TSB Recommendation A24-03

In this occurrence, the VFR helicopter pilot, who had limited training and experience operating “in the white,” attempted to cross Griffith Island in flat light and whiteout conditions that were likely created by the uniformly snow-covered and featureless terrain, an overcast sky, and snow squalls. By doing this, the pilot inadvertently flew the helicopter into instrument meteorological conditions. The urgency of the situation, combined with the pilot’s lack of experience in similar conditions, likely caused a rapid increase in mental workload as the pilot tried to analyze an unfamiliar situation and select an appropriate course of action. It is likely that while the pilot attempted to visually manoeuvre the helicopter in response to the reduced visual cues, in accordance with his reduced-visibility training, an unintentional descent resulted, and the helicopter impacted the terrain on a near-reciprocal track to the intended route.

There are several ways to mitigate risk when a pilot lacks experience in a specific operational setting. Ideally, multiple defences should be implemented to reduce risk as low as reasonably practicable. For example, operationally realistic training can help prepare a pilot for situations that may be encountered during operational taskings. Another way of mitigating the risk is to increase the level of supervision. During remote operations, this might include implementing enhanced communication protocols, such as mandatory check-ins, to support pilot decision making (PDM). Another risk mitigation strategy, which is required by regulation for multi-crew flight operations, is to develop standard operating procedures (SOPs) for company pilots. As identified by the investigation into this occurrence, single-pilot operations conducted under subparts 604, 702, 703, and 704 of the CARs are permitted without SOPs.

SOPs are widely accepted as a tool to enhance safety in multi-crew operationsFederal Aviation Administration (FAA) Advisory Circular (AC) 120-71B: Standard Operating Procedures and Pilot Monitoring Duties for Flight Deck Crewmembers (2017). and many of their benefits apply equally to single-pilot operations. SOPs assist PDM by providing pilots with pre-determined successful solutions, based on corporate knowledge and industry best practices, for specific situations that may be encountered. SOPs are particularly beneficial when a pilot lacks the knowledge or experience in a situation, and a less-than-ideal course of action could reduce safety margins. In those instances, SOPs can help reduce pilot workload, given that less mental effort is required to work through the decision-making process because that process has already been done for the pilot. The current regulatory requirements likely contribute to a perception that SOPs are more important in multi-crew than single-pilot operations. As a result, SOPs are less common, and typically less structured, in single-pilot operations than in multi-crew operations.

The TSB has investigated multiple occurrences involving single-pilot operations where SOPs were either absent because they were not required by regulation, or they were inadequate.TSB air transport safety investigation reports A21A0024, A21P0018, A20P0080, A15A0045, A14P0132, A13H0002, A11P0117, A08P0241, A07C0119, A03H0002, A00W0177, and A95A0040. To realize the full benefits of SOPs, the regulations should be amended to require SOPs for all single-pilot operations conducted under Subpart 604 (private) and Part VII (commercial) of the CARs.

From 2001 to 2003, Transport Canada (TC) issued several notices of proposed amendments (NPAs) intended to expand the requirement for SOPs to “all operated flights regardless of the number of crew or complexity of the aircraft.”Transport Canada (TC), Canadian Aviation Regulation Advisory Council (CARAC), notices of proposed amendment 2003-075, 2003-076, and 2003-077. More than 20 years after these NPAs were issued, they remain in various stages of review (Table 1).

Table 1. Notices of proposed amendments issued by Transport Canada from 2001 and 2003, and status thereof, intended to expand the requirement for standard operating procedures to all flights

*Civil Aviation Regulation Advisory Council

Some companies that engage in single-pilot operations, such as GSH, have voluntarily developed task-specific SOPs. In the absence of formal requirements and clear guidance to assist single-pilot operators with SOP development, these operators may not fully understand how to design effective procedures. For example, GSH had a task-specific SOP for operations above the tree line; however, that SOP consisted mainly of high-level guidance rather than safe flying practices such as establishing en-route decision triggers like minimum height above ground or minimum airspeed. In addition, the SOPs did not include the operational practice, employed by senior pilots at GSH and echoed by the Polar Continental Shelf Program personnel, of avoiding overflying a barren snow-covered island. As a result, this corporate knowledge was not available to the occurrence pilot who had limited experience in that operating environment.

In Canada, thousands of pilots and passengers travel on single-pilot aircraft every year. In many instances, those flights are conducted in remote areas, with minimal external support. In these environments, additional defences must be put in place to support PDM to ensure safety margins are maintained. SOPs allow for easy sharing of corporate knowledge and best practices, and they help ensure consistency among pilots. Because there is no requirement for CARs Subpart 604 and Part VII single-pilot operations to have SOPs, pilots and passengers who travel on those aircraft are at increased risk of an accident resulting from ineffective decision making and from cognitive workload in response to novel or unexpected situations.

Therefore, the Board recommended that