Transport Canada's response to the Aviation Safety Recommendations A93-01, A93-02, A93-03, A93-05, A93-06, A93-07, A93-08, A93-09, A93-10, A93-11, A93-13, A93-14, A93-15, A93-16, A93-17, A93-18, A93-19, A93-20, A93-21, A93-22 and A93-23 issued by the T...

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A93P0003 - Aviation Safety Recommendations Crash Resistant Fuel Systems Bell 212 Fuel Fitting

BACKGROUND

On 3 January 1993, at Kirkup Creek, B.C., Bell 212 C-GALH, employed in helicopter skiing operations, reportedly encountered local ice fog generated by air circulation off the main rotor. In the reduced visibility, the aircraft struck the ground, rolled over, and came to rest in its right side (A93P0003). All 13 occupants exited the helicopter without injury.

Although the investigation of this occurrence is ongoing, it is evident that there are several similarities to the accident of a ‘’heli-ski’’ Bell 212 at Blue River, B.C., in April 1990 (A90P0121). In the Blue River accident, an intense fire ensured after the helicopter rolled over; three of the 14 occupants were unable to exit and succumbed to the effects of the post-crash fire. Consequently, in April 1991, The Transportation Safety Board (TSB) made recommendations (TSB A91-04 to A91-12) relating to emergency evacuation from wide-body helicopters; Transport Canada (TC) responded favorably to the recommendations and initiated corrective measures.

The successful exit by the occupants in the Kirkup Creek accident may have been aided by modifications made to the occurrence helicopter by the operator as a result of the above initiatives. This Bell 212 was equipped with pop out windows (as recommended by TC Service Difficulty Advisory AV-92-08), conspicuously painted legs of the bench (as recommended by TC Service Difficulty Advisory AV-92-05), ceiling handholds, and shortened front-seat headrests. In addition, the passengers had received pre-flight briefings that emphasized the use of these features for exiting the aircraft in an emergency.

Although Bell 212 C-GALH did not catch on fire, a fuel hose, the mirror twin to that which was considered to be the probable fuel source in the Blue River fire, was found broken. The Aeroquip fuel hose (P/N 70-009K090W317) to the right power section was found broken at the 90-degree aluminum elbow which attaches to the fuel/oil heater.

In February 1991, as a result of the broken fuel hose in the Blue River occurrence, the TSB forwarded an Aviation Safety Advisory to TC suggesting that they assess the feasibility of replacing critical fuel fittings with frangible self-sealing fittings and valves, or more durable fittings (steel vice aluminum). It is understood that TC is now considering adopting the Federal Aviation Administration (FAA) Notice of Proposed Rule Making (NPRM) 90-24 concerning crash resistant fuel systems (including a requirement for self-sealing breakaway fuel fittings) for inclusion in TC’s Airworthiness Manual Chapters 527 and 529. This would be a positive step toward establishing a greater safety margin with respect to crashworthiness in new aircraft designs. However, under this NPRM, existing aircraft will continue to operate with fuel systems that are significantly less crash resistant that the proposed standard. The previously mentioned occurrences demonstrate the potential for fuel escaping from cracked fuel-line fittings in existing fuel systems.

The Board fully supports the initiatives contained in NPRM 90-24 as a means to enhance safety in the long term; however, the Board feels that additional measures must be sought to ensure an increased level of crashworthiness in existing fuel systems in operations where there is a high risk of roll-over, such as heli-skiing. With respect to the 90 degree aluminum elbow fuel fitting of the Bell 212, it is felt that a more robust fitting (steel), or protection or relocation of the fitting could lessen its susceptibility to damage in roll-overs. Therefore, the Board recommends that:

The Department of Transport promote the modification of the Bell 212 fuel system to enhance the crashworthiness of the aluminum elbow fitting on fuel line PN 70-009K090W317 or equivalents. A93-01

The Department of Transport assess the feasibility of incorporating more crash resistant fuel systems in all helicopters (of existing designs) manufactured in Canada and in all Canadian-registered helicopters employed in operations with a high risk of roll-over, such as heli-skiing. A93-02

Transport Canada Response:

Transport Canada has assessed the feasibility of incorporating improved crashworthy fuel systems in helicopters in response to a previous Transportation Safety Board advisory. The Department has submitted an issue paper to the Federal Aviation Administration (FAA) Aviation Rulemaking Advisory Committee (ARAC) to initiate a project for the retrofit to improved crashworthy fuel systems on helicopters.

After a review of the FAA Notice Proposed Rulemaking (NPRM) 90-24 concerning fuel system standards for new designs of rotorcraft, Transport Canada concluded that a reasonable retrofit for existing helicopters, regardless of the type of operation that the aircraft is employed in, should focus on fuel feed and vent lines and their associated fittings.

The ARAC Rotorcraft Subcommittee is considered to be the appropriate forum to assess the feasibility and scope of this retrofit program. This committee is under the sponsorship of the FAA and consists of representatives of government agencies, including Transport Canada and the European Joint Aviation Authorities (JAA), as well as the rotorcraft operators and manufacturers.

Transport Canada agrees with the recommendation that the fuel system of the Bell 212 model helicopter can be improved by using steel fittings and can assure the Board that a modification program has been started.

Bell Helicopter Textron Inc has issued a Product Change Authorization (PCA) to incorporate stainless steel elbows on new productioin model 212 and 412 helicopters and changed the design specifications to preclude the installation of aluminum elbows in future Bell designated helicopters. The company is considering what action to take about the fuel lines on existing model 212 and 412 helicopters.

A90H0002 - Frontier Air Ltd. - Beechcraft C99 Airliner C-GFAW Moosonee, Ontario - 30 April 1990

SYNOPSIS

The aircraft, a Beechcraft C99 Airliner, was on a scheduled domestic flight from Timmins, Ontario, to Moosonee, Ontario, with two pilots and two passengers on board. The aircraft crashed seven miles east-northeast of the Moosonee Airport while the crew was conducting a visual approach to land on runway 24. The aircraft was destroyed by the impact and a post-crash fire. The captain and passengers were seriously injured, and the co-pilot received fatal injuries.

The Transportation Safety Board of Canada determined that the captain inadvertently flew the aircraft into trees, during a condition of visual illusion, as a result of inadequate crew coordination in that neither pilot effectively monitored the altimeter. Contributing to the occurrence were the absence of approach lighting, the lack of company crew pairing policy, the captain's unfamiliarity with black-hole illusion and the seating position of the captain.

Safety Action Taken
(as indicated in the TSB Report)

Cockpit Resource Management

In multi-crewed aircraft, teamwork is essential to the detection of errors (such as the premature descent in this accident), and effective cockpit communications are essential to good teamwork.

Following an incident involving a Boeing 737 in which poor intra-cockpit communications led to a near collision with terrain, it was recommended that the Department of Transport promote the adoption of CRM training by commercial operators (CASB Recommendation 90-53). Subsequently, TC has encouraged the adoption of this training through articles in the Aviation Safety Letter and has provided related courses such as PDM.

The TSB recently conducted a survey on Canadian commercial pilots. Of the pilots surveyed that were employed on multi-crewed aircraft with level III to VI air carriers, 42 per cent indicated that their employer provided formal CRM training. The continuing implementation of CRM training for commercial pilots should reduce the risk of recurrence of this type of accident.

Approach Slope Indicator

Subsequent to this accident, the TSB forwarded an Aviation Safety Advisory suggesting that TC evaluate the need for an ASI and/or approach lighting for runway 24 at Moosonee. TC subsequently recommended that the Moosonee Airport authorities install ASIs and indicated that TC was prepared to render any assistance necessary to obtain the ASIs.

Survival Kit Location

Post-accident survivability often depends to a large extent on the contents and availability of aircraft survival equipment. TC published an article in the 6/92 issue of Aviation Safety Letter encouraging operators to carry survival equipment in rear baggage areas where, in the event of an accident, the equipment would be less likely to be damaged or become inaccessible.

Human Factors Training

The Board determined that the accident aircraft was inadvertently flown into trees in conditions conducive to black-hole illusion. Pilots must contend with many types of visual illusions. Between 1977 and 1990, visual illusions were identified as a contributing factor in 19 other accidents. Visual illusions, in turn, are only one of many "human factor" issues which play a role in 70 to 85 per cent of all aircraft accidents. Training and awareness programs have the potential for reducing the number of accidents attributable to human factors.

The International Civil Aviation Organization (ICAO) has undertaken several initiatives, including the production of a series of digests on various aspects of human factors in aviation and a requirement for training in human factors for all aircrew licence holders in ICAO member states. TC is advancing pilot knowledge through promotional activities, by upgrading study and reference materials (such as the Pilot Decision Making Manual for Private Pilots, and the soon to be released Pilot's Guide to Human Factors), and by increasing the human factors knowledge requirements for the issue of pilot licences. Visual illusions (including black-hole illusion) are discussed in the draft Pilot's Guide to Human Factors, and have been included in a recent update of the data bank of questions used by TC for pilot written exams.

Safety Action Required
(as indicated in the TSB Report)

Crew Pairing

The lack of a company crew pairing policy was identified as contributing to the accident. The captain and co-pilot had been in their respective crew positions for less than one month, and the accident flight was the co-pilot's first night flight in the C99, his first trip into Moosonee, and his first flight with the captain.

Crew pairing has been identified as a contributing factor in other occurrences. In July 1987, a Lockheed 1011 was involved in a near collision with a Boeing 747 as a result of a navigational error over the Atlantic Ocean. The Lockheed 1011 flight crew, who did not perform adequate navigational cross-checks, had limited experience in North Atlantic flying, with no crew member having more than six return trips (Report 87-A74947 refers). Furthermore, in 1987, the crew of a Boeing 737 Combi flew off track while on approach to Prince George, British Columbia, because of an improper navigation switch selection. Neither pilot had been in the cockpit of a Combi before (Report 87-P74128 refers). In August 1989, the flight crew of a Boeing 727 apparently failed to notice a navigation error, resulting in a loss of separation with another aircraft. The captain was not accustomed to the type of approach being flown, the co-pilot was new to the aircraft, and neither pilot was familiar with the destination (Report A89A0209 refers).

The U.S. National Transportation Safety Board (NTSB) has recognized the importance of proper crew pairing. In October 1986, following the investigation of three commuter air carrier accidents in which crew pairing was identified as a contributing factor, the NTSB recommended that the U.S. Federal Aviation Administration (FAA) caution commuter air carrier operators not to schedule on the same flight crew members with limited experience in their respective positions. Furthermore, following the crash of a McDonnell Douglas DC-9-14 on 15 November 1987, in which crew pairing was again identified as a contributing factor, the NTSB recommended that the FAA establish minimum experience levels for each pilot-in-command and second-in-command pilot, and that such criteria be used to prohibit the pairing of pilots who have less than the minimum experience in their respective positions. The FAA responded to these recommendations by bringing the crew pairing issue to the attention of air carriers and requesting that they develop, to the extent possible, appropriate crew pairing policies and procedures.

Crew pairing was also recently addressed by the Commission Of Inquiry into the Air Ontario Crash at Dryden, Ontario. It was recommended that TC encourage air carriers which lack pilots with sufficient experience on a new aircraft type to provide highly experienced pilots from outside the air carrier to assist in training the air carrier's pilots and to fly with them until an adequate level of flight experience is gained on the new aircraft type. Additionally, it was recommended that TC proffer for enactment legislation with respect to flight crew pairing. That legislation would require that one of the flight crew members, either the pilot-in-command or the first officer, have substantial flight experience on the aircraft type.

Many factors must be considered when flight crews are made up. Not only must the crew be familiar with the aircraft type, but it should also be familiar with the aspects of the operating environment specific to a particular aircraft, an operating area, the type of operation, the time of day, and, if possible, the crew members should be familiar with each other.

In view of the importance of crew pairing to effective cockpit performance and in view of the many factors which can contribute to poor crew pairing, the Board recommends that:

The Department of Transport provide guidance for air carriers to assist in the effective pairing of flight crews. A93-03

Response from Transport Canada:

The issue of crew pairing is being addressed by Transport Canada officials as a result of the recommendations contain in the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario. The subject of crew pairing has been designated as MCR 71 by the Dryden Implementation Project and is currently under active review. In addition, the Federal Aviation Administration (FAA) has issued a Notice of Proposed Rulemaking (NPRM) for a regulation which would prevent the pairing of pilots if both have 75 hours or less of operating time on the type of aircraft being flown.

There has been extensive consultation between Transport Canada Aviation (TCA) and the aviation industry on how to best implement this recommendation. It is expected that the Canadian implementation of legislation for crew pairing will be similar to that of the FAA. This legislation will be addressed by the Dryden Commission Implementation Project and its review of MCR 71.

Design Eye Reference Point

The accident investigation determined that the captain could not achieve the DERP; his thighs would have interfered with the control column and he would not have been able to achieve full rudder travel. Consequently, from his selected seat position, the captain could not see below the horizon while the aircraft was in level flight in the approach configuration. Like many other company pilots, he was not fully aware of how the safe operation of the aircraft could be compromised if his eyes were not positioned near the DERP.

The Beechcraft C99 was type-certified to FAR 23 which establishes certain cockpit visibility requirements. However, manufacturers are not required to provide guidance to pilots to enable them to position their eyes near the DERP. Furthermore, current pilot training and knowledge requirements do not address the importance of achieving optimum visibility, that is, positioning the eyes at the DERP. Hence, the Board believes that many pilots unnecessarily restrict their visibility, jeopardizing the safe operation of their aircraft, as evidenced by this accident. To assist pilots in optimizing their visibility, particularly for the approach and landing phases of flight, the Board recommends that:

The Department of Transport take the necessary steps to ensure that pilots receive appropriate guidance for positioning their eyes at or close to the Design Eye Reference Point.

Response from Transport Canada:

Transport Canada will publish an Air Carrier Advisory Circular which explains the concept of DERP and emphasizes the hazards of flying approaches from a seat position which does not approximate the proper DERP nor provide for proper monitoring of external references. In addition, this information will be published in the A.I.P. Canada to provide guidance on this issue to the entire pilot community.

Night Training on Type

ANOs require air carriers to provide their pilots with certain training before they can serve as flight crew members. This training includes take-offs and landings at night in each type of multi-engine aircraft that the pilot is to fly at night.

Neither of the occurrence pilots had received the required night training on the Beechcraft C99 nor had they received night training for any of the aircraft types that they had flown in the past for any company. For these two pilots, five different companies had not conducted night training on four different aircraft types.

The questionnaire used in the recent TSB survey on Canadian commercial pilots did not specifically address night training on type; however, it did contain a question concerning required recurrent aircraft/emergency training. Fourteen per cent of the pilots surveyed indicated that this training either had never occurred or that it had occurred less frequently than required. The survey also indicated that many pilots feel that TC audits do not go far enough towards actually verifying entries in training records.

In view of the special skills needed for safe night operations, the Board recommends that:

The Department of Transport validate its current procedures for checking that air carriers provide the required multi-engine night training. A93-05

Response from Transport Canada:

Chapter 3, Section 4, Check list OP-6, Item A.2 of the Manual of Regulatory Audits, which was published since the accident occurred, directs the audit staff to check that the flight training programme (initial and recurrent) meets the requirements of the company Operations Manual and the ANOs. A part of the Legislation/Section reference in the Manual, includes Sections 43-46 and Schedule D1 (K) of the Air Carriers Using Small Aeroplanes Order, (A.N.O., Series VII, No.3). Subsections 43 (2), (3) and (4) are explicit in stipulating the requirements for air carriers to establish and provide approved ground and flight training programs and to maintain records of the training given to each crew member certifying that he is adequately trained to carry out his assigned duties. Subparagraph (1) (b) (iii) of Section 46 of the Order specifies that flight training for each crew member will include, in each type of aircraft he is to fly:

“Take-offs and landings by day and, if he is to fly at night, by night.”

Subsection 6.3 of the Air Carrier Inspector Manual reinforces this requirement in stating :

“Each air carrier is required by Orders to maintain a record of training and checks for each crew member. The training program of the Operations Training Manual shall include an outline of the record keeping procedure established by the air carrier and shall include copied of the forms used to record the training and checks completed.”

In accordance with the National Audit Programme, TCA conducts periodic audits of air carriers to promote compliance with the aviation regulations and standards.

TCA will send a letter to all Regional Air Carrier staff recommending that they put more emphasis in checking requirements, particularly night flying training. When conducting future audits, Quality Assurance Review teams from Headquarters will ensure the checks are completed.

Safety Concern
(as indicated in the TSB Report)

Terrain Avoidance Equipment

Altitude alerter, radar altimeters and GPWS can warn flight crews of an inadvertent approach to terrain. Since GPWS became mandatory equipment on larger passenger-carrying aircraft, the number of controlled flight into terrain (CFIT) accidents has decreased markedly for these aircraft. However, smaller aircraft, such as the one in this occurrence, do not require this type of warning equipment.

The Board notes with concern that, between 1976 and 1990, there were 170 CFIT accidents with 152 fatalities involving Canadian-registered, commercially operated small aircraft. In view of the frequency and severity of such accidents, and the improved safety that has resulted from the use of GPWS in larger aircraft, the Board may conduct a study of CFIT accidents in small commercial aircraft.

A92P0191 - Recommendations Concerning In-flight Opening of Doors on Small Aircrafts

On 22 October 1991, the nose baggage door on a Cessna 404 opened on take-off. After entering a nose-high, steeply-banked turn, the aircraft stalled and crashed, killing the pilot (A91C0223). On 18 August 1992, the cabin door on a Beechcraft Bonaza opened just after take-off. Although the investigation is not yet complete, it appears that the aircraft stalled and crashed during a tight low-level turn while returning to the airport (A92P0191). Again, the pilot was killed. In its investigation report on the October 1991 accident, the Board included a "Safety Concern" assessing the underlying safety deficiencies with a view to recommending specific corrective action.

A review of Transportation Safety Board (TSB) data indicates that since 1977 there have been 33 accidents, resulting in 10 fatalities, in which a cabin, baggage or other compartment door opened in flight or on take-off. The frequency of these accidents has been consistent over time. The experience level of the pilots involved was generally high, with 26 of the 33 accident pilots having more than 500 hours total flying time. There was an even distribution of pilot licence types and only one of the accidents involved a large aircraft.

Pre-Flight Inspections

In 30 of the 33 accidents, the "offending" door was apparently not properly secured or was inadvertently left open during pre-flight preparations. As a matter of routine, an aircraft's airworthiness is checked prior to flight by inspecting the security of doors and panels. However, if a pilot becomes distracted or is otherwise inattentive when performing the pre-flight checks, an unsecured door can be overlooked. The occurrence record indicated that improper pre-flight closure of doors continues to be a significant factor in aircraft accident involving inadvertent opening of doors on take-off of in flight. Therefore, the Board recommends that:

The Department of Transport, through its various safety promotional programs, re-emphasize the need for special vigilance to confirm the security of all doors on small aircraft prior to flight. (A93-06)

Transport Canada Response:

Transport Canada agrees that the need for a properly conducted pre-flight inspection which is essential for a safe flight should be periodically re-emphasized. An article concerning the requirement to ensure the security of cabin and baggage compartment doors prior to flight will be indicated in the 1/94 Issue of the Transport Canada Aviation Safety Newsletter.

Door Latches

Twenty of the 33 accidents involved the opening of a cabin door and six involved a baggage door. Cabin and baggage door latches used on most small aircraft do not provide a conspicuous visual indication that a door is not secure; nor are these aircraft normally equipped with a “door open” warning device in the cockpit. Apparently, none of the aircraft involved in these accidents had secondary door latches installed.

Secondary latches are normally an optional product enhancement and are designed to prevent aircraft doors from fully opening when the primary latches either fail or are not properly secured. They are available from many aircraft manufacturers or third parties, generally at a relatively low cost. Some secondary latches provide a much better visual indication of unsecured doors than to the primary latches.

In order to enhance the visual conspicuity of improperly secured doors, the Board recommends that:

The Department of Transport encourage manufacturers of small aircraft to incorporate primary door latches which will provide a conspicuous visual indication of unsecured doors; and, (A93-07)

The Department of Transport promote the use of secondary door latches, especially those which provide a conspicuous visual indication if unsecured. (A93-08)

Transport Canada Response:

A review of the design standards (FAR 23) shows that requirements for direct visual inspection of the door locking mechanism and cockpit warning of external unsecured doors was introduced for commuter category airplanes in 1987. In 1988 this was expanded to include external doors forward of any engine or propeller and for any doors for which the initial movement is not inward on normal, utility and aerobatic category aircraft.

The Department contacted the three largest manufacturers of small aircraft in the United States and has confirmed that they have, in many cases, developed latches with visual indications of insecurity and fitted them to their aircraft or offered them as optional equipment. Transport Canada is satisfied that the manufacturers are fully aware of the door opening problem and are taking reasonable steps to address it.

Transport Canada will, however, encourage the operators to ensure the maintenance standards are adhered, to in order to eliminate the problem of inadvertent door openings in-flight. A Service Difficulty Advisory will be issued to warn the operators of the hazards of inadvertent door openings, and to advise them of the commercial availability of add-on kits to install secondary latches as well as the visible indications of insecurely latched doors.

In-flight Procedures

An open door in flight can generate extensive noise, airframe buffeting, loss of lift, increased drag, and adverse aircraft stability. In the data sample, all 33 aircraft should have been capable of controlled flight with the door open. However, the distraction, pre-occupation, channelized attention, panic, etc. associated with a door opening in flight apparently affected 17 of the accident pilots to such an extent that aircraft control was significantly degraded. This resulted in the pilots either stalling the aircraft, landing wit the gear up, landing hard, inadvertently flying into the ground or an object, or losing control of the aircraft while attempting to close the door. In 11 of these 17 accidents, the pilot-in-command had over 500 hours total flying time.

A pilot who is not mentally prepared for an unfamiliar situation such as a door opening in flight, may take inappropriate actions to deal with the situation. The stress inherent in such emergencies could cause pilots to narrow their normal scanning pattern, resulting in failure to monitor critical flight parameters or to perform essential actions.

Individuals are less susceptible to distraction-induce4d errors and erroneous decision-making if they are prepared for an emergency or unusual event by having a pre-determined plan of action. Guidance on the handling of open doors on take-off or during flight is not consistently provided to pilots during initial training, nor is such training required by regulation. The study and reference materials currently used by student pilots provide little discussion on this subject. Likewise, Transport Canada's publications and promotional activities do not provide significant guidance to licensed pilots.

In view of the frequency of accidents where the pilot response to the inadvertent door opening was inadequate, the Board recommends that:

The Department of Transport ensure that the general guidance concerning the handling of doors opening on take-off or during flight be provided to:

  1. student pilots during ab initio training; and
  2. licensed pilots during re-current training through reference publications and safety promotional programs. (TSB A93-09)

Transport Canada Response:

Transport Canada agrees that the information available to pilots on how to handle this type of emergency should be enhanced. The Department will provide additional guidance to student pilots and flight instructors as well as ensuring that licensed commercial pilots are checked on their knowledge of this problem.

The fourth edition of the Flight Training Manual (FTM) for aeroplanes is being amended and plans are to publish it in the spring of 1994. This edition will include additional text on this subject under the heading of flight preparation and a new section on emergencies will provide general guidance on handling this problem. When the recently published training manual for helicopters is re-issued, information and guidance on this subject will be included in the appropriate exercises.

The periodic publication “Post Flight”, which is distributed to all flying clubs and schools, Designated Flight Test Examiners (DFTE) and Flight Training Standards Inspectors (FTSI) will feature an article on this topic in the September 1993 issue. As well, this subject will also be included for discussion at forthcoming Instructor Refresher courses and at DFTE and FTSI workshops scheduled for completion by March, 1994, and during the on-going Flight Training Evaluation Team visits.

Regional inspectors will be directed to add, where appropriate, the evaluation of in-flight door opening emergency procedures when conducting Pilot Proficiency checks on pilots operating under ANO Series I, No. 2. The operators involved in the transportation of passengers under this Order will be sent an information letter outlining the TSB recommendations and which will strongly suggest their approved training programs be updated with respect to the procedures for handling the in-flight opening of doors, hatches and panels.

An Air Carrier Advisory Circular will be sent to commercial operators of small aircraft and rotorcraft on accidents involving the in-flight opening of doors windows and panels. This circular to ANO Series VII, No. 3 and No. 6 operators will ask them to review the hazards associated with the distraction and pilot preoccupation when his emergency occurs. The operators, Transport Canada and other examiners will be asked to consider, in this review, how an open door can generate excessive noise, airframe buffeting, loss of lift, increase drag and lead to instability and control problems.

Aircraft Flight Manuals

The flight characteristics of an aircraft with an open door vary by aircraft type; consequently, type specific procedures may be required in order to land safely with an open door. Some manufacturers already provide specific procedures in their safety supplements; however, the pilots' primary reference document, the Aircraft Flight Manual (AFM), normally does not contain this type of information. In order to improve the availability to information for pilots to safely handle the opening of doors on take-off or in flight, the Board recommends that:

The Department of Transport encourage manufacturers of small aircraft to include specific guidance in Aircraft Flight Manuals on the handling of inadvertent door opening on take-off or in flight. (TSB A93-10)

Transport Canada Response:

Transport Canada agrees that guidance should be provided if the inadvertent opening of a door or a hatch will create an unusual hazard that is specific to an aircraft type. A survey of manufacturers indicated that they are very much aware of the door opening problem and have included door re-closing instructions in the Aircraft Flight Manual where it is safe to do so.

Existing regulations require that the pertinent information necessary for the safe operation of the aircraft be provided under normal and emergency circumstances. The Aircraft Flight Manual (AFM) would be required to address inadvertent openings of doors or hatches if such an occurrence would require special procedures that are specific to that aircraft.

The accidents that were reviewed for these recommendations did not indicate that the handling characteristics of the aircraft with the door open or lost was degraded. There is no indication that any particular aircraft type requires an amendment to address handling with door(s) open. Changes to the flight manual are not advisable unless flight testing or service experience identifies adverse flight characteristics which would require specific operating procedures.

A91P0140 - Vancouver Island Helicopters Ltd. Bell 206B JetRanger (Helicopter) C-GVIR Sulphurets Creek, British Columbia 24 July 1991

Synopsis

The pilot was lowering a load of drill rods onto a rack beside a drill rig when the helicopter's main rotor blades struck the drill tower. As a result, the main rotor blades and the transmission were torn from the helicopter. The pilot was severely injured and died while being flown to hospital shortly after the accident.

The Board determined that the helicopter's main rotor blades struck the drill tower most likely because the pilot misjudged the clearance between them.

Safety Action Required
(as indicated in the TSB Report)

Flight and Duty Time Provisions

The helicopter in this occurrence was being operated in accordance with Air Navigation Order (ANO) VII, No. 6. Article 42.1 of this ANO establishes the allowable maximum flight and duty times and minimum rest periods for flight crews. The ANO also recognizes that increased demands are placed on pilots performing certain tasks and, therefore, requires that operators consider the effects of these demands when establishing company pilot duty time limits. Therefore, it requires that each air carrier specify flight and duty time limits, and rest periods based on factors such as the type of operation, the type of rotorcraft, the crew complement, the frequency of take-offs and landings, etc. Similar provisions exist in the ANOs for large and small aeroplanes.

Although ANOs do contain provisions to ensure that deployed helicopter pilots flying intensive external load operations, or pilots engaged in demanding specialty operations are protected by more stringent flight and duty time limits, the maximum limits found in ANOs are routinely applied without reduction. A sampling of operations manuals revealed that maximum flight and duty times are commonly applied, despite the especially fatiguing nature of certain operations. In this case, the company's operations manual only required a reduction of duty times for IFR flights. Apparently, an important provision of ANOs is being overlooked or misunderstood by carriers.

The Board considers the routine application of legislated maximum limits to be inappropriate for certain operations, particularly in view of the recent increases in flight and duty time limits. As evidenced by this accident, this can lead to fatigue, especially for pilots employed in specialty or other demanding flight operations. The Board believes that the intent of ANO VII, No. 6, Article 42.1 is not being met in its entirety. Therefore, the Board recommended that:

The Department of Transport ensure that air carriers establish company flight and duty time limits commensurate with the demands of their flight operations. A93-11

Transport Canada Response:

In April 1993, the Minister of State for Transport, because of concerns expressed by certain members of the aviation community, decided not to proceed with amendments to the Air Regulation as recommended by the Minister’s Advisory Committee on Flight and Duty Time Limitations in 1991. The Minister also decided to allow the current exemption Order, which incorporates the recommendations of the Advisory Committee, to remain in force for a two year period. This was to provide Transport Canada Aviation with an opportunity to consult with the aviation community and, at the same time, not place an undue hardship upon the aviation industry while the regulations were being reviewed.

With the promulgation of the new Commercial Air Services Regulations, company operations manuals will be required to contain specific information concerning flight time limitations, duty time limitations and rest requirements. The standards associated with the Regulations will define the limitations in reference to specific types of operations. In drafting these standards, the types of operations, frequency of take-offs and landings, departure and arrival times, crew complement and other operational requirements as outlined in the Air Navigation Orders, Series VII, Nos. 3 and 6, will be taken into consideration.

Continuing dialogue on this issue is mandatory in order to formulate legislation that is safe, reasonable and applicable to the Canadian aviation industry.

Transport Canada Aviation intends to form working groups for fixed-wing and rotorcraft operations which will include industry representatives to address these issues. The discussions will include but not be limited to the recommendations contained in the Minister’s Advisory Committee report which formed the basis for the limitations contained in the current exemption. It is anticipated that cumulative fatigue, continuous duty due to operational delays, standby (reserve), and extended range operations will be among the topics addressed. The mandate of the working groups will be to make recommendations which will form the basis of legislation

It is anticipated that the flight and duty time limitations and rest requirements which result from these working groups will provide adequate protection from fatigue for flight crew members.

A92W0177 - Trans North Turbo Air Ltd. McDonnell Douglas 369D (Helicopter) C-FBVG Exeter Lake, Northwest Territories 15 mi E 24 August 1992

Synopsis

The pilot had released a sling load of diamond drill rods at a new drill site. During the eight-mile return flight to the old drill site, with an unweighted sling assembly trailing, the helicopter broke up in flight. The helicopter burned on impact and the pilot sustained fatal injuries.

The Transportation Safety Board of Canada determined that the helicopter broke up in flight when the speed of the aircraft and length of the unweighted lanyard/sling permitted contact of the sling with the tail rotor.

Safety Action Required
(as indicated in the TSB Report)

Helicopter Slinging Equipment

Since 1976, there have been 15 reported helicopter accidents resulting from tail rotor damage caused by contact with slings. These accidents resulted in five fatalities, four serious injuries, and in most cases, substantial aircraft damage. Seven of the accidents involved flights with an intentionally empty, unweighted sling, even though the helicopter community recognizes this to be a hazardous practice. Eight accidents resulted when loads separated from the sling during transit, causing the now-empty sling to stream aft into the tail rotor.

Over the years, there have been several initiatives to reduce the incidence of helicopter rotor/sling strikes. Transport Canada (TC) has produced an educational video on slinging, has published numerous articles in its "Vortex" newsletter on unsafe equipment and practices in helicopter operations, and is currently working on regulations to cover the operational requirements for slinging. As recently as May 1992, Bell Helicopter Textron re-issued an Operations Safety Notice to caution owners and operators of helicopters that "flights with unloaded cables extending from helicopters must not be performed." Notwithstanding these measures, the use of unsafe slinging equipment in an unsafe manner continues.

Supplemental equipment in the aviation industry is normally designed and tested in accordance with Technical Standard Orders (TSO), or is type-approved under a Supplemental Type Certificate (STC). At present, helicopter slinging equipment is considered to be part of the load rather than the aircraft; therefore, it has not been subjected to a TSO or STC approval process.

Discussions with suppliers of helicopter slinging equipment revealed that most slings and associated hardware have been designed to the same standards used for the construction industry. Airworthiness requirements, such as behavioral characteristics in flight, have not necessarily been a consideration in the design or intended use of this slinging equipment.

In view of the continuing incidence of helicopter accidents resulting from empty slinging equipment coming into contact with helicopter rotors, the Board recommends that:

The Department of Transport coordinate the development and implementation of airworthiness standards and operational limitations for helicopter slinging equipment. A93-12

Transport Canada's Response:

Transport Canada Aviation (TCA) recognizes that the consequences of any mistake in slinging operations can be very serious, and therefore supports the Boards efforts in finding the best possible solution to reduce these types of occurrences.

The TSB accident analysis implies that the publication of a TSO standard and the issue of airworthiness approvals and operational limitations for sling equipment could eliminate the cause or reduce the number of accidents that occur during external load operations. However, the TSB report has not taken into account the many variables (such as the number of rotorcraft types, the variety of sling equipment, types of loads and operations), which could make the solution of the problem complex, time consuming and very costly (extensive flight testing could be required). It is felt that better results can be obtained by requiring through the new Order dealing with external load operations, that company Operations Manuals contain instructions about the type of equipment to be used for a specific operation, i.e. sling length, material, size, storage instructions, inspection schedules and procedures, etc.

One of the task of the Transport Canada Regulatory Renewal Project is to develop Aerial Work Regulations which will include operational standards and procedures related to rotorcraft external (sling) load operations. It is intended that the regulations will include a requirement for a company Operations Manual to include the information mentioned in the foregoing and an outline of crew training.

TCA participants in the Rotorcraft Subcommittee of the U.S. Federal Aviation Administration’s (FAA) Aviation Rulemaking Advisory Committee (ARAC), which has prepared draft rulemaking and advisory material for helicopter external load carriage. TCA will comment on the draft Advisory Circular with a view to adopting its contents.

A92H0003 - Risk of Collision Between: Aerospatiale ATR42 C-FLCP and de Havilland Dash 8 C-GAAM Montreal International (Dorval) Airport, Quebec 5 nm NE 17 February 1992

Synopsis

Air Atlantic Flight 1898, C-GAAM, was inbound to runway 24 Left at the Montreal International (Dorval) Airport, Quebec, from the west while Inter-Canadian Flight 664, C-FLCP, was inbound from the north to runway 24 Right. Both aircraft were operating in accordance with instrument flight rules and were being provided with radar vectors for their respective approaches. The aircraft, while on their assigned headings, conflicted one mile southeast of the final approach path of runway 24 Left.

The Transportation Safety Board of Canada determined that the cause of the risk of collision was the untimely takeover of communications at the arrival position by the instructor and the untimely opening of the low-arrival position to relieve the arrival position of excess workload. The absence of procedures, general guidelines, and supervisor training concerning the opening/closing of control positions and the management of control staff likely contributed to this occurrence.

Safety Action Taken
(as indicated in the TSB Report)

Training Procedures Montreal ACC

Following this occurrence, Montreal ACC held an internal investigation which found that, in an abnormally high percentage of incidents when training was in progress, the controller-in-training had previous experience and the controller/instructor had over-estimated the trainee's abilities. Additionally, in several incidents, the instructor and the trainee had been colleagues for a long time. As a result, Montreal ACC now requires: that trainees demonstrate their aptitude prior to commencing training in the terminal specialty; that personal friends not be placed in an instructor/trainee situation; and, that instructor controllers be briefed on monitoring procedures to be used with trainees having previous IFR experience.

Safety Action Required
(as indicated in the TSB Report)

Staffing, Opening and Closing of ATC Sectors

This risk-of-collision incident was caused in part by the untimely opening of an ATC sector.

In the CASB's Report on the Special Investigation into Air Traffic Control Services in Canada (March 1990), problems were noted with respect to, inter alia, timely decisions regarding the opening of sectors. Considerable judgement is required with respect to the timing of sector opening and closing. It was recommended in the report that the Department of Transport prescribe operating guidelines for the timing, staffing, and transfer of responsibilities for opening and closing sectors. In response, Transport Canada (TC) indicated that, due to changing operational conditions, it was impractical to develop fixed guidelines, with respect to timing, for the opening and closing of sectors.

Since 1990, the TSB has investigated two other occurrences in addition to this one in which the delayed opening or staffing of a sector was a factor (A9-0H0-008 and A90P034-7). In its final report on the latter incident, the Board expressed concern that occurrences resulting from the untimely opening of sectors were continuing. Furthermore, three recent TC Fact Finding Boards (FFB) on loss-of-separation incidents have identified factors related to the delayed opening of a sector (5400-42-38A-9203, 5400-42-48A-9207, and 5400-42-33A-9203).

The Board appreciates that there could be difficulties associated with the implementation of fixed guidelines for timing the opening and closing of sectors. The Board is also aware that Air Traffic Services agencies in other countries have experienced problems caused by the late opening of sectors and apparently have not been able to develop a formula fix either. TC has procedures regarding how sectors are to be opened and how controllers are to assume or relinquish control responsibilities. Evidently, knowing how to open a sector is not the issue; deciding when it is time to do so apparently is.

In view of the continuance of incidents in which the delayed opening of an ATC sector has been a contributing factor, operational supervisors require some form of assistance to ensure timely decisions on sector management. Therefore, the Board recommends that:

The Department of Transport provide operational supervisors with general criteria and practical training for making timely decisions on staffing, opening, and closing of sectors. (A93-13)

Transport Canada Response:

Transport Canada agrees with this recommendation. The following activities have been initiated in order to ensure that supervisory personnel are adequately trained:

  1. general criteria for the opening and closing of sectors are being developed and will be published for the guidance of all supervisors. Supervisors will be briefed on these criteria, once they are promulgated.
  2. these criteria will be reviewed on an annual basis during controller/supervisor refresher training;
  3. a formal training course is being developed for supervisory personnel. Staffing and the opening/closing of sectors will be included as a part of this training programs;
  4. the required staffing levels for the specialties/sectors in each Area Control Center have been reviewed, and adjustments to these staff levels have been approved. The approved levels are considered adequate to provide supervisors with the flexibility to staff sectors with sufficient controllers to meet normal traffic demands; and
  5. an ATS Safety Bulletin (known as SQUAWK 7700) will be published to provide all staff with information on the criteria for staffing and opening/closing sectors.

SSA93001 - A Safety Study of Piloting Skills, Abilities and Knowledge in Seaplane Operations

BACKGROUND

After a take-off run of approximately one mile, the aircraft became airborne near the end of the lake. It struck tree tops on the shore and continued to fly over rising ground until it struck trees on a ridge 1,300 feet from the lake. The aircraft crashed inverted and was destroyed by fire. Examination of the wreckage did not reveal any malfunction of the engine, airframe or controls. It was estimated that the aircraft was overloaded by approximately 200 lbs.1

Between 1976 and 1990, there were 1,432 seaplane2 accidents in Canada. During this period, 452 people died in 234 seaplane accidents. Figure 1 shows the seaplane accident experience by year.3

Since there is no requirement for seaplane operators to report the number of hours flown, the accident rate (number of accidents per one hundred thousand hours) is unknown. Seaplanes account for 19% of the Canadian aircraft fleet and 18% of the total number of accidents. However, in most parts of Canada, seaplanes operate only about six months of the year. Thus, the number of seaplane accidents would appear to be disproportionately high. Unfortunately, different annual utilization rates for landplanes and seaplanes are unknown.

It is observed, however, that aeroplanes which are most frequently float equipped, such as Piper Cub "derivatives" (J3, PA11, PA12, PA14, PA18, PA20, PA22), Cessna 172, Cessna 180, Cessna 206, Beaver, and Otter, have more fatal accidents on floats than on wheels. When these aeroplanes are on wheels, 10% of the accidents are fatal, but when on floats, 17% are fatal.

The Transportation Safety Board of Canada (TSB) conducted an examination of these 1,432 seaplane accidents in order to identify areas of seaplane operations where safety deficiencies might exist and which might require further study.

For analysis purposes, accident investigation agencies around the world, including the TSB and its predecessors, use the International Civil Aviation Organization (ICAO) Accident/Incident Data Reporting (ADREP) system. Under ADREP, accidents are assigned standardized contributing factors4. During the initial examination of the seaplane accidents, it appeared that contributing factors which could be associated with the pilots' levels of skills, abilities, and knowledge had been cited in a significant number of cases. Contributing factors such as "improper operation of...," "pilot selected unsuitable area," "operation beyond ability," "pilot failed to...(abort take-off, maintain control, follow procedures)," and "improper decisions" were frequently cited.

Link to complete study

CONCLUSIONS AND RECOMMENDATIONS

This examination of the occurrence record confirms that the incidence and severity of seaplane accidents is disproportionately high in comparison to landplanes. Loss of control during take-off, engine failure after take-off, collision with objects during take-off, and loss of control during approach and landing are the most frequent types of accident resulting in serious injuries or fatalities. The most frequently cited contributing factors in these accidents strongly indicate serious shortcomings in pilot knowledge, skills or techniques, and/or judgement in decision-making. In sum, the evidence calls into question the adequacy of current practices and requirements for initial and recurrent training from water.

Training

Presently, for training a pilot to fly seaplanes, it is assumed that the pilot need only be familiarized with the general handling characteristics of that class of aircraft. There are seldom any formal ground school sessions where the principles and practices of seaplane operations are explained, nor is any ground school required by regulations. Yet a pilot must be knowledgeable about a number of different operations and techniques to safely operate such aircraft. For example, knowledge of docking procedures, passenger safety procedures, float and hull design and construction, water leakage and drainage procedures, and proficiency in sailing, docking, glassy water, cross-wind and rough water take-offs and landings, etc.

In view of the frequency of seaplane accidents in which the pilot demonstrated inadequate knowledge of the practices and procedures for reducing the risks in operating seaplanes, or in which the pilot demonstrated inadequate technique or skills for the existing conditions, the Board recommends that:

The Department of Transport prepare comprehensive ground and flight training syllabi for the alternate seaplane endorsement; A93-14

and that

The Department of Transport consider including mandatory dual flight instruction in glassy water, cross-wind and rough water conditions in the alternate seaplane endorsement flight training syllabi. A93-15

Transport Canada Response - A93-14

Transport Canada concurs with this recommendation and will develop comprehensive ground and flight training syllabi for the alternate seaplane endorsement as a part of the ongoing Flight Training Guidance Material Enhancement Project. This is a joint Transport Canada and aviation industry project consisting of working groups whose objective is to develop new or enhanced flight training guidance in areas where additional needs are identified.

Transport Canada Response - A93-15

Transport Canada concurs with the need for instruction in glassy water, cross-wind and rough water conditions. A requirement for mandatory dual flight instruction could, however, result in a lack of continuity in training and an inordinately long wait for applicants to obtain the alternate seaplane endorsement because varied weather conditions are not always encountered within a reasonable time period. Therefore, in the absence of actual weather conditions and recognizing the need to ensure candidates receive meaningful instruction in these areas, alternative training procedures will be introduced in the flight training syllabus being developed for the alternate seaplane endorsement as a part of the Flight Training Guidance Material Enhancement Project.

Trainers' Qualifications

Seaplane conversion training may be conducted by any holder of a Commercial or Airline Transport Pilot Licence with 50 hours pilot-in-command experience on seaplanes. The pilot giving the training does not need to have ever submitted to a test of knowledge on seaplane operations, nor have any experience in training or flying training. In light of the circumstances of many of the occurrences which were studied, it is unrealistic to expect meaningful training, evaluation, and recommendation from a pilot whose only qualification is a minimum experience on seaplanes. Given the seasonal and remote nature of seaplane operations, maintaining quality control in the provision of sound pilot training for safe flight operations is a significant challenge. Yet, the occurrence record strongly indicates a need for improved methods for developing seaplane pilots' knowledge, skills, and judgement. In view of the unique requirements for safe flight operations from water, the Board recommends that:

The Department of Transport require an endorsement to the Commercial and Airline Transport licences for seaplane instruction which would entitle the holder to provide alternate seaplane flight and ground school training to pilots. A93-16

Transport Canada Response:

Transport Canada agrees that additional structure to the training for a seaplane endorsement will help instructors shape the course so that the identified performance objective are achieved. Proposed new legislation will require course approval and adherence to expanded training requirements that will be specified in the Personnel Licensing Handbook Volume1 - Flight Crew. As well, with the planned introduction of comprehensive ground and flight training syllabi to address TSB Recommendation A93-14, individuals authorized to conduct alternate seaplane training will be provided with more useful guidance.

Evaluation and Certification

The attainment of a given standard of knowledge or skill, particularly in the field of motorized equipment operation, generally requires some type of examination. Still, in the case of seaplane operations, a pilot is not required to demonstrate that he or she has acquired an acceptable level of skill, knowledge and decision-making ability. A pilot only needs to have flown the number of seaplane flying hours set out in the Personnel Licensing Handbook to obtain a seaplane rating; there is no requirement to pass a written, oral, or flight test. As a result, TC has no evidence that the applicant has reached a minimum proficiency standard. Although it is normally the trainer's responsibility to recommend the applicant for the seaplane rating, there is room for a wide variety of proficiency level assessments among trainers since there are no established proficiency standards.

To ensure that a minimum level of knowledge, skill, and decision-making ability has been attained after the completion of all required training, the Board recommends that:

The Department of Transport implement a specific knowledge and skill test for the alternate seaplane endorsement; A93-17

and that

The Department of Transport require that all seaplane endorsements be recommended by a seaplane instructor who has been designated as seaplane flight examiner. A93-18

Transport Canada Response - A93-17

Transport Canada agrees that applicants should meet specific knowledge and skills requirements for the alternate seaplane endorsement. The recommending instructor now certifies on the application for endorsement that the applicant has completed the training and experience prescribed in the Personnel Licensing Handbook, Volume 1, Flight Crew, and its competent to hold a seaplane rating.

With the development of the proposed comprehensive ground and flight training syllabi it is felt that these clearly stated performance standards will enable the recommending instructor to judge when a individual is qualified for the seaplane rating.

Transport Canada Response - A93-18

Transport Canada considers that the additional proficiency standards included in the new ground and flight training syllabi will be sufficient to allow the recommending instructor to make a valid assessment of the competency of the applicant for a seaplane endorsement.

Flying Currency for Passenger Operations

Recently, TC has moved to require five take-offs and landings in the previous six months if the licence holder wishes to carry passengers. However, no special provision has been made for the operation of seaplanes.

The Board does not believe that the conduct of five take-offs and landings in a landplane several months before a flight in a seaplane takes adequate account of the unique skills required to operate a seaplane, nor adequately safeguards the lives of the passengers aboard such aircraft. Accordingly, the Board recommends that:

The Department of Transport develop currency requirements appropriate for seaplane operations for pilots wishing to carry passengers on seaplanes. A93-19

Transport Canada Response - A93-19

The present currency requirements specify that a seaplane qualified pilot must be current on seaplanes in order to carry passengers.

Air Navigation Order, Series IV No. 2 requires, in paragraphs 9, 3 and 4, that where passengers are to be carried the holder of a pilot license shall have completed at least five take-offs and landings in the same category and class of aircraft. This requires a pilot in the aeroplane category and the single sea and multi-engine sea aeroplane class to complete these currency requirements within six months preceding the flight by day or night as appropriate.

Periodic Flight Review

For the purpose of its proposed biennial flight review, TC states that sea and land class aeroplanes shall be deemed to be the same class. Since unique skills and knowledge are required to fly seaplanes, demonstration of skill in a landplane will not confirm competence in the specific skills required for seaplane operations. Therefore, the Board recommends that:

The Department of Transport establish a mandatory periodic flight review on seaplanes for the maintenance of the operating privileges of a seaplane endorsement. A93-20

Transport Canada Response - A93-20

Transport Canada has developed a mandatory flight review that is currently undergoing consultation with the aviation industry. The flight review program recommends that a pilot complete the requirements specified in one of the following options once in each 24 month period:

  1. Completion of the proposed Flight Review program as defined in the Aviation Notice of March 5, 1992; or
  2. Attendance at a Safety Seminar conducted by Transport Canada, Aviation, or by an organization approved by the Minister which consists of:

a) a session designed to update the pilot on changes to Regulations, Orders and operating procedures; and
b) a session on Human Factors; or

3. Participation in a program approved by the Minister which is designed to enhance pilot knowledge and cognitive skills; or,

4. Successful completion of a Pilot Proficiency Check or mandatory training program as required by an applicable Air Navigation Order; or,

5. Successful completion of a flight test for a license or for the endorsement of a license for instrument rating or instructor rating privileges.

This flight review builds on proven programs that are now being delivered by Transport Canada and segments of the aviation community. As part of the ongoing consultation with the aviation industry, consideration will be given to including material specific to seaplane operations when appropriate.

Commercial Seaplane Pilot Proficiency Check

A proposed new pilot proficiency check (PPC) to be implemented by TC would require an annual check on the most complex single engine aeroplane that the pilot is to operate commercially in VFR. However, for commercial pilots engaged in seaplane operations, the expression "most complex aeroplane" might not always mean a seaplane.

The frequency of seaplane accidents involving commercial pilots suggests shortcomings with respect to the current practices for ensuring pilot proficiency. Therefore, the Board recommends that:

The Department of Transport require that a pilot proficiency check be performed on a seaplane if the pilot seeking the certification of proficiency is to operate seaplanes commercially. A93-21

Similarly, there is a requirement for pilots engaged in commercial operations to have completed within the preceding 90 days, on the same type of aeroplane they are to operate, at least three take-offs and landings. This requirement only applies to the type of aircraft, not the landing gear configuration. A seaplane pilot could therefore satisfy the requirement by having flown the same type of aircraft on wheels or skis in the preceding 90 days. By doing so, the intent of regency for take-offs and landings is defeated. Therefore, the Board recommends that:

The Department of Transport amend the 90-day requirement for commercial seaplane pilots so that the take-offs and landings must be performed on a seaplane. A93-22

Transport Canada Response - A93-21

Transport Canada agrees that the pilot proficiency check should be performed on the appropriate class of aircraft that the pilot operates. The new Air Taxi Standard which will be issued in conjunction with the new Canadian Aviation Regulations specifies the type of landing gear utilized in the performance of the competency check. This will certify the competency of each pilot in the most complex single-engine aeroplane type to be flown with the landing gear configuration, wheels, floats or skis, as appropriate to the operation.

Transport Canada Response - A93-22

Transport Canada agrees that the 90-day currency requirement should reflect the category and class of aircraft being operated by the individual pilot. Transport Canada Aviation will consult with industry through the Canadian Aviation Regulation Advisory Council regarding an amendment to the Air Taxi Regulation that would require the pilot to complete the 3 take-offs and landings within 90 days on wheels, skis or floats as appropriate.

Seaplane Pilots' Seminars

The decentralized nature of seaplane operations throughout Canada's remote regions requires that skills and techniques (beyond those acquired in initial seaplane training) be developed and passed on by experts in the field. These generally sound operating practices do not lend themselves to traditional regulatory controls. Therefore, seaplane pilots require alternative means for acquiring information to refresh and enhance their knowledge for safe seaplane operations.

Some industry representatives have indicated that local seminars would be an effective way of bringing experienced seaplane pilots together to share their experience regarding verified techniques and procedures with their peers. Therefore, in order to reinforce the foundation upon which certified seaplane pilots can build their piloting skills, abilities, and knowledge, the Board recommends that:

The Department of Transport, in collaboration with seaplane pilot associations and other aviation industry associations, require Seaplane Pilots' Seminars to be conducted regionally every year at the beginning of the normal seaplane season in strategic locations. A93-23

Transport Canada Response - A93-23

Transport Canada agrees that safety seminars can be beneficial in improving the safety of seaplane operations in Canada. The Transport Canada Regional Offices will coordinate, in conjunction with the industry associations, these seminars at appropriate times and locations.

Should you require further information, please contact Aviation Safety Analysis at asi-rsa@tc.gc.ca