- ISSUE 1/2012
- Copyright and Credits
- Guest Editorial
- Flight Operations
- Maintenance and Certification
- Recently Released TSB Reports
- Accident Synopses
- Regulations and You
- To the Letter
- Debrief: Effective Pilot/Controller Communications
- Take Five: Formation Flight
- When seconds count... annual CRM training pays off. (poster)
- Full HTML Version
- PDF Version
- The SMS Approach to Dangerous Goods in a 705 World
- COPA Corner—Electrical Fires Do Happen
- Emergency? Let Air Traffic Services Know
by Daniel Sylvestre, Civil Aviation Safety Inspector, National Operations, Civil Aviation, Transport Canada
In 2005, the National Operations Branch, along with the rest of Civil Aviation, started the Safety Management System (SMS) certification of the air operators assigned to the Branch’s Airlines Division, with final assessments completed in 2009. While there were massive efforts by both the air operators and Transport Canada (TC) to bring a successful completion to this new system, we cannot forget that day-to-day operations continued. The air operators continued to fly and TC continued with certification and surveillance activities, including activities related to the safe transport of dangerous goods by air.
As the transport of dangerous goods by air affects everybody in the air operators’ activities, such as flight operations, cabin safety, passenger handling, ground handling, cargo operations and the shipments of maintenance spares, the oversight strategies often had to be customized. In addition, the safe transport of dangerous goods involves many laws and regulations, among them the Civil Aviation Regulations (CARs), the Transportation of Dangerous Goods Act (TDGA) and associated Regulations (TDGR), and by reference, the International Civil Aviation Organization’s (ICAO) Technical Instructions for the Safe Transport of Dangerous Goods by Air.
To date, we have every indication that the implemented SMS strategies worked, allowing us to review the best practices that made it possible. We believe that one of the key ingredients to its success was that whenever a new process was initiated or developed, we returned to the SMS principles identified in TC’s documents.
One of the key principles, and the cornerstone of the air operator’s SMS, is the non-punitive reporting policy. An air operator must have a policy signed by the accountable executive that would prevent any reprisals against anyone who reports any error, omission or incident committed without malice or not while under the influence of drugs or alcohol. This results in the gathering of intelligence of what is really happening. In addition, with the air operator conducting an investigation, the root causes of the error, omission or incident can be identified, eliminated or mitigated to prevent the probability of a repeat.
The TDGR and ICAO’s Technical Instructions for the Safe Transport of Dangerous Goods by Air require that an air operator reports various types of occurrences to the State of Authorities (TC) such as:
- dangerous goods incidents and accidents; and
- undeclared or mis-declared dangerous goods in cargo or passengers' baggage.
Using the same policy of “non-punitive reporting” required by the air operator’s SMS, we have applied these principles in handling all the reports from air operators. When an air operator reports occurrences to TC, they must provide, within a 30-day time frame, the probable root cause(s), and short- and long-term corrective action plans and means to ensure that the corrective action plans are effective. To date, we have reviewed over 460 of these occurrences. Such a high number of reports demonstrates that the non-punitive reporting system works.
The collecting of this information has allowed us to:
- develop a database of occurrences and associated corrective action plans (CAP);
- develop a database of articles containing dangerous goods intercepted in passengers’ or crew members’ baggage;
- identify the current issues faced by the air operators;
- share with all air operators the best practices to improve safety; and
- develop proposals to revise and improve the TDGR.
Naturally, whenever material is shared with all air operators, ICAO’s Code of Conduct on the Sharing and Use of Safety Information is followed and any information, such as the identity of the air operators, is removed to prevent a misuse of the information.
The intelligence obtained has been quite important in improving domestic and international regulations. Since 2004, National Operations, Airlines Division has been providing a technical advisor to the member representing Canada at the ICAO Dangerous Goods Panel (DGP). Issues or difficulties identified through the occurrences reported by the air operators are then converted into working papers proposing revision to the TDGR. We have been successful in the approval of many proposals and the implementation of many changes to international regulations, including:
- the requirement that hidden dangerous goods notices contain pictograms for foreign speakers;
- an authorization to carry onboard life-saving devices such as automated external defibrillators (AED), nebulizer, and continuous positive airway pressure (CPAP) containing large lithium batteries; and
- a reformatting of the list of articles containing dangerous goods in a table format to simplify information retrieval.
Figure 1: Proportion of dangerous goods in articles intercepted in
passenger or crew baggage in the last 12 months
The analysis of the data has also allowed us to identify where the surveillance activities must be concentrated. Changes have also been made to the oversight activities. When performing a process inspection at an airport, the air operator’s dangerous goods coordinators are invited to participate. By performing such joint activities, we are able to share knowledge, discuss issues and develop possible corrective options when non-compliances are observed. When a finding is issued, it is against the air operator’s system for not discovering the non-compliance.
In order to assist air operators, on a monthly basis, the Branch publishes and communicates to all the dangerous goods coordinators of an air operator, a dangerous goods profile that lists all the contact information, air operator’s variations, approved training programs and publications, and all the expected corrective action plan(s) and their due dates. In addition, the Branch provides a list of all the latest revisions to regulatory and non-regulatory publications.
This successful approach has been shared with other states, through the assistance of TC’s International Operations, by providing training to dangerous goods inspectors from other civil aviation authorities including Bahamas, Bangladesh, Cambodia, China, Fiji, Hong Kong, Indonesia, Laos, Macao, Mongolia, Philippines, Seychelles, Singapore, South Korea, Sri Lanka, Thailand and Vietnam.
Safety management principles can be applied to any activity to reduce the risk associated with that activity. The application of SMS principles in the oversight of dangerous goods has proven to be a success story that is sure to be repeated in other sectors as well. As we continue to move forward, it is the culture change and knowledge that will facilitate the successful implementation of SMS.
Invest a few minutes into your safe return home this winter...
...by reviewing section RAC 2.7 of the Transport Canada Aeronautical
Information Manual (TC AIM), titled “Low Level Controlled Airspace.”
by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the February 2010 issue of COPA Flight, and is reprinted with permission.
Smoke in the cockpit could be the result of an electrical fire. The acrid smell of an electrical fire is very distinctive, but any smoke from the area of the instrument panel, circuit breaker panel or any panel with a number of electrical switches should be considered an electrical fire. An electrical fire is a critical emergency.
The Cessna 172 was on a local VFR flight when the pilot squawked 7700 and returned for landing. After landing, the pilot reported smoke in the cockpit and a radio failure.
An RV 7 pilot saw sparks and smoke coming from under the instrument panel. He declared an emergency, shut down the electrical system and returned for landing. After landing, there were no longer any sparks coming from under the instrument panel and the smoke had dissipated. An inspection revealed that a hose clamp had come loose, allowing a metal hose ducting in air from the outside to come in contact with a fuse bus, causing a short.
A Cessna 172R was on a local training flight when the crew noticed smoke and fumes in the cockpit. They declared an emergency, shut down all electrical systems and returned for landing. An inspection by an AME revealed a faulty landing light switch.
An instructor and student in a Cessna 152 were leaving the control zone on a local training flight when both began to smell smoke and noticed a light haze in the cockpit. The instructor then noticed the radio lights begin to flicker. He received a slight electrical shock when he attempted to select the radio to “Off”. The Battery Master Switch was selected “Off” and the smoke dissipated rapidly. The instructor then used his cell phone to get clearance to return to the airport and land. He did not declare an emergency. The tower controller did however contact the airport emergency services to stand by. Maintenance personnel discovered that the starter bendix had not disengaged after engine start. The overheated starter caused the aircraft electrical system to overheat, causing the smoke and haze.
Ten minutes after departing from the airport, the Cessna 172 cockpit filled with smoke. The pilot turned the Battery Master Switch “Off” and used his cell phone to declare an emergency and to get clearance to return to the airport for landing. During the return, the pilot reported that the smoke had dissipated, but wanted his emergency status to remain in effect. A maintenance inspection revealed a short from a bare wire.
In the first incident, we don’t know from the report if the pilot shut down his electrical system. All of the other pilots did. From previous aircraft incident/accident reports, we know that people may become incapacitated by electrical smoke in less than 3 minutes. Electrical smoke is toxic. It is imperative to turn the Master Switch “Off” immediately when electrical smoke is detected or suspected.
All of the pilots declared an emergency, either verbally or with the transponder, except the C–152 instructor, and he should have. Fortunately, the tower controller did it for him. You may not know it, but you may be partially incapacitated.
The electrical fire checklist in most aircraft read as follows:
- Turn off the battery/alternator master switches.
- Don an oxygen mask if one is available.
- Turn off all electrical switches.
- If the smoke or fire persists, use the fire extinguisher, then ventilate the cabin.
- Essential electrics can be selected back on one at a time, while watching for a re-occurrence of the smoke or fire.
“Essential” is a key word here. After an electrical fire, only select “On” those electrical services that are essential for getting the aircraft to the nearest airport. Be prepared to re-select a service back “Off” immediately if the smoke or fire returns.
Troubleshooting to find the source of the fire must be left for the maintenance people with fire trucks standing by, especially if we have used up our one-shot fire extinguisher.
What is essential in an aircraft in VFR conditions? Nothing. The engine will run perfectly well without any electrical services. We can continue to our destination or to an alternate uncontrolled airport and complete a NORDO procedure. If we have a cell phone on board, we can use it to get clearances for control zone entry and for landing as did two of the pilots mentioned above.
In IFR conditions, we may require a radio or navigation aid. We must only turn on what we absolutely require, and then only after some thought as to where the smoke may have come from, and after checking for popped circuit breakers.
Damage caused by fire in the cockpit of a King Air 100.
Photo : www.pirep.org
Pilots employed in commercial operations are now required to annually review the use of circuit breakers as the result of electrical fires that have occurred when pilots repeatedly pushed in popped circuit breakers. The Transport Canada (TC) recommendation and the industry policy is if the electrical system protected by the popped circuit breaker is not necessary for the remainder of the flight, it is not to be reset. If the system is considered to be necessary, one reset is permitted. The breaker is not to be reset if it pops again.
The incidents described above occurred in 2009. Electrical fires do happen. As we can see, following correct procedure will get us home safely in the event we encounter an electrical fire or smoke. Fly safely.
Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently flies MEDEVACs from Victoria in a Lear 25. 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.
To know more about COPA, visit www.copanational.org.
by the Safety Management Planning and Analysis Division, NAV CANADA
Recent discussion in aviation safety forums and with the pilot community suggests that some pilots may not understand the importance of letting air traffic services (ATS) know when they are concerned about the safety of their flight.
What’s an emergency?
There are many different reasons why a pilot may be concerned with safety. Some of these may sound familiar:
- you have mechanical problems or malfunctioning avionics;
- you’re concerned about low fuel;
- while you are flying VFR, the cloud bases come down and you’re forced to climb through an overcast layer in order to reach VFR over-the-top conditions;
- you’re a VFR pilot flying above scattered cloud conditions that unexpectedly change to overcast, without time for you to descend;
- yourself or a passenger become ill in-flight; or
- you’re lost.
NAV CANADA air traffic controllers and flight service specialists provide assistance to pilots in these types of situations. But we need to know that you are experiencing an emergency!
What does a controller or flight service specialist do when a pilot issues a Mayday or a Pan Pan?
The word “MAYDAY” spoken at the start of communication identifies a distress message that indicates that the aircraft is threatened by serious and/or imminent danger and requires immediate assistance.
The words “PAN PAN” identify an urgency message concerning the safety of an aircraft or other vehicle, or some person on board or within sight, which does not require immediate assistance.
Timely notification of ATS personnel about an emergency or potential issue that may impact flight safety is critical. Once a controller or specialist is made aware, there are a number of different actions that they may take depending on the nature of the situation:
Priority of service
- Given that they are aware that a situation exists, ATS personnel can better prioritize the level of assistance that may be required, offering direct routes or assistance in planning for alternate destinations.
Coordination with other ATS units
- A flight service station (FSS) or control tower may contact the area control centre for radar assistance or to coordinate between IFR and VFR aircraft (special VFR authorization).
- Controllers may coordinate the use of additional airspace, protecting emergency climbs or descents by blocking altitudes or diverting other traffic as necessary.
Notifying outside agencies
- Relaying information to a company dispatch or maintenance may yield assistance to the pilot or flight crew in resolving in-flight issues.
Notifying emergency services
- ATS personnel will do this either directly with local emergency services or through the destination unit, keeping in mind that in many smaller locations, emergency services are not on site, therefore increasing response times.
Failure to notify ATS about an emergency or potential problem may result in a delay in having the appropriate responders available. If you’re in doubt about the safety of your flight, let ATS know as soon as possible. You can always cancel later.
ICAO proposed changes
Finally, the International Civil Aviation Organization (ICAO) is proposing amendments to Annex 6 and PANS-ATM regarding fuel management for implementation on November 15, 2012. These changes include the introduction of new fuel-related terms and phraseology that differentiate MINIMUM FUEL from a FUEL EMERGENCY. It is expected that Canada will comply with the amendment. An appropriate notification will be forthcoming as well as amendments to ICAO and Canadian publications once the changes are finalized.
As soon as there is any doubt as to the safe conduct of a flight, immediately request assistance from ATC. Flight crews should declare the situation early; it can always be cancelled.
- A distress call (situation where the aircraft requires immediate assistance) is prefixed: MAYDAY, MAYDAY, MAYDAY.
- An urgency message (situation not requiring immediate assistance) is prefixed: PAN PAN, PAN PAN, PAN PAN.
- Make the initial call on the frequency in use, but if that is not possible, squawk 7700 and call on 121.5. (Note: 121.5 is not available or monitored via PAL or RCO facilities. Only tower and FSS personnel monitor 121.5 during hours of operation.)
- The distress/urgency message should contain (at a minimum) the name of the station addressed, the call sign, nature of the emergency, fuel endurance, persons on board and any supporting information such as position, altitude (climbing/descending), speed, heading and pilot’s intentions.
Minimum fuel advisory
As per the TC AIM (RAC 1.8.2), pilots may experience situations in which delays caused by traffic, weather or any other reason result in the pilot being concerned about the aircraft’s fuel state upon reaching destination. In such cases, the pilot may declare to ATC that a MINIMUM FUEL condition exists. This declaration results in ATC taking specific actions as per RAC 1.8.2 and alerts them that an emergency situation could develop.
‘Fuel emergency’ and ‘fuel priority’ are not recognized terms. On reaching an emergency situation with respect to the aircraft’s fuel state, flight crews should declare a PAN or MAYDAY to be sure of being given the appropriate priority.
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