On January 29, 2003, a Beech 99 withtwo pilots and three passengers on boardwas departing Pikangikum, Ontario, at18:38 central standard time (CST) on anight visual flight rules (NVFR) flight toPoplar Hill, Ontario. The captain, who wasthe pilot flying (PF) and sitting in the right-hand seat, completed a normal takeoff. Theflight took off from Runway 27, over a lake.About 400 ft above ground level (AGL), thePF began a climbing right turn en route.During the turn, the PF had difficulty seeingthe artificial horizon and concentrated on theaircraft’s bank angle. The first officer calledthat the aircraft was in a 2 000-feet-per-minute descent and took control. Theaircraft struck the frozen surface of the lake,bounced, and became airborne again. Thefirst officer retained control, and the captainattempted to feather the damaged right propeller.The first officer, believing that both propellers hadsustained damage, force-landed the aircraft on thelake surface. The aircraft sustained substantialdamage. No one was injured. This synopsis is basedon the Transportation Safety Board of Canada (TSB)Final Report A03C0029.

The original first officer for the flight became illand the operator sent a relief pilot as a replacement.On arrival, the relief pilot became the aircraftcaptain, based on seniority within the company. Theoriginal captain, who was now to act as the first offi-cer, had flown the first series of scheduled flights inthe left seat, and the cockpit was configured toaccommodate him. When the new captain arrived, itwas convenient for the new captain to fly from theright seat. The operator’s Operations Manual (OM)permits a left-seat-qualified pilot who receivesannual right-seat training to operate the aircraftfrom the right seat. However, the captain had neverreceived right-seat training as a captain with thecompany.

Both held valid airline transport pilot licences andtheir pilot proficiency checks and required trainingwere current. The captain had accumulated about4 800 hr of flight time in nine years of flying and hadbeen a Beech 99 aircraft captain for two years. Thefirst officer had been flying for eight years and hadabout 4 200 hr of flight time. The first officer hadalso been a Beech 99 aircraft captain for two years.

After the crew change, the flight continued toPikangikum in night visual meteorologicalconditions (VMC). During the flight, the first officer,the PF for this flight, adjusted the cockpitinstrument lighting for both crew members. Thecaptain, the non-flying pilot, found the lightingselection too bright and re-adjusted the instrumentlighting on the right side of the cockpit to a lowersetting. The flight landed at Pikangikum, andpassengers and baggage were offloaded. Threepassengers and baggage were loaded for the flight toPoplar Hill. During this time, the crew were workingin the brightly lit area of the ramp. After the aircraftwas loaded, the crew took their positions, with the

TP 185EISSN 0709-8103

Learn from the mistakes of others; you’ll not live long enough to make them all yourself . . . Issue 3/2004

LetterÏ Transport Transports

Canada Canada

Aviation Safety

When Night VFR and IFR Collide

2 ASL 3/2004

captain, the PF for the departure from Pikangikum,in the right seat. The PF did not change thelighting selection on the right side of the cockpit from the selections made during the flightinto Pikangikum.

The PF taxied to the runway, executed a normaltakeoff, and established the aircraft in a climb at1 500 feet per minute. After the first officer calledpositive rate, the PF called for the landing gear tobe selected up. Approximately 15 seconds aftertakeoff, the first officer made the required 400-ftcall. The PF called for flaps up and, after the firstofficer confirmed that flaps were selected, called forclimb power and the after-take-off checks. The firstofficer acknowledged, and the captain indicatedstarting a turn toward Poplar Hill.

The first officer was setting climb power as thePF started the turn. The PF intended to establishthe aircraft in a bank angle of 20° to 25°. However,the PF was unable to see the artificial horizonclearly. Although the aircraft was banked to one ofthe marks on the artificial horizon, the PF wasuncertain of the bank angle that was reached. ThePF concentrated on the artificial horizon, evenleaning forward trying to identify the bank angledisplayed. The PF was completing the roll-out of theturn when the first officer told the PF that theaircraft was descending at 2 000 feet per minute.The PF pulled back on the control column. Whenthe first officer saw the frozen surface of the lakeapproaching rapidly (visible because one landinglight was still on), the first officer also grasped thecontrol column and pulled back. However, the com-bined effort of both pilots did not prevent theaircraft from striking the frozen surface of the lake.The aircraft struck the frozen surface in a wings-level attitude with the landing gear retractedand bounced airborne. The aircraft was equippedwith a belly pod, which absorbed a large amount ofthe impact forces during landing. The frozensurface of the lake was covered with a layer of snowabout two feet deep, which also reduced the force ofthe impact.

The captain noted that the right propeller wasslowing and attempted to feather it. The crewagreed that the best option was to land immediatelyon the frozen surface, and the first officer completeda forced landing about 1.5 nautical miles (NM) fromthe departure end of Runway 27. The aircraft slid toa stop in about 300 ft on the frozen, snow-coveredsurface. The crew used the aircraft radios to contactcompany staff at the airstrip, and the passengersand the crew were transported to the terminal in ashort period of time.

Damage was confined to the engines and the pro-pellers and to the underside of the fuselage, wings,and flaps. Inspection of the airframe, flight controls,and engines revealed no pre-impact anomalies.There was no internal damage in the cockpit or thecabin. The flight instruments from both sides of the

instrument panel were removed and tested. Nounserviceablities were found.

Canadian Aviation Regulation (CAR) 602.115requires, for NVFR flight in uncontrolled areas,that “No person shall operate an aircraft in VFRflight within uncontrolled airspace unless, (a) theaircraft is operated with visual reference to the sur-face.” The 18:24 CST special weather report for RedLake, Ontario, 46 NM south of Pikangikum, was asfollows: wind 210° at 15 kt, gusting to 25 kt;visibility 12 statute miles (SM) in light snow anddrifting snow; ceiling 2 500 ft broken; and tempera-ture -15°C. The weather at Pikangikum was report-edly similar. The moon was in the last phase ofwaning, and there was no moonlight; it was a verydark night.Analysis—The takeoff and departure were initiatedin accordance with the company’s standard operat-ing procedures (SOPs). The aircraft captain, the PF,had completed currency requirements for the leftseat but had not completed the required annualright-seat training to operate the aircraft from the right seat. Consequently, the aircraft captainwas not current to operate the aircraft from theright seat.

The ramp was brightly lit, and there was noproblem seeing the instrument panel, so the captaindid not adjust the lighting illuminating theartificial horizon before taking off. However, oncethe aircraft was airborne, the lighting was too dimto allow the captain to see the artificial horizonclearly. The PF concentrated on the bank angle, butdid not cross-check the climb angle or otherinstruments, and a high sink rate rapidlydeveloped. When the first officer called the descent,the captain was unable to re-establish situationalawareness, and the first officer correctly tookcontrol. The damage to the propellers and theengines was such that a forced landing on the lakesurface was the only option.

The aircraft took off over a lake, and there wereno ground lights under or around the aircraft afterit left the airport area. The lack of ground andcelestial lighting created conditions that madeflight with visual reference to the surface verydifficult, if not impossible. With adequate outsidevisual references, a pilot, unsure of the aircraft atti-tude, would certainly look outside to regain theirsituational awareness. The ambient (outside) light-ing conditions after takeoff on the accident flightwould have provided little or no help to this crew inorienting the aircraft. It is highly probable that thePF was referencing only the aircraft instruments,and they were not bright enough to ascertain theaircraft attitude. In essence, this flight was notbeing conducted in accordance with VFR.

The TSB determined that the captain chose to flythe aircraft from the right seat during a nightdeparture when not current to operate the aircraftfrom the right seat, and that the captain did not set

ASL 3/2004 3

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When Night VFR and IFR Collide . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Ben McCarty Wins the Transport Canada Aviation Safety Award . .4

Canadian Aviation Safety Seminar (CASS) 2004—A Success . . . . .4

Recently Released TSB Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Fibreglass in Amateur-built and Ultralight Aircraft . . . . . . . . . . . .7

Jelly in the Fuel Filter Causes Engine Failures . . . . . . . . . . . . . . .8

Improving Stall and Spin Awareness . . . . . . . . . . . . . . . . . . . . . . .8

Taken from TSB and CADORS Files . . . . . . . . . . . . . . . . . . . . . . . . .9

COPA Corner—How Much Gas Is Enough? . . . . . . . . . . . . . . . . . . .10

Local Area Weather Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

ATAC Recognition Awards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

I Have Seen The Eyes of Death—Part 2 . . . . . . . . . . . . . . . . . . . . .12

Transborder Flights Without a Flight Plan . . . . . . . . . . . . . . . . . .14

VFR En-route Altitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

to the letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Erratum—ASL 2/2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

One Phone Call Away . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Take Five: Let’s Stop UNSARs!!! . . . . . . . . . . . . . . . . . . . . . .tear-off

Take Five: Aircraft/Vehicle Conflict . . . . . . . . . . . . . . . . . . . .tear-off

IN THIS ISSUE Page

the instrument lighting correctly for the night takeoff and was unableto use the artificial horizon effectively, resulting in the loss ofsituational awareness after takeoff and the subsequent loss of controlof the aircraft. The TSB also determined that the flight was filed as aVFR flight whereas, in essence, it was operating under IFR conditions.

The mixing of VFR and IFR procedures can be deadly in NVFRoperations. Had the crew planned for an IFR flight to begin with, theywould likely have configured the cockpit for the appropriateillumination, and they would likely have noticed any deviation from acontrolled IFR climb before it was too late. NVFR regulations comeincreasingly under attack after such accidents; pilots must recognizewhen NVFR becomes IFR and plan accordingly. Furthermore, the con-ditions under which the original captain was re-assigned to first officerduties upon arrival of the relief pilot may have contributed to the chainof events—particularly with the “convenience” of letting the originalcaptain stay in the left seat. Experienced pilots, such as the twoinvolved here, are used to changing seats all the time, and this wouldhave taken at most a few minutes. Of course, there is nothing inherentlywrong with having the captain in the right seat; the argument rather isthe judiciousness of performing a right-seat takeoff under these circum-stances. Right-seat flying skills are valuable under controlledconditions such as VFR flight, dual training, and during an emergency.With the fine line between NVFR and IFR having been crossed, theappropriateness of the decision to perform a right-seat takeoff was proven strikingly wrong. —Ed.

Airmanship is the application of flying knowledge, skill and experience, which

fosters safe and efficient flying operations.

Canadian Aviation Safety Seminar (CASS) 2004—A Success

4 ASL 3/2004

Mr. Ben McCarty was awarded the 2004 Transport CanadaAviation Safety Award for his commitment to accident preven-tion. The award was established in 1988 to foster awareness ofaviation safety in Canada, and to recognize individuals,groups, companies, organizations, agencies or departmentsthat have contributed to this objective in an exceptional way.

Mr. McCarty’s many achievements include being a foundingmember of the Canadian Aviation Regulation Advisory Council (CARAC) and the Atlantic Aircraft MaintenanceEngineer Association, serving as president of the latter sinceits inception in 1983. He has suggested regulatory changes andprovided input on new legislation, all helping to furtherenhance and foster aviation safety. Mr. McCarty has served onmany councils, such as the Canadian Federation of AircraftMaintenance Engineers Associations, Canadian AviationRegulation Council and the Civil Aviation Regulatory Committee.

“Over a 30-year period, Mr. McCarty has had a profound impact on how we approach aviation safety inCanada,” said the Honourable Minister of Transport, Tony Valeri. “His contribution and influence inaviation safety is both significant and constant, resulting in a safer and more efficient aviation system in Canada.”

The Deputy Minister of Transport, Louis Ranger, presented the award on April 20 at the 16th annualCanadian Aviation Safety Seminar (CASS) in Toronto. CASS is an international event hosted annuallyby Transport Canada for all sectors of the aviation community. It features safety workshops andpresentations by leading Canadian and international safety experts. Additional information onthe award, such as previous winners and the nomination process, can be found on our Web site at: www.tc.gc.ca/civilaviation/SystemSafety/Brochures/tp8816/menu.htm.

Ben McCarty Wins the Transport Canada Aviation Safety Award

Deputy Minister of Transport, Louis Ranger,presenting the award to Ben McCarty.

CASS 2004 came to a successful close in Torontoon April 21, where nearly 400 delegates fromindustry and government participated. Delegatesattended a very strong workshop program on dayone, followed by one and a half days ofpresentations in plenary, by industryexperts, on aviation safety and riskmanagement topics. The emphasisthroughout was placed on thecontinuing path towards theimplementation of safety managementsystems (SMS). Several question andanswer sessions allowed participants todiscuss issues directly with guest speakers.

Dr. Scott Shappell, Manager of the HumanFactors Branch of the Civil Aerospace MedicalInstitute of the Federal Aviation Administration (FAA),demonstrated HFACS (Human Factors Analysisand Classification System), which emphasizes theimportance of addressing human factors inoccurrence investigation, and the associated linksin establishing accident intervention strategies. Healso made an excellent point about the necessity forindustry to acknowledge the importance of “generalaviation,” as it is likely to become the primarypipeline for future commercial pilots, in comparisonwith past generations where the military route wasmore prevalent.

Captain Michael R. DiLollo, Director of FlightSafety at Air Transat, presented the SMS in placeat his company. He demonstrated that once acompany understands and buys into the SMS

concepts and principles, there is no need to waituntil it becomes mandatory. In support of

the argument that aviation safety is aninvestment into “cost-avoidance,” heshowed how his company, throughtheir SMS, was actually able tomeasure avoided costs and improve

safety. Captain DiLollo was unequivocalon how his company has bought into SMS

early and now reaps the benefits of havingimplemented it.

CASS has been praised again by industry as oneof the best aviation safety conferences in Canada.Since CASS 1998, coincidentally also in Toronto,the program’s quality and value for the industryhave been very strong and have improved fromyear to year. Despite its successes in recent years,however, CASS was still under represented in keyareas: chief executive officers (CEO), aerodromeoperators and air navigation service providers.Many aviation CEOs in Canada were passing onthe event, sending middle managers and line staff,as the perception may have been that the“executive” value was not considered sufficient.

ASL 3/2004 5

This led to the creation of the Canadian AviationExecutives’ Safety Network (CAESN), whichconsists of a full day of dialogue between Canadianaviation executives and key decision makers. Theinaugural CAESN meeting was held in April 2003in Montreal, concurrently with CASS 2003, andwas repeated this year in Toronto. Gathering theindustry leaders for a productive annual meetingwhile getting them to CASS at the same time wasquite a feat! Read more about CAESN on our Website at: www.tc.gc.ca/CivilAviation/SystemSafety/CAESN/menu.htm.Call for Papers—CASS 2005: Aviation RiskManagement in the 21st Century

CASS 2005 will take place April 18–20, 2005, atthe Fairmont Hotel Vancouver, in Vancouver,British Columbia. The theme of CASS 2005 is“Aviation Risk Management in the 21st Century,”

where current and future approaches to riskmanagement in aviation will be explored. A cross-section of high-profile speakers from aviation andother sectors, as well as from government andacademia, will be called upon to provide, in plenary,their insights into which approaches work bestunder which specific circumstances. Building onthis theme, a series of workshops will be offered tohelp aviation companies manage risks.

Submission Form: If you wish to present a paperat CASS 2005, please complete the instructionsfound at www.tc.gc.ca/CASS. Abstracts must besubmitted by Monday, August 23, 2004. Papers willbe selected on the basis of content and applicability.Written papers and formal presentations are dueon Monday, February 21, 2005. For moreinformation, e-mail: ssinfo@tc.gc.ca.

TSB Final Report A02P0136—AircraftStalls on Takeoff

On July 1, 2002, a rented Cessna 172N wastaking off from Boundary Bay Airport, BritishColumbia, at 12:14 Pacific Daylight Time (PDT),with the pilot and three passengers on board, for alocal pleasure flight. The takeoff on Runway 25appeared to be normal until the main wheels leftthe ground, whereupon the nose rose to a very steepattitude. The aircraft climbed to an estimatedheight of 100 to 150 ft, the right wing dropped, thenthe left wing, then the right wing again, and theaircraft struck the runway nose down and rightwing low. A fire broke out in the area of the leftcowling, fed by a broken fuel line from the left fuel

tank, but was quickly extinguished by bystanderswith portable fire extinguishers. Two passengerswere fatally injured, the pilot sustained seriousinjuries, and the third passenger died in hospitalthe next day. The aircraft was destroyed.

Findings as to causes and contributing factors 1. The elevator trim tab was set halfway between

the neutral (take-off) position and full nose-up onthe cockpit indicator, which resulted in a verystrong nose-up pitching moment at lift off,causing the aircraft to stall aerodynamically at aheight from which recovery was not possible.

2. The checklist used by the pilot contained nochallenge to verify the position of the elevatortrim tab before takeoff.

3. The flaps were set inappropriately for theattempted takeoff, adding to the instability.

4. The aircraft was overweight at takeoff; it isunlikely a weight and balance calculation wascompleted prior to flight.

5. The aural stall warning mechanism wasdefective and probably did not activate when theaircraft stalled during the accident sequence.

6. The wrong flap selector plate for the particularCessna 172 model was installed around thecockpit flap lever, which limited flap extension toa maximum of 30°.

Recently Released TSB ReportsThe following summaries are extracted from Final Reports issued by the Transportation Safety Board ofCanada (TSB). They have been de-identified and include only the TSB’s synopsis and selected findings. Formore information contact the TSB or visit their Web site at www.tsb.gc.ca. —Ed.

6 ASL 3/2004

TSB Final Report A02C0072—RunwayExcursion

On April 16, 2002, a Swearingen SA226-TCMetro II was on a scheduled flight, underinstrument flight rules (IFR), fromSt. Theresa Point to Winnipeg, Manitoba, with twopilots and 13 passengers on board. The crew wasanticipating a visual approach to Runway 36 atWinnipeg International Airport but, because of con-flicting traffic, accepted vectors for the instrumentlanding system (ILS) approach to Runway 13. Atapproximately 19:08 Central Daylight Time (CDT),the aircraft landed to the right of the runwaycentreline, then drifted further right and departedthe runway surface, damaging a runway edge light,a taxiway edge light, and a runway identificationsign. It then travelled 1 150 ft through the infieldand came to rest near the intersection ofRunways 13/31 and 18/36. There were no reportedinjuries. The aircraft’s left engine (Garrett TPE 33)sustained damage from ingested mud andvegetation. The right wing, left wing, and fuselagewere damaged when the aircraft struck the edgelights and the runway identification sign. After theaircraft stopped, the crew shut down the enginesand advised the Winnipeg Airport air trafficcontroller of their position. The airport crash alarmwas activated and emergency response personnelresponded.

Findings as to causes and contributing factors 1. The aircraft landed during heavy precipitation on

a wet runway, and it likely hydroplaned,resulting in a loss of directional control andrunway excursion.

2. The aircraft was cleared, on short notice, for anapproach to a runway with a tailwind thatexceeded MANOPS guidelines for operations on awet runway, and was cleared to land with a cross-wind that approached the limit in those guidelines.

3. The crew continued with an instrument approachin rapidly deteriorating weather conditionscharacterized by heavy rain, low visibility, wind shear, turbulence, and tailwind andcrosswind components.

Safety action—After the occurrence, the operatoradded a crew resource management (CRM) segmentto its training program for Metro pilots.

TSB Final Report A02C0145—Collisionwith Water

On June 29, 2002, at approximately 14:10 Central Standard Time (CST), a Cessna A185F seaplane was taking off fromEngemann Lake, Saskatchewan, on a visual flightrules (VFR) flight to Thomson Lake, with a pilotand two passengers on board. The aircraft wasabout 10 to 15 ft above the water, established in awings-level, nose-up climb attitude, when the pilotglanced to the left. Before the pilot was able to lookback to the front, the aircraft struck the water,overturned, and began to sink. The pilot and front-seat passenger escaped from the sinking aircraftand survived. The second passenger, who was in theleft rear seat directly behind the pilot, sustainedserious injuries to the legs, chest, and head duringthe impact, did not escape from the aircraft, anddrowned. The aircraft was substantially damaged.The accident occurred during daytime visualmeteorological conditions (VMC).

Findings as to causes and contributing factors1. The horizontal stabilizer trim was set to a nose-

down setting, resulting in a need for the pilot tomaintain back pressure on the control column tohold a nose-up climb attitude.

2. The pilot most likely unintentionally relaxed thecontrol column back pressure after takeoff,causing the aircraft to pitch nose down andstrike the water.

Findings as to risk1. The eye bolt from the upper left forward float

strut attachment had a pre-impact fatigue crackgreater than 75% of the cross section of the eye bolt.

2. Injuries sustained by the rear seat passengerlikely prevented his escape from the sinkingaircraft. The risk of injury was increased becausethe seat was not equipped with a shoulderharness.

3. The pilot’s rest period the night before theaccident was less than the minimum required byeither the Canadian Aviation Regulations (CARs)or the company operations manual.

ASL 3/2004 7

Fibreglass has been used in amateur-built aircraft for over forty years. Since theearly 1980s, with the advent of modern air-craft designs such as the Vari EZ, Long EZ,the Cozy, the Velocity, the Glassair, theSeawind and many others, the use of fibre-glass has become quite common. It is a com-posite material that is light, strong,somewhat flexible and can be shaped intomany useful aircraft structures. It is madeof two or more components: glass fibre(glass fibre reinforced plastic—GRP) and anepoxy or polyester resin. A catalyst is usedto create the chemical reaction that willbond the two parts. Over time, compositeparts are affected by cyclic variations intemperatures, weathering, rain, snow, mois-ture absorption, ultraviolet (UV) radiation andother factors. The initial methods and care of fabri-cation will influence the longevity of the part. Manybelieve that composite parts are free frommaintenance, but this is not the case. Here are twostories that recount the importance of having aninspection schedule for these parts in order toensure continuing airworthiness.

The amphibious amateur-built aircraft was madeof fibreglass and had been sitting at a local airportfor several years, when it was put up for sale. Anaircraft mechanic purchased it, inspected the struc-ture as best he could, made repairs, and put it upfor re-sale. He soon found a buyer who was hopingthat the amphibious abilities of the aircraft wouldallow him to fly from his home airport to the numer-ous good fishing spots that abounded in thenorthern region of Canada, where he lived. The air-craft was ferried successfully to the new owner’shome-base where an inspection was carried out andthe transaction completed. The new owner wasgiven flight instructions and later went off by him-self to do a fly-by. During this flight, one of thewings failed and the aircraft plummeted to theground, killing him. Investigation by theTransportation Safety Board (TSB) revealed thatone of the wing’s integral fibreglass fuel tanks haddelaminated and allowed fuel to seep through andweaken the wing spar to a point where failureoccurred. This construction flaw had gone unnoticedfor some time and the wing deteriorated and failed.

In another instance, two pilots were ferrying anamateur-built aircraft from their home strip to anearby airport. The aircraft was of a design thathad been around for over twenty years. The cabinand fuel cells were made of fibreglass and the wingswere made of metal. Fifteen minutes into the flight,the engine failed and a forced landing was initiatedon a provincial highway. There would not have beenany damage if oncoming traffic had not compelledthe pilot to veer off into a four-foot ditch.Fortunately, there were no casualties. In order totransport the aircraft, the wings were disassembledand it was noted that the cabin header tank was empty.A check of the fuel line of the wing tanks revealedthat it was blocked. Blockage was found to be due tofibreglass debris in one of the fuel tanks. A ventpipe was also found blocked by a nest of mud wasps.

Fibreglass parts need care in order to ensure con-tinued airworthiness in service. Your inspectionschedule has to take into consideration thesecomposite parts and if you are unsure of how to pro-ceed, communicate with a licensed aircraft mainte-nance engineer (AME) for assistance. Be especiallycareful with fuel cells, which are an integral part ofa wing structure, as wings flex and may increasethe risk of delamination. Commercial airlinerstoday are proof that the use of composites is verysafe. They can represent up to 30% of the totalweight of a commercial airliner. In helicopters, theyrepresent 60–80% and in today’s fighter aircraft,close to 50%. It is a very efficient material, but itneeds care too. Inspect and repair, as necessary.Happy flight.

Fibreglass in Amateur-built and Ultralight Aircraft

Recreational AviationSerge Beauchamp, Section Editor (E-mail: beauchs@tc.gc.ca)

8 ASL 3/2004

Jelly in the Fuel Filter Causes Engine Failures The owner of a Challenger ultralight aircraft had

used over 6 400 litres of a 50:1 mixture of Shell GoldPremium fuel and Quaker State TC W3 oil, withouta problem. In January, he decided to use a new fuelmixture using synthetic instead of mineral oil in hisRotax 503 DCDI engine (dual carburetor and dualignition). Immediately following this change, heexperienced the first of several in-flight engine fail-ures caused by fuel starvation. Inspection of the fuelfilter revealed a gold coloured jelly-like substanceblocking the screen of the Kimpex 07-245 filter. Thisprevented the fuel from reaching the carburetors.Fortunately, the engine failures did not result in aforced landing because the aircraft was equippedwith a parallel electrical fuel delivery system thatthe pilot activated to restart his engine.

In subsequent flights, it was necessary to replacethe filter four times because of repeated contamina-tion by the jelly-like amber coloured substance. Henoted that it was of a colour similar to the syntheticoil that he was using. In order to find the cause ofthis chemical substance, the pilot decided to do someexperimenting on the ground. First, he had todetermine that it would occur, so he set-up a 25-L Jerrycan of a 50:1 mixture of new fuel and oilidentical to the one he used in flight. He installed aKimpex filter and a length of clear 5/16-in. fuel linebetween another similar container. He transferredthe mixture from one container to the other, using a2-5 psi pump, in temperatures similar to those heencountered in flight; approximately -20°C. Heobtained the same results, a significant presence ofan amber-coloured goo or slime in the filter screen.He repeated the experiment several times. The

manufacturer wasasked to proceedwith similar tests,but has beenunable toreproduce thesame results. Thefuel filter blockageonly occurredwhen the pilotswitched from a mixture of fuel and mineral oil toone with synthetic oil.

Fuel suppliers modify the chemical constituentsof their fuel from time to time to take into accountthe seasonal temperature fluctuations, regional useand the various octane-rating environmental factorrequirements. Chemicals vary from one fuel andengine oil manufacturer to the next. The use ofdifferent fuel and oil may change the performance ofyour engine. In this case, the engine kept runninguntil fuel flow to the carburetors stopped. The chem-ical reaction creating the substance seemed to havebeen occurring inside the fuel filter; morespecifically within the fuel filter element walls. Thefiltering element itself seemed to have served as acatalyst. This is purely hypothetical, however, as wedo not know the cause at this time.

As an aircraft owner, your responsibility is toensure that the fuel and oil you use is of a typerecommended and approved by your aircraft enginemanufacturer. If any of you have experiencedsimilar situations, we would like to hear from you.Please e-mail me at beauchs@tc.gc.ca. Thank you.

Improving Stall and Spin AwarenessGeneral Aviation Advisory Circular (GAAC) 2003-04 was released on November 20, 2003 and its purpose

is to advise flight instructors of the amendment to Stall/Spin Awareness Guidance Notes—TP 13747E. It isalso intended to remind pilots of the importance of adhering to procedures for the spin manoeuvrerecommended by manufacturers of training aircraft and Transport Canada.

Stall/Spin Awareness Guidance Notes—TP 13747E, 2nd Edition, revised October 2003, is a reference tohelp flight instructors teach stalls and spins as outlined in the Flight Training Manual (FTM) and theFlight Instructor Guide (FIG). The document encourages scenario-based training and includes advice toinstructors to improve the learning of these exercises. The minimum altitude for spin recovery in Canada is2 000 ft above ground level (AGL) or a height recommended by the manufacturer, whichever is greater.

Canadian Aviation Regulation (CAR) 602.27 states: “No person operating an aircraft shall conductaerobatic manoeuvres […](d) below 2,000 feet AGL, except in accordance with a special flight operationscertificate issued pursuant to section 603.02 or 603.67.” Some training aircraft manufacturers have putforward conditional recommendations that suggest recovery at altitudes higher than those required byregulation. The majority of manufacturer’s manuals are silent on the issue of spin entry altitudes.

Pilots are therefore reminded that selecting a safe spin entry altitude is the responsibility of the pilot-in-command (PIC). The entry altitude is not governed by regulation, but pilots must make this determinationsafely with the full knowledge of the aircraft capabilities under existing conditions of aircraft configuration,pilot skill and meteorological and human factors. Keeping always within the requirements of the pilotoperating handbook (POH) or aircraft flight manual (AFM) and CAR 602.27, flight training unit (FTU) oper-ators and flight instructors are encouraged to adopt and communicate procedures outlining the conduct ofthe spin exercise best suited for their aircraft, pilots and geographical location. To read this GAAC in full, goto www.tc.gc.ca/CivilAviation/general/circulars/menu.htm.

ASL 3/2004 9

Taken from TSB and CADORS Files

The following excerpts are extracted from reportsmade available by the Transportation Safety Boardof Canada (TSB) and the Canadian Aviation DailyOccurrence Reporting System (CADORS). Mostoccurred in 2002 and are reproduced here torespond to the need for ultralight and amateur-builtaircraft pilots to familiarize themselves with thecauses of accidents. The types of accidents reportedhere are by no means solely restricted to amateur-built or ultralight aircraft.

Pre-flight inspection should cover all of themajor components: The pilot of an ARV-1 GoldenHawk ultralight aircraft reported that he was taxi-ing for takeoff and was provided with a remote air-port advisory. A few minutes later, when queried bythe controller as to his position, he reported that hehad had an incident and that the aircraft had beendamaged. During the take-off run the pilot lost con-trol in wind and gust conditions reported at 15 to20 kt. Investigation revealed that the landing gearhad failed when it became loose and was displaced,causing a pivoting moment that led to the loss ofcontrol. When control was lost, the aircraft exitedthe runway and incurred damages to the landinggear, propeller and the wings. The landing gear hadnot been secured to the structure properly and hadfailed due to wear. Give your best during the pre-flight inspection. You never know when you willfind that a major part is unairworthy.

Know your aircraft’s limits of operations:The pilot of a C.A.D.I. ultralight aircraft was flyingcircuits when he encountered crosswind conditionsthat exceeded his ability to control the aircraft dur-ing the landing sequence. The wind was at 7 to 8 ktwith gusts at 40 to 60° to the landing path. The air-craft swung to the left upon touching down, nosedover and was substantially damaged. The pilot sus-tained minor injuries. The failure to control an air-craft during landing accounts for a high percentageof accidents, especially in tail-wheel equippedaircraft. Adequate training and practice are theonly solutions to ensure safe landings under cross-wind conditions. In a similar occurrence, a pilotflying a Junior JK-05 advanced ultralight wasdoing circuits when he lost control on landing. Theaircraft veered off the runway, into the grass areaand sustained extensive damage. There were noinjuries.

Foreign object damage (FOD) causesmishap: The pilot of a float-equipped Quad CityChallenger II ultralight aircraft was on finalapproach to land when he found the controlsdifficult to operate. As he reached an altitude ofapproximately 200 ft above the water, the controlsfroze and he could not move them. The aircraft sud-denly pitched forward and the tips of the floats

struck the water and the aircraft flipped over. Thepilot received minor injuries but the aircraft washeavily damaged. It is reported that a life jacketmay have moved under the control mechanismduring flight, jamming it and causing the crash.Always secure all equipment on board your aircraft.

Steep turns at low altitude are verydangerous: The pilot of a Nordic V ultralightaircraft was seen performing tight turns at low alti-tude. During a pull-up, followed by a steep turn, theaircraft stalled and fell to the ground. The pilot wasfatally injured. Steep turns at low altitude shouldnot be executed, as a stall can occur at a time whenthere is no room allowing for a safe recovery. Thismanoeuvre requires altitude and if it is insufficientwhen a stall occurs, disaster is likely to follow.

Wearing a shoulder harness can be ablessing: The pilot of a Quad City Challenger IIultralight aircraft was simulating a forced landingwhen the aircraft struck power lines, nosed overand crashed in a field. The pilot received seriousinjuries but the passenger was more fortunate andsuffered only minor ones. They were both wearingthe 4-point harness-type safety belt and it savedthe day. The aircraft was substantially damaged.

Structural failure in flight leads to crash:The pilot and a passenger of a Bushmaster DM-3ultra-light aircraft lost their lives when theairplane they were travelling in crashed into a field,following the loss of an aileron in flight. Anobserver on the ground saw a part fly off theaircraft before it impacted the ground. Structuralfailures are rare and can be eliminated throughcareful maintenance and inspections, including theapplication of sound pre-flight inspection principlesand by limiting the parameters of operations tothose prescribed by the manufacturer of theaircraft. Keep tabs of all maintenance carried outon your aircraft, as it constitutes a very inexpensiveinsurance policy that your family will appreciate.Knowing the time in service of major aircraft parts,as well as the date and name of the person who per-formed the last inspection on your aircraft will con-firm that the maintenance schedule is indeed satis-fied and that your aircraft is airworthy.

A stitch in time saves nine: The pilot of aBushmaster ultralight aircraft was seriouslyinjured when the aircraft sustained wing damagefollowing an encounter with turbulence. As the pilotwas making a precautionary approach to land, heobserved that the stitching on the left wing wascoming undone. The aircraft rocked from side toside and then spiralled to the ground. The wing hadinflated to a point where the drag exceeded thethrust. Careful maintenance and inspection willhelp reduce the risk of failure and ensure safe flight.

10 ASL 3/2004

Back in the 1970s, I used to rent a club aircraftthat had a sticker on its instrument panel. Inorange letters it said, It is Dumb to Run Out of Gas.There must have been a good reason for the club tohave put that sticker there.

Every year, at least a few pilots fail to make it totheir planned destination because they simply runout of fuel. Some of these aircraft make precaution-ary landings at other aerodromes, which is a goodchoice, while others end up in the trees, sometimesonly a few miles short of destination.

Very few of these accidents seem to involve IFRaircraft, and almost none involve helicopters. Mostof the accidents in this category involve VFR airplanes.

The rules for VFR airplanes are pretty straight-forward. Canadian Aviation Regulation (CAR)602.88 requires the pilot to start the flight with afuel reserve of at least 30 minutes at normal cruisein the daytime, and 45 minutes if landing afterdark. It also says that you can’t change destinationsin flight, unless you can still make thatrequirement. That CAR also says that you need toaccount for “taxiing and foreseeable delays prior totake-off,” “meteorological conditions” (includingwinds), “foreseeable air traffic routings and trafficdelays” and “any other foreseeable conditions thatcould delay the landing of the aircraft.” Despite therules covering just about every possible reason fordoing so, they do not prevent people from runningout of gas.

There seem to be many reasons for running outof fuel, but there are some consistent traps that canbe avoided. One of these is that many light aircraftfuel gauges are famous for not being accurateenough to be relied upon. Quite simply, if you use

light airplane fuel gauges alone to tell you whetheryou will make it to destination, you will run out ofgas sooner or later.

One of the reasons that ultralights seem to beinvolved in very few fuel exhaustion accidents isthat many of them have transparent fuel tanks thatallow the pilot to see how much gas they have leftwhile in flight.

Few certified aircraft offer that ability to actuallysee the amount of gas that is left. That means thatthe quantity has to be verified, usually by dipstick,before flight and then the clock used as the bestindication of how much fuel is left.

Perhaps interpreting the rules themselves bringssome pilots to grief. Most pilots will tell you thatthe CARs require “Fuel for destination plus 30 min-utes by day.” Actually, the CARs require you tocarry fuel to get to destination, account for all possi-ble changes in wind, weather, air traffic control (ATC)clearances and “any other foreseeable conditionsthat could delay the landing of the aircraft” andthen “plus 30 minutes” of fuel in daytime. Justcarrying “destination plus 30 minutes” is notenough fuel to be safe every time.

Many prudent light airplane pilots add an auto-matic reserve of at least one hour. That means withfive hours of gas on board (and verified by dipstick),the trip, including possible winds and other delays,cannot add up to more than four hours. If it does,you need an intermediate stop.

By always physically verifying the amount of fuelon board (“dipping the tanks”), and never planningto use the last hour of gas on board, many fuelexhaustion accidents can be avoided.

COPA Corner—How Much Gas Is Enough?by Adam Hunt, Canadian Owners and Pilots Association (COPA)

Pre-take-off check is very important: Thepilot of a Tierra II ultralight aircraft was on thetake-off run when suddenly the left door becameunlatched. The aircraft veered to the left andcrashed adjacent to the runway. There were noinjuries but the ultralight was substantiallydamaged. The pilot declared that he forgot toensure that the door was properly latched beforeproceeding for takeoff. A checklist of items to verifyduring pre-flight, pre-start, pre-take-off and otherphases of flight should be part of the aircraft’sequipment and be used to ensure that all necessarychecks are carried out in the proper sequence. Thiswill certainly help reduce the risks of an accident.

Pre-take-off checklist should include thesafety harness: The pilot of a powered parachuteAdventure F2Q found himself at the end of his ropewhen, shortly after takeoff, he observed the harnessstraps, which were holding him to the craft, were

coming undone. He immediately turned around andproceeded to land downwind, hanging on for dearlife by the parachute lanyards. Control of the craftwas very limited but nevertheless he was able toland. He suffered serious injury and the craftsustained significant damage. A pre-flight check ofall the equipment would have reduced the risk ofsuch an accident.

Pre-landing checklist can save the day: Thepilot of an amphibious Challenger IIA ultralightaircraft had departed from a grass strip for a localflight. As he approached the lake for a water landing,the movement of motorboats along the intendedlanding path diverted his attention and he mayhave failed to check the position of the landing gear.As a result, the aircraft hit the water with the geardown and sustained serious damaged to the wingsand structure, but remained upright. No one washurt. Pre-landing checks are a must.

ASL 3/2004 11

To celebrate the millennium, ATAC established anannual award series to better profile and applaudinnovation and professionalism within commercialgeneral aviation and flight training. Past winnersinclude: Coastal Pacific Aviation, for pioneering part-nered diploma training; Moncton Flight College, forits integrated instructor training; Toronto Airways,for innovative partnering on simulation with FlyingColours; Harv’s Air Service, for developing onlineground school and marketing applications; and leCentre Québecois de Formation Aéronautique, fordeveloping online advanced training systems.

The Human Resources Study of Commercial Pilotsin Canada, released in 2001, recognized the value ofpositive initiatives to support good efforts. There is acadre of professional aviation business people andinstructors in Canada, whose dedication has had apositive influence on society in Canada, and thesecommitted individuals deserve to be recognized. TheInnovation Awards were renamed the “ATACPresident Awards” in 2002, and are given to acompany or individual that has been recognized as aleader in improving instructional techniques withintheir training facilities, or has developed a supportprogram for their instructing staff that improves

overall system safety. Examples of this recognitioninclude Dennis Cooper of Sky Wings Aviation, fordeveloping outreach programs that promote aviationto public schools, and Tom Lawson of EmpireAviation, for incorporating ISO 9001 standards forflight training.

The “David Charles Abramson MemorialFlight Instructor Safety Award” was introducedat the 2003 ATAC Annual General Meeting inQuébec City. It recognizes a flight instructor whohas made a significant contribution to aviationsafety in Canada. This award was established by theAbramson family to honour the memory of their sonwho was a truly dedicated flight instructor, and whogave greatly to others in life. To qualify for thisaward, the applicant must possess superior teachingskills, outstanding leadership qualities, and demon-strate an unusually high level of performancethrough their accomplishments and devotion for theadvancement of aviation safety. The 2003 inauguralrecipient is Mr. Aaron Speer who instructs atOttawa Aviation Services.

For more information on ATAC Awards and thenomination process, please contact ATAC at613 233-7727 ext. 309 or e-mail glennp@atac.ca.

ATAC Recognition Awardsby Glenn Priestley, Vice-President, Fixed Wing Air Taxi and Flight Training, Air Transport Association ofCanada (ATAC)

“Highly recommended reading,” that’s what theauthor of an article in issue 2/97 of the AviationSafety Letter (ASL) had to say about theMeteorological Service of Canada’s (MSC) publicationcalled Aviation Weather Hazards of British Columbiaand the Yukon. Therefore, it is fitting that when MSCwas approached by NAV CANADA to document andpublish local aviation weather across the country,they used this publication as a model.

When NAV CANADA announced a new approachto delivering aviation weather briefings by central-izing flight-briefing services, one of the users’ con-cerns was the possible loss of local area knowledge.To ensure that this type of information was system-atically captured and retained, NAV CANADAstarted the Local Area Knowledge Project (LAKP)and contracted the MSC to produce a series ofweather manuals to document this local knowledge.A series of six manuals have been published, eachcorresponding to a specific graphic area forecast(GFA) domain, with the exception of The Weather of Nunavut and the Arctic, which covers two GFA domains.

The most critical component to the project wasthe interview process. To conduct these interviews,MSC meteorologists traveled across the countryand sat down with pilots and other aviation profes-sionals to discuss local weather. The meteorologistswould ask the pilots to indicate where they wouldroutinely encounter elements such as low cloud,restricted visibility, turbulence, icing, strong windsand other aviation weather hazards. Reference was

made to different seasons and various types of syn-optic situations. To supplement the forecasters’notes, pilots were urged to actually draw on naviga-tion charts to accurately show where hazards wereencountered. Although the main focus was“Seasonal Weather and Local Effects,” several otherinteresting sections were added to supplement themanual, including “Basics of Meteorology,”“Aviation Weather Hazards,” “Weather Patterns,”and “Airport Climatology.”

Here is an excerpt from The Weather of AtlanticCanada and Eastern Quebec: “Cape Breton oftenexperiences some of the worst turbulenceencountered in the Maritime Provinces. […]Southeast winds ahead of low pressure systems willbe quite violent here, due to mountain waves. […]They occur near Chéticamp and extend out to about3 miles from the mountain peak. Here severeturbulence, downdrafts […] and wind speeds asmuch as double those of surrounding areas can beexpected. The downdrafts on the northwest side ofthe mountains will hit the water and flow outward,much like microbursts, producing patterns on thewater that are readily seen from the air. Localpilots call these patterns “cat tracks” or “cat paws”.”

The production of these aviation weathermanuals should prove to be beneficial to pilots,flight service specialists, meteorologists, and flightdispatchers alike. They can be downloaded free ofcharge from the NAV CANADA Web site atwww.navcanada.ca, under flight planning, local area weather manuals.

Local Area Weather Manualsby Bob Robichaud, Meteorological Service of Canada

12 ASL 3/2004

Understanding spatial disorientation and thehuman frailties that contribute to this seductivesiren are essential to a pilot’s longevity. Threesenses interact to keep us upright, feet firmlyplanted on terra firma: vision, proprioception(pressure sensing organs in the skin and joints),and vestibular (balance apparatus in the inner earcalled the semicircular canals). Once airborne, therules change dramatically with the two falliblesenses, proprioception and vestibular, beingnegated. Vision rules supreme as the only reliableorientation sense once the aircraft abandons theearth’s surface. Remove the natural horizon, ignoreattitude instruments and your lifespan is reducedto an average of three terror-filled minutes!

There are certain natural phenomena and e-mergency situations that may deprive a pilot oftheir vision. The brilliance of the low setting suncan temporarily blind a pilot as they flare to land.A windscreen covered with ice or oil from a failedengine can severely restrict visibility. Smoke in thecockpit can have serious consequences. Even sweatand suntan lotion can lead to temporary visualloss. A direct bird strike on the windscreen canresult in catastrophic visual impairment withplexiglass fragments, blood and feathers. Visionand aircraft control go hand in hand.

Pilots should be aware that spatialdisorientation may occur in three distinct forms—each just as seductive and deadly. Unrecognizedspatial disorientation (Type I) describes a situationwherein the pilot is disoriented, but is unaware andcontrols the aircraft using false sensoryinformation. This may occur in visual or instrumentconditions. Visual illusions are the most commonfactor contributing to Type I accidents. The pilotmisinterprets what the eyes see, often with deadlyconsequences. Many of us have experienced visualillusions in our automobiles, such as jamming thebrakes at an intersection as our vehicle starts toroll backward. The reality is the adjacent car isedging forward. Our interpretation and reaction arein error. In a carwash, the sensation is one of astationary vehicle and moving brushes, when thereverse is true.

Visual illusions encountered in flight deservespecial consideration to increase awareness andavoidance. Heavy rain causes light refraction. Thiscan lead to approaching obstacles appearing lowerthan they actually are. The potential risk is acontrolled flight into terrain (CFIT) accident orundershooting the approach in a heavy rain shower.Night flying has its perks, but the risk ofdisorientation with these illusions is much greater.

Float flying can be a risky business, and one ofthe reasons for this is the alluring tranquillity of

glassy water conditions. Float planes frequentlyapproach to land, fail to flare, dig a float or the noseand flip inverted. The reason is spatialdisorientation due to visual illusion. If you haveever walked nose-first into a spotless plate glassdoor or window, you have experienced the shockand unpredictability of glassy water.

Under certain conditions of diverse lightrefraction and terrain absorption, IFR conditionsprevail even though ceiling and visibilities are wellin the VFR domain. The result is an indiscerniblehorizon and/or lack of ground shadows or contrast,known as whiteout. Accidents are often of the CFITvariety, and can involve highly experienced crews.

Type II, or recognized spatial disorientation, iswhen the pilot is disoriented and aware of the fact,but for reason of lack of instrument proficiency orvestibular (inner ear) or proprioceptive (seat of thepants) illusions, is unable to believe the attitudeinstruments. Once in instrument conditions, theVFR pilot does not have the training or discipline tocope with loss of the natural horizon, and smoothtransition to instrument flight is most unlikely.

Acceleration without monitoring the attitudeinstruments gives an illusion of the nose pitchingup. The pilot compensates by pitching the nosedown, a very dangerous reaction when taking off ona dark featureless night. The end result can be anaircraft impacting terrain on takeoff for noapparent reason. With deceleration, the process isreversed with the illusion of the nose pitching downand the pilot reacting by raising the nose of analready slowing aircraft; a setup for a stall and spinin instrument meteorological conditions (IMC).

Type III spatial disorientation, or vestibulo-ocular disorganization, is fortunately a rarevariation. In this type, the pilot is aware of thedisorientation, but is unable to control the aircraftbecause reflex eye movements prevent instrument

I Have Seen The Eyes of Death—Part 2by Dr. John Albrecht. Continued from “I Have Seen The Eyes of Death—Part 1,” published in AviationSafety Letter 2/2004.

Example of sector whiteout conditions.

ASL 3/2004 13

interpretation. Chances of survival are remote. Thesensations of this type can be mimicked by rollingdown a grassy hill. The resulting intense vertigo(spinning) makes walking a straight lineimpossible. Controlling an aircraft would be out ofthe question!

Type III spatial disorientation can also beinduced by the pilot in-flight. This condition iscalled the coriolis effect. It results from simultaneousstimulation of two or more of the semicircularcanals in the inner ear. This can occur in IMC whenthe pilot initiates a turn and simultaneously looksup or down with head movement. The stimuli to thebrain are overpowering and produce a tumblingsensation. Rapid reflex movements of the eyes(nystagmus) make instrument interpretation andaircraft control impossible. Prevention comes with adisciplined instrument scan—eye movement only.By holding the head still, only one set of semicircu-lar canals is stimulated by the rolling movement ofthe aircraft. Vertigo and nystagmus are averted.

It is quite possible that more than one type ofdisorientation come into play in an accident. A pilotsuffering from unrecognized spatial disorientation(Type I) may receive an altitude alert from avigilant air traffic controller. Distraction or fixationmay result in progression to recognized (Type II)disorientation as instrument skill deteriorates.Over-controlling the aircraft and sudden headmovement in search for the elusive runwayenvironment may induce the coriolis effect (Type III). The odds of survival in this escalatingscenario would be close to nil!

Several factors can contribute to the likelihood ofa pilot becoming spatially disoriented. There isusually an element of surprise and unpreparednessas the VFR pilot stumbles into instrumentconditions. Anxiety can rapidly escalate to a panicstate when the outside world disappears. Withpanic goes any semblance of problem solving, whichis key to survival.

VFR flight into IMC having such a high fatalityrate, insight, avoidance and prevention are key tolongevity in aviation as a recreational pastime orcareer. Weather smarts, with sound decisionmaking, in the go/no go scenario are criticalsurvival tools. A VFR pilot receiving a briefing ofmarginal VFR or IFR conditions for the intendedroute, or an en-route update of unforecast deteriora-tion at destination, is well advised to stay on theground or press plan B into action.

“Get-home-itis” is a term that often comes intoplay with spatial disorientation accidents. It refersto the psychological pressure perceived by the pilot,whenever there is a seemingly urgent need tocomplete a flight for personal or business reasons.The next link in the accident chain is thisstatement: “Let’s take off and have a look, we can

always come back to the airport.” Once airborne,IMC may be encountered in the climb out and thesafe sanctuary of the departure runway vanishes.

When I obtained my private pilot’s licence,instrument flying was not included in the syllabus.Now it is, as well as with the night rating and com-mercial licence. This experience provides the pilotwith the ability to fly straight and level, recoverfrom unusual attitudes, turn 180° and perhaps pen-etrate a thin cloud layer—that’s it! This skill ismaximal at the time of the flight test and rapidlydeteriorates thereafter if not practiced.

A current instrument rating is good insuranceagainst a disorientation accident, but not a guaran-tee. Several scenarios come to mind of IFR driverscoming to grief. A typical example is a non-precisionapproach with circling procedure. During the circleto land, visual reference is lost but the pilot pusheson in low-level IMC rather than carrying out themissed approach procedure. On an IFR flight test,there are several critical safety checks which, ifomitted, will result in automatic failure. In the real world of IMC, similar omissions can have dire consequences!

During my years as an Aviation MedicalExaminer, I have heard some fascinating anecdotes.One private pilot en route to Tofino, BritishColumbia, inadvertently entered a band of cumulusclouds near Nanaimo, B.C. After a roller-coasterride of terror lasting close to 45 min, he and hispassengers were spit out near Courtenay, B.C., alittle older and infinitely wiser!

The real champion was a student pilot flying outof Bellingham, Washington. He was climbing out ona solo VFR flight to Oregon. Just above circuitaltitude, he entered cloud. Aware of the risk ofadjacent hills, he elected to climb. At 4 000 ft, hebroke out into brilliant sunshine, in an extremebanked attitude. After regaining control and hiscomposure, he notified Bellingham Tower of hispredicament. Cloud below as far as the eye couldsee! After orbiting for several minutes, he washanded off to Vancouver air traffic control (ATC). Acalm voice provided radar vectors northward alongthe invisible coastline. At a break in the cloud, hetransmitted his intention to descend, but wasadvised against this by ATC, as airliners were pass-ing below cloaked in cloud. Eventually, he wasguided to a cloud break over the Strait of Georgiaand authorized to shuttle down below the overcast.He then navigated VFR back to Bellingham for anuneventful landing. Survival is possible, asdemonstrated by this fortunate young pilot. He dideverything right and did not lose control of hisaircraft, despite a prolonged climb in totalinstrument conditions.

Readers interested in the full, unedited version ofDr. Albrecht’s article can e-mail the editor. —Ed.

14 ASL 3/2004

Transport Canada was recently apprised offrequent occurrences in the Pacific and AtlanticRegions concerning transborder flights without aflight plan being filed or activated.

Regulatory requirements are specific. CanadianAviation Regulation (CAR) 602.73(4) reads:“Notwithstanding anything in this Division, no pilot-in-command shall, unless a flight plan has been filed,operate an aircraft between Canada and a foreignstate.” U.S. Federal Aviation Regulation (FAR) 91.707reads: “Unless otherwise authorized by ATC, no per-son may operate a civil aircraft between Mexico orCanada and the United States without filing an IFRor VFR flight plan, as appropriate.”

Three additional sources offer various levels ofhands-on information on the topic: the AeronauticalInformation Publication Canada (A.I.P. Canada), theCanada Flight Supplement (CFS), and the FederalAviation Administration (FAA) International FlightInformation Manual. Here is a short summary oftheir content, and some of their shortcomings:- A.I.P. Canada RAC sections 3.6.1 to 3.6.4 specify

when a flight plan is required, how it can be filed,and the means by which it can be opened.References to appropriate CARs are listed.

- The CFS does include information on how to file aflight plan and how to file an arrival report, but nothow to open a flight plan.

- The FAA International Flight Information Manual,Flight Planning Notes section, provides specificinformation on the purpose of international flightplans, and the filing process. However, no informa-tion could be found concerning how to open and

close international flight plans. On the subject of flight plan requirements for

transborder flights, some 82 alleged violations wereregistered nationally over the past two years; about20 from the Atlantic Region, and the vast majorityfrom the Pacific Region. Possibly using differentsearch criteria, a Civil Aviation Daily OccurrenceReporting System (CADORS) search extracted 76similar occurrences between September 2000 andSeptember 2003. These flights had originated in theUnited States and at least 70% had landed withinthe Pacific Region. However, it is important to notethat in most cases, customs arrangements weremade for the flight. Therefore, it is fair to say a lackof awareness of transborder regulatory and/ortechnical (i.e. opening/closing) requirements seems toprevail in the general aviation community, andespecially so in the United States.

Occurrences are frequent enough, and do not yetshow an appreciable downward trend. Valuableenforcement resources are tied up investigating alarge number of cases while enforcing regulationsthat have a minimal impact on aviation safety(although the activation of an alerting service consti-tutes an important safety feature of a flight plan).

The aim of this article is to inform Canadian pilotsof this concern in order to cut down the number ofoccurrences of this type. However, since a largeproportion of these violations are committed byAmerican aircraft entering Canadian airspace,Transport Canada plans to communicate with itsFAA counterparts in order to disseminate thisimportant message to the American pilot population.

Transborder Flights Without a Flight Planby Michel Paré, Civil Aviation Safety Inspector, Regulatory Services, Transport Canada

When giving taxi clearance at a controlled airport,the ground controller often asks what the altitude inflight or the initial altitude in flight will be. Once inflight, and out of the area, the pilot will request, onoccasion, to change their cruising altitude.

The pilot may choose their VFR altitude, depend-ing on if they remain in the appropriate class ofairspace, notwithstanding the Canadian AviationRegulations (CARs).

The VFR pilot is responsible for choosing an appro-priate altitude for their flight. Air traffic control (ATC)may impose certain restrictions in certain airspaces,for example, in a control area. Example: “No higherthan…no lower than…” Specific altitudes will beassigned or approved in a class C airspace for improvedsafety, and to facilitate the exchange and flow of traffic.

Why does the controller want to know yourcruising altitude when you are taxiing? They reallywant to know your intentions so that they can plantheir traffic. If you would like to climb to 6 500 ft,they may anticipate a potential conflict with anaircraft arriving on landing. They could order thearriving aircraft to enter the control area at 3 000 ftor higher, and order you to not climb higher than2 500 ft in the area, until the two aircraft are able to

see each other, or until they have passed each other.However, if you would like to fly at only 1 500 ft, thecontroller’s strategy will surely be different.

In VFR flight, outside class C or D airspaces—that is to say in class E or G airspace—you do notrequire clearance, but must comply with visualflight rules and the CARs on cruising altitudes (seeCAR 602.34). However, if you would like to continuewith radar surveillance while it is still available,advise the controller of your changes in altitude, andremain on the frequency until you are advised thatthe radar surveillance is ending, or you advise thecontroller that you no longer require the service. Ithas happened in the past that a pilot calls the areacontrol centre (ACC) for radar surveillance and,after having been identified by the controller, leavesthe frequency without warning the controller, andnever calling back. In this case, the controller wastrying in vain to inform the pilot of traffic.

Once you are out of the control area and/or inclass C or D airspace, your altitude is at your discre-tion. It is the pilot’s responsibility, if not using radarsurveillance, to advise their intentions and changesin altitude on the appropriate frequencies.

VFR En-route Altitudeby Daniel Morissette. This article is an authorized translation of an article originally published in theJanuary-February 2004 issue of the magazine Aviation Québec.

to the letterPilots and WeatherDear Editor,

I am a dedicated ASL reader and the reason I amwriting is to express my concerns regarding inexpe-rienced pilots who choose to depart on a flight invery poor weather. I have experience as a searchand rescue (SAR) pilot, a flight safety officer, and aground school instructor. Accidents published in theASL seem to be primarily human-error related (typ-ically 80% at fault); however, weather also seems toplay a large role. While teaching ground school, Irealized that a significant percentage of pilots havea very poor grasp of weather theory, and also a poorability to decode the multitudes of weather charts,forecasts, etc. The biggest concern that I am seeing,however, is the inability of many pilots to take allthe weather data and make a meaningful mentalpicture of the weather along a proposed route. Forexample, how fronts and air masses affect stability,icing, turbulence, winds, etc. How are thesevariables accounted for in the graphic areaforecasts (GFA), aerodrome forecasts (TAF), etc?Are the METARs supporting the TAFs and GFAs?What would the weather be along the route of flightand at the proposed altitude? Where are the outs?

As a SAR pilot, I have been tasked to search for anumber of overdue aircraft. I was authorized tocarry out a search over land with weather limits of700 ft AGL and 1 SM visibility and over water in500 ft and 1 SM. These limits are quite low but wehad the benefit of multi-engine and automated air-craft, with a highly experienced crew. Why were myweather limits higher than the weather limits ofcertain pilots who have few hours of flightexperience, in a single-engine aircraft, and a poorgrasp of weather? Millions of dollars are spentsearching for overdue aircraft, in many casesbecause a pilot made a bad decision to fly inweather that was forecast to be below legal limitsor beyond their limits. Why are pilots taking this risk?

Most flying schools are teaching pilots to decodeGFAs, TAFs, and METARs, but in my opinion thisis not enough. Pilots need to understand the fore-cast weather as it would look multi-dimensionally,and that’s what I tried to impress upon them whenteaching weather. I then encouraged them to usesound pilot decision-making skills in making theirweather decisions. To improve weather knowledge,I believe Transport Canada should raise the barsignificantly in terms of weather knowledge, bothfor “ab initio” training and for re-currency.

If in-depth and permanent weather knowledgefor pilots is not universally addressed, we are likely

to keep spending millions searching for overdueaircraft that departed in poor weather. PerhapsNAV CANADA personnel should be given enforce-ment abilities to stop pilots from filing flight plansif the weather is below limits. Why can a flight ser-vice station (FSS) specialist brief a visual flightrules (VFR) rated pilot on the weather along a pro-posed route, which is known to be below visualmeteorological conditions (VMC), and also enter aVFR flight plan into the computer? The system hasno “teeth.” Is this occurring? Yes! It is depressing tothink that loss of life could be prevented time andtime again, if pilots only made better decisions. Ofcourse, millions of dollars of taxpayers’ moneywould also be saved.

Name withheld on request

Slow for Thunderstorms…Dear Editor,

Your letter is always interesting reading prior tothe joy of updating my A.I.P. Canada (AIP). Oneitem was evidently missed in your primer for thun-derstorms in the “Take Five” feature of ASL 3/2003.The most important action to take if one is unableto avoid flying into a cumulonimbus (CB) is to slowdown. This means to fly below the manoeuvring speedfor the airplane at its current loading. This requires a knowledge and understanding of Va [designmanoeuvring speed] and its implications. Also,lowering the gear in a retractable will help stabilizethe A/C [aircraft], although this action must beweighed against the additional surface for ice build-up if icing conditions exist. Having had a fewunplanned encounters myself with CBs, I wonder ifI would still be around if I had not applied theknowledge relative to Va? Pilots also need to bereminded that the placarded value for Va is forgross weight and that the speed diminishes forlower indicated airspeeds. Having given well over6 500 hr of instruction, I can state that Va is stillnot well understood amongst many pilots.

D.S. CowanKenmore, WA

Thank you D.S. The AIP, AIR section 2.7 coversinadvertent flight through thunderstorms quitenicely and indicates that you should set the powersettings for turbulence penetration airspeedrecommended in your aircraft manual. Somepublications do not use the term Va, as it isconsidered that understanding of the words“turbulence penetration airspeed” (shown in theaircraft manual) is more important at the earlystages of training than learning V speeds. —Ed.

ASL 3/2004 15

Erratum—ASL 2/2004An editorial mistake occurred in the article “When Things Aren’t...” on page 1 of ASL 2/2004. The third sentence

of paragraph 1, which ends with “...killing all onboard.” should have read “...killing 83 of the 179 on board.”

16 ASL 3/2004

Have you ever wondered whatwas in that FedEx® box whichremained unopened for fouryears by a normally zealous butnow stranded FedEx® manager,Chuck Noland (i.e. Tom Hanks),in the movie Castaway? Myguess has always been that itwas a new world-coveragesatellite phone with fullycharged batteries, user’s manualand a couple weeks worth ofgranola bars. If only...

Like other technologies,satellite phones have improved,are more accessible, more afford-able and more reliable. They arenot inexpensive by any means, but for the seriousflyers who like to venture far away from urbancenters, they provide phone coverage that astandard cellular phone can’t match.

A coroner’s inquiry into the crash of a Cessna 172near Fort Good Hope, Northwest Territories onDecember 31, 2001 (see ASL 4/2003, page 4) recom-mended that all pilots operating in the North andin remote areas carry satellite phones. Not allnorthern pilots may need to carry satellite phonesin all situations, but where communications arelimited, and in the event of an emergency, we doencourage the practice of carrying a satellite phoneor other means of communication that functionindependent of the aircraft’s electrical systems. TheJanuary-February 2004 issue of the magazine La Brousse had a very good article on this topic,where author and pilot Claude Laplante recountedthe time last summer when his investment into asatellite phone paid huge dividends. A a matter offact, it most assuredly saved his life and the life ofhis flying partner.

On August 17, 2003, Mr. Laplante and a friendwere flying in Northern Labrador in his Cessna 172on floats, exploring fjords and lakes, and planningto meet two more friends in a separate aircraft at arendez-vous point for a few days of camping andflying. Having arrived early at the rendez-vouspoint, Mr. Laplante and his friend decided to fly 10 to 12 mi. further north to Kangalaksiorvik Lake,to film known wildlife at that location. They landedsafely on the lake and spent a half-hour filmingseals and other wildlife. Unfortunately for them,the wind started to pick-up significantly, and thewaves were causing some serious handling difficul-ties. While attempting to manoeuvre the aircraftback into wind for departure, a float dug in, and invery short order, the aircraft had overturned inshallow water, giving them just enough time to exitand inflate their life jackets.

However, Mr. Laplante’s first reaction whileleaving the cabin was to ensure he had the sealedyellow plastic case, which held his satellite phone.The water depth was about 7 ft, so they were ableto sit on the inverted floats. The winds were strong,the water was cold and their clothes were wet,causing them to shiver seriously even though it wasAugust. Mr. Laplante did not lose a minute, andcalled for help. He first called a reliable friend toraise the alarm, and he followed immediately bycalling the Rescue Coordination Center (RCC), inTrenton, Ontario; a couple thousand miles away—direct dialed! He spoke to a French-speaking opera-tor at the RCC who assured him that his friend hadalready notified them and help was on the way. Arescue aircraft landed 4 hr later, within daylight,and they were flown to warmth and safety.

“What a relief to know that help is on the way,”Mr. Laplante would say later. With the aircraftunderwater, strong winds, very cold water andhypothermia looming, who knows how long it wouldtake for their friends to find them, if ever. Theywould later learn that their friends also had amishap earlier in the day and had not made therendez-vous point either… Mr. Laplante is quitesure that without his satellite phone, he and hisfriend would no longer be with us. His satellitephone is not for sale at any price.

This story is inspired by an original article byClaude Laplante, titled “Assurance-vie partéléphone satellite” (Satellite Phone Life Insurance)published in the January-February 2004 issue of La Brousse magazine. This adaptation is publishedwith permission. Private pilots and operators areencouraged to learn more about satellite phones byresearching this subject through reputable pilotsupplies shops, outdoors outfitters and on theInternet. —Ed.

One Phone Call Away

u qwewrtTransport TransportsCanada Canada

for safetyFive minutes readingcould save your life !

T KE E...Fi VACanada’s search and rescue (SAR)

crews are amongst the finest in theworld. Together, they save hundreds oflives each year in the difficult anddemanding role of rescuer.

An “UNSAR” is an unnecessarysearch and rescue alert. When our res-cuers respond to UNSARs from emergencylocator transmitters (ELT), personallocator beacons (PLB), and emergencyposition-indicating radio beacons (EPIRB),there is a cost to Canadian taxpayers;however, more importantly, rescue crewsare diverted away from real emergencieswhile endangering their own lives whenresponding to false alarms in difficultweather conditions. Fortunately, most ofthese false alarms can be avoided.Owners are strongly encouraged toensure their device is in good workingcondition and proper maintenance iscarried out to avoid inadvertenttransmission. Your emergency beaconshould be readily available andfunctioning properly when you reallyneed it—during an actual emergency! Some examples of UNSARs include:• Over 18 hours spent by CASARA and

Industry Canada inspectors locatingan Aeronca parked in a hangar. TheELT had been accidentally activated.

• 6.8 hours spent by a Canadian ForcesHercules aircraft in locating a heli-copter whose ELT was activated dur-ing maintenance.

• 4.2 hours of Canadian Forces time tolocate an ELT in a courier truck. TheELT had been shipped for maintenancearmed and with the batteries in place. To put the wasted resources into

perspective, approximate total operatingcosts for various military SAR aircraftrun anywhere from $3,000 to $5,000 per

hour and per aircraft type…no chumpchange by anyone’s standards. Of course,this does not include all the smallerCASARA aircraft.

You can help minimize this numberand amount of time spent dealing withthose incidents by: • Making sure the ELT is part of your

pre-flight check: • Secure, free of corrosion and

antenna connections are secure • Armed • Batteries are current • Listen on 121.5 to ensure the ELT

isn’t transmitting • After landing—as part of your

post-flight routine: • Listen on 121.5 to make sure you

did not set off the ELT with thatbounce on landing.

• Turn your ELT function switch to“OFF” if practical.

If your ELT does go off accidentally,let an air traffic service (ATS) unit orJRCC know, advising them of the ELTlocation and how long it was activated.This may prevent the unnecessarylaunch of search aircraft. Just turningyour ELT off without telling anyone willleave SAR officials in doubt about theincident and whether or not the searchshould continue.

Any testing of an ELT must only beconducted during the first 5 minutes ofany UTC hour and restricted in durationto not more than 5 seconds. When ship-ping your ELT for maintenance, turn theELT function switch to “OFF” andremove the batteries, if possible. Finally,take a few more minutes to review theA.I.P. Canada SAR 3.0—EmergencyLocator Transmitter.

Let’s Stop UNSARs!!!

u qwewrtTransport TransportsCanada Canada

Aircraft/V ehicle Conflict“Golf-Alpha-Bravo-Charlie cleared to landRunway 05, caution maintenance crew onTaxiway Alpha, 100 ft from Runway 05.”

A basic requirement for all pilots, airtraffic controllers, flight service specialists,airport managers and airside vehicleoperators is an ability to make decisions andexercise sound judgment.

Aircraft /vehicle conflict is a majorconcern to everyone at both controlled anduncontrolled airports. The increase infrequency and the potential for damagedequipment, serious injury, or loss of life istoo great to ignore.

What can you do?

Pilots• Report position and intentions on appro-

priate frequencies. • Acknowledge or readback instructions

using proper phraseology. • Ensure you understand instructions;

don’t assume. • Read back all hold, or crossing instructions. • Ensure flight path is, and will remain,

clear before taking off or landing. • If in doubt—hold your position or go

around, as applicable. • Expect the unexpected.

Air T raffic Controllers,Flight Service Specialists• Give clear and concise instructions/

advisory to vehicle and aircraft. • Use proper phraseology. • Advise aircraft and vehicles early of any

possible conflict. • Remind pilot and vehicle operator often

of potential conflict.

• Repeat information as often as necessaryto ensure it is understood.

• Implement a system to remind yourself ofthe locations and intentions of all traffic.

• Remember—Safety takes priority overoperational convenience.

Vehicle Operators• Know aircraft control procedures and

approved areas for vehicle movement. • Ensure you have the authority to operate

a vehicle on the airside of the airport. • Ensure aircraft manoeuvring areas are

free of potential conflict before entering. • Keep a visual look out as well as

monitoring the radio and communicateoften with ATC/FSS.

• Read back all hold short instructions. • If in doubt about an instruction or radio

transmission, request, “Say again.”• Check an area prior to entering your

vehicle to ensure a more complete,unobstructed view.

• Ensure your rotating lights and othersafety equipment are functioning.

• Vacate the runway immediately if an air-craft is observed or reported in the circuit.

• Remember aircraft are not verymanoeuvrable and the pilot’s visibility islimited, as is the controller’s and flightservice specialist’s.

Airport Managers• Review and revise training plan for vehi-

cle operators, as required. • Ensure all operators are properly trained

and kept aware of changes to procedures. • Check security gates often to ensure only

authorized vehicles and personnel haveaccess to airside.

• Check runway and taxiway signs toensure adequacy and visibility.

for safetyFive minutes readingcould save your life !

T KE E...Fi VA