Recently Released TSB Reports

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 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 www.tsb.gc.ca. —Ed.

TSB Final Report A06Q0190—Runway Overrun

On November 26, 2006, a Learjet 35A aircraft departed Brunswick, Georgia, United States, on a medical evacuation (MEDEVAC) flight to Montréal/ Pierre Elliott Trudeau International Airport, Que. On board the aircraft were two pilots, two flight nurses, and two passengers. At 05:07 Eastern Standard Time (EST), the aircraft landed on Runway 06R at Montréal and overran the 9 600-ft runway, coming to rest approximately 600 ft off the end of the runway in a grass field. The aircraft sustained damage to the left wing leading edge and the fuselage. There were no injuries.

Photo of an airplane on grass

Findings as to causes and contributing factors

  1. A “B” nut loosened, resulting in a leak and depletion of the hydraulic fluid and preventing normal operation of the flaps, spoilers, thrust reversers, and wheel brakes.

  2. The crew did not notice that there was a loss of hydraulic pressure and therefore did not plan for a landing without normal stopping systems or for the use of the emergency brake system.

  3. When the aircraft landed, the flaps were extended to only 20°, the spoilers did not deploy because there was no hydraulic or backup air pressure, the thrust reversers did not deploy, normal braking did not work, and the emergency brake system was not used. Consequently, the aircraft overran the runway.

Finding as to risk

  1. The service and condition check carried out at intervals of 15 days may not assure proper fluid level. Therefore, confirmation of proper servicing rests on the completeness of the pre-flight inspection by the crew.

  2. The flight crew’s adopted practice of performing the “through-flight” checklist, when a normal preflight was required, allowed dispatching of the aircraft without confirming a proper fluid level in the hydraulic reservoir.

  3. The pre-charged thrust reverser accumulator was not serviced according to the manufacturer’s specifications, and there was insufficient air pressure to deploy the thrust reversers.

  4. The aircraft flight manual (AFM) supplement for the thrust reverser does not provide guidelines on how to verify the accumulator air pressure. Consequently, the crew did not know how to properly check the thrust reverser accumulator pre-charge pressure.

  5. The crew erroneously thought that the aircraft was equipped with a low-hydraulic-pressure light that would warn them in case of a loss of hydraulicsystem pressure.

  6. The AFM and the quick reference handbook (QRH) indicate that the low-hydraulic-pressure light illuminates to indicate loss of hydraulic-system pressure, although, in this aircraft, there was no lowhydraulic- pressure light.

Other finding

  1. The aircraft departed for Montréal with an identified and undocumented defect that required maintenance action.

Safety action taken
As a result of the accident, the operator initiated an administrative investigation. The following actions have been taken:

  • All company aircraft underwent extensive inspections of their hydraulic systems.

  • Placards have been installed on hydraulic system accumulators indicating pressures and conditions that must be met prior to checking. Checking hydraulic accumulator pressure as well as thrust reverser accumulator pressure (if applicable) is mandatory during the normal exterior pre-flight and exterior post-flight inspections.

  • The company director of human resources, the aviation safety officer, and the chief pilot discussed the accident with company employees.

  • Exterior pre-flight inspections have been expanded beyond the manufacturer’s approved procedures.

  • Abnormal/emergency exercises that replicate this event have been incorporated into the company initial and recurrent flight training program.

  • A review of the manufacturer’s normal, abnormal, and emergency procedures is ongoing.

  • Pilots have undergone additional training on the following:

    • standard operating procedures (SOPs);

    • Learjet 35 differences training;

    • emergency braking operating procedures;

    • enhanced ground proximity warning system (EGPWS) operation, alerts, and warnings;

    • requirements of the normal exterior pre-flight inspection, “through-flight” inspection, and postflight inspection;

    • use of the minimum equipment list (MEL) as well as defect reporting and recording procedures; and

    • enhanced crew resource management (CRM) training with a focus on in-flight situation awareness and recognition of impending failures during all phases of flight.

  • A review of the cockpit checklists is ongoing.
  • The company aviation safety officer has been tasked with accelerating the development of the company safety management system (SMS) program.
  • A significant restructuring of the company was undertaken.
  • Operational co-ordination centre procedures were reviewed and refined to enhance operational control and technical dispatch procedures.


TSB Final Report A07A0029—Runway Excursion

On March 31, 2007, an Antonov AN 124-100 was on a flight from Greer, South Carolina, United States, to Gander, N.L. On arrival in Gander, the crew completed an approach to Runway 03/21. The aircraft touched down at 02:16 Newfoundland Daylight Time (NDT) but was unable to stop before reaching the end of the runway. It departed the left side of Runway 03/21, near the departure end, and came to rest approximately 480 ft off the runway surface, facing the opposite direction. Several edge lights along the runway were broken. The nine crew members and ten passengers on board the aircraft exited without injury. Aircraft damage was limited to cuts in the aircraft tires.

Analysis
There were no mechanical failures that contributed to the occurrence. Therefore, the analysis will focus on the awareness of runway conditions, the runway touchdown point, the delay in wheel braking, and the reduction in aircraft deceleration.

Final position of aircraft
Final position of aircraft

The automatic terminal information service (ATIS) report received by the crew indicated that Runway 03/21 was bare and wet and that Runway 13/31 was the active runway. Twelve minutes before landing, the crew received a special weather observation indicating that light snow was falling. The fact that the latest weather observation was a special report and was reporting snowfall should have alerted the crew that weather conditions had changed and therefore the runway selected for landing may be contaminated. However, the crew did not request an updated runway surface condition (RSC) report.

Runway 13/31 had been designated as the active runway since the winds were light from the west. Active runways are chosen for various reasons, such as surface wind direction, the predominate direction from which aircraft are approaching, and taxi distance. Snow removal personnel and equipment were maintaining only Runway 13/31 before the occurrence.

The aircraft touched down approximately 2 400 ft beyond the normal touchdown point (3 400 ft minus 1 000 ft). The fact that the aircraft touched down long and at an airspeed 14 kt below the planned airspeed indicates that the aircraft floated this additional distance before touchdown. Considering that the runway was contaminated with snow, the reduced stopping distance available greatly increased the chance of the aircraft being unable to stop on the remaining runway.

Wheel braking was applied by both pilots five seconds after the planned brake application speed of 135 kt. This brake application occurred 2 000 ft after the touchdown point, leaving only 4 800 ft of runway available for stopping the aircraft. The fact that both pilots were attempting to apply brake pressure simultaneously may indicate that both pilots were concerned about the stopping distance remaining.

Analysis of the recorded aircraft flight data indicated that the initial rate of deceleration may have been sufficient to stop the aircraft before the runway end. The crew did use reverse thrust after touchdown; however, it did not maintain maximum available reverse thrust until ensured of stopping on the available runway. Even though reverse thrust has little effect below 90 kt, that limited effect and the absence of residual forward thrust during the 15 s the idle power setting was restored may have been enough to prevent a runway overrun.

Finding as to causes and contributing factors

  1. The aircraft touched down approximately 2 400 ft past the normal touchdown point; this greatly reduced the available stopping distance.

  2. The contaminated runway surface condition increased the distance required to stop the aircraft.

  3. The delay in the application of wheel brakes, combined with the failure to maintain maximum available reverse thrust until it was ensured that the aircraft would stop on the remaining runway, contributed to the overrun.

Safety action taken
The operator has made arrangements with the Gander International Airport Authority to have, upon request, Canadian Runway Friction Index (CRFI) reporting for each third of the runway.

Following this accident, the operator completed its own investigation and developed an in-house dedicated safety assurance program for the company’s intensive flight operations via Gander Airport.

A TSB Aviation Safety Information letter has been sent to Transport Canada regarding Canadian differences with International Civil Aviation Organization (ICAO) recommended practices for reporting runway friction measurements.



TSB Final Report A07O0095—Landing Gear Collapse After Touchdown

On April 9, 2007, a Piper PA31 aircraft departed a private grass strip with a pilot and passenger on board for a short flight to the Cochrane, Ont., airport to pick up another passenger. After departing Cochrane, the pilot flew to Moosonee, Ont., and conducted a VFR approach for Runway 32. Approximately 1.5 NM from the runway, the pilot selected the landing gear down and confirmed that the landing gear was indicating down and locked. This was also verbally confirmed by the passenger, another company pilot, who was sitting in the right seat. The aircraft landed normally, and the pilot selected flaps up and boost pumps off. The pilot was about to apply brakes to slow down for Taxiway Bravo when the gear horn sounded and the right main landing gear collapsed, followed quickly by the collapse of the left-main and nose landing gear. The aircraft came to rest approximately 1 550 ft from the threshold of Runway 32, just off the right side of the runway. There were no injuries.

Photo of a crashed airplane in snow

Analysis
No faults were found with the aircraft that would indicate any mechanical failure or improper rigging of the landing gear. Retraction of the landing gear can only be accomplished if the down locks are removed during the retraction sequence. Therefore, due to the play in the landing gear handle, and the ease with which it could be bumped up, it is likely that the landing gear handle was inadvertently positioned above the locking solenoid before weight on wheels was achieved and that during the landing roll the handle was inadvertently bumped up far enough to begin the retraction sequence.

Findings as to causes and contributing factors

  1. The spring in the landing gear handle was broken and allowed easy movement of the landing gear handle past the neutral stop.

  2. During the approach, the landing gear handle was most likely placed in a position that bypassed the anti-retraction system.

  3. The landing gear handle inadvertently moved to an “UP” selection during the landing roll, which activated the gear warning horn and retracted the landing gear.
Site diagram
Site diagram




TSB Final Report A07O0165—Collision with Terrain

On June 30, 2007, a privately owned Piper Cub J3C-65 departed a privately owned, grass-covered runway near Essex, Ont., under visual meteorological conditions (VMC). This was the first flight following the annual maintenance inspection of the aircraft. Shortly after departure, the aircraft made a planned low pass parallel to the runway in an easterly direction. The aircraft then climbed to approximately 1 500 ft above ground level (AGL) in a northerly direction. Shortly afterwards, the aircraft was observed in a gradual descent, flying in a southeasterly direction. At approximately 14:20 Eastern Daylight Time (EDT), the aircraft struck the ground in a nearby field. The aircraft was destroyed by impact forces and a post-crash fire. The pilot, who was the sole occupant, did not survive.

Other factual information
There was nothing found to indicate that there was any airframe, engine, or system malfunction before or during the flight; weather conditions were ideal for VFR flight and were not considered a factor in the occurrence.

Crashed airplane on grass

The highly experienced 80-year-old pilot had a history of chronic atrial fibrillation and therefore underwent periodic cardiovascular assessments. The post-mortem examination revealed that the pilot had underlying asymptomatic atherosclerotic coronary artery disease. This put him at risk for a sudden coronary event.The development of cardiovascular disease in licensed aviation personnel is a major concern among aviation medical practitioners. To address this concern, Transport Canada has developed a set of cardiovascular guidelines intended to assist in the medical assessment of cardiovascular fitness of licensed aviation personnel. These guidelines are published in Transport Canada’s Handbook for Civil Aviation Medical Examiners (TP 13312E).

Major risk factors associated with cardiovascular disease are age, family history, hypertension, obesity, diabetes, abnormal blood lipids, and cigarette smoking. The aim of monitoring these risk factors and applying the cardiovascular guidelines is to ensure that the risk of asymptomatic coronary artery disease causing sudden incapacitation of a pilot remains extremely low.

The Transport Canada requirement for a Category 3 medical certificate is that the candidates undergo a routine electrocardiogram (ECG) at the first examination after age 40, and then subsequently within the four years preceding the examination. However, in up to 50 percent of people with advanced coronary artery disease, a routine ECG may not show indications of coronary artery disease. An exercise stress test increases the likelihood the disease will be detected. However, it is not part of the required screening process, but may form part of the medical assessment in those candidates with major risk factors.

Individuals with atrial fibrillation who have two or more of the five major risk factors—age over 65 years, structural heart disease, diabetes, high blood pressure, and previous thromboembolism—are considered above the risk threshold limit for medical certification. The pilot was over the age of 65, with no indication that any of the other four risk factors were present at the time of the occurrence. Therefore, the applicant was deemed fit for medical certification.

Analysis
The aircraft, which had just undergone its annual inspection, was observed in controlled flight before it began a slow descending turn which ended when it struck the ground. There were no mechanical deficiencies found that could have contributed to the accident. It can be concluded that the gradual descent was not the result of an airframe or control system failure. Based on the manner in which the aircraft descended to the ground and on the post mortem examination which revealed wellestablished coronary artery disease, it is probable that the pilot suffered an acute coronary event during the flight. This resulted in incapacitation and the loss of control of the aircraft.

Finding as to causes and contributing factors

  1. The pilot most likely suffered an incapacitating medical event due to well-established, underlying coronary artery disease that resulted in the loss of control of the aircraft.


TSB Final Report A07O0190—Guy-Wire Strike During Landing

On July 20, 2007, an Aerospatiale AS 350 B2 helicopter was attempting to land at a remote site near Moosonee, in northern Ontario. The selected landing area was a driveway near a communications tower, which was supported on three sides by multiple guy wires. The pilot chose to approach the driveway landing area by flying the helicopter sideways while maintaining forward visual contact with the selected landing area. As the helicopter moved sideways, the main rotor blades struck two of the top guy wires at a height of about 100 ft above ground level (AGL). The rotor blades were substantially damaged and the helicopter quickly descended and struck the ground in an inverted attitude.

The two passengers were able to extricate themselves, but could not extricate the pilot. One of the passengers knew about, and was able to get access to, a telephone located at the site. He used it to call the air ambulance unit in Moosonee. The air ambulance crew extricated the pilot from the wreckage and then transported the pilot and passengers to a local hospital. There was no fire. The emergency locator transmitter (ELT) did not activate.

Helicopter crash in field

One passenger received minor injuries. The pilot and the second passenger were seriously injured.

Analysis
There were no indications that weather or mechanical abnormalities were involved in this occurrence. The pilot was familiar with the site area and was experienced in the operation of the helicopter. The area selected to land the helicopter, although confined, was suitable for the landing. The pilot’s decision to approach the landing site by flying the helicopter sideways to his left restricted his view of the approaching guy wires, significantly increasing the possibility of contact between the main rotors and the wires.

The structural damage to the main rotor blades rendered the helicopter uncontrollable and it became inverted and entangled on one of the wires during its descent to the ground. It is possible that the wire entanglement reduced the forces during ground impact and prevented further structural damage to the aircraft and injuries to the occupants.

The ELT did not activate even though impact forces exceeded the threshold of the G-switch. The type of G-switch used in this ELT was a single-axis, ball-andspring- type switch. This type of switch will automatically activate the ELT only if a component of the impact force is in the same direction as the orientation of the switch.

During examination of the switch, black powder residue was found and the switch was seized within its casing; thus, electrical contact was never established and the ELT failed to activate. The ELT was properly attached and located in the cockpit of the helicopter as per current regulations, but the accident impact forces were in a direction that may not have activated the G-switch even if it had been serviceable. The failure of the ELT did not affect the rescue of the three injured persons because of the availability of phone service at the communications tower.

Accident site
Accident site

Finding as to causes and contributing factors

  1. The helicopter struck the guy wires supporting the communications tower as a result of being flown in a left sideward direction, which prevented the pilot from viewing the approaching tower guy wires from his position in the right front seat while focused on the somewhat restricted landing area.

Findings as to risk

  1. The single-axis, ball-and-spring G-switch in the ELT meets current specifications, but it is not effective when the impact forces are at angles that are substantially different to switch orientation.

  2. The ELT failed to activate on impact as a result of a faulty internal G-switch. The internal parts of the switch are susceptible to deterioration over time and can prevent switch operation and ELT activation.


TSB Final Report A07C0148—Collision with Power Line Tower

On August 9, 2007, a Bell 206L-3 helicopter was transporting a lineman to Tower 63 on the Sheridan power line near Cranberry Portage, Man. While hovering near the tower, the helicopter’s skid gear became entangled in the uppermost cablespan. The helicopter struck the tower and crashed on the adjacent power line right-of-way. The helicopter was substantially damaged by impact forces and fire; the pilot and passenger both sustained fatal injuries. The accident occurred during daylight hours at 09:03 Central Daylight Time (CDT).

Analysis
The damage to the helicopter engine and rotor assemblies indicates that the damage was sustained while the drivetrain was operating under power. The damage to the skid gear and tower structure was consistent with flailing damage sustained from an uncontrollable state of rotation after the helicopter became entangled in the cable and tower structure.

Wreckage next to Tower 63
Wreckage next to Tower 63

The nature of the damage to the skid gear attachment point indicates that the helicopter was hovering when it became entangled in the tower structure. The reason the helicopter was hovering so close to the tower was not determined.

The VFR weather conditions that existed at the time of the occurrence (visibility 15 mi. and a ceiling of 1 500 ft, overcast with the possibility of light rain) would not have affected the pilot’s perception of his position or complicated the task of hovering near the tower.

The passenger’s injuries and the location of his body indicated that he fell from or was ejected from the helicopter during the accident sequence. The reason for the fall or ejection was not determined.

Although there are hazards specific to helicopter operations near power lines, Manitoba Hydro did not have an audit process to ensure that safety standards and quality of services provided by contract aviation services were met. Such an audit procedure could have helped identify the need for specialized training to reduce risks in operations near power lines.

The operator did not offer or require its pilots to take any specialized training to identify and reduce exposure to power line hazards. It also had no procedure for line pilots to report hazardous operating conditions. Such programs could have reduced the risks associated with helicopter power line operations.

Findings as to causes and contributing factors

  1. The helicopter was hovering close to the power line tower structure and became entangled in the upper (non-energized) cable span. As a result, the helicopter became uncontrollable, collided with the tower structure, and crashed.

Findings as to risk

  1. The operator did not have training procedures specific to helicopter operations in the vicinity of power lines and did not have a procedure for reporting hazardous operating conditions. Such programs could have reduced the risks associated with helicopter power line operations.

Other finding

  1. Manitoba Hydro did not have an audit procedure in place that might have identified the need for specialized training for helicopter operations specific to their contract requirements.

Safety action taken

In response to information revealed during the investigation, Manitoba Hydro has taken the following safety action:

  • Manitoba Hydro forwarded “other finding” number 1 to its internal audit department in February 2008 for review and implementation.

  • Manitoba Hydro has undertaken to write and implement a “safe work procedure standard” for employees and pilots conducting power line inspections.



TSB Final Report A07O0233—Loss of Control and Impact with Runway

On August 18, 2007, a single-seat Pezetel SZD-51-1 Junior glider was on a routine local flight from the Rockton, Ont., airport with a student pilot on board. The flight was scheduled to last approximately one hour. At the end of the hour, the duty instructor at the club attempted to contact the pilot via radio, but there was no response. Shortly thereafter, the glider was seen entering the circuit and was observed on final approach to Runway 18/36. As it flew over the road near the end of the runway, the air brakes were partially deployed and then retracted. As it continued over the runway at a height of approximately 25 ft above ground level (AGL), the air brakes were fully deployed and the glider pitched nose-down approximately 45° and struck the ground. The cockpit was substantially damaged by the ground impact and the student pilot sustained fatal injuries.

Plane crash

Analysis
The pilot had been trained on and flown in other glider types owned by the gliding club. Most of the flying experience was in dual-seat trainers, which were flown both with an instructor and solo. Solo flights are monitored by an instructor on the ground via radio communication. For undetermined reasons, the instructor was not able to establish radio contact with the pilot at the expected return time.

The examination of the glider revealed no pre-impact mechanical failures. The weather was not a factor and the pilot had been trained to perform the solo flight. Unusual flight behaviour was first observed during the final approach to the runway. At the altitude the glider started the final approach, the air brakes would normally be extended to reduce altitude. No air brake deployment was observed. As a consequence, the aircraft speed and altitude were high for this stage of the approach. The first aircraft pitch-down was coincident with the air brake deployment.

The significant pitch-down attitude that followed suggests that the pilot was aware that the glider was high on the approach and was attempting to lose altitude for a successful approach and landing. The ensuing pitch oscillations were a result of overcorrecting by excessive stick inputs to try and arrest the rapid descent. Although the pilot stabilized the oscillations, the glider remained high, and due to the steep descent, it gained airspeed.

The pilot may have been hesitant to apply air brakes to correct the situation because of the previous pitch control issues. Consequently, the glider was now in a long-landing situation. As the landing distance available decreased, the pilot needed to deploy the air brakes in order to land on the remaining runway. Sensing the urgency to land the glider, the pilot may have applied forward stick coincident with air brake deployment. The final pitch-down into the runway may have been a result of these two actions.

Findings as to causes and contributing factors

  1. The pilot may not have been familiar with the flight characteristics of the glider because this was the first 28 ASL 4/2010 flight on type. The glider was flown high and fast on approach.

  2. The resultant long-landing situation may have caused the pilot to utilize air brakes and forward stick input to land the glider on the remaining runway. The final pitch-down into the runway may have been a result of these two actions.


TSB Final Report A07O0238—Collision with Terrain in Deteriorating Weather

On August 28, 2007, a Bell 206L-1 helicopter was being operated from a remote area located approximately 100 NM east of Webequie, Ont., and was destined for Cochrane, Ont. The flight departed under visual metrological conditions (VMC); however, deteriorating weather conditions were encountered en route. At approximately 21:00 Eastern Daylight Time (EDT) and five miles west of Cochrane, the pilot lost outside visual reference and the aircraft struck the ground. The aircraft was on a flight plan and therefore a communication search was started by the London flight information centre (FIC). Personnel from the operator began a ground search and located the aircraft approximately three hours after the occurrence. The aircraft was destroyed and the pilot, who was the only occupant, was seriously injured.

Helicopter crash

Other factual information
On the day of the occurrence, the pilot received a weather briefing from the London FIC for the series of flights planned for that day. The aerodrome forecast (TAF) for the Timmins, Ont., area indicated VMC. The forecast, however, was only valid until 16:00 EDT. Another TAF was expected to be issued at 10:00 EDT.

A VFR flight plan was filed for the flight to a remote location referred to as Tango 1 (T1) and for the return leg to Cochrane. The pilot departed the company’s facility in Cochrane at 09:45 EDT.

At 17:35 EDT, a satellite telephone was used at T1 to update the VFR flight plan on file with the London FIC; however, no weather information was requested. There was no contact made with the company base in Cochrane to determine the local weather conditions.

The aircraft departed T1 for Cochrane at approximately 18:00 EDT. Approximately 60 NM northwest of Cochrane, the ceiling deteriorated to about 300 ft above ground level (AGL).

The weather continued to deteriorate and eventually the pilot was flying at near treetop level and navigating by following a river that headed towards Cochrane. As the aircraft approached its destination, there was a relatively small area of improved visibility and ceiling in the general direction of Cochrane. The pilot subsequently abandoned the river navigation and attempted to fly towards Cochrane; however, visual reference to the ground was lost due to the poor weather conditions.

The aircraft struck the ground while flying in an easterly direction and travelled through the brush upright for approximately 108 ft before becoming airborne again for a short distance. It then struck the terrain in a nose-down attitude, flipped over and came to rest on its left side. The total wreckage trail was 418 ft. The entire cockpit forward of the pilot’s seat was destroyed.

Analysis
The pilot did not obtain any weather update before his departure from T1. He would not, therefore, have been aware that conditions at destination had been deteriorating throughout the day and that the latest forecast was calling for conditions below limits for VFR operations. Furthermore, the destination co-ordinates were not used for the time of sunset calculations, resulting in a 22-min error. This resulted in an arrival in the Cochrane area after sunset, with poor weather conditions present.

The pilot received the minimum instrument training required for the issuance of a commercial helicopter licence. Four years had elapsed between the time the pilot had taken this instrument training and the date of the occurrence. If not practiced, instrument flying skills deteriorate over time. In addition, because of the malfunction of the directional gyro, the pilot referenced the GPS for primary heading information. This most likely hampered the proper scan of the primary flight instruments. These two factors likely contributed to the pilot’s difficulty in flying the aircraft with reference to instruments only.

The above-mentioned instrument training is deemed sufficient to allow non-instrument-rated pilots to maintain control of the aircraft in case of inadvertent flight into instrument meteorological conditions (IMC). The pilot can then fly to an area of improving weather. However, in this instance, the weather at destination had deteriorated significantly. Returning to a previous location along the route of flight was likely discounted because it was dark and the pilot did not have a night rating or any experience flying at night. The pilot attempted to fly on instruments but became disoriented and the aircraft was inadvertently flown into the ground.

Findings as to causes and contributing factors

  1. The flight was continued at night in deteriorating weather conditions resulting in the pilot losing visual reference with the ground and becoming disoriented, which resulted in the aircraft being flown into the ground.

Findings as to risk

  1. Departing without the latest available weather increases the possibility of inadvertent flight into inclement weather.

  2. Mounting the emergency locator transmitter (ELT) in the area of the lower nose window made it vulnerable to impact damage. As a result, the ELT became detached and was separated from its external antenna during the impact sequence, increasing the risk of the ELT signal not being detected.

Safety action taken
The operator issued an operational notice to all its pilots concerning human factors, pilot decision making and standard operating procedures, with emphasis on VFR weather minima. The company also provided recommendations on how to conduct cross-country flights.

The company will continue developing and implementing the safety management systems (SMS) approach, including the addition of more Transport Canada training aids, safety reports concerning human factors and causes of occurrences. The company has completed a pilot survey regarding company safety culture; the results will be analyzed and used for future safety purposes.

The operator has also implemented a satellite tracking system on all of its aircraft. As a result, the location of its entire fleet can be monitored from its main facility in Cochrane, Ont.


TSB Final Report A08Q0187—VFR Flight into Adverse Weather and Forced Landing

On September 23, 2008, a float-equipped DHC-2 Mk 1 aircraft with the pilot and one passenger on board, was on a VFR flight from Sainte-Véronique, Que., to an outfitting operation on Lac César, Que. When the aircraft was about 30 NM from the destination, the weather deteriorated. After a few minutes, the pilot could neither continue the flight nor reverse course. For several minutes, the pilot tried to find a safe spot for a water landing, without success. He then decided to set the aircraft down in the trees. The two occupants were wearing their seatbelts, were not injured, and had no difficulty evacuating the aircraft. The aircraft sustained substantial damage. The occurrence happened at approximately 15:30 Eastern Daylight Time (EDT).

Analysis
The pilot was qualified for the flight. There was no pressure on him to return to Lac César, particularly because the flight would generate no revenue. The aircraft had no known deficiencies and was maintained in good condition for flight.

The pilot checked the local weather with the Lac César camp before departing Sainte-Véronique. According to the camp employee, the flying conditions were suitable for the return flight. The pilot did not request a weather briefing from the flight information centre (FIC), nor was he in the habit of doing so. In any event, even if he had checked with the FIC, there was nothing in the forecast to suggest that the weather would be such as he encountered en route. The pilot’s decision to make the flight was justified. When the conditions deteriorated en route, he delayed making a decision as to whether to turn back or land. It is possible that being close to his destination and being very familiar with the area influenced his decision to continue the flight until he had exhausted all options.

The pilot decided to set the emergency locator transmitter (ELT) to “ON” even though he had decided to leave the site. This decision may have had adverse consequences if one of the accident aircraft occupants was injured while walking, especially considering that there was no means of communication available to them. As well, with the main reason for activating an ELT being to save lives, the search and rescue (SAR) team was deployed in adverse weather, needlessly putting them at risk.

It was not unusual for aircraft to not arrive at the destination at the expected time. Consequently, the employee at Lac César was not overly concerned. She did not know that the pilot was unable to contact her and inform her of the occurrence because he had not brought his satellite phone with him on this trip. The call received that evening from Lac Gilberte, which became disconnected, gave reason to believe that the flight had diverted due to weather and had landed safely. However, knowing that the aircraft had departed Sainte-Véronique, that it was past its expected arrival time, and that no call had been received to explain why it was late, the emergency plan should have been activated automatically in accordance with the procedure set out in the company operations manual. Not having activated the company emergency plan could have led to grave consequences if the occupants had been seriously injured in this accident.

Finding as to causes and contributing factors

  1. The pilot delayed making a decision as to whether to turn back or land when he saw that the weather was deteriorating. Being close to his destination and being very familiar with the area probably influenced his decision to continue the flight until he had exhausted all options

Findings as to risk

  1. Although the main reason for activating an ELT is to save lives, the pilot decided to depart the site and leave the ELT set to “ON”. As a result, the SAR team was deployed in unfavourable weather conditions, needlessly putting them at risk.

  2. Not having activated the company emergency plan could have led to grave consequences if the occupants of the downed aircraft had been seriously injured.

Other finding

  1. There was nothing in the forecast to suggest that the weather would be as the pilot encountered en route. The pilot’s decision to make the flight was therefore justified.

TSB Final Report A08Q0231—Controlled Flight Into Water

On December 3, 2008, at approximately 17:21 Eastern Standard Time (EST), a privately operated Robinson R44 Raven I helicopter departed Sainte- Anne-des-Plaines, Que., with the pilot/owner and three passengers on board for a night VFR flight to the pilot’s cottage located at Lac Simon, Que. The 52-NM trip was uneventful. To establish the helicopter on approach to the lit landing pad positioned in front of the cottage, the pilot turned right onto final approach at an altitude of approximately 150 ft above the lake. On final approach, the helicopter continued the descent and struck the water. All occupants escaped uninjured. One passenger successfully swam approximately 1 000 ft to shore, while another was rescued by two persons in a rowboat. The pilot and one passenger were unable to reach the shore and drowned. The helicopter sank in 25 ft of water and was substantially damaged. The occurrence took place at approximately 18:05 EST under dark, night conditions.

Estimated Robinson R44 flight path before impact with water
Estimated Robinson R44 flight path before impact with water

Analysis
Visual cues in the environment, such as trees, buildings, objects, terrain textures, and features, plus a cross-check with the flight instruments are necessary for a pilot to adequately assess a helicopter’s speed, attitude, altitude, rate of descent, and rate of closure. The lack of visual cues inherent at night in poorly lit areas can make night flying, takeoffs, and landings challenging.

While the weather conditions were appropriate for VFR flight at night, the dark lighting conditions of the surrounding area and the approach over the dark surface of the lake provided ideal conditions for the black hole illusion. It is likely that as a result of this illusion, the pilot believed the helicopter was higher than it was during the approach to land. The pilot unknowingly flew the helicopter lower than the intended approach path, causing the helicopter to collide with the surface of the water well before reaching the desired landing area.

The minimum requirements necessary to obtain a private helicopter pilot night rating may not be sufficient to adequately educate and demonstrate to private helicopter pilots the risks involved in night flying, including visual illusions. Present night rating requirements are the same for private helicopter pilots as for private fixed-wing pilots, yet the environments in which they may operate at night can vary greatly.

Flying over the lake on approach at night ensures a helicopter is away from obstacles and allows for a shallower approach to land. However, in the event of an Maintenance and Certification Recently Released TSB Reports Recently Released TSB Reports Maintenance and Certification Regulations and You Regulations and You Accident Synopses Accident Synopses Estimated Robinson R44 flight path before impact with water unforeseen problem, the helicopter may not be within gliding distance from the shore, thereby posing a risk to the aircraft and its occupants. It is unlikely that the missing persons would have survived more than a few minutes given the cold water temperatures.

Current regulations do not specify light intensity, colour, number of lights, or approach path aids for private helicopter landing pads. The three (of four) low-intensity, solar-powered LED lights on the corners of the landing pad and the bonfire in front of the landing area would not have illuminated the surrounding area sufficiently to help the pilot judge a safe and constant approach angle over the dark, featureless surface of the water.

Finding as to causes and contributing factors

  1. It is likely that the effect of the black hole illusion caused the pilot, in full control of the aircraft, to unknowingly fly the helicopter lower than the intended approach path, causing the helicopter to collide with the surface of the water well before reaching the desired landing area.

  2. The helicopter approached the landing pad over water and, after colliding with the lake surface, the occupants had to evacuate in near-freezing water temperature, exposing them to hypothermia.
Helicopter in Lake

Findings as to risk

  1. The minimum requirements necessary to obtain a private helicopter pilot night rating may not be sufficient to adequately educate and demonstrate to private helicopter pilots the risks involved in night flying, including visual illusions.

  2. Current regulations do not specify light intensity, colour, number of lights, or approach path aids for private helicopter landing pads, thereby increasing the risk of accidents or incidents in degraded environmental conditions.
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