A94C0088 - Controlled Flight into Obstacle and Terrain - Thompson, Manitoba-01 June 1994

Safety Action Taken 
(as presented in the TSB Report)

Operator Action

The operator indicated that, subsequent to the accident, the chief pilot has taken steps to ensure that all standard procedures are adhered to. Also, a designated flight examiner was retained to act as an independent auditor of ongoing training, reporting any concerns directly to the chief pilot and the operations manager.

Revised Flight and Duty Time Regulations

The Canadian Aviation Regulation Advisory Council (CARAC) proposed regulations which deal with some of the fatigue issues raised in this report. Comments on these regulations were solicited in the Canada Gazette, Part 1 , on 12 August 1995. The proposed regulations address the following issues:

Flight Duty Time - Definition: "flight duty time" will start when the pilot reports for flight duty, is on stand-by with a reporting time of one hour or less, or reports for any duty assigned by the air carrier prior to flight duty.

Flight Duty Time - Extensions: Extensions will be limited to unforeseeable operational circumstances and be permitted only if no reasonable alternative is available. The extension is limited to a maximum of 3 hours and the subsequent rest period will be extended by an amount equal to the flight duty time extension.

Flight Duty Time - Positioning: Positioning flights (non-revenue) will now contribute towards maximum flight and duty times.

Predictable and Protected Rest Periods: When a pilot is on reserve or stand-by with more than one hour reporting time, the air carrier will be required to either provide the pilot with a daily predictable and protected rest period, or apply more restrictive flight duty times and/or extended rest periods.

If implemented, these proposed revisions should help aircrew to plan rest periods, eliminate the long periods of on-call or duty time, and provide for reasonable amounts of scheduled stand-by time.

In addition, Transport Canada intends to publish an Air Carrier Advisory Circular concerning fatigue and fatigue countermeasures.

Controlled Flight into Terrain (CFIT)

The circumstances of this occurrence are typical of a CFIT incident. CFIT occurrences are those in which an aircraft, under the control of the crew, is flown into terrain (or water) with no prior awareness on the part of the crew of the impending disaster. Over the eleven-year period from 01 January 1984 to 31 December 1994, 70 commercially operated aircraft not conducting low-level special operations were involved in CFIT accidents in Canada. In view of the frequency and severity of such accidents, the Board is conducting a study of CFIT accidents to identify systemic deficiencies. The study will include, inter alia, an examination of CFIT data involving aircraft altimeter displays, altitude alerting systems, radar altimeter systems, use of ground proximity warning systems (GPWS), and MEDEVAC flights.

Transport Canada has recently produced a video about CFIT to increase pilot and operator awareness of those factors which can contribute to CFIT accidents.

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