Aviation Safety Letter

required to develop new and amended versions of the design standards and associated guidance material. NAC is part of an international community and is involved in various working groups and committees that collaborate to continuously adapt and develop design standards and the interpretation of these standards. Each design project undertaken by an applicant follows a process unique to a company’s design methodology. Evaluating a design or design change against the standards is unique each time. It requires many highly subjective technical assessments, and as such, it requires expert flight test and engineering knowledge and skills normally acquired through significant experience in evaluating designs against international standards. NAC and Regional Aircraft Certification personnel, along with the ministerial delegate community across the country, have this expertise, and the ongoing interaction with applicants and delegates on these projects is essential to remaining current with evolving technology and approaches to aircraft design. Over the past several years, Transport Canada Civil Aviation’s (TCCA) oversight of the aviation industry has been gradually moving to a systems-based approach, based on the existence of new regulations requiring certain segments of the industry to have an approved safety management system (SMS). More recently, NAC have been busy working on determining how a company’s SMS can include the design process, and how the oversight approach can evolve into a more systems-based approach. This is in line with Transport Canada’s (TC) move to strengthen the way it conducts oversight of Canada’s entire aviation industry. This gives rigor to the way TC manages safety, as well as to their own surveillance model. Oversight (in the context of aircraft certification) is defined in TC’s Program Activity Architecture (PAA) as, “service to and surveillance of the aeronautical product design industry”. The service elements related to aircraft certification (such as establishing appropriate standards, agreeing to acceptable means and methods of compliance, and issuing approvals) are fundamental and will need to remain after the introduction of SMS to the design side of the business. The surveillance elements today consist of a risk-based Level of Involvement (LOI) policy where TCCA engineers interact with ministerial delegates during the certification projects, plus periodic audit activities (outside the context of specific projects) of delegated entities, as well as continuing airworthiness monitoring of the Canadian fleet. When an organization’s SMS includes the design piece, it is the audit side of NAC’s surveillance model, as well as how the lessons learned from continuing airworthiness surveillance is fed back into the design SMS that will have to evolve. Project-based service and surveillance will need to live on in parallel and in balance with a new oversight model that pertains to the company’s new SMS design elements. Current thinking is that neither a purely systems-based nor a purely project-based oversight model will suffice. To enable this evolution in oversight in the area of aeronautical product design, organizations will need to hold a new type of operational certificate, similar to an air operator certificate (AOC). A company’s overall SMS will include a design assurance system that provides a level of certainty that the designs are safe, and that the company will make sound and defendable determinations of compliance. It also means that the design industry will be accountable to TC for the quality of these findings and the continuing airworthiness of approved products. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations Dave Turnbull 4 ASL 2/2011 The recipient of the 2010 DCAM Flight Instructor Safety Award is Mr. William Sutherland, Manager of Corporate Safety & Quality, Moncton Flight College (MFC), Dieppe, New Brunswick. The award was presented to William on November 8, 2010, by award founders Jane and Rikki Abramson at the Air Transport Association of Canada (ATAC) Annual General Meeting and Tradeshow in Vancouver, British Columbia. “It goes this year to a young man whose achievements to date and future potential shine full of promise as a beacon for the future of aviation safety in Canada” said Mrs. Abramson. “His strong leadership, integrity, technical competence and commitment to excellence were instrumental in MFC successfully achieving the performance criteria required for certification as an Approved Training Organization (ATO) authorized to conduct flight training in Canada. The requirement to operate a flight training organization to the exacting ATO standards is an essential pre-requisite for MFC and its partner, CAE, to be able to conduct the first Multi-Crew Pilot License (MPL) training program in North America.” The annual DCAM Award promotes flight safety by recognizing exceptional flight instructors in Canada and has brought much recognition and awareness to the flight instructor community. Recognition of excellence within this segment of our industry upholds a safety consciousness that will hopefully be passed on for many years to come. The deadline for nominations for the 2011 award is September 13, 2011. For details, please visit www.dcamaward.com. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations Issuing this new kind of operational certificate will require NAC and its regional engineering colleagues to provide new and additional services and surveillance related to a company’s SMS. Some can be derived from the existing delegation system that has been in place in Canada since 1968. Others will be taken from other operational areas of aviation where SMS is already in place. The systems approach to the design side of the organizations is aimed at promoting a sound safety culture through robust design assurance processes and a positive reporting culture. Clearly, there are many challenges ahead; however, these are also exciting times and I look forward to working together to improve how we do business. Striking the proper balance between systems-based oversight and certification project-based oversight will be crucial and will require close attention. In the meantime, the NAC continues to carry out its mandate, working directly with industry and international colleagues to support a very strong and ever-demanding Canadian aeronautical design and manufacturing industry. According to the Aerospace Industries Association of Canada, Canada exports over 80 percent of its aeronautical products in an industry sector that makes up nearly 5 percent of our Gross Domestic Product. Getting speedy approvals from our foreign markets depends directly on the quality of our own approval process. Our ultimate goal is to improve safety, which is a goal that we share with the industry. Dave Turnbull Director, National Aircraft Certification Branch Transport Canada Civil Aviation 2010 David Charles Abramson Memorial (DCAM) Flight Instructor Safety Award Left to right: Wayne Gouveia, Board of Directors, ATAC; William Sutherland; Jane Abramson. ASL 2/2011 5 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations pre-flight Reducing the Risk of Landing Accidents and Runway Overruns ................................................................................. page 5 Flight Planning: A Critical Layer of Protection from Wake Turbulence ..................................................................... page 6 Instructor Refresher Courses Improve Flight Safety… and Renew your Rating .......................................................... page 7 Reducing the Risk of Landing Accidents and Runway Overruns by Martin J. Eley, Director General, Civil Aviation, Transport Canada Pre-flight Regs & you Not used Day in and day out, week after week, thousands of aircraft land in Canadian aerodromes without incident. Unfortunately, this isn’t always the case. Air travel is a complex issue and landing aircraft can be equally difficult. With unpredictable factors such as weather conditions, the surrounding terrain and human error, the fact remains that accidents can and do happen. On August 2, 2005, an Air France Airbus A340 was unable to stop on runway 24L at Toronto’s Pearson International Airport. The flight landed during reports of exceptionally bad weather—severe winds, heavy rain, and localized thunderstorms—and touched down further along the runway than usual. The aircraft came to rest in a nearby shallow ravine and burst into flames approximately 300 m past the end of the runway. There were 309 people on board: 297 passengers (2 of whom were infants) and 9 crew members. Fortunately, everyone survived and successfully evacuated the aircraft, with only 12 passengers sustaining serious injuries. The Transportation Safety Board (TBS) investigated this accident and on March 16, 2010, they issued a watchlist of items that highlight safety concerns or safety recommendations made to Transport Canada (TC). One of the watchlist items refers to landing accidents and runway overruns. A runway overrun is an occurrence where an aircraft departs from or lands on the end or one side of the runway. TC has taken a number of actions to reduce the risk of landing accidents and runway overruns and to address the TSB’s watchlist. Regulations and standards Since 2006, requirements have been in place governing landings in low visibility conditions. These regulations clearly set out the minimum conditions for landings in poor visibility. This prohibits air operators from attempting a landing when visibility is so poor that a successful landing is unlikely. A regulatory amendment on safe winter runway operations was published in the Canada Gazette Part I: Notices and Proposed Regulations. The proposal would require airport operators to develop standardized procedures related to winter runway maintenance. The proposal would also require accurate and timely reporting of surface conditions at airports in winter. These measures will lead to more reliable and safer transportation for those using Canadian airports during the winter. Additionally, TP 312 – Aerodrome Standards and Recommended Practices is being revised in cooperation with industry experts. The updated document will address: • providing additional visual aids for pilots to help assess landing distances; • harmonizing Canadian and international runway end safety area (RESA) standards; and • recognizing the engineered material arresting system (EMAS)1 as an added measure to increase safety. TC agrees that RESA is a vital component of its risk reduction plan and is committed to conforming to the International Civil Aviation Organization’s (ICAO) 150 m RESA standard, while assessing the potential benefits of extending the RESA to 300 m. TC has therefore tabled Notices of Proposed Amendment (NPA) to the Canadian Aviation Regulations to adopt a 150 m total RESA requirement. These NPAs were considered at the Canadian Aviation Regulation Advisory Council (CARAC) Technical Committee meeting, which was held from November 15 to 17, 2010. International cooperation TC is an active participant in the ICAO’s Air Navigation Commission, Aerodrome Panel and Aerodrome Design Working Group. The purpose of this participation is to develop and harmonize international standards that will reduce runway overrun and undershoot accidents. At the 2010 ICAO assembly, TC presented a working paper on runway safety that addressed incursions and excursions. At this same assembly, a proposal was made by 1 EMAS is an example of a ground arrestor system. EMAS is located beyond the end of the runway. It is designed to stop an overrunning aircraft by exerting deceleration forces on the aircraft’s landing gear. The application of EMAS can mean the difference between an accident and a minor incident. EMAS is a soft ground arrestor. This type of arrestor deforms under the weight of the aircraft tire as it runs over it. As the tires crush the material, the drag forces decelerate the aircraft and bring it to a safe stop. EMAS is popular in the U.S at airports that have difficulties complying with FAA rules on runway safety. 6 ASL 2/2011 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations ICAO to establish runway safety programs to prevent and mitigate runway accidents and incidents. TC agreed with this proposal and noted that the establishment of a runway safety program should strive as much as possible to ensure that runway incursions and runway excursions are studied and defined separately. This would help to develop the best and most appropriate measures for each type of occurrence. ICAO is also organizing a Global Runway Safety Symposium in 2011, in which TC looks forward to participating. Landing accidents and runway overruns are an unfortunate reality in aviation. TC is committed to ongoing studies and analyses to identify the hazards and the dynamics that lead to these safety risks, as well as continuing to take action to maintain a high level of safety in the air, and on land. Flight Planning: A Critical Layer of Protection from Wake Turbulence by Dave Rye, Manager, Area Control Centre Operations Moncton, NAV CANADA In recent years, NAV CANADA controllers have noticed a number of discrepancies between the weight categories in flight plans filed by air operators and the expected aircraft weight category. Most of these discrepancies are not errors, but even a small number of errors in filed flight plans should raise vigilance on the part of all pilots, dispatchers and air operators. Impact of an incorrect weight category Air traffic controllers depend on accurate weight category information in the flight plan to ensure safe wake turbulence separation. Wake turbulence is turbulent air behind an aircraft caused by any of the following: (a) wing-tip vortices; (b) rotor-tip vortices; (c) jet-engine thrust stream or jet blast; (d) rotor downwash; (e) prop wash. Wake turbulence is usually invisible, leaving pilots with no warning that they are flying into turbulence. This is the reason why, during takeoff and landing, air traffic controllers provide standard separation for all departing aircraft and for IFR traffic on approach. There are a number of different factors that will affect the strength of the vortex, and how long it persists. The strength of the vortex is governed by the weight, speed, and shape of the wing of the generating aircraft. The vortex characteristics of any given aircraft can also be changed by extension of flaps or other wing configuring devices as well as by a change in speed. However, as the basic factor is weight, the vortex strength increases proportionately. In Canada, ICAO (International Civil Aviation Organization) Doc 8643, Aircraft Type Designators, is utilized to determine aircraft wake turbulence categories and to apply the appropriate separation standard as detailed in MANOPS (NAV CANADA, Manual of Operations). Turbulence category is determined by the aircraft maximum certificated take-off mass and not by the actual take-off weight of the aircraft. Sources of discrepancies ICAO Doc 8643 is very extensive, but within a specific model there can be model variants that have different take-off weights. While most would not be noticeable to air traffic control (ATC), some models can (and do) move from one turbulence category to another, such as the KingAir Model 350 (B350) and the SW4, which are shown as both light and medium (L/M). Other aircraft may change categories due to certified weight increases for specific mission aircraft (such as AirTractor Model AT8T for agricultural or fire suppression flights) or for temporary certified increases for ferry flights. One other aircraft of note is the B757, which, while identified as a medium category aircraft, has an increased separation requirement specific to that model due to wake characteristics for following aircraft. What can you do? For aircraft types listed in more than one category in ICAO Doc 8643, NAV CANADA controllers are not permitted to modify the weight category unless the pilot- in-command specifically identifies a weight category different than the one filed. If you are filing a flight plan, double-check the weight category. Be sure that the filed weight category is reflective of the type of flight, flight permit or certificate that you are operating under, not the actual take-off weight of the aircraft. Doing so will ensure that the appropriate turbulence separation criteria is applied to your aircraft. ASL 2/2011 7 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations Instructor Refresher Courses Improve Flight Safety… and Renew your Rating by Michael Schuster, Principal Consultant, Aviation Solutions As of June 2010, there were over 3 000 Canadian flight instructor ratings in force1 . As with instrument ratings and pilot proficiency checks (PPCs), the instructor rating is not valid forever and must be renewed. The flight instructor rating is based on a class system ranging from Class 4 to Class 1, with additional privileges granted to each successive class as instructors gain more experience and additional qualifications. Many instructors elect to renew their ratings by undergoing a flight test, but there are, in fact, several different options for renewing an instructor rating. According to CAR 421.66, one way to renew an instructor rating is to attend a Flight Instructor Refresher Course (FIRC). Many instructors are unfamiliar with, or reluctant to use, this method of renewal, so let’s take a look at what a FIRC is. The FIRC originally began in 1951 as a Transport Canada (TC) initiative. Over the years, the program underwent several changes until its conclusion in 2007. TC then granted the flight training industry authority to conduct its own courses under General Aviation Advisory Circular (GAAC) 421-001. As the GAAC points out, “The safety of flying in Canada depends on the competence of the pilots and the system that supports them. The competence of pilots depends in turn on the quality of the training system that produces them.”2 The instructor community needs to ask the following question: how well do we continue to develop instructors after their initial training? In many cases, a licensed pilot completes the instructor rating with one or two Class 1 instructors and often works at the same location once rated. This means limited exposure for many flight instructors. In other words, after a year or two of teaching, the rate of acquiring new knowledge and improving instructional skill plateaus; any gaps in knowledge or bad habits that have developed may remain uncorrected for years. In addition to renewing an instructor rating, the FIRC is an outstanding avenue for professional development, which addresses the above issues. FIRCs bring together instructors from all over the country, with course sizes ranging from six to thirty participants. Throughout the course, every instructor benefits from learning the techniques, ideas, safety systems and operational considerations that are brought by others. The varied 1 www.tc.gc.ca/eng/civilaviation/standards/general-personnel-stats- stats-2300.htm 2 General Aviation Advisory Circular 421-001, June 2010 backgrounds and experience levels of those in attendance contribute to a sharing of knowledge, and the development of a support network amongst instructors. Instructors can then take what they’ve learned back to their own Flight Training Units (FTU) to share with colleagues and improve operations. The theme of best practices is central to the content that is prepared for the refresher courses. Attendees have a chance to participate in lectures, small and large group discussions and exercises, role-playing, scenario analysis, and preparing their own presentations. The courses are quite interactive and not designed to be a one-way flow of information. Course material focuses on new skills and knowledge. For instance, many instructors have been asked by an aircraft owner to teach them IFR on their private aircraft, only to find out that the aircraft is equipped with an integrated flight deck or “glass cockpit”. The instructor may have never been given any guidance during initial training on how to “teach glass”. As the National Transportation Safety Board has stated, “single engine aircraft with glass have no better overall safety record than traditional aircraft, but do have a higher fatal accident rate”3 . The goal of the refresher course is to review to a certain extent, but more so to give instructors new knowledge and skills. The FIRC modules are led by experienced flight instructors, pilot examiners and industry experts. For instance, during presentations on airspace/ADS-B/RNAV, NAV CANADA may send a controller to participate, TC may provide a presenter to discuss the implementation of SMS at FTUs, and so on. Every course has its own unique set of topics and more information is available from the course providers’ websites. Some common topics include: instructor supervision, operational control, flight-testing weak areas, and scenario- based training. The theme through all of the modules is how instructors can not only improve the quality of their work, but also the level of safety—for their students, themselves, and for the aviation industry as a whole. Applicable real-world content is integrated throughout, to keep the lessons both relevant and current. The topic of Human Factors, for example, may look at the training of English as a Second Language students. What are the statistics surrounding their safety record? What practices have been shown to improve safety in this environment? What instructional techniques are most effective? Though these topics may sound daunting at 3 Aviation International News, April 2010 8 ASL 2/2011 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations first, the courses are designed for all levels of instructors, including Class 4. The courses are also ideal for instructors not actively working in the field who wish to retain their ratings, by keeping up-to-date on the latest changes, trends and innovations in flight training. TC has laid out comprehensive guidelines for becoming an authorized FIRC provider. Like all other operators, their documents and training programs are reviewed and courses are audited. There are presently several approved course providers running courses throughout the country.4 Flight instruction is an important part of the aviation industry and flight instructors are professionals who should be constantly improving their knowledge and skills. The next time you have a renewal coming up, you may want to consider attending one of these professional development courses. They are one of the best ways to advance both the quality and level of safety in Canadian flight training. Michael Schuster is an Airline Transport Pilot (ATP) Class 1 Instructor and authorized FIRC course provider. For more information visit www.aviationsolutions.net/instructor.php or email mjs@aviationsolutions.net. 4 www.tc.gc.ca/civilaviation/general/flttrain/irc/menu.htm Instructors practicing good pre-flight briefing techniques during a role-playing exercise. If not for ice, watch for mice… Mr. Paul Harrington of Cottam, Ontario, thought this would be of interest to ASL readers. Just after main- tenance on a Cessna 172, he pushed the aircraft out to run it up, and he suddenly had a large drop on the right magneto. He decided to check the spark plugs and ignition wires, so he pushed the aircraft back in the hangar, took the cowls off, and found number 5 magneto wire with the top chewed in half, and other wires with teeth marks. In 36 years of working on aircraft, Mr. Harrington said this was the first time he had ever seen this happening. So, he wanted to share this with pilots and, aircraft maintenance engineers (AME): if you get a magneto drop, you may want to double-check the condition of the ignition wires! He replaced the right magneto harness; for some reason, the mice didn’t touch the left one. Be careful out there! ASL 2/2011 9 Most of us have never landed at a site other than an airport and probably never will. A precautionary approach is something we don’t practice or even think much about because we don’t think it applies to us. When we took our pilot training, we learned precautionary approaches for use at off-airport sites. Most of us did not have instructors who told us precautionary approaches should be performed any time we are not certain about the landing conditions at our point of intended landing, even at an airport. Many of us occasionally go to unfamiliar airports and some of them may have runway surface conditions we are not certain about. A pilot was intending to land his Piper PA-24-200T Seneca at Mont Laurier. He touched down on Runway 26 but was unable to stop the aircraft on the runway. He eventually came to a stop in the snow, 200 ft off the end of the runway. The runway was 100% ice covered at the time. Fortunately no one was injured and the aircraft received little damage. A pilot of a Cessna C-180K overflew a 2 400 foot private strip and judged it to be firm and suitable. On landing, the aircraft drifted right. Power was added and the aircraft became airborne for about 100 ft and touched down again with the right wheel on softer ground. The aircraft continued to the right until the right wheel hit a snow drift and the aircraft flipped over. The pilot was not injured. A Cessna C-172 pilot departed a northern Ontario airport for a short sightseeing flight. He returned for landing 20 minutes later and shortly after touchdown, the right wheel hit some snow that had drifted partially across the runway. The aircraft veered right and impacted the snow bank on the right side of the runway. The pilot was not injured, the aircraft was. The report about the PA 24-200T accident did not say if the pilot performed a full precautionary approach procedure, just that he overflew the airport. Doing a full precautionary approach procedure may have prevented this accident. The C-180K pilot did fly over the strip and judged it suitable. It appears that just the centre portion was suitable. He allowed the aircraft to drift to the right away from the suitable landing area and added power to attempt to correct, but the aircraft touched down before the correction took effect. He should have gone around and attempted another landing, or diverted to another landing site. The C-172 pilot did not perform a precautionary approach as he had only been gone 20 minutes. Fresh snow and a crosswind should now be a reminder for the rest of us that it only takes minutes for snow drifts to form across a runway. We should always be prepared to go around. Too often when we expect or judge a landing site safe, we put ourselves into the mindset that we are going to land. We do not have reports on runway conditions at airports without an operating control tower, flight service station (FSS) or community aerodrome radio station (CARS). Recent snow, rain or construction can leave unexpected hazards. Local pilots or city crews may clear the runways of snow. Without specific airport training, snow windrows or clumps of hard snow can be left at entrances to taxiways or runway intersections. Winds may blow snow back onto runways in hard drifts. Animals may also create runway hazards at uncontrolled airports, with deer, coyotes, dogs and birds being the most common. When we are not sure of surface conditions, a landing site, airport or not, should initially be flown over at about 1 000 ft (high pass). An initial assessment can be made of the runway surface and of the wind conditions. When the choice of runway is made, a low pass at 300 to 400 ft can be made along the runway and to the right of the runway to better assess the field conditions. Three hundred to 400 ft should safely clear all nearby obstacles and the surface conditions can be clearly seen. This pass should be made no slower than the flap up final approach speed. Partial flap during this pass will lower the aircraft pitch attitude and help with aircraft stability. The airspeed, altitude, partial flap and trim should all be set before reaching the start of the flight operations COPA Corner: Practice Precautionary Approaches More Often ................................................................................. page 9 Underwater Egress Testimonials Validate Process .......................................................................................................... page 10 Major Accident Report : VFR into IMC Claims Seven ............................................................................................... page 12 Optimistic and Ability Biases: “VFR flight into IMC won’t happen to me; but if it does I can get out of it!”........... page 17 COPA Corner: Practice Precautionary Approaches More Often by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the July 2010 issue of COPA Flight, and is reprinted with permission. Flt. Ops Maint. & Cert. Feature Pre-flight Not used Regs & you CivAv Med. Exam. Not used Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations 10 ASL 2/2011 runway so that all a pilot has to do is look to the left and inspect the runway. If the field is judged suitable, a return for a normal, soft or short field landing can be performed from a normal circuit pattern. A normal circuit pattern should be performed for the landing whenever possible, because that is what we are used to doing, and there are fewer chances of making errors. Major errors to watch for when performing precautionary approaches are: making the high pass in a dive at high speed; not having the aircraft stabilized at an appropriate airspeed and in an appropriate configuration for the low pass; and abbreviating the circuit and landing hot and long. At any airport where you would consider a precautionary approach prior to landing, it may be wise to perform a runway surface check prior to takeoff. Standing on the ramp, or sitting in the aircraft on the ramp, or even on the end of the runway will provide a good view of only a small portion of the runway surface. There could be soft areas, holes, rocks, pools of water, ice patches, clumps of ice dropped from a snow plow, wind drifts of snow, animals or birds out of your line of sight. While checking out the runway surface, check the grass near the runway for animals or birds. Walk, if it is safe and legal to do so, or taxi the entire runway length to check the surface. An assumption that the rest of the runway is in the same condition as the piece you are sitting on has resulted in more than one aircraft getting bent. We should not assume that conditions are safe just because we are landing at an airport, or that a strip is safe because someone said so. The few minutes spent doing a precautionary approach may save us a lot of down time. Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently flies MEDEVACs from Victoria in a Lear 25. Nielsen is also the author of seven flight training manuals published by Canuck West Holdings. Dale can be contacted via e-mail: dale@flighttrainingmanuals.com. High Pass Low Pass Final Approach Precautionary Approach Procedure Underwater Egress Testimonials Validate Process by Bryan Webster, Aviation Egress Systems, Victoria, British Columbia My passion for underwater egress started—ironically—in 1977 after being initiated to a high-speed water impact as a passenger in a Cessna 150. In spite of that incident, I received a float endorsement the following year, went on to a fulfilling commercial pilot career and a few years later, in 1998, I decided to become an underwater egress and survival skills course provider. Since then, I have observed more than 4 000 egress students and their behaviour while training at aquatic facilities. Putting into words how disorientation and panic are associated with underwater submersion in an inverted aircraft is very difficult. Following an impact and submersion, the sudden change to cold water and to a dark, foreign environment can often prove overwhelming when time is of the essence; more often than not, survival instincts take control and people tend to panic, limiting their ability to successfully locate the elusive door mechanisms or other emergency exits. Short of attending a training session in person, real life testimonials offer wonderful educational insights on this topic. A few years ago, I received a call from Brenda Matas, who had been traumatized in a floatplane accident years previous. I explained the program and what it could do for her. She decided to attend one of our classes and try to relive the experience, only this time with a positive outcome. Brenda had been a passenger sitting beside her husband who was piloting their Super Bushmaster on floats. Shortly after takeoff, the aircraft stalled and impacted the water hard enough to blow out the front window and badly damage the aircraft. She recounted that during the impact, there was intense water pressure violently forcing her backwards, and her only thoughts were not to do anything until it all stopped. Fortunately, the aircraft remained upright but water was rapidly flooding the cabin. Brenda quickly undid her seat belts and assisted her unconscious husband who had sustained minor head injuries. Once he regained consciousness, they quickly escaped through the side window as the aircraft inverted and began to sink. Soon after, paddles and life vests were collected from the debris floating freely about the downed craft. Fortunately for Brenda and her husband, a pleasure boat appeared shortly after the incident and the pair was rescued and given medical assistance. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations ASL 2/2011 11 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations For Brenda, this was the end of her flying days but the beginning of a nightmare, which began with agonizing dreams of being trapped under water and searching in vain for non-existent passengers, until she would wake up shaking, sweating and crying. Two years later, once their aircraft had been repaired, she attempted to regain currency by flying with an experienced instructor. However, solo flight brought back the post-crash anxiety, so Brenda and her husband seriously considered giving up flying altogether and selling their aircraft. This is when Brenda heard about underwater egress training and called me to discuss her options. After a number of discussions, she eventually agreed to attend the course and to face her fears. However, when Brenda arrived at our pool facility, she was physically shaking and had serious doubts about attending the program. We assured her that the training was professionally supervised, safe, and that she could start with the classroom session and see how she felt afterwards. She agreed, and took part in class discussions on how to handle and think about ditching, while sharing her story with her supportive group of classmates. In the pool, she again showed signs of reluctance and viewed our equipment as terrifying. Only after watching the other students take numerous turns in the simulators did she agree to do it. At the end of the day, Brenda was calm and reacting in the appropriate manner, which helped her overcome her past negative experience. In Brenda’s words: Bryan knew what I did not. He knew I had to go back to that underwater experience again and that was why he was so supportive. I finally worked up the courage to take the course and I am very happy that I did. Huge progress has been made from the gut wrenching apprehension at every landing to now having the confidence that I can think my way through an underwater egress. I now sleep well at night and plan to take the course again in the future. Thank you. A second testimonial for the underwater egress training came from a passenger, and stemmed from a more recent occurrence. There was a terrible floatplane accident in the Gulf Islands near Victoria, B.C. a couple years ago. I received a call from a person who requested underwater egress training as she had been in the area when the mishap took place. After the training I received a letter from her describing the event and how it had affected her. Dear Bryan, I am a frequent floatplane passenger. I used to work on a project that required me to travel by floatplane from Seattle to the San Juan Islands weekly for about 5 years. I have always been concerned with the door operation on floatplanes. The small recessed handles are not easy to operate, even in the best of conditions. I now live on Saturna Island, B.C. Last fall, a floatplane went down just south of our home and I helped friends and neighbours search for survivors. Needless to say, this terrible accident has affected me deeply. After the accident, I contacted a commercial floatplane pilot and he suggested that I consider taking underwater egress training. I came to your class prepared with both a strong desire to learn how to survive a floatplane ditching plus a strong desire to help make floatplane aviation safer. The training was excellent and in fact was a real eye-opener. This experience showed me how challenging it is to get out of an inverted aircraft in the water in the best of conditions. I would recommend this type of training to everyone who flies over water. In fact, it caused me to look at how to get out of any submerged vehicle in a whole new way. Sincerely, Priscilla These two stories show how devastating aircraft accidents can be and how they can affect people’s lives. Over the last few years there have been many floatplane safety- related initiatives including new promotional campaigns, improvements in aircraft emergency exit doors and windows, enhanced pre-flight safety briefings by operators, industry meetings to discuss floatplane safety, and of course a strong push to encourage licensed personnel—and passengers—to attend underwater egress training. This training not only explains the perils and how to recognize them, but it also provides the knowledge and confidence required to escape a submerged aircraft should the unthinkable happen. Bryan Webster is a commercial pilot, underwater egress and survival skills course provider, and past recipient of the Transport Canada Aviation Safety Award. He can be reached at info@dunkyou.com. Brenda Matas with her Super Bushmaster 12 ASL 2/2011 Major Accident Report: VFR into IMC Claims Seven The following article is a condensed version of Transportation Safety Board of Canada (TSB) Final Report A08P0353, a high-profile accident which took seven lives. There is a universal lesson from this extensive report. Summary On November 16, 2008, at about 1013 Pacific Standard Time, an amphibious Grumman G-21A departed from the water aerodrome at the south terminal of the Vancouver International Airport (CYVR), B.C., with one pilot and seven passengers for a flight to Powell River (CYPW), B.C. Approximately 19 minutes later, the aircraft crashed in dense fog on South Thormanby Island, about halfway between Vancouver and Powell River. Local searchers located a seriously injured passenger on the eastern shoreline of the island at about 1400. The aircraft was located about 30 minutes later, on a peak near Spyglass Hill, B.C. The pilot and the six other passengers were fatally injured, and the aircraft was destroyed by impact and post-crash fire. The emergency locator transmitter (ELT) was destroyed and did not transmit. History of the flight The pilot reviewed and discussed the weather with company dispatch at 0930 and was advised to proceed to Toba Inlet if the weather did not permit landing at Powell River. The aviation routine weather report (METAR) issued at 0900 for Vancouver recorded the wind as 110°T at 10 kts and 2 ½ statute miles (SM) visibility in mist. Cloud cover formed a ceiling at 500 ft above ground level (AGL). The temperature was 10°C, the dewpoint 9°C. Low ceilings and visibility along the coast for the area of the flight route were forecast by Environment Canada. Although the reported weather at the Toba Inlet destination was above VFR limits, weather at CYVR and CYPW was below VFR limits at the scheduled departure time. Following the weather briefing, the pilot proceeded to the aircraft to load the cargo and board the passengers. During his pre-flight briefing, he advised the passengers that the flight would be conducted at low altitude and that if anyone was concerned, they could deplane. No one deplaned. The aircraft was released by dispatch at 1001. The automatic terminal information service (ATIS) issued for CYVR at 1009 reported that the wind had decreased to 8 kts and visibility had decreased to 2 SM. The pilot requested and received authorization from Vancouver air traffic control (ATC) to depart under special VFR (SVFR) via the SALMON NORTH departure. This published VFR floatplane route requires aircraft to be equipped with an area navigation system such as a global positioning system (GPS) to identify the SALMON VFR callup/checkpoint, about 6 NM offshore. At approximately 1013, the aircraft departed the water aerodrome westbound towards the SALMON VFR checkpoint. The accident flight was the only fixed- wing VFR departure from the water aerodrome or CYVR before 1049 that day because other operators had cancelled or delayed their flights due to the low visibility. About three minutes after takeoff, approximately 2 SM east of the SALMON VFR checkpoint, ATC approved a right turn out of the CYVR control zone (a modification to the published SALMON NORTH departure route). At this point, the aircraft turned onto a track of about 308°T. A slight course change to the west was made after which the aircraft resumed the 308°T track until radar coverage ended. About four minutes after takeoff, the pilot reported to CYVR tower that the visibility was about 2 to 2 ½ SM, and that he could probably climb to 200 to 300 ft ASL. About six minutes into the flight, and about two minutes before exiting the CYVR control zone, the pilot reported his position as 7 ½ NM from CYVR and noted that visibility had improved to about 4 SM. The majority of the route was greater than 4 NM from land or other discernable features to assist navigation. The last communication from the pilot was at about 1021, when he advised ATC that he was clear of the zone. The first nine minutes of the flight appeared on CYVR radar, ending about 21 NM northwest of CYVR, about 15 miles southeast of the accident site. Radar returns show that the aircraft’s ground speed remained steady around 140 kts, normal cruise speed for this aircraft, allowing for the 8-kt to 15-kt tailwind encountered between CYVR and South Thormanby Island. Although there was no intervening terrain between the radar source and the aircraft, the radar coverage was likely limited because of the low altitude at which the aircraft flew. Of 110 valid radar returns, 10 returns (9 percent) showed the aircraft’s altitude as 0 ft ASL, 96 returns (87 percent) showed the altitude as 100 ft ASL, and 4 returns (4 percent) showed the altitude as 200 ft ASL. No radar returns showed the aircraft’s altitude higher than 200 ft ASL. Approximately 12 minutes after departure, the operator dispatch tried unsuccessfully to contact the pilot to advise him that a special weather observation at CYPW indicated that visibility had deteriorated to ⅜ SM in fog and remained below VFR limits. Shortly after 1032, local authorities learned of a probable aircraft crash in dense fog on South Thormanby Island. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations ASL 2/2011 13 At 1110, 15 minutes after the aircraft’s estimated time of arrival (ETA) at CYPW, employees from the operator at CYPW called their dispatch centre in Vancouver to say that the aircraft had not arrived. The dispatchers determined that the last recorded position was at 1025 near Sechelt, just over one third of the distance from Vancouver to Powell River. At 1210, dispatch contacted the Victoria Joint Rescue Coordination Centre ( JRCC) to report the aircraft overdue. Poor visibility around the island due to fog and cloud prevented airborne search and rescue (SAR) efforts. The wreckage was located at about 350 ft ASL on the northeast side of an unnamed 400-ft peak, about one third of a mile south-southeast of Spyglass Hill on South Thormanby Island. The wreckage was examined to the extent possible; no pre-impact mechanical failures were noted. The pilot was certified and qualified for the flight in accordance with existing regulations. The operator’s management had met with the pilot three times to discuss concerns they had with his decision making. The last meeting, about three months before the accident, was held because management was concerned that he was completing trips in what other pilots deemed to be adverse wind and sea conditions. The company believed that this behaviour was causing other pilots to feel pressured to fly in those conditions and was also influencing customer expectations. At least one fishing lodge owner favoured the accident pilot because he flew customers in and out when other company pilots would not because they felt that the conditions were too risky. The day before the accident, the pilot of a float-equipped aircraft encountered a 400-ft ceiling and estimated 1 SM visibility near Powell River and made a precautionary landing on the water to wait out the conditions. That pilot subsequently observed a Grumman Goose fly by in these conditions. Records showed that the Grumman Goose was piloted by the accident pilot. Decision making Pilot decision making (PDM) is critical to flight safety. PDM can be defined as a four-step sequence: the gathering of information, the processing of that information, making a decision based on possible options, and then acting on that decision. Once a decision has been implemented, the process starts over again as the individual now gathers information to monitor the effectiveness of the decision. Based on how that information is processed, the individual then continues through the rest of the process, and so on. Each stage in the four-step PDM process is susceptible to error. During the information-gathering step, misdirected attention can cause critical cues to go undetected. In addition, biases may prevent a pilot from recognizing cues that are different from those expected. The processing of information stage will introduce errors into the PDM process if the information is incorrect, distorted, incomplete, or misinterpreted. The assessment of the available options involves a subjective risk assessment based on experience and knowledge. Pilots usually decide on the option they perceive as most likely to result in the best outcome given their goals. The last step in the process is to implement the option that has been selected as the most appropriate. Errors at this step of the process are typically the result of implementing an inappropriate response or improperly carrying out the correct action. Pilots’ decisions can be influenced by a wide range of factors such as perception of the situation, experience, training, abilities, expectations, goals and objectives, organizational and social pressure, time-criticality and contextual elements. A VFR pilot’s decisions are largely influenced by the assessment of existing weather information, the availability of additional navigational aids, and previous experience with a route. Once a decision is made to depart or continue along a route, pilots have a tendency to continue with the selected course of action unless there are compelling reasons not to do so. Additionally, pilots often seek out elements that reinforce, not contradict, the decision made (that is, confirmation bias). Successful experience under similar circumstances can make pilots very reluctant to select a different course of action. If a pilot is suddenly faced with additional unexpected cues from the environment, there is a danger that the relevant cues go unnoticed. This can occur due to mental processing limitations as information competes for a pilot’s attention. Relevant cues can also Area map with relevant weather information locations available to the pilot Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations 14 ASL 2/2011 be missed by a pilot if they are deemed less important than others, leading a pilot to focus on cues that may erroneously support the pilot’s preferred course of action. In this occurrence, the pilot’s safety significant decisions were the decision to take off and the decision to continue the flight into adverse weather conditions. VFR-into-instrument meteorological conditions accidents Transportation Safety Board (TSB) data show that continued VFR flight into adverse weather represents a significant threat to aviation safety. While VFR- into-instrument meteorological conditions (IMC) accidents account for a relatively small portion (less than 10 percent) of all reported accidents, approximately 55 percent of those VFR-into-IMC accidents were fatal, compared to 10 percent of all other accidents. An enormous amount of research and many studies have been conducted to identify the causes of continued VFR- into-IMC accidents. Some of the main causes of these accidents are as follows: • VFR pilots can be overly optimistic on the probability of having to fly from VFR-into-IMC, and on their own abilities to fly out of IMC if encountered (ability bias); • Incorrect situational assessment can cause pilots to prolong flight into deteriorating weather because they do not realize that they are doing so; • Decision framing can play a role. If pilots frame their decisions in terms of potential losses (that is, revenue, etc.), they are more likely to prolong flight into deteriorating weather; • Pilots are motivated to complete their flights; and • Pilots may exhibit greater risk-taking behaviour as more time and effort is invested in a flight. Analysis Given the conditions at takeoff and at the accident site, as well as the forecast and reported conditions for the en route section, it is likely that most of the flight was conducted below the required VFR minima. The conditions present on the day of the occurrence would have resulted in a high likelihood that IMC conditions would be encountered. The visibility portrayed in the photograph as the aircraft taxied into the river at Vancouver (see Photo 1) displays conditions below SVFR minima for fixed-wing aircraft. A supplementary report from the Merry Island lighthouse indicated marginal visual meteorological conditions (VMC). Lighthouse reports have traditionally provided VFR pilots on the coast with a valuable resource; however, in this case, the report was inaccurate. This may have contributed to the pilot’s conclusion that weather along the route was acceptable. During his pre-flight briefing, the pilot advised the passengers that the flight would be conducted at low altitude and that, if they were concerned, they could deplane. This is not a normal part of the pre-flight briefing and indicates that the pilot was aware that the weather along the route was likely to be poor enough that, in order to maintain ground reference, the flight would have to be conducted at a lower altitude. However, the special weather reports (SPECI) issued at 0925 for Powell River showed a marginal improvement that the pilot could have interpreted as the beginning of a trend. This is inherently risky because a single weather report does not confirm that a trend has commenced. Although the large majority of weather information indicated low cloud and poor visibility along the route, the marginal improvement at Powell River and inaccurate information from Merry Island may have contributed to the pilot’s decision that weather along the route would be sufficient for a low-level VFR flight. The pilot’s commitment to the decision to depart would have increased after boarding passengers, loading baggage, and starting the engines. Once ATC approved the pilot’s request for SVFR, the onus fell on the pilot to ensure that weather outside of the control zone would permit continued flight under VFR. When departing under SVFR, VFR pilots must have an alternate plan if below-VFR weather conditions are encountered when they leave a control zone. The pilot did not request the latest available weather reports (actual weather at 1000) to determine if the weather along the planned flight route was indeed improving. Had this been done, the Photo 1. Aircraft entering river for takeoff (accident flight.) Photo courtesy of Mr. Rich Malone, who captured it with his cell phone. Photo 2. Same location as Photo 1 taken on clear day Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations ASL 2/2011 15 deteriorating weather in Powell River would have given the pilot the opportunity to reconsider his decision to depart. When the aircraft departed, the visibility on the river was little more than ½ SM. There are indications that the accident pilot had a tendency to push the weather. For instance, the day prior, the pilot was flying in below-VFR conditions. The pilot’s decision to depart was likely affected by confidence gained through previous successes under similar conditions. Once airborne, the options available to the pilot were to continue on the planned route, alter the route, return to CYVR, divert to another aerodrome, or land on the water. All these options involved risks. Since he had been navigating from SALMON using GPS, he likely relied heavily on the GPS for navigation in the absence of adequate visual cues. As he approached Thormanby Island, it is highly likely that the pilot expected that he would regain adequate visual reference with the ground. However, it is difficult to accurately assess visibility over a featureless water surface, and it likely was not apparent to the pilot that the visibility had become so poor that a change of plan was required. When the pilot finally sighted Thormanby Island, the aircraft was too close for the pilot to be able to avoid colliding with terrain. Several of the factors that influence a pilot’s decision to continue flight from VFR into IMC existed in this accident: previous successes in low visibility, difficulty in assessing actual visibility, commitment to a chosen course of action, the consequences of changing the chosen course of action, and ability bias. It is likely that one or more of these factors were contributory to this accident. CFIT The accident flight was conducted in meteorological conditions below VFR minima. There is no indication that the pilot attempted to land on the water, or to turn around, in the face of extremely low visibility and ceilings. It is highly likely that the pilot was relying on the GPS for navigation and that, as he approached Thormanby Island, his attention shifted from the GPS to looking outside the aircraft. While flying in fog, a controlled flight into terrain (CFIT) occurred during an attempt to avoid terrain. No evidence was found to indicate that the aircraft was out of control before impact. Damage to the aircraft and to the trees at the accident site indicated the aircraft’s speed and attitude immediately before impact. The long, straight, rising angle of the swath cut through the trees and the extreme damage to those trees and to the aircraft indicate that the aircraft was flying at relatively high speed and climbing rapidly before collision with terrain. Extreme damage to all the propeller blades indicates that high engine power was being developed. This combination indicates that the pilot reacted to sighting terrain seconds before impact and pulled the aircraft up into a rapid climb. However, the pull-up was initiated too late to out-climb the rising terrain that lay ahead. The accident aircraft’s flight at high speed while at low altitude and in low visibility entailed significant risks. These include: decreasing the available time to plan and react to an emergency, limiting the available options in the event of an emergency, increasing the likelihood of inadvertent descent into water or ground — particularly during a manoeuvre such as turning around — and increasing the likelihood of collision with ground-based obstacles and birds. Findings as to causes and contributing factors 1. The pilot likely departed and continued flight in conditions that were below VFR weather minima. 2. The pilot continued his VFR flight into IMC, and did not recognize his proximity to terrain until seconds before colliding with Thormanby Island, B.C. Wreckage of the Grumman Goose being examined by an accident investigator from the Transportation Safety Board of Canada. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations 16 ASL 2/2011 3. The indication of a marginal weather improvement at Powell River, B.C., and incorrect information from Merry Island, B.C., may have contributed to the pilot’s conclusion that weather along the route would be sufficient for a low-level flight. Findings as to risk 1. The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received. 2. Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety. 3. The lack of PDM training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions. 4. Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions. 5. Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions. 6. Incremental growth in the operator’s support to the client did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected. 7. Transport Canada’s (TC) guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows. 8. Previous discussions between the operator and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk. 9. There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart. 10. Because the aircraft’s ELT failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed. 11. On a number of flights, pilots on the Vancouver-Toba Inlet route, B.C., departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits. 12. The over-reliance on GPS in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers. Safety action taken Operator Immediately following the accident, the operator suspended air taxi operations and implemented several actions to reduce risk before resuming operations. Since then, the company has implemented several other voluntary safety actions that exceed TC’s requirements for VFR air taxi operations. These additional safety actions include: • Raising the minimum departure visibility from the TC-regulated 2 SM to a company limit of 3 SM from a base of operations for VFR aircraft. • Providing a PDM course, including how GPS affects decision making, to all the VFR floatplane pilots and adding PDM training to the company VFR training syllabus. • Implementing a dispatch procedure that gives the dispatcher/flight-follower co-authority over the release of the aircraft. • Conducting risk assessments of VFR routes and operations (including reviewing weather, wind, and water condition limitations) and developing a destination-specific risk rating system. • Conducting line checks at least three times a year on each VFR pilot. • Regularly monitoring the stored data of the GPS carried on the aircraft to ensure that pilots are flying within company and Canadian Aviation Regulations (CARs) limits. • Installing aviation-specific satellite tracking systems in all VFR aircraft to replace the satellite messengers previously installed in those aircraft and eliminate the need to monitor GPS data. • Conducting annual company culture surveys to identify areas needing improvement. • Providing accident investigation training for key company personnel. • Revising the company’s SMS manual to include revised risk assessment procedures and accident investigation training. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations ASL 2/2011 17 • Having pilots and dispatchers document circumstances where poor weather affects a flight and using those data for track monitoring and to determine risk exposure over an extended period. Transport Canada In December 2009, as a follow-up to the Safety Study on Risk Profiling the Air Taxi Sector in Canada, TC made available on its Web site the Pilot Decision Making Simulator, developed by inspector Gerry Binnema (now retired from TC). This unique tool allows pilots to practice aviation-related decision making in a low-risk environment. The simulator can be found on TC’s website at www.tc.gc.ca/eng/civilaviation/regserv/safetyintelligence- airtaxistudy-simulation-menu-1829.htm. Transportation Safety Board of Canada On the day this report was publicly released, the TSB issued a communique to the aviation community warning that flying in low visibility is causing too many deaths in Canada. TSB’s Bill Yearwood said, “There are some hard lessons that need to be learned and re-learned in aviation and this is one of them.” Yearwood went on to say, “VFR pilots must be able to see the ground below and ahead of them at all times. It’s almost impossible to avoid obstacles and rising ground when clouds are low, the visibility is poor and you’re flying at twice the speed of cars on the highway.” Aircraft colliding with land or water under crew control are among the deadliest accidents in aviation. They account for 5 percent of accidents but 25 percent of fatalities in Canada. The risk is even greater when aircraft venture into mountainous terrain in poor weather. That is why Collisions with Land and Water is one of the nine critical safety issues on the TSB’s highly publicized safety Watchlist. “Competition is strong and customers can put pressure on companies to complete flights”, says Yearwood. “We need to see better decisions from companies and pilots to prevent these kinds of accidents.” To read the complete final report A08P0353 on this occurrence, visit the TSB Web site at www.tsb.gc.ca. Optimistic and Ability Biases: “VFR flight into IMC won’t happen to me; but if it does I can get out of it!” by Dale Wilson, Professor, Aviation Department, Central Washington University The following article is based on research published by the author and his colleague in a paper presented at the 11th International Symposium on Aviation Psychology, in Columbus, Ohio. It serves as an addendum to the preceding story, which touched on biases, particularly the ability bias. Do you think you’re less likely than other pilots to experience a VFR-flight-into-instrument meteorological condition (IMC) accident? Do you think you’re better at avoiding VFR flight into IMC or successfully flying out of IMC should you inadvertently encounter such conditions? These are questions my colleague and I sought to answer as we reflected on the preponderance of scientific evidence indicating that most people are unrealistically optimistic and are overconfident in their abilities. For example, when university students were asked to rate the likelihood of owning their own home, obtaining a good job after graduation, or living a long life, almost all of them believed they had a greater chance than their classmates; when asked to rate their odds of developing a drinking problem, getting divorced soon after marriage, or being fired from a job, almost all of them believed they had a lower chance than their classmates. Since it’s impossible for the majority of people in a given group to have a greater (or lesser) chance of experiencing a positive (or negative) event than the median of the group, some kind of optimistic bias must be at work. This bias is seen in the high majority of cigarette smokers who believe they are at less risk of developing smoking- related health problems than other smokers; in drivers who believe they are less likely than other drivers to be involved in an automobile accident; and, in general aviation (GA) pilots who believe they are less likely than other pilots to experience an aircraft accident. Most people also believe they are superior to others when it comes to their own skills and abilities. For example, a high majority of managers rate their managerial skills as higher than those of their respective peers; U.S. college professors think they do above average work compared to other professors; Americans believe they are more intelligent than their fellow citizens; and, automobile drivers believe they are better, and are less likely to take risks, than their fellow drivers. Unfortunately, this above average effect, or ability bias, also seems to be evident in pilots; studies confirm that most pilots think they are safer, are less likely to take risks in flight, and possess greater flying skill than their peers. We administered a questionnaire to 160 pilots asking them to compare themselves to other VFR pilots with similar flight background and experience as their own Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations 18 ASL 2/2011 when rating themselves for the following: their chances of experiencing an accident due to inadvertent flight into IMC; their ability to avoid inadvertent flight into IMC; and, their ability to successfully fly out of IMC. The results were unequivocal: participants believed they were less likely than others to experience a VFR-into-IMC accident and believed they were better than average at avoiding inadvertent flight into IMC and successfully flying out of IMC. Clearly, all of us can’t be above average, nor do all of us have a lower-than-average chance of experiencing an aircraft accident, yet that is what most of us believe. Why is that? These biases are part of a family of what are known as self-serving biases that serve to protect our ego by painting an unrealistic positive view of ourselves. In fact, the strength of these biases is significantly reduced in mildly depressed people and for those with lower self-esteem; compared to so-called mentally healthy individuals (presumably most pilots), studies indicate that these people actually exhibit more accurate and realistic perceptions of reality! There is also considerable evidence supporting a link between a positive, optimistic approach to life and reduced susceptibility to physical illnesses. The troubling irony is that even though these biases seem to be good for our overall physical and mental health, they can also lead to unsafe behavior. In spite of a gradual decline in the percentage of weather- related accidents, VFR-into-IMC is still the leading cause of fatal GA weather-related accidents and continues to be a leading cause of all fatal aviation accidents in Canada and the United States. Even though a variety of environmental factors such as mountainous terrain and darkness play a role, investigators consistently cite limitations in planning, judgment, and decision making as reasons pilots initiate or continue VFR flight into unsuitable weather. The optimistic and ability biases are only two of several complex and often unconscious factors that contribute to what the aviation safety community has historically cited as the major cause of these accidents: get-home-itis. Added to this malady is the strong influence other people can have on pilot decision making: compared to other aircraft accidents, a recent study found a significantly higher percentage of VFR-into-IMC accident flights carry passengers on board. Therefore, to protect yourself from the VFR-into-IMC trap, it is vital that you recognize that your decision making is not always rational, and if left unchecked, the biases we all appear to be vulnerable to could prod you into going somewhere you shouldn’t. Dale Wilson teaches aviation safety and human factors courses at Central Washington University in Ellensburg, WA. He has written several articles on night flying, visual illusions, and VFR flight into IMC. Links to his work, including the original research paper this article is based on—“Optimistic and Ability Biases in Pilots’ Decisions and Perceptions of Risk Regarding VFR Flight Into IMC”—can be found at www.cwu.edu/~aviation/faculty_wilson.html. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Flight Operations Flight Operations ASL 2/2011 19 Recreational aviation Owners of recreational aircraft, including amateur- built aircraft, sometimes have the impression that their recreational aviation activities take place outside the mainstream of civil aviation, and therefore that certain requirements of the Canadian Aviation Regulations (CARs) do not apply, or have little application, to their aircraft. In recent years, the regulatory burden applicable to recreational aviation has been made somewhat lighter and clarifications have been made where necessary. For example, with aircraft operating under a special certificate of airworthiness in the amateur-built classification, entries regarding the technical records for the airframe, engine and propeller may be kept in the journey log (see CAR 605.92(3)). In the case of airworthiness directives, a clarification was made about exemption from requirements for owners of aircraft in the amateur-built or owner-maintenance classification (see CAR 605.84(1)(b)). Despite the above, unless the CARs say otherwise, amateur-built aircraft are subject to the same maintenance requirements as aircraft for which the Minister has issued a type certificate. Maintenance All maintenance tasks and all elementary work (see Appendix A of CAR standard 625) must be entered in the aircraft’s technical record. Aside from elementary work, a maintenance release for all maintenance tasks performed (see CAR 571.10) can be signed by the owner of the aircraft or by an aircraft maintenance engineer (AME) (see CAR 571.11). This rule also applies to repairs and modifications to amateur-built aircraft, the subject of this article. CAR 571.06 describes the conditions applicable to repairs and modifications to an amateur-built aircraft. Paragraphs 571.06(1) and (2) are of the greatest interest in this case. CAR 571.06 The first two paragraphs of CAR 571.06 address repairs and modifications. They stipulate the following: (1) Except as provided in subsection (5) and in the case of aircraft that are operated under a special certificate of airworthiness in the owner-maintenance classification, a person who signs a maintenance release in respect of a major repair or major modification on an aeronautical product shall ensure that the major repair or major modification conforms to the requirements of the relevant technical data (a) that have been approved or the use of which has been approved within the meaning of the term “approved data” in section 571.06 of the Airworthiness Manual; or (b) that have been established within the meaning of the term “specified data” in section 571.06 of the Airworthiness Manual. (2) Except as provided in subsection (5), a person who signs a maintenance release in respect of a repair or modification, other than a major repair or major modification, shall ensure that the repair or modification conforms to the requirements of the relevant technical data within the meaning of the term “acceptable data” in section 571.06 of the Airworthiness Manual. Admittedly, CAR 571.06 is difficult to understand, and the somewhat convoluted wording does not help. To make it easier to understand, here is a simplified version of these two paragraphs: a) all repairs and modifications must be performed in accordance with acceptable technical data, within the meaning of the term “acceptable data” in section 571.06 of the Airworthiness Manual; b) all major repairs and major modifications on an aircraft for which a type certificate has been issued or accepted by the Minister for the purposes of issuing a certificate of airworthiness must be performed in accordance with either “approved” technical data, within the meaning of the term “approved data” in section 571.06 of the Airworthiness Manual, or “specified” technical data, within the meaning of the term “specified data” in section 571.06 of the Airworthiness Manual; maintenance and certification Repair and Modification of Amateur-built Aircraft ...................................................................................................... page 19 Fatigue Risk Management System for the Canadian Aviation Industry: Introduction to Fatigue Audit Tools (TP 14577E) .......................................................................................................................... page 21 Repair and Modification of Amateur-built Aircraft by Maurice Simoneau, Civil Aviation Safety Inspector, Aircraft Maintenance and Manufacturing, Standards, Civil Aviation, Transport Canada TSB reports Maint. & Cert. Pre-flight Regs & you Not used Maintenance and Certification Accident Synopses Accident Synopses Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Regulations and You Regulations and You 20 ASL 2/2011 c) aircraft for which a special certificate of airworthiness in the owner-maintenance classification has been issued are exempt from the requirement to perform major repairs and major modifications in accordance with “approved data” or “specified data”, within the meaning of the terms “approved data” and “specified data” in section 571.06 of the Airworthiness Manual; major repairs and major modifications may be performed in accordance with “acceptable data”, i.e. acceptable to the Minister. The above version makes it clear that only the general rule in a) applies to amateur-built aircraft. Versions b) and c) above are exceptions to the rule; b) is an exception to a), and c) is an exception to b). General rule The general rule, as stated in a) – “all repairs and modifications must be performed in accordance with acceptable technical data, within the meaning of the term “acceptable data” in section 571.06 of the Airworthiness Manual” – is applicable to all aircraft, whether certified or not, whether used under a certificate of airworthiness or a special certificate of airworthiness, and whether used for commercial or recreational purposes. The same rule applies to all aircraft, including amateur-built aircraft. The general rule specifies that technical data must be “acceptable” in order to perform any repair or modification. The data include: a) drawings and methods recommended by the manufacturer of the aircraft, component, or appliance (manufacturer’s maintenance manual, structural repair manual, overhaul manual, service bulletins, technical instructions); b) Transport Canada advisory documents; and c) advisory documents issued by foreign airworthiness authorities with whom Canada has entered into airworthiness agreements or understandings such as current issues of Advisory Circular (AC) 43.13-1 and -2 issued by the U.S. Federal Aviation Administration (FAA), Civil Aviation Information Publications issued by the Civil Aviation Authority (CAA) of the United Kingdom, or Advisory Circulars - Joint (ACJs) issued by the Joint Aviation Authority ( JAA), or Acceptable Means of Compliance issued by the European Aviation Safety Agency (EASA). FAA Advisory Circulars 43.13-1B and 43.13-2B are recognized as the references for all amateur-built aircraft owners and manufacturers. Whether for repairing fabric coverings, refurbishing tubular members, replacing a wooden part or installing a doubler, AC 43.13 is the go-to source of information. Methods and drawings set out in airworthiness directives may also serve as acceptable data for repairs or modifications. While amateur-built aircraft owners do not have to comply with airworthiness directives, it is highly recommended that they review applicable directives in order to decide whether to comply on a voluntary basis for the purpose of improving the safety of their aircraft. However, it is possible that AC 43.13-1B and 43.13-2B do not have the answer for a particular repair or modification required. In such cases, aircraft owners could either develop their own data for a repair or modification, or they could show that their data complies with standards recognized in the aviation community or with generally accepted practices. This technical data does not need to be approved by Transport Canada. The owner must ensure that the data is appropriate to the repair or modification in question. It’s a matter of common sense! The general rule that all repairs and modifications must be performed in accordance with “acceptable” technical data is the only rule that applies to amateur-built aircraft (and to aircraft in the owner-maintenance classification), which greatly simplifies things for the owner. However, it must not be forgotten that a modification may have an impact on structural strength, performance, operation of the power unit, or flight characteristics. A modification must not be taken lightly. It is important to think before acting. Technical records Details of the repair or modification must be entered in the journey log or in the technical record, and must be accompanied by the maintenance release. It is important to enter data references; without them, the data has little value. For example, the entry might read: Lower right fuselage spar, 20 inches from the leading edge of the horizontal stabilizer: repaired by adding doubler, oxy-acetylene weld, repainted. Reference: AC 43.13-1B, chapter 4, section 5, paragraph 4.94 and figure 4-36. Maintenance and Certification Accident Synopses Accident Synopses Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Regulations and You Regulations and You Maintenance and Certification Accident Synopses Accident Synopses Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Regulations and You Regulations and You NOT GREATER THAN "A" TUBE CIRCUM. (MAX.) I 4 DAMAGE 2 A 2 A A FIGURE 4-36. Welded patch repair. ASL 2/2011 21 The described maintenance has been performed in accordance with the applicable airworthiness requirements. [signed] Ty Wright date Maintenance release After a repair or modification, owners must not forget the maintenance release, which includes the following statement or similar: “The described maintenance has been performed in accordance with the applicable airworthiness requirements.” Conclusion Every repair or modification must be performed in accordance with acceptable technical data. This data may include analyses, calculations, references, drawings, or sketches. Every repair or modification must be entered in the appropriate technical record and there must be a maintenance release for it. If a job needs to be done, it should be done well. As the owner of an amateur-built aircraft, don’t you deserve a job well done? Maintenance and Certification Accident Synopses Accident Synopses Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Regulations and You Regulations and You Fatigue Risk Management System for the Canadian Aviation Industry: Introduction to Fatigue Audit Tools (TP 14577E) This is the sixth of a seven-part series highlighting the work of the Fatigue Risk Management System (FRMS) Working Group and the various components of the FRMS toolbox. This article briefly introduces TP 14577E—Introduction to Fatigue Audit Tools. Intended for managers, this document provides an overview of tools available to help determine whether scheduling provides employees with adequate opportunities to get sufficient sleep. The complete FRMS toolbox can be found at www.tc.gc.ca/eng/civilaviation/standards/sms-frms-menu-634.htm. —Ed. Introduction The purpose of this guide is to provide an overview of various tools and techniques to ensure that work schedules meet the requirements of a Fatigue Risk Management System (FRMS). An effective FRMS consists of several levels of fatigue hazard controls (see Developing and Implementing a Fatigue Risk Management System (TP 14575E) for a detailed discussion). One of the first things that companies need to examine is whether the schedule provides employees with an adequate opportunity to get enough sleep to be fit for work (Level 1 control). 1 2 3 4 5 Hazard Assessment Error Trajectory Control Mechanism Latent Errors Sleep opportunity Sleep obtained Fatigue-related symptoms Fatigue-related errors Fatigue-related incidents Prescriptive CARs requirements Fatigue modelling Prior sleep/wake data Symptom checklists Self-reporting behavioural scales Physiological monitoring Fatigue-proofing strategies SMS error analysis system SMS incident analysis system Active Errors Hazard-Control Model for Fatigue Risk Management 22 ASL 2/2011 Designing a work schedule In the past, hours-of-service (HOS) rules have been used to ensure that a schedule provides adequate sleep opportunity between shifts and does not result in sig- nificant work-related fatigue. In principle, this appears to be a reasonable strategy. However, HOS regulations designed to be applied generically to an entire industry can be inflexible and ineffective for an individual organization. They may not guarantee sufficient sleep opportunity. In designing an FRMS, it is important to understand that there is no such thing as a perfect schedule. Work schedules need to be structured around competing needs, such as operational safety and employee family and social life. For example, the “family friendliness” of a work schedule is likely to be determined by how much time off it provides during times of high social value (i.e., afternoons, evenings, and weekends). The “sleep friendliness” of a work schedule depends on the breaks it provides during times of high sleep value (i.e., nights between 9 p.m. and 9 a.m.). While sleep should be the primary concern, other factors such as the family and social life of employees should be considered, because they can have a direct effect on whether employees are able to use the time off to sleep. Consulting with employees during the early stages of implementing an FRMS can help find a balance between these competing needs. Providing adequate sleep opportunity To determine whether a given schedule may result in work-related fatigue, calculate the sleep opportunity that it provides. There are various ways to do this. This document outlines two methods of managing sleep opportunity: • Automated fatigue audit systems. Biomathematical modelling software has been developed that can predict how much sleep an employee is likely to get in a given schedule. The software is able to calculate a fatigue likelihood score for each employee at any given point in the schedule. • Manual fatigue audit systems. For organizations with relatively simple schedules or that may not want to invest in software, manual calculations can also be performed to generate scores that provide an indication of fatigue likelihood. We conclude this introduction to TP 14577E by encouraging our readers to view the entire document at www.tc.gc.ca/media/documents/ca-standards/FRMS_14577- eng.pdf. TC AIM Snapshot: Shuttle Procedure A shuttle procedure is defined as a manœuvre involving a descent or climb in a pattern resembling a holding pattern. Shuttles are generally prescribed on instrument procedures located in mountainous areas. In the approach phase, it is normally prescribed where a descent of more than 2 000 feet is required during the initial or intermediate approach segments. It can also be required when flying a missed approach or departure procedure from certain airports. A shuttle procedure shall be executed in the pattern as published unless instructions contained in an ATC clearance direct otherwise. To ensure that the aircraft does not exceed the obstacle clearance protected airspace during a shuttle descent or climb, the aircraft must not exceed 200 KTIAS while in the shuttle descent or climb, nor exceed one minute outbound still air time. Normal aircraft speed may be flown once the aircraft leaves the shuttle pattern. (Ref: Transport Canada Aeronautical Information Manual (TC AIM), Section RAC 10.9) ASL 2/2011 23 TSB Final Report A07W0003—Loss of Control— Marginal Weather On January 3, 2007, a Cessna A185F departed Yellowknife, N.W.T., at 1019 Mountain Standard Time (MST), with a pilot and three passengers on board, for a round trip flight to Blatchford Lake Lodge, approximately 53 NM southeast. The aircraft was on a company flight itinerary with an estimated time of arrival of 1100. When there was no contact from the pilot by 1300, a communication search and track crawl was conducted by company aircraft, but this was unsuccessful in locating the aircraft. No emergency locator transmitter signal was detected at any time. At 1513, the company reported the aircraft overdue to the flight service station. An active search by the rescue coordination centre was conducted using a number of aircraft. The wreckage of the aircraft was found at 1215, January 4, 2007, on the ice at Blatchford Lake. The pilot and two passengers had sustained fatal injuries, one passenger had sustained serious injuries, and the aircraft was substantially damaged. Analysis It was determined that the aircraft stalled while in a left turn at low level. With the forward visibility through the windshield obscured by ice, the pilot was most likely flying with attitude references through his left side window. In a left turn, the descending left wing would have obstructed his visibility, leaving only a view of the snow-covered lake surface below. The conditions would have been conducive to a whiteout situation, whereby the snow-covered lake surface would blend with a snowy, obscured ceiling to disorient the pilot by eliminating all horizon references. The pilot’s manoeuvring speed was unknown, but entering a turn would have increased the stall speed, as would the effect of the ice on the wings. The use of flaps would have decreased his stall speed, but the flaps had not been deployed. The stall warning had not activated to warn of the impending stall. The calculated aircraft weight at impact was just below the maximum gross weight; however, the amount of additional weight of the airframe ice was not quantified. The centre of gravity (CG) was at or slightly aft of the aft limit. This configuration would not have created a problem under normal flight conditions, but the aft CG would have increased the difficulty in recovering from a stall. Under the operator’s Transport Canada exemption for operations below 1 000 ft AGL with less than two miles of flight visibility, the pilot had to be trained in the use of a global positioning system (GPS) receiver. There is no record of his having received the required instruction. The coordinates entered for the lodge were about a mile east of the lodge, and the pilot had turned northeast (away from the lodge) before reaching this waypoint. There is a probability that the pilot abandoned the use of the GPS when he reached the north shore of the lake, and turned left to follow the shore of the lake for navigation, since his visual reference was out his left side window with his windshield obscured by ice. His subsequent flight path continued to track eastward away from the GPS waypoint and away from the lodge, until the aircraft crashed. Map of area The pilot was required to have had a minimum of 500 hours in operations under Section 700 of the CARs or equivalent to qualify for low-level/limited visibility flight. He had about 16 hours commercial (Section 700 of the CARs) flying time with about 1500 hours of non- 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. For more information, contact the TSB or visit their Web site at www.tsb.gc.ca. —Ed. Recently released TSB reports Maint. & Cert. Pre-flight Regs & you Not used Maintenance and Certification Accident Synopses Accident Synopses Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Regulations and You Regulations and You 24 ASL 2/2011 commercial single-engine flying time. He had completed his low-level flying training, but did not adhere to the operations manual requirements that specified that the aircraft was to be operated at 80 knots indicated airspeed (KIAS) with 10° of flap. The aircraft airspeeds varied from 130 KIAS to 77 KIAS, and flaps were not deployed. The company operations manual specified that the Cessna 185 will not depart into forecast icing conditions. Freezing fog and patchy moderate mixed icing was forecast for the destination area when the aircraft departed, and the pilot report from 0651 reported rime ice upon entering clouds at 1 100 ft ASL. After departure, the pilot had initially climbed to 1 400 ft ASL, then began a continuous descent to about 1 000 ft ASL near his destination. He had encountered icing conditions as forecast and reported, as evidenced by the ice remaining on the airframe after the occurrence. The aircraft was not equipped or approved to operate in icing conditions. The cargo and baggage was not secured, nor was there any means on board for securing the baggage and cargo to the tie-down rings. Because the primary impact was oriented vertically, the unsecured items probably did not project into the cabin and passengers. It could not be determined whether the baggage carried in the passengers’ laps contributed to the severity of their injuries. The survivor was the passenger without baggage in his lap. Search and rescue (SAR) efforts were delayed for several hours because the emergency locator transmitter (ELT) did not function. The unit was capable of operating, but the impact activation switch (G switch) was oriented to sense a forward impact, not a vertical (downward) impact. Findings as to causes and contributing factors 1. The aircraft stalled at an altitude too low for the pilot to recover. 2. The aircraft’s stall speed and stall recovery characteristics were affected by the left turn, airframe icing, and the aft centre of gravity loading. 3. The pilot’s visibility was compromised by the marginal weather conditions and an ice-covered windshield, with a probability that the pilot had entered white- out conditions. Findings as to risk 1. The pilot self-dispatched on a flight that was not in accordance with the requirements outlined in the company operations manual. He continued the flight after encountering conditions beyond his capabilities in regards to training, equipment, and operating conditions. 2. The baggage and cargo were not secured, and there were no means on board for securing the baggage and cargo to the tie-down rings. 3. Two of the passengers were carrying unsecured baggage in their laps. Other finding 1. The pilot had not been trained in the use of the GPS as required by regulation for low-level flight/limited visibility flight. TSB Final Report A07W0099—Load Shift/Loss of Control on Takeoff On June 2, 2007, a de Havilland DHC-3T Turbo Otter had been loaded with a cargo of lumber at Mayo, Y.T. The aircraft was taxied to the threshold of Runway 06 and the pilot began the take-off roll at 1755 Pacific Daylight Time (PDT). At liftoff, the aircraft entered an extreme nose-up attitude and began to