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ASL Issue 2-2007: TSB Final Report A04W0200—Navigation Deviation
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Aviation Investigation Report
Navigation Deviation
Government of Canada
Department of Transport
Beech King Air C90A C-FGXH
Edmonton, Alberta
10 September 2004
Report Number A04W0200
Findings as to Causes and Contributing Factors
1. Because the flight crew did not have sufficient familiarity with the C90A EFIS (electronic flight instrument system) equipment system's presentations and operation, they used improper EHSI (electronic horizontal situation indicator) course settings and flight director mode selection on three successive instrument approaches.
2. The inability of the crew to perform at the expected standard resulted from limited recent flying time and inadequate transition training in using the new avionics.
3. While flying a missed approach procedure, the flying pilot was unable to transition to effective manual control of the aircraft. As a result, the aircraft speed decreased significantly below a safe level, and the air traffic control–assigned altitudes and headings were not adhered to.
4. On the second approach at Edmonton, the crew focussed on the GPS (global positioning system) distance reading from the final approach fix, instead of the DME (distance measuring equipment) display. This led to a premature descent, and the aircraft was operated below the minimum published step-down altitudes for the approach.
5. The crew's resource management in preparation for and during the three approaches was not sufficient to prevent the hazardous deviations from the required flight paths.
Finding as to Risk
1. The Aircraft Services Directorate (ASD) did not encourage pilots to use manual flying skills in operational flying, thus creating the potential for manual flying skills degradation from non-use.
Other Finding
1. A post-incident audit revealed a number of examples of non-compliance with the ASD Flight Operations Manual, including a lack of appropriate pilot-training record keeping. Therefore, there was no assurance that pilots would receive required training within specified time frames.
Safety Action Taken
The Aircraft Services Directorate (ASD) has corrected operational and training deficiencies that were revealed in a post-incident operations audit of the Edmonton base. Pilots who had not received the minimum flight training schedule mandated in the Fixed Wing Operations Manual were required to complete this training before their next operational flights. In addition, operational control of all flights was improved through a revised dispatch and flight-following system.
A Training Review Board convened by the ASD evaluated the performance of selected Edmonton-based pilots on the C90A. Consequently, some pilots were removed from flying duty on type.
An internal Safety Bulletin distributed to pilots flying ASD aircraft, addressed the following issues associated with this occurrence:
* errors in managing automatic flight systems;
* encouraging periodic autopilot disconnect to improve monitoring vigilance;
* flight director/autopilot management;
* flight path deviations induced by autopilot activation; and,
* timely pilot intervention to correct flight path deviations.







