Transport Canada's response to the Aviation Safety Recommendations A09-01, A09-02, A09-03, A09-04 and A09-06 issued by the Transportation Safety Board of Canada (TSB)

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A08O0189: Bounced Landing Training

Bounced Landing/Go-Around After Touchdown
Kelowna Flightcraft Air Charter Ltd.
Boeing 727-227 C-GLKF,
Hamilton Airport, Ontario

Link to TSB Report A08O0189

Summary

On 22 July 2008, a Kelowna Flightcraft Air Charter Ltd. Boeing 727-227 (registration C-GLKF, serial number 21118), with three crew members on board, was being operated as KFA281 on a cargo flight from Moncton, New Brunswick, to Hamilton, Ontario. The aircraft was vectored for an approach to Runway 06 at Hamilton Airport. At 2216 eastern daylight time, the aircraft touched down hard and bounced before touching down hard a second time. Immediately after the second touchdown, a go-around was initiated. During rotation, the tailskid made contact with the runway. The thrust reverser actuator fairing and the number 2 engine tailpipe made contact with the ground off the departure end of the runway. The aircraft climbed away and then returned for a normal landing on Runway 12. There were no injuries; the aircraft sustained minor damage.

Recommendations

Transportation Safety Board of Canada Recommendation A09-01

“The Department of Transport require air carriers to incorporate bounced landing recovery techniques in their flight manuals and to teach these techniques during initial and recurrent training.”

Transport Canada Response to Recommendation A09-01

An Advisory Circular (AC) will be prepared to air carriers that will raise awareness of the hazards and means of reducing the risks through a Safety Management System (SMS) approach.

Transport Canada will seek voluntary compliance in addressing the identified operational hazard similar to the approach taken by the Federal Aviation Administration (FAA).

Transport Canada will review the voluntary implementation of any identified mitigation and one year after the release of the AC, TC will assess the approach taken by the operators.

A07C0001: Crew Resource Management Training

Collision with Terrain
Transwest Air
Beech A100 King Air C-GFFN
Sandy Bay, Saskatchewan

Link to TSB Report A07C0001(http://www.tsb.gc.ca/eng/rapports-reports/aviation/2007/a07c0001/a07c0001.asp)

Synopsis

Transwest Air Flight 350 (TW350), a Beech A100 King Air (registration C-GFFN, serial number B190), departed La Ronge, Saskatchewan, at 1930 central standard time under instrument flight rules to Sandy Bay, with two flight crew members and two emergency medical technicians aboard. TW350 was operating under Part VII, Subpart 3, Air Taxi Operations, of the Canadian Aviation Regulations. At 1948, air traffic control cleared TW350 out of controlled airspace via the Sandy Bay Runway 05 non-directional beacon approach. The crew flew the approach straight-in to Runway 05 and initiated a go-around from the landing flare. The aircraft did not maintain a positive rate of climb during the go-around and collided with trees just beyond the departure end of the runway. All four occupants survived the impact and evacuated the aircraft. The captain succumbed to his injuries before rescuers arrived. Both emergency medical technicians were seriously injured, and the first officer received minor injuries. The aircraft sustained substantial damage from impact forces and was subsequently destroyed by a post-impact fire. The accident occurred at 2002 during the hours of darkness.

Recommendations

Transportation Safety Board of Canada Recommendation A09-02

“The Department of Transport require commercial air operators to provide contemporary crew resource management (CRM) training for Canadian Aviation Regulations (CARs) subpart 703 air taxi and CARs subpart 704 commuter pilots.”

Transport Canada Response to Recommendation A09-02

Transport Canada has accepted the recommendation in principle and in accordance with the Cabinet Directive on Streamlining Regulations (CDSR), the rule making process will commence with a more detailed risk assessment. Transport Canada is expecting to present the risk assessment and supporting recommendation to the Civil Aviation Regulatory Committee (CARC) in the spring of 2010. The resulting recommendation from CARC will trigger the rulemaking process.

A07A0134: Availability of Eye-to-Wheel Height Information - Knowledge of Visual Glide Slope Indicator System Limitations - Oversight

Touchdown Short of Runway - Jetport Inc. Bombardier BD-700-1A11 (Global 5000) C-GXPR, Fox Harbour Aerodrome, Nova Scotia

Link to TSB Report A07A0134 http://www.tsb.gc.ca/eng/rapports-reports/aviation/2007/a07a0134/a07a0134.asp)

Synopsis

On 11 November 2007, the Bombardier Global 5000 (registration C-GXPR, serial number 9211), operated by Jetport Inc., departed Hamilton, Ontario, for Fox Harbour, Nova Scotia, with two crew members and eight passengers on board. At approximately 1434 Atlantic standard time, the aircraft touched down seven feet short of Runway 33 at the Fox Harbour aerodrome. The main landing gear was damaged when it struck the edge of the runway, and directional control was lost when the right main landing gear collapsed. The aircraft departed the right side of the runway and came to a stop 1000 feet from the initial touchdown point. All occupants evacuated the aircraft. One crew member and one passenger suffered serious injuries; the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.

Recommendations

Transport Canada Response to the Aviation Safety Recommendations A09-03, A09-04 and A09-06 issued by the Transportation Safety Board of Canada (TSB)

Transportation Safety Board of Canada Recommendation A09-03

“The Department of Transport ensure that eye-to-wheel height information is readily available to pilots of aircraft exceeding 12 500 pounds.”

Transport Canada Response to Recommendation A09-03

Transport Canada agrees with the intent of the recommendation and in accordance with the Cabinet Directive on Streamlining Regulations (CDSR), the rule making process will commence with a more detailed risk assessment to identify the appropriate regulatory response. Transport Canada is expecting to present the risk assessment and supporting recommendation to the Civil Aviation Regulatory Committee (CARC) in the fall of 2010. The resulting recommendation from CARC will trigger the rulemaking process.

Transportation Safety Board of Canada Recommendation A09-04

“The Department of Transport require training on visual glide slope indicator (VGSI) systems so pilots can determine if the system in use is appropriate for their aircraft.”

Transport Canada Response to Recommendation A09-04
Pilots are trained on visual slope indicator systems during their private and commercial courses. When a pilot takes training for their night rating, further training on visual slope indicator systems takes place.

Transport Canada has reviewed the training and determined that additional training is not required. However, Transport Canada will revise the Aeronautical Information Manual (AIM) section on Approach Slope Indicator Systems with an emphasis on the following:

  • Pilots must ensure that the approach slope indicator systems is appropriate for the given aircraft type based on Eye Wheel Height (EWH) information provided by the aircraft manufacturer;
  • The aircraft manufacturer should be contacted to determine the EWH information for the given aircraft type, if this information is not already available in the Aircraft Flight Manual (AFM) or other authoritative aircraft manual (e.g.: Flight Crew Operating Manual FCOM); and,
  • Failure to assess the EWH and approach slope indicator system compatibility could result in decreased terrain clearance margin and in some cases even premature contact with terrain.

Transport Canada will also produce an Advisory Circular to highlight the above information to flight crews. These actions are to be completed by spring of 2010.

Transportation Safety Board of Canada Recommendation A09-06

The Department of Transport ensure that the Canadian Business Aviation Association (CBAA) implement an effective quality assurance program for auditing certificate holders.”

Transport Canada Response to Recommendation A09-06
Transport Canada agrees with the recommendation. A full review of the CBAA regulatory program, including the requirements to include an effective quality assurance program for auditing certificate holders, has been initiated with the results to be presented for consultation before the Canadian Aviation Regulation Advisory Council (CARAC).

In the meantime, Transport Canada continues to work with the CBAA towards strengthening their quality assurance program and will be making the required adjustments to Transport Canada’s surveillance program. To address this and other findings, as well as collaterally responding to the above TSB recommendation, Transport Canada has:

  • assigned additional resources (working and supervisory level pilot inspectors with managerial support and direction from a Chief level position) to oversee the CBAA Private Operator Certificate Program, and to improve associated processes and procedures. Such improvements include regular, scheduled communications with the CBAA, the monitoring of reported occurrences and follow up review with the CBAA; and,
  • undertaken a formal follow-up of the 2007 assessment and CBAA's progress in addressing the findings raised. The follow-up took place in spring 2009. This review found that the finding concerning CBAA implementation of a quality assurance program of their audit program had not been fully addressed and, as such, this finding remained open. The CBAA has recently notified the Department of proposed changes to their processes and procedures to address this finding. Transport Canada reviewed these changes and met with the CBAA in January 2010. Consequently the CBAA modified its quality assurance program.

Should you require further information, please contact Aviation Safety Analysis at asi-rsa@tc.gc.ca