aviation safety letter...Debrief "Debrief" debrief Fuel Starvation Maule-4—Incorrect Fuel Caps An...

TransportCanada

TransportsCanada

aviation safety letter

TP 185EIssue 2/2007

Learn from the mistakes of others; you' ll not live long enough to make them all yourself ...

In this Issue...

Runway Safety and Incursion Prevention Panel

Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error

Aviate—Navigate—Communicate

Safety Management Enhances Safety in Gliding Clubs

Near Collision on Runway 08R at Vancouver

Say Again! Communication Problems Between Controllers and Pilots

Ageing Airplane Rulemaking

Bilateral Agreements on Airworthiness—An Overview and Current Status

Exploring the Parameters of Negligence: Two Recent TATC Decisions

36 ASL2/2007

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Fuel Starvation Maule-4—Incorrect Fuel CapsAn Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)

*TC-1002136*TC-1002136

OnSeptember30,2004,aMaule-4aircraftlostpowerwhilecruisingat1200ft.Thepilotchangedtanksandturnedontheelectricfuelpump,butpowercouldnotberestoredandtheaircraftwasforcedtoland.Asthefieldwastooshort,theaircraftsustainedsubstantialdamagewhenithitafenceattheendofthelandingrollandoverturned.Whentheaircraftwasrecovered,thepilotownerwassomewhatsurprisedthatfuelremainedintherighttankandverylittlewaslostfromthelefttankaftertheaircrafthadbeeninvertedovernight.Thetypeofcapinstalledincludesaninternalflappervalve,whichcloses,therebyretainingthefuelinthetanks.

Examinationofallfueltubingdidnotrevealanyanomaliesorrestrictions.Itwasalsooutlinedthattheaircrafthadasimilarpreviousenginestoppagetwoyearsearlier.Atthattime,theaircraftwasonskisoverasnowyfieldandmadeasuccessfulforcedlanding.Shortlyafter,theenginerestartedandrannormally.Duetolackofothertangiblefactors,itwasfeltthatitmayhavebeencausedbyafuelselectormalfunctionorpositioning.Theowneralsorecallsthatwheneveroperatingwiththefuelselectoron“both,”thelefttankalwaysfedataslowerratethantheright.Hefurthermentionedhavingheardairrushingintothetankwhenopeningtheleftfuelcapforrefuellingimmediatelyafterengineshutdown.

Afterthemostrecentoccurrence,theownerwaspromptedtoverifytheadequacyoftheventingsystem,whichisdonethroughthefuelcaps(Figure1).Airpassageontheleftfuelcapwasfoundtobeerratic;sometimesitwouldlettheairthrough,butsometimesitwouldnot.Informationfromthemanufacturerindicatesthatthistypeofcapisonlytobeinstalledonaircrafthavingbeenmodifiedwithauxiliarywingtanks(locatedoutboardonthewings),asthemodificationincludestheplumbingforadifferentventingsystem.

Figure 1: Non-probed fuel cap

Thecapsusedontheoccurrenceaircraft,showninFigure1,hadbeenorderedbythepreviousownertoreplacetheoriginalcapstowhicharamairprobeisfittedtoassurepositivepressurewithinthefueltanks(Figure2).Theordervoucherindicatedthatnon-leakingcaps(non-probedcaps)wererequested.Thiswasdesiredpartlyforaestheticreasonsandalsobecauseprobedcapsallowedfueltoleakoutiftheaircraftwhenitwasparkedonunevenground.Theordervoucherincludedtheaircraftserialnumber.Themanufacturerforwardedthenon-probedfuelcapswithoutchallengingwhethertheaircraftfuelsystemwasoriginalorithadbeenmodifiedwithauxiliarywingtanks.Whiletheprobedcapsassureapositivepressureinsidethefueltanks,theairpassagethroughthenon-probedcapsreducesthepressurewithinthetankbelowthatoftheambientpressure.

Figure 2: Probed fuel cap

Consequently,anyblockagewithinthecapquicklyresultsinstoppingthefuelflowtotheengine.Asthefuelsystemincludesasmallheadertank,switchingtankswouldnormallyrestorethefuelflow,re-establishingpowertotheengine.Testbenchtrialsonsimilarsystems,operatedbyaskilledenginetechnicianawareoftheintendedfuelstarvationtest,havedemonstratedthatitrequires30–45secondstorestorefullpowerfollowingtheenginestoppage.

Theinvestigationintothisoccurrencehasraisedaconcernaboutthereplacementofpartsfordifferentaircraftmodels,whichwouldaffecttheairworthinessoftheaircraft.Theuseofnon-probedcapsonanunmodifiedairframehasshownthatventingispossiblewhenthevalvewithinthecapsisworkingproperly.However,asdemonstratedinthisoccurrence,thereisnoalternatemeansofventingincaseofmalfunction.Anychangetooriginalaircraftstatus,regardlesshowsmall,mustfirstbeauthorizedbythemanufacturer,unlessitisapprovedviaasupplementarytypecertificate(STC)—asthesechangescanandhavecreatedairworthinessdisturbances.

Slinging accidents happen mostly to experienced pilots.

STAY ALERT!

Do these sound familiar?

• confined area• awkward load• marginal weather• untrained groundcrew• customer pressure• tight schedule• fatigue• inadequate equipment• uncertain field servicing

TransportCanada

TransportsCanada

the safety problem…

Here’s how accidents happen: • getting pressured into a risky operation• accepting hazards• flying when fatigued• lacking training for the task• not sure of what’s required• operating in marginal weather• ignoring laid-down procedures• becoming distracted and not spotting a hazard

The major hazards:• obstacles in the operating area• snagged sling gear• equipment failure• deficient pad housekeeping• surface condition: snow, soft spots, etc.• incorrectly rigged load• wind condition not known beforehand• overloading

the safety team…

the PILOT• follows procedures; no corner-cutting• ensures everyone is thoroughly briefed• watches for dangerous practices and reports them• rejects a job exceeding his skill• knows fatigue is cumulative and gets plenty of rest• checks release mechanism and sling gear serviceability

the GROUNDCREW• knows the hand signals and emergency procedures• watches for hazards—and reports them• rejects a task beyond his skill or knowledge• insists on proper training in load preparation and handling

the CUSTOMER• reasonable in demands; doesn’t pressure pilot• insists on safety first• reports dangerous practices

the MANAGER• allows for weather and equipment delays• sends the right pilot with the right equipment • insists the pilot is thoroughly briefed on the requirements• supports the pilot against customer pressures• demands compliance with operating manual• provides proper training

Remember, 60% of slinging accidents occur during pick-up

ASL2/2007 352 ASL2/2007

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Table of Contentssection pageGuest Editorial .................................................................................................................................................................3To the Letter .....................................................................................................................................................................4Pre-flight ...........................................................................................................................................................................5Flight Operations .............................................................................................................................................................12Maintenance and Certification .......................................................................................................................................21Recently Released TSB Reports .....................................................................................................................................26Accident Synopses ...........................................................................................................................................................31Regulations and You ........................................................................................................................................................34Debrief: Fuel Starvation Maule-4—Incorrect Fuel Caps ............................................................................................36Take 5 — Slinging With Safety .....................................................................................................................................Tear-off

ThesecondchargewasupheldlargelybecauseofthesafetyimplicationsresultingfromtheApplicant’sactions.Ashewasapproachingtheairportinanon-standardmanner,itwasincumbentonhimtoconformtothepatternoftrafficformedbytheotherapproachingaircraft.This,theMemberimplied,waswhatwouldbeexpectedofareasonablepilotinthesamesituation.Thatmeantabandoninghistrainingprocedure,andbyfailingtodoso,heengagedinnegligentconduct.

ConclusionTheessenceofnegligencehasbeendescribedas,“theomittingtodosomethingthatareasonableperson

woulddoorthedoing[of]somethingwhichareasonablepersonwouldnotdo.”Thetwocasesdiscussedaboveillustratehowthisbasicprincipleisappliedinaviationsituations.Itisquiteoftensimplyanexerciseincommonsense.Inbothcases,thepilotsundertookactionsthatwereill-advisedinthesensethattheycreatedsituationsofunnecessaryrisk.Theriskwastoothers(aswellasthemselves)andtoproperty.Giventhegravityofthepotentialconsequencesofunnecessaryriskwithintheaviationcontext,thedecisionsreachedbytheTATCarenotsurprising.Whiletheexerciseofcommonsense,prudenceandtheavoidanceofnegligentbehaviourareimportantcharacteristicsinallouractivities,theyareparticularlysointheworldofaviation.

The Aeronautics Act—The Latest News! by Franz Reinhardt, Director, Regulatory Services, Civil Aviation, Transport Canada

BillC-6,anacttoamendtheAeronautics Actandtomakeconsequentialamendmentstootheracts,wasintroducedintheHouseofCommonsonApril27,2006.TheAeronautics ActestablishestheMinisterofTransport’sresponsibilityforthedevelopment,regulationandsupervisionofallmattersconnectedwithcivilaeronauticsandtheresponsibilityoftheMinisterofNationalDefencewithrespecttoaeronauticsrelatingtodefence.

TheActlastunderwentamajoroverhaulin1985.ManyoftheamendmentsmadeatthetimewereaimedatenhancingthecomplianceandenforcementprovisionsoftheAct,includingtheestablishmentoftheCivilAviationTribunal(CAT),whichwaslaterconvertedintothemulti-modalTransportationAppealTribunalofCanada(TATC).Asaresultofdiscussionswithstakeholders,andincontinuingeffortstoenhanceaviationsafetyandsecurity,thefollowingchangesareproposedinBillC-6.

TheDepartmentofTransport(TC)isre-shapingitsregulatoryprogramstobemore“data-driven”andtorequireaviationorganizationstoimplementintegratedmanagementsystems(IMS).ThesetypesofprogramsareincreasinglyrequiredbytheInternationalCivilAviationOrganization(ICAO)andimplementedbyleadingaviationnations.Theenablingauthorityforthesafetymanagementsystems(SMS)regulationisvalidandauthorizedundertheexistingAeronautics Act.However,forgreaterclarificationandtoprovidetheSMSframeworkwithadditionalstatutoryprotectionsfromenforcement,aswellasprotectionfromaccessundertheAccess to Information Act,TCneededtoexpandtheMinister’sauthorityundertheAeronautics Act.

AmendmentstotheAeronautics Actarealsorequiredtoprovideexpandedregulatoryauthorityoversuchissuesasfatiguemanagementandliabilityinsurance.Thecurrentenablingauthorityrelatedtofatiguemanagementdoesnotextendtoallindividualswhoperformimportant

safetyfunctions,suchasairtrafficcontrollers.Thecurrentenablingauthorityrelatedtoliabilityinsurancedoesnotextend,forexample,toairportoperators.Theamendmentswillalsoprovideforthedesignationofindustrybodiesthatestablishstandardsfor,andcertify,theirmembers,subjecttoappropriatesafetyoversightbyTC.

Inordertoobtainasmuchsafetydataaspossible,theamendmentsalsoproposetheestablishmentofavoluntarynon-punitivereportingprogram,allowingthereportingofsafety-relatedinformation,withoutfearofreprisalorenforcementactiontakenagainstthereportingparty.

Sincethemaximumlevelofpenaltiesfornon-compliancehasnotbeenupdatedsince1985,amendmentsarerequirednotonlytoalignthemwithsimilarlegislationrecentlyenacted,butalsotoactasadeterrenttofuturenon-compliance.Theproposedamendmentswillincreasethemaximumpenaltiesforcorporationsinadministrativeandsummaryconvictionproceedings(currentlycappedat$25,000)to$250,000and$1million,respectively.

CiviliansectorsarenowdeliveringsomeflightservicestotheCanadianForces.Theseflightsareconsidered“military,”butastheAeronautics Actiscurrentlywritten,theDepartmentofNationalDefence(DND)doesnothavealltheauthoritiesitneedstocarryoutaflightsafetyinvestigationthatmayinvolveciviliansinamilitaryaircraftoccurrence.TheproposedamendmentswouldprovideDNDflightsafetyaccidentinvestigatorswithpowerssimilartothoseofcivilianaccidentinvestigatorsundertheCanadian Transportation Accident Investigation and Safety Board Actwheninvestigatingmilitaryaircraftaccidentsinvolvingcivilians.TheamendmentswouldalsoclarifytheauthoritiesoftheMinisterofTransportinrelationtothoseofNAVCANADAundertheCivil Air Navigation Services Commercialization Act.

Foranyadditionalinformation,pleasevisitourWebsiteatwww.tc.gc.ca/CivilAviation/RegServ/Affairs/menu.htm.

TheAviation Safety Letter ispublishedquarterlybyTransportCanada,CivilAviation.ItisdistributedtoallholdersofavalidCanadianpilotlicenceorpermit,andtoallholdersofavalidCanadianaircraftmaintenanceengineer(AME)licence.Thecontentsdonotnecessarilyreflectofficialpolicyand,unlessstated,shouldnotbeconstruedasregulationsordirectives.Letterswithcommentsandsuggestionsareinvited.Allcorrespondenceshouldincludetheauthor’sname,addressandtelephonenumber.Theeditorreservestherighttoeditallpublishedarticles.Theauthor’snameandaddresswillbewithheldfrompublicationuponrequest.Pleaseaddressyourcorrespondenceto:

Paul Marquis, EditorAviation Safety LetterTransportCanada(AARPP)PlacedeVille,TowerCOttawaONK1A0N8E-mail:[email protected].:613-990-1289Fax:613-991-4280Internet:www.tc.gc.ca/ASL-SAN

ReprintsoforiginalAviation Safety Lettermaterialareencouraged,butcreditmustbegiventoTransportCanada’sAviation Safety Letter.PleaseforwardonecopyofthereprintedarticletotheEditor.

Note:Someofthearticles,photographsandgraphicsthatappearintheAviation Safety Letteraresubjecttocopyrightsheldbyotherindividualsandorganizations.Insuchcases,somerestrictionsonthereproductionofthematerialmayapply,anditmaybenecessarytoseekpermissionfromtherightsholderpriortoreproducingit.

Toobtaininformationconcerningcopyrightownershipandrestrictionsonreproductionofthematerial,pleasecontacttheEditor.

Sécurité aérienne — Nouvellesestlaversionfrançaisedecettepublication.

© HerMajestytheQueeninRightofCanada,as representedbytheMinisterofTransport(2007). ISSN:0709-8103 TP185EPublicationMailAgreementNumber40063845

Go to www.smartmoves.ca

Moving?Change your address onlinewith Canada Post and notify Transport Canada at the same time.

FOR CANADIAN RESIDENTS ONLY

What’s New:PleasevisittheCivilAviationWebsitetoviewtheonlineRisk-basedBusinessModelandRiskManagementPrinciplespresentation:

www.tc.gc.ca/CivilAviation/risk/Breeze/menu.htm.

ASL2/2007 �

ItismypleasuretocontributetotheAviation Safety Letter(ASL).ThisquarterlypublicationisamajorelementoftheCivilAviationDirectorate’soverallcommunicationsstrategy,andhasthepotentialtohelpallofusseehowourownresponsibilitiesmeshwiththoseofourcolleaguesinotherbranches.Suchabroadviewpointisessentialaswemoveintothemoreintegratedworldofsafetymanagement.

InpreparationfortheorganizationalchangesthatwillpositiontheDirectoratetobetterdeliveritsprogramsinthenewsafetymanagementenvironment,theroleoftheAircraftMaintenanceandManufacturingBranchiscurrentlychangingtooneinwhichitwillformapartofalargerstandardsdevelopingunit,concernednotonlywithmaintenanceandmanufacturingstandards,butalsowiththoserelatingtocommercialandbusinessaviation,airports,andairtrafficservices(ATS).However,thisisanongoingprocess,andmycolleagueshavealreadycoveredsomeofthesefunctionsinothereditorials,soatthistimeIwillrestrictmyselftothetraditionalroleoftheBranchwithintheCivilAviationDirectorate.

TheAircraftMaintenanceandManufacturingBranchconsistsofapproximately40staffinheadquarters,andafurther280staffdistributedacrosstheregions.ThePacific,PrairieandNorthern,OntarioandAtlanticRegionseachhaveaManagerofMaintenanceandManufacturing,whiletheQuebecRegion,becauseoftheconcentrationofmanufacturingactivityintheMontréalarea,hasseparatemanagersforthemaintenanceandthemanufacturingfunctions.TheBranchisprimarilyresponsibleforthedevelopmentandapplicationofregulationsandstandardsrelatedtotheproductionandmaintenanceofaeronauticalproducts,andtheiroversightinthefield.Thatincludesnotonlytheperformanceofmaintenancebyapprovedmaintenanceorganizations(AMO)andaircraftmaintenanceengineers(AME),butalsothemanagementandschedulingofmaintenancebyaircraftownersandoperators.Itencompassessuchthingsasairoperatortechnicaldispatchrequirements,thelicensingandtrainingofAMEs,theapprovalofaircraftmaintenanceschedules,andtheoversightofindustryactivitiesrelatedtotheseareas.

Likeotherbranches,wearecurrentlyinvolvedintheintroductionofsafetymanagementsystems(SMS)inaccordancewiththecivilaviationstrategyoutlinedinFlight 2010.Likethoseotherbranches,wetoohaveourownuniquechallengesinthisregard.Ontheonehand,becauseofourlongexperiencewithqualityassurance(QA)programs,wehaveaheadstartonsomeoftheQAaspectsofsafetymanagement.Ontheotherhand,mostofthisexperiencewaswiththereactiveaspectsofQA,andwasfocussedprimarilyontheactualman-machineinterface.Onlyrecentlyhavewebeeninvolvedwiththesubtletiesofhumanandorganizationalrelationships,andproactivehazardidentificationacrossawiderorganizationalspectrum.Also,someoftheforward-lookingprogramimprovementelementsofflightsafetyprogramsarenewtous.Inthisrespect,theadditionofexpertisefromotherbrancheswillbeparticularlywelcome,whichprovidesagoodillustrationofthewayinwhichtheneworganizationalstructurewillsupportthisnew,moreintegratedapproachtosafetymanagement.

Thesetrulyareexitingtimesforourindustry,andtogetherwithallofthestaffoftheAircraftMaintenanceandManufacturingBranch,Ilookforwardtoworkingcloselywithourcolleaguesfromtheotherspecialtyareastodeliveratrulyeffective,coordinated,CivilAviationProgram.

IinviteyoutotakealookattheAircraftMaintenanceandManufacturingBranch’sWebsiteatwww.tc.gc.ca/CivilAviation/maintenance/menu.htm.

D.B.SherrittDirectorStandards

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The importance of being preparedDearEditor,Iwouldliketoshareanexperiencewithotheraviatorstoshowtheimportanceofbeingprepared.Iwasalow-hourpilotwithwhatIwouldconsideraveragecross-countrytime.Aftercarefulplanningandpersuasion,IconvincedmywifetoflywithmefromToronto,Ont.,totheU.S.eastcoast.Thepassengersonthatflightincludedourone-year-olddaughter.IhadbookedaCessna182fromalocalflyingschool,andcompletedacheckoutflightandshortwrittenevaluationontheaircraftpriortothetrip.Ireviewedtheaircraftdocumentsandallappearedtobeinorder.Iwasunabletogetacopyofthepilotoperatinghandbook(POH)ortheGPSmanual(IwasnotfamiliarwithamovingmapGPSatthetime)untilthedaybeforetheflight.IhaddecidedthatIwouldspendasmuchtimeaspossible“chesterfieldflying”beforetheactualtrip.Icompletedalloftheflightplanning,andflewthetripseveraltimes,confirmingeveryactionnecessarytogetustoourintendeddestination(aboutfourhours).Inadditiontothis,Ispentanotherthreehoursgoingthroughemergencyproceduresforthe182.Havingseenallofthepreparation,mywifewasbecomingalittlenervous!Iassuredherthataccidentsareextremelyunlikely,butthatImustconsiderallpossiblescenarios.Itookgreatcareinensuringthatallofthebaggagewasweighed,taggedandproperlyloadedforsecurity,andthatwewerewithintheoperatinglimitsoftheaircraftforweightandbalance.TheflightfromTorontotoBuffalo,N.Y.,wentwell,thentoElizabethCity,N.C.,formorefuel,andfromtheretoCapeHatteras,N.C.Theceilingwasunlimited,

andinfactitwasagreatdayforflying.Werequestedflightfollowing,whichwasgrantedtousfortheflightaswell.Wewerecruisingat7500ft,whentherewasasuddenradicalvibration,followedbyanimmediatelossofpower,followedbytherightwindshieldgettingcoveredwithoil,andsmokeenteringthecockpit.Mywifesimplyaskedtwoquestions:“Whatisgoingon,”and,“arewegoingtobeOK?”Myanswerwas,“Idon’tknowwhatiswrong,butIdoknowthatwearegoingtobeOK.”Ideclaredanemergencyandrequestedvectorstothenearestairstrip.Thecontrollergaveusvectorstoanearbygrassstrip,whichwasidentifiedasbeing“rightbelowus.”Theonlythingbelowuswasforestwithnotabladeofgrassinsight.Whentakingmyflighttraining,myinstructorwasconsistentlyremindingmethatIshouldalwayslookforaplacetolandintheeventofanemergency.Ialwaystookthisadvice,andinthiscase,Irecalledafarmer’sfieldthatwehadpassedimmediatelypriortotheemergency.Iturnedtheaircraft180°andthereitwas,about2mi.fromwherewewere.Theshort,softfieldlandingwassuccessfullycompletedintoaheadwind,andweallclimbedoutoftheaircraft.TheStateTrooperatthesceneaskedhowImanagedthelandtheaircraftsafely.Isaidplanning,trainingand“chesterfieldflying.”Thepowerlossandoilspillwerecausedbyamassivefailureoftherearcylinderontherightside.Ineverdidgettotherootcauseofwhytheenginefailedinsuchaseveremanner,I’mjustgladtheoutcomewasapositiveone.

NickBartzisToronto, Ont.

to the letterTo the letter Not used Recently released

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Words on Fuel Management…

Fuelmanagementandsystemproblemsolvingmustbeapproachedwithaclearunderstandingofthefuelsystem.Airoperators’pilottrainingsyllabishouldcommunicateallspecificandappropriatesystemknowledge,withparticularattentiontofuelsystemanomalies.Forinstance,helicopterpilotsmustbeawarethatwhenaboostpumpmalfunctions,alossoffuelpressureisobserved,oranappreciabledifferenceexistsbetweentheboostpumppressures,thefuelquantitygagemayindicateanerroneousfuelquantityandappropriateaction(s)mustbetaken.Theyshouldalsobeawarethat,shouldafuelboostpumpcautionlightbefollowedbya‘FUELLOW’cautionlight,itwouldbeprudenttolandwithoutdelayatthenearestsuitableareaatwhichasafeapproachandlandingisreasonablyassured.

Clarification—Blackfly Air Article in ASL 1/2007

Thethirdparagraphofthearticle“BlackflyAironFleetExpansion”onpage11oftheAviation Safety Letter(ASL)1/2007incorrectlyimpliedthattheprincipaloperatinginspectorwastheonlyappropriatepersonforoperatorstocallatTransportCanadainordertodiscussregulatoryrequirementsassociatedwithafleetexpansion.Infact,thearticleshouldhavesuggestedthatoperators may contact any of their Transport Canada principal inspectors to assist in discussing these requirements.

ASL2/2007 5

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pre-flightRunway Safety and Incursion Prevention Panel ............................................................................................................. page 5Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error ............................... page 7COPA Corner—Did You Really Get All Your ADs? ................................................................................................... page 9Research Efforts on Survival Issues—Industry at Work ................................................................................................ page 10Deviations—Standard Instrument Departures (SID) .................................................................................................. page 11

Runway Safety and Incursion Prevention Panelby Monica Mullane, Safety and System Performance, NAV CANADA

To the letter Not used Recently releasedTSB reports




Not used CivAv Med. Exam. Not usedIn2005,NAVCANADAinvitedstakeholderstoformanindependentworkinggrouptooverseerunwayincursion-preventionactivitiesinCanada.ThiswasasaresultofthedissolutionofapreviousgroupknownastheIncursionPreventionActionTeam(IPAT),co-chairedbyTransportCanadaandNAVCANADA.

Inthecourseofitslife,IPATwastaskedwithimplementingrecommendationscontainedinreportsonrunwayincursionsproducedbybothTransportCanadaandNAVCANADA.Followingthesuccessfuladoptionoftheserecommendations,itwasdecidednottoextendIPATbeyonditsApril2005,expirydate.NAVCANADAidentifiedaneedtocontinueoversightofrunwayincursion-preventionactivities,andthisresultedintheformationoftheRunwaySafetyandIncursionPreventionPanel(RSIPP).

Membershipinthismulti-disciplinarygroupwillremainopen,butisnormallycomposedofoneprimaryandoneback-uprepresentativefromNAVCANADA,theCanadianAirportsCouncil(CAC),theCanadianOwnersandPilotsAssociation(COPA),theAirLinePilotsAssociation,International(ALPA),theCanadianAirTrafficControlAssociation(CATCA),theAirTrafficSpecialistAssociationofCanada(ATSAC),andtheAirTransportAssociationofCanada(ATAC).Additionalmembersincludeotheraviationstakeholdersidentifiedbythepanel,andobserverswithadirectinterestinrunwaysafety,suchastheTransportCanadaAerodromeandAirNavigationBranch,theTransportationSafetyBoardofCanada(TSB),andtechnicalspecialistsfromstakeholderorganizations.

Thepanel’smandateistoprovideaforumfortheexchangeofsafety-relatedinformationpertainingtothemovementofaircraftandvehiclesinthevicinityoftherunway,withtheaimofpromotingrunwaysafetyandwithaprimaryfocusonthereductionintheriskofrunwayincursions.

ThepanelacceptedthefollowingInternationalCivilAviationOrganization(ICAO)definitionofrunwayincursiononApril27,2006:

Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle, or person on the protected area of a surface designated for the landing and take-off of aircraft.

ThisdiffersfromthepreviousdefinitionusedbyNAVCANADA,whichdefinedarunwayincursionas:Any occurrence at an airport involving the unauthorized or unplanned presence of an aircraft, vehicle or person on the protected area of a surface designated for aircraft landings and departures.

Differences to note: ICAO uses “aerodromes” rather than “ airports.”

ICAO uses “incorrect” rather than “unauthorized or unplanned.”

ICAO uses “landing and take-off of aircraft” rather than “aircraft landings and departures.”

ItshouldbenotedthatNAVCANADAtracksrunwayincursionstatisticsonlyataerodromeswhereNAVCANADAprovidesservices.

RSIPPactivitiesinclude:a) Reviewingthecurrentrunwayincursion-

preventionactivitiesapplicabletooperationsatCanadianaerodromes;

b) Reviewinginternationalrunwayincursion-preventionactivitieswiththeobjectiveofidentifyingandpromotingprovenbestpractices,wherefeasible;

c) Recommendingmethodsforsharingsafetyinformationwithintheaviationcommunityandsuggestingrunwayincursionstrategies/initiatives;

d)Sharingavailablerunwayincursiondatatoidentifyandanalyzepotentialrunwayincursionsafetyissuesortrends;

e)Makingrecommendationsforrunwaysafetyandincursion-preventiontosupportingagencies;and

f ) Submittinganannualreportthatsummarizesthefindings,recommendationsandaccomplishmentsofthecommitteeoverthepastyear,fordistributiontomemberorganizationsbypanelmembers.

6 ASL2/2007

Runwayincursionsareclassifiedastotheseverityoftherisk.CategoryAeventsareonesofextremeriskwithinstantaneousactionrequiredtoavoidacollision.VeryfewrunwayincursionsareCategoryA.InCategoryBincursions,thereisasignificantpotentialforcollision.Forexample,actionisrequiredtopreventavehicleenteringarunwaywhereanaircraftisclearedtoland.CategoryCissimilartoB,butthereisampletimeanddistancetoavoidapotentialcollision.CategoryDdescribessituationswherethereislittleornochanceofcollision.Forexample,thismightbeusedtoclassifyasituationwhereavehicleproceedsontoarunwaywithoutpermission,buttherearenoaircraftlandingortakingoff.Factorssuchasweather,speedoftheinvolvedaircraft,andtimetotakeactionareconsideredinamatrixinordertodeterminetherisk.Chart1showsrunwayincursionsintermsoftheseverityoftherisk.

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Severity 2002 2003 2004 2005A 1 2 0 0B �7 15 �8 27C 284 144 126 1�7D 8� 204 188 181

Total 405 �65 �52 �45 AllRunwayIncursionsbySeverity

Chart1Runwayincursionsarealsoconsideredintermsofthesourceofthedeviation.Thecurrentgroupingsareairtrafficservices(ATS)deviations,pilotdeviationsandvehicle/pedestriandeviations.Differentapproachesmustbeusedtoreducethesevarioustypesofdeviations.Chart2showsacomparisonofpilotdeviationsbetweenCanadian-registeredaircraftandforeign-registeredaircraftin2005.

Year Quarter Canadian Foreign2005 Q1 �9 6

Q2 �9 10Q� �9 8Q4 24 7

PilotDeviation—Canadian-RegisteredAircraftversusForeign-RegisteredAircraft

Chart2AllincursionsinvolvingATSdeviationsaresystematicallyinvestigatedbyNAVCANADA.TheseinvestigationsprovidedetailedinformationastothecontributingfactorsintermsofATSandareusedtopreventfurtherincidents.

Insummary,themandateofRSIPPistoprovideaforumfortheexchangeofsafety-relatedinformationpertainingtorunwayincursions,withtheaimofpromotingrunwaysafety.

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ASL2/2007 7

The“oldview”ofhumanerrorhasitsrootsinhumannatureandthecultureofblame.Wehaveaninnateneedtomakesenseofuncertainty,andfindsomeonewhoisatfault.Thisneedhasitsrootsinhumansneedingtobelieve“thatitcan’thappentome.”(Dekker,2006)

Thetenetsofthe“oldview”include(Dekker,2006):- Humanfrailtiesliebehindthemajorityof

remainingaccidents.Humanerrorsarethedominantcauseofremainingtroublethathasn’tbeenengineeredororganizedawayyet.

- Safetyrules,prescriptiveproceduresandmanagementpoliciesaresupposedtocontrolthiselementoferratichumanbehaviour.

- However,thiscontrolisundercutbyunreliable,unpredictablepeoplewhostilldon’tdowhattheyaresupposedtodo.

- Somebadappleskeephavingnegativeattitudestowardsafety,whichadverselyaffectstheirbehaviour.Sonotattendingtosafetyisapersonalproblem;amotivationalone;anissueofmereindividualchoice.

- Thebasicallysafesystem,ofmultipledefencescarefullyconstructedbytheorganization,isunderminedbyerraticpeople.Allweneedtodoisprotectitbetterfromthebadapples.

Whatwehavelearnedthusfarthough,isthatthe“oldview”isdeeplycounterproductive.Ithasbeentriedforovertwodecadeswithoutnoticeableeffect(e.g.theFlightSafetyFoundation[FSF]stillidentifies80percentofaccidentsascausedbyhumanerror);anditassumesthesystemissafe,andthatbyremovingthebadapples,thesystemwillcontinuetobesafe.Thebasicattributionerroristhepsychologicalwayofdescribingthe“oldview.”Allhumanshaveatendency,whenexaminingthebehaviourofotherpeople,tooverestimatethedegreetowhichtheirbehaviourresultsfrompermanentcharacteristics,suchasattitudeorpersonality,andtounderestimatetheinfluenceofthesituation.

“Oldview”explanationsofaccidentscanincludethingslike:somebodydidnotpayenoughattention;ifonlysomebodyhadrecognizedthesignificanceofthisindication,ofthatpieceofdata,thennothingwould

havehappened;somebodyshouldhaveputinalittlemoreeffort;somebodythoughtthatmakingashortcutonasafetyrulewasnotsuchabigdeal,andsoon.Theseexplanationsconformtotheviewthathumanerrorisacauseoftroubleinotherwisesafesystems.Inthiscase,youstoplookinganyfurtherassoonasyouhavefoundaconvenient“humanerror”toblameforthetrouble.Suchaconclusionanditsimplicationsarethoughttogettothecausesofsystemfailure.

“Oldview”investigationstypicallysingleoutparticularlyill-performingpractitioners;findevidenceoferratic,wrongorinappropriatebehaviour;andbringtolightpeople’sbaddecisions,theirinaccurateassessments,andtheirdeviationsfromwrittenguidanceorprocedures.Theyalsooftenconcludehowfrontlineoperatorsfailedtonoticecertaindata,ordidnotadheretoproceduresthatappearedrelevantonlyafterthefact.Ifthisiswhattheyconclude,thenitislogicaltorecommendtheretrainingofparticularindividuals,andthetighteningofproceduresoroversight.

Whyisitsoeasyandcomfortabletoadoptthe“oldview”?First,itischeapandeasy.The“oldview”believesfailureisanaberration,atemporaryhiccupinanotherwisesmoothly-performing,safeoperation.Nothingmorefundamental,ormoreexpensive,needstobechanged.Second,intheaftermathoffailure,pressurecanexisttosavepublicimage;todosomethingimmediatelytoreturnthesystemtoasafestate.Takingoutdefectivepractitionersisalwaysagoodstarttorecoveringtheperceptionofsafety.Ittellspeoplethatthemishapisnotasystemicproblem,butjustalocalglitchinanotherwisesmoothoperation.Youaredoingsomething;youaretakingaction.Thefatalattributionerrorandtheblamecyclearealiveandwell.Third,personalresponsibilityandtheillusionsofchoicearetwootherreasonswhyitiseasytoadoptthisview.Practitionersinsafety-criticalsystemsusuallyassumegreatpersonalresponsibilityfortheoutcomesoftheiractions.Practitionersaretrainedandpaidtocarrythisresponsibility.Buttheflipsideoftakingthisresponsibilityistheassumptionthattheyhavetheauthority,andthepower,tomatchtheresponsibility.Theassumptionisthatpeoplecansimplychoosebetweenmakingerrorsandnotmakingthem—independentoftheworldaroundthem.Inreality,peoplearenotimmuneto

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Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Errorby Heather Parker, Human Factors Specialist, System Safety, Civil Aviation, Transport Canada

The following article is the third in a three-part series describing some aspects of the “new view” of human error. (Dekker, 2002)This new view was introduced in issue 3/2006 of the AviationSafetyLetter (ASL) in an interview with Sidney Dekker.The series presented the following topics:Thoughts on the New View of Human Error Part I: Do Bad Apples Exist? (published in ASL 4/2006)Thoughts on the New View of Human Error Part II: Hindsight Bias (published in ASL 1/2007)Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error

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pressures,andorganizationswouldnotwantthemtobe.Toerrornottoerrisnotachoice.People’sworkissubjecttoandconstrainedbymultiplefactors.

Toactuallymakeprogressonsafety,Dekker(2006)arguesthatyoumustrealizethatpeoplecometoworktodoagoodjob.Thesystemisnotbasicallysafe—peoplecreatesafetyduringnormalworkinanimperfectsystem.Thisisthepremiseofthelocalrationalityprinciple:peoplearedoingreasonablethings,giventheirpointofview,focusofattention,knowledgeofthesituation,objectives,andtheobjectivesofthelargerorganizationinwhichtheywork.Peopleinsafety-criticaljobsaregenerallymotivatedtostayaliveandtokeeptheirpassengersandcustomersalive.Theydonotgooutoftheirwaytoflyintomountainsides,todamageequipment,toinstallcomponentsbackwards,andsoon.Intheend,whattheyaredoingmakessensetothematthattime.Ithastomakesense;otherwise,theywouldnotbedoingit.So,ifyouwanttounderstandhumanerror,yourjobistounderstandwhyitmadesensetothem,becauseifitmadesensetothem,itmaywellmakesensetoothers,whichmeansthattheproblemmayshowupagainandagain.Ifyouwanttounderstandhumanerror,youhavetoassumethatpeopleweredoingreasonablethings,giventhecomplexities,dilemmas,trade-offsanduncertaintythatsurroundedthem.Justfindingandhighlightingpeople’smistakesexplainsnothing.Sayingwhatpeopledidnotdo,orwhattheyshouldhavedone,doesnotexplainwhytheydidwhattheydid.

The“newview”ofhumanerrorwasbornoutofrecentinsightsinthefieldofhumanfactors,specificallythestudyofhumanperformanceincomplexsystemsandnormalwork.Whatisstrikingaboutmanymishapsisthatpeopleweredoingexactlythesortsofthingstheywouldusuallybedoing—thethingsthatusuallyleadtosuccessandsafety.Peopleweredoingwhatmadesense,giventhesituationalindications,operationalpressures,andorganizationalnormsexistingatthetime.Accidentsareseldomprecededbybizarrebehaviour.

Toadoptthe“newview,”youmustacknowledgethatfailuresarebakedintotheverynatureofyourworkandorganization;thattheyaresymptomsofdeepertroubleorby-productsofsystemicbrittlenessinthewayyoudoyourbusiness.(Dekker,2006)Itmeanshavingtoacknowledgethatmishapsaretheresultofeverydayinfluencesoneverydaydecisionmaking,notisolatedcasesoferraticindividualsbehavingunrepresentatively.(Dekker,2006)Itmeanshavingtofindoutwhywhatpeopledidbackthereactuallymadesense,giventheorganizationandoperationthatsurroundedthem.(Dekker,2006)

Thetenetsofthe“newview”include(Dekker,2006):- Systemsarenotbasicallysafe.Peopleinthemhave

tocreatesafetybytyingtogetherthepatchworkof

technologies,adaptingunderpressure,andactingunderuncertainty.

- Safetyisnevertheonlygoalinsystemsthatpeopleoperate.Multipleinteractingpressuresandgoalsarealwaysatwork.Thereareeconomicpressures,andpressuresthathavetodowithschedules,competition,customerservice,andpublicimage.

- Trade-offsbetweensafetyandothergoalsoftenhavetobemadewithuncertaintyandambiguity.Goals,otherthansafety,areeasytomeasure.However,howmuchpeopleborrowfromsafetytoachievethosegoalsisverydifficulttomeasure.

- Trade-offsbetweensafetyandothergoalsenter,recognizablyornot,intothousandsoflittleandlargerdecisionsandconsiderationsthatpractitionersmakeeveryday.Thesetrades-offsaremadewithuncertainty,andoftenundertimepressure.

The“newview”doesnotclaimthatpeopleareperfect,thatgoalsarealwaysmet,thatsituationsarealwaysassessedcorrectly,etc.Inthefaceoffailure,the“newview”differsfromthe“oldview”inthatitdoesnotjudgepeopleforfailing;itgoesbeyondsayingwhatpeopleshouldhavenoticedorcouldhavedone.Instead,the“newview”seekstoexplain“why.”Itwantstounderstandwhypeoplemadetheassessmentsordecisionstheymade—whytheseassessmentsordecisionswouldhavemadesensefromtheirpointofview,insidethesituation.Whenyouseepeople’ssituationfromtheinside,asmuchlikethesepeopledidthemselvesasyoucanreconstruct,youmaybegintoseethattheyweretryingtomakethebestoftheircircumstances,undertheuncertaintyandambiguitysurroundingthem.Whenviewedfrominsidethesituation,theirbehaviourprobablymadesense—itwassystematicallyconnectedtofeaturesofthetheirtools,tasks,andenvironment.

“Newview”explanationsofaccidentscanincludethingslike:whydiditmakesensetothemechanictoinstalltheflightcontrolsashedid?Whatgoalswasthepilotconsideringwhenhelandedinanunstableconfiguration?Whydiditmakesenseforthatbaggagehandlertoloadtheaircraftfromthatlocation?Systemsarenotbasicallysafe.Peoplecreatesafetywhilenegotiatingmultiplesystemgoals.Humanerrorsdonotcomeunexpectedly.Theyaretheothersideofhumanexpertise—thehumanabilitytoconductthesenegotiationswhilefacedwithambiguousevidenceanduncertainoutcomes.

“Newview”explanationsofaccidentstendtohavethefollowingcharacteristics:

- Overall goal:In“newview”accounts,thegoaloftheinvestigationandaccompanyingreportisclearlystatedattheverybeginningofeachreport:tolearn.

- Language used:In“newview”accounts,contextuallanguageisusedtoexplaintheactions,situations,

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contextandcircumstances.Judgmentoftheseactions,situations,andcircumstancesisnotpresent.Describingthecontext,thesituationsurroundingthehumanactionsiscriticaltounderstandingwhythosehumanactionsmadesenseatthetime.

- Hindsight bias control employed:The“newview”approachdemandsthathindsightbiasbecontrolledtoensureinvestigatorsunderstandandreconstructwhythingsmadesenseatthetimetotheoperationalpersonnelexperiencingthesituation,ratherthansayingwhattheyshouldhavedoneorcouldhavedone.

- Depth of system issues explored:“Newview”accountsarecompletedescriptionsoftheaccidentsfromtheoneortwohumanoperatorswhoseactionsdirectlyrelatedtotheharm,includingthecontextualsituationandcircumstancessurroundingtheiractionsanddecisions.Thegoalof“newview”investigationsistoreformthesituationandlearn;thecircumstancesareinvestigatedtothelevelofdetailnecessarytochangethesystemforthebetter.

- Amount of data collected and analyzed:“Newview”accountsoftencontainsignificantamountsofdataandanalysis.Allsourcesofdatanecessarytoexplaintheconclusionsaretobeincludedintheaccounts,alongwithsupportingevidence.Inaddition,“newview”accountsoftencontainphotos,courtstatements,andextensivebackgroundaboutthetechnicalandorganizationalfactorsinvolvedintheaccidents.“Newview”accountsaretypicallylong

anddetailedbecausethislevelofanalysisanddetailisnecessarytoreconstructtheactions,situations,contextandcircumstances.

- Length and development of arguments (“leave a trace”):“Newview”accountstypicallyleaveatracethroughoutthereportfromdata(sequenceofevents),analysis,findings,conclusionandrecommendations/correctiveactions.Asareaderofa“newview”account,itispossibletofollowfromthecontextualdescriptionstothedescriptionsofwhyeventsandactionsmadesensetothepeopleatthetime,toinsomecases,conceptualexplanations.Byclearlyoutliningthedata,theanalysis,andtheconclusions,thereaderismadefullyawareofhowtheinvestigatordrewtheirconclusions.

“Newview”investigationsaredrivenbyoneunifyingprinciple:humanerrorsaresymptomsofdeepertrouble.Thismeansahumanerrorisastartingpointinaninvestigation.Ifyouwanttolearnfromfailures,youmustlookathumanerrorsas:

- Awindowonaproblemthateverypractitionerinthesystemmighthave;

- Amarkerinthesystem’severydaybehaviour;and- Anopportunitytolearnmoreaboutorganizational,

operationalandtechnologicalfeaturesthatcreateerrorpotential.

Reference:Dekker, S., TheFieldGuidetoUnderstandingHumanError, Ashgate, England, 2006.

COPA Corner—Did You Really Get All Your ADs?by Adam Hunt, Canadian Owners and Pilots Association (COPA)

Everyyear,aspartofthepreparationforanaircraft’sannualinspection,mostdiligentownersofcertifiedaircraftwillgototheTransportCanada(TC)Websiteandsearchfortheairworthinessdirectives(AD)thatareapplicabletotheiraircraft.

Thisisaccomplishedbyclickingon“AirworthinessDirectives”onTC’sContinuingAirworthinessWebInformationSystem(CAWIS)Website,www.tc.gc.ca/aviation/applications/cawis-swimn/,enteringtheaircraft’sregistrationintothesearchbox,andthencheckingtheADlistthattheCAWISsystemproduces.SomeADsthatcomeupwillbeold,non-repetitiveonesthatarealreadysignedoff,andotherswillberepetitiveonesthatneeddoingonaregularbasis.Thelistalsohastobecheckedforapplicability,asnotallADswillapplytoyourindividualaircraftserialnumber,butprettyquicklyyoucanparethelistdowntothosethatneeddoing.

Field maintenance on a Cessna 172

So,ifyoudothatsearchbyaircraftregistration,youshouldgetalltheADsforyouraircraft,right?Wrong!

ThelistthatyoujustsearchedwillgiveyouallapplicableADsforyourairframe,engineandpropeller.Itdoes

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notgiveyoutheADsthatareapplicabletoanythingelse,suchascarburetors,seatbeltsoranyafter-marketsupplementaltypecertificate(STC)installedequipment,suchasautopilots,doorsorwing-tipfairings.ThoseitemsarecontainedinaseparatemiscellaneousequipmentADlist.BecauseTChasnowayofknowingwhichaccessoriesareinstalledonyouraircraft,youhavetocheckthislisttoseewhichonesareapplicable.

AsofOctober2006,therewere551ADsonthatlist!Manyareitemslikeescapeslidesforairliners,butsomearedefinitelyequipmentthatcouldbefoundonsmallaircraft.

AgoodexampleisAD96-12-22.ThisisarepetitiveADonCessnaengineoilfilteradaptersassemblies.Thesearecommonlyinstalledonanybrandofaircraft(notjustCessnas)equippedwithaTeledyneContinentalMotorsaircraftengine,includingO-200,O-470,IO-470,TSIO-470,O-520,IO-520,TSIO-520,GTSIO-520,IO-550,TSIO-550powerplants.Itrequiresaninspectionwiththefirst100hrtime-in-serviceandtheneverytimetheengineoilfilterisremoved.Youwon’tfindthisADwithoutcheckingthemiscellaneousequipmentADlist.

Setting valve clearances

Aswellasdoingasearchbytheaircraftregistration,aircraftownersneedtocheckthemiscellaneousequipmentADlisttomakesurenoADsaremissed.ThemiscellaneousequipmentADlistontheTCCAWISsystemcanonlybefoundbyclickingon“AdvancedSearch”andthen“AllADs”beside“ListMiscellaneousEquipmentADs.”YoucanfindoutmoreaboutCOPAatwww.copanational.org.

Research Efforts on Survival Issues—Industry at Workby Jason Leggatt, Engineer-In-Training (EIT), SAFE Association

TheSurvivalandFlightEquipment(SAFE)Associationisanon-profit,professionalassociation,dedicatedtothepreservationofhumanlife,andinparticular,increasingsurvivabilityofthosefacedwiththedangersassociatedwithallaspectsofrecreational,commercialandmilitaryaviation.

Foundedin1956astheSpaceandFlightEquipmentAssociation,thenamewaschangedtotheSurvivalandFlightEquipmentAssociationin1969,tobetterreflecttheimmerginggroupofcoremembers.Anyambiguitywasdroppedin1976whenthenamewasfinallychangedtotheSAFEAssociation.SAFEisheadquarteredinOregon,butboastsaninternationalgroupofmembersandmaintainschaptersthroughtheworld,mostnotably,regionalchaptersintheUnitedStates,SAFEEuropeand,ofcourse,theCanadianchapterofSAFE.

SAFEprovidesacommonmeetinggroundforthesharingofproblems,ideasandinformation.TheAssociation’smembersrepresentthefieldsofengineering,psychology,medicine,physiology,management,education,industrialsafety,survivaltraining,fireandrescue,humanfactors,equipmentdesign,andthemanysub-fieldsassociatedwiththedesignandoperationofaircraft,automobiles,buses,trucks,trains,spacecraftandwatercraft.Individualandcorporatemembersincludeequipmentmanufacturers,collegeprofessors,students,airlineemployees,governmentofficials,aviatorsandmilitarylifesupportspecialists.Thisbroadrepresentationprovidesauniquemeetingground

forbasicandappliedscientists,thedesignengineer,thegovernmentrepresentative,thetrainingspecialistandtheultimateuser/operatortodiscussandsolveproblemsinsafetyandsurvival.

SAFE’sregionalchapterssponsormeetingsandworkshopsthatprovideanexchangeofideas,informationonmembers’activitiesandpresentationsofnewequipmentandproceduresencompassinggovernmental,privateandcommercialapplicationinthefieldofsafetyandsurvival.

FromAugust29–�0,2006theCanadianandU.S.EastCoastchaptersofSAFEhostedajointmeetinginOttawa,Ont.,tofurtherpromotetheexchangeofideasbetweenNorthAmericanmembers.Governmentandindustryexpertsbriefedcurrentprograms,suchastheejectionseatupgradefortheCF-18Hornet.AviationlifesupportequipmentandpilotflightequipmentisalsoundergoingredesignandintegrationqualificationtoprovideCanadianaircrewwithstate-of-the-arttechnology.

SAFEculminateseachyear’sactivitieswiththeannualSAFESymposium,whichwasheldinReno,Nev.,theweekofOctober2�,2006.TheSymposiumis

SAFE

Canada

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Forest Fire Season Reminder!

Forestfireseasonisonceagainuponus,andeachyearthereareaircraftviolatingtheairspaceinandaroundforestfires.Thisincludesprivate,commercialandmilitaryaircraft.Section601.15oftheCanadian Aviation Regulations(CARs)providesthatnounauthorizedpersonshalloperateanaircraftoveraforestfirearea,oroveranyareathatislocatedwithin5NMofone,atanaltitudeoflessthan�000ftAGL.Refertothe“TakeFive”originallypublishedinASL�/99,whichcanalsobefoundatwww.tc.gc.ca/CivilAviation/SystemSafety/Newsletters/tp185/3-99/T5_forestfire.htm.

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attendedbyaninternationalgroupofprofessionalswhoshareproblemsandsolutionsinthefieldofsafetyandsurvival.Presentationtopicsrangedfromcockpitdesign,restraintsystemsandinjuryreduction,on-boardoxygengenerationsystems(OBOGS),improvedpersonalprotectiveequipmentconcepts,tothelatestaircraftpassengeregressaids,safetyandcrewtraining.

TheproceedingsoftheAnnualSymposiumandotherpublications,suchasjournalsandnewsletters,arevaluablereferencesourcesfortheprofessionalinvolvedinthefieldsofaviationsafetyandsurvival.FormoreinformationabouttheactivitiesoftheSAFEAssociationandregionalandinternationalchapters,pleasegotowww.safeassociation.com.

Deviations—Standard Instrument Departures (SID)by Doug Buchanan, NAV CANADA

ManyofourbusierairportshavepublishedSIDs.AirtrafficcontrollersissuetheseSIDstopilotsoperatingonIFRflightplanstoensurethatthereisIFRseparationbetweenthedepartingaircraftandotherIFRflights.TheuseofSIDsallowspilotstoknowthedepartureroutinginadvanceandreducesvoicecommunication.AreviewofincidentreportshasrevealedanincreaseinSIDdeviationsthisyearascomparedtotheaverageoverthepastthreeyears.Inmanycases,pilotsreadbacktheSIDasissued,butdidnotcomplywiththepublishedSIDandfollowedadifferentroute.Inmostofthesecases,therewasaheadingdeviation,buttherewerealsoaltitudebusts.TheseallresultedinanactualorpotentiallossofIFRseparation,whichcouldleadtoacollision.

MostSIDsareradarvectorproceduresthatrequirefurtherairtrafficcontrolactiontogetthedepartingaircrafttotheflight-plannedroute.Inthefuture,therewillbemorePilotNavigation(PilotNav)SIDsthatprovidethemostefficientpathfromtherunwaytotheen-routestructure.PilotsareremindedtorevieweachSIDissuedandtofollowtheprocedureaspublished.Ifthereareanyquestions,pleaseaskforclarification.

TheTransportCanadaAeronautical Information Manual (TCAIM)sectiononSIDsisbeingre-writtentomakeitveryclearastowhatisexpectedofapilotreceivingaSIDclearance.Aswell,contactisbeingmadewithspecificcompaniesthathaveahighproportionofdeviations,tosharethesefindingswiththem.

Birdstrikes don’t matter? Think again!

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“Aviate—navigate—communicate.”Thistime-honouredaxiomcontinuestobeasrelevantandinstructivetodayaswhenitwasfirstcoinedmanydecadesago.Itsuccinctlysumsupinthreewordsthetaskingprioritiesthatareessentialforapilottosuccessfullyhandleanynon-routinesituationoroccurrence.Theseprioritiesareequallyapplicableforallaircraft,fromsmall,single-enginetrainingaircraft,rightuptolarge,transportcategoryjets.Thisexpressionmayhavebeencoinedintheearlydaysbyanenlightened(orfrustrated)flightinstructorinaJ-�CuborFleetCanuck,butitismoreapplicablethaneverforthepilotsoftoday’sautomatedaircraft.

A distraction can divert the pilot’s attention from primary tasks

Itiseasytodeterminehowdistractionscanoccurinasingle-pilotaircraft.TheFederalAviationAdministration(FAA)determined,“thatstall/spinrelatedaccidentsaccountedforapproximatelyone-quarterofallfatalgeneralaviationaccidents.NationalTransportationSafetyBoard[NTSB]statisticsindicatethatmoststall/spinaccidentsresultwhenapilotisdistractedmomentarilyfromtheprimarytaskofflyingtheaircraft.”1

Oneofthefirstthingsthatwelearnasfledglingpilotsisthatimproperairspeedmanagementcanleadtoastall.Nevertheless,datagatheredfromaccident/incidentinvestigationsclearlyshowshoweasilyastallcanoccur

toexperiencedpilotswhoaredistractedbyoneormoreothertasks.Distractionscanbealmostanything—evensometasksconsideredroutine—duringnormaloperations:locatingachecklist,retrievingsomethingfrombehindyourseat,lookingupafrequencyorotheraeronauticaldata,orbecomingengrossedinnavigationcalculations.Thelistisalmostendless.Theseactionsallhavethepotentialtodivertapilotfromtheprimarytaskofflyingtheaircraft.

Theobviousconclusionisthatlearninghowtoprioritizeeffectivelyandnotsuccumbtodistractionsisatremendouslyimportantskill.“Throughtrainingandexperience,youcanlearntodisciplineyourattentionmechanismssoastofocusonimportantitems.”2Unfortunately,inthecurrentenvironment,maintainingeffectiveprioritiesandavoidingdistractionsisnotgettingeasier.

Recentinnovationslikeglobalpositioningsystem(GPS)navigationandelectronicflightinstrumentsystems(EFIS)havebroughttremendoussophisticationtomoderngeneralaviationaircraft.Butthelatestavionicshavealsobroughtnewpotentialhazardsforpilots.Inthisenvironment,itisalltooeasyforthepilotto“remainheadsdown”forfartoolong.Itisalsopossibleforapilottobecomecomplacentandoverlydependantonautomatedsystems.Thiscancausethedeteriorationofbasicskills.

Theproblemofdistractionsalsoexistsinmulti-crewaircraft.Inthisenvironment,thepilotflying(PF)mustfocusonflyingtheaircraftandmustguardagainstallowingtoomuchofhisattentiontobedivertedbythetasksbeingperformedbythepilotnotflying(PNF).AnexcellentexampleoftheconsequencesofdistractionistheL-1011thatcrashedintotheFloridaEverglades,killingallonboard.TheNTSB,“citedasacausalfactorthediversionofthecrew’sattentiontoaburnedoutlightbulb.Thecrewhadbeensointentonthebulbthattheyhadnotnoticedthedescentoftheiraircraftnorhadtheyheardvariousalarmswarningoftheirclosenesstotheground.”�

flight operationsAviate—Navigate—Communicate ................................................................................................................................. page 12Flight Planning Issues ....................................................................................................................................................... page 14Safety Management Enhances Safety in Gliding Clubs ................................................................................................. page 15Near Collision on Runway 08R at Vancouver ............................................................................................................... page 16Say Again! Communication Problems Between Controllers and Pilots ........................................................................ page 17Checklist Actions After Engine Failure on Takeoff ......................................................................................................... page 18Computers in Aviation: Friend or Foe? ........................................................................................................................... page 19

Aviate—Navigate—Communicateby Captain Robert Kostecka, Civil Aviation Safety Inspector, Foreign Inspection, International Aviation, Civil Aviation, Transport Canada






1FAAAdvisoryCircularNo.AC61-67B,Subject:StallandSpinAwarenessTraining,p.ii2Human Factors for Aviation—Basic Handbook(TP1286�),p.�8�Human Factors for Aviation—Basic Handbook(TP1286�),p.�7

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Newtechnologieshavecreatednewopportunitiesforpilotstobedistracted.Theprogrammingoftheflightmanagementsystem(FMS),orcompletionofanelectronicchecklistcanlurethePFawayfromtheirprimarytask.Itisalltooeasyfortheelectronicdisplaystodivertone’sattention.Rememberthatthevariouselectronicdisplayscanactlike“facemagnets.”Makesurethatyoumaintainsituationalawarenessanddon’tallowyourselftogetsidetracked.

Arecentincidentillustratedhoweasilydistractionscanresultinimproperairspeedmanagementwithseriousconsequences.Thecrewofatransportcategoryjetwasflyingatflightlevel(FL)400andhadbeendivertedwestoftheirplannedroute.Thepilotreducedthrusttoslowtheaircraftinanticipationoftrafficdelays.“Thecaptainthenfocusedattentiontotheflightmanagementsystem(FMS)onthecentreconsoletohelpthefirstofficerdeterminefuelreservesforapossiblehold.”4Whilebothmembersofthecrewwereoccupiedwiththefuelcalculationsforapossiblehold,theairspeeddecreasedandthestickshakeractivated.“Bothpilotspushedthecontrolyokeforwardtoreducethepitchattitude,whichresultedinadescentandanincreaseinairspeed.Thiswasfollowedbythecrewreturningtheaircrafttoapitch-upattitude,withanincreaseinbodyangleofattack(AOA)andG.(Author’s note: For bodies undergoing acceleration and deceleration, G is used as a unit of load measurement.)Asecondstickshakeractivationoccurred11secondsafterthefirst.Buffetingandrolloscillationsofabout10°accompaniedthestickshakerevents.Thepitchattitudewasfurtherreducedandtheairspeedrecovered[...]ThealtitudestabilizedbrieflyatFL�86beforethecrewcoordinatedwithATCforafurtherdescenttoFL�80duetoconflictingtraffic.”5

Fortunately,therewasnodamagetotheaircraft,orinjuriestopassengersorcrew,andtheflightlandedsafelywithoutfurtherincident.Hadtherebeentrafficbelowthisaircraft,orhadasimilarairspeedmismanagementandapproachtostalloccurredclosetotheground,theconsequencesmayhavebeencatastrophic.Incidentssuchasthisservetoremindallofusoftheneedtofocusontheessentialpriorities:“aviate—navigate—communicate.”

TohelpusunderstandthecriticallyimportantrolesofthePFandPNF,let’sreviewhowthemodernflightdeckofatransportcategoryaircraftevolved.Inthelast60years,fromthepost-warboominairtransportationuntiltoday,transportcategoryaircrafthaveseentremendousincreasesintheircomplexity,performancecapabilitiesandsize.Atthesametime,technologicalinnovationshavesteadilyreducedthenumberofflightcrewmembers.

Inthe1940s,anaircraftliketheBoeingStratocruiserwouldtypicallyaccommodateasmanyas81passengersandwouldcruiseat280kt.Today,anA�40cancarrymorethan�00passengersandwillcruiseat470kt.TheflightcrewofaStratocruiserconsistedoffivemembers:aradiooperator,anavigator,aflightengineer,andtwopilots.Astheyearsprogressed,improvementsinelectronicsresultedintheradiooperatornolongerbeingneeded.Longrangenavigationsystemslikeinertialnavigationsystems(INS)eventuallymadenavigatorsunnecessary.Ultimately,thetwo-pilotflightdeckemergedduringtheearly1980s,whenincreasesinsystemautomationeliminatedtheneedforaflightengineer.Today,virtuallyalltransportcategoryaircrafthaveonlytwopilots.

4TransportationSafetyBoardofCanada(TSB)AviationInvestigationReportA05W0109,p.25TransportationSafetyBoardofCanada(TSB)AviationInvestigationReportA05W0109,p.�

Photo of Boeing Stratocruiser courtesy of www.aviation-history.com, with permission.

Copyright Airbus; photographer H. Goussé.

Transport category aircraft have seen tremendous increases in their complexity, performance capabilities and size. At the same time, technological innovations have steadily reduced the number of flight crew members.

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Copyright Airbus; photographer H. Goussé.

Modern two-crew flight deck

Thetwo-crewflightdeckbringscertainchallenges,whichareespeciallyapparentduringperiodsofhighworkload.Dependingonthecircumstances,thePNFmayalsoneedtoperformthefunctionsofoneofthecrewmembersthatwaseliminatedbyadvancesintechnology.Forexample,whenanaircraftisbeingre-routedanditisnecessarytocalculatefuelreserves,thePNFtakesontheresponsibilitiesthatwerepreviouslythoseofthenavigator.

Ifanabnormaloremergencysituationoccurs,thePNFcompletestheappropriatechecklistsandessentiallyperformsthetasksofaflightengineer.AproblemcanarisewhenthePFdependsonautomationandbecomesoverlyinvolvedinthePNF’sactivities.Adheringtothecorrectprioritieswillensurethatonecrewmemberalwaysfocusesonflyingtheaircraft.

Simulatorsprovideanoutstandingtoolforlearning.Inthesimulator,wecansafelygainfirst-handexperiencewithwindshear,catastrophicenginefailures,jammedflightcontrols,aswellaslossesofelectricalandhydraulicpower;thingsthatwewouldneverwanttoexperienceinarealaircraft.Inadditiontolearningabouttechnicalissues,thesimulatorprovidesapowerfultoolforlearningabouthumanfactors.Thesimulatorprovidesanexcellentopportunityforustolearntheessentialskillofprioritizing.

Theprimarytaskofflyingtheaircraftcanneverbecomesecondary.Thereisnothingmoreimportant.Ultimately,weneedtoremainfocusedandmaintainourpriorities:“aviate – navigate – communicate”.

Prior to joining Transport Canada, Captain Kostecka worked as a pilot and instructor for several Canadian airlines. He has flown over 12 000 hr and holds a Class 1 Flight Instructor Rating as well as type ratings on the A320, A330, A340, B757, B767, CRJ, DHC-8 and B-25.

Flight Planning Issuesby Sydney Rennick, Civil Aviation Safety Inspector, Aerodromes and Air Navigation, Civil Aviation, Transport Canada

Onpage29ofAviation Safety Letter(ASL)�/2006,MichaelOxnerprovidedanexcellentarticleonhowVFRpilotscanbenefitfromtheuseof“flightfollowing”whileflyinginCanada.Theairtrafficservices(ATS)systemalsoprovidesanadditionalservicebykeepinganeyeonthestatusorlocationofpilotswhohavefiledaproposedflightplan.ThisisdoneincaseanaircraftisoverdueanditbecomesnecessarytoalerttheCanadianArmedForcesrescuecoordinationcentre(RCC).Let’scallthisactivitysearchandrescue(SAR)tracking.

WhilethetreatmentofIFRandVFRflightplanshavemanysimilarities,therearesomedifferences.ThisarticlewilladdressVFRflightplanactivities.

ThevastmajorityofpilotsperformthecorrectactionsregardingVFRflightplans;however,therearesomepilotswhoarecausingunnecessaryworkloadsandoccasionallymisusingveryscarceresourcesbecausetheydonotunderstand(orcompletelyignore)theproperproceduresforopening,amendingorclosingVFRflightplans.Therefore,itwouldseemtobeagoodideatoreviewwhatshouldtakeplacewhenapilotfilesaVFRflightplan.

Tobegin,thepilotsubmitsaVFRflightplanthatcontainsaproposedtimeofdepartureandanestimatedelapsedtimeenroute.InCanada,andmanypartsoftheworld,theATSsystemwillbeginSARtrackingbasedontheproposeddeparturetime—thisisdonebecausetherearecircumstancesunderwhichthepilotdepartsfromaremotelocationandtheATSsystemwillnotknowtheactualtimeofdeparture.Thisisthebeginningofthesafetynet.

ThisdiffersfromtheUnitedStates,wheretheFederalAviationAdministration(FAA)doesnotstartSARtrackingunlessthepilotactivates the flight planondeparture.NotethatinCanada,theSARtrackingforaVFRflightplanwillcontinuefromtheproposeddeparturetimeuntilaspecifiedtime,oronehouraftertheestimatedtimeofarrival(ETA).Atthisprescribedtime,ifthelocationoftheflightisunknown,theairplaneisreportedmissingandasearchforthe“missing”airplanebegins.CanadianArmedForcesRCCs,atvariouslocationsacrossCanada,arenotifiedofthemissingaircraft.

Insomeinstances,SARaircrafthavebeenlaunchedtolookfora“missing”aircraftwhen,infact,thepilothad

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decidednottoflytheproposedtripanddid not cancel, close, or report changes to the VFR flight plan.

BetweenFebruary2005,andFebruary2006,therewereatleast96incidentsinvolvingVFRflightplans.Problemsaroseforavarietyofreasons.Abreakdownoftheincidentsfollows:

26transborderflightsarrivedfromtheUSAwithoutaflightplan(thereasonsareundetermined,butitmaybethatpilotsfailedtoactivatetheVFRflightplan);4�flightsdidnotfileanarrivalreport;9flightschangedflightdurationwithoutnotifyinganyone;�flightsfiledflightplansbyfax,butthepilotdidnotconfirmreceipt;�flightshadpilotswhochangedaircraftwithoutamendingtheflightplan;and12flightsdidnotdepart,andthepilotdidnotcanceltheflightplan.

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Theremaybegoodreasonsforsomeoftheerrorsnotedabove;however,itisveryunlikelythateveryincidentoccurredforagoodreason.GiventhattheCanadiantopographyandweatherconditionscansometimesbequiteharsh,IpersonallylikethewarmandfuzzyfeelingIgetfromknowingthatsomeoneiswatchingovermewhowillalertanRCCintheeventthatIamforcedtolandorcrashwhileenrouteanddonotarriveatmydestinationatthescheduledtime.Unfortunately,becauseofthescarcityofresources,itispossiblethatSARaircraftwouldnotbeabletosearchforanactualdownedairplanebecausetheyarelookingforoneormoreofthe“missing”aircraftdescribedabove.

WeareveryluckyinCanadatohaveanefficientandeffectiveSARtrackingandactivationservice.Insomecountries,thecostofSARactivityischargedtothe“missing”pilot—thinkaboutthat!

Safety Management Enhances Safety in Gliding Clubsby Ian Oldaker, Director of Operations, Soaring Association of Canada (SAC)

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Approximatelyoneyearago,theSoaringAssociationofCanada(SAC)BoardofDirectorsmadethedecisiontoimplementasafetymanagementsystem(SMS)atthenationallevel.Althoughwehavehadasafetyprograminplaceformanyyears,anSMSwouldinsertsomeadditionalsafety-managementmethods;itwouldbebasedlargelyontheTransportCanadaSMSforsmalloperators.TheSACprogramincludesastandardforimprovementstoexistingclubprogramsortheimplementationofanewprogram.

Workshopswererunacrossthecountrylastspring,atwhichpointtheprogramwasintroducedandtheparticipantsweretakenthroughtheprocessofhazardidentificationandriskassessmentfortypicalcluboperations.Althoughthereweresomequestionsaboutthevalueofthisprogramatthetime,clubshavehadapositiveattituderegardingtheneedforimprovements.Clubrepresentativeswereaskedtoreturntotheirclubsandinvolvemembersinthesetasks,whichincludearequirementtodefinestrategiestoaddressandreduceormitigatetheidentifiedrisks.Ifyou,asareaderofthisAviation Safety Letter(ASL),havenotbeeninvolvedattheclublevel,orareunawareofthisprogram,nowisthetimetoact—beforeyouflexyourwingsagainatthestartofthenewsoaringseason.Startthinkingofhowyoucancontributetoasaferclubenvironment,andhencesaferflyingoperation;askabouttheclub’ssafetyprogram,andhowyoucantakepart.

Itistooearlytoattributetheexcellentsafetyrecordforglidingin2006tothisprogram,butaheightenedawarenessoftheneedtoremainvigilantabouthazardsmayhaveplayedapart.Hazardidentificationisoneofthefirstessentialtasksofthissafetyinitiative,followedbythedesignofaclubstrategytoreducethesafetyrisks.Therecanbehazardsinthefollowingareas:Administrative(lackofemergencyprocedures),Supervisory(attheflightline),theSafety Program(poorfeedbackoflessonslearned),Airport/Airfield Infrastructure(publicaccess/signage),Airport/Airfield(poorovershootandundershootareas,grasscutting),Pilots(recurrenttraining/checks,advanced/cross-countrytraining),Pilot Experience(efforts/strategiestomaintaincurrencylevels),Weather Conditions(flightplanningandpreparationfortheanticipatedconditions).Youcanprobablythinkofmore.Ifnot,lookbackonpastincidentsandlearnfromthem.

TheSACSMSandsafetyprogramareintheirearlystagesofdevelopment.TherelevantdocumentsareavailableontheSACWebsiteatwww.sac.ca.

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Near Collision on Runway 08R at Vancouver by Glen Friesen, Senior investigator, Transportation Safety Board of Canada (TSB), Pacific Region

OnOctober29,2004,apotentiallycatastrophicnearcollisionoccurredbetweenadepartingBN2PIslanderandataxiingDash-8,onRunway08RattheVancouverInternationalAirport.At06:5�PacificDaylightTime(PDT),theVancouvertowersouthcontrollerclearedtheIslanderfortakeofffromthethresholdofRunway08R.TheIslanderwasintherotationforlift-offwhenitwentbyaDash-8thatwaspartiallyontherunway,abeamtheIslander’sleftwingtip,atTaxiwayL2.Thefinalreportonthisoccurrence(TSBfileA04P0�97)wasreleasedonNovember6,2006.

Immediatelypriortotheoccurrence,thetowercontrollerhadsevendepartingaircraftholdingshortfordepartureonRunway08Randtwoonfinal.Onthesouthsideofthethreshold,onTaxiwayA(seeillustration),wasaBN2PIslanderfollowedbyaMitsubishiMU-2.Opposite,onTaxiwayL,wasaDash-8followedbytwomoreIslanders,andasecondDash-8.TherewasathirdDash-8holdingshortofRunway08RonL2.TaxiwayL2isalsoahigh-speedexitforthereciprocalRunway26L.

Itwasstilldark;thevisibilitywas8SMandimproving.AfterthefirstDash-8onTaxiwayLdeparted,thefirstarrivallanded.ThecontrollerthenclearedtheIslanderonTaxiwayAtotaxitopositionandholdonRunway08RandrequestedthatthepilotmoveaheadtopermitaDash-8tolineupbehind.ThecontrollerthenclearedtheDash-8(believedtobeonTaxiwayL)totakepositionbehindtheIslander,withoutrealizingthattheDash-8wasdowntherunwayatL2.SincethecontrollerthoughttheDash-8andtheIslanderwerebothatthethresholdof08R,hedidnotstatethespecificentrypointforeitherone,norwasherequiredtodoso.

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TheDash-8crewatL2apparentlyacknowledgedtheirclearancetoposition;however,itwasblockedbyanothertransmission.TheDash-8atL2begantaxiingtowardRunway08R,whilelookingaheadfortheIslanderitwastofollow—whichwasinfactbehindit.

Aftertheblockedtransmission,thecontrolleraskedwhomadethelastcall.Atransmissioncamefrom“theDash-8behindtheIslander,”whichmatchedthecontroller’smindsetofthesituation,butitwasnotthesameDash-8.AcommentwasmadeabouttheIslander’slightsnotworking(therewerestilltwomoreIslanderswaitingtodepart).AseriesofconfusingandmostlyunsolicitedtransmissionsfromunidentifiedsourcestookplaceregardingnavigationlightsonIslanders.ItwasduringthisseriesoftransmissionsthattheIslanderinpositionatthethresholdofRunway08Rwasclearedfortakeoffandcompliedwiththatclearance.

AstheDash-8atL2wasmovingtowardRunway08R,thecrewwasstillunabletoseetheIslandertheywereinstructedtoline-upbehind,andbecameuneasyaboutthesituation.Thecrewelectedtoturntheaircrafttotheirright,tolooktowardthethresholdof08R.TheythensawthelandinglightsoftheIslandercomingdowntherunwayonthetake-offrun.ThecrewstoppedtheDash-8anddisplayedallexterioraircraftlightsastheIslanderrotatedinfrontofthem.

Analysis—Followingtheroutinepre-shiftreviewandbriefing,thecontrollerwasnotawarethatTaxiwayL2wasopen;onthecontroller’stwopreviousnightshifts,L2hadbeenclosedformaintenance.Whenthecontrollerscannedthedepartureflightprogressstripsforthetaxiwaydesignatorsassignedbythegroundcontroller,itwasnotrecognizedthatthedigit“2”waspartiallyobscuredbyotherinformationfortheonedepartureonTaxiwayL2.

Theairportcontroltowerisequippedwithairportsurfacedetectionequipment(ASDE).Thisgroundsurveillanceradarsystemdisplaystargetsontheairport,butithassomeinherentlimitationsandsomeunresolvedtechnicalanomalies.Thetowercontrollerdidnotrelyonthissystem,anddidnotassociateatargetonTaxiwayL2withtheDash-8,ormonitortheASDEwhentheDash-8wasclearedtopositionbehindtheIslander.

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Priortotheincident,thecontrollerwasstatingrunwayentrypositionsinallclearancesontotheactiveRunway08R,andthesepositionswerebeingreadbackbyflightcrews.Althoughnotarequirementforentryatthethreshold,thisappearedtobeacommonpractice,butitceasedintheminutesleadinguptothisincident.Inthespecifictake-offclearanceleadingtothisoccurrence,thecontrollerdidnotstatetherunwayentrypositionon08R,nordidtheIslanderpilotvoluntarilystateit,whichprecludedtheopportunityofalertingtheDash-8atL2.

Asapointofinterestforallpilotsdepartingfromanyentrylocationalongarunway,controllersarerequiredtospecifytherunwayentrylocationatanintersectionortaxiwayotherthanatthethreshold,whichismentionedintheTransportCanadaAeronautical Information Manual(TCAIM)RAC4.2.5.

Itisnotarequirementforapilottoreadbackorotherwisestatetheirrunwayentrylocation;however,ifpilotsareawareofthecontroller’srequirement,itwouldbereasonabletoexpectthatapilotwouldchallengethecontrolleriftheclearanceontoarunway,notatthethreshold,didnotincludetheintersectionnameortaxiwaylocation.

Therefore,intheory,theDash-8crewcouldhavenoticedtheabsenceofthisrequirementinthecontroller’sclearancetoline-upon08RwhentheywereatTaxiwayL2.

Ithasbeenalong-standingargumentthatacommonfrequencyallowspilotstomaintainbettersituationalawareness.NumerousaircraftweretunedintotheVancouvertowersouthfrequency.NooneadvisedthecontrollerthattherewasnoDash-8atthethresholdabletolineupbehindtheIslander.ItisunknownwhythesolepilotoftheIslanderdidnotseetheDash-8atL2taxiingontotherunwayahead.

Followingthisincident,theVancouvertowerimplementedanoperationsbulletintoremindcontrollersoftherequirementtospecifythenameofthetaxiwayorintersectionwhenissuingaclearancetopositionorfortakeoff,otherthanatthethreshold,andfurtherrecommendedthattheprocedurebeappliedtothethresholdaswell.Intheimmediateterm,theTSBisworkingwithNAVCANADAandTransportCanadatoencouragegoodairmanshippracticestosupplementthisairtrafficcontrol(ATC)requirementandenhancesafetywhilemorepermanentrequirementsarebeingconsidered.

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Say Again! Communication Problems Between Controllers and Pilotsby Gerard van Es, National Aerospace Laboratory (NLR), Amsterdam, The Netherlands

“Regardless of the level of sophistication that the air traffic system achieves by the turn of the century, the effectiveness of our system will always come down to how successfully we communicate.”

Linter and Buckles, 1993

Voicecommunicationsbetweencontrollersandpilotsareavitalpartofairtrafficcontrol(ATC)operations.Miscommunicationcanresultinhazardoussituations.Forinstance,miscommunicationhasbeenidentifiedasaprimaryfactorcausingrunwayincursions.ThecollisionbetweentwoBoeing747satTenerifein1977,demonstratesthepotentiallyfatalconsequencesofinadequatecommunication.

Eachyear,millionsoftransmissionsaremadebetweencontrollersandpilots.Mostofthesetransmissionsrelatetoinstructionsgivenbycontrollers,andtheresponsesfromthepilotstotheseinstructions.Analysisofsamplesofpilot-controllercommunicationsrecordedindifferentATCcentresrevealedthatsomekindofmiscommunicationoccurredinonly0.7percentofalltransmissionsmade.Inmorethanhalfofthese,theproblemsweredetectedandsolvedbythecontrollerorpilot.Theseareverygoodnumbers,consideringthefactthatatleasttwohumansareinvolvedinthecommunicationprocess.

Sowhatcangowrong?Inordertoanswerthisquestion,theNationalAerospaceLaboratoryNLRconducted

astudyonair-groundcommunicationproblems,usingrecordedincidentsinEurope.ThisstudywascommissionedbyEUROCONTROLaspartoftheirsafetyimprovementinitiative.AlthoughthisstudywaslimitedtothesituationinEurope,manyoftheidentifiedissuesapplytootherpartsoftheworld(e.g.NorthAmerica).TheresultsofthisstudywerepublishedintworeportsthatcanbeobtainedfromEUROCONTROL(seetheendofthisarticle).Thisarticlewillbrieflydiscusssomeoftheimportantresultsfromthesestudies.

Themosttypicalcommunicationproblemidentifiedwasrelatedtotheso-calledreadbackandhearbackerrors.Thesecomeintwoflavours:oneinwhichthepilotreadsbacktheclearanceincorrectlyandthecontrollerfailstocorrecttheerror(readback/hearbackerror),andtheotherinwhichthecontrollerfailstonoticehisorherownerrorinthepilot’scorrectreadbackorfailstocorrectcriticalerroneousinformationinapilot’sstatementofintent.Thefollowingisanexampleofatypicalreadback/hearbackerror:“theB7�7wasoutboundfromXXmaintaining6000ft.TheTu154wasoutboundfromYY,andoninitialcalltotheKKsector,wasclearedto5000ft.However,thepilotreadbacktheclearanceas6000ft,whichwasunnoticedbythe

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controller.Ashorttermconflictalert(STCA)warnedthecontrollerofthesituation,andavoidingactionwasissuedtobothaircraft.”Anexamplethatillustratesahearbackerroristhefollowing:“theaircraftwasclearedtodescendtoFL150,butacknowledgedadescenttoFL180.Thiswaschallengedbythecontroller,whotheninadvertentlyclearedtheaircrafttoFL1�0.Thisincorrectflightlevelwasreadbackbythepilot,andwasnotcorrectedbythecontroller.”Othertypicalproblemsfound,wererelatedtocaseswheretherewasacompletelossofcommunication,ortherewereproblemswiththecommunicationequipmentonthegroundorintheaircraftitself.Anexampleoflossofcommunicationsisthefollowing:“aB777wastransferredfromfrequency129.22totheXXsectorfrequency,1�4.77,andreadbackappearedtobecorrect.Approximately5minlater,theXXsectorcontrollertelephonedtoaskfortheB777tobetransferred,andwasinformedthatithadbeen.Subsequently,theB777calledfrequency129.22toadviseofhavinggonetothewrongfrequency.TheB777wasabsentfromthefrequencyforabout10–15min.”Lossofcommunicationinanyformordurationisalwaysahazardoussituation,butitisevenmoresoafterthe9/11events.

Whatiscausingalltheseproblems?Likemanysafety-relatedoccurrences,theanswerisnotsimple,astherearealargenumberoffactorsthathaveplayedaroleinthechainofeventsleadingtoair-groundcommunicationproblems.However,anumberoffactorsreallyshowedtobesignificantcontributorstotheproblem.First,similarcallsignsonthesamefrequencywasbyfarthemostfrequentlycitedfactor.Insuchcases,pilotspickedupaninstructionintendedforanotheraircraftthathadasimilarcallsign.Forthecontroller,itisnoteasytoidentifythiserror,asthetransmissionmaybeblockedwhentwoaircraftrespondtotheinstruction.Therewereevenafewcasesinwhichfouraircraftrespondedtothesameinstruction.Theuseofsimilarcallsignsshouldbe

avoidedasmuchaspossible.Whenthisisinevitable,thefollowingshouldbeconsideredtomitigatetheproblem:pilotsshouldusefullcallssigns(noclipping)intheirreadbacks;whentherearesimilarcallsignsonthefrequency,controllersshouldinformthepilotsaboutit;pilotsshouldactivelymonitoratcriticalflightstagesusingtheirheadsets(insteadofflightdeckspeakers).InEurope,theproblemofsimilarcallsignsisbeingaddressedbyEUROCONTROL.Anotherimportantfactorisrelatedtofrequencychanges.Inalargenumberofair-groundcommunicationincidentsanalyzed,pilotsforgottochangethefrequencyasinstructed,orchangedtothewrongfrequency.Pilotsshouldalwayschecktheselectedfrequencywhenevertheradiohasgoneunnaturallyquietinabusysector.TheNLRstudyidentifiedmanymorefactors,suchastheuseofnon-standardphraseology(bycontrollers),radiointerference,frequencycongestion,andblockedtransmissions.Thevastmajorityofthefactorsidentifiedarenotnew.Manyofthemhavebeentheresincecontrollersonthegroundstartedtocommunicatewithpilotsusingaradio.

Inthefuture,someoftheair-groundcommunicationproblemscouldbeeliminatedbytheintroductionofdatalink,forinstance.However,suchasystem(andothers)cannoteliminateallofourcommunicationproblems.

References used for this article:Gerard van Es, Air-groundCommunicationSafetyStudy:Ananalysisofpilot-controlleroccurrences, EUROCONTROL/NLR, 2004 (www.eurocontrol.int/safety/gallery/content/public/library/com_report_1.0.pdf).

Gerard van Es et al., Air-GroundCommunicationSafetyStudy:CausesandRecommendations, EUROCONTROL/NLR, 2005 (www.eurocontrol.int/safety/gallery/content/public/library/AGC%20safety%20study%20causes_recommendations.pdf).

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Checklist Actions After Engine Failure on TakeoffAn AviationSafetyAdvisory from the Transportation Safety Board of Canada (TSB)

OnDecember20,2005,anMU-2B-�6aircraftwastakingofffromrunway15atTerrace,B.C.,onacourierflighttoVancouver,B.C.,withtwopilotsonboard.Theaircraftcrashedinaheavilywoodedareaapproximately500meast,abeamofthesouthendofRunway15;about�00mbeyondtheairportperimeter.Apost-crashfireoccurred.Theaircraftwasdestroyedandthetwopilotswerefatallyinjured.Theaccidenthappenedat18:�5PacificStandardTime(PST),indarkconditions.Theinvestigationintothisoccurrenceisongoing(TSBfileA05P0298).

Todate,theinvestigationhasrevealedthattheleftengine(HoneywellTPE��1-6-252M)failedasaresultofthecombustioncaseassembly(plenum)rupturing.Thisenginehadaccumulated4742hrsince

thelastcontinuousairworthinessmaintenance(CAM)inspection.Investigationofthewreckagealsorevealedthattheleftenginewasnotdeliveringpoweranditsassociatedpropellerwasnotfeatheredatthetimeofimpact.Theflapswerealsofoundat20°,inthemaximumdeflectionposition.Treedamagerevealedtheaircrafthaddescendedintothetreeslaterally,atanosedownangleofapproximately2�°.

ThefollowingmakeupthechecklistactionsprescribedintheMU-2Bpilotoperatingmanual(POM)foranenginefailure:

Dead(failed)engineconditionlever—EMERGSTOP(tofeatherthepropellerandshutofffuelatthefuelcontrol)

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Dead(failed)enginepowerlever—TAKEOFF(toassistfullfeatheringofthepropeller)Landinggearswitch—UPFlapswitch—UP(afterreachingasafealtitudeandairspeed)Airspeed—BESTRATEOFCLIMB(150ktcalibratedairspeed[CAS])Trimailerons—SET(toensurenospoilerextensionandlossoflift)Power(operatingengine)—MAXIMUMCONTINUOUSPOWER

ThePOMfortheMU-2Bpermitstakeoffusingeitherflap5or20.Theadvantageofusingflap20fortakeoffisthattheaircraftwillbecomeairbornesooner;however,becauseofthegreaterdragcausedbythehigherflapsetting,theaircraft’sclimbperformancewillbereduced.

Ifoneenginefailsaftertakeoff,theresultinglossofclimbperformancecausedbytheextendedflapswouldresultintheaircraftnotbeingabletoachievetheclimbgradientrequirementsspecifiedforagivendeparturerunway.Theincreaseddragcausedbyanun-featheredpropellerwould

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furtherreduceperformance.AccordingtothePOM,thecombinationofthelossofenginepower,theextendedflapsandtheun-featheredpropellerwouldresultintheaircraftnotbeingabletomaintainaltitude.

TheMU-2Baircraftisahigh-performancetwinturbopropaircraft.About400MU-2aircraftareactiveworldwide,including�09intheUnitedStatesand16inCanada.Anumberofthemhavecrashedfollowingenginefailuresduringtakeofforimmediatelyafterbecomingairborne.Insituationsinwhichanenginefailsatacriticalstageofthetakeoff,thecrewmusttakerapidandpositiveactiontoreducethedragontheaircraftinordertomaintainapositiverateofclimb.Unlessappropriateactionistaken,thereisariskoflossofaircraftandrelatedfatalities,suchaswereobservedinthisaccident.

Basedonthecircumstancesofthisoccurrence,TransportCanadamaywishtoremindMU-2Bandothertwin-engineoperatorsoftheimportanceofensuringtherequiredchecklistactionsarecarriedoutimmediatelyafterrecognizinganenginehasfailedontakeoff.

Computers in Aviation: Friend or Foe?by Michael Oxner. Mr. Oxner is a terminal/enroute controller in Moncton, N.B., with 15 years of experience. He is a freelance aviation safety correspondent for www.aviation.ca.

Indaysgoneby,aviationwasaboutstickandrudder;pilotskillswereparamountinhandlinganairplane.Thesedays,thingsaregettingmorecomplicated.Aircraftsystemsarebecomingincreasinglyautomated;flightinformation,suchasflightstatusandweatherconditions,ismorereadilyavailable;andaircraftnavigationsystemsarechanging,allowingmoreflexibleroutesofflight,andlessdependenceontheabilityofapilottoflyaparticularcoursefromaground-basednavigationaid(NAVAID).

Computersmakeallofthispossible;theyreceiveinformationviadatalinkratherthanrequiringapilottocommunicatebyvoicewithdispatchers;theydisplaythestatusofaircraftsystemsandpositioninmorelogicalways;andtheydocomplexcalculationsforaircraftnavigation,includingautomatedguidancealongprogrammedcourses.

Withalltheseadvancesincomputertechnologyenteringthecockpit,it’snowonderthatsometimesthecomputersgetthebestofus.Eachofushas,atsomepointoranother,beeninthepositionofbeing“behindthecurve”withacomputerofsomekind.WhetheritcomesdowntoprogrammingtheclockontheVCR,playingagameonacomputer,ordealingwithahigh-techpieceofhardware,we’vealldiscoveredthatcomputersdoexactlywhatthey’retoldtodo—evenifwemakeamistakeintellingthemwhatwewantthemtodo.

Therearefewareas,however,wheresimplemistakes,suchastransposingadigit,canresultinseriousconsequences.Aircraftnavigationisoneofthoseplaceswheredangercanlurkinunexpectedplaces.

Sometimesit’saninadvertenterror;sometimesit’sgettingcarriedawaywiththenavigationequipment’scapabilities;andothertimesit’samisunderstandingofthesystemanditseffect.Hereareafewexamplesofwhenthingscangoawry,andthereasonsmaybeobvious,ortheymaybefairlysubtle.

Asacontroller,Ihavewitnessedafewofthesubtletiesofsucherrors.Once,apilothadaskedfordirectBIMKU,theintermediateapproachfix(IF)foranapproachatanairportonly�0NMaway.Itshouldhaveamountedtoaleftturnofapproximately10°;however,theaircraft’strackonradarappearedtochange110°totheleft.Whenqueried,thepilottoldmehehadinadvertentlyselectedBIMTUfromthedatabase,afixassociatedwithanotherairport,about100NMnorthofhisintendeddestination.Ifanotheraircrafthadbeenonaparallelvectoronhisleftside,thiscouldhavebeenveryinteresting,tosaytheleast.

Asimilarerrorcanbemadewhenenteringgeographicalcoordinates.Accidentallyentering45°05’�2”forlatitudeinsteadof45°50’�2”isawhoppingerrorof45NM—allbecausetwodigitsweretransposed.Similarly,closeplacementofkeysonakeypadcanresultinaccidental

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selectionofanearbykey—perhapsentering48°insteadof45°inthepreviousexample,whichwouldhavebeenevenworse.Onemethodofcrosscheckingsuchanentryforerroristocomparethegeographicalcoordinatetothedesiredentrybackwards,helpingtotakethecomplacencyfactoroutofdataentry.Itmaytakealittletime,butitmayalsobewellworththeinvestment.

Othererrorsthatcanoccurcanalsobederivedfromcomplacency.Trustingthenavigationsystemtogetyouwhereyouwanttogocanbeamistake.Quitefrequently,pilotsaskforroutingsthroughrestrictedairspacessimplybecauseadirectrouting,madepossiblebyGPSandothersystems,ismucheasiertoenterintoasystem.Lookingatchartsandpickingoutpointstakestime,andthepracticealsotendstotakeanaircraftoffanoptimaldirectrouting.However,alookatthechartsduringtheflightplanningstagemayrevealreasonswhyadirectrouteissimplynotacceptabletopilotsorcontrollers.

Sometimes,pilotsmaymakeunintentionalentriesintonavigationsystems.Whileperusingadatabaseforapproaches,apilotmayinadvertentlyactivateanapproachandmakeaturnthatATCdoesnotexpect.Evenaslightturnmaycompromiseseparationwithsurroundingaircraft,especiallyinaterminalenvironmentwherecontrollersapplyminimumseparationtouseairspaceasefficientlyaspossible.

Also,restrictedairspacesmaycomeintoplayduringthetransitionfromtheen-routephaseofflighttotheapproachphase.SaintJohn,N.B.,forexample,islocatedveryclosetotheGagetown,N.B.,restrictedarea(CYR724),anareaoflivefiring.Manypilotsof

varyingexperiencehaveaskedforclearancesallowingnavigationdirectlytofixesassociatedwithanapproach,onlytohaveATCdenytheclearance.Thereasonisthatmanypilotstendtorelyonthenavigationgeartotakethemwheretheywanttogo,butforgetaboutthepossibilityofobstaclesorrestrictedareasbetweenwheretheyareatthetimeandwherethedesiredfixis.Theapproachplatesmayhavetoonarrowafocustoshowtheproximityoftherestrictedairspace,leadingapilottobelievethereisnoreasonnottoflytoaparticularfix.

AnothercommonerroriswhenapilotasksforclearancetoanIFforanapproach.Ifaturnofmorethan90°isrequiredfortheaircrafttoturnontothefinalapproachcourse,apilotwillsometimesprogramtheautopilottoprojectawaypointbesidetheIF,ineffectmakingabaselegfortheautopilottofly.Somepilotsdoingthisdon’taskforapprovalforsuchamanoeuvre,andnavigatetoapointthatATCisnotexpecting,whichmayaffectothertraffic.Also,iftheapproachplatedoesnotprovideforsuchamanoeuvre,asanRNAVapproachmay,howdoesthepilotknowwhataltitudeissafethatfarawayfromthefinalapproachcourse?

Yes,computerscanbeourfriends;theycanoffloadalotofworkfromaflightcrew,especiallythosemenialandrepetitivecalculations,buttherearemanypitfallsthatcanturnintobigissueswithoutpropercareandattention.Familiaritywithhowasystemoperates,andwhaterroneouskeystrokesmaydo,canliterallysavelives.Takecareintheskies,andwatchthecomputerscarefully.Theydowhatthey’retoldtodo,evenifwedon’trealizewhatwe’retellingthemtodo.

Hail Damage…

WhileincruiseatFL�00afterdepartingCalgary,Alta.,thisBoeing727sustainedextensivehaildamageafteranencounterwithaseverethunderstorm.Inadditiontothedamageshown,wingleadingedges,engineinletsandlandinglightslenseswerealsodamaged.TheaircraftreturnedtoCalgaryforanuneventfullandingandwaslaterrepaired.

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maintenance and certificationAgeing Airplane Rulemaking ........................................................................................................................................... page 21Bilateral Agreements on Airworthiness—An Overview and Current Status .............................................................. page 24

Ageing Airplane Rulemakingby Blake Cheney, Acting Manager, Domestic Regulations, Regulatory Standards, Aircraft Certification, Civil Aviation, Transport Canada






Whenmanyofusthinkofageingairplanes,imagescometomindofproudlydisplayedvintagewarbirdsandotherenduringexamplesofaviation’sfirstcenturyofflight.However,perhapslessobviousistheworldoftransportandcommutercategoryairplanesthateachdaytransportpassengersandcargotodiversedestinationsaroundtheglobe.Yes,eventhestylishlypaintedandfreshlywashedpassengerjetstransportingusforbusiness,pleasureandtoholidaydestinationscouldbeconsideredinthesamebreathasthosevintagewarbirds.

ForthosefollowingtheprogressoftheFederalAviationAdministration(FAA)rulemakingactivities,collectivelyknownastheAgingAirplaneProgram,launchedfollowingtheAlohaAirlinesBoeing7�7-200accidentof1988,thesubjectofageingairplaneswillbehardlynew.Inmanyrespects,theterm“ageingairplane”itselfisgettinglonginthetooth.Whatisnewistheapproachnowbeingtakentoaddressdesignandmaintenanceissuesassociatedwithageingstructures,wiringandfueltanksafety.

RecentregulatoryactivitybytheFAA,theEuropeanAviationSafetyAgency(EASA),theBrazilianAgência Nacional de Aviação Civil(ANAC)andTransportCanadaCivilAviation(TCCA),hasbroughttobearafocusonenhancingthesafetyofthecurrentandexpectedfuturefleetofageingairplanes.Thecurrentrulemakinginitiativesrecognizethatmanyairplanesarestillinservicebeyondtheirdesignlifegoal.Thedesignlifegoalisa“lifeexpectancy”inflightcyclesorhoursthatisgenerallyestablishedearlyinthedevelopmentofanewairplaneandbasedoneconomicanalysis,pastexperiencewithothermodels,andinsomecases,fatiguetesting.Inaddition,numerousaccidentshaveraisedawarenessofsafetyissuesassociatedwiththedesignandmaintenanceofageingairplanestructuresandsystems.

Newrequirementswillfocusonre-evaluationsofexistingdesignsagainstnewairworthinessstandards,revisingmaintenanceandinspectionprograms,andimposingflightoperationsrequirementsthatwouldprohibittheoperationofairplanesthatdonotincorporaterequiredmodificationsand/orchangestotheirmaintenanceprograms.

WhiletheAlohaAirlinesaccidentwasnotthefirstageingairplanefatalaccident,itwastheonethatbroughttheissuetopublicattention.TheBoeing7�7-200wasahigh-cycleaircraftthatsufferedapartialin-flightdisintegrationinwhichan18-ftcrownsectionofthefuselagewastornapartinflight.Theaccidentinvestigationrevealedthepresenceofsmallcracksatmultiplerivetlocationsinadisbondedlapjoint,whichweresufficientinsizeanddensitytocausetheaccident.Thisphenomenonisreferredtoaswidespreadfatiguedamage(WFD).

April 28, 1988: Aloha Airlines flight 243, Boeing 737-200 near Maui, Hawaii, fuselage upper crown skin and structure separated in flight.

Historically,wemaylookbackto1977forwhatcouldbearguedasthefirstageing-airplanerelatedaccident;aDan-AirServicesBoeing707-�21CthatcrashedonfinalapproachinLusaka,Zambia.Theairplane,engagedinanon-scheduledinternationalcargoflight,happenedtobethefirstaircraftoffthe707-�00Cseriesconvertiblepassenger/freighterproductionline.Onapproach,theairplanepitchedrapidlynosedown,divedverticallyintothegroundfromaheightofabout800ft,andcaughtfire.Theaccidentwasdeterminedtobecausedbyalossofpitchcontrolfollowingthein-flightseparationoftheright-handhorizontalstabilizerandelevatorasaresultofacombinationofmetalfatigueandinadequatefail-safedesignintherearsparstructure.Shortcomingsindesignassessment,certification,andinspectionprocedureswerecontributoryfactors.Apost-accidentsurveyofthe707-�00fleetworldwiderevealedatotalof�8aircraftwithfatiguecrackspresentinthestabilizerrearspartopchord.

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A Dan-Air Services Boeing 707-300C, similar to the aircraft that crashed near Lusaka, Zambia, on May 14, 1977.

OurownCanadianexperienceinvolvedaDouglasDC-�CwingseparationnearPickleLake,Ont.,in1987.Twootherpilotsflyinginthevicinityatthetimedescribedthefinalmomentsoftheaircraftflightashavingbeeninaninvertedattitudedescentwiththeleftwingfoldedupwards.TheCanadianAviationSafetyBoard(CASBReportNo.87-C70022)determinedthattheleftwingfailedundernormalflightloadsasaresultofafatiguecrackinthecentresectionofthelowerwingskin.Itwasalsofoundthatanomaliesintheradiographspreviouslytakenduringmandatorynon-destructivetestinginspectionswerenotcorrectlyinterpreted.Asaresult,TransportCanadaconductedtheStudy of Non-Destructive Testing in Canadian Civil Aviation,whichwascompletedinJanuary1988.Thestudyidentifiedanumberofshortcomings,andrecommendedthatnon-destructivetesting(NDT)personnelcertificationstandards(CGSB,MIL-STD-410,ATA105)berecognizedasairworthinessstandards,andthatNDTworkbedoneunderanapprovedmaintenanceorganization(AMO).Canadian Aviation Regulations(CARs)571and57�wereamendedtoincludetheserequirements.In1996,TCCApublishedCAR511.�4—Supplemental Structural Integrity Itemstorequire,forallprinciplestructuralelements,thedevelopmentofanychangeorprocedurenecessarytoprecludethelossoftheairplaneorasignificantreductionintheoverallstructuralstrengthofitsairframe.

Subsequenttothe1988accident,theFAAgreatlyexpandeditsstructuralintegrityinspectionprogramandformedtheAirworthinessAssuranceWorkingGroup(AAWG)withfivefocusareastoexaminestructuralissuesrelatedtowidespreadfatiguedamageandcorrosion(www.faa.gov/regulations_policies/rulemaking/committees/arac/issue_areas/tae/aa/):

ServiceBulletinReviewSupplementalInspectionsMaintenanceProgramsCorrosionPreventionandControlProgramsRepairAssessmentPrograms.

Whereastheaccidentstodatewereraisingawarenesstoageingstructuralissues,itwasnotyetrealizedthataircraftsystemsageing-relatedfailurescouldbejustas

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catastrophic.ThatallchangedonJuly17,1996,whenTransWorldAirlines(TWA)flight800,a25-yearoldBoeingmodel747-1�1,wasinvolvedinanin-flightbreak-upaftertakeofffromJohnF.KennedyInternationalAirportinNewYork,resultingin2�0fatalities.TheaccidentinvestigationconductedbytheNationalTransportationSafetyBoard(NTSB/AAR-00/0�)indicatedthatthecentrewingfueltank(CWT)explodedduetoanunknownignitionsource.However,oftheignitionsourcesevaluatedbytheinvestigation,themostlikelycausewasashortcircuitoutsideoftheCWTthatallowedexcessivevoltagetoenteritthroughelectricalwiringassociatedwiththefuelquantityindicationsystem.

July 17, 1996: Trans World Airlines flight 800, a Boeing 747-131, in-flight break-up over the Atlantic Ocean,

near East Moriches, N.Y., 230 fatalities.

ThisaccidentpromptedtheNTSB,theFAAandindustrytoexaminetheunderlyingsafetyissuessurroundingfueltankexplosions,theadequacyoftheexistingregulations,theservicehistoryofairplanescertificatedtotheseregulations,andexistingfueltanksystemmaintenancepractices.TheNTSB/FAAaccidentinvestigationincluded:

ReviewoffueltanksystemdesignfeaturesofBoeing747andcertainothermodels;andInspectionofin-serviceandretiredairplanes.

TheTWAflight800accidentinvestigationwasstillinprogresswhen,onSeptember2,1998,Swissair(SR)flight111,aMcDonnellDouglasMD-11,experiencedanin-flightfireapproximately5�minafterdeparturefromNewYork,thatwouldultimatelyleadtotheaircraftcollidingwithwaternearPeggy’sCove,N.S.,andwouldresultin229fatalities.Theaccidentinvestigation,conductedbytheTransportationSafetyBoardofCanada(TSBAIRReportNo.A98H000�),identifiedthecockpitatticandforwardcabindrop-ceilingareasasbeingtheprimaryfire-damagedarea,andthatthemostprevalentpotentialignitionsourcewaselectricalenergy.

ItshouldbenotedthattheSRflight111occurrenceaircraftwasmanufacturedin1991,andtherefore,shouldnotbeconsideredanagedairplane.Inaddition,ahistoricalreviewconductedbytheFAAoffueltankexplosionspriortotheTWAflight800accidentrevealedthatageingwasnottheonlycontributingfactorinthedevelopmentofpotentialignitionsources.Inparticular,inMay1990,thecentrewingtankofaBoeing7�7-�00explodedduringpushbackfromaterminalgateprior

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toflight,astheresultofanunknownelectricalignitionsource;theaircraftwaslessthanayearold.Hence,thedevelopmentofsuchfailuresmayberelatedtoboththedesignandmaintenanceoftheairplanesystems.

Photos courtesy of FAA SFAR 88 Workshop, June 2001: Potential ignition sources discovered by fleet inspection.1. Frayed fuel pump wire; 2. Main tank over pressure;3. Arc through conduit; 4. Arc through pump housing.

InJanuary1999,theFAAcharteredtheAgingTransportSystemsRulemakingAdvisoryCommittee(ATSRAC).WhereastheAAWG’sfocushadbeenonstructuralintegrityandtheeffectsofstructuralcorrosionandfatigue,ATSRAC(www.mitrecaasd.org/atsrac/)wastaskedto“proposesuchrevisionstotheFederal Aviation Regulations(FARS)andassociatedguidancematerialasmaybeappropriatetoensurethatnon-structuralsystemsintransportairplanesaredesigned,maintained,andmodifiedinamannerthatensurestheircontinuingoperationalsafetythroughouttheservicelifeoftheairplanes.”

Inparallel,theAerospaceIndustriesAssociation(AIA)/AirTransportAssociationofAmerica(ATA)conductedanaircraftfuelsystemsafetyinvestigation.Theteaminspectedmultiplein-serviceairplanes,andthisindustryprogramgatheredsignificantinformationabouttheoverallintegrityofthedesignandmaintenanceoftheseaircraft.Wellover100000labour-hourswerereportedlyexpendedperforminginspectionsoftheworldfleet.AsofJune1,2000,inspectionshadbeencompletedon990airplanes,withafurther�0airplanestobecompletedshortlythereafter,operatedby160aircarriersindiverseoperatingenvironmentsonsixcontinents.

OnApril21,2001,after18monthsofdeliberation,including�monthsofpublicconsultation(includinginputsfromTransportCanadaandothercivilaviationauthorities[CAA]),theFAAissuedtheFinalRuleofSpecial Federal Aviation Regulation(SFAR)No.88.Thisnewrulepromulgatedimproveddesignstandardsfortransportcategory(large)airplanes,developed

withtheknowledgegainedfollowingthetragedyofTWAflight800.SFARNo.88includedacomprehensiverequirementformanufacturers,ownersandoperatorstoconductaone-timefleet-widere-evaluationofalllargeairplanesofthejetage,withrespecttotheirfuelsystemdesignsandmaintenancepractices,againsttherevisedandimprovedsafetystandards.TCCA,theJointAviationAuthorities( JAA),andotherCAAssupportedthisimportantsafetyinitiative.Manufacturersconductedextensivedesignreviews,andtheirfindingswerereviewedbytheairworthinessauthoritiestoverifycompliancewiththenewrequirementsandtomandatecorrectiveactionswherenecessary(www.fire.tc.faa.gov/systems/fueltank/intro.stm).

ThroughtheirparticipationintheAAWG,ATSRACand/ortheFAA’sTransportAirplaneandEnginesIssueGroup(TAEIG),EASA,TCCAandANAC(thencalledCentro Técnico Aeroespacial[CTA])havemonitoredand/orparticipatedinthedevelopmentofproposalsfortheAgingAirplaneProgramrulemakinginitiatives.

TheAgingAirplanePrograminitiativesconsistofmulti-disciplinaryregulatoryactivitiesincluding:

(1)Transport Airplane Fuel Tank System Design Review, Flammability Reduction and Maintenance and Inspection Requirements; Final Rule(issuedApril19,2001)andtheFuel Tank Safety Compliance Extension; Final Rule(issuedJuly21,2004);

(2)Enhanced Airworthiness Program for Airplane Systems / Fuel Tank Safety; Notice of Proposed Rulemaking(NPRM)(issuedSeptember22,2005);

(�)Aging Airplane Safety; Final Rule(issuedJanuary25,2005);

(4)Aging Aircraft Program: Widespread Fatigue Damage;NPRM(issuedApril11,2006);and

(5)Damage Tolerance Data for Repairs and Alterations;NPRM(issuedApril1�,2006)

OtherrelatedFAAregulatoryinitiativesinclude:

(6)Repair Assessment of Pressurized Fuselages; Final Rule(issuedApril19,2000);and

(7)Thenewapproachforrequirementsfordesignapprovalholders(partofAging Airplane Program Update,issuedonJuly21,2004).

TCCAhasrecentlyinitiatedCanadian-specificrulemakingactivitiesandhasinvokedaCanadianAviationRegulationAdvisoryCouncil(CARAC)WorkingGrouponAgeingAeroplaneRulemakingandHarmonizationInitiatives(AARHI),coveringthestructuralandnon-structuralsubjects.TheWorkingGroupisajointundertakingofgovernmentandtheaviationcommunity,representinganoverallaviationviewpoint.TheWorkingGroupwilldispositioninto

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theCanadianregulatoryframeworkthefindingsofbothAAWGandATSRAC.Atthesametime,theWorkingGroupwillseektomaximizecompatibilitywithotherregulatoryauthorities.(FormoreinformationonCARAC,pleaseseewww.tc.gc.ca/civilaviation/regserv/affairs/carac/menu.htm)

EASAhasalsoinitiatedregulatoryactivitiesthatwillstrivetobeharmonizedwiththeFAAbycreatingtheEuropeanAgeingSystemsCoordinationGroup(EASCG).EASAhasseparatelyexaminedtheageingstructuresissues,butisanticipatedtoconveneaWorkingGroupthisyeartodispositionthoseissueswithinputfromtheEuropeanindustry.

FollowingpresentationoftheCARACAARHIWorkingGrouprecommendations,TCCAwillseektopublishnewregulationsandstandardsthatwillparallelthoseoftheFAA’sAgingAirplaneProgram.ItisanticipatedthattheTCCArulemakingwillincludenewdesign

approvalholder(DAH)requirements,specificallyfortypecertificate(TC)andsupplementaltypecertificate(STC)holders,tosupplydataanddocumentsinsupportofoperatorcompliancewithrelatedflightoperationsrules.Insomecases,repairdesigncertificate(RDC)andlimitedSTC(LSTC)holdersmayalsobeaffected.TheDAHrequirementswouldreferencetechnicalstandards,andincludeconsiderationforcomplianceplanningapplicabletoexistingDAHsandapplicantsfornewandamendeddesignapprovals,toensurethatanacceptablelevelofsafetyismaintainedfortheaffectedairplanes.

TCCA,EASA,ANACandtheFAAhaveagreedtoworktogetherontheageingairplaneinitiativesinanefforttofosteracommonunderstandingoftherespectiverulemakingactivities,toprovideforcoordinatedimplementation,andtocoordinatetheeventualcompliancefindingsbetweentheappropriateCAAs,wherepossibleusingproceduresdevelopedunderthebilateralagreements.

Bilateral Agreements on Airworthiness—An Overview and Current Statusby Carlos Carreiro, International Regulations, Regulatory Standards, Aircraft Certification, Civil Aviation, Transport Canada

Whatisabilateralagreementonairworthiness?Abilateralagreementonairworthinessisanadministrativearrangementthathastheobjectiveofpromotingaviationsafetybystrengtheningtechnicalcooperationandmutualacceptanceoftasksrelatedtotheairworthinessofaeronauticalproducts.

Forthepurposeofthisarticle,wewillsimplyusetheterm“agreement”wheneverwewanttorefertoabilateralagreementonairworthiness.

Whydoweenterintoanagreement?TheCanadianAeronautics Acthasthepurposeofprovidingforsafe,efficientandenvironmentally-responsibleaeronauticalactivities,bymeansthatincludeensuringthatCanadacanmeetitsinternationalobligationsrelatingtoaeronauticalactivities.

Paragraph4.2(1)(j)oftheAeronautics ActprescribesthattheMinister(tobeconsideredtheMinisterofTransportforthepurposeofthisarticle)mayenterintoadministrativearrangementswiththeaeronauticsauthoritiesofothergovernmentsorwithorganizationsactingonbehalfofothergovernments,inCanadaorabroad,withrespecttoanymatterrelatingtoaeronautics.

BeforeentryintoCanada,aeronauticalproductsdesignedinaforeignstaterequireapprovaltoensure

Canadianairworthinessdesignstandardsarefullysatisfied,regardlessofwhethertheproductreceivedpriorcertificationbyaforeignairworthinessauthority.Conversely,thecertificationofaeronauticalproductsthataredesignedinCanadamustbevalidatedbyforeignairworthinessauthoritiesuponexportationfromCanada.Thisreview,attimes,maybeverylengthyandrequirealotofresourcesfromthecivilaviationauthority(CAA)fromboththeexportingandimportingStates.

Insummary,thepresenceofanagreementonairworthinessorcertificationofaeronauticalproductsisnotonlyverycost-beneficialforCanadianorganizationsexportingaeronauticalproductstootherforeignStates,butitalsopromotesasignificantexchangeoftechnicalcooperationamongStates.

CharacteristicsofanagreementAnagreementcanbeenteredbetween:

CanadaandanothergovernmentunderaTreaty(legallybinding);orTheMinisterofTransportorTransportCanadaCivilAviation(TCCA)andtheircounterpartoffice,asanadministrativeortechnicalcooperationarrangement(notlegallybinding).Examplesofthiskindofagreementare:TechnicalArrangementsandMemorandaofUnderstanding,amongothers.

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Anagreementcanonlyrelatetocivilaviationsafetyissues(notcommerceortradeissues),anditshouldbewithinthecurrentscopeandauthorityoftheCanadianregulations.

ForeignAffairsCanada(FAC)hasprimaryresponsibilityinlegally-bindingagreements.Forotheragreements,theMinisterofTransportorTCCAcanengagedirectly.

AnagreementcannotrelievetheMinisterofTransportoftheirstatutoryresponsibilities,which,undertheAeronautics ActandtheCanadian Aviation Regulations(CARs),cannotbetransferred.

StepstoanagreementThefollowingstepsarerequiredinorderforCanadatoenterintoanagreementwithanotherStateororganization:

1) Theremustbeamutualdesiretostrengthenandformalizetechnicalcooperationinpromotingsafety,whichwouldincreaseefficiencyinmattersrelatingtosafety,andreduceeconomicburdenduetoredundantairworthinessreviews(technicalinspections,evaluations,testing).

2) Areasofcooperationmustbedefined:Technicalassistancetobilateralpartnerintheirapprovalandcertificationactivities;Harmonizationofstandardsandprocesses;Facilitationoftheexchangeofcivilaeronauticalproductsandservices;Mutualrecognitionandreciprocalacceptanceofapprovalandcertificates;Otherareas,asmutuallyagreed.

�) EachState’slegislationandregulatorysystemmustbeassessedanddeemedtobeequivalent.Thecivilaviationregulatoryframeworkshownbelow,isusedwhenassessingequivalency.

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4) CompetenceandcapabilityofabilateralpartnermustbeassessedastotheirabilitytoachieveresultssimilartothoseobtainedbyTCCA.

5) CompliancewiththeChicagoConventionmustbeassessed.

6) Effectivenessofoversightandenforcementprogramsmustbeassessed.

7) Onceconfidenceisestablishedwithsteps1to6,negotiationsandadraftagreementmayproceed.

Theconclusionofanagreementisreachedinthefollowingmanner:

ForTreaties—Signaturesbybothgovernments(States).Fornon-Treaty(notlegallybinding)—SignaturesbyMinisterofTransportofCanadaandbilateralpartnerequivalent.(ThesignatureoftheMinistercommitsTransportCanada,andnottheCanadianGovernment.)

Intermsofthetimerequiredtoconcludeanagreement,itmaytakeupto�yearsforalegally-bindingagreement(duetothelengthyreviewprocessandlegalnature),and�monthsto2yearsforanagreementthatisnotlegallybinding(dependingonthecomplexityandscopeoftheagreement).

StatusofagreementsonairworthinessPleaserefertothefollowingWebsiteforinformationonagreementsonairworthinessthathavebeensignedbyTCCAortheGovernmentofCanada(inthecaseofalegally-bindingagreement):www.tc.gc.ca/CivilAviation/certification/Int/menu.htm.

Forfurtherquestionsorclarifications,[email protected].

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Aeronautics Act

Regulations(Canadian Aviation Regulations [CARs])

Standards(Airworthiness Manual [AWM])

Advisory Materials(Advisory Circulars)

Policies and Procedures(Policy Letters, Staff Instructions)

26 ASL2/2007

recently released tsb reports

The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include the TSB’s synopsis and selected findings. Some excerpts from the analysis section may be included, where needed, to better understand the findings. We encourage our readers to read the complete reports on the TSB Web site. For more information, contact the TSB or visit their Web site at www.tsb.gc.ca. —Ed.






TSB Final Report A04Q0003—Loss of Separation

OnJanuary1�,2004,aBoeing777,enroutefromJohnF.KennedyAirport,N.Y.,toNarita,Japan,wasatflightlevel(FL)�50onaconvergingtrackwithaBoeing767,atFL�50enroutefromParis,France,toChicago,Ill.Bothaircraftreceivedatrafficalertandcollisionavoidancesystem(TCAS)resolutionadvisory(RA),towhichtheyresponded.Thetwoaircraftpassedeachotherat1�:22EasternStandardTime(EST),within600ftlaterallyand1100ftverticallyofoneanother,approximately160NMsouthofLaGrandeRivière,Que.,inradar-controlledairspace.TheairtrafficcontrollershadnotdetectedtheconflictuntilalertedbytheATCconflictalertprogram.Therequiredseparationwas5NMlaterallyor2000ftvertically.

Findingsastocausesandcontributingfactors1. ThepotentialconflictbetweentheB767andthe

B777wasnotdetectedwhentheB767firstcontactedtheLaGrandeRivière(CYGL)sector,andnoactionwastakenbythefirstCYGLcontrollertoremindthenextcontrollerthataconflictprobehadnotbeencompleted.Thisallowedapotentialconflicttoprogresstothepointofariskofcollision.

2. AfteracceptingthehandoveroftheCYGLsector,neitherthetraineenortheon-the-jobinstructor(OJI)conductedareviewofallaircraftundertheircontroltoensuretherewerenopotentialconflicts;theconflictbetweentheB767andtheB777wasnotdetected,whichplacedtheminapotentialriskofcollisionsituation.

�. AftertheATCconflictalertprogramwarnedthetraineeandtheOJIoftheimpendinglossofseparation,theOJIwasunabletocommunicateinstructionstotheinvolvedaircraftbecauseheusedthefootpedalinsteadofthepress-to-talkswitchtoactivatetheradios.Asaresult,theaircraftprogressedtothepointwhereonlytheTCASRApreventedapotentialcollision.

Findingsastorisk1. Thereisnomedium-termconflictprobeforradar-

controlledairspacetoprovideanadditionalbackup

tothecontrollersscanningtheradarorrelyingoninformationontheflightdatastrips.

2. Thecurrentoperationalconflictalertsystemprovidesminimalwarningtimeforthecontrollerandrequiresimmediateandoftendrasticactionbyboththecontrollerandtheaircrewtoavoidamid-aircollision.

�. BecausetheTCASisnotmandatoryinCanada,therecontinuestobeanunnecessaryriskofmid-aircollisionswithinCanadianairspace.

Otherfindings1. Thelackofrealisticandrecurrentsimulationtraining

mayhavedelayedtheOJI’squickandefficientrecoveryfromalossofseparationsituation,ormayhavecontributedtohisinappropriateresponsetotheconflictalertwarning.

2. TheOJI’strainingcoursefocussedmainlyontheinterpersonalaspectsofmonitoringatrainee.Itdidnotcoverpracticalaspects,suchashowtoeffectivelyshareworkknowledgeandpracticeswithatraineeorhowtoquicklytakeoveracontrolpositionfromatraineewhenrequired.

SafetyactiontakenTheMontréalareacontrolcentre(ACC)publishedanoperationsbulletincontaininginformationtoensurethatallcontrollersinvolvedinon-the-jobtrainingknowhowtooperatetheircommunicationsequipmentandgainimmediateaccesstotheirfrequencies.Thisoperationsbulletinwasamandatoryverbalbriefingitemforallcontrollers.

TSB Final Report A04Q0041—Control Difficulty

OnMarch�1,2004,aDHC-8-�00wasproceedingfromMontréal,Que.,toQuébec,Que.,withthreecrewmembersandthreepassengersonboard.Aftertakeoff,atabout�000ftabovesealevel(ASL),theaircraftbankedleftandforcehadtobeappliedonthesteeringwheeltokeepthewingslevel.Thechecklistforarunawayailerontrimtabwascompleted,whichcorrectedthesituation;however,theflightcrewfoundthatthetrimtabindication,whichwasfullytotheright,wasnotnormal.

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EmergencyserviceswererequestedandtheaircraftcontinuedonitsflighttoQuébec.OnfinalapproachforRunway24atQuébec,thecrewwasadvisedbythecontrollerthattheairlinerequiredittonotcontinuewiththeapproach.Amissedapproachwasexecutedanditwassuggestedtothecaptainthathecomebackforano-flapslanding.Theaircraftcamebackandlandedwithnoflapswithoutincidentat10:52EST.

Findingsastocausesandcontributingfactors1. Theailerontrimtabwasimproperlyaligned,which

contributedtothetendencyoftheaircrafttorollondeparturefromMontréal.

2. Theabsenceofaplacardneartheindicator,andthearrangementofinformationinthelogbook,contributedtothecrewbeingunawareofthedefectiveailerontrimtabindicator.

Findingsastorisk1. Poortaskdistributionbetweentheassistantchief

dispatcherandtheflightdispatchercreatedconfusioninthetelephoneconversationswiththetowercontroller,whichdelayedtransmissionofthesecondordertoexecuteamissedapproach,resultinginamissedapproachatverylowaltitude.

2. Thetrimtabhadbeenimproperlyadjustedduringpriorservice;anincorrectindicationofthepositionoftheailerontrimtabinthecockpitmighthaveresultediftheindicatorhadbeenserviceable.

SafetyactiontakenAspartofitssafetymanagementsystem(SMS),theoperatorinitiatedaninternalinvestigationtodrawlessonsfromthisoccurrenceinordertousethemforcrewresourcemanagement(CRM)training.

TSB Final Report A04P0153—Air Proximity—Safety Not Assured

OnMay5,2004,afloat-equippeddeHavillandDHC-2,Mk1BeaverwasauthorizedbytheVancouvertowersouth(TS)controllerforaneastboundtakeoff,onaVFRflightplan,fromtheFraserRiverjustsouthoftheVancouverInternationalAirport,B.C.,witharightturntotheVancouver(YVR)VHFomnidirectionalrange(VOR)at1000ft.AdeHavillandDHC-8-100(Dash-8)wassubsequentlyclearedfortakeofffromtheVancouverInternationalAirportonanIFRflightplantoNanaimo,B.C.,usingRunway08R,withaRichmond8standardinstrumentdeparture(SID).TheRichmond8SIDcallsforarightturnat500ftandaclimbonheading141°magnetic(M)to2000ft.TheDash-8climbedto500ftandinitiatedaright

turnwellbeforetheendoftherunway.Thecrewreportedthrough1000ft,heading140°M,andsubstantiallyreducedtheirrateofclimb,whichbroughtthemintocloseverticalproximitywiththeBeaver.Subsequently,thepilottookevasiveactionwhenheobservedtheBeaverbelowontheleftside.TheVancouverdeparturesouth(DS)controllernoticedtheconflictandadvisedtheDash-8crewof“unverified”trafficontheirleftsideat1100ft.HeinstructedtheDash-8crewtoturnattheirdiscretiontoavoidthetraffic.TheDash-8crewturnedrightandclimbedonaheadingof190°Mtoresolvetheconflict.Theoccurrencetookplaceat08:18:47PacificDaylightTime(PDT).

½ NMseparation

Dash-8 Beaver

Findingsastocausesandcontributingfactors1. TheTScontrollerclearedtheDash-8fortakeofffrom

theRunway08Rthresholdwithoutconsideringthechangetotheaircraft’sdepartureprofilefromtheusualintersectiondeparture.Asaresult,anairproximityoccurredbetweentheDash-8andtheBeaver.

2. ThecoordinationamongtheTS,trafficadvisory(TA),andDScontrollersthatisnecessarytofulfilltherequirementfortrafficinformationandconflictresolutiondidnottakeplace.Asaresult,thetwodepartingaircraftdidnotreceivetheATCservicesspecifiedfortheclassofairspacewithinwhichtheywereflying.

�. TheTAcontroller’sattentionwasdivertedtoothertrafficunderhisresponsibility,andhedidnotseetheDash-8comingupbehindtheBeaver.Asaresult,thetwoaircraftcameintocloseproximitybeforetheDash-8crewsawtheotheraircraftandtookevasiveaction.

4. BecausetheDash-8crewexpectedaclearancetoremainat2000ft,theysubstantiallydecreasedtheirrateofclimb,creatingtheconflictwiththeBeaverandextendingitsduration.

28 ASL2/2007

TSB Final Report A04O0188—Runway Overrun

OnJuly14,2004,anEmbraer145LRaircraftdepartedPittsburgh,Pa.,onaflighttoOttawa/MacdonaldCartierInternationalAirport,Ont.,withtwoflightcrew,oneflightattendant,and28passengersonboard.At17:20EasternDaylightTime(EDT),theaircraftlandedonRunway25atOttawaandoverrantherunway,comingtorestapproximately�00ftofftheendoftherunwayinagrassfield.Therewerenoinjuries.Theaircraftsustainedminordamagetotheinboardleftmainlandinggeartire.Whentheaircraftlanded,therewerelightrainshowers.Aftertherainsubsided,thepassengersweredeplanedandbussedtotheterminal.

Findingsastocausesandcontributingfactors1. TheapproachtoRunway25washigh,fast,andnot

stabilized,resultingintheaircrafttouchingdownalmosthalfwaydownthe8000-ftrunway.

2. Theaircraftlandingwassmooth;thismostlikelycontributedtotheaircrafthydroplaningontouchdown.

�. Theanti-skidsystemmostlikelypreventedthebrakepressuresfromrisingtonormalvaluesuntil16to19secondsafterweightonwheels,resultinginlittleornobrakingactionimmediatelyafterlanding.

4. Theflightcrewwereslowtorecognizeandreacttothelackofnormaldeceleration.Thisdelayedthetransferofcontroltothecaptainandmayhavecontributedtotherunwayoverrun.

Otherfindings1. Itcouldnotbedeterminedifanelectrical,

mechanical,orhydraulicbrakeproblemexistedatthetimeofthelanding.

2. Theflightcrewdidnottakeappropriatemeasurestopreserveevidencerelatedtotheoccurrenceand,therefore,failedtomeettherequirementsoftheU.S.Federal Aviation Regulations(FARs),theCanadian

Aviation Regulations(CARs),andtheCanadian Transportation Accident Investigation and Safety Board Act(CTAISBAct).Interferencewiththecockpitvoicerecorder(CVR)obstructsTSBinvestigationsandmaypreventtheBoardfromreportingpubliclyoncausesandsafetydeficiencies.

TSB Final Report A04W0200— Navigation DeviationOnSeptember10,2004,aBeechKingAirC90AwasenroutetotheEdmontonCityCentreAirport(BlatchfordField),Alta.,fromWinnipeg,Man.,viaRegina,Sask.,underIFR.AfterdescendingintotheEdmontonterminalcontrolarea(TCA)ininstrumentmeteorologicalconditions(IMC),theaircraftwasvectoredforastraight-inLOC(BC)/DMERWY16approach.Shortlyafterinterceptingthelocalizer(LOC)neartheLEFATintermediateapproachfix(IF),theaircraftdescendedabout400ftbelowtheminimumstep-downaltitude,anddeviated69°totheleftofthefinalapproachcourse.Thecrewconductedamissedapproach8NMfromtheairport.Duringthemissedapproach,theairspeeddecreasedfrom1�0to90knotsindicatedairspeed(KIAS),andtheaircraftclimbedabovethreesuccessivealtitudesassignedbyATC.Theaircraftalsodeviated4�°fromitsassignedheadingwhilebeingvectoredtorejointhelocalizerforRunway16.Uponinterceptingthelocalizerforthesecondtime,theaircraftturnedtotherightoftheapproachcentrelineanddescendedbelowtheminimumstep-downaltitude.Aftertheaircraftdescendedbelowthecloudbase,thecrewgainedsightoftheairport,continuedtheapproachvisually,andlandedat16:17MountainDaylightTime(MDT).

Findingsastocausesandcontributingfactors1. Becausetheflightcrewdidnothavesufficient

familiaritywiththeC90Aelectronicflightinstrumentsystem(EFIS)equipment’spresentationsandoperation,theyusedimproperelectronichorizontalsituationindicator(EHSI)coursesettingsandflightdirectormodeselectiononthreesuccessiveinstrumentapproaches.

2. Theinabilityofthecrewtoperformattheexpectedstandardresultedfromlimitedrecentflyingtimeandinadequatetransitiontraininginusingthenewavionics.

�. Whileflyingamissedapproachprocedure,thepilotflying(PF)wasunabletotransitiontoeffectivemanualcontroloftheaircraft.Asaresult,theaircraftspeeddecreasedsignificantlybelowasafelevel,andtheATC-assignedaltitudesandheadingswerenotadheredto.

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4. OnthesecondapproachatEdmonton,thecrewfocusedontheGPSdistancereadingfromthefinalapproachfix(FAF),insteadofthedistance-measuringequipment(DME)display.Thisledtoaprematuredescent,andtheaircraftwasoperatedbelowtheminimumpublishedstep-downaltitudesfortheapproach.

5. Thecrew’sresourcemanagementinpreparationforandduringthethreeapproacheswasnotsufficienttopreventthehazardousdeviationsfromtherequiredflightpaths.

Findingastorisk1. Theoperatordidnotencouragepilotstousemanual

flyingskillsinoperationalflying,thuscreatingthepotentialformanualflyingskillsdegradationfromnon-use.

OtherfindingApost-incidentauditrevealedanumberofexamplesofnon-compliancewiththeoperator’sFlight Operations Manual,includingalackofappropriatepilot-trainingrecordkeeping.Therefore,therewasnoassurancethatpilotswouldreceiverequiredtrainingwithinspecifiedtimeframes.

SafetyactiontakenTheoperatorhascorrectedoperationalandtrainingdeficienciesthatwererevealedinapost-incidentoperationsauditoftheEdmontonbase.PilotswhohadnotreceivedtheminimumflighttrainingschedulemandatedintheFixed Wing Operations Manualwererequiredtocompletethistrainingbeforetheirnextoperationalflights.Inaddition,operationalcontrolofallflightswasimprovedthroughareviseddispatchandflight-followingsystem.

Aninternalsafetybulletindistributedtotheoperator’spilotsaddressedthefollowingissuesassociatedwiththisoccurrence:

errorsinmanagingautomaticflightsystems;encouragingperiodicautopilotdisconnecttoimprovemonitoringvigilance;flightdirector/autopilotmanagement;flightpathdeviationsinducedbyautopilotactivation;andtimelypilotinterventiontocorrectflightpathdeviations.

TSB Final Report A04Q0188—Runway Excursion on Landing

OnDecember1,2004,aBeechB�00wasonanIFRflightfromSaint-Hubert,Que.,toSaint-Georges,Que.,

••

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withtwopilotsandonepassengeronboard.At11:26EST,followingaRunway06RNAV(GPS)instrumentapproach,theaircraftwastoohightobelandedsafely,andthecrewcarriedoutamissedapproach.ThecrewmembersadvisedtheMontréalCentrethattheywouldattemptaRunway24RNAV(GPS)instrumentapproach.At11:46EST,theaircrafttoucheddownover2400ftpasttheRunway24threshold.Assoonasittoucheddown,theaircraftstartedtoturnleftonthesnow-coveredrunway.Fullrightrudderwasusedinanattempttoregaindirectionalcontrol.However,theaircraftcontinuedtoturnleft,departedtherunway,andcametorestinaditchabout50ftsouthoftherunway.Theaircraftsustainedsubstantialdamage.Therewerenoinjuries.

Findingsastocausesandcontributingfactors1. Becausetheaircraft’strajectorywasnotstabilized

onthefinalphaseoftheapproach,theaircraftwasdriftingtotheleftwhenthewheelstoucheddown.Thepilot-in-commandwasunabletokeeptheaircraftinthecentreofthesnow-coveredrunway,whichhadbeenclearedofsnowtoonly�6ftofitswidth.

2. Theleftmainlandinggear,thenthenosewheel,struckasnowbankleftontherunwaybythesnow-removalvehicle,andthepilot-in-commandwasunabletoregaincontroloftheaircraft.

Findingsastorisk1. Theoperator’spilotsandgroundpersonnel

demonstratedinadequateknowledgeoftheSMSprogrambynotrecognizingtheriskelementspreviouslyidentifiedbythecompany.

2. Neitherthepilot-in-commandnortheco-pilothadreceivedCRMtraining,whichcouldexplaintheirnon-compliancewithproceduresandregulations.

�. Knowingthatasnow-removalvehiclemightbeontherunway,thecrewattemptedtolandonRunway06

�0 ASL2/2007

and,afterthemissedapproach,theaircraftdidnotfollowthepublishedmissedapproachpath.

4. OntheRunway24approach,thecrewdescendedbelowtheminimumdescentaltitude(MDA)withouthavingacquiredtherequiredreferences.

5. Theaircraft’saltimeterswerenotsetonthealtimetersettingforSaint-Georges.

Otherfinding1. Theproposedapproachbanwouldnothaveprevented

thecrewfrominitiatingtheapproachbecausetheproposedbandoesnotapplytoprivatecompanies,andtheSaint-Georgesaerodromedoesnotmeetthemeteorologicalobservationrequirements.

SafetyactiontakenFollowingthisaccident,theoperatormodifieditscompanyorganizationchart.Thepositionofassistantdirectorofoperationswascreatedtoprovideleadershipatthecompany’smainbasewhenthedirectorofoperationsisabsent.Also,thecompanyappointedachiefpilotfortheLear60,responsiblefortheMontréalbase,andcheckpilotswereappointedfortheLear45,theLear�5,andtheBeechB�00.

Theoperatorestablishednewcriteriaforrunwayacceptability.Noapproacheswillbealloweduntiltherunwayisfullyclearedofsnowandisclearoftraffic.ArunwayreportforSaint-Georgesaerodromewillbeprovidedtotheflightservicestation(FSS)andsenttothepilotwherepossible.

Theoperatorestablishedvisualreferencestoenabletheuniversalcommunications(UNICOM)personneltoestimateasaccuratelyaspossiblethevisibilityandcloudceilingattheSaint-Georgesaerodrome.Furthermore,toavoidanyconfusionastothesnow-removalneed,acallsequencewasestablishedtoreachsnow-removalemployees.Also,theradioequipmentinthesnow-removalvehiclesatSaint-Georgeswasmodifiedtoallowcommunicationwiththebaseandaircraftatalltimes.

Theoperatorwillprovideanannualwinteroperationsawarenessprogramforitspilotsandgroundpersonnel.

TheCanadianBusinessAviationAssociation(CBAA)modifieditssymposiumeducationprogramtopromoteabetterunderstandingofthefactorsthatleadpilots(andothers)tonotfollowestablishedprocedures.

TSB Final Report A05Q0024—Landing Beside the Runway

OnFebruary21,2005,anHS125-600Aaircraft,withtwocrewmembersandfourpassengersonboard,tookofffromMontréal,Que.,at17:56EST,foranightIFRflighttoBromont,Que.UponapproachingBromont,theco-pilotactivatedthelightingsystemandcontactedtheapproachUNICOM(privateadvisoryservice).Theflightcrewwasadvisedthattherunwayedgelightswereoutoforder.However,theapproachlightsandthevisualapproachslopeindicator(VASI)didturnon.Theflightcrewexecutedtheapproachandtheaircrafttoucheddownat18:25EST,�00fttotheleftofRunway05Land1800ftbeyondthethreshold.Itcontinuedonitscourseforadistanceofapproximately1800ftbeforecomingtoastopinaditch.Thecrewtriedtostoptheengines,buttheleftenginedidnotstop.Theco-pilotenteredthecabintodirecttheevacuation.Oneofthepassengerstriedtoopentheemergencyexitdoor,butwasunsuccessful.Alloftheaircraft’soccupantsexitedthroughthemainentrancedoor.Bothpilotsandonepassengersustainedseriousinjuries,andthethreeremainingpassengersreceivedminorinjuries.Theaircraftsustainedmajordamage.

Findingsastocausesandcontributingfactors1. Theflightcrewattemptedanightlandinginthe

absenceofrunwayedgelights.Theaircrafttoucheddown�00fttotheleftofRunway05Land1800ftbeyondthethreshold.

2. Therunwaywasnotclosedfornightusedespitetheabsenceofrunwayedgelights.Nothingrequiredittobeclosed.

�. Poorflightplanning,non-compliancewithregulationsandstandardoperatingprocedures(SOP),andlackofcommunicationbetweenthetwopilotsrevealalackofairmanshiponthepartofthecrew,whichcontributedtotheaccident.

Findingsastorisk1. Becausetheyhadnotbeengivenasafetybriefing,the

passengerswerenotfamiliarwiththeuseofthemaindoorortheemergencyexit,whichcouldhavedelayedtheevacuation,withseriousconsequences.

2. Thearmrestofthesideseathadnotbeenremovedasrequiredandwasblockingaccesstotheemergencyexit,whichcouldhavedelayedtheevacuation,withseriousconsequences.

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accident synopses

Note: All aviation accidents are investigated by the Transportation Safety Board of Canada (TSB). Each occurrence is assigned a level, from 1 to 5, which indicates the depth of investigation. Class 5 investigations consist of data collection pertaining to occurrences that do not meet the criteria of classes 1 through 4, and will be recorded for possible safety analysis, statistical reporting, or archival purposes. The narratives below, which occurred between August 1 and October 31, 2006, are all “Class 5,” and are unlikely to be followed by a TSB Final Report.

�. Becausetheyhadnotbeengivenasafetybriefing,thepassengersseatedinthesideseatsdidnotknowthattheywererequiredtowearshoulderstrapsanddidnotwearthem;sotheywerenotproperlyprotected.

4. Thepossibilityofflyingtoanairportthatdoesnotmeetthestandardsfornightusegivespilotstheopportunitytoattempttolandthere,whichinitselfincreasestheriskofanaccident.

5. Thelandingperformancediagramsandthechartusedtodeterminethelandingdistancedidnotenabletheflightcrewtoensurethattherunwaywaslongenoughforasafelandingonasnow-coveredsurface.

SafetyactiontakenOnJuly19,2005,theTSBsentanaviationsafetyadvisorytoTransportCanada.Thesafetyadvisorystatesthat,inthisoccurrence,theprecautionsembodiedinthevariouscivilaviationregulationsdidnotpreventthisnight

landingwhentherunwayedgelightswereunserviceable.Consequently,TransportCanadamightwishtoreviewtheregulationswiththegoalofgivingairportoperatorsguidelinesonhowtoevaluatetheimpactofareducedlevelofserviceonairportuse.

Pursuanttothissafetyadvisory,TransportCanadadeterminedthatitwouldbeverydifficulttoprepareguidelinesthatwouldcoverallfactorsthataredirectlyorindirectlyassociatedwithairportcertificationoroperations.Moreover,TransportCanadabelievesthatrequiringaerodromeoperatorstoevaluatetheimpactofareducedlevelofserviceonaerodromeusewouldbeaparticularlycomplextaskthatcouldgreatlyincreasethepossibilityoferrorsinassessmentorinterpretation.However,TransportCanadaisexaminingthepossibilityofaddinginformationonthelevelofrunwaycertificationtotheCanada Flight Supplement (CFS),whichwouldprovidemoreinformationanddetailstopilotsregardinganychangetothecertificationstatusofagivenrunway.

—OnAugust5,2006,aBell B206-B3 helicopterhadlandedonalogpadinthemuskegand,afterasettlingcheck,thethrottlewasturneddowntoidle.Afterabout�0seconds,theaftfuselagedropped,andthepilotplacedthecyclicintheforwardposition.Mastbumpingwasfelt,andtheenginewasshutdownimmediately.Thetailrotordidnotcontacttheground,buttherewasconsiderabledamagetothedynamiccomponents.Therewerenoinjuries.TSB File A06W0136.

—OnAugust5,2006,aPA-25-235 Piper Pawneewasspreadingchemicalswhentheaircraftseveredanelectricalwire.ThepilotheadedtowardtheRougemont,Que.,airport,andlandednormally.Thepilotwasnotinjured.Theaircraft’spropellerandrightwingweredamaged.TSB File A06Q0134.

—OnAugust7,2006,anamateur-built basic ultralight Hipps J-3 KittenwasmanoeuvringinthevicinityofSt.Andrews,Man.Thepilothaddifficultycontrollingthepitchattitude,andforced-landedinafield.Aftertouchdown,theaircraftnosedoveronitsback.Thepilot/owner/builderwasnotinjured.Examinationbythepilotaftertheincidentindicatedthatpartoftheelevatorcontrolmechanismhadfailedinflight.TSB File A06C0128.

—OnAugust11,2006,thepilotoftheGrumman AA1 Tigerwasferryinghisnewly-purchasedaircrafttoBellingham,Wash.,whenheencounteredmountainweather,andtheaircraftdescendedrapidlyandcrashedintotrees.Thepilothadbeenflyingatabout6500ftASL,wasclearofclouds,andwasabout1mi.awayfromaridge.Heescapedwithminorinjuries,buttheaircraftwasdestroyed.HebroadcastMaydaycallsandasearchandrescue(SAR)Cormoranthelicopterpickedhimupfromthehillsideabout�hrafterthecrash.Hewastakentohospitalforevaluation.TSB File A06P0159.

—OnAugust20,2006,aBell 206L-3 helicopterwasconductingoilfieldoperations40NMnortheastofLacLaBiche,Alta.Duringdeparturefromanoilwellsite,theengine(Allison250-C�0P)lostpower.Thepilotenteredautorotation,andthehelicopterstruckthegroundatahighrateofdescent.Themainrotorseveredthetailboomatimpactandthepilotsustainedseriousinjuries.ThewreckageisbeingrecoveredtotheTSBPacificRegioncompound,andtheenginewillbeexaminedatalocalengineoverhaulfacility.TSB File A06W0143.

—OnAugust21,2006,anAerospatiale AS350 BA helicopterwasdepartingfromadrillsitewitha60-ft

�2 ASL2/2007

longline,onalocalflight.Ondeparture,thelonglinehooksnaggedatree,andthenbrokefree,flewupandfouledthetailrotorandtailboom.Thehelicopterlosttailrotorauthorityandrotatedseveraltimesbeforethepilotmadeaforcedlandinginawoodedarea.Thepilotsufferedminorinjuries.Thehelicoptersustainedsubstantialdamage.TSB File A06C0139.

—OnAugust21,2006,arentedChampion 7ECACitabriawastaxiingfromtheramptotherunwayatSteinbachSouth,Man.Beforetheaircraftreachedtherunway,itwasobservedmakingawideturn,andthendepartingthetaxiwayandstrikingaCessnaAgTruck,whichwasparkedinthegrassbesidethetaxiway.TheCitabriasustainedsubstantialdamage;theAgTrucksustainedminordamage.TSB File A06C0140.

—OnAugust2�,2006,aDHC-2BeaveronfloatstookofffromLacLouise,Que.,foraVFRflighttoLabradorCity,Nfld.Shortlyaftertakeoff,withcrosswindsofapproximately15kt,thepilotturnedtotheleft.Theaircraftendedupwithatailwind,andtherateofclimbdidnotallowittocleartheobstacles.Theaircraftstrucksometreesbeforecrashing.Theaircraftdidnotcatchfire,butitdidsustainsubstantialdamage.Thethreeoccupantsonboardreceivedminorinjuries.TSB File A06Q0147.

—OnAugust24,2006,aCessna 180 on floatscollidedwiththeembankmentofaprivately-owned,man-madewaterrunwayduringtakeoffattheTofino,B.C.,airport.Theaircraftwasdepartingwestbound(Runway28)fromthe1400x80ft-widewaterrunway.Thewindwasfrom210°Mat5kt.Thewaterrudderswereretractedforthetake-offrun.Thepilotlostdirectionalcontrolastheaircraftwasgettingonthestepandcollidedwiththeembankmentontheleftside.Therewerenoinjuries.Therewassubstantialdamagetotheaircraft.TSB File A06P0154.

—OnAugust26,2006,aBell 206B helicopterdescendedintoatreeduringalonglineoperation,whilemanoeuvringtopickupaload.Bothmainrotorbladessustainedsubstantialdamageandhadtobereplacedpriortoamaintenanceferryflight.Therewerenoinjuries.Ashorter-than-normallonglinewasinuse,thetreewasintheseveno’clockpositionrelativetothepilot,andthepilothadbeeninstructedtomoveleftofhisintendedpositionbythegroundcrew.TSB File A06W0152.

—OnAugust27,2006,afloat-equipped Cessna 175Acrashedapproximately10NMsouthofLacBeauregard,Que.Thepilot,aloneonboard,died.Aweakemergencylocatortransmitter(ELT)signalhadbeenheardatapproximately10:�2;however,theweatherconditionsmadeitimpossibletoreachtheaccidentsite,andtheaircraftwasfoundthefollowingday.Theinformationgatheredindicatesthatbeforedeparture,thepilotwas

unabletochecktheweather,whichwasforecasttobeIFRconditionsonhisroute.However,upontakeoff,despitestormstothewest,theconditionsonhisroutetothesouthwereVFR.Theangleatwhichtheaircraftenteredtheforestattheaccidentsite,indicatesthatatthetimeofimpact,theaircraftwasoutofcontrol.Theevidencesupportsthehypothesisthatthepilothadencounteredweatherconditionsforwhichhewasnotprepared.Therewasnoevidenceofamechanicalfailure.TSB File A06Q0148.

—OnAugust28,2006,aJabiru Calypso 3300 advanced ultralightcrashedonehouraftertakeofffromtheManiwaki,Que.,airport.Thepilot,aloneonboard,wasconductingalocalVFRflight.Theaircraftstruckandseveredtheupperwireofaresidentialhydroline.Theaircraftcrashedinacornfieldapproximately400ftaway.Thepilotsustainedfatalinjuries.TheaircraftwreckagewastransportedtotheTSBlaboratoryinOttawa,Ont.,forexamination.TSB File A06Q0149.

—OnSeptember2,2006,aBell 206L-1 helicopterwaspickingupagroupofkayakersattheconfluenceoftheTulsequahandTakurivers,about60NMsouthofAtlin,B.C.Aslingloadofabout700lbsofgearontheriverbankwasattachedtothelonglinebeforeadecisionwasmadetoreturnthepassengerstotheTulsequahChiefexplorationminecampbeforeflyingtheirgearout.Thehelicoptertookoffwithfourofthepassengers,butcrashedintotheriverwhenitcametotheendofthelongline,whichhadremainedattachedtotheaircraft.Twopassengersreceivedminorinjuriesandthehelicopterwasdestroyed.TSB File A06P0180.

—OnSeptember9,2006,aCessna U206GhaddepartedCopperPoint,Y.T.(northofMayo),forahuntingcamp.Whileenroutethroughmountainousterrain,thepilotrealizedthattheaircraftcouldnotoutclimbtherisingterrainofthecanyonfloor.Asthepassagewastoonarrowtopermita180°turn,thepilotforce-landedintothetrees.Thepilotsufferedminorinjuries,thepassengersufferedseriousinjuries,andtheaircraftwassubstantiallydamaged.Ahelicopterevacuatedthepilotandpassengeraftertherescuecoordinationcentre(RCC)trackedtheemergencylocatortransmitter(ELT)signal.TSB File A06W0166.

—OnSeptember12,2006,aPA28-180wasonthebaselegforRunway06RatSt-Hubert,Que.,returningfromarecreationalflight,whentheengine(LycomingO�60-�A�)stopped.Theaircraftstrucksomecablesandcarsbeforecomingtoastopinvertedonastreetinanindustrialneighbourhood.Thetwooccupants,aswellasfourpeopleontheground,receivedminorinjuries.Theaircraftwassubstantiallydamaged,butdidnotcatchfire.Theemergencylocatortransmitter(ELT)wentoffuponimpact.Fourcarswerealsodamaged.TSB File A06Q0160.

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—OnSeptember12,2006,aPA-44-180,withaninstructorandstudentonboard,wasdoingcircuitsattheCornwall,Ont.,regionalairportinpreparationforamulti-engineflighttest.Whileonatouch-and-go,justpriortolift-off,thelandinggearhandlewasmistakenlyselectedtotheupposition.Thenosegearretractedandbothpropellerscontactedtheground.Theaircraftbecameairborne,completedacircuit,andlandednormallywiththegeardown.Bothpropellersweredamagedbeyondrepairandtheenginesweresentforoverhaul.TSB File A06O0243.

—OnSeptember19,2006,afloat-equipped Piper PA-18-150wasdepartingfromaprivategrassstrip.Thepilotwasusingadollytowedbehindapick-uptrucktotakeoff.Atlift-off,afloatsnaggedthedolly.Theaircraftveeredandcrashedinthefieldatthesideofthestrip.Therewerenoinjuriesandtheaircraftwassubstantiallydamaged.TSB File A06C0149.

—OnSeptember29,2006,anamateur-built Searey amphibianaircrafttookofffromVictoriaInternationalAirport,B.C.,foralocalflight,whichwastoincludeseveralwaterlandings.Thepilotdidnotretractthelandinggearaftertakeoff.WhileflyingoverSaltspringIsland,thepilotdecidedtomakeapracticewaterlandingonSt.MaryLake.Ontouchdownonthewater,thenoseduginandtheaircraftflippedover.ThepilotwasabletoegresstheaircraftandwaspickedupbyaBeaveraircraft.Thepilotsustainedminorinjuries.Theaircraftwassubstantiallydamaged.TSB File A06P0202.

—OnSeptember29,2006,aBell 206B helicopterwasrepositioninginfrontofatemporaryhangarinMayo,Y.T,whenthetailrotorstruckthestructure.Thetailrotorblades,tailrotorgearboxandtailrotordriveshaftrequiredreplacement.Therewerenoinjuriestothepilotorgroundpersonnel.TSB File A06W0178.

—OnOctober5,2006,whiletaxiingfortakeoffatToronto/Buttonville,Ont.,aPiper PA-28-161 CherokeestruckaCessna 150M;bothwerebeingoperatedbysolostudentpilots.Thecollisionoccurredattheintersection

ofTaxiwaysCharlieandAlpha.The150hadbeenclearedsoutheastboundonTaxiwayCharlietoturnrightontoTaxiwayAlphatotheholdingbayforRunway0�.TheCherokeewassouthwestboundonTaxiwayAlphaandhadbeenheldnortheastofRunway��.TheCherokeewasclearedtocrossRunway��onTaxiwayAlpha,andfollowthe150southboundonTaxiwayCharlietotheholdingbayforRunway0�.TheCherokeemissedthereferencetothe150intheclearance,andacknowledgedwithoutreadback.ItproceededacrossRunway��payingattentiontoanaircraftontheleftatthesouthendofRunway��.Attheintersectionofthetaxiways,theCherokeeovertookthe150fromapproximatelythe8o’clockpositionwhilethe150wasintheturn.ThepropelleroftheCherokeecausedsubstantialdamagetotheouterportionoftheleftwingofthe150,andtherightwingtipoftheCherokeerodeupoverthelefthorizontalstabilizerofthe150,andovertheaftfuselageofthe150,justinfrontoftheverticalstabilizer.TSBinvestigatorsweredeployedthefollowingdaytoreviewATCcommunications,examinetheaircraft,andgatherrelevantinformation.TSB File A06O0257.

—OnOctober9,2006,anAerospatiale AS 350B helicopterwaslandingataremote,confinedandunpreparedsite.Priortotouchdown,thetailrotorstruckariseofgroundnearthecentreofthesite.Thehelicopterbegantorotatearoundtheverticalaxis,directionalcontrolcouldnotberegained,andtheskidsandtailboombrokeawayfromthefuselageduringtheensuinghardlanding.Thepilotandonepassengersustainedinjurieswhilethesecondpassengerwasuninjured.TSB File A06W0186.

—OnOctober15,2006,aLake LA-4-200aircraftwasonaflightfromWinnipeg,Man.,toSt.Andrews,Man.,withaplannedstopatSelkirk,Man.Whilelandinginglassy-waterconditions,theaircraftlandedhardandswerved.Theaircraftcametorestuprightonthesurfaceofthewater.Thepilotwasnotinjured.Theaircraftincurreddamagetotheleftsponsonandthewingoutboardofthesponson.TSB File A06C0170.

Ma, Pa, I kind of screwed up...I hit an antenna while

flying over Betty's farm and

damaged a float...

What?! Why, you reckless little...

Hold-on a minute, Pa. Let's hear

the whole story before jumping to conclusions,

OK?

Son, you did the right thing by telling

us. Why don't you explain what

happened, and in particular, what

you were thinking?

...I'll tell you what he was

thinking...nothing!!

Well, Betty's nephew was visiting, and she asked if I could do a

fly-by because the kid loves

planes...you know...

Hmm...I see...you almost bought the farm to please your girlfriend and impress

her nephew. Now, tell me, what have you learned from this?

�4 ASL2/2007

regulations and youExploring the Parameters of Negligence: Two Recent TATC Decisions ....................................................................... page 34The Aeronautics Act—The Latest News! ...................................................................................................................... page 35

Exploring the Parameters of Negligence: Two Recent TATC Decisionsby Beverlie Caminsky, Chief, Advisory and Appeals (Transportation Appeal Tribunal of Canada—TATC), Regulatory Services, Civil Aviation, Transport Canada






Inthisissue,theAdvisoryandAppealsDivisionofRegulatoryServicesagainwishestosharewithourreaderssomeinterestingdevelopmentsinCanadianaviationcaselaw.TworecentcasesreleasedbytheTransportationAppealTribunalofCanada(TATC)dealwiththeissueofnegligentconductonthepartofpilots.Inoneofthecases,theTATCReviewHearingfindingsarebeingappealedbythepilot.Intheother,thepilotchosenottoappeal.Asisourpractice,thenamesofthepeopleinvolvedhavebeendeleted,asourgoalremainssimplytobeeducational.

Case#1Inthefirstcase,theApplicantwasthepilot-in-commandofasmallprivateaircraftapproachingaruralairport.Twootheraircraftwereconductingcircuitsaroundtheairport.Thepilotjoinedthecircuit,anditwasagreedbyallthreeaircraftthatintheorderoflanding,theApplicantwouldbelast.However,afterjoiningthecircuit,theApplicantmadeasuddenhardrightturnonrightbasefortherunway,aheadoftheotherplanes.Thisactioncausedtheothertwoaircrafttotakeevasiveaction.TheApplicantwaschargedwithflyingina“recklessornegligentmanner”contrarytoCanadian Aviation Regulation(CAR)602.01.

AttheReviewHearing,theMemberupheldtheMinister’sdecision.ShefoundthattheApplicant’sactionswerenegligentandtheyendangeredlifeandproperty.BothelementshavetobeestablishedtoupholdaviolationofCAR602.01.Shealsofoundthatthedefenceofnecessitywasnotestablished.However,thefinewasreduced,giventhefactthatoneoftheothertwoplaneswasflyingcircuitsinthewrongdirection,whichpartiallycontributedtothesituation.

TheevidenceestablishedthattheApplicant’ssuddenturnoutofthecircuitcreatedahazard.Astherewasnointentiontocreateaconflict,theactionsdidnotconstituterecklessness,onlynegligence.Thefactthatallthepilotsfeltcompelledtotakeevasiveactionprovedthatthesituationendangeredlifeandproperty.

ThedefenceofnecessitywasraisedbytheApplicant,whoarguedthatheinitiatedtheturnbecausehewaslowonfuelandhadtomakeanimmediatelanding.Existingjurisprudenceidentifiesthreeelementsthatmustbeestablishedbythoseseekingtopleadnecessity.First,asituationofimminentperilexisted.Second,noreasonablelegalalternativetotheactionstakenexisted.Third,the

dangercausedbythecontraventionmusthavebeenlessthanthedangercausedbycomplyingwiththelaw.Additionally,thedefenceisnotavailabletothosewho,throughtheirownactions,createthedangercomplainedof.

TheMemberfoundthattheApplicant’sactionsbeliedtheimminenceofthedanger,asthepilotflewforseveralminutesaftertheevasiveactionbeforelanding.Consequently,thedefencefailed.

Case#2ThesecondcaseconcernsanApplicantwho,whiletaxiingtotakeoff,hitarunwaythresholdlightatanothersmallruralairport.Afewmonthslater,thesameindividualwasinvolvedinanallegednear-missincident,atthesamelocationwhilefailingtoconformtothepatternoftraffic.Theseincidentsled,respectively,tochargesunderCAR602.01andCAR602.96(�).

AttheReviewHearing,theMemberupheldbothcharges,butreducedthelengthofthelicencesuspension.

Withregardtothefirstcharge,theMemberfoundthattheApplicantwastaxiingcloselybehindanotherplane.Whenthatplanesuddenlystopped,theApplicant’splane,inpartduetoanunfortunatebrakemalfunction,veeredtotherightandhittherunwaythresholdlight.TheMemberfoundthattheApplicantwas“attemptingtorush”thetake-offprocess,andthatsuchconductfallsbelowthestandardexpectedofareasonableandprudentpilot.

ThesecondchargeresultedfromtheApplicant’sconductofapracticeforced-landingprocedurewhileasecondaircraftwasapproachingtheairportatthesametime.TheMemberfoundtheApplicanttohavebeenunreasonableinnotbreakingoffhistrainingprocedureinordertoconformtothestandardtrafficpattern.

Afterconsideringvariousmitigatingandaggravatingfactors,theMemberreducedthetotallengthofthelicencesuspensionfrom44daysto21days.

ThefirstchargeisastandardexampleoftheworkingsofthenegligenceprovisionsofCAR602.01.ThechargewassustainedbecausetheevidenceestablishedthattheApplicant’sconductfellbelowthestandardofcareexpectedofareasonablepilotanditresultedintheendangermentoflifeorproperty.

Maintenance and

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TransportCanada

TransportsCanada

aviation safety letter

TP 185EIssue 2/2007

Learn from the mistakes of others; you' ll not live long enough to make them all yourself ...

In this Issue...

Runway Safety and Incursion Prevention Panel

Thoughts on the New View of Human Error Part III: “New View” Accounts of Human Error

Aviate—Navigate—Communicate

Safety Management Enhances Safety in Gliding Clubs

Near Collision on Runway 08R at Vancouver

Say Again! Communication Problems Between Controllers and Pilots

Ageing Airplane Rulemaking

Bilateral Agreements on Airworthiness—An Overview and Current Status

Exploring the Parameters of Negligence: Two Recent TATC Decisions

36 ASL2/2007

Debrief

DebriefD

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Fuel Starvation Maule-4—Incorrect Fuel CapsAn Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)

*TC-1002136*TC-1002136

OnSeptember30,2004,aMaule-4aircraftlostpowerwhilecruisingat1200ft.Thepilotchangedtanksandturnedontheelectricfuelpump,butpowercouldnotberestoredandtheaircraftwasforcedtoland.Asthefieldwastooshort,theaircraftsustainedsubstantialdamagewhenithitafenceattheendofthelandingrollandoverturned.Whentheaircraftwasrecovered,thepilotownerwassomewhatsurprisedthatfuelremainedintherighttankandverylittlewaslostfromthelefttankaftertheaircrafthadbeeninvertedovernight.Thetypeofcapinstalledincludesaninternalflappervalve,whichcloses,therebyretainingthefuelinthetanks.

Examinationofallfueltubingdidnotrevealanyanomaliesorrestrictions.Itwasalsooutlinedthattheaircrafthadasimilarpreviousenginestoppagetwoyearsearlier.Atthattime,theaircraftwasonskisoverasnowyfieldandmadeasuccessfulforcedlanding.Shortlyafter,theenginerestartedandrannormally.Duetolackofothertangiblefactors,itwasfeltthatitmayhavebeencausedbyafuelselectormalfunctionorpositioning.Theowneralsorecallsthatwheneveroperatingwiththefuelselectoron“both,”thelefttankalwaysfedataslowerratethantheright.Hefurthermentionedhavingheardairrushingintothetankwhenopeningtheleftfuelcapforrefuellingimmediatelyafterengineshutdown.

Afterthemostrecentoccurrence,theownerwaspromptedtoverifytheadequacyoftheventingsystem,whichisdonethroughthefuelcaps(Figure1).Airpassageontheleftfuelcapwasfoundtobeerratic;sometimesitwouldlettheairthrough,butsometimesitwouldnot.Informationfromthemanufacturerindicatesthatthistypeofcapisonlytobeinstalledonaircrafthavingbeenmodifiedwithauxiliarywingtanks(locatedoutboardonthewings),asthemodificationincludestheplumbingforadifferentventingsystem.

Figure 1: Non-probed fuel cap

Thecapsusedontheoccurrenceaircraft,showninFigure1,hadbeenorderedbythepreviousownertoreplacetheoriginalcapstowhicharamairprobeisfittedtoassurepositivepressurewithinthefueltanks(Figure2).Theordervoucherindicatedthatnon-leakingcaps(non-probedcaps)wererequested.Thiswasdesiredpartlyforaestheticreasonsandalsobecauseprobedcapsallowedfueltoleakoutiftheaircraftwhenitwasparkedonunevenground.Theordervoucherincludedtheaircraftserialnumber.Themanufacturerforwardedthenon-probedfuelcapswithoutchallengingwhethertheaircraftfuelsystemwasoriginalorithadbeenmodifiedwithauxiliarywingtanks.Whiletheprobedcapsassureapositivepressureinsidethefueltanks,theairpassagethroughthenon-probedcapsreducesthepressurewithinthetankbelowthatoftheambientpressure.

Figure 2: Probed fuel cap

Consequently,anyblockagewithinthecapquicklyresultsinstoppingthefuelflowtotheengine.Asthefuelsystemincludesasmallheadertank,switchingtankswouldnormallyrestorethefuelflow,re-establishingpowertotheengine.Testbenchtrialsonsimilarsystems,operatedbyaskilledenginetechnicianawareoftheintendedfuelstarvationtest,havedemonstratedthatitrequires30–45secondstorestorefullpowerfollowingtheenginestoppage.

Theinvestigationintothisoccurrencehasraisedaconcernaboutthereplacementofpartsfordifferentaircraftmodels,whichwouldaffecttheairworthinessoftheaircraft.Theuseofnon-probedcapsonanunmodifiedairframehasshownthatventingispossiblewhenthevalvewithinthecapsisworkingproperly.However,asdemonstratedinthisoccurrence,thereisnoalternatemeansofventingincaseofmalfunction.Anychangetooriginalaircraftstatus,regardlesshowsmall,mustfirstbeauthorizedbythemanufacturer,unlessitisapprovedviaasupplementarytypecertificate(STC)—asthesechangescanandhavecreatedairworthinessdisturbances.

Slinging accidents happen mostly to experienced pilots.

STAY ALERT!

Do these sound familiar?

• confined area• awkward load• marginal weather• untrained groundcrew• customer pressure• tight schedule• fatigue• inadequate equipment• uncertain field servicing

TransportCanada

TransportsCanada




the safety team…






ASL2/2007 352 ASL2/2007

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Reg

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