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Aviation Safety Letter 3/2002

Recently Released TSB Final Reports

The following excerpts are extracted from Final Reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include only the TSB's synopsis and selected findings. We encourage our readers to read the complete Final Reports on the TSB's website at http://www.tsb.gc.ca/ - Ed.

TSB Final Report A00Q0006 - Collision with the ground

On January 13, 2000, a de Havilland DHC-2 Mk. 1 Beaver skiplane, with the pilot and five passengers on board, took off from the frozen surface of Lake Adonis, Quebec, on a pleasure flight under visual flight rules (VFR). The route had not been determined, but the flight was to last about 20 min. When the aircraft did not return, the search and rescue (SAR) service was advised. The aircraft was found crashed on a mountainside in a wooded area a little less than 5 km from its point of departure. The pilot and two passengers suffered fatal injuries. The other three passengers suffered serious injuries and hypothermia. The aircraft was destroyed by the force of the impact, but did not catch fire.

Findings as to Causes and Contributing Factors

  • The aircraft probably stalled with insufficient altitude for the pilot to execute a recovery.
  • The prevailing conditions were conducive to optical illusions associated with low-altitude flight over rising terrain.
  • The aircraft was not equipped with a stall warning system, nor was it required by regulation.
  • The pilot's decision to fly at low altitude and probably use cutback power for the climb did not allow for safe obstacle clearance.
  • The pre-flight safety briefing did not inform passengers where to find the survival equipment on board the aircraft. Consequently, they could not use the sleeping bags to protect themselves from exposure and thereby delay hypothermia.
  • Rescue was late because the mostly white aircraft blended into the snowy ground, making it difficult to locate, and the emergency locator transmitter (ELT) antenna was broken, reducing the range of the signal. Consequently, the survivors' exposure time was increased.

TSB Final Report A00O0057 - Midair Collision

On March 13, 2000, a Cessna 337 with only the pilot on board was conducting a highway traffic reporting mission and was in a left-hand orbit at 2000 ft above sea level (ASL) over a section of Highway 401 about 18 NM NE of Toronto/City Centre Airport. The aircraft was in a left turn when it passed from right to left underneath a Cessna 172. The Cessna 172, conducting a training session with one instructor and one student on board, was returning to Toronto/City Centre Airport from the practice area. Both pilots were flying under VFR. The Cessna 172 was descending on a steady southwesterly heading when the two aircraft collided. The nose gear of the Cessna 172 struck the left vertical stabilizer of the Cessna 337. Approximately half of the left vertical stabilizer and left rudder separated from the Cessna 337. The Cessna 172 nose gear assembly was damaged. Both pilots were able to maintain control of their aircraft. The Cessna 172 instructor pilot continued to Toronto/City Centre Airport and landed safely. The Cessna 337 pilot returned to Toronto/Buttonville Municipal Airport and landed without further incident. The accident occurred during daylight hours, in visual meteorological conditions (VMC).

Findings as to Causes and Contributing Factors

  • Neither the Cessna 337 pilot nor the Cessna 172 instructor or student pilot saw the other aircraft in time to avoid the collision.
  • The collision occurred in Class E airspace in a busy VFR corridor near a VFR route that is published in the Canada Flight Supplement (CFS). No frequency is specified for use by VFR aircraft flying on the route. Air traffic control (ATC) does not provide traffic information or conflict resolution to VFR aircraft in Class E airspace.
  • The aircraft were on different radio frequencies, and there was no direct communication to alert either pilot to the presence of the other aircraft.
  • The Cessna 337 pilot was conducting a highway traffic reporting mission, a task that detracted from his ability to maintain an effective lookout for other air traffic.
  • The see-and-be-seen principle of VFR separation has inherent limitations and cannot always provide positive separation, particularly in areas of high-density air traffic. The VFR corridor where the collision took place is a known high-density air traffic area.

Safety Action Taken

Transport Canada initiated a System Safety Review of VFR operations in the Greater Toronto Area following the occurrence. This is a systematic evaluation process in which a Safety Review Team identifies hazards and system deficiencies and develops mitigation plans for these hazards and system deficiencies. The operator of the Cessna 337 has taken steps to improve the safety of the operation. The aircraft is operated with landing lights, navigation lights, anti-collision lights and beacon activated.

TSB Final Report A00H0007 - Gear-up Landing

On December 4, 2000, a Beechcraft King Air A100, with two pilots on board, departed from the Ottawa/McDonald-Cartier International Airport, Ontario, on a visual flight rules (VFR) training flight. The aircraft proceeded to Ottawa/Gatineau Airport, Quebec, to conduct practice visual approaches and landings. A visual circuit and approach to runway 27 was flown with the left engine at low power, simulating an engine failure. The landing gear was not lowered before landing, and the aft fuselage and both propellers contacted the runway surface. The captain initiated a successful go-around, declared an emergency, and subsequently landed the aircraft at Ottawa/McDonald-Cartier International Airport. There were no injuries.

Findings as to Causes and Contributing Factors

  • A simulated single-engine, flapless landing was conducted with its landing gear warning horn silenced.
  • The King Air standard operating procedures do not require a redundant check of the landing gear status during single-engine approach and landing exercises.
  • The crew forgot to complete the Before Landing check and did not lower the landing gear before landing. With the landing gear warning horn effectively disabled, there was no aural warning that the landing gear was not extended, although the gear warning light was most probably illuminated.

Safety Action Taken

After the occurrence, the operator clarified the functionality of the landing gear warning system on all models of the King Air that it operates and revised its King Air SOPs to include a redundant challenge/response verification of the landing gear position before landing.

TSB Final Report A00Q0114 - Parallel Runways Incursion

A Regional Jet was on approach to runway 24 right (24R) at Montréal International Airport (Dorval), Quebec. Meanwhile, an Airbus Industries A319, was preparing to depart Dorval en route to Denver, Colorado. The A319 crew contacted the clearance delivery controller and was issued an instrument flight rules (IFR) clearance, with departure instructions that specified runway 24 left (24L). During the clearance readback, a pilot of the A319 read back runway 24R instead of 24L, but the controller did not challenge the change in runway. When the crew of the A319 contacted the ground controller (the same person as the clearance delivery controller), the controller instructed the A319 crew to taxi to runway 24R, with later instructions to contact the tower once in the holding bay of 24R. After arrival in the bay of 24R, the crew of the A319 reported to the airport controller that they were "with" him. About a half minute later, the A319 crew was cleared by the airport controller to taxi to position on runway 24L. The crew acknowledged the clearance, without repeating the runway assignment, and taxied to position on runway 24R. The Regional Jet, 1.5 mi. on final approach to 24R, was cleared to land by the airport controller, who then noticed the A319 taking position on runway 24R. The airport controller cleared the A319 crew for an immediate takeoff, and they complied. However, the crew of the Regional Jet decided the aircraft could not be landed safely and went around. The go-around was initiated when the aircraft was about 500 ft above ground level (AGL).

Findings as to Causes and Contributing Factors

  • The clearance delivery controller did not challenge the change in runway designation made during the readback of the IFR clearance. As the ground controller, he provided taxi instructions to runway 24R and the instruction to contact the tower when in the bay for 24R. Consequently, the crew of the A319 believed that runway 24R would be their departure runway.
  • the A319 was cleared to taxi to position on runway 24L. However, based on the expectation that runway 24R would be the departure runway, the aircraft was taxied to position on runway 24R, placing the A319 on the runway intended for use by the Regional Jet.
  • When cleared to position, the crew of the A319 did not read back the designation of the runway to which they had been cleared. This eliminated the possibility that they or the airport controller would detect the discrepancy by that means.
  • The airport controller cleared an aircraft to land on runway 24R without ensuring that the runway would be clear of other traffic.
Date modified:
2010-05-20