A/C down in SK - Jan '07 - Draft Report Critical of TC

[Widow]

TSB Says "Train Flight Crews to Avoid Accidents"

GATINEAU, QC, Oct. 14 /CNW Telbec/ - The Transportation Safety Board of Canada (TSB) announced today that flight crews must be better trained to work together and use all available information and tools to make the right decisions under pressure.

The TSB is calling on Transport Canada to make crew resource management (CRM) training mandatory for all operators in Canada.

Currently, only bigger airlines are required to provide CRM training to crews, and companies providing air taxi and commuter services are not held to the same standard.

This recommendation follows TSB's investigation into the crash of a medical evacuation flight in Sandy Bay, Saskatchewan, in 2007, which claimed the life of the pilot.

In the investigation, the TSB found the plane operated normally until it abandoned its landing attempt and crashed into trees beyond the end of the runway.

"This crew did not employ basic strategies that could have helped prevent the chain of events leading to this accident," said David Ross, Investigator in Charge.

"CRM training can significantly improve flight crew effectiveness and provide crews with better coping skills to face emergencies," he added, "but recurrent training is needed to change attitudes and behaviours for good."

That is why the TSB recommends that all crews flying air taxi and commuter services be required to take CRM training at regular intervals.

"Making this training mandatory for all flight crews is the first step in the right direction but training must be reinforced so that best practices are not only learned but remembered," says Mr. Ross.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation 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.

This news release, the photo gallery and the final report can be found on the TSB website at http://www.bst-tsb.gc.ca.

For further information: Transportation Safety Board of Canada, Media Relations, Telephone: (819) 994-8053

TSB Report A07C0001

Having been privy to to the draft report in order to help the widow prepare her response, I am pleased to say that criticism of TC's oversight during SMS implementation has, to some extent, remained. Other pieces of relevant and revealing information continue to be notable in their absence.

[Cat Driver]

4.1.4 Transport Canada

TC forecasts that draft regulations will be published in Part I of the Canada Gazette in December 2009 requiring CAR 703 and 704 operators to implement safety management systems (SMS) in accordance with a phased schedule. Adoption of an effective SMS by these operators should significantly mitigate the types of management and operational issues identified in this report.

Yeh, that otta do it considering the industry has not had sufficient years operating airplanes to learn how to safely fly them.

P.S.:

I have only been retired four years but my grasp of aviation acronyms is slipping rapidly.

[jeta1]

comment removed - time expired

[Widow]

There is nothing in the Act which precludes an interested party from requesting assistance in formulating a response to the draft. This widow contacted me within days of this accident and frequently contacted me for help in understanding the process, etc.

What is forbidden is the release of information contained in the draft report. I did not do that.

The TSB is fully aware of all the parties who helped the widow prepare her response. We all signed our names to our commentaries. I am quite sure they have taken/will take whatever action they see fit.

[Captain X]

One thing I see as being a problem in our industry and others is; If someone is not performing well and is let go, demoted, etc at one company. The said company will give them a letter of reference, and or, will not say anything negative about the persons performance due to legal concerns regarding defamation of character.

So how will we prevent folks who are potentially dangerous, floating from job to job without any knowledge of past problems or issues?

[Widow]

Pilot dispute over landing angle caused 2007 Saskatchewan crash: Report
By Jason Warick, Saskatoon StarPhoenixOctober 14, 2009 7:34 PM

SASKATOON — A damning report on a 2007 plane crash in northern Saskatchewan blames the deadly accident on a last-minute dispute between the pilot and co-pilot over the safest way to land.

The report, released Wednesday morning, finds fault with the airstrip, the private airline, federal regulators and the pilots themselves. The widow of pilot Rick Wolsey — the only one of the four aboard to be killed — dismissed it as an attempt at "scapegoating" her husband.

"This is a smear job against my husband," Debbie Wolsey said in a telephone interview from her Ontario home Wednesday afternoon.

"Transport Canada did not do their job to regulate. The company wasn't listening to my husband's concerns. This accident was preventable."

According to the report, the Transwest Air Beach A 100 King Air medical flight left La Ronge, approximately 400 kilometres north of Saskatoon, at 7:30 p.m. on Jan. 7, 2007. Wolsey, 51, and a co-pilot in her mid-20s, were joined by a pair of emergency medical technicians.

By 10 p.m., as the crew approached Sandy Bay, approximately 250 kilometres to the east, it was pitch black. There were few lights at the small airport, according to the report. As the woman piloted the plane toward the runway — contrary to company policy requiring the more experienced crew member to handle landings — the plane was not approaching the short runway in the proper fashion.

"The crew members did not assess the aircraft performance and did not identify runway length as a threat. Consequently, they did not discuss and agree on a point at which a safe landing was no longer possible," stated the report.

The female pilot appropriately recommended pulling up and trying the landing again, said the report. But inadequate preparation and co-operation between the two pilots led to Wolsey rejecting this suggestion until the plane was too low to pull up safely.

At some point, Wolsey took over the controls using "non-standard transfer of control" methods, adding to the confusion and further decreasing the chances of a successful climb. Wolsey attempted to pull the plane up, but, seconds later, it caught the trees just past the runway and crashed at 10:02 p.m.

"(The two pilots) had difficulty working together. Pilots had warned management not to pair them," said TSB investigator David Ross.

All of the occupants were rushed out before the plane caught fire, but Wolsey died of his injuries before help arrived, stated the report. The two medical technicians sustained serious injuries, while the female co-pilot received minor injuries.

Investigators pieced together those final moments through survivor's accounts, but also by listening to the audio recorder or "black box" in the plane.

The report recommends national pilot training on the problem of "black holes," or sensory illusions caused by acceleration forces when taking off or landing from dark airports. It said the company, Transwest Air, was deficient in supervising its staff.

The report says Transport Canada knew about problems at Transwest Air, but didn't appreciate the extent of the risk "because of the limitations of the oversight system in place at that time."

According to the report, action has been taken on a number of fronts to prevent future accidents. Transwest Air has amended and standardized its operating procedures. The company now holds annual meetings to discuss "cold temperature altitude corrections" and other issues.

The provincial government has installed a new approach at the Sandy Bay airport. In December, Transport Canada is expected to begin requiring operators to implement additional safety measures.

These measures will help, but more action is necessary, according to the report.

Debbie Wolsey, who had been married to Rick for 30 years, said her husband tried to work with the female pilot, but could not. He repeatedly told management at Transwest not to pair them together, and they finally agreed in October of 2006. But three months later, they were paired together again, and the crash occurred on their first week back together.

The female pilot, who now lives in Manitoba, could not be reached Wednesday.

[Cat Driver]

The report recommends national pilot training on the problem of "black holes," or sensory illusions caused by acceleration forces when taking off or landing from dark airports.

How do pilots get to the point they are flying a twin engine turboprop and not know something as basic as the above?

[ScudRunner]

The report recommends national pilot training on the problem of "black holes," or sensory illusions caused by acceleration forces when taking off or landing from dark airports.

How do pilots get to the point they are flying a twin engine turboprop and not know something as basic as the above?

I would tend to agree with you on this Cat, However I posted a response to Widows thread awhile back on signing some petition for Safety in my response I spelled out that if real progress towards safety in this industry is to be made we need to embrace technology and eliminate the causes which we can control as an industry with all parties involved NavCanada and TC being the big ones.

I have never been to Sandy Bay but let me take a guess at it, NDB A approach with a Circling? Now we all know the dangers of Night black hole approaches and the effects that have claimed many over the years. I think we have all been educated on these effects starting out with our night rating, and pilots who have been flying for anytime in Canuckistan will be very familiar with these dangers.

Now is the time to implement a program to get rid of the NDB's and Make them all RNAV with WAAS ideally. If we want to make real progress lobby for these changes, I feel for these people's families who die needlessly for the only reason that as a nation we are cheap and put little value in our Aviation industry.

Cut down the guess work and you will see results.


Recently we have the 406 mhz ELT rules come into effect, this deals with after one plants it in the tundra so Canada's finest can come find you a little quicker, even they succumb to the effects we just talked about up in Alert a number of years back. How bout take that time, money, resources and spend that on something to prevent the meeting of metal and dirt. Wouldn't it be safer to avoid hitting the ground in the first place? A simple approach approved for even the cheapest companies GPS's could cut down on accidents or incidents, I cannot imagine a company not taking advantage of the operational saving with such technology that will pay for it self in no time, fewer missed approaches more direct routing not to mention the costs of a crash like this one.

Most modern GPS units come with some sort of built in GPWS or terrain avoidance system, I believe it's now standard on at least the Garmins with their WAAS capability. Make that mandatory for all operators within 3 years, heck subsidize it and sell it to the people as some carbon hippy environmental tax program to stop planes burning fossil fuels by having to take the long way and waste precious gas in procedure turns or whatever getter done.

[Cat Driver]

Skudrunner, I couldn't agree with you more on the issue of pilots still flying NDB approaches in the twenty first century.

It just boggles the mind to think that you people are still using antiquated aids like the ADF when we have so many other aids that are so much more reliable and accurate.

I am getting to the point that I feel like the industry is stuck in the dark ages and I will not live to see modern technology used the way it was designed to be used.

[RatherBeFlying]

There's a whole bunch of warm, fuzzy prose in the report about CRM, SMS, SOPs, procedures, crew pairing, administration -- more than I could get through.

But please explain to me how even a private pilot can get night qualified without learning about black hole approaches and takeoffs.

Fly a circuit if there's no approach slope aid.

Establish and hold the appropriate climb attitude on the AH on takeoff or go around for at least the first 300'.

Is there any night qualified pilot on this forum who doesn't already know this?

[chancellor]

I am sure the pilot was told about it and even went through a simulated one in say Calgary or Vancouver. She probably was not afforded an actual demonstration because her 500 hr instructor was not comfortable with it. Quite possibly it was not even demonstrated while training for that position. Having worked for the company I know that in most cases the captains were not given any discretion to allow a fo to learn in challenging situations. Due to the lack of experience in many of the left seats, guidance was given by the company as to when the fo could not land or take off. Remembering that memo the fo in this case should not have been flying. I am not trying to defend her because she has responsibility in this as well, but instead of coddling some of these pilots we should be teaching them.

On a side note the approach with no slope aid and not climbing aon a missed approach has also caught many experienced drivers as well.

[flaps 10 props 85]

The report mentions inadequate training, but it fails to mention inadequate flight training standards and line-indoc. The training was just good enough to get them though their ppc/pcc rides. Both crew members ppc/pcc were marginal at best and the captain was pushed though line indoc, so the training captain wouldn't have to go up north on an overnight. You made it though another one "BO"ner. You should just stick to working the counter.

[planett]

I would love to see more RNAV approaches everywhere.

But...playing the devil's advocate here and with first hand experience..... nobody wants to pay for them. Communities don't think they should pay. Airlines don't want to pay for an approach that others will use, and NavCanada doesn't want to raise rates to subsidise them. Operators especially don't see the need for an additional expense when their "top pilots" make up their own approaches to their own minima on the cheap GPS and get the same results without all the training and equipment. Transport never goes up north anyway, so they'll never be caught.

It happens. That's why many of the RNAV approaches serve airports already equipped with ILS's. Time to get them to where they're needed.

[armchair]

This is a very long report... but, Paras 2.8, 2.9 and 2.10 are a must, must , repeat must read, so click on this link, and if you read only three paras, read those three.

http://www.bst-tsb.gc.ca/eng/rapports-r ... 7c0001.asp

This is where the accident happened, and has a lot more to do with the accident than night VFR, black holes and NDB or GPS approaches.

Overall a very good report.

[Sidebar]

This is a very long report... but, Paras 2.8, 2.9 and 2.10 are a must, must , repeat must read, so click on this link, and if you read only three paras, read those three.

http://www.bst-tsb.gc.ca/eng/rapports-r ... 7c0001.asp

This is where the accident happened, and has a lot more to do with the accident than night VFR, black holes and NDB or GPS approaches.

Overall a very good report.

The captain's and first officer's actions took the plane into the trees. However, problems with company supervision (2.14.1) and TC's oversight of the company (2.18) played major roles as well. These issues were the genesis of the accident, and also affect other operators.

Crew practices during the occurrence flight deviated from required procedures, and these types of deviations were common across the company's King Air operation. Although the company was aware of repeated CARs deviations by its flight crews, deficiencies in supervisory activities permitted the undetected development and persistence of substantial and widespread deviations from SOPs within the King Air operation, especially with the crew pairing of the captain and first officer of TW350.

Although TC safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated by the PNR managers because of the limitations of the oversight system in place at that time.

[Sidebar]

The report mentions inadequate training, but it fails to mention inadequate flight training standards and line-indoc. The training was just good enough to get them though their ppc/pcc rides. Both crew members ppc/pcc were marginal at best and the captain was pushed though line indoc, so the training captain wouldn't have to go up north on an overnight.

I think the flight training standards point is a good one. This report concludes that “the first officer and captain met competency standards on the completion of their initial flight training before they began employment as line pilots.” That may be the case, but I agree with F10P85 that these are pretty minimal standards. Five hours of training before the PPC?

According to the TSB report, the captain's line indoc (128 hrs in 36 days) was well in excess of company guidelines.

Line indoctrination was intended to assess a new captain's proficiency and decision making, and to ensure thorough familiarity with the company's bases, routes, and operations. CARs do not require line indoctrination for air taxi operations, and, although one section of the FCTM indicated that line indoctrination was required only for commuter and airline operations, another section of the FCTM also required a minimum of 20 hours of line indoctrination for multi-engine air taxi captains. The company's practice was to assess each pilot individually and, for pilots with little experience as PIC or who had been away from flying for lengthy periods, to increase the amount of line indoctrination to about 100 hours.

The captain began company line indoctrination on 23 May 2006 and received a total of 128.0 hours of flight time. During the line indoctrination, the captain flew with training pilots or other line captains. Line indoctrination records showed that the captain initially experienced difficulty in several areas, including pre-flight planning and IFR operations, but made steady progress and completed the line indoctrination program on 28 June 2006. The captain was then released to line operations and began flying with first officers. The company did not conduct any line checks on the captain and was not required to do so.

From another thread posted by Widow

SafeSkies Newsletter Vol 1, No 6 - October 15

This newsletter says “The TSB has recommended Transport Canada require Crew Resource Management training for pilots under subpart 703 air taxi and subpart 704 commuter. Industry insiders have already expressed concern that Transport Canada will deal with these issues through SMS, rather than through regulation.” I’ve been trolling Google, but haven’t found any online commentary about this. Can you enlighten us Widow?

[Widow]

SafeSkies receives a quite a lot of confidential correspondance. I have never betrayed anyone's request for anonymity. That's why no specific reference is made.

Time will tell.

[Sidebar]

SafeSkies receives a quite a lot of confidential correspondance. I have never betrayed anyone's request for anonymity. That's why no specific reference is made.

Time will tell.

Well put, and enough said. Thanks.

[flaps 10 props 85]

Jim Glass's comments in the paper and on the radio were pretty week. He said Tw was aware of the crew conflict, but no idea of the severity of it. Maybe if they had a Northern CP that actually lived in the north and work with the crews they would have known, instead he lives in Saskatoon and flies the Saab. He also said they have tighten up there record keeping and increased training, as well as making all crew take CRM. There CRM coarse last year consisted of a guy coming in and making fun of one of the pilots that was wearing his hat backwards. They didn't even get though half of the manual. The increased training must not have included surface contaimation, as that appears to be the cause of their latest crash, the T/O this spring. It also stated that SMS is in place and fully operational. It's operational alright, to the fact that they have fined crew members that have made reports on it for violation they incurred. Now no one makes reports, because of fear of being fined or fired. Looks like the system is working great. Come on Transport, when will you finally see the light with this company ?

[Captain X]

Thats too bad, things have not improved... Seeing TC is in the "Hands off" business now it will only improve from within TWA's doors. Lets hope they get it right

Jim Glass's comments in the paper and on the radio were pretty week. He said Tw was aware of the crew conflict, but no idea of the severity of it. Maybe if they had a Northern CP that actually lived in the north and work with the crews they would have known, instead he lives in Saskatoon and flies the Saab. He also said they have tighten up there record keeping and increased training, as well as making all crew take CRM. There CRM coarse last year consisted of a guy coming in and making fun of one of the pilots that was wearing his hat backwards. They didn't even get though half of the manual. The increased training must not have included surface contaimation, as that appears to be the cause of their latest crash, the T/O this spring. It also stated that SMS is in place and fully operational. It's operational alright, to the fact that they have fined crew members that have made reports on it for violation they incurred. Now no one makes reports, because of fear of being fined or fired. Looks like the system is working great. Come on Transport, when will you finally see the light with this company ?

[Dust Devil]

So speaking from the perspective of a small 703/702

I'm wondering how CRM would necessarily prevent this situation. I've never taken that training so I'm unfamiliar with what it includes.

With a limited labour pool for smaller companies who employ under 5 pilots it might not always be possible to separate crews. Sometimes people are just so unalike that the only option is not to have them work with each other. For a smaller company like mine the only option I can see is to just to terminate the employment of one of the pilots. In this case how would you pick the pilot that has to go. Also what would the labour law implications be.

I'm having a hard time understanding how TC should be so deep into how a company operates that they now need to start regulating individual relationships within an organization.

In this incident it seems that the captain did not maintain command of his aircraft. Is that the fault of TC or the operator? I'm having a hard time grasping that.

[LousyFisherman]

So speaking from the perspective of a small 703/702

For a smaller company like mine the only option I can see is to just to terminate the employment of one of the pilots. In this case how would you pick the pilot that has to go. Also what would the labour law implications be.

Assuming there is no union involved all you have to do is provide proper notice of layoff and provide proper severance. There will be no issues.

Now, choosing which pilot to layoff because of lack of work, (hey if they can't work with someone, then there is nothing to do) is why management gets paid the big bucks.

Note the important words are LAYOFF and PROPER. Do not mess around trying to save money. I have never fired anyone, I have always laid them off, even in cases of theft. The hassle is not worth saving the cost of proper severance (usually 2 weeks salary, often only 1 week)

LF

[Sidebar]

So speaking from the perspective of a small 703/702

I'm wondering how CRM would necessarily prevent this situation. I've never taken that training so I'm unfamiliar with what it includes.

With a limited labour pool for smaller companies who employ under 5 pilots it might not always be possible to separate crews.

It seems the TSB recognizes this is a problem.

TC crew pairing regulations to date have focused on crew experience and skill levels, which are concrete issues that are straightforward to assess. However, as this occurrence demonstrates, there are other aspects of the pairing that can have an impact on the crew's ability to effectively work together. Regulations and TC guidance material do not currently address the breadth of issues that can have an impact on the effectiveness of a crew pair, and that should be considered before making crew pairing selections.

Additionally, current crew pairing regulations apply only to airline operations, where there are relatively large numbers of pilots who can be scheduled to prevent ineffective crew pairings. There are no requirements for air taxi and commuter operations to have a crew pairing policy, and implementing a crew pairing policy by excluding permutations of pilots may be impractical in small commercial aviation operations where there are a limited number of pilot combinations. However, alternative strategies exist to mitigate the risk, including making operational hazards explicit to the crew members to enable them to apply CRM skills to mitigate the hazard, or providing specific CRM or flight management coaching before a flight is conducted.

http://www.tsb.gc.ca/eng/rapports-repor ... 1.asp#s2.2

[Dust Devil]

So speaking from the perspective of a small 703/702

I'm wondering how CRM would necessarily prevent this situation. I've never taken that training so I'm unfamiliar with what it includes.

With a limited labour pool for smaller companies who employ under 5 pilots it might not always be possible to separate crews.

It seems the TSB recognizes this is a problem.

TC crew pairing regulations to date have focused on crew experience and skill levels, which are concrete issues that are straightforward to assess. However, as this occurrence demonstrates, there are other aspects of the pairing that can have an impact on the crew's ability to effectively work together. Regulations and TC guidance material do not currently address the breadth of issues that can have an impact on the effectiveness of a crew pair, and that should be considered before making crew pairing selections.

Additionally, current crew pairing regulations apply only to airline operations, where there are relatively large numbers of pilots who can be scheduled to prevent ineffective crew pairings. There are no requirements for air taxi and commuter operations to have a crew pairing policy, and implementing a crew pairing policy by excluding permutations of pilots may be impractical in small commercial aviation operations where there are a limited number of pilot combinations. However, alternative strategies exist to mitigate the risk, including making operational hazards explicit to the crew members to enable them to apply CRM skills to mitigate the hazard, or providing specific CRM or flight management coaching before a flight is conducted.

http://www.tsb.gc.ca/eng/rapports-repor ... 1.asp#s2.2

Anyone have a link to an outline of a CRM course?

[Widow]

Jim Glass's comments in the paper and on the radio were pretty week. He said Tw was aware of the crew conflict, but no idea of the severity of it. Maybe if they had a Northern CP that actually lived in the north and work with the crews they would have known, instead he lives in Saskatoon and flies the Saab. He also said they have tighten up there record keeping ...

I am pretty sure the Northern CP was fully aware of what was going on and had conversations with both pilots. According the Transport Canada documents the widow received through Access to Information, the NCP left the company shortly after the accident, "and upon doing so deleted these (and all other Transwest documents) from his computer. There were no hard copies made so nothing was placed on either {name removed} or Wolsey's file."

Dust Devil - is this the link you are looking for? http://www.tc.gc.ca/civilaviation/syste ... m/menu.htm