- ISSUE 1/2009
- Copyright and Credits
- Guest Editorial
- To the Letter
- Flight Operations
- Maintenance and Certification
- Recently Released TSB Reports
- Accident Synopses
- Safety Around the World
- Use Appropriate Personal Protective Equipment On Board Aircraft
- Take Five: Personal Minimums Checklists
- PDF Version
by Bill Harrod, Civil Aviation Safety Inspector, Airlines Division, National Operations, Civil Aviation, Transport Canada
Illustration:Nick Kaloterakis, VFX Direction
QSST–Quiet Supersonic Transport
[Lockheed Martin's Skunk Works]
12-passenger business jet
Mach 1.7(1100 mph)–New York to Los Angeles:2 hr
Sonic wake = 1/100th of Concorde
Illustration:Nick Kaloterakis, VFX Direction
A2 (Green Skies at Mach 5)
[Reaction Engines' A2 Concept]
Mach 5(3 400 mph)–Brussels to Sydney:4 hr
Ultra-low carbon footprint
In one form or another, safety management systems(SMS)and travel at speeds greater than Mach 1 will unquestionably be a part of the future of change in aviation. Business travellers constantly seek more efficient travel, such as very light jets(VLJ)for point-to-point travel, and the public is slowly embracing environmentally friendly travel through the purchase of environmental offsets.
Industry and regulators alike are striving to improve upon low accident rates in the context of a future with potentially dramatically increased air travel. Additionally, industry is seeking to curb the ever-increasing costs, primary and secondary, associated with safety-related events, such as aircraft ground damage. Enter SMS: a "globalized" holistic approach to corporate safety now being implemented in countries around the world.
Fundamentally, SMS seeks to strengthen a system that is based on a reactionary mode of dealing with safety related events by enhancing personal and organizational behaviour to proactively identify, assess and prevent potentially resource-costly events:prevent vs. repair. Thus, first and foremost, the transition to SMS is a culture change both for the companies that are implementing these systems and for the Transport Canada Civil Aviation(TCCA)inspectors who oversee them.
Recognizing the significance of these cultural changes, the level of effort required to implement them, and, indeed, its own capacity to provide the necessary oversight through the transition, TCCA opted for a phased implementation approach. This phasing was carried out in terms of segments of the industry and in terms of implementation within a specific company. Initial implementation of the Canadian Aviation Regulations(CARs)for SMS included air carriers operating under CAR705.
Six carriers operating under CAR705, Air Transat, Sunwing, Air Canada, Skyservice, WestJet and Air Canada Jazz are overseen by TCCA's National Operations Branch and are well along in the transition to full implementation of SMS. Each has completed the four-phased SMS implementation and will have undergone their first full SMS assessment by the end of 2009. To be sure, there have been implementation issues to resolve:(1)the change from a prescriptive regulatory oversight approach to a performance-based approach;(2)the work required by industry to implement the new systems and by Transport Canada to oversee the implementation; and(3)the work required to sort through the details of the new processes. But along the way, both TCCA and the companies above have learned valuable lessons-lessons that are worth sharing.
Each carrier that is overseen by the National Operations Branch has prepared a short article reflecting the use of SMS in their company.
AIR TRANSAT:Aircraft Type A310
The event involved three separate but different smoke warnings, while on the ground, at approximately 10 min intervals. All indications turned out to be false and disappeared before departure. During the climb, at 2 000ft above ground level(AGL), one of these warnings-aft cargo-reappeared even though the aft cargo hold was empty. The appropriate actions were carried out and the warning disappeared.
The SMS investigation revealed that the smoke detection was subject to false warnings due to high humidity. Industry research on replacement of smoke detectors provided a retrofit option on the optical smoke detector; the Technical Operations Department presented the option for replacement of the detectors for this fleet. Based on "an increased safety factor"-a much higher reliability of an "actual warning"-the decision was made to replace the detectors. The cost:approximately $300,000. The benefits:safer travel for the public and, secondarily, the potential to save money resulting from fewer delays on the ground, fewer in-flight turn backs/diversions, and less damaged equipment.
AIR TRANSAT:Aircraft Type A310
This event involved a traffic alert and collision avoidance system(TCAS)alert and occurred in reduced visibility in haze at 7300ft. The intruding aircraft was at the same altitude and at 1.5NM to the left. There was no resolution advisory(RA), the distance between aircraft remained constant, and the crew continued in the descent. When air traffic control(ATC)was queried, they informed the crew that they did not advise them of this potential conflict, since the traffic was VFR and remaining north of the centreline.
The SMS investigation underlined the following:the aircraft involved, like six others, was equipped with a TCAS indicator of only 6NM range and the other five aircraft in the fleet had TCAS indicators of 40NM range. The Safety Department investigation revealed a disparity between aircraft and that this TCAS event would have been less traumatic and easier to manage if the longer TCAS range capability were available. The Technical Operations Department's business case for fleet rationalization to the 40NM range capability was accepted. The costs for retrofit of seven aircraft:$100,000. The benefits:safer flight for the public and increased probability of avoiding costs related to injuries caused by abrupt aircraft manoeuvring due to late awareness of TCAS events.
At Sunwing, we have found tremendous benefit from the implementation of SMS. Improvements in safety, efficiency and efficacy have been, and continue to be, realized in all areas of our operation thanks to the processes introduced by Transport Canada's SMS implementation.
On a particularly cold night, one of our Boeing 737-800s was secured and parked on the apron for an early morning departure. Although the aircraft was serviced in accordance with the manufacturer's instructions, a water line leading to the aft galley froze overnight causing damage to a coupling in the line. During the flight, warm cabin air thawed the line and water began to driponto the outflow valve causing problems with the aircraft's pressurization system. The flight crew dealt with the problem and the aircraft landed safely.
A safety investigation revealed a design issue with the potable water system and its proximity to sensitive aircraft components. As a result of this investigation, Sunwing developed and implemented its own procedures to ensure that the water line does not have an opportunity to freeze and to confirm integrity of the line prior to flight. We are currently working with the manufacturer to develop a solution to eliminate the problem at its source.
Air Canada's experience with an integrated SMS continues to be a very positive one and supports our first priority, which is safety. The benefits of SMS relate to efficiencies gained as a result of the implementation of a Safety Information Management System(SIMS)IT tool. Comprised of EtQ Reliance(R), IBI Webfocus(R)and iWay(R)products, SIMS facilitates continuous improvement in our safety processes, procedures and services via the systematic acquisition, analysis and measurement of safety of flight(hazard and occurrence)and quality(audit)data from across the entire airline.
The following event involved a missed approach and diversion of a flight planned from Barbados to Montréal,Que.,(Trudeau)with Albany,N.Y., as the alternate. The pilots initiated the approach to Montréal, but subsequently elected to carry out a missed approach procedure and proceeded to Val-d'Or,Que.
An SMS investigation was undertaken as a result of a passenger letter regarding this flight. The investigation revealed that the day in question was an extremely challenging one for the Air Canada operation because of a snowstorm that rolled through the eastern part of Canada. Approximately four hours into the flight, the flight crew received a revised flight plan from Air Canada flight dispatch with a change in the original alternate airport from Albany,N.Y., toVal-d'Or,Que. The reason for this change was that the weather in Albany had deteriorated and was now below the legally required limits, which precluded any possible approach at the airport. The weather in Montréal was blustery, with strong winds and blowing snow, but still well above the required limits for a safe landing. The Air Canada crew performed the missed approach in Montréal because the winds experienced during the approach were stronger than forecast and exceeded the crosswind limitations for the aircraft given the runway conditions. The flight later continued on to Toronto from Val-d'Or with Detroit, Mich., as the planned alternate airport, and arrangements were made to get the passengers to Montréal. The decision by the flight crew to abandon the approach was very appropriate and prudent under the conditions. All operational aspects associated with this flight were conducted in accordance with applicable Canadian Aviation Regulations(CARs) and the operational limits of Air Canada's Operating Certificate, and at no time did the operating crew compromise the safety of the passengers or of the flight by contravening any operational procedures.
While implementing SMS at Skyservice Airlines, we have strived to empower our front-line staff to report hazards. Let's first look at a definition of hazard:a source of potential harm or a situation with a potential to cause loss.
In 2005, Skyservice embarked on a communication campaign to encourage our staff to identify hazards in the workplace. This campaign has led to the development of SMS Goals &Objectives in2008 that will "Increase Proactive Hazard Reporting and Communication."
In this chart, you see an increase of 300percent on hazard identification over the previous year. This has allowed the airline to make many proactive corrective and preventative actions that maintain our safety promise of "providing the highest level of safety for our customers and employees." We have made changes to procedures, training, and equipment based on hazards identified by our safety- committed employees. Our continuing goal is to make our program more proactive and to communicate the changes with our staff.
Following takeoff, the landing gear would not retract. With the gear lever in the "UP" position, the indications were as follows:three red lights and three green. The aircraft was levelled at 5000ft and flaps were retracted on schedule. Since the forward and overhead gear lights were indicating green, the crew placed the gear lever down again, and the gear warning lights extinguished. Confident that the gear was down and locked, the crew requested radar vectors to return for landing. The crew contacted local operations, briefed the cabin crew and guests, and landed without incident.
During the investigation, foreign debris was found in and around the alternate landing gear handle access door. If this door is not fully closed, landing gear retraction is disabled. The "flight deck detail cleaning" task card was amended to require the door and surrounding area to be cleaned and secured and to have an aircraft certification authority(ACA)check security of the manual gear extension handles and access door. Boeing was also contacted about including a gear disagree non-normal checklist for the B737NG as is done for other Boeing aircraft types. Additional follow-up included establishing a single point of contact in flight dispatch to co-ordinate company actions in similar situations.
An aircraft maintenance engineer(AME)reported that some main landing gear brake assemblies were being returned from overhaul without their bleed valves lockwired. Brake assemblies do not always require bleeding after installation, so a missing lock-wire could go unnoticed. Under certain circumstances, this could create a risk of losing brake hydraulic pressure.
WestJet's Technical Operations Reliability Team co-ordinated initial follow-up. A fleet campaign was immediately undertaken to ensure that all brake assemblies in service and in stores were properly lock-wired. The issue was brought to the attention of the brake overhaul facility, which conducted additional training and quality audits. The WestJet Quality Assurance Team then took over follow-up and is now monitoring the status of all brake assemblies received. Current data indicates 100percent compliance in the last several shipments.
AIR CANADA JAZZ
The introduction of SMS at Air Canada Jazz has fostered a culture of trust and self-reporting. The following report details the events that took place on board a Dash8. This report was self-reported by the crew involved. In a punitive environment, we may not have received the report. Without the crew report, we would likely not have known about this event.
After climb out from Vancouver,B.C.(CYVR)the aircraft failed to pressurize. The crew did not notice as the caution light was obscured by sunlight. At FL190, the crew realized this and put on their oxygen masks and requested descent to 10000ft. They then proceeded into Portland, Ore.(PDX)and landed without incident.
In cruise, we received a call in the flight deck from the flight attendant that he was feeling light-headed and that some of the passengers were as well. The carbon monoxide indicator was checked and showed normal. The caution panel was then checked and the cabin pressure warning light was illuminated. A check of the pressurization panel revealed that the cabin was not pressurized. The crew donned oxygen masks and completed an emergency descent to 10000ft. Emergency checklist completed by the pilot not flying(PNF)(or first officer[F/O]).
After reaching 10000ft, a further descent continued until an uneventful landing in Portland. It was found that the cabin controller was in the dump position-the reason we assume the cabin did not pressurize. The captain completed a post-incident briefing with the crew and advised dispatch and maintenance control.
The master warning system failed to operate and advise of a problem. After the incident, it was checked several times with the advisory test switch and would not work until the cancel button was pushed many times, after which it functioned normally. F/Oadvised the cabin looked normal going through 10000ft. Other factors included the following:the aircraft was southbound with a late afternoon sun shining directly onto the caution light panel making it difficult to pick up an illuminated light. With the master warning inoperative, we were in cruise for 10to15 min before becoming aware of a problem.
The SMS investigation revealed that the crew had inadvertently left the cabin controller in the "dump" position. As part of the detailed incident report, Jazz Flight Safety recommended that:
- A joint Air Line Pilots Association(ALPA) and maintenance project team be assembled, in conjunction with Bombardier, to determine if it is possible and practical to design a guarded and visible switch to indicate when the pressurization is not in the normal position.
- A joint ALPA, flight technical, maintenance and Bombardier team examine the possibility and feasibility of retrofitting the present Dash8 series100 and 300aircraft with an independent aural warning system that would alert the pilots of an aircraft cabin altitude greater than 8500ft above sea level(ASL).
- A joint ALPA, flight technical, maintenance and Bombardier team examine the possibility and feasibility to retrofit the present Dash8 series100 and 300aircraft with an independent aural warning system to indicate any situation that would normally enable the master warning light circuitry.
- Training and standards management and line personnel liaise with Bombardier and other Dash8 operators at the next users forum to determine if there is a possibility to streamline the present checklist to minimize any unnecessary checklist items.
- Training and standards personnel discuss the value of listening to exact checklist responses versus the requirement to physically check the position of switches deemed to be critical to the correct operation of the aircraft in flight to determine the direction given to pilots operating this type of aircraft.
Closing Remarks by Jennifer Taylor-Director, National Operations
This article began by recognizing that change is the one constant in the aviation industry. The future holds increased traffic levels, supersonic flight, green skies and many other technological improvements. At the same time, the industry as a whole is embarking on an innovative approach to improve an already excellent safety record. The implementation of SMS, where personal and organizational accountability, robust safety management processes and procedures are all in place as a system, points the way to a safer future.
One segment of the aviation community that is leading the way in this regard are our Canadian CAR705 operators. I am very pleased that the six carriers overseen by National Operations have been willing to share examples of their experience with SMS with the broader aviation community. From strategic corporate plans to effective crew decision making; from safety-based decision making regarding fleet retrofits to self-reporting of incidents so that others could learn from the situation:each of these write-ups demonstrates elements of the promise that SMS holds for the future.
TC AIM Fast Fact:Composite Flight Plan or Flight Itinerary-VFR and IFR
A composite flight plan or flight itinerary may be filed that describes part(s)of the route as operating underVFR and part(s)of the route as operating under IFR. All rules governingVFR or IFR apply to that portion of the route of flight. A composite flight plan or flight itinerary shall not be filed for an aircraft that will enter airspace controlled by the U.S.Federal Aviation Administration(FAA), including Canadian domestic airspace(CDA)delegated to theFAA, as composite data cannot be correctly processed between NAVCANADA and FAA systems.
A pilot who files IFR for the first part of a flight and VFR for the next part will be cleared by ATC to the point within controlled airspace at which the IFR part of the flight ends. A pilot who filesVFR for the first part of a flight and IFR for the next part is expected to contact the appropriate ATC unit for clearance prior to approaching the point where the IFR portion of the flight commences. If direct contact with an ATC unit is not possible, the pilot may request ATC clearance through a flight information centre(FIC). It is important that the flight continue underVFR conditions until appropriate IFR clearance within controlled airspace is issued by ATC and acknowledged by the pilot.
- Date modified: