- ISSUE 2/2011
- Copyright and Credits
- Guest Editorial
- Flight Operations
- Maintenance and Certification
- Recently Released TSB Reports
- Accident Synopses
- Debrief: MET Towers: A Collision Can Happen and it Has Happened...
- The First Defence (poster)
- Take Five: Carburator Icing
- Full HTML Version
- PDF Version
- COPA Corner: Practice Precautionary Approaches More Often
- Underwater Egress Testimonials Validate Process
- Major Accident Report: VFR into IMC Claims Seven
- Optimistic and Ability Biases: “VFR flight into IMC won’t happen to me; but if it does I can get out of it!”
by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the July 2010 issue of COPA Flight, and is reprinted with permission.
Most of us have never landed at a site other than an airport and probably never will. A precautionary approach is something we don’t practice or even think much about because we don’t think it applies to us.
When we took our pilot training, we learned precautionary approaches for use at off-airport sites. Most of us did not have instructors who told us precautionary approaches should be performed any time we are not certain about the landing conditions at our point of intended landing, even at an airport. Many of us occasionally go to unfamiliar airports and some of them may have runway surface conditions we are not certain about.
A pilot was intending to land his Piper PA-24-200T Seneca at Mont Laurier. He touched down on Runway 26 but was unable to stop the aircraft on the runway. He eventually came to a stop in the snow, 200 ft off the end of the runway. The runway was 100% ice covered at the time. Fortunately no one was injured and the aircraft received little damage.
A pilot of a Cessna C-180K overflew a 2 400 foot private strip and judged it to be firm and suitable. On landing, the aircraft drifted right. Power was added and the aircraft became airborne for about 100 ft and touched down again with the right wheel on softer ground. The aircraft continued to the right until the right wheel hit a snow drift and the aircraft flipped over. The pilot was not injured.
A Cessna C-172 pilot departed a northern Ontario airport for a short sightseeing flight. He returned for landing 20 minutes later and shortly after touchdown, the right wheel hit some snow that had drifted partially across the runway. The aircraft veered right and impacted the snow bank on the right side of the runway. The pilot was not injured, the aircraft was.
The report about the PA 24-200T accident did not say if the pilot performed a full precautionary approach procedure, just that he overflew the airport. Doing a full precautionary approach procedure may have prevented this accident.
The C-180K pilot did fly over the strip and judged it suitable. It appears that just the centre portion was suitable. He allowed the aircraft to drift to the right away from the suitable landing area and added power to attempt to correct, but the aircraft touched down before the correction took effect. He should have gone around and attempted another landing, or diverted to another landing site.
The C-172 pilot did not perform a precautionary approach as he had only been gone 20 minutes. Fresh snow and a crosswind should now be a reminder for the rest of us that it only takes minutes for snow drifts to form across a runway.
We should always be prepared to go around. Too often when we expect or judge a landing site safe, we put ourselves into the mindset that we are going to land.
We do not have reports on runway conditions at airports without an operating control tower, flight service station (FSS) or community aerodrome radio station (CARS). Recent snow, rain or construction can leave unexpected hazards. Local pilots or city crews may clear the runways of snow. Without specific airport training, snow windrows or clumps of hard snow can be left at entrances to taxiways or runway intersections. Winds may blow snow back onto runways in hard drifts. Animals may also create runway hazards at uncontrolled airports, with deer, coyotes, dogs and birds being the most common.
When we are not sure of surface conditions, a landing site, airport or not, should initially be flown over at about 1 000 ft (high pass). An initial assessment can be made of the runway surface and of the wind conditions. When the choice of runway is made, a low pass at 300 to 400 ft can be made along the runway and to the right of the runway to better assess the field conditions. Three hundred to 400 ft should safely clear all nearby obstacles and the surface conditions can be clearly seen. This pass should be made no slower than the flap up final approach speed. Partial flap during this pass will lower the aircraft pitch attitude and help with aircraft stability. The airspeed, altitude, partial flap and trim should all be set before reaching the start of the runway so that all a pilot has to do is look to the left and inspect the runway. If the field is judged suitable, a return for a normal, soft or short field landing can be performed from a normal circuit pattern.
A normal circuit pattern should be performed for the landing whenever possible, because that is what we are used to doing, and there are fewer chances of making errors. Major errors to watch for when performing precautionary approaches are: making the high pass in a dive at high speed; not having the aircraft stabilized at an appropriate airspeed and in an appropriate configuration for the low pass; and abbreviating the circuit and landing hot and long.
At any airport where you would consider a precautionary approach prior to landing, it may be wise to perform a runway surface check prior to takeoff. Standing on the ramp, or sitting in the aircraft on the ramp, or even on the end of the runway will provide a good view of only a small portion of the runway surface. There could be soft areas, holes, rocks, pools of water, ice patches, clumps of ice dropped from a snow plow, wind drifts of snow, animals or birds out of your line of sight. While checking out the runway surface, check the grass near the runway for animals or birds.
Walk, if it is safe and legal to do so, or taxi the entire runway length to check the surface. An assumption that the rest of the runway is in the same condition as the piece you are sitting on has resulted in more than one aircraft getting bent.
We should not assume that conditions are safe just because we are landing at an airport, or that a strip is safe because someone said so. The few minutes spent doing a precautionary approach may save us a lot of down time.
Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently flies MEDEVACs from Victoria in a Lear 25. Nielsen is also the author of seven flight training manuals published by Canuck West Holdings. Dale can be contacted via e-mail: firstname.lastname@example.org.
by Bryan Webster, Aviation Egress Systems, Victoria, British Columbia
My passion for underwater egress started—ironically—in 1977 after being initiated to a high-speed water impact as a passenger in a Cessna 150. In spite of that incident, I received a float endorsement the following year, went on to a fulfilling commercial pilot career and a few years later, in 1998, I decided to become an underwater egress and survival skills course provider. Since then, I have observed more than 4 000 egress students and their behaviour while training at aquatic facilities.
Putting into words how disorientation and panic are associated with underwater submersion in an inverted aircraft is very difficult. Following an impact and submersion, the sudden change to cold water and to a dark, foreign environment can often prove overwhelming when time is of the essence; more often than not, survival instincts take control and people tend to panic, limiting their ability to successfully locate the elusive door mechanisms or other emergency exits.
Short of attending a training session in person, real life testimonials offer wonderful educational insights on this topic. A few years ago, I received a call from Brenda Matas, who had been traumatized in a floatplane accident years previous. I explained the program and what it could do for her. She decided to attend one of our classes and try to relive the experience, only this time with a positive outcome.
Brenda had been a passenger sitting beside her husband who was piloting their Super Bushmaster on floats. Shortly after takeoff, the aircraft stalled and impacted the water hard enough to blow out the front window and badly damage the aircraft. She recounted that during the impact, there was intense water pressure violently forcing her backwards, and her only thoughts were not to do anything until it all stopped. Fortunately, the aircraft remained upright but water was rapidly flooding the cabin.
Brenda quickly undid her seat belts and assisted her unconscious husband who had sustained minor head injuries. Once he regained consciousness, they quickly escaped through the side window as the aircraft inverted and began to sink. Soon after, paddles and life vests were collected from the debris floating freely about the downed craft. Fortunately for Brenda and her husband, a pleasure boat appeared shortly after the incident and the pair was rescued and given medical assistance.
Brenda Matas with her Super Bushmaster
For Brenda, this was the end of her flying days but the beginning of a nightmare, which began with agonizing dreams of being trapped under water and searching in vain for non-existent passengers, until she would wake up shaking, sweating and crying. Two years later, once their aircraft had been repaired, she attempted to regain currency by flying with an experienced instructor. However, solo flight brought back the post-crash anxiety, so Brenda and her husband seriously considered giving up flying altogether and selling their aircraft.
This is when Brenda heard about underwater egress training and called me to discuss her options. After a number of discussions, she eventually agreed to attend the course and to face her fears. However, when Brenda arrived at our pool facility, she was physically shaking and had serious doubts about attending the program. We assured her that the training was professionally supervised, safe, and that she could start with the classroom session and see how she felt afterwards. She agreed, and took part in class discussions on how to handle and think about ditching, while sharing her story with her supportive group of classmates.
In the pool, she again showed signs of reluctance and viewed our equipment as terrifying. Only after watching the other students take numerous turns in the simulators did she agree to do it. At the end of the day, Brenda was calm and reacting in the appropriate manner, which helped her overcome her past negative experience.
In Brenda’s words:
Bryan knew what I did not. He knew I had to go back to that underwater experience again and that was why he was so supportive. I finally worked up the courage to take the course and I am very happy that I did. Huge progress has been made from the gut wrenching apprehension at every landing to now having the confidence that I can think my way through an underwater egress. I now sleep well at night and plan to take the course again in the future.
A second testimonial for the underwater egress training came from a passenger, and stemmed from a more recent occurrence. There was a terrible floatplane accident in the Gulf Islands near Victoria, B.C. a couple years ago. I received a call from a person who requested underwater egress training as she had been in the area when the mishap took place. After the training I received a letter from her describing the event and how it had affected her.
I am a frequent floatplane passenger. I used to work on a project that required me to travel by floatplane from Seattle to the San Juan Islands weekly for about 5 years. I have always been concerned with the door operation on floatplanes. The small recessed handles are not easy to operate, even in the best of conditions. I now live on Saturna Island, B.C. Last fall, a floatplane went down just south of our home and I helped friends and neighbours search for survivors. Needless to say, this terrible accident has affected me deeply.
After the accident, I contacted a commercial floatplane pilot and he suggested that I consider taking underwater egress training. I came to your class prepared with both a strong desire to learn how to survive a floatplane ditching plus a strong desire to help make floatplane aviation safer. The training was excellent and in fact was a real eye-opener. This experience showed me how challenging it is to get out of an inverted aircraft in the water in the best of conditions.
I would recommend this type of training to everyone who flies over water. In fact, it caused me to look at how to get out of any submerged vehicle in a whole new way.
These two stories show how devastating aircraft accidents can be and how they can affect people’s lives. Over the last few years there have been many floatplane safety-related initiatives including new promotional campaigns, improvements in aircraft emergency exit doors and windows, enhanced pre-flight safety briefings by operators, industry meetings to discuss floatplane safety, and of course a strong push to encourage licensed personnel—and passengers—to attend underwater egress training. This training not only explains the perils and how to recognize them, but it also provides the knowledge and confidence required to escape a submerged aircraft should the unthinkable happen.
Bryan Webster is a commercial pilot, underwater egress and survival skills course provider, and past recipient of the Transport Canada Aviation Safety Award. He can be reached at email@example.com.
The following article is a condensed version of Transportation Safety Board of Canada (TSB) Final Report A08P0353, a high-profile accident which took seven lives. There is a universal lesson from this extensive report.
On November 16, 2008, at about 1013 Pacific Standard Time, an amphibious Grumman G-21A departed from the water aerodrome at the south terminal of the Vancouver International Airport (CYVR), B.C., with one pilot and seven passengers for a flight to Powell River (CYPW), B.C. Approximately 19 minutes later, the aircraft crashed in dense fog on South Thormanby Island, about halfway between Vancouver and Powell River. Local searchers located a seriously injured passenger on the eastern shoreline of the island at about 1400. The aircraft was located about 30 minutes later, on a peak near Spyglass Hill, B.C. The pilot and the six other passengers were fatally injured, and the aircraft was destroyed by impact and post-crash fire. The emergency locator transmitter (ELT) was destroyed and did not transmit.
History of the flight
The pilot reviewed and discussed the weather with company dispatch at 0930 and was advised to proceed to Toba Inlet if the weather did not permit landing at Powell River. The aviation routine weather report (METAR) issued at 0900 for Vancouver recorded the wind as 110°T at 10 kts and 2 ½ statute miles (SM) visibility in mist. Cloud cover formed a ceiling at 500 ft above ground level (AGL). The temperature was 10°C, the dewpoint 9°C. Low ceilings and visibility along the coast for the area of the flight route were forecast by Environment Canada. Although the reported weather at the Toba Inlet destination was above VFR limits, weather at CYVR and CYPW was below VFR limits at the scheduled departure time.
Following the weather briefing, the pilot proceeded to the aircraft to load the cargo and board the passengers. During his pre-flight briefing, he advised the passengers that the flight would be conducted at low altitude and that if anyone was concerned, they could deplane. No one deplaned. The aircraft was released by dispatch at 1001.
The automatic terminal information service (ATIS) issued for CYVR at 1009 reported that the wind had decreased to 8 kts and visibility had decreased to 2 SM. The pilot requested and received authorization from Vancouver air traffic control (ATC) to depart under special VFR (SVFR) via the SALMON NORTH departure. This published VFR floatplane route requires aircraft to be equipped with an area navigation system such as a global positioning system (GPS) to identify the SALMON VFR callup/checkpoint, about 6 NM offshore. At approximately 1013, the aircraft departed the water aerodrome westbound towards the SALMON VFR checkpoint. The accident flight was the only fixedwing VFR departure from the water aerodrome or CYVR before 1049 that day because other operators had cancelled or delayed their flights due to the low visibility.
About three minutes after takeoff, approximately 2 SM east of the SALMON VFR checkpoint, ATC approved a right turn out of the CYVR control zone (a modification to the published SALMON NORTH departure route). At this point, the aircraft turned onto a track of about 308°T. A slight course change to the west was made after which the aircraft resumed the 308°T track until radar coverage ended. About four minutes after takeoff, the pilot reported to CYVR tower that the visibility was about 2 to 2 ½ SM, and that he could probably climb to 200 to 300 ft ASL. About six minutes into the flight, and about two minutes before exiting the CYVR control zone, the pilot reported his position as 7 ½ NM from CYVR and noted that visibility had improved to about 4 SM. The majority of the route was greater than 4 NM from land or other discernable features to assist navigation. The last communication from the pilot was at about 1021, when he advised ATC that he was clear of the zone.
The first nine minutes of the flight appeared on CYVR radar, ending about 21 NM northwest of CYVR, about 15 miles southeast of the accident site. Radar returns show that the aircraft’s ground speed remained steady around 140 kts, normal cruise speed for this aircraft, allowing for the 8-kt to 15-kt tailwind encountered between CYVR and South Thormanby Island. Although there was no intervening terrain between the radar source and the aircraft, the radar coverage was likely limited because of the low altitude at which the aircraft flew. Of 110 valid radar returns, 10 returns (9 percent) showed the aircraft’s altitude as 0 ft ASL, 96 returns (87 percent) showed the altitude as 100 ft ASL, and 4 returns (4 percent) showed the altitude as 200 ft ASL. No radar returns showed the aircraft’s altitude higher than 200 ft ASL.
Approximately 12 minutes after departure, the operator dispatch tried unsuccessfully to contact the pilot to advise him that a special weather observation at CYPW indicated that visibility had deteriorated to 3/8 SM in fog and remained below VFR limits. Shortly after 1032, local authorities learned of a probable aircraft crash in dense fog on South Thormanby Island.
At 1110, 15 minutes after the aircraft’s estimated time of arrival (ETA) at CYPW, employees from the operator at CYPW called their dispatch centre in Vancouver to say that the aircraft had not arrived. The dispatchers determined that the last recorded position was at 1025 near Sechelt, just over one third of the distance from Vancouver to Powell River. At 1210, dispatch contacted the Victoria Joint Rescue Coordination Centre (JRCC) to report the aircraft overdue. Poor visibility around the island due to fog and cloud prevented airborne search and rescue (SAR) efforts.
Area map with relevant weather information locations available to the pilot
The wreckage was located at about 350 ft ASL on the northeast side of an unnamed 400-ft peak, about one third of a mile south-southeast of Spyglass Hill on South Thormanby Island. The wreckage was examined to the extent possible; no pre-impact mechanical failures were noted.
The pilot was certified and qualified for the flight in accordance with existing regulations. The operator’s management had met with the pilot three times to discuss concerns they had with his decision making. The last meeting, about three months before the accident, was held because management was concerned that he was completing trips in what other pilots deemed to be adverse wind and sea conditions. The company believed that this behaviour was causing other pilots to feel pressured to fly in those conditions and was also influencing customer expectations. At least one fishing lodge owner favoured the accident pilot because he flew customers in and out when other company pilots would not because they felt that the conditions were too risky.
The day before the accident, the pilot of a float-equipped aircraft encountered a 400-ft ceiling and estimated 1 SM visibility near Powell River and made a precautionary landing on the water to wait out the conditions. That pilot subsequently observed a Grumman Goose fly by in these conditions. Records showed that the Grumman Goose was piloted by the accident pilot.
Pilot decision making (PDM) is critical to flight safety. PDM can be defined as a four-step sequence: the gathering of information, the processing of that information, making a decision based on possible options, and then acting on that decision. Once a decision has been implemented, the process starts over again as the individual now gathers information to monitor the effectiveness of the decision. Based on how that information is processed, the individual then continues through the rest of the process, and so on. Each stage in the four-step PDM process is susceptible to error. During the information-gathering step, misdirected attention can cause critical cues to go undetected. In addition, biases may prevent a pilot from recognizing cues that are different from those expected. The processing of information stage will introduce errors into the PDM process if the information is incorrect, distorted, incomplete, or misinterpreted. The assessment of the available options involves a subjective risk assessment based on experience and knowledge. Pilots usually decide on the option they perceive as most likely to result in the best outcome given their goals. The last step in the process is to implement the option that has been selected as the most appropriate. Errors at this step of the process are typically the result of implementing an inappropriate response or improperly carrying out the correct action.
Pilots’ decisions can be influenced by a wide range of factors such as perception of the situation, experience, training, abilities, expectations, goals and objectives, organizational and social pressure, time-criticality and contextual elements. A VFR pilot’s decisions are largely influenced by the assessment of existing weather information, the availability of additional navigational aids, and previous experience with a route. Once a decision is made to depart or continue along a route, pilots have a tendency to continue with the selected course of action unless there are compelling reasons not to do so. Additionally, pilots often seek out elements that reinforce, not contradict, the decision made (that is, confirmation bias). Successful experience under similar circumstances can make pilots very reluctant to select a different course of action. If a pilot is suddenly faced with additional unexpected cues from the environment, there is a danger that the relevant cues go unnoticed. This can occur due to mental processing limitations as information competes for a pilot’s attention. Relevant cues can also be missed by a pilot if they are deemed less important than others, leading a pilot to focus on cues that may erroneously support the pilot’s preferred course of action. In this occurrence, the pilot’s safety significant decisions were the decision to take off and the decision to continue the flight into adverse weather conditions.
VFR-into-instrument meteorological conditions accidents
Transportation Safety Board (TSB) data show that continued VFR flight into adverse weather represents a significant threat to aviation safety. While VFR-into-instrument meteorological conditions (IMC) accidents account for a relatively small portion (less than 10 percent) of all reported accidents, approximately 55 percent of those VFR-into-IMC accidents were fatal, compared to 10 percent of all other accidents. An enormous amount of research and many studies have been conducted to identify the causes of continued VFRinto-IMC accidents. Some of the main causes of these accidents are as follows:
VFR pilots can be overly optimistic on the probability of having to fly from VFR-into-IMC, and on their own abilities to fly out of IMC if encountered (ability bias);
Incorrect situational assessment can cause pilots to prolong flight into deteriorating weather because they do not realize that they are doing so;
Decision framing can play a role. If pilots frame their decisions in terms of potential losses (that is, revenue, etc.), they are more likely to prolong flight into deteriorating weather;
Pilots are motivated to complete their flights; and
Pilots may exhibit greater risk-taking behaviour as more time and effort is invested in a flight.
Given the conditions at takeoff and at the accident site, as well as the forecast and reported conditions for the en route section, it is likely that most of the flight was conducted below the required VFR minima. The conditions present on the day of the occurrence would have resulted in a high likelihood that IMC conditions would be encountered. The visibility portrayed in the photograph as the aircraft taxied into the river at Vancouver (see Photo 1) displays conditions below SVFR minima for fixed-wing aircraft.
A supplementary report from the Merry Island lighthouse indicated marginal visual meteorological conditions (VMC). Lighthouse reports have traditionally provided VFR pilots on the coast with a valuable resource; however, in this case, the report was inaccurate. This may have contributed to the pilot’s conclusion that weather along the route was acceptable.
Photo 1. Aircraft entering river for takeoff (accident flight.)
Photo courtesy of Mr. Rich Malone, who captured
it with his cell phone.
Photo 2. Same location as Photo 1 taken on clear day
During his pre-flight briefing, the pilot advised the passengers that the flight would be conducted at low altitude and that, if they were concerned, they could deplane. This is not a normal part of the pre-flight briefing and indicates that the pilot was aware that the weather along the route was likely to be poor enough that, in order to maintain ground reference, the flight would have to be conducted at a lower altitude. However, the special weather reports (SPECI) issued at 0925 for Powell River showed a marginal improvement that the pilot could have interpreted as the beginning of a trend. This is inherently risky because a single weather report does not confirm that a trend has commenced. Although the large majority of weather information indicated low cloud and poor visibility along the route, the marginal improvement at Powell River and inaccurate information from Merry Island may have contributed to the pilot’s decision that weather along the route would be sufficient for a low-level VFR flight.
The pilot’s commitment to the decision to depart would have increased after boarding passengers, loading baggage, and starting the engines. Once ATC approved the pilot’s request for SVFR, the onus fell on the pilot to ensure that weather outside of the control zone would permit continued flight under VFR. When departing under SVFR, VFR pilots must have an alternate plan if below-VFR weather conditions are encountered when they leave a control zone. The pilot did not request the latest available weather reports (actual weather at 1000) to determine if the weather along the planned flight route was indeed improving. Had this been done, the deteriorating weather in Powell River would have given the pilot the opportunity to reconsider his decision to depart. When the aircraft departed, the visibility on the river was little more than ½ SM.
There are indications that the accident pilot had a tendency to push the weather. For instance, the day prior, the pilot was flying in below-VFR conditions. The pilot’s decision to depart was likely affected by confidence gained through previous successes under similar conditions.
Once airborne, the options available to the pilot were to continue on the planned route, alter the route, return to CYVR, divert to another aerodrome, or land on the water. All these options involved risks. Since he had been navigating from SALMON using GPS, he likely relied heavily on the GPS for navigation in the absence of adequate visual cues. As he approached Thormanby Island, it is highly likely that the pilot expected that he would regain adequate visual reference with the ground. However, it is difficult to accurately assess visibility over a featureless water surface, and it likely was not apparent to the pilot that the visibility had become so poor that a change of plan was required. When the pilot finally sighted Thormanby Island, the aircraft was too close for the pilot to be able to avoid colliding with terrain.
Several of the factors that influence a pilot’s decision to continue flight from VFR into IMC existed in this accident: previous successes in low visibility, difficulty in assessing actual visibility, commitment to a chosen course of action, the consequences of changing the chosen course of action, and ability bias.
It is likely that one or more of these factors were contributory to this accident.
The accident flight was conducted in meteorological conditions below VFR minima. There is no indication that the pilot attempted to land on the water, or to turn around, in the face of extremely low visibility and ceilings. It is highly likely that the pilot was relying on the GPS for navigation and that, as he approached Thormanby Island, his attention shifted from the GPS to looking outside the aircraft. While flying in fog, a controlled flight into terrain (CFIT) occurred during an attempt to avoid terrain. No evidence was found to indicate that the aircraft was out of control before impact.
Wreckage of the Grumman Goose being examined by an accident
investigator from the Transportation Safety Board of Canada.
Damage to the aircraft and to the trees at the accident site indicated the aircraft’s speed and attitude immediately before impact. The long, straight, rising angle of the swath cut through the trees and the extreme damage to those trees and to the aircraft indicate that the aircraft was flying at relatively high speed and climbing rapidly before collision with terrain. Extreme damage to all the propeller blades indicates that high engine power was being developed. This combination indicates that the pilot reacted to sighting terrain seconds before impact and pulled the aircraft up into a rapid climb. However, the pull-up was initiated too late to out-climb the rising terrain that lay ahead.
The accident aircraft’s flight at high speed while at low altitude and in low visibility entailed significant risks. These include: decreasing the available time to plan and react to an emergency, limiting the available options in the event of an emergency, increasing the likelihood of inadvertent descent into water or ground — particularly during a manoeuvre such as turning around — and increasing the likelihood of collision with ground-based obstacles and birds.
Findings as to causes and contributing factors
The pilot likely departed and continued flight in conditions that were below VFR weather minima.
The pilot continued his VFR flight into IMC, and did not recognize his proximity to terrain until seconds before colliding with Thormanby Island, B.C.
- The indication of a marginal weather improvement at Powell River, B.C., and incorrect information from Merry Island, B.C., may have contributed to the pilot’s conclusion that weather along the route would be sufficient for a low-level flight.
Findings as to risk
The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received.
Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety.
The lack of PDM training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions.
Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions.
Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions.
Incremental growth in the operator’s support to the client did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected.
Transport Canada’s (TC) guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows.
Previous discussions between the operator and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk.
There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart.
Because the aircraft’s ELT failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed.
On a number of flights, pilots on the Vancouver-Toba Inlet route, B.C., departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits.
The over-reliance on GPS in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers.
Safety action taken
Immediately following the accident, the operator suspended air taxi operations and implemented several actions to reduce risk before resuming operations. Since then, the company has implemented several other voluntary safety actions that exceed TC’s requirements for VFR air taxi operations. These additional safety actions include:
Raising the minimum departure visibility from the TC-regulated 2 SM to a company limit of 3 SM from a base of operations for VFR aircraft.
Providing a PDM course, including how GPS affects decision making, to all the VFR floatplane pilots and adding PDM training to the company VFR training syllabus.
Implementing a dispatch procedure that gives the dispatcher/flight-follower co-authority over the release of the aircraft.
Conducting risk assessments of VFR routes and operations (including reviewing weather, wind, and water condition limitations) and developing a destination-specific risk rating system.
Conducting line checks at least three times a year on each VFR pilot.
Regularly monitoring the stored data of the GPS carried on the aircraft to ensure that pilots are flying within company and Canadian Aviation Regulations (CARs) limits.
Installing aviation-specific satellite tracking systems in all VFR aircraft to replace the satellite messengers previously installed in those aircraft and eliminate the need to monitor GPS data.
Conducting annual company culture surveys to identify areas needing improvement.
Providing accident investigation training for key company personnel.
Revising the company’s SMS manual to include revised risk assessment procedures and accident investigation training.
Having pilots and dispatchers document circumstances where poor weather affects a flight and using those data for track monitoring and to determine risk exposure over an extended period.
In December 2009, as a follow-up to the Safety Study on Risk Profiling the Air Taxi Sector in Canada, TC made available on its Web site the Pilot Decision Making Simulator, developed by inspector Gerry Binnema (now retired from TC). This unique tool allows pilots to practice aviation-related decision making in a low-risk environment. The simulator can be found on TC’s website at www.tc.gc.ca/eng/civilaviation/regserv/
Transportation Safety Board of Canada
On the day this report was publicly released, the TSB issued a communique to the aviation community warning that flying in low visibility is causing too many deaths in Canada. TSB’s Bill Yearwood said, “There are some hard lessons that need to be learned and re-learned in aviation and this is one of them.”
Yearwood went on to say, “VFR pilots must be able to see the ground below and ahead of them at all times. It’s almost impossible to avoid obstacles and rising ground when clouds are low, the visibility is poor and you’re flying at twice the speed of cars on the highway.”
Aircraft colliding with land or water under crew control are among the deadliest accidents in aviation. They account for 5 percent of accidents but 25 percent of fatalities in Canada. The risk is even greater when aircraft venture into mountainous terrain in poor weather. That is why Collisions with Land and Water is one of the nine critical safety issues on the TSB’s highly publicized safety Watchlist.
“Competition is strong and customers can put pressure on companies to complete flights”, says Yearwood. “We need to see better decisions from companies and pilots to prevent these kinds of accidents.”
To read the complete final report A08P0353 on this occurrence, visit the TSB Web site at www.tsb.gc.ca.
Optimistic and Ability Biases: “VFR flight into IMC won’t happen to me; but if it does I can get out of it!”
by Dale Wilson, Professor, Aviation Department, Central Washington University
The following article is based on research published by the author and his colleague in a paper presented at the 11th International Symposium on Aviation Psychology, in Columbus, Ohio. It serves as an addendum to the preceding story, which touched on biases, particularly the ability bias.
Do you think you’re less likely than other pilots to experience a VFR-flight-into-instrument meteorological condition (IMC) accident? Do you think you’re better at avoiding VFR flight into IMC or successfully flying out of IMC should you inadvertently encounter such conditions? These are questions my colleague and I sought to answer as we reflected on the preponderance of scientific evidence indicating that most people are unrealistically optimistic and are overconfident in their abilities. For example, when university students were asked to rate the likelihood of owning their own home, obtaining a good job after graduation, or living a long life, almost all of them believed they had a greater chance than their classmates; when asked to rate their odds of developing a drinking problem, getting divorced soon after marriage, or being fired from a job, almost all of them believed they had a lower chance than their classmates. Since it’s impossible for the majority of people in a given group to have a greater (or lesser) chance of experiencing a positive (or negative) event than the median of the group, some kind of optimistic bias must be at work. This bias is seen in the high majority of cigarette smokers who believe they are at less risk of developing smokingrelated health problems than other smokers; in drivers who believe they are less likely than other drivers to be involved in an automobile accident; and, in general aviation (GA) pilots who believe they are less likely than other pilots to experience an aircraft accident.
Most people also believe they are superior to others when it comes to their own skills and abilities. For example, a high majority of managers rate their managerial skills as higher than those of their respective peers; U.S. college professors think they do above average work compared to other professors; Americans believe they are more intelligent than their fellow citizens; and, automobile drivers believe they are better, and are less likely to take risks, than their fellow drivers. Unfortunately, this above average effect, or ability bias, also seems to be evident in pilots; studies confirm that most pilots think they are safer, are less likely to take risks in flight, and possess greater flying skill than their peers.
We administered a questionnaire to 160 pilots asking them to compare themselves to other VFR pilots with similar flight background and experience as their own when rating themselves for the following: their chances of experiencing an accident due to inadvertent flight into IMC; their ability to avoid inadvertent flight into IMC; and, their ability to successfully fly out of IMC. The results were unequivocal: participants believed they were less likely than others to experience a VFR-into-IMC accident and believed they were better than average at avoiding inadvertent flight into IMC and successfully flying out of IMC.
Clearly, all of us can’t be above average, nor do all of us have a lower-than-average chance of experiencing an aircraft accident, yet that is what most of us believe. Why is that? These biases are part of a family of what are known as self-serving biases that serve to protect our ego by painting an unrealistic positive view of ourselves. In fact, the strength of these biases is significantly reduced in mildly depressed people and for those with lower self-esteem; compared to so-called mentally healthy individuals (presumably most pilots), studies indicate that these people actually exhibit more accurate and realistic perceptions of reality! There is also considerable evidence supporting a link between a positive, optimistic approach to life and reduced susceptibility to physical illnesses. The troubling irony is that even though these biases seem to be good for our overall physical and mental health, they can also lead to unsafe behavior.
In spite of a gradual decline in the percentage of weatherrelated accidents, VFR-into-IMC is still the leading cause of fatal GA weather-related accidents and continues to be a leading cause of all fatal aviation accidents in Canada and the United States. Even though a variety of environmental factors such as mountainous terrain and darkness play a role, investigators consistently cite limitations in planning, judgment, and decision making as reasons pilots initiate or continue VFR flight into unsuitable weather.
The optimistic and ability biases are only two of several complex and often unconscious factors that contribute to what the aviation safety community has historically cited as the major cause of these accidents: get-home-itis. Added to this malady is the strong influence other people can have on pilot decision making: compared to other aircraft accidents, a recent study found a significantly higher percentage of VFR-into-IMC accident flights carry passengers on board. Therefore, to protect yourself from the VFR-into-IMC trap, it is vital that you recognize that your decision making is not always rational, and if left unchecked, the biases we all appear to be vulnerable to could prod you into going somewhere you shouldn’t.
Dale Wilson teaches aviation safety and human factors courses at Central Washington University in Ellensburg, WA. He has written several articles on night flying, visual illusions, and VFR flight into IMC. Links to his work, including the original research paper this article is based on—“Optimistic and Ability Biases in Pilots’ Decisions and Perceptions of Risk Regarding VFR Flight Into IMC”—can be found at www.cwu.edu/~flight/faculty_wilson.html.
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