Aviation Safety Letter 4/2004

Recently Released TSB Reports

The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include only the TSB's synopsis and selected findings. For more information, contact the TSB or visit their Web site at http://www.tsb.gc.ca/. — Ed.

TSB Final Report A02A0272 — Risk of Collision

On August 25, 2002, at 09:36 eastern daylight time (EDT), a Cessna TU206G amphibious float-equipped aircraft was approximately 3 NM west of Lester B. Pearson International Airport (LBPIA), in Toronto, Ont., on approach to Runway 05, and was cleared to land and hold short of Runway 33L. About one minute later, a McDonnell Douglas DC-9 was authorized to taxi to position on Runway 33L for departure. Shortly thereafter, the airport controller advised the DC-9 that a Cessna 206 would land and hold short of Runway 33L, and then issued the take-off clearance.

Risk of Collision

After the Cessna 206 touched down on Runway 05, the controller issued taxi instructions to the pilot, with instructions to hold short of Runway 33L. The Cessna pilot then informed the controller that he was going around because of a landing gear problem. The controller immediately instructed the Cessna pilot to commence a hard left turn. At the same time the DC-9 flight crew, just after becoming airborne, observed the Cessna and initiated a right turn. The spacing between the aircraft was approximately 100 ft lateral and 100 ft vertical over the threshold of Runway 15R, with the DC-9 being higher. There were no injuries as a result of this incident.

Findings as to causes and contributing factors

  1. Because of the backlog of departing traffic and in an effort to expedite departures, the controller chose to use land and hold short operations (LAHSO) instead of sequential runway operations, which ultimately resulted in a near collision.

  2. The controller used LAHSO procedures between a departing and arriving aircraft on a runway pair for which this procedure was not authorized.

  3. The Cessna pilot had a landing gear problem; however, he did not advise the controller of the problem or of the risk that he may not be able to land on Runway 05 and stop before the intersection of Runway 33L.

  4. The controller did not advise the Cessna pilot that a DC-9 aircraft was departing from Runway 33L at the same time the Cessna 206 was landing on Runway 05.

  5. The controller did not advise the Cessna pilot of conflicting traffic when he issued evasive instructions, and he did not instruct the Cessna pilot to remain clear of Runway 33L.

  6. The controller did not accurately assess the possibility of a go-around when planning the use of simultaneous procedures.

Findings as to risk

  1. The aerodrome chart used by the DC-9 flight crew did not specifically identify LAHSO terminology in the depiction of LAHSO data for LBPIA, and as a result, the flight crew may not have been aware of which LAHSO operations were authorized.

  2. There are no published air traffic control (ATC) procedures for aircraft to follow in the event a go-around is necessary by a landing aircraft after the pilot has accepted a hold short clearance and is unable to comply with the restriction.

  3. The risk of an encounter by the Cessna 206 aircraft with the wake vortex of either a previously departed Boeing 737 aircraft or the DC-9 aircraft was not considered by the controller or the Cessna pilot.

Other finding

  1. The LAHSO procedure used by the controller was not included on the automatic terminal information service (ATIS). This omission was not sufficient to alert the pilots of either aircraft that LAHSO was not an authorized procedure for this runway pair.

TSB Final Report A03A0012 — Loss of Directional Control

On February 2, 2003, a Boeing 737 was on a scheduled passenger flight from Ottawa, Ont., to Halifax International Airport, N. S. At approximately 21:07 Atlantic standard time (AST), Moncton area control center (ACC) cleared the flight for the instrument landing system (ILS) approach for Runway 15. The ATIS report indicated that the ceiling at the airport was approximately 100 ft above ground level (AGL). During the descent, the crew were advised that the runway visual range (RVR) was 2 200 ft with the lights on strength five.

On landing, the pilot lost directional control of the aircraft after touchdown. The aircraft drifted to the left of the runway centreline, with the left wheel near the edge of the runway, before the captain regained directional control. After the incident, passengers were deplaned normally at the assigned gate. There were no injuries, and the aircraft was undamaged. The incident took place at 21:13 AST in the hours of darkness.

Findings as to causes and contributing factors

  1. The crew's visual cues were degraded in the final moments of the approach because of a layer of ground fog, preventing them from detecting and correcting the aircraft's left drift prior to touchdown.

  2. It is likely that a combination of drift, reverse thrust, strong gusting crosswind, and the wet runway resulted in the loss of aircraft directional control, and the continued application of right wheel braking throughout the loss of control may have delayed recovery of directional control.

Other Findings

  1. The standing water on Runway 24 prevented crews from using the best equipped and most desirable runway for landing.

  2. The installed flight data recorder (FDR) was the incorrect model for the aircraft and most of the required parameters were not being recorded.

Safety action

On February 4, 2003, the operator replaced the installed Fairchild F800 FDRs with the approved models. The operator has initiated a receiving inspection system for FDRs, and regular inventory audits will be completed to ensure that the correct spare parts are in stock.

As of September 25, 2003, the Halifax International Airport Authority had completed maintenance and modification on the drainage system around Runway 24 and on the collection pond. This included remedial work on the Runway 24 drainage system and installation of a water level alarm system and a remote pump shut off switch to help control the water level in the collection pond. In addition, when weather forecasters are predicting heavy rain, airport authority personnel will shut off the pumps at the start of the rainfall.

TSB Final Report A03A0022 — Loss of Control and Collision With Terrain

On February 14, 2003, a single engine Cessna 210N was en route from Narsarsuaq, Greenland, to Goose Bay, Nfld., a leg of a ferry flight from Prestwick, Scotland, to the United States. The pilot was conducting a straight in precision radar approach to Runway 26 at Goose Bay in instrument meteorological conditions (IMC). Six nautical miles from the airport, the pilot radioed that the attitude indicator had failed. Shortly after the transmission, control of the aircraft was lost, and the aircraft struck the ice covered surface of Hamilton Inlet, Nfld. Both the pilot and her daughter were fatally injured, and the aircraft was destroyed. The accident occurred in darkness at 18:09 AST.

Findings as to causes and contributing factors

  1. For an unknown reason, the attitude indicator gyro stopped functioning during the approach to Goose Bay.

  2. The aircraft was not equipped with a serviceable turn coordinator, which would have allowed the pilot to assess and correct the aircraft's flight attitude even after the attitude indicator had failed.

  3. Control of the aircraft was lost, and the pilot was not able to recover from the spiral dive that ensued.

Loss of Control and Collision With Terrain

Other Findings

  1. The filed alternate airport, Churchill Falls, Nfld., was below approach limits at the expected arrival time.

  2. The aircraft did not carry the fuel required for an alternate airport.

  3. The aircraft did not have the necessary equipment to carry out an IFR approach at the alternate.

  4. The emergency locator transmitter (ELT) battery was time expired and the ELT was not armed.

  5. The flight was conducted in frigid temperatures with a failed aircraft heater.

TSB Final Report A03C0094 — Loss of Pitch Control and Collision With Terrain

On April 23, 2003, a Beech 99A was on a scheduled flight from Saskatoon, Saskatchewan, to Prince Albert, Sask., to Prince Albert, Sask., with two pilots and four passengers on board. The aircraft was approximately 4 000 ft above sea level (ASL) when the crew selected the flaps for the approach to Prince Albert. A bang was heard from the rear of the fuselage. The aircraft commenced an uncommanded pitch-up to a near-vertical attitude, then stalled, nosed over, and began a spin to the left. The crew countered the spin but the aircraft continued to descend in a near-vertical dive. Through the application of full-up elevator and the manipulation of power settings, the pilots were able to bring the aircraft to a near-horizontal attitude.

The crew extended the landing gear and issued a Mayday call, indicating that they were conducting a forced landing. The aircraft struck a knoll, tearing away the belly cargo pod and the landing gear. The aircraft bounced into the air and travelled approximately 180 m, then contacted a barbed-wire fence and slid to a stop approximately 600 m from the initial impact point. The crew and passengers suffered serious but non-life-threatening injuries. All of the occupants exited through the main cabin door at the rear of the aircraft. The accident occurred during daylight hours at 18:02 central standard time (CST).

Findings as to causes and contributing factors

  1. During flight, the horizontal stabilizer trim actuator worked free of the mounting structure, and as a result, the flight crew lost pitch control of the aircraft.

  2. During replacement of the horizontal stabilizer trim actuator, the upper attachment bolts were inserted through the airframe structure but did not pass through the upper mounting lugs of the trim actuator.

  3. The improperly installed bolts trapped the actuator mounting lug assemblies, suspending the weight of the actuator and giving the false impression that the bolts had been correctly installed.

  4. Dual inspections, ground testing, and flight testing did not reveal the faulty attachment.

Loss of Pitch Control and Collision With Terrain

Other finding

  1. The nature of the installation presents a risk that qualified persons may inadvertently install Beech 99 and Beech 100 horizontal stabilizer trim actuators incorrectly. There are no published warnings to advise installers that there is a potential to install the actuator incorrectly.

Safety action

  1. On May 2, 2003, the TSB issued an occurrence bulletin (A03C0094) detailing the factual information relative to this occurrence and the Beech King Air 100 occurrence of June 1999.

  2. On June 20, 2003, the TSB forwarded a safety advisory regarding the facts of this occurrence to Transport Canada for potential safety action.

  3. Transport Canada produced a service difficulty alert (AL-2003-07, dated 2003-07-17) based on TSB occurrence bulletin A03C0094, advising of the occurrence and indicating that the installation procedures in the maintenance manual are being reassessed.

  4. Transport Canada contacted the U.S. Federal Aviation Administration (FAA), requesting their assistance and that of the aircraft manufacturer, suggesting issuance of a service letter and incorporation of warnings in the appropriate aircraft maintenance manuals.

  5. Raytheon Aircraft issued King Air Communiqué No. 2003-03 to alert appropriate operators and maintenance personnel of the possibility of incorrect installation of the actuators.
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