- Issue 4/2010
- Copyright and Credits
- Flight Operations
- Maintenance and Certification
- Recently Released TSB Reports
- Accident Synopses
- Regulations and You
- Debrief: Déja vu: The Importance of the Underwater-Egress Pre-Flight Briefing for Passengers
- Self-Paced Study Program
- Full HTML Version
- PDF Version
- A Word of Warning to All Operators Regarding Dangerous Goods
- Occurrence Reports: Where Do They Come From and How Are They Used?
- COPA Corner: Distractions Affect All of Us
- An Ounce of Prevention…Corrective Action Plans
by Micheline Paquette, Acting Program Manager, Dangerous Goods, Standards, Civil Aviation, Transport Canada
Transport Canada has identified a potential hazard associated with the carriage of undeclared dangerous goods on Canadian aircraft.
Undeclared dangerous goods take many forms, the classic example being the chemical oxygen generators carried on board in the crash of ValueJet Airlines Flight 592 on May 11, 1996. The U.S. National Transportation Safety Board (NTSB) aircraft accident report of Flight 592 identified the root cause as being a series of decisions that lead to the inadvertent loading of the chemical oxygen generators in the cargo hold. A fire ensued, engulfing combustible materials nearby, and was proliferated by the generation of oxygen gas. The aircraft crashed in the Florida Everglades and everyone on board perished. Measures had not been in place or communicated to ensure that air operator personnel—including third party personnel—were capable of recognizing dangerous goods.
Undeclared dangerous goods are found daily in passenger baggage, company materials, cargo, stores and airmail. A small percentage is reported; however, Transport Canada suspects that a considerable number of items entering the aviation transportation system are not detected for various reasons. To mitigate this hazard, and for the safety of their staff as well as their operations, air operators must ensure that company personnel know how to recognize dangerous goods and the indicators that dangerous goods are being presented for transport.
Are you a dangerous-goods operator?
The Transportation of Dangerous Goods Act, 1992 (TDG Act) and the Transportation of Dangerous Goods Regulations (TDG Regulations) apply to you if you handle, offer for transport, import, or transport dangerous goods to, from, or within Canada. The Act and Regulations also apply to aircraft that are registered in Canada but are operated outside Canada. This includes the transportation of replacement parts (i.e. spares) such as fire extinguishers, oxygen cylinders, engines, fuel pumps, fuel control units, first aid kits, life vests, etc. Activities carried out under a regulatory exemption are also subject to the TDG Regulations. Regulatory exemptions allow passengers to bring on board the aircraft articles such as aerosols, toiletry articles, cellular phones, portable computers, cigarette lighters, etc. The exemptions also permit operators to stow electric wheelchairs in the cargo hold and to carry dangerous goods such as aerosols, alcoholic beverages and perfumes for use or sale on board the aircraft during the flight. If any of these regulatory exemptions apply to your operation, you are in fact handling, offering for transport, or transporting dangerous goods.
Training is the key to understanding and complying with the TDG Regulations. This enables a person to determine whether a product is considered to be dangerous goods, whether the dangerous goods are regulated, and how to use the TDG Regulations efficiently.
International implications for Canadian non-dangerous-goods operators
Air operators who state in their operations manual that they will not conduct dangerous-goods activities and choose not to provide awareness training to their employees may encounter some delays and/or difficulties when operating outside Canada.
The International Civil Aviation Organization’s (ICAO) Annex 6 to the Convention on International Civil Aviation contains standards and recommended practices (SARP), which are applicable to member States, to regulate the aviation industry. The ICAO SARPs require that the ground and flight crew member training program include a section on the transport of dangerous goods. In the United States, the Department of Transport has already developed regulations in the Code of Federal Regulations, Title 14 to require awareness training for “will-not-carry” certificate holders. Other ICAO member States have also included such requirements.
It should be noted that Canada has not yet incorporated the ICAO SARPs into the Canadian Aviation Regulations (CARs); however, this does not relieve Canadian operators from complying with foreign regulations when travelling within their jurisdictions. Foreign authorities check foreign carriers more frequently, and failing to meet ICAO or foreign requirements may be problematic—even if the Canadian operator meets the domestic regulations.
Safety management systems
A safety management system (SMS) is an explicit, comprehensive and proactive process for managing risks. Since dangerous goods entering the transportation system present a variety of risks to aviation safety, it is important that all air operators establish a comprehensive and proactive process for dealing with dangerous goods in their own contexts. Under the principals of SMS, operators must ensure that their system as a whole promotes safe operations.
The general conditions of an air operator certificate stipulate that the holder must conduct flight operations safely and in accordance with the company operations manual. Part of those general conditions is Transport Canada’s approval of procedures for the carriage of dangerous goods in the company operations manual and the dangerous goods training program.
Transport Canada’s position
It is likely that most air operators are involved in the transport of dangerous goods in some respect. The great majority of air operators do take advantage of the regulatory exemptions to transport dangerous goods carried by passengers and to transport replacement parts. Thus, they are subject to the regulations, and Transport Canada requires, at a minimum, awareness training for all personnel involved in the processing of passengers, cargo, mail and stores; this includes third party personnel and instructions to be provided to employees in the company operations manual. This training and information assist employees in the recognition of dangerous goods and in understanding their responsibilities in preventing non-compliant or undeclared dangerous goods from entering the aviation transportation system and compromising the safety of the Canadian travelling public.
Air operators wanting to obtain more information should contact their Transport Canada Civil Aviation regional office.
by Ann Lindeis, Manager, Safety Management Planning and Analysis, NAV CANADA
In Canada, operating certificate and licence holders have obligations when it comes to reporting aviation occurrences. These obligations are set out in various acts and regulations. However, many in the aviation industry are likely unaware of how aviation occurrence reports (AOR) are generated and disseminated. There are also many misconceptions about how the information contained in occurrence reports is used.
Transparency in how safety information will be employed is an essential element to creating an effective safety culture. The purpose of this article, therefore, is to provide an overview of the occurrence reporting process in Canada from the perspectives of NAV CANADA, Transport Canada (TC), and the Transportation Safety Board of Canada (TSB).
NAV CANADA has a mandatory reporting system through which operational employees report specific types of occurrences. Such AORs are entered into NAV CANADA’s occurrence database.
The key information submitted is automatically distributed via e-mail to TC’s Civil Aviation Contingency Operations Division (CACO) and to the appropriate TSB regional office.
In addition, a summary of the previous day’s entries in the database is distributed every morning to an internal and external mailing list. Personal information, such as the names of individuals involved, is not included in the AORs.
NAV CANADA reviews all AORs submitted and identifies those considered to be operating irregularities (OI), which are defined as situations where: air traffic services (ATS) are being provided and a preliminary investigation indicates that safety may have been jeopardized, less than minimum separation may have existed, or both.
Any OI where the provision of ATS is thought to have contributed to the outcome is investigated through NAV CANADA’s operations safety investigation (OSI) process. The results of the investigation are used to identify potential mitigations to prevent recurrence.
In addition, NAV CANADA frequently exchanges information and follows up with individual operators after an aviation occurrence. Safety-specific inquiries may be directed to NAV CANADA through the following e-mail address: email@example.com.
TC uses the Civil Aviation Daily Occurrence Reporting System (CADORS) to collect information on occurrences in the National Civil Air Transportation System (NCATS). Canadian Aviation Regulation (CAR) 807.01 prescribes the requirement to report, as follows:
The holder of an ATS operations certificate shall report to the Minister any aviation occurrence information specified in the CADORS Manual in accordance with the criteria and reporting procedures specified in that manual.
Annex A of the CADORS Manual lists the types of occurrences that must be reported. Examples include collisions or risks of collision; declared emergencies; regulatory infractions; or any occurrence that deviates from normal operating procedures, may generate a high degree of public interest or concern, or could be of direct interest to specific foreign aviation authorities. The CADORS Manual is currently in the process of being updated.
Since the year 2000, almost 95 percent of the CADORS information has consisted of reports filed in accordance with the criteria for mandatory reporting. Other reports have been obtained from sources such as the U.S. Federal Aviation Administration (FAA), the TSB, airports, operators and private individuals.
NAV CANADA sends AOR information to CACO, who then forwards it to one of TC’s five regional offices, as appropriate. The information is then entered into the CADORS.
Efforts are taken to ensure quality, but because the information found in the CADORS is preliminary and subject to change, it is not always possible to guarantee the accuracy of the information.
In the interest of improving aviation safety, CADORS reports are available on TC’s Web site, at CADORS.
Identifiable information, such as the aircraft’s registration number, is removed and licence-holder information, e.g. pilot or controller names, is not entered in the CADORS. It is possible to search occurrence data from 1993 on using criteria such as date, aircraft make and model, or information included in the narrative.
CADORS data is monitored and analyzed by Civil Aviation employees to assist in the identification of hazards and trends. It provides inspectors with information related to operators under TC oversight.
Inquiries regarding the CADORS may be sent to TC through the following e-mail address: firstname.lastname@example.org.
Transportation Safety Board of Canada
Owners, operators, crew members and air traffic controllers have an obligation to report accidents and reportable aviation incidents to the TSB as soon as possible and by the quickest means available.
Approximately 2 000 aviation-related transportation occurrences are reported to the TSB each year. Any of these occurrences may be investigated if they are deemed to meet criteria based on risk, safety benefit and public expectations.
If the occurrence is not investigated, the information provided will be stored in the TSB’s database for statistical analysis. The database also allows the TSB to conduct trend analyses and determine if a safety issues investigation may be the appropriate vehicle to highlight a recurring problem.
If the occurrence is investigated, the TSB makes available factual information about the circumstances of the occurrence throughout the investigation. Safety information is shared immediately with those who can make changes to improve safety, and may take the form of recommendations, safety advisories or safety information letters.
However, for some types of information—including on-board recordings, representations to the Board, and personal information such as witness statements—there are stringent restrictions on who may access the information and how it may be used.
Information collected with respect to aviation occurrences is shared throughout the aviation community and used by operators, NAV CANADA, TC and the TSB to identify hazards and to improve safety.
The collection and use of occurrence data provides significant safety benefit to the aviation community. We trust that this article has helped to clarify how this information is collected and used, and to make clear that personal information is not included in any of this data.
This article was prepared by NAV CANADA, but was a collaborative effort between NAV CANADA, TC and the TSB. —Ed.
by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the February 2009 issue of COPA Flight, and is reprinted with permission.
Distractions are the number one cause of forgetting things.
There are two main reasons for this. The first is we are always thinking ahead of what we are doing. Therefore, when we are distracted, we tend to think we were further along in our task than we actually were.
The second is our short-term memory is very short so any distraction may cause us to lose what we were thinking of when distracted.
A pilot arrived at a maintenance hangar to pick up his C-172, which should have been ready after a 100- hour inspection. It was late afternoon and he had a flight of about 100 miles back to his home airport before grounding.
The aircraft was not ready. The chief mechanic was working on the aircraft himself in an attempt to get it out of the hangar. Shortly before the mechanic was to replace the engine cowlings, he was called to the phone. He glanced at the waiting pilot and called to another mechanic to finish up and cowl the aircraft.
The second mechanic looked the engine compartment over and everything appeared to be where it was supposed to be so he replaced the engine cowlings. The chief mechanic returned and saw the cowlings had been replaced, so he signed out the logbooks and sent the pilot on his way. The flight to the pilot’s home base was uneventful, but the next day he tried to start the aircraft and it would not start. He removed the engine cowlings and noted that three of the four sparkplug wires had become unattached from the sparkplugs.
The phone is the one of the most common distractions,
and most calls can wait.
The distraction of the telephone, coupled with the pressure to get the aircraft inspection completed, resulted in the chief mechanic not giving a full hand-over briefing to the second mechanic. He was thinking ahead to replacing the cowlings and that is what he mentioned. The second mechanic saw that the sparkplug wires were connected, but did not check to see if they were tightened.
Fortunately, the sparkplug wires did not all come loose in flight.
A rental pilot was performing a pre-flight inspection on a C-172 when the three friends he was taking on a sightseeing flight arrived at the airfield fence. The young pilot stopped what he was doing and let his friends in through the FBO [fixed-base operator]. He then completed his inspection, loaded his passengers and began taxiing the aircraft.
The FBO owner saw the aircraft taxiing with the tow bar still attached to the nose wheel and called the FSS [flight service station] specialist to request that the aircraft be stopped and shut down so the tow bar could be removed.
A commercial pilot was interrupted during his pre-flight inspection to answer a phone call from IFR Flight Data regarding his flight plan. After the call, he continued with the inspection. After starting the engines he noted the engine temperature in the right engine was climbing into the red. He shut down the engine and went to take a look. He had forgotten to remove the engine intake covers from the right engine.
Both pilots returned to where they thought they were in the inspection process. We usually think about three steps ahead of where we are during any task, so it is easy to forget steps when distracted. A good rule to follow whenever we are distracted or interrupted is to go back at least three steps from where we thought we were when distracted. If unsure, start over.
The length of our short-term memories compounds this. Our short-term memory is only about 30 seconds. We must do something specific to transfer information from short- to long-term memory. We normally do this subconsciously, but it does take some concentration.
The other problem with short-term memory is that it has a limited capacity of six to seven unrelated items. Maybe that is a good thing. When we get distracted, there are a limited number of things we can forget.
Fatigue and stress directly affect our ability to transfer information to long-term memory and to access information in our long-term memory. Therefore, when we are tired or stressed, we increase our chances significantly of forgetting to do things we intend to do. We are all tired or stressed at times. When we are, we must avoid distractions and multi-tasking. Multi-tasking is actually self-distraction. We are not as capable of multitasking as we think we are. This is why some provinces are banning cell phone use while driving.
The number one distraction for all of us is the phone/cell phone. There are times when the phone should not be answered and probably should be turned off. The vast majority of the calls we receive could be missed without the world ending. Most of the remaining calls can go to voicemail and be returned at a more convenient time.
The next most common distraction is people directly wanting our attention. This includes friends, significant others, co-workers and bosses. When we wish to talk to someone, we seldom, if ever, observe what they are doing before we interrupt them. We are a social society and most of us do not mind being talked to.
There are times, though, when we do not wish to be disturbed and times when we should not be disturbed. Be courteous and take the time to observe those you wish to talk to, to determine if now is a good time to do so. If we are not sure, we can ask if the individual has a moment. This will give them the opportunity to complete a task or to at least put themselves in a position to transfer information to long-term memory and be prepared to pay full attention to us.
Distractions affect all of us. The best we can do is to minimize them. Mistakes caused by distractions are, at least, embarrassing and, at worst, damaging.
Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently flies air charters. He still freelances as a flying instructor and seminar facilitator. Nielsen is also the author of seven flight training manuals published by Canuck West Holdings. Dale can be contacted via e-mail: email@example.com.
by Cliff Marshall, Technical Program Manager, Technical Program Evaluation and Co-ordination, Standards, Civil Aviation, Transport Canada
Taking effective corrective action is an essential part of a solid management system and central to a closed-loop, continuous improvement process.
Corrective action plans (CAP) are generally formal responses to findings and are intended to map out corrective measures. These findings can be generated from several sources, such as a certificate holder’s internal quality assurance system; investigations arising from a company’s safety reports; or a regulator’s inspections and assessments. In all cases, the findings identify a situation where a company policy, procedure, or process does not conform to either the organization’s internal policies or to regulatory requirements. A CAP is a step-by-step plan of action and schedule for correcting a finding.
Successful implementation of a CAP is highly dependent on the planning that goes into it. To adequately address non-conformances, the CAP must, at a minimum:
Define the problem: The definition should clearly identify what happened, how significant it was, where it occurred in the system, and what type of problem it was (e.g. policy, process, procedure or culture). Remember: “If you cannot say it simply, you do not understand the problem.”
Analyze the problem: The analysis should include a summary of the root cause as well as any causal factors that may have contributed to the problem. There are many techniques available to determine root cause: “5 Why’s”, “Fishbone”, the maintenance error decision aid (MEDA) process, etc. Certificate holders must adopt a method that is appropriate for their organization. Regardless of which method is used, the organization must be able to demonstrate how they arrived at the root cause and what caused the non-conformance.
Identify the corrective action(s) required: The CAP should be documented and contain sufficient detail to describe what actions will be taken to address not only the specific examples of non-conformance and any associated immediate safety issues, but also the causal factors determined during the analysis of the problem. If there are any induced hazards or risks associated with the implementation of the corrective actions, they should be assessed, mitigated or eliminated.
Set a clear timeline for the corrections to be implemented: Timelines should be aimed at implementing effective corrective actions in the shortest reasonable time period. There should be due dates, targets, and planned follow up to ensure effectiveness of the proposed corrections.
Identify responsibility for implementation: Clearly identify the person or persons within the organization who are responsible for implementing the actions.
- Identify who is responsible for managerial approval: Identify an individual within the management structure who has the authority to commit the necessary resources required to fulfill the plan and can approve the CAP.
Taking the time to develop a comprehensive CAP will not only help certificate holders address findings but, more importantly, also help them continuously improve by preventing those findings from reoccurring.
Celebrate the PNR’s “Silver Anniversary” of
The Prairie and Northern Region (PNR) encompasses approximately 60 percent of Canada’s landmass, which creates unique opportunities for communication. “Communication between people working at Transport Canada and those working in the aviation industry is crucial to maintaining and enhancing safety,” explains Kate Fletcher, the PNR’s Regional Director of Civil Aviation. “Discussing current issues and sharing thoughts and ideas in person builds a culture of engagement conducive to achieving our shared goal of aviation safety.”
For this reason, the PNR formed the Aviation Safety Council (ASC), which met for the first time in Edmonton, Alta., on October 16, 1997. As the number of participants increased, ASC meeting locations were rotated between Edmonton, Calgary, Winnipeg, Saskatoon, Yellowknife and Whitehorse. Recent meetings have included representatives of NAV CANADA, the Transportation Safety Board of Canada (TSB), airport authorities, aerodrome operators, airlines, small operators, flight training units (FTU), aircraft maintenance organizations and several industry associations.
The value of the ASC is clear to Herb Spear, the occupational health and safety representative for WestJet and a dedicated participant at the PNR’s ASC meetings. “I value the ASC meetings because Transport Canada encourages industry to raise safety concerns,” explains Herb. “ I have witnessed Transport Canada’s commitment to responding to those concerns, whether voiced by an operator or an individual.”
Since the beginning, the ASC has remained true to its original objective, which is to provide an opportunity for participants to identify safety issues and exchange information so regulators and industry can work collaboratively to ensure Canada’s air transportation system remains safe.
The 25th meeting of the ASC will take place on Tuesday, November 30, 2010, in Calgary, Alta. To attend, please register with Carol Beauchamp by e-mail at firstname.lastname@example.org. This special event will be limited to 125 participants, so please register as soon as possible.
Transport Canada’s Safety Management Systems (SMS)
Fairmont The Queen Elizabeth Hotel
November 24–25, 2010
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