Safety Action Taken
(as indicated in the TSB Report)

Cockpit Resource Management

In multi-crewed aircraft, teamwork is essential to the detection of errors (such as the premature descent in this accident), and effective cockpit communications are essential to good teamwork.

Following an incident involving a Boeing 737 in which poor intra-cockpit communications led to a near collision with terrain, it was recommended that the Department of Transport promote the adoption of CRM training by commercial operators (CASB Recommendation 90-53). Subsequently, TC has encouraged the adoption of this training through articles in the Aviation Safety Letter and has provided related courses such as PDM.

The TSB recently conducted a survey on Canadian commercial pilots. Of the pilots surveyed that were employed on multi-crewed aircraft with level III to VI air carriers, 42 per cent indicated that their employer provided formal CRM training. The continuing implementation of CRM training for commercial pilots should reduce the risk of recurrence of this type of accident.

Approach Slope Indicator

Subsequent to this accident, the TSB forwarded an Aviation Safety Advisory suggesting that TC evaluate the need for an ASI and/or approach lighting for runway 24 at Moosonee. TC subsequently recommended that the Moosonee Airport authorities install ASIs and indicated that TC was prepared to render any assistance necessary to obtain the ASIs.

Survival Kit Location

Post-accident survivability often depends to a large extent on the contents and availability of aircraft survival equipment. TC published an article in the 6/92 issue of Aviation Safety Letter encouraging operators to carry survival equipment in rear baggage areas where, in the event of an accident, the equipment would be less likely to be damaged or become inaccessible.

Human Factors Training

The Board determined that the accident aircraft was inadvertently flown into trees in conditions conducive to black-hole illusion. Pilots must contend with many types of visual illusions. Between 1977 and 1990, visual illusions were identified as a contributing factor in 19 other accidents. Visual illusions, in turn, are only one of many "human factor" issues which play a role in 70 to 85 per cent of all aircraft accidents. Training and awareness programs have the potential for reducing the number of accidents attributable to human factors.

The International Civil Aviation Organization (ICAO) has undertaken several initiatives, including the production of a series of digests on various aspects of human factors in aviation and a requirement for training in human factors for all aircrew licence holders in ICAO member states. TC is advancing pilot knowledge through promotional activities, by upgrading study and reference materials (such as the Pilot Decision Making Manual for Private Pilots, and the soon to be released Pilot's Guide to Human Factors), and by increasing the human factors knowledge requirements for the issue of pilot licences. Visual illusions (including black-hole illusion) are discussed in the draft Pilot's Guide to Human Factors, and have been included in a recent update of the data bank of questions used by TC for pilot written exams.

Safety Action Required
(as indicated in the TSB Report)

Crew Pairing

The lack of a company crew pairing policy was identified as contributing to the accident. The captain and co-pilot had been in their respective crew positions for less than one month, and the accident flight was the co-pilot's first night flight in the C99, his first trip into Moosonee, and his first flight with the captain.

Crew pairing has been identified as a contributing factor in other occurrences. In July 1987, a Lockheed 1011 was involved in a near collision with a Boeing 747 as a result of a navigational error over the Atlantic Ocean. The Lockheed 1011 flight crew, who did not perform adequate navigational cross-checks, had limited experience in North Atlantic flying, with no crew member having more than six return trips (Report 87-A74947 refers). Furthermore, in 1987, the crew of a Boeing 737 Combi flew off track while on approach to Prince George, British Columbia, because of an improper navigation switch selection. Neither pilot had been in the cockpit of a Combi before (Report 87-P74128 refers). In August 1989, the flight crew of a Boeing 727 apparently failed to notice a navigation error, resulting in a loss of separation with another aircraft. The captain was not accustomed to the type of approach being flown, the co-pilot was new to the aircraft, and neither pilot was familiar with the destination (Report A89A0209 refers).

The U.S. National Transportation Safety Board (NTSB) has recognized the importance of proper crew pairing. In October 1986, following the investigation of three commuter air carrier accidents in which crew pairing was identified as a contributing factor, the NTSB recommended that the U.S. Federal Aviation Administration (FAA) caution commuter air carrier operators not to schedule on the same flight crew members with limited experience in their respective positions. Furthermore, following the crash of a McDonnell Douglas DC-9-14 on 15 November 1987, in which crew pairing was again identified as a contributing factor, the NTSB recommended that the FAA establish minimum experience levels for each pilot-in-command and second-in-command pilot, and that such criteria be used to prohibit the pairing of pilots who have less than the minimum experience in their respective positions. The FAA responded to these recommendations by bringing the crew pairing issue to the attention of air carriers and requesting that they develop, to the extent possible, appropriate crew pairing policies and procedures.

Crew pairing was also recently addressed by the Commission Of Inquiry into the Air Ontario Crash at Dryden, Ontario. It was recommended that TC encourage air carriers which lack pilots with sufficient experience on a new aircraft type to provide highly experienced pilots from outside the air carrier to assist in training the air carrier's pilots and to fly with them until an adequate level of flight experience is gained on the new aircraft type. Additionally, it was recommended that TC proffer for enactment legislation with respect to flight crew pairing. That legislation would require that one of the flight crew members, either the pilot-in-command or the first officer, have substantial flight experience on the aircraft type.

Many factors must be considered when flight crews are made up. Not only must the crew be familiar with the aircraft type, but it should also be familiar with the aspects of the operating environment specific to a particular aircraft, an operating area, the type of operation, the time of day, and, if possible, the crew members should be familiar with each other.

In view of the importance of crew pairing to effective cockpit performance and in view of the many factors which can contribute to poor crew pairing, the Board recommends that:

The Department of Transport provide guidance for air carriers to assist in the effective pairing of flight crews. A93-03

Response from Transport Canada:

The issue of crew pairing is being addressed by Transport Canada officials as a result of the recommendations contain in the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario. The subject of crew pairing has been designated as MCR 71 by the Dryden Implementation Project and is currently under active review. In addition, the Federal Aviation Administration (FAA) has issued a Notice of Proposed Rulemaking (NPRM) for a regulation which would prevent the pairing of pilots if both have 75 hours or less of operating time on the type of aircraft being flown.

There has been extensive consultation between Transport Canada Aviation (TCA) and the aviation industry on how to best implement this recommendation. It is expected that the Canadian implementation of legislation for crew pairing will be similar to that of the FAA. This legislation will be addressed by the Dryden Commission Implementation Project and its review of MCR 71.

Design Eye Reference Point

The accident investigation determined that the captain could not achieve the DERP; his thighs would have interfered with the control column and he would not have been able to achieve full rudder travel. Consequently, from his selected seat position, the captain could not see below the horizon while the aircraft was in level flight in the approach configuration. Like many other company pilots, he was not fully aware of how the safe operation of the aircraft could be compromised if his eyes were not positioned near the DERP.

The Beechcraft C99 was type-certified to FAR 23 which establishes certain cockpit visibility requirements. However, manufacturers are not required to provide guidance to pilots to enable them to position their eyes near the DERP. Furthermore, current pilot training and knowledge requirements do not address the importance of achieving optimum visibility, that is, positioning the eyes at the DERP. Hence, the Board believes that many pilots unnecessarily restrict their visibility, jeopardizing the safe operation of their aircraft, as evidenced by this accident. To assist pilots in optimizing their visibility, particularly for the approach and landing phases of flight, the Board recommends that:

The Department of Transport take the necessary steps to ensure that pilots receive appropriate guidance for positioning their eyes at or close to the Design Eye Reference Point.

Response from Transport Canada:

Transport Canada will publish an Air Carrier Advisory Circular which explains the concept of DERP and emphasizes the hazards of flying approaches from a seat position which does not approximate the proper DERP nor provide for proper monitoring of external references. In addition, this information will be published in the A.I.P. Canada to provide guidance on this issue to the entire pilot community.

Night Training on Type

ANOs require air carriers to provide their pilots with certain training before they can serve as flight crew members. This training includes take-offs and landings at night in each type of multi-engine aircraft that the pilot is to fly at night.

Neither of the occurrence pilots had received the required night training on the Beechcraft C99 nor had they received night training for any of the aircraft types that they had flown in the past for any company. For these two pilots, five different companies had not conducted night training on four different aircraft types.

The questionnaire used in the recent TSB survey on Canadian commercial pilots did not specifically address night training on type; however, it did contain a question concerning required recurrent aircraft/emergency training. Fourteen per cent of the pilots surveyed indicated that this training either had never occurred or that it had occurred less frequently than required. The survey also indicated that many pilots feel that TC audits do not go far enough towards actually verifying entries in training records.

In view of the special skills needed for safe night operations, the Board recommends that:

The Department of Transport validate its current procedures for checking that air carriers provide the required multi-engine night training. A93-05

Response from Transport Canada:

Chapter 3, Section 4, Check list OP-6, Item A.2 of the Manual of Regulatory Audits, which was published since the accident occurred, directs the audit staff to check that the flight training programme (initial and recurrent) meets the requirements of the company Operations Manual and the ANOs. A part of the Legislation/Section reference in the Manual, includes Sections 43-46 and Schedule D1 (K) of the Air Carriers Using Small Aeroplanes Order, (A.N.O., Series VII, No.3). Subsections 43 (2), (3) and (4) are explicit in stipulating the requirements for air carriers to establish and provide approved ground and flight training programs and to maintain records of the training given to each crew member certifying that he is adequately trained to carry out his assigned duties. Subparagraph (1) (b) (iii) of Section 46 of the Order specifies that flight training for each crew member will include, in each type of aircraft he is to fly:

“Take-offs and landings by day and, if he is to fly at night, by night.”

Subsection 6.3 of the Air Carrier Inspector Manual reinforces this requirement in stating :

“Each air carrier is required by Orders to maintain a record of training and checks for each crew member. The training program of the Operations Training Manual shall include an outline of the record keeping procedure established by the air carrier and shall include copied of the forms used to record the training and checks completed.”

In accordance with the National Audit Programme, TCA conducts periodic audits of air carriers to promote compliance with the aviation regulations and standards.

TCA will send a letter to all Regional Air Carrier staff recommending that they put more emphasis in checking requirements, particularly night flying training. When conducting future audits, Quality Assurance Review teams from Headquarters will ensure the checks are completed.

Safety Concern
(as indicated in the TSB Report)

Terrain Avoidance Equipment

Altitude alerter, radar altimeters and GPWS can warn flight crews of an inadvertent approach to terrain. Since GPWS became mandatory equipment on larger passenger-carrying aircraft, the number of controlled flight into terrain (CFIT) accidents has decreased markedly for these aircraft. However, smaller aircraft, such as the one in this occurrence, do not require this type of warning equipment.

The Board notes with concern that, between 1976 and 1990, there were 170 CFIT accidents with 152 fatalities involving Canadian-registered, commercially operated small aircraft. In view of the frequency and severity of such accidents, and the improved safety that has resulted from the use of GPWS in larger aircraft, the Board may conduct a study of CFIT accidents in small commercial aircraft. Back

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