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 only the TSB's synopsis and selected findings. For more information, contact the TSB or visit their Web site at www.tsb.gc.ca. -Ed.

TSB Final Report A03O0012 - Loss of Control and Collision With Terrain

On January 21, 2003, a Eurocopter AS 350 B2 helicopter with the pilot and three passengers on board, departed on a day, visual flight rules (VFR) flight from Sault Ste. Marie, Ont., to conduct a moose survey at a location approximately 45 NM northeast of Sault Ste. Marie. During the survey, at 11:43 Eastern Standard Time (EST), the pilot communicated to the Ministry of Natural Resources ground-based radio operator that the aircraft experienced a hydraulic failure and that he was proceeding to a logging site at Mekatina to land the helicopter. As the helicopter approached the logging site, workers observed the aircraft proceed to the north and enter a left turn. As the helicopter proceeded back towards the logging operation in the left turn, control of the aircraft was lost and it crashed in the rising wooded terrain east of the logging site. The helicopter came to rest in an inverted position. All of the aircraft occupants were fatally injured. There was no post-crash fire.

the aircraft was lost and it crashed in the rising wooded terrain east of the logging site.

Findings as to causes and contributing factors

  1. After experiencing a hydraulic system failure, the helicopter departed controlled flight and crashed while manoeuvring for landing. The reason for the departure from controlled flight could not be determined.
  2. It is likely that the hydraulic pump drive belt failed in flight, precipitating the hydraulic failure.
  3. It is likely that the hydraulic circuit breaker was in the tripped position in flight, rendering the hydraulic CUTOFF and HYD TEST switches inoperative. This would result in hydraulic pressure from the main-rotor servos being depleted asymmetrically.

Findings as to risk

  1. Laboratory examination of the failed hydraulic drive belt and other similar unbroken belts from other aircraft revealed extensive cracking in the same location in all the comparison samples. A problem may exist at that location, creating a stress/strain concentration that results in a consistent and predictable failure.

Other findings

  1. The forces encountered by the pilot during the turn at low altitude may have been too extreme to overcome, making it impossible for him to recover the aircraft to level flight.
  2. The disassembly and/or examination of the four hydraulic servo controls and the components of the main-rotor controls revealed no pre-existing condition that would have prevented normal operation.
  3. Hydraulic fluid test results identified a water content that was within the maximum allowable limit.

Safety action taken

Significant safety actions were taken as a result of this occurrence. For more information, please consult the complete final report, as well as the applicable communiqué (#A02/2005, issued on March 16, 2005), on the TSB's Web site.



TSB Final Report A03Q0109 - Fuel Exhaustion and Forced Landing

On July 26, 2003, a Cessna 172M, carrying the pilot and three passengers, was on a VFR flight from Sept-Îles, Que., to Rivière-du-Loup, Que. After a short stopover at Rivière-du-Loup to drop off the passengers, the pilot decided to continue the flight to Québec, Que., without refuelling. En route, the pilot encountered adverse weather and requested clearance for special VFR to land at the Québec airport. About 9 NM from the threshold of Runway24, the engine (LycomingO-320-E2D) sputtered and then stopped. At approximately 20:09 Eastern Daylight Time (EDT), the pilot declared an emergency and carried out a forced landing onto the delaCapitale highway. The aircraft struck a street lamp, and the nose dropped before it collided with the ground. The pilot was seriously injured and the aircraft was severely damaged.

Findings as to causes and contributing factors

  1. Fuel exhaustion caused the engine to stop, requiring the pilot to carry out a forced landing onto the delaCapitale highway.
  2. The pilot did not use the Cessna172 flight manual to plan the amount of fuel required for his cross-country flight; he thought he had enough fuel to fly from Rivière-du-Loup to Québec.


TSB Final Report A04C0016 - Loss of Directional Control and Runway Excursion

On January 15, 2004, a Fairchild Metro SA227-AC had departed Kenora, Ont., and was landing on Runway11 at Dryden, Ont., with two pilots and ten passengers on board. During the landing roll, the aircraft went off the left side of the runway into deep snow. The aircraft was not damaged, except for two blown tires on the left main landing gear. The crew and passengers were not injured. The incident occurred during daylight hours at 14:57 Central Standard Time (CST).

the aircraft went off the left side of the runway into deep snow.

Findings as to causes and contributing factors

  1. The aircraft was operating in environmental conditions conducive to snow penetration into the brake assemblies during ground operations at Kenora.
  2. The brake assemblies on the left main landing gear froze, preventing the wheels from rotating during the landing roll at Dryden.
  3. The first officer's foot position and pressure application on the rudder pedals prevented effective use of differential braking and nosewheel steering to maintain directional control of the aircraft after landing.

Findings as to risk

  1. Although the practice of pilots placing their feet on the rudder pedals with their heels on the floor reduces the risk of tire damage from an unintentional brake application, it creates a risk that pilots will not be able to use the brakes to maintain directional control.
  2. The aircraft manufacturer's aircraft flight manual (AFM) does not provide emergency or abnormal procedures for frozen brakes.
  3. The company standard operating procedures (SOP) provide very limited guidance regarding frozen brakes, and the Transport Canada Aeronautical Information Manual (TC AIM) does not provide any guidance material regarding the risks associated with frozen brakes.
  4. Brake freeze-up risk management strategies are, for the most part, undocumented and inconsistently applied by the industry. Industry strategies in some cases contradict the strategies recommended by the brake manufacturer.
  5. Some vehicle movements at the Dryden aerodrome were not communicated to Winnipeg Radio, creating a risk that an aircraft movement could occur while a vehicle was on the runway.
  6. The continued operation of the runway with a disabled aircraft and vehicles within Zone1 of the runway strip increased the risk to aircraft using the runway.
  7. The passengers walked across active airport manoeuvring surfaces to the terminal building with no direct control over their movements.
  8. The potential exists for misidentifying or delaying the identification of safety deficiencies in future investigations as a result of flight data recorder (FDR) data inaccuracies or undetected cockpit voice recorder (CVR) signal attenuation from phase discrepancies.

Other findings

  1. The graded runway strip intended to reduce the risk of damage to aircraft running off the runway fulfilled its purpose for the aircraft's landing.
  2. The crew's action of shutting down both engines before the runway excursion most likely prevented structural failure of the propeller system and possible subsequent damage to the cabin integrity.

Safety action taken

The operator corrected the wiring of the cockpit audio/microphone jacks and confirmed proper operation of the CVR. The operator reported that no further problems existed with the mixed channel.

The manufacturer of the FA2100CVR, is in the process of revising the installation and operation manual for the CVR functional and intelligibility test procedures, to ensure that operators check the 120-min channels for proper operation. The TSB sent an Aviation Safety Advisory (615-A040037-1) to Transport Canada, suggesting that they may wish to consider action to ensure that pilots understand the risks associated with frozen brakes and are adequately prepared to maintain directional control on landing.



TSB Final Report A04W0032 - Landing Beside the Runway

On February 25, 2004, a Boeing 737-210C was operating from Lupin, Nun., to Edmonton, Alta. The runway visual range (RVR) provided to the flight crew prior to commencing the approach to Runway12 at Edmonton was 1 200RVR, with a runway light setting of5. The crew flew the instrument landing system (ILS) approach in darkness and touched down on the infield to the left of the runway surface, at 05:44 Mountain Standard Time (MST). The aircraft travelled approximately 1 600ft before returning to the runway. After the aircraft was brought to a full stop, aircraft rescue and firefighting (ARFF) was requested by the flight crew. One runway light, four taxiway lights, and one hold sign were struck by the aircraft. There were no injuries and the passengers deplaned via the rear airstair door.

Overhead view of Runway 12 at Edmonton

Finding as to causes and contributing factors

  • With deteriorating visibility and only runway edge lighting for guidance, the captain was unable to manoeuvre the aircraft to stay within the confines of the runway.

Findings as to risk

  1. Canadian regulations permit Category I approaches to be conducted in weather conditions equivalent to or lower than Category II landing minima without the benefit of the operating requirements applicable to CategoryII approaches-in this occurrence, the lack of adequate runway lighting.
  2. The approach was conducted in the VHF omnidirectional range/localizer (VOR/LOC) mode rather than the automatic/approach control service (AUTO/APP) mode, which disabled the desensitizing feature of the autopilot while tracking the localizer.
  3. Neither the Canadian Aviation Regulations (CARs) nor the operator's Operations Manual provides sufficient defences concerning the scheduling of crew duty periods so that extended periods of wakefulness, lack of restorative sleep, and rapid changes in crew shift times do not unduly affect crew performance.

Other finding

  1. The flight crew members were not using the company SOP for pilot monitored approaches (PMA).

Safety action taken

Transport Canada
In the past, the TSB has identified the safety deficiencies associated with conducting approaches in low visibility. The TSB investigated a landing accident in Fredericton, N.B., where the weather at the time of the accident was as follows: vertical visibility 100 ft obscured, horizontal visibility 1/8 mi. in fog, and RVR 1 200ft. On 20May1999, the TSB issued reportA97H0011. The following is an excerpt from that report:

As demonstrated by this accident, however, Canadian regulations permit CategoryI approaches to be conducted in weather conditions equivalent to or lower than CategoryII landing minima without the benefit of the operating requirements applicable to CategoryII approaches. Therefore, to reduce the risk of accidents in poor weather during the approach and landing phases of flight, the Board recommends that the Department of Transport reassess CategoryI approach and landing criteria (re-aligning weather minima with operating requirements) to ensure a level of safety consistent with CategoryII criteria. (A99-05)

Changes to the CARs, as proposed by Transport Canada, to improve the safety of runway approaches in poor visibility, were published in the Canada Gazette, PartI, on 20November2004, with a 30-day public comment period. After consideration of the comments, the regulations will be finalized and published in the Canada Gazette, PartII. The regulations will help harmonize Canadian regulations with international standards and will respond to recommendations from the TSB.

On 18May2004, the TSB issued Safety Information Letter (A040029) to Transport Canada, informing the department that an appropriate standard for ongoing preventative maintenance practices of airport visual aid facilities is not in place. Transport Canada responded to the information letter on 06July2004, stating that the current TP312 standard provides sufficient direction to airport operators on maintenance standards.

Operator

The operator has changed the schedule for its crews flying that particular route, and it is now conducted during the day, eliminating the requirement for flight crews to switch from day flying to night flying within the schedule. The operator has promulgated changes to the low visibility SOPs and PMA SOPs for B-737 aircraft operations. Within these changes is the requirement that the autopilot, if it is to be engaged below decision height, must be in AUTO/APP mode.



TSB Final Report A04P0041 - Collision with Water

On February 29, 2004, a Consolidated Aeronautics, Inc. model LA–4–200 Buccaneer departed Delta Heritage Airpark, B.C., at about 13:10 Pacific Standard Time (PST) for a local VFR flight. The departure was normal and the engine was running smoothly. Some time later, the aircraft conducted a touch‑and‑go landing on the Fraser River on an easterly heading in Plumper Reach, adjacent to Crescent Island. The aircraft appeared to be descending for another landing when it hit the water in a nose‑down, wings‑level attitude, with a high vertical speed component. Boaters arrived at the accident site in less than one minute. However, the aircraft had already sunk and there was a little floating debris. Sections of the aircraft were recovered two days later, and the pilot's body was recovered almost three months later.

the aircraft had already sunk and there was a little floating debris

Findings as to causes and contributing factors

  1. It is most likely that the pilot became incapacitated while piloting the aircraft, resulting in a loss of control and collision with the water.

Other findings

  1. Although current pilot medical examinations are intended to ensure that pilots are medically safe to fly, a rational screening policy cannot detect every risk factor that could result in incapacitation.

Safety action

  1. The Transport Canada Civil Aviation Medicine branch has initiated a project with the TSB to re‑examine the accidents with known or suspected cardiac incapacitation during the past 10years. This occurrence will be added to those to be studied. Following this review, more frequent or extensive testing may be proposed.


TSB Final Report A04P0047 - Risk of Collision on the Runway

On March 3, 2004, a privately-owned Cessna182 was on a day VFR flight from Victoria, B.C., to Vancouver International Airport, B.C. The aircraft's skin was unpainted aluminum. When the Cessna was about 5 NM from the airport, the Vancouver Tower south (TS) controller cleared the pilot to proceed directly to the threshold of Runway08 right (08R); the active runway. At the same time, a Boeing737 was taxiing to Runway 08R for departure to Calgary, Alta.

Vancouver International Airport

Just after the Cessna crossed the threshold, the TS controller cleared the Boeing737, which was holding at the threshold, to take position on Runway 08R. When the TS controller saw that the Cessna had touched down, he instructed the pilot to exit the runway to the right at Runway12, which was 4500ft from the threshold of Runway 08R, and to contact Vancouver ground control. The pilot correctly read back this instruction. Seconds later, when the TS controller assessed that the Cessna was turning off onto Runway12, he cleared the Boeing737 for takeoff. However, the Cessna pilot had passed the exit to Runway12 and remained on Runway 08R. At about 14:37 PST, with the Boeing737 now on its take-off roll, the TS controller was advised that the Cessna was still on the active runway. He immediately instructed the Cessna pilot to vacate the runway quickly at the next taxiway and to stay to the right-hand side of the runway. The Boeing737 passed abeam of the Cessna, about 200ft above and 100ft to the left, while the Cessna was still on the runway at the entrance toTaxiwayA2.

Findings as to causes and contributing factors

  1. The Cessna's landing was faster and further down the runway than normal, causing the pilot to miss the exit at Runway12 and invalidating the TS controller's air traffic management plan.
  2. The TS controller perceived the Cessna to be turning off the active runway when in fact the Cessna remained on the runway. The TS controller cleared the Boeing737 for takeoff without ensuring that the runway was clear of obstruction, resulting in a risk of collision between the Boeing737 and the Cessna.
  3. The Cessna pilot did not advise the TS controller that he was unsure of his position on the runway, or that he had missed the exit to Runway12, thereby delaying the TS controller's recognition of the developing conflict.
  4. Although the pilot of the Boeing737 scanned the runway ahead before commencing the take-off roll, he did not detect the Cessna on Runway08R, resulting in a risk of collision between the Boeing737 and the Cessna. The Cessna's low visibility due to its lack of contrast against the background, its small size, and the distance between the two aircraft were probably contributing factors.

Findings as to risk

  1. The visual scanning techniques used by controllers and pilots to detect and avoid conflicting traffic on or near a runway are not consistently effective in detecting all aircraft or other obstructions, thereby presenting a risk of a collision. Controllers who are not aware of the physiological limitations of human vision may not adjust their scanning techniques to compensate.
  2. The pilot of the Cessna acknowledged an ATC instruction to exit Runway08R at Runway12, but missed the exit and continued on Runway08R without advising the TS controller. There is no requirement for a pilot to immediately advise the tower when unable to comply with the exit instructions.
  3. The airport surface detection equipment (ASDE) radar system is equipped with a runway incursion monitoring and conflict alert sub-system (RIMCAS) software program to provide an alert to the controller of a potentially hazardous situation on the runway; this alert system was still not operational as of March2005.

Safety action taken

Transport Canada has noted that guidance material contained in the TC AIM, Section RAC1.7, provides clear guidelines as to what pilots-in-command (PIC) are expected to do when they find an ATC clearance unacceptable, but it is not clear as to what PICs are expected to do when they cannot comply with an ATC instruction. Transport Canada will therefore amend the guidance provided in Section RAC1.7 to indicate that PICs are expected to immediately advise ATC if they are not able to comply with an ATC instruction that they have received and acknowledged.



TSB Final Report A04C0051 - Loss of Visual Reference - Collision with Terrain

On March 4, 2004, a leased Bell 206B helicopter was being ferried by two pilots from Kitchener, Ont., to the helicopter's owners in Calgary, Alta. On the day of the occurrence, the helicopter departed Regina, Sask., at 13:40 CST on a VFR flight plan for Medicine Hat, Alta. The flight was crewed by two pilots. A licensed junior pilot was flying the aircraft from the right seat, while the company's chief pilot, who was acting as an instructor and was assisting with navigational duties, occupied the left seat. At approximately 14:55 CST, they encountered snow showers that greatly reduced visibility, and the chief pilot assumed control of the helicopter. The visibility continued to worsen until the pilots encountered whiteout conditions and they lost all visual reference with the terrain. Shortly thereafter, the helicopter struck the snow-covered surface of a field 4 NM southwest of the Swift Current, Sask., airport. The aircraft was destroyed. The junior pilot sustained serious injuries, while the chief pilot suffered only minor injuries. The accident occurred during daylight hours at approximately15:00 CST.

Findings as to causes and contributing factors

  1. The chief pilot's decision to continue a visual flight into instrument meteorological conditions (IMC) resulted in his inability to maintain control of the helicopter, and as a result, the helicopter was inadvertently flown into the snow-covered terrain.
  2. The chief pilot's decision to continue into deteriorating weather conditions was influenced by a mistaken expectation that the weather at Swift Current was better than the reported conditions, and by the pressure to reach Calgary on the day of the occurrence.
  3. The pilots disregarded the safe limits with regard to VFR flight, as described in the CARs.

Finding as to risk

  1. The pilots' use of GPSassisted them in navigating into weather conditions in which they could not safely fly the helicopter.


TSB Final Report A04P0110 - Loss of Control/Parachute System Descent

On April 8, 2004, at approximately 20:30 Pacific Daylight Time (PDT), a CirrusSR20 with the pilot and three passengers on board, took off on a night VFR flight from Kelowna, B.C., to Lethbridge, Alta., having originated in Seattle, Washington. The aircraft was climbing through 8800ft above sea level (ASL), when it veered quite sharply to the left. The pilot corrected the heading and continued the climb. About 45seconds after resuming heading, the aircraft again veered to the left; again the pilot corrected the heading. Three minutes later, the aircraft reached the cruising altitude of 9500ft ASL. Approximately one minute later, with the autopilot engaged, the aircraft rolled 90°to the left. The pilot disconnected the autopilot, but found himself in a spiral dive from which he was unable to recover. He shut down the engine and deployed the Cirrus airframe parachute system (CAPS).

the aircraft/parachute landed on a steep mountainside on the southern slope of Mount O'Leary, B.C.

At approximately 21:11 PDT, the aircraft/parachute landed on a steep mountainside on the southern slope of Mount O'Leary, B.C., at the 2 300-ft level. The aircraft sustained substantial damage, but there were no injuries. A search and rescue operation was initiated. The four occupants were found and rescued early the following morning and returned to Kelowna by military helicopter.

Finding as to causes and contributing factors

  1. While cruising at 9500ft with the autopilot engaged, the aircraft rolled 90°, left wing down for undetermined reasons, causing the pilot to lose control of the aircraft.

Findings as to risk

  1. The armed emergency locator transmitter (ELT) did not activate due to the low impact forces, and was not manually turned on, making it difficult for the rescue helicopter crew to locate the downed aircraft.
  2. The aircraft was overweight on departure from Seattle and Kelowna. Therefore, for all of the previous flight, and for much of the occurrence flight it was being operated outside of the envelope established by the manufacturer's flight testing.

Other finding

  1. The CAPS was successfully deployed and likely saved the occupants from fatal injuries.

Safety actions taken

The aircraft's impact forces, while being supported by the deployed parachute, are not great enough to assure activation of the aircraft's ELT. For that reason, the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual for the Cirrus Design SR20 state that after deployment of the parachute, the ELT is to be selected On.

The TSB is concerned that after losing control of an aircraft and deploying the parachute, the pilot may not remember to activate the ELT. Not having some form of automatic ELT activation increases the risk that the pilot will not be found in time.



TSB Final Report A04P0158 - Loss of Control

On May 8, 2004, a pilot flying a privately-owned Cessna 305A float plane departed Ganges Harbour on Saltspring Island, B.C., at about 08:40 PDT (Coordinated Universal Time minus seven hours), and flew to Thetis Island, B.C., to pick up a passenger. They then took off on a local flight to photograph boats and fleet activities related to an annual regatta at Thetis Island. The passenger was seated in the rear cockpit. Both rear windows of the aircraft were opened inward and secured to permit photography. During low-level manoeuvring near the fleet, just before the accident occurred, the aircraft flew in an easterly direction, south of the fleet.


The aircraft was being flown in slow flight at a high power setting; the flaps were extended 15°to 20°and the nose of the aircraft was 10°to 15°nose up. During the initial portion of the pass, the aircraft's height was estimated to be 30to 50ft above the water. As the aircraft approached Thetis Island, the engine sound increased and the aircraft began to climb in a steep attitude to 70to 100ft above the water. The aircraft then banked sharply to the left and the nose dropped abruptly to a steep, nose-down attitude. There was no recovery from the descent, and the aircraft struck the water in a left-wing-down, nose-low attitude. The pilot was fatally injured on impact; the passenger escaped through the left-side rear window and was rescued from the water by nearby boaters.

Findings as to causes and contributing factors

  1. The aircraft stalled at an altitude from which there was insufficient time or altitude to recover.
  2. High ambient sound levels reduced the effectiveness of the aural stall warning system.
  3. Mounting the stall warning system under the dash placed it outside the pilot's normal field of view and rendered the visual stall warning ineffective.
  4. Improperly-placed airspeed range markings eliminated their effectiveness as visual indicators of the normal safe-flight ranges.


TSB Final Report A04A0050 - Main Rotor Overspeed - Difficult to Control

On May 15, 2004, an AS350-B3 (Astar) helicopter was conducting aerial surveillance off the coast of Tabusintac, N.B., at an altitude of 700ft ASL. During a right turn, at approximately 16:00 Atlantic Daylight Time (ADT), the cockpit alarm sounded, accompanied by illumination of the red governor (GOV) warning light. The pilot continued the right turn and headed toward the shore for a precautionary landing. Seconds later, the rotor RPM increased above the maximum limit, and a severe rotor vibration developed. The pilot lowered the collective and reduced twist grip throttle, but there was no apparent reduction in rotor RPM. Believing that manual control of the throttle was lost, the pilot reopened the throttle to the "FLIGHT" detent, and tried to reach the overhead fuel control mode selector switch to move it to the manual position; however, the severe vibrations made it difficult to activate the caged switch. The pilot then raised the collective, attempting to decrease rotor RPM, but there was no apparent change. The aircraft was in a rapid descent and nearing the ground, so the pilot focused on landing the aircraft. After landing, a severe ground resonance developed, and the pilot lifted the helicopter into a hover to stop it. The vibrations continued, so the pilot landed a second time then pulled the ceiling-mounted fuel shut-off lever to shut down the engine. After the main rotor came to a stop, the pilot and two passengers exited the helicopter uninjured.

Findings as to causes and contributing factors

  1. The pilot had not received adequate flight training for the red GOV light emergency, and did not realize that the twist grip throttle still controlled fuel flow to the engine. Consequently, the emergency was mishandled, resulting in a severe overspeed of the aircraft's dynamic components.
  2. Examination of the digital engine control unit (DECU) confirmed the origin of the red GOV light to be an internal component "U13 optocoupler" of the DECU.


TSB Final Report A05P0032 - Settling with Power - Roll-Over

The helicopter struck the snow in a level attitude, turned over, and came to rest on its right side.

On February 11, 2005, a Bell212 helicopter was being used in heli-ski operations near Whistler, B.C. After operations on one glacier with two groups of skiers, the guides and the pilot agreed to move to the Spearhead Glacier. The skiers and guides were dropped off at the top of the glacier, and the pilot chose to pick up the skiers near the toe of the glacier. The first group down the glacier comprised 11 skiers. During takeoff from the toe of the glacier with this group, the helicopter began to settle as it turned downwind. The pilot turned it back toward the take-off area, but the helicopter continued to settle with full power applied. The helicopter struck the snow in a level attitude, turned over, and came to rest on its right side. The helicopter was substantially damaged. The main rotor chopped the tail off, the nose was crushed, and the battery was ejected. There was no fire. The passengers and pilot escaped with only minor injuries.

Finding as to causes and contributing factors

  1. Given the helicopter's gross weight, its close proximity to the glacier, and the strong downflowing winds, the helicopter was not able to climb high enough to clear the surrounding terrain. When the pilot aborted the departure, the helicopter settled with power onto the snow, dug in, and rolled over.

Other finding

  1. The fact that the helicopter was equipped with stainless steel fuel line fittings and that passenger briefings were enhanced, helped to minimize injuries from this occurrence.


Erratum - Lost in Translation!

An alert ASL reader caught a translation error on page 16 of ASL 3/2005, in the occurrence summary for A05Q0016. The third sentence, "The pilot tried in vain to correct the path using the tail rotor control pedals" should have read: "The pilot tried in vain to correct the path using the rudder pedals."- Ed.


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