Civil Aviation Safety Alert (CASA) No. 2014-03

ATTENTION:

  • CANADIAN AVIATION REGULATIONS (CAR) SUBPARTS 705 OPERATORS
  • CANADIAN AVIATION REGULATIONS(CAR) SUBPARTS 703 and 704 OPERATORS
PDF format (73 KB)
Issuing Office: National Aircraft Certification Document
No.
:
CASA 2014-03
File Classification No.: Z 5000 35 Issue No.: 01
RDIMS No.: 9490674 Effective Date: 2014-06-27

USING SMS TO ADDRESS HAZARDS AND RISKS ASSOCIATED WITH UNSTABLE APPROACHES

PURPOSE:

The purpose of this Civil Aviation Safety Alert (CASA) is threefold:

  1. To request Canadian air operators operating under subpart 705 of the Canadian Aviation Regulations (CARs) that they use—on a voluntary basis—their existing Safety Management System (SMS) to address and mitigate hazards and risks associated with unstable approaches;
  2. To advise 705 operators that beginning approximately one year after the publication of this CASA, Transport Canada Civil Aviation (TCCA) plans to direct specific surveillance activities to evaluate the effectiveness of voluntary compliance with this document and will begin looking for evidence of effective mitigations of this hazard; and,
  3. As the hazards and risks associated with unstable approaches are not limited to 705 operators, this CASA also serves to raise the concern to 703 and 704 operators who are not yet required to have a SMS, and encourage them to address the issue voluntarily.

BACKGROUND:

In its Final Report A11H0002, concerning the August 20, 2011, fatal Boeing 737 accident at Resolute Bay, NU, the Transportation Safety Board of Canada (TSB) determined that unstable approaches are a significant hazard, and has recommended that TCCA require CAR Subpart 705 operators to monitor and reduce the incidence of unstable approaches that continue to a landing. (TSB A14-01)

TCCA has determined that this hazard can be mitigated through an air operator’s existing SMS, and mitigations measures developed to manage the associated risks. TCCA committed to issue this CASA to advise industry accordingly.

TCCA is committed to reviewing the effectiveness of the recommendations contained in the CASA through inspection activities

RECOMMENDED ACTION:

TCCA requests that this hazard be assessed and mitigated through appropriate use of the following (but not limited to) SMS components:

  1. safety oversight (reactive and proactive processes);
  2. training and awareness (promotions);
  3. voluntary use of Flight Data Monitoring (in order to gain a greater understanding of unstable approaches and the causes.)

This may be determined by performing a proactive assessment of unstable approach hazards (including situations where this is more likely to occur), a review of SMS database to verify the rate of occurrence and to ensure this is being reported and finally, follow up with the pilot community to verify it is being reported and monitored through the SMS in order to verify a decrease in incidents and increased awareness of the hazard and attendant risks.

Alternatively, air operators who indicate that they do not have a problem with unstable approaches in their operation will be asked to demonstrate how they have reached this conclusion. Air operators with an established flight data monitoring program (FDM) are encouraged to use this program to gather and analyze this data.

TCCA will determine if an air operator’s SMS is capturing all risks including unstable approaches, and if so, if this risk is being analyzed and addressed properly.

CONTACT OFFICE:

For more information concerning this issue, contact Transport Canada, Civil Aviation Communications Centre by telephone at 1-800-305-2059 or by e-mail at services@tc.gc.ca.

ORIGINAL SIGNED BY

Aaron McCrorie
Director
Standards Branch

THE TRANSPORT CANADA CIVIL AVIATION SAFETY ALERT (CASA) IS USED TO CONVEY IMPORTANT SAFETY INFORMATION AND CONTAINS RECOMMENDED ACTION ITEMS. THE CASA STRIVES TO ASSIST THE AVIATION INDUSTRY'S EFFORTS TO PROVIDE A SERVICE WITH THE HIGHEST POSSIBLE DEGREE OF SAFETY. THE INFORMATION CONTAINED HEREIN IS OFTEN CRITICAL AND MUST BE CONVEYED TO THE APPROPRIATE OFFICE IN A TIMELY MANNER. THE CASA MAY BE CHANGED OR AMENDED SHOULD NEW INFORMATION BECOME AVAILABLE.

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