. Major changes need to be made in the way
we work, not just in the industry, but within the authority as well.
The goal is to transition the organization to the “end state” model by 2010, when SMS is fully implemented in
aviation enterprises—formalizing a concept of operations that Civil Aviation has been migrating towards since SMS
implementation began. This organizational model will allow further flexibility in sharing expertise and maintaining
technical competencies, as well as delivering the required level of service to the industry. Our program will be delivered
using multidisciplinary teams who are responsible for the oversight of enterprises within the industry.
To the Letter
To the Letter
Guest Editorial
Guest Editorial
guest editorial
Judy Rutherford
Director
National Organization Transition Implementation Project
page
Guest Editorial..................................................................................................................................................................3
To the Letter......................................................................................................................................................................4
Pre-flight............................................................................................................................................................................5
Recently Released TSB Reports......................................................................................................................................11
Accident Synopses............................................................................................................................................................18
Winter Operations...........................................................................................................................................................20
Maintenance and Certification........................................................................................................................................30
Recently Released TSB Reports
Recently Released TSB Reports
Table of Contents
section
Pre-flight
Pre-flight
Under the new model, headquarters will continue to be responsible for the development of policy, regulations and
standards, and the delivery of specific centralized operations. Regions will continue to be responsible for implementing
the majority of the Civil Aviation Program. A dedicated team is being formed to manage the transition issues over
the coming years. I invite you to visit the Civil Aviation Web site, www.tc.gc.ca/civilaviation, for further information and
updates, including frequently asked questions and a feedback mechanism on the organizational review project.
The Civil Aviation Medical Examiner and You: Mandatory Reporting of Unfit Pilots, Air Traffic Controllers
and Flight Engineers.........................................................................................................................................................35
Regulations and You: Safety Management Systems—Raising the Bar on Aviation Safety ....................................39
Debrief: Post-Accident Survivability—Direct-to-Airframe Helmet Cord Connections . ......................................40
Flight Crew Recency Requirements Self-Paced Study Program.................................................................................Tear-off
ASL 4/2006
Dear Editor,
The article in Aviation Safety Letter (ASL) issue
3/2004, “When Night VFR and IFR Collide,” was very
informative. To me, it reinforces the need to prohibit
turns before 1 500 ft AGL during all IFR and night
VFR operations into all operators’ SOPs. If these
procedures were implemented, trained for and reinforced
into everyday operations, this type of accident could
be prevented. Turns should only be allowed under
these circumstances: for terrain avoidance, a departure
instruction/procedure, or collision avoidance. “Black
hole” departures create the “somotogravic illusion,” which
causes the crew to believe they are in a climb when
the aircraft may indeed be descending. Under these
conditions, extra vigilance by both crew members must
be exercised in regards to aircraft vertical speed, climb
performance and airspeed. Too often, the “killer norm”
is for the pilot flying to start turning immediately after
takeoff, while the pilot not flying is transmitting on the
radio, and writing on the flight log when the aircraft,
if allowed to descend unnoticed, is seconds away from
ground contact. Operators need to implement SOPs for
their crews to train to climb straight ahead and closely
monitor aircraft performance, while maintaining a “sterile”
cockpit to at least a minimum of 1 500 ft AGL.
Dear Editor,
In a review of 35 non-fatal airline incidents attributed
primarily to crew error, it was concluded that failure
to monitor and/or challenge the pilot flying (PF)
contributed to 31 out of the 35 occurrences. In the
incidents studied, the pilot monitoring, or pilot not flying (PNF) reported that preoccupations with other duties prevented them from monitoring the PF closely enough to catch an error being made while taxiing or flying. In 13 of the 35 occurrences, the PNF was preoccupied with some form of head-down work, most commonly paperwork or
programming the flight management system (FMS).
Recently, I was assisting in the evaluation of aircraft
equipment on international routes. The captain had
approximately 20 000 hr total time, and about 3 000 hr in command on the type. The first officer was newly hired, with a new type certificate on the airplane, and
about 1 000 hr total time. About 1.5 hr after departure,
Captain Jan Jurek
International Civil Aviation Organization (ICAO)
Company discrete frequency vs ATF?
Dear Editor,
Earlier this year I lifted off from the Beaver Lake
Forestry pad, east of Lac La Biche, Alta. I made a call on
the aerodrome traffic frequency (ATF), 123.2, that my
intention was to fly to the Tanker Base at the Lac La Biche airport. A few minutes later, I called
turning from right base to final for Runway 29 at 3 500 ft and 3 mi. At about 1 mi., a CL-215 pulled out onto
the runway and began backtracking on Runway 29. At
the same time, an Astar lifted off from its hangar in a
southerly departure. Again, no contact on 123.2. After
landing at the Tanker Base, I was informed that “their”
frequency was 122.05! Exclusive use of an unpublished
frequency is unprofessional and keeps other airport
users “out of the loop”. Should all ATFs be made into
mandatory frequencies (MF)?
Name withheld upon request
Good reminder to all. Use of company discrete frequencies is
allowed but not at the expense of the ATF, or even a MF for
that matter. —Ed.
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
Distraction and interruption in the cockpit—
head-down work
The lesson? In this case, the PNF did not advise the PF
that he would reprogram the FMS after he became aware
of the deteriorating weather. The PF then abandoned
monitoring the radar at a critical moment and elected
to attend to a less critical task. Somebody must always
fly the airplane, even during automated flight. Periods of
head-down activity, such as programming the FMS, are
especially vulnerable because the PNF’s eyes are diverted
from other tasks. It is essential that the standard operating
procedures (SOPs) specify when it is recommended or
allowed to go head-down.
Pre-flight
Pre-flight
Wayne McIntyre
Saskatoon, Sask.
in cruise at FL 350, we entered an area of heavy convective
build-ups, with imbedded thunderstorms. I noticed that
the first officer, who was the PNF at the time, started
reprogramming the FMS (to circumnavigate the weather)
without first advising the captain that he was going
head-down. At that time, the aircraft was on autopilot. The PNF then experienced difficulties in entering
waypoints, and requested assistance from the captain,
who immediately helped him, abandoning the sight of
the instrument panel and the weather radar display. The
aircraft entered clouds and met severe turbulence. While
still on auto-pilot and trying to maintain the selected
flight level, the aircraft entered into a series of high-speed
stalls. It took the crew about 30 s to stabilize the flight.
To the Letter
To the Letter
Turns after takeoff—at night and IFR
Guest Editorial
Guest Editorial
to the letter
Safety Hazard Alert—Call Sign Confusion.................................................................................................................... page 5
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?................................................................ page 6
COPA Corner—Flying Clubs—Why Bother?............................................................................................................... page 7
The Canadian Business Aviation Association Column—Training to Bridge the Knowledge Gap............................. page 8
Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR) . .............................. page 8
Guest Editorial
Guest Editorial
pre-flight
Safety Hazard Alert—Call Sign Confusion
In a recent typical incident, two aircraft operated by the
same airline were approaching a busy airport from the
same direction. They had four-digit flight numbers, and
the first, third and fourth digits were identical—only
the second digit was different. The aircraft nearest to the
airport was cleared to 3 000 ft, but the crew in the other
aircraft read back that clearance and started descent from
9 000 ft. Fortunately, the controller noted this error and
intervened before there was a conflict with another flight.
From the pilot’s perspective, the problem is aural
confusion. Clearances and instructions already contain
headings, altitudes, airway and runway numbers, and
if call signs are similar, it is easy to understand how
confusion could result. Crews may be completing a
challenge/response checklist or other task when a
controller issues an instruction, and may react based on
hearing just part of the flight number. Add to this the fact
that for a given pilot, flight numbers change often. Regardless of cause, call sign confusion is occurring too
often, and airlines, pilots and controllers have to take
concerted action to reduce the probability of confusion
and the risk of a serious accident.
The root of the problem is the way air carriers assign
flight numbers. Ideally, scheduling schemes and the
assignment of flight numbers would ensure that flights
with similar call signs would not appear in the same
Until air carriers take steps to deal with the root of
the problem, awareness on the part of both pilots and
controllers is critical to reducing the risk of call sign
confusion.
NAV CANADA has recently highlighted the problem in
internal communications, reminding controllers to advise
affected crews of the existence of aircraft with similarsounding call signs on the frequency as soon as they
become aware of the situation. Pilots are encouraged to recognize when the potential for
confusion exists, and to take extra care to listen attentively.
It goes without saying that pilots should take great care
to use the proper flight number at all times. It is also very
important to use proper phraseology and to pay particular
attention to readbacks. Pilot situational awareness is
part of the solution. In several recent instances, pilots
have incorrectly accepted clearances that were clearly
inappropriate—headings or altitudes that did not make
sense based on current aircraft position or intent.
Call sign confusion is a worldwide problem and
other countries have completed valuable studies with
recommendations aimed at reducing the safety risk. NAV CANADA intends to continue its own studies and
to incorporate the lessons learned around the world in a
comprehensive aeronautical information circular (AIC)
that provides more detailed advice to air carriers, pilots
and controllers.
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
For the controller, who may be responsible for over a
dozen aircraft, the problem could also be visual confusion,
because the controller relies on call signs on radar and
other displays to distinguish among aircraft.
controller’s sector. Flight number assignment is, however,
driven by different considerations, and normally does not
address the potential for confusion. Based on incident
records, it appears that risk would be reduced by using a
maximum of three digits in flight numbers. Even when
using three digits, instances where the same three digits
are used in different positions (e.g. 461 and 416) should
be avoided. Of course there will be instances where
different airlines are using the same flight number, but
this has less potential for confusion because crews would
key on the airline name.
Pre-flight
Pre-flight
NAV CANADA tracks all operating irregularities in
an effort to identify safety hazards and find ways to
reduce the probability of accidents. Lately, we have seen
a disturbing increase in the number of instances where
similar call signs have caused confusion among pilots
and controllers, leading to situations where there is an
increased risk of loss of separation between aircraft. Call
sign confusion could also lead to an increased risk of
controlled flight into terrain or obstacles.
To the Letter
To the Letter
by Larry Lachance, Director, Safety and System Performance, NAV CANADA,
and Ross Bowie, Director, Air Navigation System Service Design, NAV CANADA
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?
The following article is the first of a three-part series describing some aspects of the “new view” of human error (Dekker, 2002).
This “new view” was introduced to you in the previous issue of the Aviation Safety Letter (ASL) with an interview by Sidney
Dekker. The three-part series will address the following topics:
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?
Thoughts on the New View of Human Error Part II: Hindsight Bias
Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error
Can perfect pilots and perfect AMEs
function in an imperfect system?
The consequences of an accident in safety-critical systems
can be death and/or injury to the participants (passengers,
etc.). Society demands operators be superhuman and
infallible, given the responsibility they hold. Society
compensates and cultures operators in a way that demands
they perform without error. This is an impossibility—
humans, doctors, lawyers, pilots, mechanics, and so on,
are fallible. It should be the safety-critical industry’s goal
to learn from mistakes, rather than to punish mistakes,
because the only way to prevent mistakes from recurring
is to learn from them and improve the system. Punishing
mistakes only serves to strengthen the old view of human
error; preventing true understanding of the complexity
of the system and possible routes for building resilience to
future mistakes.
To learn from the mistakes of others, accident and
incident investigations should seek to investigate how
people’s assessments and actions would have made sense
at the time, given the circumstances that surrounded them (Dekker, 2002). Once it is understood why their
actions made sense, only then can explanations of the human–technology–environment relationships be
discussed, and possible means of preventing recurrence
can be developed. This approach requires the belief that it
is more advantageous to safety if learning is the ultimate
result of an investigation, rather than punishment.
In the majority of accidents, good people were doing their
best to do a good job within an imperfect system. Pilots,
mechanics, air traffic controllers, doctors, engineers, etc.,
must pass rigorous work requirements. Additionally, they
receive extensive training and have extensive systems to
support their work. Furthermore, most of these people are
directly affected by their own actions, for example, a pilot
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
The application of the bad apple theory, as described
above by Dekker (2002) makes great, profitable news,
and it is also very simple to understand. If the operational
errors are attributable to poor or lazy operational
performance, then the remedy is straightforward—
identify the individuals, take away their licences, and
put the evil-doers behind bars. The problem with this
view is that most operators (pilots, mechanics, air traffic
controllers, etc.) are highly competent and do their jobs
well. Punishment for wrongdoing is not a deterrent
when the actions of the operators involved were actually
examples of “right-doing”—the operators were acting in
the best interests of those charged to their care, but made
an “honest mistake” in the process; this is the case in
many operational accidents.
This view is a more complex view of how humans
are involved in accidents. If the operational errors are
attributable to highly competent operational performance,
how do we explain the outcome and how do we remedy
the situation? This is the crux of the complex problem—
the operational error is not necessarily attributable to the
operational performance of the human component of the
system—rather the operational error is attributable to, or
emerges from, the performance of the system as a whole.
Pre-flight
Pre-flight
Before debating if bad apples exist, it is important to
understand what is meant by the term “bad apple.”
Dekker (2002) explains the bad apple theory as follows:
“complex systems would be fine, were it not for the erratic
behaviour of some unreliable people (bad apples) in it,
human errors cause accidents—humans are the dominant
contributor to more than two-thirds of them, failures
come as unpleasant surprises—they are unexpected and
do not belong in the system—failures are introduced to
the system only through the inherent unreliability of people.”
To the Letter
To the Letter
Bad Apples: Do They Exist?
Guest Editorial
Guest Editorial
by Heather Parker, Human Factors Specialist, System Safety, Civil Aviation, Transport Canada
Guest Editorial
time, given the situation, if the human performance is
to be explained in context and an understanding of the
underlying factors that need reform are to be identified.
This is much harder to do than anticipated.
In Part II, the “hindsight bias” will be addressed; a bias
that often affects investigators. Simply put, hindsight
means being able to look back, from the outside, on a
sequence of events that lead to an outcome, and letting
the outcome bias one’s view of the events, actions and
conditions experienced by the humans involved in the
outcome (Dekker, 2002). In Part III, we will explore how
to write accounts of human performance following the
“new view” of human error.
Guest Editorial
is onboard the aircraft they are flying. This infrastructure
limits the accessibility of these jobs to competent and
cognisant individuals. Labelling and reprimanding
these individuals as bad apples when honest mistakes
are made will only make the system more hazardous. By
approaching these situations with the goal of learning
from the experience of others, system improvements are
possible. Superficially, this way ahead may seem like
what the aviation industry has been doing for the past
twenty years. However, more often than not, we have
only used different bad apple labels, such as complacent,
inattentive, distracted, unaware, to name a few; labels that
only seek to punish the human component of the system.
Investigations into incidents and accidents must seek to
understand why the operator’s actions made sense at the
COPA Corner—Flying Clubs—Why Bother?
Pre-flight
Recently Released TSB Reports
Many clubs hold flying events such as fly-ins and fly-out events, where aircraft are flown on
cross-countries to far-off destinations. This will give you experience that you might not pursue on your own.
•
Some clubs organize specific training
opportunities, such as survival training or
underwater escape training.
Today, many airplane pilots don’t belong to clubs—they
just go to the airport, fly their own aircraft and then go
home again. Many times, they won’t even see or talk to
anyone else. They aren’t undergoing training or renting
their aircraft—so why bother belonging to a club?
•
Some clubs sponsor “mentor programs,” where
more experienced pilots are paired with students
and new licence holders, to help guide them
through the learning process and the first few
hundred hours of flying.
There are many types of clubs; many do rent aircraft or
provide instruction, but some offer other services, such
as operating airports or providing guest speakers and
organizing aviation events. So if you are not training or
renting, then here are some of the benefits of belonging to a club:
•
Flying clubs often have members with specific
knowledge of local weather and terrain
conditions.
•
Flying clubs often have associated aircraft
maintenance operations which can be a great
source of knowledge and help with aircraft issues.
•
Flying clubs and their members can provide
support when there are difficult circumstances to deal with—accidents, injuries or deaths.
•
You can make use of the expertise at the club—
learn from the instructors and other senior pilots.
•
You can take part in safety recency seminars and
other educational events.
•
Many flying clubs organize aviation speakers
from whom you can learn and keep up to date.
•
Being around other pilots will help motivate you
and keep you interested in flying.
Canada’s flying clubs have a lot to offer today’s pilots, even those who own their own aircraft. Belonging to
a club can help connect you to what is going on in
aviation in Canada, and just may give you better tools to lower your flying risks. Most clubs have Web sites
that list their activities, or you can find most of them at www.copanational.org under “Learning to Fly.”
ASL 4/2006
Recently Released TSB Reports
•
Pre-flight
The flying clubs of Canada have a long history. Many
of today’s clubs were formed in the 1920s with the
assistance of the Royal Canadian Air Force (RCAF),
when it was considered by the government of the day
to be in the national interest to get as many Canadians
flying as possible. During World War II, many elementary
flying training schools that were part of the British
Commonwealth Air Training Plan were run by the
nation’s flying clubs.
To the Letter
To the Letter
by Adam Hunt, Canadian Owners and Pilots Association (COPA)
The Canadian Business Aviation Association (CBAA)
has recently embarked on a major project to facilitate
aviation-oriented training for its members and the
aviation community at large. This initiative is the result
of observations from the association’s management of the
Private Operator Certificate (POC) Program.
Although CBAA’s experience is primarily with private
business aviation, its expertise can be useful to other
segments of the commercial aviation community, such
as: entity charter; air taxi; small scheduled carriers; flight
training schools; specialty operations; and maintenance
and manufacturing organizations.
In addition to organizing various seminars, CBAA
is partnering with existing training providers to offer
valuable training as a service to its members, as well as
making this training available to the aviation industry.
Visit the CBAA Web site at www.cbaa.ca for the latest
information on training seminars.
To the Letter
To the Letter
Gaps were identified in the essential skills and knowledge
required for personnel employed at all levels within the
Canadian aviation industry. One potential outcome of the
management knowledge gap, if not properly addressed,
can be ineffective implementation of safety management
systems (SMS).
There is often limited access
for small operators to highquality essential training for
such subjects as human factors,
fatigue awareness, high altitude
indoctrination, aircraft surface
contamination, low-energy
awareness, crew resource management, decision making, controlled flight into terrain, and specific
navigation operations, etc. CBAA’s new training initiative aims to fill that need.
Guest Editorial
Guest Editorial
The Canadian Business Aviation Association Column—Training to Bridge the Knowledge Gap
Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)
by Larry Cundy, Chief, Personnel Licensing, General Aviation, Civil Aviation, Transport Canada
In 1998, the International Civil Aviation Organization (ICAO), taking note of several accidents and incidents where pilots’
and air traffic controllers’ inadequate language proficiency were contributory factors, formulated Assembly Resolution A32-16,
and subsequently directed work by the ICAO Council and the Air Navigation Commission. As a direct result of that work,
ICAO adopted amendment 164 to the Standards and Recommended Practices (SARPs), Annex I to the Convention on
International Civil Aviation—Personnel Licensing, on March 5, 2003, with an effective date of November 27, 2003. This
amendment requires language proficiency for pilots, air traffic controllers and aeronautical station operators. It also calls for highquality aviation-specific language training materials and programs, as well as the development of academically-sound language
testing services.
Transport Canada (TC) acknowledges the legitimate
safety concerns that ICAO has cited in support of this
amendment; however, TC has also noted that there is
a significant amount of work required to develop the
infrastructure for standardized testing and oversight of
the test facilities and services.
In accordance with the SARPs and guidance material
developed by ICAO, the General Aviation Branch of TC
is responsible for the development and implementation of
language assessment and test standards for pilots. The Air
Navigation Services and Airspace Branch is responsible
for the implementation of these same standards for air
traffic controllers and aeronautical station operators. To
achieve a comprehensive plan within the limited time
frame for implementation, the General Aviation Branch
established the Language Proficiency Study Group
(LPSG) in September 2004. The LPSG is comprised of
representatives from the TC Licensing Division and the
The LPSG has completed a considerable amount of
work to date in accordance with the terms of reference
and work plan; this includes the development of the
required policies, procedures and draft notices of proposed
amendment (NPA) to the Canadian Aviation Regulations
(CARs).
The LPSG is currently developing formal assessment
tools and guidance material for the delegated persons
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
The Language Proficiency Study Group (LPSG)
Air Navigation Services and Airspace Branch, as well
as industry personnel from the Association Québécoise
des transporteurs aériens, Les Gens de l’air du Québec, Air
Transport Association of Canada, Canadian Owners and
Pilots Association, Air Line Pilots Association, Canadian
Air Traffic Control Association, Air Canada Pilots
Association, Canadian Aviation Maintenance Council,
Canadian Business Aviation Association, NAV CANADA and the U.S. Federal Aviation
Administration.
Pre-flight
Pre-flight
Introduction
Guest Editorial
Pre-flight
2. A language level 6 file assessment methodology and
process has been developed. This process will result in
the issue of language proficiency assessments—level 6
French and/or English for the majority of Canadian
licence holders who have already demonstrated
proficiency through training, flight testing and the
completion of written examinations. This process
is consistent with the ICAO SARPs and ICAO
Guidance Material (Document 9835, Chapter 5),
and allows TC to apply the assessment methodology
to current licence holders in advance of the 2008 implementation date.
3. Agreement was obtained through the CARAC
process and from the LPSG members to proceed with
the approval and publication process of the NPAs
to the CARs with the understanding that language
levels and validity dates would NOT BE PRINTED
on licences. This means that the language rating will
be printed on the personnel licence indicating either
French and/or English language proficiency; however,
the language level and expiry date will not be
displayed, thus avoiding any potential discrimination
on the basis of language proficiency level.
TC Civil Aviation Management Executive (CAMX) has
approved the design and implementation of a new licence
booklet format for pilot and air traffic controller licences
(decision record of meeting held on October 27, 2005).
This new licence booklet is a security-related document
that improves the entire personnel licensing process, with
a consolidated and secure pilot and air traffic controller
licence format, which includes the licence holder’s photo.
As a result of this decision, the language proficiency rating
(LPR) implementation is now integrated with the licence
booklet project. This new booklet will not only be used
for the issue of the LPR, but also for the administration
of the validity period of the LPR in cases where the
document holder has not attained an expert level 6.
Additional NPAs will be required as a function of
this decision, not only for the new licence booklet
implementation, but also for the changes associated with
the simplified endorsement format of the LPR on the
pilot and air traffic controller licence. These NPAs are
currently under development and will be presented at the
next CARAC Part IV Technical Committee meeting.
Where can I get more information?
Further LPR information will be available on the TC,
General Aviation Web site later this year, and you can
look forward to an in-depth article on the new licence
booklet in the Aviation Safety Letter (ASL) soon.
Questions and answers!
1. Why introduce a new requirement to establish
language competency of Canadian pilots? Is it
because Canada has an aviation safety problem related
to radiotelephone communications?
ASL 4/2006
As a signatory to the ICAO Convention on Civil
Aviation, Canada has agreed to implement and maintain
standards in accordance with the ICAO Annexes. ICAO
has demonstrated that there have been a number of
accidents where a significant factor was the inability to
communicate adequately by the pilot and the air traffic
controller because of a lack of proficiency in a common
language. Although there have been no accidents in
Canada related to language proficiency, TC acknowledges
this identified safety issue.
Recently Released TSB Reports
4. A document of specifications for an aviation-language
proficiency testing system has been developed, and
provides a pertinent and specific framework for test
development by language professionals. The purpose
of the test is to provide reliable, valid and practical
evaluation of pilot/flight crew language proficiency
in accordance with the ICAO language proficiency
requirements criteria, as published in ICAO Annex 1
and the Manual on the Implementation of ICAO
Language Proficiency Requirements, Document 9835.
Pre-flight
Recently Released TSB Reports
1. In 2004, the LPSG developed a work plan,
implementation procedures and NPAs to the CARs
that provided a starting point for formal industry consultation. This began with the Special Part IV
Canadian Aviation Regulation Advisory Council
(CARAC) meeting, which was held on March 31, 2005. The required NPAs were presented,
reviewed and accepted with minor revisions. The
NPAs are now waiting in the regulatory queue for the opening of a Justice Department file.
A company has been selected to develop the AviationLanguage Proficiency Testing System. Work has begun
on the development of the language proficiency test
(French and English) and is expected to be completed in
the fall of 2006.
To the Letter
To the Letter
Details of the work completed to date
What’s next?
Guest Editorial
who will be involved in the conduct of testing for the
operational language level. TC is also developing informal
assessment guidelines for assessing applicants for the
expert language level 6. To satisfy the international
requirements, these policies and procedures must not only
address future licence holders, but also existing licence
holders. For Canada, this involves the assessment of some
55 000 current Canadian licence holders.
In accordance with the ICAO standards, these new
standards will apply to private, commercial, airline
transport pilot and air traffic controller licences, but
will NOT apply to any other licences or permits (glider,
balloon, gyroplane pilot licences, ultralight, recreational,
and student pilot permits).
3. Are Francophone pilots obliged to have an English
language rating in order to be authorized to fly in
Canada, other than in Quebec and in the National
Capital Region?
Canadian licences issued after March 5, 2008, will
require either a French or an English language rating
(or both). There is no airspace restriction attached to the
language rating while operating in Canada; Frenchspeaking pilots with a French language rating will have
the same freedom to fly in Canada as they do presently.
The United States has indicated their full support for
the ICAO SARPs, and is currently developing an
implementation plan.
Pre-flight
To address this concern, TC has agreed not to endorse a
language level on the licence—only language proficiency
in English or French (or both).
11. In order to avoid the expense of language training, do
you think that air carriers will be forced to demand
a level 6 language rating from all pilots applying for
employment with them?
Since the pilot licence will only have a rating of English
or French or both, it could be a matter of company policy to
determine whether further training would be warranted
because of demonstrated ability in the use of the language.
Many of you asked for information on this topic.
Hopefully this article answered most of your questions.
As stated earlier, we will provide further information in
the near future.
Approximately 96 percent of licence holders in Canada
will receive either a French or English (or both) language
rating from TC free of charge prior to March 5, 2008.
Invest a few minutes in your safe return home this winter...
by reviewing your knowledge on airspace requirements and procedures in the TC AIM, section RAC 2.0.
Visit www.tc.gc.ca/CivilAviation/publications/tp14371/RAC/2-0.htm today!
10
ASL 4/2006
Recently Released TSB Reports
7. What is the cost to the pilots for obtaining the LPR
endorsement on their licence?
Pre-flight
The provisions of the ICAO Convention on Civil
Aviation and Annexes apply to foreign operators and
foreign pilots operating in Canada. As of March 5, 2008,
foreign pilots must be able to communicate with the air
traffic services (ATS) facility on the ground in Canada.
These pilots must, therefore, hold licences with language
ratings appropriate to the service provided by the ATS
facility on the ground.
6. Will the United States also be implementing a
language proficiency regulation?
Canadian francophone licence holders requesting an
English rating before March 5, 2008, may submit
evidence of their competency in English to TC. This process
will not involve any cost to the pilot. This will apply
only in cases where TC has not been able to establish the
pilot’s English language competency through a review of
available records.
10. Do you not think that, as a result of this new
regulation, francophone pilots will be at a
disadvantage compared to their anglophone
colleagues, with respect to employment opportunities
because they have less than a level 6 English language
rating endorsed on their pilot licence?
There are no airspace designations or airspace
restrictions, and none are planned in association
with this rating.
5. Do foreign pilots have to speak either English or
French before they are allowed to fly in Canada,
including Quebec?
TC will develop the standards for language evaluation
and will delegate the application of those standards
to the industry.
9. Will francophone pilots wishing to obtain an LPR in
English be charged a fee if they wish to have both an
English and French rating?
4. Will Canadian airspace have designated language
zones?
Recently Released TSB Reports
8. Who will be responsible for evaluating language
proficiency among pilots—TC or the aviation
industry?
To the Letter
To the Letter
Foreign citizens holding Canadian licences, as well
as Canadians requiring formal language testing after
March 5, 2008, may incur some cost. Details of the
implementation are being developed.
Guest Editorial
Guest Editorial
2. Does this new regulation apply to everyone who
holds a pilot licence or permit in Canada?
Pre-flight
On July 7, 2003, at approximately 09:58 Eastern Daylight
Time (EDT), a Beech 58TC Baron aircraft crashed into
Lake Ontario, Ont., approximately 3 NM southeast of
the Toronto City Centre Airport. The privately owned
and operated aircraft was carrying out a localizer/distance
measuring equipment (LOC/DME) B instrument
approach to Toronto City Centre Airport, after a flight
from Lansing Municipal Airport, in Chicago, Illinois.
When the aircraft did not arrive at the airport, and failed
to respond to transmissions from the tower, a search was
commenced. Patchy fog in the area resulted in ceilings
variable from zero to unlimited, and visibility from 1/8 mile to more than one mile. Several hours later, the
Metropolitan Toronto Police Marine Unit found debris
on the surface of Lake Ontario. The aircraft was located
the following day by the Ontario Provincial Police, using
a sidescan sonar. The aircraft was essentially intact, resting
vertically on its nose at a depth of 220 ft. The deceased
pilot was located in the aft cabin of the aircraft. He
received minor injuries in the impact, but failed to egress
the aircraft for unknown reasons, and died as a result of drowning.
2. Factors that contributed to the loss of situational
awareness were non-precision approach, poor
visibility, rushed or incomplete checks, level of
instrument proficiency and visual illusion created by surface-based fog.
Finding as to risk
1. Minimum altitudes on Canada Air Pilot (CAP)
approach plates are presented differently from
minimum altitudes on U.S. Federal Aviation
Administration/National Aeronautical Charting
Office (FAA/NACO) approach plates, which could create confusion and contribute to an unsafe approach.
TSB Final Report A03W0194—Power Loss and
Dynamic Rollover
On September 16, 2003, a Bell 206B was supporting a
diamond drilling crew working on the side of a mountain
about 80 NM north of Mayo, Y.T. The helicopter was
observed descending to a creek-bed staging/refuelling
area. As it reached approximately 20 ft above ground,
the observers lost sight of the helicopter behind an
embankment and then heard impact sounds. On reaching
the landing site, the observers found the helicopter lying
on its right side between two fuel drums. The helicopter
had sustained substantial damage, and the pilot, the
sole occupant, had been fatally injured. The time of the
occurrence was approximately 12:05 Pacific Daylight
Time (PDT). There was no post-crash fire.
Recently Released TSB Reports
Recovery operation of the aircraft
Findings as to causes and contributing factors
1. During the latter stages of a non-precision instrument
approach, the pilot lost situational awareness,
specifically of his altitude. As a result, he descended
ASL 4/2006
Pre-flight
Recently Released TSB Reports
below the minimum descent altitude (MDA)
and continued a controlled descent in instrument
meteorological conditions (IMC) until the aircraft
struck the water.
TSB Final Report A03O0171—
Controlled Flight into Terrain (CFIT)
To the Letter
To the Letter
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.
Guest Editorial
Guest Editorial
recently released tsb reports
Accident investigators examine the scene of the accident
11
To the Letter
With an aft longitudinal centre of gravity (CG) and a
right lateral CG, the helicopter was probably in a taillow, right-side-low attitude. When combined with the
lateral manoeuvring toward the right during the approach,
this attitude would have increased the tendency for the
fuel to migrate to the right rear corner of the fuel tank.
The fuel pump intakes probably unported, causing an
interruption in the fuel flow and a loss of power. With
the engine relight system armed, any resumption of fuel
flow could result in an engine relight, or series of relights,
but without the time required for the engine to accelerate
and transfer a useable amount of power to the rotor drive
system prior to impact.
Safety action taken
The operator has advised its pilots not to purchase or
utilize the older military style of open-earpiece helmets,
since the open-earpiece type helmet does not provide
the level of side-impact protection that a full-shell type
helmet would provide. As a result of this investigation
indicating unporting as a risk, the operator has issued a
memo to all flight crews mandating a minimum indicated
fuel load of 15 U.S. gallons during all Bell 206 operations.
TSB Final Report A04H0001—Loss of Control
On January 17, 2004, a Cessna 208B Caravan was on a
flight from Pelee Island, Ont., to Windsor, Ont., with
one pilot and nine passengers on board. The aircraft took
off from Runway 27 at approximately 16:38 Eastern
Standard Time and used most of the 3 300-ft runway for
the take-off run. It then climbed out at a very shallow
angle while turning north over the frozen surface of Lake
Erie, toward Windsor. The aircraft struck the surface of
the lake approximately 1.6 NM from the departure end of
the runway. All 10 persons on board were fatally injured.
42
50’N
Crash Site
Search Area
RWY
09/27
82 40’W
Map of crash location
Recently Released TSB Reports
1. The pilot’s open-earpiece type helmet did not
provide the level of side impact protection that a
full-shell type helmet would have, and this may have
contributed to the severity of the injuries.
Findings as to causes and contributing factors
1. At takeoff, the weight of the aircraft exceeded the
maximum allowable gross take-off weight by at
least 15 percent, and the aircraft was contaminated
with ice. Therefore, the aircraft was being flown
significantly outside the limitations under which it
was certified for safe flight.
2. The aircraft stalled, most likely when the flaps were
retracted, at an altitude or under flight conditions that
precluded recovery before it struck the ice surface of
the lake.
ASL 4/2006
Recently Released TSB Reports
1. The helicopter crashed due to a dynamic rollover that
resulted from the landing gear skid contacting the
fuel pump that was projecting from the top of a fuel
drum. It could not be determined why the helicopter
struck the fuel pump/drum.
12
PELEE
ISLAND
Finding as to causes and contributing factors
Findings as to risk
N
Pre-flight
A momentary power interruption at a crucial moment
may have distracted the pilot, and caused the helicopter
to overshoot the intended touchdown area and continue
laterally onto the fuel drum. The pilot was wearing his
helmet; however, the severity of the impact caused the
helmet to fail around the side where the shell had been
cut away to accommodate the headphone earpiece. A
full-shell helmet, which has the earpiece inside the shell,
would have been structurally stronger and afforded better
protection.
2. The operation of a helicopter at or below minimum
fuel levels is conducive to unporting, which may result
in a sudden loss of power at a crucial moment.
To the Letter
Pre-flight
Damage to the rotor drive system and the mast
indicated low or no power being transmitted from the
engine at impact, although the throttle was fully open,
and the engine was operating. The amount of fuel on
board prior to the occurrence could not be determined.
However, the quantity had been planned to be near the
minimums required by regulations. Fuel consumption
would have been considerably higher at the higher power
requirements during slinging operations, and the reserve
quantity may have been less than originally planned.
An additional shuttle of a load of hydraulic components
would have further reduced the reserve fuel quantity by
at least 2.0 gal. The pilot had abruptly departed for the
refuelling site, which may suggest a low fuel state.
Guest Editorial
Guest Editorial
Analysis
Guest Editorial
Findings as to risk
1. Despite the abbreviated nature of a September 2001
audit, the next audit of the operator was not scheduled until September 2004, at the end of the
36-month window.
3. The standard passenger weights available in the
Aeronautical Information Publication (A.I.P.) at the
time of the accident did not reflect the increased
average weight of passengers and carry-on baggage
resulting from changes in societal-wide lifestyles and
in travelling trends.
10. Incorrect information on the passenger door placards,
an incomplete safety features card, and the fact that
the operating mechanisms and operating instructions
for the emergency exits were not visible in darkness
could have compromised passenger egress in the event
of a survivable accident.
11. The dogs being carried on the aircraft were not
restrained, creating a hazard for the flight and its
occupants.
Safety actions taken
(The following are only a selection of the major safety
actions taken)
Operator
5. The Cessna Caravan de-icing boot covers up to a
maximum of 5 percent of the wing chord. Research
on this wing has shown that ice accumulation beyond
5 percent of the chord can result in degradation of
aircraft performance.
7. Repetitive charter operators are not considered to
be scheduled air operators under current Transport
Canada regulations, and, therefore, even though the
charter air operator may provide a service with many
of the same features as a scheduled service, Transport
Canada does not provide the same degree of oversight
as it does for a scheduled air operator.
8. A review of the Canadian Aviation Regulations (CARs)
regarding simulator training requirements indicates
that there is no requirement to conduct recurrent
simulator training if currency and/or pilot proficiency
checks (PPC) do not lapse.
The operator installed an aircraft de-icing
machine on Pelee Island immediately following
the accident.
•
The company now employs a second crew
member on all passenger flights.
•
In an effort to reduce perceived mission pressure
on aircraft captains, the chief pilot now reviews
the weather each day to forecast delays or
cancellations.
•
The chief pilot is reviewing every flight plan to
verify that the weight and balance program is
being followed.
Transportation Safety Board of Canada (TSB)
The TSB identified risks associated with using standard
weights, and issued two aviation safety recommendations:
The Department of Transport require that actual
passenger weights be used for aircraft involved in
commercial or air taxi operations with a capacity of nine
or fewer passengers.
(A04-01)
and
The Department of Transport re-evaluate the standard
weights for passengers and carry-on baggage and adjust
them for all aircraft to reflect the current realities.
(A04-02)
Transport Canada
In response to A04-01, Transport Canada indicated that
it continues to review the standards, and that one of
the options under consideration is to require the use of
ASL 4/2006
13
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Recently Released TSB Reports
6. At the Pelee Island Airport, the air operator did not
provide the equipment that would allow an adequate
inspection of the aircraft for ice during the pre-flight
inspection and did not provide adequate equipment
for aircraft de-icing.
•
Pre-flight
Pre-flight
4. The use of standard passenger weights presents
greater risks for aircraft under 12 500 lbs than for
larger aircraft due to the smaller sample size (nine
passengers or less) and the greater percentage of
overall aircraft weight represented by the passengers.
The use of standard passenger weights could result
in an overweight condition that adversely affects the
safety of flight.
To the Letter
To the Letter
2. The internal communications at Transport Canada
did not ensure that the principal operations inspector
responsible for the air operator was aware of the Pelee
Island operation.
9. Commercial Air Service Standard 723.91(2) does not
clearly indicate whether there is a requirement for
simulator training following expiration of a PPC.
Guest Editorial
3. On this flight, the pilot’s lack of appreciation for
the known hazards associated with the overweight
condition of the aircraft, ice contamination, and the
weather conditions was inconsistent with his previous
practices. His decision to take off was likely adversely
affected by some combination of stress and fatigue.
Guest Editorial
consistent with a slight contact with the runway. Available
information indicates that the wing scrape occurred at
02:41 Atlantic Daylight Time during the rejected landing
after the second approach. The aircraft was at a pitch
angle of 5˚ nose up, 14˚ of left bank, and a derived aircraft
height above ground of approximately 26 ft. There were
no injuries.
Guest Editorial
actual passenger weights. The TSB feels the present risks
associated with using standard weights will remain until a
new standard is put in place to ensure that actual weights
are used for aircraft carrying nine passengers or less.
In response to A04-02, Transport Canada re-evaluated
the standard weights for passengers and carry-on baggage
and, effective January 20, 2005, adjusted them for all
aircraft to reflect current realities, and amended the
guidance material.
The Federal Aviation Administration (FAA)
On March 24, 2006, TC issued Service Difficulty
Alert 2006-01R2,—Cessna 208 (Caravan) SeriesOperation Into Known or Forecast Icing Conditions
—which addresses the FAA AD and which makes further
recommendations to Canadian Cessna Caravan C208
operators. For details consult: www.tc.gc.ca/CivilAviation/
certification/continuing/Alert/2006-01.htm. Readers are
encouraged to read the full report of this major investigation
on the TSB Web site. —Ed.
On May 28, 2004, a Boeing 727-225 freighter was on a
night cargo flight from Hamilton, Ontario, to Moncton,
New Brunswick. The first officer was performing the pilot
flying (PF) duties, and the captain was conducting a line
check on the first officer. The en route portion of the flight
to Moncton was uneventful. On arrival at Moncton, the
flight crew conducted two unsuccessful approaches in
darkness and poor weather conditions before landing on
the third approach. A post-flight inspection of the aircraft
in Moncton found visible damage on the left wing. The
tip of the left outboard leading edge flap and the outboard
trailing edge flap “canoe” were abraded. The damage was
14
Findings as to causes and contributing factors
1. The captain’s decision to intervene and reject the
landing on the second approach was too late to
prevent the aircraft from contacting the runway
surface.
2. The aircraft’s wings were not leveled until after the
nose was raised, resulting in the left wing contacting
the runway.
Finding as to risk
1. The forecasted deteriorating weather was not detected
or reported in a timely manner.
Other findings
1. The aircraft landed with less than the minimum
diversion fuel required in the Flight Operations
Manual (FOM); however, the decision to carry out
the third approach could be considered reasonable in
the circumstances faced by the captain.
2. The weather conditions reported to the crew were not
representative of the actual weather conditions at the
airport. This contributed to the planning errors made
by the crew and the unnecessarily low fuel state.
Safety action taken
The section dealing with minimum required diversion fuel
in the operator’s FOM has been amended. The amended
version reads as follows:
“Upon reaching MIN DIV fuel, the flight MUST proceed
immediately to the alternate airport.”
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
TSB Final Report A04A0057—
Wing Scrape During a Rejected Landing
Close-up photograph of left outboard
leading edge flap damage
Pre-flight
Pre-flight
The FAA issued Airworthiness Directive (AD) 2005-07-01, effective March 29, 2005, and subsequently
issued AD 2006-06-06, effective March 24, 2006, which
supersedes AD 2005-07-01. The AD was the result of
several accidents and incidents involving the Cessna 208 and 208B operating in icing conditions. The purpose of
the AD is to ensure that pilots have enough information
to prevent loss of control of the aircraft while in flight
during icing conditions. The AD is applicable to Cessna
208 aircraft in Canada. For the most accurate and current
information, consult: www.airweb.faa.gov/Regulatory_and_
Guidance_Library/rgAD.nsf/MainFrame?OpenFrameSet.
To the Letter
To the Letter
The FAA released a comprehensive guide that provides
air operators of large, medium, and small cabin aircraft
with options for calculating passenger weights, to reflect
current realities.
Guest Editorial
In response to this occurrence, Transport Canada regional
staff conducted an inspection of the weather observation
service at Moncton on October 5, 2004. As a result of the
findings, the flood lights near the ceiling projector were
adjusted to reduce interference with weather observations,
and NAV CANADA has implemented new procedures
to improve the communication of information related to
changing weather conditions between the weather office
and the tower personnel.
2. The physical characteristics of the landing area did
not allow a successful landing following the rotor rpm
decay and uncommanded descent.
TSB Final Report A04C0174—Landing Gear
Collapse and Runway Excursion
On September 21, 2004, a Metro III aircraft departed
Stony Rapids, Sask., with two crew members and nine
passengers on a day, visual flight rules (VFR) flight to La
Ronge, Sask. On arrival in La Ronge, at approximately
14:10 Central Standard Time (CST), the crew completed
the approach and landing checklists and confirmed
the gear-down indication. The aircraft was landed in
a crosswind on Runway 18 and touched down firmly,
approximately 1 000 ft from the threshold.
As the helicopter turned through 100° of left turn, the low
rotor rpm warning horn sounded, and the pilot decided
to return to the pad. He allowed the left turn to continue
but, by the time the helicopter returned to the original
heading, it had drifted approximately 20 ft downhill from
the pad and was still descending. The main rotor blades
Bellcrank assembly with a part number 5453032-1 roller
on the left and a YCRS-12 bearing on the right
On touchdown, the left wing dropped and the propeller
made contact with the runway. The aircraft veered to the
left side of the runway, despite full rudder and aileron
deflection. The crew applied maximum right braking and
shut down both engines. The aircraft departed the runway
ASL 4/2006
15
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Recently Released TSB Reports
Pre-flight
1. The helicopter climbed vertically out of the hover at
near-maximum gross weight, it encountered downflowing air, which resulted in a situation in which
there was insufficient power to maintain controlled
flight. As a result, the rotor rpm decayed rapidly, and
the helicopter descended in an overpitched condition
until it struck the terrain.
Pre-flight
On June 25, 2004, at 20:20 PDT, the pilot of a
Eurocopter AS350 B2 (Astar) helicopter landed on a
recently prepared mountainside helipad, 5 NM west of
the extinct Flourmill Volcano, B.C., at 5 200 ft elevation.
With the helicopter still running at flying rotor rpm
and light on the skids, four passengers boarded with a
small amount of personal equipment and prepared for
takeoff. The pilot increased collective pitch to bring the
helicopter into the hover, but the engine parameters were
approaching their limits, and he discontinued the takeoff
and lowered the collective. The left rear passenger got
out, and the pilot again raised the collective, lifting the
helicopter into a stable 5-ft hover over the pad. Satisfied
this time with the engine readings, the pilot increased
collective pitch and climbed to approximately 20 ft while
purposely allowing the nose to swing to the left to turn
downhill for the transition into forward flight.
Findings as to causes and contributing factors
To the Letter
To the Letter
TSB Final Report A04P0240—
Blade Strike and Rollover
then struck a large tree stump adjacent to the pad and
the helicopter rolled over, coming to rest on its left side,
almost inverted. The three passengers quickly escaped
from the helicopter, but the pilot delayed his exit to shut
down the engine, which had continued to run. After he
had secured the engine, fuel valve, and electrical switches,
the pilot exited the cockpit. The four occupants received
minor injuries, and the helicopter was substantially
damaged. The emergency locator transmitter (ELT)
activated automatically at rollover. There was no fire.
Guest Editorial
Transport Canada is proposing changes to the Canadian
Aviation Regulations that will define the use of pilotmonitored approaches as part of the new approach ban
regulations.
Guest Editorial
flight was in daylight, the latter portion at night. The
flight took place in uncontrolled airspace, and there was
no record of any communication with air traffic services
(ATS) during the flight. The aircraft crashed in an open
field at 21:40. The pilot, the sole occupant of the aircraft,
sustained fatal injuries, and the aircraft was destroyed by
the impact and a post-impact fire.
Findings as to causes and contributing factors
1. The pilot continued a series of VFR flights at night
into an area of limited surface lighting with known
adverse weather conditions.
2. The smaller diameter roller reduced the required
rigging tolerances for the bellcrank-to-cam assembly
in the down-and-locked position, and allowed the
roller to eventually move beyond the cam cutout
position, resulting in the collapse of the left landing gear.
3. A rigging check was not carried out after the
replacement of the bellcrank roller. Such a check
should have revealed that neither the inboard nor
outboard bellcrank assembly met the minimum
rigging requirements for proper engagement with the positioning cam.
After the occurrence, the operator commissioned an
independent safety audit of its complete operation.
All maintenance staff of the approved maintenance
organization (AMO) responsible for this operator met to
review the company’s maintenance procedures outlined in
its maintenance policy manual. The following policy was
reinforced: “No one is to install any parts on any aircraft
without first referring to the appropriate parts and service
manuals to ensure correct part number and also that the
integrity of the affected aircraft system is still in place.”
On August 26, 2004, a Piper PA-28-235 aircraft
departed Roblin, Man., at 20:25 Central Daylight Time
on a VFR flight to Gimli, Man. The initial portion of the
16
Finding as to risk
1. The pilot did not ensure that the responsible person
who received the flight itinerary understood the
search and rescue (SAR)-notification requirements.
Safety action taken
On January 25, 2005, the TSB sent a safety advisory to
Transport Canada, suggesting that the department may
wish to consider action to improve awareness among
pilots of the need to ensure that persons responsible for
flight itineraries understand their obligations concerning
SAR notification. An article was published in issue
2/2005 of the Aviation Safety Letter, which is sent to all
Canadian licensed pilots. The article summarized the
occurrence and emphasized the need for pilots to ensure
that persons responsible for the flight itinerary fully
understand the SAR-notification requirements.
TSB Final Report A05C0123—In-Flight Collision
During Air Show
On July 10, 2005, three aircraft were engaged in a
simulated dogfighting display at Moose Jaw/Air
Vice Marshal C.M. McEwen Airport as part of the
Saskatchewan Air Show. The display team consisted of
three biplane aircraft: a Waco UPF-7 87, a Wolf-Samson
and a Pitts Special. A ground display featuring a jet-powered truck was part of the act. At approximately
16:17 Central Standard Time (CST), the three biplanes
were performing a series of crosses and chases in a
simulated dogfight scenario. As the jet-powered truck
moved into position on the 500-ft show line, the three
biplanes entered a manoeuvre called “The Dairy Turn” in
preparation for a series of crosses centered on the truck.
During the manoeuvre, the Waco and the Wolf-Samson
collided near show centre at about the 1 500-ft show line.
Both biplanes caught fire and crashed between the 1 500-ft show line and the outer runway. Both pilots were
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
TSB Final Report A04C0162—Flight Into
Adverse Weather—Collision with Terrain
2. The pilot’s instrument flying skills were most likely
not adequate to safely complete the course reversal
turn, resulting in an inadvertent descent that was not
detected and corrected in time to prevent impact with
the surface.
Pre-flight
Pre-flight
Safety action taken
Findings as to causes and contributing factors
To the Letter
To the Letter
1. An incorrect roller of a smaller diameter and type
was installed on the left main landing gear outboard
bellcrank assembly, contrary to company and industry practice.
Guest Editorial
and traveled approximately 200 ft through the infield
before the nose and right main gear were torn rearwards;
the left gear collapsed into the wheel well. The aircraft slid
on its belly before coming to rest approximately 300 ft off
the side of the runway. Three of the passengers suffered
minor injuries from the sudden stop associated with the
final collapsing of the landing gear; the other passengers
and the pilots were not injured.
Guest Editorial
To the Letter
1. The sequential manoeuvre information provided to
Transport Canada was not detailed enough to allow a thorough review of the energy management of the display.
TSB Final Report A05Q0157—Flight into
Adverse Weather—Collision with Terrain
On September 1, 2005, a float-equipped de Havilland
DHC-2 Beaver departed the outfitter base camp at
Squaw Lake, Que., at 09:25 EDT, with a passenger and a
few supplies on board, for a round-trip VFR flight to two
wilderness camps, Camp 2 and Camp Pons. The weather
in Squaw Lake was suitable for visual flight at the time of
takeoff, but was forecast to deteriorate later in the day.
The pilot completed the flights to the two camps, and on
the way back to Squaw Lake, the weather forced the pilot
to make a precautionary landing on Elross Lake, 15 NM
northwest of Squaw Lake. At 16:30, he reported to the
company via high frequency (HF) radio that he intended
to take off from Elross Lake, as there seemed to be a
break in the weather. Rescue efforts were initiated in the
evening when the aircraft did not arrive at the base camp.
The aircraft was located at 12:30 the following day, 4 NM
from Elross Lake. The aircraft was destroyed by a postimpact fire. The pilot sustained fatal injuries.
To the Letter
The Dairy Turn is a scripted manoeuvre, with the
intention to create the illusion of a close call as two of the
three aircraft cross near show centre, also involving the
jet-powered truck for visual effect. Other display team
members understood that the contract for safe separation
required the pilots to establish visual contact with each
other at specific location of the manoeuvre and maintain
separation visually. One of the aircraft had been late on its
track on occasions since the display had been developed.
This lateness had not previously caused any difficulties
for the performers. The manoeuvre had been recently
modified. Whether the contract for safe separation was
also revised could not be established.
Finding as to risk
Guest Editorial
killed on impact, and both aircraft were destroyed. All
debris fell away from the crowd toward the outer runway.
Immediate implementation of emergency procedures kept
spectators from moving toward the burning wreckage.
Findings as to causes and contributing factors
1. The Dairy Turn manoeuvre had been modified such
that a temporary loss of visual contact could occur
immediately before the aircraft crossed flight paths.
This modification made timing critical and added two
potential points of collision.
2. The manoeuvres immediately before the collision
indicated that the performers had not established a
clearly understood contract for the revised manoeuvre.
The actions of each performer negated the actions
of the other, and neither pilot took positive action to
regain visual contact.
3. The timing of the manoeuvre was lost when the Waco
turned late at show centre.
Other finding
1. Had this been a survivable accident, rescue
efforts may have been compromised by a lack of
communication. A satellite phone provides a more
effective means of communication when in remote areas.
Safety action taken
On March 3, 2006, the TSB sent a safety information
letter to Transport Canada, highlighting the criticality
of flight following communication as it relates to SAR
response in remote areas of the country, and indicating
the effectiveness of alternate means of communication,
such as satellite phones.
ASL 4/2006
Recently Released TSB Reports
Recently Released TSB Reports
Charred remnants of the air demonstration aircraft
1. The pilot attempted to cross the mountain ridge in
adverse weather, and the aircraft stalled at an altitude
from which recovery was not possible. Loss of visual
references, strong updrafts, moderate to severe
turbulence and possible wind shear likely contributed
to the onset of the aerodynamic stall.
Pre-flight
Pre-flight
Finding as to causes and contributing factors
17
Winter Operations
— On February 2, 2006, a Robinson R44 II helicopter
was operating from the PenWest Mega Gas Plant,
located approximately 40 NM south of Rainbow Lake,
Alta. The pilot was manoeuvring the aircraft to refuel
before commencing sling operations, when the main rotor
blades came into contact with the fuel tank. The aircraft
sustained substantial damage to the main rotor blades and
power train. The fuel storage tank sustained damage and
was reported as leaking. There were no injuries. TSB File A06W0023.
— On February 7, 2006, a privately-owned Piper PA-34-200 (Seneca II), was low on approach
to Runway 26L at Pitt Meadows, B.C., airport. The
aircraft struck several approach lights and a fence before
coming to rest approximately 200 ft short of the runway
threshold. The aircraft was substantially damaged, but the
pilot was uninjured. TSB File A06P0018.
— On February 12, 2006, a Cessna 172N with only a
student-pilot on board, was conducting a flight from
St-Frédéric, Que., to Montmagny, Que. While en route
the aircraft flew over a lake at low altitude, and the
left wing hit some trees. The pilot continued the flight
and conducted a touch-and-go at Montmagny before
returning to St-Frédéric, where the aircraft landed
without incident. The aircraft’s left wing leading edge
was damaged. The aircraft will be repaired before being
returned to service. TSB File A06Q0026.
— On February 18, 2006, a Cessna A185F, with only
the pilot on board, was conducting a landing on Lac
Sept-Îles, Que. The aircraft was equipped with skis
18
— On February 24, 2006, the pilot of an amateur-built
Mustang P51D70 tail dragger aircraft was on the runway
performing taxi tests, when directional control was lost,
the aircraft veered off the left side of the runway, and
struck a ditch. The landing gear collapsed and the aircraft
was substantially damaged. There were no injuries to the
pilot. TSB Report A06O0045.
— On March 5, 2006, a ski-equipped de Havilland
DHC-6-100 Twin Otter had been parked overnight on
the apron at La Ronge, Sask. The aircraft was stuck to
the snow-covered apron, and at the start of taxiing, the
skis broke free and the aircraft abruptly began moving
forward. The aircraft struck a parked DHC-2 Turbo
Beaver and a parked vehicle. The Twin Otter sustained
substantial damage to the nose cone, nose landing gear,
both engines and propellers, and the fuselage. The Turbo
Beaver sustained substantial damage to the right wing,
and the vehicle also sustained substantial damage. No
injuries occurred. TSB Report A06C0041.
— On March 5, 2006, an amateur-built Murphy Rebel,
with the pilot and one passenger on board, was flying
from Brampton, Ont., to the pilot’s cottage on Sturgeon
Lake, Ont. The pilot was landing the wheel-equipped
aircraft on the snow-covered lake, and misjudged the
depth of snow. On touchdown, the aircraft nosed over and
came to rest inverted. The pilot received minor injuries,
and the aircraft was substantially damaged. TSB Report A06O0060.
— On March 19, 2006, an MD 369 helicopter descended
into a confined area below tree line in order to drop off
an item to a ground crew member. While trying to drop
off the item, the pilot took his hand off the collective, the
aircraft drifted off to the right, making contact with the
top of a tree and severing part of the tail boom. Upon loss
of tail rotor authority, the helicopter yawed to the right,
and the tail boom struck another tree and then proceeded
ASL 4/2006
Maintenance and Certification
— On February 9, 2006, a privately-registered PA-46
Malibu was landing on Runway 33 at London, Ont.
During the touchdown, the aircraft suddenly veered to
the left. The pilot attempted to control the aircraft by
applying right rudder and brake, but the aircraft departed
the runway surface approximately 2 500 ft from the
threshold. During the runway excursion, the left main
gear and the nose gear collapsed, resulting in substantial
damage to the aircraft. The runway condition report, taken
approximately 35 min after the occurrence, was 50 percent
bare and dry, 40 percent trace of snow and 10 percent
ice. The runway friction index was 0.63. There were no
injuries. TSB File A06O0036.
and retractable wheels. Upon landing, the aircraft slid
approximately 200 ft before the left ski broke through the
crust of the snow. The aircraft nosed over, and came to a
stop on its back. Before taking off, the pilot inspected the
lake surface by riding up and down it on a snowmobile,
and decided it was suitable for landing. TSB File A06Q0031.
Winter Operations
Maintenance and Certification
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 February and April 2006, are all “Class 5,” and
are unlikely to be followed by a TSB Final Report.
Accident Synopses
Accident Synopses
Accident Synopses
Accident Synopses
Winter Operations
Artist’s impression of aircraft landing on bow wake
— On April 1, 2006, a Mooney M-20F aircraft departed
the Steinbach, Man., airport for a pleasure flight with the
pilot and one passenger on board. During final approach
for Runway 14, the aircraft landed with the landing gear
retracted. The pilot and passenger evacuated the aircraft
without injury; the aircraft sustained substantial damage.
TSB Report A06C0039.
— On April 1, 2006, a Cessna 177 aircraft departed Trail, B.C., for a VFR flight to Revelstoke, B.C., with
the pilot and two passengers on board. The fuel gauges
showed the tanks to be just under 3/4 full. The aircraft
was not refuelled at Revelstoke, and the flight departed
for Trail with the fuel gauges showing just under 1/2
full. On the return flight, a headwind and cloud were
encountered, which forced the aircraft to be flown at a
lower altitude and on an indirect route because of terrain.
Since it appeared that the aircraft did not have enough
fuel to reach Trail, a diversion to Castlegar, B.C., was
attempted. About 11 NM north of the Castlegar airport,
the engine stopped from fuel starvation. The pilot set
— On April 7, 2006, an AS 350 B1 helicopter had
dropped off six skiers atop a 5 500-ft mountain, and was
descending at about 2 000 ft/min toward a landing area at
about 1 800 ft. When the pilot began to pull in collective
pitch to arrest the rate of descent prior to landing, the
engine began to loose power and the low rotor rpm
warning horn began to sound. The helicopter descended
past the intended landing site to an unobstructed area
about 150 ft further down the mountain, where it landed
hard on snow-covered ground. The main rotors severed
the tail boom, and one main rotor blade was shed. After
exiting the aircraft, the pilot noted the engine was
smoking heavily and extinguished it using a hand-held
extinguisher and snow. The engine exhaust stack was
damaged from the inside, and contained metal debris.
TSB Report A06P0051.
— On April 19, 2006, a DHC3 on skis inbound
from Chibougamau, landed on the ice runway at Lac
Lagopède. During the landing roll, the aircraft was unable
to stop in time, and struck another DHC3, which was
parked on the runway, with the engine shut down. The left
wing leading edge of the first DHC3 was substantially
damaged. The right wing of parked DHC3 was ripped off
in the collision. None of the occupants of either aircraft
was injured. TSB File A06Q0070.
— On April 24, 2006, a Robinson R44 helicopter was
preparing to depart from Terrace, B.C. The engine
was running, and the rotor was turning while a second
company pilot was loading fuel containers into the cargo
compartment. The pilot-in-command, who was the only
person on board, got out of the helicopter to help with the
loading. While the pilot was outside, the helicopter began
to lift off, rolled onto its left side, and collided with the
ground. There was substantial damage to the helicopter,
but no injuries or fire. TSB Report A06P0064.
ASL 4/2006
19
Maintenance and Certification
— On March 28, 2006, a Bellanca 7GCBC aircraft, with
the pilot and one passenger on board, departed Pilgram
Lake, Ont., for a return to the pilot’s home strip. The pilot
stopped to refuel near Wades Landing on Lake Nipissing,
Ont. While taxiing on the frozen lake surface, the front
wheels broke through the ice. The aircraft nosed over and
came to rest upside down. The pilot and passenger were
not injured. There was substantial damage to the aircraft.
TSB Report A06O0077.
— On April 4, 2006, a Beech 200 was conducting a
flight between La Romaine (CTT5) and Natashquan
(CYNA), with two crew members on board. While the
aircraft was en route, at an altitude of 2 000 ft, the main
door detached from the aircraft. Given the short distance
between the two airports, the crew decided to continue on
to Natashquan. The aircraft landed without incident. The
door had not been locked properly before departure. TSB File A06Q0060.
Winter Operations
Maintenance and Certification
— On March 24, 2006, a Grumman Goose G-21A was
damaged on landing in Hardy Bay, Port Hardy, B.C. The
aircraft had landed in a large bow wake created by a boat.
The operator grounded the aircraft after maintenance
identified upper wrinkles in the skin above the front
windows and bent engine mounts. TSB Report A06P0044.
up for a forced landing, but during the approach to his
chosen field, the aircraft stalled and landed hard, breaking
the right main wheel and sustaining substantial damage.
The pilot sustained minor injuries, and the passengers
were uninjured. TSB Report A06P0046.
Accident Synopses
to spin out of control several times. The helicopter fell
from approximately 25 to 30 ft and spun to the ground,
finally landing on the pilot side. The pilot was not injured.
TSB Report A06P0055.
Winter Operations
Near Repeat of Mirabel De-Icing Mishap
The following is a summary of an incident in the central de-icing facility (CDF) at the Macdonald Cartier International Airport
(CYOW) in Ottawa, Ont., and was graciously provided by the CDF management team, which did its own investigation with
hopes of preventing a reoccurrence. It brings back memories of the January 21, 1995, Mirabel, Que., tragedy, when a Boeing 747
departed the de-icing facility early and three de-icing operators in the cherry-pickers were killed when their baskets were tipped to
the ground by the large aircraft. The Mirabel report can be found on the TSB Web site as file A95Q0015. —Ed.
On December 7, 2005, a Regional Jet CL600 was being
de-iced in the CDF at CYOW, in preparation for a
scheduled flight, with both engines operating. Two de-icing vehicles were in position at the tail of the aircraft,
one on each side of the aircraft with booms raised and
in the process of de-/anti-icing. The flight crew reported
hearing that the flight was “clear.” A request was made
to ICEMAN (the CDF coordinator) for departure
instructions. ICEMAN issued departure instructions to
the flight crew. The aircraft exited the de-icing bay and
proceeded on the west taxilane. The horizontal stabilizers
of the aircraft narrowly missed contacting the de-icing
vehicle booms. The de-icing vehicles and persons in the
buckets of the booms did experience “jet blast.” There
were no injuries to the individuals in the buckets or
damage to the de-icing vehicles.
The flight crew reported that SNOWMAN communicated
to them: “Your holdover times started 30 seconds ago. You
are clear.” After receiving a confirmation of de-icing fluid
mixtures from SNOWMAN, the flight crew also reported
hearing SNOWMAN reaffirm: “You are clear, contact
ICEMAN on 122.92 for taxi.” In addition, the flight
crew reported seeing SNOWMAN give a wave with his
left hand, followed by a departure of the de-icing vehicle
from the area. The flight crew reported looking left and
right to confirm the area around the aircraft was clear.
Subsequently, the flight crew requested, and received,
departure instructions from ICEMAN. At the time of
these transmissions, the elapsed time since the beginning
of the operation matched the time usually required for
this kind of de-icing operation.
At 16:21 EDT, the flight crew contacted ICEMAN to
inform him that de-icing was complete, and to request
departure instructions. After requesting, and receiving,
verbal confirmation from the flight crew that all staff
and equipment were away from the aircraft, ICEMAN
gave departure instructions to the flight crew, to exit
the CDF (via xyz route), and to contact ground control
on 121.90. The aircraft proceeded as instructed. At that
time, the de-icing vehicles were de-icing the horizontal
stabilizers, positioned on either side of, and perpendicular
to, the fuselage, and forward of the horizontal stabilizers.
Immediately after this, ICEMAN was contacted by one
of the de-icing vehicles, informing him that de-icing had
not been completed and that both vehicles were de-icing
the tail of the aircraft at the same time it had exited Bay 4.
20
Maintenance and Certification
Before departure, the flight crew was instructed to taxi to
the CDF and contact ICEMAN on frequency 122.925.
At 16:06 Eastern Daylight Time (EDT), the flight was
positioned in a de-icing bay where two de-icing vehicles
were waiting, and was instructed to contact SNOWMAN
(the de-icing crew) on 131.075. Communications
between the captain and SNOWMAN established that
the aircraft was configured for de-icing operations. The
operation was commenced, and the vehicle operators
communicated with each other on 131.075.
Winter Operations
Maintenance and Certification
Near Repeat of Mirabel De-Icing Mishap....................................................................................................................... page 20
Cold Weather Altimeter Error—Getting Cold Feet?...................................................................................................... page 22
Storage, Labelling, Handling and Application of De-/Anti-Icing Fluids in Canada................................................... page 24
How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions........................................... page 27
Accident Synopses
Accident Synopses
winter operations
Above anything else, de-icing operations require clear
and precise communications between all involved
The de-icing staff reported that they received a request
from the flight crew regarding fluid mixtures, and
reported also that the phrase “you are clear” was used
during the de-icing operation. While the phrase “you are
clear” is part of the communication standard operating
procedures (SOP) for de-icing operations, it could not be
determined at what time during the de-icing operation
this had occurred. Other than the factual history
details, the de-icing staff said this was the only reported
communications between them and the flight crew.
ASL 4/2006
Accident Synopses
and also with the flight crew on that same frequency; this
allowed the flight crew and the de-icing staff to become
confused during conversations.
Analysis
Control of de-icing area
The VHF radios in the aircraft and de-icing vehicles
functioned normally; however, there was confusion
in communications between the flight crew and
SNOWMAN that resulted in the captain believing that
the de-icing was completed.
Maintenance and Certification
Standard phraseology
According to the rules of standard phraseology, to
avoid confusion, radio messages must be preceded by
the receiving station call-sign, followed by the sending
station call-sign. While these rules may not apply to
interphone communications, the “open” nature of VHF
radio communications requires that the international
rules of radio procedure be followed. In this case, the
flight crew reported hearing the words “you are clear”
and made a number of erroneous assumptions: that the
radio transmission was directed at them; that the de-icing
operation was completed; and that all equipment and
personnel were away from the aircraft’s taxi path.
Coordination of communications
During de-icing operations, the operators of both deicing vehicles communicated with each other on 131.075,
The fact that ICEMAN issued taxi instructions when
de-icing was not completed indicates that he was not
aware that de-icing was in progress. Although he fully
discharged his responsibilities, ICEMAN probably
did not have enough information or sufficient tools to
accurately assess the situation in the CDF.
Marshaller
SNOWMAN performed the duties of marshaller and
truck driver. He was not in a position to prevent the
aircraft from advancing, given that he was behind the
aircraft. In addition, SNOWMAN was not monitoring
the ICEMAN VHF frequency of 122.925. Several air carriers prefer to place a marshaller in front
of the aircraft to minimize the possibility of the aircraft
moving until the de-icing procedure is complete and
all personnel and equipment are safely out of the way.
Some carriers utilize an interphone cord plugged
into the aircraft to maintain constant communication
between the ground crew and the flight deck. This
procedure eliminates the risk of confusion between
flight crew/marshaller communications and other VHF
communications. The de-icing contractor had not chosen
the direct interphone cord method of communication
because it was felt that the area around the aircraft was
too dangerous an environment in light of the slippery
footing conditions due to the glycol, particularly with the
engines running.
Coordination between flight crew and flight attendants
The pilots did not report consulting with the cabin crew
before releasing the brakes. Given that the pilots could
not see the aft section of the aircraft from the flight deck,
and they did not see if the de-icing vehicles had in fact
departed the area, consulting the flight attendants was
ASL 4/2006
21
Maintenance and Certification
According to the International Civil Aviation
Organization (ICAO), the following information must
be given to the flight crew on completion of de-icing:
the type of fluid used, the time of the last application,
and confirmation that the aircraft complies with the
clean aircraft concept. The flight crew released the brakes
under the assumption that this information had been
received. The flight crew reported hearing the words “you
are clear” (de-icing completed). Although this message
was not preceded by the flight call-sign or the de-icing
crew call-sign, the flight crew reported hearing “you are
clear” twice. The duration of the operation up to that
point matched the time usually required for this type of
de-icing. In addition, the flight crew reported seeing a
wave of a hand from SNOWMAN and subsequently, the
vehicle departing the vicinity of the aircraft. The flight
crew assumed the de-icing crew had left the frequency
and departed the area. The flight crew then advised
the ICEMAN that the aircraft was ready to taxi, and,
in doing so, conveyed to the ICEMAN that de-icing
was completed and the aircraft was free of obstruction.
Relying on that information, ICEMAN indicated to the
flight crew their assigned route for taxiing. The flight crew
further interpreted the issuance of taxi instructions as
confirmation that the aircraft was free of obstructions.
Winter Operations
Winter Operations
Decision to taxi
The CDF coordinator (ICEMAN) performed his
tasks in accordance with established procedures and his
assigned responsibilities. He guided the aircraft until it
was stopped at its de-icing position. The aircraft came
fully under the responsibility of the captain after it was
stopped for de-icing. Before issuing taxi instructions to
the aircraft, ICEMAN verified that the taxiway was clear.
It was not his responsibility to consult the flight crew and
de-icing personnel to determine whether de-icing of the
aircraft was complete and the aircraft was ready to taxi.
That responsibility was assumed by the flight crew when
they declared the aircraft ready to taxi.
Accident Synopses
Immediately after this, the aircraft engines were heard to
increase thrust and the aircraft began to move forward,
exiting Bay 4.
Findings
The flight crew and de-icing staff did not
use standard aeronautical terminology and
phraseology on some occasions. •
The flight crew assumed that the reported
message SNOWMAN “you are clear” meant that
the de-icing was completed. •
The line of sight from the flight deck of the tail
section did not allow the flight crew to be certain
if the de-icing vehicles were away from the
aircraft in the vehicle safety zones.
•
ICEMAN does not have a line of sight of the
entire CDF at all times.
•
Following confusion in the radio
communications, the flight crew started to taxi the aircraft before its perimeter was free of obstructions.
•
Several air carriers favour having a marshaller
in front of the aircraft and using the interphone
for ground communications during de-icing.
This de-icing operator uses the VHF radio to
communicate with the flight crew during de-icing
operations.
Safety action taken
Clear communications between flight crews and de-icing
staff was the key recommendation. All de-icing providers
and all aircraft operators must review procedures with
a focus on communication: protocols, practices and
phraseology to be used. In particular, there should
be an exclusion of the word “clear.” Furthermore, the
investigation recommended that radio communications
between staff of de-icing operators be conducted on a
separate, discrete frequency from the frequency used to
communicate with the flight crew.
The CDF management team reviewed and made changes
to the CDF SOPs. The procedures indicate that both
visual and verbal communication must be received and
acknowledged by aircraft flight crew prior to exiting CDF.
These revised CDF procedures have been provided to all
contract carriers, both at the local base and head office
levels.
Cold Weather Altimeter Error—Getting Cold Feet?
by John Tomkinson
As happens every year at this time, everyone should be
doing a review of their winter operational procedures,
and dusting off the cobwebs from a summer of flying in a
temperate climate.
of charts available in the Transport Canada Aeronautical
Information Manual (TC AIM) RAC Figure 9.1. Simple
really, but there are common misconceptions about this
procedure.
Having discussed the coming winter with many fellow
pilots and controllers over the past few weeks, I’ve found a
recurring general theme. Nearly everyone can list hazards
of icing, winter weather, slippery runways, and additional
human factors, but whenever the topic of cold weather
altimeter error comes up, I see more long faces than I
should. Discussions in online forums show that most
individuals have an idea of the implications that cold
weather has on altimeter readings, but most can’t get all
the details correct, so here is our brush-up situation.
Firstly, this and other altimeter corrections are not done
by ATC, but are the pilot’s responsibility. Radar vectoring
altitudes assigned by ATC are, however, already corrected
for cold temperatures. This correction is done by airspace
planners while establishing all minimum safe altitudes for
use by ATC.
Cold weather altimeter error is operationally similar to
flying from an area of high pressure to low pressure; the
altimeter reads higher than it really is. The degree to
which the altimeter misreads must be corrected by the use
22
Secondly, any correction applied to a published altitude
should be relayed to ATC. There is no minimum altitude
correction that can be brushed under the carpet. Even the
smallest corrections can make a big difference.
Corrections calculated by pilots are to be used to ensure
obstacle clearance during final approach fix crossings,
procedure turns, or missed approaches.
ASL 4/2006
Maintenance and Certification
Maintenance and Certification
•
SNOWMAN was not in a position to prevent
the aircraft from advancing, given that he was
behind the aircraft where he could not be seen by
the flight crew. Winter Operations
Winter Operations
Accident Synopses
In summary, it was determined that the flight crew
started to taxi the aircraft before its perimeter was
free of obstruction, following confusion in the radio
communications.
•
Accident Synopses
a conceivable and reasonable option in this particular
situation.
Accident Synopses
Winter Operations
So how can you know if your feet are cold? The following
are the guidelines in the TC AIM.
According to TC AIM RAC Figure 9.1—
Altitude Correction Chart:
With respect to altitude corrections, the following
procedures apply:
1. IFR assigned altitudes may be either accepted or
refused. Refusal in this case is based upon the pilot’s
assessment of temperature effect on obstruction
clearance.
2. IFR assigned altitudes accepted by a pilot shall not be
adjusted to compensate for cold temperatures, i.e. if a
pilot accepts “maintain 3 000,” an altitude correction
shall not be applied to 3 000 ft.
3. Radar vectoring altitudes assigned by ATC are
temperature compensated and require no corrective
action by pilots.
4. When altitude corrections are applied to a published
final approach fix crossing altitude, procedure turn or
missed approach altitude, pilots should advise ATC
how much of a correction is to be applied.
ALTITUDE CORRECTION CHART
(Ref.: TC AIM RAC Figure 9.1)
Height above the elevation of the altimeter setting sources (ft)
Aerodrome
Temperature ˚C
200
300
400
500
600
700
800
900
1 000
1 500
2 000
3 000
4 000
5 000
0
-10
-20
-30
-40
-50
20
20
30
40
50
60
20
30
50
60
80
90
30
40
60
80
100
120
30
50
70
100
120
150
40
60
90
120
150
180
40
70
100
130
170
210
50
80
120
150
190
240
50
90
130
170
220
270
60
100
140
190
240
300
90
150
210
280
360
450
120
200
280
380
480
600
170
290
430
570
720
890
230
390
570
760
970
1 190
290
490
710
950
1 210
1 500
NOTES:
1: The corrections have been rounded up to the next 10-ft increment.
2: Values should be added to published minimum IFR altitudes.
3: Temperature values from the reporting station nearest to the position
of the aircraft should be used. This is normally the aerodrome.
Everyone knows the old saying “high to low, look out below.” As we enter another winter flying season, let’s add another
reminder phrase to our repertoire, “hot to cold, don’t be so bold.” Don’t get cold feet in your altimeter this year!
John Tomkinson is an active air traffic controller in Toronto Center and a private pilot. He is also an aviation staff writer for
www.aviation.ca.
ASL 4/2006
23
Maintenance and Certification
Maintenance and Certification
A combination of high terrain or obstacles and low
aerodrome temperature can easily wear down safety
margins on your approach. Our above example has
an error of 400 ft, meaning we would have no terrain
clearance if we flew the published altitudes uncorrected.
Winter Operations
Sound like a small correction? Is it worth pulling out
charts to cross reference while briefing the approach? In
an accident report published by the Canadian Aviation
Safety Board [now the Transportation Safety Board of
Canada (TSB)], the hazards of failing to correct for even
the smallest temperature error are clear. Fortunately, there
were no fatalities in this incident:
• “The helicopter was dispatched at night, in
IFR conditions...The crew descended on the
inbound leg to 150 ft, with reference to the
pilot’s altimeter. The helicopter struck the sea ice
and was destroyed by post-impact fire. The crew
had not applied a temperature correction to the
minimum descent altitude [approximately 40 ft
to as much as 100 ft. —Ed.], and this omission—
combined with the known 50-ft error in the
pilot’s altimeter—accounted for the mistaken
belief the helicopter was higher.” (A81W0134)
Accident Synopses
For those who have never used an altitude correction
chart, here is an example of how the Canadian chart
works. The minimum safe altitude for our example
aerodrome with weather reporting is 3 000 ft, and the
field elevation is 1 000 ft; therefore, the height above
elevation of altimeter setting is 2 000 ft. The current
aerodrome temperature is -30°C. Looking at the Altitude
Correction Chart below, find the column representing 2 000 ft above the aerodrome with the row corresponding
to -30°C for temperature, and the value required to be
added to your altitude is 380 ft. To ensure that a published
altitude of 3 000 ft will truly provide obstacle clearance,
the altimeter must then be reading 3 380 ft. Additionally,
in examples shown in the current TC AIM, the corrected
indicated altitude is rounded to the next higher 100-ft
increment, so our example would become 3 400 ft.
Winter Operations
This is a follow-up article to Paul Johnson’s “Aircraft Icing for General Aviation…And Others,” which was published in the
Aviation Safety Letter (ASL) 3/2005. Some readers asked us to clarify storage, labelling, handling and application of de-icing
and anti-icing fluids.
The Canada Labour Code (CLC), Part II, is the legislation
that ensures that the health and safety of all employees
who are under federal jurisdiction while at work are
protected. The Aviation Occupational Safety and Health
Regulations (AOSHR), Part V, identifies the prescribed
standards that must be adhered to with respect to
hazardous substances, which include the de-/anti-icing
fluids used in conjunction with ground icing operations.
At airports where de-/anti-icing is not available from
a service provider, the de-/anti-icing may have to be
completed by the pilot. Under these circumstances, pilots
either have to carry the required de-/anti-icing fluid on
board their aircraft, or purchase it on-site, so they can
apply it to the aircraft themselves before takeoff.
When the above situation occurs, it is both the operator’s
and pilot’s responsibility to make sure the de-/anti-icing
fluid is properly and safely stored, labelled, handled and
applied.
The prescribed standards cover everything from the
labelling of hazardous substance storage containers
(section 5.28), to the requirement that operators must
have material safety data sheets (MSDS) on board their
aircraft for all hazardous substances an employee may
handle or be exposed to, which include de-/anti-icing
fluids. For additional information visit:
www.tc.gc.ca/civilaviation/commerce/circulars/AC0216r.htm
Use only qualified fluids. These are the only fluids that
holdover tables relate to. Use of an unqualified fluid risks
fire hazards and unknown de-ice/holdover characteristics.
For example, Isopropyl alcohol continues to be used as an
aircraft de-icing fluid, especially in remote areas; however,
it is classified as a flammable dangerous good. Only
certain limited quantities may be carried on board an
aircraft, and they must be labelled correctly and carried
24
Transportation of Dangerous Goods (TDG) Information:
www.tc.gc.ca/civilaviation/commerce/dangerousgoods/aboutus.htm
The International Air Transport Association (IATA)
Dangerous Goods Regulations Manual can be purchased at:
www.iata.org/ps/publications/9065.htm
The International Civil Aviation Organization (ICAO)
Technical Instructions for the Safe Transport of Dangerous
Goods by Air can be purchased at:
www.icao.int/anb/FLS/DangerousGoods/flsdg.cfm
The use of windshield washer fluid, aviation fuel or any
other type of non-approved fluid is not recommended.
These products have not been tested by any manufacturer
and will not guarantee any degree of protection from
snow or ice accumulation. Aviation fuel has been known
to damage windshields, causing them to turn “milky,” not
to mention the increased fire risk. An engine stack fire
during a cold start could ignite these fuel vapours quickly.
Other non-approved fluids can cause damage to rubber
seals and paintwork, necessitating expensive repairs.
Recommended de-/anti-icing practices for
small aircraft operators
The key for smaller owners/operators regarding de-/anti-icing is prevention. Having a suitable hangar,
or wing covers and tail covers, can save time and money
when it comes to de-/anti-icing your aircraft. Many
owners/operators do not have hangar space, but utilize
wing and tail covers in winter to reduce their de-/antiicing times and expenses. They are great for frost, ice and
snow coverage, but can “sweat” under certain atmospheric
circumstances, and cause the covers to freeze to the
surfaces they are protecting when the temperature drops
again. These conditions are rare, and generally the covers
are convenient for most small aircraft owners/operators.
Installation usually requires two people, but can be done
alone with a bit of practice. The covers should come off
at approximately the same time. Removing one side and
then the other to save time may lead to an accumulation
ASL 4/2006
Maintenance and Certification
Operators and pilots involved in de-/anti-icing operations
are to familiarize themselves with the CLC Part II and
AOSHR references, with particular emphasis placed
on those sections dealing specifically with hazardous
substances. In addition, Transport Canada’s TP 14052E,
Guidelines for Aircraft Ground Icing Operations, should be
reviewed for recent developments and issues pertaining to
aircraft ground icing operations.
in approved containers. Training must be conducted in
accordance with an approved training program and most
importantly, no holdover time (HOT) exists. For more
info, access:
Winter Operations
Maintenance and Certification
by Paul A. Johnson, Civil Aviation Safety Inspector, General Aviation, Civil Aviation, Transport Canada
Accident Synopses
Accident Synopses
Storage, Labelling, Handling and Application of De-/Anti-Icing Fluids in Canada
After de-icing, if anti-icing is required, spray on the
correct amount, usually between 1 mm and 3 mm. Do not
coat the critical surfaces with too thick a layer, as this may
cause aerodynamic problems after takeoff; too thin a layer,
and the fluid may not achieve the specified HOT values.
The fluid manufacturer will have instructions on proper
coverage.
Using a small sprayer to de-ice a larger aircraft, such as a
business jet, is not practical. The amount of fluid required
to correctly apply de-icing fluid can be quite large.
Typically, a small business jet requires 45 to 60 litres (12
to 15 U.S. gallons) or more to de-ice, depending on the
amount of frozen contamination to be removed. Using a
hand sprayer to apply anti-icing fluid is not recommended
either because the time involved would erode valuable
HOT. Remember, the HOT starts at the commencement
of the anti-icing procedure.
The fluids that have been developed are called Type I, II,
III, and IV.
Type I fluid was developed initially, and is used primarily,
as a heated de-icing medium. It is also used by smaller
Accident Synopses
Winter Operations
Type III fluid was developed as an anti-icing fluid similar
to Type II fluid; however, its use is intended for aircraft
with rotation speeds over 60 kt and ground acceleration
times exceeding 16 seconds.
Type IV fluid was developed as an anti-icing fluid similar
to Type II fluid but with greater HOT qualities. Its use
is also for aircraft with rotation speeds in excess of 100 kt
and ground acceleration times greater than 23 seconds.
When spraying to de-/anti-ice your aircraft, confirm
that the fluid being used is appropriate for your aircraft
type. A check in the pilots operating handbook (POH),
aircraft flight manual (AFM), or with the manufacturer,
will tell you which fluid is appropriate for your aircraft. Be
sure to follow the instructions. Generally, smaller aircraft
are limited to Type I fluid. A Type III fluid has been
developed for smaller aircraft; however, it is only available
in limited regions. It is anticipated that this fluid will be
more widely available in the next few years. The advantage
of Type III fluid is that it contains some thickeners
to increase HOT. Be sure your aircraft manufacturer
recommends the use of Type III fluid before you use it.
Some pilots believe that any fluid can be used on an
aircraft. This is not true. Do not use Type II or Type IV
fluid on an aircraft that this fluid is not approved for.
De-/anti-icing fluids are only required until the aircraft
becomes airborne, after which the on-board de-/antiicing systems operate. The rotation speed of an aircraft
is important, as this determines which de-/anti-icing
fluid should be used. Serious aerodynamic consequences
can result from incorrect fluid use. The result could be
disastrous, as the fluid will not shear off (blow off ) on the
take-off run, which may cause aerodynamic problems just
after takeoff.
ASL 4/2006
25
Maintenance and Certification
Maintenance and Certification
Placing de-/anti-icing fluid close to a high heat source,
such as a Janitrol heater, creates a fire hazard and is not
acceptable. If no such space is available, then sufficient
quantities should be made available at away bases.
Type II fluid was developed as an anti-icing protection,
and is still in use today. The thickening properties of this
fluid extend HOT compared to Type I fluid; however,
its use is intended for aircraft with rotation speeds in
excess of 100 kt and ground acceleration times greater
than 23 seconds. See When in Doubt...Small and Large
Aircraft—Aircraft Critical Surface Contamination Training
for Aircrew and Groundcrew (TP 10643), Chapter 3,
paragraph 41, “High Speed Test.”
Winter Operations
In some instances, small aircraft operators carry de-icing
fluid on board their aircraft while traveling to remote
locations where no de-/anti-icing facilities are available.
The fluids carried must be tied down in a suitable
location and labelled correctly in a secured container.
Most garden-type sprayers are not suitable as a storage
container, as they tend to leak from the pressure changes
of a flight evolution. This would create a hazardous
situation in the aircraft, a slipping risk for the crew, and
a potential environmental accident. A recommended
practice would be to carry the fluid in an appropriatelysecured, labelled container on board the aircraft with an
empty garden type sprayer on board as well (or located
at the remote destination), and mix the appropriate
concentration at the destination, using hot water. If
possible, look for a sprayer with an immersible heater
that can heat the de-icing fluid to the recommended
temperature for application. Remember, it is the heat
and spray force that melts the ice. Heated sprayers are
available from aircraft supply stores.
aircraft (rotation speeds over 60 kt and ground
acceleration times exceeding 16 seconds), for de-/antiicing; however, the protection is for a short period of time.
See When in Doubt...Small and Large Aircraft—Aircraft
Critical Surface Contamination Training for Aircrew and
Groundcrew (TP 10643), Chapter 3, paragraph 42, “Low
Speed Test.”
Accident Synopses
of frozen contaminants on the side that was exposed to
the elements first, and the pilot may not notice, or may
fail to recheck for, these contaminants.
Active frost
Where conditions are such that frost, ice or snow may
reasonably be expected to adhere to the aircraft, no
person shall conduct or attempt to conduct a takeoff in an
aircraft unless
(a) for aircraft that are not operated under Subpart 5 of
Part VII,
Maintenance and Certification
If you use a holdover table for guidance, use the correct
table for the fluid being used. There are some differences
between fluids produced, and the holdover tables address
specific fluids. Using the incorrect holdover table will lead to incorrect values for the integrity of the fluid and
your HOT.
The National Aeronautics and Space Administration
(NASA) Glenn Research Centre in Cleveland, Ohio,
has two excellent products on aircraft ground and inflight icing entitled, A Pilot’s Guide to Ground Icing and A
Pilot’s Guide to In-Flight Icing on their Web site located
at: http://aircrafticing.grc.nasa.gov/.
In certain cases, where cold snow is falling on a cold wing
and definitely not accumulating or adhering to the critical
surfaces, it may not be necessary to de-/anti-ice; however,
be prudent and double-check the critical surfaces to
ensure that no contamination is adhering or accumulating
on them. This can only be done on the walk-around while
conducting a tactile (touch) inspection of the surfaces.
Be extra careful at night or during times where visibility
is restricted, as visual detection can be impossible. Tactile
inspection is the only positive method to ascertain the
condition of the critical surfaces.
The most recent update, due in late 2006, includes a
section on de-/anti-icing general aviation aircraft.
Various methods to remove contamination were discussed
in the ASL 3/2005 article, so readers may want to read
it again. When removing frozen contamination from
the critical surfaces, also ensure that all elevator, aileron,
and flap, etc., hinge lines are clean to avoid these surfaces
refreezing after takeoff.
Flying a smaller aircraft type in the winter can provide
a great opportunity to fly in smooth, clear weather
conditions; however, these conditions can deteriorate
quickly.
Use all the resources available to you—Internet, airport
personnel or local weather—to determine ground-icing
factors. Sometimes the best decision is “don’t go”…your
life may depend on it.
CAUTION
Anti-icing fluids (Types II and IV) have been known to
remain in aerodynamically quiet areas such as elevator,
aileron, and flap, etc., hinge lines after takeoff. They may
re-freeze while airborne, causing control restrictions or
flutter. Be aware of the manufacturer’s recommendations
to inspect and clean these areas after anti-icing to
ensure no fluid remains trapped. To date, no re-freezing
problems have been recorded with Type I fluids.
26
ASL 4/2006
When you push
the weather
and get into trouble,
remember who
put you there.
Maintenance and Certification
(ii) the operator has established an aircraft
inspection program in accordance with the
Operating and Flight Rules, Standards, and
the dispatch and takeoff of the aircraft are in
accordance with that program.
The above conditions, combined with the VFR conditions
of clear sky and calm winds, enhance the chance for active
frost. If you choose to take off in these conditions, you
will have to de-ice with Type I fluid, and anti-ice with
Type II or Type IV. Owners of smaller aircraft types,
unable to use Type II or IV fluid, can de-ice with heated
Type I fluid, then reapply Type I fluid as an “anti-ice” a
second time to create a fresh layer of protection and some
additional HOT.
Winter Operations
Winter Operations
(i) the aircraft has been inspected immediately
prior to takeoff to determine whether any
frost, ice or snow is adhering to any of its
critical surfaces, or
Active frost normally occurs at night when aircraft
surfaces are at or below freezing (0°C) AND at or below
the dew point. Therefore, expect active frost conditions
when the temperature-dew point spread is small, within
about 2°C, and the dew point and aircraft temperatures
are below freezing. Active frost will actively grow in
mass and thickness, and will continue to form after being
removed; whereas inactive frost, such as hoar frost, can be
removed and normally will not form again.
Accident Synopses
Accident Synopses
Remember, Canadian Aviation Regulation (CAR)
602.11(4) states (for non-airline operations):
In Canada, flying during the winter brings many challenges. Everyone who has driven a car on a slushy highway—or
walked on an ice-covered sidewalk—knows that we need to be extra careful when weather conditions are poor. In
addition to the problems of runway contamination, we also need to ensure that the aircraft’s critical surfaces are not
contaminated with frost, ice or snow.
For years, most pilots have understood that visible ice contamination on a wing can cause severe aerodynamic and
control penalties. The continued occurrence of icing-related accidents makes it apparent that some pilots do not
recognize that even minute amounts of ice adhering to a wing can have disastrous consequences. As far as frost, ice
or snow adhering to the aircraft’s critical surfaces is concerned, no amount is acceptable. Contamination makes no
distinction between large aircraft, small aircraft or helicopters. The performance penalties and dangers are just as real. As winter approaches, it is a good idea to take a few moments to review flight operations during icing conditions. To
help you prepare for this winter’s challenges, here are a few questions that will illustrate some of what you need to know. The questions have been divided into two groups. Part A consists of general knowledge questions that are applicable
to all pilots. The questions in Part B are intended for the operators of larger and more complex aircraft that operate in
ground icing conditions.
For your convenience, references and associated links have been provided. The answers to these questions can be found on page 38.
TP 10643 When in Doubt...Small and Large Aircraft—
Aircraft Critical Surface Contamination Training for Aircrew and Groundcrew
Winter Operations
Winter Operations
by Captain Robert Kostecka, Civil Aviation Safety Inspector, Foreign Inspection, International Aviation, Civil Aviation, Transport Canada
Accident Synopses
Accident Synopses
How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions
www.tc.gc.ca/CivilAviation/general/Exams/guides/tp10643/how.htm
Canadian Aviation Regulations (CARs)
www.tc.gc.ca/civilaviation/RegServ/Affairs/cars/menu.htm
www.ntsb.gov/PressRel/2004/041229.htm
Maintenance and Certification
Maintenance and Certification
NTSB Advisory—Alert to Pilots: Wing Upper Surface Ice Accumulation
Part A: General Knowledge
1. Which of the following accidents was caused by ice
on the aircraft’s critical surfaces?
a) January 13, 1982: An Air Florida Boeing 737-200
crashed into the 14th St. Bridge and the Potomac
River, and sank shortly after taking off from
Washington National Airport. There were 74 fatalities.
b) March 10, 1989: An Air Ontario F28 crashed during
takeoff from Dryden, Ont. There were 24 fatalities.
(This crash resulted in a major investigation that
led to the Air Regulations changes that are in place
today.)
c) January 4, 2002: A Canadair Challenger crashed
during takeoff from Birmingham, England. All 5 on
board were killed.
2. For the purpose of aircraft icing, which of the
following are considered to be the aircraft’s “critical
surfaces”?
a) The wings, rotors and propellers.
b) Control surfaces, horizontal stabilizers, vertical
stabilizers or any other stabilizing surface of an
aircraft.
c) In the case of an aircraft that has rear-mounted
engines, the upper surface of the aircraft’s fuselage.
d) All of the above.
Ref.: CAR 602.11—Aircraft Icing
d) All of the above.
Ref.: TP 10643 Chapter 1, “Air Law, The Clean Aircraft Concept”
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Accident Synopses
Which of the following statements is correct?
a) A thin layer of frost may not be a problem. This is
a matter of judgement and airmanship. Takeoff is
possible in this situation. The Canadian Aviation
Regulations (CARs) only prohibit takeoff when the amount of ice, snow or frost will adversely affect safety.
With respect to this situation, which of the following
statements is correct?
b) The CARs prohibit persons from conducting or
attempting to conduct a takeoff in an aircraft that
has frost, ice or snow adhering to any of its critical
surfaces such as wings and propellers. This is called
the “clean aircraft concept.”
c) Research results have shown that fine particles
of frost or ice the size of a grain of table salt and
distributed as sparsely as one per square centimetre
over an airplane wing’s upper surface can destroy
enough lift to prevent that airplane from taking off.
d) Both b) and c) are correct.
4. Which of the following statements concerning frost
is correct?
a) Research results have shown that fine particles
of frost or ice the size of a grain of table salt and
distributed as sparsely as one per square centimetre
over an airplane wing’s upper surface can destroy
enough lift to prevent that airplane from taking off.
b) CAR 602.11(3) states: “…a person may conduct a
take-off in an aircraft that has frost adhering to the
underside of its wings that is caused by cold-soaked
fuel, if the take-off is conducted in accordance with the
aircraft manufacturer’s instructions for take-off under
those conditions.”
d) None of the above is correct.
Ref.: NTSB Advisory—Alert to Pilots: Wing Upper Surface Ice Accumulation
TP 10643 Chapter 2, “Theory and Aircraft Performance—
Frozen Contaminants”
CAR 602.11(3)
a) In this situation, you should keep quiet and trust that
everyone is doing their job. If the crew thought that
de-icing was necessary they would do it. This is not
your concern.
b) You should tell a flight attendant that there is frost on
the wings. If a flight attendant observes that there is
frost, ice or snow adhering to the wings of the aircraft,
the CARs require that they must immediately report
that observation to the pilot-in-command. The pilotin-command or a flight crew member designated by
the pilot-in-command must inspect the wings of the
aircraft before takeoff.
c) Before an aircraft is de-iced or anti-iced, the pilot-incommand of the aircraft must ensure that the crew
members and passengers are informed of the decision
to do so.
d) Both b) and c) are correct. Ref.: CAR 602.11(6)
CAR 602.11(7)
Aviation Safety Letter 1/2004
Part B: For Operators of Aircraft That Operate
in Ground Icing Conditions
1. With respect to holdover times, which of the
following statements is true?
a) Holdover time tables are referred to as holdover time
“guidelines” because this term more appropriately
represents their function in providing guidance to
flight crew and the need for the flight crew to use
judgment in their interpretation.
b) Holdover time guidelines provide an estimate of the
length of time anti-icing fluids will be effective.
c) The actual time that a fluid is effective can be less
than that published in the holdover time guidelines.
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Maintenance and Certification
Maintenance and Certification
Ref.: CAR 602.11—Aircraft Icing
TP 10643 Chapter 1, “Air Law, The Clean Aircraft Concept”
NTSB Advisory— Alert to Pilots: Wing Upper Surface Ice Accumulation
c) Both a) and b) above are correct.
As you take your seat, you notice that there is frost
on the wings. The captain welcomes everyone aboard
and says that because there is no traffic ahead on
the taxiway, he expects to be airborne very quickly.
He makes no mention of de-icing. You don’t feel
comfortable about the frost.
Winter Operations
Winter Operations
5. You are travelling as a passenger on an airliner.
Your flight has been delayed several hours because
of a mechanical problem. The passengers are quite
annoyed. Eventually, the airline has another aircraft
towed to the gate. Accident Synopses
3. It is a bright, crisp, clear winter day, and you are
the pilot of a light training aircraft. You and your
passengers are anxious to get underway. During the
walk-around, you notice that there is a thin layer of
frost on the upper surface of the wings.
Accident Synopses
4. With respect to SAE Type IV fluids, which of the
following statements is correct?
d) All of the above statements are true.
Ref.: TP 10643 Chapter 2, “Theory and Aircraft Performance—
Frozen Contaminants”
2. With respect to holdover times, which of the
following statements is true?
b) The capability of anti-icing fluid to tolerate a heavy
snowfall rate has not been evaluated; therefore
holdover times for heavy snow conditions have not
been generated.
c) Both a) and b) above are true.
d) None of the above is true.
Ref.: TP 10643 Chapter 2, “Theory and Aircraft Performance—
Frozen Contaminants” a) SAE Type I (orange) fluids are used for de-icing
or anti-icing, but provide very limited anti-icing
protection.
b) It is the heat contained by the Type I (de-ice) fluid
and the hydraulic forces that remove the frozen
contaminants.
c) Extra vigilance is required by flight crews when
conducting operations after spraying with Type I
fluids only. Flash freeze over (fluid failure) can occur
in a very short period of time after the holdover time
expires, even in very light precipitation conditions.
This results in a contaminated critical surface and an
unsafe condition for flight.
c) Both a) and b) are correct
d) None of the above.
Ref.: TP 10643 Chapter 3, “Deicing/Anti-icing Fluids—
Fluid Properties”
5. An exemption to CARs 602.11(1) and (2) has been
issued. The purpose of this exemption is to permit
Canadian air operators and foreign air operators in
Canada, utilizing aircraft with engines mounted on
the rear of the fuselage, to conduct a takeoff with
hoar-frost on the fuselage only, after it has been
determined that no other contamination is adhering
to the fuselage.
What are the conditions of this exemption?
a) Hoar-frost shall be the only acceptable contaminant
on the fuselage of aircraft with engines mounted on
the rear fuselage.
b) Prior to conducting a takeoff, the operator shall
ensure that the hoar-frost is not mixed with other
contaminants such as ice or snow. If any other
contaminant or contaminants are on the fuselage, the
operator shall de-ice the entire fuselage.
c) A copy of this exemption shall be attached to
the aircraft de-icing/anti-icing procedures in the
operator’s manual.
d) All of the above.
Ref.: TP 10643 Chapter 1, “Air Law, The Clean Aircraft Concept”
d) All of the above.
Ref.: TP 10643 Chapter 3, “De-icing/Anti-icing Fluids—Fluid Properties”
2006–2007 Ground Icing Operations Update
In July 2006, the Winter 2006–2007 Holdover Time (HOT) Guidelines were published by Transport Canada. As per
previous years, TP 14052, Guidelines for Aircraft Ground Icing Operations, should be used in conjunction with the HOT
Guidelines. Both documents are available for download at the following Transport Canada Web site: www.tc.gc.ca/
CivilAviation/Commerce/HoldoverTime/menu.htm. If you have any questions or comments regarding the above, please contact
Doug Ingold at INGOLDD@tc.gc.ca.
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Maintenance and Certification
3. With respect to SAE Type I (de-ice) fluids, which of
the following statements are correct?
b) Type IV anti-icing fluid is dyed emerald green to
provide for application of a more consistent layer of
fluid to the aircraft and to reduce the likelihood that
fluid will be mistaken for ice.
Winter Operations
Winter Operations
a) Aircraft anti-icing fluid holdover times have not been
evaluated under moderate and heavy freezing rain
conditions.
a) Type IV anti-icing fluids should only be used on
aircraft with rotation speeds (Vr) above 100 kt.
Accident Synopses
Factors including strong winds and jet blast may
reduce holdover times.
The Aircraft Certification Branch, Engineering Division............................................................................................... page 30
Inadequate Identification of Fuel Barrels......................................................................................................................... page 31
Aircraft Maintenance Operational and Functional Checks............................................................................................ page 32
Tool Control Reminder...................................................................................................................................................... page 34
The Aircraft Certification Branch, Engineering Division
by the Engineering Division, Aircraft Certification, Civil Aviation, Transport Canada
The Aircraft Certification Branch is one of the largest
in Civil Aviation in the National Capital Region, with a
staff of about 150 in eight divisions. With approximately
40 engineers, the Engineering Division is the largest
within the Branch and is grouped in six specialty areas,
representing a diverse set of technical skills, expertise
and abilities—Avionics & Electrical, Fuel & HydroMechanical Systems, Structures, Powerplants &
Emissions, Electronic Equipment Design Assurance
(Software) and Occupant Safety & Environmental
Control Systems.
These specialties are required to support the Aircraft
Certification Branch in approving the type design
of aeronautical products, otherwise known as “Type
Certification.” The products approved range from large
transport aircraft and rotorcraft to small two-seater
aircraft and the engines that power them.
“Safe skies start with safe aircraft, and safe aircraft start
with safe designs.” This phrase captures the essence of the Branch’s and the Division’s raison d’être.
Although many of the engineers in this Division have
engineering degrees and extensive industry experience
in the design of aircraft, aircraft systems, engines and
components, our role is not to design aircraft. We are
in the “design assurance” business and we work with
our Canadian aerospace industry to understand their
product designs, and validate that these designs meet
the internationally-accepted design standards. When
this is confirmed, the Director, Aircraft Certification
Branch, will issue a “Type Certificate,” which signifies
that the design meets comprehensive safety and
emissions standards.
This type certification function is one of many
related activities. We are also involved in the review
and acceptance of foreign-designed aircraft and
engines; participate in the development of the design
standards in harmonization working groups with
other foreign authorities, such as the U.S. Federal
Aviation Administration (FAA) and the European
Aviation Safety Agency (EASA); are involved with the
Continuing Airworthiness Division in reviewing the
30
How we do our job
We typically work in project teams, internally within
Transport Canada Civil Aviation (TCCA), and externally
with industry. For a new aircraft program, there will be at
least one engineer from each engineering section, with a
flight test pilot and engineer, and a project manager who
leads the team. This team works closely with the industry
engineering specialists, and delegates who are responsible
for designing and demonstrating that the new aircraft
design meets the regulatory requirements.
The certification program for a new transport-category
aircraft can take up to five years, and for an engine
the program can take up to three years. Derivatives, or
changes, to these initial designs take less time, but can
use as many resources. As a result, at any one time, an
engineer within the Engineering Division could be a team
member on as many as ten or more certification programs
running in parallel, in addition to participating in the
other activities noted above. So, the ability to multi-task is essential.
Much of the time, our business is conducted at the
industry facilities, or industry engineers meet with us
in Ottawa, Ont. Typically, day-to-day communications
with the company specialists are done via phone,
videoconference, e-mail and increasingly, via web-based
data-sharing “portals” that allow the exchange of large
documents. Today, a lead company using “design partners”
in other countries creates most large aircraft. As a result,
it is not unusual to have Engineering Division specialists
travelling to witness a “cold soak” test of an aircraft in
Iqaluit, Nun., or a flight control system test in Germany,
or an electronic engine control test in the USA.
At the beginning of an approval program, the TCCA
engineering specialists will spend considerable time with
the industry delegates to understand the proposed design
and how the company proposes to show that the design
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Maintenance and Certification
Maintenance and Certification
What we do and why
impact of design deficiencies in certified aeronautical
products and determining the appropriate corrective
action; provide technical support to regional aircraft
certification engineers, inspectors and industry involved
in the modification and repair of aircraft in the Canadian
fleet; and assess and participate in the certification and
oversight of industry design approval delegates.
Winter Operations
Winter Operations
Who we are
Accident Synopses
Accident Synopses
maintenance and certification
Accident Synopses
Winter Operations
In summary
As an essential link in the establishment of a safe aircraft,
an engineer in the Engineering Division of the Aircraft
Certification Branch has a challenging job that offers
a unique opportunity to work with both Canadian and
foreign aerospace companies that design and manufacture
aircraft, rotorcraft, engines and associated systems.
Inadequate Identification of Fuel Barrels
An Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)
On July 16, 2005, a Bell 205 A-1 helicopter was engaged
in forest fire suppression and longline slinging operations
in the province of Quebec. While hovering with an
empty water bucket on a 100-ft longline, with the bucket
15 ft above the water, the pilot felt a vibration, heard a
bang, and the engine lost power. The aircraft quickly lost
altitude, pitched nose down and to the right, then struck
the water. The two pilots were able to exit the aircraft
before it sank and were rescued by nearby firefighters.
The pilot-in-command was seriously injured, and the
other pilot sustained minor injuries. The aircraft was
substantially damaged. The investigation into this accident
(A05Q0119) is ongoing.
of fuel are ordered from local wholesalers and delivered to
the nearest fire suppression operations staging area.
The Société de protection des forêts contre le feu (SOPFEU) is
responsible for the prevention, detection, and suppression
of forest fires in Quebec. During forest fire suppression
operations, SOPFEU will contract helicopters and other
aircraft to fulfill their operational needs. Barrels (205 L)
(Note: The Aeronautical Information Manual (AIM) section
AIR 1.3.2 Aviation Fuel Handling states in part: “...A
company supplying aviation fuel for use in civil aircraft is
responsible for the quality and specifications of its products up
to the point of actual delivery. Following delivery, the operator
is responsible for the correct storage, handling, and usage of
aviation fuel…”
The on-going investigation into this occurrence revealed
that the wholesaler had mistakenly delivered four barrels
of Avgas and 36 barrels of Jet A fuel, instead of 40 barrels
of Jet A fuel. It also revealed that workers loading the
product on the truck at the wholesaler’s yard and those
delivering the product to SOPFEU had mistakenly
identified the product. The pilots using the product
did not correctly identify it before fuelling. Two of the
four helicopter operators working from the staging area
mistakenly fuelled their aircraft with Avgas.
Although a number of turbine engines may burn Avgas
as emergency fuel for a limited time without a negative
outcome, it is not the case if the same mistake is made
while fuelling a piston engine aircraft with Jet fuel. The
B205 operations manual only authorizes the use of Jet A
or Jet B. The use of Avgas in this accident is not deemed
to have been contributory to the loss of engine power.
Photo 1: View of fuel barrels at base camp
The barrels delivered were all white, and all identifying
stickers were also white. The identifying stickers included
all the necessary information, as specified by provincial
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Maintenance and Certification
Maintenance and Certification
At the end of the approval program, based on the
company and delegate activities and the TCCA engineers’
involvement, the company will have demonstrated that
the design complies with the requirements and that there
are no unsafe features. At this point, the Type Certificate
can be issued.
Winter Operations
During the approval program, there is so much compliance
data generated, it would be impossible for TCCA
engineers to review it all, so there is significant reliance on
the capability and expertise of the industry designing the
product and the delegates. The TCCA engineer must use
a risk-based approach to determine where and when to
be involved in reviewing the compliance data—focussing,
for example, on critical safety areas, unusual designs or
technology, or compliance methods.
Accident Synopses
meets the applicable safety and emission standards. The
aircraft and system design, and the standards that must be
met, are very complex and the compliance demonstration
process is similarly complex. Depending on the design
feature, compliance with the design requirements may be
demonstrated by test, engineering analysis or inspection.
Both the tests and analyses can be very complex and
expensive, the interpretation of results can be difficult,
and pass/fail criteria are often subjective. This is where
“engineering judgment” comes in.
Accident Synopses
Winter Operations
Therefore, by provincial law, the 205-L barrels of Avgas
do not have to differ in colour from a Class 2 ( Jet fuel) or Class 3 product. Colour differentiation of the
identifying stickers is also not required. The different
products, concealed in the containers, and not visible to
the user, have a different colour and smell; Avgas is blue
and Jet fuel is yellow.
Photo 2: View of fuel barrel labels
The wholesaler need only ensure that the petrol product
they deliver meets provincial regulations, i.e. the container
must be cleaned, filled, and sealed on site; and identifying
stickers affixed on the container must include the date,
the type of product, batch number, and dangerous goods
information.
The use of fuel barrels for remote aircraft operations
is widespread throughout Canada. It is of the utmost
importance to ensure that the product not only be
identifiable by name, but that it also be distinguishable
from another petrol product in a more predominant
manner. The quality control of the petrol product provided
to an aircraft operator at an airport should also be assured
when operating at an aerodrome.
Aircraft Maintenance Operational and Functional Checks
by Norbert Belliveau, Civil Aviation Safety Inspector, System Safety, Atlantic Region, Transport Canada
Aviation maintenance is a very complex industry. We
aircraft maintenance engineers (AME) maintain every
type, model and size of heavier-than-air aircraft that are
flown in the world today.
On many occasions, our profession requires that we
perform certain tasks that may demand more alertness
and care than others. One such task relates to the aircraft
“static functional checks,” or as we would refer to them,
“ground runs.” Through training and experience, functional
checks or taxiing of an aircraft are performed safely and
without incident; however, when we are under pressure,
trying to meet schedule demands, fatigued, or being
affected by any other such contributing factor, a step can
easily be overlooked and the operation can end with a
much different outcome.
are only carried out on an irregular basis. The potentially
long interval between “ground runs” may have created a
certain “system layout” or “operational” uncertainty for the
AME in the cockpit. I believe pilots call this “currency”!
The operation of an aircraft holds a lot of responsibility.
Even if an individual has previously performed this task
many times, it only takes one very important step to
be forgotten or overlooked for a serious occurrence to
happen. The dynamic environment we operate in leaves
little room for error.
The following steps are a reminder for the AMEs prior to performing aircraft operational or functional checks.
Note that this does not, and is not meant to, replace the
aircraft’s pilot operating handbook (POH) operation
checklist.
Aircraft functional checks, such as power performances,
system deficiencies, compass swings, and engine washes,
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Maintenance and Certification
Contrary to federal regulations applicable for fuel
distribution at airports and aerodromes, provincial laws
do not require the container or the identifying stickers
to differ in colour, even though the product is different.
Therefore, the different petrol products can easily be
According to the Aeronautics Act, the base camp and
fuel cache from which the helicopters were operating
are considered an aerodrome. Distributors of a petrol
product at an aerodrome are subject to federal regulations
and must ensure that the type of product is specifically
identifiable by a given colour of container, pump, and/or label.
Winter Operations
Maintenance and Certification
mistaken and lead to fuelling an aircraft with the wrong
type of fuel. Avgas is considered a Class 1 petrol product,
and under existing provincial regulations, a Class 1
product over 45 L does not require any kind of colour
coding of the container. However, a container under 45 L,
containing a Class 1 product, must be predominately red
in colour.
Accident Synopses
regulations. The only difference between the two products
was the words “100LL Avgas” and “Jet A fuel.” (See photos 1 and 2 taken on site.)
1. Confirm inspection sheets/package are completed and appropriately signed off.
2. Check records/worksheets for any special attention
required during aircraft operation.
3. Confirm personnel are trained, current and
appropriately endorsed on type.
1. Always maintain communication with ground or
apron controller, and report intentions before moving.
2. Position aircraft into the wind for optimized engine
cooling.
3. Consistently monitor engine parameters from left to
right and top to bottom for irregularities.
4. Always remain within the aircraft operating
limitations. 5. Maintain professionalism in the cockpit.
Before start:
1. Always refer to the aircraft’s POH operation
checklist. Never rely on memory.
6. Do not RUSH!
7. Keep taxi speeds to a minimum.
2. Conduct a walk around of the aircraft and area for
foreign object damage (FOD), loose items, control
locks, inlet plugs, covers, chocks, tow-bars and tie
downs.
8. While taxiing, keep hands and feet on controls at all times.
4. Verify that the nose gear torque links attachment is
secure.
5. Verify all the aircraft fluid levels. Take fuel samples, as
appropriate.
9. Be familiar with the location of on-board fire
extinguishers.
10. Verify brake operation.
11. Be familiar with the aircraft communication
equipment, frequencies, and radio licence
requirements.
9. Be prepared to shut down the engines.
Secure the aircraft:
1. Again, refer to the aircraft’s POH operation checklist.
Never rely on memory.
2. Follow the recommended engine cool down period.
3. Ensure all switches are turned off, and breakers are
checked.
4. Visually check fluid levels and surrounding areas for
fluid leaks.
5. Properly secure the aircraft.
As professionals, we must always try to lead by example.
So remember, the next time you are heading out to
perform an operational check or taxiing, once the main
aircraft cabin door is closed and you are sitting at the
controls, it is now you, the environment and that precious
aircraft!
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Maintenance and Certification
Maintenance and Certification
3. Check for personnel or parked aircraft nearby.
Reposition the aircraft to prevent damage or injuries.
8. Place a fire extinguisher nearby, and have trained
personnel on visual watch, as required.
Winter Operations
Winter Operations
5. Take along a copy of the aerodrome diagram for reference [from Canada Airport Charts on the NAV CANADA Web site, or from the Canada Air Pilot (CAP)].
7. Check that all breakers and fuses are set.
13. Be familiar with the aircraft emergency procedure
checklist.
During operation and taxiing:
4. Be familiar with airport operator’s policies,
procedures/practices, aprons, signage, runways, and designated ground run areas.
6. Ensure all panels and engine cowlings are in place
and secured, as required for engine operation.
12. Always carry a reliable flashlight when doing
functional checks at night.
Accident Synopses
Accident Synopses
Before the task:
Tool Control Reminder
possibility that it was left in the aircraft, in the same way a surgeon would leave a clamp in the body of a patient (it DID happen...). It takes a
strong work ethic and applied
discipline to achieve a perfect
tool management system, and
thankfully, licensed aviation
personnel have already
demonstrated those traits.
A meticulously maintained tool control board enhances safety
The picture above shows an example of a well- executed
tool management system, or tool control board, in an
aircraft maintenance engineer’s (AME) shop on the east
coast. The Regional Aviation Safety Officer—Maintenance
in Moncton, N.B., Mr. Norbert Belliveau, reports that,
“ since we introduced the Aviation Maintenance Tool
Management CD-ROM, many more AMEs and pilotowners have undertaken to improve their tool control
significantly.”
The purpose of a truly disciplined and regimented tool
management system in aviation is to ensure all tools,
without exception, are accounted for before and after
every job, and that one tool does not go missing, with the
Your tool management system
should allow you to immediately
notice if a tool is missing after all
tools are put back in place, either
through a numbering system, tool
shadows on the board, colourcoding, or combinations of all
three. A complete aviation tool
inventory check must be done
before and after every job. Keep
your aviation tools separate from
your home tools—we all know the hammer and the visegrip can go missing at home, but aviation wrenches and
wire-cutters must always be accounted for.
The Aviation Maintenance Tool Management CD-ROM (TP 14123) is an educational package aimed
at the aerospace industry, and can be used in the teaching
of methods to control foreign object damage (FOD) in
the various working environments that aircraft engineers
and technicians work in. This CD contains a PowerPoint
presentation and the video, Foreign Object Damage
(TP 14087). Order it today from Transact, the online
storefront for Transport Canada publications at www.tc.gc.
ca/transact/, or by calling Transport Canada’s Order Desk
at 1-888-830-4911.
Civil Aviation Safety Inspector’s (CASI) Toolkit CD
Ever wonder what work tools Civil Aviation Safety Inspectors use in the field? One such tool is the CASI Toolkit CD.
The CD contains regulations, guidelines, standards, and forms in a powerful, searchable database. In most cases, the documents are also in PDF format. Transport Canada has also recently decided to terminate the issuance of the Canadian Aviation Regulations (CARs) CD and allow all industry users to order the same CD that is issued to Civil Aviation Safety Inspectors every six months.
The CASI Toolkit CD (TP 12916) is available for purchase from Transport Canada’s online publications storefront at
by calling Transport Canada’s Order Desk at 1 888 830-4911. You can order either a single
copy ($35.00, which includes shipping, but excludes applicable taxes), or take out a subscription for future copies to be
automatically shipped to you.
www.tc.gc.ca/transact, or
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ASL 4/2006
The Civil Aviation Medical Examiner
Regulations and You
Did you know that, by law, all physicians in Canada must inform a Regional Aviation Medical Officer (RAMO) of any pilot,
air traffic controller or flight engineer who has a medical condition that could adversely affect flight safety? (Note—for purpose
of this article the term “medical certificate (MC) holder” will be used to apply equally to pilots, air traffic controllers and flight
engineers, unless otherwise stated.)
Subsection 6.5(2) of the Aeronautics Act requires that:
The holder of a Canadian aviation document that imposes
standards of medical or optometric fitness shall, prior
to any medical or optometric examination of his or her
person by a physician or optometrist, advise the physician
or optometrist that he is the holder of such a document.
Therefore, as a MC holder you must inform any
physician—not just your Civil Aviation Medical
Examiner (CAME)—of your status before each
examination or treatment. Your physician must consider
whether your condition or treatment would constitute
a hazard to aviation safety, and if this is likely, inform a
medical adviser designated by the Minister (the RAMO)
of that opinion and the reasons behind it.
You should also remember that under Canadian Aviation
Regulation (CAR) 404.06, Prohibition Regarding Exercise
of Privileges, MC holders who know, or are informed,
that they have a condition (or are prescribed treatment)
that might make it unsafe to perform their duties, must
“ground” themselves temporarily.
In some cases, a physician may choose to report a
suspected unfit MC holder confidentially—without
informing the individual. This is more likely to occur
where no on-going relationship exists between the
physician and MC holder, for example during or after an
emergency room visit.
Once a report under section 6.5 of the Aeronautics Act has
been made, it is the RAMO’s responsibility to take further
action. Although Transport Canada may use the reported
information as necessary to ensure aviation safety, the
report itself is privileged and cannot be used as evidence
in any legal, disciplinary or other proceedings. When
If your name and condition were reported confidentially,
you would likely receive a registered letter from the
RAMO requesting further clinical reports to assess your
condition. You would also be reminded of your obligation
not to fly (CAR 404.06) pending a decision in your case.
Canadian physicians are currently being reminded of
their responsibilities for reporting, and given some
guidance on the types of medical problems that might
warrant restrictions. Here are some of the symptoms and
conditions to be considered, listed by system (abridged list):
Vision
Conditions where visual impairment is temporary or
vision is temporarily affected by the use of medications
need not be reported. The MC holder should be warned
not to fly until normal vision has returned.
Reportable:
Diplopia (double vision); monocularity; altered visual
fields; eye injuries or retinal detachment; cataract
surgery; surgical correction of myopia, including
radial keratotomy (RK), photorefractive keratectomy
(PRK), laser-assisted in-situ keratomileusis (LASIK)
or other refractive eye surgery.
Ear, nose and throat
Significant deterioration in hearing must be reported. Any condition affecting balance or spatial orientation
must be reported.
Reportable:
Sudden loss of hearing, or conditions significantly
affecting hearing; middle-ear conditions; damage
to the tympanic membranes (ear drum) or the
Eustachian tubes; any condition affecting or
impinging upon the inner ear or the vestibular
(balance) organs; stapedectomy and other ear
surgery; surgery affecting the nasal passages, sinuses
or Eustachian tubes; conditions leading to voice
distortion or inaudibility.
ASL 4/2006
35
Debrief
If uncertain whether a hazard exists, your physician can
discuss your case with the RAMO hypothetically—
without revealing your identity—until it appears necessary
that a flying restriction may be necessary. This does not
necessarily mean that your medical certificate will be
suspended; however, the RAMO will make inquiries to
confirm whether you remain medically fit. If the condition
or treatment is self-limited, you would be advised not to
fly until after recovery.
you sign the “Statement of Applicant” on a Medical
Examination Report, this is considered as your consent
for giving information to a medical adviser designated by
the Minister when required under the Act.
Regulations and You
Debrief
Mandatory Reporting of Unfit Pilots, Air Traffic Controllers and Flight Engineers
The Civil Aviation Medical Examiner
the civil aviation medical examiner and you
Nervous system
Disorders of the central nervous system can be a potent
source of occult incapacitation. Lapses of consciousness or
memory in the aviation environment can be fatal.
Reportable: Syncope (fainting); unexplained loss of consciousness,
whatever the cause; seizure disorders; any significant
head injury, unconsciousness or post-traumatic
amnesia; sleep disorders of any type; migraine with
aura; severe or prolonged headaches; disorders of
coordination and muscular control.
Respiratory
Gradual deterioration of the respiratory system over the
years may not be obvious, particularly if the pilot does
not complain, or is using bronchodilator medications.
Physicians treating MC holders must remain alert to
the risk of hypoxia and trapped gas expansion (e.g.
pneumothorax) when deciding upon treatment.
36
The Civil Aviation Medical Examiner
Regulations and You
Renal system
Reportable: Renal colic (kidney or bladder stones); renal failure;
renal transplantation.
Musculoskeletal system
Reportable: Recent amputation of a limb or part of a limb;
arthritis treated with second- or third-stage
medications (e.g. Gold, azathioprine).
Psychiatric disorders
The level of tolerance for mental disorders or disease
is small. Even when symptoms are effectively treated,
the side effects of psychoactive drugs, such as selective
serotonin reuptake inhibitors (SSRI) are usually
unacceptable.
Reportable: Cognitive disorders; dementia; psychosis; bipolar
affective disorder (manic-depressive); emotional
disorders that require drug therapy or may interfere
with judgment, decision making or reaction time.
Tumours
Reportable: Any tumour that limits the ability of a MC holder to perform safely; tumours that may metastasize to
the brain.
HIV/AIDS
Reportable: Positive test for HIV; diagnosis of AIDS.
ASL 4/2006
Debrief
Debrief
Other vascular disorders
Reportable: Aortic aneurysms; surgical repair of an aneurysm;
deep venous thrombosis.
Metabolic
Reportable: Diabetes mellitus—type 1 diabetes (insulindependent) when first diagnosed (pilots and air
traffic controllers requiring insulin are considered on
an individual basis); type 2 diabetes (non-insulindependent) on first requirement for hypoglycemic
drugs, changes in type or dose of medication or
hypoglycemic attacks requiring treatment; initial
diagnosis or significant changes in treatment of
thyroid and parathyroid disease; pituitary or adrenal
disease.
Regulations and You
Cerebrovascular MC holders who show any evidence of memory loss, poor
concentration or diminished alertness must be reported.
Reportable: Transient ischemic attack (TIA) or cerebral artery
stenosis that has led to confusion, disturbance of
vision, attacks of vertigo or loss of consciousness;
stroke or any other cerebrovascular accident.
Reportable:
Spontaneous pneumothorax, lung cysts or other
conditions that may lead to problems with expansion
(this may be of less significance in air traffic
controllers); chronic obstructive pulmonary disease;
significant decreases in pulmonary function or
oxygen saturation; asthma—increasing requirements
for inhaled bronchodilators or steroids; pulmonary
embolism; sarcoidosis.
The Civil Aviation Medical Examiner
Cardiovascular The appearance of cardiovascular signs or symptoms
is of great concern and must be discussed with the
RAMO. Even benign cardiac rhythm disturbance can
cause distraction that, during critical phases of flight,
may cause an incident or accident. Medications to treat
blood pressure with side effects of fainting/postural
hypotension, arrhythmias or effects on the central
nervous system are unacceptable.
Reportable:
Cardiac inflammation and infection; acute ischemic
syndromes (heart attack, angina); revascularization
surgery (bypass or angioplasty, including stent
insertion); initial treatment of hypertension with
medication; symptoms of low blood pressure; new
heart murmurs; significant heart disease; repair or
replacement of heart valves; premature contractions;
tachyarrhythmias (fast heart rhythms); bradycardia
(slow rates) with symptoms; fibrillation; heart block
and bundle branch blocks; pacemakers.
The Civil Aviation Medical Examiner
Regulations and You
There is no general rule about how long a MC holder
should be grounded after receiving a general anesthetic.
It depends on the type of surgery, premedication, and
the anesthetic agent. Physicians should be aware that the
effect of some anesthetics may take days to wear off, and
caution is recommended.
Adverse reactions to local anesthetic are uncommon after
the effect of the anesthetic has worn off, but in cases
where they have been used for extensive procedures, such
as the removal of several teeth, flying should be restricted
for a minimum of 24 hr. One must be aware that dental
surgeons sometimes prescribe long-acting tranquillizing
agents before surgery, as well as narcotic pain-killers for
post-operative discomfort.
Contact Information
If you have any questions regarding your personal medical fitness, they should be directed to either your CAME or
RAMO. Toll-free numbers for the regional medical offices are printed on the tear-off bottom section of your medical
certificate, as well as published on our Web site (under Contacts) at www.tc.gc.ca/CivilAviation/Cam/offices.htm.
Regulations and You
Note:
Physicians should discuss in detail the side effects of any
medication that is prescribed or recommended to pilots.
Minor side effects, for example, on visual accommodation,
muscular coordination, the gastrointestinal tract, or
tolerance to acceleration, may be more serious when they
occur in flight. If in doubt, the physician should discuss
the medication with the RAMO.
Generally, MC holders are advised to avoid taking any
medication within 12 hr (or, if longer-acting, within about
five half-lives) before a flight if pharmacological effects
may affect flying. Although there are exceptions to this
rule, caution is advised.
The Civil Aviation Medical Examiner
Drugs
Reportable:
MC holders who abuse or are addicted to alcohol or
other chemical substances.
The following references are available online:
The Aeronautics Act www.tc.gc.ca/acts-regulations/GENERAL/a/aa/act/menu.html.
Ground Collisions Give Us Warning
The photo on the left shows the result of a
spectacular ground collision on July 15, 2006 in
Madrid, Spain. The wingtip of a taxiing Boeing 747-400 sliced clean the T-tail of a stationary
Embrear 145 jet. Fortunately there were no injuries,
but there was significant stress for all involved.
A more tragic ground collision occurred on July 30, 2006, at AirVenture 2006 in Oshkosh,
Wisconsin. A small Van’s RV-6 homebuilt aircraft
was struck from behind on a taxiway by a larger
aircraft, a World War II era Navy Grumman TBM
Avenger. The Avenger’s propeller tore through the
tail of the RV and fatally injured the passenger. Both
occurrences are still under investigation, but they
serve as grim reminders to all pilots to keep an alert
eye outside and to mind our distances.
ASL 4/2006
37
Debrief
Debrief
Canadian Aviation Regulation (CAR) 404.06, Prohibition Regarding Exercise of Privileges www.tc.gc.ca/CivilAviation/Regserv/Affairs/cars/Part4/404.htm#404_06.
Answers to “How Much is Too Much?” Quiz
Part A: (1) d, (2) d, (3) d, (4) c, (5) d. Part B: (1) d, (2) c, (3) d, (4) c, (5) d.
There is no such thing as a little ice. In airline operations where large numbers of aircraft are dispatched, the process of assuring
that each flight will be safe must be a team effort. In smaller commercial and in private operations, the pilot may have to perform
all the functions. In all cases, the pilot-in-command is ultimately responsible for ensuring that the aircraft is in a condition for
safe flight. If the pilot cannot confirm that the aircraft’s critical surfaces are free of contamination, takeoff must not be attempted.
Answers to the Self-Paced Study Program (tear-off)
(40)climb back to the original altitude or to a higher level
(22)five
(39)10 000
(21)shall
(38)50
(20)CIRVIS report
(37)ordinary combustible materials
(19)No
(36)5; 6
(18)True; True; True; True
(35)5-year and 2-year; 6-month
(17)3/8 SM; light snow and drifting snow
(34)personal log
(16)270 degrees at 15 kt gusting to 25 kt
(33)60; 24
(15)one hour
(32)It is a replacing NOTAM.
(14)1 500; WS
(31)A replacing or canceling NOTAM is required.
(13)hatched areas enclosed by a dashed green line
(30)1530; December 15, 2006
(12)landing and takeoff; forecast weather elements
(29)Place the ELT function switch to “ON” as soon as possible after
the crash.
(11)123.45
(28)Position, altitude and time when signal was first heard; ELT
signal strength; position, altitude and time when contact lost; and
whether ELT signal ceased suddenly or faded.
(9) It conveys the ability to follow direct routings using GPS.
(10)No
(8) 15
(7) unreliable; it transmits
(6) will
(5) 15
(27)Inspect the ELT to ensure that it is secure, free of external
corrosion, and that the antenna connections are secure; ensure
that the ELT function switch is in the “ARM” position; ensure
that ELT batteries have not reached their expiry date; and listen
on 121.5 MHz to ensure the ELT is not transmitting.
(26)121.5
(4) “X”
(25)1-888-226-7277; two hours
(3) increase
(24)one hour
(2) incidents; potentially unsafe acts or conditions
(23)flight plan
(1) 30.27 Definitions of Interest…
“Reportable Service Difficulty” means any defect, malfunction or failure of an aeronautical product, component,
equipment or part affecting, or that, if not corrected, is likely to affect, the safety of the aircraft, its occupants or any
other person.
“Unapproved Part” means any part installed or intended for installation in a type certified aeronautical product, that
was not manufactured or certified in accordance with the applicable regulations of the state of production or that is
improperly marked or that is documented in such a manner as to mislead with regard to the origin, identity or condition of the part.
(Ref.: CAR Standard 591.01 - Service Difficulty Reporting Requirements)
38
ASL 4/2006
FOR CANADIAN RESIDENTS ONLY
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The Civil Aviation Medical Examiner
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 (2006).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
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with Canada Post and notify
Transport Canada at the same time.
The new Transport Canada Aeronautical Information Manual (TC AIM) was introduced in October 2005. All Canadian-registered pilots received two free paper copies, the last of which was delivered in April 2006. The next release of the TC AIM is scheduled for October 2006. There are a few options on how to subscribe to this publication:
Paid subscription to the paper copy
• Subscribe online to the paper copy by visiting Transport Canada’s online publications storefront at www.tc.gc.ca/transact. There, you can order either a single copy ($15.00, which includes shipping, but
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•
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and ask to be added to the TC AIM e-Bulletin list. Please state your name, postal address and e-mail address.
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada
A safety management system (SMS) is a structure of
systems designed to identify and eliminate risks and
improve the safety performance of air operators. SMS
is intended to increase industry accountability, and to
nurture and sustain a safety culture, whereby employees
can confidentially report safety deficiencies without fear
of subsequent punitive action. Regulation will eventually
require all Transport Canada operating certificate holders
to implement an SMS.
The following event illustrates the value of an SMS
in advancing aviation safety when there has been a
contravention of the regulations.
On a clear January morning, an Airbus 310 departed
Halifax, N.S., for Calgary, Alta., and climbed to a cruising
altitude of 34 000 ft. After completing the routine cruise
checks, the crew settled back and the 256 passengers
relaxed and enjoyed a light breakfast. As they were
approaching Montreal, Que., the captain checked the
en-route weather while the first officer took fuel quantity
readings and compared them with the flight plan figures
required to complete the flight to destination. The first
officer suddenly realized that they had not taken on
enough fuel prior to their departure from Halifax. After
confirming the readings and manually recalculating the
minimum required fuel to complete the flight to Calgary,
he informed the captain. They both double-checked the
fuel remaining against the fuel required. The insufficient
fuel state was confirmed and they agreed to plan an
unscheduled refuelling stop in Toronto, Ont. Montreal
Centre and company dispatch were both advised of
the fuel condition and they respectively authorized and
concurred with the revised routing.
From a regulatory standpoint, the pilot-in-command and
the operator, contravened Canadian Aviation Regulation
(CAR) 602.88(2) for not carrying sufficient fuel for
the planned route. The enforcement process initiated
following this contravention is typical of what would
happen within any aviation company that operates in
accordance with an SMS.
The Aviation Enforcement Division became aware of the
event through an occurrence report in the Civil Aviation
Daily Occurrence Reporting System (CADORS),
and notified the Transport Canada principal inspector
responsible for the operator. The principal inspector
confirmed that the crew had, as required under SMS,
internally reported the incident to the operator.
In line with SMS philosophy, the operator developed
and submitted a corrective action plan (CAP) to the
principal inspector, outlining a systematic approach
to address the fuel mismanagement and to prevent a
recurrence. The CAP included revised pre-flight and
in-flight standard operating procedures (SOP) designed
to ensure accurate flight-planned fuel calculations and
accurate fuel-on-board monitoring prior to, and during,
flight. These procedures for proper fuel management were
incorporated into a mandatory training seminar for all
flight crew members. The principal inspector reviewed the CAP and was confident that it addressed the issues
that led to the initial contravention. In consultation
with the principal inspector, the Aviation Enforcement
Division could have reactivated the investigation at any
time during the process leading up to the acceptance of
the CAP, and would have, if:
the contravention had been intentional;
the incident had not been internally reported; or the principal inspector had found the CAP to be
unacceptable, and the operator had refused to address the issue.
Debrief
Don’t Forget to Subscribe to the Transport Canada Aeronautical Information Manual !
Debrief
Go to www.smartmoves.ca
Safety Management Systems—Raising the Bar on Aviation Safety
Regulations and You
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARQ)
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.
Regulations and You
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.
The Civil Aviation Medical Examiner
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.
regulations and you
Had the decision been to continue the investigation, a
letter of investigation would have been sent directly to
the operator, and the principal inspector would have been
notified. In this specific case, the investigation was closed
without further enforcement action.
Although the story in this article does not depict an
actual event, it does serve to illustrate a typical SMS
response, designed to raise the bar on aviation safety
following a regulatory contravention. For further clarification, we invite you to consult the
Aviation Enforcement Policy and Procedures—Safety
Management Systems Web site at www.tc.gc.ca/civilaviation/SMS/policy.htm.
As a reminder to all, the online version of the TC AIM is available for viewing and free download at all times. You can access it from Transport Canada’s online publications storefront at www.tc.gc.ca/transact.
2
ASL 4/2006
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
Taxi authorizations that contain the instructions “hold” or “hold short” (shall/need not) be read back by the pilot. (RAC 4.2.5)
Where possible, pilots are required to report at least ____ min before entering an MF area. (RAC 4.5.7)
A ___________ must be filed for all flights between Canada and a foreign state. (FAL 2.3.2)
On flights from Canada to the U.S., at least ________ advance notice of arrival must be provided to U.S. Customs. (FAL 2.3.2)
On flights to Canada, pilots must land at a Canada Customs authorized airport of entry (AOE). Pilots must make their own customs arrangements by calling ______________ at least _________ before flying into Canada. (FAL 2.3.2)
Pilots receiving a MANOT message are requested to maintain a radio watch on ______ MHz when operating in the vicinity of the track of the missing aircraft. (SAR 2.3)
List the four steps that should be accomplished (where practicable) during your preflight inspection of the emergency locator transmitter (ELT).
(a) __________________________________________________________________________________;
(b) ____________________________________________________________;
(c) _____________________________________________; and
(d) ____________________________________________.
(SAR 3.4)
When an ELT signal is heard in flight, the nearest ATS unit should be advised of what four pieces
of information?
(a) ________________________________________________________;
(b) ___________________;
(c) _____________________________________________; and
(d) ____________________________________________.
Answers to this quiz are found on page 38 of this ASL 4/2006.
ASL 4/2006
39
(SAR 3.4)
In the event of a crash, what should you do with the ELT’s function switch, and when? ____________________________________________________________________
(SAR 3.5)
061234 NOTAMN CYSB SUBDURY
RWY 04/22 CLOSED TIL APRX 0612151530
Runway 04/22 is expected to open at _____Z on (date) ___________. (MAP 5.6.1)
What is the significance of the term “APRX” in the above NOTAM? _____________________________
(MAP 5.6.1)
060210 NOTAMR 060202 CYND WINCHESTER
CNA8 UNMANNED AERIAL VEHICLE OPS 3NM RADIUS 450610N 752854W (APRX 9 NM NW AD) SFC TO 2400 FT MSL
0605051700 TIL 0605052300
What is the significance of the letter “R” at the end of the word “NOTAM” above? __________________
(MAP 5.6.2)
A Canadian medical certificate for a private pilot licence is valid in Canada for ___ months if under age 40,
and for ___ months if age 40 or older. (LRA 3.2.4)
In accordance with CAR 401.08, every applicant for, and every holder of, a flight crew permit, licence or rating shall maintain a ______________. (LRA 3.7.6)
The flight crew recency requirements address three time periods. To act as pilot-in-command or co-pilot you must meet the ___________________ recency requirements. If you wish to carry passengers, you must also meet the ________ requirements. (LRA 3.9)
In order to carry passengers, you must have completed __ takeoffs and landings in the same category and class of aircraft in the previous __ months. (LRA 3.9)
Class A fires are fires in ______________________________. (AIR 1.4.2)
An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error of more than ___ ft when compared on the ground against a known aerodrome or runway elevation. (AIR 1.5.1)
By ______ ft ASL the partial pressure of oxygen is such that all pilots will experience mild hypoxia and some will become symptomatic. (AIR 3.2.1)
If, on descent, the pressure in the ears (or sinuses) cannot be relieved by swallowing, yawning or Valsalva manoeuvre, it is best to _________________________________________________________. (AIR 3.8)
This questionnaire is for use from November 1, 2006, to October 31, 2007. Completion of this questionnaire satisfies
the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.
Note: The answers may be found in the Transport Canada Aeronautical Information Manual (TC AIM).
TC AIM references are at the end of each question. Amendments to this publication may result in changes to
answers and/or references.
Post-Accident Survivability—Direct-to-Airframe Helmet Cord Connections
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)
On December 7, 2005, an MBB-BO105 helicopter was operating near Marystown, N.L. The helicopter was observed
flying along the shoreline, at low altitude, in snow, and in darkening conditions. The helicopter struck the water about
1 000 ft from shore, and sank to the bottom of Mortier Bay. The pilot and passenger escaped from the helicopter;
however, they later perished in the frigid water. The TSB investigation into this accident (A05A0155) is ongoing. After
the accident, an examination of the pilot’s aviation helmet found that the end fitting of the communication cord was
fractured at the point where it attaches to the helicopter (see Figure 1).
Figure 1. Fractured cord end fitting
The communication cords for front-seat occupants connect to receptacles located on the overhead center console.
When the helicopter was recovered, the metal pins from the end fitting were still inside the receptacle. Metal
remnants from the connection show that the cord was being pulled sideways, towards the pilot’s door, when the
fracture occurred. A downward pull is required to release the connection. A break test of a similar fitting required a
70-lb pull before the cord failed. After ditching or water impact, the occupants of a capsized helicopter are prone to
disorientation. Therefore, unimpeded egress through any available exit is vital to survival. An attached communication
cord that will not release cleanly may impede this egress.
Transports
Canada
TP 185E
Issue 4/2006
aviation safety letter
In this Issue...
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?
In the past, similar BO-105 helicopters have been fitted with an intermediate “pig-tail” communication cord for
helmet connections. Instead of plugging the helmet cord into the helicopter’s receptacle, the helmet cord is instead
plugged into this intermediate cord (see Figure 2).
The helmet connection plug can release cleanly from the intermediate “pig-tail” cord receptacle as it is pulled in the
direction of travel during egress. Over a period of years, the use of the intermediate helmet cords at this operator
declined, perhaps because pilots were not aware that the cords ensure separation in an emergency. However, since this
accident, the operator has indicated that the use of intermediate “pig-tail” cords for helmet connections will now be
re-instituted where necessary.
Transport
Canada
Safety Hazard Alert—Call Sign Confusion
Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)
Recently Released TSB Reports
Debrief
Convert 1020.5 millibars into inches of mercury. ______ (GEN 1.9.2)
The SECURITAS program provides a means for individuals to report ________________ and
____________________________________ relating to the Canadian transportation system. (GEN 3.6)
Runway contaminants such as water, snow or ice will (increase/decrease) the landing distance. (AGA 1.1.5)
When a section of runway or heliport is closed, it is marked with an ___. (AGA 3.3 and AGA 5.6)
Control of ARCAL lights should be possible when aircraft are within ___ NM of the aerodrome. (AGA 7.19)
Retroreflective markers (will/will not) provide the pilot with the same visual presentation as normal runway
lighting when the aircraft is lined up on final approach. (AGA 7.20)
The removal of the audio identification from non-directional beacons (NDB), VHF omnidirectional ranges
(VOR), distance measuring equipment (DME) or instrument landing systems (ILS) warns pilots that the facility may be __________ even though ____________. (COM 3.2)
A wide area augmentation system (WAAS) NOTAM will be issued when a WAAS service is predicted not
to be available for a duration of more than ______ min. (COM 3.16.6.2)
What does the equipment suffix “G” indicate in item 10 (equipment) on a flight plan? _________________________________________________________
(COM 3.16.7)
Can VFR GPS receivers be used to replace current charts? ___ (COM 3.16.16)
For air-to-air communications between pilots in the Northern Domestic Airspace (NDA), what is the correct frequency to use? ______ MHz. (COM 5.13.3)
An aerodrome forecast (TAF) provides expected conditions for ___________________ at specific aerodromes,
whereas an area forecast chart (GFA) depicts _________________________ affecting flight at a specific time over a particular area. (MET 3.2.1)
Areas of showery or intermittent precipitation are shown on a GFA Clouds and Weather Chart as ______
____________________________________. (MET 3.3.11)
In a TAF, any cases of strong, non-conductive low level wind shear within _____ ft AGL will be coded as
“__”. (MET 3.9.3)
In a TAF, “TEMPO” is only used when the modified forecast condition is expected to last less than ________ in each instance. (MET 3.9.3)
TAF CYXU 011035Z 011123 27015G25KT 3SM RA OVC005
BECMG 1314 OVC 020
FM 1700Z 29005KT P6SM OVC030 TEMPO 1723 BKN030
RMK NXT FCST BY 17Z =
In the weather report above, the forecast wind for 1500Z is _________________________________.
(MET 3.9.3)
SPECI CYSJ 221650Z 08017G24 3/8SM R23/2000FT/N –SN DRSN VV006 M03/M05 A2953 RMK SN8 VSBY VRBL 3/4 11/2
In the weather report above, the prevailing visibility is _____ and the visibility is obscured by _____________________________________. (MET 3.15.3)
Are the winds in aviation weather forecasts and reports given in degrees true or magnetic? GFA: _____; TAF: _____; FD: _____; METAR: _____. (MET 3.3.11, 3.9.3, 3.11, 3.15.3)
Does ATC assume responsibility for obstacle clearance when you are radar identified? ___ (RAC 1.5.2)
If you observe suspicious ground activities at an abandoned airstrip, what report should you make? _____________ (RAC 1.12.2)
debrief
Regulations and You
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The Civil Aviation Medical Examiner
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Regulations and You
Flight Crew Recency Requirements
Self-Paced Study Program
Debrief
Transports
Canada
The Civil Aviation Medical Examiner
Transport
Canada
Near Repeat of Mirabel De-Icing Mishap
Cold Weather Altimeter Error—Getting Cold Feet?
How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions
Aircraft Maintenance Operational and Functional Checks
Flight Crew Recency Requirements Self-Paced Study Program
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
Figure 2. Intermediate helmet “pig tail” connection cords
Other operators may have aircraft with similar direct-to-airframe connections, and may be unaware that these can
impede egress in an emergency. Therefore, Transport Canada may wish to advise the aviation community that these
connection types may impede egress, and that an intermediate cord can help to mitigate this hazard.
Done. —Ed.
40
ASL 4/2006
TC-1001878
TC-1001878
This questionnaire is for use from November 1, 2006, to October 31, 2007. Completion of this questionnaire satisfies
the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.
Note: The answers may be found in the Transport Canada Aeronautical Information Manual (TC AIM).
TC AIM references are at the end of each question. Amendments to this publication may result in changes to
answers and/or references.
Post-Accident Survivability—Direct-to-Airframe Helmet Cord Connections
An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)
On December 7, 2005, an MBB-BO105 helicopter was operating near Marystown, N.L. The helicopter was observed
flying along the shoreline, at low altitude, in snow, and in darkening conditions. The helicopter struck the water about
1 000 ft from shore, and sank to the bottom of Mortier Bay. The pilot and passenger escaped from the helicopter;
however, they later perished in the frigid water. The TSB investigation into this accident (A05A0155) is ongoing. After
the accident, an examination of the pilot’s aviation helmet found that the end fitting of the communication cord was
fractured at the point where it attaches to the helicopter (see Figure 1).
Figure 1. Fractured cord end fitting
The communication cords for front-seat occupants connect to receptacles located on the overhead center console.
When the helicopter was recovered, the metal pins from the end fitting were still inside the receptacle. Metal
remnants from the connection show that the cord was being pulled sideways, towards the pilot’s door, when the
fracture occurred. A downward pull is required to release the connection. A break test of a similar fitting required a
70-lb pull before the cord failed. After ditching or water impact, the occupants of a capsized helicopter are prone to
disorientation. Therefore, unimpeded egress through any available exit is vital to survival. An attached communication
cord that will not release cleanly may impede this egress.
Transports
Canada
TP 185E
Issue 4/2006
aviation safety letter
In this Issue...
Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?
In the past, similar BO-105 helicopters have been fitted with an intermediate “pig-tail” communication cord for
helmet connections. Instead of plugging the helmet cord into the helicopter’s receptacle, the helmet cord is instead
plugged into this intermediate cord (see Figure 2).
The helmet connection plug can release cleanly from the intermediate “pig-tail” cord receptacle as it is pulled in the
direction of travel during egress. Over a period of years, the use of the intermediate helmet cords at this operator
declined, perhaps because pilots were not aware that the cords ensure separation in an emergency. However, since this
accident, the operator has indicated that the use of intermediate “pig-tail” cords for helmet connections will now be
re-instituted where necessary.
Transport
Canada
Safety Hazard Alert—Call Sign Confusion
Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)
Recently Released TSB Reports
Debrief
Convert 1020.5 millibars into inches of mercury. ______ (GEN 1.9.2)
The SECURITAS program provides a means for individuals to report ________________ and
____________________________________ relating to the Canadian transportation system. (GEN 3.6)
Runway contaminants such as water, snow or ice will (increase/decrease) the landing distance. (AGA 1.1.5)
When a section of runway or heliport is closed, it is marked with an ___. (AGA 3.3 and AGA 5.6)
Control of ARCAL lights should be possible when aircraft are within ___ NM of the aerodrome. (AGA 7.19)
Retroreflective markers (will/will not) provide the pilot with the same visual presentation as normal runway
lighting when the aircraft is lined up on final approach. (AGA 7.20)
The removal of the audio identification from non-directional beacons (NDB), VHF omnidirectional ranges
(VOR), distance measuring equipment (DME) or instrument landing systems (ILS) warns pilots that the facility may be __________ even though ____________. (COM 3.2)
A wide area augmentation system (WAAS) NOTAM will be issued when a WAAS service is predicted not
to be available for a duration of more than ______ min. (COM 3.16.6.2)
What does the equipment suffix “G” indicate in item 10 (equipment) on a flight plan? _________________________________________________________
(COM 3.16.7)
Can VFR GPS receivers be used to replace current charts? ___ (COM 3.16.16)
For air-to-air communications between pilots in the Northern Domestic Airspace (NDA), what is the correct frequency to use? ______ MHz. (COM 5.13.3)
An aerodrome forecast (TAF) provides expected conditions for ___________________ at specific aerodromes,
whereas an area forecast chart (GFA) depicts _________________________ affecting flight at a specific time over a particular area. (MET 3.2.1)
Areas of showery or intermittent precipitation are shown on a GFA Clouds and Weather Chart as ______
____________________________________. (MET 3.3.11)
In a TAF, any cases of strong, non-conductive low level wind shear within _____ ft AGL will be coded as
“__”. (MET 3.9.3)
In a TAF, “TEMPO” is only used when the modified forecast condition is expected to last less than ________ in each instance. (MET 3.9.3)
TAF CYXU 011035Z 011123 27015G25KT 3SM RA OVC005
BECMG 1314 OVC 020
FM 1700Z 29005KT P6SM OVC030 TEMPO 1723 BKN030
RMK NXT FCST BY 17Z =
In the weather report above, the forecast wind for 1500Z is _________________________________.
(MET 3.9.3)
SPECI CYSJ 221650Z 08017G24 3/8SM R23/2000FT/N –SN DRSN VV006 M03/M05 A2953 RMK SN8 VSBY VRBL 3/4 11/2
In the weather report above, the prevailing visibility is _____ and the visibility is obscured by _____________________________________. (MET 3.15.3)
Are the winds in aviation weather forecasts and reports given in degrees true or magnetic? GFA: _____; TAF: _____; FD: _____; METAR: _____. (MET 3.3.11, 3.9.3, 3.11, 3.15.3)
Does ATC assume responsibility for obstacle clearance when you are radar identified? ___ (RAC 1.5.2)
If you observe suspicious ground activities at an abandoned airstrip, what report should you make? _____________ (RAC 1.12.2)
debrief
Regulations and You
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
The Civil Aviation Medical Examiner
Refer to paragraph 421.05(2)(d) of the Canadian Aviation Regulations (CARs).
Regulations and You
Flight Crew Recency Requirements
Self-Paced Study Program
Debrief
Transports
Canada
The Civil Aviation Medical Examiner
Transport
Canada
Near Repeat of Mirabel De-Icing Mishap
Cold Weather Altimeter Error—Getting Cold Feet?
How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions
Aircraft Maintenance Operational and Functional Checks
Flight Crew Recency Requirements Self-Paced Study Program
Learn from the mistakes of others;
you' ll not live long enough to make them all yourself ...
Figure 2. Intermediate helmet “pig tail” connection cords
Other operators may have aircraft with similar direct-to-airframe connections, and may be unaware that these can
impede egress in an emergency. Therefore, Transport Canada may wish to advise the aviation community that these
connection types may impede egress, and that an intermediate cord can help to mitigate this hazard.
Done. —Ed.
40
ASL 4/2006
TC-1001878
TC-1001878
FOR CANADIAN RESIDENTS ONLY
Moving?
The Civil Aviation Medical Examiner
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 (2006).
ISSN: 0709-8103
TP 185E
Publication Mail Agreement Number 40063845
Change your address online
with Canada Post and notify
Transport Canada at the same time.
The new Transport Canada Aeronautical Information Manual (TC AIM) was introduced in October 2005. All Canadian-registered pilots received two free paper copies, the last of which was delivered in April 2006. The next release of the TC AIM is scheduled for October 2006. There are a few options on how to subscribe to this publication:
Paid subscription to the paper copy
• Subscribe online to the paper copy by visiting Transport Canada’s online publications storefront at www.tc.gc.ca/transact. There, you can order either a single copy ($15.00, which includes shipping, but
excludes applicable taxes) or take out a subscription for future copies; or
•
Call the Transport Canada Order Desk at 1-888-830-4911 or 613-991-4071, to order a single copy or request a subscription. They will take your credit card information and process your order.
Free e-Bulletin notification
• Register for an e-Bulletin, which means Transport Canada will send you an e-mail with a link to the latest
online version, in either HTML or PDF format. To register for an e-Bulletin, send an e-mail to MPS@tc.gc.ca
and ask to be added to the TC AIM e-Bulletin list. Please state your name, postal address and e-mail address.
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada
A safety management system (SMS) is a structure of
systems designed to identify and eliminate risks and
improve the safety performance of air operators. SMS
is intended to increase industry accountability, and to
nurture and sustain a safety culture, whereby employees
can confidentially report safety deficiencies without fear
of subsequent punitive action. Regulation will eventually
require all Transport Canada operating certificate holders
to implement an SMS.
The following event illustrates the value of an SMS
in advancing aviation safety when there has been a
contravention of the regulations.
On a clear January morning, an Airbus 310 departed
Halifax, N.S., for Calgary, Alta., and climbed to a cruising
altitude of 34 000 ft. After completing the routine cruise
checks, the crew settled back and the 256 passengers
relaxed and enjoyed a light breakfast. As they were
approaching Montreal, Que., the captain checked the
en-route weather while the first officer took fuel quantity
readings and compared them with the flight plan figures
required to complete the flight to destination. The first
officer suddenly realized that they had not taken on
enough fuel prior to their departure from Halifax. After
confirming the readings and manually recalculating the
minimum required fuel to complete the flight to Calgary,
he informed the captain. They both double-checked the
fuel remaining against the fuel required. The insufficient
fuel state was confirmed and they agreed to plan an
unscheduled refuelling stop in Toronto, Ont. Montreal
Centre and company dispatch were both advised of
the fuel condition and they respectively authorized and
concurred with the revised routing.
From a regulatory standpoint, the pilot-in-command and
the operator, contravened Canadian Aviation Regulation
(CAR) 602.88(2) for not carrying sufficient fuel for
the planned route. The enforcement process initiated
following this contravention is typical of what would
happen within any aviation company that operates in
accordance with an SMS.
The Aviation Enforcement Division became aware of the
event through an occurrence report in the Civil Aviation
Daily Occurrence Reporting System (CADORS),
and notified the Transport Canada principal inspector
responsible for the operator. The principal inspector
confirmed that the crew had, as required under SMS,
internally reported the incident to the operator.
In line with SMS philosophy, the operator developed
and submitted a corrective action plan (CAP) to the
principal inspector, outlining a systematic approach
to address the fuel mismanagement and to prevent a
recurrence. The CAP included revised pre-flight and
in-flight standard operating procedures (SOP) designed
to ensure accurate flight-planned fuel calculations and
accurate fuel-on-board monitoring prior to, and during,
flight. These procedures for proper fuel management were
incorporated into a mandatory training seminar for all
flight crew members. The principal inspector reviewed the CAP and was confident that it addressed the issues
that led to the initial contravention. In consultation
with the principal inspector, the Aviation Enforcement
Division could have reactivated the investigation at any
time during the process leading up to the acceptance of
the CAP, and would have, if:
the contravention had been intentional;
the incident had not been internally reported; or the principal inspector had found the CAP to be
unacceptable, and the operator had refused to address the issue.
Debrief
Don’t Forget to Subscribe to the Transport Canada Aeronautical Information Manual !
Debrief
Go to www.smartmoves.ca
Safety Management Systems—Raising the Bar on Aviation Safety
Regulations and You
Paul Marquis, Editor
Aviation Safety Letter
Transport Canada (AARQ)
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.
Regulations and You
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.
The Civil Aviation Medical Examiner
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.
regulations and you
Had the decision been to continue the investigation, a
letter of investigation would have been sent directly to
the operator, and the principal inspector would have been
notified. In this specific case, the investigation was closed
without further enforcement action.
Although the story in this article does not depict an
actual event, it does serve to illustrate a typical SMS
response, designed to raise the bar on aviation safety
following a regulatory contravention. For further clarification, we invite you to consult the
Aviation Enforcement Policy and Procedures—Safety
Management Systems Web site at www.tc.gc.ca/civilaviation/SMS/policy.htm.
As a reminder to all, the online version of the TC AIM is available for viewing and free download at all times. You can access it from Transport Canada’s online publications storefront at www.tc.gc.ca/transact.
2
ASL 4/2006
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Taxi authorizations that contain the instructions “hold” or “hold short” (shall/need not) be read back by the pilot. (RAC 4.2.5)
Where possible, pilots are required to report at least ____ min before entering an MF area. (RAC 4.5.7)
A ___________ must be filed for all flights between Canada and a foreign state. (FAL 2.3.2)
On flights from Canada to the U.S., at least ________ advance notice of arrival must be provided to U.S. Customs. (FAL 2.3.2)
On flights to Canada, pilots must land at a Canada Customs authorized airport of entry (AOE). Pilots must make their own customs arrangements by calling ______________ at least _________ before flying into Canada. (FAL 2.3.2)
Pilots receiving a MANOT message are requested to maintain a radio watch on ______ MHz when operating in the vicinity of the track of the missing aircraft. (SAR 2.3)
List the four steps that should be accomplished (where practicable) during your preflight inspection of the emergency locator transmitter (ELT).
(a) __________________________________________________________________________________;
(b) ____________________________________________________________;
(c) _____________________________________________; and
(d) ____________________________________________.
(SAR 3.4)
When an ELT signal is heard in flight, the nearest ATS unit should be advised of what four pieces
of information?
(a) ________________________________________________________;
(b) ___________________;
(c) _____________________________________________; and
(d) ____________________________________________.
Answers to this quiz are found on page 38 of this ASL 4/2006.
ASL 4/2006
39
(SAR 3.4)
In the event of a crash, what should you do with the ELT’s function switch, and when? ____________________________________________________________________
(SAR 3.5)
061234 NOTAMN CYSB SUBDURY
RWY 04/22 CLOSED TIL APRX 0612151530
Runway 04/22 is expected to open at _____Z on (date) ___________. (MAP 5.6.1)
What is the significance of the term “APRX” in the above NOTAM? _____________________________
(MAP 5.6.1)
060210 NOTAMR 060202 CYND WINCHESTER
CNA8 UNMANNED AERIAL VEHICLE OPS 3NM RADIUS 450610N 752854W (APRX 9 NM NW AD) SFC TO 2400 FT MSL
0605051700 TIL 0605052300
What is the significance of the letter “R” at the end of the word “NOTAM” above? __________________
(MAP 5.6.2)
A Canadian medical certificate for a private pilot licence is valid in Canada for ___ months if under age 40,
and for ___ months if age 40 or older. (LRA 3.2.4)
In accordance with CAR 401.08, every applicant for, and every holder of, a flight crew permit, licence or rating shall maintain a ______________. (LRA 3.7.6)
The flight crew recency requirements address three time periods. To act as pilot-in-command or co-pilot you must meet the ___________________ recency requirements. If you wish to carry passengers, you must also meet the ________ requirements. (LRA 3.9)
In order to carry passengers, you must have completed __ takeoffs and landings in the same category and class of aircraft in the previous __ months. (LRA 3.9)
Class A fires are fires in ______________________________. (AIR 1.4.2)
An aircraft altimeter which has the current altimeter setting applied to the subscale should not have an error of more than ___ ft when compared on the ground against a known aerodrome or runway elevation. (AIR 1.5.1)
By ______ ft ASL the partial pressure of oxygen is such that all pilots will experience mild hypoxia and some will become symptomatic. (AIR 3.2.1)
If, on descent, the pressure in the ears (or sinuses) cannot be relieved by swallowing, yawning or Valsalva manoeuvre, it is best to _________________________________________________________. (AIR 3.8)
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