Aviation Safety Letter TP 185E Issue 4/2010

identified the root cause as being a series of decisions that lead to the inadvertent loading of the chemical oxygen generators in the cargo hold. A fire ensued, engulfing combustible materials nearby, and was proliferated by the generation of oxygen gas. The aircraft crashed in the Florida Everglades and everyone on board perished. Measures had not been in place or communicated to ensure that air operator personnel—including third party personnel—were capable of recognizing dangerous goods. Undeclared dangerous goods are found daily in passenger baggage, company materials, cargo, stores and airmail. A small percentage is reported; however, Transport Canada suspects that a considerable number of items entering the aviation transportation system are not detected for various reasons. To mitigate this hazard, and for the safety of their staff as well as their operations, air operators must ensure that company personnel know how to recognize dangerous goods and the indicators that dangerous goods are being presented for transport. Are you a dangerous-goods operator? The Transportation of Dangerous Goods Act, 1992 (TDG Act) and the Transportation of Dangerous Goods Regulations (TDG Regulations) apply to you if you handle, offer for transport, import, or transport dangerous goods to, from, or within Canada. The Act and Regulations also apply to aircraft that are registered in Canada but are operated outside Canada. This includes the transportation of replacement parts (i.e. spares) such as fire extinguishers, oxygen cylinders, engines, fuel pumps, fuel control units, first aid kits, life vests, etc. Activities carried out under a regulatory exemption are also subject to the TDG Regulations. Regulatory exemptions allow passengers to bring on board the aircraft articles such as aerosols, toiletry articles, cellular phones, portable computers, cigarette lighters, etc. The exemptions also permit operators to stow electric wheelchairs in the cargo hold and to carry dangerous goods such as aerosols, alcoholic beverages and perfumes for use or sale on board the aircraft during the flight. If any of these regulatory exemptions apply to your operation, you are in fact handling, offering for transport, or transporting dangerous goods. Training is the key to understanding and complying with the TDG Regulations. This enables a person to determine whether a product is considered to be dangerous goods, whether the dangerous goods are regulated, and how to use the TDG Regulations efficiently. International implications for Canadian non-dangerous- goods operators Air operators who state in their operations manual that they will not conduct dangerous-goods activities and choose not to provide awareness training to their employees may encounter some delays and/or difficulties when operating outside Canada. The International Civil Aviation Organization’s (ICAO) Annex 6 to the Convention on International Civil Aviation contains standards and recommended practices (SARP), which are applicable to member States, to regulate the aviation industry. The ICAO SARPs require that the ground and flight crew member training program include a section on the transport of dangerous goods. In the United States, the Department of Transport has already developed regulations in the Code of Federal Regulations, Title 14 to require awareness training for “will-not-carry” certificate holders. Other ICAO member States have also included such requirements. It should be noted that Canada has not yet incorporated the ICAO SARPs into the Canadian Aviation Regulations (CARs); however, this does not relieve Canadian operators from complying with foreign regulations when travelling within their jurisdictions. Foreign authorities check foreign carriers more frequently, and failing to meet ICAO or foreign requirements may be problematic—even if the Canadian operator meets the domestic regulations. 4 ASL 4/2010 Introduction In Canada, operating certificate and licence holders have obligations when it comes to reporting aviation occurrences. These obligations are set out in various acts and regulations. However, many in the aviation industry are likely unaware of how aviation occurrence reports (AOR) are generated and disseminated. There are also many misconceptions about how the information contained in occurrence reports is used. Transparency in how safety information will be employed is an essential element to creating an effective safety culture. The purpose of this article, therefore, is to provide an overview of the occurrence reporting process in Canada from the perspectives of NAV CANADA, Transport Canada (TC), and the Transportation Safety Board of Canada (TSB). NAV CANADA NAV CANADA has a mandatory reporting system through which operational employees report specific types of occurrences. Such AORs are entered into NAV CANADA’s occurrence database. The key information submitted is automatically distributed via e-mail to TC’s Civil Aviation Contingency Operations Division (CACO) and to the appropriate TSB regional office. In addition, a summary of the previous day’s entries in the database is distributed every morning to an internal and external mailing list. Personal information, such as the names of individuals involved, is not included in the AORs. NAV CANADA reviews all AORs submitted and identifies those considered to be operating irregularities (OI), which are defined as situations where: air traffic services (ATS) are being provided and a preliminary investigation indicates that safety may have been jeopardized, less than minimum separation may have existed, or both. Any OI where the provision of ATS is thought to have contributed to the outcome is investigated through NAV CANADA’s operations safety investigation (OSI) process. The results of the investigation are used to identify potential mitigations to prevent recurrence. In addition, NAV CANADA frequently exchanges information and follows up with individual operators after an aviation occurrence. Safety-specific inquiries may be directed to NAV CANADA through the following e-mail address: operationalsafety@navcanada.ca. Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Winter Operations Winter Operations Safety management systems A safety management system (SMS) is an explicit, comprehensive and proactive process for managing risks. Since dangerous goods entering the transportation system present a variety of risks to aviation safety, it is important that all air operators establish a comprehensive and proactive process for dealing with dangerous goods in their own contexts. Under the principals of SMS, operators must ensure that their system as a whole promotes safe operations. The general conditions of an air operator certificate stipulate that the holder must conduct flight operations safely and in accordance with the company operations manual. Part of those general conditions is Transport Canada’s approval of procedures for the carriage of dangerous goods in the company operations manual and the dangerous goods training program. Transport Canada’s position It is likely that most air operators are involved in the transport of dangerous goods in some respect. The great majority of air operators do take advantage of the regulatory exemptions to transport dangerous goods carried by passengers and to transport replacement parts. Thus, they are subject to the regulations, and Transport Canada requires, at a minimum, awareness training for all personnel involved in the processing of passengers, cargo, mail and stores; this includes third party personnel and instructions to be provided to employees in the company operations manual. This training and information assist employees in the recognition of dangerous goods and in understanding their responsibilities in preventing non-compliant or undeclared dangerous goods from entering the aviation transportation system and compromising the safety of the Canadian travelling public. Air operators wanting to obtain more information should contact their Transport Canada Civil Aviation regional office. Occurrence Reports: Where Do They Come From and How Are They Used? by Ann Lindeis, Manager, Safety Management Planning and Analysis, NAV CANADA ASL 4/2010 5 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Winter Operations Winter Operations Transport Canada TC uses the Civil Aviation Daily Occurrence Reporting System (CADORS) to collect information on occurrences in the National Civil Air Transportation System (NCATS). Canadian Aviation Regulation (CAR) 807.01 prescribes the requirement to report, as follows: The holder of an ATS operations certificate shall report to the Minister any aviation occurrence information specified in the CADORS Manual in accordance with the criteria and reporting procedures specified in that manual. Annex A of the CADORS Manual lists the types of occurrences that must be reported. Examples include collisions or risks of collision; declared emergencies; regulatory infractions; or any occurrence that deviates from normal operating procedures, may generate a high degree of public interest or concern, or could be of direct interest to specific foreign aviation authorities. The CADORS Manual is currently in the process of being updated. Since the year 2000, almost 95 percent of the CADORS information has consisted of reports filed in accordance with the criteria for mandatory reporting. Other reports have been obtained from sources such as the U.S. Federal Aviation Administration (FAA), the TSB, airports, operators and private individuals. NAV CANADA sends AOR information to CACO, who then forwards it to one of TC’s five regional offices, as appropriate. The information is then entered into the CADORS. Efforts are taken to ensure quality, but because the information found in the CADORS is preliminary and subject to change, it is not always possible to guarantee the accuracy of the information. In the interest of improving aviation safety, CADORS reports are available on TC’s Web site, at www.tc.gc.ca/cadors. Identifiable information, such as the aircraft’s registration number, is removed and licence-holder information, e.g. pilot or controller names, is not entered in the CADORS. It is possible to search occurrence data from 1993 on using criteria such as date, aircraft make and model, or information included in the narrative. CADORS data is monitored and analyzed by Civil Aviation employees to assist in the identification of hazards and trends. It provides inspectors with information related to operators under TC oversight. Inquiries regarding the CADORS may be sent to TC through the following e-mail address: cadors-screaq@tc.gc.ca. Transportation Safety Board of Canada Owners, operators, crew members and air traffic controllers have an obligation to report accidents and reportable aviation incidents to the TSB as soon as possible and by the quickest means available. Approximately 2 000 aviation-related transportation occurrences are reported to the TSB each year. Any of these occurrences may be investigated if they are deemed to meet criteria based on risk, safety benefit and public expectations. If the occurrence is not investigated, the information provided will be stored in the TSB’s database for statistical analysis. The database also allows the TSB to conduct trend analyses and determine if a safety issues investigation may be the appropriate vehicle to highlight a recurring problem. If the occurrence is investigated, the TSB makes available factual information about the circumstances of the occurrence throughout the investigation. Safety information is shared immediately with those who can make changes to improve safety, and may take the form of recommendations, safety advisories or safety information letters. However, for some types of information—including on-board recordings, representations to the Board, and personal information such as witness statements—there are stringent restrictions on who may access the information and how it may be used. Conclusion Information collected with respect to aviation occurrences is shared throughout the aviation community and used by operators, NAV CANADA, TC and the TSB to identify hazards and to improve safety. The collection and use of occurrence data provides significant safety benefit to the aviation community. We trust that this article has helped to clarify how this information is collected and used, and to make clear that personal information is not included in any of this data. This article was prepared by NAV CANADA, but was a collaborative effort between NAV CANADA, TC and the TSB. —Ed. 6 ASL 4/2010 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Winter Operations Winter Operations Distractions are the number one cause of forgetting things. There are two main reasons for this. The first is we are always thinking ahead of what we are doing. Therefore, when we are distracted, we tend to think we were further along in our task than we actually were. The second is our short-term memory is very short so any distraction may cause us to lose what we were thinking of when distracted. A pilot arrived at a maintenance hangar to pick up his C-172, which should have been ready after a 100- hour inspection. It was late afternoon and he had a flight of about 100 miles back to his home airport before grounding. The aircraft was not ready. The chief mechanic was working on the aircraft himself in an attempt to get it out of the hangar. Shortly before the mechanic was to replace the engine cowlings, he was called to the phone. He glanced at the waiting pilot and called to another mechanic to finish up and cowl the aircraft. The second mechanic looked the engine compartment over and everything appeared to be where it was supposed to be so he replaced the engine cowlings. The chief mechanic returned and saw the cowlings had been replaced, so he signed out the logbooks and sent the pilot on his way. The flight to the pilot’s home base was uneventful, but the next day he tried to start the aircraft and it would not start. He removed the engine cowlings and noted that three of the four sparkplug wires had become unattached from the sparkplugs. The distraction of the telephone, coupled with the pressure to get the aircraft inspection completed, resulted in the chief mechanic not giving a full hand-over briefing to the second mechanic. He was thinking ahead to replacing the cowlings and that is what he mentioned. The second mechanic saw that the sparkplug wires were connected, but did not check to see if they were tightened. Fortunately, the sparkplug wires did not all come loose in flight. A rental pilot was performing a pre-flight inspection on a C-172 when the three friends he was taking on a sightseeing flight arrived at the airfield fence. The young pilot stopped what he was doing and let his friends in through the FBO [fixed-base operator]. He then completed his inspection, loaded his passengers and began taxiing the aircraft. The FBO owner saw the aircraft taxiing with the tow bar still attached to the nose wheel and called the FSS [flight service station] specialist to request that the aircraft be stopped and shut down so the tow bar could be removed. A commercial pilot was interrupted during his pre-flight inspection to answer a phone call from IFR Flight Data regarding his flight plan. After the call, he continued with the inspection. After starting the engines he noted the engine temperature in the right engine was climbing into the red. He shut down the engine and went to take a look. He had forgotten to remove the engine intake covers from the right engine. Both pilots returned to where they thought they were in the inspection process. We usually think about three steps ahead of where we are during any task, so it is easy to forget steps when distracted. A good rule to follow whenever we are distracted or interrupted is to go back at least three steps from where we thought we were when distracted. If unsure, start over. COPA Corner: Distractions Affect All of Us by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the February 2009 issue of COPA Flight, and is reprinted with permission. The phone is one of the most common distractions, and most calls can wait. ASL 4/2010 7 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Winter Operations Winter Operations The length of our short-term memories compounds this. Our short-term memory is only about 30 seconds. We must do something specific to transfer information from short- to long-term memory. We normally do this subconsciously, but it does take some concentration. The other problem with short-term memory is that it has a limited capacity of six to seven unrelated items. Maybe that is a good thing. When we get distracted, there are a limited number of things we can forget. Fatigue and stress directly affect our ability to transfer information to long-term memory and to access information in our long-term memory. Therefore, when we are tired or stressed, we increase our chances significantly of forgetting to do things we intend to do. We are all tired or stressed at times. When we are, we must avoid distractions and multi-tasking. Multi-tasking is actually self-distraction. We are not as capable of multi- tasking as we think we are. This is why some provinces are banning cell phone use while driving. The number one distraction for all of us is the phone/ cell phone. There are times when the phone should not be answered and probably should be turned off. The vast majority of the calls we receive could be missed without the world ending. Most of the remaining calls can go to voicemail and be returned at a more convenient time. The next most common distraction is people directly wanting our attention. This includes friends, significant others, co-workers and bosses. When we wish to talk to someone, we seldom, if ever, observe what they are doing before we interrupt them. We are a social society and most of us do not mind being talked to. There are times, though, when we do not wish to be disturbed and times when we should not be disturbed. Be courteous and take the time to observe those you wish to talk to, to determine if now is a good time to do so. If we are not sure, we can ask if the individual has a moment. This will give them the opportunity to complete a task or to at least put themselves in a position to transfer information to long-term memory and be prepared to pay full attention to us. Distractions affect all of us. The best we can do is to minimize them. Mistakes caused by distractions are, at least, embarrassing and, at worst, damaging. Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently flies air charters. He still freelances as a flying instructor and seminar facilitator. 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. An Ounce of Prevention…Corrective Action Plans by Cliff Marshall, Technical Program Manager, Technical Program Evaluation and Co-ordination, Standards, Civil Aviation, Transport Canada Taking effective corrective action is an essential part of a solid management system and central to a closed-loop, continuous improvement process. Corrective action plans (CAP) are generally formal responses to findings and are intended to map out corrective measures. These findings can be generated from several sources, such as a certificate holder’s internal quality assurance system; investigations arising from a company’s safety reports; or a regulator’s inspections and assessments. In all cases, the findings identify a situation where a company policy, procedure, or process does not conform to either the organization’s internal policies or to regulatory requirements. A CAP is a step-by-step plan of action and schedule for correcting a finding. Successful implementation of a CAP is highly dependent on the planning that goes into it. To adequately address non-conformances, the CAP must, at a minimum: 1) Define the problem: The definition should clearly identify what happened, how significant it was, where it occurred in the system, and what type of problem it was (e.g. policy, process, procedure or culture). Remember: “If you cannot say it simply, you do not understand the problem.” 2) Analyze the problem: The analysis should include a summary of the root cause as well as any causal factors that may have contributed to the problem. There are many techniques available to determine root cause: “5 Why’s”, “Fishbone”, the maintenance error decision aid (MEDA) process, etc. Certificate holders must adopt a method that is appropriate for their organization. Regardless of which method is used, the organization must be able to demonstrate how they arrived at the root cause and what caused the non- conformance. 3) Identify the corrective action(s) required: The CAP should be documented and contain sufficient detail to describe what actions will be taken to address not only the specific examples of non-conformance and any associated immediate safety issues, but also the causal factors determined during the analysis of the problem. 8 ASL 4/2010 Guest Editorial To the Letter To the Letter Guest Editorial Pre-Flight Pre-Flight Winter Operations Winter Operations If there are any induced hazards or risks associated with the implementation of the corrective actions, they should be assessed, mitigated or eliminated. 4) Set a clear timeline for the corrections to be implemented: Timelines should be aimed at implementing effective corrective actions in the shortest reasonable time period. There should be due dates, targets, and planned follow up to ensure effectiveness of the proposed corrections. 5) Identify responsibility for implementation: Clearly identify the person or persons within the organization who are responsible for implementing the actions. 6) Identify who is responsible for managerial approval: Identify an individual within the management structure who has the authority to commit the necessary resources required to fulfill the plan and can approve the CAP. Taking the time to develop a comprehensive CAP will not only help certificate holders address findings but, more importantly, also help them continuously improve by preventing those findings from reoccurring. Celebrate the PNR’s “Silver Anniversary” of Safety Speak! The Prairie and Northern Region (PNR) encompasses approximately 60 percent of Canada’s landmass, which creates unique opportunities for communication. “Communication between people working at Transport Canada and those working in the aviation industry is crucial to maintaining and enhancing safety,” explains Kate Fletcher, the PNR’s Regional Director of Civil Aviation. “Discussing current issues and sharing thoughts and ideas in person builds a culture of engagement conducive to achieving our shared goal of aviation safety.” For this reason, the PNR formed the Aviation Safety Council (ASC), which met for the first time in Edmonton, Alta., on October 16, 1997. As the number of participants increased, ASC meeting locations were rotated between Edmonton, Calgary, Winnipeg, Saskatoon, Yellowknife and Whitehorse. Recent meetings have included representatives of NAV CANADA, the Transportation Safety Board of Canada (TSB), airport authorities, aerodrome operators, airlines, small operators, flight training units (FTU), aircraft maintenance organizations and several industry associations. The value of the ASC is clear to Herb Spear, the occupational health and safety representative for WestJet and a dedicated participant at the PNR’s ASC meetings. “I value the ASC meetings because Transport Canada encourages industry to raise safety concerns,” explains Herb. “ I have witnessed Transport Canada’s commitment to responding to those concerns, whether voiced by an operator or an individual.” Since the beginning, the ASC has remained true to its original objective, which is to provide an opportunity for participants to identify safety issues and exchange information so regulators and industry can work collaboratively to ensure Canada’s air transportation system remains safe. The 25th meeting of the ASC will take place on Tuesday, November 30, 2010, in Calgary, Alta. To attend, please register with Carol Beauchamp by e-mail at carol.beauchamp@tc.gc.ca. This special event will be limited to 125 participants, so please register as soon as possible. Transport Canada’s Safety Management Systems (SMS) Information Session Fairmont The Queen Elizabeth Hotel Montréal, Quebec November 24–25, 2010 www.tc.gc.ca/civilaviation/SMS/Info/menu.htm ASL 4/2010 9 flight operations Major Accident Report: Bell 206 Down in Cranbrook, B.C. ....................................................................................... page 9 What Went Wrong: In-Flight Blackout.......................................................................................................................... page 12 Assumptions ...................................................................................................................................................................... page 14 Major Accident Report: Bell 206 Down in Cranbrook, B.C. The following is a condensed version of Transportation Safety Board of Canada (TSB) Final Report A08P0125, on the fatal crash of a Bell 206B Jet Ranger helicopter in Cranbrook, British Columbia. Readers are encouraged to read the full report on-line at www.tsb.gc.ca. Summary On May 13, 2008, a Bell 206B Jet Ranger with the pilot and two passengers on board took off on a mission to visually examine electrical power transmission lines that ran through the city of Cranbrook, B.C. To accomplish this task effectively, it was necessary for the inspection to be carried out at about 20 to 30 ft above the line or pole heights, at a ground speed of 25 kt. At about 13:06 Mountain Daylight Time (MDT), as the helicopter was flying southbound at about 120 ft above the ground, a sudden loss of engine power occurred causing rapid loss of rotor RPM. The helicopter descended quickly and landed heavily on a paved street below the flight path. The helicopter struck a pedestrian on the sidewalk adjacent to the impact point, as well as a motor vehicle. The helicopter broke into several pieces and burst into flames. The three occupants of the helicopter and the pedestrian were fatally injured at impact. The aircraft was flying south-southwest over 14th Avenue (midway between 7th and 10th Streets), at about 120 ft above ground level (AGL) and 25 kt, when the engine lost power. The final few seconds of flight were uncontrollable and in free-fall from about 85 ft AGL. The weather conditions did not contribute to the accident circumstances, and the experienced pilot was certified and qualified for the flight. The helicopter was certified, equipped, and maintained in accordance with existing regulations and procedures. The accident site was generally an open area but there were several obstructions that the pilot may have tried to avoid during descent, namely the residential power lines, tall trees, several houses, and vehicular traffic. Given those obstructions, it is unlikely that the pilot saw either the pedestrian or the car before impact. The airframe wreckage was examined to the extent possible by the TSB, and for the few airframe components that did survive the fire, no indication was found of any pre-accident anomaly or malfunction. The TSB also determined that the weight, centre of gravity (CG), as well as hover out of ground effect (HOGE) performance were all within prescribed limits. The engine, fuel control unit (FCU) and power turbine governor (PTG) were disassembled and examined in detail. They had been exposed to extreme temperatures during the post-crash fire and had suffered significant damage. The TSB tests showed no mechanical anomaly that could have affected their function; however, a latent malfunction of either the FCU or the PTG could not be ruled out. (For more details, including references to a 2005 investigation on a similar PTG, readers should refer to the complete TSB Final Report on the TSB’s Web site. —Ed.) Helicopter autorotation A critical aspect of autorotation is the entry manoeuvre immediately following the loss of engine power because the pilot must react quickly to conserve rotor RPM. Of the other factors affecting autorotative flight, the altitude at the time of the loss of engine power immediately establishes several important elements of successful descent and landing. The greater the height above the landing surface, the greater choice of suitable landing areas, the more time to establish and maintain control of the helicopter, and the longer the glide distance. Low-altitude flight reduces all these margins to the point where successful autorotative flight and landing may be impossible. The no-engine landing after an autorotative descent is a challenging manoeuvre for any helicopter pilot Telemetry data from the helicopter allowed investigators to recreate the flight path, depicted above. Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History 10 ASL 4/2010 since it involves skills not frequently practiced within an unforgiving flight regime. For this accident, several obstacles greatly restricted the pilot’s manoeuvring and choice of landing sites. Further, he was faced with the dilemma of extending the glide to avoid the houses at the expense of controlled flight. In these circumstances, the pilot had insufficient altitude to maintain functional rotor RPM following the engine power loss, and the final few seconds of flight were uncontrollable and in free-fall from about 85 ft above the road. Tail rotor unit shown at the accident scene. The main and tail rotor blades were relatively undamaged. Height velocity diagram The height velocity diagram (HVD) (see next page) shows, in graph format, those combinations of airspeed and height above the ground where either a fully developed autorotative glide can be entered or a safe landing carried out after the single-engine helicopter suffers an engine power loss. The HVD is not a limitation in the flight manual, but rather a guide to show the flight profiles where pilots are exposed to the greatest risk resulting from engine power loss, and so identifies height and speed combinations to avoid or pass through quickly. The HVD for the Bell 206B shows that a pilot should not expect to establish full autorotation from heights between 40 and 200 ft AGL, unless the airspeed is above 45 mph. In this case, the helicopter was at about 120 ft AGL and travelling at about 30 mph; with such height and speed, the helicopter could not have achieved full autorotation before it struck the ground. Regulatory requirements for flight over built-up areas The following sections of the Canadian Aviation Regulations (CARs) and Commercial Air Service Standards (CASS) prescribe the altitudes at which aircraft may be flown: CAR 602.14—Minimum Altitudes and Distance; CAR 602.15—Permissible Low Altitude Flight; CAR 702.22—Built-Up Area and Aerial Work Zone; and CASS 722.22—Built up Area and Aerial Work Zone. The accident flight was involved in aerial inspection as a commercial operation, in which case it would be bound by the requirements of Part VII of the CARs. The company was operating under the auspices of its subpart 702 certificate—Aerial Work. Subsection 702.22(2) allows a person to operate over a built-up area at altitudes and distances less than the general prohibition if the person: is so authorized by the Minister, or is authorized to do so in an air operator certificate; and complies with the CASS. To obtain such authority, subsection 722.22(1) of the CASS requires an aerial work zone plan to be submitted to the Transport Canada Aviation Regional Office at least five working days in advance of the operation, and prescribes the information that must be submitted. Furthermore, subsection 722.22(3) lists additional requirements related to this application. In this case, the operator had not applied for, or received, authorization from the Minister of Transport, nor had it submitted an aerial work zone plan. Low-altitude aerial inspection flights over built-up areas have been undertaken in Canada for at least the past 30 years, and regulatory requirements for such flights have existed in one form or another throughout. The TSB determined that much misunderstanding exists regarding the interpretation and application of altitude requirements in the CARs and associated CASS. In all likelihood, low- altitude aerial inspection flights are being carried out over built-up areas in Canada without full compliance with regulatory requirements. Analysis The cause of the loss of engine power was not determined. No evidence was found to suggest that any of the engine modules had suffered any pre-impact mechanical event that would have contributed to a loss of engine power. The accident FCU and PTG were damaged, and while it is possible that either one malfunctioned, the TSB could not make a definitive conclusion on them. Several operational conditions existed to present the pilot with a greater-than-usual challenge for an emergency landing following the loss of engine power, namely: • obstructions on the final flight path; • low airspeed; • low height above the terrain; • low rotor RPM; and • short time frame. The above factors individually represent significant difficulty for a pilot to achieve a successful outcome, but when combined, they pose operational challenges that a pilot may not overcome. The HVD shows that low altitude and low airspeed combinations present a significant challenge to pilots Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History ASL 4/2010 11 Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History in landing successfully from an event that requires an immediate landing. On the diagram, such higher-risk zones are labelled “avoid” areas and represent the worst circumstances for recovery. The accident helicopter was frequently exposed to the higher-risk avoid zones of the HVD during its passage over the built-up areas of Cranbrook. Height velocity diagram The CARs prescribe conditions for low-altitude flight in helicopters over built-up areas that, in general, ensure the manner of operation does not create a hazard, and that the altitude (height) of a flight is such that an immediate landing can be made without creating a hazard. Information contained in the flight manuals (such as the HVD) assist operators and pilots in choosing the most appropriate flight profiles for their missions and take into account helicopter performance. Accordingly, the final responsibility for safe operational practices remains with individual helicopter operators and pilots. The severity of this accident was influenced by the low altitude and airspeed, and the landing site environment. The requirements governing flights over built-up areas are found in several areas of aviation regulation; they are complex and subject to wide interpretation, such as when an aircraft is or is not over a built-up area and which requirements would apply where and under what circumstances. The helicopter performed manoeuvres over homes in the vicinity of the power lines. Therefore, the accident flight took place over a built-up area. In the absence of clear direction and guidance, companies may select the requirements that impose the least stringent conditions. Therefore, low-level aerial inspection flights over built-up areas will continue, thereby creating a hazard to persons and property on the surface. Findings as to causes and contributing factors 1. The engine lost power at an altitude and airspeed combination that did not permit fully developed autorotative flight, resulting in rapid loss of rotor RPM, an extremely high rate of descent, and a severe collision with the terrain. 2. The helicopter was being operated at a height and airspeed combination that the helicopter manufacturer had determined would, in the event of an engine power loss, preclude a successful descent and landing. 3. During the final seconds of the flight path, the pilot was hindered by several obstacles that afforded him only one clear landing site, which was beyond the gliding range of the helicopter. The pilot’s efforts to avoid the house and reach that site exacerbated the already high rate of descent. 4. The helicopter was not in a controlled descent and, coupled with the decaying rotor RPM, the pilot’s ability to control the helicopter was decreasing so rapidly that the last 85 ft of height were in free-fall. Findings as to risk 1. Flights conducted at altitudes that do not permit safe descent, manoeuvring and landing following an event that requires a single-engine helicopter to land immediately create risk to persons and property, particularly in built-up areas. 2. The CARs requirements for low-level aerial inspection flights over built-up areas are complex and subject to wide interpretation. In the absence of clear direction and guidance, companies may select the requirements that impose the least stringent conditions. Therefore, low-level aerial inspection flights over built-up areas will continue, thereby creating a hazard to persons and property on the surface. Safety action taken Transport Canada (TC) had considered the publication in the ASL of a “logic chart” to guide pilots and operators in correct decision making regarding the minimum altitudes and distances over built-up areas prescribed by the CARs; however, upon further review, it was determined to be 12 ASL 4/2010 Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History inadvisable for the intended purpose, and that guidance in this area would be better included in the Transport Canada Aeronautical Information Manual (TC AIM). Therefore, TC is now planning to publish updated guidance on flight over built-up areas in a future update of the TC AIM. The operator revised its operational practices regarding low-altitude flight and introduced a higher level of internal oversight. Additionally, it embarked upon a dedicated safety management system (SMS). Finally, BC Hydro took immediate and long-term actions to address its policies and associated procedures concerning the use of helicopters, and the development and implementation of a more extensive helicopter management system. What Went Wrong: In-Flight Blackout by R. Wicks. The following article was originally published in the March-April 2007 issue of Flight Safety Australia and is reprinted with permission. An electrical fault knocks out several key systems including engine computers, NAV and COM equipment, flight instruments, flap, and landing gear. I was transporting several passengers, and 10 NM from Adelaide [South Australia] in instrument meteorological conditions (IMC), when I heard a clunk from somewhere on the left side of the Cessna Conquest C441’s cabin. Light misty rain streaked up the windscreen and I was at 3 000 ft and had just been cleared for a Runway 05 VOR [VHF omnidirectional range] approach via the 10 NM arc. The clunk was accompanied by the appearance of red flags on the primary attitude indicator (AI), horizontal situation indicator (HSI), and altimeter. The left-hand engine instruments were out too (torque, EGT [exhaust gas temperature], fuel flow, temperatures and pressures) and the left-hand fuel computer had tripped as well. Without the fuel computer, which controls engine RPM and torque (among other things), the left-hand engine RPM surged from 96 to 100 percent. To make matters worse, the autopilot bell sounded to indicate that it had disconnected. The priority was to fly the aircraft and see if I could work out what was happening. The artificial horizon (AH) on the co-pilot’s side was operational, as was the co-pilot’s directional gyro (DG). I levelled the wings and increased the right-hand engine RPM to 100 percent to get rid of the distracting drone generated by the out-of-sync propellers. With the aircraft stable, I had to make a decision about what I was going to do next. I called Adelaide Approach on COM1, but there was no response. I set the transponder to 7600, and checked VOR1—another red flag. How was I supposed to do an 05 VOR approach? Or even an ILS [instrument landing system]? I made another call on the radio but there was no reply. My scan came to the GPS—yes, it was working! Thankfully, it was wired to the hot bus. I was now 6 NM from Adelaide with a groundspeed of 180 kt—just two minutes from the airport. I was high, but that wouldn’t be a problem in the Conquest. With my local knowledge of the airport and the fact that I was arriving from the west, over the sea, I decided to descend until I could see the coast and make a visual approach. Visibility was now about 2 km, and I could see the ocean below. I entered “direct to” in the Trimble and quickly got a bearing to the airport (I was surprised that I had turned right and needed a left turn of 20° to compensate.) A Boeing 737 had started a VOR approach a few minutes before and I hoped the approach controller knew I was experiencing problems and was keeping us separated. I selected approach flap but the electrically driven flap motor was silent. What about the landing gear? I moved the lever to the down position—again, no response. On top of everything else, I was going to have to carry out an emergency gear extension and make a flapless approach. A small bead of sweat formed on my lip—a sure sign of stress. I checked that the gear selector was down, pulled the circuit breaker and pulled the “T” handle—nothing! I was barely a kilometre from the coast but still could not see it. What now? I was approaching the very limit of my reasoning ability with the intense pressure of the situation. “Is everything alright?” asked the passenger next to me. I figured he was wondering why I kept looking at the AH on his side of the cabin. I answered, “Yes,” then really yanked on the handle. ASL 4/2010 13 Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History Yes—I had three greens! I could also just make out the faint outline of the coast. I did a quick landing check, extended the landing lights and turned off the right-hand fuel computer (both need to be off for a “manual” landing). I flashed my landing lights and got a green flash in return from the tower, indicating I was cleared to land. We touched down safely and I remembered not to use reverse thrust with the fuel computers not functioning. After landing, I received a green light to taxi and park the aircraft, though my troubles weren’t quite over. The “stop” button failed to shut down the left engine and in the end I had to use the condition lever, which cuts off the fuel, to bring it to a halt. Several passengers thanked me for a great flight as they disembarked. If only they knew! What happened? The rear bearing in the left-hand starter generator failed, causing the armature to short on the casing. Consequently, the 225-amp current-limiter blew and all items on the left-hand main bus failed. Following this incident, the company obtained a diagram showing the aircraft’s electrical distribution. This diagram is not included in the pilot’s operating handbook. Although COM2 was functioning, this aircraft had only one audio panel and its “Emerg” position supplies power to audio panel one for transmission on COM1. NAV2 had been working, though I didn’t realize it until I was visual. I spoke to the approach controller later and he told me there was no issue with the B737. He instructed the jet to overshoot when he lost my paint and couldn’t reach me on the radio. Well done! Analysis Good situational awareness, prioritization of tasks and sound decision-making skills helped this pilot out of a very unpleasant situation. It is often said that single-pilot IFR flying is one of the most challenging tasks a pilot can undertake and it is because of precisely this type of occurrence that it is so challenging. An instrument approach in cloud and rain, and in a complex aircraft such as the Conquest, when everything is going well is hard enough; add in the failure of some essential equipment, and the workload can become so great that sound decision making often goes out the window. This pilot had good situational awareness and he used that to his advantage to solve the problem caused by the loss of his primary VOR. Becoming visual over the sea and making a visual approach over familiar terrain would have eased his workload considerably. He also had a fair idea about the position of the 737 and presumed correctly that ATC would take care of the situation. The electrical system on the Conquest is designed to cope with numerous failures and still retain the ability to operate flight-critical systems. In this case, not only did the left engine starter-generator fail but it also caused a short that blew the associated current limiter. Were it just a straight-out generator failure, without a short, the problem would be simple; in all likelihood, the right engine starter-generator would have continued to power most aircraft systems through the tie-bus. The pilot would have been alerted to the off-line left-hand generator and would simply have had to manage electrical load to below the capacity of the remaining generator, in the case of the Conquest, about 200 amps. But the short apparently caused the current limiter to isolate the left-hand main bus from the available electrical supply. It may be possible that power could have been restored but that would have required a detailed knowledge of the electrical distribution system and that information was not available to our pilot. It is pleasing to read that the company has now made available the necessary information for its pilots. In any case, with the high workload occasioned by the instrument approach and the loss of several aircraft systems, including engine computers, NAV and COM equipment, flight instruments, flap, and landing gear, this pilot made a series of wise decisions that eased his workload and enabled him to concentrate on a safe visual approach and landing. How well do you know the systems on the aircraft you fly? What’s it like to do an emergency gear extension for real? What’s the effect on landing distance of having no flap or engine reverse thrust available? The airlines have comprehensive training and checking regimes, and the advantage of flight simulators to ensure their crews are current and equipped to deal with the sort of emergency this pilot experienced. Most of us flying single-pilot IFR, like the pilot in this story, do not have this facility, so constant review of aircraft systems and drills is necessary to ensure our mental workload is not too taxing when something does go wrong. (by Mike Smith, aviation consultant) 14 ASL 4/2010 Assumptions by Steven Schmidt. This article was originally published in the November-December 2008 issue of Flight Safety Australia, and is reprinted with permission. It was the mid-80’s and I’d just earned a level 2 (junior) instructors’ ticket at a gliding field in central Victoria [Australia]. The previous week had been wet, and it was touch and go whether we operated at all. We decided to operate with one aircraft—a two-seater tandem trainer called a Blanik. It had medium performance and behaved well on the winch. By operating only one aircraft with an instructor required on board, the CFI [chief flight instructor] was confident we could keep operations to the centre of the landing strip and avoid getting bogged. Debbie was my first customer for the day. She had been solo several years earlier, but her attendance to the field had been dropping off and her currency was decaying. Debbie could be described as a high maintenance pilot given to emotional outbursts and stubbornness. The single-glider operation resulted in a slow turnaround, and Debbie was obviously irritated by this. When I asked her to complete a pre-takeoff inspection of the aircraft I got an immediate and aggressive response. “Why? I’ve just seen the glider take off and land without mishap.” I responded with a pat answer and thought to myself that it was not a good beginning for an experienced pilot. I had a growing sense of foreboding. We both jumped into the Blanik and strapped in. The retrieve car was still running out the cables from the winch, so we had plenty of time for a briefing. “The day is stable so there will be no lift. It’s a good opportunity for circuit practice and spot landing. I would like you to do the launch, circuit and landing as you have done many times before,” I briefed Debbie. Propelled by the cable, she introduced back elevator smoothly, and we were climbing. I was in the back seat, where it is difficult to see at the best of times. As we started the launch, I caught a movement on the taxiway to our side. Once we had rotated into full climb, I could see a Piper Cherokee approaching the strip along the taxiway. The launch was nearly text-book perfect and as we neared the top of the launch Debbie eased the elevator fractionally forward to release the tension on the cable before releasing. She established glide speed and completed her post-launch checks. Without prompting, she spent a few moments re-familiarising herself with the aircraft and entered the circuit. She ran through her pre-landing checks early and quickly. Once settled on the downwind leg I asked, “Anything unusual about this circuit you may consider planning for?” “No,” was her response. “Well, if it were me I’d be planning for that Piper backtracking on the runway where we wish to land.” “Smartass!” was the reply. We agreed to stay high in circuit to maximize our landing options. As we turned onto the base leg the Piper stopped, facing us. “As large as the Blanik is, it still may be difficult to see. We have no radio, so ‘S’ turns will profile the aircraft and should make it easier to see us on base leg,” I advised. At the same time the Piper did a 180-degree turn into wind and faced the end of the strip. The Piper had stopped and did not move for the duration of our final leg. Debbie, who was now focused on the task declared, “He’s stopped and waiting for us.” I agreed, without further consideration. Debbie established an aiming point for the landing deep within the strip. She was landing long to avoid the Piper and deployed the airbrakes to increase the descent rate accordingly. My focus now, like Debbie’s, was on her landing. Unbeknown to both of us was the fact that the Piper pilot, having completed his run-ups into wind, had pushed the throttle forward. To those on the ground, we missed each other by feet. Debbie’s landing was excellent, but my enthusiasm was immediately crushed with the news of the near collision. Later that evening the visibly shaking pilot of the Piper approached me. He seemed sorry but asked, “Why didn’t you stay up longer? I saw you launch and expected that I had plenty of time to take off.” I replied, “It was a winter’s day, stable and no lift except from the winch, average circuit times are 6–8 minutes depending upon the launch.” To those on the ground, we missed each other by feet. Airmanship should always be practised. It’s sad, but like common sense, often such states of mind seem very uncommon. Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History ASL 4/2010 15 He then asked, “Why didn’t you broadcast your intentions?” With a little exasperation in my voice, I responded, “Our gliders do not have electrical systems and the Blaniks, which have been here for five years, have never had radios. We ‘S’ turned on base so you could see us.” To which he replied, “You are too small to see.” I took this reply with a grain of salt. The Blanik is almost 28 ft long with a wing span of 53 ft. I thought to myself that he didn’t really look. I then asked, “Why, having turned into wind, did you not take off immediately?” He replied sheepishly that he had not done his pre- takeoff checks. Twenty-five years later, I have different views. The Piper pilot clearly demonstrated poor airmanship irrespective of the breach of CARs [Australian Civil Aviation Regulations]. He did not think through his actions and put himself in a position where he could not observe incoming traffic, or give way to that traffic, as required by law and good sense. For our part, our lack of understanding of the need for a run-up into wind and pre-takeoff checks concluded in a naive assumption that the Piper pilot had seen us on final leg and was waiting for us to land. I recognize that I had been distracted by Debbie’s behaviour and a desire to pass on my training messages effectively, unfortunately at the cost of safety. Although visibility from the back seat, especially underneath the glider, was limited, I should have been more vigilant in checking her lookout, particularly in regards to the Piper. We still had height, whilst crossing the airfield threshold, to make some avoidance manoeuvres. Airmanship should always be practised. It’s sad, but like common sense, often such states of mind seem very uncommon. Having said this, we must still always strive for that elusive goal, for all our sakes. To which he replied, “ You are too small to see.” I took this reply with a grain of salt. The Blanik is almost 28 ft long with a wing span of 53 ft. Debrief Debrief Flight Operations Flight Operations Aviation Safety in History Aviation Safety in History 2010-2011 Ground Icing Operations Update In July 2010, the Winter 2010–2011 Holdover Time (HOT) Guidelines were published by Transport Canada. As per previous years, TP 14052, Guidelines for Aircraft Ground Icing Operations, should be used in conjunction with the HOT Guidelines. Both documents are available for download at the following Transport Canada Web site: www.tc.gc.ca/eng/civilaviation/standards/commerce-holdovertime-menu-1877.htm. If you have any questions or comments regarding the above, please contact Doug Ingold at douglas.ingold@tc.gc.ca. TC AIM Snapshot—Flight Operations in Rain An error in vision can occur when flying in rain. The presence of rain on the windscreen, in addition to causing poor visibility, introduces a refraction error. This error is because of two things: firstly, the reduced transparency of the rain-covered windscreen causes the eye to see a horizon below the true one (because of the eye response to the relative brightness of the upper bright part and the lower dark part); and secondly, the shape and pattern of the ripples formed on the windscreen, particularly on sloping ones, which cause objects to appear lower. The error may be present as a result of one or other of the two causes, or of both, in which case it is cumulative and is of the order of about 5° in angle. Therefore, a hilltop or peak ½ NM ahead of an aircraft could appear to be approximately 260 ft lower, (230 ft lower at ½ SM) than it actually is. Pilots should remember this additional hazard when flying in conditions of low visibility in rain and should maintain sufficient altitude and take other precautions, as necessary, to allow for the presence of this error. Also, pilots should ensure proper terrain clearance during enroute flight and on final approach to landing. (Ref: Transport Canada Aeronautical Information Manual, Section AIR 2.5) 16 ASL 4/2010 1. year, month, day, hour and minutes 2. 22:02 Mountain Daylight Time 3. extricate any person; prevent destruction by fire or other cause; avoid danger to any person or property 4. PPR: Obtain the aerodrome operator’s permission prior to use. PNR: Notify the aerodrome owner or operator prior to use in order that current information on the aerodrome may be provided. 5. Bearing and heading information to the site. 6. No. 7. The identification of the ATS unit (FSS or FIC) controlling the RCO, the aircraft identification and the name of the location of the RCO followed by R-C-O in a non-phonetic form. 8. 122.75. 9. above ground level (AGL); above sea level (ASL). 10. Unorganized scattered clouds are forecast based at 3 000 ft ASL with tops at 5 000 ft ASL. 11. From the 28 th day of the month at 1200Z to the 29 th day of the month at 1200Z. 12. Wind shear is forecast to exist in the layer from the surface to 1 100 ft AGL, with the wind at the shear height of 270° true at 50 kt. 13. Wind light and variable, temperature -15°C. 14. YXU (London VOR) 090° radial at 10 NM. 15. Inform ATC of this fact, since acknowledgement of the clearance alone will be taken by a controller as indicating acceptance. 16. Class C requires a clearance, Class D requires communication. 17. 14 lbs or 6.4 kg. 18. The ATS unit will activate the flight plan or flight itinerary, using the estimated time of departure (ETD) as the actual time of departure (ATD). 19. No. 20. broadcast. 21. 15 NM. 22. 406 MHz. 23. www.navcanada.ca under “Aeronautical Information Products”. 24. NOTAM, VFR chart updating data, VFR chart. 25. Information concerning the establishment, condition or change in any aeronautical facility, service, procedure or hazard. 26. 60 27. Complete a flight review with an instructor, attend a safety seminar conducted by Transport Canada, participate in an approved recurrent training program, complete this self-paced study program, complete a pilot proficiency check (PPC), complete the requirements for the issue or renewal of a licence, permit or rating, or complete the written exam for a licence, permit or rating. 28. ± 50 ft 29. 24 hours; be assessed by a health-care provider 30. List might include kits, basic survival manual and other resources. 31. Hold in all free lines, control lines and hoses to avoid entanglement 32. no less than the greater of (i) 100 ft, and (ii) the greatest dimension of the balloon, be it the length, width or height, plus 25 percent. 33. the first day of the month following the day on which the medical examination for the issuance or renewal of the certificate is conducted. 34. minimum sink speed 35. 70 kt. Add an amount equal to half the gust factor of 10 kt. 36. 10 kt. 37. Stay above the rising snow and wait until solid references appear beneath the aircraft. 38. lowering the collective 39. training 40. high; small Answers to the 2010 Self-Paced Study Program Call for Nominations for the 2011 Transport Canada Aviation Safety Award Do you know someone who deserves to be recognized? The Transport Canada Aviation Safety Award was established in 1988 to recognize persons, groups, companies, organizations, agencies or departments that have contributed, in an exceptional way, to aviation safety in Canada. The Award—a certificate and letter signed by the Minister of Transport—is presented to the recipient the week of National Aviation Day (February 23). Eligibility Any individual, group, company, organization, agency or department may be nominated for this Award. The nominee must be a Canadian-owned organization or a resident of Canada. Nomination categories Nominations must demonstrate that the contribution to aviation safety meets at least one of the following: a. A demonstrated commitment and an exceptional dedication to Canadian aviation safety over an extended period of time (three years or longer); b. The successful completion of a program or research project that has had a significant impact on Canadian public aviation safety; c. An outstanding act, effort, contribution or service to aviation safety. The closing date for nominations for the 2011 award is December 7, 2010. For complete details, including the on-line nomination form, visit: www.tc.gc.ca/aviation-safety-award. ASL 4/2010 17 maintenance and certification Smoke in the Cabin—Landing Light Switch Failure ..................................................................................................... page 17 Canada-U.S. Bilateral Aviation Safety Agreement ........................................................................................................ page 19 Smoke in the Cabin—Landing Light Switch Failure The following occurrence resulted in two aviation safety advisories from the Transportation Safety Board of Canada (TSB). Background On September 24, 2007, a Cessna 152 aircraft took off from the Oshawa Municipal Airport, Ont., with the pilot and passenger on board, destined to Kingston, Ont. Just after clearing the control zone, the pilot and passenger noticed an electrical odour and observed a small fire and smoke emanating from the bottom of the left dash panel where the aircraft lighting switches were located. The passenger, sitting in the right front seat, reached for and discharged the fire extinguisher. The fire was quickly extinguished, but the extinguishing agent clouded the cockpit, reducing visibility. The cockpit windows were opened and visibility improved considerably. The aircraft returned to the Oshawa airport and landed without further incident. The pilot suffered a minor burn to his leg when the plastic instrument panel melted and dripped onto his jeans. The TSB issued Final Report A07O0264 on January 14, 2009, regarding this occurrence. Front of instrument panel The TSB determined that the landing light switch installed in the occurrence aircraft was beyond its design capability and therefore was unsuitable for the circuit it was controlling. Excessive heat from arcing and oxidization within the switch weakened the switch structure and contact support, allowing the contacts to fall out or be exposed. Arcing from the contacts caused oil residue to flash, which ignited a nearby dust accumulation and started the fire. Combustion was sustained by the plastic instrument panel. The TSB stated that similar landing light switch systems are incorporated on most of the Cessna 100-series aircraft, thereby increasing the likelihood of a similar event. The TSB issued two aviation safety advisories as a result of their investigation. Advisory No. 1: Landing light switch failure The landing light electrical circuit is composed of a 15-amp push-to-reset circuit breaker in series with a single pole, single throw rocker switch, which is in series with a 28 VDC 250-watt incandescent lamp. The switch and the circuit breaker are located on the lower instrument panel to the right of and above the pilot’s knee when seated in the left-hand seat. The engine oil pressure and temperature gauges are located directly above the landing light switch. The oil pressure gauge is connected to the oil-carrying pressure line, which is directly connected to the engine. This type of circuit and instrument panel layout are common amongst the 100-series Cessna aircraft. The switch was identified as a rocker-style switch rated at 10A 250VAC, 15A 125VAC, 3/4HP125-250 VAC. No DC ratings were found for this switch. The switch showed evidence of melt damage beginning at the base and progressing upward on both sides. The same damage was evident on the interior of the switch. The switch exterior had a thick coating of dust and an oily residue, which was also found inside the switch. A scanning electron microscope (SEM) and energy dispersive spectroscopy (EDS) analysis of the residue indicated that it might have been engine oil. The landing light circuit wires remained attached to the contact but showed evidence of fire damage near where the contact enters the switch. The contact was coated with the plastic casing material and when the surface was examined there was evidence of repeated arcing, which had severely eroded the contact’s surface. Arcing within the landing light switch could have provided the ignition source necessary for a fire to start. The dust covering evident on the switch and the oil residue provided by possible seepage from the oil pressure gauge line located above the switch may have provided the kindling necessary to start a fire. The oil would consistently reach its flash point when exposed to arcing, and when it was in proximity to the dust it would cause the dust to ignite. A small section of the plastic instrument panel was tested for flammability by introducing a direct flame to the Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses 18 ASL 4/2010 plastic. The piece of panel readily ignited and sustained flame. It also produced gases that were quite harsh when inhaled, and without sufficient ventilation may cause some incapacitation to the pilot. According to the U.S. Federal Aviation Administration (FAA) Advisory Circular 43.13-1B, chapter 11 (pages 11–17), because of the initial current encountered by switches controlling 28 VDC lamp loads (incandescent lamps), the switches should have a derating factor of 8. This aircraft’s switch controls a 250-watt lamp in a circuit powered by 28 VDC, and should have a minimum DC current rating of 71 amps. The switch from the aircraft had an AC rating. The Advisory Circular has a warning that reads “Do not use AC derated switches in DC circuits. AC switches will not carry the same amperage as a DC switch.” The switch manufacturer was contacted and provided with the landing light circuit and switch information. After evaluating the information, they confirmed that the switch was not designed to handle the lamp loads described. The circuit breaker was identified as a 15-amp push-to- reset circuit breaker (CB), Cessna part number S1360-15L. The purpose of the CB in the circuit is to protect the circuit wiring, not the components attached to the wiring. The 15-amp thermal-type CB was found to be suitable for the circuit. The CB did not trip after the occurrence but, being the thermal-type of CB, it does not react instantaneously to an over-current condition. This feature is necessary because when the light switch is selected “ON”, the initial current can be as high as 15 times its rated load. If the CB were to react instantly to the initial current it would trip every time the switch was selected “ON”. A search of the FAA’s service difficulty report (SDR) database by the TSB revealed 23 events similar to this occurrence. The common terms were: smell or smoke in cockpit, landing light switch hot, landing light switch arcing, landing light switch melted, and circuit breaker did not trip. Due to the number of these aircraft presently in use worldwide, including in flight training schools, the possibility that this type of event may recur on aircraft that have the AC-rated landing light switch installed cannot be discounted. If this type of event were to occur to an inexperienced pilot, or to a student-pilot on a solo flight, the pilot’s attention could be diverted from flying the aircraft to focus on extinguishing the fire, with possible dire consequences. The TSB suggested that Transport Canada (TC), in co-ordination with the FAA and the aircraft manufacturer, may wish to take action to mitigate or eliminate the threat of fire caused by AC-rated switches in the landing light DC circuit of Cessna 152 aircraft. Advisory No. 2: Smoke-in-cabin emergency procedures The pilot and passenger followed the emergency procedures for an electrical fire in the cabin, as per the pilot’s operating handbook (POH). The procedures were performed from memory only. Acting on their own instincts, they decided to open the two cabin windows to quickly improve visibility and improve air quality in the confined area of the cockpit. Their quick actions were successful and the pilot was able to re-channel his full attention to safely flying the aircraft back to the airport. Reported cases of smoke in the cockpit abound in various types of general aviation (GA) aircraft worldwide. A pilot’s ability to fly the aircraft safely is degraded by the presence of smoke and extinguishing agents in the cockpit. Taking action to remove the smoke and fumes from extinguishing agents would increase visibility and improve the air quality within the aircraft. To ensure that pilots can quickly eliminate smoke and extinguishing agent fumes from the cockpit, further checklist or procedural items may be required. The TSB therefore suggested that TC, in concert with manufacturers and the regulatory authorities of other countries, may wish to review emergency checklist procedures dealing with smoke and fire on GA aircraft and to include an additional step to eliminate smoke or fumes. Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses Rear of instrument panel ASL 4/2010 19 Safety action taken TC contacted the FAA, the authority for the state of design, requesting their position and possible corrective action. The FAA approached Cessna who developed a corrective action plan. Landing light switch The FAA took action to mitigate or eliminate the threat of fire caused by AC-rated switches in the landing light DC circuit of Cessna 152 aircraft. Cessna co-operated with the FAA by issuing Mandatory Service Bulletins MEB09-3 and SEB09-6 dated May 11, 2009, to remove and replace all subject switches used in the landing light as well as the taxi light and rotating beacon circuits in the 100-, 200- and 300-series Cessna models with service life greater than four years. This includes the Cessna 152-series aircraft. These bulletins are to be accomplished within the next 400 hours of operation, or 12 calendar months, whichever comes first. A review of the database shows less than 1 percent of the fleet has been affected by this type of failure. Therefore, the FAA’s course of action has been to disseminate the concern by issuing a Special Airworthiness Information Bulletin (SAIB) CE-09-42, which is available at www.faa. gov/aircraft/safety/alerts/SAIB/. Smoke-in-cabin emergency procedures The FAA took action by reviewing the emergency checklist procedures dealing with smoke and fire in GA aircraft and including additional steps to eliminate smoke or fumes. The FAA’s course of action has been to disseminate this information by issuing SAIB CE-10-04, which is available at www.faa.gov/aircraft/safety/alerts/SAIB/. It recommends that owners and operators check their POH or aircraft flight manual (AFM) and add a statement: “to remove smoke and fumes from the cockpit, do the following…” If such a statement does not exist in their POH or AFM, owners and operators are encouraged to contact the aircraft manufacturer for checklist instructions for the removal of smoke or fumes from the cockpit (e.g. closing or opening heating, air-conditioning, or air vents). Considering the FAA’s issuance of the corresponding SAIB and that Cessna has forwarded the applicable service information to all subscribers of such publications, TC has not taken any additional action at this time. In closing, TC would like to remind the community that defects, malfunctions and failures occurring on aeronautical products should be reported to Transport Canada, Continuing Airworthiness in accordance with Canadian Aviation Regulation (CAR) 521 mandatory SDR requirements. These reports will serve as supporting documentation to present to the authority for the state of design or the manufacturer when corrective action is necessary. Canada-U.S. Bilateral Aviation Safety Agreement by Joel Virtanen, Civil Aviation Safety Inspector, Maintenance and Manufacturing, Standards, Civil Aviation, Transport Canada It has recently come to Transport Canada Civil Aviation’s (TCCA) attention that more awareness is required on the impact of international agreements on the Canadian aviation industry. This article will help address this concern by focusing on the Canada-U.S. Bilateral Aviation Safety Agreement (BASA), its associated maintenance implementation procedures (MIP), and how they apply to aviation professionals in Canada. On June 12, 2000, Canada and the United States signed the BASA and designated their respective civil aviation authorities as the executive agents for its implementation. The Agreement can be viewed at: www.tc.gc.ca/eng/ civilaviation/standards/int-baa-usa-2000-3676.htm. The BASA provides for, among other things, the reciprocal acceptance of airworthiness approvals and environmental testing and approval of civil aeronautical products, as well as approvals and monitoring of maintenance, alteration and/or modification facilities, maintenance training organizations, and maintenance personnel. Article III (B) of the BASA required that the U.S. Federal Aviation Administration (FAA) and TCCA— being the executive agents for the Parties—draft written methods by which such reciprocal acceptances would be made. This documented process is referred to as the Implementation Procedures generally, and the detailed procedure for the reciprocal acceptance of maintenance activities and personnel is described in the MIP. The MIP can be viewed at: www.tc.gc.ca/eng/civilaviation/standards/int- ta-usaimp2006-menu-3700.htm. The objective of the MIP is to outline the terms and conditions under which the FAA and TCCA can accept each other’s inspections and evaluations, including FAA- approved Federal Aviation Regulations (FARs) Part 145 repair stations and Canadian approved maintenance organizations (AMO). The MIP also applies to FAA- certificated airmen and Canadian aircraft maintenance engineers (AME). As a result, the findings of compliance and regulatory oversight by either agency will be accepted by the other agency. This will lead to a reduction in redundant inspections without adversely affecting aviation safety. Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses 20 ASL 4/2010 At the heart of the MIP is the requirement for a Canadian operator or AMO performing maintenance on U.S.-registered aircraft to first comply with its own maintenance regulatory requirements—including those prescribed by Canadian Aviation Regulations (CARs) Part V, Subparts 71 and 73—and then with the special requirements prescribed by the FAA and described in the MIP. The reverse is true for FAA-approved Part 145 repair stations performing maintenance on Canadian- registered aircraft—they must first comply with U.S. maintenance regulatory requirements, and then with the special requirements prescribed by TCCA. AMOs and FAA-approved Part 145 repair stations must develop and incorporate a supplement to their own approved maintenance policy manual, or equivalent. The supplement must address all of the other aviation authority’s special requirements, as identified in the MIP. The completed supplement must be submitted to the organization’s own civil airworthiness authority for approval. Who needs a supplement? Any Canadian AMO working on U.S.-registered Part 121 or 135 aircraft requires a TCCA-approved FAA supplement to their Maintenance Policy Manual (MPM). The supplement must meet all of the conditions outlined in Chapter 3 of the MIP, which identifies the special conditions set forth by each respective civil aviation authority. Interestingly, it is TCCA that will approve the FAA supplement, and not the FAA. Any Canadian CAR Part VII operator who has work done on their aircraft in the United States by an FAA- approved Part 145 repair station must ensure that the repair station has an FAA-approved Canadian supplement to their Repair Station Manual (RSM). It is important to note that neither the FAA nor TCCA will issue a supplement approval number in respect of approved maintenance facilities. It is the operator’s responsibility to ensure that the facilities that they intend to use are approved. What is in a supplement? The supplement is essentially a bridging document for the differences between the requirements for Canadian AMOs and FAA-approved Part 145 repair stations. Some of the topics covered are: major repair reporting in accordance with the registered authority’s requirements; reporting of service difficulties and suspected unapproved parts to the appropriate authority; requirements and procedures for repairs to be done in accordance with air carriers’ procedures and with data approved by the authority of registry; requirements for major repairs to be signed by an Inspection Authorization in the U.S. and an independent AME in Canada; requirements for procedures to address the registered authority’s airworthiness directives; requirements for procedures to control the maintenance; training program differences; procedures to ensure separation of quality assurance functions from maintenance functions; procedures to ensure that the work does not exceed the ratings or scope of the organization; a requirement to understand the English language (for Canadian AMOs); and a requirement to allow inspections by both authorities. Who can sign off an annual inspection? Annual inspections are excluded from the application of the BASA and MIP. A Canadian AME cannot sign off an annual inspection on U.S.-registered aircraft, and FAA-certificated airmen cannot sign off annual inspections on Canadian-registered aircraft. This situation exists due to the differences in our regulations and has been recognized and mutually agreed to by TCCA and the FAA. How are components affected? Overhauled and repaired components received from the United States with an Authorized Release Certificate (FAA form 8130-3, Airworthiness Approval Tag) are acceptable for use on Canadian-registered aircraft as long as the repaired parts or components are received from repair stations located within the continental United States, or the Districts of Columbia or Puerto Rico. Maintenance conducted by FAA-approved foreign repair stations is not acceptable for use on Canadian aircraft since foreign repair stations are not covered by the BASA. Other international agreements should be consulted to determine the eligibility of repaired or overhauled aircraft, parts or components that originate from foreign jurisdictions. Since operators could be affected by changes, and agreements are reviewed and revised from time to time, it is important to stay informed of the latest changes to the BASA. It is good practice to always check the document’s revision date to see if amendments have been made since the document was last reviewed. Compliance with foreign agreements is necessary and relatively simple as long as you are familiar with the requirements. All international agreements are posted on the TCCA Web site: www.tc.gc.ca/eng/civilaviation/standards/int- menu-3668.htm. For further details and guidance, please refer to Advisory Circular (AC) 571-002—Canada and United States Bilateral Aviation Safety Agreement Maintenance Implementation Procedures at: www.tc.gc.ca/ eng/civilaviation/opssvs/managementservices-referencecentre- acs-500-571-002-490.htm. Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses ASL 4/2010 21 Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses RECENTLY RELEASED TSB REPORTS The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include the TSB’s synopsis and selected findings. Some excerpts from the analysis section may be included, where needed, to better understand the findings. We encourage our readers to read the complete reports on the TSB Web site. For more information, contact the TSB or visit their Web site at www.tsb.gc.ca. -Ed. TSB Final Report A06Q0190—Runway Overrun On November 26, 2006, a Learjet 35A aircraft departed Brunswick, Georgia, United States, on a medical evacuation (MEDEVAC) flight to Montréal/ Pierre Elliott Trudeau International Airport, Que. On board the aircraft were two pilots, two flight nurses, and two passengers. At 05:07 Eastern Standard Time (EST), the aircraft landed on Runway 06R at Montréal and overran the 9 600-ft runway, coming to rest approximately 600 ft off the end of the runway in a grass field. The aircraft sustained damage to the left wing leading edge and the fuselage. There were no injuries. Findings as to causes and contributing factors 1. A “B” nut loosened, resulting in a leak and depletion of the hydraulic fluid and preventing normal operation of the flaps, spoilers, thrust reversers, and wheel brakes. 2. The crew did not notice that there was a loss of hydraulic pressure and therefore did not plan for a landing without normal stopping systems or for the use of the emergency brake system. 3. When the aircraft landed, the flaps were extended to only 20°, the spoilers did not deploy because there was no hydraulic or backup air pressure, the thrust reversers did not deploy, normal braking did not work, and the emergency brake system was not used. Consequently, the aircraft overran the runway. Findings as to risk 1. The service and condition check carried out at intervals of 15 days may not assure proper fluid level. Therefore, confirmation of proper servicing rests on the completeness of the pre-flight inspection by the crew. 2. The flight crew’s adopted practice of performing the “through-flight” checklist, when a normal pre- flight was required, allowed dispatching of the aircraft without confirming a proper fluid level in the hydraulic reservoir. 3. The pre-charged thrust reverser accumulator was not serviced according to the manufacturer’s specifications, and there was insufficient air pressure to deploy the thrust reversers. 4. The aircraft flight manual (AFM) supplement for the thrust reverser does not provide guidelines on how to verify the accumulator air pressure. Consequently, the crew did not know how to properly check the thrust reverser accumulator pre-charge pressure. 5. The crew erroneously thought that the aircraft was equipped with a low-hydraulic-pressure light that would warn them in case of a loss of hydraulic- system pressure. 6. The AFM and the quick reference handbook (QRH) indicate that the low-hydraulic-pressure light illuminates to indicate loss of hydraulic-system pressure, although, in this aircraft, there was no low- hydraulic-pressure light. Other finding 1. The aircraft departed for Montréal with an identified and undocumented defect that required maintenance action. Safety action taken As a result of the accident, the operator initiated an administrative investigation. The following actions have been taken: • All company aircraft underwent extensive inspections of their hydraulic systems. • Placards have been installed on hydraulic system accumulators indicating pressures and conditions that must be met prior to checking. Checking hydraulic accumulator pressure as well as thrust reverser accumulator pressure (if applicable) is mandatory during the normal exterior pre-flight and exterior post-flight inspections. • The company director of human resources, the aviation safety officer, and the chief pilot discussed the accident with company employees. • Exterior pre-flight inspections have been expanded beyond the manufacturer’s approved procedures. 22 ASL 4/2010 Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses • Abnormal/emergency exercises that replicate this event have been incorporated into the company initial and recurrent flight training program. • A review of the manufacturer’s normal, abnormal, and emergency procedures is ongoing. • Pilots have undergone additional training on the following: • standard operating procedures (SOPs); • Learjet 35 differences training; • emergency braking operating procedures; • enhanced ground proximity warning system (EGPWS) operation, alerts, and warnings; • requirements of the normal exterior pre-flight inspection, “through-flight” inspection, and post- flight inspection; • use of the minimum equipment list (MEL) as well as defect reporting and recording procedures; and • enhanced crew resource management (CRM) training with a focus on in-flight situation awareness and recognition of impending failures during all phases of flight. • A review of the cockpit checklists is ongoing. • The company aviation safety officer has been tasked with accelerating the development of the company safety management system (SMS) program. • A significant restructuring of the company was undertaken. • Operational co-ordination centre procedures were reviewed and refined to enhance operational control and technical dispatch procedures. TSB Final Report A07A0029—Runway Excursion On March 31, 2007, an Antonov AN 124-100 was on a flight from Greer, South Carolina, United States, to Gander, N.L. On arrival in Gander, the crew completed an approach to Runway 03/21. The aircraft touched down at 02:16 Newfoundland Daylight Time (NDT) but was unable to stop before reaching the end of the runway. It departed the left side of Runway 03/21, near the departure end, and came to rest approximately 480 ft off the runway surface, facing the opposite direction. Several edge lights along the runway were broken. The nine crew members and ten passengers on board the aircraft exited without injury. Aircraft damage was limited to cuts in the aircraft tires. Analysis There were no mechanical failures that contributed to the occurrence. Therefore, the analysis will focus on the awareness of runway conditions, the runway touchdown point, the delay in wheel braking, and the reduction in aircraft deceleration. The automatic terminal information service (ATIS) report received by the crew indicated that Runway 03/21 was bare and wet and that Runway 13/31 was the active runway. Twelve minutes before landing, the crew received a special weather observation indicating that light snow was falling. The fact that the latest weather observation was a special report and was reporting snowfall should have alerted the crew that weather conditions had changed and therefore the runway selected for landing may be contaminated. However, the crew did not request an updated runway surface condition (RSC) report. Runway 13/31 had been designated as the active runway since the winds were light from the west. Active runways are chosen for various reasons, such as surface wind direction, the predominate direction from which aircraft are approaching, and taxi distance. Snow removal personnel and equipment were maintaining only Runway 13/31 before the occurrence. The aircraft touched down approximately 2 400 ft beyond the normal touchdown point (3 400 ft minus 1 000 ft). The fact that the aircraft touched down long and at an airspeed 14 kt below the planned airspeed indicates that the aircraft floated this additional distance before touchdown. Considering that the runway was contaminated with snow, the reduced stopping distance Final position of aircraft ASL 4/2010 23 Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses available greatly increased the chance of the aircraft being unable to stop on the remaining runway. Wheel braking was applied by both pilots five seconds after the planned brake application speed of 135 kt. This brake application occurred 2 000 ft after the touchdown point, leaving only 4 800 ft of runway available for stopping the aircraft. The fact that both pilots were attempting to apply brake pressure simultaneously may indicate that both pilots were concerned about the stopping distance remaining. Analysis of the recorded aircraft flight data indicated that the initial rate of deceleration may have been sufficient to stop the aircraft before the runway end. The crew did use reverse thrust after touchdown; however, it did not maintain maximum available reverse thrust until ensured of stopping on the available runway. Even though reverse thrust has little effect below 90 kt, that limited effect and the absence of residual forward thrust during the 15 s the idle power setting was restored may have been enough to prevent a runway overrun. Findings as to causes and contributing factors 1. The aircraft touched down approximately 2 400 ft past the normal touchdown point; this greatly reduced the available stopping distance. 2. The contaminated runway surface condition increased the distance required to stop the aircraft. 3. The delay in the application of wheel brakes, combined with the failure to maintain maximum available reverse thrust until it was ensured that the aircraft would stop on the remaining runway, contributed to the overrun. Safety action taken The operator has made arrangements with the Gander International Airport Authority to have, upon request, Canadian Runway Friction Index (CRFI) reporting for each third of the runway. Following this accident, the operator completed its own investigation and developed an in-house dedicated safety assurance program for the company’s intensive flight operations via Gander Airport. A TSB Aviation Safety Information letter has been sent to Transport Canada regarding Canadian differences with International Civil Aviation Organization (ICAO) recommended practices for reporting runway friction measurements. TSB Final Report A07O0095—Landing Gear Collapse After Touchdown On April 9, 2007, a Piper PA31 aircraft departed a private grass strip with a pilot and passenger on board for a short flight to the Cochrane, Ont., airport to pick up another passenger. After departing Cochrane, the pilot flew to Moosonee, Ont., and conducted a VFR approach for Runway 32. Approximately 1.5 NM from the runway, the pilot selected the landing gear down and confirmed that the landing gear was indicating down and locked. This was also verbally confirmed by the passenger, another company pilot, who was sitting in the right seat. The aircraft landed normally, and the pilot selected flaps up and boost pumps off. The pilot was about to apply brakes to slow down for Taxiway Bravo when the gear horn sounded and the right main landing gear collapsed, followed quickly by the collapse of the left-main and nose landing gear. The aircraft came to rest approximately 1 550 ft from the threshold of Runway 32, just off the right side of the runway. There were no injuries. Analysis No faults were found with the aircraft that would indicate any mechanical failure or improper rigging of the landing gear. Retraction of the landing gear can only be accomplished if the down locks are removed during the retraction sequence. Therefore, due to the play in the landing gear handle, and the ease with which it could be bumped up, it is likely that the landing gear handle was inadvertently positioned above the locking solenoid before weight on wheels was achieved and that during the landing roll the handle was inadvertently bumped up far enough to begin the retraction sequence. Findings as to causes and contributing factors 1. The spring in the landing gear handle was broken and allowed easy movement of the landing gear handle past the neutral stop. 24 ASL 4/2010 Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses 2. During the approach, the landing gear handle was most likely placed in a position that bypassed the anti-retraction system. 3. The landing gear handle inadvertently moved to an “UP” selection during the landing roll, which activated the gear warning horn and retracted the landing gear. TSB Final Report A07O0165—Collision with Terrain On June 30, 2007, a privately owned Piper Cub J3C-65 departed a privately owned, grass-covered runway near Essex, Ont., under visual meteorological conditions (VMC). This was the first flight following the annual maintenance inspection of the aircraft. Shortly after departure, the aircraft made a planned low pass parallel to the runway in an easterly direction. The aircraft then climbed to approximately 1 500 ft above ground level (AGL) in a northerly direction. Shortly afterwards, the aircraft was observed in a gradual descent, flying in a southeasterly direction. At approximately 14: