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TSB Final Report A05Q0024

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 A04Q0003-Loss of Separation

On January 13, 2004, a Boeing 777, en route from John F. Kennedy Airport, N.Y., to Narita, Japan, was at flight level (FL) 350 on a converging track with a Boeing 767, at FL 350 en route from Paris, France, to Chicago, Ill. Both aircraft received a traffic alert and collision avoidance system (TCAS) resolution advisory (RA), to which they responded. The two aircraft passed each other at 13:22 Eastern Standard Time (EST), within 600 ft laterally and 1 100 ft vertically of one another, approximately 160 NM south of La Grande Rivière, Que., in radar-controlled airspace. The air traffic controllers had not detected the conflict until alerted by the ATC conflict alert program. The required separation was 5 NM laterally or 2 000 ft vertically.

Findings as to causes and contributing factors

  1. The potential conflict between the B767 and the B777 was not detected when the B767 first contacted the La Grande Rivière (CYGL) sector, and no action was taken by the first CYGL controller to remind the next controller that a conflict probe had not been completed. This allowed a potential conflict to progress to the point of a risk of collision.
  2. After accepting the handover of the CYGL sector, neither the trainee nor the on-the-job instructor (OJI) conducted a review of all aircraft under their control to ensure there were no potential conflicts; the conflict between the B767 and the B777 was not detected, which placed them in a potential risk of collision situation.
  3. After the ATC conflict alert program warned the trainee and the OJI of the impending loss of separation, the OJI was unable to communicate instructions to the involved aircraft because he used the foot pedal instead of the press-to-talk switch to activate the radios. As a result, the aircraft progressed to the point where only the TCAS RA prevented a potential collision.

Findings as to risk

  1. There is no medium-term conflict probe for radarcontrolled airspace to provide an additional backup to the controllers scanning the radar or relying on information on the flight data strips.
  2. The current operational conflict alert system provides minimal warning time for the controller and requires immediate and often drastic action by both the controller and the aircrew to avoid a mid-air collision.
  3. Because the TCAS is not mandatory in Canada, there continues to be an unnecessary risk of mid-air collisions within Canadian airspace.

Other findings

  1. The lack of realistic and recurrent simulation training may have delayed the OJI's quick and efficient recovery from a loss of separation situation, or may have contributed to his inappropriate response to the conflict alert warning.
  2. The OJI's training course focussed mainly on the interpersonal aspects of monitoring a trainee. It did not cover practical aspects, such as how to effectively share work knowledge and practices with a trainee or how to quickly take over a control position from a trainee when required.

Safety action taken

The Montréal area control centre (ACC) published an operations bulletin containing information to ensure that all controllers involved in on-the-job training know how to operate their communications equipment and gain immediate access to their frequencies. This operations bulletin was a mandatory verbal briefing item for all controllers.



TSB Final Report A04Q0041-Control Difficulty

On March 31, 2004, a DHC-8-300 was proceeding from Montréal, Que., to Québec, Que., with three crew members and three passengers on board. After takeoff, at about 3 000 ft above sea level (ASL), the aircraft banked left and force had to be applied on the steering wheel to keep the wings level. The checklist for a runaway aileron trim tab was completed, which corrected the situation; however, the flight crew found that the trim tab indication, which was fully to the right, was not normal.

Emergency services were requested and the aircraft continued on its flight to Québec. On final approach for Runway 24 at Québec, the crew was advised by the controller that the airline required it to not continue with the approach. A missed approach was executed and it was suggested to the captain that he come back for a no-flaps landing. The aircraft came back and landed with no flaps without incident at 10:52 EST.

Findings as to causes and contributing factors

  1. The aileron trim tab was improperly aligned, which contributed to the tendency of the aircraft to roll on departure from Montréal.
  2. The absence of a placard near the indicator, and the arrangement of information in the logbook, contributed to the crew being unaware of the defective aileron trim tab indicator.

Findings as to risk

  1. Poor task distribution between the assistant chief dispatcher and the flight dispatcher created confusion in the telephone conversations with the tower controller, which delayed transmission of the second order to execute a missed approach, resulting in a missed approach at very low altitude.
  2. The trim tab had been improperly adjusted during prior service; an incorrect indication of the position of the aileron trim tab in the cockpit might have resulted if the indicator had been serviceable.

Safety action taken

As part of its safety management system (SMS), the operator initiated an internal investigation to draw lessons from this occurrence in order to use them for crew resource management (CRM) training.



TSB Final Report A04P0153-Air Proximity-Safety Not Assured

On May 5, 2004, a float-equipped de Havilland DHC-2, Mk 1 Beaver was authorized by the Vancouver tower south (TS) controller for an eastbound takeoff, on a VFR flight plan, from the Fraser River just south of the Vancouver International Airport, B.C., with a right turn to the Vancouver (YVR) VHF omnidirectional range (VOR) at 1 000 ft. A de Havilland DHC-8-100 (Dash-8) was subsequently cleared for takeoff from the Vancouver International Airport on an IFR flight plan to Nanaimo, B.C., using Runway 08R, with a Richmond 8 standard instrument departure (SID). The Richmond 8 SID calls for a right turn at 500 ft and a climb on heading 141° magnetic (M) to 2 000 ft. The Dash-8 climbed to 500 ft and initiated a right turn well before the end of the runway. The crew reported through 1 000 ft, heading 140°M, and substantially reduced their rate of climb, which brought them into close vertical proximity with the Beaver. Subsequently, the pilot took evasive action when he observed the Beaver below on the left side. The Vancouver departure south (DS) controller noticed the conflict and advised the Dash-8 crew of "unverified" traffic on their left side at 1 100 ft. He instructed the Dash-8 crew to turn at their discretion to avoid the traffic. The Dash-8 crew turned right and climbed on a heading of 190°M to resolve the conflict. The occurrence took place at 08:18:47 Pacific Daylight Time (PDT).

TSB Final Report A04P0153—Air Proximity—Safety Not Assured

Findings as to causes and contributing factors

  1. The TS controller cleared the Dash-8 for takeoff from the Runway 08R threshold without considering the change to the aircraft's departure profile from the usual intersection departure. As a result, an air proximity occurred between the Dash-8 and the Beaver.
  2. The coordination among the TS, traffic advisory (TA), and DS controllers that is necessary to fulfill the requirement for traffic information and conflict resolution did not take place. As a result, the two departing aircraft did not receive the ATC services specified for the class of airspace within which they were flying.
  3. The TA controller's attention was diverted to other traffic under his responsibility, and he did not see the Dash-8 coming up behind the Beaver. As a result, the two aircraft came into close proximity before the Dash-8 crew saw the other aircraft and took evasive action.
  4. Because the Dash-8 crew expected a clearance to remain at 2 000 ft, they substantially decreased their rate of climb, creating the conflict with the Beaver and extending its duration.


TSB Final Report A04O0188-Runway Overrun

On July 14, 2004, an Embraer 145LR aircraft departed Pittsburgh, Pa., on a flight to Ottawa/Macdonald Cartier International Airport, Ont., with two flight crew, one flight attendant, and 28 passengers on board. At 17:20 Eastern Daylight Time (EDT), the aircraft landed on Runway 25 at Ottawa and overran the runway, coming to rest approximately 300 ft off the end of the runway in a grass field. There were no injuries. The aircraft sustained minor damage to the inboard left main landing gear tire. When the aircraft landed, there were light rain showers. After the rain subsided, the passengers were deplaned and bussed to the terminal.

TSB Final Report A04O0188—Runway Overrun

Findings as to causes and contributing factors

  1. The approach to Runway 25 was high, fast, and not stabilized, resulting in the aircraft touching down almost halfway down the 8 000-ft runway.
  2. The aircraft landing was smooth; this most likely contributed to the aircraft hydroplaning on touchdown.
  3. The anti-skid system most likely prevented the brake pressures from rising to normal values until 16 to 19 seconds after weight on wheels, resulting in little or no braking action immediately after landing.
  4. The flight crew were slow to recognize and react to the lack of normal deceleration. This delayed the transfer of control to the captain and may have contributed to the runway overrun.

Other findings

  1. It could not be determined if an electrical, mechanical, or hydraulic brake problem existed at the time of the landing.
  2. The flight crew did not take appropriate measures to preserve evidence related to the occurrence and, therefore, failed to meet the requirements of the U.S. Federal Aviation Regulations (FARs), the Canadian Aviation Regulations (CARs), and the Canadian Transportation Accident Investigation and Safety Board Act (CTAISB Act). Interference with the cockpit voice recorder (CVR) obstructs TSB investigations and may prevent the Board from reporting publicly on causes and safety deficiencies.


TSB Final Report A04W0200-Navigation Deviation

On September 10, 2004, a Beech King Air C90A was en route to the Edmonton City Centre Airport (Blatchford Field), Alta., from Winnipeg, Man., via Regina, Sask., under IFR. After descending into the Edmonton terminal control area (TCA) in instrument meteorological conditions (IMC), the aircraft was vectored for a straight-in LOC(BC)/DME RWY 16 approach. Shortly after intercepting the localizer (LOC) near the LEFAT intermediate approach fix (IF), the aircraft descended about 400 ft below the minimum step-down altitude, and deviated 69° to the left of the final approach course. The crew conducted a missed approach 8 NM from the airport. During the missed approach, the airspeed decreased from 130 to 90 knots indicated airspeed (KIAS), and the aircraft climbed above three successive altitudes assigned by ATC. The aircraft also deviated 43° from its assigned heading while being vectored to rejoin the localizer for Runway 16. Upon intercepting the localizer for the second time, the aircraft turned to the right of the approach centreline and descended below the minimum step-down altitude. After the aircraft descended below the cloud base, the crew gained sight of the airport, continued the approach visually, and landed at 16:17 Mountain Daylight Time (MDT).

Findings as to causes and contributing factors

  1. Because the flight crew did not have sufficient familiarity with the C90A electronic flight instrument system (EFIS) equipment's presentations and operation, they used improper electronic horizontal situation indicator (EHSI) course settings and flight director mode selection on three successive instrument approaches.
  2. The inability of the crew to perform at the expected standard resulted from limited recent flying time and inadequate transition training in using the new avionics.
  3. While flying a missed approach procedure, the pilot flying (PF) was unable to transition to effective manual control of the aircraft. As a result, the aircraft speed decreased significantly below a safe level, and the ATC-assigned altitudes and headings were not adhered to.
  4. On the second approach at Edmonton, the crew focused on the GPS distance reading from the final approach fix (FAF), instead of the distance-measuring equipment (DME) display. This led to a premature descent, and the aircraft was operated below the minimum published step-down altitudes for the approach.
  5. The crew's resource management in preparation for and during the three approaches was not sufficient to prevent the hazardous deviations from the required flight paths.

Finding as to risk

  1. The operator did not encourage pilots to use manual flying skills in operational flying, thus creating the potential for manual flying skills degradation from non-use.

Other finding

A post-incident audit revealed a number of examples of non-compliance with the operator's Flight Operations Manual, including a lack of appropriate pilot-training record keeping. Therefore, there was no assurance that pilots would receive required training within specified time frames.

Safety action taken

The operator has corrected operational and training deficiencies that were revealed in a post-incident operations audit of the Edmonton base. Pilots who had not received the minimum flight training schedule mandated in the Fixed Wing Operations Manual were required to complete this training before their next operational flights. In addition, operational control of all flights was improved through a revised dispatch and flight-following system.

An internal safety bulletin distributed to the operator's pilots addressed the following issues associated with this occurrence:

  • errors in managing automatic flight systems;
  • encouraging periodic autopilot disconnect to improve monitoring vigilance;
  • flight director/autopilot management;
  • flight path deviations induced by autopilot activation; and
  • timely pilot intervention to correct flight path deviations.


TSB Final Report A04Q0188-Runway Excursion on Landing

On December 1, 2004, a Beech B300 was on an IFR flight from Saint-Hubert, Que., to Saint-Georges, Que., with two pilots and one passenger on board. At 11:26 EST, following a Runway 06 RNAV (GPS) instrument approach, the aircraft was too high to be landed safely, and the crew carried out a missed approach. The crew members advised the Montréal Centre that they would attempt a Runway 24 RNAV (GPS) instrument approach. At 11:46 EST, the aircraft touched down over 2 400 ft past the Runway 24 threshold. As soon as it touched down, the aircraft started to turn left on the snow-covered runway. Full right rudder was used in an attempt to regain directional control. However, the aircraft continued to turn left, departed the runway, and came to rest in a ditch about 50 ft south of the runway. The aircraft sustained substantial damage. There were no injuries.

TSB Final Report A04Q0188—Runway Excursion on Landing

Findings as to causes and contributing factors

  1. Because the aircraft's trajectory was not stabilized on the final phase of the approach, the aircraft was drifting to the left when the wheels touched down. The pilot-in-command was unable to keep the aircraft in the centre of the snow-covered runway, which had been cleared of snow to only 36 ft of its width.
  2. The left main landing gear, then the nose wheel, struck a snow bank left on the runway by the snowremoval vehicle, and the pilot-in-command was unable to regain control of the aircraft.

Findings as to risk

  1. The operator's pilots and ground personnel demonstrated inadequate knowledge of the SMS program by not recognizing the risk elements previously identified by the company.
  2. Neither the pilot-in-command nor the co-pilot had received CRM training, which could explain their non-compliance with procedures and regulations.
  3. Knowing that a snow-removal vehicle might be on the runway, the crew attempted to land on Runway 06 and, after the missed approach, the aircraft did not follow the published missed approach path.
  4. On the Runway 24 approach, the crew descended below the minimum descent altitude (MDA) without having acquired the required references.
  5. The aircraft's altimeters were not set on the altimeter setting for Saint-Georges.

Other finding

  1. The proposed approach ban would not have prevented the crew from initiating the approach because the proposed ban does not apply to private companies, and the Saint-Georges aerodrome does not meet the meteorological observation requirements.

Safety action taken

Following this accident, the operator modified its company organization chart. The position of assistant director of operations was created to provide leadership at the company's main base when the director of operations is absent. Also, the company appointed a chief pilot for the Lear 60, responsible for the Montréal base, and check pilots were appointed for the Lear 45, the Lear 35, and the Beech B300.

The operator established new criteria for runway acceptability. No approaches will be allowed until the runway is fully cleared of snow and is clear of traffic. A runway report for Saint-Georges aerodrome will be provided to the flight service station (FSS) and sent to the pilot where possible.

The operator established visual references to enable the universal communications (UNICOM) personnel to estimate as accurately as possible the visibility and cloud ceiling at the Saint-Georges aerodrome. Furthermore, to avoid any confusion as to the snow-removal need, a call sequence was established to reach snow-removal employees. Also, the radio equipment in the snowremoval vehicles at Saint-Georges was modified to allow communication with the base and aircraft at all times.

The operator will provide an annual winter operations awareness program for its pilots and ground personnel.

The Canadian Business Aviation Association (CBAA) modified its symposium education program to promote a better understanding of the factors that lead pilots (and others) to not follow established procedures.



TSB Final Report A05Q0024 - Landing Beside the Runway

On February 21, 2005, an HS 125-600A aircraft, with two crew members and four passengers on board, took off from Montréal, Que., at 17:56 EST, for a night IFR flight to Bromont, Que. Upon approaching Bromont, the co-pilot activated the lighting system and contacted the approach UNICOM (private advisory service). The flight crew was advised that the runway edge lights were out of order. However, the approach lights and the visual approach slope indicator (VASI) did turn on. The flight crew executed the approach and the aircraft touched down at 18:25 EST, 300 ft to the left of Runway 05L and 1 800 ft beyond the threshold. It continued on its course for a distance of approximately 1 800 ft before coming to a stop in a ditch. The crew tried to stop the engines, but the left engine did not stop. The co-pilot entered the cabin to direct the evacuation. One of the passengers tried to open the emergency exit door, but was unsuccessful. All of the aircraft's occupants exited through the main entrance door. Both pilots and one passenger sustained serious injuries, and the three remaining passengers received minor injuries. The aircraft sustained major damage.

Findings as to causes and contributing factors

  1. The flight crew attempted a night landing in the absence of runway edge lights. The aircraft touched down 300 ft to the left of Runway 05L and 1 800 ft beyond the threshold.
  2. The runway was not closed for night use despite the absence of runway edge lights. Nothing required it to be closed.
  3. Poor flight planning, non-compliance with regulations and standard operating procedures (SOP), and lack of communication between the two pilots reveal a lack of airmanship on the part of the crew, which contributed to the accident.

Findings as to risk

  1. Because they had not been given a safety briefing, the passengers were not familiar with the use of the main door or the emergency exit, which could have delayed the evacuation, with serious consequences.
  2. The armrest of the side seat had not been removed as required and was blocking access to the emergency exit, which could have delayed the evacuation, with serious consequences.
  3. Because they had not been given a safety briefing, the passengers seated in the side seats did not know that they were required to wear shoulder straps and did not wear them; so they were not properly protected.
  4. The possibility of flying to an airport that does not meet the standards for night use gives pilots the opportunity to attempt to land there, which in itself increases the risk of an accident.
  5. The landing performance diagrams and the chart used to determine the landing distance did not enable the flight crew to ensure that the runway was long enough for a safe landing on a snow-covered surface.

Safety action taken

On July 19, 2005, the TSB sent an aviation safety advisory to Transport Canada. The safety advisory states that, in this occurrence, the precautions embodied in the various civil aviation regulations did not prevent this night landing when the runway edge lights were unserviceable. Consequently, Transport Canada might wish to review the regulations with the goal of giving airport operators guidelines on how to evaluate the impact of a reduced level of service on airport use.

Pursuant to this safety advisory, Transport Canada determined that it would be very difficult to prepare guidelines that would cover all factors that are directly or indirectly associated with airport certification or operations. Moreover, Transport Canada believes that requiring aerodrome operators to evaluate the impact of a reduced level of service on aerodrome use would be a particularly complex task that could greatly increase the possibility of errors in assessment or interpretation. However, Transport Canada is examining the possibility of adding information on the level of runway certification to the Canada Flight Supplement (CFS), which would provide more information and details to pilots regarding any change to the certification status of a given runway.


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