7.625” 8.375” 8.5”

40 ASL4/2006

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

ef

Debrief

debrief

Post-Accident Survivability—Direct-to-Airframe Helmet Cord ConnectionsAn Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)OnDecember7,2005,anMBB-BO105helicopterwasoperatingnearMarystown,N.L.Thehelicopterwasobservedflyingalongtheshoreline,atlowaltitude,insnow,andindarkeningconditions.Thehelicopterstruckthewaterabout1000ftfromshore,andsanktothebottomofMortierBay.Thepilotandpassengerescapedfromthehelicopter;however,theylaterperishedinthefrigidwater.TheTSBinvestigationintothisaccident(A05A0155)isongoing.Aftertheaccident,anexaminationofthepilot’saviationhelmetfoundthattheendfittingofthecommunicationcordwasfracturedatthepointwhereitattachestothehelicopter(seeFigure1).

Figure 1. Fractured cord end fitting

Thecommunicationcordsforfront-seatoccupantsconnecttoreceptacleslocatedontheoverheadcenterconsole.Whenthehelicopterwasrecovered,themetalpinsfromtheendfittingwerestillinsidethereceptacle.Metalremnantsfromtheconnectionshowthatthecordwasbeingpulledsideways,towardsthepilot’sdoor,whenthefractureoccurred.Adownwardpullisrequiredtoreleasetheconnection.Abreaktestofasimilarfittingrequireda70-lbpullbeforethecordfailed.Afterditchingorwaterimpact,theoccupantsofacapsizedhelicopterarepronetodisorientation.Therefore,unimpededegressthroughanyavailableexitisvitaltosurvival.Anattachedcommunicationcordthatwillnotreleasecleanlymayimpedethisegress.

Inthepast,similarBO-105helicoptershavebeenfittedwithanintermediate“pig-tail”communicationcordforhelmetconnections.Insteadofpluggingthehelmetcordintothehelicopter’sreceptacle,thehelmetcordisinsteadpluggedintothisintermediatecord(seeFigure2).

Thehelmetconnectionplugcanreleasecleanlyfromtheintermediate“pig-tail”cordreceptacleasitispulledinthedirectionoftravelduringegress.Overaperiodofyears,theuseoftheintermediatehelmetcordsatthisoperatordeclined,perhapsbecausepilotswerenotawarethatthecordsensureseparationinanemergency.However,sincethisaccident,theoperatorhasindicatedthattheuseofintermediate“pig-tail”cordsforhelmetconnectionswillnowbere-institutedwherenecessary.

Figure 2. Intermediate helmet “pig tail” connection cords

Otheroperatorsmayhaveaircraftwithsimilardirect-to-airframeconnections,andmaybeunawarethatthesecanimpedeegressinanemergency.Therefore,TransportCanadamaywishtoadvisetheaviationcommunitythattheseconnectiontypesmayimpedeegress,andthatanintermediatecordcanhelptomitigatethishazard.Done. —Ed.

TransportCanada

TransportsCanada

aviation safety letter

TP 185EIssue 4/2006

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

In this Issue...

Safety Hazard Alert—Call Sign Confusion

Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?

Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)

Recently Released TSB Reports

Near Repeat of Mirabel De-Icing Mishap

Cold Weather Altimeter Error—Getting Cold Feet?

How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions

Aircraft Maintenance Operational and Functional Checks

Flight Crew Recency Requirements Self-Paced Study Program

TC-1001878TC-1001878

TransportCanada

TransportsCanada

Flight Crew Recency RequirementsSelf-Paced Study Program

Refer to paragraph 421.05(2)(d) of the CanadianAviationRegulations (CARs).

This questionnaire is for use from November 1, 2006, to October 31, 2007. Completion of this questionnaire satisfies the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.

Note: The answers may be found in the TransportCanada AeronauticalInformationManual (TC AIM). TC AIM references are at the end of each question. Amendments to this publication may result in changes to

answers and/or references.

1. Convert1020.5millibarsintoinchesofmercury.______ (GEN1.9.2)2. TheSECURITASprogramprovidesameansforindividualstoreport________________and ____________________________________relatingtotheCanadiantransportationsystem. (GEN3.6)3. Runwaycontaminantssuchaswater,snoworicewill(increase/decrease)thelandingdistance.(AGA1.1.5)4. Whenasectionofrunwayorheliportisclosed,itismarkedwithan___. (AGA3.3andAGA5.6)5. ControlofARCALlightsshouldbepossiblewhenaircraftarewithin___NMoftheaerodrome. (AGA7.19)6. Retroreflectivemarkers(will/willnot)providethepilotwiththesamevisualpresentationasnormalrunway lightingwhentheaircraftislineduponfinalapproach. (AGA7.20)7. Theremovaloftheaudioidentificationfromnon-directionalbeacons(NDB),VHFomnidirectionalranges (VOR),distancemeasuringequipment(DME)orinstrumentlandingsystems(ILS)warnspilotsthatthe facilitymaybe__________eventhough____________. (COM3.2)8. Awideareaaugmentationsystem(WAAS)NOTAMwillbeissuedwhenaWAASserviceispredictednot tobeavailableforadurationofmorethan______min. (COM3.16.6.2)9. Whatdoestheequipmentsuffix“G”indicateinitem10(equipment)onaflightplan? _________________________________________________________ (COM3.16.7)10. CanVFRGPSreceiversbeusedtoreplacecurrentcharts?___ (COM3.16.16)11. Forair-to-aircommunicationsbetweenpilotsintheNorthernDomesticAirspace(NDA),whatisthe correctfrequencytouse?______MHz. (COM5.13.3)12. Anaerodromeforecast(TAF)providesexpectedconditionsfor___________________atspecificaerodromes, whereasanareaforecastchart(GFA)depicts_________________________affectingflightataspecifictime overaparticulararea. (MET3.2.1)13. AreasofshoweryorintermittentprecipitationareshownonaGFACloudsandWeatherChartas______ ____________________________________. (MET3.3.11)14. InaTAF,anycasesofstrong,non-conductivelowlevelwindshearwithin_____ftAGLwillbecodedas “__”. (MET3.9.3)15. InaTAF,“TEMPO”isonlyusedwhenthemodifiedforecastconditionisexpectedtolastlessthan ________ineachinstance. (MET3.9.3)16. TAFCYXU011035Z01112327015G25KT3SMRAOVC005 BECMG1314OVC020 FM1700Z29005KTP6SMOVC030TEMPO1723BKN030 RMKNXTFCSTBY17Z= Intheweatherreportabove,theforecastwindfor1500Zis_________________________________. (MET3.9.3)17. SPECICYSJ221650Z08017G243/8SMR23/2000FT/N–SNDRSNVV006 M03/M05A2953RMKSN8VSBYVRBL3/411/2 Intheweatherreportabove,theprevailingvisibilityis_____andthevisibilityisobscuredby _____________________________________. (MET3.15.3)18. Arethewindsinaviationweatherforecastsandreportsgivenindegreestrueormagnetic?GFA:_____; TAF:_____;FD:_____;METAR:_____.(MET3.3.11,3.9.3,3.11,3.15.3)19. DoesATCassumeresponsibilityforobstacleclearancewhenyouareradaridentified?___ (RAC1.5.2)20. Ifyouobservesuspiciousgroundactivitiesatanabandonedairstrip,whatreportshouldyoumake? _____________ (RAC1.12.2)

7.625”8.375”8.5”

ASL4/2006 392 ASL4/2006

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

Paul Marquis, EditorAviation Safety LetterTransportCanada(AARQ)PlacedeVille,TowerCOttawaONK1A0N8E-mail:marqupj@tc.gc.caTel.:613-990-1289Fax:613-991-4280Internet:www.tc.gc.ca/ASL-SAN

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

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

Toobtaininformationconcerningcopyrightownershipandrestrictionsonreproductionofthematerial,pleasecontacttheEditor.

Sécurité aérienne — Nouvellesestlaversionfrançaisedecettepublication.

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Transport (2006).ISSN:0709-8103TP185EPublicationMailAgreementNumber40063845

regulations and you

Safety Management Systems—Raising the Bar on Aviation Safety by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada

Asafetymanagementsystem(SMS)isastructureofsystemsdesignedtoidentifyandeliminaterisksandimprovethesafetyperformanceofairoperators.SMSisintendedtoincreaseindustryaccountability,andtonurtureandsustainasafetyculture,wherebyemployeescanconfidentiallyreportsafetydeficiencieswithoutfearofsubsequentpunitiveaction.RegulationwilleventuallyrequireallTransportCanadaoperatingcertificateholderstoimplementanSMS.

ThefollowingeventillustratesthevalueofanSMSinadvancingaviationsafetywhentherehasbeenacontraventionoftheregulations.

OnaclearJanuarymorning,anAirbus310departedHalifax,N.S.,forCalgary,Alta.,andclimbedtoacruisingaltitudeof34000ft.Aftercompletingtheroutinecruisechecks,thecrewsettledbackandthe256passengersrelaxedandenjoyedalightbreakfast.AstheywereapproachingMontreal,Que.,thecaptaincheckedtheen-routeweatherwhilethefirstofficertookfuelquantityreadingsandcomparedthemwiththeflightplanfiguresrequiredtocompletetheflighttodestination.ThefirstofficersuddenlyrealizedthattheyhadnottakenonenoughfuelpriortotheirdeparturefromHalifax.AfterconfirmingthereadingsandmanuallyrecalculatingtheminimumrequiredfueltocompletetheflighttoCalgary,heinformedthecaptain.Theybothdouble-checkedthefuelremainingagainstthefuelrequired.TheinsufficientfuelstatewasconfirmedandtheyagreedtoplananunscheduledrefuellingstopinToronto,Ont.MontrealCentreandcompanydispatchwerebothadvisedofthefuelconditionandtheyrespectivelyauthorizedandconcurredwiththerevisedrouting.

Fromaregulatorystandpoint,thepilot-in-commandandtheoperator,contravenedCanadian Aviation Regulation(CAR)602.88(2)fornotcarryingsufficientfuelfortheplannedroute.TheenforcementprocessinitiatedfollowingthiscontraventionistypicalofwhatwouldhappenwithinanyaviationcompanythatoperatesinaccordancewithanSMS.

TheAviationEnforcementDivisionbecameawareoftheeventthroughanoccurrencereportintheCivilAviation

DailyOccurrenceReportingSystem(CADORS),andnotifiedtheTransportCanadaprincipalinspectorresponsiblefortheoperator.Theprincipalinspectorconfirmedthatthecrewhad,asrequiredunderSMS,internallyreportedtheincidenttotheoperator.

InlinewithSMSphilosophy,theoperatordevelopedandsubmittedacorrectiveactionplan(CAP)totheprincipalinspector,outliningasystematicapproachtoaddressthefuelmismanagementandtopreventarecurrence.TheCAPincludedrevisedpre-flightandin-flightstandardoperatingprocedures(SOP)designedtoensureaccurateflight-plannedfuelcalculationsandaccuratefuel-on-boardmonitoringpriorto,andduring,flight.Theseproceduresforproperfuelmanagementwereincorporatedintoamandatorytrainingseminarforallflightcrew members.TheprincipalinspectorreviewedtheCAPandwasconfidentthatitaddressedtheissuesthatledtotheinitialcontravention.Inconsultationwiththeprincipalinspector,theAviationEnforcementDivisioncouldhavereactivatedtheinvestigationatanytimeduringtheprocessleadinguptotheacceptanceoftheCAP,andwouldhave,if:

thecontraventionhadbeenintentional;theincidenthadnotbeeninternallyreported;ortheprincipalinspectorhadfoundtheCAPtobeunacceptable,andtheoperatorhadrefusedtoaddresstheissue.

Hadthedecisionbeentocontinuetheinvestigation,aletterofinvestigationwouldhavebeensentdirectlytotheoperator,andtheprincipalinspectorwouldhavebeennotified.Inthisspecificcase,theinvestigationwasclosedwithoutfurtherenforcementaction.

Althoughthestoryinthisarticledoesnotdepictanactualevent,itdoesservetoillustrateatypicalSMSresponse,designedtoraisethebaronaviationsafetyfollowingaregulatorycontravention.

Forfurtherclarification,weinviteyoutoconsulttheAviationEnforcementPolicyandProcedures—SafetyManagementSystemsWebsiteatwww.tc.gc.ca/civilaviation/SMS/policy.htm.

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

ef

Debrief

Go to www.smartmoves.ca

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

FOR CANADIAN RESIDENTS ONLY

21. Taxiauthorizationsthatcontaintheinstructions“hold”or“holdshort”(shall/neednot)bereadbackby thepilot. (RAC4.2.5)22. Wherepossible,pilotsarerequiredtoreportatleast____minbeforeenteringanMFarea. (RAC4.5.7)23. A___________mustbefiledforallflightsbetweenCanadaandaforeignstate. (FAL2.3.2)24. OnflightsfromCanadatotheU.S.,atleast________advancenoticeofarrivalmustbeprovidedto U.S.Customs. (FAL2.3.2)25. OnflightstoCanada,pilotsmustlandataCanadaCustomsauthorizedairportofentry(AOE). Pilotsmustmaketheirowncustomsarrangementsbycalling______________atleast_________before flyingintoCanada. (FAL2.3.2)26. PilotsreceivingaMANOTmessagearerequestedtomaintainaradiowatchon______MHzwhen operatinginthevicinityofthetrackofthemissingaircraft. (SAR2.3)27. Listthefourstepsthatshouldbeaccomplished(wherepracticable)duringyourpreflightinspectionofthe emergencylocatortransmitter(ELT). (a)__________________________________________________________________________________; (b)____________________________________________________________; (c)_____________________________________________;and (d)____________________________________________. (SAR3.4)28. WhenanELTsignalisheardinflight,thenearestATSunitshouldbeadvisedofwhatfourpieces ofinformation? (a) ________________________________________________________; (b)___________________; (c)_____________________________________________;and (d)____________________________________________. (SAR3.4) 29. Intheeventofacrash,whatshouldyoudowiththeELT’sfunctionswitch,andwhen? ____________________________________________________________________ (SAR3.5)30. 061234NOTAMNCYSBSUBDURY RWY04/22CLOSEDTILAPRX0612151530 Runway04/22isexpectedtoopenat_____Zon(date)___________. (MAP5.6.1)31. Whatisthesignificanceoftheterm“APRX”intheaboveNOTAM?_____________________________ (MAP5.6.1)32. 060210NOTAMR060202CYNDWINCHESTER CNA8UNMANNEDAERIALVEHICLEOPS3NMRADIUS450610N 752854W(APRX9NMNWAD)SFCTO2400FTMSL 0605051700TIL0605052300 Whatisthesignificanceoftheletter“R”attheendoftheword“NOTAM”above?__________________ (MAP5.6.2)33. ACanadianmedicalcertificateforaprivatepilotlicenceisvalidinCanadafor___monthsifunderage40, andfor___monthsifage40orolder. (LRA3.2.4)34. InaccordancewithCAR401.08,everyapplicantfor,andeveryholderof,aflightcrewpermit,licenceor ratingshallmaintaina______________. (LRA3.7.6)35. Theflightcrewrecencyrequirementsaddressthreetimeperiods.Toactaspilot-in-commandorco-pilot youmustmeetthe___________________recencyrequirements.Ifyouwishtocarrypassengers,youmust alsomeetthe________requirements. (LRA3.9)36. Inordertocarrypassengers,youmusthavecompleted__takeoffsandlandingsinthesamecategoryand classofaircraftintheprevious__months. (LRA3.9)37. ClassAfiresarefiresin______________________________. (AIR1.4.2)38. Anaircraftaltimeterwhichhasthecurrentaltimetersettingappliedtothesubscaleshouldnothavean errorofmorethan___ftwhencomparedonthegroundagainstaknownaerodromeorrunwayelevation. (AIR1.5.1)39. By______ftASLthepartialpressureofoxygenissuchthatallpilotswillexperiencemildhypoxiaand somewillbecomesymptomatic. (AIR3.2.1)40. If,ondescent,thepressureintheears(orsinuses)cannotberelievedbyswallowing,yawningorValsalva manoeuvre,itisbestto_________________________________________________________. (AIR3.8)

Answers to this quiz are found on page 38 of this ASL 4/2006.

Don’t Forget to Subscribe to the Transport Canada Aeronautical Information Manual !

ThenewTransportCanadaAeronauticalInformationManual(TCAIM)wasintroducedinOctober2005.AllCanadian-registeredpilotsreceivedtwofreepapercopies,thelastofwhichwasdeliveredinApril2006.ThenextreleaseoftheTCAIMisscheduledforOctober2006.Thereareafewoptionsonhowtosubscribetothispublication:

Paid subscription to the paper copy• SubscribeonlinetothepapercopybyvisitingTransportCanada’sonlinepublicationsstorefrontat

www.tc.gc.ca/transact.There,youcanordereitherasinglecopy($15.00,whichincludesshipping,butexcludesapplicabletaxes)ortakeoutasubscriptionforfuturecopies;or

• CalltheTransportCanadaOrderDeskat1-888-830-4911or613-991-4071,toorderasinglecopyorrequestasubscription.Theywilltakeyourcreditcardinformationandprocessyourorder.

Free e-Bulletin notification• Registerforane-Bulletin,whichmeansTransportCanadawillsendyouane-mailwithalinktothelatest

onlineversion,ineitherHTMLorPDFformat.Toregisterforane-Bulletin,sendane-mailtoMPS@tc.gc.ca andasktobeaddedtotheTCAIMe-Bulletinlist.Pleasestateyourname,postaladdressande-mailaddress.

Asaremindertoall,theonlineversionoftheTCAIMisavailableforviewingandfreedownloadatalltimes.YoucanaccessitfromTransportCanada’sonlinepublicationsstorefrontatwww.tc.gc.ca/transact.

ASL4/2006 �

guest editorial

AstheDirectoroftheNationalOrganizationTransitionImplementationProject(NOTIP),itismypleasuretoprovideyouwithanupdateofthisprojectinthiseditionoftheAviation Safety Letter(ASL).TheNOTIPisresponsiblefordeterminingandimplementingchangestotheCivilAviationorganizationandworkforcetoenablethesuccessfulimplementationofasustainablesafetymanagementsystem(SMS)oversightframeworkfortheindustry,inaccordancewiththeTransportCanadaCivilAviation(TCCA)IntegratedManagementSystem(IMS).

CivilAviationhasundergonemanychangessincetheorganizationalrestructuringin1995.NewconceptsandapproacheshavebeenintroducedinsuccessivekeystrategicdocumentssuchasChallenge ‘98,Flight 2005,andmorerecently,Flight 2010.Inearly2005,TCCAhadbegunareviewofitsorganizationalstructureinresponsetoevolvingrealitiesinboththeindustryandthegovernment.By201�,46percentofthecurrentCivilAviationworkforcewillbeeligibleforretirement,orwillhavealreadyretired.Giventhecurrentandpredictedworkforcedemographics,replacingouremployeestocontinuethecurrentsafetyoversightregimeisnotfeasible.Majorchangesneedtobemadeinthewaywework,notjustintheindustry,butwithintheauthorityaswell.

Thegoalistotransitiontheorganizationtothe“endstate”modelby2010,whenSMSisfullyimplementedinaviationenterprises—formalizingaconceptofoperationsthatCivilAviationhasbeenmigratingtowardssinceSMSimplementationbegan.Thisorganizationalmodelwillallowfurtherflexibilityinsharingexpertiseandmaintainingtechnicalcompetencies,aswellasdeliveringtherequiredlevelofservicetotheindustry.Ourprogramwillbedeliveredusingmultidisciplinaryteamswhoareresponsiblefortheoversightofenterpriseswithintheindustry.

Underthenewmodel,headquarterswillcontinuetoberesponsibleforthedevelopmentofpolicy,regulationsandstandards,andthedeliveryofspecificcentralizedoperations.RegionswillcontinuetoberesponsibleforimplementingthemajorityoftheCivilAviationProgram.Adedicatedteamisbeingformedtomanagethetransitionissuesoverthecomingyears.IinviteyoutovisittheCivilAviationWebsite,www.tc.gc.ca/civilaviation,forfurtherinformationandupdates,includingfrequentlyaskedquestionsandafeedbackmechanismontheorganizationalreviewproject.

JudyRutherfordDirectorNationalOrganizationTransitionImplementationProject

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

Table of Contentssection pageGuest Editorial .................................................................................................................................................................3To the Letter .....................................................................................................................................................................4Pre-flight ...........................................................................................................................................................................5Recently Released TSB Reports .....................................................................................................................................11Accident Synopses ...........................................................................................................................................................18Winter Operations ..........................................................................................................................................................20Maintenance and Certification .......................................................................................................................................30

The Civil Aviation Medical Examiner and You: Mandatory Reporting of Unfit Pilots, Air Traffic Controllers and Flight Engineers ........................................................................................................................................................35

Regulations and You: Safety Management Systems—Raising the Bar on Aviation Safety ...................................39

Debrief: Post-Accident Survivability—Direct-to-Airframe Helmet Cord Connections .......................................40

Flight Crew Recency Requirements Self-Paced Study Program ................................................................................Tear-off

4 ASL4/2006

Turns after takeoff—at night and IFRDearEditor,

ThearticleinAviation Safety Letter (ASL)issue�/2004,“WhenNightVFRandIFRCollide,”wasveryinformative.Tome,itreinforcestheneedtoprohibitturnsbefore1500ftAGLduringallIFRandnightVFRoperationsintoalloperators’SOPs.Iftheseprocedureswereimplemented,trainedforandreinforcedintoeverydayoperations,thistypeofaccidentcouldbeprevented.Turnsshouldonlybeallowedunderthesecircumstances:forterrainavoidance,adepartureinstruction/procedure,orcollisionavoidance.“Blackhole”departurescreatethe“somotogravicillusion,”whichcausesthecrewtobelievetheyareinaclimbwhentheaircraftmayindeedbedescending.Undertheseconditions,extravigilancebybothcrewmembersmustbeexercisedinregardstoaircraftverticalspeed,climbperformanceandairspeed.Toooften,the“killernorm”isforthepilotflyingtostartturningimmediatelyaftertakeoff,whilethepilotnotflyingistransmittingontheradio,andwritingontheflightlogwhentheaircraft,ifallowedtodescendunnoticed,issecondsawayfromgroundcontact.OperatorsneedtoimplementSOPsfortheircrewstotraintoclimbstraightaheadandcloselymonitoraircraftperformance,whilemaintaininga“sterile”cockpittoatleastaminimumof1500ftAGL.

Wayne McIntyre Saskatoon, Sask.

Distraction and interruption in the cockpit—head-down workDearEditor,

Inareviewof�5non-fatalairlineincidentsattributedprimarilytocrewerror,itwasconcludedthatfailuretomonitorand/orchallengethepilotflying(PF)contributedto�1outofthe�5occurrences.Intheincidentsstudied,thepilotmonitoring,orpilotnotflying(PNF)reportedthatpreoccupationswithotherdutiespreventedthemfrommonitoringthePFcloselyenoughtocatchanerrorbeingmadewhiletaxiingorflying.In1�ofthe�5occurrences,thePNFwaspreoccupiedwithsomeformofhead-downwork,mostcommonlypaperworkorprogrammingtheflightmanagementsystem(FMS).

Recently,Iwasassistingintheevaluationofaircraftequipmentoninternationalroutes.Thecaptainhadapproximately20000hrtotaltime,andabout�000hrincommandonthetype.Thefirstofficerwasnewlyhired,withanewtypecertificateontheairplane,andabout1000hrtotaltime.About1.5hrafterdeparture,

incruiseatFL�50,weenteredanareaofheavyconvectivebuild-ups,withimbeddedthunderstorms.Inoticedthatthefirstofficer,whowasthePNFatthetime,startedreprogrammingtheFMS(tocircumnavigatetheweather)withoutfirstadvisingthecaptainthathewasgoinghead-down.Atthattime,theaircraftwasonauto-pilot.ThePNFthenexperienceddifficultiesinenteringwaypoints,andrequestedassistancefromthecaptain,whoimmediatelyhelpedhim,abandoningthesightoftheinstrumentpanelandtheweatherradardisplay.Theaircraftenteredcloudsandmetsevereturbulence.Whilestillonauto-pilotandtryingtomaintaintheselectedflightlevel,theaircraftenteredintoaseriesofhigh-speedstalls.Ittookthecrewabout�0stostabilizetheflight.

Thelesson?Inthiscase,thePNFdidnotadvisethePFthathewouldreprogramtheFMSafterhebecameawareofthedeterioratingweather.ThePFthenabandonedmonitoringtheradaratacriticalmomentandelectedtoattendtoalesscriticaltask.Somebodymustalwaysflytheairplane,evenduringautomatedflight.Periodsofhead-downactivity,suchasprogrammingtheFMS,areespeciallyvulnerablebecausethePNF’seyesaredivertedfromothertasks.Itisessentialthatthestandardoperatingprocedures(SOPs)specifywhenitisrecommendedorallowedtogohead-down.

Captain Jan JurekInternational Civil Aviation Organization (ICAO)

Company discrete frequency vs ATF?DearEditor,

EarlierthisyearIliftedofffromtheBeaverLakeForestrypad,eastofLacLaBiche,Alta.Imadeacallontheaerodrometrafficfrequency(ATF),12�.2,thatmyintentionwastoflytotheTankerBaseattheLacLaBicheairport.Afewminuteslater,IcalledturningfromrightbasetofinalforRunway29at�500ftand�mi.Atabout1mi.,aCL-215pulledoutontotherunwayandbeganbacktrackingonRunway29.Atthesametime,anAstarliftedofffromitshangarinasoutherlydeparture.Again,nocontacton12�.2.AfterlandingattheTankerBase,Iwasinformedthat“their”frequencywas122.05!Exclusiveuseofanunpublishedfrequencyisunprofessionalandkeepsotherairportusers“outoftheloop”.ShouldallATFsbemadeintomandatoryfrequencies(MF)?

Name withheld upon request

Good reminder to all. Use of company discrete frequencies is allowed but not at the expense of the ATF, or even a MF for that matter. —Ed.

to the letterG

uest Edito

rialTo

the LetterTo t

he L

ette

rG

uest

Ed

itori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

ASL4/2006 5

pre-flightSafety Hazard Alert—Call Sign Confusion ................................................................................................................... page 5Thoughts on the New View of Human Error Part I: Do Bad Apples Exist? ............................................................... page 6COPA Corner—Flying Clubs—Why Bother? .............................................................................................................. page 7The Canadian Business Aviation Association Column—Training to Bridge the Knowledge Gap ............................ page 8Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR) ............................... page 8

NAVCANADAtracksalloperatingirregularitiesinanefforttoidentifysafetyhazardsandfindwaystoreducetheprobabilityofaccidents.Lately,wehaveseenadisturbingincreaseinthenumberofinstanceswheresimilarcallsignshavecausedconfusionamongpilotsandcontrollers,leadingtosituationswherethereisanincreasedriskoflossofseparationbetweenaircraft.Callsignconfusioncouldalsoleadtoanincreasedriskofcontrolledflightintoterrainorobstacles.

Inarecenttypicalincident,twoaircraftoperatedbythesameairlinewereapproachingabusyairportfromthesamedirection.Theyhadfour-digitflightnumbers,andthefirst,thirdandfourthdigitswereidentical—onlytheseconddigitwasdifferent.Theaircraftnearesttotheairportwasclearedto�000ft,butthecrewintheotheraircraftreadbackthatclearanceandstarteddescentfrom9000ft.Fortunately,thecontrollernotedthiserrorandintervenedbeforetherewasaconflictwithanotherflight.

Fromthepilot’sperspective,theproblemisauralconfusion.Clearancesandinstructionsalreadycontainheadings,altitudes,airwayandrunwaynumbers,andifcallsignsaresimilar,itiseasytounderstandhowconfusioncouldresult.Crewsmaybecompletingachallenge/responsechecklistorothertaskwhenacontrollerissuesaninstruction,andmayreactbasedonhearingjustpartoftheflightnumber.Addtothisthefactthatforagivenpilot,flightnumberschangeoften.

Forthecontroller,whomayberesponsibleforoveradozenaircraft,theproblemcouldalsobevisualconfusion,becausethecontrollerreliesoncallsignsonradarandotherdisplaystodistinguishamongaircraft.

Regardlessofcause,callsignconfusionisoccurringtoooften,andairlines,pilotsandcontrollershavetotakeconcertedactiontoreducetheprobabilityofconfusionandtheriskofaseriousaccident.

Therootoftheproblemisthewayaircarriersassignflightnumbers.Ideally,schedulingschemesandtheassignmentofflightnumberswouldensurethatflightswithsimilarcallsignswouldnotappearinthesame

controller’ssector.Flightnumberassignmentis,however,drivenbydifferentconsiderations,andnormallydoesnotaddressthepotentialforconfusion.Basedonincidentrecords,itappearsthatriskwouldbereducedbyusingamaximumofthreedigitsinflightnumbers.Evenwhenusingthreedigits,instanceswherethesamethreedigitsareusedindifferentpositions(e.g.461and416)shouldbeavoided.Ofcoursetherewillbeinstanceswheredifferentairlinesareusingthesameflightnumber,butthishaslesspotentialforconfusionbecausecrewswouldkeyontheairlinename.

Untilaircarrierstakestepstodealwiththerootoftheproblem,awarenessonthepartofbothpilotsandcontrollersiscriticaltoreducingtheriskofcallsignconfusion.

NAVCANADAhasrecentlyhighlightedtheproblemininternalcommunications,remindingcontrollerstoadviseaffectedcrewsoftheexistenceofaircraftwithsimilar-soundingcallsignsonthefrequencyassoonastheybecomeawareofthesituation.

Pilotsareencouragedtorecognizewhenthepotentialforconfusionexists,andtotakeextracaretolistenattentively.Itgoeswithoutsayingthatpilotsshouldtakegreatcaretousetheproperflightnumberatalltimes.Itisalsoveryimportanttouseproperphraseologyandtopayparticularattentiontoreadbacks.Pilotsituationalawarenessispartofthesolution.Inseveralrecentinstances,pilotshaveincorrectlyacceptedclearancesthatwereclearlyinappropriate—headingsoraltitudesthatdidnotmakesensebasedoncurrentaircraftpositionorintent.

Callsignconfusionisaworldwideproblemandothercountrieshavecompletedvaluablestudieswithrecommendationsaimedatreducingthesafetyrisk.NAVCANADAintendstocontinueitsownstudiesandtoincorporatethelessonslearnedaroundtheworldinacomprehensiveaeronauticalinformationcircular(AIC)thatprovidesmoredetailedadvicetoaircarriers,pilotsandcontrollers.

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

Safety Hazard Alert—Call Sign Confusionby Larry Lachance, Director, Safety and System Performance, NAV CANADA, and Ross Bowie, Director, Air Navigation System Service Design, NAV CANADA

6 ASL4/2006

The following article is the first of a three-part series describing some aspects of the “new view” of human error (Dekker, 2002). This “new view” was introduced to you in the previous issue of the AviationSafetyLetter(ASL) with an interview by Sidney Dekker. The three-part series will address the following topics:Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?Thoughts on the New View of Human Error Part II: Hindsight BiasThoughts on the New View of Human Error Part III: “New View” Accounts of Human Error

Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?by Heather Parker, Human Factors Specialist, System Safety, Civil Aviation, Transport Canada

Bad Apples: Do They Exist?Beforedebatingifbadapplesexist,itisimportanttounderstandwhatismeantbytheterm“badapple.”Dekker(2002)explainsthebadappletheoryasfollows:“complexsystemswouldbefine,wereitnotfortheerraticbehaviourofsomeunreliablepeople(badapples)init,humanerrorscauseaccidents—humansarethedominantcontributortomorethantwo-thirdsofthem,failurescomeasunpleasantsurprises—theyareunexpectedanddonotbelonginthesystem—failuresareintroducedtothesystemonlythroughtheinherentunreliabilityofpeople.”

Theapplicationofthebadappletheory,asdescribedabovebyDekker(2002)makesgreat,profitablenews,anditisalsoverysimpletounderstand.Iftheoperationalerrorsareattributabletopoororlazyoperationalperformance,thentheremedyisstraightforward—identifytheindividuals,takeawaytheirlicences,andputtheevil-doersbehindbars.Theproblemwiththisviewisthatmostoperators(pilots,mechanics,airtrafficcontrollers,etc.)arehighlycompetentanddotheirjobswell.Punishmentforwrongdoingisnotadeterrentwhentheactionsoftheoperatorsinvolvedwereactuallyexamplesof“right-doing”—theoperatorswereactinginthebestinterestsofthosechargedtotheircare,butmadean“honestmistake”intheprocess;thisisthecaseinmanyoperationalaccidents.

Can perfect pilots and perfect AMEs function in an imperfect system?

Thisviewisamorecomplexviewofhowhumansareinvolvedinaccidents.Iftheoperationalerrorsareattributabletohighlycompetentoperationalperformance,howdoweexplaintheoutcomeandhowdoweremedythesituation?Thisisthecruxofthecomplexproblem—theoperationalerrorisnotnecessarilyattributabletotheoperationalperformanceofthehumancomponentofthesystem—rathertheoperationalerrorisattributableto,oremergesfrom,theperformanceofthesystemasawhole.

Theconsequencesofanaccidentinsafety-criticalsystemscanbedeathand/orinjurytotheparticipants(passengers,etc.).Societydemandsoperatorsbesuperhumanandinfallible,giventheresponsibilitytheyhold.Societycompensatesandculturesoperatorsinawaythatdemandstheyperformwithouterror.Thisisanimpossibility—humans,doctors,lawyers,pilots,mechanics,andsoon,arefallible.Itshouldbethesafety-criticalindustry’sgoaltolearnfrommistakes,ratherthantopunishmistakes,becausetheonlywaytopreventmistakesfromrecurringistolearnfromthemandimprovethesystem.Punishingmistakesonlyservestostrengthentheoldviewofhumanerror;preventingtrueunderstandingofthecomplexityofthesystemandpossibleroutesforbuildingresiliencetofuturemistakes.

Tolearnfromthemistakesofothers,accidentandincidentinvestigationsshouldseektoinvestigatehowpeople’sassessmentsandactionswouldhavemadesenseatthetime,giventhecircumstancesthatsurroundedthem(Dekker,2002).Onceitisunderstoodwhytheiractionsmadesense,onlythencanexplanationsofthehuman–technology–environmentrelationshipsbediscussed,andpossiblemeansofpreventingrecurrencecanbedeveloped.Thisapproachrequiresthebeliefthatitismoreadvantageoustosafetyiflearningistheultimateresultofaninvestigation,ratherthanpunishment.

Inthemajorityofaccidents,goodpeopleweredoingtheirbesttodoagoodjobwithinanimperfectsystem.Pilots,mechanics,airtrafficcontrollers,doctors,engineers,etc.,mustpassrigorousworkrequirements.Additionally,theyreceiveextensivetrainingandhaveextensivesystemstosupporttheirwork.Furthermore,mostofthesepeoplearedirectlyaffectedbytheirownactions,forexample,apilot

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

ASL4/2006 �

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

COPA Corner—Flying Clubs—Why Bother?by Adam Hunt, Canadian Owners and Pilots Association (COPA)

TheflyingclubsofCanadahavealonghistory.Manyoftoday’sclubswereformedinthe1920swiththeassistanceoftheRoyalCanadianAirForce(RCAF),whenitwasconsideredbythegovernmentofthedaytobeinthenationalinteresttogetasmanyCanadiansflyingaspossible.DuringWorldWarII,manyelementaryflyingtrainingschoolsthatwerepartoftheBritishCommonwealthAirTrainingPlanwererunbythenation’sflyingclubs.

Today,manyairplanepilotsdon’tbelongtoclubs—theyjustgototheairport,flytheirownaircraftandthengohomeagain.Manytimes,theywon’tevenseeortalktoanyoneelse.Theyaren’tundergoingtrainingorrentingtheiraircraft—sowhybotherbelongingtoaclub?

Therearemanytypesofclubs;manydorentaircraftorprovideinstruction,butsomeofferotherservices,suchasoperatingairportsorprovidingguestspeakersandorganizingaviationevents.Soifyouarenottrainingorrenting,thenherearesomeofthebenefitsofbelongingtoaclub:

Youcanmakeuseoftheexpertiseattheclub—learnfromtheinstructorsandotherseniorpilots.

Youcantakepartinsafetyrecencyseminarsandothereducationalevents.

Manyflyingclubsorganizeaviationspeakersfromwhomyoucanlearnandkeepuptodate.

Beingaroundotherpilotswillhelpmotivateyouandkeepyouinterestedinflying.

•

•

•

•

Manyclubsholdflyingeventssuchasfly-insandfly-outevents,whereaircraftareflownoncross-countriestofar-offdestinations.Thiswillgiveyouexperiencethatyoumightnotpursueonyourown.

Someclubsorganizespecifictrainingopportunities,suchassurvivaltrainingorunderwaterescapetraining.

Someclubssponsor“mentorprograms,”wheremoreexperiencedpilotsarepairedwithstudentsandnewlicenceholders,tohelpguidethemthroughthelearningprocessandthefirstfewhundredhoursofflying.

Flyingclubsoftenhavememberswithspecificknowledgeoflocalweatherandterrainconditions.

Flyingclubsoftenhaveassociatedaircraftmaintenanceoperationswhichcanbeagreatsourceofknowledgeandhelpwithaircraftissues.

Flyingclubsandtheirmemberscanprovidesupportwhentherearedifficultcircumstancestodealwith—accidents,injuriesordeaths.

Canada’sflyingclubshavealottooffertoday’spilots,eventhosewhoowntheirownaircraft.BelongingtoaclubcanhelpconnectyoutowhatisgoingoninaviationinCanada,andjustmaygiveyoubettertoolstoloweryourflyingrisks.MostclubshaveWebsitesthatlisttheiractivities,oryoucanfindmostofthematwww.copanational.org under“LearningtoFly.”

•

•

•

•

•

•

isonboardtheaircrafttheyareflying.Thisinfrastructurelimitstheaccessibilityofthesejobstocompetentandcognisantindividuals.Labellingandreprimandingtheseindividualsasbadappleswhenhonestmistakesaremadewillonlymakethe systemmorehazardous.Byapproachingthesesituationswiththegoaloflearningfromtheexperienceofothers,systemimprovementsarepossible.Superficially,thiswayaheadmayseemlikewhattheaviationindustryhasbeendoingforthepasttwentyyears.However,moreoftenthannot,wehaveonlyuseddifferentbadapplelabels,suchascomplacent,inattentive,distracted,unaware,tonameafew;labelsthatonlyseektopunishthehumancomponentofthesystem.Investigationsintoincidentsandaccidentsmustseektounderstandwhytheoperator’sactionsmadesenseatthe

time,giventhesituation,ifthehumanperformanceistobeexplainedincontextandanunderstandingoftheunderlyingfactorsthatneedreformaretobeidentified.Thisismuchhardertodothananticipated.

InPartII,the“hindsightbias”willbeaddressed;abiasthatoftenaffectsinvestigators.Simplyput,hindsightmeansbeingabletolookback,fromtheoutside,onasequenceofeventsthatleadtoanoutcome,andlettingtheoutcomebiasone’sviewoftheevents,actionsandconditionsexperiencedbythehumansinvolvedintheoutcome(Dekker,2002).InPartIII,wewillexplorehowtowriteaccountsofhumanperformancefollowingthe“newview”ofhumanerror.

� ASL4/2006

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)by Larry Cundy, Chief, Personnel Licensing, General Aviation, Civil Aviation, Transport Canada

IntroductionIn 1998, the International Civil Aviation Organization (ICAO), taking note of several accidents and incidents where pilots’ and air traffic controllers’ inadequate language proficiency were contributory factors, formulated Assembly Resolution A32-16, and subsequently directed work by the ICAO Council and the Air Navigation Commission. As a direct result of that work, ICAO adopted amendment 164 to the Standards and Recommended Practices (SARPs), Annex I to the Convention on International Civil Aviation—Personnel Licensing, on March 5, 2003, with an effective date of November 27, 2003. This amendment requires language proficiency for pilots, air traffic controllers and aeronautical station operators. It also calls for high-quality aviation-specific language training materials and programs, as well as the development of academically-sound language testing services.

TransportCanada(TC)acknowledgesthelegitimatesafetyconcernsthatICAOhascitedinsupportofthisamendment;however,TChasalsonotedthatthereisasignificantamountofworkrequiredtodeveloptheinfrastructureforstandardizedtestingandoversightofthetestfacilitiesandservices.

The Language Proficiency Study Group (LPSG)InaccordancewiththeSARPsandguidancematerialdevelopedbyICAO,theGeneralAviationBranchofTCisresponsibleforthedevelopmentandimplementationoflanguageassessmentandteststandardsforpilots.TheAirNavigationServicesandAirspaceBranchisresponsiblefortheimplementationofthesesamestandardsforairtrafficcontrollersandaeronauticalstationoperators.Toachieveacomprehensiveplanwithinthelimitedtimeframeforimplementation,theGeneralAviationBranchestablishedtheLanguageProficiencyStudyGroup(LPSG)inSeptember2004.TheLPSGiscomprisedofrepresentativesfromtheTCLicensingDivisionandthe

AirNavigationServicesandAirspaceBranch,aswellasindustrypersonnelfromtheAssociation Québécoise des transporteurs aériens,Les Gens de l ’air du Québec, AirTransportAssociationofCanada,CanadianOwnersandPilotsAssociation,AirLinePilotsAssociation,CanadianAirTrafficControlAssociation,AirCanadaPilots Association,CanadianAviationMaintenanceCouncil,CanadianBusinessAviationAssociation,NAVCANADAandtheU.S.FederalAviationAdministration.

TheLPSGhascompletedaconsiderableamountofworktodateinaccordancewiththetermsofreferenceandworkplan;thisincludesthedevelopmentoftherequiredpolicies,proceduresanddraftnoticesofproposedamendment(NPA)totheCanadian Aviation Regulations (CARs).

TheLPSGiscurrentlydevelopingformalassessmenttoolsandguidancematerialforthedelegatedpersons

The Canadian Business Aviation Association Column—Training to Bridge the Knowledge Gap

TheCanadianBusinessAviationAssociation(CBAA)hasrecentlyembarkedonamajorprojecttofacilitateaviation-orientedtrainingforitsmembersandtheaviationcommunityatlarge.Thisinitiativeistheresultofobservationsfromtheassociation’smanagementofthePrivateOperatorCertificate(POC)Program.

GapswereidentifiedintheessentialskillsandknowledgerequiredforpersonnelemployedatalllevelswithintheCanadianaviationindustry.Onepotentialoutcomeofthemanagementknowledgegap,ifnotproperlyaddressed,canbeineffectiveimplementationofsafetymanagementsystems(SMS).

AlthoughCBAA’sexperienceisprimarilywithprivatebusinessaviation,itsexpertisecanbeusefultoothersegmentsofthecommercialaviationcommunity,suchas:entitycharter;airtaxi;smallscheduledcarriers;flighttrainingschools;specialtyoperations;andmaintenanceandmanufacturingorganizations.

Thereisoftenlimitedaccessforsmalloperatorstohigh-qualityessentialtrainingforsuchsubjectsashumanfactors,fatigueawareness,highaltitudeindoctrination,aircraftsurfacecontamination,low-energyawareness,crewresourcemanagement,decisionmaking,controlledflightintoterrain,andspecificnavigationoperations,etc.CBAA’snewtraininginitiativeaimstofillthatneed.

Inadditiontoorganizingvariousseminars,CBAAispartneringwithexistingtrainingproviderstooffervaluabletrainingasaservicetoitsmembers,aswellasmakingthistrainingavailabletotheaviationindustry.VisittheCBAAWebsiteatwww.cbaa.caforthelatestinformationontrainingseminars.

ASL4/2006 9

whowillbeinvolvedintheconductoftestingfortheoperationallanguagelevel.TCisalsodevelopinginformalassessmentguidelinesforassessingapplicantsfortheexpertlanguagelevel6.Tosatisfytheinternationalrequirements,thesepoliciesandproceduresmustnotonlyaddressfuturelicenceholders,butalsoexistinglicenceholders.ForCanada,thisinvolvestheassessmentofsome55000currentCanadianlicenceholders.

Details of the work completed to date1. In2004,theLPSGdevelopedaworkplan,

implementationproceduresandNPAstotheCARsthatprovidedastartingpointforformalindustryconsultation.ThisbeganwiththeSpecialPartIVCanadianAviationRegulationAdvisoryCouncil(CARAC)meeting,whichwasheldonMarch�1,2005.TherequiredNPAswerepresented,reviewedandacceptedwithminorrevisions.TheNPAsarenowwaitingintheregulatoryqueuefortheopeningofaJusticeDepartmentfile.

2. Alanguagelevel6fileassessmentmethodologyandprocesshasbeendeveloped.Thisprocesswillresultintheissueoflanguageproficiencyassessments—level6Frenchand/orEnglishforthemajorityofCanadianlicenceholderswhohavealreadydemonstratedproficiencythroughtraining,flighttestingandthecompletionofwrittenexaminations.ThisprocessisconsistentwiththeICAOSARPsandICAOGuidanceMaterial(Document9��5,Chapter5),andallowsTCtoapplytheassessmentmethodologytocurrentlicenceholdersinadvanceofthe200�implementationdate.

�. AgreementwasobtainedthroughtheCARACprocessandfromtheLPSGmemberstoproceedwiththeapprovalandpublicationprocessoftheNPAstotheCARswiththeunderstandingthatlanguagelevelsandvaliditydateswouldNOTBEPRINTEDonlicences.ThismeansthatthelanguageratingwillbeprintedonthepersonnellicenceindicatingeitherFrenchand/orEnglishlanguageproficiency;however,thelanguagelevelandexpirydatewillnotbedisplayed,thusavoidinganypotentialdiscriminationonthebasisoflanguageproficiencylevel.

4. Adocumentofspecificationsforanaviation-languageproficiencytestingsystemhasbeendeveloped,andprovidesapertinentandspecificframeworkfortestdevelopmentbylanguageprofessionals.Thepurposeofthetestistoprovidereliable,validandpracticalevaluationofpilot/flightcrewlanguageproficiencyinaccordancewiththeICAOlanguageproficiencyrequirementscriteria,aspublishedinICAOAnnex1andtheManual on the Implementation ofICAO Language Proficiency Requirements, Document 9835.

What’s next?AcompanyhasbeenselectedtodeveloptheAviation-LanguageProficiencyTestingSystem.Workhasbegunonthedevelopmentofthelanguageproficiencytest(FrenchandEnglish)andisexpectedtobecompletedinthefallof2006.

TCCivilAviationManagementExecutive(CAMX)hasapprovedthedesignandimplementationofanewlicencebookletformatforpilotandairtrafficcontrollerlicences(decisionrecordofmeetingheldonOctober2�,2005).Thisnewlicencebookletisasecurity-relateddocumentthatimprovestheentirepersonnellicensingprocess,withaconsolidatedandsecurepilotandairtrafficcontrollerlicenceformat,whichincludesthelicenceholder’sphoto.

Asaresultofthisdecision,thelanguageproficiencyrating(LPR)implementationisnowintegratedwiththelicencebookletproject.ThisnewbookletwillnotonlybeusedfortheissueoftheLPR,butalsofortheadministrationofthevalidityperiodoftheLPRincaseswherethedocumentholderhasnotattainedanexpertlevel6.

AdditionalNPAswillberequiredasafunctionofthisdecision,notonlyforthenewlicencebookletimplementation,butalsoforthechangesassociatedwiththesimplifiedendorsementformatoftheLPRonthepilotandairtrafficcontrollerlicence.TheseNPAsarecurrentlyunderdevelopmentandwillbepresentedatthenextCARACPartIVTechnicalCommitteemeeting.

Where can I get more information?FurtherLPRinformationwillbeavailableontheTC,GeneralAviationWebsitelaterthisyear,andyoucanlookforwardtoanin-deptharticleonthenewlicencebookletintheAviation Safety Letter (ASL)soon.

Questions and answers!1. Whyintroduceanewrequirementtoestablish

languagecompetencyofCanadianpilots?IsitbecauseCanadahasanaviationsafetyproblemrelatedtoradiotelephonecommunications?

As a signatory to the ICAO Convention on Civil Aviation, Canada has agreed to implement and maintain standards in accordance with the ICAO Annexes. ICAO has demonstrated that there have been a number of accidents where a significant factor was the inability to communicate adequately by the pilot and the air traffic controller because of a lack of proficiency in a common language. Although there have been no accidents in Canada related to language proficiency, TC acknowledges this identified safety issue.

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

10 ASL4/2006

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

2. DoesthisnewregulationapplytoeveryonewhoholdsapilotlicenceorpermitinCanada?

In accordance with the ICAO standards, these new standards will apply to private, commercial, airline transport pilot and air traffic controller licences, but will NOT apply to any other licences or permits (glider, balloon, gyroplane pilot licences, ultralight, recreational, and student pilot permits).

�. AreFrancophonepilotsobligedtohaveanEnglishlanguageratinginordertobeauthorizedtoflyinCanada,otherthaninQuebecandintheNationalCapitalRegion?

Canadian licences issued after March 5, 2008, will require either a French or an English language rating (or both). There is no airspace restriction attached to the language rating while operating in Canada; French-speaking pilots with a French language rating will have the same freedom to fly in Canada as they do presently.

4. WillCanadianairspacehavedesignatedlanguagezones?

There are no airspace designations or airspace restrictions, and none are planned in association with this rating.

5. DoforeignpilotshavetospeakeitherEnglishorFrenchbeforetheyareallowedtoflyinCanada,includingQuebec?

The provisions of the ICAO Convention on Civil Aviation and Annexes apply to foreign operators and foreign pilots operating in Canada. As of March 5, 2008, foreign pilots must be able to communicate with the air traffic services (ATS) facility on the ground in Canada. These pilots must, therefore, hold licences with language ratings appropriate to the service provided by the ATS facility on the ground.

6. WilltheUnitedStatesalsobeimplementingalanguageproficiencyregulation?

The United States has indicated their full support for the ICAO SARPs, and is currently developing an implementation plan.

�. WhatisthecosttothepilotsforobtainingtheLPRendorsementontheirlicence?

Approximately 96 percent of licence holders in Canada will receive either a French or English (or both) language rating from TC free of charge prior to March 5, 2008.

Foreign citizens holding Canadian licences, as well as Canadians requiring formal language testing after March 5, 2008, may incur some cost. Details of the implementation are being developed.

�. Whowillberesponsibleforevaluatinglanguageproficiencyamongpilots—TCortheaviationindustry?

TC will develop the standards for language evaluation and will delegate the application of those standards to the industry.

9. WillfrancophonepilotswishingtoobtainanLPRinEnglishbechargedafeeiftheywishtohavebothanEnglishandFrenchrating?

Canadian francophone licence holders requesting an English rating before March 5, 2008, may submit evidence of their competency in English to TC. This process will not involve any cost to the pilot. This will apply only in cases where TC has not been able to establish the pilot’s English language competency through a review of available records.

10. Doyounotthinkthat,asaresultofthisnewregulation,francophonepilotswillbeatadisadvantagecomparedtotheiranglophonecolleagues,withrespecttoemploymentopportunitiesbecausetheyhavelessthanalevel6Englishlanguageratingendorsedontheirpilotlicence?

To address this concern, TC has agreed not to endorse a language level on the licence—only language proficiency in English or French (or both).

11. Inordertoavoidtheexpenseoflanguagetraining,doyouthinkthataircarrierswillbeforcedtodemandalevel6languageratingfromallpilotsapplyingforemploymentwiththem?

Since the pilot licence will only have a rating of English or French or both, it could be a matter of company policy to determine whether further training would be warranted because of demonstrated ability in the use of the language.

Manyofyouaskedforinformationonthistopic.Hopefullythisarticleansweredmostofyourquestions.Asstatedearlier,wewillprovidefurtherinformationinthenearfuture.

Invest a few minutes in your safe return home this winter...byreviewingyourknowledgeonairspacerequirementsandproceduresintheTCAIM,sectionRAC2.0.

Visitwww.tc.gc.ca/CivilAviation/publications/tp14371/RAC/2-0.htmtoday!

ASL4/2006 11

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 A03O0171— Controlled Flight into Terrain (CFIT)

OnJuly�,200�,atapproximately09:5�EasternDaylightTime(EDT),aBeech5�TCBaronaircraftcrashedintoLakeOntario,Ont.,approximately�NMsoutheastoftheTorontoCityCentreAirport.Theprivatelyownedandoperatedaircraftwascarryingoutalocalizer/distancemeasuringequipment(LOC/DME)BinstrumentapproachtoTorontoCityCentreAirport,afteraflightfromLansingMunicipalAirport,inChicago,Illinois.Whentheaircraftdidnotarriveattheairport,andfailedtorespondtotransmissionsfromthetower,asearchwascommenced.Patchyfoginthearearesultedinceilingsvariablefromzerotounlimited,andvisibilityfrom1/�miletomorethanonemile.Severalhourslater,theMetropolitanTorontoPoliceMarineUnitfounddebrisonthesurfaceofLakeOntario.TheaircraftwaslocatedthefollowingdaybytheOntarioProvincialPolice,usingasidescansonar.Theaircraftwasessentiallyintact,restingverticallyonitsnoseatadepthof220ft.Thedeceasedpilotwaslocatedintheaftcabinoftheaircraft.Hereceivedminorinjuriesintheimpact,butfailedtoegresstheaircraftforunknownreasons,anddiedasaresultofdrowning.

Recovery operation of the aircraft

Findings as to causes and contributing factors1. Duringthelatterstagesofanon-precisioninstrument

approach,thepilotlostsituationalawareness,specificallyofhisaltitude.Asaresult,hedescended

belowtheminimumdescentaltitude(MDA)andcontinuedacontrolleddescentininstrumentmeteorologicalconditions(IMC)untiltheaircraftstruckthewater.

2. Factorsthatcontributedtothelossofsituationalawarenesswerenon-precisionapproach,poorvisibility,rushedorincompletechecks,levelofinstrumentproficiencyandvisualillusioncreatedbysurface-basedfog.

Finding as to risk1. MinimumaltitudesonCanadaAirPilot(CAP)

approachplatesarepresenteddifferentlyfromminimumaltitudesonU.S.FederalAviationAdministration/NationalAeronauticalChartingOffice(FAA/NACO)approachplates,whichcouldcreateconfusionandcontributetoanunsafeapproach.

TSB Final Report A03W0194—Power Loss and Dynamic Rollover

OnSeptember16,200�,aBell206Bwassupportingadiamonddrillingcrewworkingonthesideofamountainabout�0NMnorthofMayo,Y.T.Thehelicopterwasobserveddescendingtoacreek-bedstaging/refuellingarea.Asitreachedapproximately20ftaboveground,theobserverslostsightofthehelicopterbehindanembankmentandthenheardimpactsounds.Onreachingthelandingsite,theobserversfoundthehelicopterlyingonitsrightsidebetweentwofueldrums.Thehelicopterhadsustainedsubstantialdamage,andthepilot,thesoleoccupant,hadbeenfatallyinjured.Thetimeoftheoccurrencewasapproximately12:05PacificDaylightTime(PDT).Therewasnopost-crashfire.

Accident investigators examine the scene of the accident

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

12 ASL4/2006

AnalysisDamagetotherotordrivesystemandthemastindicatedlowornopowerbeingtransmittedfromtheengineatimpact,althoughthethrottlewasfullyopen,andtheenginewasoperating.Theamountoffuelonboardpriortotheoccurrencecouldnotbedetermined.However,thequantityhadbeenplannedtobeneartheminimumsrequiredbyregulations.Fuelconsumptionwouldhavebeenconsiderablyhigheratthehigherpowerrequirementsduringslingingoperations,andthereservequantitymayhavebeenlessthanoriginallyplanned.Anadditionalshuttleofaloadofhydrauliccomponentswouldhavefurtherreducedthereservefuelquantitybyatleast2.0gal.Thepilothadabruptlydepartedfortherefuellingsite,whichmaysuggestalowfuelstate.

Withanaftlongitudinalcentreofgravity(CG)andarightlateralCG,thehelicopterwasprobablyinatail-low,right-side-lowattitude.Whencombinedwiththelateralmanoeuvringtowardtherightduringtheapproach,thisattitudewouldhaveincreasedthetendencyforthefueltomigratetotherightrearcornerofthefueltank.Thefuelpumpintakesprobablyunported,causinganinterruptioninthefuelflowandalossofpower.Withtheenginerelightsystemarmed,anyresumptionoffuelflowcouldresultinanenginerelight,orseriesofrelights,butwithoutthetimerequiredfortheenginetoaccelerateandtransferauseableamountofpowertotherotordrivesystempriortoimpact.

Amomentarypowerinterruptionatacrucialmomentmayhavedistractedthepilot,andcausedthehelicoptertoovershoottheintendedtouchdownareaandcontinuelaterallyontothefueldrum.Thepilotwaswearinghishelmet;however,theseverityoftheimpactcausedthehelmettofailaroundthesidewheretheshellhadbeencutawaytoaccommodatetheheadphoneearpiece.Afull-shellhelmet,whichhastheearpieceinsidetheshell,wouldhavebeenstructurallystrongerandaffordedbetterprotection.

Finding as to causes and contributing factors1. Thehelicoptercrashedduetoadynamicrolloverthat

resultedfromthelandinggearskidcontactingthefuelpumpthatwasprojectingfromthetopofafueldrum.Itcouldnotbedeterminedwhythehelicopterstruckthefuelpump/drum.

Findings as to risk1. Thepilot’sopen-earpiecetypehelmetdidnot

providethelevelofsideimpactprotectionthatafull-shelltypehelmetwouldhave,andthismayhavecontributedtotheseverityoftheinjuries.

2. Theoperationofahelicopteratorbelowminimumfuellevelsisconducivetounporting,whichmayresultinasuddenlossofpoweratacrucialmoment.

Safety action takenTheoperatorhasadviseditspilotsnottopurchaseorutilizetheoldermilitarystyleofopen-earpiecehelmets,sincetheopen-earpiecetypehelmetdoesnotprovidethelevelofside-impactprotectionthatafull-shelltypehelmetwouldprovide.Asaresultofthisinvestigationindicatingunportingasarisk,theoperatorhasissuedamemotoallflightcrewsmandatingaminimumindicatedfuelloadof15U.S.gallonsduringallBell206operations.

TSB Final Report A04H0001—Loss of Control

OnJanuary1�,2004,aCessna20�BCaravanwasonaflightfromPeleeIsland,Ont.,toWindsor,Ont.,withonepilotandninepassengersonboard.TheaircrafttookofffromRunway2�atapproximately16:��EasternStandardTimeandusedmostofthe��00-ftrunwayforthetake-offrun.ItthenclimbedoutataveryshallowanglewhileturningnorthoverthefrozensurfaceofLakeErie,towardWindsor.Theaircraftstruckthesurfaceofthelakeapproximately1.6NMfromthedepartureendoftherunway.All10personsonboardwerefatallyinjured.

4250’N

82 40’W

Search Area

Crash Site

PELEE

ISLAND

RWY09/27

N

Map of crash location

Findings as to causes and contributing factors1. Attakeoff,theweightoftheaircraftexceededthe

maximumallowablegrosstake-offweightbyatleast15percent,andtheaircraftwascontaminatedwithice.Therefore,theaircraftwasbeingflownsignificantlyoutsidethelimitationsunderwhichitwascertifiedforsafeflight.

2. Theaircraftstalled,mostlikelywhentheflapswereretracted,atanaltitudeorunderflightconditionsthatprecludedrecoverybeforeitstrucktheicesurfaceofthelake.

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

ASL4/2006 1�

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

�. Onthisflight,thepilot’slackofappreciationfortheknownhazardsassociatedwiththeoverweightconditionoftheaircraft,icecontamination,andtheweatherconditionswasinconsistentwithhispreviouspractices.Hisdecisiontotakeoffwaslikelyadverselyaffectedbysomecombinationofstressandfatigue.

Findings as to risk1. DespitetheabbreviatednatureofaSeptember2001

audit,thenextauditoftheoperatorwasnotscheduleduntilSeptember2004,attheendofthe�6-monthwindow.

2. TheinternalcommunicationsatTransportCanadadidnotensurethattheprincipaloperationsinspectorresponsiblefortheairoperatorwasawareofthePeleeIslandoperation.

�. ThestandardpassengerweightsavailableintheAeronautical Information Publication(A.I.P.)atthetimeoftheaccidentdidnotreflecttheincreasedaverageweightofpassengersandcarry-onbaggageresultingfromchangesinsocietal-widelifestylesandintravellingtrends.

4. Theuseofstandardpassengerweightspresentsgreaterrisksforaircraftunder12500lbsthanforlargeraircraftduetothesmallersamplesize(ninepassengersorless)andthegreaterpercentageofoverallaircraftweightrepresentedbythepassengers.Theuseofstandardpassengerweightscouldresultinanoverweightconditionthatadverselyaffectsthesafetyofflight.

5. TheCessnaCaravande-icingbootcoversuptoamaximumof5percentofthewingchord.Researchonthiswinghasshownthaticeaccumulationbeyond5percentofthechordcanresultindegradationofaircraftperformance.

6. AtthePeleeIslandAirport,theairoperatordidnotprovidetheequipmentthatwouldallowanadequateinspectionoftheaircraftforiceduringthepre-flightinspectionanddidnotprovideadequateequipmentforaircraftde-icing.

�. RepetitivecharteroperatorsarenotconsideredtobescheduledairoperatorsundercurrentTransportCanadaregulations,and,therefore,eventhoughthecharterairoperatormayprovideaservicewithmanyofthesamefeaturesasascheduledservice,TransportCanadadoesnotprovidethesamedegreeofoversightasitdoesforascheduledairoperator.

�. Areviewofthe Canadian Aviation Regulations (CARs)regardingsimulatortrainingrequirementsindicatesthatthereisnorequirementtoconductrecurrentsimulatortrainingifcurrencyand/orpilotproficiencychecks(PPC)donotlapse.

9. Commercial Air Service Standard�2�.91(2)doesnotclearlyindicatewhetherthereisarequirementforsimulatortrainingfollowingexpirationofaPPC.

10. Incorrectinformationonthepassengerdoorplacards,anincompletesafetyfeaturescard,andthefactthattheoperatingmechanismsandoperatinginstructionsfortheemergencyexitswerenotvisibleindarknesscouldhavecompromisedpassengeregressintheeventofasurvivableaccident.

11. Thedogsbeingcarriedontheaircraftwerenotrestrained,creatingahazardfortheflightanditsoccupants.

Safety actions taken (The following are only a selection of the major safety actions taken)

Operator Theoperatorinstalledanaircraftde-icingmachineonPeleeIslandimmediatelyfollowingtheaccident.

Thecompanynowemploysasecondcrewmemberonallpassengerflights.

Inanefforttoreduceperceivedmissionpressureonaircraftcaptains,thechiefpilotnowreviewstheweathereachdaytoforecastdelaysorcancellations.

Thechiefpilotisreviewingeveryflightplantoverifythattheweightandbalanceprogramisbeingfollowed.

Transportation Safety Board of Canada (TSB)TheTSBidentifiedrisksassociatedwithusingstandardweights,andissuedtwoaviationsafetyrecommendations:

TheDepartmentofTransportrequirethatactualpassengerweightsbeusedforaircraftinvolvedincommercialorairtaxioperationswithacapacityofnineorfewerpassengers.(A04-01)

and

TheDepartmentofTransportre-evaluatethestandardweightsforpassengersandcarry-onbaggageandadjustthemforallaircrafttoreflectthecurrentrealities.(A04-02)

Transport CanadaInresponsetoA04-01,TransportCanadaindicatedthatitcontinuestoreviewthestandards,andthatoneoftheoptionsunderconsiderationistorequiretheuseof

•

•

•

•

14 ASL4/2006

actualpassengerweights.TheTSBfeelsthepresentrisksassociatedwithusingstandardweightswillremainuntilanewstandardisputinplacetoensurethatactualweightsareusedforaircraftcarryingninepassengersorless.InresponsetoA04-02,TransportCanadare-evaluatedthestandardweightsforpassengersandcarry-onbaggageand,effectiveJanuary20,2005,adjustedthemforallaircrafttoreflectcurrentrealities,andamendedtheguidancematerial.

The Federal Aviation Administration (FAA)TheFAAreleasedacomprehensiveguidethatprovidesairoperatorsoflarge,medium,andsmallcabinaircraftwithoptionsforcalculatingpassengerweights,toreflectcurrentrealities.

TheFAAissuedAirworthiness Directive(AD)2005-0�-01,effectiveMarch29,2005,andsubsequentlyissuedAD2006-06-06,effectiveMarch24,2006,whichsupersedesAD2005-0�-01.TheADwastheresultofseveralaccidentsandincidentsinvolvingtheCessna20�and20�Boperatinginicingconditions.ThepurposeoftheADistoensurethatpilotshaveenoughinformationtopreventlossofcontroloftheaircraftwhileinflightduringicingconditions.TheADisapplicabletoCessna20�aircraftinCanada.Forthemostaccurateandcurrentinformation,consult:www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/MainFrame?OpenFrameSet.

On March 24, 2006, TC issued Service Difficulty Alert 2006-01R2,—Cessna20�(Caravan)Series-OperationIntoKnownorForecastIcingConditions—which addresses the FAA AD and which makes further recommendations to Canadian Cessna Caravan C208 operators. For details consult:www.tc.gc.ca/CivilAviation/certification/continuing/Alert/2006-01.htm.Readers are encouraged to read the full report of this major investigation on the TSB Web site. —Ed.

TSB Final Report A04A0057— Wing Scrape During a Rejected Landing

OnMay2�,2004,aBoeing�2�-225freighterwasonanightcargoflightfromHamilton,Ontario,toMoncton,NewBrunswick.Thefirstofficerwasperformingthepilotflying(PF)duties,andthecaptainwasconductingalinecheckonthefirstofficer.TheenrouteportionoftheflighttoMonctonwasuneventful.OnarrivalatMoncton,theflightcrewconductedtwounsuccessfulapproachesindarknessandpoorweatherconditionsbeforelandingonthethirdapproach.Apost-flightinspectionoftheaircraftinMonctonfoundvisibledamageontheleftwing.Thetipoftheleftoutboardleadingedgeflapandtheoutboardtrailingedgeflap“canoe”wereabraded.Thedamagewas

consistentwithaslightcontactwiththerunway.Availableinformationindicatesthatthewingscrapeoccurredat02:41AtlanticDaylightTimeduringtherejectedlandingafterthesecondapproach.Theaircraftwasatapitchangleof5˚noseup,14˚ofleftbank,andaderivedaircraftheightabovegroundofapproximately26ft.Therewerenoinjuries.

Close-up photograph of left outboard leading edge flap damage

Findings as to causes and contributing factors1. Thecaptain’sdecisiontointerveneandrejectthe

landingonthesecondapproachwastoolatetopreventtheaircraftfromcontactingtherunwaysurface.

2. Theaircraft’swingswerenotleveleduntilafterthenosewasraised,resultingintheleftwingcontactingtherunway.

Finding as to risk1. Theforecasteddeterioratingweatherwasnotdetected

orreportedinatimelymanner.

Other findings1. Theaircraftlandedwithlessthantheminimum

diversionfuelrequiredintheFlight Operations Manual(FOM);however,thedecisiontocarryoutthethirdapproachcouldbeconsideredreasonableinthecircumstancesfacedbythecaptain.

2. Theweatherconditionsreportedtothecrewwerenotrepresentativeoftheactualweatherconditionsattheairport.Thiscontributedtotheplanningerrorsmadebythecrewandtheunnecessarilylowfuelstate.

Safety action takenThesectiondealingwithminimumrequireddiversionfuelintheoperator’sFOMhasbeenamended.Theamendedversionreadsasfollows:

“Upon reaching MIN DIV fuel, the flight MUST proceed immediately to the alternate airport.”

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

ASL4/2006 15

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

TransportCanadaisproposingchangestotheCanadian Aviation Regulationsthatwilldefinetheuseofpilot-monitoredapproachesaspartofthenewapproachbanregulations.

Inresponsetothisoccurrence,TransportCanadaregionalstaffconductedaninspectionoftheweatherobservationserviceatMonctononOctober5,2004.Asaresultofthefindings,thefloodlightsneartheceilingprojectorwereadjustedtoreduceinterferencewithweatherobservations,andNAVCANADAhasimplementednewprocedurestoimprovethecommunicationofinformationrelatedtochangingweatherconditionsbetweentheweatherofficeandthetowerpersonnel.

TSB Final Report A04P0240— Blade Strike and Rollover

OnJune25,2004,at20:20PDT,thepilotofaEurocopterAS�50B2(Astar)helicopterlandedonarecentlypreparedmountainsidehelipad,5NMwestoftheextinctFlourmillVolcano,B.C.,at5200ftelevation.Withthehelicopterstillrunningatflyingrotorrpmandlightontheskids,fourpassengersboardedwithasmallamountofpersonalequipmentandpreparedfortakeoff.Thepilotincreasedcollectivepitchtobringthehelicopterintothehover,buttheengineparameterswereapproachingtheirlimits,andhediscontinuedthetakeoffandloweredthecollective.Theleftrearpassengergotout,andthepilotagainraisedthecollective,liftingthehelicopterintoastable5-fthoveroverthepad.Satisfiedthistimewiththeenginereadings,thepilotincreasedcollectivepitchandclimbedtoapproximately20ftwhilepurposelyallowingthenosetoswingtothelefttoturndownhillforthetransitionintoforwardflight.

Asthehelicopterturnedthrough100°ofleftturn,thelowrotorrpmwarninghornsounded,andthepilotdecidedtoreturntothepad.Heallowedtheleftturntocontinuebut,bythetimethehelicopterreturnedtotheoriginalheading,ithaddriftedapproximately20ftdownhillfromthepadandwasstilldescending.Themainrotorblades

thenstruckalargetreestumpadjacenttothepadandthehelicopterrolledover,comingtorestonitsleftside,almostinverted.Thethreepassengersquicklyescapedfromthehelicopter,butthepilotdelayedhisexittoshutdowntheengine,whichhadcontinuedtorun.Afterhehadsecuredtheengine,fuelvalve,andelectricalswitches,thepilotexitedthecockpit.Thefouroccupantsreceivedminorinjuries,andthehelicopterwassubstantiallydamaged.Theemergencylocatortransmitter(ELT)activatedautomaticallyatrollover.Therewasnofire.

Findings as to causes and contributing factors1. Thehelicopterclimbedverticallyoutofthehoverat

near-maximumgrossweight,itencountereddown-flowingair,whichresultedinasituationinwhichtherewasinsufficientpowertomaintaincontrolledflight.Asaresult,therotorrpmdecayedrapidly,andthehelicopterdescendedinanoverpitchedconditionuntilitstrucktheterrain.

2. Thephysicalcharacteristicsofthelandingareadidnotallowasuccessfullandingfollowingtherotorrpmdecayanduncommandeddescent.

TSB Final Report A04C0174—Landing Gear Collapse and Runway Excursion

OnSeptember21,2004,aMetroIIIaircraftdepartedStonyRapids,Sask.,withtwocrewmembersandninepassengersonaday,visualflightrules(VFR)flighttoLaRonge,Sask.OnarrivalinLaRonge,atapproximately14:10CentralStandardTime(CST),thecrewcompletedtheapproachandlandingchecklistsandconfirmedthegear-downindication.TheaircraftwaslandedinacrosswindonRunway1�andtoucheddownfirmly,approximately1000ftfromthethreshold.

Bellcrank assembly with a part number 5453032-1 roller on the left and a YCRS-12 bearing on the right

Ontouchdown,theleftwingdroppedandthepropellermadecontactwiththerunway.Theaircraftveeredtotheleftsideoftherunway,despitefullrudderandailerondeflection.Thecrewappliedmaximumrightbrakingandshutdownbothengines.Theaircraftdepartedtherunway

16 ASL4/2006

andtraveledapproximately200ftthroughtheinfieldbeforethenoseandrightmaingearweretornrearwards;theleftgearcollapsedintothewheelwell.Theaircraftslidonitsbellybeforecomingtorestapproximately�00ftoffthesideoftherunway.Threeofthepassengerssufferedminorinjuriesfromthesuddenstopassociatedwiththefinalcollapsingofthelandinggear;theotherpassengersandthepilotswerenotinjured.

Findings as to causes and contributing factors1. Anincorrectrollerofasmallerdiameterandtype

wasinstalledontheleftmainlandinggearoutboardbellcrankassembly,contrarytocompanyandindustrypractice.

2. Thesmallerdiameterrollerreducedtherequiredriggingtolerancesforthebellcrank-to-camassemblyinthedown-and-lockedposition,andallowedtherollertoeventuallymovebeyondthecamcutoutposition,resultinginthecollapseoftheleftlandinggear.

�. Ariggingcheckwasnotcarriedoutafterthereplacementofthebellcrankroller.Suchacheckshouldhaverevealedthatneithertheinboardnoroutboardbellcrankassemblymettheminimumriggingrequirementsforproperengagementwiththepositioningcam.

Safety action takenAftertheoccurrence,theoperatorcommissionedanindependentsafetyauditofitscompleteoperation.Allmaintenancestaffoftheapprovedmaintenanceorganization(AMO)responsibleforthisoperatormettoreviewthecompany’smaintenanceproceduresoutlinedinitsmaintenancepolicymanual.Thefollowingpolicywasreinforced:“Nooneistoinstallanypartsonanyaircraftwithoutfirstreferringtotheappropriatepartsandservicemanualstoensurecorrectpartnumberandalsothattheintegrityoftheaffectedaircraftsystemisstillinplace.”

TSB Final Report A04C0162—Flight Into Adverse Weather—Collision with Terrain

OnAugust26,2004,aPiperPA-2�-2�5aircraftdepartedRoblin,Man.,at20:25CentralDaylightTimeonaVFRflighttoGimli,Man.Theinitialportionofthe

flightwasindaylight,thelatterportionatnight.Theflighttookplaceinuncontrolledairspace,andtherewasnorecordofanycommunicationwithairtrafficservices(ATS)duringtheflight.Theaircraftcrashedinanopenfieldat21:40.Thepilot,thesoleoccupantoftheaircraft,sustainedfatalinjuries,andtheaircraftwasdestroyedbytheimpactandapost-impactfire.

Findings as to causes and contributing factors1. ThepilotcontinuedaseriesofVFRflightsatnight

intoanareaoflimitedsurfacelightingwithknownadverseweatherconditions.

2. Thepilot’sinstrumentflyingskillsweremostlikelynotadequatetosafelycompletethecoursereversalturn,resultinginaninadvertentdescentthatwasnotdetectedandcorrectedintimetopreventimpactwiththesurface.

Finding as to risk1. Thepilotdidnotensurethattheresponsibleperson

whoreceivedtheflightitineraryunderstoodthesearchandrescue(SAR)-notificationrequirements.

Safety action takenOnJanuary25,2005,theTSBsentasafetyadvisorytoTransportCanada,suggestingthatthedepartmentmaywishtoconsideractiontoimproveawarenessamongpilotsoftheneedtoensurethatpersonsresponsibleforflightitinerariesunderstandtheirobligationsconcerningSARnotification.Anarticlewaspublishedinissue2/2005oftheAviation Safety Letter,whichissenttoallCanadianlicensedpilots.ThearticlesummarizedtheoccurrenceandemphasizedtheneedforpilotstoensurethatpersonsresponsiblefortheflightitineraryfullyunderstandtheSAR-notificationrequirements.

TSB Final Report A05C0123—In-Flight Collision During Air Show

OnJuly10,2005,threeaircraftwereengagedinasimulateddogfightingdisplayatMooseJaw/AirViceMarshalC.M.McEwenAirportaspartoftheSaskatchewanAirShow.Thedisplayteamconsistedofthreebiplaneaircraft:aWacoUPF-���,aWolf-SamsonandaPittsSpecial.Agrounddisplayfeaturingajet-poweredtruckwaspartoftheact.Atapproximately16:1�CentralStandardTime(CST),thethreebiplaneswereperformingaseriesofcrossesandchasesinasimulateddogfightscenario.Asthejet-poweredtruckmovedintopositiononthe500-ftshowline,thethreebiplanesenteredamanoeuvrecalled“TheDairyTurn”inpreparationforaseriesofcrossescenteredonthetruck.Duringthemanoeuvre,theWacoandtheWolf-Samsoncollidednearshowcentreataboutthe1500-ftshowline.Bothbiplanescaughtfireandcrashedbetweenthe1500-ftshowlineandtheouterrunway.Bothpilotswere

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

ASL4/2006 1�

Guest Ed

itorial

To the LetterTo

the

Let

ter

Gue

st E

dit

ori

alPr

e-fli

ght

Pre-flight

Rece

ntly

Rel

ease

d T

SB R

epo

rts Recently Released

TSB Rep

orts

killedonimpact,andbothaircraftweredestroyed.Alldebrisfellawayfromthecrowdtowardtheouterrunway.Immediateimplementationofemergencyprocedureskeptspectatorsfrommovingtowardtheburningwreckage.

TheDairyTurnisascriptedmanoeuvre,withtheintentiontocreatetheillusionofaclosecallastwoofthethreeaircraftcrossnearshowcentre,alsoinvolvingthejet-poweredtruckforvisualeffect.Otherdisplayteammembersunderstoodthatthecontractforsafeseparationrequiredthepilotstoestablishvisualcontactwitheachotheratspecificlocationofthemanoeuvreandmaintainseparationvisually.Oneoftheaircrafthadbeenlateonitstrackonoccasionssincethedisplayhadbeendeveloped.Thislatenesshadnotpreviouslycausedanydifficultiesfortheperformers.Themanoeuvrehadbeenrecentlymodified.Whetherthecontractforsafeseparationwasalsorevisedcouldnotbeestablished.

Charred remnants of the air demonstration aircraft

Findings as to causes and contributing factors1. TheDairyTurnmanoeuvrehadbeenmodifiedsuch

thatatemporarylossofvisualcontactcouldoccurimmediatelybeforetheaircraftcrossedflightpaths.Thismodificationmadetimingcriticalandaddedtwopotentialpointsofcollision.

2. Themanoeuvresimmediatelybeforethecollisionindicatedthattheperformershadnotestablishedaclearlyunderstoodcontractfortherevisedmanoeuvre.Theactionsofeachperformernegatedtheactionsoftheother,andneitherpilottookpositiveactiontoregainvisualcontact.

�. ThetimingofthemanoeuvrewaslostwhentheWacoturnedlateatshowcentre.

Finding as to risk1. Thesequentialmanoeuvreinformationprovidedto

TransportCanadawasnotdetailedenoughtoallowathoroughreviewoftheenergymanagementofthedisplay.

TSB Final Report A05Q0157—Flight into Adverse Weather—Collision with Terrain

OnSeptember1,2005,afloat-equippeddeHavillandDHC-2BeaverdepartedtheoutfitterbasecampatSquawLake,Que.,at09:25EDT,withapassengerandafewsuppliesonboard,foraround-tripVFRflighttotwowildernesscamps,Camp2andCampPons.TheweatherinSquawLakewassuitableforvisualflightatthetimeoftakeoff,butwasforecasttodeterioratelaterintheday.

Thepilotcompletedtheflightstothetwocamps,andonthewaybacktoSquawLake,theweatherforcedthepilottomakeaprecautionarylandingonElrossLake,15NMnorthwestofSquawLake.At16:�0,hereportedtothecompanyviahighfrequency(HF)radiothatheintendedtotakeofffromElrossLake,asthereseemedtobeabreakintheweather.Rescueeffortswereinitiatedintheeveningwhentheaircraftdidnotarriveatthebasecamp.Theaircraftwaslocatedat12:�0thefollowingday,4NMfromElrossLake.Theaircraftwasdestroyedbyapost-impactfire.Thepilotsustainedfatalinjuries.

Finding as to causes and contributing factors1. Thepilotattemptedtocrossthemountainridgein

adverseweather,andtheaircraftstalledatanaltitudefromwhichrecoverywasnotpossible.Lossofvisualreferences,strongupdrafts,moderatetosevereturbulenceandpossiblewindshearlikelycontributedtotheonsetoftheaerodynamicstall.

Other finding1. Hadthisbeenasurvivableaccident,rescue

effortsmayhavebeencompromisedbyalackofcommunication.Asatellitephoneprovidesamoreeffectivemeansofcommunicationwheninremoteareas.

Safety action takenOnMarch�,2006,theTSBsentasafetyinformationlettertoTransportCanada,highlightingthecriticalityofflightfollowingcommunicationasitrelatestoSARresponseinremoteareasofthecountry,andindicatingtheeffectivenessofalternatemeansofcommunication,suchassatellitephones.

1� ASL4/2006

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

Accident Synopses

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

—OnFebruary2,2006,aRobinson R44 IIhelicopterwasoperatingfromthePenWestMegaGasPlant,locatedapproximately40NMsouthofRainbowLake,Alta.Thepilotwasmanoeuvringtheaircrafttorefuelbeforecommencingslingoperations,whenthemainrotorbladescameintocontactwiththefueltank.Theaircraftsustainedsubstantialdamagetothemainrotorbladesandpowertrain.Thefuelstoragetanksustaineddamageandwasreportedasleaking.Therewerenoinjuries.TSB File A06W0023.

—OnFebruary�,2006,aprivately-ownedPiper PA-34-200(Seneca II),waslowonapproachtoRunway26LatPittMeadows,B.C.,airport.Theaircraftstruckseveralapproachlightsandafencebeforecomingtorestapproximately200ftshortoftherunwaythreshold.Theaircraftwassubstantiallydamaged,butthepilotwasuninjured.TSB File A06P0018.

—OnFebruary9,2006,aprivately-registeredPA-46 Malibu waslandingonRunway��atLondon,Ont.Duringthetouchdown,theaircraftsuddenlyveeredtotheleft.Thepilotattemptedtocontroltheaircraftbyapplyingrightrudderandbrake,buttheaircraftdepartedtherunwaysurfaceapproximately2500ftfromthethreshold.Duringtherunwayexcursion,theleftmaingearandthenosegearcollapsed,resultinginsubstantialdamagetotheaircraft.Therunwayconditionreport,takenapproximately�5minaftertheoccurrence,was50percentbareanddry,40percenttraceofsnowand10percentice.Therunwayfrictionindexwas0.6�.Therewerenoinjuries.TSB File A06O0036.

—OnFebruary12,2006,aCessna 172Nwithonlyastudent-pilotonboard,wasconductingaflightfromSt-Frédéric,Que.,toMontmagny,Que.Whileenroutetheaircraftflewoveralakeatlowaltitude,andtheleftwinghitsometrees.Thepilotcontinuedtheflightandconductedatouch-and-goatMontmagnybeforereturningtoSt-Frédéric,wheretheaircraftlandedwithoutincident.Theaircraft’sleftwingleadingedgewasdamaged.Theaircraftwillberepairedbeforebeingreturnedtoservice.TSB File A06Q0026.

—OnFebruary1�,2006,aCessna A185F,withonlythepilotonboard,wasconductingalandingonLacSept-Îles,Que.Theaircraftwasequippedwithskis

andretractablewheels.Uponlanding,theaircraftslidapproximately200ftbeforetheleftskibrokethroughthecrustofthesnow.Theaircraftnosedover,andcametoastoponitsback.Beforetakingoff,thepilotinspectedthelakesurfacebyridingupanddownitonasnowmobile,anddecideditwassuitableforlanding.TSB File A06Q0031.

—OnFebruary24,2006,thepilotofanamateur-built Mustang P51D70 tail draggeraircraftwasontherunwayperformingtaxitests,whendirectionalcontrolwaslost,theaircraftveeredofftheleftsideoftherunway,andstruckaditch.Thelandinggearcollapsedandtheaircraftwassubstantiallydamaged.Therewerenoinjuriestothepilot.TSB Report A06O0045.

—OnMarch5,2006,aski-equipped de Havilland DHC-6-100 TwinOtterhadbeenparkedovernightontheapronatLaRonge,Sask.Theaircraftwasstucktothesnow-coveredapron,andatthestartoftaxiing,theskisbrokefreeandtheaircraftabruptlybeganmovingforward.TheaircraftstruckaparkedDHC-2TurboBeaverandaparkedvehicle.TheTwinOttersustainedsubstantialdamagetothenosecone,noselandinggear,bothenginesandpropellers,andthefuselage.TheTurboBeaversustainedsubstantialdamagetotherightwing,andthevehiclealsosustainedsubstantialdamage.Noinjuriesoccurred.TSB Report A06C0041.

—OnMarch5,2006,anamateur-built Murphy Rebel,withthepilotandonepassengeronboard,wasflyingfromBrampton,Ont.,tothepilot’scottageonSturgeonLake,Ont.Thepilotwaslandingthewheel-equippedaircraftonthesnow-coveredlake,andmisjudgedthedepthofsnow.Ontouchdown,theaircraftnosedoverandcametorestinverted.Thepilotreceivedminorinjuries,andtheaircraftwassubstantiallydamaged.TSB Report A06O0060.

—OnMarch19,2006,anMD 369 helicopter descendedintoaconfinedareabelowtreelineinordertodropoffanitemtoagroundcrewmember.Whiletryingtodropofftheitem,thepilottookhishandoffthecollective,theaircraftdriftedofftotheright,makingcontactwiththetopofatreeandseveringpartofthetailboom.Uponlossoftailrotorauthority,thehelicopteryawedtotheright,andthetailboomstruckanothertreeandthenproceeded

ASL4/2006 19

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

tospinoutofcontrolseveraltimes.Thehelicopterfellfromapproximately25to�0ftandspuntotheground,finallylandingonthepilotside.Thepilotwasnotinjured.TSB Report A06P0055.

—OnMarch24,2006,aGrumman Goose G-21AwasdamagedonlandinginHardyBay,PortHardy,B.C.Theaircrafthadlandedinalargebowwakecreatedbyaboat.Theoperatorgroundedtheaircraftaftermaintenanceidentifiedupperwrinklesintheskinabovethefrontwindowsandbentenginemounts.TSB Report A06P0044.

Artist’s impression of aircraft landing on bow wake

—OnMarch2�,2006,aBellanca 7GCBC aircraft,withthepilotandonepassengeronboard,departedPilgramLake,Ont.,forareturntothepilot’shomestrip.ThepilotstoppedtorefuelnearWadesLandingonLakeNipissing,Ont.Whiletaxiingonthefrozenlakesurface,thefrontwheelsbrokethroughtheice.Theaircraftnosedoverandcametorestupsidedown.Thepilotandpassengerwerenotinjured.Therewassubstantialdamagetotheaircraft.TSB Report A06O0077.

—OnApril1,2006,aMooney M-20FaircraftdepartedtheSteinbach,Man.,airportforapleasureflightwiththepilotandonepassengeronboard.DuringfinalapproachforRunway14,theaircraftlandedwiththelandinggearretracted.Thepilotandpassengerevacuatedtheaircraftwithoutinjury;theaircraftsustainedsubstantialdamage.TSB Report A06C0039.

—OnApril1,2006,aCessna 177aircraftdepartedTrail,B.C.,foraVFRflighttoRevelstoke,B.C.,withthepilotandtwopassengersonboard.Thefuelgaugesshowedthetankstobejustunder�/4full.TheaircraftwasnotrefuelledatRevelstoke,andtheflightdepartedforTrailwiththefuelgaugesshowingjustunder1/2full.Onthereturnflight,aheadwindandcloudwereencountered,whichforcedtheaircrafttobeflownataloweraltitudeandonanindirectroutebecauseofterrain.SinceitappearedthattheaircraftdidnothaveenoughfueltoreachTrail,adiversiontoCastlegar,B.C.,wasattempted.About11NMnorthoftheCastlegarairport,theenginestoppedfromfuelstarvation.Thepilotset

upforaforcedlanding,butduringtheapproachtohischosenfield,theaircraftstalledandlandedhard,breakingtherightmainwheelandsustainingsubstantialdamage.Thepilotsustainedminorinjuries,andthepassengerswereuninjured.TSB Report A06P0046.

—OnApril4,2006,aBeech 200wasconductingaflightbetweenLaRomaine(CTT5)andNatashquan(CYNA),withtwocrewmembersonboard.Whiletheaircraftwasenroute,atanaltitudeof2000ft,themaindoordetachedfromtheaircraft.Giventheshortdistancebetweenthetwoairports,thecrewdecidedtocontinueontoNatashquan.Theaircraftlandedwithoutincident.Thedoorhadnotbeenlockedproperlybeforedeparture.TSB File A06Q0060.

—OnApril�,2006,anAS 350 B1 helicopterhaddroppedoffsixskiersatopa5500-ftmountain,andwasdescendingatabout2000ft/mintowardalandingareaatabout1�00ft.Whenthepilotbegantopullincollectivepitchtoarresttherateofdescentpriortolanding,theenginebegantoloosepowerandthelowrotorrpmwarninghornbegantosound.Thehelicopterdescendedpasttheintendedlandingsitetoanunobstructedareaabout150ftfurtherdownthemountain,whereitlandedhardonsnow-coveredground.Themainrotorsseveredthetailboom,andonemainrotorbladewasshed.Afterexitingtheaircraft,thepilotnotedtheenginewassmokingheavilyandextinguisheditusingahand-heldextinguisherandsnow.Theengineexhauststackwasdamagedfromtheinside,andcontainedmetaldebris.TSB Report A06P0051.

—OnApril19,2006,aDHC3onskisinboundfromChibougamau,landedontheicerunwayatLacLagopède.Duringthelandingroll,theaircraftwasunabletostopintime,andstruckanotherDHC�,whichwasparkedontherunway,withtheengineshutdown.TheleftwingleadingedgeofthefirstDHC�wassubstantiallydamaged.TherightwingofparkedDHC�wasrippedoffinthecollision.Noneoftheoccupantsofeitheraircraftwasinjured.TSB File A06Q0070.

—OnApril24,2006,aRobinson R44 helicopterwaspreparingtodepartfromTerrace,B.C.Theenginewasrunning,andtherotorwasturningwhileasecondcompanypilotwasloadingfuelcontainersintothecargocompartment.Thepilot-in-command,whowastheonlypersononboard,gotoutofthehelicoptertohelpwiththeloading.Whilethepilotwasoutside,thehelicopterbegantoliftoff,rolledontoitsleftside,andcollidedwiththeground.Therewassubstantialdamagetothehelicopter,butnoinjuriesorfire.TSB Report A06P0064.

20 ASL4/2006

winter operations Near Repeat of Mirabel De-Icing Mishap ...................................................................................................................... page 20Cold Weather Altimeter Error—Getting Cold Feet? ..................................................................................................... page 22Storage, Labelling, Handling and Application of De-/Anti-Icing Fluids in Canada .................................................. page 24How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions .......................................... page 27

Near Repeat of Mirabel De-Icing Mishap The following is a summary of an incident in the central de-icing facility (CDF) at the Macdonald Cartier International Airport (CYOW) in Ottawa, Ont., and was graciously provided by the CDF management team, which did its own investigation with hopes of preventing a reoccurrence. It brings back memories of the January 21, 1995, Mirabel, Que., tragedy, when a Boeing 747 departed the de-icing facility early and three de-icing operators in the cherry-pickers were killed when their baskets were tipped to the ground by the large aircraft. The Mirabel report can be found on the TSB Web site as file A95Q0015. —Ed.OnDecember�,2005,aRegionalJetCL600wasbeingde-icedintheCDFatCYOW,inpreparationforascheduledflight,withbothenginesoperating.Twode-icingvehicleswereinpositionatthetailoftheaircraft,oneoneachsideoftheaircraftwithboomsraisedandintheprocessofde-/anti-icing.Theflightcrewreportedhearingthattheflightwas“clear.”ArequestwasmadetoICEMAN(theCDFcoordinator)fordepartureinstructions.ICEMANissueddepartureinstructionstotheflightcrew.Theaircraftexitedthede-icingbayandproceededonthewesttaxilane.Thehorizontalstabilizersoftheaircraftnarrowlymissedcontactingthede-icingvehiclebooms.Thede-icingvehiclesandpersonsinthebucketsoftheboomsdidexperience“jetblast.”Therewerenoinjuriestotheindividualsinthebucketsordamagetothede-icingvehicles.

Beforedeparture,theflightcrewwasinstructedtotaxitotheCDFandcontactICEMANonfrequency122.925.At16:06EasternDaylightTime(EDT),theflightwaspositionedinade-icingbaywheretwode-icingvehicleswerewaiting,andwasinstructedtocontactSNOWMAN(thede-icingcrew)on1�1.0�5.CommunicationsbetweenthecaptainandSNOWMANestablishedthattheaircraftwasconfiguredforde-icingoperations.Theoperationwascommenced,andthevehicleoperatorscommunicatedwitheachotheron1�1.0�5.

At16:21EDT,theflightcrewcontactedICEMANtoinformhimthatde-icingwascomplete,andtorequestdepartureinstructions.Afterrequesting,andreceiving,verbalconfirmationfromtheflightcrewthatallstaffandequipmentwereawayfromtheaircraft,ICEMANgavedepartureinstructionstotheflightcrew,toexittheCDF(viaxyzroute),andtocontactgroundcontrolon121.90.Theaircraftproceededasinstructed.Atthattime,thede-icingvehicleswerede-icingthehorizontalstabilizers,positionedoneithersideof,andperpendicularto,thefuselage,andforwardofthehorizontalstabilizers.Immediatelyafterthis,ICEMANwascontactedbyoneofthede-icingvehicles,informinghimthatde-icinghadnotbeencompletedandthatbothvehicleswerede-icingthetailoftheaircraftatthesametimeithadexitedBay4.

TheflightcrewreportedthatSNOWMANcommunicatedtothem:“Yourholdovertimesstarted�0secondsago.Youareclear.”Afterreceivingaconfirmationofde-icingfluidmixturesfromSNOWMAN,theflightcrewalsoreportedhearingSNOWMANreaffirm:“Youareclear,contactICEMANon122.92fortaxi.”Inaddition,theflightcrewreportedseeingSNOWMANgiveawavewithhislefthand,followedbyadepartureofthede-icingvehiclefromthearea.Theflightcrewreportedlookingleftandrighttoconfirmtheareaaroundtheaircraftwasclear.Subsequently,theflightcrewrequested,andreceived,departureinstructionsfromICEMAN.Atthetimeofthesetransmissions,theelapsedtimesincethebeginningoftheoperationmatchedthetimeusuallyrequiredforthiskindofde-icingoperation.

Above anything else, de-icing operations require clear and precise communications between all involved

Thede-icingstaffreportedthattheyreceivedarequestfromtheflightcrewregardingfluidmixtures,andreportedalsothatthephrase“youareclear”wasusedduringthede-icingoperation.Whilethephrase“youareclear”ispartofthecommunicationstandardoperatingprocedures(SOP)forde-icingoperations,itcouldnotbedeterminedatwhattimeduringthede-icingoperationthishadoccurred.Otherthanthefactualhistorydetails,thede-icingstaffsaidthiswastheonlyreportedcommunicationsbetweenthemandtheflightcrew.

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

ASL4/2006 21

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

Immediatelyafterthis,theaircraftengineswereheardtoincreasethrustandtheaircraftbegantomoveforward,exitingBay4.

AnalysisTheVHFradiosintheaircraftandde-icingvehiclesfunctionednormally;however,therewasconfusionincommunicationsbetweentheflightcrewandSNOWMANthatresultedinthecaptainbelievingthatthede-icingwascompleted.

Decision to taxi AccordingtotheInternationalCivilAviationOrganization(ICAO),thefollowinginformationmustbegiventotheflightcrewoncompletionofde-icing:thetypeoffluidused,thetimeofthelastapplication,andconfirmationthattheaircraftcomplieswiththecleanaircraftconcept.Theflightcrewreleasedthebrakesundertheassumptionthatthisinformationhadbeenreceived.Theflightcrewreportedhearingthewords“youareclear”(de-icingcompleted).Althoughthismessagewasnotprecededbytheflightcall-signorthede-icingcrewcall-sign,theflightcrewreportedhearing“youareclear”twice.Thedurationoftheoperationuptothatpointmatchedthetimeusuallyrequiredforthistypeofde-icing.Inaddition,theflightcrewreportedseeingawaveofahandfromSNOWMANandsubsequently,thevehicledepartingthevicinityoftheaircraft.Theflightcrewassumedthede-icingcrewhadleftthefrequencyanddepartedthearea.TheflightcrewthenadvisedtheICEMANthattheaircraftwasreadytotaxi,and,indoingso,conveyedtotheICEMANthatde-icingwascompletedandtheaircraftwasfreeofobstruction.Relyingonthatinformation,ICEMANindicatedtotheflightcrewtheirassignedroutefortaxiing.Theflightcrewfurtherinterpretedtheissuanceoftaxiinstructionsasconfirmationthattheaircraftwasfreeofobstructions.

Standard phraseologyAccordingtotherulesofstandardphraseology,toavoidconfusion,radiomessagesmustbeprecededbythereceivingstationcall-sign,followedbythesendingstationcall-sign.Whiletheserulesmaynotapplytointerphonecommunications,the“open”natureofVHFradiocommunicationsrequiresthattheinternationalrulesofradioprocedurebefollowed.Inthiscase,theflightcrewreportedhearingthewords“youareclear”andmadeanumberoferroneousassumptions:thattheradiotransmissionwasdirectedatthem;thatthede-icingoperationwascompleted;andthatallequipmentandpersonnelwereawayfromtheaircraft’staxipath.Coordination of communications Duringde-icingoperations,theoperatorsofbothde-icingvehiclescommunicatedwitheachotheron1�1.0�5,

andalsowiththeflightcrewonthatsamefrequency;thisallowedtheflightcrewandthede-icingstafftobecomeconfusedduringconversations.

Control of de-icing area TheCDFcoordinator(ICEMAN)performedhistasksinaccordancewithestablishedproceduresandhisassignedresponsibilities.Heguidedtheaircraftuntilitwasstoppedatitsde-icingposition.Theaircraftcamefullyundertheresponsibilityofthecaptainafteritwasstoppedforde-icing.Beforeissuingtaxiinstructionstotheaircraft,ICEMANverifiedthatthetaxiwaywasclear.Itwasnothisresponsibilitytoconsulttheflightcrewandde-icingpersonneltodeterminewhetherde-icingoftheaircraftwascompleteandtheaircraftwasreadytotaxi.Thatresponsibilitywasassumedbytheflightcrewwhentheydeclaredtheaircraftreadytotaxi.

ThefactthatICEMANissuedtaxiinstructionswhende-icingwasnotcompletedindicatesthathewasnotawarethatde-icingwasinprogress.Althoughhefullydischargedhisresponsibilities,ICEMANprobablydidnothaveenoughinformationorsufficienttoolstoaccuratelyassessthesituationintheCDF.

Marshaller SNOWMANperformedthedutiesofmarshallerandtruckdriver.Hewasnotinapositiontopreventtheaircraftfromadvancing,giventhathewasbehindtheaircraft.Inaddition,SNOWMANwasnotmonitoringtheICEMANVHFfrequencyof122.925.

Severalaircarriersprefertoplaceamarshallerinfrontoftheaircrafttominimizethepossibilityoftheaircraftmovinguntilthede-icingprocedureiscompleteandallpersonnelandequipmentaresafelyoutoftheway.Somecarriersutilizeaninterphonecordpluggedintotheaircrafttomaintainconstantcommunicationbetweenthegroundcrewandtheflightdeck.Thisprocedureeliminatestheriskofconfusionbetweenflightcrew/marshallercommunicationsandotherVHFcommunications.Thede-icingcontractorhadnotchosenthedirectinterphonecordmethodofcommunicationbecauseitwasfeltthattheareaaroundtheaircraftwastoodangerousanenvironmentinlightoftheslipperyfootingconditionsduetotheglycol,particularlywiththeenginesrunning.

Coordination between flight crew and flight attendants Thepilotsdidnotreportconsultingwiththecabincrewbeforereleasingthebrakes.Giventhatthepilotscouldnotseetheaftsectionoftheaircraftfromtheflightdeck,andtheydidnotseeifthede-icingvehicleshadinfactdepartedthearea,consultingtheflightattendantswas

22 ASL4/2006

aconceivableandreasonableoptioninthisparticularsituation.

Insummary,itwasdeterminedthattheflightcrewstartedtotaxitheaircraftbeforeitsperimeterwasfreeofobstruction,followingconfusionintheradiocommunications.

Findings Theflightcrewandde-icingstaffdidnotusestandardaeronauticalterminologyandphraseologyonsomeoccasions.

TheflightcrewassumedthatthereportedmessageSNOWMAN“youareclear”meantthatthede-icingwascompleted.

Thelineofsightfromtheflightdeckofthetailsectiondidnotallowtheflightcrewtobecertainifthede-icingvehicleswereawayfromtheaircraftinthevehiclesafetyzones.

ICEMANdoesnothavealineofsightoftheentireCDFatalltimes.

Followingconfusionintheradiocommunications,theflightcrewstartedtotaxitheaircraftbeforeitsperimeterwasfreeofobstructions.

•

•

•

•

•

SNOWMANwasnotinapositiontopreventtheaircraftfromadvancing,giventhathewasbehindtheaircraftwherehecouldnotbeseenbytheflightcrew.

Severalaircarriersfavourhavingamarshallerinfrontoftheaircraftandusingtheinterphoneforgroundcommunicationsduringde-icing.Thisde-icingoperatorusestheVHFradiotocommunicatewiththeflightcrewduringde-icingoperations.

Safety action takenClearcommunicationsbetweenflightcrewsandde-icingstaffwasthekeyrecommendation.Allde-icingprovidersandallaircraftoperatorsmustreviewprocedureswithafocusoncommunication:protocols,practicesandphraseologytobeused.Inparticular,thereshouldbeanexclusionoftheword“clear.”Furthermore,theinvestigationrecommendedthatradiocommunicationsbetweenstaffofde-icingoperatorsbeconductedonaseparate,discretefrequencyfromthefrequencyusedtocommunicatewiththeflightcrew.

TheCDFmanagementteamreviewedandmadechangestotheCDFSOPs.TheproceduresindicatethatbothvisualandverbalcommunicationmustbereceivedandacknowledgedbyaircraftflightcrewpriortoexitingCDF.TheserevisedCDFprocedureshavebeenprovidedtoallcontractcarriers,bothatthelocalbaseandheadofficelevels.

•

•

Cold Weather Altimeter Error—Getting Cold Feet?by John Tomkinson

Ashappenseveryyearatthistime,everyoneshouldbedoingareviewoftheirwinteroperationalprocedures,anddustingoffthecobwebsfromasummerofflyinginatemperateclimate.

Havingdiscussedthecomingwinterwithmanyfellowpilotsandcontrollersoverthepastfewweeks,I’vefoundarecurringgeneraltheme.Nearlyeveryonecanlisthazardsoficing,winterweather,slipperyrunways,andadditionalhumanfactors,butwheneverthetopicofcoldweatheraltimetererrorcomesup,IseemorelongfacesthanIshould.Discussionsinonlineforumsshowthatmostindividualshaveanideaoftheimplicationsthatcoldweatherhasonaltimeterreadings,butmostcan’tgetallthedetailscorrect,sohereisourbrush-upsituation.

Coldweatheraltimetererrorisoperationallysimilartoflyingfromanareaofhighpressuretolowpressure;thealtimeterreadshigherthanitreallyis.Thedegreetowhichthealtimetermisreadsmustbecorrectedbytheuse

ofchartsavailableintheTransportCanadaAeronautical Information Manual (TCAIM)RACFigure9.1.Simplereally,buttherearecommonmisconceptionsaboutthisprocedure.

Firstly,thisandotheraltimetercorrectionsarenotdonebyATC,butarethepilot’sresponsibility.RadarvectoringaltitudesassignedbyATCare,however,alreadycorrectedforcoldtemperatures.ThiscorrectionisdonebyairspaceplannerswhileestablishingallminimumsafealtitudesforusebyATC.

Secondly,anycorrectionappliedtoapublishedaltitudeshouldberelayedtoATC.Thereisnominimumaltitudecorrectionthatcanbebrushedunderthecarpet.Eventhesmallestcorrectionscanmakeabigdifference.

Correctionscalculatedbypilotsaretobeusedtoensureobstacleclearanceduringfinalapproachfixcrossings,procedureturns,ormissedapproaches.

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

ASL4/2006 2�

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

Forthosewhohaveneverusedanaltitudecorrectionchart,hereisanexampleofhowtheCanadianchartworks.Theminimumsafealtitudeforourexampleaerodromewithweatherreportingis�000ft,andthefieldelevationis1000ft;therefore,theheightaboveelevationofaltimetersettingis2000ft.Thecurrentaerodrometemperatureis-�0°C.LookingattheAltitudeCorrectionChartbelow,findthecolumnrepresenting2000ftabovetheaerodromewiththerowcorrespondingto-�0°Cfortemperature,andthevaluerequiredtobeaddedtoyouraltitudeis��0ft.Toensurethatapublishedaltitudeof�000ftwilltrulyprovideobstacleclearance,thealtimetermustthenbereading���0ft.Additionally,inexamplesshowninthecurrentTCAIM,thecorrectedindicatedaltitudeisroundedtothenexthigher100-ftincrement,soourexamplewouldbecome�400ft.

Soundlikeasmallcorrection?Isitworthpullingoutchartstocrossreferencewhilebriefingtheapproach?InanaccidentreportpublishedbytheCanadianAviationSafetyBoard[nowtheTransportationSafetyBoardofCanada(TSB)],thehazardsoffailingtocorrectforeventhesmallesttemperatureerrorareclear.Fortunately,therewerenofatalitiesinthisincident:

“Thehelicopterwasdispatchedatnight,inIFRconditions...Thecrewdescendedontheinboundlegto150ft,withreferencetothepilot’saltimeter.Thehelicopterstrucktheseaiceandwasdestroyedbypost-impactfire.Thecrewhadnotappliedatemperaturecorrectiontotheminimumdescentaltitude[approximately 40 ft to as much as 100 ft. —Ed.],andthisomission—combinedwiththeknown50-fterrorinthe

•

pilot’saltimeter—accountedforthemistakenbeliefthehelicopterwashigher.”(A�1W01�4)

Acombinationofhighterrainorobstaclesandlowaerodrometemperaturecaneasilyweardownsafetymarginsonyourapproach.Ouraboveexamplehasanerrorof400ft,meaningwewouldhavenoterrainclearanceifweflewthepublishedaltitudesuncorrected.

Sohowcanyouknowifyourfeetarecold?ThefollowingaretheguidelinesintheTCAIM.

According to TC AIM RAC Figure 9.1— Altitude Correction Chart:Withrespecttoaltitudecorrections,thefollowingproceduresapply:

1. IFRassignedaltitudesmaybeeitheracceptedorrefused.Refusalinthiscaseisbaseduponthepilot’sassessmentoftemperatureeffectonobstructionclearance.

2. IFRassignedaltitudesacceptedbyapilotshallnotbeadjustedtocompensateforcoldtemperatures,i.e.ifapilotaccepts“maintain�000,”analtitudecorrectionshallnotbeappliedto�000ft.

�. RadarvectoringaltitudesassignedbyATCaretemperaturecompensatedandrequirenocorrectiveactionbypilots.

4. Whenaltitudecorrectionsareappliedtoapublishedfinalapproachfixcrossingaltitude,procedureturnormissedapproachaltitude,pilotsshouldadviseATChowmuchofacorrectionistobeapplied.

Height above the elevation of the altimeter setting sources (ft)

200 300 400 500 600 700 800 900 1 000 1 500 2 000 3 000 4 000 5 000

20 20 30 30 40 40 50 50 60 90 120 170 230 29020 30 40 50 60 70 80 90 100 150 200 290 390 49030 50 60 70 90 100 120 130 140 210 280 430 570 71040 60 80 100 120 130 150 170 190 280 380 570 760 950

50 80 100 120 150 170 190 220 240 360 480 720 970 1 210 60 90 120 150 180 210 240 270 300 450 600 890 1 190 1 500

Aerodrome

Temperature ˚C

0-10-20-30-40-50

ALTITUDE CORRECTION CHART

1: �e corrections have been rounded up to the next 10-ft increment. 2: Values should be added to published minimum IFR altitudes. 3: Temperature values from the reporting station nearest to the position of the aircraft should be used. �is is normally the aerodrome.

NOTES:

(Ref.: TC AIM RAC Figure 9.1)

Everyoneknowstheoldsaying“hightolow,lookoutbelow.”Asweenteranotherwinterflyingseason,let’saddanotherreminderphrasetoourrepertoire,“hottocold,don’tbesobold.”Don’tgetcoldfeetinyouraltimeterthisyear! John Tomkinson is an active air traffic controller in Toronto Center and a private pilot. He is also an aviation staff writer for www.aviation.ca.

24 ASL4/2006

Storage, Labelling, Handling and Application of De-/Anti-Icing Fluids in Canadaby Paul A. Johnson, Civil Aviation Safety Inspector, General Aviation, Civil Aviation, Transport Canada

This is a follow-up article to Paul Johnson’s “Aircraft Icing for General Aviation…And Others,” which was published in the AviationSafetyLetter(ASL) 3/2005. Some readers asked us to clarify storage, labelling, handling and application of de-icing and anti-icing fluids.

TheCanada Labour Code(CLC),PartII,isthelegislationthatensuresthatthehealthandsafetyofallemployeeswhoareunderfederaljurisdictionwhileatworkareprotected.TheAviation Occupational Safety and Health Regulations (AOSHR),PartV,identifiestheprescribedstandardsthatmustbeadheredtowithrespecttohazardoussubstances,whichincludethede-/anti-icingfluidsusedinconjunctionwithgroundicingoperations.

Atairportswherede-/anti-icingisnotavailablefromaserviceprovider,thede-/anti-icingmayhavetobecompletedbythepilot.Underthesecircumstances,pilotseitherhavetocarrytherequiredde-/anti-icingfluidonboardtheiraircraft,orpurchaseiton-site,sotheycanapplyittotheaircraftthemselvesbeforetakeoff.Whentheabovesituationoccurs,itisboththeoperator’sandpilot’sresponsibilitytomakesurethede-/anti-icingfluidisproperlyandsafelystored,labelled,handledandapplied.

Operatorsandpilotsinvolvedinde-/anti-icingoperationsaretofamiliarizethemselveswiththeCLCPartIIandAOSHRreferences,withparticularemphasisplacedonthosesectionsdealingspecificallywithhazardoussubstances.Inaddition,TransportCanada’sTP14052E,Guidelines for AircraftGround Icing Operations,shouldbereviewedforrecentdevelopmentsandissuespertainingtoaircraftgroundicingoperations.

Theprescribedstandardscovereverythingfromthelabellingofhazardoussubstancestoragecontainers(section5.2�),totherequirementthatoperatorsmusthavematerialsafetydatasheets(MSDS)onboardtheiraircraftforallhazardoussubstancesanemployeemayhandleorbeexposedto,whichincludede-/anti-icingfluids.Foradditionalinformationvisit:www.tc.gc.ca/civilaviation/commerce/circulars/AC0216r.htm

Useonlyqualifiedfluids.Thesearetheonlyfluidsthatholdovertablesrelateto.Useofanunqualifiedfluidrisksfirehazardsandunknownde-ice/holdovercharacteristics.Forexample,Isopropylalcoholcontinuestobeusedasanaircraftde-icingfluid,especiallyinremoteareas;however,itisclassifiedasaflammabledangerousgood.Onlycertainlimitedquantitiesmaybecarriedonboardanaircraft,andtheymustbelabelledcorrectlyandcarried

inapprovedcontainers.Trainingmustbeconductedinaccordancewithanapprovedtrainingprogramandmostimportantly,noholdovertime(HOT)exists.Formoreinfo,access:

TransportationofDangerousGoods(TDG)Information:www.tc.gc.ca/civilaviation/commerce/dangerousgoods/aboutus.htm

TheInternationalAirTransportAssociation(IATA)Dangerous Goods Regulations Manualcanbepurchasedat:www.iata.org/ps/publications/9065.htm

TheInternationalCivilAviationOrganization(ICAO)Technical Instructions for the Safe Transport of Dangerous Goodsby Aircanbepurchasedat:www.icao.int/anb/FLS/DangerousGoods/flsdg.cfm

Theuseofwindshieldwasherfluid,aviationfueloranyothertypeofnon-approvedfluidisnotrecommended.Theseproductshavenotbeentestedbyanymanufacturerandwillnotguaranteeanydegreeofprotectionfromsnoworiceaccumulation.Aviationfuelhasbeenknowntodamagewindshields,causingthemtoturn“milky,”nottomentiontheincreasedfirerisk.Anenginestackfireduringacoldstartcouldignitethesefuelvapoursquickly.Othernon-approvedfluidscancausedamagetorubbersealsandpaintwork,necessitatingexpensiverepairs.

Recommended de-/anti-icing practices for small aircraft operatorsThekeyforsmallerowners/operatorsregardingde-/anti-icingisprevention.Havingasuitablehangar,orwingcoversandtailcovers,cansavetimeandmoneywhenitcomestode-/anti-icingyouraircraft.Manyowners/operatorsdonothavehangarspace,bututilizewingandtailcoversinwintertoreducetheirde-/anti-icingtimesandexpenses.Theyaregreatforfrost,iceandsnowcoverage,butcan“sweat”undercertainatmosphericcircumstances,andcausethecoverstofreezetothesurfacestheyareprotectingwhenthetemperaturedropsagain.Theseconditionsarerare,andgenerallythecoversareconvenientformostsmallaircraftowners/operators.Installationusuallyrequirestwopeople,butcanbedonealonewithabitofpractice.Thecoversshouldcomeoffatapproximatelythesametime.Removingonesideandthentheothertosavetimemayleadtoanaccumulation

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

ASL4/2006 25

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

offrozencontaminantsonthesidethatwasexposedtotheelementsfirst,andthepilotmaynotnotice,ormayfailtorecheckfor,thesecontaminants.

Insomeinstances,smallaircraftoperatorscarryde-icingfluidonboardtheiraircraftwhiletravelingtoremotelocationswherenode-/anti-icingfacilitiesareavailable.Thefluidscarriedmustbetieddowninasuitablelocationandlabelledcorrectlyinasecuredcontainer.Mostgarden-typesprayersarenotsuitableasastoragecontainer,astheytendtoleakfromthepressurechangesofaflightevolution.Thiswouldcreateahazardoussituationintheaircraft,aslippingriskforthecrew,andapotentialenvironmentalaccident.Arecommendedpracticewouldbetocarrythefluidinanappropriately-secured,labelledcontaineronboardtheaircraftwithanemptygardentypesprayeronboardaswell(orlocatedattheremotedestination),andmixtheappropriateconcentrationatthedestination,usinghotwater.Ifpossible,lookforasprayerwithanimmersibleheaterthatcanheatthede-icingfluidtotherecommendedtemperatureforapplication.Remember,itistheheatandsprayforcethatmeltstheice.Heatedsprayersareavailablefromaircraftsupplystores.

Placingde-/anti-icingfluidclosetoahighheatsource,suchasaJanitrolheater,createsafirehazardandisnotacceptable.Ifnosuchspaceisavailable,thensufficientquantitiesshouldbemadeavailableatawaybases.

Afterde-icing,ifanti-icingisrequired,sprayonthecorrectamount,usuallybetween1mmand�mm.Donotcoatthecriticalsurfaceswithtoothickalayer,asthismaycauseaerodynamicproblemsaftertakeoff;toothinalayer,andthefluidmaynotachievethespecifiedHOTvalues.Thefluidmanufacturerwillhaveinstructionsonpropercoverage.

Usingasmallsprayertode-icealargeraircraft,suchasabusinessjet,isnotpractical.Theamountoffluidrequiredtocorrectlyapplyde-icingfluidcanbequitelarge.Typically,asmallbusinessjetrequires45to60litres(12to15U.S.gallons)ormoretode-ice,dependingontheamountoffrozencontaminationtoberemoved.Usingahandsprayertoapplyanti-icingfluidisnotrecommendedeitherbecausethetimeinvolvedwoulderodevaluableHOT.Remember,theHOTstartsatthecommencementoftheanti-icingprocedure.

ThefluidsthathavebeendevelopedarecalledTypeI,II,III,andIV.

TypeIfluidwasdevelopedinitially,andisusedprimarily,asaheatedde-icingmedium.Itisalsousedbysmaller

aircraft(rotationspeedsover60ktandgroundaccelerationtimesexceeding16seconds),forde-/anti-icing;however,theprotectionisforashortperiodoftime.SeeWhen in Doubt...Small and Large Aircraft—Aircraft Critical Surface Contamination Training for Aircrew and Groundcrew (TP1064�),Chapter�,paragraph42,“LowSpeedTest.”

TypeIIfluidwasdevelopedasananti-icingprotection,andisstillinusetoday.ThethickeningpropertiesofthisfluidextendHOTcomparedtoTypeIfluid;however,itsuseisintendedforaircraftwithrotationspeedsinexcessof100ktandgroundaccelerationtimesgreaterthan2�seconds.SeeWhen in Doubt...Small and Large Aircraft—Aircraft Critical Surface Contamination Training for Aircrew and Groundcrew (TP1064�),Chapter�,paragraph41,“HighSpeedTest.”

TypeIIIfluidwasdevelopedasananti-icingfluidsimilartoTypeIIfluid;however,itsuseisintendedforaircraftwithrotationspeedsover60ktandgroundaccelerationtimesexceeding16seconds.

TypeIVfluidwasdevelopedasananti-icingfluidsimilartoTypeIIfluidbutwithgreaterHOTqualities.Itsuseisalsoforaircraftwithrotationspeedsinexcessof100ktandgroundaccelerationtimesgreaterthan2�seconds.

Whensprayingtode-/anti-iceyouraircraft,confirmthatthefluidbeingusedisappropriateforyouraircrafttype.Acheckinthepilotsoperatinghandbook(POH),aircraftflightmanual(AFM),orwiththemanufacturer,willtellyouwhichfluidisappropriateforyouraircraft.Besuretofollowtheinstructions.Generally,smalleraircraftarelimitedtoTypeIfluid.ATypeIIIfluidhasbeendevelopedforsmalleraircraft;however,itisonlyavailableinlimitedregions.Itisanticipatedthatthisfluidwillbemorewidelyavailableinthenextfewyears.TheadvantageofTypeIIIfluidisthatitcontainssomethickenerstoincreaseHOT.BesureyouraircraftmanufacturerrecommendstheuseofTypeIIIfluidbeforeyouuseit.

Somepilotsbelievethatanyfluidcanbeusedonanaircraft.Thisisnottrue.DonotuseTypeIIorTypeIVfluidonanaircraftthatthisfluidisnotapprovedfor.De-/anti-icingfluidsareonlyrequireduntiltheaircraftbecomesairborne,afterwhichtheon-boardde-/anti-icingsystemsoperate.Therotationspeedofanaircraftisimportant,asthisdetermineswhichde-/anti-icingfluidshouldbeused.Seriousaerodynamicconsequencescanresultfromincorrectfluiduse.Theresultcouldbedisastrous,asthefluidwillnotshearoff(blowoff )onthetake-offrun,whichmaycauseaerodynamicproblemsjustaftertakeoff.

26 ASL4/2006

Remember,Canadian Aviation Regulation(CAR)602.11(4)states(fornon-airlineoperations):

Whereconditionsaresuchthatfrost,iceorsnowmayreasonablybeexpectedtoadheretotheaircraft,nopersonshallconductorattempttoconductatakeoffinanaircraftunless

(a) foraircraftthatarenotoperatedunderSubpart5ofPartVII,

(i) theaircrafthasbeeninspectedimmediatelypriortotakeofftodeterminewhetheranyfrost,iceorsnowisadheringtoanyofitscriticalsurfaces,or

(ii) theoperatorhasestablishedanaircraftinspectionprograminaccordancewiththeOperating and Flight Rules, Standards,andthedispatchandtakeoffoftheaircraftareinaccordancewiththatprogram.

Ifyouuseaholdovertableforguidance,usethecorrecttableforthefluidbeingused.Therearesomedifferencesbetweenfluidsproduced,andtheholdovertablesaddressspecificfluids.UsingtheincorrectholdovertablewillleadtoincorrectvaluesfortheintegrityofthefluidandyourHOT.

Incertaincases,wherecoldsnowisfallingonacoldwinganddefinitelynotaccumulatingoradheringtothecriticalsurfaces,itmaynotbenecessarytode-/anti-ice;however,beprudentanddouble-checkthecriticalsurfacestoensurethatnocontaminationisadheringoraccumulatingonthem.Thiscanonlybedoneonthewalk-aroundwhileconductingatactile(touch)inspectionofthesurfaces.Beextracarefulatnightorduringtimeswherevisibilityisrestricted,asvisualdetectioncanbeimpossible.Tactileinspectionistheonlypositivemethodtoascertaintheconditionofthecriticalsurfaces.

VariousmethodstoremovecontaminationwerediscussedintheASL�/2005article,soreadersmaywanttoreaditagain.Whenremovingfrozencontaminationfromthecriticalsurfaces,alsoensurethatallelevator,aileron,andflap,etc.,hingelinesarecleantoavoidthesesurfacesrefreezingaftertakeoff.

CAUTIONAnti-icingfluids(TypesIIandIV)havebeenknowntoremaininaerodynamicallyquietareassuchaselevator,aileron,andflap,etc.,hingelinesaftertakeoff.Theymayre-freezewhileairborne,causingcontrolrestrictionsorflutter.Beawareofthemanufacturer’srecommendationstoinspectandcleantheseareasafteranti-icingtoensurenofluidremainstrapped.Todate,nore-freezingproblemshavebeenrecordedwithTypeIfluids.

Active frostActivefrostnormallyoccursatnightwhenaircraftsurfacesareatorbelowfreezing(0°C)ANDatorbelowthedewpoint.Therefore,expectactivefrostconditionswhenthetemperature-dewpointspreadissmall,withinabout2°C,andthedewpointandaircrafttemperaturesarebelowfreezing.Activefrostwillactivelygrowinmassandthickness,andwillcontinuetoformafterbeingremoved;whereasinactivefrost,suchashoarfrost,canberemovedandnormallywillnotformagain.

Theaboveconditions,combinedwiththeVFRconditionsofclearskyandcalmwinds,enhancethechanceforactivefrost.Ifyouchoosetotakeoffintheseconditions,youwillhavetode-icewithTypeIfluid,andanti-icewithTypeIIorTypeIV.Ownersofsmalleraircrafttypes,unabletouseTypeIIorIVfluid,cande-icewithheatedTypeIfluid,thenreapplyTypeIfluidasan“anti-ice”asecondtimetocreateafreshlayerofprotectionandsomeadditionalHOT.

The National Aeronautics and Space Administration (NASA) Glenn Research Centre in Cleveland, Ohio, has two excellent products on aircraft ground and in-flight icing entitled, A Pilot’s Guide to Ground Icing and A Pilot’s Guide to In-Flight Icing on theirWeb site located at:http://aircrafticing.grc.nasa.gov/.

Themostrecentupdate,dueinlate2006,includesasectiononde-/anti-icinggeneralaviationaircraft.

Flyingasmalleraircrafttypeinthewintercanprovideagreatopportunitytoflyinsmooth,clearweatherconditions;however,theseconditionscandeterioratequickly.

Usealltheresourcesavailabletoyou—Internet,airportpersonnelorlocalweather—todetermineground-icingfactors.Sometimesthebestdecisionis“don’t go”…yourlifemaydependonit.

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

When you push the weather

and get into trouble, remember who put you there.

ASL4/2006 2�

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions by Captain Robert Kostecka, Civil Aviation Safety Inspector, Foreign Inspection, International Aviation, Civil Aviation, Transport Canada

InCanada,flyingduringthewinterbringsmanychallenges.Everyonewhohasdrivenacaronaslushyhighway—orwalkedonanice-coveredsidewalk—knowsthatweneedtobeextracarefulwhenweatherconditionsarepoor.Inadditiontotheproblemsofrunwaycontamination,wealsoneedtoensurethattheaircraft’scriticalsurfacesarenotcontaminatedwithfrost,iceorsnow.

Foryears,mostpilotshaveunderstoodthatvisibleicecontaminationonawingcancausesevereaerodynamicandcontrolpenalties.Thecontinuedoccurrenceoficing-relatedaccidentsmakesitapparentthatsomepilotsdonotrecognizethatevenminuteamountsoficeadheringtoawingcanhavedisastrousconsequences.Asfarasfrost,iceorsnowadheringtotheaircraft’scriticalsurfacesisconcerned,noamountisacceptable.Contaminationmakesnodistinctionbetweenlargeaircraft,smallaircraftorhelicopters.Theperformancepenaltiesanddangersarejustasreal.Aswinterapproaches,itisagoodideatotakeafewmomentstoreviewflightoperationsduringicingconditions.Tohelpyouprepareforthiswinter’schallenges,hereareafewquestionsthatwillillustratesomeofwhatyouneedtoknow.

Thequestionshavebeendividedintotwogroups.PartAconsistsofgeneralknowledgequestionsthatareapplicabletoallpilots.ThequestionsinPartBareintendedfortheoperatorsoflargerandmorecomplexaircraftthatoperateingroundicingconditions.

For your convenience, references and associated links have been provided. The answers to these questions can be found on page 38.

TP1064�When in Doubt...Small and Large Aircraft— Aircraft Critical Surface Contamination Training for Aircrew and Groundcrewwww.tc.gc.ca/CivilAviation/general/Exams/guides/tp10643/how.htm

Canadian Aviation Regulations(CARs)www.tc.gc.ca/civilaviation/RegServ/Affairs/cars/menu.htm

NTSBAdvisory—AlerttoPilots:WingUpperSurfaceIceAccumulationwww.ntsb.gov/PressRel/2004/041229.htm

Part A: General Knowledge

1. Whichofthefollowingaccidentswascausedbyiceontheaircraft’scriticalsurfaces?

a) January1�,19�2:AnAirFloridaBoeing���-200crashedintothe14thSt.BridgeandthePotomacRiver,andsankshortlyaftertakingofffromWashingtonNationalAirport.Therewere�4fatalities.

b) March10,19�9:AnAirOntarioF2�crashedduringtakeofffromDryden,Ont.Therewere24fatalities.(ThiscrashresultedinamajorinvestigationthatledtotheAirRegulationschangesthatareinplacetoday.)

c) January4,2002:ACanadairChallengercrashedduringtakeofffromBirmingham,England.All5onboardwerekilled.

d) Alloftheabove.Ref.:TP1064�Chapter1,“AirLaw,TheCleanAircraftConcept”

2. Forthepurposeofaircrafticing,whichofthefollowingareconsideredtobetheaircraft’s“criticalsurfaces”?

a) Thewings,rotorsandpropellers.

b) Controlsurfaces,horizontalstabilizers,verticalstabilizersoranyotherstabilizingsurfaceofanaircraft.

c) Inthecaseofanaircraftthathasrear-mountedengines,theuppersurfaceoftheaircraft’sfuselage.

d) Alloftheabove.

Ref.:CAR602.11—AircraftIcing

2� ASL4/2006

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

�. Itisabright,crisp,clearwinterday,andyouarethepilotofalighttrainingaircraft.Youandyourpassengersareanxioustogetunderway.Duringthewalk-around,younoticethatthereisathinlayeroffrostontheuppersurfaceofthewings.

Whichofthefollowingstatementsiscorrect?

a) Athinlayeroffrostmaynotbeaproblem.Thisisamatterofjudgementandairmanship.Takeoffispossibleinthissituation.TheCanadianAviationRegulations(CARs)onlyprohibittakeoffwhentheamountofice,snoworfrostwilladverselyaffectsafety.

b) TheCARsprohibitpersonsfromconductingorattemptingtoconductatakeoffinanaircraftthathasfrost,iceorsnowadheringtoanyofitscriticalsurfacessuchaswingsandpropellers.Thisiscalledthe“cleanaircraftconcept.”

c) Researchresultshaveshownthatfineparticlesoffrostoricethesizeofagrainoftablesaltanddistributedassparselyasonepersquarecentimetreoveranairplanewing’suppersurfacecandestroyenoughlifttopreventthatairplanefromtakingoff.

d) Bothb)andc)arecorrect.Ref.: CAR602.11—AircraftIcing

TP1064�Chapter1,“AirLaw,TheCleanAircraftConcept”NTSBAdvisory—AlerttoPilots: WingUpperSurfaceIceAccumulation

4. Whichofthefollowingstatementsconcerningfrostiscorrect?

a) Researchresultshaveshownthatfineparticlesoffrostoricethesizeofagrainoftablesaltanddistributedassparselyasonepersquarecentimetreoveranairplanewing’suppersurfacecandestroyenoughlifttopreventthatairplanefromtakingoff.

b) CAR602.11(�)states:“…apersonmayconductatake-offinanaircraftthathasfrostadheringtotheundersideofitswingsthatiscausedbycold-soakedfuel,ifthetake-off is conducted in accordance with the aircraft manufacturer’s instructions for take-off under those conditions.”

c) Botha)andb)abovearecorrect.

d) Noneoftheaboveiscorrect.Ref.: NTSBAdvisory—AlerttoPilots:

WingUpperSurfaceIceAccumulationTP1064�Chapter2,“TheoryandAircraftPerformance— FrozenContaminants”CAR602.11(�)

5. Youaretravellingasapassengeronanairliner.Yourflighthasbeendelayedseveralhoursbecauseofamechanicalproblem.Thepassengersarequiteannoyed.Eventually,theairlinehasanotheraircrafttowedtothegate.

Asyoutakeyourseat,younoticethatthereisfrostonthewings.Thecaptainwelcomeseveryoneaboardandsaysthatbecausethereisnotrafficaheadonthetaxiway,heexpectstobeairborneveryquickly.Hemakesnomentionofde-icing.Youdon’tfeelcomfortableaboutthefrost.

Withrespecttothissituation,whichofthefollowingstatementsiscorrect?

a) Inthissituation,youshouldkeepquietandtrustthateveryoneisdoingtheirjob.Ifthecrewthoughtthatde-icingwasnecessarytheywoulddoit.Thisisnotyourconcern.

b) Youshouldtellaflightattendantthatthereisfrostonthewings.Ifaflightattendantobservesthatthereisfrost,iceorsnowadheringtothewingsoftheaircraft,theCARsrequirethattheymustimmediatelyreportthatobservationtothepilot-in-command.Thepilot-in-commandoraflightcrewmemberdesignatedbythepilot-in-commandmustinspectthewingsoftheaircraftbeforetakeoff.

c) Beforeanaircraftisde-icedoranti-iced,thepilot-in-commandoftheaircraftmustensurethatthecrewmembersandpassengersareinformedofthedecisiontodoso.

d) Bothb)andc)arecorrect.Ref.: CAR602.11(6)

CAR602.11(�)Aviation Safety Letter1/2004

Part B: For Operators of Aircraft That Operate in Ground Icing Conditions

1. Withrespecttoholdovertimes,whichofthefollowingstatementsistrue?

a) Holdovertimetablesarereferredtoasholdovertime“guidelines”becausethistermmoreappropriatelyrepresentstheirfunctioninprovidingguidancetoflightcrewandtheneedfortheflightcrewtousejudgmentintheirinterpretation.

b) Holdovertimeguidelinesprovideanestimateofthelengthoftimeanti-icingfluidswillbeeffective.

c) Theactualtimethatafluidiseffectivecanbelessthanthatpublishedintheholdovertimeguidelines.

ASL4/2006 29

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

Factorsincludingstrongwindsandjetblastmayreduceholdovertimes.

d) Alloftheabovestatementsaretrue.Ref.: TP1064�Chapter2,“TheoryandAircraftPerformance—

FrozenContaminants”

2. Withrespecttoholdovertimes,whichofthefollowingstatementsistrue?

a) Aircraftanti-icingfluidholdovertimeshavenotbeenevaluatedundermoderateandheavyfreezingrainconditions.

b) Thecapabilityofanti-icingfluidtotolerateaheavysnowfallratehasnotbeenevaluated;thereforeholdovertimesforheavysnowconditionshavenotbeengenerated.

c) Botha)andb)abovearetrue.

d) Noneoftheaboveistrue.Ref.: TP1064�Chapter2,“TheoryandAircraftPerformance—

FrozenContaminants”

�. WithrespecttoSAETypeI(de-ice)fluids,whichofthefollowingstatementsarecorrect?

a) SAETypeI(orange)fluidsareusedforde-icingoranti-icing,butprovideverylimitedanti-icingprotection.

b) ItistheheatcontainedbytheTypeI(de-ice)fluidandthehydraulicforcesthatremovethefrozencontaminants.

c) ExtravigilanceisrequiredbyflightcrewswhenconductingoperationsaftersprayingwithTypeIfluidsonly.Flashfreezeover(fluidfailure)canoccurinaveryshortperiodoftimeaftertheholdovertimeexpires,eveninverylightprecipitationconditions.Thisresultsinacontaminatedcriticalsurfaceandanunsafeconditionforflight.

d) Alloftheabove.Ref.: TP1064�Chapter�,“De-icing/Anti-icingFluids—FluidProperties”

4. WithrespecttoSAETypeIVfluids,whichofthefollowingstatementsiscorrect?

a) TypeIVanti-icingfluidsshouldonlybeusedonaircraftwithrotationspeeds(Vr)above100kt.

b) TypeIVanti-icingfluidisdyedemeraldgreentoprovideforapplicationofamoreconsistentlayeroffluidtotheaircraftandtoreducethelikelihoodthatfluidwillbemistakenforice.

c) Botha)andb)arecorrect

d) Noneoftheabove.Ref.: TP1064�Chapter�,“Deicing/Anti-icingFluids—

FluidProperties”

5. AnexemptiontoCARs602.11(1)and(2)hasbeenissued.ThepurposeofthisexemptionistopermitCanadianairoperatorsandforeignairoperatorsinCanada,utilizingaircraftwithenginesmountedontherearofthefuselage,toconductatakeoffwithhoar-frostonthefuselageonly,afterithasbeendeterminedthatnoothercontaminationisadheringtothefuselage.

Whataretheconditionsofthisexemption?

a) Hoar-frostshallbetheonlyacceptablecontaminantonthefuselageofaircraftwithenginesmountedontherearfuselage.

b) Priortoconductingatakeoff,theoperatorshallensurethatthehoar-frostisnotmixedwithothercontaminantssuchasiceorsnow.Ifanyothercontaminantorcontaminantsareonthefuselage,theoperatorshallde-icetheentirefuselage.

c) Acopyofthisexemptionshallbeattachedtotheaircraftde-icing/anti-icingproceduresintheoperator’smanual.

d) Alloftheabove.Ref.: TP1064�Chapter1,“AirLaw,TheCleanAircraftConcept”

2006–2007 Ground Icing Operations Update

InJuly2006,theWinter2006–200�Holdover Time (HOT) GuidelineswerepublishedbyTransportCanada.Asperpreviousyears,TP14052,Guidelines for Aircraft Ground Icing Operations,shouldbeusedinconjunctionwiththeHOT Guidelines.BothdocumentsareavailablefordownloadatthefollowingTransportCanadaWebsite:www.tc.gc.ca/CivilAviation/Commerce/HoldoverTime/menu.htm.Ifyouhaveanyquestionsorcommentsregardingtheabove,pleasecontactDougIngoldatINGOLDD@tc.gc.ca.

�0 ASL4/2006

Who we areTheAircraftCertificationBranchisoneofthelargestinCivilAviationintheNationalCapitalRegion,withastaffofabout150ineightdivisions.Withapproximately40engineers,theEngineeringDivisionisthelargestwithintheBranchandisgroupedinsixspecialtyareas,representingadiversesetoftechnicalskills,expertiseandabilities—Avionics&Electrical,Fuel&Hydro-MechanicalSystems,Structures,Powerplants&Emissions,ElectronicEquipmentDesignAssurance(Software)andOccupantSafety&EnvironmentalControlSystems.

ThesespecialtiesarerequiredtosupporttheAircraftCertificationBranchinapprovingthetypedesignofaeronauticalproducts,otherwiseknownas“TypeCertification.”Theproductsapprovedrangefromlargetransportaircraftandrotorcrafttosmalltwo-seateraircraftandtheenginesthatpowerthem.

What we do and why“Safeskiesstartwithsafeaircraft,andsafeaircraftstartwithsafedesigns.”ThisphrasecapturestheessenceoftheBranch’sandtheDivision’sraison d’être.

AlthoughmanyoftheengineersinthisDivisionhaveengineeringdegreesandextensiveindustryexperienceinthedesignofaircraft,aircraftsystems,enginesandcomponents,ourroleisnottodesignaircraft.Weareinthe“designassurance”businessandweworkwithourCanadianaerospaceindustrytounderstandtheirproductdesigns,andvalidatethatthesedesignsmeettheinternationally-accepteddesignstandards.Whenthisisconfirmed,theDirector,AircraftCertificationBranch,willissuea“TypeCertificate,”whichsignifiesthatthedesignmeetscomprehensivesafetyandemissionsstandards.

Thistypecertificationfunctionisoneofmanyrelatedactivities.Wearealsoinvolvedinthereviewandacceptanceofforeign-designedaircraftandengines;participateinthedevelopmentofthedesignstandardsinharmonizationworkinggroupswithotherforeignauthorities,suchastheU.S.FederalAviationAdministration(FAA)andtheEuropeanAviationSafetyAgency(EASA);areinvolvedwiththeContinuingAirworthinessDivisioninreviewingthe

impactofdesigndeficienciesincertifiedaeronauticalproductsanddeterminingtheappropriatecorrectiveaction;providetechnicalsupporttoregionalaircraftcertificationengineers,inspectorsandindustryinvolvedinthemodificationandrepairofaircraftintheCanadianfleet;andassessandparticipateinthecertificationandoversightofindustrydesignapprovaldelegates.

How we do our jobWetypicallyworkinprojectteams,internallywithinTransportCanadaCivilAviation(TCCA),andexternallywithindustry.Foranewaircraftprogram,therewillbeatleastoneengineerfromeachengineeringsection,withaflighttestpilotandengineer,andaprojectmanagerwholeadstheteam.Thisteamworkscloselywiththeindustryengineeringspecialists,anddelegateswhoareresponsiblefordesigninganddemonstratingthatthenewaircraftdesignmeetstheregulatoryrequirements.

Thecertificationprogramforanewtransport-categoryaircraftcantakeuptofiveyears,andforanenginetheprogramcantakeuptothreeyears.Derivatives,orchanges,totheseinitialdesignstakelesstime,butcanuseasmanyresources.Asaresult,atanyonetime,anengineerwithintheEngineeringDivisioncouldbeateammemberonasmanyastenormorecertificationprogramsrunninginparallel,inadditiontoparticipatingintheotheractivitiesnotedabove.So,theabilitytomulti-taskisessential.

Muchofthetime,ourbusinessisconductedattheindustryfacilities,orindustryengineersmeetwithusinOttawa,Ont.Typically,day-to-daycommunicationswiththecompanyspecialistsaredoneviaphone,videoconference,e-mailandincreasingly,viaweb-baseddata-sharing“portals”thatallowtheexchangeoflargedocuments.Today,aleadcompanyusing“designpartners”inothercountriescreatesmostlargeaircraft.Asaresult,itisnotunusualtohaveEngineeringDivisionspecialiststravellingtowitnessa“coldsoak”testofanaircraftinIqaluit,Nun.,oraflightcontrolsystemtestinGermany,oranelectronicenginecontroltestintheUSA.

Atthebeginningofanapprovalprogram,theTCCAengineeringspecialistswillspendconsiderabletimewiththeindustrydelegatestounderstandtheproposeddesignandhowthecompanyproposestoshowthatthedesign

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

maintenance and certification The Aircraft Certification Branch, Engineering Division .............................................................................................. page 30Inadequate Identification of Fuel Barrels......................................................................................................................... page 31Aircraft Maintenance Operational and Functional Checks ........................................................................................... page 32Tool Control Reminder ..................................................................................................................................................... page 34

The Aircraft Certification Branch, Engineering Divisionby the Engineering Division, Aircraft Certification, Civil Aviation, Transport Canada

ASL4/2006 �1

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

meetstheapplicablesafetyandemissionstandards.Theaircraftandsystemdesign,andthestandardsthatmustbemet,areverycomplexandthecompliancedemonstrationprocessissimilarlycomplex.Dependingonthedesignfeature,compliancewiththedesignrequirementsmaybedemonstratedbytest,engineeringanalysisorinspection.Boththetestsandanalysescanbeverycomplexandexpensive,theinterpretationofresultscanbedifficult,andpass/failcriteriaareoftensubjective.Thisiswhere“engineeringjudgment”comesin.

Duringtheapprovalprogram,thereissomuchcompliancedatagenerated,itwouldbeimpossibleforTCCAengineerstoreviewitall,sothereissignificantrelianceonthecapabilityandexpertiseoftheindustrydesigningtheproductandthedelegates.TheTCCAengineermustusearisk-basedapproachtodeterminewhereandwhentobeinvolvedinreviewingthecompliancedata—focussing,

forexample,oncriticalsafetyareas,unusualdesignsortechnology,orcompliancemethods.

Attheendoftheapprovalprogram,basedonthecompanyanddelegateactivitiesandtheTCCAengineers’involvement,thecompanywillhavedemonstratedthatthedesigncomplieswiththerequirementsandthattherearenounsafefeatures.Atthispoint,theTypeCertificatecanbeissued.

In summaryAsanessentiallinkintheestablishmentofasafeaircraft,anengineerintheEngineeringDivisionoftheAircraftCertificationBranchhasachallengingjobthatoffersauniqueopportunitytoworkwithbothCanadianandforeignaerospacecompaniesthatdesignandmanufactureaircraft,rotorcraft,enginesandassociatedsystems.

Inadequate Identification of Fuel BarrelsAn Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)

OnJuly16,2005,aBell205A-1helicopterwasengagedinforestfiresuppressionandlonglineslingingoperationsintheprovinceofQuebec.Whilehoveringwithanemptywaterbucketona100-ftlongline,withthebucket15ftabovethewater,thepilotfeltavibration,heardabang,andtheenginelostpower.Theaircraftquicklylostaltitude,pitchednosedownandtotheright,thenstruckthewater.Thetwopilotswereabletoexittheaircraftbeforeitsankandwererescuedbynearbyfirefighters.Thepilot-in-commandwasseriouslyinjured,andtheotherpilotsustainedminorinjuries.Theaircraftwassubstantiallydamaged.Theinvestigationintothisaccident(A05Q0119)isongoing.

TheSociété de protection des forêts contre le feu(SOPFEU)isresponsiblefortheprevention,detection,andsuppressionofforestfiresinQuebec.Duringforestfiresuppressionoperations,SOPFEUwillcontracthelicoptersandotheraircrafttofulfilltheiroperationalneeds.Barrels(205L)

Photo 1: View of fuel barrels at base camp

offuelareorderedfromlocalwholesalersanddeliveredtothenearestfiresuppressionoperationsstagingarea.

Theon-goinginvestigationintothisoccurrencerevealedthatthewholesalerhadmistakenlydeliveredfourbarrelsofAvgasand�6barrelsofJetAfuel,insteadof40barrelsofJetAfuel.Italsorevealedthatworkersloadingtheproductonthetruckatthewholesaler’syardandthosedeliveringtheproducttoSOPFEUhadmistakenlyidentifiedtheproduct.Thepilotsusingtheproductdidnotcorrectlyidentifyitbeforefuelling.TwoofthefourhelicopteroperatorsworkingfromthestagingareamistakenlyfuelledtheiraircraftwithAvgas.

(Note: The Aeronautical Information Manual (AIM) section AIR 1.3.2 Aviation Fuel Handling states in part: “...A company supplying aviation fuel for use in civil aircraft is responsible for the quality and specifications of its products up to the point of actual delivery. Following delivery, the operator is responsible for the correct storage, handling, and usage of aviation fuel…”

AlthoughanumberofturbineenginesmayburnAvgasasemergencyfuelforalimitedtimewithoutanegativeoutcome,itisnotthecaseifthesamemistakeismadewhilefuellingapistonengineaircraftwithJetfuel.TheB205operationsmanualonlyauthorizestheuseofJetAorJetB.TheuseofAvgasinthisaccidentisnotdeemedtohavebeencontributorytothelossofenginepower.

Thebarrelsdeliveredwereallwhite,andallidentifyingstickerswerealsowhite.Theidentifyingstickersincludedallthenecessaryinformation,asspecifiedbyprovincial

�2 ASL4/2006

regulations.Theonlydifferencebetweenthetwoproductswasthewords“100LLAvgas”and“JetAfuel.”(Seephotos1and2takenonsite.)

Photo 2: View of fuel barrel labels

Thewholesalerneedonlyensurethatthepetrolproducttheydelivermeetsprovincialregulations,i.e.thecontainermustbecleaned,filled,andsealedonsite;andidentifyingstickersaffixedonthecontainermustincludethedate,thetypeofproduct,batchnumber,anddangerousgoodsinformation.

Contrarytofederalregulationsapplicableforfueldistributionatairportsandaerodromes,provinciallawsdonotrequirethecontainerortheidentifyingstickerstodifferincolour,eventhoughtheproductisdifferent.Therefore,thedifferentpetrolproductscaneasilybe

mistakenandleadtofuellinganaircraftwiththewrongtypeoffuel.AvgasisconsideredaClass1petrolproduct,andunderexistingprovincialregulations,aClass1productover45Ldoesnotrequireanykindofcolourcodingofthecontainer.However,acontainerunder45L,containingaClass1product,mustbepredominatelyredincolour.

Therefore,byprovinciallaw,the205-LbarrelsofAvgasdonothavetodifferincolourfromaClass2( Jetfuel)orClass�product.Colourdifferentiationoftheidentifyingstickersisalsonotrequired.Thedifferentproducts,concealedinthecontainers,andnotvisibletotheuser,haveadifferentcolourandsmell;AvgasisblueandJetfuelisyellow.

AccordingtotheAeronautics Act,thebasecampandfuelcachefromwhichthehelicopterswereoperatingareconsideredanaerodrome.Distributorsofapetrolproductatanaerodromearesubjecttofederalregulationsandmustensurethatthetypeofproductisspecificallyidentifiablebyagivencolourofcontainer,pump,and/orlabel.

TheuseoffuelbarrelsforremoteaircraftoperationsiswidespreadthroughoutCanada.Itisoftheutmostimportancetoensurethattheproductnotonlybeidentifiablebyname,butthatitalsobedistinguishablefromanotherpetrolproductinamorepredominantmanner.Thequalitycontrolofthepetrolproductprovidedtoanaircraftoperatoratanairportshouldalsobeassuredwhenoperatingatanaerodrome.

Aircraft Maintenance Operational and Functional Checksby Norbert Belliveau, Civil Aviation Safety Inspector, System Safety, Atlantic Region, Transport Canada

Aviationmaintenanceisaverycomplexindustry.Weaircraftmaintenanceengineers(AME)maintaineverytype,modelandsizeofheavier-than-airaircraftthatareflownintheworldtoday.

Onmanyoccasions,ourprofessionrequiresthatweperformcertaintasksthatmaydemandmorealertnessandcarethanothers.Onesuchtaskrelatestotheaircraft“staticfunctionalchecks,”oraswewouldrefertothem,“ground runs.”Throughtrainingandexperience,functionalchecksortaxiingofanaircraftareperformedsafelyandwithoutincident;however,whenweareunderpressure,tryingtomeetscheduledemands,fatigued,orbeingaffectedbyanyothersuchcontributingfactor,astepcaneasilybeoverlookedandtheoperationcanendwithamuchdifferentoutcome.

Aircraftfunctionalchecks,suchaspowerperformances,systemdeficiencies,compassswings,andenginewashes,

areonlycarriedoutonanirregularbasis.Thepotentiallylongintervalbetween“ground runs” mayhavecreatedacertain“systemlayout”or“operational”uncertaintyfortheAMEinthecockpit.Ibelievepilotscallthis“currency”!Theoperationofanaircraftholdsalotofresponsibility.Evenifanindividualhaspreviouslyperformedthistaskmanytimes,itonlytakesoneveryimportantsteptobeforgottenoroverlookedforaseriousoccurrencetohappen.Thedynamicenvironmentweoperateinleaveslittleroomforerror.ThefollowingstepsareareminderfortheAMEspriortoperformingaircraftoperationalorfunctionalchecks.Notethatthisdoesnot,andisnotmeantto,replacetheaircraft’spilotoperatinghandbook(POH)operationchecklist.

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

ASL4/2006 ��

Before the task:1. Confirminspectionsheets/packagearecompleted

andappropriatelysignedoff.

2. Checkrecords/worksheetsforanyspecialattentionrequiredduringaircraftoperation.

�. Confirmpersonnelaretrained,currentandappropriatelyendorsedontype.

4. Befamiliarwithairportoperator’spolicies,procedures/practices,aprons,signage,runways,anddesignatedgroundrunareas.

5. Takealongacopyoftheaerodromediagramforreference[from Canada Airport ChartsontheNAVCANADAWebsite,orfromtheCanada Air Pilot(CAP)].

Before start: 1. Alwaysrefertotheaircraft’sPOHoperation

checklist.Neverrelyonmemory.

2. Conductawalkaroundoftheaircraftandareaforforeignobjectdamage(FOD),looseitems,controllocks,inletplugs,covers,chocks,tow-barsandtiedowns.

�. Checkforpersonnelorparkedaircraftnearby.Repositiontheaircrafttopreventdamageorinjuries.

4. Verifythatthenosegeartorquelinksattachmentissecure.

5. Verifyalltheaircraftfluidlevels.Takefuelsamples,asappropriate.

6. Ensureallpanelsandenginecowlingsareinplaceandsecured,asrequiredforengineoperation.

�. Checkthatallbreakersandfusesareset.

�. Placeafireextinguishernearby,andhavetrainedpersonnelonvisualwatch,asrequired.

9. Befamiliarwiththelocationofon-boardfireextinguishers.

10. Verifybrakeoperation.

11. Befamiliarwiththeaircraftcommunicationequipment,frequencies,andradiolicencerequirements.

12. Alwayscarryareliableflashlightwhendoingfunctionalchecksatnight.

1�. Befamiliarwiththeaircraftemergencyprocedurechecklist.

During operation and taxiing:1. Alwaysmaintaincommunicationwithgroundor

aproncontroller,andreportintentionsbeforemoving.

2. Positionaircraftintothewindforoptimizedenginecooling.

�. Consistentlymonitorengineparametersfromlefttorightandtoptobottomforirregularities.

4. Alwaysremainwithintheaircraftoperatinglimitations.

5. Maintainprofessionalisminthecockpit.

6. DonotRUSH!

�. Keeptaxispeedstoaminimum.

�. Whiletaxiing,keephandsandfeetoncontrolsatalltimes.

9. Bepreparedtoshutdowntheengines.

Secure the aircraft:1. Again,refertotheaircraft’sPOHoperationchecklist.

Neverrelyonmemory.

2. Followtherecommendedenginecooldownperiod.

�. Ensureallswitchesareturnedoff,andbreakersarechecked.

4. Visuallycheckfluidlevelsandsurroundingareasforfluidleaks.

5. Properlysecuretheaircraft.

Asprofessionals,wemustalwaystrytoleadbyexample.Soremember,thenexttimeyouareheadingouttoperformanoperationalcheckortaxiing,oncethemainaircraftcabindoorisclosedandyouaresittingatthecontrols,itisnowyou,theenvironmentandthatpreciousaircraft!

Accid

ent Synopses

Winter O

peratio

nsWin

ter

Op

erat

ions

Acc

iden

t Sy

nop

ses

Mai

nten

ance

and

Cer

tific

atio

n Maintenance and

Certificatio

n

�4 ASL4/2006

A meticulously maintained tool control board enhances safety

Thepictureaboveshowsanexampleofawell-executedtoolmanagementsystem,ortoolcontrolboard,inanaircraftmaintenanceengineer’s(AME)shopontheeastcoast.TheRegionalAviationSafetyOfficer—MaintenanceinMoncton,N.B.,Mr.NorbertBelliveau,reportsthat,“sinceweintroducedtheAviation Maintenance Tool Management CD-ROM,manymoreAMEsandpilot-ownershaveundertakentoimprovetheirtoolcontrolsignificantly.”

Thepurposeofatrulydisciplinedandregimentedtoolmanagementsysteminaviationistoensurealltools,withoutexception,areaccountedforbeforeandaftereveryjob,andthatonetooldoesnotgomissing,withthe

possibilitythatitwasleftintheaircraft,inthesamewayasurgeonwouldleaveaclampinthebodyofapatient(itDIDhappen...).Ittakesastrongworkethicandapplieddisciplinetoachieveaperfecttoolmanagementsystem,andthankfully,licensedaviationpersonnelhavealreadydemonstratedthosetraits.

Yourtoolmanagementsystemshouldallowyoutoimmediatelynoticeifatoolismissingafteralltoolsareputbackinplace,eitherthroughanumberingsystem,toolshadowsontheboard,colour-coding,orcombinationsofallthree.Acompleteaviationtoolinventorycheckmustbedonebeforeandaftereveryjob.Keepyouraviationtoolsseparatefrom

yourhometools—weallknowthehammerandthevise-gripcangomissingathome,butaviationwrenchesandwire-cuttersmustalwaysbeaccountedfor.

TheAviation Maintenance Tool ManagementCD-ROM(TP1412�)isaneducationalpackageaimedattheaerospaceindustry,andcanbeusedintheteachingofmethodstocontrolforeignobjectdamage(FOD)inthevariousworkingenvironmentsthataircraftengineersandtechniciansworkin.ThisCDcontainsaPowerPointpresentationandthevideo,Foreign Object Damage (TP140��).OrderittodayfromTransact,theonlinestorefrontforTransportCanadapublicationsatwww.tc.gc.ca/transact/,orbycallingTransportCanada’sOrderDeskat1-���-��0-4911.

Tool Control Reminder

Civil Aviation Safety Inspector’s (CASI) Toolkit CD

Ever wonder what work tools Civil Aviation Safety Inspectors use in the field? One such tool is the CASI Toolkit CD.

TheCDcontainsregulations,guidelines,standards,andformsinapowerful,searchabledatabase.Inmostcases,thedocumentsarealsoinPDFformat.TransportCanadahasalsorecentlydecidedtoterminatetheissuanceoftheCanadian Aviation Regulations (CARs)CDandallowallindustryuserstoorderthesameCDthatisissuedtoCivilAviationSafetyInspectorseverysixmonths.

TheCASI Toolkit CD(TP12916)isavailableforpurchasefromTransportCanada’sonlinepublicationsstorefrontatwww.tc.gc.ca/transact,orbycallingTransportCanada’sOrderDeskat1�����0-4911.Youcanordereitherasinglecopy($�5.00,whichincludesshipping,butexcludesapplicabletaxes),ortakeoutasubscriptionforfuturecopiestobeautomaticallyshippedtoyou.

ASL4/2006 �5

the civil aviation medical examiner and you

Mandatory Reporting of Unfit Pilots, Air Traffic Controllers and Flight Engineers

Did you know that, by law, all physicians in Canada must inform a Regional Aviation Medical Officer (RAMO) of any pilot, air traffic controller or flight engineer who has a medical condition that could adversely affect flight safety? (Note—for purpose of this article the term “medical certificate (MC) holder” will be used to apply equally to pilots, air traffic controllers and flight engineers, unless otherwise stated.)

Subsection 6.5(2) of the Aeronautics Act requires that:TheholderofaCanadianaviationdocumentthatimposesstandardsofmedicaloroptometricfitnessshall,priortoanymedicaloroptometricexaminationofhisorherpersonbyaphysicianoroptometrist,advisethephysicianoroptometristthatheistheholderofsuchadocument.

Therefore,asaMCholderyoumustinformanyphysician—notjustyourCivilAviationMedicalExaminer(CAME)—ofyourstatusbeforeeachexaminationortreatment.Yourphysicianmustconsiderwhetheryourconditionortreatmentwouldconstituteahazardtoaviationsafety,andifthisislikely,informamedicaladviserdesignatedbytheMinister(theRAMO)ofthatopinionandthereasonsbehindit.Ifuncertainwhetherahazardexists,yourphysiciancandiscussyourcasewiththeRAMOhypothetically—withoutrevealingyouridentity—untilitappearsnecessarythataflyingrestrictionmaybenecessary.Thisdoesnotnecessarilymeanthatyourmedicalcertificatewillbesuspended;however,theRAMOwillmakeinquiriestoconfirmwhetheryouremainmedicallyfit.Iftheconditionortreatmentisself-limited,youwouldbeadvisednottoflyuntilafterrecovery.

YoushouldalsorememberthatunderCanadian Aviation Regulation(CAR)404.06,Prohibition Regarding Exercise of Privileges,MCholderswhoknow,orareinformed,thattheyhaveacondition(orareprescribedtreatment)thatmightmakeitunsafetoperformtheirduties,must“ground”themselvestemporarily.

Insomecases,aphysicianmaychoosetoreportasuspectedunfitMCholderconfidentially—withoutinformingtheindividual.Thisismorelikelytooccurwherenoon-goingrelationshipexistsbetweenthephysicianandMCholder,forexampleduringorafteranemergencyroomvisit.

Onceareportundersection6.5oftheAeronautics Act hasbeenmade,itistheRAMO’sresponsibilitytotakefurtheraction.AlthoughTransportCanadamayusethereportedinformationasnecessarytoensureaviationsafety,thereportitselfisprivilegedandcannotbeusedasevidenceinanylegal,disciplinaryorotherproceedings.When

yousignthe“StatementofApplicant”onaMedicalExaminationReport,thisisconsideredasyourconsentforgivinginformationtoamedicaladviserdesignatedbytheMinisterwhenrequiredundertheAct.

Ifyournameandconditionwerereportedconfidentially,youwouldlikelyreceivearegisteredletterfromtheRAMOrequestingfurtherclinicalreportstoassessyourcondition.Youwouldalsoberemindedofyourobligationnottofly(CAR404.06)pendingadecisioninyourcase.

Canadianphysiciansarecurrentlybeingremindedoftheirresponsibilitiesforreporting,andgivensomeguidanceonthetypesofmedicalproblemsthatmightwarrantrestrictions.Herearesomeofthesymptomsandconditionstobeconsidered,listedbysystem(abridgedlist):

VisionConditionswherevisualimpairmentistemporaryorvisionistemporarilyaffectedbytheuseofmedicationsneednotbereported.TheMCholdershouldbewarnednottoflyuntilnormalvisionhasreturned.Reportable:

Diplopia(doublevision);monocularity;alteredvisualfields;eyeinjuriesorretinaldetachment;cataractsurgery;surgicalcorrectionofmyopia,includingradialkeratotomy(RK),photorefractivekeratectomy(PRK),laser-assistedin-situkeratomileusis(LASIK)orotherrefractiveeyesurgery.

Ear, nose and throatSignificantdeteriorationinhearingmustbereported.Anyconditionaffectingbalanceorspatialorientationmustbereported.Reportable:

Suddenlossofhearing,orconditionssignificantlyaffectinghearing;middle-earconditions;damagetothetympanicmembranes(eardrum)ortheEustachiantubes;anyconditionaffectingorimpingingupontheinnerearorthevestibular(balance)organs;stapedectomyandotherearsurgery;surgeryaffectingthenasalpassages,sinusesorEustachiantubes;conditionsleadingtovoicedistortionorinaudibility.

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

efD

ebrief

�6 ASL4/2006

Cardiovascular TheappearanceofcardiovascularsignsorsymptomsisofgreatconcernandmustbediscussedwiththeRAMO.Evenbenigncardiacrhythmdisturbancecancausedistractionthat,duringcriticalphasesofflight,maycauseanincidentoraccident.Medicationstotreatbloodpressurewithsideeffectsoffainting/posturalhypotension,arrhythmiasoreffectsonthecentralnervoussystemareunacceptable.Reportable:

Cardiacinflammationandinfection;acuteischemicsyndromes(heartattack,angina);revascularizationsurgery(bypassorangioplasty,includingstentinsertion);initialtreatmentofhypertensionwithmedication;symptomsoflowbloodpressure;newheartmurmurs;significantheartdisease;repairorreplacementofheartvalves;prematurecontractions;tachyarrhythmias(fastheartrhythms);bradycardia(slowrates)withsymptoms;fibrillation;heartblockandbundlebranchblocks;pacemakers.

Cerebrovascular MCholderswhoshowanyevidenceofmemoryloss,poorconcentrationordiminishedalertnessmustbereported.Reportable:

Transientischemicattack(TIA)orcerebralarterystenosisthathasledtoconfusion,disturbanceofvision,attacksofvertigoorlossofconsciousness;strokeoranyothercerebrovascularaccident.

Other vascular disordersReportable:

Aorticaneurysms;surgicalrepairofananeurysm;deepvenousthrombosis.

Nervous systemDisordersofthecentralnervoussystemcanbeapotentsourceofoccultincapacitation.Lapsesofconsciousnessormemoryintheaviationenvironmentcanbefatal.Reportable:

Syncope(fainting);unexplainedlossofconsciousness,whateverthecause;seizuredisorders;anysignificantheadinjury,unconsciousnessorpost-traumaticamnesia;sleepdisordersofanytype;migrainewithaura;severeorprolongedheadaches;disordersofcoordinationandmuscularcontrol.

RespiratoryGradualdeteriorationoftherespiratorysystemovertheyearsmaynotbeobvious,particularlyifthepilotdoesnotcomplain,orisusingbronchodilatormedications.PhysicianstreatingMCholdersmustremainalerttotheriskofhypoxiaandtrappedgasexpansion(e.g.pneumothorax)whendecidingupontreatment.

Reportable:Spontaneouspneumothorax,lungcystsorotherconditionsthatmayleadtoproblemswithexpansion(thismaybeoflesssignificanceinairtrafficcontrollers);chronicobstructivepulmonarydisease;significantdecreasesinpulmonaryfunctionoroxygensaturation;asthma—increasingrequirementsforinhaledbronchodilatorsorsteroids;pulmonaryembolism;sarcoidosis.

MetabolicReportable:

Diabetesmellitus—type1diabetes(insulin-dependent)whenfirstdiagnosed(pilotsandairtrafficcontrollersrequiringinsulinareconsideredonanindividualbasis);type2diabetes(non-insulin-dependent)onfirstrequirementforhypoglycemicdrugs,changesintypeordoseofmedicationorhypoglycemicattacksrequiringtreatment;initialdiagnosisorsignificantchangesintreatmentofthyroidandparathyroiddisease;pituitaryoradrenaldisease.

Renal systemReportable:

Renalcolic(kidneyorbladderstones);renalfailure;renaltransplantation.

Musculoskeletal systemReportable:

Recentamputationofalimborpartofalimb;arthritistreatedwithsecond-orthird-stagemedications(e.g.Gold,azathioprine).

Psychiatric disordersTheleveloftoleranceformentaldisordersordiseaseissmall.Evenwhensymptomsareeffectivelytreated,thesideeffectsofpsychoactivedrugs,suchasselectiveserotoninreuptakeinhibitors(SSRI)areusuallyunacceptable.Reportable:

Cognitivedisorders;dementia;psychosis;bipolaraffectivedisorder(manic-depressive);emotionaldisordersthatrequiredrugtherapyormayinterferewithjudgment,decisionmakingorreactiontime.

Tumours Reportable:

AnytumourthatlimitstheabilityofaMCholdertoperformsafely;tumoursthatmaymetastasizetothebrain.

HIV/AIDSReportable:PositivetestforHIV;diagnosisofAIDS.

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

efD

ebrief

ASL4/2006 ��

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

efD

ebrief

DrugsReportable:

MCholderswhoabuseorareaddictedtoalcoholorotherchemicalsubstances.

Note: Physiciansshoulddiscussindetailthesideeffectsofanymedicationthatisprescribedorrecommendedtopilots.Minorsideeffects,forexample,onvisualaccommodation,muscularcoordination,thegastrointestinaltract,ortolerancetoacceleration,maybemoreseriouswhentheyoccurinflight.Ifindoubt,thephysicianshoulddiscussthemedicationwiththeRAMO.Generally,MCholdersareadvisedtoavoidtakinganymedicationwithin12hr(or,iflonger-acting,withinaboutfivehalf-lives)beforeaflightifpharmacologicaleffects

mayaffectflying.Althoughthereareexceptionstothisrule,cautionisadvised.

ThereisnogeneralruleabouthowlongaMCholdershouldbegroundedafterreceivingageneralanesthetic.Itdependsonthetypeofsurgery,premedication,andtheanestheticagent.Physiciansshouldbeawarethattheeffectofsomeanestheticsmaytakedaystowearoff,andcautionisrecommended.

Adversereactionstolocalanestheticareuncommonaftertheeffectoftheanesthetichaswornoff,butincaseswheretheyhavebeenusedforextensiveprocedures,suchastheremovalofseveralteeth,flyingshouldberestrictedforaminimumof24hr.Onemustbeawarethatdentalsurgeonssometimesprescribelong-actingtranquillizingagentsbeforesurgery,aswellasnarcoticpain-killersforpost-operativediscomfort.

Contact Information

Ifyouhaveanyquestionsregardingyourpersonalmedicalfitness,theyshouldbedirectedtoeitheryourCAMEorRAMO.Toll-freenumbersfortheregionalmedicalofficesareprintedonthetear-offbottomsectionofyourmedicalcertificate,aswellaspublishedonourWebsite(underContacts)atwww.tc.gc.ca/CivilAviation/Cam/offices.htm.

Thefollowingreferencesareavailableonline:The Aeronautics Actwww.tc.gc.ca/acts-regulations/GENERAL/a/aa/act/menu.html.

Canadian Aviation Regulation (CAR) 404.06, Prohibition Regarding Exercise of Privilegeswww.tc.gc.ca/CivilAviation/Regserv/Affairs/cars/Part4/404.htm#404_06.

ThephotoontheleftshowstheresultofaspectaculargroundcollisiononJuly15,2006inMadrid,Spain.ThewingtipofataxiingBoeing�4�-400slicedcleantheT-tailofastationaryEmbrear145jet.Fortunatelytherewerenoinjuries,buttherewassignificantstressforallinvolved.

AmoretragicgroundcollisionoccurredonJuly�0,2006,atAirVenture2006inOshkosh,Wisconsin.AsmallVan’sRV-6homebuiltaircraftwasstruckfrombehindonataxiwaybyalargeraircraft,aWorldWarIIeraNavyGrummanTBMAvenger.TheAvenger’spropellertorethroughthetailoftheRVandfatallyinjuredthepassenger.Bothoccurrencesarestillunderinvestigation,buttheyserveasgrimreminderstoallpilotstokeepanalerteyeoutsideandtomindourdistances.

Ground Collisions Give Us Warning

38 ASL4/2006

Answers to “How Much is Too Much?” Quiz

PartA:(1)d,(2)d,(3)d,(4)c,(5)d.PartB:(1)d,(2)c,(3)d,(4)c,(5)d.

There is no such thing as a little ice. In airline operations where large numbers of aircraft are dispatched, the process of assuring that each flight will be safe must be a team effort. In smaller commercial and in private operations, the pilot may have to perform all the functions. In all cases, the pilot-in-command is ultimately responsible for ensuring that the aircraft is in a condition for safe flight. If the pilot cannot confirm that the aircraft’s critical surfaces are free of contamination, takeoff must not be attempted.

(1)30.14

(2)incidents;potentiallyunsafeactsorconditions

(3)increase

(4)“X”

(5)15

(6)will

(7)unreliable;ittransmits

(8)15

(9)ItconveystheabilitytofollowdirectroutingsusingGPS.

(10)No

(11)123.45

(12)landingandtakeoff;forecastweatherelements

(13)hatchedareasenclosedbyadashedgreenline

(14)1500;WS

(15)onehour

(16)270degreesat15ktgustingto25kt

(17)3/8SM;lightsnowanddriftingsnow

(18)True;True;True;True

(19)No

(20)CIRVISreport

(21)shall

(22)five

(23)flightplan

(24)onehour

(25)1-888-226-7277;twohours

(26)121.5

(27)InspecttheELTtoensurethatitissecure,freeofexternalcorrosion,andthattheantennaconnectionsaresecure;ensurethattheELTfunctionswitchisinthe“ARM”position;ensurethatELTbatterieshavenotreachedtheirexpirydate;andlistenon121.5MHztoensuretheELTisnottransmitting.

(28)Position,altitudeandtimewhensignalwasfirstheard;ELTsignalstrength;position,altitudeandtimewhencontactlost;andwhetherELTsignalceasedsuddenlyorfaded.

(29)PlacetheELTfunctionswitchto“ON”assoonaspossibleafterthecrash.

(30)1530;December15,2006

(31)AreplacingorcancelingNOTAMisrequired.

(32)ItisareplacingNOTAM.

(33)60;24

(34)personallog

(35)5-yearand2-year;6-month

(36)5;6

(37)ordinarycombustiblematerials

(38)50

(39)10000

(40)climbbacktotheoriginalaltitudeortoahigherlevel

Answers to the Self-Paced Study Program (tear-off)

Definitions of Interest…

“Reportable Service Difficulty” meansanydefect,malfunctionorfailureofanaeronauticalproduct,component,equipmentorpartaffecting,orthat,ifnotcorrected,islikelytoaffect,thesafetyoftheaircraft,itsoccupantsoranyotherperson.“Unapproved Part” meansanypartinstalledorintendedforinstallationinatypecertifiedaeronauticalproduct,thatwasnotmanufacturedorcertifiedinaccordancewiththeapplicableregulationsofthestateofproductionorthatisimproperlymarkedorthatisdocumentedinsuchamannerastomisleadwithregardtotheorigin,identityorconditionofthepart.

(Ref.: CAR Standard 591.01 - Service Difficulty Reporting Requirements)

7.625”8.375”8.5”

ASL4/2006 392 ASL4/2006

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

Paul Marquis, EditorAviation Safety LetterTransportCanada(AARQ)PlacedeVille,TowerCOttawaONK1A0N8E-mail:marqupj@tc.gc.caTel.:613-990-1289Fax:613-991-4280Internet:www.tc.gc.ca/ASL-SAN

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

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

Toobtaininformationconcerningcopyrightownershipandrestrictionsonreproductionofthematerial,pleasecontacttheEditor.

Sécurité aérienne — Nouvellesestlaversionfrançaisedecettepublication.

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Transport (2006).ISSN:0709-8103TP185EPublicationMailAgreementNumber40063845

regulations and you

Safety Management Systems—Raising the Bar on Aviation Safety by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada

Asafetymanagementsystem(SMS)isastructureofsystemsdesignedtoidentifyandeliminaterisksandimprovethesafetyperformanceofairoperators.SMSisintendedtoincreaseindustryaccountability,andtonurtureandsustainasafetyculture,wherebyemployeescanconfidentiallyreportsafetydeficiencieswithoutfearofsubsequentpunitiveaction.RegulationwilleventuallyrequireallTransportCanadaoperatingcertificateholderstoimplementanSMS.

ThefollowingeventillustratesthevalueofanSMSinadvancingaviationsafetywhentherehasbeenacontraventionoftheregulations.

OnaclearJanuarymorning,anAirbus310departedHalifax,N.S.,forCalgary,Alta.,andclimbedtoacruisingaltitudeof34000ft.Aftercompletingtheroutinecruisechecks,thecrewsettledbackandthe256passengersrelaxedandenjoyedalightbreakfast.AstheywereapproachingMontreal,Que.,thecaptaincheckedtheen-routeweatherwhilethefirstofficertookfuelquantityreadingsandcomparedthemwiththeflightplanfiguresrequiredtocompletetheflighttodestination.ThefirstofficersuddenlyrealizedthattheyhadnottakenonenoughfuelpriortotheirdeparturefromHalifax.AfterconfirmingthereadingsandmanuallyrecalculatingtheminimumrequiredfueltocompletetheflighttoCalgary,heinformedthecaptain.Theybothdouble-checkedthefuelremainingagainstthefuelrequired.TheinsufficientfuelstatewasconfirmedandtheyagreedtoplananunscheduledrefuellingstopinToronto,Ont.MontrealCentreandcompanydispatchwerebothadvisedofthefuelconditionandtheyrespectivelyauthorizedandconcurredwiththerevisedrouting.

Fromaregulatorystandpoint,thepilot-in-commandandtheoperator,contravenedCanadian Aviation Regulation(CAR)602.88(2)fornotcarryingsufficientfuelfortheplannedroute.TheenforcementprocessinitiatedfollowingthiscontraventionistypicalofwhatwouldhappenwithinanyaviationcompanythatoperatesinaccordancewithanSMS.

TheAviationEnforcementDivisionbecameawareoftheeventthroughanoccurrencereportintheCivilAviation

DailyOccurrenceReportingSystem(CADORS),andnotifiedtheTransportCanadaprincipalinspectorresponsiblefortheoperator.Theprincipalinspectorconfirmedthatthecrewhad,asrequiredunderSMS,internallyreportedtheincidenttotheoperator.

InlinewithSMSphilosophy,theoperatordevelopedandsubmittedacorrectiveactionplan(CAP)totheprincipalinspector,outliningasystematicapproachtoaddressthefuelmismanagementandtopreventarecurrence.TheCAPincludedrevisedpre-flightandin-flightstandardoperatingprocedures(SOP)designedtoensureaccurateflight-plannedfuelcalculationsandaccuratefuel-on-boardmonitoringpriorto,andduring,flight.Theseproceduresforproperfuelmanagementwereincorporatedintoamandatorytrainingseminarforallflightcrew members.TheprincipalinspectorreviewedtheCAPandwasconfidentthatitaddressedtheissuesthatledtotheinitialcontravention.Inconsultationwiththeprincipalinspector,theAviationEnforcementDivisioncouldhavereactivatedtheinvestigationatanytimeduringtheprocessleadinguptotheacceptanceoftheCAP,andwouldhave,if:

thecontraventionhadbeenintentional;theincidenthadnotbeeninternallyreported;ortheprincipalinspectorhadfoundtheCAPtobeunacceptable,andtheoperatorhadrefusedtoaddresstheissue.

Hadthedecisionbeentocontinuetheinvestigation,aletterofinvestigationwouldhavebeensentdirectlytotheoperator,andtheprincipalinspectorwouldhavebeennotified.Inthisspecificcase,theinvestigationwasclosedwithoutfurtherenforcementaction.

Althoughthestoryinthisarticledoesnotdepictanactualevent,itdoesservetoillustrateatypicalSMSresponse,designedtoraisethebaronaviationsafetyfollowingaregulatorycontravention.

Forfurtherclarification,weinviteyoutoconsulttheAviationEnforcementPolicyandProcedures—SafetyManagementSystemsWebsiteatwww.tc.gc.ca/civilaviation/SMS/policy.htm.

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

efD

ebrief

Go to www.smartmoves.ca

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

FOR CANADIAN RESIDENTS ONLY

21. Taxiauthorizationsthatcontaintheinstructions“hold”or“holdshort”(shall/neednot)bereadbackby thepilot. (RAC4.2.5)22. Wherepossible,pilotsarerequiredtoreportatleast____minbeforeenteringanMFarea. (RAC4.5.7)23. A___________mustbefiledforallflightsbetweenCanadaandaforeignstate. (FAL2.3.2)24. OnflightsfromCanadatotheU.S.,atleast________advancenoticeofarrivalmustbeprovidedto U.S.Customs. (FAL2.3.2)25. OnflightstoCanada,pilotsmustlandataCanadaCustomsauthorizedairportofentry(AOE). Pilotsmustmaketheirowncustomsarrangementsbycalling______________atleast_________before flyingintoCanada. (FAL2.3.2)26. PilotsreceivingaMANOTmessagearerequestedtomaintainaradiowatchon______MHzwhen operatinginthevicinityofthetrackofthemissingaircraft. (SAR2.3)27. Listthefourstepsthatshouldbeaccomplished(wherepracticable)duringyourpreflightinspectionofthe emergencylocatortransmitter(ELT). (a)__________________________________________________________________________________; (b)____________________________________________________________; (c)_____________________________________________;and (d)____________________________________________. (SAR3.4)28. WhenanELTsignalisheardinflight,thenearestATSunitshouldbeadvisedofwhatfourpieces ofinformation? (a) ________________________________________________________; (b)___________________; (c)_____________________________________________;and (d)____________________________________________. (SAR3.4) 29. Intheeventofacrash,whatshouldyoudowiththeELT’sfunctionswitch,andwhen? ____________________________________________________________________ (SAR3.5)30. 061234NOTAMNCYSBSUBDURY RWY04/22CLOSEDTILAPRX0612151530 Runway04/22isexpectedtoopenat_____Zon(date)___________. (MAP5.6.1)31. Whatisthesignificanceoftheterm“APRX”intheaboveNOTAM?_____________________________ (MAP5.6.1)32. 060210NOTAMR060202CYNDWINCHESTER CNA8UNMANNEDAERIALVEHICLEOPS3NMRADIUS450610N 752854W(APRX9NMNWAD)SFCTO2400FTMSL 0605051700TIL0605052300 Whatisthesignificanceoftheletter“R”attheendoftheword“NOTAM”above?__________________ (MAP5.6.2)33. ACanadianmedicalcertificateforaprivatepilotlicenceisvalidinCanadafor___monthsifunderage40, andfor___monthsifage40orolder. (LRA3.2.4)34. InaccordancewithCAR401.08,everyapplicantfor,andeveryholderof,aflightcrewpermit,licenceor ratingshallmaintaina______________. (LRA3.7.6)35. Theflightcrewrecencyrequirementsaddressthreetimeperiods.Toactaspilot-in-commandorco-pilot youmustmeetthe___________________recencyrequirements.Ifyouwishtocarrypassengers,youmust alsomeetthe________requirements. (LRA3.9)36. Inordertocarrypassengers,youmusthavecompleted__takeoffsandlandingsinthesamecategoryand classofaircraftintheprevious__months. (LRA3.9)37. ClassAfiresarefiresin______________________________. (AIR1.4.2)38. Anaircraftaltimeterwhichhasthecurrentaltimetersettingappliedtothesubscaleshouldnothavean errorofmorethan___ftwhencomparedonthegroundagainstaknownaerodromeorrunwayelevation. (AIR1.5.1)39. By______ftASLthepartialpressureofoxygenissuchthatallpilotswillexperiencemildhypoxiaand somewillbecomesymptomatic. (AIR3.2.1)40. If,ondescent,thepressureintheears(orsinuses)cannotberelievedbyswallowing,yawningorValsalva manoeuvre,itisbestto_________________________________________________________. (AIR3.8)

Answers to this quiz are found on page 38 of this ASL 4/2006.

Don’t Forget to Subscribe to the Transport Canada Aeronautical Information Manual !

ThenewTransportCanadaAeronauticalInformationManual(TCAIM)wasintroducedinOctober2005.AllCanadian-registeredpilotsreceivedtwofreepapercopies,thelastofwhichwasdeliveredinApril2006.ThenextreleaseoftheTCAIMisscheduledforOctober2006.Thereareafewoptionsonhowtosubscribetothispublication:

Paid subscription to the paper copy• SubscribeonlinetothepapercopybyvisitingTransportCanada’sonlinepublicationsstorefrontat

www.tc.gc.ca/transact.There,youcanordereitherasinglecopy($15.00,whichincludesshipping,butexcludesapplicabletaxes)ortakeoutasubscriptionforfuturecopies;or

• CalltheTransportCanadaOrderDeskat1-888-830-4911or613-991-4071,toorderasinglecopyorrequestasubscription.Theywilltakeyourcreditcardinformationandprocessyourorder.

Free e-Bulletin notification• Registerforane-Bulletin,whichmeansTransportCanadawillsendyouane-mailwithalinktothelatest

onlineversion,ineitherHTMLorPDFformat.Toregisterforane-Bulletin,sendane-mailtoMPS@tc.gc.ca andasktobeaddedtotheTCAIMe-Bulletinlist.Pleasestateyourname,postaladdressande-mailaddress.

Asaremindertoall,theonlineversionoftheTCAIMisavailableforviewingandfreedownloadatalltimes.YoucanaccessitfromTransportCanada’sonlinepublicationsstorefrontatwww.tc.gc.ca/transact.

7.625” 8.375” 8.5”

40 ASL4/2006

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

efD

ebrief

debrief

Post-Accident Survivability—Direct-to-Airframe Helmet Cord ConnectionsAn Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)OnDecember7,2005,anMBB-BO105helicopterwasoperatingnearMarystown,N.L.Thehelicopterwasobservedflyingalongtheshoreline,atlowaltitude,insnow,andindarkeningconditions.Thehelicopterstruckthewaterabout1000ftfromshore,andsanktothebottomofMortierBay.Thepilotandpassengerescapedfromthehelicopter;however,theylaterperishedinthefrigidwater.TheTSBinvestigationintothisaccident(A05A0155)isongoing.Aftertheaccident,anexaminationofthepilot’saviationhelmetfoundthattheendfittingofthecommunicationcordwasfracturedatthepointwhereitattachestothehelicopter(seeFigure1).

Figure 1. Fractured cord end fitting

Thecommunicationcordsforfront-seatoccupantsconnecttoreceptacleslocatedontheoverheadcenterconsole.Whenthehelicopterwasrecovered,themetalpinsfromtheendfittingwerestillinsidethereceptacle.Metalremnantsfromtheconnectionshowthatthecordwasbeingpulledsideways,towardsthepilot’sdoor,whenthefractureoccurred.Adownwardpullisrequiredtoreleasetheconnection.Abreaktestofasimilarfittingrequireda70-lbpullbeforethecordfailed.Afterditchingorwaterimpact,theoccupantsofacapsizedhelicopterarepronetodisorientation.Therefore,unimpededegressthroughanyavailableexitisvitaltosurvival.Anattachedcommunicationcordthatwillnotreleasecleanlymayimpedethisegress.

Inthepast,similarBO-105helicoptershavebeenfittedwithanintermediate“pig-tail”communicationcordforhelmetconnections.Insteadofpluggingthehelmetcordintothehelicopter’sreceptacle,thehelmetcordisinsteadpluggedintothisintermediatecord(seeFigure2).

Thehelmetconnectionplugcanreleasecleanlyfromtheintermediate“pig-tail”cordreceptacleasitispulledinthedirectionoftravelduringegress.Overaperiodofyears,theuseoftheintermediatehelmetcordsatthisoperatordeclined,perhapsbecausepilotswerenotawarethatthecordsensureseparationinanemergency.However,sincethisaccident,theoperatorhasindicatedthattheuseofintermediate“pig-tail”cordsforhelmetconnectionswillnowbere-institutedwherenecessary.

Figure 2. Intermediate helmet “pig tail” connection cords

Otheroperatorsmayhaveaircraftwithsimilardirect-to-airframeconnections,andmaybeunawarethatthesecanimpedeegressinanemergency.Therefore,TransportCanadamaywishtoadvisetheaviationcommunitythattheseconnectiontypesmayimpedeegress,andthatanintermediatecordcanhelptomitigatethishazard.Done. —Ed.

TransportCanada

TransportsCanada

aviation safety letter

TP 185EIssue 4/2006

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

In this Issue...

Safety Hazard Alert—Call Sign Confusion

Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?

Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)

Recently Released TSB Reports

Near Repeat of Mirabel De-Icing Mishap

Cold Weather Altimeter Error—Getting Cold Feet?

How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions

Aircraft Maintenance Operational and Functional Checks

Flight Crew Recency Requirements Self-Paced Study Program

TC-1001878TC-1001878

TransportCanada

TransportsCanada

Flight Crew Recency RequirementsSelf-Paced Study Program

Refer to paragraph 421.05(2)(d) of the CanadianAviationRegulations (CARs).

This questionnaire is for use from November 1, 2006, to October 31, 2007. Completion of this questionnaire satisfies the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.

Note: The answers may be found in the TransportCanada AeronauticalInformationManual (TC AIM). TC AIM references are at the end of each question. Amendments to this publication may result in changes to

answers and/or references.

1. Convert1020.5millibarsintoinchesofmercury.______ (GEN1.9.2)2. TheSECURITASprogramprovidesameansforindividualstoreport________________and ____________________________________relatingtotheCanadiantransportationsystem. (GEN3.6)3. Runwaycontaminantssuchaswater,snoworicewill(increase/decrease)thelandingdistance.(AGA1.1.5)4. Whenasectionofrunwayorheliportisclosed,itismarkedwithan___. (AGA3.3andAGA5.6)5. ControlofARCALlightsshouldbepossiblewhenaircraftarewithin___NMoftheaerodrome. (AGA7.19)6. Retroreflectivemarkers(will/willnot)providethepilotwiththesamevisualpresentationasnormalrunway lightingwhentheaircraftislineduponfinalapproach. (AGA7.20)7. Theremovaloftheaudioidentificationfromnon-directionalbeacons(NDB),VHFomnidirectionalranges (VOR),distancemeasuringequipment(DME)orinstrumentlandingsystems(ILS)warnspilotsthatthe facilitymaybe__________eventhough____________. (COM3.2)8. Awideareaaugmentationsystem(WAAS)NOTAMwillbeissuedwhenaWAASserviceispredictednot tobeavailableforadurationofmorethan______min. (COM3.16.6.2)9. Whatdoestheequipmentsuffix“G”indicateinitem10(equipment)onaflightplan? _________________________________________________________ (COM3.16.7)10. CanVFRGPSreceiversbeusedtoreplacecurrentcharts?___ (COM3.16.16)11. Forair-to-aircommunicationsbetweenpilotsintheNorthernDomesticAirspace(NDA),whatisthe correctfrequencytouse?______MHz. (COM5.13.3)12. Anaerodromeforecast(TAF)providesexpectedconditionsfor___________________atspecificaerodromes, whereasanareaforecastchart(GFA)depicts_________________________affectingflightataspecifictime overaparticulararea. (MET3.2.1)13. AreasofshoweryorintermittentprecipitationareshownonaGFACloudsandWeatherChartas______ ____________________________________. (MET3.3.11)14. InaTAF,anycasesofstrong,non-conductivelowlevelwindshearwithin_____ftAGLwillbecodedas “__”. (MET3.9.3)15. InaTAF,“TEMPO”isonlyusedwhenthemodifiedforecastconditionisexpectedtolastlessthan ________ineachinstance. (MET3.9.3)16. TAFCYXU011035Z01112327015G25KT3SMRAOVC005 BECMG1314OVC020 FM1700Z29005KTP6SMOVC030TEMPO1723BKN030 RMKNXTFCSTBY17Z= Intheweatherreportabove,theforecastwindfor1500Zis_________________________________. (MET3.9.3)17. SPECICYSJ221650Z08017G243/8SMR23/2000FT/N–SNDRSNVV006 M03/M05A2953RMKSN8VSBYVRBL3/411/2 Intheweatherreportabove,theprevailingvisibilityis_____andthevisibilityisobscuredby _____________________________________. (MET3.15.3)18. Arethewindsinaviationweatherforecastsandreportsgivenindegreestrueormagnetic?GFA:_____; TAF:_____;FD:_____;METAR:_____.(MET3.3.11,3.9.3,3.11,3.15.3)19. DoesATCassumeresponsibilityforobstacleclearancewhenyouareradaridentified?___ (RAC1.5.2)20. Ifyouobservesuspiciousgroundactivitiesatanabandonedairstrip,whatreportshouldyoumake? _____________ (RAC1.12.2)

7.625” 8.375” 8.5”

40 ASL4/2006

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

ef

Debrief

debrief

Post-Accident Survivability—Direct-to-Airframe Helmet Cord ConnectionsAn Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)OnDecember7,2005,anMBB-BO105helicopterwasoperatingnearMarystown,N.L.Thehelicopterwasobservedflyingalongtheshoreline,atlowaltitude,insnow,andindarkeningconditions.Thehelicopterstruckthewaterabout1000ftfromshore,andsanktothebottomofMortierBay.Thepilotandpassengerescapedfromthehelicopter;however,theylaterperishedinthefrigidwater.TheTSBinvestigationintothisaccident(A05A0155)isongoing.Aftertheaccident,anexaminationofthepilot’saviationhelmetfoundthattheendfittingofthecommunicationcordwasfracturedatthepointwhereitattachestothehelicopter(seeFigure1).

Figure 1. Fractured cord end fitting

Thecommunicationcordsforfront-seatoccupantsconnecttoreceptacleslocatedontheoverheadcenterconsole.Whenthehelicopterwasrecovered,themetalpinsfromtheendfittingwerestillinsidethereceptacle.Metalremnantsfromtheconnectionshowthatthecordwasbeingpulledsideways,towardsthepilot’sdoor,whenthefractureoccurred.Adownwardpullisrequiredtoreleasetheconnection.Abreaktestofasimilarfittingrequireda70-lbpullbeforethecordfailed.Afterditchingorwaterimpact,theoccupantsofacapsizedhelicopterarepronetodisorientation.Therefore,unimpededegressthroughanyavailableexitisvitaltosurvival.Anattachedcommunicationcordthatwillnotreleasecleanlymayimpedethisegress.

Inthepast,similarBO-105helicoptershavebeenfittedwithanintermediate“pig-tail”communicationcordforhelmetconnections.Insteadofpluggingthehelmetcordintothehelicopter’sreceptacle,thehelmetcordisinsteadpluggedintothisintermediatecord(seeFigure2).

Thehelmetconnectionplugcanreleasecleanlyfromtheintermediate“pig-tail”cordreceptacleasitispulledinthedirectionoftravelduringegress.Overaperiodofyears,theuseoftheintermediatehelmetcordsatthisoperatordeclined,perhapsbecausepilotswerenotawarethatthecordsensureseparationinanemergency.However,sincethisaccident,theoperatorhasindicatedthattheuseofintermediate“pig-tail”cordsforhelmetconnectionswillnowbere-institutedwherenecessary.

Figure 2. Intermediate helmet “pig tail” connection cords

Otheroperatorsmayhaveaircraftwithsimilardirect-to-airframeconnections,andmaybeunawarethatthesecanimpedeegressinanemergency.Therefore,TransportCanadamaywishtoadvisetheaviationcommunitythattheseconnectiontypesmayimpedeegress,andthatanintermediatecordcanhelptomitigatethishazard.Done. —Ed.

TransportCanada

TransportsCanada

aviation safety letter

TP 185EIssue 4/2006

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

In this Issue...

Safety Hazard Alert—Call Sign Confusion

Thoughts on the New View of Human Error Part I: Do Bad Apples Exist?

Transport Canada Update—ICAO Amendment 164—Language Proficiency Rating (LPR)

Recently Released TSB Reports

Near Repeat of Mirabel De-Icing Mishap

Cold Weather Altimeter Error—Getting Cold Feet?

How Much is Too Much? Test Your Knowledge of Operations During Icing Conditions

Aircraft Maintenance Operational and Functional Checks

Flight Crew Recency Requirements Self-Paced Study Program

TC-1001878TC-1001878

TransportCanada

TransportsCanada

Flight Crew Recency RequirementsSelf-Paced Study Program

Refer to paragraph 421.05(2)(d) of the CanadianAviationRegulations (CARs).

This questionnaire is for use from November 1, 2006, to October 31, 2007. Completion of this questionnaire satisfies the 24-month recurrent training program requirements of CAR 401.05(2)(a). It is to be retained by the pilot.

Note: The answers may be found in the TransportCanada AeronauticalInformationManual (TC AIM). TC AIM references are at the end of each question. Amendments to this publication may result in changes to

answers and/or references.

1. Convert1020.5millibarsintoinchesofmercury.______ (GEN1.9.2)2. TheSECURITASprogramprovidesameansforindividualstoreport________________and ____________________________________relatingtotheCanadiantransportationsystem. (GEN3.6)3. Runwaycontaminantssuchaswater,snoworicewill(increase/decrease)thelandingdistance.(AGA1.1.5)4. Whenasectionofrunwayorheliportisclosed,itismarkedwithan___. (AGA3.3andAGA5.6)5. ControlofARCALlightsshouldbepossiblewhenaircraftarewithin___NMoftheaerodrome. (AGA7.19)6. Retroreflectivemarkers(will/willnot)providethepilotwiththesamevisualpresentationasnormalrunway lightingwhentheaircraftislineduponfinalapproach. (AGA7.20)7. Theremovaloftheaudioidentificationfromnon-directionalbeacons(NDB),VHFomnidirectionalranges (VOR),distancemeasuringequipment(DME)orinstrumentlandingsystems(ILS)warnspilotsthatthe facilitymaybe__________eventhough____________. (COM3.2)8. Awideareaaugmentationsystem(WAAS)NOTAMwillbeissuedwhenaWAASserviceispredictednot tobeavailableforadurationofmorethan______min. (COM3.16.6.2)9. Whatdoestheequipmentsuffix“G”indicateinitem10(equipment)onaflightplan? _________________________________________________________ (COM3.16.7)10. CanVFRGPSreceiversbeusedtoreplacecurrentcharts?___ (COM3.16.16)11. Forair-to-aircommunicationsbetweenpilotsintheNorthernDomesticAirspace(NDA),whatisthe correctfrequencytouse?______MHz. (COM5.13.3)12. Anaerodromeforecast(TAF)providesexpectedconditionsfor___________________atspecificaerodromes, whereasanareaforecastchart(GFA)depicts_________________________affectingflightataspecifictime overaparticulararea. (MET3.2.1)13. AreasofshoweryorintermittentprecipitationareshownonaGFACloudsandWeatherChartas______ ____________________________________. (MET3.3.11)14. InaTAF,anycasesofstrong,non-conductivelowlevelwindshearwithin_____ftAGLwillbecodedas “__”. (MET3.9.3)15. InaTAF,“TEMPO”isonlyusedwhenthemodifiedforecastconditionisexpectedtolastlessthan ________ineachinstance. (MET3.9.3)16. TAFCYXU011035Z01112327015G25KT3SMRAOVC005 BECMG1314OVC020 FM1700Z29005KTP6SMOVC030TEMPO1723BKN030 RMKNXTFCSTBY17Z= Intheweatherreportabove,theforecastwindfor1500Zis_________________________________. (MET3.9.3)17. SPECICYSJ221650Z08017G243/8SMR23/2000FT/N–SNDRSNVV006 M03/M05A2953RMKSN8VSBYVRBL3/411/2 Intheweatherreportabove,theprevailingvisibilityis_____andthevisibilityisobscuredby _____________________________________. (MET3.15.3)18. Arethewindsinaviationweatherforecastsandreportsgivenindegreestrueormagnetic?GFA:_____; TAF:_____;FD:_____;METAR:_____.(MET3.3.11,3.9.3,3.11,3.15.3)19. DoesATCassumeresponsibilityforobstacleclearancewhenyouareradaridentified?___ (RAC1.5.2)20. Ifyouobservesuspiciousgroundactivitiesatanabandonedairstrip,whatreportshouldyoumake? _____________ (RAC1.12.2)

7.625”8.375”8.5”

ASL4/2006 392 ASL4/2006

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

Paul Marquis, EditorAviation Safety LetterTransportCanada(AARQ)PlacedeVille,TowerCOttawaONK1A0N8E-mail:marqupj@tc.gc.caTel.:613-990-1289Fax:613-991-4280Internet:www.tc.gc.ca/ASL-SAN

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

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

Toobtaininformationconcerningcopyrightownershipandrestrictionsonreproductionofthematerial,pleasecontacttheEditor.

Sécurité aérienne — Nouvellesestlaversionfrançaisedecettepublication.

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Transport (2006).ISSN:0709-8103TP185EPublicationMailAgreementNumber40063845

regulations and you

Safety Management Systems—Raising the Bar on Aviation Safety by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada

Asafetymanagementsystem(SMS)isastructureofsystemsdesignedtoidentifyandeliminaterisksandimprovethesafetyperformanceofairoperators.SMSisintendedtoincreaseindustryaccountability,andtonurtureandsustainasafetyculture,wherebyemployeescanconfidentiallyreportsafetydeficiencieswithoutfearofsubsequentpunitiveaction.RegulationwilleventuallyrequireallTransportCanadaoperatingcertificateholderstoimplementanSMS.

ThefollowingeventillustratesthevalueofanSMSinadvancingaviationsafetywhentherehasbeenacontraventionoftheregulations.

OnaclearJanuarymorning,anAirbus310departedHalifax,N.S.,forCalgary,Alta.,andclimbedtoacruisingaltitudeof34000ft.Aftercompletingtheroutinecruisechecks,thecrewsettledbackandthe256passengersrelaxedandenjoyedalightbreakfast.AstheywereapproachingMontreal,Que.,thecaptaincheckedtheen-routeweatherwhilethefirstofficertookfuelquantityreadingsandcomparedthemwiththeflightplanfiguresrequiredtocompletetheflighttodestination.ThefirstofficersuddenlyrealizedthattheyhadnottakenonenoughfuelpriortotheirdeparturefromHalifax.AfterconfirmingthereadingsandmanuallyrecalculatingtheminimumrequiredfueltocompletetheflighttoCalgary,heinformedthecaptain.Theybothdouble-checkedthefuelremainingagainstthefuelrequired.TheinsufficientfuelstatewasconfirmedandtheyagreedtoplananunscheduledrefuellingstopinToronto,Ont.MontrealCentreandcompanydispatchwerebothadvisedofthefuelconditionandtheyrespectivelyauthorizedandconcurredwiththerevisedrouting.

Fromaregulatorystandpoint,thepilot-in-commandandtheoperator,contravenedCanadian Aviation Regulation(CAR)602.88(2)fornotcarryingsufficientfuelfortheplannedroute.TheenforcementprocessinitiatedfollowingthiscontraventionistypicalofwhatwouldhappenwithinanyaviationcompanythatoperatesinaccordancewithanSMS.

TheAviationEnforcementDivisionbecameawareoftheeventthroughanoccurrencereportintheCivilAviation

DailyOccurrenceReportingSystem(CADORS),andnotifiedtheTransportCanadaprincipalinspectorresponsiblefortheoperator.Theprincipalinspectorconfirmedthatthecrewhad,asrequiredunderSMS,internallyreportedtheincidenttotheoperator.

InlinewithSMSphilosophy,theoperatordevelopedandsubmittedacorrectiveactionplan(CAP)totheprincipalinspector,outliningasystematicapproachtoaddressthefuelmismanagementandtopreventarecurrence.TheCAPincludedrevisedpre-flightandin-flightstandardoperatingprocedures(SOP)designedtoensureaccurateflight-plannedfuelcalculationsandaccuratefuel-on-boardmonitoringpriorto,andduring,flight.Theseproceduresforproperfuelmanagementwereincorporatedintoamandatorytrainingseminarforallflightcrew members.TheprincipalinspectorreviewedtheCAPandwasconfidentthatitaddressedtheissuesthatledtotheinitialcontravention.Inconsultationwiththeprincipalinspector,theAviationEnforcementDivisioncouldhavereactivatedtheinvestigationatanytimeduringtheprocessleadinguptotheacceptanceoftheCAP,andwouldhave,if:

thecontraventionhadbeenintentional;theincidenthadnotbeeninternallyreported;ortheprincipalinspectorhadfoundtheCAPtobeunacceptable,andtheoperatorhadrefusedtoaddresstheissue.

Hadthedecisionbeentocontinuetheinvestigation,aletterofinvestigationwouldhavebeensentdirectlytotheoperator,andtheprincipalinspectorwouldhavebeennotified.Inthisspecificcase,theinvestigationwasclosedwithoutfurtherenforcementaction.

Althoughthestoryinthisarticledoesnotdepictanactualevent,itdoesservetoillustrateatypicalSMSresponse,designedtoraisethebaronaviationsafetyfollowingaregulatorycontravention.

Forfurtherclarification,weinviteyoutoconsulttheAviationEnforcementPolicyandProcedures—SafetyManagementSystemsWebsiteatwww.tc.gc.ca/civilaviation/SMS/policy.htm.

The Civil A

viation M

edical Exam

inerReg

ulations and

YouRe

gul

atio

ns a

nd Y

ou

The

Civ

il A

viat

ion

Med

ical

Exa

min

erD

ebri

ef

Debrief

Go to www.smartmoves.ca

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

FOR CANADIAN RESIDENTS ONLY

21. Taxiauthorizationsthatcontaintheinstructions“hold”or“holdshort”(shall/neednot)bereadbackby thepilot. (RAC4.2.5)22. Wherepossible,pilotsarerequiredtoreportatleast____minbeforeenteringanMFarea. (RAC4.5.7)23. A___________mustbefiledforallflightsbetweenCanadaandaforeignstate. (FAL2.3.2)24. OnflightsfromCanadatotheU.S.,atleast________advancenoticeofarrivalmustbeprovidedto U.S.Customs. (FAL2.3.2)25. OnflightstoCanada,pilotsmustlandataCanadaCustomsauthorizedairportofentry(AOE). Pilotsmustmaketheirowncustomsarrangementsbycalling______________atleast_________before flyingintoCanada. (FAL2.3.2)26. PilotsreceivingaMANOTmessagearerequestedtomaintainaradiowatchon______MHzwhen operatinginthevicinityofthetrackofthemissingaircraft. (SAR2.3)27. Listthefourstepsthatshouldbeaccomplished(wherepracticable)duringyourpreflightinspectionofthe emergencylocatortransmitter(ELT). (a)__________________________________________________________________________________; (b)____________________________________________________________; (c)_____________________________________________;and (d)____________________________________________. (SAR3.4)28. WhenanELTsignalisheardinflight,thenearestATSunitshouldbeadvisedofwhatfourpieces ofinformation? (a) ________________________________________________________; (b)___________________; (c)_____________________________________________;and (d)____________________________________________. (SAR3.4) 29. Intheeventofacrash,whatshouldyoudowiththeELT’sfunctionswitch,andwhen? ____________________________________________________________________ (SAR3.5)30. 061234NOTAMNCYSBSUBDURY RWY04/22CLOSEDTILAPRX0612151530 Runway04/22isexpectedtoopenat_____Zon(date)___________. (MAP5.6.1)31. Whatisthesignificanceoftheterm“APRX”intheaboveNOTAM?_____________________________ (MAP5.6.1)32. 060210NOTAMR060202CYNDWINCHESTER CNA8UNMANNEDAERIALVEHICLEOPS3NMRADIUS450610N 752854W(APRX9NMNWAD)SFCTO2400FTMSL 0605051700TIL0605052300 Whatisthesignificanceoftheletter“R”attheendoftheword“NOTAM”above?__________________ (MAP5.6.2)33. ACanadianmedicalcertificateforaprivatepilotlicenceisvalidinCanadafor___monthsifunderage40, andfor___monthsifage40orolder. (LRA3.2.4)34. InaccordancewithCAR401.08,everyapplicantfor,andeveryholderof,aflightcrewpermit,licenceor ratingshallmaintaina______________. (LRA3.7.6)35. Theflightcrewrecencyrequirementsaddressthreetimeperiods.Toactaspilot-in-commandorco-pilot youmustmeetthe___________________recencyrequirements.Ifyouwishtocarrypassengers,youmust alsomeetthe________requirements. (LRA3.9)36. Inordertocarrypassengers,youmusthavecompleted__takeoffsandlandingsinthesamecategoryand classofaircraftintheprevious__months. (LRA3.9)37. ClassAfiresarefiresin______________________________. (AIR1.4.2)38. Anaircraftaltimeterwhichhasthecurrentaltimetersettingappliedtothesubscaleshouldnothavean errorofmorethan___ftwhencomparedonthegroundagainstaknownaerodromeorrunwayelevation. (AIR1.5.1)39. By______ftASLthepartialpressureofoxygenissuchthatallpilotswillexperiencemildhypoxiaand somewillbecomesymptomatic. (AIR3.2.1)40. If,ondescent,thepressureintheears(orsinuses)cannotberelievedbyswallowing,yawningorValsalva manoeuvre,itisbestto_________________________________________________________. (AIR3.8)

Answers to this quiz are found on page 38 of this ASL 4/2006.

Don’t Forget to Subscribe to the Transport Canada Aeronautical Information Manual !

ThenewTransportCanadaAeronauticalInformationManual(TCAIM)wasintroducedinOctober2005.AllCanadian-registeredpilotsreceivedtwofreepapercopies,thelastofwhichwasdeliveredinApril2006.ThenextreleaseoftheTCAIMisscheduledforOctober2006.Thereareafewoptionsonhowtosubscribetothispublication:

Paid subscription to the paper copy• SubscribeonlinetothepapercopybyvisitingTransportCanada’sonlinepublicationsstorefrontat

www.tc.gc.ca/transact.There,youcanordereitherasinglecopy($15.00,whichincludesshipping,butexcludesapplicabletaxes)ortakeoutasubscriptionforfuturecopies;or

• CalltheTransportCanadaOrderDeskat1-888-830-4911or613-991-4071,toorderasinglecopyorrequestasubscription.Theywilltakeyourcreditcardinformationandprocessyourorder.

Free e-Bulletin notification• Registerforane-Bulletin,whichmeansTransportCanadawillsendyouane-mailwithalinktothelatest

onlineversion,ineitherHTMLorPDFformat.Toregisterforane-Bulletin,sendane-mailtoMPS@tc.gc.ca andasktobeaddedtotheTCAIMe-Bulletinlist.Pleasestateyourname,postaladdressande-mailaddress.

Asaremindertoall,theonlineversionoftheTCAIMisavailableforviewingandfreedownloadatalltimes.YoucanaccessitfromTransportCanada’sonlinepublicationsstorefrontatwww.tc.gc.ca/transact.