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The following summaries are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include the TSB's synopsis and selected findings. Some excerpts from the analysis section may be included, where needed, to better understand the findings. We encourage our readers to read the complete reports on the TSB Web site. For more information, contact the TSB or visit their Web site at http://www.tsb.gc.ca/. -Ed.

TSB Final Report A03O0171-Controlled Flight into Terrain (CFIT)

On July 7, 2003, at approximately 09:58 Eastern Daylight Time (EDT), a Beech 58TC Baron aircraft crashed into Lake Ontario, Ont., approximately 3 NM southeast of the Toronto City Centre Airport. The privately owned and operated aircraft was carrying out a localizer/distance measuring equipment (LOC/DME) B instrument approach to Toronto City Centre Airport, after a flight from Lansing Municipal Airport, in Chicago, Illinois. When the aircraft did not arrive at the airport, and failed to respond to transmissions from the tower, a search was commenced. Patchy fog in the area resulted in ceilings variable from zero to unlimited, and visibility from 1/8 mile to more than one mile. Several hours later, the Metropolitan Toronto Police Marine Unit found debris on the surface of Lake Ontario. The aircraft was located the following day by the Ontario Provincial Police, using a sidescan sonar. The aircraft was essentially intact, resting vertically on its nose at a depth of 220 ft. The deceased pilot was located in the aft cabin of the aircraft. He received minor injuries in the impact, but failed to egress the aircraft for unknown reasons, and died as a result of drowning.

Recovery operation of the aircraft
Recovery operation of the aircraft

Findings as to causes and contributing factors

  1. During the latter stages of a non-precision instrument approach, the pilot lost situational awareness, specifically of his altitude. As a result, he descended below the minimum descent altitude (MDA) and continued a controlled descent in instrument meteorological conditions (IMC) until the aircraft struck the water.
  2. Factors that contributed to the loss of situational awareness were non-precision approach, poor visibility, rushed or incomplete checks, level of instrument proficiency and visual illusion created by surface-based fog.

Finding as to risk

  1. Minimum altitudes on Canada Air Pilot (CAP) approach plates are presented differently from minimum altitudes on U.S. Federal Aviation Administration/National Aeronautical Charting Office (FAA/NACO) approach plates, which could create confusion and contribute to an unsafe approach.


TSB Final Report A03W0194-Power Loss and Dynamic Rollover

On September 16, 2003, a Bell 206B was supporting a diamond drilling crew working on the side of a mountain about 80 NM north of Mayo, Y.T. The helicopter was observed descending to a creek-bed staging/refuelling area. As it reached approximately 20 ft above ground, the observers lost sight of the helicopter behind an embankment and then heard impact sounds. On reaching the landing site, the observers found the helicopter lying on its right side between two fuel drums. The helicopter had sustained substantial damage, and the pilot, the sole occupant, had been fatally injured. The time of the occurrence was approximately 12:05 Pacific Daylight Time (PDT). There was no post-crash fire.

Accident investigators examine the scene of the accident
Accident investigators examine the scene of the accident

Analysis

Damage to the rotor drive system and the mast indicated low or no power being transmitted from the engine at impact, although the throttle was fully open, and the engine was operating. The amount of fuel on board prior to the occurrence could not be determined. However, the quantity had been planned to be near the minimums required by regulations. Fuel consumption would have been considerably higher at the higher power requirements during slinging operations, and the reserve quantity may have been less than originally planned. An additional shuttle of a load of hydraulic components would have further reduced the reserve fuel quantity by at least 2.0 gal. The pilot had abruptly departed for the refuelling site, which may suggest a low fuel state.

With an aft longitudinal centre of gravity (CG) and a right lateral CG, the helicopter was probably in a tail-low, right-side-low attitude. When combined with the lateral manoeuvring toward the right during the approach, this attitude would have increased the tendency for the fuel to migrate to the right rear corner of the fuel tank. The fuel pump intakes probably unported, causing an interruption in the fuel flow and a loss of power. With the engine relight system armed, any resumption of fuel flow could result in an engine relight, or series of relights, but without the time required for the engine to accelerate and transfer a useable amount of power to the rotor drive system prior to impact.

A momentary power interruption at a crucial moment may have distracted the pilot, and caused the helicopter to overshoot the intended touchdown area and continue laterally onto the fuel drum. The pilot was wearing his helmet; however, the severity of the impact caused the helmet to fail around the side where the shell had been cut away to accommodate the headphone earpiece. A full-shell helmet, which has the earpiece inside the shell, would have been structurally stronger and afforded better protection.

Findings as to causes and contributing factors

  1. The helicopter crashed due to a dynamic rollover that resulted from the landing gear skid contacting the fuel pump that was projecting from the top of a fuel drum. It could not be determined why the helicopter struck the fuel pump/drum.

Findings as to risk

  1. The pilot's open-earpiece type helmet did not provide the level of side impact protection that a full-shell type helmet would have, and this may have contributed to the severity of the injuries.
  2. The operation of a helicopter at or below minimum fuel levels is conducive to unporting, which may result in a sudden loss of power at a crucial moment.

Safety action taken

The operator has advised its pilots not to purchase or utilize the older military style of open-earpiece helmets, since the open-earpiece type helmet does not provide the level of side-impact protection that a full-shell type helmet would provide. As a result of this investigation indicating unporting as a risk, the operator has issued a memo to all flight crews mandating a minimum indicated fuel load of 15 U.S. gallons during all Bell 206 operations.



TSB Final Report A04H0001-Loss of Control

On January 17, 2004, a Cessna 208B Caravan was on a flight from Pelee Island, Ont., to Windsor, Ont., with one pilot and nine passengers on board. The aircraft took off from Runway 27 at approximately 16:38 Eastern Standard Time and used most of the 3 300-ft runway for the take-off run. It then climbed out at a very shallow angle while turning north over the frozen surface of Lake Erie, toward Windsor. The aircraft struck the surface of the lake approximately 1.6 NM from the departure end of the runway. All 10 persons on board were fatally injured.

Map of crash location
Map of crash location

Findings as to causes and contributing factors

  1. At takeoff, the weight of the aircraft exceeded the maximum allowable gross take-off weight by at least 15 percent, and the aircraft was contaminated with ice. Therefore, the aircraft was being flown significantly outside the limitations under which it was certified for safe flight.
  2. The aircraft stalled, most likely when the flaps were retracted, at an altitude or under flight conditions that precluded recovery before it struck the ice surface of the lake.
  3. On this flight, the pilot's lack of appreciation for the known hazards associated with the overweight condition of the aircraft, ice contamination, and the weather conditions was inconsistent with his previous practices. His decision to take off was likely adversely affected by some combination of stress and fatigue.

Findings as to risk

  1. Despite the abbreviated nature of a September 2001 audit, the next audit of the operator was not scheduled until September 2004, at the end of the 36-month window.
  2. The internal communications at Transport Canada did not ensure that the principal operations inspector responsible for the air operator was aware of the Pelee Island operation.
  3. The standard passenger weights available in the Aeronautical Information Publication (A.I.P.) at the time of the accident did not reflect the increased average weight of passengers and carry-on baggage resulting from changes in societal-wide lifestyles and in travelling trends.
  4. The use of standard passenger weights presents greater risks for aircraft under 12 500 lbs than for larger aircraft due to the smaller sample size (nine passengers or less) and the greater percentage of overall aircraft weight represented by the passengers. The use of standard passenger weights could result in an overweight condition that adversely affects the safety of flight.
  5. The Cessna Caravan de-icing boot covers up to a maximum of 5 percent of the wing chord. Research on this wing has shown that ice accumulation beyond 5 percent of the chord can result in degradation of aircraft performance.
  6. At the Pelee Island Airport, the air operator did not provide the equipment that would allow an adequate inspection of the aircraft for ice during the pre-flight inspection and did not provide adequate equipment for aircraft de-icing.
  7. Repetitive charter operators are not considered to be scheduled air operators under current Transport Canada regulations, and, therefore, even though the charter air operator may provide a service with many of the same features as a scheduled service, Transport Canada does not provide the same degree of oversight as it does for a scheduled air operator.
  8. A review of the Canadian Aviation Regulations (CARs) regarding simulator training requirements indicates that there is no requirement to conduct recurrent simulator training if currency and/or pilot proficiency checks (PPC) do not lapse.
  9. Commercial Air Service Standard 723.91(2) does not clearly indicate whether there is a requirement for simulator training following expiration of a PPC.
  10. Incorrect information on the passenger door placards, an incomplete safety features card, and the fact that the operating mechanisms and operating instructions for the emergency exits were not visible in darkness could have compromised passenger egress in the event of a survivable accident.
  11. The dogs being carried on the aircraft were not restrained, creating a hazard for the flight and its occupants.

Safety actions taken
(The following are only a selection of the major safety actions taken)

Operator

  • The operator installed an aircraft de-icing machine on Pelee Island immediately following the accident.
  • The company now employs a second crew member on all passenger flights.
  • In an effort to reduce perceived mission pressure on aircraft captains, the chief pilot now reviews the weather each day to forecast delays or cancellations.
  • The chief pilot is reviewing every flight plan to verify that the weight and balance program is being followed.

Transportation Safety Board of Canada (TSB)

The TSB identified risks associated with using standard weights, and issued two aviation safety recommendations:

The Department of Transport require that actual passenger weights be used for aircraft involved in commercial or air taxi operations with a capacity of nine or fewer passengers. (A04-01)

and

The Department of Transport re-evaluate the standard weights for passengers and carry-on baggage and adjust them for all aircraft to reflect the current realities. (A04-02)

Transport Canada

In response to A04-01, Transport Canada indicated that it continues to review the standards, and that one of the options under consideration is to require the use of actual passenger weights. The TSB feels the present risks associated with using standard weights will remain until a new standard is put in place to ensure that actual weights are used for aircraft carrying nine passengers or less. In response to A04-02, Transport Canada re-evaluated the standard weights for passengers and carry-on baggage and, effective January 20, 2005, adjusted them for all aircraft to reflect current realities, and amended the guidance material.

The Federal Aviation Administration (FAA)

The FAA released a comprehensive guide that provides air operators of large, medium, and small cabin aircraft with options for calculating passenger weights, to reflect current realities.

The FAA issued Airworthiness Directive (AD) 2005-07-01, effective March 29, 2005, and subsequently issued AD 2006-06-06, effective March 24, 2006, which supersedes AD 2005-07-01. The AD was the result of several accidents and incidents involving the Cessna 208 and 208B operating in icing conditions. The purpose of the AD is to ensure that pilots have enough information to prevent loss of control of the aircraft while in flight during icing conditions. The AD is applicable to Cessna 208 aircraft in Canada. For the most accurate and current information, consult: www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/MainFrame?OpenFrameSet.

On March 24, 2006, TC issued Service Difficulty Alert 2006-01R2,-Cessna 208 (Caravan) Series-Operation Into Known or Forecast Icing Conditions-which addresses the FAA AD and which makes further recommendations to Canadian Cessna Caravan C208 operators. For details consult: http://www.tc.gc.ca/eng/civilaviation/certification/continuing-alert-2006-01-679.htm. Readers are encouraged to read the full report of this major investigation on the TSB Web site. -Ed.



TSB Final Report A04A0057-Wing Scrape During a Rejected Landing

On May 28, 2004, a Boeing 727-225 freighter was on a night cargo flight from Hamilton, Ontario, to Moncton, New Brunswick. The first officer was performing the pilot flying (PF) duties, and the captain was conducting a line check on the first officer. The en route portion of the flight to Moncton was uneventful. On arrival at Moncton, the flight crew conducted two unsuccessful approaches in darkness and poor weather conditions before landing on the third approach. A post-flight inspection of the aircraft in Moncton found visible damage on the left wing. The tip of the left outboard leading edge flap and the outboard trailing edge flap "canoe" were abraded. The damage was consistent with a slight contact with the runway. Available information indicates that the wing scrape occurred at 02:41 Atlantic Daylight Time during the rejected landing after the second approach. The aircraft was at a pitch angle of 5˚ nose up, 14˚ of left bank, and a derived aircraft height above ground of approximately 26 ft. There were no injuries.

Close-up photograph of left outboard leading edge flap damage
Close-up photograph of left outboard leading edge flap damage

Finding as to causes and contributing factors

  1. The captain's decision to intervene and reject the landing on the second approach was too late to prevent the aircraft from contacting the runway surface.
  2. The aircraft's wings were not leveled until after the nose was raised, resulting in the left wing contacting the runway.

Findings as to risk

  1. The forecasted deteriorating weather was not detected or reported in a timely manner.

Other findings

  1. The aircraft landed with less than the minimum diversion fuel required in the Flight Operations Manual (FOM); however, the decision to carry out the third approach could be considered reasonable in the circumstances faced by the captain.
  2. The weather conditions reported to the crew were not representative of the actual weather conditions at the airport. This contributed to the planning errors made by the crew and the unnecessarily low fuel state.

Safety action taken

The section dealing with minimum required diversion fuel in the operator's FOM has been amended. The amended version reads as follows:

"Upon reaching MIN DIV fuel, the flight MUST proceed immediately to the alternate airport."

Transport Canada is proposing changes to the Canadian Aviation Regulations that will define the use of pilot-monitored approaches as part of the new approach ban regulations.

In response to this occurrence, Transport Canada regional staff conducted an inspection of the weather observation service at Moncton on October 5, 2004. As a result of the findings, the flood lights near the ceiling projector were adjusted to reduce interference with weather observations, and NAV CANADA has implemented new procedures to improve the communication of information related to changing weather conditions between the weather office and the tower personnel.



TSB Final Report A04P0240-Blade Strike and Rollover

On June 25, 2004, at 20:20 PDT, the pilot of a Eurocopter AS350 B2 (Astar) helicopter landed on a recently prepared mountainside helipad, 5 NM west of the extinct Flourmill Volcano, B.C., at 5 200 ft elevation. With the helicopter still running at flying rotor rpm and light on the skids, four passengers boarded with a small amount of personal equipment and prepared for takeoff. The pilot increased collective pitch to bring the helicopter into the hover, but the engine parameters were approaching their limits, and he discontinued the takeoff and lowered the collective. The left rear passenger got out, and the pilot again raised the collective, lifting the helicopter into a stable 5-ft hover over the pad. Satisfied this time with the engine readings, the pilot increased collective pitch and climbed to approximately 20 ft while purposely allowing the nose to swing to the left to turn downhill for the transition into forward flight.

As the helicopter turned through 100° of left turn, the low rotor rpm warning horn sounded, and the pilot decided to return to the pad. He allowed the left turn to continue but, by the time the helicopter returned to the original heading, it had drifted approximately 20 ft downhill from the pad and was still descending. The main rotor blades then struck a large tree stump adjacent to the pad and the helicopter rolled over, coming to rest on its left side, almost inverted. The three passengers quickly escaped from the helicopter, but the pilot delayed his exit to shut down the engine, which had continued to run. After he had secured the engine, fuel valve, and electrical switches, the pilot exited the cockpit. The four occupants received minor injuries, and the helicopter was substantially damaged. The emergency locator transmitter (ELT) activated automatically at rollover. There was no fire.

Findings as to causes and contributing factors

  1. The helicopter climbed vertically out of the hover at near-maximum gross weight, it encountered down-flowing air, which resulted in a situation in which there was insufficient power to maintain controlled flight. As a result, the rotor rpm decayed rapidly, and the helicopter descended in an overpitched condition until it struck the terrain.
  2. The physical characteristics of the landing area did not allow a successful landing following the rotor rpm decay and uncommanded descent.


TSB Final Report A04C0174-Landing Gear Collapse and Runway Excursion

On September 21, 2004, a Metro III aircraft departed Stony Rapids, Sask., with two crew members and nine passengers on a day, visual flight rules (VFR) flight to La Ronge, Sask. On arrival in La Ronge, at approximately 14:10 Central Standard Time (CST), the crew completed the approach and landing checklists and confirmed the gear-down indication. The aircraft was landed in a crosswind on Runway 18 and touched down firmly, approximately 1 000 ft from the threshold.

Bellcrank assembly with a part number 5453032-1 roller on the left and a YCRS-12 bearing on the right
Bellcrank assembly with a part number 5453032-1 roller on the left and a YCRS-12 bearing on the right

On touchdown, the left wing dropped and the propeller made contact with the runway. The aircraft veered to the left side of the runway, despite full rudder and aileron deflection. The crew applied maximum right braking and shut down both engines. The aircraft departed the runway and traveled approximately 200 ft through the infield before the nose and right main gear were torn rearwards; the left gear collapsed into the wheel well. The aircraft slid on its belly before coming to rest approximately 300 ft off the side of the runway. Three of the passengers suffered minor injuries from the sudden stop associated with the final collapsing of the landing gear; the other passengers and the pilots were not injured.

Findings as to causes and contributing factors

  1. An incorrect roller of a smaller diameter and type was installed on the left main landing gear outboard bellcrank assembly, contrary to company and industry practice.
  2. The smaller diameter roller reduced the required rigging tolerances for the bellcrank-to-cam assembly in the down-and-locked position, and allowed the roller to eventually move beyond the cam cutout position, resulting in the collapse of the left landing gear.
  3. A rigging check was not carried out after the replacement of the bellcrank roller. Such a check should have revealed that neither the inboard nor outboard bellcrank assembly met the minimum rigging requirements for proper engagement with the positioning cam.

Safety action taken

After the occurrence, the operator commissioned an independent safety audit of its complete operation. All maintenance staff of the approved maintenance organization (AMO) responsible for this operator met to review the company's maintenance procedures outlined in its maintenance policy manual. The following policy was reinforced: "No one is to install any parts on any aircraft without first referring to the appropriate parts and service manuals to ensure correct part number and also that the integrity of the affected aircraft system is still in place."



TSB Final Report A04C0162-Flight Into Adverse Weather-Collision with Terrain

On August 26, 2004, a Piper PA-28-235 aircraft departed Roblin, Man., at 20:25 Central Daylight Time on a VFR flight to Gimli, Man. The initial portion of the flight was in daylight, the latter portion at night. The flight took place in uncontrolled airspace, and there was no record of any communication with air traffic services (ATS) during the flight. The aircraft crashed in an open field at 21:40. The pilot, the sole occupant of the aircraft, sustained fatal injuries, and the aircraft was destroyed by the impact and a post-impact fire.

Findings as to causes and contributing factors

  1. The pilot continued a series of VFR flights at night into an area of limited surface lighting with known adverse weather conditions.
  2. The pilot's instrument flying skills were most likely not adequate to safely complete the course reversal turn, resulting in an inadvertent descent that was not detected and corrected in time to prevent impact with the surface.

Finding as to risk

  1. The pilot did not ensure that the responsible person who received the flight itinerary understood the search and rescue (SAR)-notification requirements.

Safety action taken

On January 25, 2005, the TSB sent a safety advisory to Transport Canada, suggesting that the department may wish to consider action to improve awareness among pilots of the need to ensure that persons responsible for flight itineraries understand their obligations concerning SAR notification. An article was published in issue 2/2005 of the Aviation Safety Letter, which is sent to all Canadian licensed pilots. The article summarized the occurrence and emphasized the need for pilots to ensure that persons responsible for the flight itinerary fully understand the SAR-notification requirements.



TSB Final Report A05C0123-In-Flight Collision During Air Show

On July 10, 2005, three aircraft were engaged in a simulated dogfighting display at Moose Jaw/Air Vice Marshal C.M. McEwen Airport as part of the Saskatchewan Air Show. The display team consisted of three biplane aircraft: a Waco UPF-7 87, a Wolf-Samson and a Pitts Special. A ground display featuring a jet-powered truck was part of the act. At approximately 16:17 Central Standard Time (CST), the three biplanes were performing a series of crosses and chases in a simulated dogfight scenario. As the jet-powered truck moved into position on the 500-ft show line, the three biplanes entered a manoeuvre called "The Dairy Turn" in preparation for a series of crosses centered on the truck. During the manoeuvre, the Waco and the Wolf-Samson collided near show centre at about the 1 500-ft show line. Both biplanes caught fire and crashed between the 1 500-ft show line and the outer runway. Both pilots were killed on impact, and both aircraft were destroyed. All debris fell away from the crowd toward the outer runway. Immediate implementation of emergency procedures kept spectators from moving toward the burning wreckage.

The Dairy Turn is a scripted manoeuvre, with the intention to create the illusion of a close call as two of the three aircraft cross near show centre, also involving the jet-powered truck for visual effect. Other display team members understood that the contract for safe separation required the pilots to establish visual contact with each other at specific location of the manoeuvre and maintain separation visually. One of the aircraft had been late on its track on occasions since the display had been developed. This lateness had not previously caused any difficulties for the performers. The manoeuvre had been recently modified. Whether the contract for safe separation was also revised could not be established.

Charred remnants of the air demonstration aircraft
Charred remnants of the air demonstration aircraft

Findings as to causes and contributing factors

  1. The Dairy Turn manoeuvre had been modified such that a temporary loss of visual contact could occur immediately before the aircraft crossed flight paths. This modification made timing critical and added two potential points of collision.
  2. The manoeuvres immediately before the collision indicated that the performers had not established a clearly understood contract for the revised manoeuvre. The actions of each performer negated the actions of the other, and neither pilot took positive action to regain visual contact.
  3. The timing of the manoeuvre was lost when the Waco turned late at show centre.

Finding as to risk

  1. The sequential manoeuvre information provided to Transport Canada was not detailed enough to allow a thorough review of the energy management of the display.


TSB Final Report A05Q0157-Flight into Adverse Weather-Collision with Terrain

On September 1, 2005, a float-equipped de Havilland DHC-2 Beaver departed the outfitter base camp at Squaw Lake, Que., at 09:25 EDT, with a passenger and a few supplies on board, for a round-trip VFR flight to two wilderness camps, Camp 2 and Camp Pons. The weather in Squaw Lake was suitable for visual flight at the time of takeoff, but was forecast to deteriorate later in the day.

The pilot completed the flights to the two camps, and on the way back to Squaw Lake, the weather forced the pilot to make a precautionary landing on Elross Lake, 15 NM northwest of Squaw Lake. At 16:30, he reported to the company via high frequency (HF) radio that he intended to take off from Elross Lake, as there seemed to be a break in the weather. Rescue efforts were initiated in the evening when the aircraft did not arrive at the base camp. The aircraft was located at 12:30 the following day, 4 NM from Elross Lake. The aircraft was destroyed by a post-impact fire. The pilot sustained fatal injuries.

Findings as to causes and contributing factors

  1. The pilot attempted to cross the mountain ridge in adverse weather, and the aircraft stalled at an altitude from which recovery was not possible. Loss of visual references, strong updrafts, moderate to severe turbulence and possible wind shear likely contributed to the onset of the aerodynamic stall.

Other finding

  1. Had this been a survivable accident, rescue efforts may have been compromised by a lack of communication. A satellite phone provides a more effective means of communication when in remote areas.

Safety action taken

On March 3, 2006, the TSB sent a safety information letter to Transport Canada, highlighting the criticality of flight following communication as it relates to SAR response in remote areas of the country, and indicating the effectiveness of alternate means of communication, such as satellite phones.


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