- Issue 3/2012
- Copyright and Credits
- Guest Editorial
- Flight Operations
- Maintenance and Certification
- Recently Released TSB Reports
- Accident Synopses
- Regulations and You
A Just Culture
- Authorized? Be sure! Runway Incursions Are Real! (poster)
- Safety in the air starts on the ground—Maintenance (poster)
- Full HTML Version
- PDF Version
by Dan Cook, Chairman, Flight Training & Safety Committee, Soaring Association of Canada (SAC)
Last year, two gliders collided head-on over the Rockies near Invermere, B.C., and sadly both pilots were killed. Both gliders carried GPS data loggers, which are common in cross-country gliding; this has helped in the accident analysis. It appears that one glider was flying towards the setting sun and the other had the sun behind it. Based on their altitudes, it is likely that the glider flying into the sun would have had the mountains behind it, making it more difficult to identify the glider given that it would have appeared stationary against the rough background terrain of the mountain.
Gliding also has unique challenges compared to powered flight. Generally, when a power pilot identifies another aircraft, the pilots try to avoid each other or maintain maximum separation. With gliders, the presence of another glider generally indicates the potential for lift; as soon as a glider circles or climbs, other gliders are drawn to the source of lift and separation decreases, sometimes to a few hundred feet. Separation and safety are maintained by communications and/or thermal and ridge protocols as the gliders circle together or dolphin fly along the lift. This becomes more difficult to manage in popular soaring locations with dozens of gliders or during soaring contests.
In Europe, which has more gliders and less usable airspace, this challenge was heightened. It reached a point where the European gliding community identified mid-air collision as their number-one hazard for gliding. Conventional airborne collision avoidance systems (ACAS) were of little use due to their false alarm rates caused by the close proximity necessary for gliding without being in danger of collision. This requirement should not be confused with transponders used for collision avoidance in controlled airspace or with commercial aviation. Low power consumption transponders are now available to meet glider requirements, and some soaring clubs near high commercial traffic areas are now equipping their gliders with transponders. However, this does not ensure the glider-to-glider alerting required at most of our more remote gliding locations, which are away from commercial air traffic and often in ground radar shadows. An inexpensive flight alarm (FLARM) was specifically developed in Europe to address the glider-to-glider or close proximity warning requirement without false alarms. The device uses GPS and an altitude barometric sensor to transmit 3D information at a distance of 3–5 km to other FLARM units. The FLARM’s close-formation motion-prediction algorithms identify potential conflicts for up to 50 other signals and warn the pilot using sound and visual cues.
A few years ago, the gliding community in Switzerland experienced several fatal accidents due to glider collisions over the Alps; since voluntarily implementing FLARM, they have not reported any more fatal accidents due to collisions. For the North American market, Power FLARM was developed due to different spectrum management requirements and a desire to include the ability to detect Mode C/S and automatic dependent surveillance-broadcast (ADS-B) signals up to 100 km away to provide glider pilots with a greater capacity to avoid general aviation or commercial airline traffic. In addition, the device is certified as an International Gliding Commission (IGC) data logger to keep downloadable track information. It can store and warn of obstacles in a database, comes in portable or panel-mount variations, and can feed different display devices.
It is not known if Power FLARM would have prevented the accident last year, but users of the devices are satisfied they work well. With the addition of any devices to improve warning, it is up to the pilot to maintain a proper scan and not let a disciplined approach break down. There will always be obstacles, non-equipped aircraft, birds, and malfunctions that will require vigilance. Also, once the information is received, the pilot must take action.
Power FLARM is now approved for use in Canada and in the U.S.A. The Flight Training and Safety Committee for the Soaring Association of Canada is recommending that all glider owners equip their aircraft with Power FLARM (at a cost of less than $2,000), especially those used in competitions or congested soaring areas where ridge or wave soaring is common. In addition, aircraft operating near gliding operations or involved in close-proximity flying with other aircraft in the context of flight schools, parachute operations, helicopter operations, aerobatics or formation flying would greatly benefit from this technology. Contest operations are introducing safety management systems (SMS), and it is hoped the process will reinforce the need for Power FLARM in competitions.
by Alexander Burton. This article was previously published in the July 2011 issue of COPA Flight, and is reprinted with permission.
Aviation safety is always a question of risk management. Each flight involves both risk and benefit. Our job as pilots is to maximize the benefit and manage the inherent risk using the best tools at our disposal. The success of how we go about managing risk and the level of risk we are willing to accept can often be traced back to the type and extent of the training we receive or choose to seek out. As Jay Hopkins wrote, “One of the basic attributes of professionals is that they are always seeking to learn more about their profession.”
Single-Pilot Resource Management (SRM), first introduced in 2005 by the National Business Aviation Association and now gaining significant ground in the U.S., is a system designed to help reduce the number of aviation accidents resulting from human error by teaching pilots about their own limitations and providing training guidelines for single pilots operating the new very light jets (VLJ).
While the system was originally developed for training VLJ pilots, it has rapidly been adapted for other technically advanced aircraft (TAA) and it is entirely compatible with the needs of all pilots flying single-pilot aircraft, technically advanced or not. The principles of SRM apply just as well to the single pilot flying at 60 kt as to the single pilot flying at 250 kt.
Accidents statistics for both GA and commercial operations demonstrate clearly: pilot error is the most common cause of aviation accidents. In the United States, between 70 and 90% of all airline and military aviation accidents are traced back to pilot error.
In Canada, pilot error was found to be a “broad cause/factor” in 84% of all aviation accidents and 96% of fatal accidents. As a good friend of mine likes to say, “The biggest threat to aviation safety is the loose link between the yoke and the rudder pedals.”
Most pilots are familiar with the concept of Crew Resource Management (CRM) which focuses on the interactions occurring in the two crew environment. CRM training has been successful in reducing the number and frequency of aviation accidents resulting from the difficulties encountered in a multi-crew environment.
SRM training is designed to provide the assistance needed by pilots operating in a single crew environment and, just for perspective, in the United States GA accounts for 96% of the total number of aircraft, 60% of the total flight hours and 94% of the fatal aviation accidents.
A significant proportion of all aviation and a disproportionate percentage of fatal accidents, at least in North America, involve single-pilot operations.
The practical application of SRM centres on what are called the “5 P’s”. The 5 P’s are based on the idea that five essential variables impact a pilot’s environment and can cause him or her to make a single critical decision or several less critical decisions that when added together can create a critical outcome. 
The 5 P variables are: the Plan, the Plane, the Pilot, the Passengers and the Programming.
Using the 5 P’s, the pilot will review the essential variables of the flight, the 5 P’s, at those points during the flight sequence when decisions are typically most likely to be effective: during the pre-flight planning session; prior to takeoff; at mid point during the flight unless the flight is longer than two hours, in which case an hourly review is suggested; prior to descent for landing and just prior to the final approach fix or, if on a VFR flight, just prior to entering the traffic pattern as preparations for landing begin.
Using this system helps the pilot remain alert and aware of the variables that directly affect the safety of the flight and gives him or her scheduled and regular opportunities to review and re-evaluate how the flight is progressing and whether or not a new plan may be required.
Disciplined use of the 5 P’s is, essentially, a “wake up and smell the coffee” prod for the pilot at each of the critical points in the flight sequence.
The “Plan” contains all the basic elements of cross-country planning including weather, routing, fuel requirements and required publications and other information. The Plan is not completed and fixed for all time prior to the flight; it must be reviewed on a regular basis as a flight progresses.
Things change: takeoff can be delayed; unexpected changes in the weather may occur; NOTAMS due to forest fires or police activity may be issued; the extra cup of coffee you drank before jumping in the machine may not allow you to continue for the initially planned time of the flight.
While the initial plan stage is a perfect time to evaluate whether or not a flight should be carried out, it is also an ongoing critical variable of the flight that must be reviewed as the flight progresses and new information becomes available.
“We are what we repeatedly do.
Excellence, then, is not an act
but a habit.”- Aristotle
The “Plane” incorporates all the elements of mechanical and functional aspects of the machine itself. Is the plane capable of the planned flight? Is all maintenance up to date? Do we have sufficient fuel, equipment, avionics, survival supplies, charts and clothing? In TAA aircraft a review of the Plane expands to include items like database currency, automation status and emergency backup systems that were not at all common only a few years ago.
Pilot proficiency and currency may also be included when inventorying and reviewing the “Plane” or may be included in the following P, the “Pilot”.
The “Pilot” is a critical variable in all flights. Traditionally, most of us have been taught the IMSAFE acronym and it is a good place to start. Once again, however, a one-time assessment of the pilot, the person on whom all others in the aircraft and all those poor, non-aviating souls walking about below are dependent, is really not sufficient.
Just as the weather and the condition of the aircraft change throughout the duration of the flight, so too does the condition of the pilot. Fatigue, stress, the effects of low altitude hypoxia and the cumulative effects of noise and vibration all reduce the effectiveness of the person driving the aircraft.
There are reasons why 61% of all aviation accidents occur on landing. At the end of a flight pilot performance is at its lowest point. According to a study carried out by the Australian Bureau of Air Safety Investigation, Department of Transport and Regional Development, the most commonly assigned factor in fatal aviation accidents was poor judgement; judgement is a human capability very susceptible to fatigue.
A review of the condition of the pilot at regular, planned intervals during any flight is one excellent way to increase air safety.
The “Passengers” on a flight can also be a critical variable in safety. Particularly for GA and business aviation, passengers can have significant influence over what a pilot does or does not do and their influence on the pilot can significantly affect how a flight is carried out.
The worst scenario, perhaps, is when one or more of the passengers is also a pilot. There is an old saying: if you ask four rabbis the same question you will get at least five different answers. The same, no doubt, is true of pilots.
When interacting with non-pilots, the pilot in command of the flight must remember passengers do not always understand or appreciate the risks involved in a particular flight. We’ve all heard some variation on the story of the hunters who wanted to get just one more case of beer or one more trophy deer on the aircraft. Setting and maintaining a positive and clearly defined relationship between the pilot and passengers is a critical factor in flight safety.
The “Programming”, most applicable to TAA aircraft, also has importance for less well equipped machines. While pilots of TAA aircraft enjoy many benefits from the new technology, that very technology itself can become a challenge. For VFR flight, particularly, pilots may become so engrossed in their screens and devices they may become distracted and forget to look outside and maintain positive situational awareness.
Pilots flying TAA aircraft must be familiar and comfortable with their fancy devices prior to flight. A good time to learn use of an unfamiliar piece of equipment is on the ground not during a difficult flight segment.
For all flights, organizing the navigational equipment and instrumentation you will use to assist your efforts to achieve safe flight must be evaluated and re-evaluated at appropriate intervals during the flight, whether that is modern, electronic wizardry or maps, watches and pencils.
In his book, Target Risk 2: A New Psychology of Safety and Health, Gerald J. S. Wilde, a professor emeritus of psychology at Queen’s University in Kingston, Ontario, proposes what he refers to as the Risk Homeostasis theory.
The theory of Risk Homeostasis, in short, states that people become accustomed to and comfortable with a particular level of risk. If that level of risk is reduced by some change in the environment, the addition of anti-lock braking systems for example, people tend to respond by driving faster and reducing the distance behind the next vehicle in order to maintain the level of risk with which they are comfortable: people adapt their behaviour to changes in environmental conditions. Few of us willingly embrace change regardless of its form or stated purpose.
As Wilde says, “...safety and lifestyle dependent health is unlikely to improve unless the amount of risk people are willing to take is reduced.”
Systematically implementing SRM into a pilot’s personal procedures is one way to guide and assist him or her toward becoming more safety conscious and toward consciously reducing the level of risk he or she is willing to accept as normal.
Alexander Burton is a Class I instructor, pilot examiner and a regular contributor to several aviation publications both in Canada and in the U.S. He is currently Base Manager for Selair Pilots’ Association in cooperation with Selkirk College, operating their satellite base in beautiful Abbotsford, B.C. (CYXX). He can be contacted at: email@example.com.
 Hopkins, Jay. “The Professional Pilot”, Flying, Jan. 10, 2010.
 Wiegmann, D. A., S.A. Shappell (2001), “Human Error Analysis of Commercial Aviation Accidents Using the Human Factors Analysis and Classification System (HFACS)” (pdf) Federal Aviation Administration. www.faa.gov/data_research/research/med_humanfacs/oamtechreports/2000s/media/0103.pdf.
 Transport Canada, Human Factors for Aviation, Basic Handbook (TP 12863) p. 3.
 Kane, Robert (2002), Air Transportation (14th ed.), Kendall/Hunt Publishing Company, p. 751, ISBN 0787288810.
 “Managing Risk through Scenario Based Training, Single Pilot Resource Management, and Learner Centered Grading,” Summers, Michele M; Ayers, Frank; Connolly, Thomas; Robertson, Charles. Sept. 2007, www.faa.gov/training_testing/training/fits/guidance/media/RM_thorugh_SBT.pdf.
 Wilde, Gerald J.S. (2001). Target Risk 2: A New Psychology of Safety and Health.
 Wilde, Gerald J.S. “Risk homeostasis theory: an overview”, Injury Prevention, 1998; 4:89-91.
By Brooke Hutchings, NAV CANADA
Canada’s rugged terrain and immense size often result in challenging flights. Throw in our diverse and unpredictable weather conditions, and those challenges intensify. Aircrew have their hands full; however, one thing that pilots do not have to worry about is the provision of alerting service to activate search and rescue (SAR) when an incident occurs. Why? NAV CANADA provides alerting protection to all portions of the flight information region (FIR) where they provide service.
The Canadian Aviation Regulations (CARs) require pilots to file an arrival report as soon as practicable after landing, but not later than one hour after their estimated time of arrival (ETA) (24 hours for a flight itinerary) or by the specified SAR time if non-standard. But what exactly does the provision of SAR “alerting service” by an area control centre (ACC) entail?
If an arrival report is not received at the expected time, ACC air traffic operations specialists (ATS) are required to notify the appropriate joint rescue coordination centre (JRCC) of the overdue aircraft and commence a communications search on a priority basis.
Initial calls actually begin as early as 15 minutes prior to the overdue time, enabling the ATS to potentially locate the pilot prior to involvement of the JRCC, and respond quickly to the JRCC at the overdue time. The communications search involves advising the company and contacting all facilities or contacts at the destination or last reported point. It may involve requesting a police search of the destination airport. During this time, any filed phone numbers will be called, and airports along the route of flight will also be contacted. Within one hour of the overdue time, the ACC must report on the results of the search to the JRCC. If the communications search is unsuccessful, the JRCC will take further actions as required, such as launching search aircraft.
What many may not be aware of is that in addition to providing pilots with enroute and destination SAR protection, ACC ATS also provide departure alerting to proposed flights on an IFR flight plan. If an aerodrome does not have air traffic services onsite that are able to observe the safe departure, then ACC ATS are required to monitor the flight to ensure it departs safely and initiates communications with ATC as expected. Onsite air traffic services include an open control tower, an FIC or an FSS with visibility to the runways. For example, when London Tower closes in the evening; even though the London FIC is open, they do not provide aerodrome advisory service and do not have the required visibility. Since the Sault Ste. Marie FSS, which is responsible for providing remote aerodrome advisory service (RAAS) during that time, is not onsite, responsibility for departure alerting reverts to the Toronto ACC. The flight will be considered overdue one hour after the estimated time of departure (ETD) and the JRCC must be notified. Initial calls to the pilot, company or departure facility may be made as early as 45 minutes after the proposed departure time.
Often, the ACC ATS will find that an aircraft overdue on departure never even arrived at the proposed departure point. The ACC is still obligated to locate the aircraft and ensure its safety. More often, the flight is simply running late.
What further complicates the search activity is when the aircraft has one call-sign inbound (e.g. ABC123) and has a proposed departure outbound with a change in call-sign (e.g. ABC124). The aircraft can still be inbound when the ACC ATS is notified by an overdue departure warning to search for the outbound aircraft.
Remember, once airborne, if you cancel your IFR but retain your flight plan, you are still being provided with alerting services.
Pilots flying VFR on one leg and IFR on another should also be aware of the differences between VFR and IFR alerting services. A FIC will “assume departure” for VFR flights departing remote uncontrolled aerodromes, and VFR alerting service is initiated automatically, but the ACC does not have that luxury. The ACC cannot “assume departure” for IFR flights departing uncontrolled aerodromes as this can negatively affect IFR clearances, separation standards and conflict prediction in the IFR environment. The only exception to this is IFR flight itineraries that remain outside controlled airspace.
Some companies use satellite tracking for their aircraft. This can be especially handy if the dispatcher has real-time data available for the ACC ATS when contacted. Better yet, if those companies could be proactive and call to amend their flight plans when running late, it would help reduce the number of unnecessary communications searches.
In the aviation world, as in life, plans often change unexpectedly. If you find yourself in this position, simply call a NAV CANADA facility and update or cancel your flight plan. Even if you are departing an aerodrome with a control tower, it is important to keep your flight plan up to date.
Updating your “flight plan on file” on a regular basis, and including cell phone numbers, will help reduce the time spent in the communications search stage and may reduce the time required to initiate rescue assistance when actually needed.
Your timely call will help ensure continuous and expeditious service for all and prevent unnecessary activation of SAR operations.
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