REGIONNAIR-SEPT-ILES, QUEBEC - 12 AUGUST 2000
Raytheon Beech 1900D C-FLIH
Safety Action Taken (as presented in the TSB Report)
On 13 August 1999, Transport Canada (TC) conducted a post-occurrence audit of Régionnair Inc. The findings of this inspection, primarily regarding training shortcomings and the lack of qualified management personnel, resulted in the suspension of the company's air operator certificate effective that date. The company's response to the identified shortcomings resulted in the reinstatement of the air operator certificate on 18 August 1999.
TC, Safety Systems, gave three crew resource management courses specifically for the company in March, August, and December 1999. Twenty-four Régionnair pilots were trained and qualified. An additional course was offered to all pilots on 15 January 2000.
Subsequent to the TSB's safety recommendation (A96-11) in 1996 to raise commercial operators' awareness of the risks associated with flight operations in marginal visual flight conditions, many of TC's national aviation safety promotional efforts, safety awareness programs, and regional education programs have focused on the issue of weather.
A combined TC/industry study group is reviewing the safety data and the issues surrounding approaches in poor weather. Regulatory recommendations concerning approach bans, in the form of a notice of proposed amendment, were submitted to the General Operating and Flight Rules Technical Committee of TC in December 1999.
TC has issued special aviation notices and aeronautical information circulars and made entries in Aeronautical Information Publication concerning global positioning system (GPS) use. TC has also published a number of articles in the Aviation Safety Letter and Aviation Safety Vortex newsletters addressing the operating limitations and safe use of GPS. Aviation Safety Letter, issue 4/2000, contains an article titled "Dangers of Flying Home-made GPS Approaches". The author warns pilots that this practice "is like playing Russian roulette with the lives of all on board".
TC, Commercial and Business Aviation, is drafting a commercial and business aviation advisory circular (CBAAC) to emphasize to operators the importance of maintaining records of pilot flight duty hours and flight hours. The CBAAC will emphasize the importance and various parties' responsibilities regarding the recording of duty and flight hours of pilots who fly for more than one operator.
Since the occurrence, Régionnair appointed a new director of flight operations and established a safety program. The newly selected safety officer attended a safety officers' course in October 2000. Both persons met the TC requirements for the positions.
The Nav Canada Sat Nav office is working with TC and the US Federal Aviation Administration to phase in full use of GPS for all phases of flight in Canada. The Safety of Air Taxi Operations (SATOPS) Final Report recommends that TC continue to publish articles in the Aviation Safety Letter and Aviation Safety Vortex newsletters about the safe, proper use of GPS and the hazards associated with its misuse.
Safety Action Required
(as presented in the TSB Report)
Low Visibility and Low Ceiling Approaches
The Board believes that there will continue to be inadequate defences against the risks associated with pilots descending below the decision height/minimum decent altitude in an attempt to land in visibility conditions that are unsafe because of a delay in the timely implementation of an approach ban. Therefore the Board has recommended that:
The Department of Transport expedite the approach ban regulations prohibiting pilots from conducting approaches in visibility conditions that are not adequate for the approach to be conducted safely. (A02-01)
Transport Canada's response:
Transport Canada has prepared sixteen (16) Notices of Proposed Amendments (NPA 2000- 001, 002, 006, 007, 008, 009, 010, 011, 012, 106, 107, 108, 116, 117, 194, and 195 attached) to address the TSB Recommendation A02-01 concerning approach ban regulations.
These NPAs are currently under review at the Department of Justice and it is expected that the final product will be published in the June 2002 issue of the Canada Gazette. The TSB will be sent a copy of the approved version once available.
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