- ISSUE 3/2006
- Insert from the Director General of Civil Aviation
- Copyright and Credits
- Dangerous Goods Carried in Toolboxes
- Guest Editorial
- To the Letter
- Recently Released TSB Reports
- Accident Synopses
- Maintenance and Certification
- Flight Operations
- Regulations and You
- CASS 2007 Call for Papers
- Civil Aviation Contact Information
- Full HTML Version
- PDF Version
- New Series of Operation Update Seminars Well-Attended by Pilots
- Ten Questions for the Author of "10 Questions"
- David Larrigan Wins the Transport Canada Aviation Safety Award
- Blackfly Air on Training
- The Canadian Business Aviation Association Column-Responsibility and Accountability
- "Keep your eyes on the hook!" Video Now Available!
- COPA Corner-Aircraft Type Clubs Can Reduce Your Risks
- Inadvertent Transponder Code 7500
The popular Operation Update series of seminars, designed for general aviation pilots flying in and around the Lower Mainland, B.C., was resurrected in the fall of 2005. NAV CANADA considers this an opportune time to resume these seminars, as this airspace continues to be complex, with on-going changes as a result of the Lower Mainland Aeronautical Study and the Vancouver Terminal Reorganization Study.
When the seminars were first introduced in 1985, Transport Canada was tasked with reducing the number of incursions in Class C airspace in the Lower Mainland of British Columbia. (Class C airspace is controlled airspace within which both IFR and VFR flights are permitted, but VFR flights require a clearance to enter. Air traffic control [ATC] separation is provided to all IFR aircraft, and as necessary to resolve possible conflicts between IFR and VFR aircraft.)
Between 1999 and 2001, NAV CANADA, in collaboration with Transport Canada and the Transportation Safety Board of Canada (TSB), delivered 12 pilot safety seminars for general aviation pilots at flying clubs and schools at various airports in the Lower Mainland and on Vancouver Island. Over 400 pilots with a diverse mix of backgrounds and experience attended the free seminar.
The latest series of Operation Update seminars has been organized by Lana Graham, Regional Safety Manager, Vancouver, and is being conducted by Warren Le Grice, Program Specialist, IFR Training, Vancouver area control centre (ACC). A recipient of both the Chairman’s Award for Safety and the Chairman’s Award for People, Le Grice has merged his passions for teaching and aviation to deliver the seminars on an array of safety-related topics, spanning over two decades. Response from pilots has been very enthusiastic. Two fall classes and four classes scheduled in the spring promptly filled up, mostly by word of mouth. In all, some 150 pilots will have attended.
The seminars are not meant to instruct pilots on aviator skills, but rather, are a method of highlighting some of the procedures and communication skills required when operating in our complex aviation environment.
As an example, trend analysis shows that altitude deviation, or what pilots more commonly refer to as "altitude busting," is an increasing concern both internationally and in Canadian airspace. Through these seminars, NAV CANADA can share this concern and possible impacts that such occurrences have on our daily activities. At the same time, we can gather additional information to enhance our own understanding of the issues pilots are facing when operating in complex areas.
The Operation Update seminars discuss Canadian and U.S. airspace structure, Lower Mainland airspace and flight procedures, Vancouver and Victoria terminal operations, flying in the VFR terminal area (VTA), how to get the most from our NAV CANADA weather Web site, and the value-added interpretive weather briefing service from flight service specialists at the flight information centre (FIC).
Laminated frequency cards and NAV CANADA aviation weather services guides are handed out. The seminar normally concludes with a tour of the Vancouver ACC provided by a volunteer, such as Rick Korstad, Unit Procedures Specialist. This helps to put a face on our ATC operations.
Judging from the overwhelmingly positive feedback and requests for repeat seminars, our initiative was once again a timely and valued information service. It is intended that through this innovative education program, NAV CANADA will contribute in a meaningful way to promote safety awareness amongst the aviation community in our increasingly busy and complex skies.
Next up: Safety Day
As a follow up to this initiative, our regional safety managers will be conducting a Safety Day with safety officers from industry. There is much valuable safety trend analysis being conducted both within NAV CANADA and by our customers in general aviation. Our purpose with Safety Day will be to provide a platform for the exchange of safety information and for finding solutions that reduce the transfer of risk on both sides.
Sidney W.A. Dekker
If the success of this year’s Canadian Aviation Safety Seminar (CASS) can be measured by participation alone, then Halifax was a success! Nearly 400 people attended CASS-a testament to the dedication to safety in civil aviation in Canada, and in Atlantic Canada in particular. All are to be congratulated for their efforts.
The theme of this year’s CASS was "Human and Organizational Factors: Pushing the Boundaries." To set the stage, Sidney W. A. Dekker, Professor of Human Factors at Lund University in Sweden, opened the plenary session with a provocative discussion on the new view of human factors and system safety.
We took some time to speak with Professor Dekker to get his views on a variety of issues related to human factors, and how to advance the cause of safety. Here is what he had to say.
1. What could North Americans learn from Europeans in managing safety?
The safety management system (SMS) is about a partnership between the industry and the regulator. Those partnerships, and the lack of an adversarial relationship, are something that by very nature have already existed in Europe. You’ve already taken the safety management idea from the natural European interaction. It seems to be more accepted in Europe that systemic doesn’t necessarily just refer to a static conglomerate of stakeholders, but rather it refers to a completely new way of systems behaving. Systems behave in a certain way that requires a new set of models, a new set of ideas, a new set of indicators to monitor and manage. In Europe, systemic means "a new way in which a system behaves."
2. Why do we have the same accidents over and over again?
Are we really having the same accidents? I would say yes, some. So yes, we’ve seen them before, but now they have been exported to other parts of the world, where regulation is not as strong. When you look at our part of the world, have we really seen these accidents before? When we look at our part of the world we are having accidents where failures, in really safe systems, are preceded not by component failures, but by normal work. Organizations are having accidents by drifting into failure (e.g. Alaska 261), when there are goal conflicts between production and safety resulting from resource scarcity, for example. We should not be surprised to see the leakage from these pressures. The goal is to figure out how to help organizations acknowledge, work on, and resist these pressures.
3. What is the "new view" of human error?
The new view of human error sees human error as a consequence, not a cause; it is a start, not a conclusion. The sources of mistakes are structural, not personal. The other part of the definition says that accidents are a structural by-product of people doing normal work; the systems are functioning normally.
4. The new view sounds fine, but we live in the real world, and when people make mistakes, there are consequences. In this new view, what happens to responsibility?
Responsibility is an important part of the new view. The new view says you cannot hold someone responsible if they do not have the requisite authority. As soon as you begin discussions about responsibility, you begin discussions about organizations. Responsibility cannot be spoken of in a vacuum.
5. How would you suggest commercial aviation move from the old view to the new view of human error, given the current safety programs we have [crew resource management (CRM), threat and error management (TEM), line operations and safety audit (LOSA), safety management systems (SMS), etc.]?
These initiatives, in principle, are not old view. They want to take people’s working conditions seriously; they want to take behaviour in context, which is, therefore, a new view. They are very much about understanding the conditions in which people work, and how they create safety. However, the risk in many of these programs is that they seem to see concepts, like error violation, as conceptually non-problematic. In these programs, we count errors and violations, and we use this information to determine how safe an operation is. The assumption that by counting errors and violations, you can measure safety, is problematic, as the real data lies much deeper. What do these errors and violations really mean?
6. The new view may be fine for big operators, but what could small operators do?
Small operators could learn to ask the right questions. When they see a human error problem, they could see it as an organizational problem. How does one go about asking a good question? Are you asking why from inside the tunnel (from the operator’s perspective, during the sequence of events before the negative outcome occurred)? Are you probing what the operator saw? What the operator heard? These questions work in reactive situations. What about in the proactive
sense? What are good questions to ask? It costs a lot of resources to ask good questions. Another thing small operators could do is freeze old view countermeasures-don’t knee jerk, pull licences, punish, write letters, etc. We need to step back and look forward.
7. What human factors training/education do inspectors/industry need to operate in an SMS world?
If you want to educate industry, and you want the regulator to collaborate in creating safety first, you need an organizational safety vocabulary so you can talk about the major risks. This may be very contextual. We need to turn people into system thinkers. Some of our models of accident causation are old. We need to shift our thinking and metaphors to understand that a system is something that lives, it can get sick from harmful pressures. We need to teach people how to look for other things-higher variables, such as: are they taking past experience as a measure of future success? You cannot see the universal but in the particular-but the particulars quickly stop making sense if you have no general concepts to relate them to. We need to invest in facilitating discussions between generalists and specialists. Technical people need education and updating, as do generalists. This will ensure they are capable of questioning their own assumptions. There should definitely be an opportunity for interactions where specialists and generalists learn from each other.
8. What qualities do aviation managers need to possess to be more proactive in managing safety?
Take domain expertise seriously. If you don’t, you do so at your own peril. Technical expertise alone does not qualify you to be a manager. You have to learn some skills that apply to running a group of people.
9. How do you detect and mitigate drift (the slow incremental departure from initial written guidance on how to operate a system)?
Get in fresh perspectives. Never stop asking questions. Ensure your people have a constant sense of unease. Recognize that that which is acceptable or normal, is not necessarily safe.
10. What’s next after SMS?
What you have to watch out for is that SMS does not become the nuts and bolts of the 21st century, where all we do is check whether documentation and processes meet specified criteria of quality because safety is an emergent property-it is more than the sum of quality parts. We have to go beyond SMS as a set of separate components, and learn more about how our people can get to see the big picture, because it is in the big picture that big accidents happen-not in the breakdown of any one component.
Mr. David Larrigan of British Columbia has received the 2006 Transport Canada Aviation Safety Award for his demonstrated commitment and exceptional dedication to aviation safety over the past 50 years. The award was presented to Mr. Larrigan on April 25 at the 18th annual Canadian Aviation Safety Seminar (CASS) in Halifax, N.S.
David Larrigan (left) receiving his award from Assistant Deputy Minister, Safety and Security, Marc Grégoire
Mr. Larrigan spent 16 years with the Royal Canadian Air Force as a pilot and flight instructor, and retired with the rank of Colonel. He then spent 21 years with Transport Canada, rising to the position of Director General of Aviation, Pacific Region. He has spent the last 13 years as a consultant to the aviation industry with a primary role as the airside safety officer with the Vancouver International Airport Authority.
He wrote the first Surface Movement Guidance Control System Plan and commissioned the first category (CAT) III runway in Canada. He was instrumental in establishing a foreign object debris management program that has become the template for airports around the world. He is a recognized expert in airport foreign object damage (FOD) control programs around the globe.
At the British Columbia Institute of Technology (BCIT), Mr. Larrigan promoted and guided the development of the first dedicated airport operations diploma program in Canada. He continues to be active in many industry committees, task forces, conferences and meetings promoting aviation safety. He was the recipient of the 2005 British Columbia Aviation Council Lifetime Achievement Award in Aviation.
Click on image to enlarge
Blackfly Air on Training
Blackfly Air is on the move, expanding and hiring-they must be doing something right! A growing aviation business presents new challenges, which can be faced in a structured way with a proper safety management system (SMS) in place. The arrival of new personnel requires training, and your current personnel require recurrent training. That is a fact for all aviation organizations. Here is what the SMS guidance material has to say on that topic.
Of course, you need properly-trained personnel to ensure the quality and safety of the operations in your organization. Clear expectations, explicit work instructions, such as maintenance work instructions and standard operating procedures (SOPs) serve two purposes. They let employees know what is expected of them and they allow management to expect consistency in the conduct of operations and to compare what is expected against actual performance. If a deficiency is identified or an event occurs, one of the pieces of the investigation will be to review the quality and the safety of the work instructions or SOPs, and the adequacy of the training provided. Your existing training program will need to incorporate the components related to SMS.
As you develop your SMS, you are adapting it to suit the size, management style and needs of your company. That means that no two systems will look exactly alike. Training, therefore, in how you have chosen to operate, becomes important in helping to ensure that your goals are indeed achieved.
- Existing employees will need detailed briefings on your SMS, your management commitment to it, and their part in making it work.
- New employees will need to be familiarized with how your SMS operates, and in many cases, you will probably find that you have to train them on the basic concepts of SMS as well.
- All employees will need periodic refresher briefings or discussion to make sure that everyone fully remembers what you are trying to do and how it needs to become, and remain, a part of the organization’s lifeblood.
- In flight training operations, although student pilots are not employees, they should be aware of your SMS and be trained in how to report safety deficiencies and hazards in the same manner that they now understand and report aircraft airworthiness problems. If they are commercial pilot students, they will be required to have a basic understanding of SMS principles as part of their licensing requirements.
- In some cases, external stakeholders will need to be aware of your SMS processes so that they can provide you with appropriate documentation and follow-up, when necessary.
Whether you are involved in flight or maintenance operations, to make the SMS work you need to take time to train and, yes, also to document that you did so. You will need to measure whether the person understands the training received, or to what extent existing employees have the understanding you hope they have.
What can you include in any of the above types of training?
Here are some examples:
- SMS principles including the continuous improvement loop.
Details of your company SMS including:
- Company safety policy
- SMS policy manual (documentation)
- Roles and responsibilities
- Safety reporting system
- Analysis of accidents/incidents
- Emergency response plan
- Special procedures
- Non-punitive reporting policy
- Emergency equipment review
- Applicable Canadian Aviation Regulation (CAR) review
- Operations manual review, including company-specific procedures such as operations specifications for special authorities like low visibility operations.
Pick those that will benefit your specific operation, and then add others that are unique to your type of activity. While many of these training topics are items that require procedural training, remember that in the SMS context, you are focusing on safety-related issues as part of an integrated management plan.
In addition to the obvious benefits gained from training, it is an indication to the employee that management thinks this is important enough to devote dedicated time to it, and it shows to others (customers, insurers, regulators) that you have taken carefully-planned steps to make safety consciousness a fully integrated part of the operation.
Who will provide this training? For some of these topics, you will probably have some staff members who have the expertise necessary to provide the training to others. For other topics, you may have access to outside consulting resources. Feel free to call on your regional Transport Canada office, especially for briefings on SMS principles.
For further information, refer to Chapter 4 of Safety Management Systems for Small Aviation Operations- A Practical Guide to Implementation (TP 14135), at http://www.tc.gc.ca/eng/civilaviation/publications/tp14135-1-menu-2078.htm, and Safety Management Systems for Flight Operations and Aircraft Maintenance Organizations- A Guide to Implementation (TP 13881).
Canadian Aviation Regulation (CAR) 604 authorizes the Canadian Business Aviation Association (CBAA) to establish business aviation operational safety standards, and issue Private Operator Certificates in accordance with those standards. The CBAA safety standards are performance-based and the certification system is structured on an integrated safety management system (SMS) concept. The CBAA certification system is designed to provide a balance between safety and efficiency.
The traditional certification system relied heavily on Transport Canada’s direct oversight for numerous administrative approvals. Although the business aviation industry has an enviable safety record, the traditional system is unsustainable and does not cultivate active operator participation. In order to meet safety performance objectives, proactive operator involvement is a key element identified in both Flight 2005-A Civil Aviation Framework for Canada and Flight 2010-A Strategic Plan for Civil Aviation. Private operators recognize that proactive risk management is an effective way to improve safety performance. An important factor in making an integrated management system work is the understanding of the relationships within the framework. Companies, flight departments, regulators, technicians, pilots, dispatchers, inspectors, etc., all have designated functions. Individual responsibilities and accountabilities should be clearly identified and documented within the SMS framework. An SMS provides effective tools for everyone.
In today’s complex and integrated environment, it is not sufficient to be a good technician, pilot, dispatcher or inspector; everyone needs to understand and accept the inherent responsibilities and accountabilities.
The Canadian business aviation community is one of the first groups to implement the Civil Aviation Strategic Plan directives. We are very pleased with the transition that has already occurred. To reach its full potential, the business aviation community will need full participation from all. We are all individually responsible and accountable for aviation safety.
The new helicopter ground crew safety video that we announced in Aviation Safety Letter 1/2006, "Keep your eyes on the hook! Helicopter External Load Operations-Ground Crew Safety" (TP 14334), is now available for purchase, in either VHS or DVD format! While the video is targeted primarily at helicopter ground crews involved in external load operations, it is also applicable for helicopter pilots, operators, and clients who use such heli-services. The video contains several scenarios and testimonials on precarious and challenging slinging operations from all regions in Canada. Order it today from Transact, the online storefront for Transport Canada publications at www.tc.gc.ca/transact/, or by calling Transport Canada’s Order Desk at 1 888 830-4911.
One of the sciences that studies groups and how they work is social psychology. Research in this area tells us much about the value of being part of a group for the individual members. Some of the general benefits include: meeting the need to belong, providing information to members of the group, providing rewards and achieving collective goals.
One of the most useful groups that a pilot and aircraft owner can belong to is an "aircraft type club." These clubs cater to the owners and pilots of one specific aircraft type or a series of types. Because of this focus on a single aircraft type and its variants, these clubs can provide a lot of detailed information on aircraft maintenance considerations and type-specific aircraft piloting skills. Belonging to a type club can give you the information you need to reduce your risks in owning and flying your individual aircraft-now that is worthwhile!
Type clubs organize fly-ins where you not only mingle with other pilots, but experience the thrill of parking your aircraft next to its long-lost siblings. The fly-in above was a successful meeting of Challenger ultralight owners and pilots at Château Montebello, Que., in January 2005. Photo: A. Hunt
Aircraft type clubs are common-there are literally hundreds of these clubs around the world providing services to many, if not most, aircraft types that have been produced in any significant numbers. There are type clubs for certified aircraft, warbirds, sailplanes, amateur-builts and ultralights.
Type clubs vary a lot in the services they offer and how they work. Some are simply volunteer clubs run by one enthusiast, using a free Web service to provide a Web site. These often have minimal publications or services. On the other end of the scale, some of the largest types clubs have a full-time staff and offer a wide range of services.
Here are services that some type clubs offer:
- A magazine to pass on type-related information, news and events;
- A Web site, often with type-specific buyer’s checklists;
- Technical question support from aircraft type experts;
- Buyer’s guides;
- Conventions and fly-ins;
- Information on applicable Airworthiness Directives, Service Bulletins and Service Letters;
- Information on available Supplemental Type Certificates;
- Type-specific classified ads (often online);
- Background and aircraft type historical information;
- Maintenance tips publications;
- Operating tips information;
- Maintenance and aircraft systems courses;
- Aircraft type conversion training programs;
- Type-specific insurance (often available in the U.S. only!);
- Formation flying training;
- Many other possible services.
In some cases, with highly popular aircraft designs, there are competing type clubs that all offer services for the same aircraft type or types. In those cases, the owner has a choice of clubs, or they can just join them all!
COPA supports aircraft type clubs-they serve a great need in the aviation world, providing type-specific technical information and support that is not provided by anyone else. Consider joining and supporting the club for the type of aircraft that you own or fly-most of them are well worthwhile.
COPA has listed all the aircraft type clubs that we are aware of on the COPA Web site. We welcome submissions of clubs that we don’t know about yet.
What if you check and discover that there is no type club for your aircraft type? Well then, consider starting one. With free Web services on which to post a Web site, it can be done at no cost. If nothing else, you will meet many more fans of the aircraft type you own and learn a lot about your individual aircraft along the way! In the next COPA Corner, I will address the benefits for pilots who do not own an aircraft to be members of a traditional flying club.
The COPA Web site is http://www.copanational.org/.
The pilots involved were a flight instructor and a commercial student pilot. The aircraft was a single engine trainer. A code of 7500 had been inadvertently left on the transponder, which had gone unnoticed by this crew in their walk-around. The training flight departed on a three airport, round robin cross-country trip encompassing about 250 mi. Several minutes after takeoff, the flight entered a radar coverage area causing a warning alarm at the area control centre (ACC). In an attempt to contact the aircraft in order to ensure things were all right, the ACC asked the flight service station (FSS) to relay a message on the en-route frequency. Unfortunately, the radio strength and readability between FSS and the aircraft was poor.
The pilot believed FSS had requested that he select code 7500 for flight following. He believed he was complying with a legitimate request, so he read back the code and confirmed it was entered in "the box." FSS had actually asked the pilot to confirm he was squawking 7500, and could query the pilot no further so as not to upset a potentially dangerous situation. Confirmation of the code 7500 is confirmation of a hijack. Communication with the aircraft was lost; however, the aircraft was still within radar coverage. The miscommunication was further compounded since air traffic services (ATS) were then required to execute the hijack procedure, and as a result, the RCMP responded with emergency security measures. A Canadian Military DHC8 in the area did attempt to contact the aircraft, but was unsuccessful.
The flight plan was reviewed by ATS, and the RCMP dispatched personnel to the first airport on the flight plan, an airport with a mandatory frequency (MF), to intercept the flight upon landing. The student pilot successfully executed a touch-and-go and was then off to airport two, unaware of the security measures in position on the apron.
The authorities had interpreted this as the pilot, upon seeing the cruiser, making a getaway. This development was relayed to the shift supervisor at ATS, who advised the RCMP to advance to the next airport on the flight plan, again an aerodrome traffic frequency (ATF) airport, again a touch-and-go. Same result.
Approximately an hour and a half into the flight, and as the aircraft was arriving at the third airport on the flight plan, FSS was able to make radio contact again. Again, the FSS asked the pilot to confirm he was squawking a transponder code of 7500. The pilot again positively confirmed code 7500. All efforts were made by FSS to avoid provoking the escalation of a serious situation in the cockpit, as this was being treated as a real hijack.
As the aircraft approached the airport, the RCMP was again awaiting the arrival of the aircraft. This time the plane did land. As the pilot entered the ramp, the police cruisers intercepted the progress of the aircraft and apprehended the unfortunate pilots. After several hours of interrogation, the pilots were free to return to their aircraft.
The event occurred as a result of a lack of a thorough cockpit safety check and not questioning an unusual request from an air traffic controller. These are both symptoms of complacency in the cockpit. There was no evidence of a regulatory infraction of Canadian Aviation Regulation (CAR) 602.01. The possibility that this aircraft was operated in a reckless or negligent manner as to endanger, or be likely to endanger, the life or property of any person, does not apply since the pilot believed he was complying with a legitimate ATS request. However, there was a great deal of labour and expense engaged in this undertaking, as ATS and the RCMP had to treat the event as an actual hijacking.
Your PIREP could save My life!
The fifteenth annual search and rescue (SAR) workshop will be held in Gatineau, Que., October 4–7, 2006. The a tradeshow, SAR games, training sessions and an awards banquet. Co-hosted by the National Search and Rescue Secretariat and the Sûreté du Québec, in association with the Association Québécoise des Bénévoles en Recherche et Sauvetage, SARSCENE 2006 kicks off on October 4 with the tenth annual SARSCENE games. The workshop is a unique opportunity for SAR personnel to share their expertise and ideas, with over 600 participants from air, ground and marine organizations across Canada, and around the world. Take time to see the Outaouais and National Capital Region! Don’t miss the early registration discount deadline of August 31, 2006. For more information contact the Secretariat at 1 800 727-9414, e-mail SARSCENE2006@nss.gc.ca, or visit http://www.nss.gc.ca/.
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