Recommendation A09-03

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Assessment of the Response from Transport Canada to Aviation Safety Recommendation A09–03

Availability of Eye–to–Wheel Height Information

Background

On 11 November 2007, a Bombardier Global 5000 (registration C–GXPR, serial number 9211), operated by Jetport Inc., departed Hamilton, Ontario, for Fox Harbour, Nova Scotia, with two crew members and eight passengers on board. At approximately 1434 Atlantic standard time, the aircraft touched down seven feet short of Runway 33 at the Fox Harbour aerodrome. The main landing gear was damaged when it struck the edge of the runway, and directional control was lost when the right main landing gear collapsed. The aircraft departed the right side of the runway and came to a stop 1000 feet from the initial touchdown point. All occupants evacuated the aircraft. One crew member and one passenger suffered serious injuries; the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.

The Board concluded its investigation and released report A07A0134 on 10 November 2009.

Board Recommendation A09–03 (10 November 2009)

Knowledge of aircraft eye–to–wheel height (EWH) is necessary to assess whether a visual glide slope indicator (VGSI) system is appropriate for the aircraft type being flown. In this occurrence, the EWH information for the Global 5000 was not available. Therefore, the crew members could not have assessed whether the VGSI was appropriate for their aircraft type.

The investigation also determined that many pilots are not aware of the EWH of the aircraft they operate. Furthermore, the topic of EWH is rarely addressed in any type of pilot training.

Without EWH information, crews will not be able to assess the appropriateness of the VGSI system they are using.

Therefore, the Board recommended that:

The Department of Transport ensure that eye–to–wheel height information is readily available to pilots of aircraft exceeding 12 500 pounds.

A09–03

Response

Transport Canada's Response to A09–03 (05 February 2010)

Transport Canada (TC) agrees with the intent of the recommendation, and in accordance with the Cabinet Directive on Streamlining Regulations, the rulemaking process will commence with a more detailed risk assessment to identify the appropriate regulatory response. TC is expecting to present the risk assessment and supporting recommendation to the Civil Aviation Regulatory Committee (CARC) in the fall of 2010. The resulting recommendation from the CARC will trigger the rulemaking process.

Board Assessment of the Response to A09–03 (05 May 2010)

TC's response to the recommendation indicates that it agrees with the intent of the recommendation and that it will conduct a detailed risk assessment to identify the appropriate regulatory response. The risk assessment is expected to be complete in the spring of 2010, with resulting recommendations to be presented to the CARC to trigger the rulemaking process. However, TC has not yet issued or recommended specific courses of action that, if implemented, would reduce or eliminate the deficiency identified in Board Recommendation A09–03.

Additionally, the Board is concerned that the length of time required to address the safety deficiency will be excessive. In view of the limited number of manufacturers involved in the production and sale in Canada of aircraft exceeding 12 500 pounds, the Board believes that TC has tools available to rectify this safety deficiency on an interim basis outside the rulemaking process.

The response is assessed as Satisfactory Intent.

Next TSB action

TSB staff will continue to monitor the state of availability of EWH information, and will follow up TC's response in conducting its risk assessment and rulemaking processes.

Transport Canada Response to A09–03 (21 January 2011)

Transport Canada indicated that a risk assessment was presented at the October 2010 CARC meeting and a risk control option was accepted. TC will publish an article in the Aviation Safety Letter. Completion is planned for the fall of 2011. TC will also provide additional information in the Aeronautical Information Manual (AIM) to advise air operators and pilots that if they do not have eye–to–wheel height information, to contact the manufacturer of their aircraft.

Board Reassessment of the Response to A09–03 (09 March 2011)

The Board is pleased that an article will be published and that additional information will be added to the AIM. However, while these two actions will raise awareness, they will not ensure that EWH information is readily available to pilots of aircraft exceeding 12 500 pounds. While TC's initial response to this recommendation indicated that it agreed with the intent of the recommendation to ensure that EWH information be readily available to pilots of aircraft exceeding 12 500 pounds, in its latest response it appears that TC is passing on the responsibility of ensuring the information is available to the air operators and pilots.

In view of the limited number of manufacturers involved in the production and sale in Canada of aircraft exceeding 12 500 pounds, the Board expected that TC would take a more proactive approach in ensuring that this information be readily available to pilots and endeavored to raise awareness of this issue with the different manufacturers. This would have resulted in long–term results, as well as a global approach to mitigation of this deficiency. In addition, the success of the approach taken by TC will be difficult to assess in the future.

TC's action taken to date will not substantially reduce or eliminate the safety deficiency.

Therefore the Board assesses TC's response as Satisfactory in Part.

Next TSB action

TSB staff will continue to monitor the state of availability of EWH information.

Transport Canada's Response to A09–03 (30 September 2011)

"May 2011 Input:
Transport Canada will publish additional information in the AIMAGA section 7.6.1 – Approach Slope Indicator Systems Eye–Wheel–Height article for the Fall 2011 publication.

TCCA is in the process of revising Appendix 6 of the Aerodrome Design Manual to link to guidance material which contains the listing of Eye–Wheel–Height in the approach configuration. The revision would be to have the manufacturer's post their information on their websites in the same fashion as Boeing.

Boeing's website:
http://www.boeing.com/commercial/airports/faqs/icaoadmpart4.pdf

September 2011 update:
Additional information in the AIMAGA section 7.6.1 – Approach Slope Indicator Systems Eye–Wheel–Height article will be published in the fall 2011 publication of AIM."

Board Assessment of the Response to A09–03 (07 March 2012)

The Board recommendation called for TC to ensure that eye–to–wheel height information is readily available to pilots of aircraft exceeding 12 500 pounds. The intent of the recommendation was for TC to compel manufacturers to publish EWH information in approved aircraft documents used by flight crews.

The Board is pleased that additional information was published in the AIM and that TC is in the process of revising Appendix 6 of the Aerodrome Design Manual. However, while this is commendable as it should raise awareness of the issue, it does not achieve the intent of Recommendation A09–03.  

First, these documents do not target manufacturers.

Second, it seems to place the onus on pilots. Section 7.6.1.3 of the AIM now states that:

Pilots and/or air operators must ensure that the approach slope indicator system to be used is appropriate for the given aircraft type, based on the EWH for that aircraft. If this information is not already available in the Aircraft Flight Manual (AFM) or other authoritative aircraft manuals (e.g.: Flight Crew Operating Manual [FCOM]), the aircraft manufacturer should be contacted to determine the EWH information for the given aircraft type.

This strongly suggests that the responsibility of having EWH information readily available rests with pilots and/or operators, compelling them to seek the information rather than having such information made available to them.

While the AIM article underscores the importance of using the appropriate VGSI system for a particular aircraft, TC's action taken to date will not substantially reduce or eliminate the safety deficiency.

The response is considered Satisfactory in Part.

Next TSB action

The TSB will continue to monitor the state of availability of EWH information.

The deficiency file is assigned an Active status.

Transport Canada’s response to A09-03 (04 December 2012)

On 16 October 2012, TC provided an update to Recommendation A09-03. The cover letter, stated in part:

"Transport Canada believes that the intent of the Recommendation A09-03 (Eye Wheel Height) has been met. No further action is contemplated at this time."

The attachment to this letter stated the following:

Transport Canada has published Advisory Circular AC700-026 (Aircraft Eye Wheel Height Information) to inform operators and pilots on updated information with respect to approach slope indicator systems and aircraft Eye Wheel Height (EWH) in the landing configuration that was published in the October 2011 issue of the Transport Canada Aeronautical Information Manual (TC AIM).

Issue 1 /2012 of the Aviation Safety Letter (ASL) included an article and illustration reminding readers there is an update available in the AIM regarding approach slope indicator systems. The article encouraged readers to take a few minutes to read the Section AGA 7.6.1.3 of the AIM.

Transport Canada has advised its domestic manufacturers and major foreign regulatory authorities during the summer of 2012, of the two publications above and that air operators will be directed to contact the manufacturer to obtain EWH information for their aircraft type if it is not readily available in the Aircraft Flight Manual or Flight Crew Operating Manual (FCOM).

On 04 December 2012, as part of its response to the TSB annual reassessment of active recommendations project, TC stated:

TC published Advisory Circular AC700-026 (Aircraft Eye Wheel Height Information), published Aviation Safety Letter (ASL) article, advised its domestic manufacturers and major foreign regulatory authorities, of the two publications above and that air operators will be directed to contact the manufacturer to obtain EWH information for their aircraft type if it is not readily available in the Aircraft Flight Manual or Flight Crew Operating Manual (FCOM). Transport Canada sent a letter to the TSB October 16, 2012 informing them of these publications and suggesting that this recommendation be closed.

Board assessment of the response to A09-03 (06 March 2013)

The Board is pleased that since Recommendation A09-03 was issued in 2009, TC has taken the following actions:

  • Published an article in Issue 1/2012 of the Aviation Safety Letter (ASL) reminding readers there is an update available in the AIM regarding approach slope indicator systems.
  • Added information and a caution in section 7.6.1.3 of the AIM.
  • Published Advisory Circular (AC) No. 700-026 to inform operators and pilots of updated information with respect to approach slope indicator systems and aircraft eye wheel height (EWH).
  • Advised its domestic manufacturers and major foreign regulatory authorities during the summer of 2012, of the publications above and that air operators will be directed to contact the manufacturer to obtain EWH information for their aircraft type if it is not readily available in the aircraft flight manual or Flight Crew Operating Manual (FCOM).

While all of the above actions are commendable as they should raise awareness of the issue and facilitate accessibility to EWH information, they still do not achieve the intent of Recommendation A09-03, which was to have EWH information readily available to pilots of aircraft exceeding 12 500 pounds by compelling manufacturers to publish it in approved aircraft documents.

TC has indicated that no further action is contemplated at this time and that they suggest that this recommendation be closed.

The response is considered Satisfactory in Part.

Board assessment of the response to A09-03 (06 March 2013)

The Board is pleased that since Recommendation A09-03 was issued in 2009, TC has taken the following actions:

  • Published an article in Issue 1/2012 of the Aviation Safety Letter (ASL) reminding readers there is an update available in the AIM regarding approach slope indicator systems.
  • Added information and a caution in section 7.6.1.3 of the AIM.
  • Published Advisory Circular (AC) No. 700-026 to inform operators and pilots of updated information with respect to approach slope indicator systems and aircraft eye wheel height (EWH)
  • Advised its domestic manufacturers and major foreign regulatory authorities during the summer of 2012, of the publications above and that air operators will be directed to contact the manufacturer to obtain EWH information for their aircraft type if it is not readily available in the aircraft flight manual or Flight Crew Operating Manual (FCOM).

While all of the above actions are commendable as they should raise awareness of the issue and facilitate accessibility to EWH information, they still do not achieve the intent of Recommendation A09-03, which was to have EWH information readily available to pilots of aircraft exceeding 12 500 pounds by compelling manufacturers to publish it in approved aircraft documents.

TC has indicated that no further action is contemplated at this time and that they suggest that this recommendation be closed.

The response is considered Satisfactory in Part.

Next TSB action

There remains some residual risk but no further action is planned by the recommendation recipient and continued reassessments will not likely yield further results.

The deficiency file is assigned a Dormant status.