Recently Released TSB Reports

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The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include the TSB’s synopsis and selected findings. Some excerpts from the analysis section may be included, where needed, to better understand the findings. We encourage our readers to read the complete reports on the TSB Web site. For more information, contact the TSB or visit their Web site at -Ed.

TSB Final Report A03P0247-Loss of Engine Power-Collision with Terrain

On August 17, 2003, a Bell 204B helicopter was involved in forest fire suppression at Bonaparte Lake, B.C. At about 11:05 Pacific Daylight Time (PDT), the helicopter departed a staging site, eastbound, slinging an empty water bucket on a 100-ft longline. Shortly after takeoff, the helicopter emitted a high-pitched, oscillating sound. The flight path and behaviour of the helicopter were normal as it went out of view over some trees. Immediately thereafter, there was a pronounced slap sound of the main rotor blade, followed by sounds of impact with the trees. The helicopter struck the ground just short of a small clearing adjacent to a fire road, about 0.25 NM southeast of the staging site. A post-impact fire ensued, which destroyed the helicopter. The main driveshaft assembly remained attached to the engine and transmission input quill assembly. The water bucket was found in a tree, detached from the longline, on the approach to the accident site. The longline was wrapped around another tree and lay in a direct line to the helicopter. The pilot was fatally injured.

Circle indicates where the bucket got caught
Circle indicates where the bucket got caught

Findings as to causes and contributing factors

  1. An imbalance of the engine compressor rotor assembly developed during the operation of the engine, resulting in contact between the rotor and stator assemblies. The contact led to the destruction of the compressor rotor assembly and engine failure. No conclusion could be reached with respect to the mode of failure that caused the imbalance.
  2. The combination of altitude, terrain features and the trailing longline, negatively affected the pilot’s ability to complete a successful emergency landing in autorotation.

Findings as to risk

  1. Some procedures used in the engine overhaul process were not in accordance with the manufacturer’s overhaul manual; failure to comply with the manufacturer’s instructions could compromise the integrity of the assembly and result in failure.
  2. Field adjustments to the engine fuel control takeoff trim without the confirmation of an N1 topping check for accuracy, introduce a risk of frequent or continuous operations at gas generator speeds and internal temperatures beyond established limits.
  3. An inconsistent placement of the external cargo release switch increases the risk of pilot confusion during an emergency when trying to activate the external cargo hook-release mechanism, possibly complicating an emergency landing.
  4. The foot pedal backup quick release is an approved system. However, its effectiveness is reduced because it requires the pilot to take one foot off of a primary flight control in an emergency.

Safety action taken

In December 2003, a Federal Aviation Administration (FAA) inspection of the engine overhaul company’s facilities and procedures was conducted. It was determined by the FAA that, at the time of the inspection, the inspectors "[were] confident that the company [had] the data, experience and knowledge to properly overhaul the engines for which they are rated."

All Canadian operators of the T5311B engine were advised of the safety concerns identified during the overhaul process at the company’s facilities.

The helicopter operator has standardized the cyclic grips in all of its aircraft (excluding the Robinson 44s, which are incompatible for such a modification), so that the switches are the same in each type. It has also moved the emergency (manual) release to the collective in its Eurocopter AS350 and is searching for supplemental type certificates (STC) applicable to the rest of its fleet. The rationale is that the emergency-release systems (isolated pull handles or foot pedals) in the other aircraft also require the use of either hands or feet for operation; therefore, requiring the pilot to let go of a flight control in order to release an external load via the emergency release. With the manual release on the collective, activation is possible without requiring pilots to remove their hands or feet from primary flight controls.

TSB Final Report A04C0098-Loss of Control and Collision with Terrain

On May 18, 2004, at approximately 17:00 Eastern Daylight Time (EDT), a de Havilland DHC-2 Beaver aircraft with one pilot and three fish camp guests departed the company’s water base, 22 km south of Sioux Lookout, Ont., on a day VFR flight to a remote fish camp located at Fawcett Lake, Ont. A second company DHC-2 Beaver arrived later with more guests, only to discover that the first group had not arrived. The accident aircraft was found overturned in the lake and authorities were alerted. Ontario Provincial Police divers recovered the bodies of the pilot and the three passengers. The aircraft sustained substantial damage. There was no fire.

View of the wreckage during recovery operation
View of the wreckage during recovery operation

Findings as to causes and contributing factors

  1. The pilot flew a high-drag approach configuration for which his proficiency was not established.
  2. The pilot most likely allowed the airspeed to decrease to the point that the aircraft stalled on approach at an altitude at which recovery was unlikely.
  3. The impact was non-survivable because of the high impact forces.

Findings as to risk

  1. The pilot did not secure the cargo prior to flight, which allowed the cargo to shift forward on impact.
  2. The weight and centre of gravity (C of G) were not indicated in the operational flight plan and load record, and the aircraft’s weight and C of G could only be estimated.

TSB Final Report A04W0114-Upset on Water Landing

On June 4, 2004, a Cessna A185F seaplane departed Four Mile Lake, Alta., on a VFR flight to Taltson River, N.W.T. The purpose of the flight was to transport three passengers to a site on the river known as Ferguson’s Cabin. At approximately 17:00 Mountain Daylight Time (MDT), as the aircraft was landing on the water near Ferguson’s Cabin, the left float dug in, and the left wing struck the water. The aircraft immediately cartwheeled and came to rest floating inverted in the river, with only the bottoms of the floats visible at the surface. The pilot and the front seat passenger sustained serious injuries; however, they managed to exit the submerged and damaged aircraft through a broken window in the left cabin door. Four fishermen in boats responded to the accident, removed the survivors from the cold water and transported them to a warm shelter. The rear seat occupants drowned. One decedent was found inside the aircraft and the second decedent was found two days after the accident, outside the aircraft, near the position where the aircraft had crashed, in 55 ft of water.

Landing area at Ferguson’s Cabin
Landing area at Ferguson’s Cabin

Findings as to causes and contributing factors

  1. For undetermined reasons, the aircraft contacted the water in a nose-low attitude on landing or entered a nose-low attitude shortly after touchdown. As a result, the left float dug in and the aircraft cartwheeled.
  2. The survivors were unable to locate the interior door handles after the seaplane became inverted and submerged in the water, thus preventing them from using the doors as emergency exits.

Findings as to risk

  1. Seaplane passengers who do not receive underwater egress information during a pre-flight briefing or on a safety-feature card may not be mentally prepared for an emergency exit from a submerged aircraft.
  2. The life preservers were not stowed in an area that made them easily accessible to the occupants.
  3. The pilot and front passenger were not wearing their available shoulder harnesses during the landing, as required by regulation.
  4. The baggage was not secured in the baggage compartment, which increases the risk of injury to the occupants during the crash or could impede their exit from the aircraft.
  5. The weight of the baggage in cargo area 1 probably exceeded the compartment’s structural limit and increased the probability of damage to the aircraft.

Safety action taken

Transport Canada (TC) published a comprehensive article on underwater egress in the Aviation Safety Letter (ASL) 1/2005 and updated safety promotion material. The Department also reviewed the safety-feature card/placard information required under section 703.39 of the Canadian Aviation Regulations (CARs), and this information was deemed appropriate for seaplane operations.

Safety concern
Risk of Drowning in Survivable Seaplane Accidents

Based on historical data, occupants of submerged seaplanes who survive the accident continue to be at risk of drowning inside the aircraft. The TSB believes that existing defences against drowning in such circumstances may not be adequate. In light of the potential loss of life associated with seaplane accidents on water, the TSB is concerned that seaplane occupants may not be adequately prepared to escape the aircraft after it becomes submerged. The Board is also concerned that seaplanes may not be optimally designed to allow easy occupant egress while under water.

Pilots must clearly instruct all passengers on the location and usage of all door handles and emergency exits.
Pilots must clearly instruct all passengers on the location
and usage of all door handles and emergency exits.

TSB Final Report A04Q0089-Risk of Collision Between Airbus A320 and Cessna 172

On June 13, 2004, at 09:33:44 EDT, an Airbus A320 was cleared for takeoff on Runway 24 of Québec/Jean Lesage International Airport, Que. Sixteen seconds later, the controller instructed a Cessna 172 to taxi to position on Runway 30. At 09:34:50, the controller saw the Cessna 172 roll and take off toward the intersection of Runways 30 and 24. Immediately, the controller ordered the Airbus A320 to abort takeoff twice. Seeing that the Airbus A320 was continuing its take-off run, he ordered the Cessna 172 three times to turn left. None of these attempts to contact the pilots was successful because the transmit function of the airport control radio had been previously disabled by the controller in an attempt to improve radio reception quality. Approximately 1 000 ft from the intersection, at rotation speed, the captain of the Airbus A320 saw the Cessna; he immediately ordered the co-pilot not to take off until they had crossed Runway 30. The Cessna flew over the Airbus A320, about 200 ft above it, at the intersection of the two runways. There were no injuries.

Quebec Airport Elevation 244

Findings as to causes and contributing factors

  1. The Cessna 172 took off without clearance from Runway 30, causing a risk of collision with the Airbus A320.
  2. The controller instructed the Cessna 172 to taxi to position on Runway 30, but did not instruct it to wait and did not advise that the Airbus A320 was taking off on Runway 24. The controller did not anticipate that the Cessna 172 might take off without clearance, causing a risk of collision with the Airbus A320.
  3. Given that the controller deactivated the transmit button for the air frequency, neither the Airbus A320 nor the Cessna 172 could hear the controller’s instructions to abort takeoff.

Findings as to risk

  1. The Air Traffic Control Manual of Operations (ATC MANOPS) does not clearly define criteria for numbering aircraft in the departure sequence.
  2. Some controllers in the Québec tower misunderstood the operation of some functions of the radio console.
  3. Canadian and U.S. phraseologies used to clear an aircraft onto a runway are similar in wording to International Civil Aviation Organization (ICAO) phraseology to hold an aircraft short of a runway. Those similarities open the door to misinterpretation by crews, with potential for catastrophic consequences.

Other findings

  1. The absence of simulation of emergency situations and equipment failures in ongoing training contributed to the controller’s inability to solve the problem that he was confronted with.
  2. A review by the TSB of NAV CANADA’s evaluations revealed that the division responsible for NAV CANADA’s evaluations did not realize that some controllers were not complying with standard practices and procedures.

Safety actions taken

NAV CANADA has indicated that the following safety actions have been taken since this incident:

  1. Improvements have been made in the area of individual competency verifications in the Québec tower in the last year. Observations of operational skills application are to be of a minimum of four hours, based on major operational duties as per the unit task analysis. Any discrepancies identified as being critical, result in removal from operational duties followed by retraining, as required. Activities related to the monitoring of the application of operational communication skills have also been bolstered, and results are mathematically calculated according to a grid based on the errors detected and the relative seriousness of each error. In all cases where individual controllers do not maintain unit standards, they are removed from operational duties and provided with remedial training, as required.
  2. As a result of a NAV CANADA Head Office Unit evaluation, the Québec tower manager has issued Operations Bulletin Number 04 40, published on 15 July 2004, outlining the results of the recent Head Office evaluation concerning identified deficiencies in phraseology. In addition, the control tower supervisors were instructed to increase their monitoring and to make direct interventions whenever it was observed that controllers were not conforming to approved phraseology. Supervisors
    were also directed to be more rigorous in the evaluation of communication skills, and a grid was implemented to facilitate the rating of individual performance in this area and facilitate the establishment of corrective actions when required.
  3. Through recent changes implemented in the operations safety investigations reporting process on staff utilization, NAV CANADA will further assess the decision-making processes of operational supervisors and implement changes where necessary.
  4. NAV CANADA undertook a major rewrite of the basic visual flight rules air traffic control (VFR ATC) training course delivered at its training facility and implemented the new curriculum in June 2004. Emergency procedures are taught using instructor-led classroom activities that include the associated phraseology. Non-compliance situations by a pilot are taught in the classroom and are practised in a number of exercises in the dynamic 360-degree airport simulator throughout the course.

TSB Final Report A04H0004-Reduced Power at Takeoff and Collision with Terrain

On October 14, 2004, a Boeing 747-244SF was being operated as a non-scheduled international cargo flight from Halifax, N.S., to Zaragoza, Spain. At about 0654 coordinated universal time (UTC), 3:54 Atlantic Daylight Time (ADT), the aircraft attempted to take off from Runway 24 at the Halifax International Airport. The aircraft overshot the end of the runway for a distance of 825 ft, became airborne for 325 ft, and then struck an earthen berm. The aircraft’s tail section broke away from the fuselage and the aircraft remained in the air for another 1 200 ft before it struck terrain and burst into flames. The aircraft was destroyed by impact forces and a severe post-crash fire. All seven crew members suffered fatal injuries.

TSB Final Report A04H0004—Reduced Power at Takeoff and Collision with Terrain

Findings as to causes and contributing factors

  1. The Bradley take-off weight was likely used to generate the Halifax take-off performance data, which resulted in incorrect V speeds and thrust setting being transcribed to the take-off data card.
  2. The incorrect V speeds and thrust setting were too low to enable the aircraft to take off safely for the actual weight of the aircraft.
  3. It is likely that the flight crew member who used the Boeing Laptop Tool (BLT) to generate take-off performance data did not recognize that the data were incorrect for the planned take-off weight in Halifax. It is most likely that the crew did not adhere to the operator’s procedures for an independent check of the take-off data card.
  4. The pilots did not carry out the gross error check in accordance with the company’s standard operating procedures (SOP), and the incorrect take-off performance data were not detected.
  5. Crew fatigue likely increased the probability of error during calculation of the take-off performance data, and degraded the flight crew’s ability to detect this error.
  6. Crew fatigue, combined with the dark take-off environment, likely contributed to a loss of situational awareness during the take-off roll. Consequently, the crew did not recognize the inadequate take-off performance until the aircraft was beyond the point where the takeoff could be safely conducted or safely abandoned.
  7. The aircraft’s lower aft fuselage struck a berm supporting a localizer antenna, resulting in the tail separating from the aircraft, rendering the aircraft uncontrollable.
  8. The company did not have a formal training and testing program on the BLT, and it is likely that the user of the BLT in this occurrence was not fully conversant with the software.

While we would have liked to publish the remainder of the TSB’s extensive conclusions on this report, space considerations prevented us to do so. Therefore our readers are encouraged to read the complete Final Report of this major investigation in the Air Reports section of the TSB Web site: -Ed.

TSB Final Report A05P0018-Control Difficulty Due to Airframe Icing

On January 19, 2005, a Beechcraft King Air 200, with two pilots and two paramedics on board, departed Prince George Airport, B.C., at 12:28 Pacific Standard Time (PST) on an IFR medical evacuation (MEDEVAC) flight to Cranbrook, B.C. The flight was dispatched to transport two patients from Cranbrook to Kelowna, B.C. During cruise flight at 15 000 ft ASL, the aircraft was in icing conditions. The aircraft’s ice-protection equipment dealt effectively with the icing conditions until about 45 min after takeoff, when the aircraft began to accumulate ice at a rate that exceeded the capabilities of the ice-protection equipment. The airspeed decreased to the point that a descent was required and, despite the crew selecting maximum available engine power, the aircraft descended from 15 000 ft to 10 800 ft; below the minimum obstacle clearance altitude (MOCA) for the area. Vancouver ATC issued emergency vectors to guide the aircraft down the Arrow Lakes area to avoid high terrain. Several minutes later, the pilots advised that they were clear of cloud and proceeding to Kelowna. Accumulated ice, up to 6 in. thick, was shed during the approach to Kelowna, where an uneventful landing was made.

Findings as to causes and contributing factors

  1. The pilot-in-command (PIC) did not review the available graphical area forecast (GFA) weather information and was not sufficiently informed to avoid the forecast icing conditions.
  2. The severe in-flight icing conditions caused an ice accumulation that the aircraft’s ice-protection systems were unable to prevent or remove. As a result, the aircraft entered a power-on stall condition and an uncontrollable descent.
  3. The PIC did not detect the severe ice accumulation in sufficient time to alter the flight route to avoid the icing conditions.

Safety action taken

Following an internal investigation into the occurrence, the company, as an interim safety action, distributed a memorandum to advise flight crews to review all available weather data before flights. The company has since developed a syllabus, examination and emergency checklist regarding severe icing, and has implemented them as part of its training program to provide flight crews with more in-depth knowledge of severe icing conditions and exit strategies.

TSB Final Report A05O0147-Collision with Water

On July 18, 2005, the pilot of a Cessna A185F seaplane was on his first return flight of the season from his cabin at Norcan Lake, Ont., to his home near Constance Lake, Ont. This flight, conducted according to VFR, included a stop for fuel at Centennial/Black Donald Lake. After refuelling, the pilot took off and, at approximately 10:45 EDT, the aircraft was about 100 ft above the north shore of the eastern section of Constance Lake, proceeding in a southerly direction.

At approximately 10:50 EDT, the aircraft cartwheeled on the lake, travelling in a northwesterly direction and adjacent to the north shore of the eastern section of the lake. The aircraft came to rest inverted in the lake with most of the aircraft visible. It floated approximately 500 ft east, then came to rest on the bottom of the lake, with only the bottom of the floats visible. Some local residents attempted a rescue, but they were unable to get the pilot out of the aircraft. The pilot had manoeuvred himself into the right seat, but he was unable to exit the aircraft, and drowned.

TSB Final Report A05O0147—Collision with Water

Findings as to causes and contributing factors

  1. For undetermined reasons, the aircraft cartwheeled after contacting the water and came to rest in an inverted position.
  2. The pilot was unable to exit the aircraft, and drowned.

Findings as to risk

  1. The pilot had not flown a training flight with an instructor for more than four years. This likely resulted in a degradation of his skills and decision-making processes.
  2. The current recency requirements in Canada allow pilots to go for extended periods without retraining on critical flight skills, presenting a risk that pilots will be ill-prepared to deal with unusual or critical flight situations when they arise.
  3. The design of the door lock mechanism on the Cessna A185F prevents opening the doors from the outside when locked from the inside. This same design is currently being used in all of Cessna’s new production single-engine aircraft.
  4. The exterior door handles are not easily discernable when the handles are closed and visibility is poor.
  5. The pilot was not wearing his prescription glasses while flying.
  6. The emergency locator transmitter (ELT) switch was not in the armed position, preventing activation on impact.

Other finding

  1. It could not be determined whether the pilot had complied with the recency requirements of subsection 401.05(2) of the CARs.

Safety concern

The following safety concern is similar to the one published in report A04W0114, described earlier in this article. Based on historical data, occupants of submerged seaplanes who survive the accident continue to be at risk of drowning inside the aircraft. Existing defences against drowning in such circumstances may not be adequate. In light of the potential loss of life associated with seaplane accidents on water, the TSB is concerned that seaplane occupants may not be adequately prepared to escape the aircraft after it becomes submerged. Of equal concern is that the rescuers, in this occurrence, could not access the cabin from outside.

New Video on the Web: Keep Your Eyes on the Hook!

Transport Canada’s newest aviation safety video, Keep Your Eyes on the Hook! Helicopter External Load Operations-Ground Crew Safety (TP 14334 ), is now available to view on the Web at

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