Recently Released TSB Reports

Recently Released TSB Reports Icon

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—Ed.

TSB Final Report A04A0110—Runway Excursion

On August 31, 2004, a Boeing 727-200 cargo aircraft was on a scheduled cargo flight from Toronto, Ont., to Halifax, N.S., with stops at Montréal, Que., and Moncton, N.B. The aircraft landed on Runway 29 at Moncton at about 12:22 Atlantic Daylight Time (ADT). After touchdown, the aircraft hydroplaned and departed the runway at the Taxiway Charlie intersection. It crossed the taxiway and came to rest on an abandoned runway threshold, a short distance from the taxiway. Damage was limited to tread damage to the four main landing gear tires, and destruction of a taxiway light. There were no injuries.

Runway Excursion
Aircraft moments after runway excursion

Findings as to causes and contributing factors

  1. The crew did not anticipate the effects of the adverse landing conditions and elected to continue the approach and landing.
  2. The pilot was unable to maintain directional control of the aircraft because of the combination of hydroplaning and a crosswind.
  3. Once the tires contacted the runway, there was insufficient time for the pilot to avoid the runway excursion.

Finding as to risk

  1. The flight data recorder (FDR) portion of the cockpit voice and flight data recorder (CVFDR) had not been checked in accordance with regulations, and therefore, poor data quality with some of the parameters on the recorder had not been identified.

Safety action taken

Since the occurrence, the operator has modified flight operations procedures and training with respect to slippery runway conditions. Also, flight crew and maintenance procedures have been amended for the maintenance and testing portions of the CVFDR.

TSB Final Report A05Q0008—Collision with Terrain

On January 24, 2005, at approximately 15:00 Eastern Standard Time (EST), the pilot of an Aérospatiale AS350 BA helicopter, with four hunters and one guide on board, was conducting an approach to an unserviced landing area on the edge of a lake, located in the James Bay area, 60 NM from La Grande-4, Que. At the end of the approach, the helicopter began to hover, and then started to descend into whiteout and loose snow conditions. The downdraught of the main rotor lifted the snow, causing a total loss of visual reference. After the left ski touched the snow-covered surface, the helicopter rolled onto its left side into snow that was several feet deep. During the rollover, the rotor blades struck the ground and the gearbox partly separated from the fasteners. Some blades penetrated the cockpit, fatally injuring the guide and the pilot, who was wearing a helmet. The four passengers sitting it the rear seats were not wearing seat belts, and received minor injuries. Two of the passengers were ejected from the aircraft, and ended up approximately 10 ft from the wreckage; the two others remained in the cabin. The survivors were evacuated by two other helicopters at approximately 16:30 EST.

Accident Site
View of wreckage and accident site

Findings as to causes and contributing factors

  1. The pilot did not detect that the slope on the landing area exceeded the maximum bank angle allowed for the aircraft, because the existing whiteout conditions made him lose his sense of depth. The helicopter rolled onto its left side following a dynamic rollover.
  2. The pilot did not notice the helicopter’s lateral displacement because the snow lifted by the rotor downdraught and the icing on the aircraft’s windows prevented him from seeing external references.

Findings as to risk

  1. The front seats did not conform to Service Bulletin 25.00.63, and separated from their anchorages when the helicopter rolled onto its left side.
  2. The occupants seated in the rear seats were not given a safety briefing before departure. They were not wearing seat belts, did not know where the emergency locator transmitter (ELT) is found or how to use it, and they did not know that the helicopter had survival equipment on board.

Other findings

  1. Service Bulletin 25.00.63, relating to the strengthening of the front seats, had not been carried out on the helicopter, but this did not contribute to the injuries suffered by the occupants of those seats.
  2. The investigation found that the other pilots who transported the occupants of the accident helicopter did not give the passengers a safety briefing, as required by the Canadian Aviation Regulations (CARs.)
  3. The survival equipment, which was in the left-hand baggage hold, was not accessible after the accident because the aircraft was resting on its left side.

TSB Final Report A05A0059—Stall and Loss of Control During Climb

On May 27, 2005, a de Havilland DHC-8-100 (Dash-8) aircraft was a passenger revenue flight from St. John’s, N.L., to Deer Lake, N.L., with 36 passengers and crew on board. During the climb-out from St. John’s, the indicated airspeed (IAS) gradually decreased to the point that the aircraft entered an aerodynamic stall. The aircraft descended rapidly, out of control, losing 4 200 ft before recovery was effected, approximately 40 s later. The incident occurred during daylight hours in instrument meteorological conditions (IMC). There were no injuries, and the aircraft was not damaged.

Findings as to causes and contributing factors

  1. During the climb, the captain inadvertently selected vertical speed (VS) mode on the automatic flight control system (AFCS) instead of the intended IAS mode, and neither flight crew detected the selection error.
  2. The operator’s standard operating procedures (SOPs) did not have a prescribed method for ensuring the correct selection of AFCS climb modes.
  3. The flight crew did not activate the pneumatic de-ice equipment while climbing in icing conditions.
  4. The flight crew did not detect the decreased airspeed until the aircraft was near the stall.
  5. The aircraft stalled at a higher-than-normal airspeed, with little advance warning, most likely due to accumulated ice on critical surfaces.
  6. The captain, believing that they had encountered severe turbulence, did not recognize that the aircraft had stalled, and did not apply the standard stall recovery technique.

Findings as to risk

  1. Typically, flight crews receive only limited training in stall recognition and recovery, where recovery is initiated at the first indication of a stall. Such training does not allow pilots to become familiar with natural stall symptoms, such as buffet, or allow for practice in recovering from a full aerodynamic stall.
  2. A significant proportion of Dash-8 pilots may hold outdated beliefs on the use of pneumatic de-icing equipment.

Safety action taken

The TSB issued Safety Advisory A050019-1 on July 22, 2005, on the subject of inadvertent selection of inappropriate AFCS modes of operation. The letter suggested that Transport Canada (TC) ensure that operators have incorporated measures into their procedures to ensure the correct selection and monitoring of AFCS climb modes. On October , 2005, TC responded, advising that a copy of the advisory had been passed on to all TC Regions, and that the Department would take the necessary action, as required. Since the occurrence, the operator has revised its SOPs to contain a challenge and response action whenever AFCS modes are engaged in the climb.

The TSB also issued Safety Advisory A50018-1 on July 22, 2005, on the subject of timely selection of pneumatic de-icing equipment. The advisory suggested that TC consider additional action to ensure that pilots are conforming to published de-icing procedures, and to dispel old beliefs about the proper use of pneumatic de-icing equipment. On October , 2005, TC responded, advising of additional efforts to move this information into published guidance material in the near future. As well, TC published an article in Aviation Safety Letter (ASL) 2/2006. This article informed pilots of the need to conform to published de-icing procedures, and attempted to dispel old beliefs about the use of pneumatic de-icing equipment.

Since the occurrence, the operator has directed its trainers to re-emphasize procedures for activation of pneumatic boots, as described in its SOPs and the aircraft flight manual (AFM). To reduce the likelihood of monitoring errors, the operator has directed all crews not to conduct paperwork during critical phases of flight. These duties are to be performed during level flight only while en route.

As a result of recent stall and upset occurrences in turbojet airplanes, TC has reinforced the need for appropriate training for the prevention of an airplane stall and for stall recovery. TC released Commercial and Business Aviation Advisory Circular (CBAAC) No. 0247—Training and Checking Practices for Stall Recovery on August 24, 2005.

TSB Final Report A05O0120—Aircraft Control Difficulty

On June 9, 2005, a Cessna TU206G was departing Hamilton, Ont., for Burlington Airpark, Ont. The aircraft departed from Runway 0 at approximately 12:00 Eastern Daylight Time (EDT) with only the pilot on board. During the take-off rotation and the initial climb, the aircraft had an increasing tendency to pitch nose-up. The pilot applied full nose-down trim, but the aircraft tendency to pitch nose-up continued. Excessive forward pressure on the control wheel was required to maintain an appropriate pitch attitude during the climb-out, and subsequent return to the Hamilton airport. The aircraft landed without further incident.

Findings as to causes and contributing factors

  1. The aircraft maintenance engineer (AME) misinterpreted the elevator trim tab travel limits and mis-rigged the elevator trim tab such that limited nose-down trim was available.
  2. The second AME did not detect the rigging error during the independent inspection because he relied on the first AME’s explanation of the rigging procedure.

Safety action taken

In an effort to minimize the risk of a mis-rigged control system, the operator included the requirements of Airworthiness Notice (AN) C010 in the maintenance control manual.

TSB Final Report A05Q0119—Collision with Water

On July 16, 2005, a Bell 205 A-1 helicopter, with a pilot and a loadmaster on board, was engaged in forest fire suppression operations at Solitude Lake, Que., about 25 NM northwest of Port-Cartier, Que. At approximately 12:20 Eastern Daylight Time (EDT), the helicopter hover taxied from a fuel cache site located at the south end of the lake. The helicopter was slinging an empty water bucket on a 100-ft longline. While decreasing power to bring the helicopter to a hover, the pilot felt a vibration, followed by a loud bang, and what seemed to be a loss of power. The helicopter quickly lost altitude and pitched nose down and to the right before striking the water. The pilot and loadmaster managed to exit the helicopter while it was sinking, and were rescued by nearby firefighters. The pilot-in-command was seriously injured. The loadmaster sustained minor injuries. The helicopter was substantially damaged.

Bell 205 A-1

Findings as to causes and contributing factors

  1. The helicopter was positioned too far from shore to provide adequate visual references for longline operations, and it is likely that the water bucket inadvertently entered the water while the helicopter was transitioning from a hover taxi to a hover.
  2. The anchor effect of the water bucket may have caused the helicopter to swing downwards, and there was insufficient time, altitude, or visual references to prevent the helicopter from striking the water.
  3. The pilot was not wearing the available shoulder harness during longline operations, which likely contributed to the severity of his injuries.

Findings as to risk

  1. Although there was no effect on engine performance, the presence of unauthorized parts and the unbent first stage compressor blade locking tabs denote a lack of quality control on the part of both maintenance facilities involved.
  2. Although the fuel product identifying stickers met provincial regulations, the similarity between the stickers may lead to misidentification of the fuel product.
  3. The crew members were not wearing lifejackets, as stipulated in the company operations manual. Although both survived their injuries, the pilot did not know how to swim, and may have drowned had he not been rescued by nearby firefighters.

Other findings

  1. Many military and commercial parts share the same part numbers, and therefore, the accompanying tag is not sufficient to confirm that the part is authorized for commercial use. Its validity must be cross-referenced with the Commercial and Government Entity (CAGE) code. It is not mandatory to indicate the CAGE code on the accompanying tag.
  2. The lack of a CAGE code on the accompanying tag resulted in the issuance of a certificate of airworthiness (C of A) without the benefit of complete and adequate documentation.

Safety action taken

On June 5, 2006, the TSB issued Safety Information Letter A060026-1—Inadequate Identification of Fuel Barrels to the Director General of Civil Aviation. The Safety Information Letter highlighted the criticality of proper identification of fuel barrels. The use of fuel barrels for remote helicopter operations is widespread throughout Canada.

On April 11, 2007, the TSB issued Aviation Safety Information Letter A070004—Inadequate Identification of Parts to the Director General of Civil Aviation. The Aviation Safety Information Letter highlighted the fact that the identification on a data plate or the scribe on a part, along with its tag confirming its traceability, are not sufficient to attest that the part is authorized for commercial use. Its validity must be checked against a CAGE code, which identifies the manufacturer and the purchaser. These codes are available on the Business Identification Number Cross-reference System (BINCS) Web site.

Transport Canada published an article entitled “Inadequate Identification of Fuel Barrels” in the Aviation Safety Letter (ASL)4/2006. The ASL is distributed worldwide to over 90 000 readers.

TSB Final Report A05A0161—Wing Contact with Runway During Landing

On December 25, 2005, a Boeing 737-700 was on a scheduled passenger flight from Toronto, Ont., to Halifax, N.S. Just before touchdown on Runway 14, in low-visibility conditions, the aircraft rolled right and moved toward the right side of the runway. The aircraft then rolled to the left, and the left wing struck the runway. None of the passengers or crew members was injured, and the aircraft taxied to the terminal. The incident occurred at 19:24 Atlantic Standard Time (AST), during the hours of darkness.

Boeing 737-700

Findings as to causes and contributing factors

  1. The crew did not carry out a pilot-monitored approach in accordance with company procedures, and therefore, disabled a critical safety defence established to manage landing safely in the low-visibility conditions.
  2. The transition from the approach to the landing phase became destabilized when the co-pilot disconnected the autopilot, resulting in the aircraft wing contacting the runway when the aircraft was being manoeuvred to correct the situation.
  3. The co-pilot’s inability to keep the aircraft stabilized during the transition to landing and his selection of the take-off/go-around (TOGA) mode were likely the result of his limited experience on type, and the stress from the low-visibility and relatively-high workload conditions.
  4. The captain did not take control or command a go-around once the transition became destabilized.

Finding as to risk

  1. The touchdown point, in conjunction with the delay in application of reverse thrust, increased the risk of a runway overrun.

Other finding

  1. Significant data were lost to the investigation because the cockpit voice recorder (CVR) was not shut down after it was determined that the aircraft wing had struck the ground, depriving the investigation team of possible important information.

Safety action taken

The flight crew were given simulator training in low-visibility approaches, and completed line checks with a company check pilot.

A memorandum was issued to all dispatch personnel, advising them that, when passing on runway visual range (RVR) information to flight crew, they must also include the applicable runway along with the time and date. The memorandum will be included in the next flight dispatch operations guide revision. Guidance on the required information will be given during training for dispatch personnel.

Revisions to flight crew training procedures have been introduced that place additional emphasis on hazards associated with low-visibility transition to visual references during instrument approaches, and on the requirement to use monitored approach procedures in these conditions. In addition, training will involve discussion of procedures to be carried out in the event of loss of visual reference below decision height (DH), such as missed approach and rejected landing procedures.

The approach procedures for Category I and II instrument landing system (ILS) approaches are being harmonized to make both procedures as similar as possible.

Amendments to the operator’s company operations manual have been issued, outlining the changes to the approach ban limits.

The operator has completed an internal risk assessment and has entered into discussions with NAV CANADA, Transport Canada, and other industry organizations to explore the possibility of conducting auto-landings on Category I ILS approaches.

Transport Canada
Aviation regulations have been amended to prohibit commercial air operators from beginning an approach when visibility is so poor that a successful approach to a landing is unlikely.

The regulations establish, for all runways where visibility is reported, the minimum visibility for the crew to begin an approach in what is termed an approach ban.

The amendments also extend the requirements to runways where conditions are reported by an instrument-rated pilot or qualified person rather than a sensor. In addition, the regulations help harmonize Canadian regulations with international standards, and respond to recommendations from the TSB.

These changes came into force December 1, 2006, and affect commercial air operators. The most significant changes to the approach ban affect commercial air operators holding operating certificates under the Subparts 702, 703, 704 and 705 of the Canadian Aviation Regulations (CARs), operating airplanes in instrument flight rules (IFR). Minimal changes to the approach ban affect IFR commercial helicopter operations, and IFR aircraft operations by private operators and general aviation.

For more information regarding the new approach ban regulations, visit the Transport Canada Web site.

TSB Final Report A06W0104—Loss of Control and Collision with Terrain

On July 3, 2006, a Bell 206B Jet Ranger helicopter was departing from a prepared helicopter landing area adjacent to the Nose Mountain, Alta., fire observation tower at approximately 18:15 Mountain Daylight Time (MDT). A pilot and three initial attack firefighters were on board. The landing area was located in a clearing, on a mountain plateau, situated at the north edge of a steep escarpment. After lifting off, the pilot hover taxied around a pile of brush on the west side of the clearing and departed in a westerly direction, toward the escarpment. When the helicopter overflew the rim of the escarpment, it began to yaw to the right. The pilot was unable to control the yaw with the application of full left pedal. As the helicopter rotated through 180°, the pilot lowered the collective to regain directional control. The helicopter descended onto the escarpment, rolled over, and came to rest on its left side. One firefighter sustained fatal injuries and another firefighter sustained serious injuries. The pilot and the third firefighter sustained minor injuries. The impact forces activated the onboard emergency locator transmitter (ELT). The helicopter was substantially damaged, but there was no post-impact fire.

Bell 206B

Findings as to causes and contributing factors

  1. The conditions of a shifting tailwind, over-gross weight, and high-density altitude collectively exceeded the rotor and engine performance limits of the helicopter, and the helicopter was unable to take off in the distance available.
  2. Rotor performance was further lost when the helicopter flew out of ground effect over the rim of the escarpment, precipitating a degenerating situation of insufficient power available, and the helicopter could not sustain flight.
  3. In the conditions encountered during the takeoff, the helicopter entered a vulnerable regime where unanticipated right yaw occurs. There was insufficient tail rotor thrust to counter the torque from the main rotor, and the helicopter turned right.
  4. Although the pilot’s recovery actions arrested the right turn, there was insufficient height to prevent the helicopter from striking the terrain.
  5. The inhospitable characteristics of the terrain immediately below the helicopter prevented the pilot from carrying out an uneventful landing, and the helicopter rolled over on touchdown.
  6. The weight of the helicopter at takeoff was incorrect because of inaccurate estimates of the weights of the firefighters, their gear, and the equipment. For the existing conditions, the take-off weight exceeded both the maximum gross weight limit and the hover out of ground effect (HOGE) ceiling limit.
  7. The main rotor penetrated the left-side cockpit and cabin, contributing to the severity of the injuries to the passengers.
  8. It is probable that the passenger in the rear left seat was not wearing the available shoulder harness; this likely increased the severity of his injuries.
  9. There was no system in place for the Alberta Ministry of Sustainable Resource Development, Forest Protection Branch (ASRD-FPB) to provide helicopter pilots with actual individual weights of fire crew and their personal gear.

Bell 206B
Forward left view of main rotor strike damage to cockpit

Safety action taken

On December 11, 2006, the TSB issued Safety Information Letter A060041—Passenger and Equipment Weights in Helicopter Fire-Fighting Operations to the Director, Wildfire Operations, Alberta Ministry of Sustainable Resource Development. The Safety Information Letter identified that assiduous monitoring of passenger and equipment loads is the sole solution to prevent overloading of helicopters, and that a process to provide pilots with accurate firefighter crew and gear weights may help to ensure that helicopters involved in firefighting activities in Alberta are flown within prescribed weight and balance limits. In response to Safety Information Letter A060041, the ASRD-FPB advised that it was taking the following actions:

  • The “Equipment List and Weights” in the ASRD-FPB’s pilot’s handbook will be reviewed.
  • The elevation of the tower and fuel cache sites will be added to the ASRD-FPB publications and 2007 air operations maps.
  • High-quality weigh scales will be purchased for use by crews at the primary fire bases and warehouses.
  • A copy of the Safety Information Letter has been distributed to all ASRD-FPB area offices.
  • The pilot responsibilities and ASRD representative responsibilities have been clarified in sections 6.10 and 6.11 of the ASRD-FPB standard operating procedures (SOPs), as follows:
    • The pilot is responsible for completing the load calculation correctly, using the proper performance chart information, as per the company’s operations manual, Canadian Aviation Regulations (CARs) and the Commercial Air Service Standards (CASS).
    • The pilot is responsible for computing the allowable payload.
    • The pilot shall check, or be informed of, any subsequent passenger/cargo manifested weights completed under the initial load calculation, to ensure that allowable payloads are not exceeded.
    • The ASRD representative responsible for a flight (for example, crew leader, loadmaster, wildfire ranger, forest officer) is responsible for providing the pilot with a complete passenger/cargo manifest, including accurate weights, and advising the pilot of all dangerous goods being carried.
    • The passenger/cargo manifest/weights form can be used to record the information given to the pilot.

On May 14, 2007, the FPB advised that all the proposed remedial actions had been implemented. As well, aviation audits were conducted at three of the four major Mountain Pine Beetle controls within Alberta, and the issue of providing accurate weights was reviewed and stressed at a recent training course for Type 1 and Type 1F initial attack leaders.

Date modified: