RECENTLY RELEASED TSB REPORTS

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 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 http://www.tsb.gc.ca/. —Ed.

TSB Final Report A06P0087—Collision with Terrain

On May 18, 2006, a Cessna T207A departed from the Pemberton, B.C., airport, at about 15:00 Pacific Daylight Time (PDT) on a visual flight rules (VFR) flight to Edmonton, Alta. The aircraft initially climbed out to the east and subsequently turned northeast to follow a mountain pass route. The pilot was alone on this aircraft repositioning flight and had been conducting air quality surveys for Environment Canada’s Air Quality Research Section in the Pemberton area. The aircraft was operating on a flight permit and was highly modified to accept various types of probes in equipment pods suspended under the wings, a camera-hatch-type provision in the centre belly area, and internal electronic equipment. About 30 min after the aircraft took off, the Coastal Fire Service responded to a spot fire and discovered the aircraft wreckage in the fire zone. A post-crash fire consumed most of the airframe, and the pilot was fatally injured. The accident occurred at about 15:06 PDT.

Aerial view of impact area (circle) into rising terrain. The majority of the aircraft fuselage was consumed by fire.

Aerial view of impact area (circle) into rising terrain. The majority
of the aircraft fuselage was consumed by fire.

Findings as to causes and contributing factors

  1. The pilot entered the valley at an altitude above ground that did not provide sufficient terrain clearance given the aircraft’s performance.
  2. The pilot encountered steeply rising terrain, where false horizon and relative scale illusions in the climb are likely. Realizing that the aircraft would not likely be able to out-climb the approaching terrain, he turned to reverse his course.
  3. The aircraft’s configuration, relatively high weight, combined with the effects of increased drag from the equipment, density altitude, down-flowing winds, and manoeuvring resulted in the aircraft colliding with terrain during the turn.

Findings as to risk

  1. A detailed flight plan was not filed and special equipment, such as laser radiation emitting devices and/or hazardous substances were not reported. The absence of flight plan information regarding these devices could delay search and rescue efforts and expose first responders to unknown risks.
  2. Transport Canada (TC) does not issue a rating or endorsement for mountain flying training. There are no standards established to ascertain the proficiency of a pilot in this environment. Pilots who complete a mountain flying course may not acquire the required skill sets.
  3. There was no emergency locator transmitter (ELT) signal received. The ELT was destroyed in the impact and subsequent fire. Present standards do not require that ELTs resist crash damage.
  4. “Flight permits-specific purpose” are issued for aircraft that do not perform as per the original type design but are deemed capable of safe flight. Placards are not required; therefore, pilots and observers approved to board may be unaware of the limitations of the aircraft and the associated risks.
  5. The TC approval process allowed the continued operation of this modified aircraft for sustained environmental research missions under a flight permit authority. This circumvented the requirement to meet the latest airworthiness standards and removed the risk mitigation built into the approval process for a modification to a type design.

Other findings

  1. The fuel system obstruction found during disassembly was a result of the post-crash fire.
  2. The aircraft was operated at an increased weight allowance proposed by the design approval representative (DAR). Such operation was to be approved only in accordance with a suitably worded flight permit and instructions contained in the proposed document CN-MSC-011; however, this increased weight allowance was not incorporated to any flight authority issued by TC.

Safety action taken

TC issued Aviation Safety Letter 1/2007 with an attached leaflet, titled “Take Five...for safety—Flying VFR in the Mountains” to provide some mountain flying guidance to pilots.

TSB Final Report A06C0204—Cargo Door Opening on Takeoff

On December 13, 2006, a Boeing 727-227 departed from Regina, Sask., on a scheduled cargo flight to Hamilton, Ont. Shortly after rotation, the crew noticed that the aft-cargo-door warning light was illuminated, and irregular indications for the No. 3 engine followed. The crew decided to shut down the No. 3 engine and divert to Saskatoon, Sask., at an altitude of 10 000 ft. The aircraft landed safely at 07:10 Central Standard Time (CST) with aircraft rescue and fire fighting (ARFF) on standby. The aft cargo door was found open, with the door handle stowed in the locked position. There were no injuries. The aircraft sustained minor damage to the aft-cargo-door hinges. There was no damage to the door structure or latching mechanism.

Aft cargo door open with the handle stowed in the locked position

Aft cargo door open with the handle stowed in the locked position

Findings as to causes and contributing factors

  1. The aft cargo door was most likely closed but not locked before takeoff, and it opened after departure due to aerodynamic forces.
  2. The ground crew did not check the aft cargo door for security before takeoff, and as a result, the door was not locked.
  3. The flight crew members did not discover the unlocked aft cargo door during the walk-around inspection, nor did they notice the aft cargo door warning light before departure.

Findings as to risk

  1. The ramp attendants were not required by their procedures to ensure that the cargo doors were properly closed.
  2. The instructional placard on the aft cargo door describing how to lock the door contained misleading instructions.

Safety action taken

After the occurrence, the operator amended its ramp operations manual by introducing a checklist that requires ramp attendants to ensure the security of cargo doors. The checklist is required to be initialled by ramp personnel after the completion of each aircraft loading operation.

On February 27, 2007, the TSB issued two occurrence bulletins concerning the instructions on the cargo door placard, and the cargo door closing procedures. The purpose of occurrence bulletins is to apprise Transport Canada and others in the aviation community in a timely manner of certain information that may raise potential operational or technical concerns.

TSB Final Report A06Q0188—Low-fuel Emergency

On November 21, 2006, a Bombardier CL-600-2B19 with 49 passengers and 3 crew members on board was conducting a scheduled flight from Vancouver, B.C., to Prince George, B.C. At about 15:14 Pacific Standard Time (PST), the aircraft was cleared for a non-precision approach on Runway 33 at the Prince George airport. While established on final approach, the flight crew was informed of a special weather observation, indicating conditions below the published minima. The flight crew continued the approach and set the flaps to 45°. Upon reaching the final approach fix (FAF), the flight crew conducted a missed approach and noted that the flaps remained jammed at 45°. The flight crew members diverted to their alternate airport: Grande Prairie, Alta. The aircraft was cleared to maintain 15 000 ft and vectored toward Grande Prairie. At 15:37 PST, the flight crew requested radar vectors to Fort St. John, B.C.—about 155 mi. away—and declared an emergency due to a low fuel prediction at destination. At 16:16 PST, the aircraft landed without further incident at Fort St. John with about 500 lbs of fuel remaining—equivalent to less than 10 min of flight. There were no injuries.

One of the flap system actuators being analyzed by the TSB

One of the flap system actuators being analyzed by the TSB

Findings as to causes and contributing factors

  1. The maintenance program for Bombardier CL-600-2B19 flap system actuators in place at the time of the occurrence did not allow for the detection of problems in the flap actuators at an early enough stage to prevent flap failure.
  2. The flaps failed at the 45° position, increasing drag significantly. The subsequent increase in fuel consumption required the crew to declare an emergency and divert to Fort St. John, which was a closer airport, landing with less than 10 min of fuel remaining.
  3. A thorough knowledge of the flap system and consistency in the maintenance documentation would have allowed the maintenance personnel to identify and solve the problem sooner.
  4. Repetitive flap failures on the occurrence aircraft were the consequence of faulty actuators caused by contamination such as water.

Findings as to risk

  1. Water ingress into the flap system, combined with cold weather operations, is the leading cause of flap system failure on CL-600-2B19 aircraft.
  2. The quick reference handbook (QRH) does not take into consideration the impact of flap failures at 45° following a missed approach. Consequently, the flight crews are not fully aware of the impact it would have on the aircraft climb performance for obstacle clearance or the impact on fuel consumption.
  3. There is no cruise performance data available with flaps extended. Therefore, the flight crew could not determine the optimum altitude and speed to attain the best fuel economy.

Other finding

  1. The practice of recycling a circuit breaker to rectify a problem has inherent risks; however, in this occurrence, it was a reasonable action on the part of the crew.

Safety action taken

On December 1, 2006, the operator issued a flight operations memo to its pilots, titled CRJ Fuel Policy Adjustment. A risk-based assessment was completed and eight airports were identified to be isolated enough to warrant an extra 30 min of fuel contingency when the forecast weather is less than 1 000 ft and the visibility is 3 mi. This memo was effective immediately and is now part of the company fuel policy for flight planning purposes. The operator initiated a conference with Air Canada Technical Services (ACTS), Eaton Aerospace, and Bombardier to discuss the design, operation, and support of the recent flaps and actuator issues. Shortly after, Bombardier announced the formation of a flap working group, including six operators, whose mandate is to work with Eaton Aerospace and Bombardier to complete a system redesign to remove the high seasonal failures of the flap system.

The operator has been an active participant in the flap working group and has assisted in the creation of the maintenance task currently being applied to the entire fleet via the Airworthiness Directive (AD) and Service Bulletin (SB) 601R27-150.

At the beginning of January 2007, the operator formalized a process where any Canadair Regional Jet (CRJ) 100/200 that experienced a flap failure would require senior management approval before the aircraft was returned to service.

On February 14, 2007, the TSB issued Aviation Safety Advisory A06Q0188-D2-A1 (Potential Fuel Exhaustion Due to a CL-600-2B19 Flap Failure) to Transport Canada (TC). The Safety Advisory suggests that TC may wish to advise other Canadian CL-600-2B19 operators and those foreign regulatory authorities that administer CL-600-2B19 aircraft of the circumstances of this occurrence and the possible impact of flap system failures on fuel management.

As a result of this Safety Advisory, Bombardier Aerospace issued All Operators Message (AOM) 1047, dated March 10, 2007, to alert all operators of this incident and the possible impact of flap system failures on fuel management.

TC drafted a document outlining CRJ flap operational issues and considerations. This document will be offered to Bombardier for its review and awareness. The document will be transmitted to all affected operators of Canadian-registered aircraft, as well as foreign civil aviation authorities, by way of a Service Difficulty Advisory.

On February 16, 2007, the TSB issued Board Concern A06Q0188-D1-C1 (Bombardier CRJ Flap Failures) to the Minister of Transport. The Board Concern states that, despite best efforts by the industry and regulators to reduce the number of flap failures in the CRJ fleet, that number is increasing. The Board requested that the Minister advise the Board of its action plan, both short and long term, to substantially decrease the number of flap failures on CRJ aircraft.

The Minister advised that short- and medium-term actions will include increasing awareness through Bombardier Aerospace AOMs and aircraft flight manual revisions. Long-term solutions will include a full system review to increase flap reliability through design and maintenance requirement changes.

On March 1, 2007, the TSB issued Aviation Safety Advisory A06Q0188-D3-A1 (Maintenance Intervals on Bombardier CRJ Flap System Actuators) to TC. The Safety Advisory states that, since 2005, there has been an increasing number of flap failures experienced by CRJ aircraft and suggests that TC, in conjunction with the manufacturers and operators, may wish to initiate a review of maintenance requirements for the actuators on CRJ aircraft.

As a result of this Safety Advisory, Bombardier Aerospace and TC Engineering are reviewing the existing certification maintenance requirements (CMRs) for the CRJ flap system, including the overall system design.

On July 18, 2007, TC issued AD CF-2007-10 addressing the Bombardier CL-600-2B19 aircraft flap failures. The AD became effective on 31 July 2007 and includes both the operational and maintenance requirements.

TSB Final Report A07Q0063—Loss of Control and Collision with Terrain

On April 1, 2007, a Piper PA31-350 Navajo was on a visual flight rules (VFR) flight from Sept-Îles, Que., to Wabush, N.L. The pilot, who was the aircraft’s sole occupant, took off around 06:30 Eastern Daylight Time (EDT). Shortly before 07:00 EDT, the aircraft turned off its route and proceeded to Grand Lac Germain to fly over the cottage of friends. At approximately 07:00 EDT, the aircraft overflew the southeast bay of Grand Lac Germain. The pilot then overflew a second time. The aircraft proceeded northeast and disappeared behind the trees. A few seconds later, the twin-engine aircraft crashed on the frozen surface of the lake. The pilot was fatally injured, and the aircraft was destroyed by impact forces.

Aerial view of the accident site

Aerial view of the accident site

Finding as to causes and contributing factors

  1. The aircraft stalled at an altitude that was too low for the pilot to recover.

Findings as to risk

  1. The aircraft was flying at an altitude that could lead to a collision with an obstacle and that did not allow time for recovery.
  2. The steep right bank of the aircraft considerably increased the aircraft’s stall speed.
  3. The form used to record the pilot’s flight time, flight duty time, and rest periods had not been updated for over a month; this did not allow the company manager to monitor the pilot’s hours.
  4. At the time of the occurrence, the company operations manual did not make provision for the restrictions on daytime VFR flights prescribed in section 703.27 of the Canadian Aviation Regulations (CARs).

Other findings

  1. The fact that the aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice recorder (CVR) limited the information available for the investigation and limited the scope of the investigation.
  2. Since the aircraft was on a medical evacuation (MEDEVAC) flight, the company mistakenly advised the search and rescue centre that there were two pilots on board the aircraft when it was reported missing.

TSB Final Report A07C0114—Power Loss—Collision with Water

On July 1, 2007, a Eurocopter AS 350 B-2 helicopter with the pilot and one passenger on board was being ferried to Points North Landing, Sask., from a fuel cache located approximately 42 NM to the southwest. An electronic flight notification was sent by the passenger to another member of his survey company based at Points North Landing, indicating an arrival time of 19:05 Central Standard Time (CST). When the helicopter did not arrive, the survey company initiated emergency procedures at 19:45 CST. Debris was found the following day in Bernick Lake, approximately 25 NM southwest of Points North Landing. The helicopter was found at the bottom of the lake with extensive damage. Both occupants sustained serious injuries upon water impact and drowned when the helicopter sank.

Corrosion pitting as found in No. 3 bearing

Findings as to causes and contributing factors

  1. The No. 3 bearing of the engine’s power turbine failed and engine power was automatically reduced to about ground idle, requiring the pilot to conduct an autorotation. The bearing likely failed when corrosion pitting occurred during a period where the required storage procedures were not followed.
  2. The pilot conducted a forced landing into the lake because the en route altitude selected was too low to permit an autorotation to shore, because the pilot’s response to the engine power loss slowed the establishment of an effective autorotation toward the shore, or because he was attempting to land near the shoreline of the lake in response to the first indication of the impending bearing failure.
  3. The pilot likely misjudged the height of the helicopter above the water and executed the flare and landing prematurely. Premature initiation of the flare would result in the loss of the kinetic energy of the main rotor blades at a height from which the pilot would have been unable to control the water landing.

Finding as to risk

  1. Although regulations require pilots to fly the helicopter at a distance and height that would enable an autorotation to shore, there is no information provided in the basic flight manual with respect to glide ratios.

Other finding

  1. Although not a factor in this occurrence, the pressure in the hydraulic accumulators was below specification.

Safety action taken

The company is reviewing its long-term storage procedures.

TSB Final Report A08O0035—Runway Overrun

On February 17, 2008, a Boeing 737-700 was carrying 86 passengers and 6 crew members on a scheduled flight from Calgary, Alta., to Ottawa, Ont. The aircraft had been cleared for an instrument landing system (ILS) approach to Runway 07 at Ottawa’s MacDonald Cartier International Airport. The crew was advised of a considerable tailwind on approach, but that this tailwind decreased to nil by touchdown. Braking action was variously reported as poor and fair. At 22:58 Eastern Standard Time (EST), the aircraft touched down but was unable to stop before the end of the runway. The aircraft came to rest approximately 200 ft off the departure end of Runway 07. There were no injuries to the passengers or crew and there was no damage to the aircraft.

Findings as to causes and contributing factors

  1. The crew had difficulty with aircraft energy management due to the strong tailwind for the revised runway, and this resulted in an unstabilized approach.
  2. The captain became task saturated while coaching the first officer during the final stages of the approach. He did not make an assessment that the approach was unstabilized at either the 1 000-ft above field elevation or, subsequent to that point, when conditions indicated otherwise.
  3. The runway was more slippery than reported and, combined with the long and fast landing, resulted in an increase to the required landing distance. This increase in the required landing distance was in excess of the remaining runway available and this resulted in the overrun.
  4. The speed brakes were not armed and their late activation added marginally to the stopping distance.

Findings as to risk

  1. Contrary to the NAV CANADA Air Traffic Control Manual of Operations (ATC MANOPS), the braking action report did not include the aircraft type and time. This reduces the usefulness of a braking report, as crews cannot put the information into context with their own aircraft and expected landing time.
  2. Misinterpretation of weather information by ATC personnel to determine runway use could result in inappropriate operational decisions.
  3. Errors in automatic terminal information service (ATIS) generation could result in a situation where flight crews are making in-flight decisions based on incorrect or missing information.
  4. Airport grid maps were available in both the tower and ground vehicles, but were neither required nor used to provide co-ordinates for the aircraft’s position. This could result in confusion as to aircraft position and delays in rescue response in other occurrences.
  5. The operator’s flight operations manual performance charts for Canadian Runway Friction Index (CRFI) restricted runways are predicated on an autobrake setting of Max, but the flight operations manual does not define a CRFI restricted runway. It is possible that the flight operations manual description of autobrake settings 2 or 3 could lead crews to use those settings where the use of autobrake setting Max would be more appropriate.

Site diagram

Site diagram

Other finding

  1. The Ottawa MacDonald Cartier International Airport decelerometer equipment was not checked following the occurrence to determine calibration status.

Safety action taken

NAV CANADA
NAV CANADA issued direction in the form of an operations letter to remind controllers of the ATC MANOPS requirement to use the proper format when issuing runway conditions and braking action reports. This operations letter was the subject of a mandatory verbal briefing. In addition, the Winter Operations Bulletin, issued nationally, contains a clear reminder to use techniques and phraseology in accordance with the ATC MANOPS and the NAV CANADA Flight Services Manual of Operations (FS MANOPS) to enhance positive, effective two-way communications.

On February 25, 2008, an operations bulletin was published, stating “upon receipt of an Airfield Condition Report, Clearance Delivery shall make two copies of the report and provide one copy to ground control and one copy to airport control.” Local Procedures, paragraph 200.1j, were amended accordingly. This measure ensures that as soon as a report is received via fax, the controllers are made aware of it.

The Ottawa tower conducted a thorough review of airfield condition reports using a database covering a two-month (winter) period to identify discrepancies between the English and French vocabularies stored in the system. Digital ATIS functionalities have been reviewed and the necessary corrections have been made to the English/French vocabulary. The controllers have also been provided with instructions on how the vocabulary can be amended locally, if required.

Operator
Minimum equipment list (MEL) 78-1 thrust reverser inoperative has been amended to read: “When calculating landing distance required, 20 percent shall be added to flight landing distance calculations.” The baseline calculated landing distances do not give credit for reverse thrust.

An aircraft communications addressing and reporting system (ACARS) landing distance calculator for landings in normal conditions has been added. The ACARS can be used in conjunction with braking reports or CRFI information. When a CRFI is entered, the calculations are based on Max autobrake.

In consultation with the aircraft manufacturer (sections 10A, 10B, and 10C—Landing Performance Data), the note advising the autobrake setting to be used when landing on runways with CRFI information available has been revised. Until now, autobrake settings less than Max were permitted if “optimum conditions” were present. This has been removed, as accurate landing distance information is not always available for landings on runways with CRFI information available for autobrake settings less than Max. As a result, regardless of other conditions, the autobrake will now always be set to Max when landing on a runway with CRFI information available.

The 2009 recurrent ground training will refer to this incident in regards to overload, fixation, and strategies to recognize and mitigate those conditions. The discussion will be organized around the flight data animation of the flight as it progressed, with specific focus on:

  • initial plan, briefing and performance calculation (CRFI/runway surface condition);
  • runway change and process followed to accommodate that change, including landing performance;
  • flight profile and strategy employed in energy management and configuration;
  • stable approach criteria and threat associated with continuing an unstable approach;
  • phenomenon of workload and the resultant “fixation” and “single channel of attention” as it applied to this crew (missed 1 000-ft call, speed brake not armed):
    • reference to accidents at Burbank and Chicago Midway airports and impact of fixation,
    • reference information gathered by the operator’s gatekeepers in pilot unstable approach debriefs (flight data monitoring [FDM] program),
    • how to recognize and manage the phenomenon of fixation/single channel; and
  • actual excursion and management of ATC, aerodrome emergency services, flight attendants, and passengers will be discussed in joint crew resource management (CRM). 

Blackfly Air
Click on image above to enlarge.

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