TSB calls on Transport Canada to simplify approach and landing weather minima and to prevent approaches in very low visibility

From Transportation Safety Board of Canada 

DORVAL, QC, May 21, 2020 /CNW/ – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18Q0030) into a runway overrun that occurred in Havre-Saint-Pierre, Quebec, in February 2018. Among the issues identified, the investigation found that the rules that govern instrument approaches in Canada are too complex, confusing and ineffective at preventing pilots from conducting approaches that are not allowed, or banned, because they are below the minimum weather limits.

On 26 February 2018, a Beechcraft King Air A100 operated by Strait Air (2000) Ltd. was conducting charter flight NUK107 under instrument flight rules, from the Sept-Îles Airport, Quebec, to the Havre St-Pierre Airport, Quebec, with two crew members and six passengers on board. Prior to departure, the weather at Havre St-Pierre aerodrome indicated a visibility of ¾ of a statute mile in light snow. Although below the one mile of visibility published on the approach chart, visibility was at the minimum limit permitted for this flight. Enroute, the crew received the updated weather, which indicated that the visibility had deteriorated to just ¼ mile in heavy snow—well below the minimum visibility allowed to conduct the approach. However, the pilot believed he could continue the approach safely. When the pilot saw a small patch of runway, he continued the landing, touching down just 700 feet before the end of the runway. Without enough runway to slow down, the aircraft overran the end and came to a stop in a large snowbank approximately 220 feet beyond the end of the runway. The aircraft sustained substantial damage, and four of the occupants received minor injuries.

Elsewhere in the world, aerodromes use the published visibility as the minimum limit, to determine if an approach is authorized. If the reported visibility is lower than what is published, air traffic control (ATC) will not let an aircraft carry out the approach. In Canada, flight crews are permitted to conduct approaches in visibility conditions that are below what is published. Transport Canada (TC) regulations applicable to approach limits are complex and contain many exceptions that can be misinterpreted. Flight crews have to consult multiple reference documents and consider a variety of factors to determine if an approach is allowed. The current rules also make it difficult for ATC to determine whether an approach is authorized. As a result, ATC will clear an aircraft for an approach regardless of the published minima, leaving the ultimate decision to conduct the approach to the flight crew.

This investigation found that, based on the pilot’s interpretation of the various factors and exceptions relating to the approach ban, he incorrectly believed that he was allowed to conduct the approach. As well, the approach ban did not prevent the pilot from conducting the approach in weather conditions that were below the minimum limits.

Today the Board is making two recommendations to address these issues:

First, that TC review and simplify operating minima for approaches and landings at Canadian aerodromes.

Second, that TC introduce a mechanism to stop approaches and landings that are actually banned.

Finally, the investigation found issues with a number of the company’s Standard Operating Procedures (SOPs) including the pre-flight inspection and planning for the approach. In this occurrence, a deviation from SOPs at a critical moment of the flight was a key factor that contributed to the runway overrun. Therefore, the Board is concerned that, if TC does not provide the necessary oversight of flight operations by assessing the effectiveness of crew resource management, threat-and-error management, decision-making, and SOPs, these procedures may not be effective, increasing the risk of an accident, particularly an approach-and-landing accident.

Runway overruns is a key safety issue on the 2018 Watchlist, and has been on the TSB Watchlist since 2010.

Poor visibility and vehicle tracking data error contributed to 2019 runway incursion at Toronto/Lester B. Pearson International Airport

From Transportation Safety Board of Canada

Richmond Hill, Ontario, 12 May 2020 — The Transportation Safety Board of Canada (TSB) today released its investigation report (A19O0006) into a runway incursion by snow removal vehicles that took place in 2019 at the Toronto/Lester B. Pearson International Airport, Ontario.

On 28 January 2019, a Sky Regional Airlines Embraer ERJ 170-200 was preparing to depart on Runway 06L for a flight from Toronto/Lester B. Pearson International Airport (CYYZ), Ontario, to Dallas-Fort Worth International Airport (DFW), Texas, United States. At the same time, a group of four snow removal vehicles was operating north of this runway and had been instructed by ground control to turn left onto Taxiway C to continue their operations. However, heavy snow had obscured visual cues on the taxiways and the vehicles inadvertently lined up with the entrance to Taxiway C2 instead. They kept moving toward Runway 06L, when three of the vehicles continued past the runway holding position. The ground controller then instructed the vehicles to stop, which they did just before reaching the runway surface. The tower controller instructed the flight crew of the departing aircraft to abort the takeoff. After rejecting the takeoff, the aircraft came to a stop on the runway just short of the intersection with Taxiway C2, with the plows approximately 200 feet to the left of the aircraft. None of the vehicles nor the aircraft were damaged and no injuries were reported.

The investigation found that, in December 2018, a transponder from one of the snow removal vehicles (PLOW 170) was installed onto another (PLOW 862) without the transponder code being updated. As a result, the vehicle was incorrectly identified on the ground radar system. It was also found that, at the time of the occurrence, the NAV CANADA control tower at CYYZ did not have procedures to follow if there was a mismatch between a vehicle call sign and its transponder code.

Additionally, the investigation determined that because of reduced visibility from blowing snow, the operator of the lead vehicle, PLOW 862, was not aware that the vehicle was on Taxiway C2, as it approached the holding position. As a result, the operator was not looking for, nor expecting to see, any of the visual cues that would have alerted him that the vehicle was approaching an active runway. Further, some of the visual cues at the runway holding position were obscured by snow, while others may not have been working. The cues were not conspicuous enough to alert the operator of PLOW 862 to the vehicle’s proximity to the runway. This led to the first three vehicles proceeding past the holding position towards the runway.

The ground controller recognized the incursion by PLOW 862 and instructed the vehicle to stop four times; however, the first two instructions were addressed to PLOW 170 rather than PLOW 862, because of the transponder mismatch. Immediately after the ground controller used the correct call sign, PLOW 862 came to a stop after crossing the holding position on Taxiway C2.

The risk of collisions from runway incursions has been on the TSB Watchlist since its inception in 2010 and calls for effective defences tailored to address identified hazards at airports and in aircraft, vehicles, and air traffic service facilities across Canada.

Following this occurrence, the Greater Toronto Airports Authority (GTAA) amended its standard operating procedure to ensure that the correct code is displayed by NAV CANADA’s systems when a new transponder is installed on an airport vehicle. Also, in response to TSB Recommendation A18-04, NAV CANADA has amended its abort takeoff phraseology to include repetition as a method to ensure that the instructions are sufficiently compelling to be recognized during periods of high workload, such as takeoff.

Plane from Yellowknife slides off runway in Kugaaruk and into snowbank

News from CBC News – link to story and updates

No passengers on board Buffalo Airways plane, crew members safe

Beth Brown · CBC News · Posted: Apr 28, 2020

A Buffalo Airways plane sits in a snowbank at the runway in Kugaaruk, Nunavut, on Tuesday. The plane landed around 1 p.m. MT. All crew members on board are safe and there were no passengers. (Submitted by Barnaby Immingark)

A King Air plane operated by Buffalo Airways slid off the runway in Kugaaruk, Nunavut, on Tuesday, during low visibility weather.  

The plane landed around 1 p.m. MT., according to a resident. All crew members on board are safe and there were no passengers, according to Buffalo Airways.

In a news release, Buffalo Airways said the aircraft “slid off the side of the runway and into a snowbank” on Tuesday afternoon.

NAV Canada reporting shows winds were around 50 km/h and snow was blowing moderately at the time. 

The Transportation Safety Board has been notified as part of the company’s emergency response plan, the release said. 

The aircraft was en route from Yellowknife, according to flight tracking website FlightAware.

With files from Salome Avva

Operators of 787s warned after latest ILS deviation incident at Hong Kong

From Flight Global – link to story

By David Kaminski-Morrow. 25 April 2020

Hong Kong authorities have warned Boeing 787 operators of possible adverse autopilot behaviour during localiser capture at the city’s international airport, after the latest in a string of incidents involving the type.

A newly-issued NOTAM instructs carriers to check a Boeing flight crew operations bulletin referring to “anomalies” in localiser capture and possible misbehavior by the autopilot flight-director system, particularly during ILS approaches to runways 25R and 25L.

It states that the issue can lead to “proximity to high grounds”, adding that – if it doubt – crews should climb back to minimum sector altitude and conduct a missed approach.

The NOTAM follows an incident on 21 April involving an Air Canada 787-9, arriving from Vancouver, which had been cleared for an ILS approach to 25L.

Transportation Safety Board of Canada says the crew contacted air traffic control after reaching the waypoint LOTUS, located about 15nm from the threshold, and reported being established on the ILS.

After controllers advised the crew to switch to the Hong Kong tower frequency, they observed the aircraft “overshooting the localiser” of 25L and descending to 3,900ft – below the minimum sector altitude of 4,300ft.

Controllers contacted the crew to warn of terrain and the pilots corrected the flightpath to re-intercept the ILS. The crew reported receiving a “false capture” of the ILS, says the safety board, which adds that the pilots had visual contact with both the terrain and the airport at the time.

The safety board indicates that only four occupants were on board the 787 (C-FNOH), suggesting it was operating a special freight supply service.

Boeing has been working on a resolution to the issue, which has affected several 787 flights into Hong Kong including four between July and October last year involving aircraft operated by Virgin Atlantic, Ethiopian Airlines, and Etihad Airways.

Canada asks Iran to delay download of Flight 752 black boxes due to coronavirus

News from The Globe and Mail – link to story

OTTAWA, THE CANADIAN PRESS, PUBLISHED APRIL 12, 2020

A woman pauses at a makeshift memorial prior to a ceremony in Montreal, Jan. 19, 2020, to remember those who lost their lives in Ukraine International Airlines Flight 752 which was shot down shortly after takeoff in Iran on Jan. 8, 2020.GRAHAM HUGHES/THE CANADIAN PRESS

The investigation into Iran’s downing of a commercial jetliner that killed dozens of Canadians in January has hit a snag due to COVID-19.

Canada and other countries had been waiting months for Iran to hand over the flight recorders from the doomed Ukraine International Airlines Flight 752 so their data can be downloaded and analyzed.

Yet while the Transportation Safety Board of Canada says Iranian authorities reached out last week to see when interested countries would be available to have representatives on hand for the process, travel bans imposed due to COVID-19 have made it impossible to attend now.

As a result, the TSB says Canada and other countries who lost citizens when the plane was shot down have asked that Iran put off downloading and analyzing the data from the so-called black boxes until travel restrictions have been lifted.

Flight 752 was shot down by the Iranian military on Jan. 8, killing all 176 people on board, including 55 Canadians and 30 permanent residents.

The federal government recently appointed former Liberal cabinet minister Ralph Goodale as an adviser on the matter after the families of some of those killed on the plane complained COVID-19 was detracting from efforts to hold Iran to account.

TSB investigates fire in landing gear of Air Canada plane in Montreal

News provided by Global News – link to full story and updates

BY STAFF THE CANADIAN PRESS Posted February 25, 2020

An Air Canada Jazz aircraft sits at a terminal at the Ottawa airport on April 13, 2012.
 An Air Canada Jazz aircraft sits at a terminal at the Ottawa airport on April 13, 2012. Adrian Wyld/The Canadian Press

The Transportation Safety Board of Canada is investigating after a suspected fire broke out in the landing gear of an Air Canada Jazz plane as it landed at Montreal-Trudeau International Airport Tuesday morning.

The agency said no injuries were reported and no emergency evacuation of the plane was required.

The Dash 8 aircraft was heading to the gate after arriving from Ottawa at about 6 a.m. when the fire was spotted in the landing gear, according to the TSB.

A spokesperson said airport firefighters were quickly able to put it out, and the plane was then towed to the gate to allow passengers to disembark.

Air Canada characterized the incident as “a failure on one of the ball bearings on one of the wheels,” which caused smoke and sparks.

“In accordance with our procedures, the pilots requested the presence of emergency vehicles as a precaution,” the company said in a statement.

The Transportation Safety Board said it was sending a team of investigators to the site to inspect the plane’s landing gear and speak with the crew.© 2020 The Canadian Press

TSB will deploy an investigator to Dryden, Ontario, following a runway excursion

Provided by Transportation Safety Board of Canada/CNW

WINNIPEG, Feb. 25, 2020 /CNW/ – The Transportation Safety Board of Canada (TSB) will deploy an investigator tomorrow to the Dryden Regional Airport, Ontario, following a runway excursion that occurred on 24 February 2020. The TSB will gather information and assess the occurrence.

TSB deploys an investigator to the Montréal Trudeau International Airport, Quebec, following an incident during the taxi phase

Provided by Transportation Safety Board/CNW

DORVAL, QC, Feb. 25, 2020 /CNW/ – The Transportation Safety Board (TSB) is deploying an investigator to the Montréal Trudeau International Airport, Quebec following an incident during the taxi phase of an Air Canada aircraft after landing. The TSB will gather information and assess the occurrence.

TSB is deploying a team of investigators to a Cessna 150 aircraft accident near Montréal/Les Cèdres Airport, Quebec

Provided by Transportation Safety Board of Canada (TSB)

DORVAL, QC, Feb. 17, 2020 /CNW/ – The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the site of a Cessna 150 aircraft accident that occurred near Montréal/Les Cèdres Airport, Quebec. The TSB will gather information and assess the occurrence.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

TSB issues safety warnings after investigating fatal Labrador crash

News provided by CBC News – link to full story and updates

U.K. resident Alan Simpson, 73, died in crash last spring

Jacob Barker · CBC News · Posted: Jan 27, 2020

This is the wreckage of the Piper aircraft that crashed last spring near Makkovik. (Submitted by Sam Rutherford)

The federal agency that investigates air accidents is telling pilots to “maintain situational awareness” following its investigation into a fatal plane crash in Labrador last spring. 

In May, a small Piper aircraft that was being ferried from the United States to the United Kingdom via Greenland crashed into the side of a hill outside Makkovik.

Alan Simpson, one of the two men piloting the plane, died in the crash. The other pilot, Samuel Rutherford, got out with minor injuries following a harrowing rescue by Makkovik’s ground search and rescue team in blizzard-like conditions.

According to the findings of the investigation by the Transportation Safety Board, the plane crashed about 60 metres below the peak of a hill about 685 metres high. 

While the highest point of elevation on the route was about a thousand metres, the flight plan showed the pilots would climb to about 600 metres, and then to climb to a higher altitude about midway through the flight where wind conditions were said to be more favourable.

A map in the Transportation Safety Board investigation report shows the crash location, about 70 kilometres outside the town. (Transportation Safety Board)

The report said the pilots filed a visual flight plan — meaning using their eyes instead of instruments to see what’s in front of them — before leaving so they could manoeuvre around weather and terrain while remaining clear of clouds. 

“In this occurrence, the plan to initially fly VFR [visual flight rules] below the highest terrain elevation along the route introduced two hazards: flying over rising terrain in deteriorating weather conditions, and flying over snow-covered featureless terrain,” the report says.

The TSB classified the crash as a “controlled flight Into terrain,” which happens “when an airworthy aircraft under the control of the flight crew is flown unintentionally into terrain, obstacles, or water, usually with no prior awareness by the crew.”

“In this occurrence, the altitude that was planned and flown was lower than the highest elevation of terrain along a route where visual references to the ground were reduced,” reads the report.

“The ferry pilot knew the hill existed and had planned to fly around it or over the top if visual reference was lost; however, that plan was not executed, and impact occurred without warning.”

Pilot’s reflections

Rutherford travelled back to Labrador last summer to thank the team that came to his rescue. 

He says one of his main takeaways from the report was this line: 

“It is important for pilots to operate aircraft with adequate clearance from obstacles and terrain along a VFR route. In such situations, it is important that pilots maintain situational awareness in order to reduce the risks associated with flight into rising terrain by using all available means.”

That didn’t happen in their crash, he told CBC in a Facebook message.

“The situational awareness was not maintained.  Either visually by the handling pilot, or by use of the aircraft systems (the terrain database had not uploaded correctly),” he wrote

“The hill was the only place for miles around without any trees — until then, using visual cues to maintain situational awareness had worked perfectly (even without the terrain database).”

Sam Rutherford, seen here in the Makkovik clinic after the crash, travelled back to Labrador last summer to thank the team that rescued him and tried to rescue his co-pilot. (Submitted by Sam Rutherford)

He said he believed Simpson thought the big white shape in front of him was a very long body of water.

“But it was was actually a rising hill with no trees. Visually identical, very different in reality,” he said.

Rutherford again thanked the rescue crews who came to his aid.

“They gave Alan and myself a chance by putting their own lives on the line. Thank you,” he said.