Sonicblue TSB Report to be Released

[safetywatch]

The Transportation Safety Board of Canada will hold a Media Availability
to Release its Final Report into the Sonicblue Cessna Caravan accident near Port Alberni, B.C.

(Gatineau, Quebec, January 14, 2008) C The Transportation Safety Board of Canada (TSB) will release, on January 15, 2008, its final report (A06P0010) into the Sonicblue, a Cessna 208B aircraft, engine power loss and forced landing incident that occurred on 21 January 2006 in Port Alberni, British Columbia. The report will be released on January 15, 2008 at 01:00 p.m. Eastern Standard Time and a spokesperson will be available for interviews in Richmond, British Columbia.

[Hedley]

It really took the TSB two years to investigate the
accident of a single-engine cessna?

[Widow]

It really took the TSB two years to investigate the
accident of a single-engine cessna?

ROFL ... I would guess there were a lot of "interested parties" who had an interest in stymying the findings of the report.

[pelmet]

Many of their reports are complete and sitting on the shelf. How do I know? Because their annual report says that they have been completed(and I have called and had them delivered). Why are they not on the web site where a pilot could read about it and avoid an accident? Because they are waiting to be translated into french. Safety takes a back seat to that.

[Widow]

Don't forget, they don't always DO a report ...

[the_professor]

Many of their reports are complete and sitting on the shelf. How do I know? Because their annual report says that they have been completed(and I have called and had them delivered). Why are they not on the web site where a pilot could read about it and avoid an accident? Because they are waiting to be translated into french. Safety takes a back seat to that.

Chalk up another notch against the provision that costs us taxpayers between $5B and $10B per year -- the provision of everything in both languages.

Why they wouldn't release the report immediately in its language as-produced, followed by the translation (once available) is just asinine.

[safetywatch]

I will post some key parts after 10.00 am tomorrow and from the findings you will see why it took 2 years to see the light of day. The TSB guys did their job, but TC have tried to interfere with the content - fortunately there is enough left to go after them!

[Widow]

Broken engine part led to 2006 Sonicblue plane crash that killed three
Larry Pynn, Vancouver Sun
Published: Tuesday, January 15, 2008

A broken engine part caused a Sonicblue Airways Cessna 208B Caravan to lose power while flying between Port Alberni and Vancouver on the afternoon of Jan. 21, 2006.

But it was inadequate regulations by Transport Canada that undercut the ability of pilot Ed Huggett to safely glide back to Port Alberni Regional Airport that cloudy afternoon.

Instead, he crashed the single-engine turbine plane into trees while attempting a landing on a logging road, killing himself and two passengers -- an adult male and three-year-old boy. Four women passengers and a 17-month-old girl survived but with serious injuries.

Those are the findings today of a much-anticipated report by the federal transportation safety board, which urges Transport Canada to adopt tougher safety standards for single-engine aircraft flying on instrument flight rules over mountainous terrain.

Instrument flight rules mean pilots rely on instruments to fly in clouds, whereas visual flight rules require pilots to see where they are going. Single-engine aircraft are at extra risk on instrument flight rules over mountains because they cannot rely on a second engine to stay airborne.

The safety board report calls for the use of terrain awareness and warning system (TAWS) technology to warn pilots of such aircraft that they are approaching the ground -- something required in the U.S., but not in Canada. The aircraft had been flying at 2,700 metres above broken cloud at the time, in theory high enough to glide back to Port Alberni.

Had the aircraft been equipped with TAWS, the pilot would have known "there were no terrain risks" and he could have continued his glide to Port Alberni rather than "descending into mountain region to maintain visual reference with the ground."

The report says Transport Canada removed the restriction on single-engine aircraft flights on instrument flight rules over designated mountainous regions in December 2000 "in response to a report from industry proposing a need for changes..."

But making the change without requiring TAWS technology meant the "level of safety...was significantly reduced," the report said.

That finding is especially troubling to Surrey's Jonathan Huggett, father of the pilot. "What kind of airline system are we running in this country?" he said.

"The overall lesson from this tragic event is that this is a classic example of human life being unnecessarily put at risk when economic issues are allowed to override the protection of public safety....The deregulation of airline fares has lead to an economic race to the bottom."

The board also supports better training for pilots in the event of an engine loss over mountains when flying instrument flight rules.

The report also notes that the global positioning system unit on the Sonicblue aircraft "had an expired aviation database that was more than seven years out of date."

Regulations do not require a more modern GPS with "moving map displays, obstacle information, as well as the positions of towns, cities, roads, or other geographical features that could potentially be used to identify emergency landing sites if there are no airports within gliding range."

Huggett and other family members of the deceased have filed a law suit in B.C. Supreme Court in connection with the crash, which resulted in Transport Canada grounding Sonicblue.

"We'll be going after them in the worst possible way," Huggett said.

The safety board investigation determined that a "fatigue crack" in one compressor turbine blade ultimately led to destruction of all 58 blades and the plane's loss of power. New blades had been installed on the Pratt & Whitney engine during an overhaul on Nov 7, 2005.

TSB Report A06P0010

[safetywatch]

and if you think that is bad - hang on to your hat - its going to get worse - much worse. The TSB report shows that the Caravan 208B doesn't meet CARS for SEIFR. There are documents obtained under discovery for the trial which will be kept under wraps until the trial starts in October 2008 which will blow you away. and if this isn't bad enough there is evidence that TC has attempted to tamper with the TSB investigation and influence its outcome.

[Widow]

and if this isn't bad enough there is evidence that TC has attempted to tamper with the TSB investigation and influence its outcome.

... why doesn't that surprise me safetywatch?

[2R]

From what i heard that guy done a good job of trying to save himself and passengers.His luck just ran out when he caught a tree on final for the road in that narrow valley .Perhaps it was obscured by some windscreen oil or ice .

Did they mean just this Van or all off them not meeting CARS ???

[Widow]

From the report:

4.2 Action Required
4.2.1 Propulsion System Reliability
SEIFR authorization is based in part on the improved reliability of turbine engines as compared to piston engines. An essential element for SEIFR approval is that mean time between failure (MTBF) of the engine must remain high. Canadian Aviation Regulations (CARs) require the MTBF of the engine to be better than 0.01 per 1000 hours (that is, less than 1 failure per 100 000 hours of flight time).

Other Canadian-approved flight operations such as extended range twin-engine operations (ETOPS) are authorized in part because of the increased reliability of modern turbine engines. ETOPS are governed by TP 6327, Safety Criteria for Approval of Extended Range Twin Engine Operations (ETOPS). Appendix A of that publication recognizes that:

No single parameter by itself, without other data/information, can adequately qualify reliability. There are a number of variables, maintenance and operating statistics and general information about the operational experience of a particular power unit, which characterize propulsion system reliability.

To ensure the reliability of propulsion systems used for ETOPS, TP 6327 requires a record of all engine shutdown events both ground and in flight for all causes (excluding normal training events) including flameout. It also requires a list of all occurrences where achieved thrust was below the intended level, for whatever reason.

Although many of the rules governing ETOPs cannot be applied directly to single-engine operations, the underlying concept used to monitor propulsion system reliability could be applied to SEIFR to ensure a similar level of safety for crews and passengers.

While the engine type that was involved in this accident met the established reliability standard, it is important to note that, had the total number of In Flight Shut Down (IFSD) events (that is, loss of propulsion for all causes) been considered, the failure rate for the entire propulsion system would not have met the CARs standard in 7 of the last 10 years.

Any system failure that results in a loss of power and an emergency landing represents an elevated risk to the travelling public. Because the outcome of an engine failure in SEIFR operations can be catastrophic, the propulsion system reliability assessment should take into account all relevant variables and should not be limited to MTBF values alone.

Therefore, the Board recommends that:

The Department of Transport take into account all propulsion system failures when assessing the safety of single-engine commercial operations.

A07-08

Sounds to me like all Caravans.

[grimey]

From what i heard that guy done a good job of trying to save himself and passengers.His luck just ran out when he caught a tree on final for the road in that narrow valley .Perhaps it was obscured by some windscreen oil or ice .

Did they mean just this Van or all off them not meeting CARS ???

from the report:

2.2 Pilot Reaction to the Engine Failure

It could not be determined why the pilot initially turned right, away from Port Alberni, while declaring the emergency. However, during that manoeuvre, the aircraft's rate of turn increased and the aircraft then rolled out on a heading direct to the Port Alberni Regional Airport. This suggests that the pilot had selected the onboard GPS to display the nearest airports, and then tightened the turn to line up with the Port Alberni Regional Airport.

The pilot then requested information to help him avoid high terrain, suggesting that he believed that there could be high terrain on his direct path to the Port Alberni Regional Airport. There is no capability for air traffic controllers to provide such navigational guidance. Additionally, there is currently no requirement for aircraft used in SEIFR operations to be equipped with TAWS. As a result, the pilot would have had no capability to locate or identify obstacles if he entered IMC.

The 360º descending turn conducted by the pilot may suggest that the pilot had seen a break in the cloud, and descended through it to maintain visual conditions. That manoeuvre allowed the pilot to avoid flight into cloud below safe IFR altitudes and in an area where he suspected there was high terrain.

A post-accident evaluation determined that there were no terrain risks between the aircraft and the airport when the engine failed. The pilot did not know this because the ground was obscured by cloud. Had the aircraft been equipped with a serviceable TAWS, it would have informed the pilot that there were no terrain risks between the point of the engine failure and his intended emergency landing field. With this information, he may have continued with his original plan to fly directly to the Port Alberni Regional Airport rather than descending into a mountainous region to maintain visual reference with the ground.

The last radio transmissions from the pilot indicated that he was clear of cloud in visual conditions, and that he had time to identify a potential landing area. He transmitted a Mayday call, and indicated that he was setting up for an emergency landing on a logging road. Because this procedure was being flown in visual conditions, the pilot would have been able to rely on his previous training to accomplish the emergency landing.

[safetywatch]

To meet CARS you have to below .01 events/1000 hours and TC measured that based on P&WC data which wasn't adequate. Basically if the event wasn't related to a P&WC supplied item it didn't count. In fact TSB showed that the real reliability is consistently well above .01 and has been as high as .025. To put it simply the Caravan 208B cannot be used for SEIFR flights based on the TSB analysis

[safetywatch]

Follow up to my last report - when TC have known that the Caravan 208B doesn't meet CARS for 18 months and have done nothing about it - how do you spell "CRIMINAL NEGLIGENCE"

[Ralliart]

CBC Radio called me today to request an on-air interview later today to speak with another pilot, I think particularily they were looking for an instructor, to discuss thoughts about this report and details in general about flying in these conditions.

I declined to comment on my personal thoughts seeing as I was not involved in this incident and do not need the 15 minutes of fame so typically seen with the useless tools the media finds to interview after accidents, whom have limited knowledge and were not involved in the first place.

Anyhow, the CBC report should be later today after 5pm I believe they said. I'm sure they will be successful and find the tool they are looking for to discuss their interests.

[safetywatch]

All TV stations are carrying the story on the evening news: Global, CTV, CBC and City. Also CBC Radio at 12.05 today has extended interview. CKNW is carrying an interview with Bill Yearwood at the moment

[2R]

Good to see that the media is still interested in the Fatal Accidents .Perhaps fruitful discussions will prevent more deaths .

Perhaps they should talk to a Caravan expert or at least someone familiar with the operations like a former sonic pilot.

[Chuck Ellsworth]

and if this isn't bad enough there is evidence that TC has attempted to tamper with the TSB investigation and influence its outcome.

Mr. Huggett don't forget to keep in touch with me.

All we need is a subpoena and I have a couple of TCCA inspectors who will tell the truth under oath.

You want proof of tampering with justice....I can direct you to some that involves one of TC' s Regional Directors.....in fact you know him I believe.

Remember a TC inspector will not testify against their own or can not, but a subponea in a criminal trial will allow them to tell the truth.

By the way this has no connectoin to my case against TCCA, it involves their own....

[boeingboy]

That's a pretty long stretch to say the PT6 has such a high failure rate it can't be used for SEIFR. This data would be taken from the worldwide fleet of PT-6 engines and would eliminate factors such as poor maintenance.

Fine - we all know TC isn't the greatest at times - but lets not go saying an aircraft doesn't meet regs and they knew it. To say they are criminally neglagent (for this point) is just plain ignorant.

So the real question becomes - why did the part fail? Was it a manufactoring defect?

[safetywatch]

I am afraid you are wrong. The data is on the last page of the TSB report. It is plotted out for all to see and shows every year that the 0.01 has been exceded. It is not my opinion. It is a statement of fact from TSB. It may be an incovenient truth but that is not my problem. And regarding criminal negligence, when you knowingly put someones life at risk that is what it is. TC have had the same graph from TSB for 18 months.

[Chuck Ellsworth]

This data would be taken from the worldwide fleet of PT-6 engines and would eliminate factors such as poor maintenance.

Fine - we all know TC isn't the greatest at times -

Any chance there might be a connection here between Sonic Blue and TC oversight, or lack thereof?

[Widow]

From the report:

TC first permitted SEIFR operations in Canada in 1993. At that time, the associated standard prohibited such operations in designated mountainous regions. Experience since 1993 has validated the premise behind SEIFR, which was that the reliability of modern turbine engines has made engine failure a low-probability event. Additionally, recent SEIFR rules published by the United States Federal Aviation Administration and the Australian Civil Aviation Safety Authority (CASA) do not contain prohibitions for flight over mountainous terrain. TC removed the restriction to SEIFR operations in designated mountainous regions in December 2000 in response to a report from industry proposing a need for changes to the regulations and standards governing SEIFR.

Unlike the Canadian regulations, Section 135.154 of the United States Federal Aviation Regulations does not allow the operation of "a turbine-powered airplane configured with six to nine passenger seats, excluding any pilot seat, unless that airplane is equipped with an approved terrain awareness and warning system that meets as a minimum the requirements for Class B equipment in Technical Standard Order (TSO)-C151."

And just why is that? Sounds negligent to me. What were they thinking ... oh yeah, it's only single engine, under 10 pax - who cares, right?

[Widow]

Any chance there might be a connection here between Sonic Blue and TC oversight, or lack thereof?

Gonna bet you know what my answer to that is. Obviously Safety Watch is in.

Oh, and would love to see that "report from industry proposing a need for changes to the regulations and standards governing SEIFR."

[goldeneagle]

From the report:

TC first permitted SEIFR operations in Canada in 1993.

It's to bad the report itself doesn't have the facts correct.

I did my first single engine ifr ppc in september of 1989, with a TC inspector on board. I was flying the line on a 208, IFR every day, less than a week after that ride. The operation was very definitely approved by TC, had inspectors around quite regularily.

Beware the 'facts' you quote, because they are quite often very inconveniently incorrect.