King Air out of controll

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CD
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Post by CD »

You don't really give a lot of information to work with, do ya? :wink:

Anyways, here are the links that you're looking for:

ASL Issue 2-2007: TSB Final Report A04W0200—Navigation Deviation

~~~~~~~~~~~

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.
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Hedley
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Post by Hedley »

Was that "criminal negligence", by any chance?

Who precisely is the great guru who decides when something is "criminally negligent" and when it isn't?

Keep in mind that when a cop is tossed off the force, if
a civilian had done the same thing, he'd have gone to
jail for a loong time.
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Post by Bushav8er »

So we had better see a 602.01 violation soon!! And certainly more as the crew wasn't properly trained...

Lets see how many violations we can come up with...and how many are actually laid! Don't forget...this would also involve the "Operator"!
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Post by altiplano »

When I read that report part of me chuckled - "probably TC" - in a half serious way...

I can't believe it! Multiple approaches with gross deviation... Descent below MDA, 69 degree deviation from the inbound, multiple blown altitudes and headings on vectors... was it 90 KIAS in the missed? I don't know about the C90 but blue line on the 200 is 121...

I hope these guys only fly in the Prairie region because if this was in the rocks we'd be reading an accident report.

I think we should see fines. I know guys that have had to pay for less, way less...
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Post by Cat Driver »

I think we should see fines. I know guys that have had to pay for less, way less...
Unfortunately this is TCCA we are reading about.

These guys will in all likelyhood end up in management.
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Post by Hedley »

... end up in management
That's not as bad as it sounds. At least then, they won't be flying any more.

For those of you who haven't been unfortunate enough to spend time in large organizations, this "promoting of incompetence" is actually quite common, and is sometimes the only way you can get rid of a donkey. Promote him to "Vice-President in Charge of Long Term Planning" and hope you never hear from him again.
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Post by 55+ »

48 flying hours per year is what Transport Canada gives it's people so what do you expect......... :roll:
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Post by altiplano »

55+ wrote:48 flying hours per year is what Transport Canada gives it's people so what do you expect......... :roll:
Competence.
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Post by Cat Driver »

48 flying hours per year is what Transport Canada gives it's people so what do you expect.........
A rational person would expect that if they are a danger to aviation and they are incapable of flying the airplane safely....DON'T GIVE THEM A FU.KIN AIRPLANE TO FLY!

But I degress we are not talking about aviation ...we are talking about the people who have oversite of aviation and they can do no wrong.
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Post by Cat Driver »

delete
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Post by xsbank »

That is so awful and yet so pathetic at the same time! These are our regulators, flying around in the clag in aircraft that they don't fly enough nor understand.

How can you go flying with new instrumentation, in IFR conditions, in an airplane that both crew really have no clue about? I can't even begin to catalogue the problems here...Oh wait, that's how the Queen of the North was run into rocks and sank...oh never mind.

I told you we have bigger problems than gun control in this country.

I am thoroughly embarrassed by this whole story and I am almost ashamed to admit I'm a pilot, even though I am not employed by them nor ever likely will. Wonder if Merlin was flying?
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Post by Doc »

So TC inspectors can't fly. There's a shock! Anybody who's ever been stuck behind one doing their 20 minute preflight checks has known that for years! Next they'll be delaying their departures by 13 hours because they're sleepy?
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Post by ScudRunner »

hmm I wonder who conducted there last Audit, perhaps there OC should be pulled untill things are straightend out at this company. :wink:
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Post by Cat Driver »

O.K. I have done some reading on this issue.

Two things bother me about this, one is in the TSB rendition the TCCA Edmonton Regional office is referred to as the operator and their office as the Edmonton base.....

...one would just assume they were a commercial operation instead of the regulator.

The other thing tha caught my attention was this bit.
The flight crew did not consult the passengers about the operation of the aircraft during the flight.
That from TC's own rendition.

What the fu.k kind of pilots do they have that don't consult with the passengers about how to fly the aircraft.

Definately something wrong with their CRM.
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Post by Greg87 »

I don't think a fine is a good solution... it would only be passed down the line and anyone paying transport canada fees would pay the fines for them! Gotta be nice to work for the government.

I have to say I don't think it's fair to brand all TC pilots together though... some of them are OK guys, I know one who flys a B-25 on his days off, or sometimes a Beech 18. I guess there are exceptions to every rule.
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Post by Cat Driver »

I have to say I don't think it's fair to brand all TC pilots together though... some of them are OK guys, I know one who flys a B-25 on his days off, or sometimes a Beech 18. I guess there are exceptions to every rule.
There are good and bad pilots in both the industry and in TC.

Where the real difference lies is in how the bad are treated in industry versus in TC.

Can you imagine what it would be like if pilots in industry had the protection from accountability that the government ones have?
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The hardest thing about flying is knowing when to say no


After over a half a century of flying no one ever died because of my decision not to fly.
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Post by . ._ »

Cat, you're scaring me.

all is good. Happy place. Happy place.....




Image

OK, I'm better.

-istp :)
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Post by Cat Driver »

istp:

We flew that sucker IFR all over Africa, Europe, South America and North America from 1996 to 2000.

She has been parked in Paris Orley airport ever since.
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The hardest thing about flying is knowing when to say no


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Post by 55+ »

A rational person would expect that if they are a danger to aviation and they are incapable of flying the airplane safely....DON'T GIVE THEM A FU.KIN AIRPLANE TO FLY!

But I degress we are not talking about aviation ...we are talking about the people who have oversite of aviation and they can do no wrong.




Certainly valid comments by all..... Interesting though the number of people who want to get in to TC despite it all. Time off/benefits/vacation/salary/weekends and stat holiday’s off/pension/travel/conferences/per Diems and on and on...........
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Post by Cat Driver »

Certainly valid comments by all..... Interesting though the number of people who want to get in to TC despite it all. Time off/benefits/vacation/salary/weekends and stat holiday’s off/pension/travel/conferences/per Diems and on and on...........
There is also the other side of the coin 55+, I have known a lot of really good people in TC who finally came to the decision that all those benefits were not worth the frustrations of having to conform to the system..

My guess is that if there were some changes in the culture at the top TCCA would have a far more stable and effective work force.

What do you think having been on both sides of the fence?
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The hardest thing about flying is knowing when to say no


After over a half a century of flying no one ever died because of my decision not to fly.
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Re: King Air out of controll

Post by TC Guy »

clunckdriver wrote:Maybe TC Guy would like to comment.
Like everyone else here, I would suggest that these pilots require additional training.

Apart from that, LOL... no.

-Guy
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Post by More Hawker Than Sidley »

Well....one of the important things we have to remember is that when an accident or incident happens.....the idea is not to assess blame so much as a solution as to how to put safe-guards into play to prevent any further accidents/incidents from happening. We could take the positive outlook and say TC is providing us numerous example as to how NOT to fly an aircraft. So, what this shows is the double standard in that these guys will get put on the Initial course for the King Air again, with a free trip to Ottawa with all expenses paid....why? That's the way TC does it and the double standard is that if we did it they would be all over us. Second point as Hedley & Cat mentioned that these guys get promoted up..Peter Principle alive and well. Problem is, CAT, you mentioned there should be some new management at the top....so, if we promote these./?@##'s to upper management, guess who we have running TC? Isn't this what has been happening for years? ? ? ?mhts
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Post by Cat Driver »

....so, if we promote these./?@##'s to upper management, guess who we have running TC? Isn't this what has been happening for years? ? ? ?
M.H.T.S.:

That is correct, that is how we have gotten to this quality of management in TCCA.

Maybe I'm just a simple minded dreamer but please listen to what my thoughts are on this.

This is part of the record with my meetings with the Director General Transport Canada, the first of which he came to my home.

When I outlined my allegations against Merlin Preuss and Dave Nowzek he took the normal position that I knew he would.

He said what you are trying to convince me of is I have a systemic problem of dishonesty within the upper levels of TCCA?

I said yes you do and I can prove it.

He said what do you want out of all this?

I said three things, if my allegations are proven to be true I want you to.

(1) Fire all TC employees who have been proven to be dishonest and abused their office.

(2) Advise every operator in Canada that you do not condone such behavior by any TC official and you have fired them.

(3) I want to be repayed for my losses caused by their actions.

He shuffeled around a bit to digest these three simple requests and finally said how much money do you want. I replied I'll settle for $250,000 tax free just to get on with my life.

He then said what makes you think it is worth that much on what do you base that number.

So I said o.k. maybe I was a bit quick there and didn't really think about it clearly so I want $500,000 tax free is that fair or do you want to keep upping the ante? He quickly grasped where that was going and said to both me and my wife, O.K. I have the power to recommend to treasury board that you be reimbursed for your losses if your allegations are proven to be true. We settled on $250,000.

Anyhow I won on all points of my allegations against named TCCA officials after another year and a half of their investigation and received zero of my requests.

B U T if the DG had lived up to our agreement I would suggest that regardless of how stupid the replacements of the fired managers are they have enough neurons to know that if they are caught in corrupt behaviour they will be fired and that will at least be some improvement in how TCCA is managed.

I still believe that.

And the above discussion between me and the DG is on record and indisputable by TCCA.

Now please pin this statement to your wall so you will never forget it.

Of the three requests that I asked for I would settle for number two as being more important to me than number three.

Think what you may of me and who I am but I do care about this industry and those who work in it.
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The hardest thing about flying is knowing when to say no


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Re: King Air out of controll

Post by yycflyguy »

TC Guy wrote:
clunckdriver wrote:Maybe TC Guy would like to comment.
Like everyone else here, I would suggest that these pilots require additional training.

Apart from that, LOL... no.

-Guy
:lol: ah yes, the politically correct answer not to answer :lol:
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Post by l_reason »

Makes me feel good inside to know these guys are making sure I do my job safely!

How can we find out who was at the controls? They need a kick in the nuts and a fresh copy of MS flight sim. :lol:
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