Recommendation A02-02

REASSESSMENT OF THE RESPONSES FROM TRANSPORT CANADA TO AVIATION SAFETY RECOMMENDATION A02-02

LOW CEILING APPROACHES

Background

The Régionnair Inc. Raytheon Beech 1900D, serial number UE-347, operating as Flight GIO347, was on a scheduled flight from Port-Menier to Sept-Îles, Quebec, with two pilots and two passengers on board. The aircraft departed Port-Menier for Sept-Îles Airport at 2334 eastern daylight time. The aircraft crashed at 2357 while on approach to the airport, one nautical mile short of the runway, in reported weather conditions of 200-foot ceiling and one-quarter statute mile visibility. A post-crash fire destroyed the wings, the engines, and the right midside of the fuselage. The captain was fatally injured. The first officer was seriously injured, and the two passengers received minor injuries.

The Board concluded its investigation and released report A99Q0151 on 19 March 2002.

Board Recommendation A02-02 (19 March 2002)

Most pilots adhere to regulations, rules, and standard operating procedures because it is good airmanship to do so. Education directed at pilots and others in the air industry attempts to instill safety cultures that will result in safer flight. Transport Canada (TC) actively promotes good airmanship and attempts to educate persons about safe practices and the risks in disregarding safe practices. However, for whatever reason - operational pressures, pride, commitment to the job - some pilots continue to conduct approaches in weather conditions where there is little chance of completing a safe landing. Unfortunately, many of these approaches result in accidents, injuries, and deaths directly attributable to the weather conditions and the pilots' decisions. Airmanship and education are evidently not effective in curtailing accidents of this type. Such accidents will continue to occur unless further action is taken. The Board believes that an enforceable, regulatory barrier is required.

The proposed approach ban addresses the visibility issue to a large extent but does not address the ceiling issue. Although regulations exist to prohibit pilots from descending below the applicable decision height (DH) or minimum decision altitude (MDA) descent altitude for their approach, these regulations are not enforceable. In recent years, the Board has investigated a number of accidents where the visibility was reasonable, but the ceiling was below the limits stated in Canada Air Pilot for the particular approach flown. Therefore, the Board recommended that:

The Department of Transport take immediate action to implement regulations restricting pilots from conducting approaches where the ceiling does not provide an adequate safety margin for the approach or landing.
A02-02

Response to A02-02 (31 May 2002)

TC concurs with this Board Recommendation and agrees that including a ceiling limit in the approach ban merits consideration. TC is also aware of the difficulty in creating a practical and enforceable regulation based on the known limitations of the available weather observation services and the associated implications of defining what ceiling and sky condition could be used to constitute an adequate safety margin.

TC will bring forward this recommendation to the Canadian Aviation Regulation Advisory Council (CARAC) Technical Committee. An issue paper will be prepared for submission to the Commercial Air Service Operations (CASO) Technical Committee for February 2003, which will include the recommendation from the report; the statistics supplied by the TSB; a proposed rule and recommendation and the need to form a CASO working group to study the issue.

Board Assessment of the Response to A02-02 (21 February 2003)

Given TC's acceptance of the deficiency and its intention to pursue this issue in the same vein as the visibility-related Notice of Proposed Amendment (NPA), the response is assessed as being Satisfactory Intent.

Next TSB action

TSB staff will continue to monitor TC's future actions related to this recommendation. It should be noted that, due to the complexity of these issues, it will have taken over three years to have the 16 NPAs related to Recommendation A02-01.

Response to A02-02 (14 December 2005)

In preparing to bring forward this issue to the CARAC Technical Committee Part VII for further consultation and discussion with stakeholders, TC studied the recommendation and developed Issue Paper 459307.

The result of this study concluded that the implementation of an approach ban using ceiling criteria is not presently feasible due to inaccuracies inherent in the current technology and that, until technological developments permit consistently accurate readings (of cloud height) at various points on the approach, in a cost-effective manner, implementing the TSB recommendation would have a negative impact on both airport operators and air operators, would not enhance safety and thus would not be in the public interest.

TC believes that the revised approach ban being promulgated with respect to visibility reinforces current regulations and enhances safety.

A Commercial and Business Aviation Advisory Circular (CBAAC) will be released when the proposed changes to the approach ban are published in Part II of the Canada Gazette. Because weather conditions have always affected aviation safety, and will continue to compromise safety for those pilots who choose to ignore the regulations, the CBAAC addressing the revised approach ban criteria will include a section reminding pilots of the legal requirements to continue an approach beyond the MDA or DH.

Board Reassessment of the Response to A02-02 (12 July 2006)

TC's letter dated 14 December 2005 indicates that it studied the recommendation and developed an issue paper (TC 459307 refers) that concluded that the implementation of an approach ban using ceiling criteria is not presently feasible. TC believes that, until technological developments permit consistently accurate readings (of cloud height) at various points on the approach, in a cost-effective manner, implementing the TSB recommendation would have a negative impact on both airport and air operators, not enhance safety, and not be in the public interest. TC concludes that the revised approach ban NPA being promulgated with respect to visibility reinforces current regulations and enhances safety. A CBAAC is to be released when the approach ban NPA is published in Part II of the Canada Gazette. It will, in part, remind pilots of the legal requirements to continue an approach beyond the MDA or DH. Because TC's proposed action, if fully implemented, will substantially reduce the safety deficiency, the assessment is still assigned Satisfactory Intent.

Next TSB action

TSB staff will monitor the progress of the draft improvements to determine if this course of action addresses the deficiency associated with Recommendation A02-02.

Response to A02-02 (07 February 2007)

TC's response reviews its study of Recommendation A02-02, which concludes that implementing an approach ban based on ceiling criteria would not enhance safety as it is presently not feasible due to technological limitations. Furthermore, TC believes that its CBAAC 0237, issued in advance of the revised approach ban regulations, reminds pilots of the legal requirements in order to continue an approach beyond the MDA or DH. Finally, TC indicates that it considers its work in response to Recommendation A02-02 complete.

Board Reassessment of the Response to A02-02 (24 July 2007)

TC's response is, for the most part, a repeat of information contained in previous responses. TC's release of CBAAC 0237 and the promulgation of the revised approach ban regulations constitute the completion of TC's efforts to address the deficiency identified in Recommendation A02-02. Because the revised approach ban regulations do not contain an approach ban using ceiling criteria, the TC action in response to Recommendation A02-02 is limited to CBAAC 0237, which includes a reminder of the required visual reference necessary to continue the approach to land contained in Section 602.128 of the Canadian Aviation Regulations. This action has to some degree reduced the risks underlying Recommendation A02-02.

Therefore, because the action taken will reduce but not substantially reduce the deficiency, the assessment is changed to Satisfactory in Part.

Next TSB action

TSB staff will follow up in writing with TC as to options that could further mitigate the risks associated with the deficiency identified in Recommendation A02-02.

Response to A02-02 (06 March 2008)

In its 06 March 2008 response, TC states that it studied the recommendation and developed an issue paper titled "Implementing an Approach Ban Using Ceiling Criteria for Commercial Operations." The result of this study concluded that the implementation of an approach ban using ceiling criteria is not presently feasible due to inaccuracies inherent in the current technology and that, until technological developments permit consistently accurate readings (of cloud height) at various points on the approach, in a cost-effective manner, implementing the TSB recommendation would have a negative impact on both airport operators and air operators, would not enhance safety, and thus would not be in the public interest.

TC believes that the revised approach ban being promulgated with respect to visibility reinforces current regulations and enhances safety.

TC considers this recommendation CLOSED because

  • it has completed the task communicated to the Board in response to the recommendation;
  • implementation of the original recommendation is not feasible until technological developments permit;
  • being that the revised approach ban is being implemented, the underlying risks should be substantially reduced.

TC has decided not to take further action.

Board Reassessment of the Response to A02-02 (13 August 2008)

TC's promulgation of the approach ban regulation has established approach limits based on visibility, and its issuing of CBAAC 0237 has the potential to increase pilots' knowledge of safety issues that relate to conducting approaches in bad weather.

Although this action taken by TC will reduce some risks associated with approaches in bad weather, it does not address the deficiency underlying this TSB Recommendation—specifically that "airmanship and education are evidently not effective in curtailing accidents in situations where the visibility was reasonable, but the ceiling was below the limits stated in Canada Air Pilot for the particular approach flown." Such accidents will continue to occur unless further action is taken. The Board continues to believe that an enforceable, regulatory barrier is required.

Therefore, because the action taken will reduce but not substantially reduce the deficiency, the assessment remains as Satisfactory in Part.

Next TSB action

TSB staff will continue to monitor occurrences reflecting similar type deficiencies upon which this recommendation was based.

Review of A02-02 Deficiency File Status (23 September 2009)

A search of the TSB database indicates that since the implementation of the Approach Ban Regulation on 01 December 2006, a total of 33 accidents occurred in Canada during the approach phase. None of these accidents are related to approaches conducted where the ceiling was not providing an adequate safety margin for the approach or landing. This would indicate that the new Approach Ban Regulation, with respect to visibility, seems to have had a positive effect. Additionally, TC considers this recommendation closed and plans no further action.

Therefore, the assessment remains at Satisfactory-in-Part.

The Board also concludes that, as no further action is planned to be taken by TC, continued reassessment will not likely yield further results.

Next TSB action

TSB Air Branch staff will not actively monitor TC's regulatory activities to restrict pilots from conducting approaches where the ceiling does not provide an adequate safety margin for the approach or landing.